News and views from Music City SCALE



Music City SCALE (Symposium for Cosmetic Advances & Laser Education), the premier medical dermatology and cosmetic/aesthetic meeting in the United States, is primed to showcase its 14th annual meeting in Nashville, TN from May 9-11, 2019. The meeting started as a concept to promote aesthetic and cosmetic safety to everyone. Since then it has grown in size and scope. Music City SCALE brings to Nashville the best of the best in faculty and live demonstrations. SCALE keeps with its core mission to teach and mentor those in dermatology, cosmetic and aesthetic medicine, and related specialties.

Drs. Brian Biesman and Michael Gold have built on years of academic and clinical experience to bring together those in these spaces who understand that SCALE is more than just another meeting. It is an event that is not like others, where they strive towards excellence in everything that they do. Everyone in attendance will leave with new tips and pearls to take back to their practices, which will lead to better clinical outcomes for their patients—both medical and cosmetic.

SCALE has grown in size and stature over the past 14 years, from 50 attendees and 10 vendors at the first meeting to its current size. The meeting now requires as large a venue as Music City Center, Nashville’s amazing new convention center. There will be over 125 vendors at this event, making it one of the most impressive exhibit halls that there is in the myriad of meetings that are out there.

Let’s not forget that the meeting is in Nashville—the “it” city in the United States for the past several years. The growth and energy seen in Nashville is certainly another reason why you would want to come and experience Music City. From the amazing music to the incredible new restaurants that are being established here, Nashville has the best of the best.

SCALE INSIGHTS: Devices and Combinations

San Diego dermatologist Sabrina Fabi, MD presented on advancements in aesthetic devices at SCALE 2018. She says that the audience expressed significant interest in the growing application of device-based interventions off the face. “Off the face treatments with a combination of different lasers and devices to address skin laxity and cellulite were popular last year as this is a part of the market that continues to grow,” she says.

Also growing is market interest in thread lifts, as a new generation of devices has emerged that is differentiated from products of the past. “The live demonstration on Silhouette Soft Instalift Threads was great, and I know this procedure has grown in my practice,” Dr. Fabi remarks. She says the treatment is of particular interest, “for the patient trying to avoid using a lot of injectables to lift the corners of the mouth and jowls.”

SCALE presenters often use the podium time to preview what’s ahead in a particular area. Dr. Fabi says that last year, “We previewed the use of dilute Radiesse to tighten the skin of both the face and body.” Since then, she notes, consensus guidelines on the use of dilute Radiesse were published in Dermatologic Surgery (November 2018).



Acne is a near ubiquitous condition, affecting patients across a spectrum of ages. Advancements in the field continue to develop, and Julie C. Harper, MD, of Birmingham, AL, is slated to address hot topics in acne at SCALE 2019.

High on her agenda is to highlight efforts to remove barriers to access to isotretinoin for acne. “Barriers to isotretinoin use are lessening,” Dr. Harper says. “An amicus brief was submitted to the Supreme Court of New Jersey stating that there is not a substantiated association between the use of isotretinoin and the development of inflammatory bowel disease. This was sponsored by the AMA, AAD, AARS and the New Jersey Medical Society and the New Jersey Dermatological Society.”

There is also additional data on isotretinoin and depression that may help squash long-simmering controversy. “We have a meta-analysis of studies looking at depression associated with isotretinoin and when the data is compiled, it appears that the net effect of the drug in the population is improvement in depression,” Dr. Harper notes.

“We also have a publication now that says we don’t need to delay superficial chemical peels, nonablative lasers, and cutaneous surgery in individuals treated with isotretinoin,” Dr. Harper adds. “We are checking labs at a reduced frequency as well. This is the drug that gets a portion of people to a cure. We should be using this drug more frequently and getting to it faster.”

In terms of lingering research questions, Dr. Harper says that the role of P. acnes is “still intriguing.” Data now suggests all P. acnes bacteria are not created equal. “It appears that there are ‘good’ P. acnes and ‘bad’ P. acnes. P. acnes also exists within the context of the cutaneous microbiome.” These discoveries could have therapeutic implications. Dr. Harper highlights lingering questions: “Do we need to be killing all P. acnes? Are there ways to shift the phylotypes back toward ‘good’ P. acnes? Do we need to be concerned about maintaining microbial diversity on the skin surface to best treat acne?”

Looking to the future, Dr. Harper anticipates the possible approval of a topical sebum inhibitor in the antiandrogen clascoterone (Winlevi, Cassiopea).

SCALE INSIGHTS: Acne Management

During her lecture on acne and current concepts in management, Linda Stein Gold, MD, addressed shifting understanding about the problem of acne scarring. “Acne scarring occurs with nodulocystic acne but also with superficial lesions like papules,” she says. The evidence shows that early treatment is beneficial. “The earlier we treat, the less likely we will see scarring occur. One study showed that the fixed combination adapalene 0.3%/BP 2.5% when used over six months not only prevented new scars from occurring but also diminished existing scars.”

Dr. Stein Gold addressed the myths and realities of therapeutic sebum modulation. While clinicians would welcome a treatment to decrease sebum, no effective topical options exist, despite what patients may read on the Internet. “We have not been able to decrease sebum production with topical medication to date,” Dr. Stein Gold says. “There is misinformation on the Internet that appropriate moisturizers may do this. They do not.” Topical retinoids do not decrease sebum production, Dr. Stein Gold points out. “We have a new topical anti-androgen on the horizon which may accomplish this goal.”

The problem of antibiotic resistance persists, and it is important that dermatologists prescribe responsibly. Speaking at SCALE 2018, Dr. Stein Gold shared pearls for proper prescribing with short course oral antibiotics. “Combination therapy with potent topical medication and oral antibiotics are effective in getting acne under control, but for many patients it is possible to stop the antibiotics after four to five months and just continue on the topical medication and maintain control,” she emphasizes.


What is attractiveness? It’s a question with no clear answer but with obvious implications for core aesthetic physicians. Speaking at SCALE 2018, Chicago facial plastic surgeon Steven Dayan, MD, presented on his “Special Theory of Relativity in Aesthetics.”

“In my theory I define what is natural and attractive using a theoretical model based on relativity,” Dr. Dayan explains. “For those in clinical practice, the greatest barrier to converting a patient into undergoing a procedure is helping them to overcome the fear of looking unnatural. Yet, as a specialty we have neglected to define what looking natural is. I attempted to cross this chasm with my presentation and paper.”

Dr. Dayan says he felt that his theory was well received. “I went on to publish the theory in The Journal of Cosmetic Dermatology, where Michael Gold, MD is the Editor-in-Chief. So SCALE is a great meeting to release new ideas and then if it meets the criteria of good evidence it may lead to publication in a Pubmed indexed journal.”

Noting that, “I love to teach and share ideas that tackle the bigger picture,” Dr. Dayan says that he enjoys lectures that explore the “why” of practice. “While there are plenty of lectures and courses on how to do a better injection, there is often less discussion about why we put a product in a certain place. And it is my impression that if we better understand why we fill a lip or elevate a corner of the mouth or widen the palpebral fissure, then we can better address our patients’ needs and concerns. Our treatment effects are rooted in the biology and psychology of human behavior and that is the type of topic I prefer to present on.”

As a researcher with more than 75 major studies, including phase 3 trials, and more than 120 published scientific articles, Dr. Dayan also likes to share new research findings with others. “Last year I spoke on PRP and nutraceutical supplements for hair growth. It was a great opportunity to share not only my research findings but also my clinical experiences as well as how to make it work successfully in my practice.”

Dr. Dayan also enjoys making predictions about clinical trends. “I usually put forth a nugget or two that I think will happen in the coming year… and certainly my thoughts on newer toxins coming to market has proven true. I feel that my insights into the excitement around PRP would continue to expand,” he says. “Also discussions around the corporatization of medicine touches a sensitive nerve and continues to be front and center in many practitioners’ minds. This, too, can be expected to continue on as a hot topic.”


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About Practical Dermatology

Practical Dermatology is the monthly publication that provides coverage of medical care, cosmetic advancements, and practice management for clinicians in the field. With straight-forward, how-to advice from experts in various fields, we strive to enhance quality of care and improve the daily operation of dermatology practices.