Treating common skin conditions such as rosacea and melasma with appropriate topical agents, chemical peels, devices and cosmeceuticals can build trust among patients who may require additional dermatological services, experts say.
Treating common skin conditions such as rosacea and melasma can build a bridge to aesthetic treatments, said experts at last year’s annual Cosmetic Bootcamp in Aspen, Colo.
Dr. LupoIn particular, said Mary P. Lupo, M.D., appropriately used procedures for these chronic skin conditions can be "a great way to increase your practice's cash-payment business. I'm all about physicians having more control over their lives and practices and being less dependent on government and insurance companies. Instead of being worried about the future, figure out how you can make your practice more profitable." She is a New Orleans-based dermatologist in private practice.
For women in their 20s and 30s with rosacea, Dr. Lupo often recommends salicylic acid peels.
Dr. BersonAccording to Diane S. Berson, "Salicylic acid is lipophilic. Therefore, it penetrates the sebaceous gland and helps remove some of the oil. It's also related to aspirin, so it has anti-inflammatory properties." She is an associate professor, Department of Dermatology, Weill Medical College of Cornell University, and an assistant attending dermatologist, New York Presbyterian Hospital, New York.
Dr. Lupo added, salicylic acid peels are "a fee-for-service, cash procedure you can add on that's reasonably priced. Patients will be happy with this," and open to antiaging and aesthetic treatments such as Botox Cosmetic (onabotulinum toxin A, Allergan) in the future.
However, Drs. Berson and Lupo advised against using glycolic acid peels on patients with rosacea who have sensitive skin. Because glycolic acid is a small, hydrophilic molecule, explained Dr. Berson, "It penetrates the dermis and can be irritating."
Regarding devices for rosacea, said Dr. Lupo, "I have used the m22 (Lumenis) intense pulsed light (IPL) device, the 532 nm laser and the Excel V (Cutera)." The Laser Genesis 1,064 nm micro-pulsed capability, an add-on feature to the Excel V, also can help, she said. Additionally, said Dr. Lupo, the Regenlite Transform pulsed-dye laser (PDL, Chromogenex) treatment offers a biostimulatory effect that helps to treat inflammatory skin conditions.
Nevertheless, Dr. Lupo cautioned against positioning vascular lasers as a cure for rosacea. "Make no promises about the duration of benefits with these devices." Rather, she tells patients that if they are compliant with their skincare regimens, "The results will last for years. But there is an element of unpredictability with rosacea." Post-procedure, she said, some patients remain clear for six months, others for three years, depending on their compliance levels.
Newer prescription approaches to rosacea include subantimicrobial dosing of doxycycline (40 mg once daily), which provides anti-inflammatory effects without raising concerns for side effects or antibiotic resistance, said Dr. Lupo.
Dr. Berson, who also uses subantimicrobial doxycycline, added that the topical vasoconstrictor Mirvaso (brimonidine, Galderma) requires even application to avoid streaking.
Cosmeceuticals for Rosacea
Among cosmeceuticals that can be dispensed from the office, said Dr. Lupo, "Make sure you have products specifically geared toward rosacea. I love the nonchemical, inorganic sunscreens for patients with rosacea." In this category, she said that zinc-containing sunscreens from Elta M.D. (Swiss American Products) are her workhorses. Other ingredients she recommends for rosacea include anti-inflammatory botanicals such as niacinamide and feverfew, along with the topical vasoconstrictor caffeine. Dr. Berson added, "Look for anti-inflammatories that contain flavonoids," which are found in soy, green tea and red wine.
Calming the redness of rosacea also requires restoring the skin's barrier function, said Drs. Berson and Lupo. In this regard, said Dr. Lupo, "Theraplex has some effective products geared toward people with inflammatory medical conditions." These products can help not only patients with rosacea and eczema, but also people undergoing dermatologic procedures who need a gentle emollient, she said.
Among procedures for melasma, said Dr. Lupo, "None are a slam dunk."
However, Dr. Lupo said she's had good results with the Excel V (Cutera). Some physicians in Europe and Asia use this device's 532 nm laser at a five mJ/cm2 setting, usually combined with the Laser Genesis (1,064 nm) procedure performed by the same device, she said. However, "I personally had better results with the 1,927 nm fractional thulium laser alone than the 1,540 nm, 1,550 nm or 1,565 nm laser."
Dr. Berson also recommends the Clear + Brilliant Permea (Solta) for melasma. Dr. Lupo added, "The difference between the Clear + Brilliant and the 1,927 nm on your Fraxel Dual (Solta) is a matter of density and energy." She typically sets the Clear + Brilliant on high for many skin conditions. "But for melasma, you'll probably want to set it a little lower." When using the thulium laser, she added, she typically uses an energy level of five mJ/cm2 for Asian patients and 10 mJ/cm2 for Caucasians, both with a density setting of three or four.
Additional procedures that Drs. Lupo and Berson recommend for melasma include salicylic acid, lipohydroxy acid (a proprietary form of salicylic acid called LHA, LaRoche-Posay), glycolic acid and alphahydroxy acid peels. One case Dr. Lupo presented involved an African-American patient with melasma who presented - in the days before fractional laser resurfacing - with severe post-inflammatory hyperpigmentation (PIH) after receiving an overly aggressive peel and poor post-peel care from a non-core provider.
Dr. Lupo said she was able to completely resolve the PIH with intense pulsed light (IPL, Lumenis) set at low levels, along with several light chemical peels. However, she added, because melasma has the most inconsistent results and the highest relapse rate among skin conditions treated, she recommends using newer fractional lasers instead - or, for a less aggressive intervention, salicylic acid peels. Similarly, she said that for PIH, "I have had great results using the SilkPeel DermalInfusion (Medisys)."
Due to melasma's high relapse rate, Dr. Lupo added, "Maintenance protocols are essential. Sometimes you even need to know if patients are cooking - infrared heat can flare melasma."
Topicals & Cosmeceuticals for Melasma
For melasma, said Drs. Berson and Lupo, hydroquinone remains the gold standard among prescription skin lighteners. Topical retinoids, anti-inflammatory agents and combination products also can help, said Dr. Lupo.
In patients with melasma who also have acne and/or PIH, added Dr. Berson, "One can also use azelaic acid, along with a retinoid." In the former area, Dr. Lupo said she prescribes Finacea (azelaic acid, Bayer).
"It is considered safe for pregnant women," said Dr. Berson. For these patients, "I also prescribe topical erythromycin gel, and I'll even do intralesional injections on their cysts. But to be completely safe, use azelaic acid," perhaps in combination with blue light.
Cosmeceuticals that can help improve melasma include botanicals, antioxidants and anti-inflammatory agents, said Dr. Lupo. "I highly recommend Heliocare (polypodium leucotomos extract, Biopelle). It's like the icing on the cake" after procedures and prescription products because it delivers the additional 20 percent to 30 percent improvement many patients are still looking for, she said. "It's a very good adjunctive treatment," Dr. Lupo added, with good science behind it, said Dr. Berson. Additional uses for Heliocare include polymorphous light eruption and other photosensitizing conditions, said Dr. Lupo.
Dr. Berson is a consultant for Allergan, Medicis, Galderma, LaRoche-Posay and Procter & Gamble.
Dr. Lupo is a trainer and clinical investigator for Allergan, and a trainer for Medicis/Valeant, but has no ownership interests in these companies. She is also a speaker for Lumenis and Cutera.