Bio-active polymers
in therapeutics
Synthesis with the contribution of
C. Beylot
V. Garcia
P. Fallet
S. Gonzales
Introduction
The field of Aesthetic Dermatology is
broad and is spreading
- Above all, skin aging: treatment for skin
aging has become the main reason why
patients consult in æsthetic dermatology.
- But also: dyschromia, telangiectasia,
hirsutism, acne and traumatic scars…
- And Pathologic conditions: port wine
naevus, genodermatoses….
History
The history of æsthetic dermatology is
both vast and vague. 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.
Let us 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.
Definitions
Recommendation 1
Aesthetic Dermatology
and Plastic Surgery
Aesthetic Dermatology is that branch of
Dermatology that specializes in the evaluation
and enhancement of the cutaneous
appearance.
Aesthetic Dermatology also takes into
consideration the prevention and
treatment of photo damage, the corrective
nature and treatment of dermatosis, all of
which have an æsthetic dimension with an
impact on QOL.
Although the term of Cosmetic
Dermatology is often employed, we prefer
and recommend the use of the term
(A)Aesthetic Dermatology.
Historically, Aesthetic Dermatology has
been and continues to be richly embedded in
medical and surgical Dermatology. That is
because many dermatologic conditions/
diseases are regarded by the patient
as an appearance problem and nor
necessarily associated with a specific
symptomatology.
Recommendation 2
Aesthetic Dermatology
and Plastic Surgery
Aesthetic Dermatology and Plastic surgery
are those complementary divisions of medicine
that not only focuses on the appearance of the
skin but also remodeling its shape.
In order to accomplish this goal, these
doctors share similar tools and techniques
such as botulinum toxin, fillers, chemical
peels and lasers.
R&D
We need more evidence-based æsthetic
dermatology procedures and æsthetic sciences.
Aesthetical research should incorporate
appropriate objective and sensitive methods to
collect and evaluate clinical and metrological data.
Recommendation 3
Methods of assessment
To evaluate, measure and monitor treatments
outcomes, to compare effectiveness of different
products, procedures over time validated,
sensitive and objective methods need to be used.
It is recommended to use:
- in vivo methods with non-invasive tools:
– Examination of anti-wrinkling compounds
with silicone replicas.
– Hydration, evaluated by measurement
of transepidermic water loss.
– Sebaceous secretion evaluated by xxxxxx.
– Exploration of mechanical properties of
the skin: deformability, elasticity, plasticity
and fatigability.
- non invasing imaging tools:
– Cross-polarized photography and UV-
photography.
– Parallel-polarized photography.
– Comparative measure of skin thickness
and skin echogenicity.
– Primos system.
– Subepidermal low echogenic band
(SLEB) by Echography.
– RCM – reflectance confocal microscopy.
Recommendation 4
The case of skin cancer
In the field of prevention and treatment
of Skin Cancer, development of new novel
non-invasive or minimally invasive æsthetic
dermatology treatments is recommended
such as, topical immunomodulators and
MetALA-PDT.
They imply effective evaluation of novel
non-invasive, imaging-based procedures that
will allow efficient, painless diagnosis.
Health
professional
specific role –
their Information
and their
Formation
The United States and Europe have
been observing a common trend: a boom
in æsthetic procedures, a wish expressed
by dermatologists to pool resources and
more recently, a request by academics to
develop this area of expertise and
consider it as a fully-fledged specialty.
However, dermatologists are not the
only “players” concerned by æsthetic
medicine, which is of interest not only
to other practitioners (gynecologists,
stomatologists, ENT specialists,
endocrinologists, GPs…) but also non-
practitioners ( nurses, physiotherapists,
æstheticians…) and has therefore
become a highly competitive sector.
Consequently, both US and European
dermatologists need to increase training
in æsthetic dermatology as well as
information intended for patients and
the general public.
 |
Aesthetic dermatology. Biometrological assessment methods for skin aging.
Skin Echography:
– Skin thickness and echogenecity.
– Transducers 20 to 25 Mhz, resolutiob axial 70 µm, latteral 120 µm.
From Ultrasonography in dermatology. Dorothee Dill-Müller1, Jan Masch2, JDDG; 2007 - 5:689-707 |
Recommendation 5
A need to define the place
of players
Consensus “Experts Panel” composed by
dermatologists from different countries
doing æsthetics should to be created to
better define its place in medicine,
specifically in regard to ethics and what
term(s) should be used to define these
medical doctors.
We also need to have terms for other core
and non-core medical doctors in æsthetics.
For example, Spanish Society for
dermatologists doing Aesthetics is named
Society of Cosmetic Dermatology.
In Italy, a Society of these professionals is
already there and is called Plastic
Dermatology that includes mainly
Dermatologists and Plastic surgeons.
Recommendation 6
Guidelines for therapeutic
and decision procedure
Education and Training needs to be done
at Academic Level for authorities to
recognize the legitimacy of the procedures.
These Aesthetics procedures needs to be
evaluated with a more scientific rigour and
more evidence based medicine.
Thierry Michaud and Cherie Ditre |
 |
Recommendation 7
Training
Training on æsthetic dermatology
must be part of every dermatologist’s
university educational path (resident,
intern) and should cover both theoretical
and practical aspects: botox, fillers,
lasers, peeling, cosmetology… as well as
involve academics and private doctors.
In addition to this basic education,
learned societies should set out “Good
Practice” guidelines, validate new
products and emerging techniques and
help in the carrying out and financing
of scientific studies.
The “Aesthetic”
Patient
Information for the General
Public enables to convey high quality
messages, to educate the patient and
enhance the role of dermatologists.
Several options are possible: press
campaign, websites for the general
public…
Recommendation 8
Patient’s Information
Patient’s Information is indispensable
before any medical procedure in
accordance with European legal
framework.
Information can be given in waiting
rooms (posters on main procedures possible,
data sheet on diseases or treatments
available…), by the doctor (quotes, consent
forms, æsthetic passport…) via websites or
advertising (in countries that allow it).
Recommendation 9
Patients ask for a global
management
The “æsthetic” patient is not ill. He/She is
demanding, which therefore implies for the
doctor not only to develop communication
skills: attentive listening, availability, quality
in follow-up, managing objections and
possible adverse events, but also rethink
work organization and higher education so
as to offer better global patient
management.
Regulatory
Status – Ethical
aspects –
Dispensing
In Europe the roles of the health
professional and his/her roles is spelled out
by specific legislation which is similar in all
EU countries with some specific variations.
In the US the states themselves make the
laws and societies make guidelines for the
roles of the health professionals and their
assistants.
“Commercialization” of medicine is
forbidden in France, even if legislation
varies within European countries (see
appendix page 16-17). On the other hand,
marketing of æsthetic dermatology in the
United States is culturally accepted and
promoted through dispensing and
advertising. In Europe, the cultural context
remains very “medical” even for æsthetic
treatments, and each country has its own
way of functioning.
Evolution of cosmetic and æsthetical
medical treatments has made clear the
need for a very thoughtful and careful
legislation that separates pure cosmetics
from medical treatments and at the same
time provide a flexible boundary for
approaches that lie in between.
Recommendation 10
Status for products in UE,
a question from experts
Despite the existence of European
definitions, there are still some uncertainties
around some products such as peelings,
fillers and others.
The current regulatory definitions are
too strict and are not able to cover all the
existing Aesthetic products.
Do we have to adapt an existing
Regulation or create a new one ?
Recommendation 11
Adaptation of the Regulation
The recommendation may be to
extend/adapt the European Medical Device
Definition to include the æsthetic products
used at professional level.
For Dermatologists: one of the main
criteria to use a product is its global
Quality (quality of the finished product
and of its manufacturing). So, it means
that all the æsthetics products for
professional use as Medical Device should
have a MD status (peeling) and maybe
extending the classification of these
products to Class IIa.
Cherie Ditre, Thierry Michaud and Olivier Fontaine. |
 |
Recommendation 12
Ethical aspects
It is the responsibility of manufacturer to
remind the conditions of use, the risk of
misusage of the products and to introduce the
appropriate warnings on the leaflet of the MD.
It is also important for the manufacturer
to try to control the distribution of its
æsthetic products dedicated for professional
use in the context of the “free circulation” of
products within Europe.
Recommendation 13
Dispensing and advertising
There are differences between European
countries regarding dispensing and
advertising and we observe that some
physicians are dispensing products. At
European level, there is no regulation
around dispensing.
Other
Recommendation 14
Dermatoporosis
Dermatoporosis is a new concept.
It is a Chronic Cutaneous Insufficiency and
Fragility Syndrome.
Research aimed to prevent/reverse
Dermatoporosis. It is justified and needed to
follow two directions: prevention and
treatment espacially to regulate sun
exposure.
Education to regulate sun exposure is
essential in prevention; however, the main
focus is on the development of more
effective, easy-to-use photoprotective
measures, including topical and systemic
products.
- UV protective measures are fundamental.
- Photopreventive and Treatment research also
involves significant effort in the development
of active principles that achieve these goals in
a safer and more efficient manner.
- Emollients for skin barrier integrity.
- Intervention programs – æsthetic
products may ameliorate it, such as
retinaldehyde, size-defined hyaluronic acid,
CD44 activators and hyaluronic acid
inducers.
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