TRASER: An innovative device for the treatment of nasal telangiectasias.

BACKGROUND: Destruction of blood vessels by selective photothermolysis has been successfully achieved using a number of different laser and light systems, none of which provide significant independent variation in parameters such as wavelength. OBJECTIVE: To evaluate the safety and efficacy of a novel configurable device in the treatment of nasal telangiectasias. METHODS: Fifteen subjects aged 42-73 with Fitzpatrick skin types I and II were treated for nasal telangiectasias of various sizes. Efficacy was measured by blinded analysis of pre and post images and self-assessment by the subjects. The primary endpoint was a 2-point improvement of telangiectasia based on a 5-point Telangiectasia Scale comparing the pre-treatment photograph to the post-treatment photograph at 30 days post final treatment by an independent reviewer. Treatment completion was defined as >75% vessel clearance. The TRASER (Total Reflection Amplification of Spontaneous Emission Radiation) was configured to produce a narrow spectral output, peaking at 541 ± 5 nm, with 20-40 millisecond pulses over an energy density range of 15-40 J/cm2 utilizing a 12 mm spot size were delivered with contact sapphire cooling tip at approximately 10°C. RESULTS: All 13 subjects (100%) in the efficacy population achieved procedure success at the end of the final treatment, that is a 2-point improvement of telangiectasis on the telangiectasia scale (pre- vs. post-treatment). A single treatment was effective in >75% of patients with at least a 75% reduction in blood vessels. Larger vessels responded well to longer pulse durations (40 milliseconds) while smaller vessels responded best to shorter pulse durations (25 milliseconds). No serious adverse events (SAEs) were recorded. LIMITATION: Short-term (1 month) follow up. CONCLUSION: The TRASER device is a safe and effective option for treatment of nasal telangiectasias with all subjects meeting primary endpoint success at the end of treatment and the majority of subjects demonstrating clearance after only one treatment. These treatments were well tolerated and provided high patient satisfaction. Lasers Surg. Med. 49:625-631, 2017. © 2017 Wiley Periodicals, Inc.

Retrospective analysis of the treatment of melasma lesions exhibiting increased vascularity with the 595-nm pulsed dye laser combined with the 1927-nm fractional low-powered diode laser.

BACKGROUND: Melasma presents a significant challenge to laser surgeons. Aggressive treatments often result in rebound melasma or post-inflammatory pigmentary alteration. Recent reports suggest melasma pathogenesis may have a vascular component. Spectrocolorimetry can detect subtle or sub-clinical telangiectatic erythema within melasma lesions. For certain patients identified by spectrocolorimetry, effective melasma treatment may include vascular-targeted therapy together with pigment-specific treatment modalities. Such combined therapies may reduce the likelihood of melasma recurrence. OBJECTIVE: To evaluate the efficacy of treating melasma lesions exhibiting subtle or sub-clinical telangiectatic erythema with the 595-nm pulsed dye laser (PDL) combined with the 1927-nm fractional low-powered diode laser (FDL). METHODS: A retrospective review was performed over a 2-year period as follows. Evaluated patients (n = 11) include 10 women and 1 man, average age of 38.7 years, and Fitzpatrick skin types II-IV. Each patient exhibited melasma lesions with subtle or sub-clinical telangiectatic erythema identified by spectrocolorimetry. Each underwent a series of treatments (average of four) at approximate 4-6 week intervals of the PDL followed by the FDL. Treatments were performed same-day, sequentially, with 10-15 minute interim time allowance for skin cooling. The following PDL parameters were utilized: 10 mm spot, 10-20 ms pulse duration, 7.5-8.5 J/cm2 fluence, 30/30 DCD. Eight passes with the FDL (Clear + Brilliant® Permea™, Solta Medical, Hayward, CA) were then performed utilizing a "low" treatment level. Clinical endpoint was mild erythema and edema. Patients were encouraged to practice strict photoprotection and apply topical skin lightening agents, but compliance was not measured. An independent physician evaluated photographs taken at baseline and at follow-up after last treatment session (average follow-up of 96 days). A quartile improvement score was used to grade the improvement of melasma and underlying telangiectatic erythema. At time of data analysis, patient satisfaction was self-graded on a three-point scale (0 = not satisfied, 1 = satisfied, 2 = very satisfied). RESULTS: Six out of eleven patients (54%) demonstrated greater than 50% improvement in melasma presentation. Improvement in melasma generally paralleled improvement in erythema. No rebound melasma, post-inflammatory changes, or adverse events were noted. Patient satisfaction responses averaged 1.6, with all (10) patients reporting 1 "satisfied" or 2 "very satisfied." CONCLUSIONS: Melasma lesions exhibiting subtle or sub-clinical telangiectatic erythema may be improved by combined vascular-targeted laser therapy together with fractional low-powered diode laser therapy. A parallel improvement in telangiectatic erythema suggests a relationship between the underlying vasculature and hyperpigmentation. There is a low risk of adverse effects and overall patient satisfaction is high. Follow-up to optimize treatment parameters and determine long-term durability is needed. Lasers Surg. Med. 49:20-26, 2017. © 2016 Wiley Periodicals, Inc.

Improvement of erythema dyschromicum perstans using a combination of the 1,550-nm erbium-doped fractionated laser and topical tacrolimus ointment.

BACKGROUND AND OBJECTIVE: Erythema dyschromicum perstans (EDP) is a cosmetically distressing, acquired pigmentary disorder of unknown etiology for which few successful therapies exist. Herein, we present the successful use of non-ablative fractional photothermolysis in combination with topical tacrolimus ointment. STUDY DESIGN/PATIENTS AND METHODS: A 35-year-old female with biopsy-confirmed EDP underwent a series of fractionated non-ablative treatment sessions utilizing the 1,550 nm erbium-doped fiber laser in combination with topical tacrolimus ointment over a period of 5 months. RESULTS: The patient's EDP improved by greater than 75% and results were maintained at the 8-month follow-up visit. CONCLUSION: The combination of non-ablative fractional photothermolysis and topical tacrolimus ointment is a potential safe and effective therapeutic option for erythema dyschromicum perstans. Additional prospective, comparative studies are warranted. Lasers Surg. Med. 49:60-62, 2017. © 2016 Wiley Periodicals, Inc.

Best Reconstructive Techniques: Improving the Final Scar.

BACKGROUND: Abnormal cutaneous scarring is due to excessive growth of fibrous tissue in response to traumatic or iatrogenic tissue injury and may adversely affect a patient's quality of life. The success of a surgical procedure is often tied to the cosmetic outcome. OBJECTIVES: To provide a synthesis of available literature and provide guidelines for the management of cutaneous scars with laser technology. MATERIALS AND METHODS: An extensive review of the medical literature was conducted to assess optimal treatment methods for cutaneous scars based on scar features, location, and skin phototype. Recommendations and algorithms were described based on this review and our current clinical experience. RESULTS: Combination therapy with laser and non-laser modalities offers a safe and effective method for scar revision. CONCLUSION: Armed with an understanding of relevant available therapies, skillful dermatologic surgeons may drastically improve the final scar cosmesis. This review discusses current and emerging laser therapy approaches to scar revision.

Paradoxical adipose hyperplasia secondary to cryolipolysis: An underreported entity?

BACKGROUND AND OBJECTIVE: Cryolipolysis is a non-invasive, safe, and effective treatment for localized fat reduction. Paradoxical adipose hyperplasia (PAH) is a rare adverse effect in which patients develop painless, firm, and well-demarcated tissue masses in the treatment areas approximately 3-6 months following cryolipolysis. The incidence of PAH has been estimated at 0.0051% or 1 in 20,000 treated patients. We report two cases of PAH seen in our practice, which may suggest the incidence is greater than previously reported. STUDY DESIGN/PATIENTS AND METHODS: A 44-year-old man underwent cryolipolysis for unwanted fat in the pectoral region. At 4 month follow-up, the patient had well-demarcated tissue growth in the treatment areas. He elected to undergo additional cryolipolysis treatment to the areas. Two months later, he was found to have further tissue growth in the treatment areas. The patient then underwent corrective treatment with liposuction. A 52-year-old man underwent cryolipolysis for unwanted lower abdominal fat. At one year follow-up, he had a well-demarcated, subcutaneous mass on the lower abdomen corresponding to the treatment site. The patient elected to undergo corrective treatment with liposuction. Adipose tissue samples from the treated and non-treated areas, for control, were collected, processed, and stained to evaluate cellularity and tissue structure. RESULTS: In our practice, the incidence of PAH is 0.47% or 2 in 422 cryolipolysis treatments. This is 100 times greater than the device manufacturer's reported incidence. Histopathologic examination of the subcutaneous tissue mass showed an increased number of adipocytes, fibrosis, and scar tissue in the treated areas when compared to controls. No lipoblasts, a marker of malignant neoplastic proliferation, were identified on the histopathologic examination of the affected tissues. CONCLUSION: The incidence of PAH is likely underreported. Further investigation is necessary to elucidate its mechanism of action. By understanding the pathogenesis, this rare adverse effect may be avoided, or even utilized as a therapeutic alternative for the treatment of congenital or acquired lipodystrophy.

Vitamin D deficiency in mycosis fungoides and Sézary syndrome patients is similar to other cancer patients.

BACKGROUND: The purpose of this study was to determine the prevalence of vitamin D deficiency in CTCL patients and whether supplementation corrects vitamin D deficiency or treatment outcome. PATIENTS AND METHODS: Three hundred eleven CTCL patients including 27/311 (8.7%) with Sézary syndrome (SS), 169 cancer controls, and 69 normal controls from the M.D. Anderson clinics had 25(OH)D3 levels determined and categorized as deficient (< 20 ng/mL),insufficient (20-29 ng/mL), or sufficient (≥ 30 ng/mL). Clinical response was determined according to a change in percent body surface area involvement. RESULTS: Low 25(OH)D3 (< 30 ng/mL) levels were present in 76.9% of mycosis fungoides/SS patients, 75.2% of cancer controls, and 66.7% of healthy controls (P » .05, .07) and in 30% to 39% of historical normal controls. Correction of deficiency was successful in 35% or 55 of 156 patients who were given dealer's choice of either vitamin D2 at 50,000 IU orally (p.o.) biweekly or D3 1000 IU p.o. daily. Correction of vitamin D levels was noted in 27 of 100 (27%) patients given D3 and 28 of 56 (50%) given D2. Responses to standard CTCL therapy was similar among patients with corrected and persistently low levels (P » .51). CONCLUSION: To our knowledge,this is the first study of vitamin D status in CTCL patients. Vitamin D deficiency was present in CTCL and other cancer patients compared with normal and historical controls. Correction of vitamin D deficiency and type of vitamin D supplementation used did not affect the overall clinical disease response.

Vemurafenib-related cutaneous side effects ameliorated by acitretin.

BACKGROUND: Vemurafenib is a BRAF kinase inhibitor that improves the survival of patients with metastatic melanoma, who have the V600E BRAF mutation. The development of cutaneous neoplasms, including squamous cell carcinomas (SCCs), keratoacanthomas (KAs), and hyperkeratotic papules is one of the most common adverse effects of this therapy. Systemic retinoids, such as isotretinoin and acitretin, have been used for chemoprophylaxis in individuals at high risk of developing many non-melanoma skin cancers, such as immunosuppressed solid organ transplant recipients. These agents may reduce and delay the growth of skin cancers by exerting their effects during the promotion and progression stages of carcinogenesis. OBSERVATIONS: We report a series of two patients with stage IV metastatic melanoma who presented to our Dermatology clinic for evaluation of a florid eruption of hyperkeratotic neoplasms (verrucae, actinic keratoses, and SCCs) within one month of initiating vemurafenib. After one month of acitretin, substantially fewer new neoplasms were observed in both patients. CONCLUSIONS: Although not definitive, these cases suggest that acitretin may have a role in chemoprevention of a subset of patients with rapidly developing vemurafenib-associated neoplasms and slowing the progression of more aggressive SCCs and KAs. Future studies to evaluate acitretin may substantially improve the morbidity associated with vemurafenib.

Chemotherapy-induced alopecia.

Chemotherapy-induced alopecia is a distressing side effect common to certain treatment regimens in oncology. Unfortunately, chemotherapy-induced alopecia is an often overlooked or minor factor among our current research priorities and thus advances in amelioration have been minimal. This review offers a comprehensive examination of the clinically relevant basic science, clinical research, and current management options for chemotherapy-induced alopecia. We emphasize that hair loss secondary to chemotherapy is not as random or nonspecific in patterns or extent of disease, as one would initially perceive. Patient support and education information and templates are provided to facilitate patient treatment.

Ulcerated plaque under a ruby ring in an immunosuppressed patient.

We report a primary inoculation fungal infection in a 76-year-old man with acute myeloid leukemia. The patient presented with a painful red plaque located where he routinely wore a ruby ring. Histopathology revealed multiple branching septate hyphae. Cultures confirmed Fusarium and Candida parapsilosis infection. A short discussion of these organisms follows.

Antineoplastic agent-associated serpentine supravenous hyperpigmentation: superficial venous system hyperpigmentation following intravenous chemotherapy.

PURPOSE: To review the clinical characteristics and associated antineoplastic agents in patients who developed hyperpigmentation of the superficial venous system after chemotherapy. BACKGROUND: Serpentine supravenous hyperpigmentation was the term coined by Hrushesky to describe increased pigmentation of the skin immediately overlying the venous network used for intravenous infusion of 5-fluorouracil. Subsequently this phenomenon has been observed in individuals treated with other chemotherapeutic agents. METHODS: A 45-year-old woman with breast cancer who developed serpentine supravenous hyperpigmentation after intravenous 5-fluorouracil is described. Published reports of other individuals who developed antineoplastic agent-associated serpentine supravenous hyperpigmentation are reviewed. RESULTS: Serpentine supravenous hyperpigmentation has most commonly been associated with 5-fluorouracil. Other chemotherapy drugs including alkylating agents, antibiotics, anti-microtubules, and proteasome-inhibitors have also caused this distinctive pattern of pigmentation. Serpentine supravenous hyperpigmentation occurs predominately in men who are receiving treatment for solid tumors. CONCLUSIONS: Serpentine supravenous hyperpigmentation is an uncommon sequelae of antineoplastic therapy. Treatment with the associated drug may be continued since this adverse reaction to the chemotherapeutic agent is benign and self-limiting. The hyperpigmented streaks gradually resolve spontaneously after the medication has been stopped.