COVID‐19 Pandemic: Consensus guidelines for preferred practices in an aesthetic clinic

Strict infection control measures in response to the current COVID‐19 pandemic are expected to remain for an extended period. In aesthetic clinics, most procedures are provided on one to one basis by the physician or therapist. In such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. The meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from SARS‐CoV‐2 infection. Consensus guidelines for “preferred practices” were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorized into low‐risk, moderate risk, and high‐risk based on the likelihood of transmission of SARS‐CoV‐2 virus from the patient to the treating physician or therapist. While not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPEs may vary from country to country, the local guidelines should also be followed to prevent COVID‐19 infection in aesthetic clinics.     

Improving aseptic injection standards in aesthetic clinical practice

The rise in popularity and demand for nonsurgical injectable aesthetic procedures is inherently accompanied by an increase in reported complications, particularly those related to infection. Aseptic technique is under the control of aesthetic practitioners and can be modified to minimize the potential for cross‐contamination and infection. This should be a key consideration during all clinical procedures, particularly those involving breach of the skin's natural defenses and the use of soft tissue filler. A consensus group of five UK expert aesthetic clinicians were convened to discuss current best practice for aseptic techniques in medical aesthetics. The aim of the consensus group was to recommend a step‐by‐step procedure to achieve optimal aseptic practice in private clinics, and define important considerations for reducing infection risk during the whole patient journey: pre‐, during‐ and postaesthetic procedure. Recommendations were based on current evidence and extensive clinical experience. Various procedure recommendations were made to achieve and maintain a high standard of asepsis and infection control. Guidance was divided into three phases for patients and health care professionals, covering preprocedure (including patient selection), during‐procedure, and postprocedure considerations. Although adherence to standard hospital guidance on handwashing and cleanliness measures is a cornerstone of controlling cross‐contamination, aesthetic clinics carry a high potential risk of infection—particularly as popular treatments with dermal fillers primarily involve the face. This expert consensus guidance recommends procedures to mitigate the potential risks of asepsis.     

Standards for aseptic techniques in medical aesthetic practices in the Benelux: Consensus recommendations

Introduction

While the demand for aesthetic procedures is rising, complications are rising alongside. Infection is a frequent complication, there is therefore an increased need for strict aseptic technique, particularly in procedures breaching the skin. The level of training of practitioners carrying out these procedures varies and there are no comprehensive guidelines on aseptic aesthetic practice in the Benelux region.

Objective

Developing a step-by-step procedure for achieving and maintaining a high standard of aseptic conditions in a standard aesthetic practice in the Benelux region.

Methods

A consensus group of 10 aesthetic medical practitioners (dermatologists, plastic surgeons, and cosmetic physicians) representing the Benelux region convened to discuss best practice for aseptic techniques in medical aesthetics. Step-by-step procedures were recommended to achieve optimal aseptic practice in private facilities and define important considerations for reducing infection risk. Recommendations were based on current evidence and extensive clinical experience.

Results

Recommendations were made to achieve and maintain a high standard of asepsis and infection control. Guidance included maintaining high standard aseptic conditions of the injecting room, the injecting area on the patient, the injection procedure, the materials, and procedures commonly used to achieve aseptic conditions.

Conclusions

This expert consensus summary publication recommends aseptic procedures, setting a standard with the goal of minimizing rates of complications in aesthetic clinical practice in the Benelux region.     

Psychological aspects of aesthetic and cosmetic surgery: Clinical and therapeutic implications

Recently there is a surge in cosmetic and aesthetic surgery procedures. Several patient seeking various cosmetics procedures present to aesthetic surgery clinics and demanding procedures which are out of proportion. Several of these patients have under‐recognized or untreated psychiatric disorders. Proper screening and evaluation of these patients could save money and resources. This brief review focuses on current trends, clinical and psychological assessment and expectations on the part of patients and recommendations regarding management of these patients.     

Long-term aesthetic outcomes with injectable poly-l-lactic acid: observations and practical recommendations based on clinical experience over 5 years

Background Facial rejuvenation techniques have evolved in recent decades driven by a paradigm shift to restoration of lost volume, and an increase in the number of available products. As clinical experience has increased, practitioners have further refined the use of these products. Objectives To share observations and practical recommendations based on clinical experience with the aesthetic use of injectable poly‐l ‐lactic acid (PLLA) in patients followed for up to 5 years. Methods Literature review and retrospective case history review of the first 100 patients treated with injectable PLLA, many of whom have been followed for over 5 years. Results Use of injectable PLLA, alone or in combination with other products, has provided excellent and long‐lasting (up to 5 years) aesthetic results for most of the reviewed patients. Typically, patients have received one or two touch‐up sessions between years 2 and 4 after initial full correction. There were minimal adverse events of papule formation; these eventually resolved. Conclusions Injectable PLLA is a safe and effective option for achieving long‐term patient satisfaction with soft‐tissue augmentation.     

Daylight‐mediated photodynamic therapy for actinic damage in Latin America: consensus recommendations

Although conventional photodynamic therapy (c‐PDT) using methyl aminolevulinate cream (MAL) is effective for the treatment of grade I‐II facial and scalp actinic keratosis (AK), it is associated with treatment‐related pain for some patients. Daylight‐mediated PDT (DL‐PDT) has shown similar efficacy to c‐PDT, was nearly painless, and was well tolerated. Overall, DL‐PDT effectively treats AK and offers a simpler and better tolerated treatment option than c‐PDT. This consensus panel provided recommendations on the use of DL‐PDT in Latin America (LATAM) for the treatment of actinic damage associated with few or multiple AKs. The panel was comprised of eight dermatologists from different LATAM countries who have experience using PDT for the treatment of actinic damage. The panel reviewed the relevant literature and provided personal expertise with regard to using DL‐PDT for the treatment of photodamage with or without AK. The recommendations formulated by the expert panel provide evidence‐based guidelines on all aspects of DL‐PDT for the treatment of actinic damage associated with AK in different regions of LATAM. These recommendations provide guidance for dermatologists to ensure maintenance of efficacy and safety of DL‐PDT when treating actinic damage, associated with few or multiple AKs in sun‐exposed skin.     

International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit) – part II: wrinkles on the middle and lower face,neck and chest

Background Azzalure^® (Galderma SA), a newly approved European botulinum neurotoxin type A (BoNT‐A), is derived from Dysport? (Ipsen Ltd.), which has a 20‐year history of product consistency and has been widely used for various aesthetic and therapeutic applications. Azzalure^® and Dysport? are collectively referred to as BoNT‐A (Speywood Unit) after the unit of their activity, and are distinct from other commercial BoNT‐A preparations. Consensus has been developed for the treatment of upper facial wrinkles with BoNT‐A (Speywood Unit). Objective To provide consensus recommendations on the treatment with BoNT‐A (Speywood Unit) for wrinkles on the middle and lower face, neck and chest region. Methods The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus based on their extensive experience. Results The recommended final concentration of BoNT‐A (Speywood Unit) is 200 Speywood Units/ml after reconstitution. The consensus recommendations were provided for nine indications, including lower eyelid wrinkles, bunny lines, drooping nasal tip, perioral wrinkles, masseter hypertrophy, drooping mouth corners, dimpled chin, platysmal bands and décolleté wrinkles. For each indication, anatomy of the region to be treated was discussed, as were potential side‐effects. The consensus recommendations included the number and location of the injection points, dose range of each point and the total injection, as well as specific injection technique. Conclusion These recommendations provide a guideline for physicians who wish to perform safe and efficacious treatment with BoNT‐A (Speywood Unit) on the less commonly treated middle and lower face, neck and chest region.     

The signature featureTM: A new concept in beauty

Signature Feature^TM (SF) is a universal, yet highly personalized treatment approach to aesthetic facial enhancement that applies to all patients, independent of age, gender, or ethnicity. Its philosophical basis maintains that a patient's beauty is anchored by their most distinctive invariant features (invariant features like eyes, nose, cheekbones, or jawline), and preservation of such signature features should be an essential consideration in any aesthetic treatment plan. The principles central to the SF concept include: (a) identifying the patient's most distinctive signature feature, (b) matching the patient's persona to their signature feature while preserving alignment with their cultural/ethnic aesthetic, and (c) highlighting the patient's signature feature by increasing the “signal‐to‐noise” ratio between the strength of the signature feature and those factors that may be interfering with it (lines, wrinkles, and sun damage). Every patient represents a new combination of treatment challenges which are not only related to the patient's physical baseline characteristics but also by their subjective self‐perceptions. This subjective gray area is where the SF treatment approach has the greatest contribution to the patient's positive self‐perception and self‐esteem, as the practitioner can help the patient realize their own personal brand through enhancement of their signature feature using an array of aesthetic options.     

Recommendations for treatment of nail psoriasis during the COVID‐19 pandemic

The novel coronavirus disease 2019 (COVID‐19) pandemic has resulted in a paradigm shift in disease management. Since immunosuppression may cause increased susceptibility to COVID‐19, there is uncertainty as to whether systemically treated nail psoriasis patients are at increased infection risk. While specific data on nail psoriasis treatments and COVID‐19 is lacking, we present clinical trial data on rates of upper respiratory infections, nasopharyngitis, viral infection, pneumonia and overall infections. Some systemic medications and biologics are associated with increased in infections risk compared to placebo in clinical trials. However, this data should be regarded cautiously since clinical trials on nail psoriasis, particularly controlled studies, are lacking. Our recommendations may be helpful in guiding physicians managing nail psoriasis patients during the COVID‐19 pandemic.     

Conversion of aesthetic lasers and intense pulsed light sources into inherently eye‐safe units

BACKGROUND: Laser systems used in aesthetic treatments pose a serious risk to the eyes of bystanders and equipment operators. Although much safer than lasers, intense pulsed light (IPL) sources are also not without risk.

OBJECTIVE: To present a technology that can convert most lasers and IPL units used in aesthetic clinics into inherently eye‐safe devices not requiring the use of protective eyeglasses, thus making them Class I devices. With the exception of Q‐switched lasers, this new technology also dramatically reduces the potential hazards of lasers that do not attain Class I level to below that attributed to flashlamps. A device that eliminates the annoying glare generated by the reflection of pulsed light from the skin is also presented.

MATERIALS AND METHODS: The new eye‐safe technology is based on the attachment of a highly efficient wide‐angle forward scattering optical diffuser to the distal end of the laser delivery handpiece. This device is used in contact with the treated area without modification of the conventional treatment parameters and preserves clinical efficacy. The handpiece is designed to act as an eye‐safe, extended diffusing light source complying with Class I eye safety standards in most laser types. The technology also makes IPL devices safer by reducing the radiance of the flashlamp, which is hazardous when viewed directly by operators or bystanders. Skin glare is also eliminated by a liquid crystal, glare‐free window activated in synchronization with the treatment pulses.

RESULTS: Clinical hair removal results with an 80?degree diffuser did not reveal any difference when compared with results obtained with the original laser source. The incorporation of a diffuser in an IPL unit has not modified its clinical efficacy.

CONCLUSION: With the exclusion of Q‐switched lasers, it is possible to convert a large number of lasers and IPL units utilized in aesthetic treatments into inherently eye‐safe units, thereby considerably enhancing the comfort and safety of aesthetic clinics without sacrificing clinical efficacy.     

Cosmetic gynecology—An emerging field for the dermatologist

Introduction

Cosmetic gynecology is an expanding field with a steep rise in awareness and demand for procedures to enhance the aesthetic appearance of female genitalia.

Aim

This article aims to provide an overview of aesthetic gynecology for a practicing dermatologist.

Methods

A study conducted in India showed a rising trend in the demand of aesthetic vaginal procedures from 3.9% in 2012 to 28.97% in 2015.

Conclusion

Several aesthetic modalities such as peels, platelet rich plasma, and energy-based devices and surgical modalities have been in use, though serious evidence for efficacy of many of these procedures is lacking.     

Chemical peels in aesthetic dermatology: an update 2009

Background/Objectives Peelings are among the oldest and most widespread aesthetic procedures used in aesthetic dermatology worldwide. More than 50 commercial peelings are currently available on the European market. Materials and Methods In the present review, we summarise the current knowledge on chemical peels. Results/Conclusions A state‐of‐the‐art peeling procedure will take into account the depth of the targeted structure and the skin condition of the patient to choose carefully among the variables such as chemical class of the peeling agent, concentration, frequency and pressure of the application. The usual classification of chemical peels comprises superficial, medium and deep peels. For superficial peels alpha‐hydroxy‐acids and most recently lipo‐hydroxy acid are used to induce an exfoliation of the epidermis. Medium‐depth agents such as trichloroacetic acid (< 50%) cause an epidermal to papillary dermal peel and regeneration. Deep peels using trichloroacetic acid (> 50%) or phenol based formulations reach the reticular dermis to induce dermal regeneration. The success of any peel is crucially dependent on the physicians understanding of the chemical and biological processes, as well as of indications, clinical effectiveness and side effects of the procedures.     

Treatment of acne in the aesthetic patient: A round table update

Background

The popularity of social media appears to be increasing the acceptance of cosmetic treatments, prompting more consumers to seek cosmetic treatments. As the estimated prevalence of acne vulgaris among adult women may be as high as 54%, acne is commonly observed among patients presenting for cosmetic treatments. Concomitant treatment of acne in the aesthetic patient population will improve overall clinical outcomes.

Aims

The goal of this work was to deliver a high-quality ethical and evidence-based educational program to physicians and adjunctive health care providers to advance patient care.

Methods

This paper is based on a webcam presentation with roundtable discussion by several notable experts in their field.

Results

A range of topical medications, injectable products, chemical peels, and energy-based devices are available for treating acne vulgaris. In most instances, these are compatible with rejuvenation procedures in the aesthetic patient.

Conclusion

The growth of social media is raising awareness of aesthetic procedures and appears to be increasing the number of patients seeking aesthetic treatment. Educating patients about the importance of treating acne vulgaris can improve overall treatment outcomes. In most instances, the presence of acne is not a barrier to aesthetic care.     

COVID‐19: Topical agents and therapeutic prevention of nasal viral acquisition

Since the spread of SARS‐CoV‐2 became a pandemic, the number of cases has been continuously growing worldwide. Numerous recommendations and suggestions have been published to prevent the acquisition and spread of the SARS‐CoV‐2, especially to protect health workers and front‐line caregivers. SARS‐CoV‐2 is transmitted by aerosol, rendering air defense with suitable ventilation and adequate mask use pivotal. Recently, locally applied antiseptic, antiviral, or structure competitive receptor blockers were suggested to attack the virus at its main point of invasion, the nasal mucosa and nasopharynx. We discuss the most plausible and safe ideas to reduce viral load at the point of entry, and subsequently the spread of SARS‐CoV‐2 to the lower respiratory tract, lungs, and other organs. In addition, we analyze the value and recommend clinical trials employing topical trichloroacetic acid (TCA), a substance well known from dermatologic and cosmetic procedures. It has been proven to successfully block the nasal entry for airborne allergens, preventing the development of allergic rhinitis and asthma, and to be curative for early stages of viral infections entering through the oral mucosa. For SARS‐CoV‐2, TCA in a single, short‐time application is expected to remodel the nasal and nasopharyngeal epithelia, eliminating both the receptors and cells responsible for viral entry and subsequent viral spread to the lower respiratory tract. Moreover, this may have therapeutic benefits for those recently infected by reducing local viral replication. Such procedures are cheap, safe, and can be conducted in almost every setting, especially in regions with inadequate financial and logistic resources.     

Case series of post‐purpuric darkness on the periorbital area after aesthetic surgery

Periorbital hyperpigmentation (POH) is a common condition encountered in dermatology practice. POH is caused by various exogenous and endogenous factors including excessive pigmentation, postinflammatory hyperpigmentation (PIH) secondary to eczema, periorbital edema, excessive vascularity, and aging. Recently, we have experienced several patients who complained of POH with an unusual pattern. Their pigmented lesions had several features in common. The pigmentation occurred bilaterally after aesthetic surgery involving the periorbital region. Periorbital post‐purpuric darkness should be distinguished from common POH. Practitioners should ask patients about history of prior aesthetic surgery and make their patients aware that the dark colors are composed of various pigments such as hemosiderin, which make treatment troublesome. Conservative management with expectations for gradual spontaneous regression or laser therapy with multiple wavelengths including 1,064‐nm laser for PIH and 650 or 694‐nm laser targeting heme‐derived pigments may be considered as treatment options.     

Bio‐AlcamidTM in drug‐induced lipodystrophy

The development of new drugs to counter human immunodeficiency virus (HIV) infection has led to an increase in lipodystrophic syndrome among HIV‐infected individuals receiving combination therapy. Bio‐Alcamid^TM is a recently developed polymeric substance that can be implanted to compensate for adipose effects. We have implanted this substance in 73 patients with up to three years' follow‐up. The aesthetic results were deemed excellent by both physicians and patients. No implant dislocation, implant migration, granuloma, allergic reaction or intolerance were recorded.     

Clinical practice guidelines for the management of atopic dermatitis 2018

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. The current strategies to treat AD in Japan from the perspective of evidence‐based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity‐related patient outcomes with respect to several important points requiring decision‐making in clinical practice.     

Treatment of psoriasis with topical agents: Recommendations from a Tuscany Consensus

Psoriasis is a chronic and relapsing inflammatory skin disease, clinically characterized by erythematous and scaly plaques. Treatment approach is mainly driven by disease severity, though several factors should be considered in order to identify the optimal therapeutic choice. Mild psoriasis may be treated with a wide array of topical agents including corticosteroids, vitamin D analogs, keratolytics, and calcipotriol/betamethasone propionate compound. Because guidelines may not provide practical indications regarding the therapeutic approach, the use of topical agents in psoriasis is more individually tailored. In order to homogenize the standard of care, at least in a local setting, we collected the real‐life‐based recommendations for the use of topical therapies from an expert panel, the Tuscany Consensus Group on Psoriasis, representing all leading centers for psoriasis established in Tuscany. With this document, this consensus group sought to define principles guiding the selection of therapeutic agents with straightforward recommendations derived from a real‐life setting.