Moderator: What cosmetic dermatology issues are you most often encountering in your practice today?

Dr. Tanghetti: Photodamage is presently the single largest concern of the patients in our clinical practice. This is true for all age groups, but it's particularly important to women older than 50 years. Interestingly, ours is not just a cosmetic practice-80% of the patients we see every day consult us for issues relative to general dermatology. Still, the most frequent question many of these patients ask is, "What can I do to treat photodamaged skin?" Although patients may choose from a variety of treatment options, most emphasize that they don't want any downtime, they don't want others to know what they're doing, and they want the treatment to be effective.

Dr. Lupo: Presently, the focus of our work seems to be on nonablative skin rejuvenation, although we still perform some ablative procedures. Nonablative procedures include injection of fillers or Botox® Cosmetic and certain less invasive laser and light treatments that improve and enhance the appearance of the skin. We can perform nonablative techniques in the office, and they involve little or no patient downtime due to crusting or oozing. Nor do patients feel the need to hide away to conceal the temporary disfigurement that results from procedures such as laser resurfacing.

Moderator: What treatments are you using to complement cosmetic procedures?

Dr. Tanghetti: First and foremost, we use topical retinoids, because they are the only class of drugs with clinical evidence in support of their efficacy. These drugs are FDA approved; they've undergone rigorous testing. We're also using glycolic acid and other cosmeceuticals, but many of these agents are actually associated with more hype than clinical data. Agents such as vitamin C and growth-factor products are available, but little clinical evidence supports their efficacy.

In fact, with the exception of glycolic acid, little evidence supports the efficacy of any of them. Thus, a data-driven physician is left with few rational choices for topical treatment. The retinoids are high on this list.

Dr. Lupo: Before performing a cosmetic procedure in the office, we usually recommend some form of pretreatment. The patient should be following a skin-care protocol to enhance the benefits to be gained from the procedure.

If started early, such protocols may be preventative of photodamage as well. The 2 main practices that we emphasize for our patients are: daily use of sun protection and a topical retinoid. Although we also use cosmeceuticals, these agents don't provide the consistency of results seen with the retinoids. As a result, we usually use cosmeceuticals to complement a retinoid program.

It is important for patients to remember that improving the skin is an ongoing process. An occasional visit to the dermatologist's office simply isn't enough to make a patient's skin look better. Rather, the dermatologist acts similarly to a personal trainer, recommending routines that the patient should perform on his or her own on a daily basis.

Moderator: How do you use retinoids to complement the cosmetic procedures performed in your office?

Dr. Tanghetti: We use a retinoid as pretreatment for most of the procedures we perform. Some good clinical data on patients who have undergone CO2 laser treatments and then chemical peels show that a retinoid applied before the procedure prepares the skin. Pretreatment with a topical retinoid speeds healing time and increases epidermal turnover. As a result, healing improves. With laser resurfacing, a retinoid serves as both pretreatment and posttreatment. On its own, pulsed dye laser (PDL) has been shown to be effective for wrinkles. It helps resolve pigmentation problems and improves rhytids. For nonablative procedures, such as PDL, we use a retinoid throughout the process. Using topical retinoids in combination with PDL is producing some excellent results. The preliminary results indicate that retinoids complement the nonablative modalities, such as PDL and intense pulse light. The combination appears to produce a quicker response than the retinoid used alone. However, the retinoid used alone still achieves a good response.

Following microdermabrasion, we usually wait 1 or 2 days before starting the topical retinoid. This gives the skin time to normalize its absorption capability. However, the patient uses the retinoid right up until we perform the procedure. The retinoid enhances the treatment by speeding and improving wound healing.

For areas of the face-the upper lip, for example-where lines are deeper, we use a filler or a laser procedure, such as laser resurfacing. Botox® Cosmetic is especially good for deeper rhytids. If we're treating texture-that is, the fine crinkly skin that's in these areas-we use a topical retinoid.

Dr. Lupo: Both pretreatment and posttreatment regimens usually involve the retinoids. These vitamin A derivatives are well recognized among our patients; the FDA approval of Retin-A for photoaging was widely publicized. Sun damage-visible as speckling of the skin, fine lines, and elastosis-characterizes this condition. More recently, the FDA has approved a product called Avage®, which is tazarotene, for photoaging. Tazarotene originally received FDA approval in the 1990s for the treatment of psoriasis and acne. Used in pretreatment and posttreatment regimens, Avage® helps patients manage their own skin on a day-to-day basis. Their skin looks better, without constant visits to the dermatologist's office. Applying retinoids before chemical peels, intense pulsed light or CoolTouch® laser treatments, microdermabrasion, and other procedures helps prepare the skin. It also improves the treatment results. Avage® is based on sound clinical data; it is FDA approved for photoaging and provides good results.

Moderator: How do the retinoids rank in efficacy?

Dr. Tanghetti: Of the retinoids that are available, Avage® seems to be the strongest and most effective. A recent trial compared Renova® with Avage® in 186 patients with photodamaged skin.1 The study evaluated 50% or greater improvement, and Avage® came out on top, producing a quicker, more complete response. There was a suggestion that the response was better in all areas, but the trial was designed to answer only 1 question: "Does Avage® work quicker and more completely at 50% or greater improvement?" The answer is yes.

Dr. Lupo: In our practice, we've found that compared with Retin-A Micro® and Renova®, Avage® produces the best results. It improves photoaging and minimizes the appearance of the pores. Moreover, it softens overall skin texture and diminishes the cobblestoned appearance, or elastosis, of sun-damaged skin.

Moderator: Retinoids in general can cause irritation. How do you manage this irritation to get the best results?

Dr. Tanghetti: Retinoids do cause irritation. This is one of the issues we confront when using these drugs in clinical practice. Still, dermatologists seem to excel in managing sensitive patients using retinoids. We reeducate our patients on how to take care of their skin while using a topical retinoid. First we instruct patients to stop using soap cleansers. A new group of more suitable products is now available. Soap manufacturers, such as Procter & Gamble, understand that for patients using retinoids, nonsoap cleansers are the best way to cleanse and prevent irritation.

In addition, patients should wash with warm-not hot-water. Patients who take long hot showers or baths should apply the topical retinoid at the opposite time of day they bathe. For example, if a patient prefers to shower in the morning, he or she should apply the retinoid at night. And, patients with dry skin often see better results by washing with a nonsoap cleanser, drying the skin, applying an emollient, and then waiting 15 to 20 minutes before applying Avage®. This allows the moisturizer-which is often composed mostly of water-to be absorbed or vaporized. A bit of lipid remains, but this is not an impediment to the absorption of a drug such as Avage®, which is an ester. Patients should work the medication into the skin carefully and try not to apply any directly below the nostrils, at the sides of the mouth, or in the perinasal areas. Moisture accumulates in these areas, and they have a tendency to become irritated.

Because some patients with atopic dermatitis or severe xerosis are very sensitive to the retinoids, we may start them with a lower strength cream or a weaker topical agent. We also encourage patients to understand that the first 4 to 6 weeks of treatment with a topical retinoid-the period of retinization-is the most difficult. Some clinicians have their patients apply the topical retinoid every other day for this period. In addition, when we use a topical retinoid, we often use a cream because it is less irritating than a gel. If our patients are using Avage®, we generally have them use a 0.1% cream. If they are using Renova®, it is usually the 0.05% rather than the 0.02% strength. We start off using Avage® 2 times a week and then increase it to 3 to 4 times a week, or every other day. Patients can eventually increase to daily use after 4 to 6 weeks.

Dr. Lupo: In our practice, to avoid irritation with any product, we recommend a mask treatment, using the following protocol: First, the patient washes his or her face with an emollient cleanser, avoiding those that contain salicylic or glycolic acid or any abrasive particles. The patient then rinses the face with cool water, pats it dry, and applies a raisin-size amount of the retinoid product. After evenly applying the agent over the entire face, the patient rubs it in and leaves it on for 5 to 10 minutes. Then, the patient rinses off the product and applies a moisturizer. This mask treatment lasts from 1 to 3 months, with the length of the application gradually increasing from 5 to 10 to 15 minutes and so forth. Eventually, the patient can tolerate retinoid treatment through the entire night, applying moisturizer directly on top of it, without rinsing it off the face. Some dermatologists recommend initially applying a retinoid every second or third night and combining it with a moisturizer. Nonetheless, any skin-care routine calls for a gentle cleanser-one that will not be abrasive to the skin.

---

Reference: 1. Lowe NJ, Sewon K, Tanghetti E, et al. Tazarotene 0.1% cream versus tretinoin 0.05% emollient cream in the treatment of photodamaged facial skin: A multicenter, double-blind, randomized, parallel group study. Poster #111 to be presented at: 62nd Annual Meeting of the American Association of Dermatology; February 6­11, 2004; Washington, DC.

Avage is a registered trademark of Allergan, Inc.

Botox is a registered trademark of Allergan, Inc.

Renova and Retin-A Micro are registered trademarks of OrthoNeutrogena.

CoolTouch is a registered trademark of CoolTouch Corporation.

The views and opinions expressed in this supplement are those of the faculty and do not necessarily reflect the views of Dermatology Times, Cosmetic Surgery Times, Advanstar Communications, Inc, or Allergan, Inc.