Top aesthetic dermatologists share what they think the most significant innovation of the last year in dermatology was and discuss their favorite devices. Look for the full interviews on DermTube.com.
Microneedling: A New Mainstay
“My favorite device, not surprisingly is microneedling…I have so many lasers and devices in my offices. I don’t use most of them every day. However, I do use my microneedling device every day, several times a day—either alone or in combination with other treatments.”
—Tina Alster, MD
The Combination Effect
“I don’t think that there’s anything brand new on the market. I think it’s a question of how we can use things together. So when we’re talking about combining our fillers with our neuromodulators, which we’ve been doing forever, but how about adding technology now...and you put that together with your skincare packages, we’re seeing much greater effect for all our patients.”
—Suneel Chilukuri, MD
Bioengineered Molecules: Advancing Cosmeceuticals
“The bioengineered molecules, which mimic growth factors, are really starting to show the kind of improvements we want to see with the home skincare regimen without having a prescription and without visiting the doctor’s office. I think it’s a good complement to in-office procedures for patients to be able to go home and do something at home that actually makes a difference.”
—Joely Kaufman, MD
PRP: The Next Breakthrough?
“When asked about the most significant dermatologic innovation in 2017, I think that’s a really tough question…we’ve seen dermatologists really be involved with so many pioneering technologies from neuromodulators to fillers and chemical peels and tumescent liposuction and cryolipolysis and laser resurfacing and pulsed dye lasers and so many different things...For alopecia areata we have topical therapies and oral therapies, but now there actually is some data on platelet rich plasma (PRP). We’ve incorporated PRP into our practice and we’re starting to see results and I think that’s pretty exciting to actually have data to fall back on for some of our patients at this point.”
—Joel L. Cohen, MD
“I think there are a lot of things that are vying to be innovations and maybe as they progress will be an innovation. PRP is probably the thing that is most likely to want to succeed. I don’t know that it has succeeded. I think it’s on the cusp of succeeding and that depends on if we as dermatologists can figure out if it works, if it doesn’t work, what the reality is, what the results are.”
—Joel Schlessinger, MD
Revance Next-Generation Neuromodulator
Revance Therapeutics’ next-generation neuromodulator daxibotulinumtoxinA for Injection (RT002) delivered positive top-line results in alleviating moderate-to-severe glabellar lines in two pivotal SAKURA Phase 3 trials with duration of effect up to six months. RT002 appeared generally safe and well tolerated in both studies.
The percent of RT002-treated patients who had none or mild wrinkles and achieved at least a two-point improvement from baseline on both validated physician and patient assessments were 73.6 percent in SAKURA 1 and 74 percent in SAKURA 2, compared to placebo at Week 4. At that time point, 88 percent of RT002-treated patients in SAKURA 1 and 91 percent of RT002 patients in SAKURA 2 said they were very satisfied or satisfied with treatment. All secondary endpoints measuring reduction in severity of glabellar lines with RT002 compared to placebo were highly statistically significant at every time point evaluated to 24 weeks.
RT002 is in development for the treatment of aesthetic and therapeutic conditions, including glabellar lines, cervical dystonia, and plantar fasciitis. This proprietary, stabilizing excipient peptide technology eliminates the need for human- and animal-based components, which carry a potential risk of transmitting pathogens. If approved by the FDA, RT002 would be the first neuromodulator with a long-acting duration of about six months, Revance believes.
Dan Browne, President and CEO of Revance, spoke with Practical Dermatology® at the October 2017 ASDS meeting.
An Innovative Combination
“It’s all about innovation in science for us. Despite its success there haven’t really been any new improvements in toxins in many years. There have been new indications, but not on the molecule side. And for us, it’s all about combining the toxin and the peptide...So, when we think about the remarkable science, we considered how to take this peptide and toxin to create a new entity. How do we...improve duration? How do we improve safety? Then how can we be the first?
“We plan to be the first long-lasting neuromodulator. We’re the first toxin to remove all the animal and human excipient—those excipients are not in our formulation. And it’s really the first new innovation in 30 years of neuromodulators. The currently marketed neuromodulators are really good products. They’re good companies, but they all work about the same. The uniqueness is the science—our highly purified daxibotulinumtoxinA combined with our proprietary, stabilizing excipient peptide.”
Longer Duration of Effect
“It’s exciting—you can really feel the buzz in the dermatology community. They want to see impactful innovations. It’s not a number or statistical value, it’s the experience that comes from this longer duration. Investigators tell us their patients like what they’re seeing. They like the durability of it. Obviously, you’re addressing some of the tolerability of not having to repeat injections. And quite frankly, you just have a more satisfied population.
“I think because of the quality of the products, if you ask a physician, ‘Do you like your use of neuromodulators?’ they’ll say, ‘Yes, it is a workhorse product in my clinic.’ If you ask them what’s the number one downside: They’ll say ‘Duration.’
“We really want to address the fundamental issues: Can it work better? Can we get higher response rates? Can we get longer duration? But most importantly, if we add those together, it’s a better experience that the patient can see and feel. And it’s the experience the physician has, too. The physician may see more patients coming in who want to have treatment..who aren’t being treated today with a neuromodulator who now will have a product that will address some of their concerns.”
Standing Out in the Crowd
“What’s most important for us—if we’re going to compete—is to be different. And there has to be a clinically meaningful reason and a commercially meaningful reason for patients to ask for it. So, over the next couple of years, we have to take the data we generate...and package it for commercial consumption. That way, upon approval, the patient comes in to the doctor’s office and asks for Revance’s long-acting neuromodulator.
“We want to get the data presented and published by the best thought leaders...And we want to take a very evidence-based approach. We think it’s really important that the data end up in the label...this is company A’s label, company G’s label, company M’s label, and here’s the Revance label. They’re fundamentally different. You’re seeing better response rates. You’re seeing better duration.”
Safe and Stable
“RT002 has no human- and animal-based components. That is clearly a first. We hope to get that in our product labeling. All the other products have a warning. Removing that will be an advantage. There are two fundamental things that are different in daxibotulinumtoxinA for injection...It stabilizes the protein, with or without refrigeration. And it stabilizes once you reconstitute it with saline without aggregation.
“So, that peptide—by removing all those animal excipients that aren’t needed—stabilizes the drug and also allows us to attach the drug at the site of injection. The other neuromodulators don’t...have a peptide. So our ability to ‘attach’ the excipient peptide technology is really critical in having a stable drug at the site of injection.”
A Technology Platform
“As we talked to [aesthetic physicians], cervical dystonia and plantar fasciitis are obviously not dermatologic indications, but physicians really are excited about them because it allows them to look at Daxi as truly a innovative formulation based on a technology platform...
“What they’re seeing in glabellar lines is not an exception, it’s holding true in muscle movement. It’ll hopefully apply in plantar fasciitis. So, physicians will look at all the data, because they want to understand how well that drug is working, how it’s going to be used, and that’s it’s not just a one off. It’s really an important data set that I think reinforces the uniqueness of our neuromodulator.”
Blue’s Clues: Time to Protect for Device Light?
By Denise Mann, MS, Editor at Large
It’s fairly well established that the blue or high-energy visible (HEV) light from tablets, smart phones, and other devices can damage the eyes and disrupt circadian rhythms, but a small, yet growing body of evidence suggests that this somewhat ubiquitous wavelength may also cause or worsen pigmentation issues. One study Pigment Cell & Melanoma Research (July 2014) showed that blue-violet light induced a significantly more pronounced hyperpigmentation that lasted up to three months compared with ultraviolet light.
To counteract such damage, many companies are offering up HEV blockers in their sunscreens, foundations, and other cosmetics. There’s even an ingredient (Liposhield) that, when added to moisturizing creams and lotions, sunscreens and the like, will protect the skin from damaging HEV light.
“We know that visible light and incandescent lighting can cause worsening of hypermelanosis,” says Seemal R. Desai, MD, FAAD, Founder & Medical Director at Innovative Dermatology in Dallas. “One of the things that we always counsel patients on is to wear lots of sunscreen, but what we sometimes fail to always stress to them is that lots of sunscreen don’t block the wavelengths of visible light.”
Iron oxide sunscreens do block visible light, but they are also not always cosmetically elegant, he says.
Andrew Alexis, MD, Chairman of the Department of Dermatology and Director of the Skin of Color Center at Mount Sinai St. Luke’s and Roosevelt hospitals in New York, agrees. “There is increasing evidence that visible light causes increased pigment production so when it comes to someone who has a condition like melasma, we tend to make a lot of efforts to block ultraviolet light, but we don’t really discuss visible light.” This may need to change, and he says that it wouldn’t be a bad idea for people prone to pigment disorders to wear iron-oxide sunscreens while on their blue-light emitting devices.
On a positive note, blue light doesn’t appear to cause the genetic changes that lead to skin cancer, nor does it cause reddening or swelling of the skin.
Exposure to blue light may weaken the skin’s barrier function, accelerating aging. But the research is weak here, says Adam Friedman, MD, FAAD, an associate professor of dermatology in the department of dermatology at George Washington School of Medicine and Health Sciences in Washington, DC.
“There was one study in the Journal of Investigative Dermatology in hairless mice that found that blue light delays epidermal barrier recovery, which doesn’t necessarily relate directly to skin aging,” he says. “Increased pigmentation seems to be the main issue with blue light.”
The truth is more research is needed.
Much of the attention to “screen face” comes from the cosmetic industry touting new cosmetics that shield these wavelengths, he says. “At the end of the day, ultraviolet radiation is much more damaging.“
For someone with melasma or post-inflammatory pigment alteration in an exposed area, maybe protection would be appropriate, he says. “For now, this is more hypothesis and hype rather than validated science, and it is distracting from what we do know and need to focus on: UVA and UVB.”