JCPM2024.09.17

The following is an edited transcript of the Journal Club with Pearls & Marketing (JCPM) of September 17, 2024, with Charles Runels, MD.  

-> The pdf of the transcript of this live journal club can be seen here <-<

See the video recording here…

Topics Covered

• Acne and Acne Scars: What really works? A Review
• The magic three
• Chemical peels
• Vampire Facial®
• A method for becoming an expert.
• A Study of Traumatic Scars that Has Implications for Every PRP Study
• Saline vs. PRP for treating scars with the Vampire Facial®
• More Proof that Saline is Not a Placebo
• A Marketing Template
• The Two Most Valuable Classes in All of Your Life
• References
• Helpful Links

Charles Runels, MD
Author, researcher, and inventor of the Vampire Facelift®, Orchid Shot® (O-Shot®), Priapus Shot® (P-Shot®), Priapus Toxin®, Vampire Breast Lift®, and Vampire Wing Lift®, & Clitoxin® procedures.

Transcript

Welcome to our Journal Club. I have papers that could help you treat and educate your patients about acne and scars—not just acne scars but traumatic scars. The pictures in this paper are very impressive.^[1] 

Finally, I’ll give you some marketing ideas that could be helpful. These ideas are cheap and have been used successfully by many in our group. Some of them you’ve seen, but maybe it would help to review some basic ideas.

As always, I’m trying to come in under 30 minutes to make this meeting less of a commitment for you. They’re not all open source, but I put three of the four papers in your handout section.

Acne and Acne Scars: What really works? A Review

I think it’s one of those things that the people who need it need severely; it’s an understatement what they say in this paper about acne being both physically and emotionally bothersome.

I suffered from severe cystic acne as a teenager to the point that I had more than one adult during my high school years approach me and ask me what was wrong and what disease I had.

It was so severe they didn’t even recognize it as acne. I remember once looking in the mirror as a teenager and wondering what the shape of my nose was because it was so full of pus.

But the reason I think, in some ways, that was a blessing is later, as a physician, I think I understood my patients better. The ones that hide, the people that are over a hundred pounds overweight, the people who are maybe horrifically scarred, an accident. I call them the invisible population. The people who won’t go to Walmart at 2 p.m. If they go at all, they wait until 2 A.M., and there are thousands of those people.

And, of course, I used that extra time to read a lot and usually had three to five part-time jobs at the same time I was in school. So, some good things came of it. And now I have a special hatred for acne.

So why do I say all that?

I think on our small planet now, where it’s ever-shrinking due to technology, if you’re going to do something, you should determine to be as good as anyone on the planet at doing it or consider not doing it. Acne is one of those things that you can decide at almost any age that you will be good at and pull it off.

For example, at 64, if I determine I will be an excellent thoracic surgeon, it’s not happening. I don’t even have the energy to think about the grueling training that would involve, or going back to my ER days, when I would sleep about every third night because it was fun. But at 64, I think it’s legitimate that I could determine to be very good at treating acne or very good at doing some of the cosmetic work that is done, say cosmetic botulinum toxin or cosmetic fillers. I don’t think you become very good at it overnight, but you could legitimately become world-class within a few months, and it’s needed.

The Magic Three

So, especially because much of what we do involves beauty with our platelet-rich plasma, and now microneedling and our Vampire Facial® is becoming more talked about. I think it’s useful to keep up with the research. And this article I put in your handout section is a very nice review article on acne treatments.^[2] You can see it’s not a long list; many of you are already familiar with it. Both the acne and its acute phase and after someone grows out of it or is healed from it because of your treatments, they’re left with scarring. So, you have those two components of acne.

This article talks mostly about the acute phase.^[3] I won’t go too much into this except to say that there’s a combination that they talk about of combining topical clindamycin or oral antibiotics combined with Retin-A and benzoyl peroxide. That’s sort of their magic three to start with.

And, of course, you have Accutane if you go to that level. That’s one I would not want to be using a lot of, but you could become knowledgeable and skillful at using it if you wish. With all the different therapies we have now, there’s an argument for less need for Accutane, but when it works, it’s life-changing. That’s one I would not want to use a lot, but you could become knowledgeable and skilled with its use very easily.

Chemical Peels

After being around for 20 years, I have become much less aggressive than I was 20 years ago. Back in 2000, when Dr. Obagi first came out with his Obagi Blue peel, he recommended a 10%- 15% TCA solution. His beautiful idea was that you mix it with a blue dye and the frosting that that blue dye helped to more easily interpret the frosting that keeps from burning people, which I never did.

But I met two beautiful women who had been horrifically scarred by a very prominent physician, two of them in my town for whom, well, not where I practice now, but a nearby town and a physician for whom I have great respect. So, I thought if that could happen to him, it could happen to me. So, I quit using the strong TCA solutions, but they talk about it here in this article.

Presently, just so you know, my current choice is very low, which is what I consider to be a safe peel. It’s about a 5% TCA solution. About a year ago, we covered a study where they looked at microneedling with PRP versus microneedling combined with a low percentage TCA peel, trichloroacetic acid peel. The TCA combined with microneedling in that study outperformed microneedling with PRP.

This study references a study about using microneedling in the acute phase, and I’ll pull that up in a moment.^[4] 

But here’s more about perspectives on new acne treatments. And they mentioned microneedling, which we do, and microneedle patches, which I have not used. Maybe some of you have done this, and if you have, I’d love to open the mic so you could tell us about it. Just raise your hand so you can tell us all about it.

If you’ve done one of these patches where you use absorbable needles impregnated with medications, please raise your hand so you can tell us about it. I have never done it, but they mentioned it for scar formation/treatment.

In a moment, I’ll pull up a study that discusses using it for actual acute active acne. Of course, the great thing about it is that you don’t have to worry about the change in pigment for darker skin like you do with laser therapies.

But be sure to tell people to stay out of the sun with the microneedling. One of our providers called me the other day; where she treated a woman of Indian descent with microneedling, and her patient traveled to India soon after the microneedling, was out in the sun a lot, against the advice of our provider, and then was upset that she thought the microneedling did cause a change in pigment.

So, they do have to stay out of the sun after you do the treatment.

But if they are compliant, you can do microneedling with every skin type, which, of course, you can’t so freely do with laser therapies.

I think this article truly is sufficiently thorough that if you decide, I would like to treat active acne, not just scarring, but also bring to my practice those suffering from active acne, which is going to be mostly those in the teenage years to early 20s. But as you know, many of you’re doing hormone replacement for women, and this is a very common side effect of giving testosterone to women, so they get better from the… their sex gets better. They think better, and they lose weight, and they have energy, and then it’s like they’re going through puberty again. So, you can use some topical androgen blockers or the combination they mentioned here.

If you decide to make this a new cash flow for your business, I’ll tell you how to make that happen in the marketing part I’m about to show you at the end of this call.

But if you were going to make this a big part of your practice, I’d recommend this paper and know all the references of this paper, and you would be there.

A Method for Becoming an Expert

When I did research as a chemist years ago, I’m sure you guys have done this, but I was taught that if you really want to be an expert at something, you choose an area of narrow range and read the most recent papers because, if they did their research, their references would be sound and thorough.

So, you read the most recent papers, then read all the references to those most recent papers (then read the references in the references), and then you’re an expert.

So, if you deal with acne that way, that’s a strategy for getting up to speed—to expert status.

So that’s a review article. This was the one they referred to in the last article, where they mentioned microneedling as just a strategy for delivering drugs.^[5] And, of course, in our case, PRP, through the multiple openings you provide in the dermis.

They mentioned acne, alopecia, superficial cancers, scars, psoriasis, and herpes. And I know my brilliant wife frequently does this with her lichen sclerosus patients. So, they get not only end trials and subdermal injections, but in the sclerotic areas especially, they get microneedling and then topical PRP as part of her strategy for treating lichen sclerosis.

So, this goes into those patches, those microneedle patches. See the dissolving microneedles? I haven’t used those, and I’d love to know more about them if anybody’s used them. Raise your hand so you can teach us about it. But then, and it’s beautiful, I love these papers where they illustrate them like the old-school scientific American papers and the modern version of the New England Journal. They make the illustrations beautiful.

Some of you have the new radiofrequency microneedling, and we talk about how that’s helpful for active acne. But I think you can make a strong case for a light microneedling followed by your, of course, PRP is antibacterial, but you could do a very light TCA on top of your microneedling as a treatment in the office.

This one was very helpful; they’re talking about traumatic scars.^[6]

A Study of Traumatic Scars that Has Implications for Every PRP Study

But of course, when the implications of what they say here affect every procedure we do with our PRP… let me explain.

 So they compared subcision with saline and microneedling, and they used a cannula, fan it out, and undermined it with saline and then microneedle on top of it. And then, they did the same thing with platelet-rich plasma, and they looked to see if there was a difference in the two groups.

And then, if you look at how they prepared the platelet-rich plasma, they did it with something that looks homemade. They used six milliliters of blood and one and a half CCs of ACD solution. Then, they did the centrifuges for 15 minutes at 3,600 RPMs.

This would be less desirable if you’re in the U.S., but I do like that it’s done. I’ve lectured in India, and if you go to India, the people are beautiful, and the culture’s amazing. They were doing astronomy; I think before much of the world was able to write, and they wrote the best sex book ever (Kama Sutra). And they’re spiritual, and they’ve got resources, and they have a work ethic.

But the poverty there is just heart-wrenching. If you’ve ever driven all day across India and have seen the degree of poverty. It’s heart-wrenching. So, the idea is that they could have a medication in a place where there’s not a pharmacy on the corner, a medication that the patient could supply. I’m not going to fuss if they don’t use an FDA-approved kit, but I think in the U.S., you’re risking your license if you don’t. FDA approved preparing PRP to go back into the body; no PRP company has paid me to say that.

Anyway, that’s what they did. The conclusion was that both groups improved, which is important to all of our procedures. Both groups improved, but the improvement persisted for the same amount of time. However, group B, which is the PRP, enhanced the results and was the best of the two groups.

More Proof that Saline is Not a Placebo

So, how does that apply to everything we’re doing?

Some of you guys have seen me rant when I see a paper, like the one published on lichen sclerosus. I was not involved in this study and greatly respect the author, but the paper used saline as a placebo, and the placebo had a 50% improvement rate.^[7] There was not a statistical difference between the placebo and the PRP arm, but the placebo was not a placebo.

The first thing to note is that subcision and microneedling with PRP help scars, and it helps more than saline does.^[8] 

And you have seen it, but I’ll show it now. Multiple papers in the dermatology literature talk about saline not being a placebo and even talking about it; you can see you’re using it for nerves, using it for scars, and for some other things like leishmaniasis.^{[9] [10] [11] [12] [13] [14] [15] [16] [17]}

And so that’s not a new idea that undermining and subcising scars with these papers are not recent, but that’s two years ago. But they go back further than that—five years ago.

Saline is not a placebo, but this paper has more implications than just that.

And this is what I think is perhaps the most important implication: If both groups showed benefit, undermining or subcising with saline is an effective treatment, just not as effective as platelet-rich plasma. Therefore, those studies that use saline as the placebo arm for the P-Shot® or the O-Shot® should thought compromised.

Second, even if you’re using platelet-rich plasma, the hydrodissection itself is important, so the physical disruption, undermining, or hydrodissection with the liquid is part of the treatment.

If so, the next conclusion is that it makes a difference where exactly the needle is inserted because it matters what you are hydro-dissecting.

Obviously, if you were not subdermal and you are, say, under the muscle, or you are off over here to the side and not under the scar, or you were intradermal instead of subdermal, all those things might change the way you do or the effectiveness of the procedure. So I think this study not only points out that saline is a treatment but not as effective as PRP, it points out that when we do our procedures, it makes a very big difference where you put the needle because the hydrodissection is part of the treatment.

So, for example, when you do the O Shot® procedure, if you’re treating for urinary incontinence and you are not directly beneath the urethra, or you’re too close to the urethral vesicle junction, or you’re too deep. If you’re in the urethra, then you won’t get the same results. You’re not going to kill anybody. If you goof up doing IV antibiotics in someone who’s hypertensive and septic, well, they die.

Here if your needle is in the wrong place, I guess maybe the skin looks younger, but you don’t treat the scar, and in the O-Shot®, maybe you do a douche with a PRP because you went through one of the rugae or you just missed it and they have no effect at all.

So, nothing bad happens, but it’s extremely important that the procedure be done in the way that we think is most effective until we find a better way. This is part of the purpose of our group: that we have a protocol that has been proven to have a high success rate over the past decade. And until we find and agree on something that works better, we should follow that protocol. That doesn’t mean we don’t add other things to it.

And as you know, many in the group have helped us develop these protocols. So this is partly me being a facilitator and curator and not trying to be the king of PRP but facilitating communication in our group.

A Marketing Template

This will look old school, but it’s a way of thinking about something you’ve looked at a lot that I hope makes it click into place. I can go down and look at my piano. It has keys, and the right person can sing a new song to make you cry. Another one can bang around on it, and nothing happens, and you want to leave the room, but it’s the same piano keys.

Maybe that’s not a good analogy, but let me go through the process and see what I mean by how you think about these keys to marketing.

First, think about the idea: if you’re doing social media, I’m not knocking it. Many of you have made a lot of money at it. Some people in our group have made a lot of money because we have personalities in our group, and Dr. Jackie and Dr. Miami, we’ve got the Beverly Hills RN. We’ve got many people in our group that have a large following.

But if you think about what’s involved with that, you must post social media content proverbially several times a day. And then tomorrow, for sure next week, whatever you’ve produced is old news. It’s way down in someone’s feed, not looked at so much. But when you make a web page, it’s there, but maybe it doesn’t get looked at. But, if you have the name of everybody who’s come to see you and their email address, you can bring them there routinely.

But if you collect everyone’s name and email address and you send them an email and that email takes them to a web page that talks about one problem. So, you have their name, and then let’s say you want to market what we just talked about: microneedling for acne scars.

Then, the page will be about acne scars, not microneedling. So, when they land there, you’re talking about acne scars.

Think of the web page as a literal page in a filing cabinet that would present to a patient what their problem is, what causes it, the ways that you know how to fix it, and the other ways that might be available that perhaps you don’t.

That web page is sitting in your website, which is essentially an electronic filing cabinet.

So, how is that different from, say, a post on social media?

If you think of that page as a presentation of what you know about the disease and how to improve it, then you think of your email that goes out to all your people as a way to bring them there to learn what you are teaching. 

And even if they do that much, that is where most doctors stop.

But then, if you set that email to go out automatically at a certain time, you get a new patient every time. So, you get a new patient tomorrow, Wednesday, and you have it set to go three weeks from the first time they saw you to that patient. And then you have another email that says about microneedling for traumatic scars that goes out four weeks from now.

Now, on Thursday, everybody that comes to see you for the first time gets three weeks from now on a Thursday, that email, and four weeks from now, the one about traumatic scars.

You have this collection of emails that you make going out for every patient, and there are different names for that process, but there’s a way to set that up. So that’s not just one series or stack of emails; it could be a stack for different interests. So you have a woman who’s in for hormone replacement; she gets a series of emails, but she’s also getting another series for cosmetic work because she’s interested in that.

So there can be methodically and strategically placed communications going out automatically, some of which eventually if you practice this in some reasonable way for an hour or so a week, you’ll have a big enough stack, and it becomes your intellectual property. The patients start flowing enough that you have to hire partners, or you start turning away some people, and you’re seeing more of the people you want to take care of or have the problem you want to take care of because your emails are attracting those people to the web page.

And on the web page, you collect the money.

So, in the process, you’re collecting everyone’s name and email address, and then you have a web page that talks about the problem. You will find a video on the web page describing what you will do. The video can be transcribed, and then on that same page, there’s a place to either book an appointment and not pay you if it’s not so expensive or book an appointment and even pay you at the same time they make the appointment.

Then, you stack the email, and you repeat it.

So, (1) make a web page, (2) put a video on it, (3) put, on the page, a link to schedule an appointment or to find out more with a phone call, (4) write an email that takes them to that page that talks about that problem, that mentions your solution somewhere on the page, then (5) stack it to go out automatically,  and then you repeat it for another problem (could be the same procedure).

So, for microneedling, you might have a page about traumatic scars, another for acne, another for anti-aging, smoker’s lines, alopecia, and lichen sclerosis. And for every problem you want to take care of, you have a separate web page for that problem and its associated treatment.

So you get this collection, and without realizing it, that methodical building of that becomes a very valuable, truly an asset, like something that’s worth money to you because it’s bringing in people who want what you know how to do to the point to where you can hire other people to do it for you or do less of it at a higher price because you’re the expert.

That’s the process.

The Two Most Valuable Classes in All of Your Life

Class Number One

The dean of my medical school at the University of Alabama said the most important class he ever took was: What do you think it was?

A typing class.

I don’t know about you, but I’m 64, I learned to type. I did a 3-month class… I think it was three months, I don’t remember, but it was a big portion of a school year where I went for an hour every day and learned typing with a mechanical typewriter.

And then they got the freaking electric typewriters. And now, of course, even that’s primitive.

I agree that was probably the most important class I took. I will not hire anyone who types less the 50 words per minute. Even the man changing your oil filter must type into his computer in the garage.

The Second Most Important Class

Hearing the dean of your medical school say that the most important class he ever took was typing seems counterintuitive, given that he’s the dean of a medical school. But I agree.

Perhaps the next most important class or thing that I learned, if I had to pick one other thing, was my self-education about how to do just what I described: without anyone’s help, being able to make a web page, make a button on the page that makes appointments or takes money, put a video on the web page, and stack emails that take people to that page (which tells them how to find healing).

I do not do fancy coding nor know how to build my own app, but I know how to make a webpage, write an email, stack it, put a video on the webpage, and make a link where people can either pay me or schedule an appointment.

Those things have been so dramatically helpful to me that I would put it right up there with learning to type.

I will periodically do a typing class once a day for a week or so since I got out of medical school to ensure I’m not slow.

And I still to this day study the best software and ways to do just what’s on that list: write an email, stack it, put a video and words on a webpage that explains something, and can collect the money and book an appointment.

You may not want to learn to do that.

I don’t think it’s difficult, but it’s probably as frustrating as learning to type, at least in the beginning. You can probably learn it in six weeks.

I created an online course that teaches those skills and more. Many people in the course got it, but that doesn’t mean they’re not still learning it and doing it because it’s like typing. Once you learn it, you start using it—and when you practice it, you learn how to use it better.

If you follow this process and you’re like me and don’t want to dance, sing, tell jokes, or even try to look pretty on social media, this allows you to do what comes naturally to you, which is to teach people how to be well. And you’ll have all the patients you could ever want to come to see you for the problems you most want to take care of.

Comments

Barbara, so using progesterone for your acne. Electric typewriters were a godsend, weren’t they? Holy smoke, I can’t believe I went through medical school with whiteout and an old Royal manual typewriter. My parents gave me an electric typewriter in my senior year of medical school.

I hope that tonight’s 30 minutes was helpful to you.

Have a good night. Bye-bye.

References

Asghar, Aneela, Zahid Tahir, Aisha Ghias, Usma Iftikhar, and Tahir Jameel Ahmad. “Efficacy and Safety of Intralesional Normal Saline in Atrophic Acne Scars.” Annals of King Edward Medical University 25, no. 2 (June 24, 2019). https://doi.org/10.21649/akemu.v25i2.2867.

Bagherani, Nooshin, and Bruce R Smoller. “Introduction of a Novel Therapeutic Option for Atrophic Acne Scars: Saline Injection Therapy.” Global Dermatology 2, no. 6 (2016). https://doi.org/10.15761/GOD.1000159.

Bokey, E. L., J. P. Keating, and P. Zelas. “HYDRODISSECTION: AN EASY WAY TO DISSECT ANATOMICAL PLANES AND COMPLEX ADHESIONS.” ANZ Journal of Surgery 67, no. 9 (September 1997): 643–44. https://doi.org/10.1111/j.1445-2197.1997.tb04616.x.

Cass, Shane P. “Ultrasound-Guided Nerve Hydrodissection: What Is It? A Review of the Literature” 15, no. 1 (2016): 3.

“Clinical Benefit of Intra-Articular Saline as a Comparator in Clinical Trials of Knee Osteoarthritis Treatments_ A Systematic Review and Meta-Analysis of Randomized Trials | Elsevier Enhanced Reader.” Accessed April 6, 2022. https://doi.org/10.1016/j.semarthrit.2016.04.003.

El-Amawy, Heba Saed, and Sameh Magdy Sarsik. “Saline in Dermatology: A Literature Review.” Journal of Cosmetic Dermatology 20, no. 7 (2021): 2040–51. https://doi.org/10.1111/jocd.13813.

Goldstein, A. T., L. Mitchell, V. Govind, and D. Heller. “A Randomized Double-Blind Placebo-Controlled Trial of Autologous Platelet-Rich Plasma Intradermal Injections for the Treatment of Vulvar Lichen Sclerosus.” J Am Acad Dermatol 80 (2019). https://doi.org/10.1016/j.jaad.2018.12.060.

Li, Yuwei, Xinhong Hu, Gaohong Dong, Xiaoxia Wang, and Tao Liu. “Acne Treatment: Research Progress and New Perspectives.” Frontiers in Medicine 11 (July 10, 2024): 1425675. https://doi.org/10.3389/fmed.2024.1425675.

Popp, Lothar W. “Improvement in Endoscopic Hernioplasty: Transcutaneous Aquadissection of the Musculofascial Defect and Preperitoneal Endoscopic Patch Repair.” Journal of Laparoendoscopic Surgery 1, no. 2 (January 1991): 83–90. https://doi.org/10.1089/lps.1991.1.83.

Saltzman, Bryan M., Timothy Leroux, Maximilian A. Meyer, Bryce A. Basques, Jaskarndip Chahal, Bernard R. Bach, Adam B. Yanke, and Brian J. Cole. “The Therapeutic Effect of Intra-Articular Normal Saline Injections for Knee Osteoarthritis: A Meta-Analysis of Evidence Level 1 Studies.” The American Journal of Sports Medicine 45, no. 11 (September 1, 2017): 2647–53. https://doi.org/10.1177/0363546516680607.

Searle, Tamara, Firas Al-Niaimi, and Faisal R. Ali. “Saline in Dermatologic Surgery.” Journal of Cosmetic Dermatology 20, no. 4 (2021): 1346–47. https://doi.org/10.1111/jocd.13996.

Twisy, Howida Omar. “Subcision with Platelet-Rich Plasma and Microneedling versus Subcision with Saline and Micro-Needling in Posttraumatic Scars.” Archives of Dermatological Research 316, no. 8 (August 19, 2024): 537. https://doi.org/10.1007/s00403-024-03226-3.

Yang, Dan, Minglong Chen, Ying Sun, Yunpan Jin, Chao Lu, Xin Pan, Guilan Quan, and Chuanbin Wu. “Microneedle-Mediated Transdermal Drug Delivery for Treating Diverse Skin Diseases.” Acta Biomaterialia 121 (February 2021): 119–33. https://doi.org/10.1016/j.actbio.2020.12.004.

Tags

Journal Club, acne treatment, scars, traumatic scars, acne scars, cosmetic procedures, microneedling, platelet-rich plasma, PRP, Retin-A, clindamycin, benzoyl peroxide, Accutane, chemical peeling, TCA peel, radiofrequency microneedling, subcision, saline, PRP injections, lichen sclerosis, androgen blockers, hormone replacement, skin care, acne solutions, cosmetic fillers, skin pigmentation, laser therapy, marketing strategies, email automation, patient education, cosmetic botulinum toxin, acne research, skin health, Vampire Facial®, Vampire Facial® procedure, Vampire Facial.

Helpful Links

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