Novel treatments, techniques offer new approaches for cosmetic medicine

By Louise Gagnon – Correspondent, The Chronicle

In cosmetic medicine, trend is toward skin quality as a primary focus of treatment, experts agree

Therapies that improve the quality and texture of skin, emerging treatments for cellulite, a novel neuromodulator, and non-hydroquinone options to treat melasma are all innovations that dermatologists who offer cosmetic treatments look forward to potentially being able to incorporate in their practices.

“[Restylane’s] Skinboosters work well,” said Toronto dermatologist Dr. Lisa Kellett, a dermatologist in Toronto and Director of DLK on Avenue, in an interview with The Chronicle of Skin & Allergy.

“They do not provide volume. Rather, they smoothen out the superficial skin. They improve the texture and appearance of superficial skin. When people have very fine wrinkles, you do not want to chase them [the wrinkles] with a filler. The skin that surrounds the mouth and eyes can be made smoother.”

Skinboosters differ from traditional fillers with respect to the schedule of injections, said Dr. Kellett. “We give three injections that are done a month apart, with a ‘top up’ at around six months,” explained Dr. Kellett.

Dr. Julia Carroll, Toronto dermatologist and a founder of Compass Dermatology in Toronto, agreed that therapies aimed at enhancing skin quality are in demand and will become more available to patients.

“You will see a trend toward skin quality being a focus of treatment,” said Dr. Carroll, citing offerings like Galderma’s Restylane Skinboosters, Teosyal’s Redensity beauty booster, and Allergan’s Juvéderm Volite, which is scheduled to be released in the autumn of 2018 in Canada. “These are either lightly cross-linked or not cross-linked injectable treatments that are meant to hydrate and firm the upper dermis.”

Longer range data available
Cellulite is a cosmetic condition that female patients seek to treat to modify the unwanted appearance of dimples in the thighs and buttocks, and three-year data are now available that support the efficacy of stabilized-guided subcision, or Cellfina, in the treatment of cellulite.

“Virtually every patient is a lot happier with Cellfina,” said Dr. Shateel Sapra, a dermatologist based in Oakville, Ont., who focuses on cosmetic dermatology at ICLS Dermatology & Plastic Surgery. “Anesthetic is first applied before treatment. Cellfina is effective for deep, dimpled cellulite as it smoothens out the skin.”

The three-year study involved 45 patients who were photographed prior to treatment and at several points in time afterward, out to three years post-procedure (Dermatol Surg 2017 Oct; 43(10)).

“It [Cellfina] is providing hope for a condition that we did not have adequate treatments for previously,” said Dr. Vince Bertucci, a dermatologist and Medical Director at Bertucci MedSpa in Woodbridge, Ont. “The key thing is patient selection. It is about making sure that individuals have good skin quality and not lax skin. If the dimpling that is present is related to skin laxity, that patient will not do as well [with Cellfina] as someone who has good skin elasticity.”

There is some temporary bruising that can develop post-procedure with Cellfina but it can be easily hidden during recovery from treatment, according to Dr. Bertucci.

New approach to Tx for cellulite
Another therapy that may offer benefit in the treatment of cellulite is collagenase clostridium histolyticum (CCH), known by the brand name Xiaflex. The product is presently indicated for the treatment of Dupuytren’s contracture, noted Dr. Carroll.

“The same therapy could be used for the treatment of cellulite,” explained Dr. Carroll. “It would be injected.”

Two Phase III clinical trials of CCH for the treatment of cellulite have been launched with a target of 840 women with moderate-to-severe cellulite scheduled to be enrolled in the trials. A Phase 2b trial of CCH for the treatment of cellulite demonstrated it was well-tolerated and that most toxicities such as bruising, injection site pain, and pruritus, were confined to the local injection area.

Patients with melasma are seeking non-hydroquinone options and one of the latest alternatives is oral tranexamic acid, which can be used to provide relief for patients with the skin discoloration characteristic of melasma.  A recent study of 44 patients compared the impact of tranexamic acid to placebo in the treatment of moderate-to-severe melasma.

At three months, there was a 49% decrease in the modified Melasma Area and Severity Index score among patients exposed to tranexamic acid vs. 18% in the control group (J Am Acad Dermatol 2018 Feb; 78(2):363–369).

“There is significant improvement in cellulite with it, but you have to be careful in using it because it can cause clotting of the blood,” said Dr. Sapra.

Dr. Bertucci agreed that it is important to screen patients to ensure that they have no clotting disorder or family history of deep vein thrombosis or are smokers before initiating oral tranexamic acid treatment.

“Assuming that they have no contraindications, there is more and more evidence to suggest it may be beneficial to treat melasma with oral tranexamic acid, [with the acid acting] as an adjunct to existing therapies,” said Dr. Bertucci.

Topical tranexamic acid may present another option for patients with melasma, noted Dr. Sapra, pointing to a product like Discoloration Defense, by SkinCeuticals, which includes tranexamic acid, niacinamide, hepes, and kojic acid, which, when it becomes available, will be another therapy for patients with melasma.

Dr. Kellett noted that one of the possible toxicities with prolonged hydroquinone treatment is ochronosis. “There is a move away from using hydroquinone,” said Dr. Kellett. “We are looking at alternatives to hydroquinone [such as topical tranexamic acid].”

New neuromodulator under study
A neuromodulator known as daxibotulinum toxin A, RT002, is being investigated for the treatment of glabellar lines. The uniqueness of this neuromodulator is its prolonged duration of effect. “It has been shown to last at least six months,” pointed out Dr. Carroll. “The clinical trial program is progressing.”

Dr. Bertucci echoed that the 24-week duration of effect observed in studies is impressive. “The product may be giving clinically meaningful results, lasting eight weeks longer than [other botulinum toxins],” said Dr. Bertucci.