SCALE Notes

SCALE Insights: Eczema Pipeline/Acne Myths

Linda Stein Gold, MD

“There is a very active pipeline of new molecules,” says dermatologist Linda Stein Gold, MD of the therapeutic field for atopic dermatitis and eczema. “New molecules include a topical phosphodiesterase type 4 inhibitor, several topical JAK inhibitors, and tapinarof, which is an aryl hydrocarbon reductase inhibitor. These drugs are not steroids and can be used on the face as well as the body.”

Increasingly, dermatologists have recognized that eczema is not just a disease of childhood and that the condition can persist well into adulthood. Given the range of patients affected by the condition and its impact on quality of life, prescribers are increasingly interested in expanding the treatment options to respond to clinical needs. Importantly, Dr. Stein Gold says, “These drugs offer new mechanisms of action and good safety profiles.”

Dr. Stein Gold also discussed another disease known to persist into adulthood: acne. Given the nearly ubiquitous nature of the disease, it may come as no surprise that misinformation abounds. Dr. Stein Gold addressed fact and fiction in acne, sharing treatment tips for doctors and offering strategies to enhance patient education.

“Topical retinoids are still the cornerstone for the treatment of acne and should be thought of for inflammatory and comedonal acne,” Dr. Stein Gold reminds. “We have new formulations of tretinoin lotion and tazarotene lotion that have improved tolerability profiles.” She adds, “Trifarotene is the first topical drug that was specifically studied on the face and trunk and shown to be safe and effective in both areas.”

When it comes to acne patients, “advise them that much of what they read on the internet has only a kernel of truth,” she says. “Acne takes time to clear and nothing works overnight.” But there is room for optimism. “We do have the tools to get most patients to clear or almost clear,” Dr. Stein Gold asserts.

SCALE Insights: Countering Cellulite

Elizabeth Tanzi, MD

Cellulite is one of the most common cosmetic concerns for women and has remained among the hardest to treat. But that may be changing. Dermatologist Elizabeth Tanzi, MD spoke about Soliton’s Rapid Acoustic Pulse (RAP) technology, which she says, “represents an exciting treatment for the appearance of cellulite because the results are consistent and actually improved over the course of the study.” This, Dr. Tanzi says, “is different than the transient results delivered by non-invasive devices to date. Another perk of the Soliton treatment is that there is no recovery time.”

Dr. Tanzi is optimistic about RAP technology. “There is much to be learned about Rapid Acoustic Pulse technology in the future, such as the optimal number of treatments, best candidates for the procedure, and longevity of results,” she says.

Another key development in the world of cellulite is the FDA approval of Qwo from Endo. “The Qwo treatment for the appearance of cellulite is also exciting, in that it’s an easily administered injectable treatment that delivers long-lasting results to improve the dimples of cellulite without the need for a large capital investment,” Dr. Tanzi says.

As this new agent comes to market, physicians will continue to identify best practices. “It remains to be seen if the bruising after treatment will be a significant concern for patients,” Dr. Tanzi says. “As with the Soliton device, it will be important to define the best candidates for the procedure in order to obtain optimal results.”

Some observers believe 2021 will be the year of the leg. “There are many reasons to be enthusiastic about the cellulite landscape in 2021,” Dr. Tanzi notes. “Aesthetic dermatologists will have access to two novel treatment options that have delivered significant cosmetic results in well-done clinical trials. Although there will never be a ‘cure’ for cellulite, these two treatments represent a great step forward in our ability to address the concerns of our patients.”

SCALE Insights: The Future of Hair Loss

Andy Goren, MD

Hair loss can be a confusing issue for patients as well as physicians. Data confirm that rates of androgenetic alopecia (AGA) are rising. What remains unclear is what’s causing the increase.

According to Andy Goren, MD, social selection may drive the increase of androgenetic alopecia. He and his research team looked at the strongest predictor of AGA in men: a genetic variant (length of the CAG) linked to the androgen receptor gene on the X chromosome. In women, this same genetic variant is associated with ovulation at a later age and lower risk for premature ovarian failure. As society norms shift and more individuals worldwide postpone having children, this decision could favor women with the short CAG variant and favor male offspring exhibiting AGA.

From a practical standpoint, research is leading the way to a topical treatment for chemotherapy-induced alopecia. A topical scalp cooling agent that works via vasoconstriction may protect the hair follicle for chemotherapeutic exposure.

Additionally, Dr. Goren spoke about a novel booster under development that is likely to increase the efficacy of minoxdil in female pattern hair loss. Poor compliance with treatment may explain some of the poor response to minoxidil. “A novel ‘after minoxidil’ spray is likely to improve styling after minoxidil application,” Dr. Goren suggests.

This finding highlights a crucial aspect of management of patients with hair loss. “It is often that we fail to understand the response to various treatments due to compliance,” Dr. Goren maintains. “Patient compliance is paramount for successful topical hair loss treatments.”

Hot Topic: When Bad Things Happen to Good Doctors

Steven Dayan, MD

“We all have had bad things happen to us when it comes to clinical practice,” says facial plastic surgeon Steven Dayan, MD. “Sometimes the fickle finger of fate is thrust upon us, and we must learn to recognize it, live with it, and move on in a more enlightened way.” That was the gist of his presentation to SCALE attendees aimed at helping physicians learn from and move past unfavorable events.

“All greatness comes with setbacks, and even the best doctors doing all the right things might have a drastic complication,” Dr. Dayan acknowledges. “Today with fillers, it is rare, but something bad can happen even from what seems like such a benign treatment. The worst case is vascular compromise and perhaps even blindness.”

Most doctors know their options in terms of medical interventions. But, Dr. Dayan asks, “How do you as a doctor handle the psychological impact?” He discussed a concept—“Second Victim” phenomenon—that is known in primary care and anesthesia. This concept holds that the physician involved in an unintended adverse event is victimized by the event via trauma. “The concept is not talked about in aesthetic medicine, so I wanted to bring it to light,” Dr. Dayan says.

Dr. Dayan offered some strategies for dealing with unexpected bad events. “The key is to talk to peers, especially those who have been through it. Surprisingly, friends and family are not the best to provide comfort, because they may not understand what has happened. They don’t get it that bad things can happen, and often they focus on the bad event and not what the second victim is experiencing.” Dr. Dayan advocates for professional societies to provide hot lines physicians can call for psychological assistance and/or peer support. “My guess is a lot of senior leaders would happily volunteer to take calls to help out others experiencing a bad event. And while they could not give out medical advice, they could be available for psychological support.”

The three-step Accept, Evaluate, Define (AED) Plan can help physicians respond to bad events, Dr. Dayan says. “Accept what happened, Evaluate what you could have done differently, and Define a plan to move forward with new tools and methods in place to do everything possible to reduce the same bad occurrence from repeating,” he says.

“Most importantly, realize that you have to keep moving forward,” Dr. Dayan says, “Eventually the bad event becomes a scar, and we all have scars. Scars are reminders that you are stronger because it means you have survived an injury. In evolutionary history, scars serve a purpose to make one appear more attractive because it is a sign of strength, health, and good genes. Every scar has a story—a story of survival and story of strength.”