Field Notes from the American Academy of Dermatology March 27-31, Denver, Colorado, USA

Approximately 20,100 dermatologists and others associated with dermatology attended the annual meeting of the AAD March 27-31 in Denver, Colorado, USA.

The phrase “Talk of the Town,” referring to a person, event or topic that just about everyone is talking about, often with interest may well apply at the annual meeting. The topic being glucagon-like peptide-1 (GLP 1). This is a hormone that the body naturally makes in the gut. It is involved in regulating blood sugar levels by stimulating the pancreas to release more insulin and reducing glucagon secretion, controlling blood sugar and regulating appetite. Originally developed to treat type 2 diabetes, GLP 1 injections are currently widely used to treat weight management. GLP 1 regulates appetite by slowing down how quickly food leaves the stomach, reducing the desire to eat large portions of food. People taking GLP 1 prescription(s) have benefited from a lower risk of serious heart problems including heat attack, stroke, slowing down kidney disease progression, improve fatty liver disease, reduced joint pain and improve conditions associated with sleep apnea. However, these benefits do come with risks and negative long-term use effects that involve skin, including loss of facial fat and volume leading to sagging skin, wrinkles, thinner lips, more visible facial lines and muscle loss. For these reasons, GLP 1 was a hot topic of discussion this year at the AAD meeting.

Historically dermatologists did not receive comprehensive training in nutrition and its impact on skin health. The popularity of GLP 1 treatments and current consumer trend of wellness/clean cosmetics seems to be promoting dermatologists increasing interest in nutritional interventions for skin and hair care, as indicated by the large attendance in the Hot Topics symposium.

Hot topics

‘Hot Topics’ is a popular symposium consistently requested by registrant consensus covering a variety of topics reflecting AAD member concerns and interests.

During the Hot Topics symposium Anthony Fernandez, MD, Cleveland, Ohio presented “Biologics and Psoriasis: The Beat Goes On.” Dr. Fernandez reported on a study where an obese patient with psoriasis was treated with GLP 1 resulting in a noticeable improvement in the condition. He described GLP-1 as a 30 amino acid peptide that acts as a hormone responding to food ingestion improving caloric impulse control resulting in an anti-inflammatory response. It impacts the brain increasing the sense of satiety for appetite control. The stomach and pancreas increase insulin production, reducing glucagon production (1). However long-term use has resulted in hair loss in studies impacting 92.5% of women and 75.6 % of men in a recent study.

Zoe Draelos, MD, Dermatology Consulting Services, High Point, North Carolina presented “Cosmeceuticals: Naturally Absurd.” Dr. Draelos presented emerging innovative ingredients used in cosmetic products. Exosomes are found in urine, saliva, blood and cerebrospinal fluid. The size being 30-150 nm in diameter. They were discovered 30 years ago and thought to function solely as a method of cellular waste disposal. More recently they are shown to be a method of intercellular communication allowing transfer of molecules between cells. Exosomes contain an outer lipid bilayer with an interior that may contain proteins, lipids, DNA, microRNA and messenger RNA. They have the potential to signal biological functions, provide therapeutic benefits, pharmacological effects and serve as a biomarker for disease diagnosis. In dermatology exosomes are being evaluated for drug delivery, mRNA transfer promoting protein production in wound healing and scarring, and reversing aging by providing new genetic material. Studies indicate that keratinocyte derived exosomes can modulate melanin synthesis, umbilical derived exosomes can increase fibroblast collagen 1, fibronectin, and elastin gene expression. Dermal papilla derived exosomes can regulate hair follicle growth and stimulate outer root sheath proliferation. Dr. Draelos noted that topical exosomes can be challenging to formulate and deliver to the target treatment location, must be adequately preserved and may not be compatible with various emulsifiers. Currently most studies have been in vitro and animal models, double blind placebo controlled human studies are needed for validation of the claimed benefits. Dr. Draelos went on to discuss clock gene cosmeceuticals, based on circadian rhythms. Circadian rhythms are the body’s endogenous 24-hour physiologic metabolic and behavioral rhythm. All of the body organs including skin are subject to cycles based on a biological clock. Skin care products are being designed to complement these rhythms according to Dr. Draelos. There is a small, paired structure in the hypothalamus of the brain that functions as the body’s master circadian pacemaker, regulating daily cycles of behavior and physiology. It receives light from the retina and synchronizes the body’s internal clock to the external light-dark environment. The clock is controlled by hormones, melatonin, cortisol and cytokines. Circadian rhythms are important in skin with clocks in keratinocytes, fibroblasts, melanocytes, mast cells and hair follicles. Skin functions affected by circadian rhythms include free radical production and neutralization, DNA damage and repair, keratinocyte and fibroblast differentiation /proliferation and barrier and immune functioning. Circadian clock dysregulation can lead to skin damage from UVR and premature aging (2, 3). Another cosmeceutical topic presented by Dr. Draelos was prebiotic skin care. The concept being that probiotics include the addition of actives or nutrients that promote beneficial bacteria while inhibiting harmful organisms on the skin’s surface. Most probiotic skin care products are based on sugars or plant oils. Topical bacterial skin probiotics include lactobacillis and bifidobacterium. True probiotic skin care products must be refrigerated because preservatives used in most skin care products will kill the probiotic organisms. Dairy propionic bacteria are frequently used in skin care due to their safety profile. It is important that probiotic bacteria adhere to skin, is resistant toward potential pathogens and produces antimicrobial substances. Beyond probiotics, postbiotic skin care products are non-viable bacterial products or metabolic by-products from probiotic bacteria. They are produced during the fermentation process of probiotic bacteria. Examples include enzymes, peptides, peptidoglycan-derived muropeptides, polysaccharides, cell surface proteins and organic acids. Many skin care products contain postbiotic substances, including lactic acid and glycerol. Dr. Draelos’ concluding remark regarding cosmeceuticals is that understanding the science behind cosmeceuticals can assist in mastering the facts and making the category seem less absurd.

Dr. Jules Lipoff, Philadelphia, Pennsylvania presented Artificial Intelligence (AI) in dermatology. Dr. Lipoff noted that AI first appeared in dermatology with a paper published in Nature reporting a 2017 study that AI successfully achieved dermatologist-level accuracy in a melanoma classification. A variety of AI technologies are currently being used in dermatology. ChatGPT is used for patient education and documentation, Natural Language Processing (NLP), a system that uses clinical notes and other data to optimize treatment plans, analyze medical literature to help diagnose skin conditions and provide treatment suggestions are currently in common use. Convolutional Neural Networks (CNN), an image-based system to support diagnosis of skin condition by evaluating changes in edges and shapes of skin images over time. Robotic process automation that automatically fills in forms, extracts data from file. It mimics how people would use a computer to complete tasks. CNN AI has an 80% reliability in malignant vs. benign classification for melanoma detection and shown a 10% higher accuracy than manual microscopy in diagnosing onychomycosis. AI has shown variable results in skin tone representation; it is less accurate for darker skin tones. Dr. Lipoff mentioned a study report that found one AI study accuracy was 17% accurate for darker skin diagnosis compared to 70% accuracy for Caucasian skin types. Another concern is potential for data breach of sensitive patient health information.

Dr. Neal Bhatia, San Diego, California presented “Drug Abuse Old and New,” elaborated on the abuse of GLP 1 agonists. He mentioned that while GLP 1 agonists suppress key inflammatory pathways involving TNF-α, IL-17, and NF-κβ, there is a risk for misuse in weight-sensitive people including adolescents and adults in sports or people with eating disorders to trigger extreme weight loss. People with eating disorders may develop severe gastrointestinal distress and pancreatitis. Unapproved FDA sources, counterfeit products and incorrect dosing are also of concern. Dr. Bhatia mentioned a study with 416, 503 volunteers, after receiving GLP 1 treatment, 132 people developed body dysmorphic disorder, being dissatisfied with their appearance after significant weight loss. He noted that the term “The Cycle of Ozempic Face” describes rapid weight loss from use GLP 1 agonist(s) leading to formation of fat pads in the cheeks, temples and under-eye areas of the face. The reduction of fat makes the face look gaunt, hollow or “older”. When fat disappears quickly, the skin often does not have time to tighten, resulting in skin sagging, jowls, and deeper wrinkles. In this case cosmetic intervention is needed to correct skin that appears old and tired.

Science of Cosmeceuticals and Nutritionals

Another very well attended session was entitled “Science of Cosmeceuticals and Nutraceuticals” directed by Dr. Draelos. This session investigated the science surrounding topicals and oral supplements for enhancing appearance and improving health span. The aim of the session was to assist in assessing the current state of cosmeceutical and nutraceutical science.

Dr. Draelos presented “Cosmeceuticals in the Digital Age,” noting that digital cameras possess poorer resolution than a film camera. Edge enhancement is used in all phone cameras to increase image sharpness, but what is seen in the phone camera(s) is not what one sees in a mirror. The phone identifies sharp boundaries and increases contrast but also magnifies fine lines and wrinkles. Imaging errors have created the consumer need for personal image processing with various apps. An example is Facetune developed in 2013 and downloaded 200 million times as of 2023. Digital apps can remove acne lesions, smooth skin, apply cosmetics, whiten teeth, change hair style and color, modify facial architecture. AI machine learning is used to analyze facial features and provide personalized image enhancement recommendations. Side effects of image manipulation include body dysmorphia, dissatisfaction with one’s actual appearance, erosion of self-esteem, social anxiety and isolation, unrealistic beauty standards that are impossible to attain. The growing popularity of virtual cosmetics and cosmeceuticals is promoting the elimination of the cosmetic counter attendant.

Dr. Cheri Frey, Washington, DC, Director of Cosmetic Dermatology, Department of Dermatology, Howard University, presented on the topic “Cosmeceutical Fads and Facts 2026.” Dr. Frey discussed the influence and clinical implications of social media with respect to misinformation, product misuse, self-treatment and instructing the patient to understand and apply evidence-based strategies toward appropriate skincare. She mentioned that social media has surpassed the physician as the first stop for skincare and many patients initiate multi-step regimen before ever consulting a dermatologist, complicating diagnosis and treatment. A 2023 publication in JAMA by Rajagopal et al., reported that patients who sourced skincare information from social media were significantly more likely to present with product-induced dermatitis and less adherent to prescribed regimens. Dr. Frey went on to discuss the popularity of Korean skincare, a distinct philosophy. Korean skincare focuses on skin barrier-centric care, strengthening natural skin defense, gentle actives in mild formulations to reduce irritation, multi-step layering sequential application to promote product synergy. She noted that social media has popularized snail mucin as a potent moisturizer and skin reparative agent. However, there are reports of allergic sensitization to snail mucin caused by protein components hypothesized to be cross-reacting with people sensitive to shellfish and dust mites. Another ingredient promoted on social media is beta-glucan, a polysaccharide derived from oats, yeast, and fungi. It is reported to have immunomodulatory and skin barrier-active properties. Biological activity appears to be mediated by acting on the Dectin-1 receptor in skin activating innate immune and barrier repair pathways in keratinocytes and dermal fibroblasts. The net result being immune modulation reducing inflammation, fibroblast stimulation supporting dermal architecture and skin barrier support associated with low epidermal water loss and reduced barrier permeability. Aquaxyl™ ( INCI: Xylitylglucoside-Anhydroxylitol-Xylitol) a patented natural technology derived from a sugar-based process is another ingredient designed to moisturize and improve the skin barrier. In limited studies 1.5% Aquaxyl™ was shown to be statistically more effective moisturizing skin when formulated with 3% glycerin compared to the same base with just 3% glycerin in a 28-day study when 25 volunteers had their skin measured with corneometry and transepidermal water loss (TEWL). Dr. Frey mentioned that when people use the Korean skin care regimen of over layering, and multiple actives are applied simultaneously, studies have shown there is an increased potential for sustained skin barrier irritation and increased TEWL, resulting in secondary complications that include post inflammatory hyperpigmentation and a potential misdiagnosis. Dr. Frey discussed skin cycling, this involves rotating active ingredients used during the day with recovery nights to maximize product efficacy and minimize irritation. The regimen aims to strategically introduce potent ingredients including retinoids while providing ample time for the skin barrier to recover. Another topic presented was the “tween” skincare craze. Adolescents as young as 8-10 years old are increasingly adopting complex skin care routines. An immature skin barrier is more susceptible to irritation and sensitization; antiaging ingredients being used in some cases are inappropriate for pediatric use. The driver for this craze is social media and is increasing the risk of irritant contact dermatitis, barrier disruption and sensitization in adolescent skin that tends to be more reactive than adult skin.

Dr. Heather Woolery-Lloyd, Director, Skin of Color Division, University of Miami Miller School of Medicine, Miami, Florida, presented “Late Breaking Skin of Color Cosmeceutical Concepts,” discussing the mechanism of malassezin, a yeast metabolite of Malassezia furfur acting as a natural indole metabolite shown to induce selective apoptosis in hyperactive melanocytes without damaging skin cells. It also acts as an aryl hydrocarbon receptor (AhR) agonist and activaton of the AhR pathway leading to decrease of tyrosinase, tyrosinase-related protein (TYR-1) and dopachrome tautomerase (DCT/TRP-2). Dr. Woolery-Lloyd described a 12-week study with 20 adult women evaluating a cream with 0.75% malassezin applied to one side of the face and the other side treated with 4% hydroquinone found a significant reduction of melasma with no statistical difference between sides (4, 5). She went on to note that Niosome Technolgy is currently experiencing a resurgence in popularity due to advancements in nanotechnology and the demand for higher performance, targeted skincare. Niosomes are thought to be next generation liposomes having advantages including improved chemical stability, cost-effective, acts as a penetration enhancer as it penetrates the lipid bilayer for deeper epidermal/dermal delivery and encapsulates both hydrophilic and lipophilic actives in bilayer format. Dr. Woolery-Lloyd reviewed recent publications regarding the effect of visible light on melasma, a disorder of hyperpigmentation. The study showed that visible light alone can stimulate immediate pigment darkening and worsen melasma spots after a single dose of visible light equivalent to 1 hour of sun exposure. Another study by Dumbuya et.al. evaluated tinted sunscreens protecting against visible light-induced photodamage and melasma relapses. Using transmittance spectroscopy to measure blocking of high energy visible light (400-500 nm) before and after irradiation with 200 J/cm² of filtered blue light.

The study authors concluded that high energy visible light absorbance and blocking potential correlated with iron oxide levels. Non-tinted sunscreens demonstrated limited protection beyond UV spectrum with the lowest high energy visible light blocking potential. Mineral tinted sunscreens including iron oxides, titanium and zinc oxides provide superior performance blocking high energy visible light absorbance and blocking potential compared to darker-tinted chemical (organic) sunscreens or tinted hybrid chemical plus mineral sunscreens. The combination of iron oxides with both zinc oxide and titanium dioxide performed the best (6, 7).

Dr. Saranya Wyles, Mayo Clinic Department of Dermatology, Mayo Clinic Center for Aesthetic Medicine and Surgery, Presented “Exosomes: Reality or Fiction?” Dr. Wyles started her presentation describing an emerging trend “Regenerative Medicine” a branch of medicine that uses innate reparative mechanisms to develop new treatments to heal tissues and organs to restore form and function lost to aging, disease, or damage.

Recent advances in translational and nanomedicine have created the ability to develop targeted drug delivery systems at a greater pace.

Regenerative medicine includes surgical approaches, procedures using lasers and energy devices, cell and gene therapies and acellular therapies including drug, biologics, growth factors, peptides, polynucleotides and exosomes (8, 9).

Dr. Wyles noted that exosomes are of interest because it is expected to have a market size of US $1.4 billion by 2028, and is suitable for skin rejuvenation, hair growth, and post-procedural healing. What needs to be established remains safety, how effective and how well-regulated this technology is. Current concerns dermatologists have regarding exosome treatments are false marketing claims including “FDA-registered,” and unregulated products being injected at medical spas. Social media is providing misinformation as celebrities endorse treatments without clinical backing. The FDA position on exosomes is that they are considered biologic drugs requiring an Investigational New Drug (IND) application. A physician typically will submit an application to use an investigational drug to study an unapproved drug or an approved product for a new indication in a new patient population.

Injectable exosomes are not FDA-approved. South Korea and China currently lead in exosome-based cosmetics, and the EU is developing regulations for exosome therapies, the US is testing exosomes in clinical trials. From the perspective of a drug, the FDA is considering injectable applications including customized exosome therapies based on patient need.

Walking the Exhibit Floor

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More than 350 exhibiting companies were showcasing the latest in devices, pharmaceuticals, color cosmetics, skin and hair care products, Journal publications, textbook publishing, and other miscellaneous items. An interesting exhibitor was Korean skincare brand Anua. Anua recently launched a Barrier Reboot^TM line, an example of K Beauty philosophy, the core technology being ML3 Precursors^TM reportedly designed to replicate the skin’s native barrier structure and support its ability to regenerate. The formulations are the result of a collaboration with researchers at Korea Advanced Institute of Science and Technology (KAIST) and a team of dermatologists lead by Dr. Muneeb Shah. The technology consists of a multi-lamellar delivery system encapsulating ceremide, fatty acids, and cholesterol precursors, these are the foundational components the skin uses to rebuild its protective barrier. Dr. Shah codeveloped the launch, he is well known on TikTok with approximately over 17 million followers.

Another interesting exhibitor, Acaderma, a skin care company founded on academic research embracing Holistic Skin Longevity Solutions. The company started with two research scientists studying cellular and molecular mechanisms of longevity and biological resilience, Dr. Shuting HU and Dr. James Simon, professor at Rutgers, The State University of New Jersey. Longevity is multi-dimensional and all the 14 hallmarks of aging need to be addressed rather than single-target approaches. The company research seeks novel bioactive compounds that activate skin’s intrinsic repair and longevity systems, typically natural ingredients that have in vitro and in vivo data accompanied with patents. A cornerstone ingredient she-Haw EX® is a patented bioactive derived from Kinkeliba, a West African plant with high antioxidant activity, shown to sooth and heal a damaged skin barrier. It is positioned as a super-healing ingredient with anti-inflammaging properties. All formulations are evaluated with double-blind clinical trials. Such studies fill a huge gap in the botanical medicinal world where good clinical studies are generally lacking.