Botox (OnabotulinumtoxinA) for Treatment of Migraine Symptoms

Migraine is one of the most common types of headache, and it is the second most common cause of neurological disorders, with an annual prevalence of about 15% of the population.

In an article published in Pain Research and Management in 2022, a study was highlighted that aimed to evaluate the effect of BoNT-A (Botox) on the duration and intensity of migraine attacks. This study set out to assess the effect of Botox on the duration and intensity of migraine attacks. In addition, effective injection sites were explored.
The findings showed immense promise in that, when used in individuals with chronic migraine, Botox decreased the frequency of migraine attacks per month. In addition, it was seen to influence pain intensity and migraine related disabilities. Medication use was also reduced as were emergency room visits.

The fact that the Botox injections were well tolerated, and undoubtedly led to a better quality of life for the participants, makes this is very viable option in the treatment of migraine. The average total dose is approximately 150 units to cover the corrugator, procerus, frontalis, temporalis, occipitalis, cervical paraspinals, and trapezius. It often requires up to three treatments for the best efficacy in reducing the intensity and number of headaches.

In individuals who suffer from vestibular migraine (migraine with vertigo) treatment reduced the frequency of migraines and improved the debilitating effects of these incidents. In addition, use of Botox reduced the frequency of attacks per month among individuals with chronic refractory migraine (migraine that is seemingly resistant to treatment and can occur up to eight days a month).

In conclusion, use of Botox can be a cost-effective option for treatment of various types of migraine, including chronic, episodic, unilateral, and vestibular types. By reducing the frequency and decreasing the severity of pain, Botox is a very viable treatment option for those suffering from migraine headaches.

Letybo (Korean Botox)

LetYbo is a botulinum toxin type A injectable product used for various cosmetic and medical purposes. It works by temporarily paralyzing or weakening targeted muscles, reducing the appearance of wrinkles and fine lines. Unlike Botox and Dysport, LetYbo has unique characteristics that set it apart. The FDA approved LetYbo based on evidence from three clinical trials of 1,271 patients with moderate to severe wrinkles between the eyebrows for efficacy and safety.

LetYbo is primarily used for aesthetic purposes, particularly in the treatment of facial wrinkles and lines, such as frown lines, forehead lines, crow's feet, and bunny lines. It can also be used to lift and contour eyebrows, slim the jawline, and soften neck bands. Store unopened Letybo vials in a refrigerator between 2°C to 8°C (36°F to 46°F) in the original carton to protect from light. Do not freeze.

LetYbo is also utilized for non-surgical procedures such as hyperhidrosis, migraine headaches, and urinary incontinence. While it belongs to the same class of botulinum toxin type A products as Botox and Dysport, it distinguishes itself through its unique formulation and molecular structure. This distinction may result in variations in onset time, duration of effect, and diffusion patterns. Some practitioners and patients report that LetYbo may have a quicker onset of action and longer-lasting results compared to its counterparts. Additionally, LetYbo may offer a more natural and smoother appearance due to its diffusion properties.

LetYbo has just received FDA approval for cosmetic use in the United States, making it a viable option for patients seeking aesthetic enhancements. Its availability globally varies, with some regions having approved its use for cosmetic and medical applications. In the United States, LetYbo is typically administered by licensed healthcare professionals, including dermatologists, plastic surgeons, and certified injectors, ensuring safe and effective treatment outcomes.

LetYbo’s emergence underscores the ongoing pursuit of innovation in the quest for beauty and aesthetics, offering patients new possibilities.  LETYBO is a promising addition to the arsenal of products available in the field of aesthetics and cosmetic medicine. Its unique properties and potential benefits make it an attractive option for patients looking to rejuvenate their appearance without surgery.

This is the latest toxin coming from Korean skincare. It is said to have a faster onset as little as 24 hours and lasts up to 4 months. This will be the 6th toxin to market starting with Botox Cosmetic, Xeomin, Dysport, Daxxify, and Jeuveau.

Top 11 Neurotoxins worldwide:
Botox (Allergan), Dysport (Galderma), Xeomin (Merz), Jeuveau (Evolus), Daxxify (Revance), Azzalure, Reloxin, Bocoture, PurTox, Neuronox and LetYbo.

Testosterone on the face

Microscopic skincare: Testosterone

This article discusses the potential of using a single ingredient at a microscopic level for skincare, focusing on testosterone's rejuvenating effects. It discusses a 1967 study on hormone application for anti-aging, emphasizing the importance of objective measures like biopsy samples. The lecture also covers the role of fibroblasts, elastin, and collagen in skin health, and the localized effects of testosterone propionate compared to systemic hormones like estrogen. Ethical considerations of past studies and the benefits of compounding pharmaceuticals for personalized treatment are also highlighted.

This article explores the potential of using a single ingredient at a microscopic level for skincare, specifically testosterone, and its rejuvenating effects. It discusses a 1967 study on hormone application for anti-aging, emphasizing the importance of objective measures like biopsy samples. The lecture also covers the role of fibroblasts, elastin, and collagen in skin health, and the localized effects of testosterone propionate compared to systemic hormones like estrogen.

The article highlights the importance of understanding the endocrine function in skincare and the potential side effects of hormone use. It emphasizes the need for objective data in skincare studies, such as biopsy samples, to avoid biases associated with subjective visual assessments. Testosterone propionate is a stable form of testosterone that can be used topically to avoid whole-body effects and has significant anti-aging properties.

Testosterone treatment can lead to noticeable improvements in skin texture and hair growth, making skin appear younger and increasing hair density and length. The effects are localized to the treated area, indicating its targeted action. The untreated side remained unchanged, demonstrating the hormone's targeted action.

The article also discusses the localized effects of testosterone gel, which has a localized effect on the treated area, rather than a systemic effect on the whole body. The lecture emphasizes the importance of proper formulation for topical application and monitoring for any potential side effects.

Ethical considerations of past studies and the benefits of compounding pharmaceuticals for personalized treatment are also highlighted. Overall, the article provides valuable insights into the potential of using a single ingredient at a microscopic level for skincare and the ethical implications of these studies.

Botox for Erectile Dysfunction

Publication year: 2022

• Journal name: Journal of Sexual Medicine

The 2022 study published in the Journal of Sexual Medicine evaluates the use of Botulinum neurotoxin, specifically BoNT-A, as a treatment for erectile dysfunction (ED) in men who do not respond to traditional therapies, particularly phosphodiesterase type 5 inhibitors (PDE5i). ED is a common condition, affecting between 3% and 76. 5% of men globally, with the likelihood increasing with age. Beyond the physical implications, ED significantly impacts psychological well-being and interpersonal relationships, underscoring the need for effective interventions. The study's objective was to assess both the efficacy and safety of intracavernosal injections (ICI) of BoNT-A in men with ED who have not benefitted from conventional treatments.

The research followed a structured methodology, involving a prospective, double-blinded, randomized controlled trial with 70 male participants who had been refractory to PDE5i. These patients were randomly assigned to receive either 100 units of BoNT-A or saline solution as a control. Assessments were conducted through various measures, including the erection hardness score (EHS), peak systolic velocity (PSV), end-diastolic velocity (EDV), and the Sexual Health Inventory for Men (SHIM) questionnaire. Evaluations occurred at baseline and then again at 2, 6, and 12 weeks post-injection, with statistical analysis focused on mean comparisons, marking significance at a p-value of less than 0. 05. The results revealed that patients in the BoNT-A group experienced notable advancements in the primary outcome measures compared to controls.

Specifically, the EHS showed a statistically significant mean score increase. The PSV demonstrated a mean increase of p = 0. 005, while the EDV had favorable changes with a p-value of less than 0. 001. In terms of the SHIM scores, there was a significant rise recorded at both 6 and 12 weeks, peaking with a 5-point improvement from the baseline scores. It's important to note that, despite 18 patients reporting erections sufficient for penetration, only three were able to achieve vaginal intercourse. Interestingly, despite the presence of various comorbidities and known risk factors, these did not seem to significantly influence the treatment response.

In conclusion, the study indicates that intracavernosal administration of BoNT-A could be an effective alternative for managing ED in patients who do not respond to PDE5i therapies, showcasing both efficacy and a favorable safety profile. However, the transient nature of BoNT-A's effects indicates the potential need for repeated treatment sessions, similar to established injectable treatments like PGE1. The small sample size and single-center nature of the trial restrict its generalizability, and the lack of long-term follow-up data restricts insights into sustained efficacy and safety.

Going forward, further large-scale, multicentric trials would be beneficial to gain a deeper understanding of the long-term safety and optimal dosing strategies for BoNT-A in treating ED. Additionally, exploring the efficacy of combined treatments, integrating BoNT-A with currently available ED medications, could lead to improved clinical outcomes. From a clinical standpoint, these findings highlightBoNT-A's potential as a valid treatment option for men with ED, particularly those who have exhausted traditional avenues. Clinicians must carefully select patients, assessing individual health conditions and previous treatment responses, to effectively integrate this emerging therapy into their practices. This advancement in the treatment of ED could significantly enhance the therapeutic options available to practitioners, ultimately benefiting patients.

Tirzepatide vs. Semaglutide Once Weekly in Patients with Type 2 Diabetes

Paper info

• Publication year: 2021

• Journal name: The New England Journal of Medicine

In this study, we will delve into the findings from the SURPASS-2 trial, which evaluates the efficacy and safety of tirzepatide compared to semaglutide in patients with type 2 diabetes inadequately controlled on metformin. Type 2 diabetes poses significant challenges to health globally, prompting the need for effective management strategies. GLP-1 receptor agonists are well-established in this role, effectively managing blood glucose and aiding in weight loss. However, tirzepatide, a novel dual agonist that targets both GLP-1 and GIP, has emerged as a promising option that may offer additional benefits in glycemic control and weight reduction over traditional GLP-1 receptor agonists like semaglutide. The primary objective of the SURPASS-2 trial was to assess the efficacy and safety of once-weekly tirzepatide at doses of 5 mg, 10 mg, and 15 mg, compared to semaglutide 1 mg. The study enrolled 1,879 participants across 128 sites, who were randomized in a 1:1:1:1 ratio to receive either tirzepatide or semaglutide. The main endpoint focused on the change in glycated hemoglobin, or HbA1c, from baseline to week 40, while secondary outcomes included changes in body weight and the achievement of glycemic targets. The results were striking. Tirzepatide demonstrated greater reductions in HbA1c levels compared to semaglutide at all doses tested. Specifically, the mean decrease in HbA1c was -2. 01% for the 5 mg dose, -2. 24% for the 10 mg dose, and -2. 30% for the 15 mg dose, all statistically significant with p-values less than 0. 001 when compared to semaglutide. In terms of weight loss, tirzepatide also showed advantages, with a mean weight reduction of -7. 6 kg for the 5 mg dose, -9. 3 kg for the 10 mg dose, and -11. 2 kg for the 15 mg dose. In contrast, semaglutide resulted in a mean weight reduction of -5. 7 kg. Furthermore, the study found that 82% to 86% of participants receiving tirzepatide achieved an HbA1c target of less than 7. 0%, compared to 79% of those receiving semaglutide. Regarding safety, adverse events were reported similarly across the groups, with gastrointestinal issues being the most common. Nausea was reported in 17-22% of tirzepatide recipients compared to 18% for semaglutide, while diarrhea affected 13-16% of those taking tirzepatide versus 12% for semaglutide. In conclusion, tirzepatide has proven to be both noninferior and superior to semaglutide in reducing HbA1c levels and body weight. This suggests its potential as a preferred option for managing type 2 diabetes, with a comparable safety profile to existing treatments. The robustness of this study is enhanced by its large sample size and an active comparator design, enabling direct comparisons. However, it is important to note the limitations, including the open-label nature of the trial, which may lead to biases, as well as the need for further investigation into long-term safety and efficacy beyond the 40-week observation period. Looking forward, future studies should focus on long-term outcomes and explore how tirzepatide affects cardiovascular risk factors, given its dual mechanism of action. Additionally, patient-reported outcomes should be examined to understand better the implications on quality of life associated with this treatment. In clinical practice, the findings suggest that tirzepatide represents a significant advancement in diabetes management, providing enhanced glycemic control and weight loss with just a single weekly injection. This is crucial for improving patient compliance and overall outcomes for those inadequately controlled on metformin alone.

PDO Threads as an Alternative in Nonsurgical Procedures in Facial Rejuvenation

Paper info

• Publication year: 2020

• Journal name: Facial Plastic Surgery

The increasing interest in minimally invasive cosmetic procedures has highlighted the necessity for non-surgical alternatives to facial rejuvenation. Traditional surgical rhytidectomy, while effective, comes with risks of complications and long recovery times. This has led to a growing demand for less invasive options that can still provide significant aesthetic improvements. Thread lifting using polydioxanone, or PDO threads, offers a promising solution. This technique not only ensures minimal downtime but also has low complication rates, making it an appealing choice for many patients interested in facial rejuvenation. The objective of this paper is to examine the viability of PDO threads as a non-surgical facial rejuvenation option. It addresses the mechanisms behind their effectiveness, the procedures involved, appropriate patient selection, and the potential outcomes that can be expected. To conduct this examination, the study design involved a comprehensive review of existing literature related to PDO thread usage and its clinical applications in the field of facial rejuvenation. The population studied primarily consisted of patients aged between 40 and 50 years, who exhibited mild signs of aging. Notably, patients with excessive skin laxity or unrealistic expectations were excluded from this analysis. The intervention itself involves the insertion of PDO threads, which are synthetic absorbable sutures, into targeted areas of the face. This method not only provides an immediate lifting effect but also promotes collagen production, which is vital for enhancing skin texture and elasticity. Regarding the outcomes assessed, the study looked into complications, the effectiveness of aesthetic results, and patient satisfaction levels as reported across various studies and follow-ups. The results of using PDO threads have shown promising effects. They stimulate collagen synthesis during their absorption period, which typically lasts about four to six months. As the threads undergo hydrolysis, patients experience enhanced skin texture and elasticity. This technique effectively addresses common aging concerns, including jowls and nasolabial folds. Complications reported are generally mild, consisting of bruising, swelling, asymmetry, and skin dimpling. These issues typically resolve without the need for additional intervention. Initial levels of patient satisfaction have been favorable; however, it is worth noting that long-term effectiveness remains to be comprehensively evaluated. The comparison between PDO threads and non-absorbable sutures indicates a clear advantage for the former. Non-absorbable options often lead to higher complication rates, and patient dissatisfaction due to challenging removal processes. In conclusion, PDO threads offer cosmetic benefits with low morbidity and minimal downtime, making them an attractive option for patients looking for facial rejuvenation without the need for invasive surgery. Successful outcomes are contingent upon proper patient selection, a deep understanding of facial anatomy, and a comprehensive knowledge of vector techniques during the thread insertion process. While this paper highlights several strengths, such as the promising balance between aesthetic results and minimal invasiveness of PDO threads, it also acknowledges limitations. Many studies reviewed lack long-term follow-up data that could provide valuable insights into the sustainability of results. Additionally, patient satisfaction can be subjective, complicating efforts to assess overall effectiveness accurately. Looking ahead, there is a call for future studies to focus on standardized protocols that incorporate long-term monitoring of aesthetic outcomes and complication rates. Furthermore, exploring the quantitative impact of PDO threads across different skin types and demographics would deepen our understanding and application of this technique to diverse patient populations. Clinically, the findings endorse the use of PDO thread lifting procedures within aesthetic practices as a legitimate tool for non-surgical facial rejuvenation. A well-executed PDO thread treatment can enhance the array of options available to practitioners, serving as either an alternative or an adjunct to traditional surgical interventions, thereby improving patient care and satisfaction in facial aesthetic services.

Cosmetic Treatments with Energy-Based Devices in Skin of Color

Paper info

• Publication year: 2023

• Journal name: Facial Plastic Surgery

Today, we delve into the findings of a recent paper published in *Facial Plastic Surgery* in 2023, which reviews cosmetic treatments using energy-based devices specifically for patients with Fitzpatrick skin types 4 to 6—those with darker skin tones. The paper begins by outlining the concerns associated with using traditional energy-based devices in these patients. Historically, these devices have been linked to significant complications such as hyperpigmentation and scarring due to excessive heat generation. Given the growing diversity in the population seeking cosmetic treatments, it's crucial to develop safe and effective solutions tailored for these skin types. The objective of this narrative review was to consolidate recent studies and explore various energy-based devices that have shown promise in treating skin of color. This includes technologies like radiofrequency (RF) devices, microfocused ultrasound (MFUS), fractional laser treatments, and the short-pulse neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. Now, let's look at the outcomes for each treatment modality. Starting with radiofrequency skin tightening devices, these have proven effective for tightening the skin while avoiding excessive heat, thereby significantly reducing the risk of adverse effects like pigmentation changes. Clinical observations have noted positive results in treating rhytids and for general skin rejuvenation. Next, microfocused ultrasound stands out as a non-invasive option that provides lifting and tightening effects. It achieves this by delivering thermal coagulation deep within the skin, which stimulates collagen production without compromising safety for darker skin tones. In terms of fractional laser resurfacing, both ablative and non-ablative options were assessed. However, non-ablative lasers were favored for their safety profile regarding pigmentation. These lasers have effectively addressed issues like acne scars, textural irregularities, and dyschromias, making them a suitable choice for patients with higher Fitzpatrick skin types. The short-pulse Nd:YAG laser emerged as particularly transformative for skin of color. Its capability to target various chromophores with minimal inflammation and pain enhances its applicability. Additionally, when used in conjunction with chemical peels and microneedling, it maximizes treatment outcomes, showcasing synergistic effects.

The results presented in the paper exemplify treatment efficacy vividly through clinical images. These images display notable improvements in hyperpigmentation, overall skin tone, and textural issues in treated patients. In summary, the authors emphasize advancing technology in energy-based devices has paved the way for safer and more effective options for patients with darker skin. It is vital to tailor treatment strategies to address the unique characteristics and concerns these patients face to optimize results. The strengths of this review are significant. It offers a comprehensive synthesis of existing data, presents innovative therapies suitable for darker skin types, and underscores the importance of individualized treatment plans. On the flip side, its limitations include potential biases stemming from subjective clinical outcomes and a lack of large-scale trials, indicating a need for further research to confirm long-term safety profiles.

Looking forward, the paper highlights the necessity for ongoing studies to explore the long-term safety and efficacy of energy-based devices across larger, diverse populations. Developing standardized treatment protocols catering to varying dermatological needs is also crucial. In terms of clinical relevance, these findings can greatly guide dermatologists and cosmetic surgeons, providing them with evidence-based treatment options that emphasize safety and effectiveness for patients of color. This focus not only enhances patient satisfaction but also improves overall outcomes in cosmetic dermatology. That wraps up our discussion on this important topic. Stay tuned for our next episode where we’ll explore more advancements in cosmetic dermatology!