Toward Racial and Ethnic Equality in Aesthetic Practice, Part 2

Part two of a series continues a dialogue about challenges and opportunities in aesthetic medicine.

Cheryl Burgess, MD; Jeanine B. Downie, MD; José Raul Montes, MD; Wendy W. Lee, MD; and Melissa Kanchanapoomi Levin, MD

How can your peers make sure their private/group/academic practice is appropriate with ethnic minorities? Wendy W. Lee, MD: Being at a university, we have strict guidelines in place to ensure the ethical treatment of all, which includes appropriate behavior of ethnic minorities. It is important to have guidelines in place no matter what type of practice you are in, and these guidelines should apply to providers, patients, and staff. José Raúl Montes, MD: We have to elaborate a universal Mission Statement with specific guiding principles, that promotes inclusiveness and repudiates discrimination based on race, ethnicity, gender, and sexual preference. Jeanine Downie, MD: My peers can make sure their practice is appropriate with ethnic minorities by hiring ethnic minorities, training everyone in cultural sensitivity and racial diversity, and being aware of ethnic differences and practices. With racial issues and diversity, common sense rules. If you think something is offensive, then simply avoid it. How can anyone become a better, more capable, and more empathetic physician to race and race issues with patients of color? Dr. Montes: The phrasing of this question has an implicit bias due to the plea for becoming “empathetic.” The fact that empathy is required admits that there’s a position of privilege. Someone who has to make a conscientious act of showing empathy is clearly standing on a pedestal. Empathy is a concession that people make toward others; not a change in their way of thinking. If anything, you should take care of yourself first in order to become educated and freed from your own prejudice. Dr. Lee: Awareness comes from keeping an open mind and listening to all points of view. It is important to place everyone on an even playing field, no matter the color of their skin. Be sensitive to others and how they may have been mistreated in the past, working with them to change that behavior and make them feel comfortable and safe. Melissa Kanchanapoomi Levin, MD: As physicians, we cannot deny that we are in positions of power and privilege. With this collective power and privilege, we should be at the forefront of these conversations. The public health crisis of COVID-19 has demonstrated the systemic and underlying racism in our health institutions. There are steps an individual aesthetic physician can take: Acknowledge our biases, the lack of diversity in our field across medical school and residency training, research, leadership, and clinical exposure. Get involved in mentorship to support and provide mentorship and opportunities to black communities. Perform a comprehensive review of your practice: clinical expertise, hiring practices, staff training, marketing, communication. Focus on ensuring that your practice and skillset is inclusive to all patients and staff members. Create a plan to work on your practice’s biases and how to dismantle them. Dr. Downie: Everyone can be a better and more empathetic physician to race and race issues with skin of color patients by listening, reading, and caring. Cultural sensitivity training and awareness is critical, and I believe there should be more of it within our academic halls when we are giving conferences. Care enough to treat all of your patients the same—with respect and dignity. There is a doctor from New Jersey who will remain unnamed. I was rotating with him and considering taking a job offer with him back in the late 90s when I was just finishing my chief residency year at Mount Sinai Medical Center. He would go in the white patients rooms’ and say “Good morning, Mr. [Last Name]. How are you? It’s a pleasure to see you. I’m Dr. [Anonymous], etc.” However, in the rooms with African-American patients, he would walk in and say “What’s up, my man? How you doing?” and embarrass the heck out of me and say it in some crazy Bill Cosby type of voice. I was horrified. Not the place for me to work, I decided rapidly! What can your specialty do to support its members who are part of racial/ethnic minorities and/or to support permanent positive change in terms of racism? Dr. Lee: ASOPRS is very supportive of not only its members, but also staff, volunteers, members in training, attendees of our meetings, and vendors who participate in our meetings. Our society does not discriminate based on gender, age, or race and is very aware of and sensitive to issues in the world surrounding inequality with a no tolerance policy. Dr. Downie: I have mentioned some different things that pharmaceutical companies and industry can do. In addition, we need to have more ethnic minorities become residents in the many different dermatology programs across the country. We need to foster proper discussion of what is racist and what is not racist, even if it makes some people/docs uncomfortable. It is better to make doctors uncomfortable than to make patients upset. Permanent positive change comes from being anti-racist. It is not enough to consider yourself not a racist. If you hear something, say something. The best example of this that I can give is if you are constantly listening to your Auntie Louise talking smack about black people, gay people, or Latino people, say something. Aunt Louise doesn’t feel comfortable talking to ethnic minorities about her racism at all. But she feels comfortable talking to you. So take her down. Defend us. Say something. Speak up. Silence is not helpful, and that’s how this idiocy has been allowed to continue for as long as it has. Be sympathetic, be empathetic. That is all. Read more, listen more, and learn. That is the most effective way to combat ignorance and hatred in our society. I always say, “If you’re not part of the solution then you’re part of the problem.” Defeating widespread and systemic racism will be a slow and steady process. I firmly believe that it can happen. It will happen with one person at a time. Minorities cannot take on this fight by ourselves. It is not up to only minorities, it is actually up to all of us. We need help, and we would be obliged if everyone from all backgrounds would lend us a hand. Access Part 1 of this dialogue online here.

Topical Fixes for Skin of Color

Multiple products are now available to prevent and treat hyperpigmentation concerns. Here’s what experts recommend.

Corey L. Hartman, MD; Pearl E. Grimes, MD, FAAD; Andrew F. Alexis, MD, MPH; Nikolaos Metaxotos MD, PhD; and Jaime Piquero-Casals, MD, PhD

For decades, hydroquinone-based products were the only effective treatment options for pigmentation issues, such as melasma, and while these are still often considered the gold standard, many new therapies are emerging to help treat and prevent melasma and postinflammatory hyperpigmentation in skin of color. Here, experts from around the world share their favorite products and strategies for addressing these skin conditions. Focus on SPF and Hyperpigmentation As a Black dermatologist, I can tell you that pigmentation issues plague patients of all skin types. My patients with darker skin types (Black, Indigenous, People of Color – BIPOC) are often distressed by the discoloration that inflammation can leave behind after the flare has resolved. Conditions like acne, eczema, and seborrheic dermatitis are common, but often the reason patients seek treatment isn’t because of the inciting inflammatory skin problem. Instead, they seek care for the “stain it leaves behind,” as I call it. My lighter-skinned patients are more prone to pigmentation from sun damage and melasma, since they lack the inherent melanin that protects from sunburn and photodamage. Aside from treating the underlying condition, which is always important, the next step is reducing the dark spots and providing a more even complexion. Sunscreen is paramount to treatment of any discoloration as the sun is a major influence on hyperpigmentation and melasma. The SPF should be in the range of 30-50. I tell my patients that anything more than 50 is a waste of money, and anything less than 30 is a waste of time. More important than the number on the bottle is whether or not the sunscreen is chemical or physical. Chemical sunscreens have been historically more elegant, but they are full of potential problems. A quarter of the population is allergic to one of the 10 or so common chemicals in sunscreens, and it seems as though every year we discover more about the ways that the chemicals impact our bodies beyond our skin. Physical sunscreens are mineral-based and non-allergenic. They were historically thick and opaque leaving a white cast or an iridescence on skin, particularly skin of color. Today’s formulations, however, have come a long way and are quite elegant, leaving no trace once properly applied. For these reasons, I exclusively recommend physical sunscreens to my patients My favorites are: Isdin Eryfotona Actinica. This fast-absorbing, ultralight emulsion contains zinc oxide. It spreads well, has a mild, pleasant smell and does not leave the skin feeling oily. It is a favorite of all skin types, especially those with oily skin and men. As a bonus, it contains an enzyme clinically proven to repair DNA existing damage. SkinBetter SunBetter Sheer Sunblock Stick. This novel vehicle provides a transparent layer of broad-spectrum protection regardless of skin type. It protects against UVA, UVB and infrared light with 100 percent mineral actives and is water-resistant for up to 80 minutes. La Roche-Posay Anthelios Mineral Sunscreen. This 100 percent mineral sunscreen with zinc oxide and titanium dioxide is ideal for sensitive skin. Packed with antioxidants, it is an efficient way to protect from the sun and prevent free radical formation. When it comes to treating dark spots, a good daily retinol is always an important step to properly exfoliate and maintain the even complexion, but when first getting started, a lightening agent is a must. My favorites are: Cyspera. This latest entry to the pigmentation market is a unique cream that contains cysteamine. The only product of its kind on the market, Cyspera boasts head-to-head trials showing superiority when compared to prescription Tri-Luma. The latter contains hydroquinone, which has some potential safety concerns, and a steroid which cannot be used for long periods of time. Cyspera not only lightens dark spots but provides a more even overall complexion than hydroquinone products can. There is no risk of halo hypopigmentation with Cyspera and it is well tolerated even by those with sensitive skin. It has been a game changer for my patients and has become my go to treatment for melasma and post-inflammatory hyperpigmentation. SkinCeuticals Discoloration Defense. Boasting the highest concentration of tranexamic acid, Skinceuticals Discoloration Defense offers a novel skin lightening agent that works well for melasma and hyperpigmentation with little to no irritation. Discovered by OB/GYNs when prescribed to women with heavy menstrual cycles, the oral version has a risk of blood clots. The topical form provides similar benefit without the risk. AlumierMD Intellibright Complex. The unique mix of natural lightening agents like arbutin, kojic acid, licorice root extract, and others provides a great product that is free of chemicals. The vehicle is a soothing serum that provides hydration. The Ordinary Azelaic Acid Suspension 10%. This product is unique due to the inclusion of azelaic acid, a pigment reducer that naturally occurs in skin and blocks the production of excess melanin in the skin. Known for its mild application, azelaic acid is also a key ingredient to keep rosacea and acne in check, so it accomplishes multiple skin goals. Corey L. Hartman, MD, FAAD Skin Wellness Dermatology Birmingham, Alabama Consider Combinations When treating Melasma and PIH, I am an ardent champion of combination therapies that are customized for each individual, factoring in the correct diagnosis, skin type, severity of the condition, history, goals, and other considerations. Taking a multi-modality approach is especially important in treating pigmentary disorders in more melanized skin to ensure patient safety and optimal outcomes. My combination therapies feature a carefully curated mix of products for photoprotection, topical lightening agents, paired with resurfacing treatments if needed. Adequate photoprotection is key and 100 percent essential. I am a big proponent of using physical sunscreens. Recent studies now document the role of visible light for induction of persistent hyperpigmentation in skin types IV through VI. Hence, it is important to incorporate visible light protection when possible. Iron oxide has been shown to be very beneficial in blocking visible light, it can be used alone or in combination with Zinc and Titanium. Dumbuya, Grimes et al documented the impact of iron oxide containing formulations against visible light-induced skin pigmentation in skin of color individuals in a study in Journal of Drugs in Dermatology. While hydroquinone is the gold standard or “mothership” for treating pigmentation disorders such as melasma or post-inflammatory hyperpigmentation, there is an emerging paradigm spectrum of non-hydroquinone ingredients to incorporate into treatment regimens including cysteamine, tranexamic acid, and resveratrol to name a few. Standard non-hydroquinone ingredients that are frequently used include azelaic acid, kojic acid, niacinamide, arbutine, licorice, retinoids, and alpha hydroxyl acids. Regarding resurfacing procedures, I personally prefer peels, particularly in darker racial ethnic groups. They have a broader safety profile. I use lasers for cases that are more recalcitrant. In summary, disorders of pigmentation such as melasma and post-inflammatory hyperpigmentation can be challenging, however new and effective treatments are emerging. Pearl E. Grimes, MD Director, The Grimes Center Of Medical And Aesthetic Dermatology Director, The Vitiligo & Pigmentation Institute of Southern California in Los Angeles Pair OTCs with Rx For hyperpigmentation, I recommend 5% cysteamine cream (Cyspera), a novel formulation that is a great alternative to hydroquinone (HQ). It should be used in a short-contact fashion, washing it off after 15 minutes. I also recommend multimodal topical containing tranexamic acid, phenylethyl resorcinol, plankton extracts, tetrapeptide-30, niacinamide, marine exo-polysaccharides (Lytera 2.0). A blinded split-faced study at Skin of Color Center comparing this formulation to hydroquinone 4% in the treatment of melasma showed significant improvement from baseline and statistically comparable results to hydroquinone. Azelaic acid 15% foam (Finacea) is an alternative to HQ. Hydroquinone 4%/fluocinolone 0.1%/tretinoin 0.05% (Tri-Luma) is the gold standard with grade A evidence. It is a first-line treatment for melasma but also useful for PIH and other hyperpigmentation disorders. Andrew F. Alexis, MD, MPH Professor and Chair, Department of Dermatology Mount Sinai West and Mount Sinai Morningside Director, The Skin of Color Center at Mount Sinai in New York City Think Vitamin C Topical treatment using cosmetic products is recommended as a prevention for mild hyperpigmentation conditions. Ingredients of choice include Vitamin C and Arbutin (a glucoside of hydroquinone). Vitamin C in its natural form (Ascorbic Acid) is unstable so modern skincare uses stabilized forms of the molecule, which have proven stable, safe and effective like Ascorbyl Palmitates and Ethyl Ascorbic Acid. Dr. Age Microlift Cream and Serum contains Vitamin C Tetraisopalmitate with an excellent safety profile, that acts against photoageing, hyperpigmentation, tissue inflammation and promotes tissue healing. The depigmentation effect—inhibition of Tyrosinase Activity & Inhibition of Melanogenesis—can work very well on all skin types that present post-inflammatory hyperpigmentation. This specific form of Vitamin C has a superior percutaneous penetration because of its lipid-solubility. After skin penetration, it is converted to Vitamin C and liberates all its properties. Nikolaos Metaxotos MD, PhD Plastic Surgeon, Athens, Greece Explore New Ingredients The mainstay of melasma and PIH treatment remains prevention of exposure to sunlight and depigmenting topical agents. Photoprotection must include protection against blue light as its role in pigmentation disorders is now well recognized. Broad-spectrum sunscreen should be applied regularly to sun-exposed areas of melasma or PIH. Various topical agents have been proposed to interfere at different steps in melanogenesis. The main mechanisms of action of these agents include inhibition of melanin production and melanosome transfer, increased keratinocyte turnover, and anti-inflammatory and antioxidant effects. Useful cosmeceuticals include a combination of vitamin C, phytic acid, green tea leaf extract and grape seed extract that helps improve dark spots (Melaclear, Isdin*). Use of Melaclear twice a day together with sunscreen (Eryfotona Actinica, Isdin) for 12 weeks has been shown to prevent signs of aging and improve skin quality on the face. Other non-hydroquinone depigmenting agents are 4-butylresorcinol, hydroxyphenoxy propionic acid and niacinamide. These actives are well tolerated and reduce the appearance of dark spots. Glycolic acid, an alpha-hydroxy acid (AHA) with exfoliating properties, helps to smooth the skin, diminishing the appearance of imperfections. It is a highly effective treatment treatment for pigmentation disorders in darker skin types. In studies on skin explants, glycol concentrations of 8% to 25% (Glicoisdin, Isdin) have been shown to induce a desquamative effect and increase dermal collagen levels in a dose-dependent manner. Mane Course: Tips for Hair Care When it come to hair products for his patients, Dr. Hartman recommends: LivSo Moisturizing Pack. This trio of products promotes healthy manageable hair by first providing comfort and balance to the scalp through exfoliation, repair and moisturization. Consisting of a shampoo, conditioner and moisturizing lotion, LivSo provides hydration and promotes strength of the hair shaft and reducing irritation of the scalp found commonly in seborrheic dermatitis. It is ideal for all hair textures including curly and textured hair and provides moisture without weighing the hair down. Old Spice Thickening System Treatment. Inevitably if a person lives long enough, hair thinning will occur. But that doesn’t mean that it cannot be treated. Infused with biotin, the shampoo lifts hair to ultimate fullness while gently cleansing. The conditioner contains vitamin C, a potent antioxidant designed to keep hair strong and provide defense against ultraviolet light. The leave-on treatment contains castor oil, which increases hair’s thickness and volume. It’s a great, easy way to effortlessly promote a thicker head of hair. Viviscal Pro Vitamins and Thin-to-Thick Elixir. This system of oral vitamins and topical serum are a crowd favorite in my practice. The vitamins strengthen the hair to promote growth and reduce breakage in an easy tolerated pill that doesn’t cause nausea. Its blend of vitamin C, flax seed extract, and zinc help hair to grow for longer periods. In-office procedures such as chemical peels have also been proposed in the management of PIH and melasma; however, patients must be carefully selected because of the risk of skin irritation. More recently, systemic approaches for the treatment of PIH and melasma have been proposed. There is a growing interest in oral antioxidant supplements like extract of Polypodium leucotomos, green tea extract and vitamin C. These ingredients improve photoprotection by decreasing oxidative stress and limiting its effects. In difficult-to-treat melasma, we published a case series of patients treated with chemical peels and a home treatment schedule. Each morning they applied a depigmenting serum containing 4-butyl resorcinol, hydroxy-phenoxy propionic acid and niacinamide (Pigment Expert, ISDIN ampoules); a specific SPF 50+ sunscreen; and took an oral supplement containing 480 mg of Polypodium leucotomos, green tea extract, Vitis vinifera, vitamins C, E, and D, and carotenoids (Sunisdin, Isdin). At night, they applied a triple combination compounded medication with 4% hydroquinone, 0.025% tretinoin and 1% hydrocortisone in a gel-cream for a duration of 16 weeks. With this treatment protocol, we observed very good results with no relapse at the 12-week follow-up, with continued daily home therapy. Jaime Piquero-Casals, MD, PhD Dermatologist in private practice, Dermik Clinic, Barcelona, Spain *Dr. Piquero-Casals is a Medical Advisor for ISDIN SA.

5 Things to Know About New Fillers

A global perspective on fillers hitting the US market this year.

Hassan Galadari, MD

The RHA (Resilient Hyaluronic Acid) Collection of dermal fillers hits the market from Revance this fall. The RHA dermal fillers are designed with a crosslinking method that preserves the hyaluronic acid network in efforts to more closely mimic natural HA found in the skin. Results of an 18-month, head-to-head, randomized, controlled study published in Dermatologic Surgery, found high levels of improved satisfaction immediately after injection and in the long-term for both investigators and participating subjects for RHA 2, 3, and 4. Three-dimensional (3D) skin topography measurements showed better long-term improvement of nasolabial fold volume with gels in the RHA Collection. The RHA line has been available outside the US for some time, and we have gained a substantial amount of experience with these products. Here are five things to know. 1. The RHA line is made up of four distinct gels. Three of these have been approved in the US. RHA1 is still in the pipeline in the US and is used for the treatment of fine lines and treatment of the tear trough. 2. RHA4 is a unique gel that may be injected in both the deep and superficial fat compartments to achieve lift and volume. The product is easily integrated into the tissue and does not have a boggy effect when volumizing the mid face, even when placed superficially. This is due to its pliability and stretching properties. 3. Both RHA2 and RHA3 may be used for the injection of the lips. RHA2 is mainly used for older patients to achieve a natural result and in the younger population group who have never had their lips injected in the past and want to try that out. RHA3 is the main filler for natural volumizing of the lips. 4. The RHA line has been formulated to cater mainly to the animated face. There is a respect that static lines change where fillers are injected and the face is in motion; current materials do not have the properties that take that into consideration. 5. When compared to other fillers that are FDA approved, the RHA line will provide a much needed gradient that will fill a particular niche. That would be that natural results should be seen not just in still pictures, but when showing emotion.

A Good Problem to Have: Where Should I Spend Money in My Practice?

Allyson Avila, JD; Wendy Lewis; Jay A. Shorr, BA, MBM-C, CAC XIV; and Mara Shorr, BS, CAC XIV

Let’s say you had an extra $50,000 to spend on growing your practice. What would you do first? Our practice management pros have some ideas that are definitely worth considering. Trade Up By Wendy Lewis In the post-COVID landscape, $50,000 may actually go a little farther than it once did. Take advantage of special offers from vendors who want your business right now. For example, there are some great deals to be made on capital equipment that can add a treatment that may be missing from your current menu. Many device brands are offering tempting deferred payments and trade-ins for old clunkers. Trade up anything that is an expensive coat hanger and replace it with better technology that is faster, easier to delegate, and delivers superior outcomes for patients. That’s a win-win. Tedious paperwork, filing, chart notations, prescriptions, and other grunt work processes that can be streamlined or automated will save staff time and make them happier and more productive. It also improves the operation of your practice and cuts down on the potential for human error and employee theft. Invest in a state-of-the-art customizable and upgradable practice management software and get your staff trained properly. Most importantly, two things you should do right now are to jump on voice search for your business and add a programmable voice assistant to your website. The former will allow your business to be found by Alexa and Siri when a prospective patients asks, “Where is the best laser clinic near me?” The latter will make your practice more accessible to patients after hours by responding to simple questions, offering directions, scheduling live/virtual consultations and more. Consumers have become more comfortable with these early iterations of AI. You may capture more patients through being more visible and easier to connect with.If you have any funds left over and are so inclined, consider hiring a marketing manager for your practice or promoting someone on staff into that role. For group practices, this role is a must-fill. For solo practices, it is a nice to have. In some states, it may be more economical to enlist an experienced marketing agency to help. Whichever route you take, you will need an omnichannel marketing program to maximize your practice’s potential and stay connected with patients in a meaningful way. Save for (Another) Rainy Day By Mara Shorr, BS, CAC XIV and Jay A. Shorr, BA, MBM-C, CAC XIV In the best of times, we may all spend differently because we know that the well will always be full or continuously replenished; given today’s economy, expendable capital resources must be spent wisely to maximize the greatest return on investment (ROI). It is important to have a reserve of capital to plan for the unexpected, especially after what we have all been through with the COVID-19 pandemic. Still, marketing is and should always be a top priority. Even when business slows down, you must remain front and center in the patient’s mind so they know you are still there. Once the patient wants to return to having procedures, the practices that remain visible will be the winners. This includes SEO, since it keeps your website fresh, visible, and showcases you as one of the leaders in the industry. Once the initial contact request is made (e-mail or telephone), however, it is up to your practice to convert that lead into a consult, and the consult to a treatment. It’s also important to beef up your presence on social media. Keep your posts fresh with new content, special offers, and other diverse and educational content.It’s not just what you spend the money on that matters. What you don’t spend it on matters, too. Now is not the time to invest in new capital equipment. The possibility of having to close again while incurring additional debt is not in your best interest. Stick with what you have for now. Cover Your Assets By Allyson Avila, JD It is highly recommended that all doctors/practices have insurance policies that cover them in the event of a sexual harassment claim, yet the typical insurance policy does not cover such claims and specifically excludes the coverage. Without sexual harassment insurance, which is contained in an Employment Practices Liability Policy and Directors/Officers policy, the doctor/practice is personally liable to the accuser should they be successful in their claim. Many of these claims also include punitive damages, which could cost hundreds of thousands of dollars. Without the insurance, the doctor/practice has to pay for any damages awarded and any out-of-pocket costs to hire an attorney to defend the claim. Sexual harassment comes in many forms and includes such claims as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when this conduct explicitly or implicitly affects an individual’s employment, unreasonably interferes with an individual’s work performance, or creates an intimidating, hostile, or offensive work environment.” The claims can be asserted by an employee, vendor, or patient. Other insurance coverage that a doctor/practice should have is advertising injury coverage. This protects the doctor/practice against claims of stolen ideas, invasion of privacy, libel, slander, and copyright infringement related to advertising. This is an important component of a general liability policy and is becoming increasingly necessary. Many practices are creating websites using other people’s photographs or content without realizing they may be infringing on someone else’s trademark or copyrighted material. Without the coverage, the doctor/practice is on the hook for damages, which are usually very costly.Although adding the above coverage to a policy costs less than $50,000, it is well worth the investment so that you can be sure that you are adequately protected. With the money that is left over, you can buy some piece of mind.

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