Trends and Trendsetters of 2014

From Challenge to Innovation: Addressing Antibiotic Resistance

The CDC's Annual Get Smart: Know When Antibiotics Work initiative this year included a focus on dermatology. The American Acne and Rosacea Society (AARS), joined by partner Galderma Laboratories, LP, supported the CDC initiative. Dermatologists have been concerned about antibiotic resistance for some time, as dermatologist Michelle Henry, MD, notes. Still, there is room for improvement. Ahead, Dr. Henry addresses issues of antibiotic resistance in dermatology.

The issue of antibiotic resistance has created some challenges in the management of acne, but has it also presented opportunities?

Michelle Henry, MD: As a dermatologist in today's world, it is very important to be cognizant of the number of antibiotics that are prescribed to our patients. Given the rise in resistance rates and the fact that dermatologists are high prescribers of antibiotics, we need to stand behind the CDC rallying cry of “the right prescription, for the right patient, for the right amount of time.” We have seen P. acnes become increasingly resistant to topical and oral antibiotics, which may potentially cause a decrease in treatment efficacy against acne; however, there have been some opportunities for dermatologists to tap into antibiotic-free treatment options, such as Epiduo (adapalene and benzoyl peroxide) Gel 0.1%/2.5%, and for physicians to implement strict monitoring guidelines that work within the confines of their individual practice.

What are some of the innovations you have implemented in acne management to reduce the use of antibiotics?

Dr. Henry: I never use topical or oral antibiotics in monotherapy, as this increases resistance. There are also many available clinically superior regimens, which is why I use all other non-antibiotic medication in my armamentarium prior to instituting an antibiotic treatment. When I do use oral antibiotic therapy I try to limit the treatment course to less than three to four months. When utilizing a topical antibiotic, I always combine with benzoyl peroxide to limit potential for resistance.

To what extent do patients ask about or even request antibiotic therapy for acne? Have you had to change your approach to patient education in this regard?

Dr. Henry: I think that patients are becoming better educated regarding antibiotic usage. There has been an increase in both medical journals and consumer magazines regarding concerns over multidrug resistant bacteria. This has definitely led to an increase in conversation about antibiotic resistance in my office. Again, I do attempt to use all other topical and oral treatment modalities before using an antibiotic and keep the treatment course to less than three to four months. Further, in my cosmetic patients, I limit topical antibiotics to avoid seeding resistant bacteria with procedures such as injectable dermal fillers.

You specialize in Mohs surgery. How has the use of antibiotics pre- and post-surgery changed, and what have been the greatest recent innovations in this regard?

Dr. Henry: The use of antibiotics in cutaneous surgery is a controversial topic. While the treatment of surgical site infections is relatively straightforward, the use of prophylactic antibiotics in cutaneous surgery remains a topic of discussion. Recent evidence suggests that antibiotic prophylaxis is not needed in most circumstances, given the low rate of bacteremia in sterile and clean dermatologic procedures. The decision of whether or not to use antibiotics for prophylaxis should be carefully considered and individualized to each patient's particular situation; however, I routinely avoid antibiotics unless a patient has implantable devices, hardware or other medical comorbidities that increase their risk for wound infection, joint infection, or endocarditis.

Michelle Henry, MD is a Harvard trained, board certified dermatologist practicing Mohs Micrographic, reconstructive and cosmetic surgery at Sadick Dermatology in New York City.

Responding to a Need: Skincare for Cancer Patients

A Q&A with Cynthia Bailey, MD

Cynthia Bailey, MD is a dermatologist in private practice in Sebastopol, CA. After being diagnosed with breast cancer, Dr. Bailey developed products for use by patients undergoing chemotherapy. Ahead, she discusses that experience. Her skincare and practice website is www.drbaileyskincare.com.

The impetus to develop the new line was borne from your personal experience. Could you share with us a little about that and how you came to see a need?

Dr. Bailey: For my 55th birthday, I started chemo. Several weeks before, I was given the diagnosis of the most deadly type of breast cancer, called high grade triple-negative breast cancer. I was also told I carry the BRCA gene mutation for hereditary breast and ovarian cancer. It was a shock, to say the least. I've carried this time bomb of a gene mutation all my life and never knew it. Apparently, I inherited it from a side of my family I know nothing about.

Actually, because one of these really deadly cancers was not bad enough, I was the lucky person who got to have two—one in each breast—which meant my prognosis was even more dire. Both tumors were small, thank goodness, because I found them on my own monthly breast self-exam. But both were this highly deadly type of cancer. My only hope of surviving was to submit to really aggressive chemo before having a double mastectomy. I didn't want chemo. My oncologic surgeon was very frank with me. He said, “Don't take this the wrong way, but you are stupid if you don't have chemo. This cancer will kill you otherwise, and surgery alone won't cure it.”

I didn't just need chemo, I needed a very aggressive type of chemo called dose dense chemo. It uses the old-fashioned and very toxic regimen of Adriamycin, Cytoxan, and Taxol given at high dosage every two weeks. To keep you safe and ready for chemo again in just two weeks, your bone marrow is artificially stimulated to produce neutrophils with a Nulasta shot. The every-two-week chemo infusions went on for four months. It was grueling. I am an atopic with sensitive skin, and I knew my skin was going to take a hit. I did not want eczema, excoriations, and portals of entry for staph. That's why I created my Chemotherapy Skin Care Kit. I was basically my own living laboratory and fragile patient. As a dermatologist, I had the expertise to help myself. As the owner of a skincare store full of high quality skincare products I had a great range of products to work with.

What are some of the unique skincare needs of patients with cancer?

Dr. Bailey: On chemo, cell turnover is diminished drastically. For the skin, it means that skin cells don't rejuvenate. Skin is dry, scaly, and itchy.

Chemo patients are also immunosuppressed and prone to skin infections. Getting an infection means being given systemic antibiotics, which can lead to more GI distress than you already have from the chemo drugs themselves. Getting antibiotics also means being at greater risk of getting yeast infections. Chemo is bad enough without the antibiotic misadventures, so I wanted to keep my skin healthy. Also, fingernails and fingertips become dry and brittle. Fingertips fissure on chemo. Hangnails and fingertip fissures can get infected, and being in and out of medical facilities is really risky for picking up MRSA-type staph. I didn't want any of that. That's why I added Bag Balm and gloves to my chemo kit.

How did you go about developing the line? What are unique features for patients with cancer?

Dr. Bailey: I developed the line with three major principles in mind: hydrating skin care, being hypoallergenic, and being really simple to use. I am a skincare expert with a highly successful and popular skincare website. I used the best of my products and put them to the test. I used only deeply hydrating products that were also hypoallergenic. I created really simple skincare instructions to take the guesswork out of skincare for exhausted and overwhelmed chemo patients like myself.

The chemo experience is huge. You have no idea how huge until you are that patient. Chemo patients need simple and dependable ways to stay safe while they undergo chemo. This includes keeping their biggest organ, their skin, from becoming a danger to their health or another source of suffering.

I found out the first thing every chemo patient has to do before starting chemo is go to “Chemo Teach.” At “Chemo Teach,” you are given a huge list of do's and don'ts for your personal care and a bag full of prescriptions for everything from constipation to anxiety. What you are not given is really good products or advice to keep your biggest organ, your skin, healthy, safe and trouble-free. Creating a simple skincare routine with safe products is a necessity and a comfort, which was all part of my goal. My skin stayed healthy and comfortable on chemo, and I never once needed antibiotics to treat a skin infection!

What has the experience of developing/launching the line taught you about patient care? About your role as a dermatologist?

Dr. Bailey: My experience with cancer and developing a product line to help myself and others has taught me that there are so many people going through this process, that it's huge and that we are all in a daze. I had no idea how totally overwhelming it is. I decided to use my 30 years of training and patient care experience to create a turnkey skincare routine for myself and not deviate from it. I wanted something that was guaranteed to help keep my skin as comfortable, healthy, and safe as possible while I underwent chemotherapy. This is what I am offering to patients, like myself, who are embarking on the chemo experience. I didn't just want to survive, but I wanted to thrive and help fellow and future cancer victims become thrivors as well. I feel like protecting and preserving skin care is a perfect starting point to this process.

Global Aesthetic Update: Automated Injectors

By Hassan Galadari

Hassan Galadari, MD is an assistant professor of dermatology at the United Arab Emirates University and is in practice at Galadari Derma Clinic in Dubai.

During recent years, the field of soft tissue augmentation has seen a boom in materials used and innovation in the techniques by which they are injected. The idea of an automated injector that would compensate for pushing the plunger has always been something of a fascination, especially when talking about the possibility of trigger fingers occurring after many years of injecting. Many studies have looked into the use of automated injectors and found that patients suffered less pain. The amount of filler used was also significantly less. This was further corroborated by 3D images, which revealed better correction in the area where the injector was used. While the idea of an automated injector is not new, the old devices were bulky, large and their use required hand/foot coordination as you had to push on a foot pedal to drive the filler from your syringe. There was a necessity to create a less tedious device.

The Teosyal Pen is a hand-held device that is as long, albeit a little wider, than a regular pen. It fits snuggly in your pocket and can be taken from one room to the other. The machine has two modes, continuous flow and single drop, both of which come in three speeds. In addition to its practicality, the strength of the automated injector lies in creating a pretty much painless experience for the patient. This occurs because the speed by which the filler comes out remains constant in the flow mode and does not rely on the contraction of hand muscles, which fluctuate during injections. The other major benefit is the ability of the device to easily inject the other side of the face without the doctor having to move around the patient. This is possible because most of the movements to change angles occur from the wrist and not the elbow and shoulder. Injecting using the non-dominant hand is also possible, as all that is needed is a push of a button rather than a push of the plunger.

The learning curve to use the injector in the hands of experienced injectors is a shallow one. It may be a bit more challenging for those who may be the most adamant about not changing from their trusted hand and those who desire the ability to “feel” the product that is injected. Another relative downside would be the inability to withdraw before pushing the plunger.

The injector does have its positives. Patients love seeing their doctor using new tools, especially if they cause little pain. For patients, this tells them that their doctor is always flirting with new technology—this time, a technology that works.

The device was recently launched during the Teoxane Expert Day in Barcelona in October, with sales to start by the beginning of next year.

Connectivity Evolution: The Growth of Practice Apps

A Q&A with Steven Hacker, MD

Steven Hacker, MD is creator of AppForMyPatiens, founder of The Medical Entrepreneur Symposium, and author of The Medical Entrepreneur Pearls, Pitfalls & Practical Business Advice for Doctors (Nano 2.0 Business Press, 2010). His practice is in Delray Beach, FL.

How are patients using apps? Is there evidence that their use—or interest in their use—has grown as a tool for connecting with their physicians and their practices?

I think patients are still mostly using apps to monitor their own health and wellness efforts. Certainly there is growth—not yet complete awareness, though—of apps as another time efficient tool to communicate and connect with physicians and their practices. For instance, AppForMyPatients is new, so many physicians and patients are not yet aware that they can use this app to purchase skincare products and well known brands from their dermatologist or plastic surgeon.

I think it is purely an awareness thing right now…lack of awareness by the physician that he or she can create an app for their practice instantly on AppForMyPatients and it will do things his/her patient portal doesn't do, such as market services and sell products to patients, and then lack of awareness by the patient that an app, like AppForMyPatients, exists that ultimately will replace a website for a medical practice. 

What are some potential benefits of having a practice app? Are there potential pitfalls?

The benefits of having a practice app like AppForMyPatients is it enables the physician to give their patients a mobile solution that enhances the engagement of their existing patients with their own practice. By engagement, I mean connectivity between the physician and his patient, in a simpler, time efficient manner, so the patient remains engaged in that physician's practice and doesn't look for alternative physicians based on their own physician not using technology to its fullest potential.

I think patients really appreciate that their physician can offer them a mobile solution, such as AppForMyPatients, since it reflects an appreciation and respect by the physician of the patient's time demands. In particular, another benefit unique to our specialty of an app like AppForMyPatients is the ability to market their services, promote their expertise, recruit patients for research, and dispense skincare products to their patients. 

The potential pitfalls of a practice app would be similar to most pitfalls relating to health technologies today in medicine would be related to abuse or lack of protection of privacy issues. 

What do you predict for the role of apps and other technologies to connect patients and practices in the next five years?

I predict that apps will completely replace websites as a source of not only connectivity but also marketing potential to our patients. Today's app is yesterday's website and I really think all connectivity between physician and patient will be mobile and through sophisticated applications like AppForMyPatients where dermatologists and plastic surgeons can enable their patients to see what their practice offers their patients in terms of expertise and customer service.

The app will be the ultimate connectivity tool between the patient and the practice. The mobile application will enable sophisticated video and teledermatology applications that become a customer service tool initially and a revenue enhancement tool ultimately.

Forging New Paths in Pediatric Dermatology Research

A new research alliance aims to create collaborative networks to better understand and manage pediatric skin diseases in children

In 2012, the Society for Pediatric Dermatology formed a research network called the Pediatric Dermatology Research Alliance (www.pedraresearch.org), or PeDRA for short. According to the society, PeDRA was crafted in response to unmet research needs in pediatric dermatology. Its mission is to facilitate high-quality collaborative clinical, translational, educational, and basic science research in pediatric dermatology. In November, the second annual PeDRA conference convened, with more than 100 clinicians, researchers, government leaders, and patient advocacy representatives gathering to discuss study ideas, hear updates on collaborative projects already launched, and learn about best practices in multicenter research and clinical study design. Ahead, PeDRA co-chair Amy Paller, MD reflects on how the unique aim of the alliance addresses the most pressing issues physicians face in pediatric dermatology today.

Amy Paller, MD, MS, is Department Chair of Dermatology and Walter J. Hamlin Professor of Dermatology and Pediatrics-Dermatology at Northwestern University.

Can you offer a snapshot perspective on the state of care and recent innovations in pediatric dermatology today?

Little has advanced for care of skin disorders in children, according to Dr. Paller. “Most of new therapeutics were developed and tested in adults, and are used off-label in children,” she notes. “The pediatric intervention of the decade, propranolol for treating infantile hemangioma, was discovered serendipitously through observation and only after its efficacy was determined did studies start to discover its mechanism of action.” However, modest advances have improved care in certain disease states. “Simple dilute bleach baths to date have revolutionized the care of pediatric atopic dermatitis,” says Dr. Paller. “And the most exciting discoveries of the decade are finding the underlying genetic cause for hundreds of genetic disorders with cutaneous manifestation using whole exome sequencing,” Yet, Dr. Paller observes that even this progress has not translated yet into new therapeutic interventions for affected children.

What is the concept of PeDRA and can you briefly describe its mission and agenda?

“PeDRA was created within the Society for Pediatric Dermatology in response to this need to focus more research and drug discovery/testing attention on pediatric skin disease. Officially founded in 2012, Dr. Lawrence Eichenfield and I were elected its first co-Chairs together with a steering committee that includes five additional pediatric dermatologists,” Dr. Paller recounts. “PeDRA recognizes the power of a collaborative network of individual researchers linked together towards a multicenter effort, and patterned itself on other highly successful pediatric networks such as CARRA (Childhood Arthritis and Rheumatology Research Alliance) and COG (Children's Oncology Group). Our mission is to promote and facilitate high quality collaborative clinical, translational, educational and basic science research in pediatric dermatology,” says Dr. Paller. “Our coalition brings together scientists and clinicians to better understand skin disease in infants and children and, through pooling of resources, allows an exponential expansion of the patient base for clinical studies.” 

The product is unparalleled combined expertise in conducting clinical trials, performing outcome/QOL/epidemiology research, expertise in bench investigations, linking institutions with tremendous resources, and joining with scientist or industry partners who are eager to collaborate, according to Dr. Paller.

Those who make up PeDRA come from a variety of backgrounds, as well, Dr. Paller explains. “Our members may be active members (board-certified dermatologists, non-dermatologists physicians, and research scientists) who devote significant professional effort to care or research related to pediatric dermatology. We welcome Trainee members, Affiliate members, Corporate members who are devoted to advancing the field of pediatric dermatology, and Advocacy Partner members who represent patient advocacy groups focused on skin conditions that affect children,” says Dr. Paller. “We now have bylaws that define our seven-member Executive Committee, which is part of a larger Board of Directors that includes Chairs of our many committees. The website (pedraresearch.org), provides information about PeDRA and is welcoming new members.”

In what ways would you say PeDRA is creating innovation in the research and treatment of
pediatric skin diseases?

“At this time, PeDRA is bringing together interested individuals to learn more about collaborative work and to find common areas of interest in meeting needs. To this end, two stand-alone annual meetings with NIH sponsorship have been run, the last in early November 2014, with almost 100 participants,” says Dr. Paller. The annual meeting focuses on learning and networking, including among groups in five areas of focus: inflammatory skin disease (eczema, psoriasis, connective tissue disease, hair and nail, acne/hidradenitis); genetic (EB, ichthyoses, basal cell nevus and other tumor syndromes); birthmarks (especially vascular and pigmented lesions); neonatal dermatology; and tumors and skin complications of cancer care. “Each group already has several projects launched or in planning stages that address clinical problems. These range from surveys of current care practices to epidemiological studies to development of registries to track adverse effects to collaborative work with scientists who need pediatric materials to testing therapeutic interventions,” says Dr. Paller.

PeDRA has also been networking with industry to discuss unmet needs and start dialogue about the need for designing new therapeutics and testing them for pediatric disorders, according to Dr. Paller. She further notes that the organization is also starting conversations with the FDA to provide a platform for communication and to encourage prioritization of moving forward new treatment modalities to help children with skin disease. “Patient coalition groups have been involved from the beginning to help the group to reach patients and providing additional insight into the needs of patients,” she says. “The increased capability of the networked PeDRA organization includes large datasets for mining, national biobanking to pool materials for scientific invesitgation, and a well organized network of clinical trial sites for facilitating drug and device testing as relevant to children with skin issues,” says Dr. Paller.

At this time, members are from the US and Canada, but according to Dr. Paller, PeDRA is actively collaborating with other groups internationally—and considering opening membership to international colleagues in the future. For example, she notes, “We've teamed with Carsten Flohr from UK for a survey on eczema; the PeDRA Pediatric Psoriasis group has teamed with a group of clinician-investigators who are psoriasis experts in Europe to run an ongoing retrospective and upcoming prospective analysis of the use, efficacy and safety of systemic interventions and phototherapy for pediatric psoriasis.”

What advice do you have for colleagues and
particularly younger physicians about facilitating new innovations both in pediatric derm and beyond?

“The key is to think beyond what's in the journals and textbooks when you see a patient in the clinic setting,” Dr. Paller explains. “Why does the disorder exist in this patient? Why does it manifest as one sees clinically? How is it impacting the patient beyond what is seen on the skin? If treatment is not straightforward, how can one leverage the understanding of what underlies disease to ‘think outside the box' and consider a different approach, even if never tried before,” says Dr. Paller. To that end, Dr. Paller recommends getting involved in PeDRA and getting extra training to tackle the questions (such as a Master's degree in Clinical investigation or Epidemiology/statistics or public health, or bioinformatics, etc.) and bring that expertise as well as creativity and energy to PeDRA projects through the Early Investigator's group and other channels the organization offers. “PeDRA is a wonderful organization for networking, collaborating, meeting others outside the usual sphere (e.g., researchers, coalition partners, industry leaders), and finding seasoned mentors to help advance a young person's career,” Dr. Paller observes.

To learn more about PeDRA and join its initiative, visit www.pedraresearch.com.

Advancing Innovation

A pioneer in light technology discusses a new initiative for innovation in dermatology.

With R. Rox Anderson, MD

Sparking innovation can be a challenging endeavor, but a new group has set out to accomplish just that in the field of dermatology. Advancing Innovation in Dermatology (AID) is a not-for-profit organization committed to fostering community and innovation in dermatology. In an exclusive interview with DermTube.com, excerpted ahead, AID founding member Dr. Rox Anderson discusses the rationale for forming the initiative and discusses how it will foster innovation in the field.

R. Rox Anderson, MD is Professor of Dermatology at Harvard University and director of the Wellman Center for Photomedicine, the world's largest laboratory dedicated to light and optical technologies in medicine.

You have been involved in advancing innovation in dermatology and have launched an initiative to foster innovation. Can you tell us about the group and the program?

“Advancing Innovation in Dermatology (AID) is a not-for-profit small foundation that is, as the name says, trying to stimulate innovative, new solutions to problems that are actually worth solving in dermatology,” says Dr. Anderson. “AID is a relatively new group and is very interested in the interface between academic dermatology, industry, and clinical problem-solving in dermatology. So how do you foster innovative research that's aimed at solving problems and get it all the way out there—through the FDA, through start up companies, or existing drug and device companies: That's what AID is about,” Dr. Anderson notes.

Can you summarize the current state of innovation in dermatology?

“I think of dermatology as being a very innovative field in medicine… I've had a lot of opportunity to work with lasers and other energy-based devices and I think we lead the pack, if you look at other medical specialties,” notes Dr. Anderson. At the same time, it's frustrating because there are so many good problems to go after and we only have limited resources of time and human energy to do it.” Despite the barriers, says Dr. Anderson, “I do believe that dermatology is one of the most innovative opportunities to make a difference. The skin is the window into all the rest of the body. So, in a way, innovation is not just about skin and skin disease, but how can you use the skin as kind of a playground for lots of other things. I think there are plenty of opportunities for us to be innovative,” he observes.

Why is innovation important and how do you foresee it increasing?

“Innovation is the way change happens. Sometimes it's uncomfortable, but if you want to do something new and actually make a difference, so to speak, from what we're doing now, it's part and parcel of that,” says Dr. Anderson. “When you actually have new ideas and technologies, it's somewhat uncomfortable. You're changing the old paradigms and it's somewhat threating. You have to do a new education process. It's not as simple as simply making something new and incorporating it into dermatology. The effect of all this is ultimately to change what we do and how we do it. But there's this uncomfortable period of adoption and education, and I think this is another thing that we make a lot of progress with.”

To see the full interview, visit DermTube.com. Search key: Innovation. And for more information on Advancing Innovation in Dermatology, visit www.advancing-derm.com.

A New “Solution” to In-Office Dispensing

A Q&A with Leslie Baumann, MD

A skincare expert, Dr. Baumann has devised a way to simplify product dispensing for aesthetic and dermatology practices with the benefits of group buying power and ongoing staff support and training.

Steve Yoelin, MD is an oculoplastic surgeon in practice at YouAesthetics in Yorba Linda, CA.

What are some general guidelines for appropriate skincare recommendations in the office?

Leslie Baumann, MD: In order to get good results and good patient outcomes it's important to make sure that you give patients the right products. I found that you really have to identify their skin type first before you decide what products to give patients. The way I do it in my practice is with a questionnaire that asks a lot of historical questions, and that determines what their skin type is. I have identified 16 different skin types and I have a regimen preset for each type.

What are some pros and pitfalls for effective dispensing?

Dr. Baumann: Staff training is really difficult because if your staff isn't giving the patient the right products they are not going to have good outcomes, and they are not going to come back and repurchase from you. I find that staff training is very difficult because when you get a new employee, you are so busy seeing patients that you don't always have time to sit down and teach them what you want them to know about skincare. I have developed a standardized approach for training my staff, so that everybody who comes on board is trained the same.

One of the biggest problems, of course, we all have as dermatologists is our patients going and buying products on the Internet instead of buying from us.

What is your new system and how is it intended to improve office dispensing?

Dr. Baumann: I developed the Skin Type Solutions system for use in my office, and now other dermatologists around the country are using it. The patient takes the quiz and determines their skin type and then I have a preset regimen that's composed of many different brands that we recommend to the patient.

I have expanded this to The Skin Type Solution Franchise System. This is a franchise where we go in and we put a store in a physician's office, we train your staff, and we negotiate deals with the brands so that you get the products at the lowest prices. We deliver ongoing training to both your staff and your patients. Instead of having to order products from five to eight different companies, you actually only order from Skin Type Solutions Franchise, and they negotiate the prices for you and take the products back if they are not selling in your practice. It's a turnkey solution for in-office skincare retail, and it was developed over years and years of experience selling products in my practice.

I was first at the University in Miami and then went into private practice, and I loved skincare products, but I found that selling them in my practice was so difficult, because of the inventory and calculating the prices and how much to sell the products for, and following up with the patients, so the Skin Type Solutions Franchise offers a streamlined approach that I developed over many years.

Our motto is medical advice on skincare, because I truly believe that patients should get their skincare from their doctor. Especially as dermatologists, we are the ones trained, we have gone through years of school, and we know more about what's right for our patients.

Where can dermatologists learn more?

Dr. Baumann: To learn more about the Skin Type Solution Franchise System go to stsfranchise.com. There is information there as well as a variety of ways to contact us and we will send you information about how to get started. The initial startup for the displays is about $2,000, the initial inventory is about $10,000, and the one-time franchising fee is $5,000. So for about $17,000 you can get your practice going and start selling skincare products in a couple of weeks.

The first few practices we opened were general derm practices that didn't sell any skincare at all. We went in and trained their staff, and within a week they were having very dramatic sales. We can turn unused office wall space into a profit center, and your patients will have better outcomes.

Whether you are treating psoriasis or atopic dermatitis or doing fillers and Botox or laser, even skin cancer, all of these patients will have better results if they are on the right skincare. This is a way for you to ensure that your patients are getting the right skincare without having to take time yourself to deliver that advice to the patients.

New Technology Aims to Improve Safety and Outcomes with Aesthetic Injectables

A Q&A with Steve Yoelin, MD

What are the main risks associated with cosmetic injectables? Which are inherent to the products and which are technique dependent?

Steve Yoelin, MD: The big risk with any dermal filler, regardless of composition, is the possibility of intravascular injection. However, most instances of intravascular injection, which may be common, are most likely inconsequential due to collateral circulation within the face.

When intravascular injection does occur, many variables impact the outcome. These variables include, but are not limited to, speed of injection, amount of material injected, type of material used, size of the vascular structure in question, and the region of the face in question.

Many practitioners feel that, when injecting dermal fillers in a bolus-type fashion, the injector should aspirate prior to injecting in order to develop a better idea as to whether or not the needle tip may have inadvertently penetrated a vascular structure. However, aspiration is not a surefire way to ensure that the needle tip is not in a vascular structure because of the possibility that no “flash” is visible in the barrel of the dermal filler syringe even when the needle is, in fact, in a blood vessel.

The hyaluronic acid class of dermal fillers—the largest such class in the US in terms of market share—has the advantage of reversibility because the enzyme hyaluronidase reverses the effect of hyaluronic acid.

A comprehensive understanding of facial anatomy will improve patient outcomes and risk profiles. In order for practitioners to improve their understanding of facial anatomy, a variety of educational options are available. For example, company-sponsored on-label programs and continuing medical education (CME) programs represent insightful educational options.

Additionally, a variety of companies are developing alternative educational approaches. For example, TruInject, a biotechnology startup based in Orange County, CA, is developing an interactive training device to provide practitioners with simulated injecting experience (see sidebar).

Most current educational programs focus on either learning via demonstration from an experienced practitioner or via direct practice on a live model with feedback from an experienced practitioner. In contrast, TruInject is one of the first companies to pioneer an approach in which practitioners practice on a virtual model. n

Read more from Dr. Yoelin in the November/December edition of Modern Aesthetics® magazine: ModernAesthetics.com.