Integrating Skin Care Into an Injectable Practice

By Steven Dayan, MD

Steven H. Dayan, MD, FACS is in private practice (www.drdayan.com) in Chicago. He is a Clinical Assistant Professor at the University of Illinois and author of the book Thrive.

By now, we are all well aware of the explosive increase in demand for non-surgical aesthetic enhancement, particularly over the last decade. This trend has been led by neuromodulators and hyaluronic acids—the two most popular treatments—but not far behind are skin care regimens like chemical peels and microdermabrasion. And while we can clearly see the benefits these products have had on our ability to improve physical traits of beauty, what is becoming increasingly apparent is the significant effect these treatments have on self-esteem and quality of life for our patients.

As our treatments evolve beyond providing beauty benefits on to well-being enhancement, the importance of augmenting or enhancing the overall patient experience is becoming further defined and increasingly important. The progressive aesthetic physician is recognizing that the packaged experience certainly improves the physical outcomes, but also improves patient psyche and strengthens their loyalty to the practice. And a key component to making this a reality is a strong emphasis on skin care. Unfortunately for many non–dermatologists, the importance of skin care is often overlooked, leading to missed opportunities in maximizing of clinical outcomes and increasing patient satisfaction.

Testing the Benefit of Skin Care

At-home skin care targets aesthetic enhancement in areas not addressed by injections. Moreover, a dedicated commitment to skin care is essential toward achieving comprehensive improvement in the patient's appearance, particularly in areas of skin tone, texture, and pigmentation. From an evolutionary perspective, homogenized skin tone communicates health and vitality, as opposed to heterogeneous skin with dark spots and wrinkles, which suggests aging and disease. Intuitively, the addition of a skin-brightening regimen could serve to complement cosmetic treatments, increase patient satisfaction, and improve the overall experience at our office.

To assess this hunch, we set up a small clinical trial incorporating three different versions of skin care (SkinCeuticals, Inc.) following injections with hyaluronic fillers and neuromodulators (Merz Aesthetics, Inc.). This study enrolled a total of 20 patients and was formalized with IRB approval.

The filler used, from the Belotero product line, is recognized for its monophasic cohesive polydensified matrix (CPM) technology allowing for incorporation into tissues providing a natural result. Our participating skin care line, SkinCueticals, is well known for its contribution to the medical literature since inception by its founder Dr. Sheldon Pinnell. Many topical cosmeceutical products have anecdotally shown to improve visible signs of aging. Few products are backed by clinical studies to confirm their safety and efficacy; SkinCeuticals continues to address the need for research in the skin care industry.

A total of 20 healthy volunteers were enrolled to receive 30-60 units of incobotulinumtoxin A and 4cc of hyaluronic acid injections in the cheeks, nasolabial folds and lips. Each subject was then randomized to receive one of three prescribed skin care regimen for a total of 12 weeks in conjunction with injections. Group 1 (n=10) received an Advanced Brightening System (ABS) cosmeceutical regimen, comprised of a cleanser, antioxidant, exfoliator, retinol, and a sunscreen. Group 2 (n=5) received the same ABS regimen plus a series of six alpha-hydroxy acid Pigment Balancing Peels (PBP) every two weeks. Group 3, which served as the control group, received a basic skincare regimen consisting of a cleanser, moisturizer, and SPF 50 sunscreen.

Each patient's skin was assessed via the 9-point Fitzpatrick Wrinkle Assessment Scale (FWAS) by the principal investigator and three blinded reviewers. Self-esteem was also evaluated at baseline and at week 12 using the validated Heatherton-Polivy Self Esteem Scale (HPSS). Patient's global aesthetic improvement was also evaluated using a 5 point Global Aesthetic Improvement Scale (GAIS) ranging from very much improved (a score of 1) to worse (a score of 5). Additionally, subjects' skin quality was assessed on a 9-point ordinal Skin Appearance Scale (SAS).

All three groups demonstrated aesthetic improvement across all assessment scales. No adverse events were noted with the use of the skin care regimen throughout the entire study. At the 8-week evaluation point, subjects who received the ABS experienced a 44 percent improvement in their FWAS skin scores. Group 2, receiving the more aggressive skin care treatment (ABS + PBP), demonstrated a 58.1 percent improvement and the control group 3, receiving a basic skin care regimen, exhibited a 41 percent improvement. Our primary conclusion was that the more aggressive the regimen the greater the aesthetic improvement. A similar pattern was also found in the SAS assessments; Patients receiving ABS with or without PBP were found to have improvement ranging from 40 percent to 150 percent in skin tone, pigmentation, spots, and radiance. When patients subjectively evaluated their overall appearance, using the GAIS scale, once again a similar pattern emerged. Patients in Group 1 who received the ABS noted a score of 1.9, corresponding with much improved. Group 2, ABS plus PBP, average score was 1.8 and this improvement status continued on through the 12 weeks the study. Group 3 experienced scores of 2.4, which correlated with an average improvement in appearance.

One could surmise that unblinded subjects receiving a more comprehensive treatment would rate themselves with greater improvement, however we found a strong corollary between blinded evaluator scores and subject self-assessments. Those that received the most aggressive treatment (Group 2) showed the greatest blinded evaluator GAIS improvement. This seems to corroborate the subject's perceptions that the more aggressive treatment yielded the best results. When evaluating self-esteem scores in all 20 subjects, those in group 1 and 2 were more likely to exhibit an increased improvement. Patients in Group 2 (ABS + PBP) experienced improvement in 12/20 self-esteem categories. The average increase in self-esteem scores ranged from eight to 12 percent, with some categories scoring higher: 20 percent reporting more satisfaction with their appearance and 33 percent more confident in their abilities.

A Vital Role

Considering the continuing surge of neuromodulator and filler treatments, it is sensible to reflect upon all possible avenues of enhancing a patient's overall experience and clinical outcomes. Filler and neuromodulators each have their limitations; there is evidence that neuromodulators reduce skin sebaceous activity and fillers, hydrophilic by nature, may draw moisture away from the skin.

Our pilot trial highlights the importance of skin care as a complement to popular injectables. In order to treat the aesthetic patient comprehensively, it is prudent to recognize the importance of the skin's appearance. A face that has volume replaced and wrinkles reduced, consistent with a youthful look, will look unnatural if paired with overly mottled dyschromic sun damaged skin. Physicians play a vital role in improving the natural aesthetic look by highlighting the importance of proper skin care and providing intensive support for all of the patient's skin care needs. Additionally, patient compliance with both in-office procedures and at-home skin care regimens is important to maintain the results of medical interventions. As awareness increases, the number of physicians who offer skin care options within their offices should also proliferate.

Customizing a specific skin care regimen for their patients allows physicians to further personalize the provided care, complement the aesthetic improvement of in-office procedures, and help differentiate their service from other practices focusing exclusively on in-office treatments.