Carbon dioxide laser guidelines

Treatment of Acne Keloidalis Nuchae by Simply Combining Two Conventionally Available Modalities: Ablation with Carbon Dioxide Laser and Intralesional Triamcinolone Acetonide

Acne keloidalis nuchae is a chronic inflammatory condition affecting the occipital area or nape of the neck characterized by fibrotic papules, firm pustules, and nodules that coalesce into keloid like mass or plaques. It was first described by Kaposi in 1969. It is also known as lichen keloidalis nuchae, dermatitis papillaris capillitia, and folliculitis nuchae scleroticans. If not treated in the early stages of the disease it tends to be refractory to conventional methods like topical, intralesional steroids with antibiotics or retinoids. Surgical interventions remain the only choice in such cases. Various surgical modalities including surgical excision with primary or secondary closure, split-thickness skin grafts, and laser-assisted treatments have been tried. Most surgical methods have longer downtime with a higher chance of relapse. We studied the results of a combined treatment option carbon dioxide laser ablation followed by intralesional triamcinolone injection in the same sitting. This outpatient procedure has shown good results with no relapse and less downtime.

Combined Carbon Dioxide Laser with Photodynamic Therapy for Nodular Basal Cell Carcinoma Monitored by Reflectance Confocal Microscopy

Introduction: Basal cell carcinoma (BCC) represents around 80% of all malignant skin cancers worldwide, constituting a substantial burden on healthcare systems. Due to excellent clearance rates (around 95%), surgery is the current gold-standard treatment. However, surgery is not always possible or preferred by patients. Numerous non-surgical therapies, sometimes combined, have been associated with promising tumor free survival rates (80-90%) in non-melanoma skin cancers (NMSCs). Most research has enrolled superficial basal cell carcinomas (sBCCs), with limited recent studies also involving low-risk nodular BCCs (nBCCs). Given lower efficacy rates compared to surgery, close monitoring during the follow-up period is essential for patients treated with non-surgical therapies. Monitoring with dermoscopy is constrained by low sensitivity rates. Reflectance confocal microscopy (RCM) is more sensitive in monitoring non-surgically treated NMSCs. Case presentation: A 41-year-old woman with a single nBCC relapse following photodynamic therapy (PDT) located on the dorsum of the nose presented to our center. Given the aesthetically sensitive location of the lesion and the patient's preference for a non-surgical approach, a combined treatment of CO2 laser and PDT was prescribed. A superpulsed CO2 laser (power: 0.5-3 W, frequency: 10 Hz, spot size 2 mm) with two PDT sessions (2 weeks apart) were conducted. At 6 weeks follow-up, monitoring performed with RCM revealed a reduction but not eradication of basaloid tumor islands. Another 2 sessions of PDT were recommended. At 3, 12 and 30 months of follow-up, the nasal dorsum area of the previous nBBC lesion was noted to be slightly hypopigmented (observed clinically), with a mild erythematous background (observed by dermoscopy). RCM evaluation confirmed the absence of RCM BCC criteria. The cosmetic outcome was very much improved. Conclusions: Combined CO2 laser and PDT for the treatment of a localized nBCC on the dorsum of the nose of a 41-year-old proved to offer tumor free survival at 30-month follow-up, as monitored with RCM. RCM is useful for the evaluation of non-surgical therapies as it has comparably higher sensitivity than dermoscopy and is especially useful in cases of suspected late recurrence. Further studies are needed to validate ongoing tumor free survival following this combined nonsurgical approach in the treatment of nBCC.

Carbon Dioxide Laser Rejuvenation of the Facial Skin

This article reviews the evaluation and techniques for facial skin rejuvenation using the fractionated carbon dioxide laser. It includes a detailed overview of laser skin rejuvenation and discusses the potential complications associated with this procedure. A review of clinical outcomes in the literature is also included.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

A Split Face Comparative Interventional Study to Evaluate the Efficacy of Fractional Carbon Dioxide Laser against Combined use of Fractional Carbon Dioxide Laser and Platelet-Rich Plasma in the Treatment of Acne Scars

Background

Fractional carbon dioxide laser (FCL) is an established treatment option for acne scars, but use of platelet-rich plasma (PRP) as an adjuvant still requires elaborate studies.

Aim

To compare the efficacy and safety of FCL alone and combined use of FCL with PRP in the treatment of acne scars.

Materials and Methods

This was a split-face (right-left) comparative study including 32 patients with moderate to severe acne scars. The patients underwent three sessions of FCL along with PRP and FCL alone on right and left sides of the face, respectively, at an interval of 6 weeks. Goodman and Baron qualitative and quantitative scores were used for the evaluation of results along with visual analog scale (VAS) for patient satisfaction and physician assessment of scars. Adverse effects following the procedure were also evaluated and compared.

Results

There was significant improvement of scars over both sides of the face, but the difference between right and left sides was not statistically significant according to Goodman and Baron qualitative (p 0.9115) and quantitative score (p 0.6957). On assessing VAS score, patients were more satisfied with the right side, but the values were not statistically significant (p 0.8571). Physician assessment grading showed comparable results over both the sides (p 1). There was no difference in adverse effects between both sides of the face.

Conclusions

Inclusion of intradermal PRP to FCL did not produce any statistically significant synergistic effects in the treatment of acne scars.

Efficacy and Safety of Lasers in Treating Syringomas: A Review of the Literature

Syringomas are benign adnexal neoplasms that may induce psychological stress when they are large or disfiguring or present in delicate regions such as the periorbital area. Despite the availability of various lasers for syringomas, no consensus has been established on the optimal laser setting and side effects of these therapies. The current review aims at understanding the efficacy and safety of various laser therapies available for the treatment of syringomas. A literature search was carried out using PubMed and Ovid databases for articles published from Jan 2000 through Mar 2022. Screening the eligible articles yielded twenty-seven studies, comprising clinical studies, case series, and case reports, which were included in this review. The CO₂ laser is the most widely used ablative laser therapy but is usually associated with adverse events. Pinhole and multiple drilling methods using CO₂ laser yielded excellent cosmetic results with minimal adverse effects. Fractional lasers reduced the downtime and complications compared to non-fractionated ones. Non-ablative fractional lasers could be advantageous in terms of easy operation, minimal side effects and moderate recovery period compared with ablative lasers. Large clinical trials are needed to generate strong evidence to guide clinicians in choosing the most appropriate laser therapy for syringoma treatment.

Successful Novel Treatment of Granuloma Faciale Using CO2 Emulated Er:YAG Laser Ablation

Granuloma faciale is a rare, benign inflammatory skin disease that has multiple medical treatment modalities due to its frequent unresponsiveness to treatment. This skin disease presents as a single, well-demarcated red-brown to violaceous, raised lesion, most commonly on the face, in middle-aged White men. Its etiology is unknown; sun exposure is thought to have some implications in its formation. Treatment modalities for granuloma faciale include topical therapy, intralesional injections, systemic therapies, phototherapy, lasers, cryotherapy, and surgical excision. In this article, we will highlight a rare case of granuloma faciale and its novel and successful treatment with a carbon dioxide emulated Er:YAG laser.

Interventions for infantile haemangiomas of the skin

BACKGROUND

Infantile haemangiomas (previously known as strawberry birthmarks) are soft, raised swellings of the skin that occur in 3% to 10% of infants. These benign vascular tumours are usually uncomplicated and tend to regress spontaneously. However, when haemangiomas occur in high-risk areas, such as near the eyes, throat, or nose, impairing their function, or when complications develop, intervention may be necessary. This is an update of a Cochrane Review first published in 2011.

OBJECTIVES

To assess the effects of interventions for the management of infantile haemangiomas in children.

SEARCH METHODS

We updated our searches of the following databases to February 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, LILACS, and CINAHL. We also searched five trials registries and checked the reference lists of included studies for further references to relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of all types of interventions, versus placebo, active monitoring, or other interventions, in any child with single or multiple infantile haemangiomas (IHs) located on the skin.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome measures were clearance, a subjective measure of improvement, and adverse events. Secondary outcomes were other measures of resolution; proportion of parents or children who consider there is still a problem; aesthetic appearance; and requirement for surgical correction. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 28 RCTs, with a total of 1728 participants, assessing 12 different interventions, including lasers, beta blockers (e.g. propranolol, timolol maleate), radiation therapy, and steroids. Comparators included placebo, an active monitoring approach, sham radiation, and interventions given alone or in combination.Studies were conducted in a number of countries, including China, Egypt, France, and Australia. Participant age ranged from 12 weeks to 13.4 years. Most studies (23/28) included a majority of females and different types of IHs. Duration of follow-up ranged from 7 days to 72 months.We considered most of the trials as at low risk of random sequence generation, attrition bias, and selective reporting bias. Domains such as allocation concealment and blinding were not clearly reported in general. We downgraded evidence for issues related to risk of bias and imprecision.We report results for the three most important comparisons, which we chose on the basis of current use. Outcome measurement of these comparisons was at 24 weeks' follow-up.Oral propranolol versus placeboCompared with placebo, oral propranolol 3 mg/kg/day probably improves clinician-assessed clearance (risk ratio (RR) 16.61, 95% confidence interval (CI) 4.22 to 65.34; 1 study; 156 children; moderate-quality evidence) and probably leads to a clinician-assessed reduction in mean haemangioma volume of 45.9% (95% CI 11.60 to 80.20; 1 study; 40 children; moderate-quality evidence). We found no evidence of a difference in terms of short- or long-term serious adverse events (RR 1.05, 95% CI 0.33 to 3.39; 3 studies; 509 children; low-quality evidence), nor in terms of bronchospasm, hypoglycaemia, or serious cardiovascular adverse events. The results relating to clearance and resolution for this comparison were based on one industry-sponsored study.Topical timolol maleate versus placeboThe chance of reduction of redness, as a measure of clinician-assessed resolution, may be improved with topical timolol maleate 0.5% gel applied twice daily when compared with placebo (RR 8.11, 95% CI 1.09 to 60.09; 1 study; 41 children;low-quality evidence). Regarding short- or long-term serious cardiovascular events, we found no instances of bradycardia (slower than normal heart rate) or hypotension in either group (1 study; 41 children; low-quality evidence). No other safety data were assessed, and clearance was not measured.Oral propranolol versus topical timolol maleateWhen topical timolol maleate (0.5% eye drops applied twice daily) was compared with oral propranolol (via a tablet taken once per day, at a 1.0 mg/kg dose), there was no evidence of a difference in haemangioma size (as a measure of resolution) when measured by the proportion of patients with a clinician-assessed reduction of 50% or greater (RR 1.13, 95% CI 0.64 to 1.97; 1 study; 26 participants; low-quality evidence). Although there were more short- or long-term general adverse effects (such as severe diarrhoea, lethargy, and loss of appetite) in the oral propranolol group, there was no evidence of a difference between groups (RR 7.00, 95% CI 0.40 to 123.35; 1 study; 26 participants; very low-quality evidence). This comparison did not measure clearance.None of our key comparisons evaluated, at any follow-up, a subjective measure of improvement assessed by the parent or child; proportion of parents or children who consider there is still a problem; or physician-, child-, or parent-assessed aesthetic appearance.

AUTHORS' CONCLUSIONS

We found there to be a limited evidence base for the treatment of infantile haemangiomas: a large number of interventions and outcomes have not been assessed in RCTs.Our key results indicate that in the management of IH in children, oral propranolol and topical timolol maleate are more beneficial than placebo in terms of clearance or other measures of resolution, or both, without an increase in harms. We found no evidence of a difference between oral propranolol and topical timolol maleate with regard to reducing haemangioma size, but we are uncertain if there is a difference in safety. Oral propranolol is currently the standard treatment for this condition, and our review has not found evidence to challenge this. However, these results are based on moderate- to very low-quality evidence.The included studies were limited by small sample sizes and risk of bias in some domains. Future trials should blind personnel and participants; describe trials thoroughly in publications; and recruit a sufficient number of children to deduce meaningful results. Future trials should assess patient-reported outcomes, as well as objective outcomes of benefit, and should report adverse events comprehensively. Propranolol and timolol maleate require further assessment in RCTs of all types of IH, including those considered problematic, as do other lesser-used interventions and new interventions. All treatments should be compared against propranolol and timolol maleate, as beta blockers are approved as standard care.

Treatment of facial lesions of multicentric reticulohistiocytosis by carbon dioxide laser

The carbon dioxide (CO2) laser is a versatile tool that has applications in ablative lasing and caters to the needs of routine dermatological practice as well as the esthetic, cosmetic, and rejuvenation segments. We report a case of multicentric reticulohistiocytosis with cosmetically disfiguring confluent papules over the scalp, forehead, nasolabial folds, chin, and retroauricular region. We used CO2 laser in superpulse mode for ablating the lesions in three sittings. The lesions regressed completely and no recurrence was observed over a regular follow-up of 8 months.