Aesthetics June 2017

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VOLUME 4/ISSUE 7 - JUNE 2017

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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. RadiesseÂŽ - http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/PMAApprovals/ucm439066.htm.

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Special Feature: Lasers

Cosmeceuticals in Pregnancy

09:58 Writing 17/05/2017 Awards Entries

Practitioners discuss how to successfully rejuvenate the face using lasers

Dr Charlene De Haven details skincare ingredients pregnant patients should avoid

Julia Kendrick provides seven top tips on how to create a winning awards entry

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Contents • June 2017 06 News The latest product and industry news 14 Clinic Launches A look at the latest clinic openings across the UK

CLINICAL PRACTICE 18 News Special: Mainstream Media and Aesthetics Aesthetics investigates the media’s influence on patients 20 Special Feature: Lasers Practitioners discuss their use of lasers for skin rejuvenation

Special Feature Lasers Page 20

24 CPD: Oral Supplements Dr David Jack outlines how supplement ingredients can support ageing skin 28 Skin Hydration Nurse prescriber Lorna Bowes advises on hydrating the skin 33 Treating the Neck and Décolletage Dr Jane Leonard discusses treatment methods for the ageing neck 36 Aesthetics Awards 2017 Details of the Awards categories and entry process 39 Hyperpigmentation Disorders Dr Barbara Kubicka summarises treatments for hyperpigmentary disorders 45 Case Study: Combining PRP, HA and Succinic Acid Dr Daniel Sister describes the benefits of combining PRP with HA and

succinic acid, and presents a clinical case study

52 Cosmeceuticals in Pregnancy Dr Charlene De Haven outlines cosmeceutical ingredients to be aware

of when treating pregnant patients

54 Advertorial: Almirall A combination approach for unwanted female facial hair 55 Abstracts A round-up and summary of useful clinical papers

56 Writing a Winning Award Entry Aesthetic PR consultant Julia Kendrick shares her top tips to maximise your chances of securing this valuable business asset

59 Digital Marketing Mistakes Marketing consultant Adam Hampson provides tips for digital marketing skills 62 Advertorial: SkinCeuticals Presenting the Double Defence system 63 Creating an App for Your Business Digital technology professional Michael Rowland discusses app development 67 In Profile: Dr Firas Al-Niaimi Consultant dermatologist Dr Firas Al-Niaimi reflects on his career in aesthetics 68 The Last Word Aesthetic nurse prescriber Frances Turner Traill argues why every clinic

should have a Lone Working Policy

NEXT MONTH • IN FOCUS: Sun • Treating Gingival Hyperpigmentation • Microneedling • Hand Rejuvenation

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Clinical Contributors Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his nonsurgical aesthetic practice.

Lorna Bowes is an aesthetic nurse and trainer.

With extensive experience of delivering aesthetic procedures, she trains and lectures regularly on procedures and business management in aesthetics.

Dr Jane Leonard is a GP and cosmetic doctor. She specialises in skin conditions, antiageing medicine and bio-identical hormones. She has also spent time in dermatology research and has had her work published in Australia.

IN PRACTICE

In Practice Writing a Winning Award Entry Page 56

Dr Barbara Kubicka completed her medical qualifications with a two-year post-graduate course in Aesthetic Medicine at the College International de Medicine Esthetique in Paris. She founded her clinic clinicbe in 2012.

Dr Daniel Sister is a cosmetic, antiageing and hormone specialist. Since receiving his medical doctorate at the Paris Medical School, he has specialised in minimally invasive antiageing procedures.

Dr Charlene DeHaven is a board-certified doctor in both internal medicine and emergency medicine, with an emphasis on age management and health maintenance. She currently lectures at the University of Washington.

Entry to the Aesthetics Awards 2017 closes June 30! www.aestheticsawards.com

Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228

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Editor’s letter Everyone here at Aesthetics HQ is still on a massive high after we scooped the bronze trophy for ‘Best Awards Event by a Publisher’ for our prestigious Aesthetics Awards! The fantastic accolade was presented to us at the Amanda Cameron Awards Awards event, which recognises the Editor best of the best in awards programmes. A huge well done to the team, who work tirelessly to make sure the Aesthetics Awards is an unmissable evening, and of course, thank you to everyone who comes along and creates the wonderful atmosphere and buzz throughout the evening. Turn to p.12 to read more. Don’t forget, you still have until June 30 to enter – turn to p.36 for all the details and p.56 for some expert guidance on creating a winning entry from PR consultant and Aesthetics Awards judge, Julia Kendrick. She shares her top tips on choosing what categories to enter and how to make your submission stand out from the crowd!

I’m sure you all read or heard about a particular story in the press last month that caused quite a stir amongst aesthetic professionals – a beauty therapist claimed that her clients’ use of botulinum

toxin had negatively impacted their sex lives. Despite having no evidence to support the claims, the story quickly went viral, leading us to question the impact the media can have have on consumers and the treatments they choose to have. Turn to p.18 to find out what practitioners thought and how we can promote positive messages to the public.

For June’s Special Feature, we look at using lasers to rejuvenate the face from the perspectives of four different practitioners who are keen to share the best nuggets of their expertise with you on p.20.

Do you work alone? Have you thought about all the implications this could have on safe practice? Aesthetic nurse prescriber Frances Turner Traill shares advice on creating a lone-working policy on p.68, which will hopefully make you think about your processes and make positive changes where necessary.

As always, we’re keen to learn about the latest techniques you are using to enhance your treatment results for patients. If you’re interested in sharing your best practice advice and educating other practitioners in the specialty then drop us an email via editorial@aestheticsjournal.com or call one of our journalists on 0207 148 1292. We look forward to hearing from you!

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies. qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments.

Dr Tonks has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years.

Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook. for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

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Industry

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #SublativeRF Dr Dan Dhunna @DrDanDhunna Sometimes the Dr must become the patient. I can smell my skin burning but I only trust @dr_haus #sublativeRF Will look amazing soon!!

#Lecture Mr Olivier Branford @OlivierBranford Looking forward to giving a lecture on social media in Belfast next week at the annual meeting of @ABSGBI #ABSConf17 #breastsurgery

Allergan successfully acquires ZELTIQ Allergan’s $2.4 billion dollar deal to acquire medical and cooling technology company ZELTIQ Aesthetics has successfully been completed, according to an announcement by the global pharmaceutical company. In February 2017, Allergan revealed its plans to purchase ZELTIQ and its flagship CoolSculpting System, to broaden its product range to include body contouring. Now the deal has become official, with ZELTIQ stakeholders approving the transaction during its stakeholder meeting on April 27. “We are thrilled to complete the acquisition of ZELTIQ, which immediately expands our world-class global aesthetic business into the highlycomplementary and fast-growing body contouring segment,” said Bill Meury, chief commercial officer of Allergan.

He added, “CoolSculpting gives Allergan the most comprehensive and dynamic portfolio of products for plastic surgeons, dermatologists and other aesthetic providers across the globe.”

Technology

#Safety Dr Heather Furnas @drheatherfurnas Great lecture on #safety of dermal #fillers by Dr Arthur Swift #plasticsurgery #dermatology #ASAPS2017 @ASAPS

New HIFU device introduced by Skyncare

#Anniversary Miss Sherina Balaratnam @MissBalaratnam Celebrating our 2nd year anniversary in #Beaconsfield.

Thank you to our patients, supplier partners, colleagues and family for your support #Training Medikas @Medikas1 Great presentation by @DrStefanieW @neostrata symposium in London.

Congratulations to @LornaBowes.

#Launch Dr Rabia Malik @DrRabiaMalik Thank you to everyone that came and supported @thepeelboutique launch! So excited for this new venture #Masterclassess Mrs Sabrina Shah-Desai @perfecteyesltd Two more masterclasses & a final periorbital workshop in Kuwait with my local counterpart – amazing Dr. Ghanima. Now it’s off to Bahrain

A new high intensity focused ultrasound (HIFU) device for non-surgical facelifts and body contouring treatments has been released in the UK by aesthetic technology provider Skyncare.

The HIFU-Pro delivers HIFU energy that bypasses the epidermis to target the underlying structural tissues of the deep dermis and the superficial muscular aponeurotic system. This aims to stimulate a remodelling process, thickening the connective tissue layers and tightening the skin, while activating fibroblast cells that can produce collagen to lift and rejuvenate the skin’s appearance.

Rob Knowles, a biomedical engineer and one of the directors of Skyncare, said, “The HIFU-Pro offers the latest non-surgical facelift and body contouring treatments from one advanced, compact device. Its market leading 10-line treatment cartridges not only produces an unparalleled focal-point uniformity for superior results, but also reduces treatment times by up to 50%.” According to Knowles, after a treatment that takes less than an hour, the device can deliver immediate results that improve for up to six months and last between two to three years.

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Awards

Nominate finalists for the PHI Clinic Award for Professional Initiative of the Year

Aesthetics

Vital Statistics

In a survey of 200 people, 76% reported that dissatisfaction with their facial appearance had prevented them from having their photograph taken (Sinclair Pharma, 2017)

The most prestigious awards ceremony in medical aesthetics has introduced a new accolade for 2017 and Aesthetics want your say on who should win. This award, supported by state-of-the-art cosmetic practice PHI Clinic, will recognise the important role that both patient-focused and professional campaigns play in promoting consumer education and patient safety. Entries for the award are open to associations, companies and individuals who can demonstrate they have run a successful campaign that has had benefit to the specialty as a whole. The winner will be selected from the finalists using a combination of Aesthetics’ reader votes and judges’ scores, with voting constituting a 30% share of the final score. Editor of the Aesthetics journal Amanda Cameron said, “This year we have introduced the award for Professional Initiative as we wanted to recognise companies and people that really advance our aesthetic specialty, with exceptional expertise and creative thought. The winner will be shown to have initiated something special that advances the world of aesthetics in an ethical manner.” Readers are encouraged to nominate who they believe are worthy of the accolade, by going to: www.smartsurvey.co.uk/s/Industry_Initiative. Nominations will be open until June 20. You can also enter yourself for the award by going to www.aestheticsawards.com.

LED

FDA gives approval to Lightfusion LED The Lightfusion LED platform has been approved by the US Food and Drug Administration (FDA) as a Class 2 medical device for the treatment of periorbital wrinkles. The device harnesses light energy, delivering different wavelengths of light to alter biological activity aiming to promote collagen and elastin synthesis, improve blood flow and eliminate toxins. According to UK supplier Skinbrands, Lightfusion has been created with a modular design so that it can be positioned on the face without being claustrophobic. It can also be used to treat the neck, décolleté and hands. Amanda Coveney, managing director of Skinbrands said of the approval, “The FDA endorsement is a significant milestone and coincides with the launch of Lightfusion in the US with distributers Silhouette Tone LLC and Refine LLC. We are hugely excited about the opportunities represented by the US launch and are developing a portfolio of products to expand the Lightfusion line for the aesthetic and medispa market.”

Podcast listening grew 23% between 2015 and 2016 in the US (Edison Research, 2016)

In 2017, it is estimated that 9,730 deaths in the US will be attributed to melanoma (American Cancer Society, 2017)

59% of facial skincare users in China are prepared to do more exercise in order to improve their skin (Mintel, 2017)

The number of women aged between 19 and 34 having botulinum toxin treatments in the US has risen by 41% since 2011 (American Society for Aesthetic Plastic Surgery, 2017)

According to a 2015 study, data from subjects in Germany and China indicated a link between traffic-related air pollution and increased liver spots on the face (Journal of Investigative Dermatology, 2015)

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Events diary 15th - 17th June 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting, Helsinki www.bapras.org.uk

4th - 6th July 2017 British Association of Dermatologists 97th Annual Meeting, Liverpool www.bad.org.uk

15th - 16th September 2017 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

23rd September 2017 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

2nd December 2017 The Aesthetics Awards 2017, London www.aestheticsawards.com

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Lasers

BMLA launches new laser standards The British Medical Laser Association (BMLA) has introduced its ‘Essential Standards’ for the safe use of laser and light sources in non-surgical aesthetic applications at its annual conference in May. In 2010, laser and IPL treatments for cosmetic applications were deregulated in England, with only healthcare professionals who treat disease, disorder or injury required to register with the Care Quality Commission. According to the association, there is a need for new standards to improve patient safety due to the increasing number of laser and IPL clinics. The BMLA has since developed a set of standards for the use of non-surgical aesthetic application of laser and IPL, which covers the three key aspects: treatment delivery procedure, operator proficiency and the treatment environment/equipment.

Jon Exley, honorary secretary of the BMLA said, “Responsible providers will now have the BMLA Essential Standards as their reference to delivering safe treatments. These Standards are already being adopted by some local authorities and are helping inform the work currently being undertaken by the Joint Council for Cosmetic Practitioners (JCCP).” He continued, “Whilst there are many who would hope for regulation from the Government, in the current circumstances, the industry must work together to improve standards and the BMLA Essential Standards are a huge step forward in achieving this.”

27th - 28th April 2018 The Aesthetics Conference 2018, London www.aestheticsconference.com

Dermal filler

Monalisa launches in UK

UK distributor YouGlo has introduced a new hyaluronic acid dermal filler to the UK. According to the company, Monalisa is a pure, cross-linked HA soft tissue filler that aims to reduce the appearance of fine lines, deep wrinkles and noticeable volume loss. Monalisa comes in three forms, Soft, Mild and Hard, which vary in particle size and are suitable for different areas. The HA is manufactured in the US and the final product is made in South Korea. Director and co-founder of YouGlo, Dr Maryam Borumand, said, “MonaLisa is a great brand of filler to incorporate in the clinic as it is competitively priced yet leads to excellent results, which means patients are always satisfied and keep coming back. Also, the cross-linked nature of the product means it lasts as long as other hyaluronic acid fillers in the market. The other benefit is that there is no residual BDDE or impurities in the product, making it extremely safe to use.”

Skin cancer

Study claims causes of two rare melanomas are not linked to sun exposure According to a study published in Nature journal, researchers in Australia have discovered two rare forms of melanoma that are not caused by sun exposure, unlike the cutaneous melanoma linked to UV radiation.

The genetic study, led by researchers at the Melanoma Institute Australia, QIMR Berghofer Medical Research Institute and The University of Sydney, identified that acral and mucosal melanomas have a different cause, although it is still unknown what that is.

“This is by far the largest study to have looked at the whole genome in melanoma, and it has proven these less common melanomas are strikingly different in terms of their causes,” said professor Richard Scolyer, medical director of the Melanoma Institute Australia and a lead author of the study.

According to the Melanoma Institute Australia, researchers are now working on finding out more about the uniqueness of acral and mucosal melanomas.

Breast implants

Mentor receives FDA approval for MemoryGel Breast implant manufacturer Mentor has received FDA approval to market MemoryGel Xtra silicone gel-filled breast implants in the US. This implant aims to offer extra fullness and projection to women. Dr Louise Strock from the American Board of Plastic Surgery said, “I look forward to being able to provide women with this new style of implant to consider, as they evaluate the options associated with breast implant surgery.”

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Radiofrequency

SSA to distribute Indiba Deep Beauty The Indiba Deep Beauty radiofrequency device will now be distributed in the UK exclusively through Silver Street Associates (SSA). The device aims to rejuvenate and tighten the skin and treat facial lines and wrinkles, under-eye bags, double chins, ageing skin, loose-arm skin, as well as cellulite. According to SSA, the device can achieve this by raising the internal temperature of human tissues, increasing capillary circulation and oxygenating the tissues, and draining and eliminating impurities.

Sales director of SSA, Mark Allen, said, “We are very excited to be distributing Indiba in the UK and look forward to Indiba becoming as well known as it is in Spain.

Although Indiba is new to the UK, it has been tried and tested in Europe and Asia for almost 30 years and has had hundreds of clinical trials and scientific papers released about the wonderful effects it can generate.”

Allen added, “Indiba can be used to complement surgery and other aesthetic practices. Clinical references using our aesthetic and therapeutic radiofrequency, demonstrating the efficiency of the system around Indiba treatment protocols, are supported by more than 150 scientific publications in the fields of plastic surgery, aesthetic medicine, sports medicine, traumatology and physiotherapy.”

Pigmentation

MAG launches MeLine Intimate UK aesthetic product supplier Medical Aesthetic Group (MAG) has introduced MeLine Intimate, the new addition to the MeLine pigmentation range. The product has been developed for depigmenting the intimate area and to improve the overall skin quality.

It combines a professional treatment with a homecare treatment.

Among the active ingredients are retinoids, which aim to stimulate epidermal cell turnover and exfoliation in the stratum corneum and reduce melanin production; lactobionic acid to increase the thickness of the skin; phytic acid and tranexamic acid, aiming to treat hyperpigmentation and kojic acid, which aims to eliminate free radicals. Medical director of Innoaesthetics, Dr Victor García Guevara, said of the product, “Intimate pigmentation is a growing market, every time more and more patients are conscious about this pathology and with MELINE you can treat not only the intimate areas but all the pigmentations, having different treatments if the patient has a melasma problem in a phototype skin I-IV, phototype IV-VI or solar lentigines, and the company is providing different clinical studies.”

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Dr Askari Townshend, Founder & Medical Director of ASKINOLOGY What techniques are you currently using for facial skin rejuvenation?

At ASKINOLOGY, I have access to many different treatments and most fall into three groups: treating lines and wrinkles, colours and laxity. I rarely use just one modality – tackling the problem in different ways often gives better results. I’ve been using the new 3JUVE facial skin rejuvenation platform from Lynton Lasers more and more – it is convenient with three modalities on one platform to treat each of the groups already mentioned.

This also allows my staff and I to combine treatments without having to leave the room or fire up other systems.

So, how does the Lynton 3JUVE treatment work?

The 3JUVE combines three different skin rejuvenation technologies, a fractional 2940 nm laser for the treatment of fine lines and wrinkles, a 585 nm IPL for treating general skin discolouration, and radiofrequency which helps lift and tighten skin.

Switching from one modality to another is quick and easy to enable combination treatments without difficulty. This also means that we can create truly bespoke treatment plans for our patients.

Can you tell us a little more about the science behind the Lynton 3JUVE and how it gets results?

The first technology, fractional laser 2940 nm, creates tiny micro-spots of ablation in the epidermis alongside some thermal trauma, which together, induce a wound-healing response, resulting in the remodelling of collagen fibres. This stimulated collagen renewal helps to dramatically reduce static wrinkles and fine lines on a patient’s face. The second technology, 585 Lynton IPL, selectively targets melanin (pigment) and/or haemoglobin (vascular) causing a photothermal effect, eliminating unwanted pigmentation and reducing the appearance of discolouration. The third technology, radiofrequency, utilises electromagnetic radio waves to cause micro-vibrations within the tissue to induce advanced dermal heating, stimulating fibroblast cells to produce new collagen and elastin creating stronger, firmer dermal tissue. This is especially useful for treating a loss of firmness, particularly seen around the eye and jawline areas.

This column is written and supported by

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Ageing

Patients believe stress to be biggest contributor to ageing A survey of 1,000 women has suggested that the majority over the age of 30 who live in Surrey and the South East believe stress and anxiety has aged them more than other lifestyle factors. Out of the 1,000 women surveyed by Surrey-based clinic health + aesthetics, nearly 30% said stress and anxiety has had a detrimental impact on their looks since turning 30, which was followed by a lack of sleep at 21%.

Other lifestyle factors such as sun damage, smoking and alcohol intake rated lower on the poll at 13% combined, and 18% said having children has made a significant impact on how they’ve aged. Dr Rekha Tailor, medical director of health + aesthetics said of the results, “It’s concerning that women don’t recognise the impact that lifestyle choices can have on their skin, particularly exposure to the sun.”

Suncare

New products released by Murad The latest products launched by Murad aim to defend users from harsh city conditions such as pollution and UV. The City Skin Age Defence SPF 50 is a 100% mineral sunscreen that contains lutein, an antioxidant that aims to protect the skin from blue light emitted from electronic devices; polymer matrix, a ‘second skin’ that works to block the penetration of environmental toxins; iron oxides, which are said to provide protection against infrared radiation, and zinc oxide and titanium dioxide for protection against UVA and UVB rays. Also new to the collection is the City Skin Overnight Detox Moisturizer for detoxifying and neutralising pollutants that have accumulated during the day. The key ingredients in this formulation include marrubium plant stem cells, which are antioxidants that aim to strengthen the skin’s protective barrier during sleep; a botanical blend of sunflower, cucumber and barley, that are said to reverse pollution related dehydration and smooth lines and wrinkles; and vitamin C, which aims to help to correct pigmentation, brighten the skin and even its tone.

Dermatology

Study identifies potential cause of eczema A new study published in the Journal of Allergy and Clinical Immunology (JACI) has suggested that the cause of eczema is due to a protein deficiency.

Researchers indicated through a human model system in which the epidermis was modified using molecular techniques to become filaggrin-deficient, that a lack of this protein can cause development of the itchy inflammatory skin condition through affecting other proteins and pathways in the skin.

Lead investigator and professor of dermatology at Newcastle University, Nick Reynolds said, “We have shown for the first time that loss of the filaggrin protein alone is sufficient to alter key proteins and pathways involved in triggering eczema.”

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BACN UPDATES CADAVER TRAINING The BACN has entered into a partnership with the London Medical Education Academy to offer discounted Facial Anatomy Cadaver training for its members, with interactive sessions on dissection and injection. BACN members can book onto these courses through the website, and we are piloting two dates in Nottingham on June 22 and July 31. Spaces are filling quickly, and are exclusive to BACN members.

SHADOWING PROGRAMME The BACN has also started offering our new Shadowing Programme for members wishing to observe treatments by experienced practitioners within the mentor’s clinic setting. We now have more than 20 BACN mentors around the country that are able to offer this service. BACN members can contact head office at sgreenan@bacn.org.uk if they are interested in finding out more.

BACN CONFERENCE 2017 Our conference is open for booking! We have also announced our first speakers for the main conference on September 16 in Birmingham at the ICC. We are proud to announce that Dr Tapan Patel, Dr Kate Goldie, and independent nurse prescriber Melanie Recchia will be presenting during the day. There will be more speakers announced in the coming weeks, and booking for our Workshops and Drinks Reception on Friday 15 September will be open imminently. With 75% of the exhibition space already occupied, remaining exhibitor space is now limited. To book, contact conference@bacn.org.uk

BACN SUMMER MEETINGS Glasgow: June 5 Leeds: June 12 – special morning session with Sinclair Pharma, open to all nurses.

There are a number of BACN local meetings taking place throughout the year – get in touch with your regional leader to find out more.

MEET A MEMBER Adele Dean is an independent nurse prescriber and has been a nurse for more than 30 years. Adele is committed to patient safety with a focus on holistic individual patient needs and quality treatments. She has worked in aesthetics for the last two years, and is currently the BACN Regional Leader for central England. Adele is continually learning, and values the BACN for its emphasis on patient safety and vast support to members.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Awards

The Aesthetics Awards receives prestigious accolade The most distinguished and reputable awards event in medical aesthetics has been recognised for its success, innovation, expertise and professionalism, by the prestigious Awards Awards. The Aesthetics Awards achieved a bronze trophy on May 12 for the category Best Awards Event by a Publisher (under 700 attendees) at the event, which recognises the hard work and dedication awards ceremonies make to their industries and specialities. In order to receive bronze, the Aesthetics Awards were able to demonstrate: a strong judging panel and a rigorous judging process, positive feedback from attendees and sponsors, novelty and innovation at the ceremony itself and success in terms of continuity of growth. The Awards Awards, run by the Global Conference Network, acts as the arbiter of individual award programmes, and rewards excellence and exceptional quality.

Brand director of Aesthetics, Suzy Allinson said, “We are thrilled to have won the bronze trophy for Best Awards Event by a Publisher. This is the first time we have entered our Awards into anything like this, so to be recognised straight away speaks volumes about the fantastic event we run and the effort the whole team put into it.” She continued, “This award shows just what a credible event the Aesthetics Awards is.”

Industry

New partnership announced UK distributor Healthxchange Pharmacy and the British Association of Cosmetic Nurses (BACN) has announced a partnership to promote clinical excellence and patient safety through training. As part of the new collaboration, Healthxchange Pharmacy will join the BACN at its annual conference in Birmingham on September 16, as well as two regional gatherings in Edinburgh and Bristol later in the year.

Healthxchange Pharmacy’s marketing director, Steve Joyce said he is thrilled about establishing this new working relationship, “Healthxchange are excited for what the partnership will offer over the coming year and are looking forward to working with the BACN to help provide further professional development, promote safe clinical practice and exciting networking opportunities for its members.”

On the Scene

‘The French Touch’, London The first Filorga UK event took place on April 20 at The King’s Fund in Cavendish Square, London. Introduced

by Rebecca Denham, national business development manager for the UK, Dr Uliana Gout began the evening with an in-depth presentation and live demonstrations with three Filorga epidermal peels. Next, Dr Javier Beut from Spain presented on anatomy and physiology and Dr Philippe Hamida-Pisal demonstrated the Art Filler in combination with NCTF 135HA for biostimulation, in both the cheeks and hands. Dr Hamida-Pisal said of the event, “The conference and workshop organised by Filorga was an amazing opportunity to interact with highly qualified delegates and some of the most knowledgeable professionals from the aesthetic field.”

Aesthetics aestheticsjournal.com

News in Brief Vida Aesthetics launches online skincare store A new online store has been developed by UK distributor Vida Aesthetics. Vida Essential is a digital shop that offers products such as creams, skin-tightening serums and makeup.

Eddy Emilio, director of Vida Aesthetics, said, “Our brands are carefully chosen to ensure customers get the best results possible. We are continuously seeking new products and brands in skincare, makeup and other cosmetics, so our members can be sure of new lines to try way before they hit the high street.”

Dr Lori Nigro to conduct free workshop this month Aesthetic practitioner Dr Lori Nigro will lead a free pigmentation, preparation and peeling workshop on behalf of aesthetic company mesoestetic in London on June 13. Managing director of mesoestetic’s UK distributor, Wellness Trading, Adam Birtwistle said, “The free workshop is a great opportunity for practitioners to learn more about treating pigmentation from Dr Nigro who works with cases on a daily basis and has seven years of industry experience.”

Acquisition Aesthetics announces collaboration with Intraline Medical aesthetic company Intraline has joined forces with training provider Acquisition Aesthetics to provide its delegates with comprehensive starter packs that contain sample products to use, extensive literature samples and consent forms. Co-founder of Acquisition Aesthetics Dr Lara Watson said, “It’s an exciting time for us to introduce Intraline to our delegates and they have really enjoyed using the products. The packaging of Intraline dermal fillers is vibrant and modern and we find that the results achieved with them are great.”

Allergan reports 5% increase in Q1 net revenues Allergan has reported a total net revenue of $3.6 billion in its continuing operations performance for the first quarter of 2017.

According to a news release from Allergan, the increase of 5%, with the prior year quarter, was driven by higher revenues in sectors including facial aesthetics, Botox Therapeutic, eye-care and regenerative medicine products. Brent Saunders, Allergan chairman and CEO said, “Many of our key brands continued to deliver significant year-over-year growth, led by Botox, our Juvéderm collection of fillers, and our regenerative medicine business, Linzess and Lo Loestrin.”

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Aesthetic Clinic Launches A look at the latest clinic openings across the UK

RejuvaMed Skin Clinic, Lancashire

Cliniva Medispa, Barnsley

Dr Grant McKeating has launched a second clinic, located in the Ribble Valley town of Clitheroe. The new RejuvaMed Skin Clinic in Holmes Mill will be offering services including injectables, PDO threads, vein removal, body contouring, facials and chemical peels. Included in the product offering is the Plasma IQ, Thermavein, 3D-lipo, HydraFacial, and the ZO Skin Health range. The clinic will also house the new RejuvaMed Vein Centre and these procedures will be conducted by local vascular surgeon Mr Rob Salaman. Dr McKeating said, “The new RejuvaMed Vein Centre offers a full range of treatments for vein problems, from radiofrequency ablation of varicose veins, through to microsclerotherapy and Thermavein. This inclusion adds an extra dimension to the clinic.” He added, “The Ribble Valley needed an aesthetics clinic offering our full range of services – there is no comparable clinic in the immediate location. We have an amazing location integrated with the Holmes Mill hotel and leisure complex redevelopment. We will form part of the heart of the town.”

EF MEDISPA, West Midlands A new franchise by multi-award-winning aesthetic group EF MEDISPA will open at the Calthorpe Estate in Edgbaston near Birmingham’s city centre in September. The new clinic will be the first EF MEDISPA in the West Midlands and will combine aesthetic treatments and the region’s first Drip and Chill intravenous nutrition vitamin infusion lounge. EF MEDISPA founder Esther Fieldgrass, said of the new franchise, “We are delighted to be launching EF MEDISPA in the prestigious Edgbaston area and with seasoned entrepreneurs Dal and Harchie Basra at the helm, I am sure it will be a great success.”

Cliniva Medispa in Barnsley opened its doors to patients, friends and aesthetic colleagues on May 2 to celebrate its grand opening. Founded by aesthetic nurse prescriber and trainer Jacqueline Naeini, Cliniva Medispa comprises six treatment rooms and a training centre that can accommodate 14 delegates for the Cliniva Cosmetic Training courses.

Naeini said, “After nine years of working in two different locations, one for my clinic and one for my training, I’m now delighted to have everything in one place in my own building. It’s taken us nine months of renovations and I couldn’t be prouder and happier with the results.”

From its new base, the medispa will offer aesthetic treatments, facial and skin consultations, permanent cosmetic makeup, one-to-one and group makeup application classes, and massages. In addition, Naeini will hold regular aesthetic training classes in a separate clinic room, and the area is also available for rent to other trainers. Speaking of the event, she said, “Our open evening was very successful with around 300 people through the door, which was very exciting. Myself and the team are looking forward to treating lovely clients and training lovely delegates here!”

EpIlium and Skin, London Paris-based ophthalmological plastic surgeon Dr Bernard Hayot has launched EpIlium and Skin medical and beauty clinic on George Street in London. Epilium and Skin clinics have been present in France for 15 years under the direction of Dr Hayot, who is an international trainer and was reported to be among the first in France to use botulinum toxin for wrinkles. Joining Dr Hayot at the London clinic will be a team set to deliver treatment not only in aesthetic medicine but also surgical procedures, from breast reduction and augmentation to hair transplants.

Dr Hayot said, “Facial surgery has greatly evolved over the last

15 years. We are more aware of the causes of ageing, so we can treat the consequences more optimally. For each and every one of my patients, I promise to obtain a natural, harmonious result that respects their personality. I am very much looking forward to introducing my approach to a new client base here in London.”

If you want to see your clinic featured online or in an upcoming issue of the journal email editorial@aestheticsjournal.com

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Clinic launch

3D-lipo Flagship Clinic, Leamington Spa

Elite Aesthetics, Kent

Aesthetic device manufacturer 3D-lipo welcomed guests to the official launch of the 3D-lipo flagship clinic in Leamington Spa, Warwickshire, on May 5. The drop-in event, which ran from 11am until 5pm, gave attendees the chance to explore the new practice – which is the first clinic solely dedicated to 3D-lipo treatments – and learn more about the treatment offering, as well as enjoy a glass of prosecco with fellow guests.

To celebrate the launch, live treatment demonstrations took place, as well as free consultations and full body assessments using a body mapping device. The clinic offers a consultation room and three treatment rooms, where patients can receive a range of body sculpting treatments, as well as prescriptive facials. Managing director of 3D-lipo Roy Cowley said, “I am so proud to be launching our first flagship clinic in the very heart of Leamington Spa, where I first started out in business many years ago. 3D-lipo has truly taken the industry by storm due to its amazing results and celebrity following and I couldn’t be more thrilled to be bringing our revolutionary treatments to my original hometown of Leamington Spa, directly from our leading brand, 3D-lipo.”

Guests enjoyed welcome canapés and champagne at the Elite Aesthetics clinic launch in Greenhithe, Kent on March 29. Fashion influencer, presenter and celebrity stylist Naomi Isted hosted the event and welcomed patients, industry guests, friends and family of clinic staff to the opening. During the event, sponsors of the launch, Skinade, Swisscode, TruPRP and Inmode, were thanked, and the clinic charity, the Ellenor Foundation, was announced. The ribbon was cut by the Mayor John Burrell and Mayoress Eija Burrell of Dartford. Dr Shirin Lakhani, clinic owner and medical director, said of the event, “We were delighted by the support we have received from friends, colleagues and patients on the launch of the new clinic. The evening was a tremendous success and we look forward to continuing to provide our patients with the best possible care and service in our stunning new premises.”

NeoStrata European Symposium, London Aesthetics reports on the first NeoStrata European Symposium Delegates from as far as South Africa and South America met at the Royal College of Physicians on May 19-20 for the first NeoStrata European Symposium, organised by the UK distributor, AestheticSource. The two days consisted of talks and demonstrations from international speakers Professor Mukta Sachdev from India and Professor Beth Briden from the US, as well as UK practitioners Anna Baker, Dr Stefanie Williams, Dr Uliana Gout, Dr Sandeep Cliff and Dr Martin Wade. NeoStrata Company’s director of product development and strategic product innovation Peter Konish also spoke at the event; discussing the complexities

of the ingredients and unique formulations used to create the products. Delegeates learnt how to best manage acne, rosacea and pigmentation, as well as receiving valuable advice on successful peeling, combination treatments and choosing appropriate skincare for each patient. In addition, they had an exclusive preview of two new NeoStrata professional products; the Retinol Peel and the ProSystem Bionic Oxygen Treatment. Professor Briden presented the supporting clinical study for the Retinol Peel, whilst Dr Williams shared before and after photographs from her recent case studies and Baker performed a live demonstration of the peel in use.

Delegates also had an insight into key skincare trends amongst consumers from the symposium’s chairs Nadine Baggott and Wendy Lewis. The award-winning journalists both shared their top tips for marketing and selling skincare to patients.

Director of AestheticSource Lorna Bowes said, “As well as educating we do hope we also inspired delegates, helping them to work confidently with NeoStrata products and protocols to offer their patients clinically-proven skincare that generates unsurpassed results.

We hope they left confident that they have the tools to offer their patients the best care, comfortable with the fact that the products and regimes work – as the studies prove!”

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Galderma GAA 2017: Creating a Masterpiece, London Aesthetics takes a look at the 14th Galderma Aesthetic Academy meeting Aesthetic practitioners gathered at the 14th Galderma Aesthetic Academy (GAA) on April 28 at the Royal College of General Practitioners (RCGP) in London. Due to its growing popularity, the annual conference was split for the first time into two events; one in London and one in Leeds.

During the London event, delegates learnt more about the Galderma portfolio; the pharmaceutical company this year wanted to focus this event around patient satisfaction. The aim was to inspire the delegates to ‘create a masterpiece’ by selecting the right products and the right positioning of the products to enhance, restore and refresh patients.

The agenda began with a 9am registration, followed by a welcoming talk at 9:45am by the head of aesthetic business, Toby Cooper, who introduced the chairs; Dr Beatriz Molina and Dr Christian Jessen.

Dr Molina and Dr Jessen then welcomed the panel of experts, Mrs Sabrina Shah-Desai, Jackie Partridge and Dr Christoph Maraschino.

Throughout the day there was a mix of topics discussed and live injectable demonstrations took place. Dr Christopher Martchin, who is a senior consultant dermatologist at Akademikliniken in Stockholm, perfomed an engaging presentation showing the injections of the

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lower face using cannula in the Achieving ideal Contouring talk. Dr Molina said of the event, “The audience were very interactive this year with lots of challenging questions for Dr Jessen and I. For us, it was important to stress that safety is always a priority. We both believe that knowledge of anatomy and knowledge of the products is a must, and of course we must not forget that we are treating our patients to help them feel better. For this reason we must customise our patients, treatments; each face is different and requires a different approach.”

She concluded, “We hope that the audience enjoyed the day.”

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There is a good reason to be concerned that patients will believe negative press; a trial in 1993 by psychologist Daniel Gilbert tested the theory of whether belief is automatic when we are first exposed to an idea or whether belief is a separate process that follows. In the study, 71 participants read statements about robberies, and then suggested a jail sentence based upon the information they had just read. Some of the lines in the statements they read were true, and the others – ones that made the crimes sound much worse – were false. Participants were told that false statements would appear in red and true statements would appear in green. While reading the material, some of the participants were also purposely distracted.

Gilbert found that participants who were distracted and didn't have time to process what they read gave the robbers worse jail sentences; they hadn't had time to analyse the green versus red statements and instead took the statement as a whole to make their decision.

Participants who were not interrupted gave the robbers more realistic sentences and suggested the robbers Aesthetics investigates the effect of negative receive less jail time, indicating that those who take time to fully understand what they read have a clearer industry press on patients and whether it judgement.2 British psychologist Dr Jeremy Dean said influences their treatment choices of the study, "Believing is not a two-stage process involving first understanding, then believing. Instead, In May 2017, beauty therapist Deborah Mitchell made a claim understanding is believing, a fraction of a second after reading it, you in an article published by the Daily Mail that suggested believe it until some other critical faculty kicks in to change your mind."3 patients who had been having botulinum toxin treatments were In other words, people are likely to believe what they read instantly, damaging their sex lives. Mitchell, who has practised beauty unless they take time to consider it further. therapy for more than 25 years, said, “The thing these ladies were doing to delay the ageing process and make themselves more attractive seemed to be having the opposite effect. Instead of enhancing their sexual life, their heavy Botox [sic] use seemed to be sabotaging it.” Mitchell claimed this was due to toxin creating ‘frozen faces’ that were unable to communicate and show true thoughts and feelings towards their partners.1 Practitioners interviewed for this feature believe there are no clinical studies to support these claims. Consultant dermatologist Dr Stefanie Williams says, “The main thing to say is that there is no clinical evidence and it is just guess work. I certainly have not seen any anecdotal evidence in patients that I treat; and don’t know of Jenny O’Neill any controlled studies confirming this. It’s also hard to image how that might work as a mechanism of action.”.”

Aesthetic practitioner Dr Preema Vig adds, “This article alludes to ‘heavy Botox’ users with frozen mask-like faces that have rendered Is negative press an issue? them incapable of smiling and communicating their feelings. There Patients may be left feeling nervous after what they have read in the are many variables that would need to be researched before being press, Dr Williams says, “Scare mongering articles may make patients able to scientifically identify ‘Botox’ [sic] as affecting ‘sex lives’.” anxious, as many patients can't distinguish between scare mongering The consumer media, over the years, has printed numerous without supporting scientific evidence, and evidence-based reports.” negative stories on aesthetic treatments and their outcomes, Consultant physician at University College London Hospitals leading one to ask: what effect does this have on our patients?

(UCLH) and medical director of Adonia Medical Clinic, Dr Ifeoma Ejikeme, adds, “I think these kinds of stories can be damaging Do we believe what we read? to patients’ perceptions of cosmetic treatments as they aren’t an Dr Williams says, “I do worry that articles like this could make patients accurate representation of the majority of patients seeking aesthetic anxious about the side effects of botulinum toxin and could be putting treatments.” Dr Vig also points out that, “There is a lot of media the wrong idea in their head, even though there are no studies to misconception – the article in question speaks about the treatment support it.” She adds, “With an article on a huge platform like that, of patients to the point where they are unable to move their facial there is always a danger people will believe it.” muscles, which is not the norm for leading practitioners – this is

Consumer Media and the Aesthetics Specialty

“We should be sharing much more informative articles about procedures on our websites and through social media”

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

Insider News

further compounded by social media platforms that showcase ‘enhanced’ visual representation.” There is a worry amongst some practitioners that patients may read something that gives them unrealistic expectations of what can be achieved, or will be tempted to seek a treatment they don’t need. Dr Ejikeme says, “There is a concern that patients may seek treatments for the wrong reasons after what they have seen in the press. Studies do suggest that for cosmetic treatments there is a higher incidence of body dysmorphia,4 so patients and their practitioners need to have careful conversations to ensure they are seeking surgical and non-surgical treatments for the right reasons.” However, aesthetic nurse prescriber Jenny O’Neill believes that coverage of the aesthetics specialty is good, regardless of whether it’s positive or negative, “I think what the patient hears, reads and sees, can influence them both positively and negatively. Either way, it creates awareness, and highlights that the treatment exists, as many patients have no idea to what is even possible, so it gives us an opportunity to educate.”

Does the press influence patient decisions?

There are some negative stories that seem to linger in the press, and one of those stories is of Leslie Ash. The actress famously suffered an allergic reaction to a silicone filler in 2002 and was ridiculed for her ‘over-done’ lips, which turned out to be a permanent procedure.5 Although it happened 15 years ago, it is at the forefront of many patient’s minds, according to O’Neill, “Still to this day, nine out of ten patients who are thinking about having a lip treatment will say to me, ‘I don’t want to look like Leslie Ash!’ It’s such a good example of how negative press can still influence people.” O’Neill continues, “But this gives us the chance to educate patients about what dermal fillers are, and what they are like these days; we’ve advanced a lot in the past 15 years. I explain that we use hyaluronic acid-based dermal fillers, which are not permanent like the one Leslie Ash had.”

Summary Stories about the aesthetics industry are unlikely to go away, especially those that often reflect negatively on the specialty. But is there anything practitioners can be doing to counteract negative news? O’Neill says, “We should be sharing much more informative articles about procedures on our websites and through social media, with good before and after photographs, a reassuring view of what is possible and what the normal expectations would be. We need to produce interesting articles – people who walk through the clinic door have no idea what is possible until you sit and talk about it with them, because that sort of information is not always published.”

Dr Williams concludes, “They only thing we can and must do is to continue to educate patients with the true facts about the treatments we offer.”

REFERENCES 1. Deborah Mitchell, Why Botox kills your sex life – by a beauty therapist whose clients have been sharing their marital woes with her for over 25 years, Mail Online (2017) <http://www. dailymail.co.uk/femail/article-4470692/Why-botox-kills-sex-life-beauty-therapist.html> 2. Alyson Shontell, Why You Believe Everything You Read, Business Insider (2011)<http://www. businessinsider.com/why-you-believe-everything-you-read-2011-1?IR=T> 3. Jeremy Dean, Why You Can’t Help Believing Everything You Read, (2017) <http://www.spring. org.uk/2009/09/why-you-cant-help-believing-everything-you-read.php> 4. David B Sarwer, Canice E Crerand, Body dysmorphic disorder and appearance enhancing medical treatments, ScienceDirect, (2007) <http://fulltext.study/download/903290.pdf> 5. Claire Oliver, Lip Service – What happened to Leslie Ash? Air Aesthetics (2012) <http://www. airaesthetics.co.uk/2012/01/16/lip-service-what-happened-to-leslie-ash/>

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Lasers for Rejuvenation Practitioners share their advice for successful facial rejuvenation using ablative and non-ablative lasers The panel: Dr Maria Gonzalez (MG) is a consultant dermatologist and the director of the Specialist Skin Clinic in Cardiff. She has more than 20 years’ experience in clinical and academic dermatology.

Dr Anita Sturnham (AS) is a GP and the founder of the Nuriss Skincare and Wellness Centre. She offers a range of laser treatments in her clinics based in London.

Dr Miguel Montero (MM) is the medical director and principal practitioner at Discover Laser in Burley. He is a member of the European Laser Association and the British Medical Laser Association.

Dr Nina Sheffield (NS) is the medical director of RTW Skin in Kent. She has been using lasers in her clinic for the past 12 years.

Why do you advocate the use of lasers in your clinic?

MG: In order to achieve thorough facial rejuvenation, you need to get adequate stimulation of collagen and, to do that, you need to wound the skin. I think lasers, in particular non-ablative lasers, are able to do this well and the downtime is not significant. Using lasers is my favourite way of rejuvenating skin because the majority of my patients will get a good result.

AS: Ablative lasers have been shown to be effective in counteracting photoageing through entire epidermal ablation, stimulation of neocollagenesis, and dermal remodelling. The controlled thermal injury to the epidermis and the dermis triggers a wound-healing response. The end result, reepithelisation and dermal remodelling, leads to smoother, more youthful looking skin.

What facial concerns can you rejuvenate with lasers?

AS: We use lasers to treat acne, rosacea, birthmarks, melasma, photoageing, irregular pigmentation, ectatic vessels and erythema, pilosebaceous inflammation, loss of volume and elasticity.

MG: In my clinic, people fall into three broad categories – those who have predominantly pigmentary problems such as solar lentigines; those who have predominantly facial redness issues, such as telangiectasia or weathering of the cheek area, and then those whose concern is predominantly related to wrinkles. You may find someone with terribly wrinkled skin and not one pigmented lesion, but then, of course, you can have any of the three mixed up.

All patients tend to have some textural problems, slightly rougher skin, and pores that are more open.

MM: Aesthetic concerns often depend on a patient’s age group and sex. Men are generally the easier ones to treat as they’re not really that worried about having too many lines and wrinkles. Big concerns in my male patients, however, are broken veins, sun damage and rosacea. For women, they are more concerned with lines and wrinkles, however, very often, they are also concerned with the pigmentation associated with sun damage, redness and broken veins. In particular, I see female patients after or around the time of their menopause as that’s when major skin changes generally occur.1 How do you consult a patient prior to a laser treatment?

AS: Prior to performing any laser treatment, we take a full medical and dermatological history, we scan and examine the skin and work hard to understand our patient’s agenda.

MG: In my group of patients, who are generally 45+ and less experienced with aesthetic treatments, they want your opinion during the consultation and do not come in demanding particular treatments – I think that’s more common amongst younger patients.

My patients are open to suggestions of what will make their skin look better. Patients will want to know what results they can expect, as laser treatments are expensive, so the first thing I do is show examples of my own patients who have got reasonable results.

They’re not stock photos from a company where you never know where they came from; I get permission from my own patients to use their before and afters. Then we go through a very long information leaflet on all the possible issues around lasers – typical ones include pain, redness, and the fact that pigmentation will darken immediately after treatment. I also always mention the potential for scarring in all laser consultations, even though I’ve never seen scarring with any of my patients. You have to inform patients of the worst possibilities.

“I always mention the potential for scarring in all laser consultations, even though I’ve never seen scarring with any of my patients” Dr Maria Gonzalez

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Aesthetics Journal

MM: We have a discussion of what their problem is and what I think is going to help them make it better. We also plan for possible downtime. Patients can’t have treatment if they have an important event coming up as they will need to be prepared for swelling and redness for at least 24 hours. You also have to discuss their day-to-day lifestyle – people have very active lives nowadays so they can’t have a laser treatment and go for a 10K run on a sunny day – that would be an absolute nightmare. You also have to consider things like sports, saunas and swimming – patients may need to adjust their life a little bit when they go to have treatment.

MG: If people are going to bruise they need to know about it in the consultation because bruising cannot be covered up easily; even by the best makeup. For me I think this is the worst side effect for women, even though it’s not harmful – you need to tell them what to expect in case they want to take time off work or change plans.

NS: I never tell patients that they will have one procedure and achieve all of their expectations – the response of the skin can be very difficult to judge. If somebody in their late 60s comes to me and has never had anything done before, I can’t make them look 20 years younger. You need to repair skin slowly to make it work again.

How do you decide which laser to use?

AS: When considering our treatment options, we assess a number of factors, such as whether we need to be targeting the epidermis or superficial dermis. We consider our patient’s skin type, sensitivity, skin concerns, medical history and lifestyle history before commencing laser treatments. We also consider our endpoint when selecting the laser. For example, we may want to stimulate collagen, reduce pores and outbreaks, and break down uneven pigmentation. The laser is carefully selected considering all of these factors. There are many laser devices on the market. For example, vascular pigmentation and other pigment irregularities can be treated by lasers emitting light at 532, 585, 595, 755, 800, and 1064 nm wavelengths. Lasers emitting 1,320-1,540 nm use intracellular and interstitial water as target chromophores. Pulsed dye lasers can work well to treat photoageing. I enjoy the multi-functional modalities of the Harmony XL pro, manufactured by Alma lasers. I find this platform allows me to deliver such a broad spectrum of treatments including both ablative and non-ablative treatments.

MM: We should also consider how deep the skin concerns are to decide how to effectively target them. For general rejuvenation in patients who want tighter, fresher skin, I tend to combine IPL with fractional laser for best results. I don’t think there’s a single tool that will tackle all the concerns in one go. Very often when we have pigmentation it affects different levels of the skin, so there isn’t a single wavelength that is going to tackle those concerns.

There are also different degrees of redness and wrinkling. Unless you are able to tackle different layers you are not going to be able to deliver a good result. I am currently using the fractional non-ablative ResurFX by Lumenis as it allows me not only the flexibility to select the energy, shape and density of every shot, but the non-sequential scanning keeps the skin protected, allowing the minimal downtime that our patients demand

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nowadays, while still delivering good results. I find the results I am getting are very similar to those shown in published papers – so in my opinion the claims the company makes are based on very good science.

MG: My personal preference is to use the targeted treatments for pigmentation – I think you get excellent results with non-ablative devices with shorter downtime. For more weathered skin types, you have to address the telangiectasia as that is usually their main problem. My first choice for this would be a pulsed dye laser, however IPL is also useful – obviously it’s not a laser, but it can be used for pigmentation as well. Wrinkling is a difficult one and much harder to treat with lasers. In my opinion, you have to use an ablative laser or you won’t get very far.

What does treatment involve?

NS: Before treatment we find out if patients are prone to cold sores or viral infections and prescribe anti-viral medication for five days prior to treatment as it may risk further infection if treated with a laser. Then on the day of treatment they come one hour earlier than the appointment, so we can apply numbing cream and take pictures from different angles before the procedure begins. You could apply a nerve block but, to be honest, after doing this procedure for many years, I find that numbing cream works as well as any nerve blocker.

In my clinic, the Madonna eye lift for periorbital resurfacing is popular. Lower parameters on the DEKA laser can be used to achieve good results following three treatments. Around the eyes, the procedure takes about half hour, while full face rejuvenation takes about 45 minutes. Treating the periorbital area can be a little bit fiddly – practitioners need to be more careful and precise. The procedure is not pleasant but it’s not painful; patients will feel a little pin-prick sensation. Immediately after, they will feel a sunburn sensation and tightness around the eyes so we should warn them to expect this, as it will last about 90 minutes to two hours.

What pre-procedure preparation do you recommend?

AS: Skin will typically be prepared with four to six weeks of cosmeceutical grade skincare, prior to having laser treatment, to ensure optimum safety and results. We advise our patients to have a consistent skincare regimen and encourage them to use products that start to target their areas of concern. For example, if we are treating hyperpigmentation, we would encourage bi-daily use of a serum rich in pigment stabilisers, such as alpha arbutin or L-ascorbic acid. A good quality SPF product – minimum SPF 30 – is essential for daily use and adding in a night product, ideally with retinol will be beneficial. We advise avoiding sun exposure prior to any laser treatment and throughout their treatment course, and certainly look to stop sensitising skin products in the days leading up to the laser treatment.

MM: Vitamin A can sensitise skin to lasers so I recommend patients stop using it a couple of days before a laser treatment.

MG: Usually I don’t mind what people are using up until the day. I don’t stop people using retinoid cream because they are likely to have been using it for a while so, in my opinion, when they show up to me it doesn’t really matter. My main advice is if they were never using sun protection, then they should start using it. We will have to delay treatment if they have a tan.

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Choosing a laser can be difficult. What should practitioners look out for in clinical studies and are there any other key considerations they should make?

AS: Clinical studies provide useful data and enable clinicians to practise evidence-based medicine. In order to assess the relevance of a study to your patient demographic, you should identify the study population used. Are the patients in the study similar to your own patients in terms of demographic, skin type and skin concerns? Assess factors such as the method in which patients were recruited, dropout rate and look at the study design. Identifying possible sources of bias is also essential to establishing the validity of a study. It is useful to assess the outcome measures and whether these were statistically significant.

MG: It’s important to make sure that the paper you’re reading isn’t just sponsored by the company itself. Also consider the number of studies – sometimes studies are not reproducible so you can’t rely on one study. A year on after you bought the system there could be two or three studies pop up that don’t match the original results. If you can get data from more than one unbiased study that would be helpful.

MM: I’m looking for two types of results – clinical papers based on good science on how results are achieved, but also papers based on real experiences in a case series; practitioners who have been treating patients for eight months to a year and then reviewed and compared all of this data, are useful.

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conditions, severity of concerns and the age of the patient. In my experience, though, about 80-90% of patients are satisfied with results. I believe this is based on managing their expectations in the consultation. I tell them that this is never going to have the same effect as plastic surgery; we’re also never going to cure any disease. Having a frank, honest conversation about what is achievable with a laser is important. If you undersell and over deliver then you’re onto a winner – patients will generally be very satisfied with results.

What about aftercare?

AS: Sun avoidance and a good quality SPF are essential. We encourage continuing the cosmeceutical skincare programme throughout the laser programme. Depending on the type of laser used, some products such as alpha hydroxy acids, beta hydroxy acids and retinol may be stopped for a few days post-laser treatment and replaced with very gentle emollient-based products instead.

MG: I usually ask patients not to use any of the things they use normally for three days after non-ablative treatments such as glycolic or salycylic acid. I recommend using only bland emollients; honestly, they can just use E45 cream. For ablative treatments, they can’t use anything until the skin has actually healed, which can be about a week later. I’ve never found patients were missing out on using a more expensive ‘post-laser’ cream. E45 is easy to use and people know it – they don’t have to look very far to buy it either.

Before

After

NS: In addition, I’d recommend considering the cost of servicing for the type of device you purchase, as lasers should be serviced regularly.

NS: If skin is sun damaged, not very elastic, has lost tone or has very little texture, then we advise them to use prescribed products.

They will be on this product for at least four weeks prior to a resurfacing procedure. Ensure skin is cleaned properly and all makeup is removed prior to treatment.

What results can patients expect to see?

MG: I think you really need to wait four to five weeks after a facial rejuvenation treatment to see the best results. After a treatment for telangiectasia, it looks like nothing has happened at first and then four weeks later there’s suddenly a big improvement.

Patients need to be realistic about how long to wait before they see results. For solar lentigines, lasers are brilliant because they just flake off and then they’re gone.

Figure 1: Before and after one treatment using the DEKA SmartXide2 CO2 laser, followed by Juvéderm Voluma dermal filler injection.

Images courtesy of Dr Nina Sheffield.

MM: For epidermal pigmentation, you could see results after one treatment as it’s very easy to target. For deeper pigmentation or rosacea, it could take three to four treatments. For concerns such as lines and wrinkles that require collagen stimulation with fractional lasers, the average number of treatments in my clinic is four, based a month apart. You can never say you will see 100% improvement – results can vary depending on pre-existing skin

NS: We supply patients with an aftercare kit which will include sterile wipes and moisturising cream. We also invite them back to clinic for a complementary hydrating facial – offering them a bit of pampering after the discomfort of the procedure and to give back moisture to the skin. As well as this, it helps for us to remove the tiny flakes as their skin rejuvenates, as I really don’t want patients to pick and remove them themselves.

MM: We work with AesthetiCare and use the Heliocare suncare range which I find really good, as the products can be used on very different skin types. I also recommend vitamin C and retinol products, in association with a glycolic acid wash. I’ll tailor a skincare recommendation to each individual patient post laser treatment.

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What side effects/complications could occur?

MM: You can risk damage to the deep tissue, causing deep pitted scarring – although this has never happened to me. Darkening of pigmentation can be an issue for a few days. There’s also a risk of blisters and burns so it’s important to cool the skin. The erythema and swelling can last about 24 hours but in some patients, it may last a little longer. It’s vital that practitioners learn how much energy you can apply to a particular skin type, although this is something that is becoming less of an issue the more patients we treat with fractional laser.

NS: Usually complications are avoidable if the proper consultation has been done and a proper medical history has been taken.

Practitioners should first check skin types as some lasers are not suitable for darker skin. For example, if you use an alexandrite on a Fitzpatrick skin type V then you are likely to burn the patient. Some patients may be on medication that could be photosensitive leading to burns, so it’s important you have all their medical history correct. Some patients may forget to tell you what medication they’re on or be embarrassed to tell you that they take recreational drugs such as cannabis, which could be photosensitive and lead to a burn.2 You should also avoid treating over moles as we don’t want to disturb or irritate them.

In the UK & Ireland, Aster International are currently bringing the next generation of lasers from GME Germany to the UK market, for epilation, cosmetic skin procedures, psoriasis, vitiligo and inflammatory skin conditions.

FEATURED: GME EXSYS308 - Excimer EPL - effective treatment for vitiligo & psoriasis.

MG: For ablative lasers you shouldn’t even treat patients under three to four months from their first treatment – that tells you how long it takes the skin to completely settle.

For practitioners starting out, what advice do you give?

MG: The key point is knowing how to assess photoageing effectively. When you can do that you can recommend the appropriate laser for that presentation on that particular day.

MM: My best tip for new practitioners is to think of layering and combining treatments for best results. We have to get better at combining treatments to deliver the best outcomes for our patients.

NS: Getting your website right is also important – ensure you describe and promote your treatments appropriately in a way that patients will understand. I try all treatments in my clinic – I know exactly how it feels and the outcome you can expect.

This means that I am sympathetic to the patient’s discomfort.

Patients can see my before and after pictures as well.

MEL: 100 to 200 mj/cm2

Before

After 3 Treatments

After 12 Treatments

MG: I would add that, generally, the protocols set by the laser manufacturer are meant to guide you, but you should develop your own approach, based on safe practice. Use more than just what you see – for example, I find that with my Q-switch laser, I also listen to the sound of it as you find it tells you when you are being too aggressive or when the skin type is not appropriate.

Use all of your senses to ensure that you are getting the best results and that the patient is safe.

REFERENCES 1. Dr Diana Howard, ‘How does menopause affect the skin? (UK: The International Dermal Institute, 2017) <http://www.dermalinstitute.com/uk/library/12_article_How_Does_ Menopause_Affect_the_Skin_.html> 2. ‘Study of possible correlation between photosensitivity reaction and marijuana’ (US: FactMed, 2014) <http://factmed.com/study-MARIJUANA-causing-PHOTOSENSITIVITY%20 REACTION.php>

01295 760 686 info@asterinternational.com www.asterinternational.com

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Oral Skincare Supplements Dr David Jack reviews current research on the use of oral supplements for ageing skin Over the past forty or so years, the role of diet and nutrition in general health has become increasingly apparent, with strong links being discovered between certain diseases and suboptimal dietary habits.38 It follows, therefore, that the skin, like any other organ system, must be subject to dietary related effects and in turn, dietary optimisation may improve skin health and age-related changes. At present, there is very little conclusive research in this field, despite the great interest, when compared to, say, the effect of diet on the cardiovascular system. That being said, from a personal observation, the number of products reaching the market making claims to improve skin health have been increasing substantially over the past few years.

This article aims to outline the nutritional requirements of healthy skin, describe some of the hypothesised mechanisms by which certain oral supplements are thought to work at the level of the skin, and summarise some of the current research in this interesting and developing field.

Ageing skin and nutritional requirements The science of skin ageing is an interesting and developing field, with significant advances being made over the past 20 years. As the skin ages, certain predictable changes occur at each physiological/ anatomical level, with variations depending on gender, geophysical location, race and genetics. The world of aesthetics and active skincare is driven largely by targeting the underlying causes of these changes, from the hierarchy of anatomy (using, for example, surgery or botulinum toxins and fillers to volumise and reduce the tension on the facial musculature on the skin), to the histological (using resurfacing techniques such as fractional ablation and radiofrequency to improve dermal thickness and structure) and finally, cellular and molecular (using skincare and peels). Now, nutraceuticals are being used to optimise cellular function and the molecular environment of the skin.

It is useful to think of ageing in terms of these hierarchies, particularly when considering the role of oral supplements in skin ageing. In addition, the different factors influencing skin ageing, both intrinsic (cellular) and extrinsic (environmental) are important to consider. The

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beneficial role of antioxidants in skincare has been recognised now for some time,2,12 but the role of oral antioxidants and the creation of an ideal antioxidant extracellular environment via dermal blood supply is an emerging and interesting field.

As mentioned, numerous products claiming to have antiageing effects on the skin have reached the market in recent years, however, the evidence for their efficacy has been limited to only a few basic and subjective studies. In the same way that concentrated doses of oral medications for particular diseases have been refined and tested, it is likely that in future years we will see refinement of oral supplements via ongoing research. Currently there is a fairly limited number of molecules that are used in oral skin supplements that have a substantial evidence-base supporting their use in supplements. These include vitamins, such as vitamin C and vitamin E, and other antioxidants, such as glutathione, as well as micronutrients. Such molecules are believed to have multiple roles in maintaining and supporting collagenesis and maintenance of skin barrier function.1,2 It is clear that nutrition plays a role in skin health, with numerous conditions being associated with deficiencies in both micro- and macro-nutrients.1 For example, the deficiencies can cause scurvy (vitamin C deficiency), epidermolysis bullosa (zinc or selenium deficiency) and pellagra (vitamin B3 {niacin} deficiency). Of the macro-nutrients, glucose levels have been shown to have an important role in keratinocyte differentiation and proliferation, with high glucose levels inhibiting proliferation but enhancing calcium induced differentiation.2 Lipids similarly have an important role in skin integrity and barrier function, the major epidermal lipids being ceramides, fatty acids and cholesterol. Ceramides, in particular, have been shown in in-vitro controlled studies on skin cells and animal models to have major roles in cell signalling, proliferation, differentiation and apoptosis in keratinocytes.2 This type of data is not currently available in in-vivo human medical controlled trials. Likewise, several amino acids, including arginine, ornithine and proline have been shown to increase collagen synthesis in human dermal fibroblasts, and amino acid mixtures from Mytilus galloprovincialis and Rapana venosa extracts accelerate wound healing via increasing dermal collagen production.3 Proteins and peptide fragments are important in providing the building blocks for skin proteins and signalling molecules, and an adequate protein intake is believed to be essential with advancing age for the skin.40 The role of antioxidants and micro-nutrients in skin ageing has been widely documented, usually based on topical application of antioxidant preparations.1 In contrast, the role of oral micronutrient and antioxidant supplements is less widely studied. The most widely-recognised oral preparation, with substantial evidence for an indication, is vitamin A in the role of acne. Isotretinoin, the oral vitamin A preparation first released by Roche, following FDA approval in the United States in 1982, clearly illustrates the marked effects (of reduction in sebum production) that high dose oral antioxidant and vitamin preparations can have on skin physiology and repair.4 With this in mind, I will now explore some of the roles of various vitamins and other molecules present in some of the oral supplements which purport to have antiageing benefits.

Vitamin A Vitamin A is a group of fat-soluble polyunsaturated organic compounds deriving from both animal (retinoids) and plant (carotenoid) sources. In addition to their potent antioxidant effects, the vitamin A compounds also play important roles in proliferation,

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differentiation and apoptosis of many cell types, including skin cells,8 and in mediation of several important immune functions. Although carotenoids have antioxidant effects, they must first be converted to retinoids to exert physiological effects on the skin via nuclear hormone receptors.9 Topical vitamin A compounds have been shown to enhance repair of the skin following UV-related damage via multiple mechanisms, including increasing proliferation of keratinocytes and dermal fibroblasts, inhibition of matrix metalloproteinases10 and, interestingly, can have converse anti-proliferative effects in skin conditions where there is hyperproliferation of keratinocytes, such as psoriasis.11 Similarly, there is evidence that vitamin A compounds have beneficial effects when used in other skin conditions including acne12 (both topically and orally), ichthyosis13 and non-melanoma skin cancers.14 In addition, vitamin A deficiency is associated with delayed wound healing and in the pathogenesis of atopic dermatitis.15 It must be noted that deficiency cannot be compared with optimal nutrition in the studies referenced, as they may have differing mechanisms.

As mentioned above, vitamin A is found in both animal and plant sources, the former being mostly retinyl esters (including retinyl palmitate) and the latter provitamin A carotenoids (including β-carotene, α-carotene and β-cryptoxanthin), which are cleaved and metabolised into retinol following enterocyte absorption via a mechanism believed to involve protein mediated transport and possibly passive diffusion at higher doses.16 Hydrolysis of retinyl palmitate and other vitamin A esters occurs mostly in the duodenum before absorption distally in the small intestine, where they are thought to be incorporated into micelles before being transferred into brush border cells.16 Absorption efficiency of retinol is estimated to be 75100%, whereas β-carotene ranges from 3-90%.17 Following absorption, the vitamin A compounds are then incorporated into chylomicrons at the basal surface of the enterocytes, where they enter the lymph for further transport and a portion travel via the portal route for storage in the liver.17 As mentioned above, there is substantial evidence for the use of oral preparations of vitamin A in acne, however, the routine use of vitamin A preparations for antiageing purposes requires more study to conclusively support its use. In addition, the use of oral vitamin A preparations in females of child bearing age must be considered carefully given the risk of teratogenic effects.14 Other contraindications include hepatic insufficiency, excessively high blood lipids and tetracycline treatments.

Vitamin E Similar to vitamin A, vitamin E is a fat-soluble vitamin. Its active form, D-α-tocopherol, is known to have multiple important antioxidant effects in the skin,42 particularly related to UV related damage, and has been shown to have a synergistic antioxidant effect with vitamin C;18,19 with vitamin C regenerating oxidised vitamin E back to its active form.19 Levels of vitamin E in the skin are a sensitive marker of oxidative damage – even with a single exposure to UV irradiation, skin levels can become depleted.19 In response to UV irradiation, treatment with vitamin E has been shown to reduce expression of matrix metalloproteinases, therefore reducing collagen breakdown, and reducing damaging pro-inflammatory prostaglandins and cytokines, cyclo-oxygenase-2 and NADPH oxidases.21 Animal studies have also demonstrated beneficial effects of vitamin E supplementation both topically and orally on UV-related photocarcinogenesis and pigmentation.22 In addition, vitamin E deficiency has been linked to skin ulceration and abnormal collagen cross-linkage.23 There is much interest in the combined use of vitamins C and E together in supplements. Although there are numerous topical cosmeceuticals

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containing both molecules, few are of sufficient concentrations and are stable when exposed to light and air to be effective when applied to the skin.19 Could oral supplementation be a potential solution to this problem? One randomised controlled human study has shown improvements in repair-related gene expression using fermented papaya supplements rich in vitamin C and E,24 however, there is little evidence in the literature at present regarding vitamin E supplementation in terms of optimal dosing and definitive objective measurable outcomes for antiageing purposes.

Vitamin C The benefits of vitamin C (ascorbic acid) administered topically,2 orally25 and parenterally26 have been widely documented since the early twentieth century. As a water-soluble vitamin deriving mostly from dietary fruit and vegetables, vitamin C is mostly taken up via active transport in the small intestine via sodium-dependent SVCT1 transporters, which have a much stronger affinity for the L-ascorbic acid isoform of vitamin C27 than for the D-ascorbic acid form. Similarly, in highly metabolic tissues such as enterocytes and schwann cells, a similar sodium dependent transporter, SVCT2 is responsible for uptake.27 In the skin, vitamin C has numerous antioxidant effects and interacts at multiple levels to attenuate UV-related damage and protect skin cells and extracellular structures from oxidative damage.25 Vitamin C significantly reduces levels of pro-oxidative species in the skin through its action as a reducing agent, improves epidermal moisture content and has beneficial effects on wound repair and dermal collagenesis.28 Indeed, the latter is illustrated by vitamin C deficiency resulting in scurvy, where there is delayed wound healing, subcutaneous micro haemorrhages and thickening of the stratum corneum. As mentioned above, vitamin C and vitamin E have a close relationship when it comes to UV protection of the skin, with multiple synergistic effects.29 Similarly, the bioavailability of both vitamin E and non-haem iron is known to be increased by vitamin C.29 Multiple studies have suggested only minor differences in the bioavailability of natural vs. synthetic sources of vitamin C when taken orally, however, it is thought that dietary sources of natural vitamin C (from fruits and vegetables) will have additional benefits resulting from the concomitant consumption of other micro- and macronutrients and photochemicals.29 Oral doses of up to 2,000mg per day are known to be safe for general consumption, however, individual doses of 200mg and above have lower relative bioavailability, prompting suggestions that multiple lower doses or slow release formulations will result in higher overall bioavailability.30,31 However, there is an argument to suggest that the body may take the vitamin C it needs and any additional vitamin C is excreted; thus, the dropoff in bioavailability would be related to body requirements.

Collagen Oral supplementation of hydrolysed collagen has become popular in the past few years in the treatment of skin ageing, however, the mechanism of action of such supplements is not fully understood.32 Most collagen supplements do not contain large collagen molecules, but instead contain hydrolysed collagen derived diand tri-peptides such as Gly-Pro-Hyp, among others, from mostly marine plant sources. Recent in-vivo studies have shown in animal models that supplementation with radiolabelled hydrolysed collagen peptides can in fact result in increased uptake of these peptides into the skin, with a particular predominance of Gly-ProHyp and Pro-Hyp, leading to the hypothesis that supplementation may influence dermal neocollegenesis.32 This remains to be

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fully explored and the action fully elucidated. In addition, whether supplementation of hydrolysed collagen fragments has any additional benefit versus simple amino acid or protein supplementation remains to be proven. In addition, no conclusive study has shown any definitive statistically significant benefit in a measurable antiageing end point from supplementation with oral hydrolysed collagen.33

Vitamin D The fat-soluble, cholesterol-derived vitamin D has multiple important roles in skin physiology, including angiogenesis, wound healing and modulation of innate immunity. Vitamin D3 is also known to have an anti-proliferative effect on keratinocytes,34 and has been used to treat conditions where keratinocyte hyperproliferation is a key feature, including psoriasis.34 Humans have the ability to synthesise vitamin D isoforms from cholesterol via the action of UV exposure and the cytochrome system, and also via renal mechanisms.2 Lack of UV exposure is therefore implicated in many cases of reduced vitamin D levels, particularly in those with darker skin types. Oral supplementation of vitamin D has been used for many years and is recognised to be of benefit in deficiency (see NICE guidelines for recommendations),45 however, supplementation for antiageing purposes has not been studied.

Glutathione There has been much interest in the use of the thiol tripeptide glutathione (GSH) in antiageing skincare and as a depigmentation agent in the past few years.35 Indeed, I recently published a review article in this journal on this interesting molecule.35 As one of the most potent endogenous antioxidants, and present in almost every body cell, glutathione has important effects on a wide range of physiological processes including P450 reactions, DNA synthesis and repair, and amino acid transport.46 With ageing, it is known that glutathione stores generally decrease throughout the body, so supplementation is proposed to have antiageing effects by replacing depleted stores. Glutathione is stored and used in cells, then the stores are generally depleted resulting in decreased overall stores at advanced ages.37 In the skin, glutathione has important antioxidant effects, and can influence melanin expression via a dose-dependent mechanism. The latter effect may have applications in reduction of age-related hyperpigmentation.36 Previously it was thought that oral ingestion of glutathione does not result in increased plasma levels of GSH, however, recent studies have suggested that orobuccal administration of ‘fast-slow’ release tablets (fast orobuccal absorption, slower gastrointestinal uptake) can in fact produce elevated plasma levels, raising interest in oral supplementation of glutathione as an antiageing skin supplement.36,37 Further investigation will be required to correlate raised plasma levels with the purported skin benefits.

Copper, zinc and selenium The first line of defence of all human cells against damage by excessive reactive oxygen species is a number of endogenous antioxidant enzymes, including superoxide dismutase (SOD), catalase, thioredoxin reductase and glutathione peroxidase.5 The function of these enzymes are dependent on the trace elements copper, zinc and selenium at the active enzymatic sites and have important roles in protection of the skin against UV damage via their action on the plasma membranes of keratinocytes.2 Deficiency of any of these trace metals can have significant effects on skin function.2 Indeed, selenium has been implicated in psoriasis, possibly as a result of decreased levels of glutathione peroxidase, and in recessive

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dystrophic epidermolysis bullosa.6 Likewise, copper, which has important roles in collagen maturation and melanin synthesis, has been implicated in the pathogenesis of Steely-Hair syndrome – a disorder that affects copper levels in the body and is characterised by sparse, kinky hair. 7 Supplementation via the oral route is therefore considered beneficial from an antiageing and reparative point of view but further study is required to fully appreciate the role of these in supplements.

Conclusion The emergence of oral supplements in antiageing is an interesting and developing field. There is growing evidence supporting the benefits of a varied, antioxidant enriched diet in ageing,43,44 supported by adequate macro-nutrients. It can be postulated therefore, that oral supplementation of antioxidants and even macro and micro-nutrients could have beneficial effects on skin ageing and repair, however, there are relatively few studies examining the roles of particular oral supplements and elucidating ideal doses and the effects such supplements have on the skin over time. Over the past few years, numerous dietary supplements have been brought to the market that claim to have antiageing effects on the skin, however, most do not have substantial evidence for statistically significant effects on the physical end-points they claim to improve. In the future, it is likely that such supplements become more commonplace and hopefully the evidence to support their use is developed further.

In this article, I have summarised the major groups of molecules used in oral skin supplements, however, it is likely that numerous other molecules will be added to this list in the future.

Disclosure: Dr David Jack owns and distributes the Integrative Beauty supplement range, which was launched in April 2017.

Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his non-surgical aesthetic practice, having worked in this sector part-time for almost seven years.

REFERENCES 1. Lakdawala N, Babalola O, 3rd, Fedeles F, McCusker M, Ricketts J, Whitaker-Worth D, GrantKels JM. The role of nutrition in dermatologic diseases: facts and controversies. Clin Dermatol.

2013;31:677–700 2. Park K, Role of Micronutrients in Skin Health and Function Biomol Ther (Seoul). 2015 May; 23(3): 207–217 3. Badiu DL, Luque R, Dumitrescu E, Craciun A, Dinca D. Amino acids from Mytilus galloprovincialis (L.) and Rapana venosa molluscs accelerate skin wounds healing via enhancement of dermal and epidermal neoformation. Protein J. 2010;29:81–92 4. US Food & Drug, Drugs@FDA: FDA Approved Drug Products, (2017) <http://www.accessdata.fda. gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=018662> 5. Dröge W, Free radicals in the physiological control of cell function Physiol Rev. 2002 Jan;82(1):4795 6. Naziroglu M, Yildiz K, Tamturk B, Erturan I, Flores-Arce M. Selenium and psoriasis. Biol Trace Elem Res. 2012;150:3–9. doi: 10.1007/s12011-012-9479-5 7. Menkes JH. Kinky hair disease: twenty five years later. Brain Dev. 1988;10:77–79. doi: 10.1016/S03877604(88)80074-3.

8. Lee DD, Stojadinovic O, Krzyzanowska A, Vouthounis C, Blumenberg M, Tomic-Canic M. Retinoidresponsive transcriptional changes in epidermal keratinocytes. J Cell Physiol. 2009;220:427–439 9. Johnson EJ. The role of carotenoids in human health. Nutr Clin Care. 2002;5:56–65 10. Fisher GJ, Wang ZQ, Datta SC, Varani J, Kang S, Voorhees JJ. Pathophysiology of premature skin aging induced by ultraviolet light. N Engl J Med. 1997;337:1419–1428 11. Jean J, Soucy J, Pouliot R. Effects of retinoic acid on keratinocyte proliferation and differentiation in a psoriatic skin model. Tissue Eng Part A. 2011;17:1859–1868 12. Kligman AM. The treatment of acne with topical retinoids: one man’s opinions. J Am Acad Dermatol. 1997;36:S92–95 13. Van Hattem S, Bootsma AH, Thio HB. Skin manifestations of diabetes. Cleve Clin J Med. 2008;75:772, 774, 776–777 14. Niles RM. The use of retinoids in the prevention and treatment of skin cancer. Expert Opin Pharmacother. 2002;3:299–303 15. Mihaly J, Gamlieli A, Worm M, Ruhl R. Decreased retinoid concentration and retinoid signalling pathways in human atopic dermatitis. Exp Dermatol. 2011;20:326–330

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16. Reboul E Absorption of Vitamin A and Carotenoids by the Enterocyte: Focus on Transport Proteins Nutrients. 2013 Sep; 5(9): 3563–3581 17. During A, Harrison EH. Mechanisms of provitamin A (carotenoid) and vitamin A (retinol) transport into and out of intestinal Caco-2 cells J Lipid Res. 2007 Oct;48(10):2283-94 18. Lin JY, Selim MA, Shea CR, Grichnik JM, Omar MM, Monteiro-Riviere NA, Pinnell SR. UV photoprotection by combination topical antioxidants vitamin C and vitamin E. J Am Acad Dermatol. 2003;48:866–874 19. Burke KE, Interaction of vitamins C and E as better cosmeceuticals Dermatol Ther. 2007 Sep-Oct;20(5):314-21 20. Thiele JJ, Traber MG, Packer L. Depletion of human stratum corneum vitamin E: an early and sensitive in vivo marker of UV induced photo-oxidation. J Invest Dermatol.

1998;110:756–761 21. Wu S, Gao J, Dinh QT, Chen C, Fimmel S. IL-8 production and AP-1 transactivation induced by UVA in human keratinocytes: roles of D-alpha-tocopherol. Mol Immunol.

2008;45:2288–2296 22. Burke KE, Clive J, Combs GF, Jr, Commisso J, Keen CL, Nakamura RM. Effects of topical and oral vitamin E on pigmentation and skin cancer induced by ultraviolet irradiation in Skh:2 hairless mice. Nutr Cancer. 2000;38:87–97 23. Igarashi A, Uzuka M, Nakajima K. The effects of vitamin E deficiency on rat skin. Br J Dermatol. 1989;121:43–49 24. Bertuccelli G, Zerbinati N, Marcellino M, Nanda Kumar NS, He F, Tsepakolenko V, Cervi J, Lorenzetti A, Marotta F Effect of a quality-controlled fermented nutraceutical on skin aging markers: An antioxidant-control, double-blind study Exp Ther Med. 2016 Mar;11(3):909-916 25. McArdle F, Rhodes LE, Parslew R, Jack CI, Friedmann PS, Jackson MJ. UVR-induced oxidative stress in human skin in vivo: effects of oral vitamin C supplementation. Free Radic Biol Med. 2002;33:1355–1362 26. Chen P, Stone J, Sullivan G, Drisko JA, Chen Q. Anti-cancer effect of pharmacologic ascorbate and its interaction with supplementary parenteral glutathione in preclinical cancer models Free Radic Biol Med. 2011 Aug 1;51(3):681-7 27. Savini I., Rossi A., Pierro C., Avigliano L., Catani M.V. SVCT1 and SVCT2: Key proteins for vitamin C uptake. Amino Acids. 2008;34:347–355 28. Peterkofsky B. Ascorbate requirement for hydroxylation and secretion of procollagen: relationship to inhibition of collagen synthesis in scurvy. Am J Clin Nutr. 1991;54:1135s–1140s 29. Carr AC, Vissers MCM, Synthetic or Food-Derived Vitamin C—Are They Equally Bioavailable? Nutrients. 2013 Nov; 5(11): 4284–4304 30. Levine M., Conry-Cantilena C., Wang Y., Welch R.W., Washko P.W., Dhariwal K.R., Park J.B., Lazarev A., Graumlich J.F., King J., et al. Vitamin C pharmacokinetics in healthy volunteers: Evidence for a recommended dietary allowance. Proc. Natl. Acad. Sci. USA. 1996;93:3704–3709 31. Yung S., Mayersohn M., Robinson J.B. Ascorbic acid absorption in humans: A comparison among several dosage forms. J. Pharm. Sci. 1982;71:282–285 32. Yazaki M, Ito Y, Yamada M, Goulas S, Teramoto S, Nakaya MA, Ohno S, Yamaguchi K, Oral Ingestion of Collagen Hydrolysate Leads to the Transportation of Highly Concentrated GlyPro-Hyp and Its Hydrolyzed Form of Pro-Hyp into the Bloodstream and Skin J Agric Food Chem. 2017 Mar 22;65(11):2315-2322 33. Birnbaum JE, McDaniel DH, Hickman J, Dispensa L, Le Moigne A, Buchner L, A multicenter, placebo-controlled, double-blind clinical trial assessing the effects of a multicomponent nutritional supplement for treating photoaged skin in healthy women J Cosmet Dermatol. 2017 Mar;16(1):120-131 34. Abramovits W. Calcitriol 3 microg/g ointment: an effective and safe addition to the armamentarium in topical psoriasis therapy. J Drugs Dermatol. 2009;8:s17–22 35. Jack D, Glutathione Aesthetic Journal Sept (2015) 36. Schmitt B, Vicenzi M, Garrel C, Denis FM, fects of N-acetylcysteine, oral glutathione (GSH) and a novel sublingual form of GSH on oxidative stress markers: A comparative crossover study. Redox Biol. 2015 Dec; 6: 198–205 37. Buonocore D, Grosini M, Giardina S, Michelotti A, Carrabetta M, Seneci A, Verri M, Dossena M, Marzatico F, Bioavailability Study of an Innovative Orobuccal Formulation of Glutathione Oxid Med Cell Longev. 2016; epub 38. Scarborough, Peter, et al. “The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006–07 NHS costs.” Journal of Public Health 33.4 (2011): 527-535.

39. Zague, Vivian. “A new view concerning the effects of collagen hydrolysate intake on skin properties.” Archives of dermatological research 300.9 (2008): 479-483.

40. Cosgrove, Maeve C., et al. “Dietary nutrient intakes and skin-aging appearance among middle-aged American women.” The American journal of clinical nutrition 86.4 (2007): 1225-1231.

41. EMC, Roaccutane 10mg Soft Capsules, (2015) <http://www.medicines.org.uk/emc/ medicine/1727/spc> 42. Boelsma, Esther, Henk FJ Hendriks, and Len Roza. “Nutritional skin care: health effects of micronutrients and fatty acids.” The American journal of clinical nutrition 73.5 (2001): 853-864.

43. Cutler, Richard G. “Antioxidants, aging and longevity.” Free radicals in biology 6 (1984): 371-428.

44. Sánchez, Gregorio Martínez. “Antioxidants and ageing.” International Biophilia Rehabilitation Conference Proceedings Proceedings of IBRC 2009: The 7th International Biophilia Rehabilitation Conference. Biophilia Rehabilitation Academy, 2009.

45. NICE, Vitamin D deficiency in adults - treatment and prevention, (2016) <https://cks.nice. org.uk/vitamin-d-deficiency-in-adults-treatment-and-prevention> 46. Scholz, RW, Graham KS, Gumpricht E, Reddy CC, Mechanism of interaction of vitamin E and glutathione in the protection against membrane lipid peroxidation Ann NY Acad Sci (1989) 570 p514–517

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Skin Hydration Aesthetic nurse prescriber Lorna Bowes details the role of hydration in healthy skin From looking through the myriad of consumer marketing, it appears to be easy to get airbrushed, glowing, well-hydrated skin; you apply vast amounts of high street moisturisers and that does the trick.

We’re also told that by drinking eight glasses or two litres of water a day this will give us the hydrated, youthful skin we are looking for and even flush out toxins. But what actually delivers the dewy look so sought after by our patients?

Dr Katie Rodan, board certified dermatologist from the US, is credited with providing the simple explanation that, “Human’s are not like plants. Our skin doesn’t perk up when we consume water, water goes through the intestines, gets absorbed into your bloodstream, and is filtered by kidneys. Then it hydrates cells.”1 This view is shared by nutrition scientist Heather Yüregir, “Just drinking water for the sake of drinking water really has no effect on improving the appearance of skin. It is just a common misconception.”2

Water balance in the skin Hydrobalance – the water balance in our skin – is a balance between adequate supply and generation of water and prevention or reduction of trans epidermal water loss (TEWL) in the stratum corneum (SC), which is the outer layer of the skin, moderated by both lipids and natural moisturising factor (NMF).3 The stratum corneum comprises mature keratinocytes and, on average, is 15 cell layers thick.4 The structure of the stratum corneum can be described as similar to ‘bricks and mortar’; the ‘bricks’ are the keratinocytes, and the lipids and amino acids are the ‘mortar’.4 Amino acids, as well as other osmolytes in the stratum corneum such as glycerol, lactic acid, taurine and urea, act as a humectant, a substance used to reduce loss of moisture.5 NMF is only found in the cells of the stratum corneum, and is highly humectant, being composed of water-binding chemicals.6 Being able to maintain a good level of hydration, even in a dry environment and in conditions such as ichthyosis vulgaris, where patients have reduced levels of NMF, is important for the various enzymes that have activity in the stratum corneum and rely on a moist environment to function.7

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detergents, pollution, air travel, air conditioning, and even friction from clothing, as well as the dryness associated with autumn and winter months when humidity may be lower and patients are more likely to take hot baths.6 It is important to note that TEWL is not the same as perspiration. TEWL is better described as insensible water loss through the skin, and is now used as an indicator of the integrity of the SC.9 Perspiration is carried out by eccrine sweat glands, distributed evenly over most of the body.10 Severe dehydration can affect the skin, causing tenting, and skin turgor;11 in these instances increased water consumption can improve skin thickness and density, however in healthy and adequately hydrated patients, increasing water consumption will not reduce fine lines and wrinkles, nor will it prevent other signs of ageing associated with genetics, or damage from UV and the environment.12,13 However, topical application of emollients may improve skin barrier function and improve the appearance and feel of dry skin.14 Lipids also make up around 10% of the SC by weight, and play a critical role in maintaining the watertight barrier that is in the skin.15 Dry, dehydrated skin leads to abnormal desquamation of corneocytes16 shedding of the outer layer of the skin, leading to clumps of corneocytes that leave skin looking uneven and dry, which appears as ashen coloured in darker skin.17

Components in the skin In total, the skin contains approximately 30% water, and this quantity of water is visible through the plumpness, elasticity and resilience of skin.

Lower layers of the skin, including the layers of the SC, are hydrated by body fluids rather than the humectant properties of the SC.5 The main cells of the dermis are fibroblasts, and the fibres of the dermis are collagen fibres and elastin fibres; with collagen fibres making up 70-80% of the dry weight of the dermis. Key dermal collagens are collagen type I (85% of skin collagen), collagen type III (15% of skin collagen) and small amounts of collagen types IV and VII. Elastin fibres only make up around 2% of dry dermal weight. Both collagen and elastin rely heavily on dermal water content being adequate. The ground substance of the dermis is made up of glycosaminoglycans, hyaluronic acid and dermatan sulphate, with smaller quantities of heparin sulphate and chondroitin sulphate.18 Glycosaminoglycans and ground substance provide various key functions; binding water, providing transport of nutrients, hormones, and waste products, lubricating the various dermal components such as collagen and elastin during skin movement and providing bulk and cushioning or shock absorbency.18 So, what actions can we take, or encourage our patients to take to increase hydration levels in the skin?

Before

After

Figure 1: Before and after treatment for dark circles and wrinkles around the eyes.

Patient underwent four sessions of mesotherapy by Dr Olga Antonym.

Before

After

Water loss It is important that the water content of the SC is at least 10% for our skin to feel and look ‘correctly hydrated’; when skin becomes dry, cracks and fissures appear.8 Most people with dry skin do not have an underlying disease, but are exposed to factors such as hot water,

Figure 2: Before and after treatment for dark circles and puffiness around the eyes. Patient underwent six sessions of mesotherapy by Dr Barbara Kubicka.

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Treatment options Topical treatments Moisturisers The aim of moisturisers is to increase moisture levels in the skin, but this can be achieved in various different ways – reduction in evaporation and sweating, increased non-negative matrix factorisation (NMF), increased gylcosaminoglycans and improved skin barrier function. Moisturisers come in different carrier or vehicle formulations such as:19 • • • • •

Ointment (approx. 80% oil, 20% water) Cream (approx. 50:50 oil: water) Lotion (approx. 70% water 30% oil) Serum (water-based) Gel (water-based emulsion)

The vehicle used is often also one of the moisturising ingredients.

For cosmetic preparations, creams, lotions and gels are commonly used, while moisturisers and serums tend to be carriers for active ingredients including antioxidants.20 Humectants Humectants are the sponges of the skin – drawing water from the environment and atmosphere or from the dermis and underlying tissues. They are fundamentally short-lasting hydrators, but many humectants also deliver other properties that can claim to be antiageing or anti-wrinkle in addition to the transient hydration they offer. Glycerin (glycerol), urea, hyaluronic acid and its salt (sodium hylaronate), sorbitol, propylene glycol and hydroxy acids are all humectants. The hydroxy acid group of humectants is particularly interesting, as they also have widely reported antiageing properties.

Gluconolactone, a polyhydroxy acid, is made up of multiple hydroxyl groups, as opposed to a single hydroxyl group like first generation AHAs (e.g. glycolic acid); the multiple hydroxyl groups attract water, providing enhanced moisturisation.21 Lactobionic acid, a bionic polyhydroxy acid from milk sugar, is a potent antioxidant which also has powerful humectant properties, strongly attracting and binding water. It is suitable for all skin types22,23 and its unique hydra-film delivers moisture, softness and smoothness to the skin.24 Maltobionic acid has similar moisturising and hydration properties, and these advanced third generation hydroxy acids, lactobionic and maltobionic acid, are also powerful antioxidants trapping oxidation and promoting metals. They also prevent oxidative Before

After

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damage to lipids as well as inhibiting matrix metalloproteinases (MMPs) to preserve the dermal matrix increasing glycosaminoglycans and plumping and firming the skin, delivering anti-glycation effects, and demonstrating significant antiageing effects.23,24,25 Emollients Emollients such as cetyl stearate, glyceryl stearate, octyl octanoate, decyl oleate and isostearyl alcohol, are used to soften and smooth the skin, and can fill in the gaps between the corneocytes, creating a smoother appearance. They may also be occlusive oils that offer an airtight barrier against water loss from the skin, thereby increasing hydration.26 Injectables Mesostherapy Various dermal filler ingredients have been demonstrated as effective biostimulants, increasing hydration and fibroblast activity.

The technique known as meostherapy has been used around the world since it was coined in the 1950s by Dr Michael Pistor.27 Ingredient choice has been based on those that can improve fibroblast function and activity and improve biosynthesis of the extracellular matrix, increasing hydration.28 Organic silicium (SI(OH)4) is essential for wound healing,29 and has been used in mesotherapy solutions for many years, particularly for its benefits in increasing collagen production.30 Various studies have demonstrated the effects of organic silicium,31 one demonstrating a 2,400% increase in hyaluronan synthase 2 (HAS2) gene expression; HAS2 is responsible for the majority of high molecular weight HA synthesis in humans.32 Silicium (Si) is a natural trace element present in the mammalian diet and is important for the normal health of bone and the connective tissues.33,34,35 Indeed, dietary Si deprivation in growing animals appears to cause abnormal growth and defects of the connective tissues. Moreover in connective tissue, silicium is present as organic silicium Si(OH)4.36,37 However, much of the evidence points to a direct involvement of Si in extracellular matrix synthesis and/or its stabilsation, particularly so for collagen, which is one of the main structural proteins of bone and connective tissues.35,38 Higher levels of Si are reported to be associated with healthy connective tissues (such as aorta, bone, trachea, tendon) and especially their connective tissue components, collagen and elastin, compared to non-connective tissues including liver, kidney and spleen.39,40 There is a 4-5 fold difference in (Si) between connective versus non-connective tissues (adult rats). Serum Si levels is a serum marker of type I collagen turnover.41 Si/collagen molar ratio is 1:6 in bones of rats, independent of age. This supports a structural role for Si(OH)4 as a cross-link between collagen units by the way of hydrogen bonds.42 In addition, it was recently demonstrated that organic silicium present in some injectable products could lead to a 25 fold hyaluronan synthase 2 gene expression, a 4 fold collagen type 1 and a 2.5 fold elastin gene expression when added in vitro to human skin fibroblasts, explaining why it can be so effective for skin rejuvenation purposes.43

Figure 3: Before and after treatment for sagging skin, abdomen. Patient underwent four sessions of mesotherapy by Dr Rodrigo Ayoub.

Hyaluronic acid HA has been in use now for well over 20 years, since the launch of Hylaform,

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a cockerel comb derived HA,44 followed by the many HA fillers that are available. This popularity has led to further research into the biostimulatory effects HA can have, as well as research into using the HA as a carrier medium for a variety of clinically-proven ingredients that also exhibit specific biostimulatory effects. In 2014 Baspeyras published a paper on the efficacy of a non-reticulated HA-based mesotherapy cocktail on radiance and elasticity. The study objectively demonstrated the efficacy and the tolerance of a non-cross-linked HA filler in sustainably improving skin elastic parameters and complexion radiance.45 A recent study in Clinical, Cosmetic and Investigational Dermatology presented experiments by Deglesne with Eurofins BioPharma Product Testing Spain SLU, an external independent certified laboratory, who reviewed the effects of HA on human fibroblast viability, collagen type I and elastin gene expression.46 This study used a resorbable medical device, long-chain non-cross linked HA at 6.66mg/ml for dermal biorevitalisation that includes a combination of other ingredients, including vitamins to support specific biologic reactions and cellular respiration, fatty acids to support the epidermal barrier function, coenzymes, antioxidants, polyphenols, amino acids and trace elements for cell nutrition. The authors reviewed the effect of the HA product on collagen type 1 and elastin genes REFERENCES 1. Rodan K & Fields K. ‘Write Your Skin a Prescription for Change’, 2009.

2. Yüregir H, ‘Food for the skin’, Nutrition Bulletin, 2009, 34, pp.383-387. <http://onlinelibrary.wiley. com/wol1/doi/10.1111/j.1467-3010.2009.01778.x/full.> 3. Cohen JL, Daya SH, et al., ‘Systematic Review of Clinical Trials of Small- and Large-Gel-Particle Hyaluronic Acid Injectable Fillers for Aesthetic Soft Tissue Augmentation’, Dermatologic Surgery, 39(2), (2012).

4. Baumann L, Saghari S, ‘Basic Concepts of Skin Science’, Cosmetic Dermatology: Principles and Practice, 2009, 2, pp.4-7.

5. Draelos ZD, ‘Cosmetic Dermatology: Products and Procedures’, 2011.

6. Bauman L, Saghari S, ‘Cosmetic Dermatology: Principles and Practice’, 2009, 2, pp.3-6.

7. Sybert V & Dale B, ‘Icthyosis vulgaris: identification of a defect in synthesis of filaggirn correlated with an absence of keratohyalin retention (abstr)’, Dermatology, (1993) 2000, p.773.

8. Draleos Z, ‘Therapeutic Moistruziers’, Dermatologic Clinics, 2000, 18, pp. 597. <https://www.ncbi. nlm.nih.gov/pubmed/11059367> 9. Kligman A, ‘The biology of the stratum corneum’, In: Montagna W, Jr. Lobitz W Eds. The Epidermis.

New York, NY: Academic Press; (1964), pp.387-433.

10. Champion RH & Burton JL et al., ‘Textbook of Dermatology’ 1992, 3.

11. Vivanti A & Harvey K et al., ‘Clinical assessment of dehydration in older people admitted to hospital: what are the strongest indicators?’, Archives Gerontology Geriatrics, 2008, 47, pp.340– 355. <https://www.ncbi.nlm.nih.gov/pubmed/17996966> 12. Williams S & Krueger N et al., ‘Effect of fluid intake on skin physiology: distinct differences between drinking mineral water and tap water’, International Journal Cosmetic Science, 2007, 29, pp.

131–138. <https://www.ncbi.nlm.nih.gov/pubmed/18489334> 13. Mac-Mary S & Creidi P et al., ‘Assessment of effects of an additional dietary natural mineral water uptake on skin hydration in healthy subjects by dynamic barrier function measurements and clinic scoring’, Skin Research Technology, 2006,12, pp.199-205. <https://www.ncbi.nlm.nih.gov/ pubmed/16827695> 14. Loden M, ‘Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders’, American Journal of Clinical Dermatology, 2003, 4, pp.771-788. <https://www.ncbi.nlm.nih.gov/ pubmed/14572299> 15. Bauman L, Saghari S, ‘Cosmetic Dermatology: Principles and Practice’, (2009) 2, p.91.

16. Wildnauer R & Bothwell J, ‘Stratum corneum biomechanical properties. I. Influence of relative humidity on normal and extracted human stratum corneum’, J invest Dermatol, (1971), pp.56-72. <https://www.ncbi.nlm.nih.gov/pubmed/5556501> 17. Orth D. Appa Y, ‘Gycerine: a natural ingredient for moisturizing skin’, In: Loden M. Maibach H, eds.

Dry Skin and Moisturizers. Boca Raton, FL, CRC Press; (2000), p.214.

18. Blackwell Publishing, ‘The function and structure of the skin’, 2007. <https:// www.blackwellpublishing.com/content/BPL_Images/Content_store/Sample_ chapter/9781405146630/978140514663_4_002.pdf> 19. Burton J, Cliff S, ‘The Role of Moisturisers in Skincare’, Aesthetics. <https://aestheticsjournal.com/ feature/the-role-of-moisturisers-in-skincare> 20. Gupta AK & Gover MD et al., ‘The treatment of melasma: a review of clinical trials’, Journal of the American Academy Dermatology, 2006, 55, pp.1048-65. <https://www.ncbi.nlm.nih.gov/ pubmed/17097400> 21. Ditre CM & Griffin TD et al., ‘Effects of alpha hydroxyacids on photoaged skin: a pilot clinical, histologic and ultrastructural study’, Journal of the American Academy Dermatology, 1996, 34, pp.187-95. <https://www.ncbi.nlm.nih.gov/pubmed/8642081> 22. Briden ME, Green BA , ‘The next generation hydroxyacids’, Procedures in Cosmetic Dermatology: Cosmeceuticals, 2006, 2.

23. Green BA & Briden ME, ‘PHAs and bionic acids: next generation hydroxy acids’, Clinical Gate, 2009. <http://clinicalgate.com/phas-and-bionic-acids-next-generation-hydroxy-acids/> 24. Green BA., Edison BL, Wildnauer RH, Sigler ML, ‘Lactobionic acid and gluconolactone: PHAs for photoaged skin’, Cosmetic Dermatology (2001) 9, pp.24-8.

25. Green BA, Edison BL, Wildnauer RH, Maltobionic acid, a plantderived bionic acid for topical anti-

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that demonstrated increases in the expression of messenger RNA for collagen type 1 and elastin as early as 24 hours with maximal expression at 48 hours. In this in vitro study, the authors found that the HA injectable could promote a nearly tenfold increase in type 1 collagen gene expression and a 14-fold increase in elastin gene expression, demonstrating that the biorevitalisation product used can, at least in vitro, modulate human skin fibroblasts and produce glycosaminoglycans increasing the hydration of the skin.46

Conclusion In conclusion, adequate hydration of all layers of the dermis can aid a patient in reaching their antiageing goals, and by targeting the SC, epidermis and dermal components with ingredients, whether applied topically or using mesotherapy and injection techniques, there is a body of evidence supporting certain key ingredients.

Lorna Bowes is an aesthetic nurse prescriber and trainer. With extensive experience of delivering aesthetic procedures, she trains and lectures regularly on procedures and business management in aesthetics.

Bowes is director of AestheticSource.

aging’, Am Acad of Dermatol,’ (2006) 54(3): AB37.

26. Grimes PE & Green BA et al., ‘The use of polyhydroxy acids (PHAs) in photoaged skin’, Cutis, 2004, 73, pp. 3-13 <https://www.ncbi.nlm.nih.gov/pubmed/15002656> 27. Deglesne PA, Arroyo R, Ranneva E, Deprez P. ‘Clinical, Cosmetic and Investigational Dermatology’, (2016) 23; 9: pp.41-53.

28. Iorizzo M & De Padova MP et al., ‘Biorejuvenation: theory and practice’, Clinics in Dermatology, 2008, 26, pp.177-181. <https://www.ncbi.nlm.nih.gov/pubmed/18472058> 29. Seaborn CD & Nielsen FH, ‘Silicon deprivation decreases collagen formation in wounds and bone, and ornithine transaminase enzyme activity in liver’, Biological Trace Element Research, 2002, 89, pp.251-61. https://www.ncbi.nlm.nih.gov/pubmed/12462748 30. Maya V, ‘Mesotherapy’, Indian Journal of Dermatology, Venereology and Leprology, 2007,73, pp.60-62. http://www.ijdvl.com/article.asp?issn=0378-6323;year=2007;volume=73;issue=1;spage=6 0;epage=62;aulast=Vedamurthy 31. Ranneva J, Deglesne PA, ‘Organic silicium increases the synthesis of hyaluronan synthase 2 gene transcript coding for the enzyme responsible for native hyaluronic acid production’, 7th European Dermatology Congress, (2016).

32. Papakonstantinou E, Roth M, Karakiulakis G., ‘Hyaluronic acid: A key molecule in skin aging’, Dermato-endocrinology, 2012 4(3), pp.253-258. doi:10.4161/derm.21923.

33. Nielsen FH, ‘Nutritional requirements for boron, silicon, vanadium, nickel, and arsenic: current knowledge and speculation’, Federation of American Societies for Experimental Biology, 1991, 12, pp.2661-7 <https://www.ncbi.nlm.nih.gov/pubmed/1916090> 34. Nielsen FH, ‘Update on the possible nutritional importance of silicon’, Journal of Trace Elements in Medicine and Biology, 2014, 4, pp.379-82. <https://www.ncbi.nlm.nih.gov/pubmed/25081495> 35. Jugdaohsingh R, ‘Silicon and bone health’, Journal of Nutrition Health and Aging, 2007, 2, pp.

99-110. <https://www.ncbi.nlm.nih.gov/pubmed/17435952> 36. Schwarz K & Milne DB, ‘Growth-promoting effects of silicon in rats’, Nature, 1972 239, pp. 333-4. <https://www.ncbi.nlm.nih.gov/pubmed/12635226> 37. Elliot MA & Edwards HM Jr, ‘Effect of dietary silicon on growth and skeletal development in chickens’, Journal of Nutrition, 1991, 2, pp. 201-7. <https://www.ncbi.nlm.nih.gov/pubmed/1995789> 38. Reffitt DM & Ogston N, et al., ‘Orthosilicic acid stimulates collagen type 1 synthesis and osteoblastic differentiation in human osteoblast-like cells in vitro’, Bone, 2003, 2, pp. 127-35. <https://www.ncbi. nlm.nih.gov/pubmed/12633784> 39. Carlisle EM, ‘Silicon as an essential trace element in animal nutrition’, Ciba Foundation Symposium, 1986, 121, pp.123-39. <https://www.ncbi.nlm.nih.gov/pubmed/3743227> 40. Schwarz K A, ‘bound form of silicon in glycosaminoglycans and polyuronides’, Proceedings of the National Academy of Sciences, 1973, 70, 1608-12. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC433552/> 41. Jugdaohsingh R & Watson AI et al., ‘The decrease in silicon concentration of the connective tissues with age in rats is a marker of connective tissue turnover’, Bone, 2015, 75, pp.40-8. <https:// www.ncbi.nlm.nih.gov/pubmed/25687224> 42. Jugdaohsingh R & Pedro LD et al., ‘Silicon and boron differ in their localization and loading in bone’, Bone, 2014, 1, pp. 9-15. <https://www.ncbi.nlm.nih.gov/pubmed/25687224> 43. Deglesne P-A, Arroyo R, Ranneva E, Deprez P., ‘In vitro study of RRS HA injectable mesotherapy/ biorevitalization product on human skin fibroblasts and its clinical utilization’, Clinical, Cosmetic and Investigational Dermatology, (2016) 9, pp.41-53. doi:10.2147/CCID.S95108.

44. Beer K, ‘A Randomized, Evaluator-Blinded Comparison of Efficacy of Hyaluronic Acid Gel and Avian-Sourced Hylan B Plus Gel for Correction of Nasolabial Folds’, Dermatologic Surgery, (2007) 33, 8, p.928.

45. Basperyras M & Rouvrais C et al., ‘Clinical and biometrological efficacy of a hyaluronic acid-based mesotherapy/biorevitalisation product: a randomised controlled study’, Archives of Dermatological Research, 2013, 305, pp.673-82. <https://www.ncbi.nlm.nih.gov/pubmed/23715889> 46. Deglesne P A & Arroyo R et al., ‘In vitro study of RRS HA injectable/mesotherapy biorevitalisation product on human skin fibroblasts and its clinical utilization’, Clinical, Cosmetic and Investigational Dermatology, 2016,9, pp. 41-53. <https://www.dovepress.com/in-vitro-study-of-rrs-ha-injectablemesotherapybiorevitalization-produ-peer-reviewed-article-CCID>

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M-ULT-UKI-0083 Date of preparation February 2017

Before

After 180 days

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard.

Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue.

Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

References: 1. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed April 2016 2. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 3. Ulthera System Instructions for Use, 1001393IFU Rev H 4. Lee HS, et al. Dermatol Surg. 2011;1-8 5. Data on File: ULT-DOF-008 – Ultherapy Mechanism of Action White Paper 6. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 7. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 8. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 *stimulates new collagen and elastin which can reverse the signs of ageing

Contact Merz Aesthetics NOW and ask for an Ultherapy® Information Pack Tel: +44 (0) 333 200 4140 • Email: customerservices@merz.com • www.ultherapy.co.uk

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‘Turkey neck’ The platysma is a vertical muscle that runs throughout the whole neck. It lacks support from surrounding connective tissue, which leaves it practically free-floating. As we age, the muscle fibres of the platysma shorten and contract which creates the classical platysmal bands, which are the most obvious and feared sign of the ageing neck, commonly referred to as ‘turkey neck’.2 ‘Tech neck’ We are now living in the world of the ‘selfie’, with increased pressure to look picture perfect 100% of the time. We capture our lives using our smartphones, but constant overuse of technical devices means we spend more time looking down at our phones than looking at each other. The constant head tilt leads to excessive pressure and creasing of the delicate skin in the neck area, which can result in accelerated formation of lines and wrinkles.3

An Introduction to Treating the Neck and Décolletage Dr Jane Leonard provides an overview of the different types of treatments available for the ageing neck and décolletage

The consultation

When we think of aesthetic treatments and antiageing, by default, our thoughts often focus on the face. However, I find that it is the disharmony between a youthful face and an ageing neck and décolletage that is the giveaway of a person’s true age. In an ideal world, antiageing treatments should take a more holistic approach; combining aesthetic treatments whilst optimising health and wellness. But so often, patients wishing to treat the neck and décolletage only seem to come into clinic once the damage has already been done, leading the patient to seek corrective rather than preventive aesthetic treatment.

Today, patients are well informed of the importance of investing in good skincare, sun protection and starting aesthetic treatments early to optimise their antiageing effects, rather than fighting lines and wrinkles when they appear. However, despite an increase in patient education, it always surprises me how much the neck and décolletage are neglected. Even where skincare and SPF are applied, the extent of their application tends to stop at the neckline.

As with any aesthetic consultation, the first step is to establish the patient’s concerns.

Having an open discussion with the patient and exploring how much the problem affects their life on a day-to-day basis is a good starting point. Also discussing previous treatments and how long the problem has been bothering them gives a good insight into the extent of the issue.

In addition to covering the routine medical assessment, it is also useful to discuss lifestyle factors, in particular, smoking, diet, exercise and skincare regime, including SPF use.

Classically, the main patient concerns related to the neck and décolletage include: • Skin laxity • Fine lines • Wrinkles • Crepey skin • Double chin

Treatment choices i

ii

iii

iv

Figure 1: Depiction of the loss of definition of the cervicomental angle1

The ageing neck After the periorbital area, the skin on the neck is the most delicate. The neck contains far less elastin fibres compared to the face, resulting in a weaker supporting structure to the collagen matrix. In addition, the neck also lacks fatty structures to give extra support to the less elastic skin. The combined effect of sagging jowls, submental fullness, inelastic skin and the formation of platysmal bands contribute to the loss of the cervicomental angle, which is the hallmark of the ageing neck (Figure 1).1

Fortunately, there is a wealth of minimallyinvasive treatment options available for treating the ageing neck and décolletage.

This is where the value of a thorough initial assessment comes in to guide the best treatment choices for the individual needs of each patient.

Botulinum toxin – ‘Nefertiti lift’ Named after the famous youthful jawline of the Egyptian queen, the Nefertiti neck

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

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Contact Merz Aesthetics NOW and ask for Belotero Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com 1. BEL-DOF-003 V2 Belotero® technology, June 2015. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI: 10.1159/000354384.

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lift involves injections of botulinum toxin into the lower jaw and neckline.4 The amount of injections is variable depending on the patient in terms of muscle bulk and definition. This treatment is best suited to patients with early signs of the ageing neck, in particular mild jowling and platysmal bands. Assessment includes visualising contraction of the platysmal bands, which is best achieved by asking patients to bite down on their back teeth. The bands are injected vertically along the neck. It is essential that the depth of injection is intradermal to avoid diffusion of toxin into deeper structures of the neck, which can affect speech and swallowing.5 Dermal fillers Hyaluronic acid (HA)-based dermal fillers aim to replenish lost moisture and improve volume and elasticity, making them a suitable option for treating the delicate skin of the décolletage. Once treated, the skin appears plumper and the lines and wrinkles are effectively smoothed.6 Compared to traditional HA dermal filler injection, the treatment involves superficial microinjections of filler to create small blebs along the valley of wrinkle. Don’t be afraid to slightly overcorrect, as the cross-linked structure of the HA that is specifically formulated for skin boosters mean it is best suited to treat the skin in the delicate décolletage area. A slightly ‘over-corrected’ appearance will settle with time, and, in my experience, will actually give the best result. It is best to review the results after two weeks. Due to the large surface area of the décolletage, repeat treatments are often needed to achieve optimal and longer lasting results. The results generally last between six to nine months and how long they last depends on the condition of the skin initially, especially the degree of elasticity and depth of wrinkles.

Threadlift The threadlift offers an alternative to the traditional facelift in patients with concerns about sagging skin of the neck and jowl formation in the lower jaw. Threads are usually made from polydioxanone (PDO), which are inserted into the dermis to create a mechanical lift, which is maintained by collagen formation.7 There are two main types of thread: free floating cogged or barbed; and suspension threads, which need to be anchored to a stable structure of the face or scalp.8 The choice of thread is decided by the clinical indication, whether it is for skin rejuvenation or elevation of ptotic skin. In the case of the ageing neck, elevation of the drooping neck tissue against the effects of gravity is the main priority and is best treated with a PDO thread.

There are many different techniques that can be used. The number of points needed to create elevation is best decided on a case-by-case basis. Patient selection and management of patient expectations are essential. Threadlifting, however, has more potential side effects and downtime than injectables. The most common ones being: swelling, haematoma, seroma formation, infection, migration of the sutures, puckering and dislodging of the thread position which may result in asymmetry. If dislodging happens, then this will need review and possible correction.8 As with any aesthetic procedure, it is worth investing adequate time to ensure the patient fully understands the pros and cons, and that the risks and recovery time are acceptable to them before going ahead.

Devices There are many different devices on the market that have demonstrated results in the treatment of the ageing neck and décolletage. The specifics of each device are worthy of an individual

Aesthetics

write up to fully explain the complete mode of action. In summary, however, all devices share the same fundamental action: using thermal energy to create local heating of the dermis of the skin to stimulate fibroblast activity and increase collagen production in the subcutaneous tissues. The increased temperature results in contraction of collagen fibres, which causes contraction of the overlying tissues creating traction on the surface of the skin.9 The overall effect is to tighten and smooth the overlying skin, lifting out fine lines and wrinkles and improving the overall texture of the skin.

The different technologies include: • Radiofrequency • Ultrasound • Laser resurfacing with fractional CO2 laser Combination therapy Many of the treatments discussed work best synergistically, so it is useful to explore the option of combination treatment depending on the practitioner’s experience and patient choice.

Other treatments such as platelet rich plasma (PRP) therapy, mesotherapy, microneedling and skin peels can provide great alternative treatments or ‘add-ons’ to the patient treatment regime to support the rejuvenation process.

Summary Skincare and sun protection are fundamental to maintain the results of the chosen treatment and provide antiageing effects in the long term. Patient education is essential from start to finish of the patient’s journey through their treatment. Skincare, sun protection and lifestyle adaptations, mainly smoking cessation, diet and reducing alcohol intake are important to improve skin health and weight control, which all have an impact on the ageing process of the neck and décolletage.

The neck and décolletage are all too frequently forgotten when it comes to preventative treatment. As a result, aesthetic treatment in these areas will likely remain commonly sought-after. Although the neck and décolletage were traditionally challenging to treat, the emergence of high-tech devices, advanced techniques such as threadlifting, combined with the mainstay of injectables and optimum skincare, mean that the ageing neck and décolletage can be successfully treated with visible results.

Dr Jane Leonard is a GP and cosmetic doctor. She specialises in skin conditions, antiageing medicine and bio-identical hormones. Dr Leonard achieved a first class honours degree in Anatomical Sciences, specialising in head and neck. She has also spent time in dermatology research and has had her work published in Australia.

REFERENCES: 1. Scarborough et al, ‘Exploring Aesthetic Interventions: Treating the Sagging Jawline and Platysmal Banding: A Simplified Technique’, The Dermatologist, 15 1 (200) <http://www.the-dermatologist.com/ article/6765> 2. Mark M Hamilton, Anatomy and Physiology of the aging neck, Neck Rejuvenation, (2014) Elsevier, Pennsylvania 3. Leah Bourne, Another thing we have to worry about now: teck neck, StyleCaster, (2014) <http:// stylecaster.com/beauty/tech-neck/> 4. Phillip M Levy, ‘The ‘Nefertiti lift’: A new technique for specific recontouring of the jawline’. Journal of Cosmetic and Laser, Vol 9 (2007) 5. Chloé Gronow, Tightening the Neck, Aesthetics journal, (2016), <https://aestheticsjournal.com/feature/ tightening-the-neck> 6. Dr Aamer Khan, Treating the Décolletage, Aesthetics journal, (2015), <https://aestheticsjournal.com/ feature/treating-the-decolletage> 7. Otto, J, ‘PDO Threads for skin rejuvenation and facial tissue anti-ptosis,’ Body Language (2015).

8. Paola Rosalba Russo and Salvatore Piero Fundaro, The invisible face lift 2nd edition Manual of Clinical Practice, (2014) Officina Editoriale Oltrarno; Rome 9. Kathryn Senior, Jaw and Neck Rejuvenation, Aesthetics journal, (2014), <https://aestheticsjournal.com/ feature/jaw-and-neck-rejuvenation>

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

Aesthetics Awards Special Focus

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DON’T MISS YOUR CHA

ENTER NOW! WWW.AES TH E C E R E M ONY The prestigious Aesthetics Awards ceremony will take place on December 2 at the Park Plaza Westminster Bridge Hotel in central London. Around 700 guests will come together to celebrate best practice, outstanding customer service, training, innovation and clinical excellence in 2017. With a lively networking and drinks reception, delicious three-course meal, fantastic performance from a top comedian and, of course, the awards presentation itself, the evening is not to be missed! Submit your entry by June 30 for your hard work and achievements to be recognised this year.

“We hoped we’d succeed somehow, but winning was beyond our expectations so we’re delighted to take home this Award!”

Tania Pirazzini (Profhilo), winner of The Barry Knapp Award for Product Innovation, supported by Oxygenetix 2016

COMPANY AWARDS • • • • • •

Distributor of the Year Wholesaler of the Year (NEW) Best UK-based Manufacturer (NEW) Best UK Subsidiary of a Global Manufacturer (NEW) Best Clinic Support Partner (NEW) The Healthxchange Award for Sales Representative of the Year

PRODUCT AWARDS • • • •

Cosmeceutical Range/Skin Treatment of the Year The Harley Academy Award for Injectable Product of the Year Energy Treatment of the Year (NEW) The Barry Knapp Award for Product Innovation of the Year, supported

by Medical Aesthetic Group

TRAINING PROVIDER AWARDS • The Enhance Insurance Award for Best Independent Training Provider • Best Supplier Training Provider (NEW)

REGIONAL CLINIC AWARDS • • • • • •

The Cosmedic Pharmacy Award for Best Clinic Midlands & Wales The John Bannon Award for Best Clinic Ireland The Dermalux Award for Best Clinic London The iS Clinical Award for Best Clinic South England Best Clinic North England Best Clinic Scotland

Enhance Insurance

36

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Advice

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Support

Aesthetics | June 2017

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Aesthetics Awards Special Focus

ANCE TO WIN IN 2017!

STHETICSAWARDS.COM OTHER CLINIC AWARDS • • • •

HOW TO E NT E R

The AestheticSource Award for Best New Clinic, UK & Ireland The Profhilo Award for Best Clinic Group, UK & Ireland (3 clinics or more) The Alumier Labs Award for Best Clinic Group, UK & Ireland (10 clinics or more) The Consentz Award for Best Clinic Reception Team of the Year

CLINIC, COMPANY OR ORGANISATION AWARD • The PHI Clinic Award for Professional Initiative of the Year (NEW)

INDIVIDUAL PRACTITIONER AWARDS • The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year • The SkinCeuticals Award for Medical Aesthetic Practitioner of the Year • The Schuco International Award for Outstanding Achievement in Medical Aesthetics – the winner of this category will be selected by the Aesthetics team and announced at the ceremony. Entries are not accepted.

“The Aesthetics Awards shine a spotlight on excellence in our clinical practice. It’s our chance to differentiate ourselves in an unregulated market and to come together to celebrate. I definitely think everyone should enter.”

Frances Turner Traill, winner of The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year 2016

Aesthetics | June 2017

Visit aestheticsawards.com and click the ‘Categories’ tabs to view the wide range of categories you can enter!

Read the entry criteria of your chosen category carefully to submit the most valuable information Draft your answers offline and ask a friend or colleague to proof read them to check their readability and accuracy Submit your answers with supporting documents and images to provide a thorough application by June 30 Check the September issue of the journal or visit aestheticsawards.com on September 1 to see if you’re a finalist!

Late entries and/or amendments to entries will be charged an administration fee of £100+VAT per entry. Call 0203 096 1228 or email support@aestheticsjournal.com if you have any questions.

37

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Hyperpigmentary Disorders

TCA peel (33% but other percentages can be considered), topical creams, as described in the literature1,10 e.g. triple combination cream – fluocinolone acetonide 0.01%, hydroquinone 4% and tretinoin 0.05%; bleaching solution – 2% mequinol (4-hydroxyanisole, 4HA) and 0.01% tretinoin, intense pulsed light (IPL) treatment and lasers.

Dr Barbara Kubicka presents an overview of the main types of hyperpigmentary disorders and discusses her preferred approaches to treatment

Melasma

Hyperpigmentation is a very common skin condition that can affect patients of all skin types, genders and ages.1 It is a benign condition, but one should not underestimate the potential social and psychological impact of its cosmetic appearance. However non-threatening to health, it can be a distressing aesthetic concern, especially if the affected area is the face, which is obviously more difficult to conceal.

There are different types of hyperpigmentation depending on aetiology and manifestation. Each of them has a slightly different response to the treatment, so correct diagnosis is crucial to avoid difficulties and complications.

Genetic disposition to hyperpigmentation (especially in regards to melasma) is known as a key factor, so it is very important to gather a detailed family history; as hyperpigmentation is often the result of genetics combined with external or internal factors.2,3 While hyperpigmentation can affect patients of all skin types, it is more prevalent in those with Fitzpatrick skin types IV to VI.2,3 Epidemiology studies have suggested that hyperpigmentation is the most common reason that ethnic patients seek the help of dermatologists or an aesthetic physician.4-9 It is crucial to establish ethnic background in skin type assessment, especially with patients of mixed race.

Yet, for all patients, there is a common exogenous factor contributing to hyperpigmentation – the sun. Sun damage can be visible even years after exposure, hence, effective sun protection is a must for prevention and while treating hyperpigmentation.

In this article the key types of pigmentation disorders that are commonly seen within an aesthetic clinic and their causes will be outlined and the potential treatment options, together with potential risks and complications, will be Before discussed. An overview of these treatments and their potential side effects are summarised in Table 1.

Melasma, or chloasma faciei, is a symmetrical hyperpigmented lesion of the sun-exposed skin, characterised by hyperpigmented macules and irregular borders. Melasma is commonly associated with hormonal factors and is mostly prevalent among women.3,13 Only 10% of men suffer from melasma.14 There is an association between pregnancy and melasma – during pregnancy there is a visible increase of expression of oestrogen receptors on melanocytes. Furthermore, higher levels of oestrogen in the blood stimulate enzymes involved in melanogenesis, in particular TYR, TRP1 and TRP2.1 Melasma also becomes more visible after sun exposure as the melanocytes become enlarged.1 UV exposure results in persistent over expression of α-MSH (again responsible for activating melanocytes due to inflammatory processes) as well as elevations in inducible nitric oxide synthase (iNOS). This results in local increase of inflammation which leads again to melanocytes hyperactivation.3,1,3 There are three types of melasma, which are defined according to the area in which it appears on the face and the depth of the pigment. These include central facial melasma, malar melasma or mandibular pattern melasma, and the depth of pigment types include epidermal melasma, dermal melasma or mixed-type melasma. The second classification is more important to identify as it will influence the treatment process.3 Melasma treatment is extensive and can take years. To maintain the results of treatment, patients are likely to require long-term maintenance (more than a year) and a lifetime commitment to photoprotection with SPF application every day. The subject of melasma has been studied in detail and there are many evidencebased studies available, which can assist with choosing the most appropriate treatment methods.2,15-19 The following treatment protocol is a general guideline and has been recommended in literature.13 First line treatment First line topical treatment that affects the melanin synthesis pathway is usually recommended as followed: photoprotection and camouflage, topical agent hydroquinone (HQ), triple combination therapy – 4% HQ, 0.05% tretinoin and 0.01% flucinodone acetonide (as a modification of Kligman’s Formula).13 After

Solar lentigines The most common and recognised hyperpigmentation disorders are solar lentigines,10 usually referred to as age or liver spots.

These are small, superficial patches of darker pigmentation, presented on exposed parts of the body – most commonly on the hands, face and décolletage. They vary in size and number and tend to increase with age. They are relatively easy to treat and there are a variety of different treatment approaches to consider, which can include, but are not limited to:1,10 cryotherapy;11

Figure 1: Patient presenting with lentigines pigmentation before and four weeks following last treatment using IPL (three sessions, three weeks apart) and 20-35% TCA peel (two sessions).

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Suitable fo Solar Lentigines

Suitable for Melasma

Suitable for PIH

Cryotherapy

YES

NO

NO

Post-treatment hypopigmentation/hyperpigmentation

Topical creams

YES

NO

NO

Post-treatment hypopigmentation/hyperpigmentation

Bleaching solution

YES

YES

YES

Post-treatment hypopigmentation/hyperpigmentation

Chemical peels, light therapy, IPL, Lasers

YES

YES

YES

Burns are an immediate outcome that can leave scarring in the form of hyper or hypopigmentation

Treatment

Potential Side Effects

Hydroquinone (HQ)

NO

YES

YES

Dermatitis • Nail discolouration • Permanent leukoderma • Hypopigmentation • Ochronosis

Retinoids

NO

YES

YES

Dermatitis

Azalic acid 20% cream

NO

YES

YES

Mild irritation

Kojic acid 1.4%

NO

YES

YES

• Dermatitis • Increase of skin sensitivity

Arbutin

NO

YES

YES

• Minimal irritation • Hyperpigmentation after higher dose

Niacinamide

NO

YES

YES

No studies regarding safety on darker skin types. Minimal irritation.

N-acetyl glucosamine

NO

YES

YES

Very mild skin irritation

Ascorbic acid

NO

YES

YES

Mild irritation

Liquorice

NO

YES

YES

Minimal irritation

Soy

NO

YES

YES

Currently being studied

Figure 2: Summary of treatments and their potential complications and adverse reactions. YES indicates the treatment would be considered for that particular indication.2,9,28 Before

After

Third line treatment Third line treatment uses IPL and laser. IPL is usually effective only on superficial melasma.13 The use of more advanced lasers or combination lasers for melasma and post-inflammatory hyperpigmentation (PIH) still requires more research, which is currently being conducted.20

Combination treatments Other topical depigmentation agents can also be used in combination with any of the previously mentioned procedures. They are substances that have been described in literature such as azeliac acid 20% cream,2 kojic acid 1-4%,2 arbutin, niacinamide, N-acetyl glucosamine, ascorbic acid, liquorice and soy.2,21 When it comes to chemical Figure 3: Patient presenting with lentigines pigmentation before and after treatment using three courses of 20-35% TCA peel, six weeks apart. Picture taken eight weeks after last treatment. peels, I prefer to use combination products like MeLine, Dermamelan and Cosmamelan, Second line treatment which are readily available preparations that are a blend of As a second line treatment, chemical peels can be used bi-weekly, many depigmenting agents and should be used as a second with the strength depending on skin type. The exact strength will be line treatment.20,22 In my experience, the combination treatment depending on the patients’ preparation prior to the chemical peel. allows for a reduction of side effects and improved results, The darker the skin, the weaker the chemical peel needs to be to be as well as a safer profile in skin of colour as there is a lower used safely. The most commonly used in chemical peels are glycolic percentage of acids that increase the risk of post-inflammatory acid 20-70%, lactic acid, salicylic acid 20-30%, TCA, tretinoin, phytic hyperpigmentation.23-26 I have also noticed an interesting trend of acid, and mandelic acid. The substance used will be dependent on combining plasma-based devices with depigmenting agents to skin type, sensitivity, ethnic background and skin preparation.13 increase transdermal penetration of products, thus increasing the

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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After

Figure 4: Patient presenting with melasma before and after a combination treatment of 12 weeks using IPL and TCA peel MeLine and hydroquinone.

absorption of the active substance. However, this hasn’t yet been studied in much detail.

Post-inflammatory hyperpigmentation PIH occurs as a result of inflammation or injury.2 It can also be induced as a side effect of certain medicines and even of certain cosmetic treatments.

This is an acquired condition that can affect all skin types, although Fitzpatrick skin types IV-VI are affected more often and potentially with greater severity, raising the possibility of a psychosocial impact on the patient.2 A family history of PHI, medications that cause sensitivity to light, and prolonged use of bleaching products are also known to cause or increase the risk of PIH.12,27 In addition, fungal or viral skin infections, allergic reactions, contact dermatitis or rashes can trigger a rise in melanocyte activity, which are stimulated by prostanoids, cytokines, chemokines, and other inflammatory mediators, as well as reactive oxygen species that are released during the inflammatory process, leading to PIH.2 The first step in managing PIH is to understand and treat the underlying cause. This is also important in determining an appropriate treatment that will not exacerbate the condition, for example, by using skin preparations that are too strong, causing dermatitis. Early treatment is likely to lead to faster results and prevent further hyperpigmentation. After treating the underlying cause, current research indicates the same algorithm as the treatment of melasma.

Side effects and complications There are several possible complications and side effects for hyperpigmentation treatments, which are briefly outlined in Figure 2.

Conclusion

Aesthetics Dr Barbara Kubicka completed her medical qualifications with a two-year postgraduate course in Aesthetic Medicine at the College International de Medicine Esthetique in Paris. Her early career included NHS, but since 2010 she has worked full time as an aesthetic physician. She founded clinicbe in 2012 with a uniquely holistic philosophy, combining skin and healthcare.

REFERENCES 1. Reinhart Speeckaert, Mireille Van Gele, Marijin M, Speeckaert, Jo Lambert, Nanja Van Geel, ‘The biology of hyperpigmentation syndromes’, Pigment Cell & Melanoma Research, 2014 p.512–524.

2. Erica C Davis, Valerie D Callender, ‘Postinflammatory Hyperpigmentation, A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color’, The Journal of Clinical and Aesthetic Dermatology’, 2010, 3(7) pp.20-31.

3. Ai-Young Lee, ‘Recent progress in melasma pathogenesis’, Pigment Cell & Melanoma Research’, 2015 p.648–660.

4. Goh, C.L., Dlova, C.N, ‘A retrospective study on the clinical presentation and treatment outcome of melasma in a tertiary dermatological referral centre in Singapore’, Singapore Med J, 1999;40:455– 458.

5. Moin, A, Jabery, Z, Fallah, N, ‘Prevalence and awareness of melasma during pregnancy’, Int J Dermatol, 2006;45:285–288.

6. Achar, A, Rathi, S.K, ‘Melasma: a clinico-epidemiological study of 312 cases’, Indian J Dermatol, 2011;56:380–382.

7. Tamega Ade, A, Miot, L.D., Bonfietti, C, Gige, TC, Marques, ME, Miot, HA, ‘Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women’, J Eur Acad Dermatol Venereol, 2013;27:151–156.

8. Handel, AC, Lima, PB, Tonolli, V., Miot, LD, Miot, HA, ‘Risk factors for facial melasma in women: a case-control study. Br J Dermatol. 2014;171:588–594.

9. KrupaShankar DS1, Somani VK, Kohli M, Sharad J, Ganjoo A, Kandhari S, et al. ‘Cross-sectional, multicentric clinico-epidemiological study of melasma in India’, Dermatol Ther, 2014.

10. Lance H Brown, ‘Treating Solar Lentigines: Traditional treatments at a glance – plus a look at a cutting-edge option’, The Dermatologist, 2002.

11. Robert A Schwartz, ‘Lentigo Treatment & Management’, Medscape, 2016.

12. Halder RM, Grimes PE, McLaurin CI, et al, ‘Incidence of common dermatoses in a predominately black dermatologic practice, Cutis, 1983;32:388–390.

13. Krupa Shankar, Kiran Godse, Sanjeev Aurangabadkar, et al, ‘Evidence-Based Treatment for Melasma: Expert Opinion and Review’, Dermatology and Therapy, 2014, 4(2) p.165-186.

14. Gertrude-Emilia Costin, Stanca-Ariana Birlea, ‘Is There An Answer? What is the mechanism for melasma that so commonly accompanies human pregnancy?’ IUBMB Life, 2006.

15. Kimbrough-Green CK, Griffiths CE, Finkel LJ, et al, ‘Topical retinoic acid (tretinoin) for melasma in black patients. A vehicle-controlled clinical trial’, Arch Dermatol, 1994;130(6):727–733.

16. Haddad AL, Matos LF, Brunstein F, Ferreira LM, Silva A, Costa D, Jr, ‘A clinical, prospective, randomized, double-blind trial comparing skin whitening complex with hydroquinone vs. placebo in the treatment of melasma’, Int J Dermatol, 2003;42(2):153–156.

17. Kang WH, Chun SC, Lee S, ‘Intermittent therapy for melasma in Asian patients with combined topical agents (retinoic acid, hydroquinone and hydrocortisone): clinical and histological studies’, J Dermatol, 1998;25(9):587–596.

18. Godse KV, ‘Triple combination of hydroquinone, tretinoin and mometasone furoate with glycolic acid peels in melasma’, Indian J Dermatol, 2009;54(1):92–93.

19. Chan R, Park KC, Lee MH, et al, ‘A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma’, Br J Dermatol, 2008;159(3):697–703.

20. Pooja Arora, Rashmi Sarkar, Vijay K Garg, Latika Arya’, ‘Lasers for Treatment of Melasma and Post-Inflammatory Hyperpigmentation’, Journal of Cutaneous and Aesthetic Surgery, 2012, 5(2) p.93–103.

21. Bahareh Ebrahimi, Farahnaz Fatemi Naeini, ‘Topical tranexamic acid as a promising treatment for melasma’, Journal of Research in Medical Sciences, 2014 19(8) p.753-757.

22. Aleksandr Kuradovets , Luisa Leon , Victor Garcia Guevara , Fernando Bouffard Fita, ‘Innovation in the concept of controlled chemical dermabrasion: ME LINE, with depigmenting, rejuvenating and recovering effects on phototypes I-IV?’, Clinical Study 2015.

23. Taylor SC, Torok H, Jones T, et al, ‘Efficacy and safety of a new triple-combination agent for the treatment of facial melasma’, Cutis, 2003;72(1):67–72.

24. Sarkar R, Kaur C, Bhalla M, Kanwar AJ, ‘The combination of glycolic acid peels with a topical regimen in the treatment of melasma in dark-skinned patients: a comparative study’, Dermatol Surg, 2002;28(9):828–832.

25. Grimes PE, ‘The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups’, Dermatol Surg, 1999;25(1):18–22.

26. Balina LM, Graupe K, ‘The treatment of melasma, 20% azelaic acid versus 4% hydroquinone cream’, Int J Dermatol, 1991;30(12):893–895.

27. Song JY, Kang HA, Kim MY, et al, ‘Damage and recovery of skin barrier function after glycolic acid chemical peeling and crystal microdermabrasion’, Dermatol Surg, 2004; 30:390–394.

28. Rita Lee, ‘How to Treat Hyperpigmentation – A Review of Brightening Ingredients’, Just about Skin, 2014.

Hyperpigmentation is, in many cases, a lifetime condition, therefore it is important to be able to offer our patients a variety of treatments that are effective and safe and that will not cause further skin damage. Furthermore, with an increasing number of cosmetic procedures, we start to see more and more post-treatment hyperpigmentation, so awareness of potential risk factors (darker skin types, family history, medications that cause sensitivity to light, and prolonged use of bleaching products) is as important as the treatment itself.

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Cellular Matrix ÂŽ hydration & regeneration

The Patientâ&#x20AC;&#x2122;s Platelet Rich Plasma combined with Hyaluronic Acid for Skin Regeneration

0845 5050601 www.rosmetics.co.uk 53 Worcester Road, Bromsgrove, B61 7DN United Kingdom

0041 21 864 01 11 www.regenlab.com En Budron B2, CH - 1052 Le Mont Switzerland

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Case Study: Combining PRP, HA and Succinic Acid Dr Daniel Sister describes the benefits of combining platelet-rich plasma with hyaluronic acid and succinic acid to treat the signs of ageing, and presents a clinical case study of successful results As aesthetic practitioners, we now have a sound understanding of how the face ages, as well as many adequate treatment options at our disposal. However we are still searching for ways in which to further improve skin quality and correct skin damage.

In order to continue developing treatment options, I decided to conduct a trial with the objective of evaluating the benefits of mixing three ingredients, platelet rich plasma (PRP), hyaluronic acid (HA) and succinic acid. My aim was to deliver a successful treatment option that tackles both the ageing of the face and the quality of the skin, which I will discuss in this article.

Hyaluronic acid We know the significance and limitations of injecting HA into the skin. HA is a glycosaminoglycan, a natural substance existing in the body that is made up of disaccharide units. It can recreate some volume and increase the amount of collagen in the dermis through fibroblast stimulation. This ‘revolumisation’ also promotes water retention at various levels, increasing skin turgor and hydration. Unfortunately, these benefits are only short term and HA only temporarily replaces the volume from the continuously disappearing collagen and elastin, but does not re-create it.1 Multiple elements are involved in the ageing of the face, which are not limited to collagen and fibroblast depletion. Fat loss and bone resorption are also a cause of ageing, and in order to tackle this more effectively, we need more than HA.

PRP PRP is not a volumetric filler but a biological cell therapy that uses the patient’s own platelets and enriched plasma. PRP is defined as a high concentration of the patient’s blood platelets in a small volume of plasma.2 We recognise that PRP enhances cell proliferation over the short term and induces cell differentiation of fibroblast-like cells to myofibroblast-like cells in the long term, suggesting that fibroblast differentiation to myofibroblasts may underline the action mechanism of PRP in soft tissue regeneration.

PRP also aims to stimulate the osteoblasts, therefore having a positive effect upon the bone resorption. Moreover, the different growth factors contained in PRP (explained below) will also aim to generate a transitory neo-vascularisation.2 Platelets contain a variety of small molecules, also known as growth factors or cytokines, which interact with local cells and even send signals that initiate a variety of important events,

such as cell division and migration.2 The growth factors promote tissue healing and bio-cellular regeneration, and were discovered in 1953. In 1986, Italian developmental biologist Rita LeviMontalcini and American biochemist Stanley Cohen won a Nobel prize for demonstrating how the growth and differentiation of a nerve growth factor and epidermal growth factor is regulated.3 Now we know of more than 30 different growth factors, but the most important ones for aesthetic rejuvenation are:

Platelet Derived Growth Factor (PDGF-AA, PDGFBB, PDGF-AB) Characteristics:2 • Chemoattractive to mesenchymal stem cells and endothelial cells (meaning that it will recruit immune cells into the damaged tissue) • Differentiates between fibroblasts and osteoblasts • Up-regulates effects of other growth factors on cells such as macrophages • Promotes the synthesis of the extra cellular matrix through mitogenes of mesenchymal stem cells Transforming Growth Factor Beta (TGF beta 1, TGF beta 2) Characteristics:5,6 • Promotes cell mitosis • Improves the synthesis of collagen • Has a sheath fibroblast • Stimulates the DNA synthesis, proliferates various types of cells Vascular Endothelial Growth Factor (VEGF)7 Characteristics: • Stimulates angiogenesis • Chemoattractive for osteoblast Epidermal Growth Factor (EGF)8 Characteristics: • Plays an important role in the regulation of cell growth, proliferation, and differentiation by binding to its receptor EGFR • Induces epithelial development and promotes angiogenesis • Stimulates proliferation and differentiation of epidermis cells, costimulating angiogenesis PRP-combination studies In 2016, a study published in the Journal of Cosmetic Dermatology looked at varying degrees of facial ageing signs in 94 female patients, who were treated with PRP and HA. The combination was injected into the deep dermis and hypodermis.9 Patients were asked to rate their personal satisfaction with their skin texture, pigmentation, and sagging. In addition, the overall results were rated by three independent physicians and the patients themselves. The outcomes were peer-reviewed and correlations between the degree of the aesthetic scores and the number of injections were explored. Compared to the baseline, the PRP and HA injections provided clinically visible improvement on facial skin.

Also of interest is the publication by Liu Yawei et al that studied the influence of PRP lysates on fibroblast proliferation. Cells were exposed to platelet lysates that had been pre-incubated at pH levels 5.0, 7.1 and 7.6. Platelets pre-incubated in an acidic

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environment of pH 5.0 induced the highest degree of fibroblast proliferation, indicating that a low pH can stimulate fibroblast proliferation, which supports the concept of mixing PRP with a low pH acid HA.10

Sodium succinate Although studies such as the ones above have indicated that mixing PRP and HA offers a satisfactory treatment for skin ageing, there is another factor to take into consideration.11 As we age, there is a natural accumulation of free radicals both in and under the skin, which will result in a deterioration of the colour and texture of facial skin, causing premature ageing by damaging the cells and their DNA.12 There is research that investigates skin pigmentation treatment from a chemical point of view.13 These findings point towards succinic acid as a possible treatment. As succinic acid is a dicarboxylic acid with metal-chelating potential and a particular affinity to copper, it was suggested that it also could reduce pigmentation by acting on the enzyme, tyrosinase, which controls the production of melanin.14,15 Copper has a vital role in the activity of this enzyme and the chelation of the copper in the tyrosinase will aim to effectively block the enzyme activity, therefore engineering complete enzyme function loss and restricting the production of melanin and, thus, the development of pigmentation.26 As succinic acid is a weak acid (only partly ionised) it also has an antioxidant action; this was demonstrated in an experiment on Wistar rats,18 where the succinate was able to modulate the intensity of the antioxidant effects. When sodium succinate is introduced into the dermis, it releases succinic acid, which, as demonstrated in the study, will develop its antioxidant activity. The mechanism is an inhibition of the free oxygen radicals (melanic effect), and of the oxidising action of the tyrosinase (needed for the processing of the tyrosine and then dopamine).19 Succinic acid – which has the same action as ascorbic acid –will decrease the intensity of the melanin colour from the oxidised state (black), and in the reduced state (brown).20 Dr Reza Mia conducted an in vitro trial combining HA and sodium succinate. He suggested that, when combined, they act synergistically to stimulate fibroblast cells in both number and metabolic activity. The result was greater when compared to HA mono-component therapy.21 He concluded, “The effect on the metabolic processes can include strengthening cellular respiration, normalising ion transport, increasing protein synthesis and increasing energy production, through the stimulation of the Krebs cycle in mitochondria.”21 Cellular respiration takes place in the mitochondria through the Krebs cycle. This is where and when pyruvate is transformed from glycolysis to produce nicotinamide adenine dinucleotide (NADH) and adenosine triphosphate (ATP), which requires a succession of reactions and intermediate molecules. Succinate is one such molecule forming the complete chain in the cycle.23,24 The result of the Krebs cycle is the restoration of a cell’s function, improvement in skin elasticity, firmness and tightness, improvement in colour and texture and also a diminution of skin-ageing signs.

Combining the three The ageing of the face is a result of a combination of different factors and therefore requires a combination of ‘tools’, summarised below: • For dehydration and volume loss: As the main goal of HA is to

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increase the collagen amount and density in the skin, thereby increasing hydration and volume, it is logical to use this as a scaffolding.

• For deceleration of the metabolism: Succinic acid aims to stimulate the Krebs cycle and its use should reverse this deceleration and improve both the fibroblasts and their metabolic processes, as well as fighting pigmentation.21 • Slowing down or stopping bone resorption: One of the major roles of PRP is to slow down or stop bone resorption on the eye sockets and mandibular line, while stimulating the collagen formation. It also aims to improve the muscle tone and vascularisation.2

Case study protocol In my study (February 2017), a group of 14 patients were recruited.

The patients were female, aged 35 to 65, not pregnant, not breastfeeding and not having any other treatment for skin pigmentation or skin improvement during the time of the study.

The two projected aims were as follows: 1. That PRP would improve the dermal-epidermal layer of the skin and collagen formation due to the growth factors present in the plasma.

2. That hyaluronic acid associated with succinic acid (stimulation of the Krebs cycle) would also improve the collagen, with an added action to treat the skin pigmentation and elasticity.

The patients were treated on the right side of the face with 5ml of PRP. On the left side of the face the same patients had the combination treatment of 3ml of PRP and 2ml of a 1.1% combination of HA and succinic acid (Xela Rederm) mixed together via a twoway connector (a small tube with one hole at each end, allowing to fix a syringe at each end, in order to mix both contents). The trial treatment consisted of one treatment session only, with PRP alone and PRP mixed injections (with HA and succinic acid) using a 30G needle, spread evenly following my protocol (for both sides of the face): • First, the products are injected deep, in contact with the periosteum under the eyes, to improve the eye socket and the under-eye pigmentation, then along the jawline and into the nasolabial folds to stimulate the osteoblasts.

• The products are then injected intramuscularly into the cheeks, crow’s feet, glabella and platysma bands. Then, more superficially subdermally, in the style of mesotherapy.

• Finally, the remaining product is rubbed into the skin through the microinjection points using the glove (not gauze).

The entire group was evaluated before treatment, two weeks later, and again four weeks later. Patient consent forms were recorded, as well as the following: • Photographs were taken under normal, UV and polarised light, always in the same position and exposure to produce objective results.

• Analysis of collagen, hydration, pigmentation, elasticity and erythema were performed with a skin analysis machine above the temporal area and the zygomatic area on the right and left side (at each point three measurements were taken, to create an average). The measurements were taken by the same technician, in the same room, with the same conditions to offer

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additional objective results.

• Patients were asked what they thought of their skin improvement and to rate it on a scale from 1 to 10 (10 being the best) to provide subjective results.

Risks and complications As PRP is an autologous product, there is no known risk of allergy, lumps, granuloma or asymmetrical results. Moreover, PRP is bactericidal, which decreases the risk of infection.25 As with any injection, patients taking any type of medication that could increase bleeding (e.g. anti-coagulants, aspirin, omega 3, evening primrose oil) should take extra precautions and be made aware of the risk. Patients with known sensitivity or allergy to HA or succinic acid should be tested before using the product.

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Results On the subjective patient appreciation scale, when asked (in private) to note their skin condition and improvement, all 14 patients gave a firm positive answer, noting the amelioration of their skin one week post treatment. On a scale from 0 to 10, they all graded the treatment at ‘8’ on how happy they were with the condition and improvement of their skin, and some also mentioned receiving favourable comments from friends or family, while others volunteered to write testimonials.

In regards to the pictures taken, we noted that there was a clear diminution of the pigmentation, a fuller face aspect, and a definite healthier look. Under UV light the pigmentation improvement was even more obvious.

However, even more obvious are the objective results. Below are the average of three measurements on two different points (zygomatic and eye areas) both on the right side (PRP alone) and left side (PRP,

100

Average HYDRATION (R+L ZYGO)

Average ELASTICITY (R+L ZYGO)

79.24 71.06

72 61.17 54

70.35

59.98

72.76

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78.44 72.51 69.46

(L Zygo)

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80.41

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65.07

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15

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36 0

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35.61 35.2

(L Eye) 30.57

30.22

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Figure 1: These graphs show the results for the patient’s left and right side of the face in the four core areas; hydration, elasticity, erythema and pigmentation

18

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9

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Disclosure: Dr Daniel Sister is the creator of the Dracula PRP Therapy treatment.

Dr Daniel Sister is a cosmetic, antiageing and hormone specialist. Since receiving his medical doctorate at the Paris Medical School, he has built a global reputation specialising in minimally invasive antiageing procedures. Dr Sister appears regularly on television and radio and has written a number of books including Your Hormone Doctor, with Leah Hardy and Susie Rogers.

Figure 2: Patient 1 before treatment (day 0), after first treatment (day 14) and after second treatment (day 20). Redness is significantly reduced leaving a more even complexion. It should be noted that the patient went for a one week vacation without using correct sun screen just after the first treatment – the excess of pigmentation shown in image 1 cleared without any other treatment right after.

Day 0

Day 14

Day 20

Figure 3: Patient 2 before treatment (day 0), after first treatment (day 14) and after second treatment (day 20).

Day 0

Day 14

Day 20

Figure 4: Patient 3 before treatment (day 0), after first treatment (day 14) and after second treatment (day 20). Note the skin is more plump and healthier in appearance.

HA and succinic acid) (Figure 1). The first conclusion of the study is that PRP alone, when injected correctly (deep/medium deep/sub dermal) does objectively improve the skin on all parameters (elasticity, hydration, pigmentation and erythema). The second point is that it works much faster than was previously thought; starting one week after treatment and continuously improving during the whole month and thereafter. Finally, it is apparent that the addition of HA and succinic acid to the PRP generates an even greater improvement, which, in my opinion, validates the concept of mixing the products. All patients’ photos on individual measurements are on file. All treatments were well tolerated and no side effects were reported.

Conclusion Our patients are always seeking new treatments that maximise results whilst minimising both cost and the number of treatments required. From a practitioners’ perspective we often treat using a range of products in order to provide synergistic effects. Patients can have a number of different requirements from a treatment, therefore, those treatments that address more than one concern are increasingly popular. The addition of succinic acid to a HA filler, which is then mixed with plasma, delivers a new and valuable treatment which targets multiple signs of ageing on the face, whist minimising the number of injections required.

In the future I intend to perform further research on the effects of combining PRP with HA and succinic acid on the treatment of scars.

REFERENCES 1. Ramos-Torrecillas J, Luna-Bertos Ed, Manzano-Moreno FJ, García-Martínez O, Ruiz C, Human fibroblast-like cultures in the presence of platelet-rich plasma as a single growth factor source: clinical implications.

2. Angela M. Duffy, David J. Bouchier-Hayes, & Judith H. Harmey, Vascular Endothelial Growth Factor (VEGF) and Its Role in Non-Endothelial Cells: Autocrine Signalling by VEGF, Madame Curie Bioscience Database, (2017) <https://www.ncbi.nlm.nih.gov/books/NBK6482/> 3. Nobel prize, The Nobel Prize in Physiology or Medicine 1986, (2017) <http://www.nobelprize.org/ nobel_prizes/medicine/laureates/1986/press.html> 4. T F Deuel & J S Huang, Platelet-derived growth factor. Structure, function, and roles in normal and transformed cells, J Clin Invest (1984) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC425220/> 5. UniProt, UniProtKB - P61812 (TGFB2_HUMAN) (2017) http://www.uniprot.org/uniprot/P61812 6. UniProt, UniProtKB - P01137 (TGFB1_HUMAN) (2017) <http://www.uniprot.org/uniprot/P01137 7. Angela M. Duffy, David J. Bouchier-Hayes, & Judith H. Harmey, Vascular Endothelial Growth Factor (VEGF) and Its Role in Non-Endothelial Cells: Autocrine Signalling by VEGF, Madame Curie Bioscience Database, (2017) 8. Sandra A. Carson, Robin Chase M.S, Elena Ulep B.S, Antonio Scommegna, Robert Benveniste, Ontogenesis and characteristics of epidermal growth factor receptors in human placenta, American Journal of Obstetrics and Gynecology <http://www.sciencedirect.com/science/article/ pii/0002937883902491> 9. Betul Gozel Ulusal, Platelet-rich plasma and hyaluronic acid - an efficient bio stimulation method for face rejuvenation, Journal of Cosmetic Dermatology, sept 5 (2016) vol 6, issue 1, 112-119 10. Yawei Liu, Anders Kalen, Olof Risto and Ola Wahlstrom, Fibroblast proliferation due to exposure to a platelet concentrate in vitro is pH dependent, Wound Rep Reg (2002): 10: 336-340 11. Berezoskiy, V.A, et al, ‘Connected to the question of human skin physiological renovation,’ The Ukrainian magazine of dermatology, venereology & cosmetology, 3(2011).

12. Zarubina, Lukk, Shabarov: Antihypoxic and antioxidant effects of exogenous succinic acid and aminothiol succinate containing antihypoxants. Bull. Exp. Bio. Med. 2012: 153(3) 336-9 13. Domingoa jl, Gómeza M, Llobeta JM, Corbellab J. Citric, malic and succinic acids as possible alternatives to deferoxamine in aluminum toxicity. Journal of Toxicology: Clinical Toxicology 1988; 26(1-2) 14. Olivarez G, Solano F, Garcia Barron JC: conformation dependant post translational glycosylation of tyrosinase. Journal of Biological Chemistry 2003. 278. 15735-15743 15. Uchidaa R, Ishikawaa S, Tomodaa H: Inhibition of tyrosinase activity and melanin pigmentation. Acta Pharmaceutica Sinica B2014-4 (2) 141-145 16. Cohen BE, Elbuluk N. Microneedling in skin of color: A review of uses and efficacy. J Am Acad Dermatol 2016; 74(2): 348–55 17. Tsepkolenko V, Medvedeva I. Redermalization: Results and Prospects. Les nouvelles esthetiques 2010; 5 (63) 18. Antihypoxic and Antioxidant Effects of Exogenous Succinic Acid and Aminothiol Succinate-Containing Antihypoxants. IV Zarubina et al Bull Exp Biol Med 153 (3), 336-339. 7 2012.

19. Olivarez G, Solano F, Garcia Barron JC: conformation dependant post translational glycosylation of tyrosinase. Journal of Biological Chemistry 2003. 278. 15735-15743 20. Uchidaa R, Ishikawaa S, Tomodaa H: Inhibition of tyrosinase activity and melanin pigmentation. Acta Pharmaceutica Sinica B2014-4 (2) 141-145 21. Dr Reza Mia, Combining HA with Sodium Succinate, Aesthetics journal, (2016) 22. Holt, Z. (2012) ‘Krebs Cycle Broken Down’, <http://understandingbiologyandlife.blogspot. co.za/2012/12/krebs-cycle-broken-down.html> 23. Chemisty for Biologists, Royal Society of Chemists (2017) <http://www.rsc.org/Education/Teachers/ Resources/cfb/respiration.htm> 24. Liskina I.V. et al., ‘Comparative Clinical-morphological research of the effects made on skin by hyaluronic acid containing substances’, The Ukranian Magazine of Dermatology, Venerology & Cosmetology, 2(2010) 25. Lorenzo Drago, Monica Bortolin, Christian Vassena, Silvio Taschieri and Massimo Del Fabbro, Antimicrobial activity of pure platelet-rich plasma against microorganisms isolated from oral cavity, BMC Micrbiology, (2013) http://bmcmicrobiol.biomedcentral.com/articles/10.1186/1471-2180-13-47 26. Chen Z, Mayer LM, Weston DP, Bock MJ, Jumars PA, Inhibition of digestive enzyme activities by copper in the guts of various marine benthic invertebrates, Environ Toxicol Chem, (2002) <https:// www.ncbi.nlm.nih.gov/pubmed/12069309>

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Using Skincare During Pregnancy and Breastfeeding Dr Charlene DeHaven details which common skincare ingredients to avoid during pregnancy and when breastfeeding It is understandable that patients who are expecting may be concerned about issues accompanying those special times of life not directly related to the pregnancy or post-pregnancy period. Skin problems, such as acne, tend to be more recurrent and are a response of the pilosebaceous unit to androgen levels,1 and therefore questions may arise about which skincare products can be used safely.

Concern related to topical products depends upon ingredient penetration through the skin to the developing foetus in the case of pregnancy, or to the infant in the case of breastfeeding (lactation). There are a few exceptional ingredients that will be discussed below but, in general, most skincare products are not absorbed through the skin into the body as a whole, therefore not of concern.

Stratum Corneum

Stratum Lucidum.

Stratum Granulosum

Stratum Spinosum.

Stratum Basale.

Efficiency of the skin barrier The skin is biologically designed as a barrier and it is quite efficient at ‘keeping things out’, including substances placed on it, and also at ‘keeping things in’, such as bodily fluids. The cornified envelope, the outermost layer of stratum corneum, is particularly impermeable to substances.2,3 As cells of the epidermis move upward during their normal transit from basal layer to stratum corneum, they extrude their intracellular contents and nuclei. The term ‘cornified’ refers to an almost horny layer, composing the outermost skin that is formed from lipid-rich (fatty) material, from which water has evaporated, leaving a cornified or horny coating that composes our outermost skin. The cornified envelope, if viewed under magnification, would show a horny-looking pattern of flattened skin cells surrounded by lipid-rich material. Furthermore, the epidermis has very few blood vessels compared to deeper layers of dermis. The combination of an efficient skin barrier and lack of vascularity means that topical penetration is difficult (Figure 1).

Dermis

Figure 1: The graphic above illustrates the efficient skin barrier of epidermis. Note the lack of blood vessels in this area.

Non-systemic design of topicals Despite an efficient skin barrier, some of the ingredients in high-quality skincare products are designed to penetrate the skin barrier and reach a site of action within the epidermal and dermal layers.

Skin penetration in these cases is difficult but not impossible with sophisticated formulation techniques. However, in contrast to medicines, skincare products are generally designed to be ‘non-systemic’ – a term referring to the fact that they are not delivered throughout the body by the circulatory network. Systemically delivered topical products are classified as medicines and fall into a different regulatory category.4 Thus, for most topical skincare products,

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systemic delivery of ingredients to the uterus and breast does not occur. Some exceptional cases will be discussed below. Because it is almost impossible for the end-user to know specifics about quality control or formulation techniques for individual skincare products, individual ingredients that are even potentially harmful are best avoided during pregnancy and lactation. During these times, even the smallest risk of toxicity related to possible systemic absorption is unacceptable.

For all of these ingredients, the overriding recommendation is for the pregnant or lactating woman to consult her general practitioner and reliably follow his/her specific recommendations for which concern for the patient is sincere.

If a patient misses a favourite skincare product during pregnancy or while nursing, remind them that these times of life are usually short and the use of the product may begin again after only a brief interlude.

Hydroquinone Hydroquinone should be considered unsafe during pregnancy and lactation. Its use during these times should be avoided because of potential toxic effects.5 Hydroquinone is widely used throughout the world as a skin lightening ingredient.

Hydroquinone fully penetrates the skin barrier, enters the capillary network of the circulation, and is systemically delivered.

It has been estimated that 35% to 45% is systemically absorbed following topical use in humans,6 and within a few minutes of skin application, hydroquinone levels are measurable in urine.7 Due to a lack of human studies, it has not been specifically proven that hydroquinone crosses the placenta but its molecular weight is small enough to potentially do so.8 A single study has been published involving the use of hydroquinone during pregnancy with no increase in adverse events, however, the sample size of pregnant women was small.9 Animal studies have been performed; maternal toxicity and foetal anomalies of weight and bone were shown but these doses were higher than the average human use.10 Even considering the lack of human studies, I believe the use of hydroquinone should be avoided during pregnancy and lactation due to its high absorption through the skin and general toxicity profile.

Vitamin A and tretinoin Topical vitamin A may be considered safe during pregnancy and lactation.11 However, because obstetricians are so wary of the

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teratogenic effects of very high doses of oral vitamin A, some will recommend avoiding all vitamin A products, including topical vitamin A, during pregnancy. Conversely, oral vitamin A is available in some countries in prenatal vitamins in doses of 1500 IU. The absolute amount of oral vitamin A required for teratogenicity is unknown but is most likely in the range of 20,000-50,000 IU, which is far above usual intake or even supplementation.

Birth defects have been associated with oral Vitamin A intakes of 25,000 IUs, although causality was not definitely proven. As a result, the Teratology Society recommends that, during pregnancy, vitamin A doses should be below 25,000 IU because of the risk of teratogenicity.12 However, as dietary amounts of vitamin A in pregnant adults living in developed countries exceed deficiency amounts, obstetricians do not recommend routine oral vitamin A supplementation.13 Information about tretinoin is somewhat conflicting. Under these circumstances, avoidance might be the safest option. The United States Pharmacopeia Dispensing Information recommends avoiding topical tretinoin during pregnancy.14 Some studies of women taking tretinoin during pregnancy revealed no difference in birth defects compared to women who had not taken it.13 Other sources have noted that birth defects have been found in women using tretinoin, thus providing suggestive evidence that topical tretinoin is a potential foetal developmental toxin14,15 It is difficult to find human data because studies involving humans are very rare, but ultimately, I believe it is best to avoid tretinoin.

Mention should be made of another oral vitamin A derivative, isotretinoin, that is absolutely to be avoided during pregnancy because it is so teratogenic.16 In fact, female patients taking isotretinoin for acne must use a very reliable method of contraception and have regular pregnancy tests for monitoring.17

Hydroxyacids Both beta hydroxyacids (BHAs) and alpha hydroxyacids (AHAs) are frequently used for acne treatment. Glycolic acid is probably the most frequently used AHA and its concentration, time of application, and overall formula pH may vary widely. All of these parameters will affect absorption through the skin but, even so, systemic absorption would be minimal at best.18 AHAs can be considered safe during pregnancy.19 Animal studies have been conducted with glycolic acid but do not apply to humans because the doses were so high and far out of proportion of anything

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considered even close to human use.17 Salicylic acid is the prototype BHA and the situation for topical use and potential toxicity in pregnancy or nursing is the same as for the AHAs. No human studies have been conducted but absorption is minimal at best.20 This is in contrast to therapeutic doses of oral salicylates that may be problematic to the foetal cardiovascular system, if taken during the third trimester of pregnancy.21

Considered safe Below are other ingredients and products patients may frequently use that they may feel concerned about using during pregnancy and nursing.

Benzoyl peroxide Benzoyl peroxide is also frequently used topically for acne in varying concentrations.

It is generally considered safe during pregnancy and lactation.22 Sunscreens Use of sunscreens is recommended during pregnancy and lactation, as in all other times of life.

The physical sunscreens zinc oxide and titanium dioxide are considered safe during pregnancy.21 Chemical sunscreens include two general classes – the PABA (para aminobenzoic acid) derivatives and the cinnamic acid derivatives. Even at doses higher than used in sunscreens, chemical sunscreen actives do not penetrate the skin barrier.21 Topical antibiotics Topical antibiotics are often prescribed for acne and the occurrence or severity of acne may increase during pregnancy.

These topical antibiotics are prescription products and classified as medicines rather than skincare topicals. Short term usage of topical antibiotics are considered safe during pregnancy.23 Levels of both clindamycin and erythromycin, both common antibiotics used for acne, are not detectable in the circulation following application.24,25

Summary Most topical skincare products are safe during pregnancy and lactation due to minimal absorption, related both to an efficient skin barrier and formulation design. A few topical products are exceptions and it is probably best to avoid these during pregnancy and nursing. Importantly, products containing hydroquinone and isotretinoin, and, most likely, tretinoin as well, should be avoided.

Dr Charlene DeHaven is a board-certified physician in both Internal Medicine and Emergency Medicine, with an emphasis on age management and health maintenance. She currently serves on the lecture faculty for the University of Washington Department of Family Medicine.

REFERENCES 1. Cooper AJ, Harris VR, Modern management of acne. Med J Aust. (2017) Jan 16;206(1):41-45.

2. Moore DJ, Rawlings AV, The chemistry, function and (patho) physiology of stratum corneum barrier ceramides. Int J Cosmet Sci. (2017) Mar 24. Doi: 10.1111/ics.12399. (Epub ahead of print) 3. Schmalling S, A better corneo. Skin Inc. (2016) Nov;64-67.

4. How delivery systems change skin care effectiveness. Ronert MA. Skin Inc. 2014 Jun. 5. US FDA Pregnancy Category C. Hydroquinone Cream. <www. drugs.com> 6. Pina Bozzo, Angela Chua-Gocheco and Adrienne Einarson, Safety of skin care products during pregnancy, Can Fam Physician, (2011) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3114665/> 7. RC Wester, J Melendres, X Hui, R Cox, S Serranzana, H Zhai, D Quan, HI Maibach, Human in vivo and in vitro hydroquinone topical bioavailability, metabolism, and disposition. J Toxicol Environ Health A. (1998) Jun 26;54(4):301-17.

8. GG Briggs, RK Freeman. Lippincott, Williams and Wilkins, Drugs in pregnancy and lactation. Hydroquinone. (2014).

9. Mahé A, Perret JL, Ly F, Fall F, Rault JP, Dumont A. The cosmetic use of skin-lightening products during pregnancy in Dakar, Senegal: a common and potentially hazardous practice. Trans R Soc Trop Med Hyg. 2007;101(2):183–7. Epub 2006 Oct 4.

10. Rockville MD, United States Pharmacopoeia Dispensing Information. United States Pharmacopoeial Convention. (1997).

US Pharmacopoeial Convention.

11. GJ Nohynek, WJ Meuling, WH Vaes, RS Lawrence, S Shapiro, S Schulte, W Steiling, J Bausch, E Gerber, H Sasa, H Nau, Repeated topical treatment, in contrast to single oral doses, with Vitamin A-containing preparations does not affect plasma concentrations of retinol, retinyl esters or retinoic acid in female subjects of child-bearing age, Toxicol Lett (2006) May 5. 163(1):65-76.

12. Teratology Society position paper: recommendations for Vitamin A during pregnancy. The Teratology Society. Teratology. 1987.

35:269-275.

13. Vitamins A, E, and K. Nutrition during pregnancy: Part I: weight gain. Part II: nutrient supplements. Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. 1990. Washington DC: National Academies Press.

14. L Shapiro, A Pastuszak, G Curto, G Koren, Is topical tretinoin safe during the first trimester? Canada Fam Physician. (1998) Mar. 44:495-8.

15. Are topical retinoids teratogenic? Veraldi S, Rossi LC, Barbareschi M. G Ital Dermatol Venereol. 2016 Dec. 151(6):700705.

16. Isotretinoin. US FDA Pregnancy Category X.<www.drugs.com> 17. ROACCUTANE Patient Information Leaflet, (2017) <http://www. leeclinicdermatology.ie/userfiles/Roaccutane%20Patient%20 Information%20Leaflet.pdf> 18. FA Andersen, Final report on the safety assessment of glycolic acid, ammonium, calcium, potassium, and sodium glycolates, methyl, ethyl, propyl, and butyl glycolates, and lactic acid, ammonium, calcium, potassium, sodium, and TEA-lactates, methyl, ethyl, isopropyl, and butyl lactates, and lauryl, myristyl, and cetyl lactates, Int J Toxicol. (1998) 17(Suppl1):1-241.

19. Bozzo P, Chua-Gocheco A, Einarson A , Safety of skin care products during pregnancy. Can Fam Physician. 2011 Jun. 57(6):665-667.

20. KF Rothman, PE Pochi, Use of oral and topical agents for acne in pregnancy, J Am Acad Dermatol. 1988. 19(3):431-42.

21. Aspirin. US FDA Pregnancy Category D, <www.drugs.com> 22. KF Rothman, PE Pochi, Use of oral and topical agents for acne in pregnancy, J Am Acad Dermatol. 1988. 19(3):431-42.

23. Chien AL, Qi J, Rainer B, Sachs DL, Helfrich YR, Treatment of acne in pregnancy. J Am Board Fam Med. (2016) Mar Apr. 29(2):254-262.

24. EJ Van Hoogdalem, TL Baven, I Spiegel-Melsen, IJ Trepstra, Transdermal application of clindamycin and tretinoin from topically applied anti-acne formulations in man, Biopharm Drug Dispos. (1998). 29(9):563-9.

25. JB Schmidt, R Knobler, R Neumann, C Poitschek. Z Hautkr, External erythromycin therapy of acne. (1983). 58(24):1754-60.

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Amplifying Laser Efficacy: Partnering with Vaniqa® (eflornithine) Insights & Key Learnings from the ACE Masterclass with Dr Maria Gonzalez In aesthetic practice, hair removal can be seen as a ‘peripheral’ service, yet in my clinic we are seeing a huge demand from patients, making it one of our top treatment offerings. I believe this trend is in part due to the significant cultural pressure on women to have less hair in general – let alone those who have been diagnosed with female facial hirsutism (FFH) which affects between 5 and 15% of women1 and can impact across a broad age range. I see lots of younger women in clinic who are upset by their facial hair. Unwanted facial hair is a major social issue: patients can become isolated and have a deep sense of shame some even have encountered hostility at work, so this is an issue I take very seriously.

Efficacy of Laser Hair Removal (LHR) LHR is an efficacious hair removal method and while many patients can achieve excellent results, there are limitations depending on patients’ skin and hair types which can mean some must still rely on additional methods of hair removal. I would classify around 30% of my patients as ‘difficult to treat’: these tend to have fair or red hair, or are perhaps in an older age category with white hair. It can also be difficult to achieve a satisfactory result for Asian patients using LHR alone, as these patients tend to have fine facial hair alongside darker skin tones (skin types 4 – 5). For these ‘difficult to treat’ patients, I believe it is important to consider adjunct therapies to amplify the efficacy of LHR. Amplifying Laser Efficacy: Partnering with VANIQA® (eflornithine 11.5% cream) For ‘difficult to treat’ patients who are not achieving sufficient results through LHR alone, we can now offer an additional adjunctive option in the form of VANIQA® (eflornithine 11.5% cream). VANIQA® is the only topical non-hormonal prescription FFH treatment proven to slow the growth of facial hair. This FDA-approved cream is suitable for all skin and hair types, including dark, coarse, and light vellus hair.2,3,4 Regrowth rates differ significantly between the face and other areas of the body: from three months on the legs, to as little as 4-6 weeks for facial hair regrowth - often leading to patient Adapted from Hamzavi et al, 2007 disappointment and 54

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frustration. VANIQA® offers practitioners a valuable option to help prolong the time between treatment and hair regrowth.

It works by inhibiting ornithine decarboxylase, preventing synthesis of polyamines which are essential for hair growth.4 As VANIQA® is not a depilatory cream, the specific method of action means it can be used alone or in combination with any other hair removal methods or treatments.2 When used in combination with LHR, VANIQA® is proven to enhance results: clinical studies have demonstrated a significant 30% improvement in results following LHR and VANIQA® combination treatments.5 When used twice-daily between and after laser hair removal treatments, VANIQA® delivers significantly faster, more complete results than LHR alone – meaning that patients were ‘hair-free’ for a longer time (vs LHR alone).5 Conclusion VANIQA® can provide a valuable adjunct treatment option for those patients who struggle to achieve excellent hair reduction results with LHR alone. As a simple twice-daily and cosmetically acceptable treatment, VANIQA® can be easily incorporated into patient’s skincare regimes and has a generally well-tolerated safety profile for long-term use.6 Consistency is key, so it’s important to manage patient expectations around usage and adherence to treatment, however in general I find that this treatment combination of VANIQA® and LHR delivers good results for those more challenging patients.

Find Out More Discover more about how VANIQA® can support your treatment approach for female facial hirsutism by visiting https://vaniqa.co.uk/ VANIQA® is available from Wigmore Medical: pharmacy@wigmoremedical.com T: 020 7491 0111 | F: 020 7491 2111

REFERENCES 1. Azziz R. Obstetrics & Gynae 2003; 101: 995-1007.

2. Shapiro J, Lui H. Skin Therapy Letter 2005/6; 10: 1-4.

3. Smith S, et al. Dermatol Surg 2006; 32: 1237-43.

4. VANIQA Summary of Product Characteristics. Available at: www.medicines.org.uk/emc/medicine/21243.

Accessed Mar 2017 5. Hamzavi I et al. J Am Acad Dermatol 2007; 57: 54-9.

6. Schrode K et al. Poster 294 presented at 58th AAD Congress, 2000, 10-15 March, San Francisco; USA,.

Aesthetics | June 2017

Job code: UKEFL3691b Date of prep: May 2017

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A summary of the latest clinical studies Title: Safety and Efficacy of Bilateral Submental Cryolipolysis With Quantified 3D Imaging of Fat Reduction and Skin Tightening Authors: Bernstein EF, Bloom JD Published: JAMA Facial Plastic Surgery, April 2017 Keywords: Cryolipolysis, submental fat, fat reduction Abstract: The study population consisted of 14 participants who were treated in the lateral and central submental area. A small-volume cup applicator was used to administer 2 cryolipolysis treatments, delivered in 45-minute treatment cycles in 2 sessions. For the first treatment session, all participants received bilateral treatments with approximately 20% overlap of the treatment area. At the 6-week follow-up visit, participants were reassessed, and then they were treated a second time. Caliper measurements were recorded to assess fat thickness reduction. Treatment efficacy was objectively evaluated using 2- and 3-dimensional imaging. Among the 14 participants (12 women and 2 men), the adverse effects of the procedure were typically mild and included numbness and tingling, which resolved without intervention by the 12-week follow-up. An independent review of digital photographs revealed an 81.0% (95% CI, 65.9%91.4%; P = .02) correct identification rate (34 of 42 images) of the pre- and post-treatment images. Caliper measurements demonstrated a mean (SD) fat layer reduction of 2.3 (0.8) mm (range, 0.7-3.5 mm).

Three-dimensional imaging revealed a mean (SD) reduction in fat volume of 4.82 (11.42) cm3 (from a reduction of 32.69 cm3 to an increase of 13.85 cm3). Results of participant surveys indicated that 13 participants (93%) were satisfied with the cryolipolysis treatment.

The study demonstrates that bilateral submental cryolipolysis is well tolerated and produces visible and significant fat layer reduction.

Title: Prevalence of Body Dysmorphic Disorder in Plastic Surgery and Dermatology Patients: A Systematic Review with Meta-Analysis Authors: Ribeiro RVE Published: Aesthetic Plastic Surgery, April 2017 Keywords: Body dysmorphic disorder, dermatology Abstracts: The aim of study was to evaluate the prevalence of body dysmorphic disorder in plastic surgery and dermatology patients, by performing a systematic review of the literature and meta-analysis.

PRESCRIBING INFORMATION (Please consult the Summary of Product Characteristics (SmPC) before prescribing.)

Vaniqa 11.5% Cream eflornithine Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women. Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart.

Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects. Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product.

For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application. The condition should improve within eight weeks of starting treatment. Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic /renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if

The most relevant studies published originally in any language were analyzed. The literature search was performed using the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scielo databases. The final sample comprised 33 publications that were submitted to meta-analysis. The study verified that 15.04% of plastic surgery patients had body dysmorphic disorder (range 2.21-56.67%); patient mean age was 34.54 ± 12.41 years, and most were women (74.38%). Among dermatology patients, 12.65% (range 4.52-35.16%) had body dysmorphic disorder; patient mean age was 27.79 ± 9.03 years, and most were women (76.09%). Both plastic surgeons and dermatologists must adequately assess their patients to identify those with a higher likelihood of body dysmorphic disorder and should arrange multidisciplinary care for such individuals.

Title: Windmill Flap Nipple Reduction: A New Method of Nipple Plasty Authors: Yu Y, Wei L, Shen Y et al.

Published: Aesthetic Plast Surg, April 2017 Keywords: Nipple hypertrophy, nipple reduction, Asian patients Abstract: Nipple hypertrophy is a common aesthetic issue for Asian women. In this article, we propose a new method to reduce both the height and diameter of the nipple without affecting its function. Sixteen female patients, between the ages of 24-41 years, underwent a new nipple reduction method in our department between May 17, 2010, and May 5, 2014. Three crescent-shaped lines were drawn from the top of the side wall of the nipple, extending to the areola. This design reduces both the diameter and height of the nipple with minimal tissue manipulation.

Before surgery, the mean diameter and height of the nipple were 15.9 ± 2.7 and 18.3 ± 3.1 mm, respectively, with the patient in the supine position. Immediately after surgery, the mean diameter and height of the nipple were 9.1 ± 1.7 and 7.9 ± 2.1 mm, respectively.

No major complications, such as nipple necrosis, infection, delayed wound healing, or loss of sensation, were noted. This new surgical technique allows the creation of a new nipple of the desired height and diameter with excellent aesthetic results and without significant complications.

applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed).

Interactions: No interaction studies have been performed.

Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding.

Ability to drive and use machines: Vaniqa has no or negligible effects on the ability to drive and use machines.

Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000).

Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects.

Legal Category: POM Marketing Authorisation Number(s): EU/1/01/173/003 NHS Cost: (excluding VAT) Tube containing 60g - £56.87 Marketing Authorisation Holder: Almirall, S.A., Ronda General Mitre, 151, 08022 Barcelona, Spain.

Further information is available from: Almirall Limited, Harman House, 1 George Street, Uxbridge, Middlesex, UB8 1QQ, UK. Tel: (0) 207 160 2500. Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk Date of Revision: 04/2017 Item code: UKEFL3336a

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Almirall Ltd.

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Writing a Winning Award Entry Aesthetic PR consultant and awards judge Julia Kendrick shares her top tips to maximise your chances of securing this valuable business asset Award season is here! It’s that time of year when aesthetic businesses of all shapes and sizes crack their knuckles and get down to some serious writing. If you’re still wondering whether it’s worth all the extra time and effort – consider the impact on your trust and credibility by placing the phrase ‘award winning’ at the centre of your PR and marketing efforts. It not only looks and sounds good, it also translates to real business benefits: attracting new patients, media attention and broader industry recognition and collaboration. In this niche industry, the competition for those allimportant accolades is intense. So how can you maximise your chances?

Having experienced this process from both a development side – creating awardwinning entries for myself and for clients – as well as judging other categories and seeing the calibre of submissions, I’ve got a fairly unique perspective. In this article, I’ll be sharing my top seven tips for successfully creating a winning entry. Best of luck!

1. Prep for success Most people might worry about the writing stage of an award entry and how to succinctly and powerfully reflect their achievements and stand out from the other entries. However, the key to a successful entry is not just snappy language and a well-

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crafted pitch, it’s showcasing a multitude of evidence to back up your claims. The evidence-gathering process is vitally important and can take quite a bit of time to pull together, so I always recommend making a head start to ensure you can produce meaningful numbers confidently and quickly when the time comes to getting the entry down on paper. To help avoid feeling overwhelmed during the fact-finding process, I suggest dividing and conquering the tasks among your team to ensure you get everything you need within a fixed deadline. Obviously, depending on which award category you’re entering, you may require more specific evidence, but there are numerous overarching points which are useful to strengthen and differentiate your entry, such as: • Clinic growth (number of new patients, percentage increases) • Revenue growth (percentage increase) • Staffing increases and training • Clinic facilities improvements/increases (e.g. additional premises or treatment rooms) • Number of new treatment offerings • Mentions in the media (highlight key publications) • Average number of treatments Most award categories are focused on performance or results over a limited oneyear time period; however, I would strongly recommend not only gathering the specific year-on-year data for the above criteria, but also to demonstrate past year results versus when you first launched. This provides additional power, perspective and gravitas to your entry – showcasing how well you have done overall, not just in the given timeframe.

2. Laser vs. shotgun approach

The evidence-gathering process is vitally important and can take quite a bit of time to pull together, so I always recommend making a head start to ensure you can produce meaningful numbers confidently and quickly

Before putting pen to paper, take the time to go through each award category and create a shortlist of those you have the best chance of winning. Go through the details, noting what you are being asked to demonstrate in each entry and check: do you have all the evidence you need? Have you accurately tracked your results? Competition is fierce, so a ‘shotgun’ approach of entering everything with low-quality and poorly tailored entries will just be a huge waste of your precious time (and will also annoy the judges). Whittle it down to JUST those categories of which you have got compelling data, great results and hard evidence to showcase to the judges; a focused ‘laser’ approach.

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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3. Hone your USPs Many awards categories start off by asking you to describe your clinic, your ethos and your overall approach. Far from being a cursory introduction, this is your first big chance to create an impression with the judges so take the time to craft this section carefully, as you will use it repeatedly across your various entries. In addition, this section of the entry can often be used in the promotional activities of the award – being featured on main websites where you are likely to be seen not just by industry peers, but by members of the public as well – so best face forward! The challenge is to weave ‘standard’ information (such as when you were established, number of staff etc.) in amongst a more compelling overview of your unique selling points (USPs). This is the ideal place to reflect your vision and mission, highlighting what truly sets you apart from other clinics and outlining the personal beliefs or values which you incorporate into your business practice.

As always with all USPs and business positioning, it’s not the comprehensive list of treatments on offer which matters the most: it’s communicating how you approach your work, what you do differently and the impact you have on your patients that makes a lasting impression!

4. Read the question!

This step is my own personal bugbear when judging entries: nothing riles me so much as when entrants just ignore the question and attempt to ‘cover up’ with irrelevant information! You would be amazed at how many award entries simply do NOT provide the information clearly outlined in each category section and, as a result, earn their place on the judges’ reject pile.

If you’ve done your preparation upfront and carefully selected your entries based on what you can substantiate, much of the work here should already be done. It’s easy to fall victim to ‘snow blindness’ if you’re been spending hours developing multiple entries – so just take the time to go back and double-check that you’ve properly answered each question and, if in doubt, enlist the support of a fresh pair of eyes to make sure you don’t lose out on any ‘easy’ marks due to a misunderstanding.

5. Showcase the evidence The more you can provide by way of tangible evidence, the more convinced judges will be of your credibility. Key metrics and benchmarks are the backbone

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of any winning entry: judges want you to be able to demonstrate success through specific achievements, as well as beautiful patient results. So ensure you are clear: how many calls did you receive, what was the boost in sales (numbers or %), how many people used it, how many new patients did you attract, how much media coverage did you get (and where)? The more you can substantiate, the better.

Without tangible evidence, entries will be considered mostly hot air – so if you haven’t already, start crunching those numbers! When it comes to visual results, treatment-oriented entries tend to request before and after images and this is another easy area for judges to dock points.

I have seen entries where requested imagery was simply not provided, or was of such shockingly low quality as to be impossible to accurately identify the effects of treatment (bad lighting, use of makeup, different before/after angles – the list goes on!) Adhering to best practice for before and after imagery is critical to supporting a winning entry, so make sure the images are of the highest possible quality to truly showcase the effects of your work.

6. Get others to sing your praises The key principle of PR is the power of third party endorsements, so use these within your entries. Make sure you have a bank of written or video testimonials from your patients, partners or media to do the talking for you on the impact of your business or the treatment results you’ve achieved. Not only can you include these in your entries, you can repurpose them as great testimonials for your PR and marketing!

7. Polish and prune Entries which are vastly over (or under) the word count limits are another big pitfall, so take the time to prune and polish your submission for clarity and brevity ahead of time. Double-check the word count for every section and make sure you have encapsulated your points powerfully and concisely. Poorly constructed, waffled entries not only make for boring reading, they may be automatically rejected if there is an online submission process which chops off entries at a given word count. Understandably, this can result in unnecessary last-minute stress if you have to go back and re-work entries, possibly whilst the deadline looms! Bullet points can be a fantastic way to cut down word count and also allow the judges to see your key points in an easy-to-digest format.

Maximising award participation and wins Without a doubt, creating a winning award entry can be a time-consuming endeavour, but the value and return on investment for you, your clinic and your brand is huge. Every stage of the process can be leveraged within your PR and marketing to drive visibility and audience engagement – from entry, through to shortlisting, finalist status and (hopefully) winning! Each provides a valuable milestone to engage with both new and existing patients, as well as partners and local media – through your clinic blogs, newsletters and social media.

This is especially important if there is a required element of public voting to secure your winning status.

A final tip is to take a ‘plan for success’ approach with your entries. Work on the basis that you will win that award and plan your mini-campaign in advance, to reduce the stress and burden on you and the team in the immediate aftermath and to maximise the exposure as quickly as possible. This could include a marketing email to your patient database announcing the win and kick starting a special offer, a special blog post with pictures of the event, a press release to local media, social media posts or advertising. Finally don’t forget to update your website and all promotional materials with that ‘award-winning’, ‘commended’ or even ‘finalist’ message and upload the award logos as soon as possible – you’ve earned it!

Julia Kendrick is an awardwinning communications and PR consultant specialising in medical aesthetics. With over 12 years’ experience, Kendrick aims to deliver a unique strategic approach to help aesthetic brands, clinics and practitioners build and grow their reputation, stand out from the crowd and secure tangible business growth. Kendrick is a regular industry media contributor, congress presenter and trainer.

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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Preventing Digital Marketing Errors Marketing consultant Adam Hampson discusses the common mistakes clinic owners make when utilising digital marketing tools and advises how to maximise your return on investment In my experience, a successful digital marketing strategy usually comes down to a combination of three overarching elements: budget, channels and conversion. Different treatments will appeal to different audiences, which means that they may be best marketed on different digital channels to make the most of your budget.1 Unfortunately, many clinics rush into marketing activities without first checking whether they fit with their digital marketing strategy. They might spend big on Google AdWords for one campaign and then write it off as not working; or write a cluster of blogs, then forget to blog for months; perhaps they take advantage of a deal to advertise on a national website but attract no local business, so they decide online advertising doesn’t work. But the reason these actions may not create the right results is that the clinics are trying to reach anyone and everyone – i.e. ‘spray and pray’ marketing – rather than figuring out who they’re talking to first. Simple steps such as identifying your target audience for each treatment, learning how best to reach them, and focusing on a clear and simple marketing message can transform your digital marketing.

Below, you’ll find examples of some of the most common errors I have found that aesthetic clinics make when using online marketing tools, and advice about how you can avoid them when planning your digital marketing strategy.

Setting up Google AdWords incorrectly Google AdWords is the pay per click (PPC) advertising that you see in prominent positions on Google’s search engine results pages (SERPs) when you carry out a search.2 You can spot a Google ad by the small ‘Ad’ icon at the beginning of the listing. Thanks to the targeting options such as keywords, location, and audience demographics, it is possible to ensure that your ads are seen by people who are actively searching for a specific treatment or service.

That being said, it does take time, experience and knowledge to learn how to set up Google AdWords correctly. One of the most common Google AdWords mistakes I come across is people actually setting it up incorrectly – usually by not doing enough keyword research – and thinking it doesn’t work. With the right approach, it’s hard to imagine any business that wouldn’t benefit from incorporating Google ads into their digital marketing. But what makes the right approach? You should start by identifying which keywords you want to feature in your ad campaigns – think about the words your clients will use to search, such as ‘bodycontouring treatments’ or ‘filler injections’ and remember that Google rewards relevance, so be specific; two- or three-word phrases are usually more targeted than single keywords.3 You should also think about negative keywords4 – Google defines these as ‘A type of keyword that prevents your ad from being triggered by a certain word or phrase. It tells Google not to show your ad to anyone who is searching for that phrase’. You might want to eliminate specific negative keywords from your campaigns, either because they don’t convert or because they don’t bring in relevant traffic. To give a non-surgical example, if you are promoting

‘bodysculpting’ or ‘fat freezing’ treatments, you may decide to list ‘lose fat’ as a negative keyword because people who use this term are often looking for a diet or healthy eating plan rather than cryolipolysis. You may also want to list words such as ‘free’, ‘cheapest’ or ‘low price’ as negative keywords to deter those shopping on price. Having a wellresearched list of negative keywords and a well-written ad can help you to increase the click-through rate (CTR) for your ads, reduce your cost per click (CPC) and increase the return on your investment (ROI).

Takeaway: Negative keywords are as important as the keywords you want to target

Not adhering to advertising legislation As a Google Certified Partner, due to our experience in running Google AdWord campaigns, we’ve found that the search engine does strictly enforce advertising legislation when approving campaigns.

These days, you could be running a campaign for a bodysculpting treatment but, if you mention botulinum toxin anywhere on your website, the bodysculpting ad will go to Google’s team for review and, in my experience, it’s unlikely to get approved.

It doesn’t matter that botulinum toxin and bodysculpting are two unrelated treatments – botulinum toxin should not be mentioned by name in any promotional context as it’s a prescription-only medication and, therefore, Google will not want to drive traffic to a site that is flouting current legislation.

Google may also reject ads that link through to aesthetic websites that over-promise the results of a treatment or feature misleading images, so it’s important to consider the impression your entire site creates, as well as offering a dedicated landing page for each campaign. Staying up-to-date with the latest aesthetics advertising guidelines and legislation will not only protect your reputation but will also help you to create Google ads that the search engine is happy to approve.

Takeaway: Ensure that your entire website meets aesthetics advertising guidelines

Failing to include Google Display Network Many businesses do not include the Google Display Network5 in their digital marketing strategy when purchasing Google AdWords, most often because they’re not aware of it or how advertising on this platform works.

The Google Display Network comprises

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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more than two million websites that have agreed, via tools such as Google AdSense, to feature advertising relevant to their audience.6 It’s estimated that the Google Display Network can reach 90% of people on the internet.7 Using Google Display advertising, you can create text, image, video or interactive ads and place them on websites that are relevant to what you’re selling and visited by your target audience. This lets you capitalise on traffic to other domains and build brand awareness. You can either browse the Google Display Network to choose where your ads are shown or task Google with suggesting the most appropriate sites for you to approve.5 Takeaway: Consider advertising on the Google Display Network to expand your online reach

Inconsistent and inappropriate content marketing Content marketing is an area open to plenty of mistakes. It could be that you don’t blog at all or, if you do, that your blogs don’t have enough substance to make them valuable to readers, or that you only publish new content inconsistently. Also, do your blogs reflect the keywords you want to target? Are you sure that you’re creating the most relevant content for the audience you want to reach? To make your content marketing effective, you need to focus on generating interest and value for your target audience. This doesn’t just have to be through blogs; videos, infographics, social media posts, e-newsletters, memes and audio content such as podcasts can all form an integral part of your content marketing strategy.

The more relevant people find your content, the longer they will stay on your website, decreasing your bounce rate,8 i.e. the percentage of people who leave after only viewing the web page they came in on, and increasing the dwell time9 – two positive signals to Google to rank your website higher in searches.10 Great content will also reflect well on your professional authority.

Even with fantastic content, a surprising number of businesses fail to tell people that it exists. With this in mind, it’s important to have a strategy to promote new content. This can include: • Posting links to your blog on Facebook, Twitter and LinkedIn • Using bite-sized key points from your blog as statuses and tweets • Featuring new articles in your clinic newsletter

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• Creating Pinterest boards for your content • Turning snippets from your articles into Instagram memes • Adding buttons that enable people to instantly share your content on their favourite social networks Takeaway: Let people know when you post new content and where to find it

Misunderstanding your social media audience You’ve no doubt read or been advised that your business should have a presence on social media, but getting started can be daunting. Should you be on every platform?

How often should you post? What should you post? How can you build engagement?

One mistake that businesses make is to fall back on that ‘spray and pray’ approach, either posting duplicate content to multiple platforms or carrying out a flurry of activity and then going quiet for weeks.

Social media can take up huge amounts of time, so you have to have a plan to keep focused. We recommend that you begin by identifying your target audience and pinpointing just one or two social media platforms that you want to concentrate on initially, i.e. those where your audience is most likely to spend time. Once you decide where to focus your attention and who you’re talking to, you can begin to create content that reflects your audience.

Takeaway: Identify who you’re talking to and research their favourite social media platforms before you begin posting

Using Facebook ads for the wrong treatments It can take time to build up a strong presence on social media. For this reason, many businesses decide to boost their visibility with PPC advertising on platforms such as Twitter, LinkedIn, Instagram and Facebook.

Each platform offers a strong choice of advertising options that can work well for aesthetic businesses.11,12 Facebook tends to be the most widely used among our clients.

Although Facebook advertising can be cost effective,13 it’s important to do your research and be selective about what you advertise before you run a campaign.

Social media ads are comparable to television ads in that they’re the filler thrown in between the content that people have actually chosen to view. Yes, Facebook ads can be targeted to a suitable audience, but you can’t guarantee interest. This is in contrast to Google ads, where the searcher has actively typed in the keyword you

want to target. To make the most of your Facebook advertising budget and secure the best ROI, think carefully about the most appropriate treatments and types of posts for this channel.14 This may take some trial and error initially. You should also keep an eye on the insights that Facebook provides in your Ad Manager dashboard15 so that you can fine tune your ads to reflect the needs of your audience.

Takeaway: Promote the right treatments on the right channels

Conclusion Each digital marketing campaign you run needs its own strategy. Different people prefer different online channels, and different channels may be appropriate for promoting different treatments. The only way to know is to do your research or engage a marketing agency who can offer the value of their experience. Above all, aim to be consistent, focused on your target audience, and committed to providing great value.

Adam Hampson is the founder and director of Cosmetic Digital, a web design and digital marketing agency that works with clients in the aesthetic and medical cosmetic sector. He is also a public speaker on aesthetics marketing and branding.

REFERENCES 1. Lars Lofgren, Are you marketing in the right channel?, <http:// larslofgren.com/marketingbasics/marketing-in-the-right-channel> 2. Google AdWords, <https://adwords.google.com/intl/en_uk/ home/> 3. Marketing Donut, Nine steps to choosing keywords for Google AdWords, <http://www.marketingdonut.co.uk/online-marketing/ online-and-ppc-advertising/nine-steps-to-choosing-keywordsfor-google-adwords> 4. Google AdWords Help, Negative keywords, <https://support. google.com/adwords/answer/105671?hl=en-GB> 5. Google Display Network, <https://www.google.co.uk/ads/ displaynetwork/> 6. Google AdSense, <https://www.google.com/adsense/ start/#/?modal_active=none> 7. Google AdWords Help, About the Google Display Network, <https://support.google.com/adwords/answer/2404190?hl=enGB> 8. Google Analytics Help, Bounce Rate, <https://support.google. com/analytics/answer/1009409?hl=en> 9. Ahrefs, Dwell Time: Does this ranking factor really live up to the hype?, 4 October 2016, <https://ahrefs.com/blog/dwell-time/> 10. Backlinko, Google’s 200 Ranking Factors: The Complete List, < http://backlinko.com/google-ranking-factors>, November 2016 11. AdEspresso by Hootsuite, Twitter Ads vs Facebook Ads: The Metrics You Need to See, <https://adespresso.com/academy/ blog/twitter-ads-vs-facebook-ads-the-metrics-you-need-tosee/>, April 2015 12. Aggregate, What’s the best PPC channel? Facebook vs.

AdWords vs. Twitter vs. LinkedIn, <http://aggregateblog.com/ ppc-channel-comparison/>, February 2017 13. WordStream, Does Facebook Advertising Work? [Data], <http:// www.wordstream.com/blog/ws/2016/01/25/does-facebookadvertising-work>, March 2017 14. Facebook Business, Facebook Adverts, <https://www.facebook. com/business/products/ads> 15. Buffer Social, The Complete Guide to Facebook Ads Manager: How to Create, Manage, Analyze your Facebook Ads, <https:// blog.bufferapp.com/facebook-ads-manager>, January 2017

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

Advertorial SkinCeuticals

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Aesthetics Journal

SkinCeuticals: Taking A ‘Double Defence’ Approach Against Atmospheric Skin Ageing

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Results confirmed that a daily antioxidant regime of SkinCeuticals’ C E Ferulic or Phloretin CF significantly reduces the oxidative damage caused by O3 exposure, and provides a substantial protective function against the signs of atmospheric skin ageing, such as fine lines, wrinkles and discolouration – specifically:1 • Reducing lipid peroxidation: Shown by a reduction in HNE proteins, which are generated by free radical attack on fatty acids in skin exposed to ozone pollution • Preventing inflammation: Shown by a reduction in the NFkB pathway • Preventing collagen loss: O3 exposure significantly decreases Type I and Type III collagen The powerful effects of these antioxidants help to give the skin elasticity, support collagen production and resist inflammation – critical factors in eliminating the harsh effects of O3 exposure on skin.

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REFERENCES CF: RED UCTION OF p5 3 I NDU C T I ON 1. Giuseppe PHLORETIN Valacchi, Alessandra Pecorelli, Giuseppe Belmonte, Erika Pambianchi, Franco Cervellati, Stephen Reducing p53 induction is a n i nd i caEffects t i o n o f p rev ent i o n a nd Lynch, Yevgeniy Krol, Christian Oresajo. Protective during CUVA exposure. of Topical Vitamin Compound Mixtures Against OzoneInduced Damage In Human Skin. Journal of Investigative Dermatology (Articles in Press). Available from: <http://www.

80 jidonline.org/article/S0022-202X(17)30184-7/fulltext> 60

CELLS / MM SKIN

C E FE RULIC: E NVIRONMENTAL PROT ECT ION

ENVIRONMENTAL PROTECTION

UVA /UVB

antiox idants ef f ectiv ely neut ralise free radicals on t h e upper layers of the skin.

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Digital App Development

to note that push notifications must be permitted by the phone user. If not, they can be reminded whilst using the app.

Creating an App Digital technology professional Michael Rowland explains the benefits of creating an app for your clinic and the steps you need to take to make it happen Apps are everywhere and their popularity is ever increasing. According to statista, the number of mobile app users in the UK rose from 31.7 million in 2013 to 41.4 million in 2016.1 Running an app for your business could achieve nothing more than the typical enthusiastic ‘we are on the App Store buzz so often heard today. However, when executed correctly, an app for your clinic could be an innovative marketing tool that drives your business forward.

What are an app’s useful features?

An app with useful features for new or existing customers to download onto their mobile or tablet device can be an effective way of marketing your services so that you can increase your sales and profitability, while maintaining patient loyalty. Many businesses try to achieve this through digital marketing or social media but the creation of an app can take you to the next level. Using the latest technology to make it exciting and easy for the consumer to communicate with your business and having a visual reminder on their phone/ tablet may help to increase patient retention and sales. It is important that the app is helpful, user-friendly and includes features that will improve your patients’ experience of your clinic. The list of possible features is endless, but can include some of the following, which I find to be particularly important for developing your business.

Booking You may already have a booking system in place, but by seamlessly incorporating this into an app, it can give new and existing customers the ease to book an appointment with a few taps without having to search for your website. With the visual reminder of your brand on your patient’s phone, it only takes a couple of taps for them to book in the middle of the night, or during a busy day. With an increasing trend towards the convenience of making electronic bookings and a reluctance from some consumers to book by phone,2 having the ability to book via an app is an extremely user-friendly feature.

Push notifications Push notifications are messages that app users get sent directly to their phone from your business.3 The notifications are generally only a short sentence, meaning that they are a quicker way of reaching your patients than email. Unless you plan on calling each patient, it is perhaps the most direct and effective way to communicate with them, which can increase your brand presence and again, serve as a visual reminder of your clinic. You can send updates regarding cancellations/availability, special offers, seasonal greetings, or whatever else you may have to say. Consumers can tap the message and be taken directly to a page within the app or to a website. It is important

Social media sharing Another seemingly minor but excellent feature, is the ability to easily share your app across social media to help create brand recognition and encourage followers to download it. You can also show off your social media content through a stream within the app, in order to encourage new followers across all of your social media platforms.

Either way, integrating your social media and app content provides an excellent way to increase and maintain a valuable digital presence.

Easy contact The ‘easy contact’ feature, such as tap to call, tap to email, and tap for directions/navigation makes getting in touch with you a simple and timely process for the user. The easier your users find it to get in touch, or to share your content, the more likely it is that they will do so. Again, having an app on their homescreen makes it easier for patients who would otherwise have to search for your website.

Other options As stated, the list of features is endless and there are numerous functions that you might want to consider that can be of benefit to your aesthetic clinic. You can consider placing a feature such as an ‘about us’ section to share the credentials of all your staff members, a section that discusses your treatment portfolio so that patients may learn about your offerings before booking a consultation, or you can even include patient testimonials and videos to share previous patients’ experiences of treatment.

What considerations should be made before moving forward?

If you are starting out and are on a very tight budget, you may wish to focus on developing your website, social media following and your patient base before considering launching an app.

If you or one of your colleagues are skilled in app development and software coding then you can develop an app yourself and you won’t have to pay a company to do this for you. These skills can be learnt; however, they may take a lot of time and can be challenging for some. You will also need to be familiar with the approval conditions such as legal requirements for each country, data collection and storage, and intellectual property.6 If you

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do not have these skills, then to progress it may be necessary to consider contacting an app development company.

App development companies can be expensive and the price may vary according to the features included, the development time, and whether you want a bespoke app or are happy to use a template. Template apps are those that have already been built and the logo/images are adapted for each company; which sometimes means that they may be limited in flexibility. Template app development companies typically charge a setup fee and a monthly payment plan, which might generally total to about £1,000 across the year.

On the other hand, bespoke apps are tailored specifically to individual clinics and aim to offer a unique user experience. Apps that include the bespoke features discussed above usually start between £4-5,000 upfront, but design and build elements may increase this price. Of course, this format is company dependent and will vary; for example, some companies may look to offer the template price format for bespoke apps. Depending on your budget and the services you require, you might want to consider the options before approaching app development companies.

So, how do you get an app made for your business?

After you have decided to move forward and create an app for your business, it is time to design and develop it. As the majority of practitioners may well not be skilled at coding, we will focus on the process you will go through when working with an app development company.

Design Once you have chosen the unique features that you want to incorporate in your app, which will be relevant and helpful to your patients, you will also need to decide on the design. Your branding should be consistent throughout; keeping to the same colour codes, the same logo, and the same images that your business uses for marketing, on your website and social media. You should always think about using icons for links, and always consider reducing text; an app is meant to be intuitive and very simple. If you would like to create the design yourself, your app development company will give you a template to construct your design. Once submitted they will usually confirm or get back to you with any useful comments for improvement. You can alternatively ask your

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The visual reminder of an app serves as a way to emphasise your unique brand app team to produce a modern and effective design for you that will appeal to your target market. They can follow your strict guidelines, or create a design that they believe will meet your needs.

notifications to prompt them to use the app again. However, you don’t want to overdo it, so limit push notifications to between one and four a week.

Summary Development and launch The design of the app will need to be considered and developed into a functional app. The time it takes for a company to design and build varies, and depends on whether you want a template app or a semi/ fully bespoke app. In my experience, the process usually takes about four weeks.

After the design is approved and the app is built, testing must be conducted to ensure that it is user-friendly and all features work smoothly. Once the app has been finalised and tested, you must gain approval to place it onto an app store to be downloaded onto your patient’s device. In our experience, all apps should go into the Apple App store and Google Play store because they are the biggest market share for smartphones.7 Windows’ Microsoft Store is also offered as an option, but due to its smartphone market decline, it is not generally advised as a first option.8 Approval from the Google Play Store usually takes a day, while the average Apple App Store approval is five working days, however it can sometimes take a few weeks.4

How can you make sure your app is downloaded and used?

Once your app is live on an app store, you should build excitement about your app’s release and encourage people to use it by talking about its useful features on social media and to the patients attending your clinic. You should also have a link to your app on your website and ensure that your website showcases the fact that you have an app in a prominent position, such as at the top of the homepage. As well as this, the most effective way for downloads (other than your brand and location being searchable on the app stores) is having your website updated so that smartphone users are automatically taken to the relevant app store when they search for your clinic on their mobile or tablet.

To further encourage people to use your app once downloaded, you can also ensure that you are sending out engaging push

Nowadays, apps can be used as an effective marketing method and, as time goes on, an app for your business will continue to become even more important due to their expected increase in popularity1 and the growth of technology. For example, in the near future you could be able to seamlessly book an appointment via voice command.9 Being able to communicate with your patients using the ease and availability of an app means that there can be a positive impact in all elements of your business. In addition to this, the constant visual reminder of an app serves as a way to emphasise your unique brand and increase your patient loyalty.

Disclosure: Michael Rowland is the managing director of Oappso, which designs and develops bespoke apps.

Michael Rowland has has a keen interest and experience in coding, having completed courses such as Sun Certified Java Developer. He is the founder of Oappso, which designs and builds apps specifically for businesses in the cosmetic and medical aesthetic specialties.

REFERENCES 1. statista, ‘Number of mobile app users in the United Kingdom (UK) from third quarter 2013 to second quarter 2016 (in million users)’, 2016, <https://www.statista.com/statistics/277672/ forecast-of-mobile-app-users-in-the-united-kingdom-uk/> 2. Travel Weekly, 80% booking holidays online finds study, 2013, <http://www.travelweekly.co.uk/articles/41280/80-bookingholidays-online-finds-study> 3. Urban Airship, Push Notifications Explained, 2017, <https:// www.urbanairship.com/push-notifications-explained> 4. Shiny Development, Average App Store Review Times, 2017, <http://appreviewtimes.com> 5. Apple, App Store Review Guidelines, 2017, <https://developer. apple.com/app-store/review/guidelines/> 6. Vincent, J, 99.6 percent of new smartphones run Android or iOS, 2017, The Verge, <https://www.theverge. com/2017/2/16/14634656/android-ios-market-shareblackberry-2016> 7. Stephenson, B, Microsoft’s Windows phone retreat sees massive 81% decline in revenue in FY17 Q2, ON MSFT, 2017, <https://www.onmsft.com/news/microsofts-windows-phoneretreat-sees-massive-81-decline-in-revenue-in-fy17-q2> 8. The Economist, How voice technology is transforming computing, 2017, <http://www.economist.com/news/ leaders/21713836-casting-magic-spell-it-lets-people-controlworld-through-words-alone-how-voice>

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

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“Be part of the community – interact, ask, learn, read, reflect – that’s the best advice I can give” Dr Firas Al-Niaimi highlights the importance of continued research in dermatology and aesthetics Born in the Middle East and raised in Manchester, Dr Firas Al-Niaimi has had a varied and successful medical career. Yet, of all his achievements, he says that becoming a consultant dermatologist with numerous publications under his name is what he is most proud of.

Dr Al-Niaimi first developed an interest in dermatology while studying for his undergraduate medical degree at the University of Amsterdam in 1995. His family had moved to the Netherlands while his father, a now-retired professor of oncology, completed a research project. “My dad certainly played a major role in influencing me to get into medicine, as I could see how rewarding it was to him,” he says.

“The curriculum in the Netherlands was slightly different to the UK; which meant that students had a whole month dedicated to dermatology,” he explains, adding, “We had one professor who was very enthusiastic about dermatology, and that certainly evoked enthusiasm in me.” He continues, “I found it particularly interesting to browse through the colourful atlas, looking at all the images and appreciating that you can visualise all of the pathology. As a third-year medical student I was very lucky to be able to focus my training early.” Upon his return to the UK, Dr Al-Niaimi began his medical rotations in the North West, prior to starting the national training in an accredited dermatology programme, The North-West Deanery Training in Manchester.

He explains that it was during this time that he recognised that dermatology had a strong cosmetic component to it and could see the benefits of using lasers.

“In Manchester, we had one of the first NHS dermatology laser units where we performed many advanced cases of treatment,” he explains. Following his formal national training in dermatology, Dr Al-Niaimi went on to complete a one-year fellowship in advanced dermatolgic surgery and lasers at St John’s Institute of Dermatology in London where he currently holds an honorary consultant position. Since then,

he has completed advanced cosmetic and laser training in the US, while his interest and expertise has developed significantly.

“Lasers can bring sophistication in terms of treatments and precision. I enjoy offering laser treatments because the results can be very rewarding and I can really make a difference to patients’ lives,” he says.

Dr Al-Niaimi now divides his time between his private practice on Harley Street, his work as the medical director for four sk:n clinics in London and The London Scar Clinic. In addition, he lectures on the Skin Ageing and Aesthetic Medicine Master’s course at Manchester University and is on the executive committee of the British Medical Laser Association, as well as the editorial board of several dermatological and aesthetic journals. Dr Al-Niaimi is also a key opinion leader for many pharmaceutical and lasers companies, and is regularly invited to speak around the globe. Participating in dermatological and aesthetic research has become a key part of Dr Al-Niaimi’s career.

“If you look closely at aesthetic treatments, I think it’s fair to say that many are still lacking strong evidence supporting their efficacy,” he says, continuing, “I think it’s important that practitioners always critique a treatment method or treatment that is available and try to seek answers with regards to the evidence, complications and improvements of the treatments.”

A thorough understanding of the skin is of course vital to all aesthetic practitioners, says Dr Al-Niaimi, “If you do not have any dermatology knowledge then my advice is to spend time with a dermatologist or enrol on post-graduate training. If you don’t have the time or desire to do so, please do understand your limits when it comes to certain dermatological conditions and refer them to someone who has more understanding.” He adds, “Sadly, every now and then, I do come across some treatments that were inappropriately performed due to a misdiagnosis of a dermatological condition.”

While reaching his goal of becoming a

consultant dermatologist is of course a huge achievement, it is apparent that Dr Al-Niaimi has accomplished much more than this.

He explains, “At this current stage, I have more than 130 scientific publications under my name and over 200 presentations in the UK and around the world, in addition to academic prizes. I have also written a book on specialty examinations and several chapters of other books.” He admits, “I think that I can probably conclude that, for my age of under 45, I’ve not done bad when it comes to my beloved specialty.”

Do you have an ethos/motto that you follow?

My ethos is to treat patients the way you’d want your family to be treated. You should also individualise treatments for each patient.

What is your industry ‘pet hate’?

I do not like the overt commercialisation that sometimes occurs. We are dealing with patients who look up to us as trusted practitioners, so should always bear that in mind.

How do you see the aesthetics specialty developing in the next five years?

The more studies we perform, the more research we conduct, and the more we publish, will hopefully lead to safer interventions and successful treatment of challenging conditions.

What’s your best piece of advice to practitioners starting out in aesthetics?

Spend time with an experienced colleague, preferably more than one so you can be exposed to different styles and methods of work, listen to your patients, start slow, understand and know your limits, attend national and international conferences, and be part of the community – interact, ask, learn, read, reflect – that’s the best advice I can give.

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

@aestheticsgroup

Aesthetics Journal

Aesthetics aestheticsjournal.com

What should the policy include?

A lone working policy can help to encourage a strong safety ethos among employees and reduce the risk of potential legal disputes. According to guidance provided by Peoplesafe, a company which specialises in lone worker safety, the policy should reflect the hypothetical dangers that employees face when working alone and offer best-practice guidance.4

The Last Word Aesthetic nurse prescriber Frances Turner Traill explains why she believes every aesthetic practitioner should have a ‘lone working policy’ There are many times and situations in which aesthetic practitioners may find themselves working alone. Some practitioners will solely run a practice, some will be working late after their colleagues have gone home, while others may be caught off guard when a colleague calls in sick. There is nothing wrong with working alone, as long as the right safeguards are in place. However, this is not a mandatory requirement and therefore, not every aesthetic practitioner has one.

In this article I shall be arguing why every practitioner should adopt a lone working policy, and why by not doing so, they are putting the safety of themselves and their patients at risk.

What is ‘lone working’ and why is this an issue?

The NHS defines lone working as, ‘Any situation in which someone works without a colleague nearby or when someone is working out of sight or earshot of another colleague.’1 This means that a member of staff doesn’t have to be completely alone in their clinic to be classed as a ‘lone worker’, they may just be in a treatment room with the door closed.

In my opinion, lone working is something that isn’t talked about enough. There isn’t

much guidance for those setting up clinics on their own and some practitioners may not realise the importance of creating such a policy, and therefore, are practising without one. When you work under the umbrella of the NHS, this is all done for you. But when you go into your own aesthetic practice, you need to ensure that this is covered.

Is it essential to have a policy?

Although there is no legal prohibition on working alone, the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999, state that all employers have legal responsibilities to evaluate all risks to health and safety, and this includes the risks involved with lone working.2 For those of us working specifically in aesthetics, Part One of the Health Education England (HEE) report on non-surgical cosmetic interventions also specifies that to ensure that practitioners can deliver safe procedures, then they must understand the pitfalls of lone working.3 Having a policy in your clinic is the easiest and most efficient way of ensuring this.

Without a policy, you could be putting yourself and your patients at risk. If you want to operate a safe practice, you need provisions in place.

Public service union Unison advises that a lone working policy should include risks, key definitions, your organisational commitment, clearly-defined responsibilities, guidance on reporting incidents, plus any relevant support and contact details; fundamentally it should contain any guidance needed to protect you and your patients.2 If you have a lone working policy, then as soon as you find yourself working alone, the policy will kick in. Some of the key information that I believe should be contained in the policy is as follows: • Personal safety measures – Staff should take all reasonable precautions to ensure their own safety, as they would in any other circumstances. You must ensure that there is a robust system in place for opening and closing the clinic by someone who is working alone. Staff will ensure they have a mobile phone; they are responsible for checking that it is charged, in working order, and with sufficient credit remaining with the relevant provider, when opening or closing the clinic on their own.

• Assessing Risks – On a periodic basis or when an incident occurs a risk assessment will be done by an experienced member of staff to establish if any process/procedural changes are required.

• Planning – Staff should be fully briefed on the protocols to be followed should they find themselves at risk whilst working alone. Communication, checking-in and fall back arrangements must be in place to deal with known risks.

• Security of premises – Staff working alone must ensure they are familiar with the exits and alarms within the clinic in the case of an emergency. There must be access to a telephone and first aid equipment for staff working alone. If there is any indication that the clinic has

Reproduced from Aesthetics | Volume 4/Issue 7 - June 2017

In Practice News

been broken into, a staff member must not enter alone, but must escalate the situation to the appropriate person and/or organisation.

Once this policy is in place, it should be integral in your staff training to ensure everyone knows the policy and are working in accordance to it.

The solution We need to get the discussion going and raise awareness of the issue of lone working through peer groups, such as the British Association of Cosmetic Nurses (BACN) regional groups and the Aesthetic Complications Expert (ACE) group. One solution could be for aesthetic associations to create a standard lone working policy, which can be given out to members. In my opinion, it is essential to be part of a peer group or wider network so issues like this can be discussed.

District nurses in the NHS, who I have spoken to, have an electronic tag team system. This system has GPS tracking, so when they are on their own, somebody somewhere always knows where they are, and if they are not responding within a certain period, then an alert will be sent out. Some of these devices can detect if the worker has a fall, and then send out an alarm to a nominated person. We don’t do this in aesthetics but I think it is something we could adopt, cost-dependant.

If practitioners want to implement a lone working policy, but are still unsure where to turn, then they could look at hiring a business consultant, but be sure to make sure they have experience in creating such policies. They could also speak to fellow, experienced practitioners, who I’m sure would be happy to help.

Summary In an unregulated specialty such as aesthetics, it is so important to protect yourself and your patients. Many of us work alone, so a risk assessment and a lone working policy will identify precautions that will keep you and your patients safe. Whilst we may practice alone sometimes, or all the time, we should not work in isolation, and instead, be part of wider network, such as the BACN or other aesthetic associations.

Frances Turner Traill is an independent nurse prescriber with clinics in Glasgow and the Highlands. She is an active board member of the BACN and winner of the Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year 2016.

REFERENCES 1. NHS, Business Services Authority, Framework agreement extended to provide NHS lone worker services for staff, (2017) <https://www.nhsbsa.nhs.uk/nhs-protect-frameworkagreement-extended-provide-nhs-lone-worker-services-staff> 2. Working alone, a health and safety guide on lone working for safety representatives, (2017) <https://www.unison.org.uk/content/uploads/2013/06/On-line-Catalogue178763.pdf> 3. HEE, PART ONE: Qualification requirements for delivery of cosmetic procedures: Nonsurgical cosmetic interventions and hair restoration surgery, (2015) <https://www.hee.nhs. uk/sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20one%20 update%20v1%20final%20version.pdf> 4. Ian Johannessen, Lone Working: Everything An Employer Needs To Know, (2017) <https:// peoplesafe.co.uk/resources/basics/lone-working-guide/#Policy>

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