Ablative fractional resurfacing for involuted hemangioma residuum.

BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

Treatment of superficial infantile hemangiomas of the eyelid using the 595-nm pulsed dye laser.

BACKGROUND: Despite the proven effectiveness of the 595-nm pulsed dye laser (PDL) in treating superficial infantile hemangiomas, many physicians are reluctant to treat such lesions involving the eyelid. OBJECTIVE To examine the safety and efficacy of the 595-nm PDL for the treatment of superficial infantile hemangiomas of the eyelid. MATERIALS & METHODS: Records were reviewed for patients with superficial infantile hemangiomas of the eyelid treated with 595-nm PDL. Pre- and post-treatment photographs were compared. Reviewers rated the degree of improvement of the hemangioma as excellent (76-100%), good (51-75%), moderate (26-50%), or poor (0-25%) and indicated whether the hemangioma was 100% clear. Side effects of scarring, atrophy, hyperpigmentation, and hypopigmentation were assessed. RESULTS: Twenty-two patients met the study criteria. Eight (36.4%) demonstrated complete clearance of their hemangioma, 17 (77.3%) received an improvement rating of excellent, and five (22.7%) received a rating of good. No scarring, atrophy, or hypopigmentation was noted. Two patients (9.1%) were noted to have hyperpigmentation in the treated area. CONCLUSION: Early treatment with the 595-nm PDL can safely and effectively diminish proliferative growth and hasten resolution of superficial infantile hemangiomas of the eyelid.

Successful treatment of atrophic postoperative and traumatic scarring with carbon dioxide ablative fractional resurfacing: quantitative volumetric scar improvement.

OBJECTIVE: To assess the safety and efficacy of ablative fractional resurfacing (AFR) for nonacne atrophic scarring. DESIGN: In this before-and-after trial, each scar received 3 AFR treatments and 6 months of follow-up. SETTING: Private academic practice. PATIENTS: Fifteen women with Fitzpatrick skin types I to IV, aged 21 to 66 years, presented with 22 nonacne atrophic scars between June 1 and November 30, 2007. Three patients (3 scars) were excluded from the study after receiving 1 AFR treatment and not returning for follow-up visits. The remaining 12 patients (19 scars) completed all 3 treatments and 6 months of follow-up. INTERVENTIONS: Each scar received 3 AFR treatments at 1- to 4-month intervals. MAIN OUTCOME MEASURES: Erythema, edema, petechiae, scarring, crusting, and dyschromia were graded after treatment and through 6 months of follow-up. Skin texture, pigmentation, atrophy, and overall appearance were evaluated after treatment and through 6 months of follow-up by the patient and a nonblinded investigator. A 3-dimensional optical profiling system generated high-resolution topographic representations of atrophic scars for objective measurement of changes in scar volume and depth. RESULTS: Adverse effects of treatment were mild to moderate, and no scarring or delayed-onset hypopigmentation was observed. At the 6-month follow-up visit, patient and investigator scores demonstrated improvements in skin texture for all scars (patient range, 1-4 [mean, 2.79]; investigator range, 2-4 [mean, 2.95]), pigmentation for all scars (patient range, 1-4 [mean, 2.32]; investigator range, 1-4 [mean, 2.21]), atrophy for all scars (patient range, 1-4 [mean, 2.26]; investigator range, 2-4 [mean, 2.95]), and overall scar appearance for all scars (patient range, 2-4 [mean, 2.89]; investigator range, 2-4 [mean, 3.05]). Image analysis revealed a 38.0% mean reduction of volume and 35.6% mean reduction of maximum scar depth. CONCLUSION: The AFR treatments represent a safe, effective treatment modality for improving atrophic scarring due to surgery or trauma.

Fractionated CO2 laser resurfacing: our experience with more than 2000 treatments.

Fractionated carbon dioxide (CO(2)) laser resurfacing combines the concept of fractional photothermolysis with an ablative 10,600-nm wavelength. This technology allows for the effective treatment of rhytides, photodamage, and scars, with shorter recovery periods and a significantly reduced side effect profile as compared to traditional CO(2) laser resurfacing. In this article, the authors review the concept of fractional photothermolysis, the expanding array of indications for use of fractionated CO(2) lasers, and their preferred treatment technique.

Nodular pretibial myxedema.

A 30-year-old man with previously diagnosed and treated Graves disease presented for consultation regarding asymptomatic nodules over his anterior tibias. He was euthyroid at the time of presentation. The nodules arose symmetrically beneath the sites of pressure from his military boots. A biopsy specimen showed an accumulation of acid mucopolysaccharides consistent with pretibial myxedema. The patient had recently stopped smoking and chewing tobacco, which are known risk factors for the development of pretibial myxedema. Following diagnostic punch biopsies, the patient experienced a rapid resolution of the nodule on his right leg and a appreciable reduction in size of the nodule on the left leg. Three months later, the nodules are beginning to enlarge once again.

Epidermodysplasia verruciformis.

A 29-year-old woman presented for evaluation of an ulcerated nodule on her right temple in the presence of numerous additional scaly papules, plaques, and seborrheic keratosis-like lesions that were distributed on her forehead, frontal scalp, and temples. Further examination showed pityriasis rosea-like lesions on her neck, back, and arms and verruca plana-like lesions on the dorsa of the hands and forearms. A biopsy specimen of the ulcerated nodule showed a nodular basal-cell carcinoma. Two additional biopsy specimens from her forehead showed one invasive and one in-situ squamous-cell carcinoma. Both biopsy specimens demonstrated histopathologic evidence of epidermodysplasia verruciformis.

Nephrogenic fibrosing dermopathy.

A 75-year-old woman with end-stage renal disease on hemodialysis presented with a 2-month history of progressive skin thickening of the lower extremities. A punch biopsy specimen showed plump fibroblasts entrapping collagen bundles and positive staining for CD34 and procollagen. These changes were consistent with a diagnosis of nephrogenic fibrosing dermopathy (NFD). Nephrogenic fibrosing dermopathy is a rare, sclerosing disorder in patients with renal failure, which may be mistaken for scleromyxedema. The etiology of NFD is unclear but may be associated with systemic involvement, antecedent surgical procedures, gadolinium, or an underlying hypercoagulable state. The treatment is limited, and only a few reported cases have shown remission after stopping dialysis in transient renal failure.

Erythrokeratoderma variabilis.

A 51-year-old woman presented with well-demarcated, erythematous patches and hyperkeratotic plaques that were arranged symmetrically on the upper extremities. Her skin lesions first appeared at age 17, and there was a family history of similar skin lesions in nine of her eleven siblings. Physical and emotional stress increased the number and intensity of her skin lesions as did chocolate. The distribution of lesions on her skin had changed over time; however, the lesions consistently appeared symmetrically and favored the extensor surfaces of her extremities. The physical examination, histopathologic findings, and family history were consistent with a diagnosis of erythrokeratoderma variabilis (EKV), a rare genodermatosis caused by various mutations in connexin genes. Connexin genes code for proteins that form intercellular channels called gap junctions that allow for transport and signaling between neighboring cells in the epidermis. Mutations in connexin-31 and connexin-30.3 are known to cause the EKV phenotype, which presents as erythematous patches and hyperkeratotic plaques. Studies to examine the effectiveness of treatment of EKV have not been performed; however, several case reports suggest the efficacy of oral retinoids. After 4 months of acitretin 25 mg per day, our patient experienced near complete clearance of her skin lesions.

Folliculotropic mycosis fungoides.

A 72-year-old man presented with a 4-year history of asymptomatic erythematous plaques on his face, neck, and scalp. He had no systemic symptoms or lymphadenopathy. Histopathologic examination of a skin biopsy specimen showed a dense, diffuse infiltrate of lymphocytes and plasma cells, with epidermotropism and folliculotropism. T-cell receptor (TCR) gene rearrangement analysis performed on skin biopsy specimen showed a monoclonal cell population. A diagnosis of folliculotropic mycosis fungoides (MF) was made. This clinicopathologic variant of MF is usually associated with ordinary patch-plaque lesions. The prognosis of folliculotropic MF is best estimated using the TNM staging criteria. Many clinicians feel that this variant of MF portends a worse prognosis; however, there are no studies to support this idea. Folliculotropic MF may be more resistant to superficial therapies because of the depth of the neoplastic T-cells in the follicle.

Athletic skin injuries: combating pressure and friction.

Because the skin is the athlete's first line of defense, it is exposed to friction and pressure in nearly every athletic setting. Whether applied acutely or chronically, friction and pressure often cause skin trauma, such as abrasions, chafing, calluses, blisters, talon noir (black heel), and acne mechanica. Sports medicine clinicians, who regularly see skin injuries, can speed healing by making a timely diagnosis, recommending effective treatment, and discussing prevention strategies.