Traumatic Tattoo: Use of the Variable Pulsed Erbium:YAG Laser

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of removing traumatic tattoos in the skin by laser. The objective was to achieve selective dermabrasion on the tattoo site without injuries to the surrounding skin, as in the classical mechanical dermabrasion.

METHODS

Four patients with traumatic tattoos in the face were treated by a variable pulsed erbium:YAG laser. The fluence of the ablative pulses was 5 J/cm(2). The end-point for the treatment was the macroscopic removal of the foreign bodies. Postoperatively, silver sulphadiazine or polyvinylpyrrolidone was applied daily until wound closure occured. Use of a total sun block was mandatory for a period of 6 months. Pre- and post-operative photographs were taken of all cases. The results were evaluated by a panel of four independent observers, who were asked to judge the percentage of tattoo clearance as well as any evidence of pigmentation problems or scarring.

RESULTS

All results were rated from good to excellent. In all patients, a nearly complete clearance of the traumatic tattoo was achieved in one laser session. No scarring, skin atrophy, or hypo- or hyperpigmentation was observed. Furthermore, a high patient satisfaction rate was achieved.

CONCLUSION

The selective ablation of scar/foreign body tissue is a safe procedure. Compared to results reported with 1064-nm laser treatments, where several laser procedures are necessary, better clearance and scar quality was observed. Compared to mechanical dermabrasion, the procedure is more reliable and causes fewer side effects.

A randomized, double-blind comparison of two topical anesthetic formulations prior to electrodesiccation of dermatosis papulosa nigra

BACKGROUND

Liposomal lidocaine 4% (L.M.X.4 cream, Ferndale Laboratories Inc., Ferndale, MI, USA) has been proposed as a more rapidly acting topical anesthetic than the eutectic mixture of lidocaine 2.5% and prilocaine 2.5% (EMLA cream, AstraZeneca LP, Wilmington, DE, USA) for venipuncture and laser procedures. However, their anesthetic efficacy has not been previously compared for electrosurgical destruction of superficial skin lesions.

OBJECTIVE

To test the hypothesis that L.M.X.4 and EMLA differ in anesthetic efficacy when applied under occlusion for 30 minutes prior to electrodesiccation of papules of dermatosis papulosa nigra.

METHODS

Forty adults were randomly assigned to treatment with either agent for 30 minutes under Tegaderm. The study drug was administered for an additional 30 minutes if the electrodesiccation of the first few papules was too painful.

RESULTS

One subject treated with EMLA versus none treated with L.M.X.4 experienced complete anesthesia after a single 30-minute application. Nineteen of 20 (95%) subjects treated with EMLA versus 18 of 20 (90%) subjects treated with L.M.X.4 required only a single application (p = .49). Pain scores after the initial 30-minute application (scale: 0 = none to 10 = very severe) were EMLA 3.3 +/- 2.2 (mean +/- SD) versus L.M.X. 4 2.9 +/- 2.0 (p = .46).

CONCLUSION

EMLA and L.M.X.4 provide comparable levels of anesthesia after a single 30-minute application under occlusion prior to electrodesiccation of superficial skin lesions.

[Pigmented lesions of the genital mucosa]

Pigmented lesions of the genital mucosa are more frequent in women than in men. They represent a spectrum of different benign entities. A biopsy is always recommended when the diagnosis cannot be made with certainty on clinical examination and dermatoscopy. Differential diagnostic considerations include melanocytic nevi, blue nevi and syndromes featuring lentigines. Malignant melanomas of the penis and vulva are uncommon tumors which usually appear in elderly patients. They frequently present as painless palpable nodules at routine examination. The treatment consists of excision with histological control of the margins. An aggressive surgical approach has not been shown to prolong the poor 5-year survival. Cooperation with gynecologists and urologists is essential for the optimal management of such patients.

Selective laser trabeculoplasty (SLT) complicated by intraocular pressure elevation in eyes with heavily pigmented trabecular meshworks

PURPOSE

To report and assess the complication of intraocular pressure (IOP) elevations after selective laser trabeculoplasty (SLT) in patients with heavily pigmented trabecular meshworks.

DESIGN

Noncomparative, observational case series.

METHODS

Retrospective analysis of the medical files of four glaucoma patients with heavily pigmented trabecular meshwork, who presented with IOP elevations after SLT.

RESULTS

All four glaucoma patients presented with post-SLT IOP elevations. Three had features of pigmentary dispersion syndrome, and the fourth had a heavily pigmented trabecular meshwork. Two patients had previous argon laser trabeculoplasty (ALT) in the same eye in which SLT was performed, and one had a previous ocular trauma. Eventually, three of the patients required surgical trabeculectomy.

CONCLUSIONS

This case series suggests that post-SLT IOP elevations can be a serious adverse event in some glaucomatous patients. It is recommended by the authors that patients with a deeply pigmented trabecular meshwork, taking multiple topical medications and having previous ALT treatment, should be considered at higher risk for this complication.

[Clinical observation of the effect of crystallitic dermabrasion on skin superficial scars]

OBJECTIVE

To observe the changes in histopathology and clinical effect after the treatment of superficial scars in human faces and exposed parts of human extremities with crystallitic dermabrasion.

METHODS

The machine made in Italy can produce the high speed crystallite to the surface of the scar, resulting in the alveolate wounds. At the same time the crystallitic drill make the accidental scar smooth.

RESULTS

Two thousands and five hundreds and thirty eight suffers were treated for 2-10 times. The appearance of the scars was improved. Six patients complicated with milium, Eleven got hypopigmentation, eight got hypomelanotation. Eighty percent patients of this groups got pigmentation after the treatment. This signs disappeared or improved after 2-6 months. Histopathology demonstrated the scar area became small, the fibroblasts increased remarkably and the collagenous fiber arranged regularly. The cells in the stratum spinosum proliferated actively.

CONCLUSIONS

Crystallitic dermabrasion is a simple and safe method for the treatment of skin superficial scars.

Pigmented speckling as a sign of basal cell carcinoma

BACKGROUND

Basal cell carcinoma may present as a discrete skin-colored papule, which may mimic other common skin tumors.

OBJECTIVES

We present pigmented speckling as a clinical sign for basal cell carcinoma.

METHODS

Twenty cases of basal cell carcinoma with pigmented speckling were collected and their clinical and histologic features were reviewed.

RESULTS

There were 12 men and 5 women. The patients' average age was 70.5 years (range 33-90 years). Fifteen of the 17 tumors were on the head and neck, and 2 tumors were on the shoulders and back. Clinical examination revealed a "speckled appearance" of brown-black pigmentation within and/or at the border of the tumors. Histopathology showed basal cell carcinoma with melanin pigment (positive for Fontana-Masson stain and negative for Perl's stain) within nests of tumor cells.

CONCLUSION

The speckled pigmentation of a basal cell carcinoma is a distinguishing feature, which may be useful in the differential diagnosis of this tumor from other discrete skin tumors.

The use of lasers and intense pulsed light sources for the treatment of pigmentary lesions

Lasers and intense pulsed light sources are frequently used for the treatment of pigmented lesions, and the appropriate selection of devices for different lesions is vital to achieving satisfactory clinical outcomes. In dark-skinned patients, the risk of post-inflammatory hyperpigmentation is of particular importance. In general, long-pulse laser and intense pulsed light sources can be effective with a low risk of post-inflammatory hyperpigmentation (PIH) when used for the treatment of lentigines. However, for dermal pigmentation and tattoo, Q-switched lasers are effective, with a lower risk of complications. In the removal of melanocytic nevi, a combined approach with a long-pulse pigmented laser and a Q-switched laser is particularly applicable.

Chemical peeling in ethnic/dark skin

Chemical peeling for skin of color arose in ancient Egypt, Mesopotamia, and other ancient cultures in and around Africa. Our current fund of medical knowledge regarding chemical peeling is a result of centuries of experience and research. The list of agents for chemical peeling is extensive. In ethnic skin, our efforts are focused on superficial and medium-depth peeling agents and techniques. Indications for chemical peeling in darker skin include acne vulgaris, postinflammatory hyperpigmentation, melasma, scarring, photodamage, and pseudofolliculitis barbae. Careful selection of patients for chemical peeling should involve not only identification of Fitzpatrick skin type, but also determining ethnicity. Different ethnicities may respond unpredictably to chemical peeling regardless of skin phenotype. Familiarity with the properties each peeling agent used is critical. New techniques discussed for chemical peeling include spot peeling for postinflammatory hyperpigmentation and combination peels for acne and photodamage. Single- or combination-agent chemical peels are shown to be efficacious and safe. In conclusion, chemical peeling is a treatment of choice for numerous pigmentary and scarring disorders arising in dark skin tones. Familiarity with new peeling agents and techniques will lead to successful outcomes.

Treatment of Exogenous Ochronosis With a Q-Switched Alexandrite (755 nm) Laser

BACKGROUND

Exogenous ochronosis is a cutaneous disorder characterized by blue-black or slate-gray hyperpigmentation resulting from the prolonged use of certain topical agents, most commonly hydroquinones. It is notoriously difficult to treat.

OBJECTIVE

To report the effectiveness of a quality-switched (QS) 755-nm alexandrite laser in treating hydroquinone-induced exogenous ochronosis.

METHODS

Hydroquinone-induced exogenous ochronosis in two patients was treated with a QS alexandrite laser. The first patient received six treatments (average fluence=7.8 J/cm(2)) at 2-month intervals. The second patient received four treatments (average fluence=6.9 J/cm(2)) at 4-month intervals. Biopsies of lesional skin were obtained before and after laser treatment for histologic evaluation.

RESULTS

Significant lightening of the pigmented skin areas was achieved in both patients without scarring or textural changes. Decreased dermal pigmentation was observed on histologic examination of treated skin specimens.

CONCLUSION

The QS alexandrite laser can effectively treat exogenous ochronosis without untoward side effects.

Idiopathic isolated perioral hyperpigmentation and treatment with the erbium:YAG laser

Perioral hyperpigmentation is commonplace in practice; it can be a physiological finding or reflect a systemic life-threatening disease or syndromes, this is treated with different types of application. A 20-year-old female with isolated perioral hyperpigmentation and treatment of this lesion with an erbium:YAG laser is shown. There were no other signs and symptoms in this patient. Another pathological finding could not be determined during examinations, laboratory tests and radiological studies. The erbium:YAG laser was applied to the hyperpigmented area. There was no complication after laser application and an aesthetically successful result with patient satisfaction was achieved in both early and late terms. According to our knowledge this is the first report, which has described the isolated idiopathic type of perioral hyperpigmentation.

Cutaneous laser surgery in darker skin phototypes

Effective laser surgery in patients with darker skin phototypes can be achieved despite a greater inherent risk of side effects. Although the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, the risks may never be eliminated completely. Therefore, thorough patient preoperative preparation and education regarding the risks of cutaneous laser surgery will remain an essential aspect of treatment in patients with darker skin tones. As more refined laser techniques evolve, the ability to safely and effectively treat these patients will continue to improve.

Microthrombectomy reduces postsclerotherapy pigmentation: multicenter randomized trial

OBJECTIVE

Postsclerotherapy pigmentation occurs in nearly 30% of patients. Hemosiderin, from degradation of the venous thrombus, is the possible cause. The hypothesis that early removal of the thrombus may eliminate or decrease the incidence of pigmentation has not been proved or documented. The objective of this study was to investigate the effects of early microthrombectomy on incidence of postsclerotherapy pigmentation.

MATERIAL AND METHODS

This multicenter, randomized, controlled study involved 101 patients with varicose veins (100 women, 1 man; mean age, 46 years [range, 25-68 years]). Patients were divided into two groups, with veins 1 mm or less in diameter (group 1, n = 50) or veins 3 mm or less in diameter (group 2, n = 51). Group 1 was treated with Sotradecol (STD) 0.25%, and group 2 with STD 0.50%. In each patient, an area of varicosities was selected and divided into halves. One half was randomized to microthrombectomy and the other half served as control. Microthrombectomy was performed 1 to 3 weeks after treatment in the randomized half. Standard photographs were obtained before and 16 weeks after treatment, and were evaluated by three independent reviewers who were blinded to treatment assignments. Each reviewer received an identical set of pretreatment and posttreatment 10 x 15-cm color photographs of the study area, and completed a scoring sheet. Average of the scores was used to evaluate primary (pigmentation) and secondary (overall clinical improvement) end points. The paired t test and chi-square test were used for statistical analysis.

RESULTS

In group 1, microthrombectomized areas had statistically significant less pigmentation (P =.0047) and better overall clinical improvement scores (P =.0002) compared with the control side. In group 2 there was no significant difference between the two areas, but patients reported significant relief of pain and inflammation associated with postsclerotherapy thrombophlebitis.

CONCLUSION

In veins 1 mm or smaller, microthrombectomy reduced pigmentation and improved overall clinical results. In veins 3 mm or smaller, statistical significance was not achieved, but thrombectomy resulted in faster resolution of the postsclerotherapy pain and inflammation. On the basis of these results, microthrombectomy after sclerotherapy is recommended.

Erbium:YAG laser skin resurfacing: a Pakistani experience

BACKGROUND AND OBJECTIVES

To evaluate the use of the erbium:YAG laser for resurfacing in type IV skin patients in Pakistan.

STUDY DESIGN/MATERIALS AND METHODS

Ten patients with skin type IV underwent laser skin resurfacing with an erbium:YAG laser to treat wrinkles, acne/chickenpox scars and hyperpigmentation. An evaluation was done by the treating physician and a photographic evaluation and grading was done by a blinded observer.

RESULTS

The treating physician's records show no erythema, pigmentary alteration, infection or scarring at the 3-month follow-up. The blinded observer's evaluation of the 3-month photographs showed moderate to excellent improvement in 80% of patients in their respective underlying condition.

CONCLUSION

The erbium:YAG laser is safe and effective in treating wrinkles, acne/chickenpox scars and hyperpigmentation in skin type IV patients.

Single-pass CO2 laser skin resurfacing of light and dark skin: extended experience with 52 patients

BACKGROUND

Multiple-pass carbon dioxide (CO2) laser skin resurfacing has been a favored treatment modality for photodamaged and acne-scarred skin over the past several years. Its association with numerous side effects and complications, particularly prolonged erythema and dyspigmentation, however, has dampened the initial enthusiasm reserved for its use. By reducing the laser-associated tissue ablation depth and degree of thermal necrosis, it is possible that the incidence of these side effects can also be reduced.

PURPOSE

To evaluate the clinical efficacy and side effect profile of single-pass CO2 laser skin resurfacing in a large series of patients.

MATERIALS AND METHODS

A total of 52 consecutive patients (skin photo-types I-VI) with mild facial rhytides,atrophic scars, or infraorbital hyper-pigmentation underwent single-pass treatment with a high-energy, pulsed CO2 laser. Side effects to treatment were closely monitored and tabulated. Clinical improvement using a quartile grading scale was assessed independently by two masked medical evaluators at 1, 3, 6, and 12 months postoperatively.

RESULTS

Significant clinical improvement was seen in all patients, with peak improvement scores noted 12 months. Greater clinical improvement was seen in patients with darker skin tones despite the near universal incidence of transient postoperative hyperpigmentation in these patients.

CONCLUSIONS

Single-pass CO2 laser skin resurfacing can improve the appearance of fine rhytides, mild atrophic scars, and infraorbital hyperpigmentation in all skin types. The severity and duration of side effects and complications are reduced with this technique (compared with multiple-pass procedures)and may offer a possible solution to the problem of treating patients with darker complexions.

The effect of combination treatment of the recalcitrant pigmentary disorders with pigmented laser and chemical peeling

BACKGROUND

The pigmentary disorders including melasma, freckles, postinflammatory hyperpigmentation, or acquired bilateral nevus of Ota-like macules, etc. are usually resistant to all treatment modalities, and are therefore very frustrating to the patient and clinician.

OBJECTIVE

The purpose of this study was to demonstrate the effect of the combination treatment of recalcitrant pigmentary disorders with pigmented laser and chemical peeling and to observe any side-effects.

METHODS

Twenty-four patients with recalcitrant facial pigmentary disorders were treated with the Q-switched alexandrite laser at fluences of 7.0-8.0 J/cm2 or the pigmented lesion dye laser (PLDL) at fluences of 2.0-2.5 J/cm2, and at the same session, 15-25% trichloroactic acid (TCA) with or without Jessner's solution were used for the chemical peeling. And the results were clinically analyzed.

RESULTS

In the assessment by the patients, 63% of them considered the result as "clear, excellent, or good" in respect to the color and 54% of them assessed that the size of the lesion had cleared more than 50%. In the assessment by a clinician, 67% of the patients were categorized into the grade of clear, excellent, or good. There were no significant complications with this combination method.

CONCLUSIONS

The combination treatment with pigmented laser and chemical peeling is effective, safe, and relatively inexpensive treatment modalities in the recalcitrant pigmentary disorders.

Facial resurfacing in patients with Fitzpatrick skin type IV

BACKGROUND AND OBJECTIVES

Though post-inflammatory hyperpigmentation (PIH) is probably the most common complication of laser resurfacing and appears to correlate directly with the intensity of the patient's natural pigmentation, there is very little data that specifically addresses the risks of dyspigmentation in more darkly pigmented patients (Fitzpatrick skin types IV and above). The objective of this study was to evaluate the long-term dyspigmentation of patients with skin type IV having radial laser resurfacing.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective review of the clinical efficacy, incidence of dyspigmentation and other adverse effects, as well as the pre/post-operative protocol of 22 patients with Fitzpatrick skin type IV who were a minimum of 1 year post-operative following facial laser resurfacing.

RESULTS

The average patient achieved greater than 50% improvement, indicating adequate treatment being delivered. PIH occurred in 68% of patients, starting 1 month post-operative and lasting 3.8 months. There was no correlation to pre-treatment or type of laser used as far as incidence of PIH. True hypopigmentation was not seen in this group of 22 patients.

CONCLUSIONS

PIH is the most common complication of facial resurfacing in patients with skin type IV. It is not preventable by choice of laser or skin care regimen pre-operative, but appears to respond to appropriate treatment once it has developed.

Laser eradication of pigmented lesions and tattoos

Laser treatment of pigmented lesions can be a rewarding experience when appropriate lesions are treated. Accurate diagnosis of pigmented lesions is needed before treatment. In some lesions, adjuvant topical therapy is greatly beneficial, and for others it may be the only option. The treatment of melanocytic nevi is controversial but worth pursuing. All tattoos respond well to Q-switched lasers; the appropriate wavelength depends on the color of ink. Amateur and traumatic tattoos clear readily with laser treatment. Cosmetic tattoos should be approached with caution. In addition, the use of laser-responsive ink and higher-powered or shorter-pulsed (picosecond) lasers may further enhance the ability to treat tattoos.

Laser resurfacing of darkly pigmented patients

Hyperpigmentation following laser resurfacing in darker-skinned individuals is common but treatable. This pigmentation is usually heralded by persistent erythema and can be prevented in most patients if aggressive laser resurfacing is curtailed and conservative or single-pass techniques are applied. Avoiding excessive intraoperative frictional trauma when removing the desiccated tissue Avoiding excessive intraoperative frictional trauma when removing the desiccated tissue and potentially irritating agents or infections in the pre- or postoperative period is also instrumental in avoiding long-term complications.

Surgical management of post-burn skin dyspigmentation of the upper limb

The technique and results of surgery in 23 patients with skin dyspigmentation of the upper limb are presented. The study population was divided into two groups. Group A (n=15 patients) had hyperpigmented skin grafts in the palm or the palmar aspect of the digits. All patients underwent excision of the hyperpigmented grafts and coverage with split-thickness plantar skin grafts. The plantar grafts gave an excellent colour and texture match and all patients were satisfied with the result. Group B (n=8 patients) had post-burn hypopigmentation on the dorsal aspect of digits, hand or forearm. These patients underwent dermabrasion and thin split-thickness grafting harvested from the upper thigh or buttock. All grafts healed well with no residual hypopigmentation. However, the graft was slightly hyperpigmented when compared to the surrounding skin. Despite this complication, all patients were satisfied and considered this slight hyperpigmentation much better than the preoperative hypopigmentation. The pathogenesis of skin dyspigmentation and other treatment techniques are discussed.

Laser treatment of imipramine-induced hyperpigmentation

BACKGROUND

Blue or slate-gray hyperpigmentation is seen with a variety of medications, including imipramine. We describe a patient with significant imipramine-induced pigmentation.

OBJECTIVE

The purpose of this study was to describe an effective laser treatment resulting in improvement of imipramine-induced hyperpigmentation, without discontinuing the medication.

METHODS

The patient underwent treatment with carbon dioxide, erbium, alexandrite, and ruby lasers to hyperpigmented areas. Tissue biopsy specimens taken before treatment, immediately after treatment with the alexandrite laser, and at clearing were analyzed by light microscopy.

RESULTS

The Q-switched alexandrite and ruby lasers resulted in clinical improvement in the patient's hyperpigmentation and a decrease in pigment granules on light microscopy.

CONCLUSION

Both the Q-switched alexandrite and ruby lasers are effective treatments for imipramine-induced hyperpigmentation. The improvement is progressive with successive sessions.

Minocycline-induced hyperpigmentation: treatment with the Q-switched Nd:YAG laser

BACKGROUND AND OBJECTIVE

Cutaneous hyperpigmentations are well-documented, but nevertheless rare side-effects of high-dose or long-term minocycline therapy. The pigmental changes, may last for years, even though therapy has been abrogated. To date, no safe and effective therapy has been described to target this cosmetically disturbing sequela.

STUDY DESIGN/MATERIALS AND METHODS

A 57-year-old female patient with extensive pigmental changes of the face due to long-term minocycline therapy was treated in eight consecutive sessions with the Q-switched Nd:YAG-laser (1,064-nm wavelength, 5- to 7-nsec impulse length).

RESULTS

A 90% resolution of the pigmentation could be achieved after five treatments. After the last session the lesions were completely gone; no hypopigmentation scars, or other side-effects were observed.

CONCLUSION

Treatment with the Q-switched Nd:YAG laser seems to be an effective, safe, and easily applicable strategy for the therapy of minocycline-induced hyperpigmentations.