Update in Cosmetic Dermatology

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Editors
Prof. Antonella Tosti, M.D. Dr. Doris Hexsel, M.D.
Leonard M. Miller School of Medicine Clinica Hexsel de Dermatologia
Department of Dermatology Pontifícia Universidade Católica do Rio
University of Miami Brazilian Center for Studies in Dermatology
Miami Porto Alegre
Florida Rio Grande do Sul
USA Brazil

ISBN 978-3-642-34028-4 ISBN 978-3-642-34029-1 (eBook)

DOI 10.1007/978-3-642-34029-1
Springer Heidelberg New York Dordrecht London

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Contents

1 Skin Evaluation Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Débora Zechmeister do Prado, Amanda Stapenhorst,
Carolina Siega, and Juliana Schilling de Souza
2 Cellulite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Doris Hexsel and Rosemarie Mazzuco
3 Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Gabriella Fabbrocini and Maria Pia De Padova
4 Subcision® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Mariana Soirefmann and Rosemari Mazzuco
5 Hirsutism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Ticiana C. Rodrigues and Poli Mara Spritzer
6 Striae Distensae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Taciana Dal’Forno
7 Cosmeceuticals in Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Aurora Tedeschi, Lee E. West, Laura Guzzardi, Karishma H. Bhatt,
Erika E. Reid, Giovanni Scapagnini, and Giuseppe Micali
8 Photodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Mariana Soirefmann, Manoela Porto,
and Gislaine Ceccon
9 Botulinum Toxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Doris Hexsel and Cristiano Brum
10 Cryosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Cleide Eiko Ishida
11 Electrosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Sarita Martins de Carvalho Bezerra and Marcio Martins Lobo Jardim
12 Injectable Treatments for Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Adam M. Rotunda

v
vi Contents

13 Cosmetic Procedures in Asian Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Evangeline B. Handog, Ma. Teresita G. Gabriel,
and Jonathan A. Dizon

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Skin Evaluation Systems
1
Débora Zechmeister do Prado, Amanda Stapenhorst,
Carolina Siega, and Juliana Schilling de Souza

Core Messages
• Skin evaluation and its correct interpretation are of extreme importance for
clinical diagnosis and also in research.
• Skin evaluation must start with a clinical exam and different assessment
methods can be chosen according to the conditions or treatment results to
be assessed.

1.1 Introduction

Skin evaluation and its correct interpretation are of extreme importance. Skin evalu-
ation requires efficient and well-defined methods to diagnose the skin conditions or
diseases and also to follow treatment response. These methods include the use of
technological and validated resources, such as devices and scales.
In this chapter, qualitative, semiquantitative, and quantitative skin evaluation
methods will be discussed. The qualitative methods are subjective and range from
physical examination to the clinical evaluations, including the photographic docu-
mentation. The semiquantitative methods include the grade and photographic scales,

D.Z. do Prado (*)

Independent Clinical Research Consultant,
Porto Alegre, RS, Brazil
e-mail: [email protected]
A. Stapenhorst
Department of Biomedicine, Brazilian Center for Studies in Dermatology, Universidade Federal
de Ciências da Saúde de Porto Alegre – (UFCSPA), Porto Alegre, RS, Brazil
C. Siega • J.S. de Souza
Department of Research, Brazilian Center for Studies in Dermatology, Sociedade Brasileira de
Profissionais em Pesquisa Clínica – SBPPC, Porto Alegre, RS, Brazil

A. Tosti, D. Hexsel (eds.), Update in Cosmetic Dermatology, 1

DOI 10.1007/978-3-642-34029-1_1, © Springer-Verlag Berlin Heidelberg 2013
2 D.Z. do Prado et al.

which were created to facilitate the rating of specific skin conditions. Quantitative
methods are based on objective measurements of certain skin features, such as
photodamage signs, pigmentation, sebum, and hydration.

1.2 Qualitative Evaluation of Skin

1.2.1 Clinical Exam

The dermatological exam begins with physician’s questions to the patients about
their skin condition and related symptoms. Demographic data, including age, gender,
and race, besides previous conditions, medications, and family medical history are
important elements. The skin should be always evaluated in a well-illuminated place,
with direct light. The exam is performed from head to toe, including hair, mucosa,
nails, and ganglions. It is also recommended using instruments, such as dermato-
scope, Wood’s lamp, and digital photography, according to each patient’s needs.

1.2.1.1 Dermatoscope
The dermatoscope is a magnifier used to diagnose skin pigmentation disorders and
to distinguish benign from malignant lesions, including melanomas [32]. Digital
dermatoscopes allow keeping and enlarging images and for further analysis
(Fig. 1.1).

1.2.1.2 Wood’s Lamp

Wood’s lamp is an ultraviolet light used to diagnose some hair and skin conditions
(Fig. 1.2) such as melasma, vitiligo, and porphyria. When fluorescence is applied
onto the skin, the epidermal pigment is highlighted, but the same does not happen
to the dermal pigment.

1.2.1.3 Photographic Documentation

Photographic assessment of the skin can be important to record patient’s medical
history, to follow up patients, and also when a second opinion is sought. Photographic
assessment significantly improves patients’ understanding on their diagnostic and
treatment progression [27].
Before acquiring the images, it is suggested to ask patients to sign an informed
consent form for photographs, especially if the patient can be recognized. Define
high-quality standards to create and maintain photographic patient records as well
as to guarantee and maintain patient anonymity and confidentially [19].
Standard photographic methodology is recommended to collect and store
patient’s images. The images should be always taken using the same parameters,
such as camera settings, patient position, and light. Some pictures require a point-
source flash, while others require elimination of shadows caused by using a ring
flash [19].
The minimum setup needed to document face and body is composed by digital
camera; proper light source; appropriate computer to store, analyze, and display the
digital files; and a trained photographer.
1 Skin Evaluation Systems 3

Fig. 1.1 Digital dermatoscope, used to

diagnose pigmentation disorders

The photographer is responsible for controlling the standards previously defined

when taking the photographs. Moreover, he/she must be patient, especially early on
to keep the patient calm to achieve good quality images.
Most of the current digital cameras available in the market offer high resolution.
For dermatological use, a resolution of four million pixels is enough [27]. Low-
resolution images should be avoided.
Light source positioning is crucial for the photograph quality. Wrong positioning
of the lights can create shadows, compromising the skin evaluation. The background
must be neutral, monochromatic, and non-reflective, preferably dark. A dark and
opaque background provides greater control of the illumination over the subject. The
positioning of light source should be the same at all time points for the same subject.
The relatively equal position of the subject to the camera enables the acquisition
of the same field size before and after treatment. Makeup, jewelry, and clothing that
might interfere the images should be removed. For facial photographs, usual
4 D.Z. do Prado et al.

Fig. 1.2 Wood’s lamp, an

ultraviolet light used to
diagnose hair and skin
conditions

positions are front, oblique view (45°), and lateral (left and right), and a neutral face
expression during the shoot is required (Fig. 1.3).
A standardized setup and imaging procedure is recommended for better correla-
tions between before and after treatment images. Further correlation between the
two images could be accomplished using anatomical landmarks. The after treatment
image should be compared to the before image immediately after acquisition for
consistency and to retake if necessary.
Some objective imaging tools were developed to standardize the photographic
position and to assure the photographic quality. Companies like Canfield ScientificTM
and FotoFinder SystemsTM developed a series of methods and equipments to obtain
standardized, reproducible, serial medical photographs and documentation reduc-
ing the photographic variables of images.
The OMNIA Imaging System (Canfield Scientific, USA) is a device that stan-
dardizes nine photographic angle positions (90°, 67.5°, 45°, 22.5° for left and right
1 Skin Evaluation Systems 5

Fig. 1.3 Photographic studio

sides and center 0º) (Fig. 1.4). It can also be coupled with image software such as
MirrorTM (Canfield ScientificTM, USA), which will be discussed in Sect. 1.4.1.
FotoFinderTM is a photographic system that can be customized for a specific study.
All images can be exported and sent to a central server database maintaining their
authenticity. Another integrated option is FotoFinder Mediscope TowerstationTM, which
automatically controls a digital camera permanently connected to the computer.

1.2.2 Qualitative Skin Scales

Qualitative scales permit a more specific evaluation of the skin characteristics,

increasing the accuracy of the evaluation. A number of scales have been developed,
and the most used for cosmetic purposes are mentioned below.
The Fitzpatrick classification (Table 1.1) known as the Fitzpatrick skin types or
Fitzpatrick phototypes depends on the amount of melanin in the skin. It allows
evaluating the pigment sensibility to UV light [15].
6 D.Z. do Prado et al.

Fig. 1.4 OmniaTM device used to take standard photographs

Table 1.1 Fitzpatrick skin classification

Skin type Skin color Tanning ability
I Pale skin Always burns, does not tan
II Fair skin Burns easily, tans poorly
III Darker white skin Tans after initial burn
IV Light brown skin Burns minimally, tans easily
V Brown skin Rarely burns, tans darkly easily
VI Dark brown or black skin Never burns, always tans darkly
Source: Fitzpatrick [15]

The Glogau scale (Table 1.2) is another qualitative skin scale [16]. It is a systematic
skin classification of photoaging that permits comparison of therapies and clinical
results. Clinical signs of photoaging of the skin include rhytids, lentigines, keratoses,
telangiectasia, loss of translucency, loss of elasticity, wrinkles, and sallow color.
The Baumann scale, also called Skin Type Indicator (Table 1.3), identified 16
skin types categorized according to four scales: oily versus dry (O/D), sensitive
versus resistant (S/R), pigmented versus nonpigmented (P/N), and tight versus
wrinkled (T/W). By answering a 64-question test, the reader is assigned a four-letter
type (“OSNW,” for example, would mean that a person’s skin has been rated as oily,
sensitive, and nonpigmented, with a tendency to wrinkle) [5].
1 Skin Evaluation Systems 7

Table 1.2 Glogau classification of aging skin

Skin type Description Characteristics
Type I Mild Early photoaging
Early pigmentary changes
No keratoses
Fine wrinkles
Early 20s or 30s
Type II Moderate Early to moderate photoaging
Early senile lentigines
No visible keratoses
30s to 40s
Type III Advanced Advanced photoaging
Dyschromia and telangiectasia
Visible keratoses
Wrinkles at rest
50 plus
Type IV Severe Severe photoaging
Dynamic and gravitational wrinkling
Multiple actinic keratoses
60s or 70s
Source: Glogau [16]

Table 1.3 The Baumann Skin Type Indicator

Oily Dry
Pigmented Nonpigmented Pigmented Nonpigmented
Wrinkled OSPW OSNW DSPW DSNW Sensitive
Tight OSPT OSNT DSPT DSNT Resistant
Wrinkled ORPW ORNW DRPW DRNW Sensitive
Tight ORPT ORNT DRPT DRNT Resistant
Abbreviations: D dry, N nonpigmented, O oily, P pigmented, R resistant, S sensitive, T tight, W
wrinkled

1.3 Semiquantitative Skin Evaluation

Semiquantitative evaluation qualifies the object, turning them into numbers in order
to quantify them. However, it is important to differentiate between ordinal scales in
which numbers are assigned to range a condition and those in which the ranking
generates a sum, as the Likert scale [31].
The Likert scale is a popular method that allows the researcher to quantify opin-
ion-based items. Questions are typically grouped together and rated or responded to
base on a five-point scale. This scale typically ranges in order from one extreme to
the other, such as (1) very interested, (2) somewhat interested, (3) unsure, (4) not
very interested, and (5) not interested at all.
8 D.Z. do Prado et al.

Table 1.4 Ranges of Griffiths scale Store Damage

0 No damage
2 Mild damage
4 Moderate damage
6 Moderate/severe damage
8 Severe damage
Source: Griffiths et al. [17]

In general, the semiquantitative scales are developed to evaluate a specific skin

condition or a treatment. They can be also photonumeric. On the following exam-
ples of semiquantitative methods (scales), some specific cosmetic skin conditions
will be better explained.

1.3.1 Skin Aging

Griffiths developed a photonumeric scale to assess the severity of cutaneous photo-

damage and its response to treatment [17] (Table 1.4).
An analogical visual scale for lip volume evaluation was developed by Rossi and
colleagues [36]. This scale is very useful for soft tissue augmentation treatment
evaluation. Another validated scale for evaluation of lip fullness was developed and
published by Carruthers and colleagues [9].
Shoshani and coauthors validated the Modified Fitzpatrick Wrinkle Scale
(MFWS) as a nasolabial wrinkle severity assessment tool. It is a reliable method for
the quantitative evaluation of the nasolabial folds [38].
Day and coauthors proposed the Wrinkle Severity Rating Scale to describe the facial
folds appearance. It ranges from extreme (score 5) to nonexistent (score 0) [11].
Other semiquantitative dermatological scales include: Fitzpatrick for perioral
facial wrinkles [14], Lemperle Wrinkles Scale [30], Facial Attributes Scale [33],
among others (Table 1.4).

1.3.2 Pigmentary Disorders

The visual hyperpigmentation scale consists of a series of plastic cards, printed with
10 different skin colors (A–J) and 10 pigment scores for each skin color (1–10),
corresponding to 100 possibilities to graduate hyperpigmentation [41].
Melasma Area and Severity Index (MASI) is a score that objectively measures
the severity of melasma [28]. It is obtained through the visual inspection of the face,
without any risks for the patient. The face is divided in four areas: forehead, right
malar region, left malar region, and chin, corresponding to 30, 30, 30, and 10 % of
the face, respectively. Before calculating the MASI, it is necessary to graduate the
areas of the face according to the following variables: afflicted area, hyperpigmenta-
tion, and homogeneity of hyperpigmentation. Pandya and colleagues assessed this
tool, and state MASI is a reliable measure of melasma severity [35].
1 Skin Evaluation Systems 9

Hyperpigmentation/melasma status [42], color designation of melasma [18], and

physician and patient global assessment (PGA) [42] are other commonly utilized
tools to evaluate melasma improvement with therapy.
Wood’s light is also a useful tool in the assessment of melasma (see Sect. 1.2.1.2).
Although it does not measure melasma severity, it can accurately assist in the determina-
tion of the presence or absence of pigmentation and its location. It can also distinguish
between pigmentary changes and changes due to superficial circulation or scarring.

1.3.3 Botulinum Toxin

Some photonumerical scales were created to evaluate the areas of face treated by
botulinum toxin.
The four-point glabellar frown line scale was developed and validated by Hornek
and colleagues (The Smile Group). It consists of an atlas with standardized photo-
graphs of glabellar frown lines [25]. Years later, the same group led by Hund devel-
oped the four-point clinical severity scores for lateral canthal lines (crow’s feet) [26].
Other validated grading scales for dynamic wrinkles (those that could be treated
with botulinum toxin) were published, such as the validated grading scale for crow’s
feet [6], validated grading scale for marionette lines [8], and validated grading scale
for forehead lines [7].
Minor’s test or iodine-starch test evaluates before and after hyperhidrosis treat-
ments by showing residual areas of sweating in the treated areas. The colorful com-
plex formed by Minor’s test allows the visualization of the area covered by the effects
of botulinum toxin on sweat glands, also known as diffusion or fields of anhydrotic
effect. Hexsel and coauthors reinforced a standardized technique to perform Minor’s
test and created the Sweating Intensity Visual Scale. It is an objective scale to grade
the sweat intensity and can be used to categorize degree of hyperhidrosis [22].

1.3.4 Cellulite

While the previous classification of cellulite [34] describes different grades of

cellulite, which is very important, there are additional key morphological
aspects that affect cellulite severity and, therefore, can be targeted by treatment
options. For this reason, Hexsel, Dal’Forno and Hexsel created and validated
the cellulite severity scale (CSS) [21] as a new method to objectively measure
and grade cellulite severity. The proposed new scale expands the current
classification allowing a comprehensive measurement of the intensity of the
condition. Four important clinical and morphological aspects and the previous
classification are assessed in this scale: A) Number of evident depressions; B)
Depth of depressions; C) Morphological appearance of skin surface alterations;
D) Grade of laxity, flaccidity, or sagging skin; E) Classification by Nürnberger
and Müller. It is an objective method that can facilitate patient follow-up and
measure treatment outcomes.
10 D.Z. do Prado et al.

1.3.5 Quality of Life

There are scales developed with the aim of measuring the impact of some diseases
or conditions in patient’s quality of life. Some of the most used scales include the
DLQI for all cutaneous diseases [2], melasma quality of life questionnaire
(MelasQol) [4], the Acne Quality of Life Scale [20], Psoriasis Disability Index [13],
and Cellulite Quality of Life Scale (Celluqol®) [23].

1.4 Quantitative Skin Evaluation

1.4.1 Imaging Measurement Tools

In vivo imaging of the skin has improved the assessment of initial versus treated
skin within cosmetic procedures and research.
Unfortunately, many of these systems use software exclusively for PCs with
Windows operating systems. Thus, they cannot take advantage of the graphics pre-
sentation possible with the speed of Apple’s new Power Mac G5 with its 64-bit
processor offering 8 GB of RAM [1].

1.4.1.1 Three-Dimensional Skin Microphotography

Three-dimensional microphotography with equipments like PrimosTM measurement
device (Canfield ScientificTM) has been shown to quantitatively measure skin rough-
ness, wrinkles, and nodule formations and to track changes over time. It can help
evaluating the efficacy of non-ablative laser therapy used to minimize acne scarring
and facial lines.
The absolute measurement of wrinkle depth by light transmission of a silicone
replica (Skin-Visiometer® SV 600) is considered a simple way to diagnose the
topography of the skin surface. The device works based upon a parallel light source
and a black and white CMOS camera with 640 * 480 pixels that reads the topogra-
phy of the skin by light transmission of a very thin, especially blue-dyed silicone.
The very viscous two-part silicone, mixed under vacuum to avoid bubbles, fills even
the smallest skin depths and reproduces them in detail. The replica reproduces the
heights and depths of the skin as a negative, that is, wrinkles are higher in the replica
as the silicone is thicker in this place. These special parameters have been created to
describe the skin topography volume and unfolded surface, which can be displayed
quickly in a colored 3D image.
Skin EvidenceTM (La Licorne, France) and Visioscope® (Courage-Khazaka,
Germany) are also capable of analyzing skin relief (see Sect. 1.4.1.3).

1.4.1.2 Quantitative Reproducible Facial Image Analysis

VisiaTM and VisiaTM CR (Canfield ScientificTM, USA) are imaging booths in a self-
contained unit that generates quantitative values for skin features. It provides new
detection and analysis of subsurface vascular and melanin conditions. It separates
the color signatures of red and brown skin components for analysis of conditions
1 Skin Evaluation Systems 11

Fig. 1.5 VisiaTM imaging booth

such as rosacea, spider veins, melasma, acne, and wrinkles. There is a true UV
photo mode that provides the most complete data for sun damage and a UV
fluorescence imaging to reveal porphyry (P. acnes). It consists of an interactive sys-
tem through which the dermatologist uses a digital imaging booth with a high-reso-
lution camera to process images with proprietary software (Fig. 1.5). The software
is designed to evaluate skin surface imperfections and show the patient the potential
results of cosmetic procedures [1]. All the high-resolution images are stored in file,
registered under the patient’s name, allowing a complete procedure follow-up.
MirrorTM imaging software (Canfield ScientificTM, USA) can simulate treatment
results and also objectively measure some efficacy parameters expressed in centi-
meters, such as brown lift (Fig. 1.6) and field effects promoted by botulinum toxin
action (Fig. 1.7). Furthermore, this software measures and analyzes facial angles
which can be helpful in preoperative analysis and planning the procedure [46]. The
ease and speed of image alteration lies at the heart of this sophisticated software,
making patient consultations streamline and informative.
The Visioscan® VC 98 (Courage-Khazaka, Germany) is an accurate equipment
that provides a high degree of stability visualizing a sharp, non-glossy image of the
skin surface shown by a special UV-A light video camera with a high-resolution
black and white video sensor and a ring-shaped UV-A light source for uniform illu-
mination of the skin. The device can be used in various fields of application, such as
the clinical diagnosis in dermatology, due to its capacity to quantitatively and quali-
tatively describe clinical parameters of the skin surface: skin smoothness, skin
roughness, scaliness, and wrinkles.
12 D.Z. do Prado et al.

Fig. 1.6 Results of a patient before and after treatment measured by MirrorTM imaging software

1.4.1.3 Biometrical Image Tools

Skin Evidence™ Visio (La Licorne, France) is a biometrical tool designed to facili-
tate an early and accurate diagnosis and to evaluate objectively the treatment results
(Fig. 1.8). It is an imaging device that contains standardized illumination with nor-
mal and polarized light together with a quantitative analysis for skin surface (cuta-
neous microrelief) [3], pigmentation, vascular abnormalities, sebum measurement,
hair distribution, and growth (Fig. 1.9). Skin EvidenceTM is a system based on four
separate parts: a high-performance computer, a video probe, a unified probe, and
software. The probes are connected to the computer by a USB cable.
Visioscope® BW 30 (Courage-Khazaka, Germany) is a handheld video camera
with a special UV light source designed to visually magnify skin, hair, and scalp on a
video screen. The camera shows a skin area of 6 × 8 mm and monitors the skin texture
(smoothness, wrinkles), desquamation (scaliness), skin impurities (reddening, pig-
mentation spots, acne, comedones, etc.), hair structure, dandruff, and condition of the
scalp. There is also a color version (Visioscope® Color 32) that is a handheld video
camera connected with a video monitor very similar to Visioscope BW 30, with white
light source instead to UV light. It is recommended for use in viewing and diagnosing
skin, hair, and scalp conditions. The camera records a color view of 6 × 8 mm.
Dermascan® (Cortex Technology, Denmark) is a high-resolution ultrasound
equipment (Fig. 1.10) that provides a dimensional measurement and diagnoses the
structural changes of the skin. It displays the layers of the epidermis, dermis, and
subcutaneous tissues in a color LCD panel, in 2D or 3D resolution. The exam is