Combination Therapies During COVID-19

The idea of combining treatments for optimal cosmetic results isn’t a new concept. But could combination therapies offer additional benefits during COVID-19? Joel L. Cohen, M.D., a Board-Certified and Fellowship-trained dermatologist in Denver, Colo., says, yes.

With many patients working from home during the pandemic, Dr. Cohen has observed that increasing numbers are open to combining treatments that may require additional downtime.

Since his practice was closed for seven weeks as a result of stay-at-home orders during early stages of the pandemic, Dr. Cohen says that the patients who would come in routinely for maintenance treatments are now asking for more targeted procedures to get them back on track.

These are a few of the combination treatments Dr. Cohen says have become commonplace during the pandemic.

Luminosity, Texture and Pigment

Thulium laser (ex: LaseMD ultra or Moxi) + Q-switch laser or BBL

“Somebody might say, ‘Well, I really like the thulium 1927 nm laser that I'm doing for maintenance, but I have a little bit more downtime available and I have some isolated brown spots that we've treated before with a q-switch laser or BBL.’ It can take four or five days for the coffee grounds to clear with the addition of the treatment of isolated lentigines,” Dr. Cohen says.

Skin Tone and Texture

Halo: General + targeted

While Dr. Cohen says that historically he’s used the Halo hybrid fractional laser on many of his patients at the end of a work week to limit downtime to essentially the weekend (or a long weekend), more patients are now requesting he target specific areas more aggressively, which extends downtime.

Patients may say, “I've got these skin tags on my upper eyelids and I've got these sebaceous glands on my nose and my cheeks. I know my Halo usually is about four days to heal, but if this other stuff can be done and it's a [full] week that's fine because I'm home and I think this is a good time to do it because I have the downtime,” says Dr. Cohen.

Poikiloderma of Civatte (Neck discoloration) and Laxity

Pulse dye laser + nonablative fractional + RF

Another successful combination treatment is for neck discoloration and skin laxity in the same session.

“I'll do pulsed dye laser, some non-ablative fractional, and then I'll have them cool their skin for a little bit. Then, bipolar fractional radiofrequency, like Genius RF, for laxity at the same visit,” Dr. Cohen says. “[Patients are] limiting the number of times they go out, so we're addressing color as well as laxity on the same visit.”

Melasma

Chemical peel + injectables

While he would typically stay away from combining injectables with another treatment on the same day, Dr. Cohen says there are some he is comfortable performing.

“I don't do botulinum toxin, and then have a patient do a laser procedure that involves a rolling type of handpiece over that specific area… because that could potentially spread the neuromodulator to an adjacent yet unintended muscle,” he says.

However, noting the increase of patients coming into the practice with melasma (or acne flares), instead of using a laser that comes in contact with the skin and rolls on the skin or may cause significant swelling, he is doing same-day treatments of specific non-injected areas with a chemical peel, especially for melasma with Jessner’s solution (or salicylic acid peels for acne).

“Patients have often been indoors for two months, and now they're going out to do some limited things,” he says. “When they do go out, they're often so happy to go outside… that they sometimes forget their routine…and often are not putting on sunscreen and not wearing a hat, even though they may remember to wear their mask. Many of these people are bumping into a friend or a neighbor in a parking lot or on their street, and unexpectedly standing in the sun for several minutes or longer. So, I'm seeing horrible melasma on the forehead, where I'm not seeing it as much on the upper lip, nose or cheeks. I have actually done much more add-on spot treatments with a chemical peel at the same appointment as botulinum toxin …and I feel pretty good about doing that in the circumstances when there's no adjacent muscle that I'm really worried about in the event that they have some swelling from the chemical peel. I try to do the peel first, in general, as there is a bit of light rubbing on the skin in the preparation as well as application of the peel, but again I’m not generally doing this in the area(s) where they are going to get their injections.”