Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Ablative fractionated CO2 laser treatment of photoaging: a clinical and histologic study.

BACKGROUND: Ablative fractional photothermolysis (AFP) has been reported to be effective for changes in skin pigmentation and texture associated with photoaging. METHODS: A prospective study for the treatment of photoaging using a fractionated ablative carbon dioxide laser in 10 subjects. Assessment of laser efficacy was made using two modalities: histologic examination of skin biopsies and blinded physician clinical photographic assessment. For the histologic portion of the study, patients were randomized to treatment with the device at settings of pulse durations of 500, 1,000, 1,500, and 1,800 µs. Depth of injury was assessed based on histologic evaluation of depth of thermal coagulation. For the clinical portion of the study, treatment was administered to the face using a carbon dioxide laser at settings of 30 W, 500-µm pitch (density of treatment equivalent to ablation of 25% of the skin), and variable pulse duration of 1,000 to 1,500 µs. RESULTS: The mean score for dyschromia had improved 47.5% (95% confidence interval (CI) = 44.1-50.9%), for skin texture 56.0% (95% CI = 51.9-60.1%), for skin laxity 56.0% (95% CI = 51.3-60.7%), for rhytides 52.5% (95% CI = 48.3-56.7%) and for overall cosmetic outcome 61.5% (95% CI = 56.4%,66.6%) 6 months after treatment. Histologic data revealed a proportional increase in depth of thermal coagulation at each pulse duration. The mean ablation depth was 283 µm for a pulse duration of 500 µs, 375 µm for 1,000 µs, 767 µm for 1,500 µs, and 1.05 mm for 1,800 µs. CONCLUSIONS: We present a histologic analysis documenting the correlation between longer pulse duration and ablation depth using an AFP device. We identified that pulse duration settings up to 1,800 µs could be used safely with an ablation depth up to 1.1 mm, correlating with injury into the deep reticular dermis.

The effect of cold-air anesthesia during fractionated carbon-dioxide laser treatment: Prospective study and review of the literature.

BACKGROUND: Forced cold-air anesthesia has been reported to decrease the discomfort associated with various dermatologic laser therapies. OBJECTIVE: We sought to evaluate the effect of cold-air anesthesia on patient comfort during ablative fractionated carbon-dioxide (CO(2)) laser treatment for photoaging. METHODS: We conducted a prospective split-face study to evaluate the effect of cold-air anesthesia on patient comfort during ablative fractionated CO(2) laser treatment for photoaging. Both patients and physicians rated the perceived discomfort of the treatment on each half of the face on a pain scale of 0 to 10. In addition, patients were asked to evaluate the side effects of the procedure (erythema, edema, crusting, scaling) on each half of the face. At 6 months posttreatment, blinded physician photograph evaluation was performed of 5 clinical indicators of photoaging. RESULTS: For the side of the face treated with topical anesthesia alone, the mean patient-reported pain score was 7.47. On the side treated with cold-air anesthesia and topical anesthesia, the mean pain score was 4.27 (P < .01). For the side treated with topical anesthesia alone, the mean physician-reported pain score was 7.8, relative to the side treated with cold-air anesthesia and topical anesthesia, for which the mean physician-reported pain score was 3.73 (P < .01). LIMITATIONS: Although significant differences were found in pain tolerance with fractionated CO(2) laser with the use and absence of forced-air cooling, additional large-scale studies are needed to confirm the device's use in patient tolerability and side-effect profile. CONCLUSION: The use of forced cold-air device in conjunction with topical anesthesia provides a well-accepted modality for patient comfort during ablative fractionated CO(2) resurfacing.

Safety of tumescent and laser-assisted liposuction: review of the literature.

BACKGROUND: Tumescent liposuction (TL) allows the removal of large volumes of fat with minimal blood loss or postoperative morbidity, excellent cosmesis, and a remarkable safety profile. OBJECTIVE: To review the literature on the safety of tumescent liposuction, liposuction under general anesthesia and laser-assisted liposuction. RESULTS: Aggregate safety data on liposuction under tumescent anesthesia reveals over 100,000 body areas treated with liposuction. There were no serious complications of death, emboli, hypovolemic shock, perforation of thorax or peritoneum, thrombophlebitis, seizures, or toxic reactions to drugs. In contrast, in the plastic surgery literature, liposuction under general anesthesia was associated with complications of deep venous thrombosis or pulmonary embolus, abdominal or other organ perforation, infection, and bleeding. Most recently, survey data in the European literature analyzed data showed 72 cases of severe complications from liposuction, including 23 deaths in a 5-year period from 1998 to 2002. The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism. CONCLUSION: Tumescent local anesthesia utilizing lidocaine with epinephrine allows the removal of large volumes of fat with minimal associated blood loss and postoperative morbidity.

Career trajectory and job satisfaction trends in Mohs micrographic surgeons.

BACKGROUND: Although many residents and fellows in Mohs surgery express an interest in academics, departure from academics occurs for many trainees or junior faculty. OBJECTIVE: We designed a survey, issued to all American College of Mohs Surgeons (ACMS) members in 2009, to assess reasons for practice selection. RESULTS: A response rate of 65.0% (n=455) was obtained. Of all ACMS members, 33.9% started in academic positions, and 66.1% started in private practice. Retention rates in private practice (61.2%) were significantly higher than in academics (28.0%) (p<.001). The rationale for selection of an academic career included referral base and teaching and research opportunities. Reasons for selection of a private practice career were higher salary, autonomy over resources, and geographic flexibility. There were high rates of departure from academics early on; reasons for departure included lack of support from the academic chair and lack of autonomy over resources. Surgeons leaving academia were able to perform Mohs surgery and continue interests in research and teaching with benefits of greater autonomy over resources in private practice. CONCLUSIONS: Novel efforts to retain academic Mohs surgeons are needed to ensure continued success and evolution of the specialty.

Malignancy arising within cutaneous tattoos: case of dermatofibrosarcoma protuberans and review of literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin with high rates of local recurrence. Several reports describe a frequent history of local trauma. In one prior case, a DFSP arising in a tattoo site has been reported. Mohs micrographic surgery (MMS) has been used successfully for treatment. OBJECTIVE: To present a case of dermatofibrosarcoma protuberans arising in the site of a prior and current tattoo, and treated with Mohs micrographic surgery. METHODS: We present findings of a case of a DFSP arising in a tattoo and a review of Medline literature on the association between tattoos and cutaneous malignancy, and treatment of DFSP with MMS. RESULTS: Review of the literature confirms multiple reports of DFSP arising in sites of local trauma, as well as malignancies arising in sites of tattoos. The recurrence rate for MMS treatment of DFSP (0-6.6%) was found to be significantly lower than that for patients treated with wide local excision (13% to 95%). CONCLUSIONS: DFSP should be considered in the differential diagnosis of neoplasms arising within areas of tattoos. Sites of local trauma and tattoos may show predilection for benign and malignant changes and should be evaluated during regular skin exams. Review of the literature confirms MMS is an ideal treatment modality for DFSP as the tumor often extends far beyond clinical margins.

Treatment of acne scarring using a dual-spot-size ablative fractionated carbon dioxide laser: review of the literature.

BACKGROUND: Fractional photothermolysis has been reported in the literature to improve pigmentary and textural changes associated with acne scarring. OBJECTIVE: To review the literature for the treatment of acne scarring using nonablative fractional laser (NAFL) and ablative fractional laser (AFL) resurfacing. METHODS: Review of the Medline literature evaluating NAFL and AFL for acne scarring. RESULTS: NAFL and AFL are safe and effective treatments for acne scarring. It is likely that the controlled, limited dermal heating of fractional resurfacing initiates a cascade of events in which normalization of the collagenesis-collagenolysis cycle occurs. We present the results of a patient treated using a novel dual-spot-size AFL device. Three months after the final treatment, the patient reported 75% improvement in acne scarring and 63% overall improvement in photoaging. CONCLUSIONS: Fractionated resurfacing for the treatment of acne scarring is associated with lesser risks of side effects of prolonged erythema and risks of delayed-onset dyspigmentation and scarring which complicate traditional ablative laser resurfacing approaches. We present herein preliminary data suggesting that a dual-spot-size AFL device presents novel advantages of improving texture and pigmentation in acne scarring and photoaging.

Practice models and roles of physician extenders in dermatologic surgery.

BACKGROUND: The prevalence of physician extenders (PEs) has increased significantly in dermatologic surgery over the last decade. METHODS: An analysis was performed of the staff in dermatologic surgery practices, roles of PEs, and level of supervision. RESULTS: Mohs fellowship-trained (MMSFT) dermatologic surgeons were more likely to employ registered nurses (n=85, 73.9%) than non-fellowship-trained (NMMSFT) surgeons (n=65, 50.0%, p<.05) (dermatologists who reported performing Mohs without having completed a Mohs College fellowship). NMMSFT surgeons (n=46, 35.4%) were 33% more likely to employ physician assistants than MMSFT surgeons (n=30, 26.1%, p=.05). Both surgeon types reported that their physician assistants and nurse practitioners spent the majority of their time treating medical dermatology patients, but NMMSFT surgeons were twice as likely as MMSFT surgeons to have their PEs involved in performing or assisting with cosmetic procedures. MMSFT surgeons (38.5%) were twice as likely to have direct supervision of their PEs as NMMSFT surgeons (16.1%, p=.01). CONCLUSIONS: PEs are highly prevalent in dermatologic surgery practices and are playing direct roles in the delivery of dermatologic care. Promoting patient safety through appropriate extender supervision and reporting of patient outcomes are highly needed as this sector of the dermatologic surgery workforce continues to expand.

Subcuticular incision versus naturally sourced porcine collagen filler for acne scars: a randomized split-face comparison.

BACKGROUND: Subcuticular incision is performed to release fibrotic bands beneath acne scars and to stimulate neocollagenesis. Naturally sourced porcine collagen has been approved for filling moderate to deep facial wrinkles and nasolabial folds. To our knowledge, naturally sourced porcine collagen filler has not yet been tried as a treatment for correcting atrophic acne scars. OBJECTIVE: To objectively assess and directly compare the efficacy and safety of subcuticular incision versus naturally sourced porcine collagen dermal filler in correcting atrophic and rolling acne scars. MATERIALS AND METHODS: We performed a prospective, randomized, split-face, single-blind study to evaluate intermediate long-term efficacy of subcision and collagen dermal filler on 20 unilateral faces. Patients and blinded physicians evaluated results. RESULTS: Patients rated subcision as superior to collagen dermal filler at 3 months (p=.03). At 6 months, subcision had a slightly higher rating than collagen dermal filler (p=.12). Blinded evaluators leaned toward subcision at 3 months (p=.12) and at 6 months showed no preference (p=.69). CONCLUSION: Subcuticular incision and naturally sourced porcine collagen dermal filler appear to be efficacious for improving atrophic and rolling acne scars. Patients may prefer subcuticular incision over collagen dermal filler. Blinded evaluators found no significant difference between the treatments.

Treatment of lower eyelid rhytids and laxity with ablative fractionated carbon-dioxide laser resurfacing: Case series and review of the literature.

BACKGROUND: An increasing array of minimally invasive treatment modalities have evolved for periorbital rhytids. Nonablative fractional photothermolysis has been demonstrated to be effective for periorbital rhytids. OBJECTIVE: We sought to prospectively evaluate eyelid tightening with an ablative fractional photothermolysis laser. METHODS: We conducted a prospective, single blinded study for lower eyelid laxity in 25 subjects with a series of 2 to 3 treatment sessions. RESULTS: The number of treatment sessions required for significant improvement of eyelid laxity ranged from 2 to 3, with an average of 2.44 sessions. For skin texture, the mean score decreased from 3.6 to a mean of 1.2 at 6 months posttreatment (P < .05) for a 62.6% mean improvement. For skin laxity, the mean score decreased from 3.3 to 1.3 at 6 months posttreatment (P < .05) for a 65.3% mean improvement. For rhytids, the mean score decreased from 3.5 to 1.3 at 6 months posttreatment (P < .05) for a 62.1% mean improvement. For overall cosmetic outcome, mean score decreased from 3.6 to 1.2 at 6 months posttreatment (P < .05) for a 65.7% mean improvement. Patients noted moderate postoperative erythema and edema that resolved by the 1-week posttreatment visit. Patients reported minor crusting and oozing that resolved within 48 to 72 hours. LIMITATIONS: This is a prospective, single blinded study in 25 patients with varying degrees of laxity and photoaging affecting eyelid skin. Additional studies assessing degree of improvement for patients with varying degrees of laxity and photoaging at variable parameters are needed. CONCLUSION: Eyelids can achieve significant improvement in skin texture and laxity with ablative fractional photothermolysis.

Fractionated CO2 laser skin rejuvenation.

Fractional photothermolysis has been reported in the literature to improve both the pigmentary and textural changes associated with photoaging. The objective of the study was to review the literature of non-ablative fractional laser (NAFL) and ablative fractional laser (AFL) resurfacing for the treatment of photoaging. This is a review of the Medline literature evaluating NAFL and AFL for photoaging. Review of the literature supports the use of NAFL and AFL as safe and effective treatments for photoaging. It is likely that the controlled, limited dermal heating of fractional resurfacing initiates a cascade of events in which normalization of the collagenesis/collagenolysis cycle occurs. The advent of fractionated resurfacing for the treatment of photoaging is a significant advance over ablative laser resurfacing treatments, which were complicated by prolonged erythema, delayed onset hypopigmentation, and scarring.

Alexandrite laser for the treatment of port wine stains refractory to pulsed dye laser.

BACKGROUND: The 755-nm ms pulsed Alexandrite laser (MSPAL) has been reported to be successfully in the treatment of port wine stains (PWS) that are refractory to pulsed dye laser (PDL). MATERIALS & METHODS: This was a prospective pilot study to assess the degree of improvement after a series of treatments with a MSPAL for hypertrophic, nodular, and macular PWS refractory to PDL. Treatment was administered to the PWS using the 755-nm MSPAL at settings of 3-ms pulse duration, 8- to 12-mm spot, 40 to 60 J/cm(2), and dynamic cooling of 60/40. Patients received a series of two to four treatment session, given at 6- to 8-week intervals. RESULTS: The eight patients in this study had undergone a mean of 25.9 treatment sessions with PDL over 8.8 years. The number of MSPAL sessions required for significant improvement of PWS ranged from two to four (mean 2.6). From before treatment to 2 months after treatment, the mean score decreased from 3.2 to 1.4 for skin color (56.3% mean improvement, 95% confidence interval (CI)=53.2-59.4%), from 2.5 to 1.0 at (60.0% mean improvement, 95% CI=55.9-64.1%) for skin texture, and from 3.2 to 1.3 (59.4% mean improvement, 95% CI=56.2-62.6%) for overall cosmetic outcome (all p<.05). DISCUSSION: In this pilot study, PDL-resistant PWS responded significantly to a series of MSPAL treatments. Given the potential for adverse effects and narrow therapeutic index, treatment with conservative parameters and close observation of tissue response are essential.

Fractionated carbon dioxide laser treatment of photoaging: prospective study in 45 patients and review of the literature.

BACKGROUND: Ablative fractional photothermolysis (AFP) has been reported to be effective for photoaging. OBJECTIVE: To perform a clinical trial in 45 patients with moderate to severe skin photoaging to quantify improvement with AFP. MATERIALS AND METHODS: A prospective, single-blind study in 45 patients who presented for desired treatment of photoaging. Patients received a series of two to three treatments with AFP. RESULTS: Thirty-nine women (86.7%) and six men (13.3%) were enrolled. Patients received two or three treatment sessions (mean 2.4). There were no incidence of adverse events of scarring, prolonged erythema (lasting more than 7 days), postinflammatory hyper- or hypopigmentation, or infection in the 108 treatment sessions given during this study. Mean improvement was 48.5% (95% confidence interval (CI)=44.6-52.4%) for skin texture, 50.3% (95% CI=46.1-54.5%) for skin laxity, 53.9% (95% CI=49.5-58.5%) for dyschromia, and 52.4% (95% CI=47.9-56.9%) for overall cosmetic outcome (all p<.05). CONCLUSIONS: Significant improvement in photoaging of the face can be achieved using an AFP device with skin types I to III after a series of two to three treatments.

"Bullfrog neck," a unique morphologic trait in HIV lipodystrophy: case series and review of the literature.

BACKGROUND: Human immunodeficiency virus (HIV)-associated lipodystrophy is a syndrome that occurs primarily in individuals who are being treated with highly active antiretroviral therapy (HAART). OBSERVATIONS: We describe 3 patients with an 8- to 15-year history of HIV disease and HAART who presented a unique feature of HIV lipodystrophy, the "bullfrog neck." In addition to their features of facial lipoatrophy and "buffalo hump," patients had the unique feature of circumferential enlargement of the neck. All patients were undergoing treatment with the same non-nucleoside reverse-transcriptase inhibitor (NRTI) medication, efavirenz. CONCLUSIONS: We present a novel finding of the bullfrog neck in 3 patients with classic features of HIV lipodystrophy. The dysmorphic features of HIV lipodystrophy present a significant therapeutic challenge because the current repertoire of treatments is only modestly effective, and the disease in patients who continue HAART regimens over the long term will progress. Review of the recent literature suggests that the individual protease inhibitors and NRTIs used may play a role in the development and progression of HIV lipodystrophy.

Clinical and echographic analysis of ablative fractionated carbon dioxide laser in the treatment of photodamaged facial skin.

BACKGROUND: Ablative fractional photothermolysis (AFP) has been reported to be effective in the treatment of photoaging. MATERIALS AND METHODS: Treatment was administered using an AFP device and assessed photographically 3 months after treatment by a blinded physician. Ultrasound measurements evaluated skin thickness and subepidermal low echogenic band thickness (SLEB), the portion of the papillary dermis filled with solar elastosis. RESULTS: Three months after treatment, the mean score improved 61.0% (95% confidence interval (CI)=56.8-65.2%) for dyschromia, 54.3% (95% CI=51.6-57.0%) for skin laxity, 51.5% (95% CI=49.6-53.4%) for rhytides, and 60.2%9 (95% CI=56.8-63.6%) for overall cosmetic outcome. Patients had a significant decrease in SLEB in all anatomic sites treated (0.078 cm at baseline, 0.038 cm at 3 months, 40.0% decrease) (p<.001). Total skin thickness increased with AFP (0.163 cm at baseline, 0.188 cm at 3 months, 10.3% increase) (p<.05). CONCLUSIONS: In this pilot study, AFP improved pigmentary and textural components of photoaged skin. Future investigation is warranted to validate the results demonstrating that high resolution ultrasound can be used as a quantitative tool to assess skin changes after AFP.

Treatment of CO2 laser induced hypopigmentation with ablative fractionated laser resurfacing: case report and review of the literature.

BACKGROUND: The carbon dioxide laser (CO2) has been proven to be an effective device for the treatment of photoaging. However, it is associated with adverse side effects including prolonged erythema, edema, burning, milia, acne, crusting and hypo-/hyperpigmentation. Delayed onset hypopigmentation after CO, laser resurfacing can markedly detract from clinical outcomes. To overcome the disadvantages of traditional ablative and non-ablative resurfacing, fractional photothermolysis (FP) has been introduced. FP has been demonstrated in early case reports and case series to produce significant improvement in hypopigmentation of acne and surgical scars. CASE REPORT: A 53-year-old Caucasian female with Fitzpatrick type I skin presented with a nine-month history of delayed onset hypopigmentation following ablative CO2 laser resurfacing. After a series of three treatments at eight-week intervals with an ablative fractionated CO2 laser device, the hypopigmentation and line of pigmentary demarcation between the face and neck improved by 75 percent. CONCLUSION: Ablative fractional resurfacing is a safe and potentially effective modality for the treatment of CO2 laser induced hypopigmentation on the face.

Review of the literature: Treatment of dyspigmentation with fractionated resurfacing.

BACKGROUND: Traditional ablative laser resurfacing is associated with adverse side effects, including prolonged erythema, edema, burning, milia, acne, crusting, and hypo- and hyperpigmentation. Fractional photothermolysis (FP) has been introduced to overcome the disadvantages of traditional ablative and nonablative resurfacing. With FP, the microscopic, pixilated pattern of wounding in the dermis results in significant skin pigmentary and textural improvements without the adverse effects of prolonged wound healing and risks of dyspigmentation associated with traditional ablative resurfacing. FP has been reported to improve hypo- and hyperpigmentation in a variety of cutaneous conditions. OBJECTIVE: To review the dermatologic literature on the use of FP for treatment of dyspigmentation. RESULTS: Review of the Medline literature identified 35 studies on treatment of cutaneous conditions associated with dyspigmentation with ablative FP (AFP) and nonablative FP (NAFP). Specifically, we found treatment of melasma, postinflammatory hyperpigmentation, nevus of Ota, hypo- and hyperpigmented scars, poikiloderma of Civatte, laser-induced hypo- and hyperpigmentation, and dyschromia associated with photoaging. CONCLUSIONS: AFP and NAFP are potentially effective modalities for the treatment of dyspigmentation of the face and neck. The authors have indicated no significant interest with commercial supporters.

Recent advances in combination treatments for photoaging: review of the literature.

BACKGROUND: Photoaging of the skin is a condition characterized by a combination of physical findings including dyspigmentation, fine wrinkles, telangiectasias, tactile roughness, and precancerous change. A combination approach, treating these changes in skin pigmentation and texture simultaneously, is often required to ensure patient satisfaction. OBJECTIVE: To review the dermatologic literature on the use of combination treatments in photoaging using Medline. RESULTS: Review of the Medline literature identified 24 studies of combination approaches to photoaging in which physician and patient evaluation of efficacy of the treatment approaches were performed. Ten studies contained histologic evidence that combination approaches to photoaging, including nonablative and ablative laser resurfacing, topical retinoids, and topical photosensizers with lasers and light sources, produced cutaneous repair of photodamaged skin. These studies documented histologic improvement in various features of photodamaged skin, including change in epidermal and dermal thickness and stratum corneum compaction, greater type I and III collagen production, and less sunburn cell and thymine dimer formation after ultraviolet light exposure. CONCLUSIONS: Review of the literature demonstrates the progress of dermatologic science in understanding the cellular and molecular mechanisms of ultraviolet light-induced damage and in the development of novel combination approaches for repair of photodamage and prevention of cutaneous malignancy.

Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature.

Kwashiorkor is a type of protein-calorie malnutrition often seen in children of impoverished countries and famine. The condition occurs in the setting of insufficient protein intake in the presence of sufficient caloric intake. We report a case of a 8-month-old male infant in the suburban Detroit, MI, USA who presented with diffuse edema, erythroderma and desquamation, a "bull-dog" face, diarrhea, and irritability, consistent with kwashiorkor as a result of severe dietary restriction. The mother had placed the child on a severely restrictive diet, consisting only of RICE DREAM((R)) milk, sweet potatoes and bananas, with the assumption that it would help his rash. Nineteen prior cases of kwashiorkor induced in infants by dietary restriction of "well intending" parents have been reported in the US literature. Malnutrition is often under diagnosed or misdiagnosed in developed countries such as the United States. The results, if unrecognized or untreated, may be devastating. This makes it imperative that physicians consider this diagnosis, recognize potential risk factors and be prepared to accurately assess overall nutritional status of patients.

Progressive macular hypomelanosis arising in a young African American woman in association with pregnancy and a toxic nodular goiter.

The authors present the case of a 23-year-old woman of French-Caribbean descent who presented with progression of hypopigmented, scaly ovoid macules on her neck, chest, abdomen and back. She was two months pregnant at the time of the onset of the pigmentary change was also simultaneously diagnosed with a toxic nodular goiter of her thyroid gland. Initial fungal culture, KOH and biopsy were positive for fungal hyphae, and she was treated with four weeks of oral ketaconazole and topical selenium sulfide shampoo. As she had continued progression of her hypopigmented lesions after treatment for pityriasis versicolor, a thorough physical examination (under room light and Wood's lamp) and repeat biopsy were performed. On examination, she demonstrated persistence of the ovoid hypopigmented macules on her neck, chest and abdomen with interval improvement of the superficial scaling. Under Wood's lamp examination, hypopigmented lesions demonstrated a characteristic follicular pink fluorescence associated with porphyrin production by Propionobacterium acnes (P. acnes) described previously in the lesions of progressive macular hypomelanosis (PMH). PMH was confirmed histologically by the findings in the second biopsy of a decrease in epidermal melanin pigment and the persistence of pityriasis versicolor was ruled out by an absence of fungal hyphae. Based upon the literature suggesting improvement of PMH with antibiotic therapy to decrease P. acnes colonization, she was treated with 10% benzoyl peroxide wash, clindamycin 1% solution and oral, twice-daily tetracycline 500 mg. During six months of this treatment, she experienced re-pigmentation of many of her existing skin lesions and cessation of the development of new hypopigmented macules.