Maybe more really is better

Combining the treatments, however, often yields better results. Most physicians learn this through practice. But that's not enough, according to Vic A. Narurkar M.D., president and founder of the Bay Area Laser Institute in San Francisco.

"We really need to systematically study combination therapies," Dr. Narurkar tells Dermatology Times.

Two - or more - better than one

"Most of the current literature on non-invasive facial rejuvenation involves monotherapy," Dr. Narurkar says.

But anecdotal evidence suggests that combinations of therapies can be much more effective. What's more, no single therapy has proven as effective as initially claimed.

Part of the problem is the way research is conducted. Companies tend to sponsor research on their device only. Consequently, results are often biased.

"One of the biggest disappointments has been nonablative devices," Dr. Narurkar says.

In practice, they have been more hype. They hardly tighten the skin as promised, he says.

"I'm not against company-sponsored research," Dr. Narurkar insists. "But there should be independent evaluation of data."

Especially problematic is company marketing. There may be a paper that shows a nonablative device reduces wrinkles by 80 percent, but few patients will respond that well, Dr. Narurkar says. What's more, he says, the paper may not have mentioned that patients also had some botulinum toxin and filler treatment prior to laser therapy, because the company wants to promote its laser.

Instead, treatment combinations should be more systematically studied.

"We do know that there are synergies between different modalities," Dr. Narurkar says.

Combining botulinum toxin with filler in a deep groove, for example, will often give a better result (than either alone). Botulinum toxin will arrest the static lines and the filler will plump out the groove. Evidence also suggests that pulsed light can enhance botulinum toxin and that pretreating the face with certain creams can improve the effects of a photofacial. Some dermatologists have also noticed that a series of photofacials followed by fillers can extend the longevity of the fillers - perhaps because photofacials stimulate the patient's own collagen production.

Research for solid evidence

None of these effects, however, Dr. Narurkar says, have yet been proven scientifically, and he sees a need for such scrutiny.

To that end, Dr. Narurkar has launched his own research. A study by Jean Carruthers, M.D., and Alastair Carruthers, M.D., showed that botulinum toxin and pulsed light work synergistically (Int Ophthalmol Clin. 2005;45(3):143-51). Dr. Narurkar teamed with the study authors and other colleagues to produce an additional study to support this find.

Recently, Dr. Narurkar embarked on a retrospective study to assess multiple devices with and without botulinum toxin and fillers. Combination therapy emerged as the clear winner. He presented initial findings at the European Academy of Dermatology and Venereology in Barcelona, Spain.

Encouraging continued research

Dr. Narurkar hopes that in the future, more prospective studies will be performed to clearly define how each therapy - device, botulinum toxin or filler - contributes to overall facial rejuvenation.

"In order to address all the components of the aging face, dermatologists should really evaluate more than one technology," he says, "because all a patient really wants is to look better."