Botox is used very commonly to decrease the size of the masseters and to improve symptoms such as grinding, headaches, and TMJ disorders. Decreasing the size of the masseters leads to a slimming of the lower face. This type of non-surgical lower face contouring is very popular, particularly among Asians.

A recent review published in Dermatologic Surgery went through different injection methods for botulinum injections of the masseters in East Asians. Five different methods for injecting the masseters were described.

Different patients have different patterns of masseter hypertrophy and Dr. Nakatsui can decide which is the best way to inject you. Care must be taken when injecting as some of the side effects of injection include a sunken appearance to the cheek, focal bulging of the masseter, and weakening of the risorius muscle, which would affect your smile.

There are many hair changes attributable to anticancer therapies. In approximately 65% of patients treated with chemotherapy and in up to 100% of areas treated with radiotherapy can lead to hair changes.

These can manifest as hair loss (alopecia), pigment changes, textural changes, and changes in hair cycle.

Hair Loss

Chemotherapy induced hair loss typically begins weeks after the first dose of chemotherapy and represents what is called an anagen effluvium, predominantly in areas of increased friction on the scalp. Eyebrows and eyelashes may also be affected. Usually asymptomatic, it can be associated with itch or pain. Two to six months after the chemotherapy has finished, the hair typically begins to regrow, although the hair loss can be persistent.

For this holiday season, our clinic will be closed from December 24, 2020 to December 31, 2021, although we will continue to answer phones to book appointments during regular office hours.

The office will be completely closed from January 1 to January 3, 2021, and we will not be answering phones on those days. We will also be closed all statutory holidays and including Easter Monday. Thank you and have a great holiday season! See you in 2021!

A phase 2b study  by Asana Biosciences regarding a novel new medication for moderate to severe chronic hand eczema has shown some encouraging results. The medication is called gusacitinib and is a dual JAK/SYK inhibitor. The study showed statistically significant improvements in chronic hand eczema severity compared to placebo. It had an acceptable safety profile and was well tolerated. The most common side effects were headache, nausea, nasopharyngitis, and upper respiratory tract infection. A phase 3 trial is being finalized.

Cryomodulation and nanosecond pulsed electric field treatment are two new technologies for the treatment of benign lesions like seborrheic keratoses. Cryomodulation is a technique using cooling technology to treat sunspots and seborrheic keratoses. The first to market device is Glacial RX by R2 Technologies.

Another new technology is nanosecond pulsed electric field treatment, which is a nonthermal, energy based technology used to treat seborrheic keratoses and other conditions. It will be interesting to see how effective these two new technologies will be.

A recent article in Dermatologic Surgery suggests that injectors (and patients) should be aware of the effects of needle size on the properties of fillers. Various types of fillers (monophasic and biphasic) were injected through 30G needles and the size and properties of the fillers were analyzed after they had been injected through the needles.  

Both monophasic (e.g. Juvederm products) and biphasic (e.g. Restylane) fillers were affected by the smaller needle size. They were affected in terms of the size of the extruded particles and in the properties (G’) of the extruded particles. Interestingly, biphasic fillers seemed to be affected more than monophasic fillers. In addition, larger particles seemed to be affected more than smaller particles as we would intuitively expect. 

Injectors should consider the size of the needle being used to inject fillers (especially biphasic fillers and fillers of larger particle size) as this might affect the performance and durability of the filler.

Reference: 

Soft Tissue Filler Properties Can Be Altered by a Small-Diameter Needle. Dermatol Surg 2020 Sep;46(9):1155-1162.

Nuceiva is the newest neuromodulator on the market for the treatment of glabellar frown lines. Whereas Botox is referred to as abobotulinumtoxin A, Nuceiva is referred to as prabotulinumtoxin A.

Similar to other brands such as Botox, Xeomin, and Dysport, Nuceiva™ works to smooth out creases in the face by decreasing muscle contraction.

It has been approved by Health Canada and the FDA.

Marketed as Jeuveau by a company called Evolus in the United States, it originated with a South Korean company called Daewoong. Nuceiva™ was authorized for sale by Health Canada in August of 2019 and was subsequently officially brought to the Canadian market by Clarion Medical Technologies in October 2019. It is also available in the European Union.

Nuceiva™ usually lasts about 3 to 4 months although this varies from person to person. A study published in Dermatologic Surgery in 2019 showed similar efficacy to Botox.

Bleach baths are a controversial therapy for patient with atopic eczema, also known as atopic dermatitis (AD). In recent years, there has been an increase in the use of bleach baths to decrease the severity of the eczema. However, a recent review showed that while bleach baths did seem to decrease the severity of atopic eczema, it was no more effective than water baths alone. There has been a lot of research into the effect of bleach baths on Staphylococcus bacteria and it seems like the concentration of bleach used in bleach baths may not be high enough to kill bacteria. There may be other anti-inflammatory properties that have yet to be discovered.

With all of the conflicting data out there, the best summation is probably what was stated in the latest Canadian consensus statement on pediatric atopic eczema: “bleach baths have not been consistently shown to improve outcomes in AD and may be used at the discretion of the treating health care provider.”

Reference:
Lansang P et al, Approach to the Assessment and Management of Pediatric Patients With Atopic Dermatitis: A Consensus Document. Section IV: Consensus Statements on the Assessment and Management of Pediatric Atopic Dermatitis. J Cutan Med Surg.2019;23(5):32S-39S.

Pulsed dye laser (PDL) is a very effective treatment for redness of the face due to enlarged blood vessels. It has proven to be very safe and effective. However, there is some discomfort from the laser pulses and while most patients have no difficulty tolerating treatment without any anesthetic, some patients do find it difficult to tolerate. Topical anesthetic can be used to decrease the discomfort of laser treatments but there has always been the question of whether the vasoconstrictive properties (i.e. constriction of blood vessels) of the anesthetic might have an adverse effect on outcome if you are trying to get rid of blood vessels.

A recent study by Chunharas et al in April of 2020 (Lasers Surg Med. 2020 Apr;52(4):307-314) demonstrates that topical anesthesia with lidocaine and tetracaine do not interfere with the efficacy of pulsed dye lasers. This is great news for those who want to receive treatments with pulsed dye lasers.

Thank you for your patience! As Phase 2 is set to open on June 12, 2020, we are happy to announce that we are reopening as well! We have been following the Chief Medical Officer of Health instructions and have therefore not been able to see any of our patients since March 16, 2020, except for skin cancer patients and those with urgent needs.

We are happy to announce that we will be booking appointments for all those we had to cancel over the last few months, as well as accommodate those on our wait list. We look forward to see you back again! We thank you for your patience and understanding as we ourselves need to go through our phased approach to booking.

Sincerely,

Dr. Nakatsui

Prabotulinumtoxin A

In 2002, Botox (onabotulinumtoxin A) was the first botulinum toxin to gain FDA approval for the “temporary treatment of glabellar lines in adults.”  A recent study published in Dermatologic Surgery reviewed two Phase 2 randomized, multicenter, double-blind, placebo controlled trials with 2100 patients showed that a new version called prabotulinumtoxin A had a similar onset of action, duration of action, and adverse event profile as compared to Botox. On the market currently, we have Botox, Dysport, and Xeomin for the treatment of lines and wrinkles. We may see another agent available soon.

References:

1. Dermatol Surg. 2019 Dec;45(12):1610-1619

Temporary Closure

On Monday, March 16, 2020, the Nakatsui DermaSurgery Centre decided to take a leading initiative and temporarily close operations to help mitigate the spread of COVID-19. This was not an easy decision. In the end, we are confident that this was the best decision to protect our patients, our staff, and our community. We have stopped all non-essential services and are in the process of contacting patients who were scheduled to see us in the next two weeks to let them know what is happening. We will do our best to reschedule everyone as soon as possible once the situation improves. For our current patients who have more urgent medical needs, Dr. Nakatsui will make himself available to see you.

It is important to remember we should not panic as this infection will be well managed for the vast majority of those affected. However, we must assist our health care system by “flattening the curve” and preventing the exponential rise in COVID-19 and reducing the number of serious cases.

We will still be answering our phones and responding to emails for the time being. If you have any questions and concerns, please feel free to contact us at 780-482-1414 or via email at info@nakatsuiderm.com. At this time, we are monitoring the situation daily and will post when we reopen. 

For more information on COVID-19, please check the www.alberta.ca website. In addition, Dr. Nakatsui wanted to let you know about two other interesting links that contain updated information on global infection rates and a comparison between American and Canadian infection rates.

A recent study on SPF published in the Journal of the American Academy of Dermatology (JAAD, 2018; 78: 902-910) demonstrates that higher sun protection factor sunscreens really do provide additional benefit. This study evaluated skiers in a double-blind, split-face, randomized study. In this study, skiers in Vail, Colorado wore SPF 50 on one side of the face and SPF 100 on the other side of the face. They were allowed to do their normal activities and were then evaluated the next day to see if there was any evidence of sunburn erythema. The SPF 100 sunscreen side was found to be significantly more effective in protecting against sunburn.
The study supports our belief that if you are going to be out in a lot of sun, the higher the sun protection factor, the better! Another factor that may be important is that many of us apply far less sunscreen than we should, so you might think you are getting an SPF 50. However, you might be applying such a thin layer that you are only getting the equivalent of SPF 20! Consequently, make certain you apply enough sunscreen to provide adequate protection and if you decide to go to a higher sun protection factor, all the better. Your skin will thank you.

Sunscreen helps protect against the development of sun damage and skin cancers. We have many patients who either worked or played outside for many years and they are now seeing the after effects many years later. If you don’t believe it, go to Australia and see what percentage of people have skin cancer. Skin cancer is not fun. Protect your skin–it will thank you later.

Hot Tub Itch

There is nothing quite like slipping into a hot tub after a day of battling the winter elements. The positive memories of the experience can quickly fade if the event is followed by hot tub itch, medically known as pseudomonas folliculitis.  If an itchy rash consisting of elevated bumps, some pus filled, appears within 12 to 48 hours after a hot tub immersion then it is likely hot tub folliculitis. These bumps may develop into dark red, tender papules.

What causes hot tub itch?

A hot tub rash occurs when a bacteria known as Pseudomonas enters the pores of the skin causing an infection. Pseudomonas lives naturally and without consequence in the skin of about 15% of the population.

If Pseudomonas is introduced into improperly treated and maintained hot tub water the bacteria will take up residence in it. Once this happens it is very difficult to ‘evict’ because the bacteria develops a slimy layer that protects it from recommended levels of hot tub disinfectants. Super chlorination may help to get rid of the problem but it might be necessary to drain and scrub the tub with bleach in order to ward off the infestation.

The second way that pseudomonas may infect hot tub enthusiasts is at a ‘hot tub party.’ Large numbers of people in a hot tub may cause a temporary drop in the disinfectant levels in the tub. This allows the pseudomonas from a carrier (the 15% of the population who carry pseudomonas naturally) to travel to other participants at the party. The hot water causes skin pores to open and the bacteria finds new hosts in the follicles of fellow partiers. Once the party is over and the tub is vacated the disinfectant levels increase and the remaining bacteria is killed before it has time to become established in the water. The party goers however go home with an unexpected and often unwelcome companion in the form of hot tub itch.

What can be done to treat hot tub itch?

Hot tub folliculitis given time will resolve spontaneously however most people do not like the appearance and the itch can drive them crazy. An antibiotic (Cipro) will rid the body of the bacteria and a medicated cream containing 2% hydrocortisone is helpful in managing the itch.

Author: Patricia Johnston