Supplement Individual Article: Algorithm for Pre-/Post-Procedure Measures in Racial/Ethnic Populations Treated With Facial Lasers, Nonenergy Devices, or Injectables.

BACKGROUND: Cosmetic procedures with lasers, nonenergy devices, and injectables are increasing in popularity among patients with skin of color. Published algorithms address measures to reduce side effects related to aesthetic procedures; however, none focus on reducing adverse events in skin of color. METHODS: An expert panel of dermatologists and plastic surgeons conducted face-to-face and online meetings to develop an algorithm for measures before, during, and after using aesthetic devices (energy and nonenergy-based) and injectable treatments based on the best available evidence for skin of color. Published algorithms and literature searches for aesthetic procedures provided guidance for the current algorithm. A modified Delphi method was used to reach a consensus to apply outcomes of literature searches, along with expert opinion, resulting in the current algorithm. RESULTS: The four sections of the algorithm outline an approach to optimize outcomes with specific before, during, and after procedure considerations. Pre-procedural consultation includes the development of a specific treatment plan based on individual patient goals and risk profile (including history and signs that may predict a higher risk for pigmentary or scarring complications). Before the procedure, sun avoidance and sunscreen use are emphasized; herpes simplex virus 1 prophylaxis and bleaching agents are administered if indicated. During the procedure, skin cleansing products are addressed, along with judicious techniques to minimize unintended cutaneous injury or inflammation. Post-procedural sunscreen and gentle skincare that may include skin-lightening agents or formulations designed to prevent infection and promote optimum healing are advised. CONCLUSIONS: The algorithm strives to optimize treatment outcomes for patients with skin of color by providing their physicians with guidance on measures before, during, and after office-based medical aesthetic procedures. J Drugs Dermatol. 2022;21:9(Suppl 1):s3-10.

INDIVIDUAL ARTICLE: Algorithm for Nonenergy and Injectable Treatment Pre-/Post-Procedure Measures.

BACKGROUND: Nonenergy and injectable treatments are frequently used for facial rejuvenation. Many publications have addressed methods to reduce adverse events related to the procedure; however, no algorithm exists on temporol before, during, and after measures for nonenergy and injectable treatments. METHODS: A panel of dermatologists and plastic surgeons convened a virtual meeting to develop an algorithm for measures before, during, and after nonenergy and injectable treatments based on the best available evidence and the panelists' experience and opinion. For the project, a Delphi method was applied, which was adapted from face-to-face meetings to a virtual meeting to discuss the outcome of literature searches to reach a consensus on the algorithm. RESULTS: The four sections of the algorithm address measures for optimizing outcome before, during, and after the procedure. Prevention includes avoiding excessive sun exposure and the use of a broad-spectrum sunscreen with an SPF 30 or higher. Before nonenergy-based and injectable treatments, the avoidance of alcohol, retinol peels, and agents such as acetylsalicylic acid and non-steroidal anti-inflammatory drugs, amongst other agents, is advised. Isopropyl alcohol, chlorhexidine, or hypochlorous acid (HOCl) prepare the skin before nonenergy and injectable treatments. The advisors recognize HOCL as particularly useful as it is active against bacterial, viral, fungal microorganisms and biofilm. The literature is inconsistent about the use of topical agents and skincare before and after the procedure. CONCLUSIONS: The algorithm aims to support an optimal treatment outcome for their patients, providing physicians with guidance on measures before, during, and after nonenergy and injectable treatments. J Drugs Dermatol. 2021;20:11(Suppl):s3-10.

Physician survey on pre-/postprocedure measures for injectable treatments.

INTRODUCTION: Every year in the United States, over 1 billion dollars are spent on aesthetic injectables, such as soft tissue fillers and neurotoxins. In 2018, the total amount of injectable treatments performed surpassed 2 671 130 procedures. While often mild and transient, adverse events (AEs) can occur following these procedures. AEs may include common side effects such as bruising, or rare, but serious AEs such as infections. While previous investigators have evaluated methods of reducing risks of AEs due to the treatment procedure itself, few investigations have evaluated measures employed before and/or after treatment (ie, peri-procedure). METHODS: An electronic survey was sent to aesthetic clinicians with experience performing injectable treatments. The survey collected information regarding general information (eg, demographics and specialty), type of injectable devices used, current peri-procedures, and an exploration of future options for peri-procedural measures. RESULTS: Most aesthetic clinicians did not use prophylactic topical or systemic antimicrobials, nor prophylactic topical antiviral therapy. However, approximately 65% of clinicians reported using prophylactic systemic antivirals for patients with a history of herpes simplex virus. A variety of products were used to prepare the skin prior to injectable procedures. Postprocedure, multiple over-the-counter wound repair products were recommended by >70% of injectors. However, there was a large variety of products recommended with no majority consensus. CONCLUSIONS: Currently, there are no peri-procedural standards of practice when performing aesthetic injectable treatments. Efforts are underway for the development of best-practice algorithms.

Pre-/postprocedure measures for minimally invasive, nonenergy aesthetic treatments: A survey.

BACKGROUND: Non-energy based devices used in aesthetic medicine include treatments such as microdermabrasion, microneedling, threads, and chemical peels. Practitioners may use these devices to address signs of facial photo- and chronological aging (fine lines, wrinkles, pigmentary, and skin textural changes). Currently, consensus papers or guidelines are lacking in peri-procedural measures or their potential role in the prevention or treatment of adverse events in non-energy based aesthetic procedures. AIMS: To explore current practices using non-energy devices, a survey was developed to identify trends in peri-procedure treatment measures. PATIENTS/METHODS: The survey was sent electronically to 2000 dermatologists and 388 plastic surgeons. Randomly selected sites included those practicing medical aesthetics using non-energy devices for facial rejuvenation. The survey gathered information related to practitioner demographics, types of devices used, and peri-procedural measures for non-energy device-based treatments. RESULTS: The survey was active from February to May 2019. Nine hundred and twenty clinicians opened the survey, and 109 surveys were completed, providing a total response rate of 11.8%. The results revealed inconsistencies with regards to skin preparation strategies and post-procedure care. While the majority of clinicians indicated a need for topical treatments to reduce inflammation, prevent scarring, and shorten time to healing, a standard of care was not observed. CONCLUSIONS: The results of this survey confirm a lack of standardized measures for peri-procedural care when using non-energy based devices for aesthetic medicine treatments. These findings emphasize the need for evidence-based recommendations for optimizing patient outcomes, reducing and managing adverse events, and shortening time to healing.

Pre-/postprocedure measures for laser/energy treatments: A survey.

BACKGROUND: Laser and energy-based devices may be used for many cutaneous indications, including facial resurfacing, improving skin conditions, and reducing signs of photoaging. Currently, no consensus papers or guidelines exist concerning peri-operative agents and specifically their use for laser skin resurfacing and their potential/possible role in prevention or treatment of side effects. AIM: To explore current practice using laser and energy devices, a survey was developed to identify the trends in pre- and postprocedural treatment measures. METHODS: The survey was sent out digitally to 300 randomly selected US dermatologist and plastic surgeon physicians practicing medical esthetics using laser and other energy devices treatment for facial rejuvenation. The survey gathered information on demographics, types of devices used in the clinic and pre-/postprocedural measures for facial laser, and other energy-based devices treatment. RESULTS: The survey was active from June 15, to July 15, 2018, and fifty-eight dermatologists and plastic surgeons completed the survey (19.3% response rate, 58/300). The results showed inconsistency in skin preparation strategies and postprocedure wound care. The majority of survey participants (55/58 [96%]) reported prophylactic oral antiviral use pre- and post-treatment; however, there was inconsistency about when to start and when to stop the use. A similar inconsistency existed in the recommended period of post-treatment sun protection before and after treatment. CONCLUSION: The results of the survey confirmed the lack of consistency in the types and duration of pre- and postprocedural measures-emphasizing the need for evidence-based recommendations to optimize outcomes, prevent infection, enhance comfort, and reduce downtime.

Novel mechanisms of Collagenase Santyl Ointment (CSO) in wound macrophage polarization and resolution of wound inflammation.

Collagenases are useful in enzymatic wound debridement. Clostridial collagenase, marketed as Collagenase Santyl Ointment (CSO), is FDA approved for such use. Building on the scientific premise that collagenases as well as collagen degradation products may regulate immune cell function, we sought to investigate the potential role of CSO in wound inflammation. We tested the hypothesis that in addition to enacting debridement, CSO contributes to the resolution of persistent wound inflammation. Wound macrophages were isolated from PVA sponges loaded with CSO or petrolatum and implanted in mice. Significant increase in pro-reparative and decrease in pro-inflammatory polarization was noted in macrophages of acute as well as diabetic wounds. Wound macrophages from CSO-treated group displayed increased production of anti-inflammatory cytokines IL-10 and TGF-ß, and decreased levels of pro-inflammatory cytokines TNF-α and IL-1ß. The active ingredient of CSO, CS-API, induced the expression of mϕheal /M(IL-4) polarization markers ex vivo. CS-API treatment attenuated transactivation of NF-κB and significantly induced STAT6 phosphorylation. A significant role of a novel PGE2-EP4 pathway in CS-API induced STAT6 activation and the mϕheal /M(IL-4) polarization was identified. Taken together, findings of this work reposition CSO as a potential agent that may be effective in resolving wound inflammation, including diabetic wounds.

Identification and Characterization of Novel Matrix-Derived Bioactive Peptides: A Role for Collagenase from Santyl® Ointment in Post-Debridement Wound Healing?

Debridement, the removal of diseased, nonviable tissue, is critical for clinicians to readily assess wound status and prepare the wound bed for advanced therapeutics or downstream active healing. Removing necrotic slough and eschar through surgical or mechanical methods is less specific and may be painful for patients. Enzymatic debridement agents, such as Clostridial collagenase, selectively and painlessly degrade devitalized tissue. In addition to its debriding activities, highly-purified Clostridial collagenase actively promotes healing, and our past studies reveal that extracellular matrices digested with this enzyme yield peptides that activate cellular migratory, proliferative and angiogenic responses to injury in vitro, and promote wound closure in vivo. Intriguingly, while collagenase Santyl® ointment, a sterile preparation containing Clostridial collagenases and other non-specific proteases, is a well-accepted enzymatic debridement agent, its role as an active healing entity has never been established. Based on our previous studies of pure Clostridial collagenase, we now ask whether the mixture of enzymes contained within Santyl® produces matrix-derived peptides that promote cellular injury responses in vitro and stimulate wound closure in vivo. Here, we identify novel collagen fragments, along with collagen-associated peptides derived from thrombospondin-1, multimerin-1, fibronectin, TGFß-induced protein ig-h3 and tenascin-C, generated from Santyl® collagenase-digested human dermal capillary endothelial and fibroblastic matrices, which increase cell proliferation and angiogenic remodeling in vitro by 50-100% over controls. Using an established model of impaired healing, we further demonstrate a specific dose of collagenase from Santyl® ointment, as well as the newly-identified and chemically-synthesized ECM-derived peptides significantly increase wound re-epithelialization by 60-100% over saline-treated controls. These results not only confirm and extend our earlier studies using purified collagenase- and matrix-derived peptides to stimulate healing in vitro and in vivo, but these Santyl®-generated, matrix-derived peptides may also represent exciting new opportunities for creating advanced wound healing therapies that are enabled by enzymatic debridement and potentially go beyond debridement.