It’s pretty cool when modern medicine comes up with a treatment that replaces or reduces the need for invasive surgery. In the case of Xiaflex, a new injectable treatment for people with Dupuytren’s disease, this may well be the case.

Dupuytren’s, by way of background, is a disease in which fibrous collagen-laden tissue builds up in the palm and fingers, creating nodules and cords. These cause the fingers to curl inward, making it difficult to straighten out the hand. It most commonly affects the ring and little fingers of the hand.

Until recently, a surgical procedure known as fasciectomy was the standard treatment, but it was plagued by issues of incomplete treatment, recurrence of the original contracture, potential for nerve injury, and other problems.

Recently, collagenase – an enzyme that breaks down collagen – was tried as a treatment for this problem, injecting the enzyme into the abnormal tissue. The collagenase enzyme is marketed under the name “Xiaflex”.

The good news: it works, helping about two-thirds of patients regain significantly improved motion in their hand. This is an injection performed in the office – talk about minimally invasive! The results of the study can be seen here, in the New England Journal of Medicine (link).

While I don’t perform hand surgery, I think this is a significant breakthrough.

Here’s the potential cosmetic application: injections of collagenase have been shown in a few preliminary studies, to be helpful for cellulite. Millions of women would love to improve their cellulite, right? This could be the next Botox, people!

So far, the company is only selling the product to hand surgeons and rheumatologists, and only for Dupuytren-specific applications. FDA approval for the other application is pending…

There’s hundreds over beauty creams out there…and most of them are glorified moisturizers, and are a waste of money. Fact is, if you were stranded on a desert island, and for some reason, wanted to have a basic skin care program that was simple and was scientifically proven to work, you would only need 2 items: good sunscreen and retin-A cream.

Retin-A really works. And it has been scientifically tested, shown to be safe for long term use, and shown to be effective, which is more than you can say for most of the other over-the-counter products.

Retin-A is a Vitamin A derivative. It works by doing several good things to the skin simultaneously: it thickens the dermis of the skin, stimulates new collagen production, helps to exfoliate and thin out the dead surface layer (statum corneum), reduces hyperpigmentation (brown spots) and suppresses the formation of early skin cancers. Oh yeah, and it treats acne, fine lines and wrinkles, texture issues and actinic keratoses while you’re at it.

However, Retin-A isn’t perfect. It makes the skin more sun sensitive. And the first six weeks of therapy can actually make the skin look temporarily worse, as it goes through the initial red and irritated phase. Some people get a temporary flare-up of their acne. You have to go through the “I hate it” phase, before you get to the “I love it” phase. It’s also not good for patients that have rosacea or are pregnant.

Many of the side effects can be managed fairly well once you learn about how to use the product best. For example, don’t start with the most potent concentration of retin-A cream, start with the lowest dose, and gradually work your way up to the stronger formulations, as your skin acclimatizes to the effect of Retin-A.

Helpful hints for Retin-A:

– Start out using your product every other night. More is not better.
– Wash your face (or other area of treatment)
– Wait 20-30 minutes
– Apply a pea-sized amount of cream to your finger. More is not better.
– Dab the cream/gel around the area to be treated and rub it in.
– Wash off your hands.
– Keep your product out of your eyes.
– If you are treating wrinkles around the eyes, you may apply the product under the eyes and to the crow’s feet areas. Avoid applying to the upper eyelids.

Renova cream: what is it?

As people age, their skin becomes much drier and less able to tolerate a product like Retin A. Enter Renova. Renova contains the same active ingredient in Retin A, but it is in a heavier moisturizing base. People who have dry skin, and find Retin-A too drying, may prefer Renova, as long as they are not acne-prone. Renova is heavy enough that it may cause a flare of acne in someone with pre-existing acne. So, if you have the unlucky combination of acne and wrinkle issues, I would stick with a Retin-A formulation, instead of Renova.

Of course, both Retin-A and Renova are prescription strength products. They are significantly more powerful than any creams you might purchase over-the-counter.

We’ll discuss the less-potent cousins of retin-A next time….

Developed at Massachusetts General Hospital, Zeltiq is a novel fat melting device, which uses the application of controlled cooling to melt fat non-surgically. The idea, known as cryolipolysis, takes advantage of the finding that fat cells freeze before skin cells do. Thus, if the temperature of the tissues can be lowered to just the right point, the fat cells will be lysed, but the overlying skin will be OK.

The gadget that does this is known as “Zeltiq”. And it does seem to work. Each outpatient treatment takes about an hour, and the results take about 3 months to appear. So far, it seems to work best on the abdomen and flank (“love handle”) areas. While the results are not nearly as dramatic as those of liposuction, there are clear improvements seen in the pre and post-procedure treatment photos.

A recent pilot study by Coleman and associates found that Zeltiq treatment gave a reduction of 20.4% at 2 months and 25.5% at 6 months in the thickness of the subcutaneous fat layer, which was measured by ultrasound. Although 9 of 10 patients in this small pilot study complained of temporary numbness in the treated areas, this normalized after 3-4 weeks. Biopsies showed no damage to the nerve fibers, which is an important consideration in any fat reduction treatment, as the insulating membranes around nerve fibers have a high fat content. None of the patients had any skin damage or pigment changes.

While the Zeltiq is not FDA approved as yet for fat reduction, it has received the European “CE” mark.

I give this new technology a “looks promising” rating!

Mederma is a non-prescription cream, which has been used for years to help improve scar healing. Its main active ingredient is an onion extract – derived from a particular type of onion – called allium cepa, which is rich in the bioflavinoid compund known as quercetin.Recently, I reviewed the published studies on this product: and the results, quite honestly, are mixed. Some studies show little or no benefit on scar healing, while others report positive results. Here’s a few summaries for you to look at.Doesn’t work:

1. Chung and associates, from the famed Beth Israel hospital in Boston, did a propsective double-blinded study, comparing the effects of the onion extract versus petrolatum gel (vaseline) on fresh surgical incisions. Each product was applied three times daily for 8 weeks. Results were rated at 2, 8, 12 weeks by non-biased evaluators for cosmetic appearance, redness and thickness. Result: no significant difference.

2. Jackson and Shelton, from MD Anderson Cancer Center in Houston, looked at surgical scars resulting from skin cancer removal with the Moh’s technique. Again, an ointment was applied three times daily for one month, and the results were compared. They found no benefit in the pre-treatment versus post-treatment levels of scar redness or itchiness with the onion extract, and actually found that the petrolatum group had less redness.

3. In an animal model, wound-healing guru and plastic surgeon Tom Mustoe and associates looked at the effect of Mederma on hypertrophic scarring. They found no significant reduction in scar redness, scar elevation or scar volume. They did see some changes in collagen organization when the scar tissue was examined under the microscope.

Does work:

1. A study by Draelos examined the effect of Mederma on the appearance of surgical scars from the removal of skin lesions using the superficial shave technique, versus no additional treatment. She found that the Mederma treatment was statistically better than no treatment, improving scar softness, redness, texture and overall appearance.

2. Another study compared the effectiveness of onion extract versus silicone sheeting or silicone sheeting together with onion extract on hypertrophic and keloid scars. After 6 months of treatment, they found the combination treatment worked the best. The onion extract by itself seemed to improve scar color, but did not change scar height or itching of the scar.

Bottom line:

Using Mederma is certainly better than doing nothing for your scar. It’s inexpensive, widely available, and well tolerated. It encourages people to do scar massage – which is also helpful to help scars become softer and more pliable.

However, I think there are other more scientifically-convincing products available for scar therapy. I usually recommend one of the many forms of topical silicone products for my patients, in addition to scar massage, sun avoidance, and if needed, IPL or kenalog treatments.

Latisse, the eyelash enhancing formula made by Allergan, has recently received its FDA approval and is now available. We discussed this breakthrough product in one of my earlier blog chapters – I expect it to be very popular.

We’ll be carrying it at our office – and let me tell you, the ladies on my staff are very excited to try it! I’m interested to see how it compares to earlier non-pharmaceutical strength formulations, like “MD Lash”.

More details as they become available…

Here’s a hot topic: can you melt fat by injecting certain active substances into it, and is this safe to do? Those are the key questions to be determined when in comes to injection lipolysis, also known as Lipodissolve, Flab-jab, and a number of other proprietary names.

Currently, the two most commonly used drugs, the soybean-derived phosphatidylcholine (PC) and a bile-salt derivative called deoxycholate (DC), are not FDA-approved for this purpose. These are injected, sometimes with a cocktail of other ingredients, into the fat, using a grid-like pattern. This is typically repeated at intervals, until the desired results are seen, or the patient gives up, or runs out of money!

While this procedure is poorly-understood and needs a whole lot more research to determine the best way to do it, here’s what we do know from the scientific studies:

1) The injections don’t “melt” fat – they cause the fat cells to rupture, killing the fat, which is then replaced by scar tissue;
2) The DC seems to be more effective in causing the effect, compared to the PC;
3) Some studies have found no benefit whatsoever; others have seen a measurable effect, with a reduction in fat;
4) We don’t really know the optimal dosage and mix of ingredients;
5) We don’t know where the “melted” fat goes, and whether this process has side effects;
5) Some people have reactions to the injections, with pain, swelling and lumpiness. Fortunately, most of these reactions are usually transient;
6) Some people have no response to the treatment, other than the inevitable thinning of their wallet. These people usually come to me later, for actual liposuction.

So far, I feel that injection lipolysis should be classified as an experimental procedure. Although I’m very interested in it, I don’t offer it to my patients. I feel that the details really need to be worked out first. Liposuction is still the undisputed standard for fat removal.

Regulatory approval would also help me feel better about this technique. When the FDA, Health Canada, the UK’s Medicines and Healthcare Products Regulatory Agency (MHRA), and the Brazilian version of the FDA all speak out against this procedure, that should tell you something. It’s probably not “ready for prime time” yet.

The research wing of ASAPS (American Society for Aesthetic Plastic Surgery) has a study going on this right now. I’ll post the results as soon as they are available. Personally, I’d like for this technique to work – it would add another useful method to those we use currently, and would be minimally-invasive, as well. We’ll have to wait and see…

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