Some cosmetic procedures have uses in patients with chronic and difficult to treat conditions. Once evidence-based options for these patients have been used with little to no success, adding a cosmetic procedure may help the patient achieve some disease control. Jennifer Holman, MD, presented on the use of cosmetic therapies for treating patients with various chronic conditions at the 2019 Society of Dermatology Physician Assistants conference in Scottsdale, AZ.
Neurotoxins, such as Botox, are being found to be effective for several chronic diseases. One consideration Dr Holman noted is that neurotoxins are expensive as insurance may not cover them. She said she charges patients “at cost” for medical purposes, not her aesthetic prices.
One area where neurotoxins are showing efficacy is the treatment of hyperhidrosis. For axillary hyperhidrosis, Dr Holman recommended diluting 4 cc and using 50 units per axilla every 6 months. She noted that neurotoxins in the hands and feet are painful. While the arms can take a few minutes to inject, the hands and feet can take 20 to 30 minutes, she said. She has patients hold 2 frozen water bottles when not working on the hand to help with the pain, as well as applies some topical anesthesia.
For the scalp, “Blowtox” is a popular trend to extend the duration of blow outs. “Scrotox” is another trend that is used to address genital sweating. For Bromhidrosis, 50 units per axilla every 6 months helps with the odor, said Dr Holman. It also helps with genital odor. Case reports have also shown success for patients with chromhidrosis, which is a rare condition that causes an individual to sweat in color. Neurotoxins are less effective for facial hyperhidrosis, she added.
If a patient has post-herpetic neuralgia that is unresponsive to traditional therapies, neurotoxins can be used and works really well, said Dr Holman. She said she marks the area of sensitivity, administers 100 units to the affected area, spacing injections 1 to 2 cm apart, and administers a second treatment 2 weeks later, which is more localized to the dermatome.
Dr Holman also uses neurotoxins as a part of her treatment of rosacea. A microtox to treat rosacea with neurotoxins involves small doses, 7 cc per 100 units and 0.05 cc microdroplets for total of 8 to 12 units per cheek. She recommended changing the needle frequently and using a small needle when performing a microtox.
In her practice, she uses SkinPen 0.5 with 8 cc per 100 unit of Botox combined with 1550 nm intense pulsed light device (IPL). She performs IPL first followed by the neurotoxin.
This technique can also be used for oily skin, she said, as neurotoxins have bene found to decrease pore size and reduce sebum production.
She also recommended neurotoxins for preventing rhinophyma, as well as treating it early and as a part of post-surgical care. In addition, she uses neurotoxins to obtain better cosmetic outcomes for patients with nonmelanoma skin cancer on the forehead or around the eyes, as well as for scar revision.
Platelet rich plasma (PRP) is another cosmetic treatment that has been effective for conditions such as alopecia, as well as improved healing following fractional ablative laser treatments. Dr Holman also noted that for patients wanting “natural treatments,” PRP could be offered as an option.
For her patients with hair loss, she uses traditional treatments and checks for underlying conditions that could affect hair loss or treatment outcomes. Her protocol for using PRP includes treating patients monthly 3 times for 3 months and maintenance every 4 to 6 months. She did not recommend topical anesthetic or microneedling in the scalp. She noted that PRP was effective for treating shedding with telogen effluvium and has success in treating patients with central centrifugal cicatricial alopecia and lichen planopilaris. In addition, she recommends PRP for under the eyes, noting that it even addresses dark circles in patients with darker skin types.
Microneedling can be used to treat acne, striae, and for facial rejuvenations, said Dr Holman. It can also be used for drug delivery, she said. For example, patients with thick actinic keratoses can undergo microneedling with levulan kerastick to help deliver the drug. The incubation time needs to be reduced with this procedure, she added. In addition, she recommended microneedling for melasma with tranexamic acid in addition to traditional methods, noting she has had success in patients with darker skin types.
She concluded her presentation by strongly recommending providers take before and after photos to document gradual changes from these procedures.
Holman J. Cosmetic Pearls for Difficult Medical Dermatology Patients. Presented at: 2019 Fall Society of Dermatology Physician Assistants Conference; November 20, 2019; Scottsdale, AZ.