Evaluation of Efficacy of a Skin Care Regimen Containing Methyl Estradiolpropanoate (MEP) for Treating Estrogen Deficient Skin

BACKGROUND: Aging is a complex process due to the interplay of intrinsic factors (such as genetics and hormones) and extrinsic factors (including ultraviolet radiation and pollution). A significant cause of intrinsic aging in women is the loss of estrogen as a result of the onset of menopause. OBJECTIVE: A single site experience trial to assess the efficacy of Emepelle (Biopelle, Ferndale Pharma Group, Ferndale, MI), a skin care regimen containing Methyl Estradiolpropanoate (MEP)®, for the treatment of Estrogen Deficient Skin (EDS). The secondary objective was to assess patient tolerability and satisfaction. METHODS: Fourteen female subjects aged 53-68 years who were amenorrheic for 1-10 years (mean, 5 years), with at least a Grade II in Wrinkling (fine to moderate-depth wrinkles, moderate number of lines) and score of at least 5 (of 9; moderate-to-severe) in elastosis on the clinician-assessed Fitzpatrick-Goldman Classification of Wrinkling and Elastosis Scale, and a 3 or greater on the Investigator Facial Skin Hydration Scale, were included in the study. The subjects were instructed to apply the product Emepelle Serum in the morning, and the product Emepelle Night Cream in the evening to the entire freshly washed and dried face. Follow up visits were performed at 8 weeks, 14 weeks, and 20 weeks to evaluate efficacy and safety. Canfield Visia Complexion Analysis and standard photography was performed at baseline and at each follow up visit. RESULTS: On a 0-4 Facial Hydration Scale, 100% of study participants by week 20 showed at least one-grade improvement and 93% saw two grades or more improvement in hydration. 100% of study participants showed aesthetic improvements per investigator-assessed Global Aesthetic Improvement Scale (GAIS) at week 14. By week 20, 93% of study participants responded that the combination of Emepelle Serum and Night Cream regimen helped improve wrinkles, texture, and color, and 86% of study participants responded that Emepelle helped improve sun-damage, thickness, and integrity. In the Quality of Life questionnaire, 86% responded that Emepelle helped alleviate some or all of the skin issues they developed since entering menopause. Investigator clinical assessment scored patients with a 53% improvement in texture, 21% improvement in keratoses, and 15% improvement in laxity on the Alexiades-Armenakas Comprehensive Grading Scale for Assessment of Skin Aging and Photodamage by the end of the study at week 20. CONCLUSIONS: Patients in the study indicated satisfaction with the formulations of Emepelle Serum and Night Cream. Younger patients showed significant improvement by about 8 weeks. For patients who have been in menopause longer, significant improvement was seen by week 20, suggesting MEP’s potential ability to reactivate dormant estrogen receptors. J Drugs Dermatol. 2019;18(12):1226-1230.

Treatment-induced remission of medulloblastoma using a chemotherapeutic regimen devoid of vincristine in a child with Charcot-Marie-Tooth disease

Charcot-Marie-Tooth (cmt) disease is the most common form of inherited neuropathy. Core features include peripheral neuropathy and secondary axonal degeneration, with a noted distal predominance of limb-muscle wasting, weakness, and sensory loss. Given the significant prevalence of cmt, superimposed neoplastic disease can be encountered within this patient population. Malignancies that are treated with vincristine (a microtubule-targeting agent), even at low doses as part of standard treatment, pose a significant challenge for patients with cmt. Here, we present the case of a child with cmt who was successfully treated for medulloblastoma without vincristine, a standard drug used for treatment of that disease, to avoid the risk of severe debilitating neuropathy. This report is the first of a patient successfully treated for medulloblastoma without vincristine.

Combination of Fractional Resurfacing and Dermabrasion Techniques to Improve Aesthetic Outcomes of Facial Grafts

The use of full-thickness skin grafts (FTSG) in facial reconstruction during dermatologic surgery is well-established. Surgical sites that commonly receive a skin graft include the scalp, nose and ear

OnabotulinumtoxinA and Hyaluronic Acid in Facial Wrinkles and Folds: A Prospective, Open-Label Comparison

Background

OnabotulinumtoxinA and hyaluronic acid are effective in improving moderate to severe facial wrinkles and folds, with treatment selection traditionally based upon facial area.

Objectives

This prospective, multicenter, open-label, crossover study evaluated physician-rated efficacy and patient-rated outcomes following moderate to severe facial wrinkles and folds treatment with onabotulinumtoxinA and hyaluronic acid.

Methods

152 subjects (25-65 years) were randomized (1:1) to a treatment-sequence of onabotulinumtoxinA/hyaluronic acid or hyaluronic acid/onabotulinumtoxinA, with initial treatment administered on day 1 and 6 additional visits: week 2 (touch-up); week 4 (crossover); week 6 (touch-up); and weeks 8, 12, and 24 (follow-up).

Results

Between 92% and 100% of subjects in each treatment-sequence group exhibited at least some improvement from baseline at each study visit in the Physician Aesthetic Improvement Scale and the Objective Observer and Patient Global Assessments of Improvement, with no significant between-sequence differences. Subjects reported looking 3 to 6 years younger at each visit, with significant improvements in glabellar, lateral canthal, and horizontal forehead lines, and nasolabial folds. Treatments were well tolerated.

Conclusions

OnabotulinumtoxinA and hyaluronic acid provide clinically meaningful improvements as rated by physicians, objective observers, and subjects, with clinical synergy in aesthetic effects and duration of response regardless of treatment administration order in subjects seeking improvement in moderate to severe facial wrinkles and folds.

Level of Evidence 2

Maintenance of the Anatomic Contours in Auricular Reconstruction: The Button Technique

Background and Objective:

Reconstructing the contours of the auricle is a unique challenge. Various bolster techniques have been tried to help prevent complications such as hematoma, seroma, and morbidity. Here, we describe a simple technique using a button to maintain the natural ear contour when it is at risk of a poor aesthetic outcome.

Materials and Methods:

A 77-year-old man underwent resection of a squamous cell carcinoma of the postauricular skin on the right ear, which involved the helical margin. A skin graft was chosen to close the defect. However, on initial inspection of the repair, buckling of the scaphoid fossa, collapse of the antihelical fold, and notching of the helix were observed. When these buckling changes persisted even after the anesthesia-related swelling resolved the following day, a button bolster was placed for 2.5 weeks to provide support for the cartilage.

Results:

Standardized digital imaging revealed maintenance of the original contours and sulci of the ear with an excellent cosmetic result.

Conclusion:

Recreation of the auricular contours is critical for an excellent cosmetic outcome. Using a button bolster is worth considering as it is of low cost, can easily fit into the natural ear contours, and can provide a rigid structure to ensure maintenance of the ear shape.

Combination Ablative Approach to Laser Therapy in Advanced Aging of the Face

BACKGROUND AND OBJECTIVE

Misperceptions have persisted regarding scanning full-field erbium laser that have caused it to be overshadowed by fractional ablative resurfacing. This can lead to sub-optimally treating the periocular and perioral skin. Our report describes the utility of a combined approach of fractional ablative CO2 with full-field erbium ablation for full face rejuvenation. Each laser has a role in creating the optimal outcomes for advanced photoaging in the fewest treatments.

METHODS

A patient with severe photodamage and etched-in lines underwent full face fractional ablative CO2 (CO2RE, Syneron Candela) and full-field ablative perioral and periocular erbium laser (Contour TRL, Sciton Inc.). The pre-procedure consultations included evaluation of the severity of the photodamage and etched-in lines, as well as discussion of patient goals and appropriate treatment options. Photos of similar patients and post-treatment recovery were reviewed. Fully ablative lasers are generally avoided in Fitzpatrick skin type IV-VI. Prior to treatment, full face nerve blocks and topical anesthesia was provided. Full facial fractional ablative CO2 laser was then applied in one orthoganol pass to the whole face. This was followed by treating the infraorbital and perioral skin with four passes of full field erbium laser. Visualized residual lines were focally treated. Marked improvement was seen in a single treatment session.

RESULTS

Standardized digital imaging revealed dramatic improvement in skin texture and etched lines.

CONCLUSION

For appropriately selected patients, combination fractional ablative CO2 and full-field ablative erbium resurfacing for facial rejuvenation is safe, efficacious and merits consideration. J Drugs Dermatol. 2018;17(7):796-799.

Naturopathic Self-Treatment of an Atypical Fibroxanthoma: Lessons for Dermatologic Surgery

BACKGROUND

Alternative therapies are favored by some patients. In skin cancer, this may be to try to avoid surgery out of fear for the procedure and its functional or cosmetic consequences. Frequently, use of these therapies is not curative and can cause harm. Our objective is to detail a case where black salve was used as a natural remedy for an atypical fibroxanthoma and resulted in a severe burn. We highlight the challenges of communicating effective treatment options for those who have strong beliefs concerning natural remedies after a cancer diagnosis.

CASE REPORT

A 78-year-old man was referred for excision of a small atypical fibroxanthoma of the scalp. He had reservations about conventional treatments, he initially declined surgery. Later, he was found to have a severe burn over the site of the biopsy-proven AFX, extending to 20% of his scalp. He was found to have been applying black salve. Hospital admission and multiple stages of scalp reconstruction with Head and Neck Surgery were required.

CONCLUSION

For patients who desire to use alternative medicine, communication is all important. Integrative approaches to use traditional therapy while reconciling patient beliefs in natural medicine can improved oncologic, functional, and psychosocial outcomes. J Drugs Dermatol. 2018;17(6):683-685.

Impact of Comprehensive, Minimally Invasive, Multimodal Aesthetic Treatment on Satisfaction With Facial Appearance: The HARMONY Study

BACKGROUND

Individuals seeking aesthetic treatment have concerns regarding multiple facial areas.

OBJECTIVES

Assess the aesthetic impact and satisfaction achieved with a multimodal approach to aesthetic treatment using a combination of minimally invasive treatments.

METHODS

Prospective, multicenter, rater-blinded, 4-month HARMONY study evaluated patient satisfaction and aesthetic impact of a combination of fillers (VYC-20L, HYC-24L, and HYC-24L+), onabotulinumtoxinA, and bimatoprost. Males and females aged 35 to 65 years received on-label, staged treatment with fillers, as needed per investigator assessment, on day 1, with touch ups allowed on day 14. Bimatoprost was self-administered once daily for 17 weeks. OnabotulinumtoxinA was injected into glabellar lines, crow's feet lines, or both at month 3. Primary effectiveness measure was mean change from baseline on the FACE-Q 10-item Satisfaction with Facial Appearance Overall Scale.

RESULTS

Of 100 patients treated, 93 underwent at least the 4-month posttreatment assessment and were assessed for efficacy. The FACE-Q Satisfaction with Facial Appearance Overall Scale total score increased from baseline (41.2) to month 4 (72.9; P < 0.00001; effect size, 2.7). Improvement following multimodal treatment was observed on FACE-Q individual items. Self-perceived age decreased from 0.2 years older than actual age at baseline to 4.6 years younger at month 4. Nearly all patients (99%) rated themselves as improved or much improved on the Global Aesthetic Improvement Scale. Investigator assessments also demonstrated improvement. Mild to moderate adverse events occurred in 42 patients.

CONCLUSIONS

Minimally invasive, multimodal treatment resulted in improvements in FACE-Q scores and perceived age, indicating a high degree of patient satisfaction and a younger facial appearance.

LEVEL OF EVIDENCE 4

Temporal Association of Herpes Zoster Eruption Post-Aminolevulinic Acid Hydrochloride Photodynamic Therapy for Actinic Keratoses

<p>Herpes zoster is a common and painful disease caused by the reactivation of the varicella-zoster virus with a higher incidence and severity associated with increasing age as well as compromised immune status. Acute inciting events for this eruption are not always known, but can include illness, stress, and mechanical injury. Photodynamic therapy (PDT) is a widely used treatment modality for precancerous skin lesions that has not been previously associated with provoking a herpes zoster outbreak. We present a case of herpes zoster eruption occurring after PDT for actinic keratoses in a patient with Non-Hodgkin Lymphoma (NHL).</p> <p><em>J Drugs Dermatol. 2017;16(8):817-818.</em></p>.

Topical cannabinoids in dermatology

Topical cannabinoids are increasingly utilized by dermatology patients for a range of disorders; however, the acceptance of these over-the-counter products has far outpaced scientific investigation into their safety and efficacy. Here, we review the studies of topical cannabinoids in skin conditions and assess their current place in dermatology practice.

Combined Heart and Kidney Transplantation: A 23-Year Experience

BACKGROUND

We report clinical experience with combined heart and kidney transplantation (HKTx) over a 23-year time period.

METHODS

From June 1992 to August 2015, we performed 83 combined HKTx procedures at our institution. We compared the more recent cohort of 53 HKTx recipients (group 2, March 2009 to August 2015) with the initial 30 previously reported HKTx recipients (group 1, June 1992 to February 2009). Pre-operative patient characteristics, peri-operative factors, and post-operative outcomes including survival were examined.

RESULTS

The baseline characteristics of the two groups were similar, except for a lower incidence of ethanol use and higher pre-operative left-ventricular ejection fraction, cardiac output, and cardiac index in group 2 when compared with group 1 (P = .007, .046, .037, respectively). The pump time was longer in group 2 compared with group 1 (153.30 ± 38.68 vs 129.60 ± 37.60 minutes; P = .007), whereas the graft ischemic time was not significantly different between the groups, with a trend to a longer graft ischemic time in group 2 versus group 1 (195.17 ± 45.06 vs 178.07 ± 52.77 minutes; P = .056, respectively). The lengths of intensive care unit (ICU) and hospital stay were similar between the groups (P = .083 and .39, respectively). In addition, pre-operative and post-operative creatinine levels at peak, discharge, 1 year, and 5 years and the number of people on post-operative dialysis were similar between the groups (P = .37, .75, .54, .87, .56, and P = .139, respectively). Overall survival was not significantly different between groups 2 and 1 for the first 5 years after transplant, with a trend toward higher survival in group 2 (P = .054).

CONCLUSIONS

The most recent cohort of combined heart and kidney transplant recipients had similar ICU and hospital lengths of stay and post-operative creatinine levels at peak, discharge, and 1 and 5 years and a similar number of patients on post-operative dialysis when compared with the initial cohort. Overall survival was not significantly different between the later and earlier groups, with a trend toward higher overall survival at 5 years in the more recent cohort of patients. In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation is safe to perform and has excellent outcomes.

New Uses of AbobotulinumtoxinA in Aesthetics

BotulinumtoxinA (BoNT-A) is now widely established for the main approved indication of reducing glabellar lines, and is also widely used off-label to improve the appearance of wrinkles and lines in other parts of the face. The number of aesthetic procedures continues to increase as the patient population becomes more diverse, in particular with increasing numbers of people of color and men. Further developments in treatment may continue to expand the audience for BoNT-A by making procedures more comfortable and by delivering a more natural, less static appearance. These may be achieved through use of combinations of BoNT-A with other aesthetic procedures, tailoring the dose of toxin to the patient's muscle mass or by using novel injection and application techniques. Beyond amelioration of facial lines, encouraging results have been seen with the use of BoNT-A to improve the appearance of hypertrophic and keloid scars and even to prevent them. Studies have been conducted with scars in various parts of the body and further research is ongoing. Dermatological and other medical uses for BoNT-A are also active areas of research. Injections of BoNT-A have been shown to reduce signs and symptoms of acne, rosacea, and psoriasis, to reduce neuromuscular pain, and to bring about significant improvements in a number of rare diseases that are caused or exacerbated by hyperhidrosis. This paper reviews these new uses for BoNT-A, looking at the rationale for their use and discussing the results of published case studies and clinical trials. These areas have shown great promise to date, but more and larger clinical studies will be required before these treatments become a clinical reality. To this end details are also provided of clinical trials currently listed in the main clinical trials database to highlight research areas of particular interest.

Safety and Patient Satisfaction of AbobotulinumtoxinA for Aesthetic Use: A Systematic Review

A systematic review of the published literature (from January 2000 to January 2016) to ascertain the safety of, and patient satisfaction with, the aesthetic use of abobotulinumtoxinA was conducted. In addition to the licensed indications, other special populations were considered for discussion. The potential impact of neutralizing antibodies and systemic toxicity were also addressed. A total of 364 papers were screened and 86 were found to be relevant to the population, intervention(s), and outcomes stipulated in the protocol. The safety and patient satisfaction data from these publications are discussed in this review.

Microneedling therapy with and without platelet-rich plasma

Microneedling therapy is an increasingly popular treatment of several dermatologic conditions. Platelet-rich plasma (PRP) may serve as a valuable adjunct to improve the regenerative effects of treatment. We review the evidence comparing the results of microneedling therapy with and without PRP. Based on the current preliminary literature, PRP appears to augment the cosmetic outcomes of microneedling without increasing the risk for adverse events.

Topical Approaches to Improve Surgical Outcomes and Wound Healing: A Review of Efficacy and Safety

<p>Surgical procedures are an important piece of a dermatologist's daily practice. Therefore, the optimization of post-surgical wound healing is an area of utmost importance and interest. Although low risk, one notable barrier to proper wound healing is surgical site infection.</p> <p>In an attempt to mitigate this risk and improve surgical outcomes, multiple topical products continue to be used both pre- and postprocedure. Traditionally, this includes both topical antibiotics and antiseptics. However, these products are not without consequence.</p> <p>The overuse of topical antibiotics as prophylaxis for infection has contributed to increased bacterial resistance, and in fact is no longer recommended by the American Academy of Dermatology in clean post surgical wounds. Topical antiseptics, including chlorhexidine and povidone-iodine, can have a cytotoxic effect on keratinocytes and may actually impede wound healing as a result. In addition, chlorhexidine in particular can produce both otologic and ocular toxic effects when used on the face. Emerging products, such as hypochlorous acid, may be a potential alternative to the more commonly used agents, as it has effective antimicrobial actions and minimal adverse effects. Therefore, the purpose of this review is to highlight several topical products used to optimize post-surgical wound healing and discuss both their efficacy and safety.</p> <p><em>J Drugs Dermatol. 2017;16(3):209-212.</em></p>.

Transcriptomic Signature of the CD24hi CD38hi Transitional B Cells Associated With an Immunoregulatory Phenotype in Renal Transplant Recipients

The role of B cells after transplant regarding allograft rejection or tolerance has become a topic of major interest. Recently, in renal transplant recipients, a B cell signature characterized by the overexpression of CD19⁺ CD38^hi CD24^hi transitional B cells has been observed in operationally tolerant patients and in belatacept-treated patients with significantly lower incidence of donor-specific antibodies. The phenotypic and functional characterization of these transitional B cells is far from exhaustive. We present the first transcriptomic and phenotypic analysis associated with this cell phenotype. Three populations were studied and compared: (i) transitional CD24^hi CD38^hi , (ii) CD24⁺ CD38^- , and (iii) CD24^int CD38^int B cells. Transcriptome bioinformatic analysis revealed a particular signature for the CD24^hi CD38^hi population. Phenotypic analysis showed that CD24^hi CD38^hi transitional B cells also expressed CD9, CD10, CD1b and inducible T cell costimulator ligand (ICOS-L) markers. In addition, we found enrichment of IL-10⁺ cells among CD24^hi CD38^hi cells expressing ICOS-L and CD1b, the latter showing regulatory properties. Renal transplant recipients treated with belatacept exhibited significant expression of CD1b. Our results show that transitional CD24^hi CD38^hi B cells exhibit a distinct and specific profile, and this could be helpful for understanding of immune-regulatory mechanisms and immune monitoring in the field of organ transplant and autoimmune disease.

Multi-Center Pilot Study to Evaluate the Safety Profile of High Energy Fractionated Radiofrequency With Insulated Microneedles to Multiple Levels of the Dermis

In this multi-center pilot study, the safety pro le of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for safety in the treatment of the aging neck and face. A newly designed insulated microneedle system delivers a signi cant coagulative thermal injury into the dermis while sparing the epidermis from RF injury. Thirty- ve healthy subjects from seven aesthetic practices were evaluated, and data from each were incorporated in this case report. The subjects received a single treatment using settings that delivered the highest RF energies suggested from the new recommended protocols. The depth of thermal delivery was adjusted before each pass and all subjects received a minimum of two to three passes to the treated areas. Before and after photographs along with adverse effects were recorded. This case report demonstrates the ability to deliver significant RF thermal injury to several layers of the dermis with insulated microneedles safely with little injury to the epidermis and minimum downtime.

Safety and Efficacy Evaluation of Pulsed Dye Laser Treatment, CO2 Ablative Fractional Resurfacing, and Combined Treatment for Surgical Scar Clearance

BACKGROUND & OBJECTIVE

Surgical scars are an unwanted sequela following surgical procedures. Several different treatment modalities and approaches are currently being employed to improve the cosmesis of surgical scars with each having varying degrees of success. The objective of this study was to assess the ef cacy and safety pulsed dye laser treatment, CO2 ablative fractional resurfacing, and a combined treatment with these two modalities for the cosmetic improvement of surgical scarring that occurred following the surgical removal of skin cancer from different anatomic areas.

MATERIALS AND METHODS

Twenty-five patients with surgical scarring most frequently on the face following recent surgical excision of skin cancer with Mohs surgery were included in this multicenter, prospective clinical study. Patients were randomized into 4 treatment arms, namely, pulsed dye laser alone, CO2 laser alone, a combined treatment with these two modalities, and CO2 ablative fractional resurfacing on the same day of surgery to half of the scar, followed by a combined treatment with the two modalities to that half of the scar. Patients in each study arm received a total of 3-4 treatments, while those patients in Arm 4 underwent an additional treatment with CO2 laser immediately after surgery. Patients were followed up at 1 and 3 months after the final treatment session.

RESULTS

No adverse events were seen. Significant improvements in the appearance of scars were achieved in all study arms, as as- sessed by the Vancouver Scar Scale and Global Evaluation Response scales, with the best clinical outcomes seen in those scars that underwent a combination treatment. All patients reported very high satisfaction from treatment.

CONCLUSION

Both pulsed dye laser treatment and CO2 ablative fractional resurfacing, when used as a monotherapy, are safe and effective in the treatment and improvement of recent surgical scarring. When both of these modalities are used in combination, however, they appear to potentially have a synergistic effect and an accelerated outcome on the cosmesis of recent surgical scars. <em>J Drugs Dermatol. 2016;15(11):1315-1319.</em>.

Self-Resolving Eruptive Keratoacanthomas After Full-Field Erbium Laser Resurfacing

Keratoacanthoma (KA) is a subtype of squamous cell carcinoma whose development has been linked to excessive sun exposure, immunosuppression, and trauma. Given the rapidly expanding therapeutic armamentarium for anti-aging modalities in dermatology, reports of KA secondary to invasive cosmetic procedures are on the rise. We present a case of eruptive KAs after full- eld ablative Erbium:YAG 2940 nm laser resurfacing of the face that resolved with minimal intervention. This case demonstrates the potential for a rare yet signi cant laser complication that may warrant discussion during the consenting process. <em>J Drugs Dermatol. 2016;15(11):1453-1455.</em>.

Metastatic Zosteriform Squamous Cell Carcinoma in an Immunocompetent Patient

Background:

Although described in several reports of internal malignancies metastasizing to the skin, zosteriform metastases have been reported in only two cases of cutaneous squamous cell carcinoma (SCC). In both of these reports, the patients were immunosuppressed related to renal transplantation.

Objective:

We present a case of an immunocompetent patient with zosteriform metastases originating from a recurrent cutaneous SCC. The lesions were present along the maxillary division of the trigeminal nerve.

Methods:

Biopsies from eight lesions were studied using hematoxylin and eosin (H&E) and with immunohistochemistry.

Results:

Neural involvement was detected in H&E preparations before and during excision of the metastatic nodules by Mohs micrographic surgery. The tumor cells reacted with antikeratin antibodies. The patient has had no evidence of recurrence or metastases 30 months following surgery.

Conclusion:

To our knowledge, this is the first case of cutaneous SCC with zosteriform metastases in a patient with an intact immune system. SCC should be included in the differential diagnosis of lesions presenting in a dermatomal distribution.

Challenges, Considerations, and Strategies in Hand Rejuvenation

Hand rejuvenation is an increasingly requested procedure in dermatology. Dorsal hand augmentation with soft tissue filler is one aspect of hand rejuvenation. Calcium hydroxyapatite is FDA approved for this purpose, while at the present time other filler products are utilized but are considered off-label for dorsal hand augmentation. This article reviews the relevant anatomy, the general and filler-specific techniques commonly employed, and potential complications that may arise. <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(7):809-815.

Objective Melanin Measurements: Review of Novel Dosimetry Guidance Device for Intense Pulsed Light in Aesthetic Treatments

A melanin meter has been created to assess real time skin pigmentation to optimize settings for visible light aesthetic applications.

METHODS

A handheld meter was applied to non sun-damaged skin on the back of volunteers to measure skin pigmentation prior to treatment with IPL light sources over a range of pulse widths and ascending fluences. Curves for maximum epidermal tolerances as a function of pigmentation were determined. These curves were then tabulated for each pulse width in device software to provide guidance in the selection of fluences. Based on these findings, the device was applied in over 300 patients at a comprehensive laser and cosmetic dermatology center.

RESULTS

A pigment meter evaluation led to treatment parameter guidance in intense pulsed light applications. These suggested ranges for settings based on the melanin index score proved useful, accurate, and safe in applications over a broad range of skin colors and across various anatomic units of the skin.

CONCLUSION

A pigment meter can be used to identify appropriate settings with IPL treatments in order to enhance safety and efficacy when treating epidermal pigmented lesions, vessels, general photodamage and excessive hair (where the principles of selective photothermolysis are applied).

A Randomized, Blinded Study to Validate the Merz Hand Grading Scale for Use in Live Assessments

BACKGROUND

The Merz Hand Grading Scale (MHGS) is a 5-point scale used to grade appearance of the dorsum of the hand. The MHGS has been previously validated for assessment of photographed hands but not for live assessment.

OBJECTIVE

The purpose of this randomized, blinded study was to validate the MHGS for live assessment of the hands in the clinical setting.

METHODS

Three physician raters completed a scale qualification program that included MHGS training, ratings of standardized hand photographs, and statistical analysis for reliability. Eighty-four subjects (28 males, 30% Fitzpatrick skin Types IV-VI, mean age of 42 years), randomized to 2 live assessment sessions for independent and blinded observation of dorsa of their right hands, completed the study.

RESULTS

Overall MHGS intrarater weighted Kappa value was 0.74 (0.68-0.79 [CI 95%]). First- and second-time hand-rating agreement scores ranged from 64% to 75%. Interrater weighed Kappa values ranged from 0.59 to 0.71, representing between-rater paired results of each combination of raters.

CONCLUSION

High-weighted Kappa values and agreements demonstrate that consistency at different time points can be achieved individually and by different raters for live assessments. The MHGS is a suitable instrument for live assessment in the clinical setting.

A Combination Approach to Perioral Rejuvenation

Fine lines and wrinkles, loss of volume, texture changes, and solar lentigines around the mouth are the result of both extrinsic and intrinsic factors, and are common concerns seen in cosmetic practice. Perioral rejuvenation can be addressed using a variety of noninvasive means including botulinum toxin, fillers, and laser resurfacing. In clinical practice, a multifaceted treatment plan utilizing a variety of noninvasive means to address the multiple tissue changes is often undertaken. Combining botulinum toxin with fillers or laser resurfacing has previously been shown to produce more desirable and longer lasting results. Here we report the results of using a sequential approach with all three modalities.

Therapeutic approaches to cellulite

Cellulite is a condition that affects the vast majority of women. Although it is of no danger to one's overall health, cellulite can be psychosocially debilitating. Consequently, much research has been devoted to understanding cellulite and its etiopathogenesis. With additional insights into the underlying causes of its clinical presentation, therapeutic modalities have been developed that offer hope to cellulite sufferers. This review examines evidence for topical treatments, noninvasive energy-based devices, and recently developed minimally invasive interventions that may finally provide a solution.

Injectable agents affecting subcutaneous fats

Mesotherapy is an intradermal or subcutaneous injection of therapeutic agents to induce local effects, and was pioneered in Europe during the 1950s. For the past 2 decades, there has been significant interest in the use of mesotherapy for minimally invasive local fat contouring. Based on the theorized lipolytic effects of the agent phosphatidylcholine, initial attempts involved its injection into subcutaneous tissue. With further studies, however, it became apparent that the activity attributed to phosphatidylcholine mesotherapy was due to the adipolytic effects of deoxycholate, a detergent used to solubilize phosphatidylcholine. Since then, clinical trials have surfaced that demonstrate the efficacy of a proprietary formulation of deoxycholate for local fat contouring. Current trials on mesotherapy with salmeterol, a b-adrenergic agonist and lipolysis stimulator, are underway-with promising preliminary results as well.

Perioral Rejuvenation With Ablative Erbium Resurfacing

BACKGROUND AND OBJECTIVE

Since the introduction of the scanning full-field erbium laser, misconceptions regarding ablative erbium resurfacing have resulted in its being largely overshadowed by ablative fractional resurfacing. This case report illustrates the appropriateness of full-field erbium ablation for perioral resurfacing.

METHODS

A patient with profoundly severe perioral photodamage etched-in lines underwent full-field ablative perioral resurfacing with an erbium laser (Contour TRL, Sciton Inc., Palo Alto, CA) that allows separate control of ablation and coagulation. The pre-procedure consultations included evaluation of the severity of etched-in lines, and discussion of patient goals, expectations, and appropriate treatment options, as well as a review of patient photos and post-treatment care required. The author generally avoids full-field erbium ablation in patients with Fitzpatrick type IV and above. For each of 2 treatment sessions (separated by approximately 4 months), the patient received (12 cc plain 2% lidodaine) sulcus blocks before undergoing 4 passes with the erbium laser at 150 μ ablation, no coagulation, and then some very focal 30 μ ablation to areas of residual lines still visualized through the pinpoint bleeding. Similarly, full-field ablative resurfacing can be very reliable for significant wrinkles and creping in the lower eyelid skin--where often a single treatment of 80 μ ablation, 50 μ coagulation can lead to a nice improvement.

RESULTS

Standardized digital imaging revealed significant improvement in deeply etched rhytides without significant adverse events.

CONCLUSION

For appropriately selected patients requiring perioral (or periorbital) rejuvenation, full-field ablative erbium resurfacing is safe, efficacious and merits consideration.

Treatment of Periorbital Veins With Long-Pulse Nd:YAG Laser

Periorbital veins (POVs) are a common cosmetic concern. Anatomically, POVs are formed by superficial facial veins that start from the bridge of the nose, travel as supraorbital and infraorbital veins, and join venous branches from the lateral forehead and scalp. In patients with fair skin, or in patients whose facial skin is atrophied, POVs can become prominent. This can lead to a fatigued appearance, with perceived "dark circles" around the patients' eyes. Previously described surgical therapies for prominent POVs are invasive and can leave unsightly scars, and sclerotherapy has been reported to lead to embolization that could lead to blindness. Here, we give examples of the use of 1,064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser to non-invasively treat or at least minimize prominent POVs. We discuss various techniques, and review treatment schedules to achieve the optimal cosmetic outcome. Furthermore, potential pitfalls, such as local site reaction and laser-specific tissue damage, are explored. Overall, Nd:YAG laser does appear to be a safe and effective treatment for POVs that requires minimal post-treatment care.

Treatment of Acne Scars With High Intensity Focused Radio Frequency

In this multi-site case series, the efficacy of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for treating acne scars. A novel delivery system that uses insulated microneedles to deliver a desired thermal effect to multiple depths of the dermis while sparing the epidermis from RF injury was used. Four (4) healthy subjects from four different practices were evaluated and used in this case report. The subjects were treated between 3 or 4 times depending on the severity of the acne scars presented. The depth of thermal delivery was adjusted before each pass and all subjects received at a minimum, three passes to the treated area. Before and after photographs along with adverse effects were recorded. The theory behind the use of insulated needles with the active RF delivery at the distal tip is to allow for significant thermal injury to several layers of the dermis while avoiding thermal injury to the epidermis. This case report demonstrates significant improvement on acne scars and that all skin types should be safely treatable with minimum downtime realized.

Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

Before or after: is there a connection between the use of adjunctive nonmelanoma skin cancer treatments and subsequent invasive tumors?

Although the therapeutic gold standard for basal cell carcinomas (BCCs) is surgical excision, imiquimod, fluorouracil cream, and photodynamic therapy are frequently used. All 3 modalities have been shown to be efficacious for the treatment of superficial BCCs as well as other nonmelanoma skin cancers; however, recent reports have emerged implicating these agents in causing more aggressive recurrent subtypes of BCCs. Here we review this literature as well as offer an alternative explanation for these tumors.

A case of multiple atypical nevi with co-localized Basal cell carcinomas on the scalp: insight into the pathogenesis

The authors report a case of a 29-year-old female with multiple lesions on the scalp containing an atypical nevus and a co-localized basal cell carcinoma (BCC) in the same specimen. This is the first description of such a case in the literature. The peculiar co-existence of these 2 neoplasms in the same specimen in multiple skin lesions raises the possibility of an unknown mutation(s) that increases the risk of developing both conditions; and this case illustrates that the signaling pathways mediating the development of atypical nevi may interact with those associated with BCCs. Additionally, crosstalk between melanocytes and basal keratinocytes, which are both located in the basal layer of the epidermis, may contribute to the development of these coexisting neoplasms.

Administration of low doses of IL-2 combined to rapamycin promotes allogeneic skin graft survival in mice

Human CD4(+) CD25(+) FoxP3(+) regulatory T cells (Tregs) prevent allogeneic graft rejection by inhibiting T cell activation, as has been shown in mouse models. Recently, low-dose IL-2 administration was shown to specifically activate Tregs but not pathogenic conventional T cells, leading to resolution of type 1 diabetes in nonobese diabetic mice. We therefore tested the ability of low-dose IL-2 to prevent allogeneic skin graft rejection. We found that while IL-2 alone was inefficient in preventing rejection, combined with rapamycin, IL-2 treatment promoted skin graft survival both in minor disparate and semi-allogeneic skin graft combinations. Tregs are activated by this combined treatment while conventional CD4(+) cell expansion and activation are markedly inhibited. Co-administration of anti-CD25 antibodies dramatically reduces the effect of the IL-2/rapamycin treatment, strongly supporting a central role for Treg activation. Thus, we provide the first preclinical data showing that low-dose IL-2 combined with rapamycin can significantly delay transplant rejection in mice. These findings may form the rational for clinical evaluation of this novel approach for the prevention of transplant rejection.

Early-life exposure to the SSRI paroxetine exacerbates depression-like behavior in anxiety/depression-prone rats

Selective serotonin reuptake inhibitor (SSRI) antidepressants are the mainstay treatment for the 10-20% of pregnant and postpartum women who suffer major depression, but the effects of SSRIs on their children's developing brain and later emotional health are poorly understood. SSRI use during pregnancy can elicit antidepressant withdrawal in newborns and increase toddlers' anxiety and social avoidance. In rodents, perinatal SSRI exposure increases adult depression- and anxiety-like behavior, although certain individuals are more vulnerable to these effects than others. Our study establishes a rodent model of individual differences in susceptibility to perinatal SSRI exposure, utilizing selectively bred Low Responder (bLR) and High Responder (bHR) rats that were previously bred for high versus low behavioral response to novelty. Pregnant bHR/bLR females were chronically treated with the SSRI paroxetine (10 mg/kg/day p.o.) to examine its effects on offspring's emotional behavior and gene expression in the developing brain. Paroxetine treatment had minimal effect on bHR/bLR dams' pregnancy outcomes or maternal behavior. We found that bLR offspring, naturally prone to an inhibited/anxious temperament, were susceptible to behavioral abnormalities associated with perinatal SSRI exposure (which exacerbated their Forced Swim Test immobility), while high risk-taking bHR offspring were resistant. Microarray studies revealed robust perinatal SSRI-induced gene expression changes in the developing bLR hippocampus and amygdala (postnatal days 7-21), including transcripts involved in neurogenesis, synaptic vesicle components, and energy metabolism. These results highlight the bLR/bHR model as a useful tool to explore the neurobiology of individual differences in susceptibility to perinatal SSRI exposure.

Evaluation of the efficacy and safety of a lidocaine and tetracaine (7%/7%) cream for induction of local dermal anesthesia for facial soft tissue augmentation with hyaluronic Acid

Injection of dermal fillers for soft tissue augmentation is a minimally invasive cosmetic procedure with growing popularity. However, patients often express concern about pain with such procedures. A topical anesthetic cream formulated with lidocaine/tetracaine 7%7% was approved by the United States Food and Drug Administration in 2006 and recently reintroduced to the market for use during superficial dermatological procedures. A Phase 3 study was conducted to assess the efficacy and safety of lidocaine/tetracaine 7%7% cream versus placebo cream when used to induce local dermal anesthesia during injections with hyaluronic acid. Mean visual analog scale scores significantly favored lidocaine/tetracaine 7%7% cream. A significant percent of subjects also indicated that lidocaine/tetracaine 7%7% cream provided adequate pain relief and that they would use lidocaine/tetracaine 7%7% cream again. Investigators also rated lidocaine/tetracaine 7%7% cream significantly better than placebo cream for providing adequate pain relief and on the assessment of pain scale. Lidocaine/tetracaine 7%7% cream was safe and well tolerated with most subjects reporting no erythema, edema, or blanching. No related adverse events were reported with lidocaine/tetracaine 7%7% cream; one related adverse event of erythema was reported with placebo cream. The results of this study indicate that lidocaine/tetracaine 7%7% cream is efficacious and safe at providing pain relief for soft tissue augmentation with hyaluronic acid.

Scientific skepticism and new discoveries: an analysis of a report of zinc/phytase supplementation and the efficacy of botulinum toxins in treating cosmetic facial rhytides, hemifacial spasm and benign essential blepharospasm

INTRODUCTION

A recent paper in the Journal of Drugs in Dermatology by Koshy and colleagues (2012, 11( 4 ):507-512) report on "Effect of Dietary Zinc and Phytase Supplementation on Botulinum Toxin Treatments" and conclude by claiming the discovery of "a potentially meaningful role for zinc and/or phytase supplementation in increasing the degree and duration of botulinum toxin effect in the treatment of cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm". The purpose of this paper is to examine these published claims for possible methodological and design errors and potential sources of bias.

METHODS

The authors evaluated the published results in comparison to the published literature on zinc deficiency, the role of phytase, prior reports of an effect of zinc on activity of botulinum toxin, issues of study design and execution and if the reported results of the study supported the study's conclusions.

RESULTS

Multiple issues are present in the reported study, which appear to invalidate its conclusions. These areas include lack of direct evidence for the presence of clinical or subclinical zinc deficiency in the study population or for the level of phytate in the study population sufficient to interfere with zinc absorption in these subjects. Additionally, there is ambiguity as to the actual dose of zinc used as well as in the study design itself. Also there is a failure of the study through the "unmasking" of the crossover design. There is potential financial conflict of interest in the study execution that may have biased the reported results. Finally there is inadequate data presented to evaluate the claims made of a "new discovery" as to the three disease entities reported on and the various botulinum toxins used in each of the three treatment arms of the study.

DISCUSSION

Based on this evaluation, it appears that a high level of clinical and scientific skepticism is warranted concerning any claim of a beneficial effect of zinc and phytase supplementation on the efficacy or potency of any botulinum toxins in the reported conditions.

Efficacy of incobotulinumtoxinA for treatment of glabellar frown lines: a post hoc pooled analysis of 2 randomized, placebo-controlled, phase 3 trials

BACKGROUND

Botulinum neurotoxin type A trials in aesthetic indications have used differing efficacy parameters and responder definitions.

OBJECTIVE

To analyze the treatment efficacy and duration of incobotulinumtoxinA for glabellar frown lines using pooled data from 2 large, Phase 3, placebo-controlled trials, and end points similar to those used in previous botulinum neurotoxin type A studies.

MATERIALS AND METHODS

IncobotulinumtoxinA and placebo groups comprised 366 and 181 subjects, respectively. The efficacy of a single 20-U treatment of incobotulinumtoxinA or placebo was evaluated by investigator-assessed and subject-assessed responder rates (≥ 1-point improvement from baseline), mean score, and mean change from the baseline glabellar frown line severity score.

RESULTS

At all follow-up visits, responder rates and mean change from the baseline score (investigator-assessed and subject-assessed) were significantly greater for incobotulinumtoxinA versus placebo (p < .0001). The maximum investigator-assessed responder rate (93.1%) was achieved at Day 30 after treatment, when the mean improvement on the 4-point facial wrinkle scale peaked at 1.88. Treatment effect declined over time but the investigator-assessed responder rate was 45.7% at the end of the study.

CONCLUSION

Superiority of incobotulinumtoxinA over placebo for treating glabellar frown lines was confirmed. IncobotulinumtoxinA achieved a maximum responder rate of 93.1% and a long duration of treatment effect: 45.7% of subjects showed efficacy at 120 days.

An interrater and intrarater reliability study of 3 photographic scales for the classification of perioral aesthetic features

BACKGROUND

Validated aesthetic rating scales for the perioral area provide objective evaluations for clinical trials and practice.

OBJECTIVE

To confirm the reliability of 3 scales for evaluating dermal filler and neurotoxin treatments of the perioral area.

MATERIALS AND METHODS

Three lip-specific photographic scales were developed from standardized 2-dimensional images to evaluate Perioral Lines at Rest (POL), Oral Commissures (OCS), and Perioral Lines at Maximum Contraction (POLM) severity scales. Each 4-grade scale (none to severe) had 3 representative images per grade. Physician validators rated volunteers on each scale (2 rounds of live review). Volunteers provided 2 series of self-assessments. Physician and subject intrarater reliability were based on the comparison of round 1 and round 2 scores (mean weighted kappa coefficient). Other measures were physician interrater agreement (intraclass correlation) and subject/physician interrater agreement (Pearson correlation).

RESULTS

Physician intrarater agreement was almost perfect or substantial (POL, 0.725; OCS, 0.789; POLM, 0.826). Overall, physician interrater agreement was almost perfect for all 3 scales and ranged from moderate to substantial by grade. Subject intrarater agreement and subject/physician interrater agreement were substantial.

CONCLUSION

All scales demonstrated a high degree of intrarater and interrater reliability during the validation process. Physician concordance was good; subject ratings were reliable and comparable to physician assessments.

Polypodium leucotomos as an Adjunct Treatment of Pigmentary Disorders

INTRODUCTION

Extracts of the tropical fern Polypodium leucotomos appear to possess beneficial properties for the skin attributed to the presence of numerous compounds within the extract that have antioxidant and photoprotective properties. Orally administered Polypodium leucotomos may provide protection against the detrimental photoaging effects of sunlight and can also help reduce the frequency and severity of polymorphous light eruption. Polypodium leucotomos has also been shown to be beneficial for the prevention and potential treatment of several aesthetically relevant conditions.

OBJECTIVE

The purpose of this review is to investigate the beneficial role of Polypodium leucotomos as an adjunct treatment for vitiligo, melasma, and postinflammatory hyperpigmentation.

RESULTS

Based on a review of relevant literature including the results of a randomized, placebo-controlled study, the oral administration of Polypodium leucotomos significantly improved the severity of melasma in women after 12 weeks. Three randomized, double-blind, placebo-controlled studies have demonstrated significant improvements in vitiligo when oral Polypodium leucotomos therapy was combined with psoralens plus ultraviolet A and narrowband ultraviolet B. No controlled studies have assessed the efficacy of Polypodium leucotomos for the treatment of postinflammatory hyperpigmentation; however, its known antioxidant and anti-inflammatory properties and demonstrated effectiveness for melasma support its use for treating this condition. No adverse events have been associated with the use of Polypodium leucotomos.

CONCLUSION

In addition to preventing many harmful effects associated with sunlight exposure, orally administered Polypodium leucotomos also appears to provide adjunctive benefits in treating vitiligo, melasma, and may have the potential to help with postinflammatory hyperpigmentation.

Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers

IMPORTANCE

Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events.

OBJECTIVES

To quantify adverse events associated with MMS and detect differences relevant to safety.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times.

EXPOSURE

Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events.

RESULTS

Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events.

CONCLUSIONS AND RELEVANCE

Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Long-term safety of abobotulinumtoxinA for the treatment of glabellar lines: results from a 36-month, multicenter, open-label extension study

BACKGROUND

Because abobotulinumtoxinA treatment for glabellar lines must be repeated regularly to prevent recurrence, understanding the safety and effectiveness of long-term, repeated administration of abobotulinumtoxinA is important.

OBJECTIVE

To report the long-term safety and efficacy of abobotulinumtoxinA in patients with moderate to severe glabellar lines.

METHODS AND MATERIALS

AbobotulinumtoxinA was administered to 1,415 patients in multiple cycles over 24 months as a fixed dose of 50 U or as a dose based on muscle mass and sex (women: 50-70 U; men: 60-80 U). Adverse events were assessed after each visit on days 7, 14, and 30 and monthly thereafter; monitoring continued every 3 months for a total safety monitoring duration of 36 months or less.

RESULTS

Nine hundred ninety-one (70%) patients reported treatment-emergent adverse effects (TEAEs); most events were mild (70%) or moderate (20%) in severity. The rate of TEAEs did not increase over 24 months of repeated treatment (mean 5.6 cycles; range 1-9). Treatment-related eyelid ptosis followed 53 of 7,938 (0.7%) treatments, all of which resolved spontaneously.

CONCLUSIONS

Multiple cycles of abobotulinumtoxinA treatment over 24 months were well tolerated and effective for the correction of glabellar lines, with no evidence of cumulative safety problems.

Erbium laser resurfacing for actinic cheilitis

Actinic cheilitis is a precancerous condition characterized by grayish-whitish area(s) of discoloration on the mucosal lip, often blunting the demarcation between mucosa and cutaneous lip. Actinic cheilitis is considered to be an early part of the spectrum of squamous cell carcinoma. Squamous cell carcinoma specifically of the lip has a high rate of recurrence and metastasis through the oral cavity leading to a poor overall survival. Risk factors for the development of actinic cheilitis include chronic solar irradiation, increasing age, male gender, light skin complexion, immunosuppression, and possibly tobacco and alcohol consumption. Treatment options include topical pharmacotherapy (eg, fluorouracil, imiquimod) or procedural interventions (eg, cryotherapy, electrosurgery, surgical vermillionectomy, laser resurfacing), each with their known advantages and disadvantages. There is little consensus as to which treatment options offer the most clinical utility given the paucity of comparative clinical data. In my practice, laser resurfacing has become an important tool for the treatment of actinic cheilitis owing to its ease of use and overall safety, tolerability, and cosmetic acceptability. Herein the use of erbium laser resurfacing is described for three actinic cheilitis presentations for which I find it particularly useful: clinically prominent actinic cheilitis, biopsy-proven actinic cheilitis, and treatment of the entire lip following complete tumor excision of squamous cell carcinoma. All patients were treated with a 2940-nm erbium laser (Sciton Profile Contour Tunable Resurfacing Laser [TRL], Sciton, Inc., Palo Alto, CA).

Purpura and fillers: a review of pre-procedural, intra-procedural, and post-procedural considerations

Injectable aesthetic fillers are associated with the common and expected side effect of purpura or bruising. There are pre-procedural, intra-procedural and post-procedural considerations that can potentially minimize bruising. Traditional and newer techniques are discussed in this review and the benefits and risks of each technique will be provided.

Minimizing skin cancer surgical scars using ablative fractional Er:YAG laser treatment

BACKGROUND AND OBJECTIVE

Scars from skin cancer surgery on the face can be quite prominent and not easily obscured by makeup. This report evaluates the use of an ablative fractional Er:YAG laser device for minimizing or blending scar lines in two patients who underwent repair of skin cancer defects on the face.

METHODS

Two patients underwent surgery to remove facial skin cancer tumors. The resulting scars after reconstruction of these skin cancer defects on the left cheek (Case 1) and right cheek (Case 2) each received 3 treatments with a fractional ablative laser device (ProFractional-XC, Sciton, Inc., Palo Alto, CA). Treatments were spaced about 1 month apart. Topical anesthetic cream applied 1 hour before treatment minimized patient discomfort during the procedure. Treatment depths ranged from 150 to 200 microns, 2 passes were performed, and coverage per pass was typically 22% and then 11% in the coagulation mode. Results were evaluated by digital photography before the initial treatment, approximately 4-5 weeks after each of the 3 treatments, and at approximately 7 months after the surgical procedures.

RESULTS

The fractional Er:YAG laser device significantly improved postsurgical scar lines in each patient without significant adverse effects. Prior to the laser sessions, these scars demonstrated hypopigmentation, hyperpigmentation, neovascularization, or diminished pore structures compared to the surrounding skin. These pigmentary, vascular or textural issues were all significantly improved by the fractional ablative Er:YAG laser.

CONCLUSION

The ablative fractional laser device of the present report safely minimizes and improves facial scars demonstrating not only textural alterations but also some pigmentary and vascular changes after reconstruction of skin cancer defects.