 John Wolf
Professor and Chairman
Department of Dermatology
Baylor College of Medicine
Houston, Texas, USA
Definition
Aesthetic (cosmetic) dermatology
is an explosively popular
subject with no clear definition and
ambiguous boundaries. The goal of this
short paper is to explore the history and
definition of æsthetic dermatology and to
establish a framework for an in-depth
discussion of a subject far too expansive to
cover definitively in this paper.
In spite of the growing popularity of
æsthetic (or cosmetic?) dermatology, there is
no clear consensus on even which word to
use or exactly what either actually means.
Therefore, let us begin with a definition,
however vague, of terms.
Aesthetic (æsthetic) is derived from a
Greek word (aisthetikos) meaning “of
sense perception.” As an adjective
æsthetic may be defined as “of or
concerning the appreciation of beauty or
good taste.” Cosmetic (from the Greek
kosmetikos, “skilled in arranging”) as an
adjective has been defined as “pertaining
or relating to qualities of beauty.” Used as
a noun, it refers to a material or substance
used to enhance beauty.
Therefore, both “æsthetic” and
“cosmetic” refer to an appreciation of and a
desire to enhance beauty and might reasonably
be used interchangeably. My personal bias
favors the, to me, somewhat more elegant
“æsthetic,” the term chosen for this paper.
The nature and territorial boundaries of
æsthetic dermatology are more difficult to
define. I will offer a few reflections on the
subject. First, it is my belief that æsthetic
dermatology is now and has always been
a legitimate branch of dermatology, along
with medical, surgical, pediatric
dermatology and dermatopathology, etc.
Indeed, in addition to purely æsthetic or
cosmetic efforts ranging from Botox to laser
surgery, there is a clear æsthetic dimension
to the treatment of many skin diseases. A short
list of skin disorders with a significant
cosmetic impact would include acne,
rosacea (including rhinophyma), seborrheic
dermatitis, psoriasis, eczema, xerosis,
melanoma, vitiligo, verruca, actinic keratoses,
benign and malignant tumors, and
a variety of hair and nail diseases.
Thus, most “medical” and “general”
dermatologists are also, sometimes ironically,
practicing “æsthetic” dermatology.
These days, the specialty of dermatology
is often divided into “medical” and
“surgical” divisions. Although such
demarcations are somewhat arbitrary and
misleading, they do provide some structure
for analysis and discussion. In that sense, it
may be useful to apply the same terms to the
field of æsthetic dermatology. For the
purpose of discussion, I will now offer the
following lists (inevitably incomplete)
of some of the techniques and procedures
of æsthetic dermatology.
Medical Aesthetic Dermatology
- Treatment of cosmetically significant skin
disorders.
- Sunscreens.
- Moisturizers, emollients, humectants.
- Soaps and cleansers.
- Keratolytics.
- Topical retinoids (tretinoin, adapalene,
tazarotene, retinol).
- Superficial chemical peels (trichloroacetic,
hydroxy and salicylic acids).
- Cosmetics.
- Cosmeceuticals.
- Topical therapy of actinic keratoses
(5-FU, imiquimod, diclofenac sodium gel).
- Minoxidil and/or propecia for
androgenetic alopecia.
- Treatment of alopecia areata (including
topical, intralesional, systemic, and
immunotherapy).
- Treatment of vitiligo (including
photochemotherapy and punch grafts).
- Treatment of hyperhidrosis (aluminum
salts, electrophoresis, botulinum toxin).
- Bleaching agents for dyschromia
(hydroquinone, kojic acid, etc.).
- Hair and nail care products (shampoos,
conditioners, hardeners, biotin).
Procedural Aesthetic Dermatology
- Cryosurgery (lentigines, actinic and
seborrheic keratoses, etc.).
- Electrodesiccation/cautery (warts,
angiomas, telangiectasia, sebaceous
hyperplasia, etc.).
- Shave excisions.
- Punch excisions (pitted scars, etc.).
- Curettage.
- Epilation.
- Deep chemical peels (phenol, etc.).
- Laser and intense pulsed light.
- Botulinum toxin (rhytids, hyperhidrosis,
etc.).
- Fillers (collagen, fibrin, fat, hyaluronic
acid, silicone).
- Aesthetic (“plastic”) surgery (blepharoplasty,
lifting procedures, etc.).
- Dermabrasion.
- Sclerotherapy.
- Liposuction.
- Mohs surgery (What? Remember that this
procedure pioneered by Fred Mohs is a
tissue conservation technique).
Obviously, these lists overlap and the
interface between medical and
procedural æsthetic dermatology is often
blurred. Nevertheless, the two lists do
illustrate the incredible breath and depth
of the field of æsthetic dermatology and
how deeply imbedded it is in the
specialty. From an historical perspective,
it becomes clearer that æsthetic
dermatology is not really a particularly
new field.
The history of
dermatology
To place the history of æsthetic
dermatology in proper perspective, we need
to consider briefly the history of
dermatology as a whole. This is especially
important if my thesis is correct – that
æsthetic dermatology has always been a part
of the specialty of dermatology.
The history of dermatology is a rich
tapestry of images and ideas. John Crissey, a
noted historian of dermatology and author
of two textbooks and an atlas, has divided
the history of dermatology into five periods:
- Protodermatology
- The Era of Classification and
Description (1776-1850)
- The Era of Clinical Science (1840-1900)
- The Era of North American
Dermatology (1857-1946)
- The Era of International Dermatology
"Old Man and Grandson", by Dominico Ghirlandaio, a Renaissance Grand Master |
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Protodermatology refers to the period
of prehistory or ancient history. The origins
of dermatology (like those of medicine itself)
are lost in what we often call poetically “the
mists of time.” The first human skin diseases
obviously arose with the rise of the first
human populations. The nature of these
diseases and the attempts to treat them are
lost to history. With the development of
classical ancient civilizations such as those of
Egypt, Greece, and Rome, the historical
record began and many dermatological
conditions and treatments were recorded.
The Era of Classification and
Description was the time when dermatology
as a specialty emerged. The great names
were Plenck, Willan, Bateman, Biett,
Cazanave, and Alibert. Willan’s publication
of On Cutaneous Disease – in 1798 was to
many the birth of dermatology. This text
contained the first comprehensive, orderly
classification of skin diseases.
The Era of Clinical Science introduced
morphology, pathology (Unna’s great
textbook), microscopy, and microbiology.
The prominent historical names are Hebra,
Kaposi, Neumann, Auspitz, and Unna. This
was followed by the Era of North American
Dermatology, when training programs were
established along with The American Board
of Dermatology (1932), The Society of
Investigative Dermatology (1937), and The
American Academy of Dermatology (1938).
The enormous growth of North American
dermatology was fueled at least in part by
the war-induced European immigration that
included giants like Stephen Rothman and
Marion Sulzberger. This Era also saw the
evolution of laboratory science, stimulated
by Rothman, Sulzberger, Pillsbury, etc.
The final period of International
Dermatology, in which we live and practice,
is characterized by the concept of The
Global Village. Skin diseases and the specialty
of dermatology (including æsthetic
dermatology), are now truly global.
The history of
æsthetic dermatology
The history of æsthetic dermatology is both
vast and vague. A complete narrative history
would be the subject of a textbook not a short
paper. However, while I cannot produce here
a complex narrative history, I can offer several
historical observations, footnotes, descriptions,
and concepts that should help us to clarify the
history of the field.
Let us begin with Protodermatology. The
earliest years are a lost landscape where skin
diseases and cosmetic concerns were
undoubtedly addressed but not recorded.
Later, there were many descriptions of
æsthetic concerns and interventions. In
Egypt, for example, fragrances including
perfumed bath oils and cosmetics were
utilized. Frankincense and Myrrh were
placed in the body cavities of mummies,
whose skin was also preserved using sodium
sesquicarbonate, thus carrying æsthetic
dermatology beyond the grave. Egyptian
mummies have also been unearthed wearing
elaborate wigs.
The Turks, Greeks, and Romans all
enjoyed baths, often with perfumed oils and
emollients for æsthetic as well as medical
purposes. Greek physicians, including
Hippocrates (460-370 BC), Diocles,
Archigenes, and Kriton also prescribed dyes,
depilatories, aloe, bleaches, and
antiperspirants. Galen (130-200 AD) was
perhaps the most influential physician of all
time; his theories, often inaccurate,
dominated medical thought for 15 centuries.
Yet, he may be considered one of the fathers
of æsthetic dermatology, since he invented
cold cream (unguentum infrigidans)by
melting white wax and olive oil in which
rosebuds had been macerated. Such
products for centuries were referred to as
Galenicals (utilizing animal fats, mineral oil,
wax, and botanicals rather than chemicals).
Were these cosmetics or, since they were
thought to possess medicinal properties, the
first cosmeceuticals?
Similar examples of æsthetic dermatology
may be found in pre-Columbian Mexico and
South America. Murals, tomb paintings,
mummies, and terra cotta figurines illustrate
the use of nail polish, facial makeup
(including mascara), pierced ears, tattoos,
and scarification. The Aztecs even had a god
of skin diseases, Xipe Totec, and a goddess
who dispensed a wood tar ointment.
I will now fast-forward to the Era of
International Dermatology, since virtually all
of the specific tools of contemporary
æsthetic dermatology were developed after
1950. The preceding Eras were not
irrelevant, however, since they saw the
establishment of dermatology as a medical
science and witnessed the evolution of the
clinical and laboratory science on which it is
based. Here, indeed, is a challenge for
æsthetic dermatology – to establish the same
solid scientific base for its own techniques
and procedures.
Some specific
historical milestones
Topical Retinoids In Photodamage
Retinoids in dermatology have been
developed over three generations: (1) first,
nonaromatic retinoids including tretinoin
(all-trans-retinoic acid) and isotretinoin (13-
cis-retinoic acid); (2) mono-aromatic
retinoids (etretinate and acetretin); and (3)
polyaromatic retinoids (adapalene and
tazarotene). The topical retinoids (tretinoin,
adapalene, and tazarotene) were first
introduced for the treatment of acne (a
good example of medical æsthetic
dermatology). Later, Kligman and his
colleagues at the University of Pennsylvania
observed serendipitously in the mid 1980’s,
that topical tretinoin attenuated the
appearance of periorbital rhytids in women
being treated for acne. This same group
also published supporting data from studies
on the albino hairless mouse and from an open-label, uncontrolled trial of tretinoin
0.05%. In 1988, Weiss, et al. published a
positive double-blind, vehicle-controlled
study of tretinoin 0.1%. Large multicenter
trials followed in 1991 and 1992. Since then,
numerous laboratory and clinical studies
(Voorhees, Griffiths, Kang, etc.) have clearly
established the cosmetic efficacy of topical
tretinoin in photodamaged skin. Recent
smaller studies now support a role for
adapalene and tazarotene.
Botulinum Toxin
The history of botulinum toxin records
a fascinating evolution – from deadly poison
and the stuff of spy novels to perhaps
the most widely performed æsthetic
procedure in the world. Let us examine
a few sentinel events in this history (Thomas
Rohrer, Ken Beer).
- 1920 – first efforts of isolation
(Dr. Herman Sommer).
- 1946 – isolation of botulinum toxin type A
(BTX-A) by Edward Shantz for the U.S. Army.
- 1950’s and 1970’s – first medical uses (Drs.
Vernon Brooks and Alan Scott).
- 1979 – first batch of BTX-A (“Botox”) (Shantz).
- 1979, 1985, 1989 – FDA approval for
treatment of strabismus, blepharospasm,
and hemifacial spasm.
- 1987-1992 – observation and development
of botulinum toxin for treatment of dynamic
rhytids (Jean and Alastair Carruthers).
- 1997 – FDA-approved BTX-A source
(Allergan, Inc.).
- 2003 – FDA approval for glabellar rhytids.
Today, botulinum toxin is used for
many purposes, medical and cosmetic, on
and off label. As with topical tretinoin
and photodamage, we owe this discovery
to serendipitous but acute observation of
an unanticipated clinical occurrence.
Thus, Albert Kligman and Jean Carruthers
are to be applauded for opening doors
that might well have remained closed for
many years.
The Dermatologic Uses of Lasers
The first laser (a normal mode ruby laser)
was introduced in 1961. Argon and
continuous wave carbon dioxide lasers soon
followed. An early pioneer and, to my
knowledge, the first dermatologist to
explore and advocate the clinical use of
lasers, was Leon Goldman of Cincinnati.
Dr. Goldman also employed lasers to create
some striking sculptures, demonstrating the
artistic/æsthetic temperament that resides in
many, perhaps most, dermatologists.
Since those early days, the number and
type of medical lasers and their applications
have replicated like rabbits. This plethoric
proliferation means that, for me at least, a
more detailed history of dermatologic lasers
must wait for another day.
Cutaneous Filler Substances
The use of various dermal fillers to
smooth, sculpt, and otherwise reconfigure
the human face has become enormously
popular. One article I read recently listed
25 biodegradable, 9 non-biodegradable, and
2 slowly biodegradable fillers. I will comment
briefly on 4: fat, collagen, hyaluronic acid
(HA), and silicone.
The earliest use of a filler substance
employed fat (Neuberg, 1833, autologous
fat transfer). Later, Brunings (1911) was the
first to employ a syringe for free fat transfer.
Peer, in 1950, reported a 50% survival rate
for fat transferred using that technique.
Today, fat is widely utilized as a filler
substance, often in conjunction with
liposuction (Llous, 1978) and micro
liposuction (Fournier, 1986).
A major development in the history of
soft tissue augmentation was the use of
bovine collagen as a filler substance.
Investigations are suggested to have begun
as early as the 1950’s, with Zyderm I
(Collagen Corp.) being approved by the FDA
in 1981. Zyderm II and Zyplast followed and
also gained FDA approval. Human-derived
collagen (the CosmoDerm family of products produced by Inamed Aesthetics) has now
been added to our list of options.
Hyaluronic acid (HA) is a linear
polysaccharide residing in the extra cellular
matrix of connective tissue (human and
other animal species). At least 5 fillers
incorporating HA have been approved by
the FDA: Hylaform, Restylane, Perlane,
Juvederm, and Captique. These fillers are
becoming increasingly popular.
Silicone, which may be produced as a
solid, gel, or liquid, is really not a single
substance but a complex family of often
dissimilar substances. The history of the
æsthetic uses of silicone is complex and
confusing, with many horror stories of
adverse responses to the use of possibly
impure preparations. Since the medical use
of silicone is currently severely restricted,
I will not at this time plunge into those
turbulent waters.
J.Wolf’s presentation. |
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