In review

Dr Nicole Chiang looks to coronavirus and beyond for the biggest advancements in dermatologyrelated aesthetics this year

To say that 2020 has been an eventful year would be an understatement. But while the pandemic has had an effect on all aspects of our lives and the world we live in, it has also sparked some interesting developments and trends. The field of dermatology in particular has been impacted, with coronavirus-related changes filtering through into aesthetics overall. Here, I’ll round up the defining trends.

COVID-19 AND DERMATOLOGY

Since the beginning of the pandemic, we have seen a rise in several associated skin conditions. This is most commonly due to the preventative measures we take to protect ourselves against the coronavirus infection, such as regular hand washing, use of disinfectants and personal protective equipment (e.g. face masks, visors and goggles). These problems are most commonly reported by healthcare workers, but as the pandemic continues, they are increasingly seen in the general population.

Hand dermatitis

We have seen hugely increased awareness of hand hygiene worldwide. Proper hand hygiene is thought to reduce the likelihood of transmissible disease spread by 24-31%.1 However, regular hand washing can negatively affect skin barrier, as alkaline soaps and alcohol, very hot or very cold water, repeated glove use and rough paper towels all contribute to an acute loss of skin surface lipids. As the skin surface lipids are depleted, the attenuated skin barrier exhibits an increase in transepidermal water loss (TEWL), which leads to increased epidermal penetration of irritants and allergens, propagating an inflammatory response that ultimately results in hand dermatitis.

There has since been an increase in measures suggested to prevent hand dermatitis including the use of products that are free of common allergens like fragrance or those with added moisturisers; and applying moisturisers immediately after hand washing. Persistent hand dermatitis has become a common skin complaint seen in dermatology clinics as medical treatments are often needed to control the condition.

Maskne

As face masks have become a necessity when leaving the house, we are seeing a rise in facial acne related to wearing face masks, a condition dubbed “maskne”. There are several contributing factors:

1. Constantly adjusting the face mask and touching the face to apply a face mask increases the likelihood of transferring oil, dirt and irritants onto the face

2. Moisture from breathing trapped in the face mask increases the growth of bacteria and yeasts

3. The tight-fitting nature of masks causes blockage of follicular openings.

These factors contribute to the resurgence of acne, as well as flares of common skin conditions such as rosacea and perioral dermatitis. To minimise maskne, several preventative strategies are recommended, including wearing a custom-fitted mask made from soft cotton or silk, cleansing properly with a gentle facial cleanser, double cleansing if make-up has been applied and using spot treatments on the face.

Skin rash as a sign of covid-19

With an increase in skin rashes seen in coronavirus-positive individuals, a rash is thought to be the fourth key sign of a coronavirus infection.2 Results from a survey among Spanish dermatologists through the Spanish Academy of Dermatology revealed five major patterns of skin rash related to covid-19.

1. Chillblain-like lesions (small, itchy swellings on the skin) on the hands and feet (19% of cases)

2. Vesicular eruptions (small blisters) on the trunk and limbs, often associated with itching (9%)

3. Urticarial lesions resembling nettle rash, mostly on the trunk (19%)

4. Maculopapular rash (small flat and raised red bumps)

5. Livedo or necrosis (blotchy red or blue rash with a net-like pattern).

Overall, it is hard to determine whether these skin manifestations are directly related to the coronavirus infection, or a complication of the infection. There can also be other causes related to the skin rash, and it is important to advise our patients not to self-diagnose, and to refer to a dermatologist.

Teledermatology

The world of teledermatology has accelerated in 2020. Teledermatology may involve sending photographs or dermoscopic images to a dermatologist for advice on diagnosis or management, or using video conferencing to discuss a skin issue. Many dermatologists have resorted to using teledermatology to assess and manage patients remotely, especially during lockdown periods. Common platforms used include Microsoft Teams and Zoom.

A major concern about using teledermatology is whether it is accurate enough for the diagnosis of skin lesions, especially when it comes to skin cancers. A Cochrane review of 22 studies published in December 2018 revealed that less than 7% of malignant skin lesions were missed by teledermatology. Using magnified images, in addition to photographs of the lesion, has been shown to improve accuracy.4

“While the pandemic has had an effect on all aspects of our lives and the world we live in, it has also sparked some interesting developments and trends”

THE ZOOM EFFECT

With so many people working from home and using video conferencing platforms such as Zoom; we have seen the rise of the “Zoom effect”. As a result of spending a large amount of time on video conferences and seeing ourselves on screen, many have identified imperfections, skin lesions and skin conditions on their faces which they were once oblivious to. As the pandemic continues, we have seen a rise in the number of people seeking treatments to improve their skin and aesthetic appearance.

BLACK SKIN

Since the George Floyd protests, the impact of the Black Lives Matter movement has increased rapidly. This has led to an increased awareness of the need for racial equality in many areas, including the world of dermatology, where it has been realised that there is a lack of representation of dark skin types in textbooks and journals. This is thought to have a negative impact on the knowledge and care for patients of darker skins.

Mind the Gap, a handbook detailing clinical signs of skin conditions in black and brown skin types, was published by a second-year medical student at St George’s, University of London and went viral worldwide. The book led to a call for an increase in representation of skin of colour images used in dermatology education. Platforms such as The Black Skin Directory, set up by aesthetician Dija Ayodele, gained increased attention as one of the few UK resources specifically for skin of colour patients to get skincare advice and connect with practitioners skilled in treating dark skin.

SKINCARE

The skincare industry is one of the fastest growing worldwide [reference?] and the demand for products continued to intensify in 2020. With no access to beauty salons and skin clinics during lockdown, many resorted to at-home skincare and treatments to treat their skin and aesthetic concerns.

“Clean beauty” remains a popular trend, with more and more people favouring products with natural or organic ingredients. Although it may seem attractive to have natural and pesticide-free substances in our skincare, one danger is that these ingredients are unregulated, unlike more scientificallystudied, evidence-based ingredients.

“As the pandemic continues, we have seen a rise in the number of people seeking treatments to improve their skin and aesthetic appearance”

Personalisation

As our patients are increasingly digitally savvy, and have become more educated about skincare, many are now very inquisitive about their skincare ingredients. We have seen a rise in brands that produce personalised, bespoke skincare products with ingredients and formulations tailor-made to the individual’s skin – brands like Mxt and Skinsei allow patients to customise the ingredients of their products based on skin quizzes.

Scalp is the new skin

In 2020, scalp care became the “new” skincare. There is a new wave of haircare products that focus on the health of the scalp, with an emphasis on treating the scalp as an extension of the skin. Instead of just shampooing and conditioning our hair, there is a trend to incorporate scalp-scrub cleansers, masks and treatments into our haircare routines.

PSYCHODERMATOLOGY

It is now well known that skin disease can take a toll on the mind and affect psychological wellbeing. The hormone cortisol that we release when we are stressed, emotionally distressed and anxious can cause inflammation which worsens many inflammatory skin diseases including eczema, psoriasis, acne and rosacea. Stress also causes an increase in hair shedding, which contributes to hair loss. There is also evidence that stress has a destructive effect on collagen, giving rise to more wrinkles.

Many of our patients are mindful that their psychological wellbeing can manifest its signs on the skin, aggravating existing skin disease and skin ageing. This has led to the availabilty of more resources on mindfulness and habit reversal to help improve our minds for better skin.

THE NATURAL LOOK

2020 undoubtably saw an increase in demand for people wanting to have cosmetic treatments, but patients were increasingly yearning for a more natural look. Many now prefer to have “tweakments” to enhance, rather than alter, their appearance. Botulinum toxin and dermal filler treatments remain popular, but there is an increasing trend towards procedures performed in “microdoses” to avoid looking overdone. 

Treatments such as platelet-rich-plasma (PRP) and device-based procedures such as radiofrequency and high-intensity focused ultrasound (HIFU) gained traction, as they are thought by some to be “natural” and without the introduction of foreign substances into the body.

MALE AESTHETICS

This year, male celebrities including Simon Cowell and Gordon Ramsay opened up in the media about the cosmetic treatments they have to enhance their appearance. Men opting for aesthetic treatments is gradually becoming destigmatised. In general, the two main goals for men seeking aesthetic treatments are to look less tired and to enhance their masculinity.