The Academic Chair: Achieving Success in a Rapidly Evolving Health-Care Environment: AOA Critical Issues.

There is a growing consensus that an accomplished curriculum vitae and prior achievement as an academician may not correlate with success as a chairperson of a contemporary academic orthopaedic department. As surgeons, formal professional education, research expertise, and clinical experience often are inadequate to foster the necessary skills and experience in executive leadership, change management, business administration, and strategy. The recruiting and hiring processes to fill academic leadership roles have been slow to adapt and recognize the skills that are necessary to be a successful chairperson. Recent research has identified emotional competency, resiliency, leadership, communication, results orientation, and personnel development as skills that correlate with success in academic leadership. Formal courses and training in executive leadership and business management may be helpful in enhancing knowledge and skills in these disciplines.

Academic Orthopaedic Leadership: Current Challenges and Lessons Learned: AOA Critical Issues.

Health-care reform, market competition, cost containment, and pressure for productivity have dramatically impacted the practice of orthopaedic surgery and academic surgical training. Orthopaedic leaders and training programs are striving to identify and solve these contemporary challenges. Herein, we focus on 4 areas that currently pose important challenges to modern orthopaedic surgical departments and academic hospital systems, including the demanding and evolving skill sets that are required of physician leaders, the effects of the changing medical-legal environment on academic medicine, the impact of increased clinical productivity emphasis on surgical education, and departmental leadership transitions.

An Open Label Clinical Trial to Evaluate the Efficacy and Tolerance of a Retinol and Vitamin C Facial Regimen in Women With Mild-to-Moderate Hyperpigmentation and Photodamaged Facial Skin.

A 12-week open-label, single-center clinical usage trial was conducted to determine the effectiveness of a dual product regimen consisting of a 0.5% retinol treatment and an anti-aging moisturizer with 30% vitamin C in women with mild to moderate hyperpigmented and photodamaged facial skin. Clinical grading of several efficacy parameters, tolerability evaluations, subject self-assessment questionnaires, and digital photography were completed at baseline and at weeks 4, 8, and 12. A total of 44 women completed the study. Effective ingredients incorporated into the 0.5% retinol treatment included encapsulated retinol for a retinol concentration of 0.5%, bakuchiol, and Ophiopogon japonicus root extract. The anti-aging moisturizer with 30% vitamin C contained 30% vitamin C in the form of tetrahexyldecyl ascorbate (THD ascorbate), alpha-tocopheryl acetate (vitamin E) and ubiquinone (coenzyme Q10). The facial regimen produced a statistically significant decrease (improvement) in clinical grading scores for all parameters assessed at weeks 8 and 12 when compared with baseline scores. In addition, the majority of these parameters were improved at week 4. The test regimen was well-perceived by the subjects for various inquiries regarding facial skin condition, product efficacy, and product attributes. Several tolerability parameters were assessed with no statistically significant increase except for dryness. A statistically significant increase in clinical grading scores for dryness on the face occurred at weeks 4 and 8 when compared to baseline scores. The increase in dryness is expected when introducing a retinol product to a facial regimen and the dryness did not persist to the week 12 time point.

A placebo-controlled, double-blind clinical trial to evaluate the efficacy of Imedeen(®) Time Perfection(®) for improving the appearance of photodamaged skin.

OBJECTIVE: To assess the efficacy of Imedeen Time Perfection for improving the appearance and condition of photoaged skin in healthy women. METHODS: This randomized, double-blind, placebo-controlled clinical trial enrolled healthy women, 35-60 years of age, with Fitzpatrick I-III and Glogau II-III skin types and mild-to-moderate facial fine lines/wrinkles. The eligible subjects were randomized to receive two tablets daily of either Imedeen Time Perfection (Imedeen) or a matching placebo for 12 weeks. Efficacy assessments included investigator rating of 16 photoaging parameters (ie, global facial appearance and 15 individual facial parameters and the average of all parameters), instrumentation (ie, ultrasound dermal density, moisture level of the stratum corneum, transepidermal water loss, cutometry), and subjects' self-assessment. Differences in the mean change from baseline to week 12 values on these outcomes were compared between Imedeen and placebo using analysis of variance or a paired t-test. RESULTS: Seventy-four subjects with primarily Fitzpatrick skin type III (78%-79%) and Glogau type III (53%-58%) completed the study (Imedeen: n=36; placebo: n=38). The mean difference in change from baseline to week 12 for global facial assessment significantly favored Imedeen over placebo (-0.52; P=0.0017). Additionally, the mean differences in the average of all facial photoaging parameters (-0.29), mottled hyperpigmentation (-0.25), tactile laxity (-0.24), dullness (-0.47), and tactile roughness (-0.62) significantly favored Imedeen over placebo (P≤0.05). Significantly greater increases in ultrasound dermal density (+11% vs +1%; P≤0.05) and stratum corneum moisturization (+30% vs +6%; P≤0.05) were also observed for Imedeen than for placebo. There were no significant differences on other instrumental outcomes. CONCLUSION: The results of this study suggest that Imedeen Time Perfection can positively affect the appearance of photoaged skin, moisturization, and skin density over 12 weeks of treatment.

Long-term Multi-product Facial Regimen in Subjects with Moderate-to-severe Photodamage and Hyperpigmentation.

BACKGROUND: Photoaged skin is primarily a result of chronic sun exposure. Irregular pigmentation and wrinkling are common clinical manifestations. Monotherapy with retinoids, growth factors, and skin lighteners have proven beneficial. However, long-term treatment with a multi-product facial regimen has not been assessed. OBJECTIVES: This single-center clinical trial was conducted to assess the efficacy and tolerance of a topical multi-product regimen when used by subjects with moderate-to-severe photodamage and hyperpigmentation on the face over a course of 24 weeks. METHODS: Subjects were supplied with a six-product regimen to use on their face (cleanser, growth factor serum, skin brightener, moisturizer, retinol, and sunscreen). Products were used according to specific application instructions. Clinical grading and tolerability assessments were performed at baseline and at follow-up visits at Weeks 4,8,12,18, and 24. Standardized digital photographs were taken and self-assessment questionnaires were conducted. Image analysis for skin-tone evenness and brightness was also conducted. RESULTS: Seventy-two subjects completed the 24-week study. All clinical efficacy parameters showed statistically significant improvements over baseline at all visits. Plateau effects for these improvements were not seen at 24 weeks. The facial regimen was well-tolerated. Subject questionnaires showed the regimen was highly rated at all visits. CONCLUSION: This six-product, comprehensive facial regimen was shown to be clinically effective and well-tolerated for the treatment of moderate-to-severe photodamage and hyperpigmentation over 24 weeks. Additional benefits may occur with continued use.

Facial primer provides immediate and long-term improvements in mild-to-moderate facial hyperpigmentation and fine lines associated with photoaging.

BACKGROUND: Photoaged skin results from various environmental factors, most importantly chronic sun exposure. Dyschromia and fine lines/wrinkles are common clinical manifestations of photodamaged skin. PURPOSE: This single-center clinical trial was conducted to assess the efficacy and tolerability of a new multifunctional facial primer (camouflage, broad-spectrum SPF 50, and a treatment for hyperpigmentation) when used by females with mild-to-moderate facial hyperpigmentation and fine lines due to photoaging over a course of 12 weeks. PATIENTS AND METHODS: Subjects were provided test material (Even Up-Clinical Pigment Perfector) and supporting products to use on their face and neck. Products were used according to specific application instructions. Clinical grading for efficacy and tolerability assessments were performed by an expert grader at baseline, baseline (post-application primer), week 4, week 8, week 12, and week 12 (post-application primer). Standardized digital photographs were taken, and self-assessment questionnaires were conducted. RESULTS: Twenty-eight female subjects completed the 12-week trial. The facial primer improved scores for the appearance of hyperpigmentation and other photoaging parameters immediately after the first application. The treatment also showed a progressive improvement in the clinical assessment of hyperpigmentation and other photoaging parameters over the 12-week trial. These long-term benefits can be attributed to an improvement in the underlying skin condition. The facial primer was well tolerated. Subject questionnaires showed that the product was highly rated at all visits. CONCLUSION: The facial primer was shown to be effective and well tolerated for immediate and long-term improvement in the appearance of mild-to-moderate hyperpigmentation and fine lines associated with photodamage when used over a 12-week period.

Orthopaedic Surgeons' View on Strategies for Improving Patient Safety.

BACKGROUND: Many strategies have been introduced to improve safety in health care, but it is not clear that these efforts have reduced errors. This study assessed the experienced safety culture and preferred means of improving safety among orthopaedists. METHODS: Members of the Science of Variation Group and Ankle Platform were invited to complete an eighty-nine-question survey. Outcomes measured were the modified Patient Safety Climate in Healthcare Organizations (PSCHO) questionnaire, which measures safety as perceived by hospital personnel, and the degree of enthusiasm expressed for seventeen means of improving safety. RESULTS: The questionnaire was completed by 387 (92%) of the 422 participants. The rate of problematic responses, those implying a lack of safety climate, in the modified PSCHO questionnaire was 18%. In multivariable linear regression analysis, working in a non-teaching hospital (ß, 3.7; 95% confidence interval [95% CI], 1.3 to 6.2; p = 0.003), having a safety program (ß, 4.8; 95% CI, 0.74 to 8.8; p = 0.020), and male sex (ß, 3.7; 95% CI, 0.079 to 7.3; p = 0.045) were associated with higher perceived safety as measured by the PSCHO questionnaire. The majority of participants were very enthusiastic about making safety everyone's responsibility (75%), promoting better communication (80%), standardizing procedures (58%), and standardizing equipment and supplies (63%) to improve safety. CONCLUSIONS: We found a high problematic response rate concerning the perceived safety climate among surgeons, but there was a high rate of enthusiasm for means of improving safety. Knowledge of the variation in perceived safety and the enthusiasm for strategies to improve safety among surgeons can serve as a starting point for cultural change.

An Open Label Clinical Trial of a Multi-Ingredient Anti-Aging Moisturizer Designed to Improve the Appearance of Facial Skin.

An open label clinical trial was conducted to determine the effectiveness of a multi-ingredient anti-aging moisturizer designed to improve the appearance of facial skin. Parameters studied included fine lines and wrinkles, clarity/brightness, visual roughness, tactile roughness, evenness of skin tone (redness), evenness of skin tone (hyperpigmentation) and overall appearance. Thirty-seven female subjects, ages 35-60 years completed the study. Effective ingredients incorporated into the facial anti-aging moisturizer include: Astragalus membranaceus root extract, a peptide blend including palmitoyl tripeptide-38, standardized rosemary leaf extract (ursolic acid), tetrahexyldecyl ascorbate (THD ascorbate) and ubiquinone (coenzyme Q10). Subjects were instructed to apply the moisturizer twice daily, once in the morning and once in the evening. Subjects were evaluated at baseline and after 4, 8, and 12 weeks of product usage. Clinical evaluations were conducted at each visit. A self-assessment questionnaire was conducted at week 4, week 8, and week 12. The self-assessment questionnaire included product efficacy inquiries and product aesthetic inquiries. Digital photography was conducted at baseline, week 8, and week 12. After 8 weeks of twice daily use, clinical evaluation results show that the multi-ingredient anti-aging moisturizer produced a statistically significant improvement in the scores of all clinical grading parameters assessed compared to baseline. A greater statistically significant improvement was seen at 12 weeks. At week 12, there was a statistically significant percentage of favorable results versus unfavorable results in all product efficacy and product aesthetic self-assessment questionnaire results. Digital photography supported the clinical grading and self-assessment questionnaire results. Additionally, the multi-ingredient anti-aging moisturizer is judged to be mild and well tolerated. Several tolerability parameters were assessed at all time points with no statistically significant increase in any of the scores compared to baseline.

Pilot Study of Topical Copper Chlorophyllin Complex in Subjects With Facial Acne and Large Pores.

BACKGROUND: Acne vulgaris is one of the most common skin diseases treated by dermatologists. Salts of copper chlorophyllin complex are semi-synthetic naturally-derived compounds with antioxidant, anti-inflammatory and wound healing activity that have not been previously tested topically in the treatment of acne-prone skin with enlarged pores. OBJECTIVES: This single-center pilot study was conducted to assess the efficacy and safety of a liposomal dispersion of topically applied sodium copper chlorophyllin complex in subjects with mild-moderate acne and large, visible pores over a course of 3 weeks. METHODS: Subjects were supplied with the test product, a topical gel containing a liposomal dispersion of sodium copper chlorophyllin complex (0.1%) with directions to apply a small amount to the facial area twice daily. Clinical assessments were performed at screening/baseline and at week 3. VISIA readings were taken and self-assessment questionnaires were conducted. RESULTS: 10 subjects were enrolled and completed the 3-week study. All clinical efficacy parameters showed statistically significant improvements over baseline at week 3. The study product was well tolerated. Subject questionnaires showed the test product was highly rated. CONCLUSIONS: In this pilot study, a topical formulation containing a liposomal dispersion of sodium copper chlorophyllin complex was shown to be clinically effective and well tolerated for the treatment of mild-moderate acne and large, visible pores when used for 3 weeks.

Efficacy and Tolerability of Steroid-Free, Over-the-Counter Treatment Formulations in Infants and Children With Atopic Dermatitis.

BACKGROUND: Two steroid-free, over-the-counter skin protectant products have been developed for the care and treatment of atopic dermatitis (AD)-Eucerin Eczema Relief Body Crème (Body Cream) for daily skin moisturization and Eucerin Eczema Relief Instant Therapy cream (Instant Therapy) for treatment of AD flare-ups. We tested the efficacy and tolerability of these formulations in infants and children with AD. METHODS: Study 1: Body Cream was applied twice daily to the lower legs of 64 children with a history of AD (aged 3 months to 12 years) for 14 days. Study 2: Instant Therapy was applied to active lesions and surrounding skin of 29 children (aged 3 months to 12 years) with active atopic lesions. Assessments were performed at baseline and Days 7 and 14. Symptoms were assessed using the Atopic Dermatitis Severity Index in Study 2. RESULTS: Body Cream significantly improved skin hydration and reduced itching, burning/stinging, erythema, and tactile roughness. Instant Therapy significantly improved skin hydration and AD symptoms, notably pruritus, erythema, and lichenification. Both products were safe and well tolerated. DISCUSSION: Body Cream and Instant Therapy were effective and well tolerated in the treatment of AD in children. These products provide steroid-free, nonprescription therapy for the maintenance and treatment of acute eczema and were proven effective and safe in infants as young as 3 months.

A Marine Protein-based Dietary Supplement for Subclinical Hair Thinning/Loss: Results of a Multisite, Double-blind, Placebo-controlled Clinical Trial.

INTRODUCTION: Since skin and hair quality are potent vitality signals, and hair growth deficiency can cause significant psychological morbidity. In addition to clearly-defined hair loss disorders, milder forms of hair thinning or hair loss appear to be increasingly common, with a suggestion that sub-optimal diets and stressful lifestyles may be involved. METHODS: Here we assess the value of a dietary marine-extract based dietary supplement in premenopausal women with subclinical hair thinning or hair loss conditions. This multi-site, randomized double-blind, placebo-controlled clinical trial was conducted with impact on hair shedding rate and hair fiber diameter (assessed by phototrichogram) as primary end points upon consumption of the oral supplement compared to a placebo. A total of 96 eligible female subjects were enrolled aged 21-55 years of age from Asian, Caucasian, and Hispanic ethnic backgrounds. RESULTS: This study showed that hair shedding was significantly reduced in the first 3-6 months of daily consumption of the oral supplement. Moreover, phototrichogram image analysis revealed a statistically significant increase in the mean vellus-like hair diameter after 6 months of supplement consumption, when compared to the mean vellus-like hair diameters measured at baseline. DISCUSSION: These results support the view that a nutritional supplement approach may be useful for women in this age group to deal with subclinical hair thinning or hair loss conditions, and those components of this marine extract-based oral supplement may be a useful adjunct.

Surgeons' attitudes are associated with reoperation and readmission rates.

BACKGROUND: Attitudes influence how people make decisions. In an effort to decrease pilot judgment-related accidents, the Federal Aviation Administration teaches new pilots about hazardous attitudes that are believed to be incompatible with safe flight: macho, impulsive, worry, resignation, self-confidence, and antiauthority. If these attitudes are hazardous for pilots and their passengers, they may also be incompatible with the reliable and safe delivery of surgical care. QUESTIONS/PURPOSES: The purposes of this study were (1) to ascertain to what extent surgeons harbor hazardous attitudes; and (2) to determine their relationship, if any, to reoperation and readmission rates. METHODS: We selected validated aviation psychology tools that are used to measure these attitudes in pilots. We converted the aviation scenarios to analogous situations for surgeons and invited all surgeons from one academic program to participate in this study. A total of 41 surgeons were eligible to participate; 37 (90%) completed the attitude prevalence protocol and 31 (76%) had complete reoperation and readmission data for the correlation and regression analysis. Attending orthopaedic surgeons completed the Modified Surgeon Hazardous Attitude Scale as well as a series of additional instruments. RESULTS: Levels of macho thought to be hazardous in pilots were present in nine (24%) surgeons. Similar, elevated levels of self-confidence were found in three (8%) surgeons. High levels of impulsivity were found in 5% (two surgeons) and high levels of antiauthority were found in 3% (one surgeon). Only one (3%) surgeon reported elevated levels of worry and no surgeon reported hazardous levels of resignation. Thirty percent (11 surgeons) of surgeons harbored at least one elevated attitude level. In a regression model, macho attitude levels predicted 19% of the variation in surgeons' rate of readmissions and reoperations. CONCLUSIONS: High levels of hazardous attitudes may not be consistent with the routine delivery of safe surgical care in a teamwork setting where human factors and safe systems are the key to success. Further research is needed to determine if abnormally high levels of these hazardous attitudes impact patient care. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Determinants of disability after proximal interphalangeal joint sprain or dislocation.

BACKGROUND: Sprain or dislocation of the proximal interphalangeal joint may be a useful example of the counterintuitive aspects of recovery as the prognosis is excellent, but protectiveness in response to discomfort often hinders the stretching exercises that are a key component of the recovery process. OBJECTIVE: The aim of this study was to investigate the relationship between disability and pain self-efficacy in this context. METHODS: A total of 82 patients (54 men and 28 women) were enrolled in this prospective study. Finger motion was measured, and the patients completed measures of upper limb-specific disability (the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), symptoms of depression (Patient Health Questionnaire-9), effective coping strategies in response to pain (the Pain Self-Efficacy Questionnaire), and a pain scale at enrollment. RESULTS: Patients were enrolled a mean of 48 days after injury. The final multivariable model accounting for greater disability included lower self-efficacy, greater symptoms of depression, and gender (women have more disability). Lower self-efficacy was also the strongest predictor of pain intensity and finger stiffness. CONCLUSIONS: Effective coping strategies such as self-efficacy facilitate recovery (less disability, pain, and stiffness) after proximal interphalangeal joint sprain/dislocation. LEVEL OF EVIDENCE: Prognostic level I.

Hydroquinone-free Skin Brightener System for the Treatment of Moderate-to-severe Facial Hyperpigmentation.

OBJECTIVE: To evaluate the efficacy and tolerability of a multimodal skin-brightening regimen in subjects with facial hyperpigmentation. DESIGN: Open-label, single-center clinical study with clinical assessments at baseline, Week 4, Week 8, and Week 12. TREATMENT: Subjects were instructed to apply the skin-brightening complex onto their facial skin, twice daily, for 12 weeks. Subjects also applied a nonprescription retinol product, moisturizer, and sunscreen. PARTICIPANTS: Twenty-one subjects, aged 41 to 65 years, with Fitzpatrick skin types II to IV and moderate-to-severe facial hyperpigmentation completed the study. MEASUREMENTS: Overall hyperpigmentation and tolerability (objective and subjective) assessments were conducted at all visits. In addition, global improvement in hyperpigmentation was assessed at all follow-up visits. A self-assessment questionnaire was completed by subjects at Week 12. RESULTS: At baseline and Weeks 4, 8, and 12, subjects were assessed for overall hyperpigmentation and global improvement. Standardized digital photographs were also taken of the subjects' facial skin at all visits. Subjects completed a self-assessment questionnaire at Week 12. Statistically significant reductions in mean Overall Hyperpigmentation scores and significant improvements in mean Global Improvement scores compared to baseline were observed at all follow-up visits (all p<0.001). These clinical observations were supported by standardized digital photography. In addition, the skin-brightening regimen was highly rated by subjects on all of the questionnaire parameters. CONCLUSION: The results from this study suggest that the multimodality skin-brightening regimen may provide a comprehensive and optimal treatment option to help reduce facial hyperpigmentation.

Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life.

Two over-the-counter products have been clinically tested for efficacy and tolerability in the treatment of atopic dermatitis. Study 1 evaluated a daily maintenance Body Cream (Eucerin Eczema Relief Body Crème) applied twice daily for 14 days, followed by treatment withdrawal for 5 days (regression period) in subjects with a history of atopic dermatitis. Study 2 evaluated an acute treatment (Eucerin Eczema Relief Instant Therapy [Instant Therapy]) for active atopic dermatitis lesions administered for 14 days. Skin barrier function, hydration, tolerability, and relief of symptoms were assessed at baseline, day 7, and day 14. Study 2 also measured itch relief and treatment impact on work, social activities, and sleep. Body Cream significantly improved skin hydration and barrier function (P<.001) at 14 days, with improvements persisting through the 5-day regression phase. Itching was significantly improved in 93.8% of subjects (P<.001). Instant Therapy treatment of atopic dermatitis lesions significantly improved skin hydration and barrier function, as well as symptoms of erythema, pruritus, excoriation, and lichenification, with rapid improvement of itch reported within minutes of the first treatment application. Instant Therapy significantly reduced itch intensity and frequency, and demonstrated beneficial improvements in subjects' quality of life. Body Cream and Instant Therapy were both safe and well tolerated.

Informed shared decision-making and patient satisfaction.

BACKGROUND: Evidence suggests that when patients have a role in medical decisions they are more satisfied with their health care. OBJECTIVE: To assess predictors of patient satisfaction, ratings of the provider's informed shared decision-making (ISDM), and disability among patients with orthopedic pain complaints. RESEARCH DESIGN: A total of 130 patients with nontraumatic painful conditions of the upper extremity were enrolled. Medical encounters were audio recorded and coded by 2 independent coders. Eight ISDM elements and a total ISDM score were evaluated. Bivariate and multivariable analyses were used to answer the study questions. MEASURES: Participants completed the Princess Margaret Hospital Patient Satisfaction with their Doctor Questionnaire to measure satisfaction; the Disabilities of Arm, Shoulder and Hand questionnaire; the Patient Health Questionnaire-9 to measure depression; the Whiteley Index to assess heightened illness concerns; and the pain catastrophizing scale to assess coping strategies in response to pain. RESULTS: Less health anxiety, female gender, the ISDM element Identify choice, and any specific diagnosis determined 22% of the variation in satisfaction. Less health anxiety and unemployed unable to work compared with full-time working status were associated with a better rating of shared decision-making on the ISDM. Catastrophic thinking, female gender, symptoms of depression, and any specific diagnosis were associated with greater disability. Catastrophic thinking and symptoms of depression were the greatest contributors to the variation in disability. CONCLUSIONS: Psychologic factors are the strongest determinants of patient satisfaction, ratings of shared decision-making on the ISDM, and upper-extremity disability. Health anxiety is the most important factor in ratings of patient satisfaction and ISDM, whereas depression and catastrophizing are salient predictors of disability. LEVEL OF EVIDENCE: Prognostic level I.

Clinical efficacy and safety of a multimodality skin brightener composition compared with 4% hydroquinone.

There are numerous common skin disorders involving hyperpigmentation, including solar lentigines, postinflammatory hyperpigmentation, melasma, freckles, and dyschromia from photoaging. While these conditions are of an aesthetic nature, there is great interest in newer, safer, and more effective treatment modalities. Topical hydroquinone (HQ) has been the gold standard of skin lighteners for many years. However, regulatory authorities around the world are now questioning its safety. A randomized, double-blind, half-face study was conducted in females with moderate to severe facial hyperpigmentation to assess the efficacy and tolerability of 3 new skin brightener formulations containing SMA-432, a prostaglandin E2 inhibitor, compared with 4% HQ. Each subject was assigned 2 of the 4 test materials and was instructed to apply the product on the assigned side of the face twice daily for 12 weeks. Evaluation visits were conducted at baseline and at 4, 8, and 12 weeks. At each visit, subjects were evaluated by a blinded investigator for clinical efficacy and tolerability using grading scales. Standardized digital photography and Chroma Meter assessments were also taken. Self-assessment questionnaires were completed at weeks 4, 8, and 12. Sixty-eight Caucasian subjects (136 half faces) completed the study. All test materials significantly reduced Overall Hyperpigmentation and improved the Investigator's Global Hyperpigmentation Improvement rating at weeks 4, 8, and 12 compared with baseline. SMA-432 exhibited a dose-dependent improvement in hyperpigmentation. There were no major tolerability issues with any of the test materials. Self-assessments were generally favorable for all test materials. At the completion of the trial, subjects rated one of the tested multimodality brightener compositions as the most favorable product and 4% HQ as the least favorable. This study demonstrated that the new non-HQ-containing skin brightener formulations were as effective and equally well tolerated as the gold standard, 4% HQ, in females with facial hyperpigmentation.