The Effect of Fat Grafting on Scars Hyperpigmentation: A Systematic Review and Meta-Analysis

BACKGROUND

Hyperpigmented scars, particularly in exposed body areas, can be difficult to conceal and may evoke psychological distress. While the precise causes of scar dyschromia are not fully understood, alterations in melanogenic activity appear to hold more significance than changes in melanocyte quantity. Current treatments encompass laser interventions. However, it is essential to consider their costs and potential complications in relation to their limited proven effectiveness. Fat grafting has gained interest as a scar modulation technique due to its regenerative properties, and its efficacy in reducing scar hyperpigmentation is currently under investigation.

METHODS

A systematic review and meta-analysis was reported according to PRISMA guidelines. PubMed, Embase, and Cochrane Library databases were accessed. PROSPERO registration number is CRD42023457778. The primary outcome was a change in scar pigmentation after fat grafting. Pigmentation changes after fat grafting were calculated using the standardized mean difference (SMD) between baseline and postoperative scores according to POSAS and VSS scales. Bias assessment was conducted according to the National Institute for Health and Clinical Excellence quality assessment tool.

RESULTS

A total of 8 articles meeting inclusion and exclusion criteria were identified, involving 323 patients with hyperpigmented scars treated with fat grafting. A significant difference in scar pigmentation was noted after treatment with fat grafting according to observers' ratings, with a SMD of - 1.09 [95% CI: - 1.32; - 0.85], p<0.01. The SMD for patient-reported scar pigmentation after treatment with fat grafting was - 0.99 [96% CI: - 1.31; - 0.66], p<0.01. Four studies provided objective measurements of melanin changes after fat grafting and revealed inconsistent findings compared to subjective observations.

CONCLUSIONS

Fat grafting shows promise in ameliorating hyperpigmented scars based on subjective assessments, but further corroborating evidence from objective measures is required.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty

BACKGROUND

Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique for preventing postoperative tear trough deformity. Its drawbacks include retraction, limited volume, transcutaneous fixation, and a complex insertion technique. The minced lower eyelid fat graft was introduced to overcome these drawbacks.

OBJECTIVES

The aim of this study was to compare the outcome of preperiosteal pedicle fat flaps with minced free fat graft in TCLB.

METHODS

Participants who underwent the pedicle fat flap procedure from April 2019 to April 2020 (Group A) and the minced free fat graft from May 2020 to May 2021 (Group B) with at least 6 months of follow-up were included. Subjective (pain, infraorbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes, satisfaction (visual analogue scale score) at the last follow-up, and reoperation rates were compared.

RESULTS

There were 142 participants (94% females) with a mean age of 48.4 years (range: 21-71) and a follow-up of 8.2 months (range: 6-36). There were 73 participants in Group A and 69 in Group B, with no significant differences in age (P = .6), sex (P = .7), or follow-up (P = .3). In addition to TCLB, Groups A and B had simultaneous upper eyelid and eyebrow procedures (53% vs 49%, P = .2), lateral canthal plication (77% vs 83%, P = .4), and pinch skin excision (82% vs 88%, P = .3). Groups A and B did not have significant differences in postoperative numbness (6.8% vs 1.4%, P = .2), chemosis (11% vs 10%, P = 1), skin wrinkles (12.3% vs 8.7%, P = .6), hyperpigmentation (1.4% in both groups), bumps (2.7% vs 7.2%, P = .3), tear trough deformity (0.0% in both groups), satisfaction score (97.7% vs 98.1%, P = .4), or reoperation rate (12.3% vs 5.8%, P = .2).

CONCLUSIONS

The desired aim of fat redistribution in TCLB seems to be equally achievable with minced fat graft and pedicle fat flap techniques.

LEVEL OF EVIDENCE: 4

Vitamin C mesotherapy versus diode laser for the esthetic management of physiologic gingival hyperpigmentation: a randomized clinical trial

BACKGROUND

Physiologic gingival hyperpigmentation is a common esthetic concern that affects individuals of various ethnicities, and can have a significant impact on individual's self-confidence and overall quality of life. Thus, this study aimed to clinically assess the effectiveness of intra-mucosal injection of vitamin C versus 980 nm diode laser for the management of physiologic gingival hyperpigmentation.

METHODS

Twenty-six healthy non-smoker individuals with physiologic gingival hyperpigmentation were randomly assigned to two groups. Group I received intra-mucosal injection of vitamin C (L-Ascorbic acid 1000 mg/5 ml), and group II was managed using diode laser (980 nm, 1.5 W, continuous wave mode). Clinical evaluation of pigmentation intensity and distribution was performed preoperatively, and at 1, 2 and 3 months postoperatively using two different color assessment indices; Dummett-Gupta Oral Pigmentation Index (DOPI), and Gingival Pigmentation Index (GPI). Additionally, the study assessed pain intensity and patients' satisfaction.

RESULTS

Pigmentation scores decreased significantly between pre-operative visit and different follow-up visits for both treatment modalities (p < 0.0001*). When compared to the vitamin C mesotherapy group, the laser group demonstrated significantly lower gingival pigmentation scores (p < 0.0001*). However, both treatment modalities were equally satisfying for the patients.

CONCLUSIONS

Vitamin C mesotherapy and diode laser are both effective in the management of physiologic gingival hyperpigmentation. While diode laser yields better and earlier results, vitamin C mesotherapy offers a cost-effective, safe and minimally invasive approach that is equally satisfying for the patients seeking esthetic enhancements.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov (NCT05608057) on (01/11/2022).

Lipofilling Enriched with Adipose-Derived Mesenchymal Stem Cells Improves Soft Tissue Deformities and Reduces Scar Pigmentation: Clinical and Instrumental Evaluation in Plastic Surgery

BACKGROUND

Scars and soft tissue deformities (S-STDs), often resulting from hemifacial atrophy, trauma, and outcomes of burns, were usually associated with hyperpigmentation of overlying skin.

OBJECTIVES

This study aimed to evaluate the long-term effects of fat grafting commonly called "Lipofilling" enhanced with adipose-derived mesenchymal stem cells (Lipofilling-AD-MSCs) for treating S-STDs with pigmentary changes.

METHODS

A cohort study has been performed. 50 patients affected by S-STDs with hyperpigmentation treated with Lipofilling-AD-MSCs and 50 patients treated with Lipofilling not enhanced (Lipofilling-NE) were prospectively assessed. The pre-op evaluation included a clinical evaluation, a photographic assessment, magnetic resonance imaging, and ultrasound. Post-op follow-up was performed at 1, 3, 7, 12, 24, 48, weeks, and then annually.

RESULTS

Improvement in volume contours and pigmentation was clinically assessed. All people who underwent the treatments (Lipofilling-AD-MSCs and Lipofilling-NE) were satisfied with the improving pigmentation, texture, and volume contours with some differences. However, the results reported displaying a better trend in patients treated with Lipofilling-AD-MSCs to be more satisfied than patients treated with Lipofilling-NE (p < 0.0001).

CONCLUSIONS

In conclusion, Lipofilling-AD-MSCs was the preferred option for improving the contour deformities related to increased pigmentation of scars.

LEVEL OF EVIDENCE IV

Evidence obtained from cohort studies.

Clinical application of 675 nm laser therapy for dorsal hand skin hyperpigmentation

BACKGROUND

Noninvasive skin rejuvenation treatment is growing in recognition to aesthetic medicine.

AIM

The objective of the study was to assess the efficacy and the safety of the 675-nm laser source treatment of photodamaged hands.

MATERIALS AND METHODS

The study included 21 patients (6 males and 15 females) with a mean age of 63 (± 9) years. Patients were treated with -two to three sessions of the 675-nm laser with a 1-month interval between sessions. Photos of each patient were collected at baseline, and 3 months after the last laser session. The 5-point Global Aesthetic Improvement Scale (GAIS) was recorded with their final assessment session (3 months).

RESULTS

The total GAIS scores showed satisfactory results: 15 patients (71%) experienced 4 score (excellent improvement) changes and 6 patients (29%) experienced 3 score (good improvement) changes. Clinical images showed good efficacy and visible aesthetic results for the management of photodamaged skin. No serious adverse effects were recorded.

CONCLUSION

This study demonstrates the safety and efficacy of for the aesthetic improvement of skin pigmentation and texture for photodamaged hands.

Treatment of facial pigmented disorders with a 785-nm picosecond Ti:sapphire laser in Asians: A report of three cases

Since the advent of the theory of selective photothermolysis, the importance of targeting the chromophore and minimizing the surrounding damage has been extensively discussed. Picosecond-domain laser (ps-laser) treatment with a wide range of wavelengths is an emerging option for various pigmented lesions; however, no definitive treatment choice has been confirmed. The authors aimed to investigate the efficacy and safety of a ps-laser with a 785-nm wavelength for the treatment of facial pigmented lesions in Asians. Three Korean patients with facial pigmented lesions were recruited for the study. A 785-nm ps-laser with a fractionated and an unfractionated handpiece was utilized to administer the treatment. The clinical outcome was evaluated by a clinician by comparing pre- and post-treatment photographs. All patients exhibited a significant improvement in pigmented lesions including freckles, lentigines, and melasma, after three to four sessions of treatment. No adverse events, including post-inflammatory hyperpigmentation or hypopigmentation were observed. In conclusion, this novel 785-nm Ti:sapphire ps-laser may be an effective and safe modality for treating pigmented lesions in skin of color.

Fractional Ablative Carbon Dioxide Lasers for the Treatment of Morphea: A Case Series and Literature Review

Morphea is an inflammatory, immune-mediated disease of unknown aetiology. It is characterised by excessive collagen deposition, which leads to the hardening of the dermis and subcutaneous tissues. The disease is associated with cosmetic and functional impairment, which can affect the patients’ quality of life. Fractional ablative lasers (FALs) are currently used for the treatment of many skin diseases that are connected to tissue fibrosis due to the low risk of side effects and their great effectiveness. This study aimed to improve the aesthetic defects that are caused by morphea lesions and assess the efficacy and safety of FAL use in this indication. We also reviewed the literature on the subject. We present four women with biopsy-proven morphea, manifesting as hyperpigmented plaques and patches. One of the patients additionally had morphea-related knee joint contracture. Four fractional CO2 laser sessions, separated by one-month intervals, were performed and produced significant improvements in dyspigmentation and induration. An improved elasticity and a decrease in dermal thickness were also obtained, as proven by measurements using DermaLab Combo. No severe adverse effects occurred. Based on these cases presented by the authors, fractional CO2 lasers appear to be an effective, well-tolerated, and safe therapeutic option for patients suffering from morphea.

Adipose Tissue Grafting Improves Contour Deformities Related Hyperpigmentation of Face

Contour deformities of face are commonly associated with overlying skin hyperpigmentation. Such hyperpigmentation causes aesthetic problems as well as makes contour deformities more prominent. Conventional surgical and cosmetic approaches to treat hyperpigmentation have limitations and therefore it is imperative to use other innovative techniques to simultaneously heal the contour deformity and also to remove hyperpigmentation. The current study aims to evaluate the effect of autologous adipose tissue in improving contour deformities related hyperpigmentation of face. One hundred patients with contour deformities related hyper-pigmentation of overlying skin were enrolled from February 2017 to January 2018. Adipose tissue was harvested from each patient and processed under sterilized conditions. Purified fat collected in a 10cc Luer-Lok syringe was transferred to 1cc syringes and injected into affected areas of face. The patients were followed for 12 months after adipose tissue injections. Both subjective and objective assessment was performed before treatment and 12 months after adipose tissue injections. Results indicated that after adipose tissue grafting, there was a statistically significant improvement in hyperpigmentation of skin. Most of the patients were highly satisfied after use of adipose tissue injections. Image J scanning also showed significant changes in hyperpigmentation of face after adipose tissue use. In all parameters, the patient exhibited statistically significant improvement. In conclusion, autologous fat grafting is a promising and effective therapeutic approach for hyperpigmentation associated with contour deformities of face.

Firm, hyperpigmented subcutaneous nodule in the inguinal fold of an infant

Subcutaneous juvenile xanthogranuloma (JXG) of the inguinal fold, an unusual location, was diagnosed in an infant. Subcutaneous JXG should be included in the differential diagnosis of subcutaneous nodules of the lower body, despite the absence of the characteristic yellowish hue usually associated with JXG.

A pediatric case of unusual melanocytic proliferation of the nail

Pigmentation of the nail plate, or melanonychia, is typically a benign condition caused by melanocyte activation. Although rare, melanonychia may be the initial presentation of melanoma, thus all cases require an in-depth examination. Evaluation in pediatric patients can prove especially difficult as benign cases have a higher prevalence of atypia compared to adults. Lack of specific treatment guidelines in the pediatric population can make diagnosis and treatment challenging. We report a pediatric patient with melanonychia with atypical features that required significant evaluations and collaboration to ultimately reach a treatment plan.

Whitening effects of adipose-derived stem cells: a preliminary in vivo study

Many studies have reported various growth factors secreted from adipose-derived stem cells (ADSCs). In particular, regenerative effects in skin have received much attention in the clinical fields. The in vitro whitening effects of ADSCs have been reported. A previous study demonstrated that ADSCs secrete growth factors that inhibit both melanin synthesis and tyrosinase activity. This study aimed to investigate the in vivo whitening effect of ADSCs using mouse models. In the study, ADSCs were isolated from the adipose tissue of C57BL/6 mice and cultured. The ADSCs (1 × 10(6) cells in 30 μl of Hanks' balanced salt solution [HBSS]) then were injected intradermally in the dorsal area of the right ear, and 30 μl of HBSS was injected on the left ear as a control. After 7 days, both ears were irradiated with ultraviolet B (UVB) (150 mJ/cm(2)) three times at 2-day intervals. The sections of each ear were stained with hematoxylin-eosin, Fontana-Masson, and HMB-45 (a melanocytic cell-specific monoclonal antibody). The histologic parameters evaluated included inflammation (+/-), erosion (+/-), and melanin formation (graded on a scale of 1 to 3). No significant differences in inflammation or erosion were observed by hematoxylin and eosin staining (inflammation: p = 0.388; erosion: p = 0.355). However, significantly more melanin formation was observed in the control group than in the ADSC injection group by Fontana-Masson and HMB-45 staining (Fontana-Masson: p = 0.025; HMB-45: p = 0.015). The study findings suggest that ADSCs inhibit melanin formation induced by UV exposure. Potentially, ADSCs may be used as anti-aging agents, including skin whitening. Before human clinical studies can be conducted, further study is required to determine the mechanisms underlying the whitening effects of ADSCs and the safety of ADSC use.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Integrating techniques to re-establish dentogingival esthetics

The aim of this article was to report the clinical case of a male patient of 20 years with hyperpigmented gingiva and moderate fluorosis, whose smile was reestablished by the use of a laser assisted depigmentation procedure, an enamel microabrasion technique, followed by at-home bleaching and subsequent remineralization therapy. The association of these techniques presented excellent results and the patient was satisfied. All techniques are painless, fast and easy to perform, in addition to preserving the hard and soft dental structure. Treatment showed immediate and permanent results; these techniques must be divulged among professionals and their patients.

Periocular hyperpigmentation: a review of etiology and current treatment options

BACKGROUND

Periocular "dark circles" fall among the most difficult chief complaints to address. In most cases, we have little information regarding etiology and no gold-standard treatment option. The extent of the problem is reflected in the sheer number of products on the market advertised to either lighten or cover the pigmentation.

OBJECTIVE/METHODS

To present dermatologists with a complete review of the literature with regard to anatomy, definition, etiology, and treatment of periocular hyperpigmentation.

CONCLUSIONS

Our understanding of the causes and treatment of periocular hyperpigmentation continues to advance. Nevertheless, we are in need of additional controlled clinical trials and novel therapeutic options. Individual patients will likely benefit most from a combination of approaches. Although more randomized clinical studies are necessary, Pfaffia paniculata/Ptychopetalum olacoides B.⁄Lilium candidum L.-associated compound cream seems to be a promising option, with 90% improvement. For patients with increased melanin deposition, quality-switched ruby laser therapy could offer a better treatment option. In the hands of experienced professionals, a surgical option might be suitable, either by autologous fat transplantation or hyaluronic acid filler.

Treatment of gingival physiologic pigmentation in adolescents by liquid nitrogen cryosurgery: 24-month follow-up

Although gingival pigmentation is physiologic in most cases, esthetic concerns regarding "black gums" are common among adolescents. Numerous procedures have been suggested to treat this problem. The aim of this study was to evaluate the efficacy of cryosurgery with liquid nitrogen for the removal of physiologic gingival pigmentation (PGP) in adolescents. Melanin pigmentation of the anterior segments in 15 patients was treated using liquid nitrogen. Standard digital photographs were taken preoperatively and at 3, 12, and 24 months postoperatively. Photographs were analyzed digitally and showed significant differences in gingival color between the preoperative and postoperative follow-ups. Cryosurgery successfully removed PGP in adolescents.

Hyperpigmented burn scar improved with a fractionated 1550 nm non-ablative laser

Scars sustained following injury in patients with darker skin types can present a treatment challenge. These scars often hyperpigment and may remain refractory to first line treatments such as topical retinoids and hydroquinone. Additionally, more aggressive treatment interventions such as ablative resurfacing, chemical peels, and Q-switched laser therapy may actually worsen the pigmentation. We describe a 22-year female with a hyperpigmented scar and Fitzpatrick type IV skin that improved markedly following treatment with a fractionated erbium doped fiber laser. The improvement was maintained at least 1 year following the last procedure.

Laser treatment of pigmented lesions for Asians

The term Asian refers to East Asians of the Pacific Rim who share not only a common heritage and skin type but also the same set of clinical skin problems. Pigmentation of the skin is often considered the number one esthetic skin concern in Asians. Asians idealize unblemished complexion of facial skin and are less tolerant to facial dyschromia than White. The problems of ephelides (freckles), nevi of Ota, and melasma are common and difficult to treat. This article reviews laser treatment of pigmented lesions in Asians.

Fractional resurfacing

Fractional resurfacing produces a distinctive thermal damage pattern by creating discrete columns of thermal damage referred to as microthermal treatment zones. It characteristically spares the tissue surrounding each microthermal treatment zone leading to fast epidermal repair. Fractional resurfacing has been successfully used in treating a variety of skin conditions including melasma, dyschromia, lentigenes, wrinkles, and acne scars with minimal downtime. It is safer to use off the face and in darker skin types.

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.