Confetti-like Sparing: A Diagnostic Clinical Feature of Melasma.

Diagnostic uncertainty when a patient presents with melasma-like Undings can lead to suboptimal treatment and inaccurate prognostic expectations. In this study, the authors present a unique clinical feature of melasma that they term the "Fitzpatrick macule" and test its Utility in establishing diagnostic certainty. The "Fitzpatrick macule" is a confetti-like macule of regularly pigmented skin located within a larger patch of melasma hyperpigmentation. To test its diagnostic Utility, the authors compared clinical photography of known cases of melasma with common mimickers, such as poikiloderma of Civatte and solar lentiginosis, and determined the positivity rate of the Fitzpatrick macule in each scenario. Their results show that 89.1 percent of clinical photographs of melasma were positive for the presence of Fitzpatrick macules compared to 1.1 percent that were negative. In contrast, 37.5 and 56.3 percent of clinical photographs of poikiloderma of Civatte were positive and negative for Fitzpatrick macules, respectively. Solar lentiginosis showed a 5.6 percent positivity and a 77.8 percent negativity for Fitzpatrick macules. The sensitivity and specificity of Fitzpatrick macules for melasma was 99 and 83 percent, respectively. In summary, the authors report a highly sensitive and specific clinical feature of melasma. In cases of diagnostic uncertainty, the presence of Fitzpatrick macules may aid in establishing a diagnosis of melasma.

Facial rejuvenation via the sequential combined use of multiple laser modalities: Safety and efficacy.

BACKGROUND AND OBJECTIVES: Multi-modal combination treatments for facial rejuvenation offer the potential to achieve superior results in a single treatment session. In this study, we evaluate the safety and efficacy of combining multiple laser modalities in a single treatment session. METHODS: Fifty patients underwent a multi-modal facial laser resurfacing procedure consisting of the sequential use of 595 nm pulsed dye laser, 755 nm alexandrite laser, superficial fractionated and fully ablative CO2 laser, superficial fully ablative erbium-YAG laser, and deep fractionated ablative CO2 laser in a single treatment session. Improvements in dyspigmentation, rhytides, telangiectasia, and skin texture were assessed. Patient satisfaction, healing times, and tolerability of procedure was also evaluated. RESULTS: Highly significant improvements in all clinical parameters were demonstrated at both short- and long-term follow-up evaluations. Patients reported a high satisfaction rate. CONCLUSION: Mega-combination treatment utilizing a variety of laser devices in a single treatment session is safe and highly effective at achieving facial rejuvenation. This approach represents an efficient use of both patient and physician time and resources. Lasers Surg. Med. 48:577-583, 2016. © 2016 Wiley Periodicals, Inc.

Delayed granulomatous reactions to facial cosmetic injections of polymethylmethacrylate microspheres and liquid injectable silicone: A case series.

Polymethylmethacrylate microsphere (PMMA) and liquid injectable silicone (LIS) fillers are non-biodegradable, synthetic polymers utilized for long-term soft-tissue augmentation. Delayed granulomatous reactions to permanent fillers are a rare yet significant event that can occur months to years post procedure and are often refractory to treatment and associated with significant cosmetic morbidity. We report a case series of 4 patients who developed granulomatous reactions to PMMA or LIS, 15 months to 5 years post injection. The etiology of granulomatous reactions to permanent fillers is still poorly understood, with foreign-body reactions and/or biofilms purported to play a role. Real-time biochemical analysis with polymerase chain reaction should be performed when the index of suspicion for the presence of a biofilm is high.

Comparative Results in Treatment of Keloids With Intralesional 5-FU/Kenalog, 5-FU/Verapamil, Enalapril Alone,Verapamil Alone, and Laser: A Case Report and Review of the Literature.

BACKGROUND: The pathogenesis of keloids involves a hyperproliferative state due to molecular abnormalities, cellular driving pathways, such as TGF, VEGF, and the inactivation of proapoptotic genes. We reviewed the literature and compared various treatment combina- tions in the treatment of keloids in a one patient observation. METHODS AND MATERIALS: Treatment modalities consisted of: intralesional 5- uorouracil (5-FU)/triamcinolone (TMC), 5-FU/verapamil, enal- april alone, verapamil alone, and fractional carbon dioxide laser. Size, height, and softness of the keloid, pain, itching, and pain were assessed. RESULTS: 5-FU based treatments proved to be more ef cacious than the other modalities. 5-FU + TMC demonstrated the largest reduc- tion in keloid height and rmness. The greatest degree of scar softening and average size reduction was achieved with 5-FU/ TMC (80% and 70% reduction, respectively), followed by 5-FU/verapamil (50% and 33% reduction, respectively). The same combinations led to the greatest reduction in scar height (70% and 33%, respectively). All treatments led to resolution of pain and itching in the keloid. CONCLUSION: The favorable effects of the 5-FU + verapamil combination are new and deserve further exploration. J Drugs Dermatol. 2016;15(11):1442-1447..

Multicenter prospective cohort study of the incidence of adverse events associated with cosmetic dermatologic procedures: lasers, energy devices, and injectable neurotoxins and fillers.

IMPORTANCE: Common noninvasive to minimally invasive cosmetic dermatologic procedures are widely believed to be safe given the low incidence of reported adverse events, but reliable incidence data regarding adverse event rates are unavailable to date. OBJECTIVE: To assess the incidence of adverse events associated with noninvasive to minimally invasive cosmetic dermatologic procedures, including those involving laser and energy devices, as well as injectable neurotoxins and fillers. DESIGN, SETTING, AND PARTICIPANTS: A multicenter prospective cohort study (March 28, 2011, to December 30, 2011) of procedures performed using laser and energy devices, as well as injectable neurotoxins and soft-tissue augmentation materials, among 8 geographically dispersed US private and institutional dermatology outpatient clinical practices focused on cosmetic dermatology, with a total of 23 dermatologists. Participants represented a consecutive sample of 20 399 cosmetic procedures. Data acquisition was for 3 months (13 weeks) per center, with staggered start dates to account for seasonal variation. EXPOSURES: Web-based data collection daily at each center to record relevant procedures, by category type and subtype. Adverse events were detected by (1) initial observation by participating physicians or staff; (2) active ascertainment from patients, who were encouraged to self-report after their procedure; and (3) follow-up postprocedural phone calls to patients by staff, if appropriate. When adverse events were not observed by physicians but were suspected, follow-up visits were scheduled within 24 hours to characterize these events. Detailed information regarding each adverse event was entered into an online form. MAIN OUTCOMES AND MEASURES: The main outcome was the total incidence of procedure-related adverse events (total adverse events divided by total procedures performed), as verified by clinical examination. RESULTS: Forty-eight adverse events were reported, for a rate of 0.24% (95% CI, 0.18%-0.31%). Overall, 36 procedures resulted in at least 1 adverse event, for a rate of 0.18% (95% CI, 0.13%-0.25%). No serious adverse events were reported. Adverse events were infrequently associated with known risk factors. CONCLUSIONS AND RELEVANCE: Noninvasive to minimally invasive cosmetic dermatologic procedures, including energy, neurotoxin, and filler procedures, are safe when performed by experienced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and transient.

Ablative CO2 lasers for skin tightening: traditional versus fractional.

BACKGROUND: With patients more resistant to invasive treatments and those that result in significant downtime, there has been a rise in using lasers to improve skin laxity and induce tissue tightening as an alternative to surgery. Traditional and fractional ablative resurfacing induces skin tightening through precise dermal heating and a wound-healing effect. OBJECTIVE: The purpose of this review was to discuss the mechanism of action of using ablative lasers to induce skin tightening and compare traditional versus fractional technologies. MATERIALS AND METHODS: A review of the literature was performed. RESULTS: The authors discuss traditional and fractional ablative lasers for achieving skin tightening. CONCLUSION: Neocollagenesis and dermal remodeling seen after ablative resurfacing contributes to the clinical improvement seen in tissue tightening. Fractional photothermolysis may enhance tissue tightening effects of ablative lasers because of its ability to ablate deeper into the reticular dermis without significant risk for scarring.

Comparison of intense pulsed light with 1,927-nm fractionated thulium fiber laser for the rejuvenation of the chest.

BACKGROUND: Rejuvenation of the aging chest is important to prevent noticeable disparities between the treated skin of the face and that of the untreated chest. OBJECTIVE: To compare a high-density thulium fiber laser (TFL)-based protocol for the rejuvenation of the aging chest with intense pulsed light (IPL). METHODS AND MATERIALS: We conducted a retrospective chart review comparing patients treated with IPL and those treated with TFL in combination with a quality-switched alexandrite laser and long pulsed dye laser. Blinded photographic assessment of overall improvement, rhytides, skin texture, dyspigmentation, and telangiectasia was performed. Patient satisfaction was assessed in a standardized follow-up survey. Cost and practicality were compared. RESULTS: At a mean follow-up of 45.8 days for IPL and 78.3 days for TFL, the two protocols had comparable clinical efficacy in achieving rejuvenation of the chest. Differences existed in terms of cost and practicality. CONCLUSION: TFL can be used at high density and in simultaneous combination with other targeted laser modalities to achieve rejuvenation of the aging chest. IPL achieves similar clinical efficacy. The choice between treatment modalities depends on physician and patient preferences.

Effect of pulse width of a variable square pulse (VSP) erbium:YAG laser on the treatment outcome of periorbital wrinkles in Asians.

BACKGROUND: Uses of appropriate laser parameters are essential for an optimum outcome with minimal risks of complications. OBJECTIVE: To evaluate the effect of pulse width of a variable square pulse (VSP) Er:YAG laser on the treatment outcome. METHODS: Twenty-four Thais with periorbital wrinkles received two treatments with a low-fluence, VSP Er:YAG laser resurfacing 1 month apart. Subjects were randomly divided into two groups and treated with two different parameters including a pulse width of 0.3 ms (short pulse, SP) for one group and a pulse width of 250 ms (super-long pulse, SL) for the other group. Assessments were evaluated at baseline, 1-month and 3-month follow-up visits. RESULTS: After one treatment, 63.7% and 33.4% of the subjects in the SP and SL groups, respectively, were assessed to have obvious to marked improvement of their wrinkles. After two treatments, a higher percentage of the subjects were rated to have obvious to marked improvement including 91% and 66.7% in the SP and SL groups, respectively. There was no significant difference in therapeutic outcome between the SP and SL groups. CONCLUSIONS: There was no significant difference in efficacy and side effects, between the SP and SL groups. However, a trend toward better response with the shorter pulse width was observed.

Topically applied physiologically balanced growth factors: a new paradigm of skin rejuvenation.

Synergistic interaction of multiple growth factors (GF) in skin controls the processes that promote skin repair. GFs have been shown to affect different pathways of skin repair and rejuvenation with many GFs working in close cooperation with one another and with other endogenous agents. Intrinsic and extrinsic aging of skin reduces both the levels of natural GFs and the number and activity of fibroblasts. Supplementing skin's endogenous GFs may enhance natural repair processes and accelerate the reversal of damage caused by intrinsic and extrinsic skin aging. In spite of their large molecular weight, evidence suggests that a small fraction of topically applied GFs penetrating into superficial epidermis can elicit a fibroblast-mediated response in the dermis. GF mixture secreted by human fibroblasts grown in conditions resembling the physiological condition of dermis, and present at high concentrations in a stable formula is most likely to provide an ideal cosmeceutical product. This naturally balanced mixture is also likely to contain other important, but as yet unidentified, substances that affect skin healing. Such a complex mixture cannot be reproduced using synthetic substances. Clinical studies have shown that topical application of products containing high concentrations of a physiologically balanced mixture of GF appears to reverse the signs of skin aging. A synergistic combination of antioxidants, matrix building agents and skin conditioners with physiologically balanced GF provides a novel and comprehensive paradigm of skin rejuvenation.

Complications of fractional CO2 laser resurfacing: four cases.

BACKGROUND AND OBJECTIVE: Fractional ablative laser therapy is a new modality which will likely be widely used due to its efficacy and limited side-effect profile. It is critical to recognize, characterize, and report complications in order to acknowledge the limits of therapeutic efficacy and to improve the safety of these devices. STUDY DESIGN/MATERIALS AND METHODS: The photographs, treatment parameters, and clinical files of four female patients aged 54-67 who had scarring or ectropion after fractional CO(2) laser resurfacing on the face or neck were carefully reviewed to search for any possible linking factors. RESULTS: Patient 1 developed erosions and swelling of the right lower eyelid 2 days postoperatively, which developed into scarring and an ectropion. Patient 2 developed linear erosions and beefy red swelling on the right side of the neck which developed into a tender, band-like scar over 1-month. Patient 3 developed stinging and yellow exudate in multiple areas of the neck 3 days postoperatively. Cultures grew methicillin-resistant Staphylococcus aureus. Despite appropriate treatment, she developed multiple areas of irregular texture and linear streaking which developed into scars. Patient 4 developed an asymptomatic patchy, soft eschar with yellowish change on the left side of the neck. Azithromycin was started, however at 2-week follow-up she had fibrotic streaking which developed into horizontal scars and a vertical platysmal band. The treatment and final outcome of each patient are described. CONCLUSION: Scarring after fractional CO(2) laser therapy may be due to overly aggressive treatments in sensitive areas (including excessive energy, density, or both), lack of technical finesse, associated infection, or idiopathic. Care should be taken when treating sensitive areas such as the eyelids, upper neck, and especially the lower neck and chest by using lower energy and density. Postoperative infections may lead to scarring and may be prevented by careful taking of history, vigilant postoperative monitoring and/or prophylactic antibiotics.

The short pulse carbon dioxide laser versus the colorado needle tip with electrocautery for upper and lower eyelid blepharoplasty.

BACKGROUND/OBJECTIVE: Various techniques for blepharoplasty have been described, including those performed with the assistance of the short pulse carbon dioxide laser and those performed with the assistance of the Colorado microdissection needle attached to an electrocautery unit. Although the superiority of the carbon dioxide laser to cold steel has been demonstrated for the performance of eyelid blepharoplasty, no studies have ever compared the carbon dioxide laser to the Colorado needle. STUDY DESIGN/MATERIALS AND METHODS: This is a paired comparison study in which 12 healthy patients underwent bilateral blepharoplasty of their upper and/or lower eyelids by a single surgeon. For each patient, a short pulse carbon dioxide laser was used on one side, and a Colorado needle attached to an electrocautery unit was used on the other. Intraoperative times were recorded. At five post-operative visits patients were evaluated for post-operative healing parameters including edema, erythema, scar width, and bruising. Finally, excised tissue was assessed histologically for thermal damage. RESULTS: Comparing both techniques, no difference in patient or physician-measured parameters of healing were noted up to 1 month post-operatively. However, Colorado needle assisted blepharoplasty resulted in slightly shorter intraoperative times. It also resulted in less thermal damage on a histologic level, although these differences were not clinically significant. CONCLUSIONS: For the performance of blepharoplasty, the Colorado needle tip with electrocautery offers benefits equivalent to those of the short pulsed CO2 laser but has the advantage of shorter intraoperative times and lower cost.

Fractional carbon dioxide laser and plasmakinetic skin resurfacing.

Photodamage is one of the most common reasons that patients visit a dermatologist's office. Carbon dioxide (CO(2)) laser resurfacing has always been the gold standard for reversing photodamage. Because of the relatively high incidence of side effects and the prolonged downtime associated with CO(2) resurfacing, new technologies have emerged to address photodamage. Portrait skin regeneration (PSR) is a novel device that has been developed to treat photodamage, and this device yields fewer side effects and downtime than traditional CO(2) laser resurfacing. At our center, we have performed more than 500 high-energy PSR treatments and have developed a unique and highly effective treatment protocol. In addition, fractional CO(2) laser resurfacing has emerged as the latest technology developed to combat photoaging. This technology yields impressive results and is much safer and causes less downtime than traditional CO(2) laser resurfacing. In this article, we will review our treatment techniques and protocols as well as address patient selection, preoperative and postoperative care, and anesthesia.

Endogenous growth factors as cosmeceuticals.

Growth factors play an important role in reversing the effects of skin aging mediated by chronological and environmental factors. Excessive oxidation of intra- and extracellular components result in breakdown of collagen and elastin network in the dermis and produce the effect of facial aging. Topical application of human growth factors in multiple clinical studies has been shown to reduce the signs and symptoms of skin aging, including statically significant reduction in fine lines and wrinkles and increase in dermal collagen synthesis. More double-blind and controlled studies are needed to confirm the preliminary clinical effects of growth factor products, and more controls on product quality and stability need to be established.

Effect of pulse width of a 595-nm flashlamp-pumped pulsed dye laser on the treatment response of keloidal and hypertrophic sternotomy scars.

BACKGROUND: Flashlamp-pumped pulsed dye lasers (PDLs) have successfully treated keloidal and hypertrophic scars. OBJECTIVE: The objective was to investigate the effect of pulse width of a PDL in treating keloidal and hypertrophic scars. METHODS: On each of 19 patients, keloidal or hypertrophic median sternotomy scars were divided into two segments. Both segments on all patients were randomly treated with a 595-nm PDL at a fluence of 7 J/cm(2) and pulse widths of 0.45 and 40 ms to both segments, every 4 weeks for a total of three treatments. Scar volume, height, erythema, and pliability were measured at Weeks 0, 4, 8, and 24. RESULTS: The volume of segments treated with 0.45- and 40-ms pulses decreased significantly after two treatments. Segments treated with a 0.45-ms pulse width showed significantly greater improvement than those treated with 40-ms pulses after three treatments. Elasticity of 0.45-ms segments was significantly higher than those of 40-ms segments, following two treatments. Pulse width had no significant effect in improvement of scar erythema. CONCLUSIONS: A pulse width of 0.45 ms of PDL was more effective in decreasing scar size and improving scar pliability than that of 40 ms. A 595-nm PDL was safe and effective in treatment of hypertrophic scars and keloids in dark-skinned individuals. This study was supported in part by an educational grant from the Dermatological Society of Thailand.

The treatment of melasma with fractional photothermolysis: a pilot study.

BACKGROUND: Melasma is a common pigmentary disorder that remains resistant to available therapies. Facial resurfacing with the pulsed CO2 laser has been reported successful but requires significant downtime, and there is a risk of adverse sequelae. OBJECTIVE: To determine if melasma will respond to a new treatment paradigm, fractional resurfacing. METHODS: Ten female patients (Fitzpatrick skin types III-V) who were unresponsive to previous treatment were treated at 1- to 2-week intervals with the Fraxel laser (Reliant Technologies, Palo Alto, CA, USA). Wavelengths of 1,535 and 1,550 nm were both used, and 6 to 12 mJ per microthermal zone with 2,000 to 3,500 mtz/cm2 were the treatment parameters. Four to six treatment sessions were performed. Responses were evaluated according to the percentage of lightening of original pigmentation. Two physicians evaluated the photographs, and each patient evaluated her own response. RESULTS: The physician evaluation was that 60% of patients achieved 75 to 100% clearing and 30% had less than 25% improvement. The patients' evaluations agreed, except for one patient, who graded herself as 50 to 75% improved as opposed to the physician grading of over 75%. There was one patient with postinflammatory hyperpigmentation and no patient with hypopigmentation. No downtime was necessary for wound healing. CONCLUSIONS: Fractional resurfacing affords a new treatment algorithm for the treatment of melasma that combines decreased risk and downtime with significant efficacy. This treatment modality deserves further exploration to maximize benefits.

Review of photorejuvenation: devices, cosmeceuticals, or both?

BACKGROUND: Both the public and the medical profession have placed a lot of attention on reversal of signs of aging and photodamage, resulting in numerous cosmeceutical products and nonablative laser techniques designed to achieve these results. OBJECTIVE: The purpose of this report is to briefly review both the cosmeceutical products and nonablative laser techniques that appear to be most promising based on published studies. After this review, recommendations for potential enhancement of benefits by combining cosmeceuticals and laser treatments will be explored. RESULTS: Pulsed dye lasers targeting microvessels, intense pulsed light targeting both melanin and microvessels, and midinfrared lasers targeting dermal water and collagen all appear to have some ability to improve skin texture, color, and wrinkling. Retinoids, vitamin C, alpha-hydroxy acids, and topical growth factors may also stimulate repair mechanisms that result in similar improvements in photodamaged skin. CONCLUSION: Although supported only by theoretic considerations and anecdotal reports, it seems logical that the concurrent use of appropriate cosmeceuticals with nonablative laser photorejuvenation should result in enhanced benefits.

Long-pulsed dye laser treatment for facial telangiectasias and erythema: evaluation of a single purpuric pass versus multiple subpurpuric passes.

BACKGROUND AND OBJECTIVE: Subpurpuric treatments with the pulsed dye laser can be effective for treatment of vascular lesions, although less so than when purpuric fluences are used. Increased efficacy may be achieved by performing multiple passes at the time of treatment. We performed a split-face bilateral paired comparison of multiple low-fluence subpurpuric passes compared with a single high-fluence purpuric pass in the treatment of facial telangiectasias. MATERIALS AND METHODS: Nine patients were included in the study. One cheek was chosen to be treated with four passes of a nonpurpuric fluence, and the contralateral cheek was treated with a single purpuric pass. Reductions in vessel density, diameter, arborization, and background erythema were evaluated 3 weeks after treatment. RESULTS: We found a 43.4% reduction in surface area covered by telangiectasias on the cheek treated with a single purpuric pass compared with 35.9% on the cheek treated with four subpurpuric passes. The purpuric fluences produced greater reduction in vessel diameter and arborization, whereas the subpurpuric protocol was more effective in reducing background erythema. Purpuric fluences were also noted to produce more significant edema and transient hyperpigmentation in one patient. CONCLUSION: The multipass subpurpuric approach to treatment with the pulsed dye laser is both cosmetically acceptable and effective, although purpuric treatments may be required to effectively eliminate larger-caliber, more highly networked vessels.

Endogenous growth factors as cosmeceuticals.

BACKGROUND: Research into the pathophysiology of photodamaged skin has revealed correlations with certain aspects of acute and chronic wound healing. In wound healing, growth factors accumulate at the wound site and interact synergistically to initiate and coordinate wound healing. OBJECTIVES: To review the effects of topical growth factors in wound healing and their potential use in treating photodamaged skin. METHODS: A mixture of multiple growth factors derived from human fibroblasts was applied topically to 14 patients twice daily for 60 days to stimulate the remodeling phase of wound healing. RESULTS: A total of 78.6% of patients with photodamaged skin showed clinical improvement at 60 days. New collagen formation increased by 37%, and epidermal thickening increased by 27%. CONCLUSIONS: These data, as well as other studies of growth factors in wound healing, demonstrate positive cosmetic and clinical outcomes of topical application of growth factors for the treatment of photodamaged skin.