SYNERGY VERSUS INTERFERENCE IN COMBINATION PROTOCOOLS

Dr Shirin Lakhani offers a regenerative, evidence-based perspective on optimising treatment combinations to achieve better clinical outcomes

DR SHIRIN LAKHANI

Dr Shirin Lakhani is a GP and aesthetic practitioner specialising in intimate health, sexual dysfunction, and menopause. A lack of NHS care for women has led Dr Lakhani to offer treatments for lichen sclerosus, vaginal atrophy and many more intimate health issues. She is a significant voice of authority within the intimate health space.

A lthough combination treatments are frequently discussed , they are often inadequately defined in routine clinical practice. In my experience, effective combination therapy requires a thorough understanding of biological principles, mechanisms of action, and patient variability, followed by the structured, evidence-based application of this knowledge rather than simply increasing the number of treatments or introducing unnecessarily complex protocols.

Combination therapy must be intentional, with each modality providing a distinct, complementary effect. Properly selected and sequenced treatments can improve tissue quality, reduce downtime, and increase satisfaction, while poor choices may yield suboptimal outcomes. Combining modalities that enhance each other is key to maximising benefits and minimising risks.

UNDERSTANDING SYNERGY IN COMBINATION TREATMENTS

When developing combination treatments, it is necessary to have a comprehensive understanding of how each treatment functions at the cellular and tissue levels. Combining modalities is beneficial only when their mechanisms are compatible or mutually supportive. Treatments that induce controlled trauma can be effectively paired with those that promote healing and regeneration.

It is equally important to identify ineffective or counterproductive combinations. Some treatments may seem compatible superficially but can interfere with each other at the biological level. For example, in skincare, retinol is commonly perceived as drying, prompting patients to use moisturiser concurrently. However, retinol increases cell turnover and stimulates fibroblast activity, while the simultaneous application of a moisturiser can inactivate retinol and hinder exfoliation, reducing the effects.

Clinical treatments should work with underlying repair mechanisms. If a therapy relies on inflammation for tissue repair, it should not be combined with anti-inflammatory interventions, as suppressing inflammation would impair regeneration and lead to inferior outcomes.

PATIENT AND DEVICE CONSIDERATIONS

When developing combination protocols, I evaluate both patient-specific and device-specific factors. For individuals with significant photodamage, compromised skin quality, or structural alterations, combination therapy is often preferable, as a single modality seldom addresses all contributing factors. In such cases, synergistic treatments give superior and longer-lasting outcomes.

Combination therapy can reduce downtime by including treatments that promote healing, which is important for patients needing effective results in shorter recovery periods.

Device selection is also crucial, and treatments must be biologically compatible. For example, administering non-steroidal anti-inflammatory drugs in conjunction with platelet-rich plasma (PRP) treatments suppresses inflammation, which is essential for tissue repair, and inhibits platelet function. In my clinical experience, patients who use anti-inflammatories during PRP therapy exhibit significantly reduced outcomes compared to those who do not.

MAINTAINING AN EVIDENCE-BASED APPROACH

Innovation is vital in aesthetic medicine, but it must be supported by robust evidence. Prior to implementing a new treatment or combination, I conduct a comprehensive literature review. This approach applies to devices, injectables, supplements, and emerging regenerative techniques. I place more value in independent studies that demonstrate safety, efficacy, and reproducibility.

However, published evidence represents only one aspect of the evaluation process. Real-world outcomes are equally important. Structured in-house clinical evaluations, conducted following comprehensive training, provide critical information on treatment performance within my patient population. These analyses enable protocol refinement based on observed results. Importantly, I conduct these evaluations independently of manufacturers to maintain objectivity.

I integrate a treatment more broadly into practice only after establishing its safety, efficacy, and reproducibility.

REGENERATIVE MEDICINE

Regenerative medicine forms the foundation of my approach to combination therapy in aesthetic practice. Rather than focusing solely on correction, I prioritise improving tissue quality so that the skin and underlying structures are better able to respond to, and benefit from, subsequent treatments. This regenerative-first philosophy allows combination protocols to be designed more strategically, with each modality building on the biological effects of the previous one. This approach is applied across all treatment types, including energy-based devices and injectables. By incorporating regenerative modalities early within a combination protocol, it is often possible to enhance healing, optimise collagen stimulation, and improve overall tissue function, creating a more receptive environment for further intervention.

When using dermal fillers, I favour biostimulatory products. Biostimulatory treatments promote collagen production and tissue remodelling, supporting longer-term structural improvement. When tissue quality has been enhanced in this way, subsequent interventions tend to perform more effectively and produce more natural, durable results. Improved tissue quality is not simply an added benefit, but a critical determinant of overall outcome.

PRP IN COMBINATION THERAPY

PRP is integral to regenerative aesthetics, but its effectiveness depends heavily on appropriate patient selection and product quality. PRP efficacy relies on the patient’s natural regenerative capacity. Patients with significant comorbidities, platelet disorders, or poorly controlled autoimmune conditions may exhibit suboptimal responses.

PRP has a variable reputation in aesthetic medicine, often attributable to inconsistent preparation methods and low platelet concentrations, both of which affect perceived efficacy.

Systems such as Arthrex ACP are designed to address these challenges by producing a more consistent platelet concentrate compared to standard single-spin tube systems. By increasing platelet yield and standardisation, these systems seek to improve reliability and clinical outcomes, particularly in applications such as facial rejuvenation and hair restoration, where predictable results are critical.

Although different PRP platforms may be selected based on clinical requirements, volume needs, and specific indications, the underlying principle remains unchanged: high-quality PRP preparation is essential for achieving significant regenerative outcomes.

COMBINING REGENERATIVE TREATMENTS WITH OTHER MODALITIES

In my clinical practice, regenerative treatments are seldom administered in isolation. For example, combining PRP with radiofrequency microneedling can enhance outcomes by stimulating collagen production and concurrently supporting healing and tissue repair. In certain cases, a single combined treatment may reduce the number of sessions required for a single modality, thereby improving patient experience and treatment costs. Enhancing skin quality through regenerative treatments also increases the success of subsequent traditional procedures, thereby reinforcing the value of strategic combination therapy.

EXPECTATIONS AND TIMELINES

Even when combination therapy accelerates visible improvements, it is essential to acknowledge biological timelines. Collagen synthesis and tissue remodelling require time. For most regenerative treatments, the final results are observed after two to three skin cycles, approximately 12 weeks. I ensure patients are informed of this timeline, even when early improvements are apparent.

Combination therapy may enhance outcomes, but it cannot completely override physiological processes.

COST CONSIDERATIONS WITH COMBINATION TREATMENTS

Cost remains one of the biggest challenges associated with combination treatments. While patients are often open to multimodal approaches, adding multiple high-cost interventions can be difficult to justify. In my experience, the most successful combinations are those that provide a clear increase in value without disproportionately increasing cost.

In certain instances, combination therapy may lower overall costs by decreasing the number of treatments needed to achieve the desired outcome. This should be discussed during consultation, especially when patients focus on upfront costs as opposed to long-term value.

THE FUTURE OF COMBINATION THERAPY

Looking forward, I anticipate that combination therapy in aesthetic medicine will increasingly emphasise regenerative, biologically driven outcomes. There is a growing interest in autologous fillers and PRP-based technologies, showing patient preferences for natural results and heightened caution towards synthetic or long-lasting foreign materials.

There has also been a clear shift away from overcorrection. More and more, patients want to look refreshed, healthier, and more like themselves, rather than dramatically altered. Combination therapy enables clinicians to enhance collagen production, support cellular repair, and improve tissue quality while respecting individual anatomy and identity.

Combination therapy should not be about increasing the number of treatments, but more about selecting the appropriate treatments, in the correct sequence, for each individual patient.