LAS VEGAS The way Dr. Vic A. Narurkar sees it, multimodal therapy is integral to most noninvasive dermatologic treatments.
"We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They complement each other, but we need to do controlled studies to see if there is true synergy, for example, between injectables and fractional resurfacing."
He discussed the role of multimodal therapy for treating several conditions:
▸ Acne and acne scarring. Prevention options include topical and systemic agents and devices for acute treatment. "We then can correct acne scars with Fraxel laser and injectable fillers such as Juvéderm," said Dr. Narurkar, a dermatologist who practices in San Francisco. Posttreatment acne still needs to be controlled with topical agents.
Isolaz, a device from Aesthera Corp., uses pneumatics to cleanse pores mechanically; it is cleared by the Food and Drug Administration to treat pustular and comedonal acne as well as mild to moderate acne vulgaris. "I call this dermatologic fantasy, because it's this extrusion of pores that we all strive for," said Dr. Narurkar, who is also associate professor of clinical dermatology at the University of California, Davis.
"You get mechanical cleansing by the application of gentle suction. What's interesting about this technology is that you can see immediate impact, similar to cortisone injections. If you combine it with topical retinoids and topical antibiotics, you get an even better result."
▸ Rosacea. Prevention and management options include topical agents such as azelaic acid, metronidazole or sulfur, and oral antibiotics. Treatment of diffuse and isolated telangiectasias "is most effective with the use of vascular laserspulsed dye or pulsed KTP [potassium-titanyl-phosphate]or with the second- and third-generation intense pulsed light sources," he said.
▸ Melasma. Dr. Narurkar called this condition "the sin of dermatology," noting that melasma is difficult to treat and manage. "We pretreat with hydroquinones or retinoids," he said. "The only laser I'll use for therapy-resistant melasma is nonablative fractional resurfacing with the Fraxel Re:Store Laser. I haven't had success with any other laser and you can still get recurrence if it is not managed topically."
For posttreatment, he suggests hydroquinones and retinoids and daily use of a broad spectrum sunscreen. "If patients can avoid birth control pills and other estrogen agents, that's even better," he said.
▸ Skin rejuvenation. For optimal results he recommends "the four Rs": retain and replenish with skin care and sunscreen, resurface with devices, relax with botulinum toxins, and refill with dermal fillers.
Acute treatment of mild to moderate photoaging can be achieved via photofacials with pulsed light sources, vascular and pigmented lesion lasers, and mild nonablative fractional resurfacing.
Treatment of moderate to severe photoaging can be achieved with photodynamic therapy and aggressive nonablative and ablative fractional resurfacing. "For advanced photoaging, you can enhance IPL [intense-pulsed light] and PDL [pulsed dye laser] treatments with Levulan," he said. "You need fewer treatments, there are more immediate results, but there is significantly more down time."
Dr. Narurkar disclosed that he is a consultant to and has performed clinical trials for Aesthera Corp., Allergan Inc., BioForm Medical Inc., Palomar Medical Technologies Inc., and Reliant Technologies Inc.
'We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined.' DR. NARURKAR