Light-emitting diode 415 nm in the treatment of inflammatory acne: an open-label, multicentric, pilot investigation.

BACKGROUND: The management of acne remains a challenge, with current therapies linked to significant side effects and patient non-compliance. Phototherapy using blue light has been proven in the treatment of acne vulgaris and offers the clinician an effective alternative. OBJECTIVE: To determine the effect of narrowband light-emitting diode (LED) blue light in the reduction of inflammatory and non-inflammatory lesions in patients with mild to moderate acne and to evaluate patient tolerance of the therapy. METHODS: Forty-five patients were treated with high-intensity pure blue light, 415 nm and 48 J/cm2, receiving two treatments of 20 minutes per week for a period of 4-8 weeks. Clinical assessment was performed at baseline, and 2, 4 and 8 weeks after treatment. A patient's therapeutic response was measured using a global improvement scoring system. RESULTS: The mean improvement score was 3.14 at 4 weeks and 2.90 at 8 weeks. Nine patients experienced complete clearing at 8 weeks. The treatment was well tolerated, with 50% of patients highly satisfied with the treatment. CONCLUSION: This open-label study suggests the therapeutic efficacy of high-intensity LED pure blue light in the treatment of acne vulgaris with no reported side effects.

Mohs micrographic surgery-induced pemphigus.

BACKGROUND: Pemphigus is an autoimmune blistering disease that presents with flaccid intraepidermal blisters, erosions of the skin and mucous membranes, acantholysis, and in vivo bound and circulating autoantibodies against keratinocyte antigen. Currently a handful of reports incriminate surgical trauma as an initiating factor in this disease. OBJECTIVE: To document pemphigus evolving in a wound after Mohs micrographic surgery. METHODS: Case report. RESULTS: We present a case of pemphigus that started in a Mohs surgical wound after the excision of a squamous cell carcinoma (SCC) from a 49-year-old woman. Biopsy of the preoperative lesion did not reveal pemphigus. Biopsy of the postoperative lesion revealed pemphigus with no residual SCC. CONCLUSION: We suggest that Mohs surgery, like any other skin surgery, may nonspecifically activate pemphigus. This change must be differentiated from postoperative wound infection and other causes of poor wound healing.

A correlation of alpha-smooth muscle actin and invasion in micronodular basal cell carcinoma.

BACKGROUND: Actin is largely responsible for cell motility and is only sparsely found in normal epithelial cells. An altered expression of actin in some malignancies may facilitate aggressive invasion. Micronodular basal cell carcinoma (BCC) has been shown to require more surgical stages, wider tissue margins, and deeper defects for extirpation during Mohs micrographic surgery relative to nodular BCC. OBJECTIVE: To provide preliminary data regarding a possible correlation between alpha-smooth muscle actin (alpha-SMA) expression within the cells or stroma of micronodular BCC and aggressive invasion. In addition, the incidence of alpha-SMA expression in micronodular, morpheaform, and nodular BCC is evaluated. METHODS: Nine micronodular basal cell carcinomas (7 primary, 2 recurrent) were evaluated for neural invasion, depth of tissue invasion, and alpha smooth muscle actin antibodies. The presence of alpha-smooth muscle actin antibodies was assessed using immunoperoxidase staining and compared with 13 morpheaform (13 primary, 0 recurrent) and 12 nodular (12 primary, 0 recurrent). RESULTS: Six of the nine micronodular (67%), eight of the 13 morpheaform (62%), and 0 of the 12 nodular (0%) BCCs stained positive for alpha-SMA. Of the six micronodular BCCs that stained positive for alpha-SMA, three invaded the fascia or muscle and three displayed neural invasion. In contrast, of the three micronodular BCCs that stained negative for alpha-SMA, none invaded the fascia or muscle and only one exhibited neural invasion. CONCLUSION: Actin was present in 66% of micronodular, 62% of morpheaform, and 0% of nodular BCC. The presence of actin in micronodular BCC may be a marker for aggressive invasion.

Rapid HMB-45 staining in Mohs micrographic surgery for melanoma in situ and invasive melanoma.

BACKGROUND: Accurate interpretation of frozen sections in the treatment of melanoma by Mohs micrographic surgery may be difficult. OBJECTIVE: Our purpose was to review the literature on the role of Mohs micrographic surgery in the treatment of melanoma and to demonstrate the added benefits of using rapid HMB-45 staining in Mohs micrographic surgery for the treatment of melanoma. METHODS: Twenty cases of melanoma were included in our study. Histologic diagnosis in each case was made by means of excisional biopsy specimens and permanent sections. Mohs micrographic surgery was performed with 3-mm margins used for each stage. Each Mohs frozen section was stained with HMB-45. In addition, routine frozen sections stained with hematoxylin-eosin were also prepared for comparison. All tissues were also sent for permanent sections. These permanent sections were cut similarly to Mohs-oriented sections because they were sectioned horizontally. Since they were serving as the standard, no staining with HMB-45 was performed on these permanent sections. Further stages with 3-mm margins were taken until tissues stained negative. Frozen sections were compared with permanent sections at each stage of resection. RESULTS: Eleven of the 20 cases stained positive with HMB-45 antibody on the first Mohs stage. These results were consistent with findings on permanent sections. Ten of the 11 cases were cleared by the first stage. One of the 11 cases required 3 stages because margins were not cleared and the specimens stained HMB-45 positive. However, permanent sections in this case revealed no tumor in the second stage. Nine of 20 cases did not stain with HMB-45 on the first layer of Mohs excision. This was consistent with findings on permanent sections. CONCLUSION: HMB-45 staining serves as a rapid technique to aid in the interpretation of frozen sections during Mohs micrographic surgery in the treatment of melanoma.

Ocular damage due to chlorhexidine versus eyeshield thermal injury.

BACKGROUND: Ocular damage may occur from a number of mechanisms during laser use. OBJECTIVE: To review issues relevant to ocular protection during laser resurfacing. METHODS: The authors were consulted to evaluate the thermal energy transferred from the outer to the inner (ie, corneal contact) surface of stainless steel eyeshields following direct exposure to the carbon dioxide (CO2) resurfacing laser beam. Measurements were obtained using thermocouples (attached to the inner surface of the eyeshields) and analyzed with a computer-based acquisition system. RESULTS: A maximum eyeshield temperature increase of 13 degrees C above the ambient temperature was noted following one pass with a CO2 resurfacing laser (Sharplan continuous CO2 laser with Clinicon SureScan scanner, 15 W, 950 microsec pulse duration, square spot of 9 mm). CONCLUSION: The eyeshields analyzed in this study minimized thermal transfer following a single direct hit with a CO2 resurfacing laser. An understanding of the potential mechanisms of ocular injury is essential in preventing its occurrence.

Increased glycosaminoglycans production in sclerosing basal cell carcinoma-derived fibroblasts and stimulation of normal skin fibroblast glycosaminoglycans production by a cytokine-derived from sclerosing basal cell carcinoma.

Sclerosing basal cell carcinoma (S-BCC) is characterized by an abundant stroma. There is evidence that some tumor cells secrete cytokines that are mitogenic for stromal fibroblasts (FBs). From this study we report increased glycosaminoglycan (GAG) production by cultures of S-BCC FBs in comparison to cultures of nodular BCC (N-BCC) FBs and normal skin FBs. GAG production was measured by cetylpyridinium chloride precipitation of incorporated [3H]-glucosamine. The sclerosing BCC FBs demonstrated a significant increase in production of GAG over control FBs (P <.001) and over N-BCC FBs (P<.001). Values reported as a mean percentage +/- SEM for GAG production by S-BCC over control normal skin FBs are 359+/-28 and over N-BCC FBs are 266+/-27. In additional experiments, cell extract dilutions from S-BCC tumor, normal dermis, and normal epidermis were incubated with cultures of normal skin FBs. S-BCC-conditioned media was also incubated with normal FBs and GAG production was measured. For both S-BCC extracts and conditioned media, a dose response curve was established showing increased GAG production by normal FBs in relation to increasing the concentration of S-BCC extract or conditioned media. When S-BCC extract was added to normal FBs there was increased GAG production in comparison to normal FBs incubated with dermal or epidermal extracts (P<.001) for both. Two growth factors, transforming growth factor-beta (TGF-beta) and platelet-derived growth factor (PDGF), already known to be mitogenic for FBs, were incubated with N-BCC and normal FBs in an effort to elucidate the potential cytokine(s) released by S-BCC, causing increased GAG production by surrounding FBs. Neither of these cytokines proved to be effective in promoting a significant increase in GAG production. Our findings support the hypothesis that BCCs release factors that alter stromal FB production of GAG.

Effect of perilesional injections of PEG-interleukin-2 on basal cell carcinoma.

BACKGROUND: Multiple modalities are available for the treatment of basal cell carcinoma (BCC). The most commonly used modalities include simple excision, Mohs micrographic surgery, curettage and electrodessication, cryosurgery, and irradiation therapy. Interleukin-2 (IL-2) is a cytokine produced chiefly by activated T lymphocytes and has effects on various components of the immune system. Until now the primary clinical use of IL-2 has been in advanced stages of metastatic melanoma and renal cell carcinoma. Systemic administration of IL-2 is known to cause significant toxicity. OBJECTIVE: The objective of this study was to evaluate the therapeutic efficacy and safety of perilesional PEG-IL-2 injections in patients with BCC in an open label, uncontrolled pilot study. METHODS: Patients with histologically confirmed primary BCC over 18 years of age were included in the study. Lesions were treated by injecting a total volume of 0.5 cc of IL-2 in a radial fashion in the subcutaneous tissue. Injection dosages ranged from 3000 to 1,200, 000 IU in one to four weekly dosages. A total of 12 tumors were treated in eight patients. RESULTS: Overall response rates were as follows: complete response in 8 of 12 treated tumors (66.6% cure rate), partial response in 3 of 12 injected tumors (25% partial response rate), stable disease with no improvement in 1 treatment site (8.4%). Side effects included local pain, swelling, and erythema, and in one patient flulike symptoms. There were no significant changes of blood tests as compared to baseline levels. CONCLUSIONS: The therapeutic response induced by perilesional PEG-IL-2 injections was found to be an encouraging, safe, and well-tolerated treatment of BCC. Further studies including a larger patient population and long-term follow-up are necessary in order to substantiate these findings.

Short-pulse carbon dioxide laser resurfacing of the neck.

BACKGROUND: Carbon dioxide (CO(2)) laser resurfacing of the face has become an increasingly popular procedure. However, laser resurfacing of the neck has been largely avoided because of fears of scarring or pigmentation changes. OBJECTIVE: Our purpose was to evaluate the efficacy of treatment and incidence of complications after short-pulse CO(2) laser resurfacing of the neck. METHODS: A total of 308 patients received concomitant face and neck CO(2) laser resurfacing. A 90 -micros pulse duration CO(2) laser without a scanner was used in all cases for 2 passes on the neck (10.6-microm wavelength, 500-mJ pulse energy, 90-micros duration, 3-mm spot size) and a continuous CO(2) laser with a computer-generated scanner (396-micros dwell time, 18 W) was used for 3 passes over the face except for the perioral area, which received 4 passes. The incidence of scarring or permanent pigmentation changes was determined. Forty patients who had been treated at least 6 months but no longer than 18 months earlier were randomly surveyed by phone to assess the degree of improvement. RESULTS: Of the 308 patients treated, there were no cases of scarring or permanent pigmentation changes. Surveyed patients reported a 39% improvement in rhytides and tightening on the neck. CONCLUSION: Resurfacing of the neck can be performed safely in conjunction with resurfacing of the face. Patients may be offered improvement in the neck with little chance of scarring or permanent pigmentary changes when resurfacing on the neck is performed by means of a short-pulse duration laser for a limited number of passes instead of the more aggressive laser parameters previously used such as continuous long-pulse duration treatments.

Efficacy of hydroquinone cream (USP 4%) used alone or in combination with salicylic acid peels in improving photodamage on the neck and upper chest.

BACKGROUND: Salicylic acid, hydroquinone, and glycolic acid have been proved effective in the treatment of photodamaged facial skin. Few reports are available on the treatment of photodamage on the neck and upper chest. OBJECTIVE: This study's purpose was to evaluate the efficacy of a cream containing 4% hydroquinone and 2% glycolic acid (LUSTRA) used alone or with salicylic acid peels in reversing actinic damage on the neck and upper chest. METHODS: Nineteen women with moderate to advanced photodamage on the neck and upper chest applied a cream containing 4% hydroquinone and 2% glycolic acid twice daily on photodamaged areas for 12 weeks. Nine of these subjects had salicylic acid peels every 3 weeks. Improvements were assessed by the investigator, the subjects, and Mexameter readings measuring melanin and erythema levels. RESULTS: The result shows that there was a 33-71% improvement in photodamage, hyperpigmentation, texture, fine lines, dryness, tone, and clarity in both groups. There were no significant differences between the two treatments. CONCLUSION: Hydroquinone 4% cream with 2% glycolic acid is safe and effective in improving photodamage on the neck and upper chest when used alone or in combination with salicylic acid peels.

Delayed infections following full-face CO2 laser resurfacing and occlusive dressing use.

BACKGROUND: Carbon dioxide (CO2) laser resurfacing has become an increasingly popular procedure for the treatment of facial rhytides and solar damage. Yet despite ongoing advancements in laser technology, CO2 laser resurfacing is still a risk-laden procedure that may lead to complications such as infection. Occlusive dressings increase the healing rate and decrease pain intensity in patients who receive full face laser resurfacing. It has been said that the use of occlusive dressings in postresurfacing patients may increase the risk of infection, which typically presents 2-10 days after the procedure. OBJECTIVE: The purpose of this article is to report the incidence of infection following full-face CO2 laser resurfacing of 354 patients who were treated with occlusive dressings. In addition, factors which may have contributed to the delayed onset in three of the four infections are discussed. METHODS: Three hundred fifty-four patients received full-face CO2 laser resurfacing. Either a continuous wave CO2 laser with a computer-generated scanner (396 microseconds dwell time, 18 W) or a pulsed CO2 laser (500 mJ pulse energy, 90 microseconds pulse duration) were used in all cases of resurfacing. Postoperatively all patients were treated with occlusive dressings and empiric oral cephalexin. Postoperatively patients were monitored at weekly intervals during the first month and then at 3 and 6 months. RESULTS: Of the 354 patients who received full-face laser resurfacing, there were 4 cases of culture-proven infection, which translates to an infection rate of 1.13%. Three of the four infections developed 3-5 weeks after the procedure. CONCLUSION: This study reports an infection rate of 1.13% following full-face CO2 laser resurfacing and occlusive dressing use in 354 patients. Because infection may develop many weeks after the procedure, patients should be educated to maintain proper wound care hygiene and to avoid "double dipping" of wound care products until wounds are completely healed.

Authors in Dermatologic Surgery.

Authors of scientific papers have been evaluated in the past by how frequently the medical literature cites them. In this analysis, we specifically identify those individuals who have contributed to the field of cutaneous surgery through publications in Dermatologic Surgery. We further analyze those publications frequently cited in Dermatologic Surgery, allowing us to determine topics of utmost value and interest. Using a citation database provided by the Institute for Scientific Information, we first identify all publications and citations from 1981 to 1999 for Dermatologic Surgery and the Journal of Dermatologic Surgery and Oncology (the previous name for this journal). Of the original articles published during this time frame, 3099 authors published 2167 papers. We quantify the publications from each author, and identify 57 authors with at least 10 original articles. When expanding the database parameters to include original articles, reviews, notes, and proceedings (as defined by the Science Citation Index), we find that the eight authors with the greatest number of publications are the same individuals with the greatest number of original articles. This reflects significant contributions to the field of cutaneous surgery by these authors. This analysis further identifies source papers for authors in Dermatologic Surgery. Publications frequently cited include those papers discussing laser surgery, with Dermatologic Surgery serving as the most frequently cited journal.

Clinical presentation of actinic keratoses and squamous cell carcinoma.

BACKGROUND: Actinic keratosis is a skin lesion that can progress to squamous cell carcinoma but cannot always be clinically distinguished from a squamous cell carcinoma. OBJECTIVE: The purpose of this article is to describe the clinical presentation of actinic keratoses and squamous cell carcinoma. METHODS: The author's clinical experience and a review of the literature were used to describe actinic keratoses and squamous cell carcinoma. RESULTS: There is a continuum and a progression from actinic keratoses to squamous cell carcinoma so that there is no way to reliably distinguish between the two diagnoses. CONCLUSION: Because it can be impossible to distinguish between an actinic keratosis and squamous cell carcinoma, treatment of actinic keratoses should be aggressive to stop the progression to squamous cell carcinoma.

Hair removal using an 810 nm gallium aluminum arsenide semiconductor diode laser: A preliminary study.

BACKGROUND: Laser hair removal is a popular treatment method for removing unwanted hair. Several laser systems are available for laser hair removal. The gallium aluminum arsenide semiconductor diode (GAASD) laser is one of the newer laser modalities to be studied. OBJECTIVE: To evaluate the efficacy of the GAASD laser system in removing unwanted hair. METHODS: Twenty-six patients with brown or black hair growth were treated with the GAASD laser at fluences of 20-80 J/cm2. Hair regrowth was measured 4 weeks after the first treatment, 4 weeks after the second treatment, 4 weeks after the third treatment, and 4 weeks, 8 weeks, and 8 months after the fourth treatment. CONCLUSION: GAASD laser treatment resulted in hair growth delay in all treated regions. Repeated laser treatments did not produce an increased number of vellus hairs. The percentage of hair reduction fluctuated between 5% and 13% with the second or third treatment averaging the highest percent reduction. In all cases, the percentage of hair reduction of the treatment sites evaluated at 8 months after the fourth treatment was less than both the second and third treatments (highest average percent reduction) and the fourth (last) treatment.

Treatment of Hailey-Hailey disease (or benign familial pemphigus) using short pulsed and short dwell time carbon dioxide lasers.

BACKGROUND: Surgical intervention of Hailey-Hailey disease (HHD) may be required to achieve prolonged remission or cure. Excisional surgery, dermabrasion, and continuous carbon dioxide (CO2) laser therapies have been utilized with success, though patients may experience considerable morbidity. OBJECTIVE: To evaluate the use of short pulsed and short dwell time CO2 lasers in the treatment of HHD. METHOD: Case report and review of the relevant literature. RESULTS: A 26-year-old woman with refractory axillary HHD was initially treated with a short dwell time CO2 laser. The right axilla was treated with two passes at a fluence of 25 J/cm2, and the left axilla with three passes at 28 J/cm2. Three years later, several foci within each axilla that periodically blistered were further treated with two passes of a short pulsed CO2 laser at a fluence of 15 J/cm2. At a 3.5-year follow-up, the patient reported continued resolution of her left axilla but disease persistence in her right axilla. CONCLUSION: HHD can be effectively treated with a short dwell time CO2 laser if appropriate laser parameters are used.

Treatment of facial rhytids with a nonablative laser: a clinical and histologic study.

BACKGROUND: Current facial resurfacing modalities (laser, chemical peels, and dermabrasion) remove the epidermis and thus cause open wounds which carry significant risks and extended recovery periods. The nonablative laser is a novel Nd:YAG system designed to alleviate facial rhytids without injuring the epidermis. This new modality may offer patients rhytid removal without the risk seen in currently used resurfacing techniques. OBJECTIVE: To describe a novel nonablative laser system and assess its safety profile and efficacy. METHODS: Ten patients received laser treatments of their periocular rhytids and postauricular skin. Clinical variables (rhytid severity, hyperpigmentation, hypopigmentation, scarring, and level of discomfort) were assessed at 1 and 3 months posttreatment. Postauricular skin biopsies were taken both pre- and posttreatment for histologic analysis. RESULTS: Patient discomfort was minimal. Three months posttreatment, 4 of 10 patients showed a one-point improvement in periocular rhytid severity when judged on a six-point scale. The results were not statistically significant. Biopsy analysis showed a small posttreatment increase in the amount of dermal collagen in three patients. A small decrease in collagen was noted in one patient. Three patients also showed a small posttreatment increase in the degree homogenization of dermal collagen. No change from baseline was noted in other assessed histologic parameters. Complications observed included hyperpigmentation in three patients and pitted scarring in three patients. CONCLUSIONS: The nonablative laser gave clinically subtle and statistically insignificant improvement in rhytid severity. Unfortunately its use was associated with complications that included hyperpigmentation and scarring. This technology may eventually offer patients a new resurfacing option, but its efficacy and complication rate must be improved first.