How to Use Hyaluronidase: Clinical Pearls

Joel Cohen, MD

Derek Jones, MD

Dr Joel Cohen and Dr Derek Jones, two of the leading experts in cosmetic dermatology, provide us with some important information on the use of hyaluronidase…


  1. Many clinicians consider hyaluronidase as standard of care, i.e., it is in the office.
  2. Be aware with Voluma because it is a vycross technology not a hyal-cross technology—therefore, its not as easy to dissolve with hyaluronidase, so it may take more concentration.
  3. It takes a fair amount of hyaluronidase to erase nodules with Voluma.
  4. How much hyaluronidase should you use? Some use 150 units per mL;  A simple rule of thumb for each 10th of a cc of Restylane, use about 5 units of Vitrase; (remember that the units across every brand may not be the same); 10 units if you’re trying to dissolve Juvederm; and probably about 15 units for Voluma.
  5. A bottle of Vitrase has 200 units per bottle-so you actually do have to reconstitute with some things so you get more out of it.
  6. Hyalnex is 150 units per bottle.
  7. The shelf-life for the hyaluronidases is very short.
  8. Many people use compounded products, but we’re not sure if they are as effective.
  9. There are a lot of issues with compounding and there will be a lot more regulations coming up.


Hair Today Gone Tomorrow

Jerry Shapiro, MD

Dr Shapiro, an expert in hair loss treatment, provided the audience with a practical approach to treating hair loss. Dr Shapiro practices in Vancouver, Canada and New York, New York. In Canada, he sees 60-70 patients per day and 70 percent of his patients are female. 35 percent are PHL and telogen effluvium, 30 percent are alopecia areata, and 35 percent are cicatricial alopecias.

In this summary, we will provide an overview of hair loss in women with a focus on Female Pattern Hair Loss.

Hair Loss in Women

It’s important to know that at least one third of women experience hair loss and the effect of hair loss on patients’ emotions is often greatly underestimated by physicians. As a clinician, it is imperative that you spend a good amount of time talking to your patients about their hair loss and trying to assess an approximate duration of time since their hair loss began. Of note, the youngest cases of MPHL and FPHL that Dr Shapiro has seen is age eight and it happens suddenly versus gradually.  Another important step in evaluating hair loss is to assess the pattern. We should all be familiar with the Ludwig classification of Female Pattern Hairloss ranging from classes I to III. Also of importance is to address whether the hair loss is thinning or shedding. The key question for shedding is to ask “is there hair on your pillow” and “is there hair in your food.” You need to lose 50 percent of scalp hair to notice any change clinically. The next step in the evaluation is to determine whether the hair is falling out from the roots or whether it is breaking. Hair loss from the roots can be associated with AGA, telogen effluvium, or alopecia areata; hair breaking with tinea capitis, cosmetics/trichotillomania, or hair shaft abnormalities A thorough evaluation also includes taking a good family history and assessing hair care practices.

When talking to your female patients, you need to address any systemic illnesses, recent childbirth, recent surgery and any psychosocial stressors. Psychosocial stressors such as bereavement, break-up/divorce, and bankruptcy can initiate a telogen effluvium. New medications can initiate hair loss within one to three months. (Some of these medications include acetretin, heparin, interferon alfa, isotretinoin, and many more.)

Factors that might indicate an androgen excess and thus can contribute to hair loss include seborrheic dermatitis, acne, hirsutism,  and irregular menstrual cycles. Other important questions include signs of hypo or hyperthyroidism, heavy menstruation, and a vegetarian diet.

Five Stages of the Clinical Evaluation

  1. Distribution of hair loss
  2. Inflammation, scale and erythema
  3. Scarring vs. non-scarring
  4. Quality of hair shaft
  5. Pull test

There are several new diagnostic tools available for the scalp and these include dermascopy (10-fold magnification), videodermascopy (50-100-fold magnication), and folliscope which magnifies the scalp 50-100 times.

Alopecia in women can be categorized as Female Pattern Hair Loss, alopecia areata, and cicatricial alopecia: lichen planopilaris. In patients with Female Pattern Hair Loss, this is a crucial time to utilize the Ludwig Classification for FPHL.

Female Pattern Hair Loss

When assessing women with Female Pattern Hair Loss, it is important to test for any signs or symptoms of androgen excess. If there are no signs or symptoms, you can determine the class of hair loss based on the Ludwig stage. If there are signs or symptoms of androgen excess, an endocrine work-up should be performed. You may want to consider referral to either an endocrinologist or a gynecologist. From there, you can assess the Ludwig stage.

Ludwig stages I or II can be treated with topical minoxidil solution for one year. If there is no improvement, you may want to add:

  1. Antiandrogen therapy + OCA (if childbearing age)
  2. Hair transplation if donor area dense
  3. Hair prosthesis
  4. Hair cosmetics

If the patient has Ludwig stage III, a hair piece could be considered.

In conclusion, it is important to remember that patient education is crucial. There are websites available such as, and





Tightening Tissue and Zap the Fat

Mathew M. Avram, MD, JD

Dr. Avram provides his clinical pearls regarding the use of lasers in tissue tightening….

The Good News, The Bad News, and Overall Conclusions….

  1. Each of the available technologies can achieve some degree of tissue tightening.
  2. They are the best alternative to surgery.
  3. They are getting better.
  4. For the most part, they are safe in skilled hands.
  5. The benefits, if any, require months to be seen.
  6. Too often, no improvement is seen clinically.
  7. It is difficult to predict who will benefit and who will not.
  8. Tissue tightening can non-invasively provide improvement of skin laxity in a safe manner.
  9. Remember that the results are unpredictable.
  10. The technologies do not approach results of a face lift.
  11. It is very important to educate patients as to the limits of these devices prior to treatment.

Laser Treatment of Pigmented Lesions

Mitchel P. Goldman, MD

Dr. Goldman provides us with some key takeaway points regarding the laser treatment of pigmented lesions…

  1. Nevus of Ota respond to Q-switched laser—we’ve never seen a report of it becoming melanoma; Picosecond is efficacious as well perhaps with fewer treatments.
  2. There are various approaches to treating lentigines—multiple treatments with lasers combined with bleaching agents, sun screen and sun avoidance In addition, resurfacing and chemical peels may also be effective.
  3. Both congenital nevi and aquired nevi can go away with laser treatment; acquired nevi may be easier to remove (sometimes only 1 treatment is needed); Picosecond also shows benefit with perhaps fever treatments.
  4. Melasma—this is one of the most difficult conditions to treat; it typically has a peak in ages 40-50 and is more around the central face. The most important part of treatment is protection from both sun and other light. Laser and IPL treatment is best when combined with skin bleaching agents. We have found Lytera™ to work best.
  5. Infraorbital Pigmentation-Q-Switch Ruby Laser can help with this; PDL and non-ablative and ablative fractionated and confluent resurfacing is also helpful.
  6. What about lentigo maligna? Q-Switch Alexandrite Laser + zyclara may be an appropriate procedure; however, long-term results are unknown; this is also an alternative approach to patients who do not want to undergo surgery.


BeautiPHIcation-Clinical Pearls

B. Kent Remington, MD

Dr Remington, a leading expert in aesthetics, provides us with clinical pearls with regards to the aesthetic consult…

  1. The patient consult is extremely important-spend ample focused time with your patients and find out the “real” reason that the patient wants to look more youthful, not the “stated” reason.
  2. Remember that patients come to physicians for direction.
  3. Pay special attention to details—as dermatologists we are image enhancers and we do all of the creative work—this full face enhancement project is what changes the patients personal self concept and self esteem.
  4. Remember to see in “double vision”—the first vision is to see what the face needs and demonstrate these needs to your patient, so they can visualize it as well ; the second vision is to able to see the end result before you start.
  5. Look for the patient’s best feature and point these out to the patient as they often already know what it is or used, combine this observation with a positive sincere compliment  and enhance that feature by performing subtle changes to the face.
  6. Remember that we never really finish a face, maintenance therapy is required.
  7. Educate your patients about the importance of maintenance therapy, most patients intuitively know that they already maintain their house, car, teeth their hair and the face is no different.
  8. Insist on baseline photos of your patients—this allows you to share before and after photos with your patients; therefore, showing them the positive changes.
  9. Have your patients bring an older good resolution  photos of themselves front relaxed view usually in their early 20’s—be sure that the photo is in high resolution. The patient needs to understand we are not trying to make them look like this 25 year old photo ,but it is to look at past symmetry, harmony and balance of the face and compare where they  are now.
  10. Have a careful planned approach with each patient—each patient has a different recipe for a successful outcome.
  11. When taking baseline photos of your patients, take more than just a frontal view—3/4 and profile views are extremely important.
  12. Patient perception and reality needs to be managed closely.