Eyebrow lifting using multidirectional absorbable thread

Background

Thread lifting is a common procedure in minimally invasive esthetic techniques and can also be used to raise the drooping soft tissue of the forehead by vertically inserting threads into the forehead.

Aims

This study aimed to examine the effect of forehead thread lifting on enhancing upper eyelid opening.

Methods

Fifteen patients were included in this study, all of whom underwent eyebrow thread lifting with MINT LIFT® UP. Photographs of the patients were taken before, immediately after, and 1 and 12 weeks after surgery. Changes in the position of the eyebrows and eyelids were measured. The paired t-test was used to determine the statistical significance of differences.

Results

At 1 week after surgery, the eyebrows were at a lower level compared with before surgery, and no significant changes in eye-opening were observed. However, at 12 weeks after surgery, the eyebrows and upper eyelids were both significantly elevated when compared to the preoperative state.

Conclusions

Eyebrow lifting can be performed using multidirectional thread lifting.     

Effect of pdo facelift threads on facial skin tissues: An ultrasonographic analysis

Background

Recent studies demonstrate that PDO threads, after being introduced into the facial skin, provide benefits due to collagen formation around the thread and improved vascularization.

Aims

This work aims to report the ultrasound and photographic follow-up after the execution of the facelift thread technique, thus evaluating the anti-aging treatment that PDO threads will provide for human facial skin.

Methods

The facelift will be performed using PDO thread 18G cannulated Sculpt i- Thread FML 100 × 185 mm, and 29G PDO thread Needled Flat i-Thread 38 × 50 mm. A total of 10 patients were selected for the study; all of them had medium-grade facial ptosis and aged 40–50 years old. In order to control tissue changes after thread, insertion ultrasound measurements will be made with Philips ultrasound 12 MHz linear probe at maximum resolution, initial evaluations and control of 30, 60, 90, and 120 days, measuring the skin layers: epidermis\dermis and hypodermis. Photographic control was performed before and after 120 days of intrusion of the PDO threads.

Results

The formation of collagen around the PDO thread was evidenced through ultrasound images in all patients in this study, as well as improvement in the appearance of the skin and sagging, evaluated by photographic control.

Conclusions

We can define that the PDO threads used for the facelift are effective in the formation of collagen around the thread (observed through the increase in the dermal layer), and improvement of the condition of the anti-aging factor through sagging skin, vascularization and thinning of the superficial fat layer (observed through the reduction of the subcutaneous or hypodermis layer).     

Deformation characteristics of hydrogel products based on cross-linked hyaluronic acid

Background

The cross-linked hyaluronic acid (HA) fillers are the viscoelastic hydrogel with a dominant elasticity rather than a viscosity as a useful medical device in the soft tissue augmentation. These HA fillers undergo deformation to begin the biodegradation by the biochemical and physical environment of the body, and result of deformations are closely related to clinical performance.

Aims

The specific equation of molding index is newly generated and proved with Collin's equation, which is used for strong elastomers, for selecting optimal product in facial treatment.

Methods

In this study, the results of amplitude sweep test from five marketed HA fillers were mathematically demonstrated for the proper clinical application.

Results

The increment of loss modulus by deformation was evaluated as a useful factor for the maintenance of optimal shape molding performance and resistance to external deformation of the cross-linked HA gel. From this study, the equation of molding index for weak viscoelastic hydrogels like HA products can be applied for choosing which products even in aesthetic plastic field. This molding index equation is compared to Collins' equation that index of deformation as elastomer like rubber and then found the positive correlation between two equations.

Conclusion

This study could provide a basic theory that achieve useful clinical performance according to characteristics among many types of medical devices based on the molding index.     

Survival advantage of women in localized melanoma mainly relies on clinical-pathological differences by sex. A retrospective study of 1,607 patients in Valencia,Spain

Background

Among melanoma patients,women have a better prognosis than men but the differences might be due to a different presentation of melanoma.

Objectives

The aim of this study was to identify differences in clinical presentation and survival in cutaneous melanoma between men and women in a Spanish population stratified by age.

Materials & Methods

In total, 1,607 consecutive patients with localized cutaneous melanoma and complete clinical and pathological information were evaluated. Average follow-upwas 5 years. Patients were stratified by age into three groups: ≤45 years, 46-60 years, and >60 years. Disease-free survival, overall-survival and disease-specific survival were generated using the Kaplan-Meier method. Multivariate survival analyses were evaluated using Cox modelling.

Results

Melanoma presented more frequently in the trunk in male patients and in the lower extremities and acral location in female patients. Men presented thicker tumors than women. However, for histological type, mitotic rate and ulceration there were no significant differences between the sexes. In the univariate survival analyses, women showed better disease-free, overall and disease-specific survival in the younger age group, compared with males of the same group. After adjusting for anatomical site, Breslow thickness, mitotic rate and presence of ulceration, there were no differences between males and females in any of the three age groups.

Conclusion

The superior survival for women over men did not persist after adjusting for multiple prognostic variables such as anatomical site, Breslow thickness, mitotic rate and ulceration.

     

A novel microcoring technology: A completely new concept of enlarged pore treatment

Background

Enlarged facial pores are a common dermatological and cosmetic concern, which are difficult to treat because their pathogenesis is multifactorial. Many technological treatments have been developed to treat enlarged pores. Despite these efforts, enlarged pores remain problematic for many patients.

Objectives

Microcoring technology has recently been developed to treat pores and serve as a leading primary treatment option to address these concerns.

Methods

Three patients underwent a single treatment of rotational fractional resection. The 0.5 mm diameter rotating scalpels were used to resect the skin pores in the cheek region. The resected site was evaluated 30 days after treatment, and the patients underwent scanning in bilateral 45° views at 60 cm from the face with the same brightness setting.

Results

The three patients improved in terms of enlarged pores and had no severe skin-related adverse effects. Furthermore, the three patients showed satisfactory treatment outcomes after 30 days of follow-up.

Conclusion

Rotational fractional resection is a new concept that produces measurable permanent results for enlarged pore removal. These cosmetic procedures produced promising outcomes in a single treatment. However, the current clinical procedures trend demands minimally invasive treatment for enlarged pores.     

Eyebrow lifting with barbed threads: A simple,safe, and effective ambulatory procedure

Introduction

Changes in brow positioning are one of the first facial aging signs. A more beautiful and younger look can be achieved by repositioning the tissues involved in brow descent and sagging eyelids.

Methods

We report the outcome of eyebrow thread lifting in a series of patients who came to our clinic to improve their gaze. Response to treatment was assessed at 6- and 12-months using FACE-Q^™ upperlids and eyebrow/forehead scales.

Results

A total of 38 patients with mild-to-moderate brow ptosis or without ptosis underwent eyebrow thread lifting (mean age 35.5, all female). No serious complications were observed during or after treatment. All patients were satisfied with the outcome of the intervention. Mean FACE-Q^™ scores improved at six months compared with baseline. A statistically significant increase in mean FACE-Q^™ scores was still seen at 12 months and was more evident in younger women. Patients were able to go back to their daily lives the day after the procedure.

Conclusion

Eyebrow thread lifting is a minimally invasive procedure able to overcome mild-to-moderate ptosis with excellent aesthetic results. In the absence of ptosis, thread lifting is a good choice to reposition the brow and improve the gaze. The technique is simple to perform and safe.     

Prolonged viability of human organotypic skin explant in culture method (hOSEC)

BACKGROUND:

Currently, the cosmetic industry is overwhelmed in keeping up with the safety assessment of the increasing number of new products entering the market. To meet such demand, research centers have explored alternative methods to animal testing and also the large number of volunteers necessary for preclinical and clinical tests.

OBJECTIVES:

This work describes the human skin ex-vivo model (hOSEC: Human Organotypic Skin Explant Culture) as an alternative to test the effectiveness of cosmetics and demonstrate its viability through cutaneous keratinocytes'' proliferative capacity up to 75 days in culture.

METHODS:

The skin explants obtained from surgeries were cultured in CO₂-humid incubator. After 1, 7, 30 and 75 days in culture, skin fragments were harvested for analysis with histomorphological exam (HE staining) on all days of follow-up and immunohistochemistry for Ck5/6, Ck10 and Ki-67 only on the 75th day.

RESULTS:

On the 7th day, the epidermis was perfect in the dermoepidermal junction, showing the viability of the model. On the 30th day, the epidermis was thicker, with fewer layers on the stratum corneum, although the cutaneous structure was unaltered. On the 75th day, the skin became thinner but the dermoepidermal junctions were preserved and epidermal proliferation was maintained. After the 75th day on culture, the skin was similar to normal skin, expressing keratinocytes with Ck5/6 on supra-basal layers; Ck10 on differentiated layers; and viability could be assessed by the positivity of basal cells by Ki-67.

CONCLUSION:

The hOSEC model seems a good alternative to animal testing; it can be used as a preclinical test analogous to clinical human skin test with similar effectiveness and viability proven by immunohistological analyses.     

In vitro and in vivo study of the efficacy of a new sebum control essence

Background

People with oily skin often suffer from skin problems such as oily face, blackheads, acne, and enlarged pores. It is necessary to regulate oily skin with skin care products.

Aims

To develop an effective sebum control essence to reduce oiliness of skin.

Methods

The composition of the essence was designed in consideration of different oil control mechanism targets. The skin irritation was assessed in 30 volunteers by a single application close patch test. The efficacy of the essence was evaluated by in vitro experiment, short- and long-term clinical trials with over 60 volunteers.

Results

The results of both in vitro and clinical trials showed that the essence had significant oil control and moisturizing effect, the skin oil content decreased by 21.8% within 8 h and 30.05% after 28 days, which indicated that the essence could achieve rapid and persistent sebum control efficacy. In addition, the essence could relieve the problems of enlarged pores, blackheads and whiteheads in long-term use.

Conclusions

The essence developed in this study can alleviate the problems of oily skin from many aspects, and achieve an excellent effect in oily skin regulation. It is suitable for a daily application in oily skin regulation.     

Is it possible to obtain long-lasting results with thread lift in the brow region? Introduction of a new suspension technique and evaluation of 50 patients

Background

Eyebrow region is a dynamic region, and it has a thinner skin prone to wrinkles and sagging. Descended brows could be repositioned immediately with fewer complications by the use of the threads. Despite all its advantages, the main drawback of absorbable thread lift is its short duration of lifting effect.

Aims

This report aims to describe our thread lift technique we have implemented to counteract the descent of the brows and evaluate our results in 50 patients.

Patients/Methods

A retrospective chart review was carried out over a period of 1 year from September 2019 to 2020 for the patients who underwent thread lifting for eyebrows in a private clinic in Ankara. Complications after the procedure, durability of the results, global esthetic improvement scale (GAIS) score, and patient satisfaction survey scores were recorded.

Results

The study group was composed of 50 female patients with a median age of 34 years. The median duration of the procedure is 15 months. Nine (18%) patients experienced complications related to the procedure including ecchymosis, edema, erythema, skin dimpling, and pain. Three weeks after the procedure, the position of the eyebrows of eight (16%) patients were improved, 18 (36%) patients were much improved, and 24 (48%) patients were very much improved according to GAIS.

Conclusions

So far, the most disappointing feature of the threads was the poor long-term sustainability of the outcomes. Our thread lift technique for brows offers a significant improvement in the position of the eyebrows in a short time with decreased downtime. More importantly, it can be possible to improve the longevity of the results with this approach.     

Macrocystis pyrifera ferment-containing creams for optimizing facial skin rejuvenation

Background

There is an increasing demand for facial skin rejuvenation. Specialized aesthetic skincare treatments may be one of the first steps to help prevent or treat facial signs of aging. This article discusses aesthetic skin care for facial skin rejuvenation, particularly data on two creams containing Macrocystis pyrifera ferment.

Methods

The authors convened a dermatology advisory board to discuss challenges and practices in using skincare for facial rejuvenation, combining their expert opinion and experience on facial rejuvenation with preclinical and clinical data on two creams containing Macrocystis pyrifera ferment and a review of the literature.

Results

Preclinical and clinical studies on Macrocystis pyrifera ferment and two creams containing the ferment exhibit anti-inflammatory, anti-aging, and healing properties. In preclinical studies, the ferment demonstrated collagen type I enhancing properties in ex vivo skin models, and skin cells treated with the ferment migrated faster than untreated cells in the in vitro study. In clinical studies measuring visible anti-inflammatory activity, the ferment alone and the ferment-containing products significantly decreased erythema, and in anti-aging studies, they improved visible skin aging parameters. Finally, in clinical studies on the stratum corneum, the two creams increased moisture levels and decreased transepidermal water loss (TEWL), reflecting healing by enhancing barrier strength and recovery.

Conclusions

The Macrocystis pyrifera ferment and creams containing the ferment are effective skin care treatment products to decrease the visible effects of inflammation and signs of aging while promoting healing by enhancing barrier resilience and recovery.     

Lactic Acid as a New Therapeutic Peeling Agent in the Treatment of Lifa Disease (Frictional Dermal Melanosis)

Background:

Lifa disease (frictional dermal melanosis) is a common dermatological problem. Full strength lactic acid has been proved to be effective and safe peeling agent in the treatment of melasma.

Objective:

To assess the effectiveness and the safety of lactic acid chemical peeling in the treatment of lifa disease.

Materials and Methods:

This open label therapeutic trial was conducted in Department of Dermatology in Najaf and Baghdad Teaching Hospitals, from March 2007-October 2008. Full strength lactic acid (92%, pH 3.5) was used as a peeling agent. The treatment sessions were done every 2 weeks until the desired response was achieved (but not more than 6 sessions). The response to therapy was evaluated by objective and subjective methods. All patients were followed monthly for 3 months after the last treatment session.

Results:

52 patients with typical clinical features of lifa disease were included. All patients were slim with prominent bones and low body mass index, and gave history of using the lifa (washing agent) during bathing. The number of sessions ranged from 2-6 sessions. The pigmentation was improved in all patients as revealed by objective and subjective methods, and this response was statistically highly significant. No significant side effects were recorded in all treated patients. The improvement has been sustained without any obvious relapse throughout the follow-up period.

Conclusion:

Lactic acid peel is a new, non-costly mode of therapy in treating dermal melanosis in patients with lifa disease.     

Clinical course of psoriasis patients that discontinued biologics during the COVID-19 pandemic

Background

Since psoriasis is a chronic disease, it is not recommended to discontinue the treatment agents used. However, in real life, the treatment of psoriasis patients may be interrupted for various reasons. During the pandemic period, the treatment of many patients was also interrupted.

Objectives

To evaluate relapse and clinical worsening in psoriasis patients whose biological therapy was interrupted during the pandemic and reveal associated factors.

Methods

The study included patients aged ≥18 years, who were followed up with moderate and severe chronic psoriasis controlled by the last biological agent [Psoriasis Area Severity Index (PASI) 75 response achieved] but had to discontinue their treatment during the pandemic. The patients' demographic and clinical characteristics, clinical course after the discontinuation of these agents, presence of clinical worsening, and relapse were evaluated. Risk factors were analyzed with the logistic regression analysis.

Results

The study included 169 patients, with a mean age of 47.3 ± 14.5 (18–87) years. The mean biologics-free time was 18.2 ± 12.3 (2–56) weeks. Clinical worsening was detected in 41.4% and relapse in 48.5% of the patients. The significant risk factors for clinical worsening and relapse in both univariate and multivariate analyses were alcohol use during the biologics-free period, total time off biologics, and the presence of an additional triggering factor. The use of secukinumab and ustekinumab was found to be a protective factor against clinical worsening in multivariate analyses.

Conclusion

As the biologics-free period is prolonged, the likelihood of clinical worsening and relapse increases, therefore, we do not recommend discontinuing biological agents.     

A systematic review of natural health product treatment for vitiligo

Background

Vitiligo is a hypopigmentation disorder affecting 1 to 4% of the world population. Fifty percent of cases appear before the age of 20 years old, and the disfigurement results in psychiatric morbidity in 16 to 35% of those affected.

Methods

Our objective was to complete a comprehensive, systematic review of the published scientific literature to identify natural health products (NHP) such as vitamins, herbs and other supplements that may have efficacy in the treatment of vitiligo. We searched eight databases including MEDLINE and EMBASE for vitiligo, leucoderma, and various NHP terms. Prospective controlled clinical human trials were identified and assessed for quality.

Results

Fifteen clinical trials were identified, and organized into four categories based on the NHP used for treatment. 1) L-phenylalanine monotherapy was assessed in one trial, and as an adjuvant to phototherapy in three trials. All reported beneficial effects. 2) Three clinical trials utilized different traditional Chinese medicine products. Although each traditional Chinese medicine trial reported benefit in the active groups, the quality of the trials was poor. 3) Six trials investigated the use of plants in the treatment of vitiligo, four using plants as photosensitizing agents. The studies provide weak evidence that photosensitizing plants can be effective in conjunction with phototherapy, and moderate evidence that Ginkgo biloba monotherapy can be useful for vitiligo. 4) Two clinical trials investigated the use of vitamins in the therapy of vitiligo. One tested oral cobalamin with folic acid, and found no significant improvement over control. Another trial combined vitamin E with phototherapy and reported significantly better repigmentation over phototherapy only. It was not possible to pool the data from any studies for meta-analytic purposes due to the wide difference in outcome measures and poor quality ofreporting.

Conclusion

Reports investigating the efficacy of NHPs for vitiligo exist, but are of poor methodological quality and contain significant reporting flaws. L-phenylalanine used with phototherapy, and oral Ginkgo biloba as monotherapy show promise and warrant further investigation.     

Evaluation of concordance between labelling and content of 52 hair dye products: overview of the market of oxidative hair dye

Background

Hair dyes contain strong allergens and are widely available. Correct labelling is a necessity in order to provide information about the contents.

Objectives

To compare the labelling and content of hair dyes.

Materials and methods

In total, 52 hair dyes, from 11 different countries, were bought over the counter. High-pressure liquid chromatography was used for the analysis of p-phenylenediamine (PPD), toluene-2,5-diamine (2,5-TDA), and three oxidation products of PPD.

Results

There was good agreement between labelling and content, although seven of the 52 products (13.5%) studied were incorrectly labelled. There were differences in the geographical use of PPD and 2,5-TDA; 2,5-TDAwas more common in European products, while PPDwas more common in products purchased outside Europe andwas present in higher concentrations.

Conclusion

All dyes purchased in Europe contained PPD and 2,5-TDA at levels within the limits defined by European legislation, however, levels were higher in some products purchased outside Europe. Only a small group of hair dyes sold in Europe were mislabelled. Further improvement in labelling, by providing the concentration of chemicals, may facilitate products to be purchased both locally and within the global market, when travelling or on the internet.

     

Anti-wrinkle properties of Angelica gigas Nakai root extracts using mineral-rich water

Background

Angelica gigas Nakai is used as an herbal pharmaceutical material in Korea.

Aims

To investigate the anti-wrinkle effects of A. gigas Nakai root extracts (ARE) using mineral-rich water in in vitro and clinical trials.

Materials and methods

The cell viability of ARE was evaluated using a water-soluble tetrazolium salt assay. After evaluating ARE's cytotoxicity, we used an enzyme-linked immunosorbent assay kit to assess the effects of ARE on type I collagen in human dermal fibroblasts (HDFs). During a double-blinded in vivo clinical study, participants were randomly assigned to use the sample and placebo formulations for the left and right sides of their face over an 8-week period. We evaluated the anti-wrinkle properties of the formulations using PRIMOS Lite and a global photodamage score.

Results

A. gigas Nakai root extracts cytotoxicity was evaluated in HDFs. We demonstrate that ARE increased type I collagen production by 40% at 50 μg/ml as compared with the control. The use of an ARE lotion significantly reduced the presence of crow's feet wrinkles in comparison with the use of the placebo after 8 weeks. Additionally, use of the ARE lotion led to decreased photodamage scores, indicating anti-wrinkle effects.

Conclusion

The use of ARE with mineral-rich water has anti-wrinkle effects in in vitro and clinical trials.     

Whitening and moisturizing enhancing effects of three-dimensional human adipose-derived mesenchymal stem cell-conditioned medium-containing cream

Background

High-functional cosmetic products combined with the concept of “treatment” cosmetics are being introduced to the market. Cosmetic products containing a skin-derived microbiome, a three-dimensional (3D) stem cell culture medium, and low-molecular-weight collagen are being introduced, and these products are leading the cosmeceutical market. We aimed to confirm the potential of a 3D stem cell culture medium-containing cream as a skin-whitening and moisturizing product.

Aim

To determine the enhancing effects of a cream containing 3D adipose tissue-derived mesenchymal stem cell-conditioned media (3D ADMSC-CM) on whitening and moisturization.

Methods

The inhibitory activities of tyrosinase (TYR) and melanin were confirmed using 3D ADMSC-CM. Furthermore, hyaluronic acid expression in 3D ADMSC-CM was verified. The clinical efficacy of the cream containing 3D ADMSC-CM was established by evaluating its antioxidant properties and effects on skin tone, radiance, freckles, and moisturization.

Results

The use of 3D ADMSC-CM suppressed the inhibitory effects of TYR and melanin by approximately 24% and 33%, respectively, and increased the expression of hyaluronic acid synthase. A significant difference was observed after 4 weeks of using 3D ADMSC-CM in the skin antioxidant evaluation. After 2 and 4 weeks of use, skin tone and radiance increased and skin freckles decreased significantly. Under extremely cold and dry weather conditions, the use of the cream increased skin moisturization.

Conclusions

The 3D ADMSC-CM cream evaluated in an environment similar to the human body was found to enhance skin whitening and moisturization and can therefore be used in the skin care and cosmetic industries as a biocosmetic product.     

Descripción de los pacientes que reciben biológicos como primer tratamiento sistémico en el registro BIOBADADERM durante el periodo 2008-2016

Introduction and objectives

Biologic drugs are usually prescribed as second-line treatment for psoriasis, that is, after the patient has first been treated with a conventional psoriasis drug. There are, however, cases where, depending on the characteristics of the patient or the judgement of the physician, biologics may be chosen as first-line therapy. No studies to date have analyzed the demographics or clinical characteristics of patients in this setting or the safety profile of the agents used. The main aim of this study was to characterize these aspects of first-line biologic therapy and compare them to those observed for patients receiving biologics as second-line therapy.

Cutaneous lesions caused by mechanical injury

Background

To date, the term ‘acne mechanica’ defines different cutaneous lesions caused by mechanical injury.

Objective

To re-define the spectrum of cutaneous lesions caused by mechanical injury by determining their clinical and histological characteristics, to discuss and identify triggering and pathophysiologic elements.

Methods

Clinical, histological and pathophysiological differences of 135 published cases of acne mechanica were analysed and compared to cases provided from our clinics.

Results and Conclusions

Mechanical factors cause 2 types of mainly inflammatory cutaneous lesions: one presents with inflammatory papules, open comedones or has no comedonal lesions. We propose using the term ‘folliculitis mechanica’. The second type corresponds to a flare-up of acne in areas prone to the condition. These lesions present the typical clinical and histological features of acne vulgaris, comprising inflammatory and retentional lesions. Treatment may include topical products, including adjunctive care for reconstruction of the cutaneous barrier and the microbiome. Conventional acne medication should be used in cases of acne flare-up.

     

Rosácea papulopustulosa: respuesta al tratamiento con azitromicina oral

Introduction

Oral tetracyclines and topical antibiotics have been used to treat papulopustular rosacea (PPR) for years, but it is not uncommon to find patients who do not respond to this standard treatment. In such refractory cases, oral azithromycin has proven to be an effective option.

Trichoscopic evaluation of dental pulp stem cell conditioned media for androgenic alopecia

Background

Conditioned media (CM) derived from mesenchymal stem cells (MSC) is known to induce hair regrowth in androgenic alopecia.

Objectives

The objectives of the study were to assess the efficacy and safety of one type of MSC-CM, the CM derived from dental pulp stem cells obtained from human exfoliated deciduous teeth (SHED-CM) and to compare the efficacy of SHED-CM with and without dihydrotestosterone synthesis inhibitor (DHT-inhibitor).

Methods

Eighty-eight male androgenic alopecia subjects with Hamilton-Norwood Classification (H-N C) I–VII were evaluated by trichoscopy to explore which trichoscopic factors statistically correlated with H-N C. After being screened, 33 subjects received six SHED-CM treatments at 1-month intervals. Clinical severity was assessed through global and trichoscopic images from baseline to 9th month.

Results

SHED-CM was effective for 75% of subjects regardless of disease severity, concomitant DHT-inhibitor use, and age. Adverse effects including pain and small hemorrhages were transient and mild. We also found that clinical hair status evaluated by absolute values of three quantitative trichoscopic factors (maximum hair diameter, vellus hair rate, and multi-hair follicular unit rate) showed a good correlation with H-N C stages, and what is more—a scoring system of these three factors can be a possible predictor of SHED-CM efficacy.

Conclusions

We have shown that SHED-CM provides global and trichoscopic image improvement for androgenic alopecia, regardless of concomitant DHT-inhibitor use.