JAN-FEB 2019

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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FADE OUT © GETTY IMAGES 30 JANUARY/FEBRUARY 2019 | Med Esthetics stopped at least a week prior to the in-offi ce treatment to reduce the risk of excessive injury to the skin. "I stop the topical retinoid seven days before any chemical peel or laser treatment to reduce the risk of crusting and erosions and excessive injury to the dermis. I have them resume their retinoids 24 hours later," says Dr. Alexis. BRIGHTENING SUN-DAMAGED SKIN When addressing unwanted pigmentation resulting from sun damage, topical lightening agents, such as retinoids, sun protection and avoidance, and in-offi ce procedures are also utilized. But there are some differences when working with patients with skin of color. "Up to skin type IV, I use a 532nm KTP laser for photoaging-related pigmentation changes, including solar lentigines," says Dr. Alexis. "For higher Fitzpatrick types, I prefer a nonablative fractional laser, particularly the 1,927nm low-powered diode laser." Over the years, as patients have seen positive results on their facial skin, they are becoming increasingly concerned with unwanted pigmentation on their hands, arms and chests. "For photodamage, I use a lot of Fraxel laser and a lot of peels, both in isolation and in combination, for the face, arms, hands and chest," says Dr. Roberts. "The Aerolase Lightpod Neo is also working well for pigment on the chest. The choice typically depends on budget. If the patients doesn't have the budget for a laser treatment, then we go with peels." ADDRESSING ACNE-RELATED PIH Acne, in and of itself, is an upsetting skin concern that can leave long-term physicial reminders in the form of scars and hyperigmented areas of skin. In skin of color, this excess pig- mentation can linger long after the blemishes have cleared. "For acne-associated PIH, my goal is to treat both the acne and the pigmentation at the same time, so with that in mind, I rely more on topical retinoids and azelaic acid as opposed to hydroquinone," says Dr. Alexis. "But with acne, there is also a scarring component. In order to treat both the pigmentation and the textural concerns, I also use the 1,550nm fractional nonablative laser or salicylic acid peels." LICHEN PLANUS PIGMENTOSUS A less common pigmentation concern that is more likely to occur in patients with skin of color is lichen planus pigmentosus. "This is a very diffi cult-to-treat condition that thankfully is not extremely common, but it's not rare," says Dr. Alexis. "It is particularly seen in individuals with either South Asian and Latin American ancestry." An infl ammatory condition, lichen planus pigmentosus presents with bluish-gray areas of pigmentation involving the face, the neck and, in other cases, the trunk or extremities. Treatment involves fi rst addressing the abnormal infl ammation with topical and oral anti-infl ammatories. "Then we treat the residual pigmentation with bleaching agents, lasers, peels and sun protection," says Dr. Alexis. He prescribes immunomodulatory oral agents, such as hydroxychloroquine. "Oral retinoids, such as oral tretinoin, also can be useful as well as oral doxycycline for its anti- infl ammatory effect at an antimicrobial dose," he says. Dr. Alexis waits until the infl ammation is under control before addressing the existing pigment. "This is a slow- burning infl ammatory condition. I want to ensure that the infl ammation is completely resolved and the patient is in remission before introducing devices and procedures," he says. "That course of medical treatment, before introducing cosmetic treatments, is longer than with other pigmentation concerns. It may be in the range of four to six months. The topical bleaching agent, however, can be started much earlier in the course—even right away—as long as anti- infl ammatory, immuno-modulating therapy is on board at the same time." Like melasma, lichen planus pigmentosus can recur and, therefore, requires long-term maintenance. "For long-term control, I typically use a topical calcineurin inhibitor, such as tacrolimus ointment or tacrolimus cream. This helps regulate the abnormal infl ammation," says Dr. Alexis. Pigmentation problems are one of the top concerns for patients with skin of color. They are notoriously diffi cult to treat, due to a high rate of recurrence and a high-risk of treatment-related PIH. But new products and techniques are constantly emerging. "The treatment of pigmentation concerns is a fast-growing fi eld, so keep up with it," says Dr. Roberts. "Just when you think you know all the treatments, there is a new one that can provide better outcomes for our patients." Inga Hansen is the excutive editor of MedEsthetics. Topical retinoids and azelaic acid address both active acne and acne-related PIH.

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