In this podcast, Hilary Baldwin, MD, FAAD, and Jeffrey Fromowitz, MD, FAAD, discuss the burden of rosacea, management tips, available treatments, antibiotic stewardship, and more.

Managing Papulopustular Rosacea

Learn more about what treatments are on the rise for plaque psoriasis, the latest management advice and what trends are shaping the future of the disease. 

The changing treatment landscape of plaque psoriasis

Findings from a cohort study of psoriasis patients suggest that new users of adalimumab or infliximab may be at increased risk for serious infection compared to users of etanercept.

Data also showed that infection risk was lower for ustekinumab while remaining comparable for secukinumab, ixekizumab, brodalumab, guselkumab, or apremilast versus etanercept.

A team of investigators from France, led by Laetitia Penso, MSc, evaluated patient data from the National Health Data System in order to comprehensively capture real-world risk for serious infection associated with biologics use.

“All adults with psoriasis, defined as receiving at least 2 prescriptions of a topical vitamin D derivative within a 2-year period, registered in the database between January 1, 2008, and May 31, 2019, were eligible,” Penso and colleagues indicated.

They included those who had not had or used prescriptions of a biologic or apremilast within the previous year.

The investigators defined serious infection as infection leading to hospitalization.

As such, the primary endpoint they sought was the occurrence of a serious infection as well as time to first occurrence. They further assessed serious infection outcomes, such as gastrointestinal, cutaneous, eyes, ear-nose-throat, musculo-skeletal, pulmonary, and nervous system, among others.

They also took note of patient sociodemographic characteristics as well as any previous or current use of nonbiologic antipsoriatic agents, nonsteroidal anti-inflammatory drugs (NSAIDs), and systemic corticosteroids.

A total of 44,239 patients were new users of a biologic/biosimilar or a targeted synthetic antipsoriatic agent.

Of this population, 29,618 (66.9%) were prescribed a tumor necrosis factor inhibitor first, 6658 (15.0%) an interleukin (IL) 12/23 inhibitor, 4093 (9.3%) an IL-17 inhibitor, 526 (1.2%) an IL-23 inhibitor, and 3344 (7.6%) apremilast.

Penso’s team thus reported that 1656 serious infections occurred across the entire evaluated population, with gastrointestinal (38.9%) being the most frequently observed type of infection—followed by skin (19.6%) and pulmonary infections (14.8%).

The overall crude incidence rate was 25.0 (95% CI, 23.8-26.2) per 1000 person-years, and the median time to event was 9 months.

“After adjusting for time-dependent covariables, risk of serious infections was higher for new users of adalimumab ([hazard ratio] HR, 1.22; 95% CI, 1.07-1.38) or infliximab (HR, 1.79; 95% CI 1.49-2.16) vs etanercept, whereas ustekinumab was associated with a lower risk of having a serious infection (HR, 0.79; 95% CI, 0.67-0.94),” Penso and team wrote.

Patients who used guselkumab or apremilast did not demonstrate any increased risk for serious infection versus new users of etancercept. However, risk was higher among those with concomitant use of NSAIDs (HR, 1.47; 95% CI, 1.25-1.73) or systemic corticosteroids (HR, 2.32; 95% CI, 1.95-2.76).

“The findings of this study are important because recent biologic agents, including secukizumab, ixekizumab, brodalumab, and guselkumab, were compared with one another,” Penso and colleagues wrote.

They noted that observational studies have produced conflicting results in regard to biologic use and risk of infections. One potential explanation offered by the investigators was the differences between study populations, namely the condition treated by the biologic and inclusion/exclusion criteria.

Nevertheless, they acknowledged that additional observational studies to confirm these findings among psoriasis patients are warranted.

The study, “Association Between Biologics Use and Risk of Serious Infection in Patients With Psoriasis,” was published online in 

This article was originally published by our sister publication HCP Live

Articles

Gastrointestinal infections were the most common serious infections associated with biologics, according to a cohort analysis.

Biologics for Psoriasis May Increase Serious Infection Risk

Zoe Diana Draelos, M.D., is a consulting professor of dermatology, Duke University School of Medicine, Durham, N.C. She is investigator, Dermatology Consulting Services, High Point, N.C., and a Dermatology Times Editorial Advisor and co-medical editor.

Microblading has become very popular for females with thinning eyebrows and males who also desire increased eyebrow thickness. Microblading is basically a superficial eyebrow area tattoo. The tattoo ink color is selected and blended to match the hair color of the female and then small cuts are made in the eyebrow area to mimic hairs. The pigment is pushed into the cuts to create a semipermanent tattoo. Microblading is designed to last 1 to 3 years, but most women require a yearly touch-up. Some of the tattoo ink is removed with scabbing that follows the procedure, which may necessitate a touch-up shortly after the initial procedure. With time, additional tattoo ink will become phagocytized by white blood cells and transported to lymph nodes, accounting for pigment fading.

It is critical that no water contact the freshly microbladed area for 1 week. This is because washing and water can remove the pigment that was superficially deposited in the skin until healing occurs. Once the skin has healed, the pigment is trapped in the skin. Avoiding water contact includes not only washing but also sweating and swimming.

Microblading has largely replaced eyebrow tattooing because the small cuts resemble hairs better than a solid tattooed line. Microblading is also not permanent, allowing for changes in the eyebrow architecture with aging. Loss of subcutaneous fat on the forehead results in lowering of the eyebrows and loss of the natural eyebrow arch. Semipermanent microblading allows for the adjustment of eyebrow contour with aging. Many postmenopausal women notice loss of the lateral third of the eyebrow with estrogen deficiency. This loss removes the very feminine eyebrow curve, creating a more flattened eyebrow appearance characteristic of male facial architecture. Microblading can recreate the lateral eyebrow in an artistic manner in the hands of an excellent technician.

The biggest challenge to microblading is finding a skilled technician who has the same vision of the patient’s eyebrows as the patient. I recommend patients take a younger picture of themselves to the salon to show the technician how to recreate the desired eyebrow. It is best to recreate the youthful eyebrow of the patient rather than to try to create eyebrows randomly selected by the patient from a magazine picture. Even though microblading is not permanent, the patient will be saddled with a poor result for at least a year. Asking around about friends’ experiences and getting recommendations from others who have undergone the procedure is the best way to ensure an attractive result. Microblading costs between $500 and $1200, depending on the location and reputation of the salon.

Q: What is the safest way to groom unruly eyebrows?

One of the reasons mature women undergo microblading is because eyebrow growth no longer occurs due to overplucking. If a woman heavily plucks her eyebrows to achieve the Greta Garbo look, eventually traumatic plucking will result in failure of the eyebrow hairs to grow. Most eyebrow hair removal methods involve some type of potential trauma to the hair follicle. Threading, waxing, and tweezing all yank the hair from the follicle. Gentle removal of unwanted eyebrow hairs is very important. Using a good pair of tweezers and exerting firm, steady pressure until the hair is epilated is important. Do not yank or aggressively pull the hair. Also, only pluck hairs that would never be acceptable in well-groomed eyebrows. Avoid the temptation to pluck eyebrows to meet current fashion standards.

It is hard for young female patients to imagine a day when their eyebrows will not grow; however, this day will come even for those with bushy eyebrows. Moderation in plucking is important. Tell female patients to only pluck those hairs that they would never want to regrow at any time in their life.

There are many different opinions on the optimal female eyebrow. Basically, eyebrows should be shaped by the female patient to frame the eye in the most attractive manner possible. I generally give patients who desire eyebrow assistance, either for too much or too little growth, the following 3 points. I tell them to get a pen to use as a straight line for identification of facial landmarks.

The eyebrow should start at a point defined by a line drawn from the corner of the nose to the inner canthus.

The eyebrow should arch at a point defined by a line drawn from the corner of the nose to the midpupil.

The eyebrow should end at a point defined by a line drawn from the corner of the nose to the lateral canthus.

Eyebrows that follow these ideal proportions, laid out originally by the ancient Greeks, are appropriate for all sizes and ethnicities of female faces. In contrast, the male face is characterized by a flattened eyebrow without the female arch.

In this month's Cosmetic Conundrums column, Dermatology Times® Chief Medical Editor Zoe Diana Draelos, MD, explores the world of eyebrows, including microblading, grooming, and shape. 

Examining Eyebrows

In this episode, we provide an update on a story we broke regarding benzene contamination being detected in various sunscreens and after-sun care products. Now, Johnson & Johnson has conducted its own internal testing and is recalling 5 different aerosol sunscreen products from Neutrogena and Aveeno. Listen as Christoper Bunick, MD, PhD, associate professor of dermatology, Yale University and 

 editorial advisory board member explains what this means for the sun protection industry and the next steps for the FDA.

Podcasts

Christoper Bunick, MD, PhD, provides an update on benzene contamination in sunscreen, including a recent recall from Johnson & Johnson. 

The Cutaneous Connection: Episode 27- Benzene Contamination Update

The FDA will not meet the Prescription Drug User Fee Act (PDUFA) goal date of July 27 for abrocitinib (PF-04965842; Pfizer), a potential treatment of moderate to severe atopic dermatitis in adults and adolescents, according to an announcement from Pfizer.

The FDA cited its ongoing review of Pfizer's ORAL Surveillance, a post-marketing safety study evaluating tofacitinib in rheumatoid arthritis patients. Originally set for April 2021, the FDA extended the review of abrocitinib’s New Drug Application (NDA) by 3 months to July.

Abrocitinib is a once-daily, oral Janus kinase 1 (JAK1) inhibitor for moderate to severe AD in patients 12 years and older. Inhibition of JAK1 is said to influence interleukin (IL)-4, IL-13, IL-22, IL-31 and interferon gamma–all of which are thought to be involved in the pathophysiology of AD.

Fillings for the drug are supported by positive results from studies in the abrocitinib JAK1 Atopic Dermatitis Efficacy and Safety (JADE) global development program. The submitted studies include JADE MONO-1 and JADE MONO-2, which investigated abrocitinib as a monotherapy; and JADE COMPARE, which evaluated the drug compared to placebo in patients on background topical therapy while also comparing the drug to an active control arm consisting of dupilumab (Dupixent; Sanofi and Regeneron) vs placebo.

In JADE COMPARE, abrocitinib met all co-primary endpoints and both doses (100 mg and 200 mg) of abrocitinib demonstrated superiority over placebo at week 16 and was sustained until week 16.

Meanwhile, results from JADE MONO-1 also met all co-primary and secondary endpoints, including a proportion of patients who achieved an IGA score of 0 or 1 and at least a 2-point improvement, and a proportion of patients who achieved 75% or more change from baseline in their Eczema Area and Severity Index (EASI) score. Secondary endpoints included a proportion of patients achieving a 4-point or more reduction in itch severity measured with the pruritus numerical rating scale (NRS) and the magnitude of decrease in the Pruritus and Symptoms Assessment for Atopic Dermatitis (PSAAD).

Additionally, results from JADE MONO-2 met all primary and secondary endpoints while demonstrating statistical superiority to placebo. Investigators reported both doses (100 mg and 200 mg) of abrocitinib subjects achieved EASI-75, EASI-90, PP-NRS and IGA responses in a greater proportion vs placebo.

Pfizer provides update on u. S. Fda review of abrocitinib and xeljanz® filings | pfpfizeruscom. Accessed July 22, 2021. https://www.pfizer.com/news/press-release/press-release-detail/pfizer-provides-update-us-fda-review-abrocitinib-and

The FDA did not meet the PDUFA goal date for abrocitinib (PF-04965842; Pfizer), a potential treatment of moderate to severe atopic dermatitis in adults and adolescents.

FDA Delays Approval for Abrocitinib for Atopic Dermatitis

John Jesitus is a medical writer based in Westminster, CO.

Although data and expertise regarding psoriasis in skin of color (SOC) continue to grow, patients of color remain underdiagnosed, underrepresented in clinical trials, and often unable to access dermatologic care. Addressing these inequities requires broadening the scope of educational materials, raising awareness among communities of color, and expanding outreach from clinical-trial sponsors and investigators, an expert tells 

“The bottom line is that there is underrepresentation of nonwhite racial ethnic groups in psoriasis studies,” says Andrew Alexis, MD, MPH. He is Vice-Chair for Diversity and Inclusion in the Department of Dermatology and a dermatologist at the Center for Diverse Skin Complexions at Weill Cornell Medicine in New York.

Underrepresentation fuels misconceptions and misrepresentations. Historically, says Alexis, the prevalence of psoriasis in nonwhite racial/ethnic groups has been thought to be low, particularly among people of African descent. However, he says, more recent data have shown that psoriasis is hardly rare among populations of color. A study published in 2014 revealed prevalence rates of 3.6% 1.9%, and 1.6%, respectively, among whites, African Americans, and Hispanics.

 A subsequent analysis showed a rate of 3.1% among nonwhite, non-Hispanic groups, 2.5% among Asian Americans, 1.9% among Hispanic Americans, and 1.5% among African Americans.

“There’s a chance that these figures are still underreported,” says Alexis, “because psoriasis may be underdiagnosed in populations of color.

” One contributor to this situation, he says, is disparities in access to dermatologic care, which have been well documented.

 Disparities in access also may explain the tendency for greater psoriasis severity at diagnosis in black and Latino patients, he says.

“The erythema that is characteristic of psoriasis may appear somewhat differently in the background of melanin-rich skin,” adds Alexis. In Fitzpatrick types V and VI, he explains, background pigmentation can make erythematous psoriasis plaques appear violaceous, dark brown, reddish-brown, or gray. Morphologically, East Asian patients have been reported to have a tendency toward smaller, less widespread plaques than do Caucasian patients, despite higher expression of interleukin (IL)-17 and IL-17A-regulated pro-inflammatory cytokines.

Regardless of race or ethnicity, adds Alexis, the hypo- or hyperpigmentation left behind after psoriatic lesions resolve can last weeks to months and bother patients as much as psoriasis itself. Studies show that psoriasis imposes a higher psychosocial burden, and greater quality-of-life (QOL) impairment, for patients of color.

 Although reasons for these differences are not entirely clear, says Alexis, they may include pigmentary alterations, cultural sensitivities, and perceptions of disease. Cultural biases also may contribute to observed racial/ethnic differences in Dermatology Life Quality Index (DLQI) scores,

 which he says is an area that warrants further study.

Differential diagnosis of scaly psoriatic plaques also may prove more challenging in SOC, Alexis says. Specifically, features of sarcoidosis, cutaneous T-cell lymphoma, hypertrophic discoid lupus, and lichen planus, all of which occur more commonly in populations of African descent, can overlap with those of psoriasis. “Being aware of this differential diagnosis and having approaches to arrive at the accurate diagnosis are the key recommendations to improve outcomes.”

Recommended approaches involve examining the whole patient, focusing on lesion distribution, color, and morphology. For example, involvement of the scalp, nails, intergluteal cleft, elbows, and knees suggests psoriasis, whereas lichen planus, which is marked by flat-topped scaly plaques often involving the wrists, also may have distinctive lesions in the oral or genital mucosa.

“As with other inflammatory diseases in skin of color,” says Alexis, “we need to address both the active inflammatory lesions and the postinflammatory sequelae.” In some cases, he says, it is probably acceptable simply to treat the active inflammatory lesions and allow time to resolve the pigmentary changes. “But in many instances, patients would prefer active treatment of hyperpigmentation. Adding topical bleaching agents like hydroquinone or a topical retinoid such as tazarotene to their routine can be helpful.” Alexis suggests waiting until lesions have completely resolved before adding hydroquinone.

“On the other hand,” he says, “tazarotene is not solely a bleaching agent—it’s also a treatment for psoriasis. So tazarotene has the advantage of being able to help treat a psoriatic plaque and manage hyperpigmentation at the same time.”

 In a recent study, fixed-combination halobetasol plus tazarotene achieved 2-point investigator global assessment (IGA) improvements in 41.8% of white participants and 39.3% of Hispanic/Latino participants.

When treating patients of color with psoriasis, cultural nuances that dermatologists must consider range from traditional beliefs and practices to haircare. In the former area, the belief of many Hispanic patients that blood or organ disease causes skin conditions may lead patients to request additional testing.

Scalp psoriasis is relatively common regardless of ethnicity but may present more severely in African-American women due to less frequent hair washing—once every week or 2 on average, though the interval could be longer depending on the hair style.

 Rather than recommending a treatment that requires more frequent washing than a patient’s hairstyle warrants, Alexis may recommend a once-weekly medicated shampoo, plus additional topical therapies that can be left on the scalp. “For example, there are topical corticosteroid solutions or oil-based vehicles that tend to be more compatible for most women of African ancestry who have scalp psoriasis.”

Together, the challenge of weaving topical therapies into patients’ haircare regimens and the impact of scalp psoriasis in some patients of color prompt Alexis to use a lower threshold for systemic therapies in these patients. “For someone with moderate-to-severe scalp psoriasis that’s not responsive to topical therapy, I would consider oral apremilast, for example, or a biologic.” In a phase 2b trial of apremilast in Japanese patients with moderate-to-severe psoriasis, subjects achieved similar results to those of the full population in phase 3 trials.

Conversely, clinical results and toxicities of methotrexate, acitretin, and cyclosporine may be impacted by genetic polymorphisms that occur at different rates in different racial and ethnic groups.

 Additionally, phototherapy in SOC can temporarily darken both patients’ overall complexions and any PIH they may have. However, says Alexis, patients may accept these changes if appropriately counseled pretreatment.

Regarding biologics, growing evidence shows safety and efficacy for psoriasis across ethnic groups. The EASE study of etanercept (50 mg twice weekly, open label), for example, showed comparable clinical improvements and adverse-event rates among white, black, Hispanic, and Asian patients.

 A subanalysis of 2 pivotal brodalumab trials revealed similar results for patients of all racial and ethnic groups.

Among Asian patients, studies of adalimumab in Japanese populations have shown results consistent with US phase 3 results.

A study of secukinumab in 441 Chinese patients posted Psoriasis Area and Severity Index (PASI) rates of 97.7% and 87.2% for 300 and 150 mg doses at week 12, with continued safety through 52 weeks.

 Additionally, subanalyses of the ERASURE secukinumab trial showed that Japanese and Korean patients achieved PASI scores commensurate with those of the full population.

However, a growing body of evidence requires dermatologists to consider potential differences in biologic efficacy between ethnic groups. For instance, the phase 3 REVEAL trial of adalimumab showed superior efficacy in white patients versus nonwhite patients, with week 12 PASI scores of 72% versus 63%.

 Pooled data from 4 phase 3 secukinumab studies likewise show that Hispanic subjects were nearly twice as likely to achieve PASI 75 as non-Hispanic participants (odds ratio: 1.97).

While ustekinumab has demonstrated efficacy in treating Taiwanese, Korean, Japanese, and Chinese patients with psoriasis, Chinese patients treated with the 45 mg dose achieved the greatest numeric improvement.

 A subanalysis of the VOYAGE 1 and 2 guselkumab trials showed that this drug outperformed adalimumab at week 24 in white and Asian patients, but not black patients, possibly due to the small number of black patients included (guselkumab n = 12).

Performing studies like the foregoing remains very important, says Alexis. “But what would be even better would be studies that enroll a more diverse patient population. Then these subpopulation analyses would be more robust.”

Solving this problem, he says, begins with carefully considering local demographics when selecting investigator sites for large clinical trials. “Next would be encouraging investigators to inform their communities broadly about studies that they’re conducting and including populations that historically have had less access to information on clinical trials.”

The latter amounts to a call to action upon study sponsors and investigators to make efforts to inform and enroll integral and diverse patient populations, Alexis says. “It’s recognized as a concern within organizations such as the Skin of Color Society (of which he is Scientific Committee Co-Chair).” Efforts by the Society to help narrow the representation gap in all dermatologic disease states are in planning phases, he adds.

For the future, says Alexis, the specialty should continue in the direction of improving educational resources so that examples of how psoriasis presents across the spectrum of diverse populations and skin complexions are represented, and practitioners are better able to recognize and diagnose psoriasis in subpopulations. Simultaneously, he advised raising awareness in the community that psoriasis is by no means limited to individuals of European ancestry. “That could contribute to earlier diagnosis and optimal treatment for patients of color with psoriasis.”

1. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. 

2. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis prevalence in adults in the United States [published online ahead of print, 2021 Jun 30]. 

. 2021;10.1001/jamadermatol.2021.2007. doi:10.1001/jamadermatol.2021.2007

3. Kurd SK, Gelfand JM. The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES 2003-2004 [published correction appears in 

4. Fischer AH, Shin DB, Gelfand JM, Takeshita J. Health care utilization for psoriasis in the United States differs by race: an analysis of the 2001-2013 Medical Expenditure Panel Surveys. 

5. Kim J, Oh CH, Jeon J, et al. Molecular phenotyping small (Asian) versus large (Western) plaque psoriasis shows common activation of IL-17 pathway genes but different regulatory gene sets. 

6. Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. 

7. Kerr GS, Qaiyumi S, Richards J, et al. Psoriasis and psoriatic arthritis in African-American patients--the need to measure disease burden. 

8. Shah SK, Arthur A, Yang YC, Stevens S, Alexis AF. A retrospective study to investigate racial and ethnic variations in the treatment of psoriasis with etanercept. 

9. Desai SR, Alexis AF, Jacobson A. Successful management of a black male with psoriasis and dyspigmentation treated with halobetasol p ropionate 0.01%/tazarotene 0.045% lotion: case report. 

10. Alexis AF, Desai SR, Han G, Jacobson A. Fixed-combination halobetasol propionate and tazarotene lotion for psoriasis in patients with skin of color. 

11. Moy JA, McKinley-Grant L, Sanchez MR. Cultural aspects in the treatment of patients with skin disease. 

12. Kaufman BP, Alexis AF. Psoriasis in skin of color: insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-white racial/ethnic groups [published correction appears in 

13. Ohtsuki M, Okubo Y, Komine M, et al. Apremilast, an oral phosphodiesterase 4 inhibitor, in the treatment of Japanese patients with moderate to severe plaque psoriasis: efficacy, safety and tolerability results from a phase 2b randomized controlled trial. 

14. McMichael A, Desai SR, Qureshi A, Rastogi S, Alexis AF. Efficacy and safety of brodalumab in patients with moderate-to-severe plaque psoriasis and skin of color: results from the pooled AMAGINE-2/-3 randomized trials. 

15. Asahina A, Nakagawa H, Etoh T, Ohtsuki M; Adalimumab M04-688 Study Group. Adalimumab in Japanese patients with moderate to severe chronic plaque psoriasis: efficacy and safety results from a phase II/III randomized controlled study. 

16. Asahina A, Torii H, Ohtsuki M, et al. Safety and efficacy of adalimumab treatment in Japanese patients with psoriasis: results of SALSA study. 

17. Cai L, Zhang JZ, Yao X, et al. Secukinumab demonstrates high efficacy and a favorable safety profile over 52 weeks in Chinese patients with moderate to severe plaque psoriasis. 

18. Wu NL, Hsu CJ, Sun FJ, Tsai TF. Efficacy and safety of secukinumab in Taiwanese patients with moderate to severe plaque psoriasis: subanalysis from ERASURE phase III study. 

19. Ohtsuki M, Morita A, Abe M, et al. Secukinumab efficacy and safety in Japanese patients with moderate-to-severe plaque psoriasis: subanalysis from ERASURE, a randomized, placebo-controlled, phase 3 study. 

20. Menter A, Gordon KB, Leonardi CL, Gu Y, Goldblum OM. Efficacy and safety of adalimumab across subgroups of patients with moderate to severe psoriasis. 

21. Adsit S, Zaldivar ER, Sofen H, et al. Secukinumab is efficacious and safe in Hispanic patients with moderate-to-severe plaque psoriasis: pooled analysis of four phase 3 trials. 

22. Zhu X, Zheng M, Song M, et al. Efficacy and safety of ustekinumab in Chinese patients with moderate to severe plaque-type psoriasis: results from a phase 3 clinical trial (LOTUS). 

23. Gordon KB, Blauvelt A, Foley P, et al. Efficacy of guselkumab in subpopulations of patients with moderate-to-severe plaque psoriasis: a pooled analysis of the phase III VOYAGE 1 and VOYAGE 2 studies. 

Dr. Alexis has been a grant recipient/researcher and consultant for Almirall, Amgen, Bristol Myers Squibb, Galderma, Leo Pharma, Menlo Therapeutics, Novartis, and Valeant (Bausch Health). He also has been a consultant and speaker for Pfizer and Sanofi and Regeneron; a grant recipient/researcher for Arcutis and Cara Therapeutics; a consultant for AbbVie, Allergan, Beiersdorf, Cassiopea, Dermavant, Janssen, L’Oreal, Scientis Pharma, Sol-Gel, VYNE Therapeutics, UCB, and Unilever; and a speaker for AstraZeneca.

Addressing underdiagnosis, underrepresentation, and undertreatment in skin of color patients with psoriasis.

Psoriasis Strategies in Skin of Color

Social media is not just for entertainment but can also be used as a valuable tool to strength your aesthetic practice, according to a panel discussion at Aesthetics Biomedical’s 

In the panel discussion “How To Strengthen Your Aesthetic Practice Through Social Media Partnerships & Campaigns,” panelists Shino Bay Aguilera, MD, Fort Lauderdale, Florida, Ava Shamban, MD, Beverly Hills, California, Joie Tavernise, LE, New York, New York, Jennifer Stieber, NP, Nashville, Tennessee, Frankie Grande, a Broadway performer and social media mogul, and moderator Sheldon Larson, chief marketing officer at Aesthetics Biomedical, Phoenix, Arizona, chatted about the best practices for using social media to your advantage and how implementing social media campaigns and utilizing influencers can extend your patient outreach and improve your aesthetic practice overall.

The discussion began with Larson asking Shamban about how she boosts user engagement on Instagram.

“I think the most important thing about social media is creating a narrative and really writing a story where you are the star,” she said. “So, to be the main focus of the story, it needs to be well-rounded.”

Shamban said she tries to control her online narrative by displaying a mix of her life, from showing off her hobbies like cooking to sharing what she does in the office to promos. She tries to share as much as she can while also avoiding sharing private aspects of her life, such as her children.  

Larson added that his brand has noticed that user-generated content boosts engagement vs branded content. This includes the good, the bad, and the ugly such as before and after photos. 

He went on to ask Grande how aesthetic practitioners can begin working with influencers to help promote their practice.

Grande said that his biggest tip to practices looking to collaborate with influencers is that before you approach an influencer, have your social channels carefully curated and ready for the traffic that influencers are going to push to you. 

“I can’t tell you the amount of times I’ve worked with brands and I’ve looked at their Instagram and their last 3 pictures are not the ones that represent your brand…,” he said.

Grande also said to that although some influencers may have a large number of followers, they might not have the right personality for your brand. To combat this, he suggests doing a test drive with the perspective influencer to ensure their personality is the best fit for your brand. 

Larson then asked Stieber and Tavernise about how they balance their social media channels between branded content and user generated content. 

Stieber began by stating that it is hard to generate content, but her practice produces content every day to create a large backlog and will post that content a week to a month later, with live events and real-time news posted as soon as possible.

For Tavernise, her practice posts a lot of stories and frequently answers users’ questions about behind the scenes content, as well as before and after shots, product recommendations, and explanations of treatments.

“I love social media in that way, especially Instagram, because I think during COVID it was huge for me to connect with my clients and to connect with new people,” said Tavernise.

Finally, Larson asked Aguilera what was most important to showcase when showing aesthetic treatments on social media such as Vivace microneedling (Aesthetics Biomedical) or Botox (onabotulinumtoxinA; Allergan Aesthetics).

In order to be an influencer, Aguilera said, aesthetic practitioners should be themselves and stray away from imitation. He advised to think about your presence as a whole with peers and family before thinking about your brand.

“Even if you have 1 follower, you are an influencer,” he emphasized. “You are influencing that 1 person, so that’s why I am very passionate about content and social media and remembering who is watching on the other side of the screen — young little girls and people with dysmorphia. So, you have to be very responsible, and you have to practice for the patient, not practice only for profit.”

A group of expert panelists gathered to discuss how social media can benefit your practice and how to best use it to your advantage. 

Reinforcing Your Aesthetic Practice Through Social Media

Aesthetics Biomedical’s Perspectives: The Evolution of Aesthetics symposium

, Victor Ross, MD, a board-certified dermatologist and dermatologic surgeon, San Diego, California, spoke about the newest advances in technology for both microneedling and energy-based devices. 

The goal of these new technologies is to maximize the results of the procedures while minimizing patient downtime. With traditional radio frequency (RF) devices, physicians must think about RF, energy flow, and tissue resistance and how that amounts to heat accumulation. The overall results were modest as a large volume of area was being heated, resulting in a small change in temperature. 

What has replaced the bipolar technique of RF is fractional RF. In fractional RF, the needles are insulated and isolated in place into a predetermined depth causing more heat to be created deeper and resulting in restored skin elasticity. This also did not have results Ross was satisfied with. 

According to Ross, one of the most predictable ways to achieve some skin tightening is with RF microneedling.

An issue that Ross brought up is heat vs no heat. Heat can cause pain for the patient, but many times is needed for results. Also, there can be a recall caused by a gap between the needles and the skin and many companies claim that their devices go deeper than what may be reality. 

He went over the Vivace (Aesthetics Biomedical) microneedling device. The system offers ergonomic pieces and has LEDS, noninsulated or insulated needles, and offers settings to change power levels to make microneedling easier. When using the device, physicians can change frequency from 1 to 2 megahertz. 

Another device he went over another microneedling device, that uses 5 needles to go into the desired depth and has a long heating time of 4 seconds. They are larger than the typical microneedling device and it offers a cooling tip. It can make procedures longer due to low frequency of the needle.

The Agnes device (Agnes Medical) was also discussed. It uses a single needle to treat the face and the negative of this device is that each time the needle is used, the physician must push it down with their hands which can be tiring, according to Ross.

Combination therapy was something Ross does a lot of, using a laser, along with a RF microneedling device to treat the skin. This decision on whether to use this type of therapy will be decided on how long the patient can have downtime as it is an aggressive treatment.

To make microneedling better, in Ross’s opinion, would be better control of needle sharpness, better motors to push the needles down into the skin, and have reliable endpoints for their depths.

Tixel (Novoxel), a thermal mechanical action for fractional treatment, was the last device that Ross highlighted, and it is a fractionating device, the size of a postage stamp, and made of titanium alloy. It can heat up to approximately 400 degrees Celsius, but because contact time is so low, it does not hurt the patient. It can repair skin very quickly and efficiently. Currently, it is available overseas.

“So, Tixel was a new exciting way to use a new practice and fight key that adds to our weaponry that you can use to make your skin fresher and better,” Ross concluded. 

Victor Ross, MD, board-certified dermatologist and dermatologic surgeon in San Diego, California, spoke about different technologies available for microneedling and energy-based devices. 

Deep Dive into Microneedling with Energy-Based Devices

Shino Bay Aguilera, MD, board certified dermatologist, Fort Lauderdale, Florida, knows how to start a symposium in style. Opening Aesthetics Biomedical’s

 Perspectives: The Evolution of Aesthetics 

symposium as the keynote speaker, the physician created a spectacle appearing in a circle of sparks, spiritedly salsa dancing for a cheering audience. As he made his way to the stage, Aguilera danced through the crowd, scooping up Vivian Bucay, MD, FAAD, dermatologist, San Antonio, Texas, and spinning her in circles. 

The excitement didn’t stop at the stage, as he led a progression of diverse models in front of a large video screen, perfectly setting up the tone of his presentation.

His keynote address, “Diversity in Aesthetics & Mindfulness” reflected his sprightful opening as he discussed his background growing up in Panama and multi-raced identity, all while in a cloud of fog and strobe lights. 

His focus on equality and equity centered on his explanation of the primitive brain and limbic system; explaining that these systems result in the need for acceptance and acknowledgement.

As patients age, these needs create a market for the physical and emotional beauty industry. However, Aguilera noted, physicians must be aware of, and move away from, euro-centric aesthetics and ideals of beauty. He highlighted how different races of people age and how euro-centric aesthetic treatments can disrupt this process negatively. This is an important acknowledgement as he explained the rising people of color (POC) patient population since 2000. 

Staying cognizant of how POC and cultural features integrate into aesthetics, beauty trends also become a note of contention, he said. When posting and contributing to these trends, he said, it’s important to understand any racial or prejudicial links. He used examples of the fox eye, and Russian lips trends to show this link. 

Elaborating on the role of social media in aesthetics, Aguilera made note of its negative effects on self-esteem and the increasing rate of dysmorphia. From Zoom and Snapchat dysmorphias to the use of heavy filters in photographs, he said, the rates of suicide in these vulnerable populations are high. 

Switching gears to wellness, the physician talked about wellness in aesthetics and how stress effects not only aging of the skin, but also hair graying as well. Cortisol being the main cause of this, he notes, the hormone can be healthy, however, “too much of a good thing is detrimental,” he said.

In the presentation, Aguilera showed images of 2 people, 1 that looked heavily aged, and 1 that looked more ageless, highlighting that “aging gracefully is 20% nature and 80% nurture.”

Wrapping up his keynote address, he left the audience with ways to help stress and create more wellness in day-to-day life.

“Thoughts become things.” He explained that intrusive negative thoughts can manifest physically, especially through skin aging and hair graying.

The law of attraction. He stopped the presentation to demonstrate to the audience how to manifest love. Manifestation is known as intentionally creating reality through beliefs and actions. To manifest, one must,

Surrender, become open to opportunities as they come.

Working with intention. He said that every morning, he creates an intention of happy patients, and successful procedures. Creating positive intentions, he said, helps keep away negativities.

Be proactive, not reactive. Plan for what could happen, instead of reacting to what did.

Change your reaction. Aguilera shared with the audience a grounding and stress-releasing breathing exercise to help with difficult situations.

Opening the symposium in a circle of sparks and salsa dancing, Shino Bay Aguilera, MD, talks the importance of diversity and wellness in aesthetics. 

 Shino Bay Aguilera, MD, Opens ABM Perspectives with a Bang

POLL: Which way do you prefer to learn about the latest updates in dermatology?

New and forthcoming options bring opportunity for optimizing patient care.

New Video Game Aimed at Dermatologist Education

Level Ex has announced its Top Derm Game as its expansion into the dermatology specialty.

St. Jude Registry Aims to Better Understand Pediatric Melanoma

St. Jude Children’s Research Hospital researchers have created a registry to better understand pediatric melanoma.

Alma Hybrid Laser Receives FDA 510(k) Clearance

Alma today announces the FDA clearance of its Alma Hybrid combination platform, which includes an ablative 10,600 nm (CO2) laser and nonablative 1570 nm laser for skin resurfacing.

Engage patients in treatment compliance and lifestyle changes to achieve optimal outcomes.

Chat Room Referral Could Redefine the Physician-Patient Relationship

In this month's Legal Eagle column, David J. Goldberg, MD, JD, explores chat room referrals and how they could possibly alter the physician-patient relationship.

FDA Decision Delayed for Baricitinib for Atopic Dermatitis

The FDA has decided to delay the PDUFA goal date for baricitinib for treatment of adults with moderate to severe atopic dermatitis.

Christoper Bunick, MD, PhD, provides an update on benzene contamination in sunscreen, including a recent recall from Johnson & Johnson.

In this month's Cosmetic Conundrums column, 

® Chief Medical Editor Zoe Diana Draelos, MD, explores the world of eyebrows, including microblading, grooming, and shape.

This week’s edition of The Mainstream Patient features stories about a new TikTok-inspired acne treatment, skin care ingredient absorption, injectable psoriasis treatments, plus more.

ICYMI, some of this week’s featured content includes systemic treatment for pediatric AD, a new video game for dermatologists, St. Jude's registry for pediatric melanoma, and more. 

Weekly Roundup: July 19-23

 dives into injectable psoriasis treatments, features a new TikTok trend using sea salt water to treat acne, and explains why there is a rise in Black people getting fillers and Botox. Also, 

details what sun allergies are and reveals how skin care ingredients are really absorbed into the skin. Finally, 

highlights hormone testing as the next big thing in skin care. 

People on TikTok Are Using Sea Salt Water Treatments to Clear Their Acne

The Injectable Psoriasis Treatment You Probably Didn’t Know About

Why More Black People Are Getting Fillers & Botox

What Are Sun Allergies? Plus, Signs You May Be Experiencing Them

The Truth About How Skincare Ingredients Get Absorbed Into the Skin