"Hot" KTP-laser treatment of facial angiofibromata.

BACKGROUND AND OBJECTIVE: Treatment of facial angiofibromata (AF) relied largely upon cutaneous resurfacing. While effective, resurfacing affects large areas with attendant risks of dyspigmentation, infection, and scarring. We investigated the pulsed KTP (532 nm) laser energy for its high absorption by melanin and hemoglobin as a photothermal destructive method for treating AF. STUDY DESIGN/MATERIALS AND METHODS: In five patients (Fitzpatrick phototypes II-;VI), AF were treated with the KTP laser (10 ms, 20 J/cm(2), 2 mm beam) using stacked pulses (2-3.3 Hz) or passes. No cooling device was employed. Each pulse evoked puffs of steam and caused progressive flattening of AF. Normal intervening skin was strictly avoided. Patients underwent one to five sessions in which as many as 100 lesions were treated. RESULTS: Individual lesions responded with complete flattening in one or two treatments. While this effect has persisted for 18-;24 months, slow recrudescence is expected. Transient hypopigmentation and hyperpigmentation were localized to treated skin. No scarring, infection, or other adverse events were observed. Patient satisfaction with this method was high due to rapid healing time ( < 10 days), minimal pain, ease of wound care, and efficacy. CONCLUSIONS: "Hot" KTP laser is an effective and safe method of treatment for facial AF. Limiting treatment only to lesional skin allowed rapid healing and very limited adverse effects despite the increased non-specific thermal damage caused by high fluence, long pulse duration, and an absence of superficial tissue cooling.

Tattoo darkening and nonresponse after laser treatment: a possible role for titanium dioxide.

OBJECTIVE: To examine relationships between chemical composition, biopsy findings, and clinical outcome in laser-treated tattoos. DESIGN: Observational nonblinded retrospective study. SETTINGS: University-based dermatology clinic and private practice. PARTICIPANTS: Twenty patients who underwent biopsy of laser-treated tattoos. MAIN OUTCOME MEASURES: Biopsy specimens were analyzed after laser treatment, and the depths of changed particles were recorded. Ultrastructure of the changed particles was examined by electron microscopy. Presence of inorganic chemicals was determined by x-ray diffraction. Correlation between x-ray diffraction, microscopy, and clinical response was attempted. RESULTS: Of the 20 tattoos, 7 lightened, 9 failed to change, and 4 darkened after laser treatment. There was a significant association between presence of titanium dioxide and poor response to laser therapy. Microscopic studies showed variable changes in the ink particles, but there was a trend toward residual deep green pigment in the resistant tattoos. Also, round dark stippling was observed superficially in the darkened specimens. CONCLUSIONS: Titanium is overrepresented in tattoos that respond poorly to laser treatment. Further studies are necessary to show whether this metal is the primary cause of this poor response.

New methods in cutaneous resurfacing.

The ongoing effort to create an optimal method of skin rejuvenation has led to several new treatment options. Microdermabrasion and various nonablative laser resurfacing systems produce minimal skin injury, whereas current RF resurfacing devices may create both ablative or nonablative effects. The less invasive methods do limit the length of an uncomfortable healing time; however, studies appear to indicate that the results are less impressive than those produced by more destructive techniques and may prove only temporary over the time frame of a year. Efficacy and durability of clinical improvement seem to be inversely related to the wounding depth, the length of the healing period, or both. The search continues for the perfect method of skin rejuvenation, which minimizes cost, healing time, adverse effects, and discomfort and maximizes efficacy, response durability, and reproducibility. With advancements in technology, rejuvenation methods slowly approach these elusive goals.

Electrosurgical facial resurfacing: a prospective multicenter study of efficacy and safety.

BACKGROUND: A novel electrosurgical technology that uses a bipolar electrode-tipped stylet to deliver relatively low-radiofrequency energy through an electrically conductive medium has been developed. OBJECTIVE: To evaluate the efficacy and safety of the radiofrequency resurfacing system for the treatment of facial wrinkles. DESIGN: Multicenter, prospective, noncomparative study with longitudinal follow-up. SETTING: Four US academic dermatologic surgery clinics. PATIENTS: Ninety-five patients with mild to severe photodamage (Fitzpatrick classes I-III) involving periorbital (75 treatment sites) and perioral (50 sites) facial skin. INTERVENTION: Radiofrequency resurfacing with the use of 2 to 3 passes at 125 or 139 V. MAIN OUTCOME MEASURES: Wrinkle and cosmetic improvements evaluated by patients, investigators, and, by means of photographs, an independent panel of 5 evaluators. RESULTS: All evaluators determined a positive mean improvement in wrinkles for both periorbital and perioral anatomic sites, with greater improvement for patients with more severe wrinkles at baseline. An increased number of passes and higher voltage settings had a positive impact on wrinkle improvement. Transient postinflammatory hyperpigmentation occurred in 26% of periorbital and 4% of perioral sites. Hypertrophic scars occurred in 3.8% of treatment sites, with all but 1 scar resolving by 6 months. For the most part, healing was rapid, pain was minimal, and erythema largely resolved within 2 months. Other untoward effects were relatively few and short-lived. CONCLUSIONS: At the study settings used, radiofrequency resurfacing is an effective modality in the treatment of periorbital and perioral wrinkles in patients with Fitzpatrick class I, II, and III photodamage. There is less severe postoperative morbidity than seen with carbon dioxide or coagulating erbium:YAG lasers. The potential risks are similar to those seen with other resurfacing modalities.

Ber-EP4-positive phenotype differentiates actinic keratosis from superficial basal cell carcinoma.

BACKGROUND: Well-defined histopathologic criteria exist to distinguish actinic keratosis (AK) from superficial basal cell carcinoma (BCC). A similar morphology of downwardly budding dysplastic keratinocytes may occur in both entities, creating potential for errors in diagnosis. A marker that could reliably distinguish these two lesions would overcome this difficulty in diagnosis. OBJECTIVE: To investigate whether Ber-EP4 staining is useful in distinguishing AK from superficial BCC, and to determine whether AK exhibits a cellular phenotype that is more consistent with BCC or squamous cell carcinoma (SCC). METHODS: We subjected tissue sections from superficial BCC, AK, and squamous intraepithelial neoplasia (SIN) demonstrating epidermal budding to immunohistochemical staining with monoclonal antibody Ber-EP4. RESULTS: Abnormal keratinocytes in all specimens of superficial BCC (5 of 5) were Ber-EP4 positive; all AK (10 of 10) and SIN (8 of 8) were Ber-EP4 negative. CONCLUSION: Ber-EP4 staining reliably distinguishes AK from superficial BCC. The lack of Ber-EP4 staining of AK supports the currently accepted pathogenetic dogma that SIN and SCC arise from AK, but BCC does not.

Management of cutaneous verruciform xanthoma.

Verruciform xanthoma is an uncommon mucocutaneous condition of uncertain cause that only occasionally affects the skin. The histopathology is distinctive for the presence of foamy histiocytes present within elongated dermal papillae. Although simple excision of intraoral lesions is reportedly curative, treatment of cutaneous lesions has not been previously reported. We describe a 62-year-old man with a large lesion of verruciform xanthoma affecting both inguinal folds. Immunohistochemical staining, reverse transcriptase polymerase chain reaction for human papilloma virus, and ultrastructural analysis were performed to investigate the pathogenesis of this lesion. The results of these studies support the theory that the source of lipid in dermal histiocytes is degenerating keratinocytes. Initial treatment with wire loop electrosection, pulsed dye (585 nm) laser, and x-ray therapy of this patient proved unsuccessful. Preliminary success has been achieved using wide surgical excision with primary closure.

Treatment of multiple eruptive hair cysts with erbium:YAG laser.

BACKGROUND: Eruptive vellus hair cysts (EVHC) frequently resist a variety of treatment modalities. While pulsed carbon dioxide (CO2) laser has been used effectively for facial EVHC, this laser presents significant risks for hypertrophic scarring when used on truncal sites. Due to absorption of 2940 nm energy by both tissue water and protein, the erbium:yttrium-aluminum-garnet (Er:YAG) laser ablates more cleanly and creates less residual thermal injury in the wound bed. This laser might prove efficacious and safe in treating nonfacial EVHC. OBJECTIVE: To assess treatment efficacy and wound healing after Er:YAG laser ablation of EVHC. METHODS: Two patients with 32 truncal EVHC were treated with pulsed Er:YAG laser using a drilling technique followed by second intention healing. RESULTS: Laser treatment sites healed without permanent dyspigmentation or hypertrophic scarring. No lesion recurrence was observed. CONCLUSION: Er:YAG laser ablation is an effective method for treating EVHC at anatomic sites prone to hypertrophic scar formation.

Multi-electrode radio frequency resurfacing of ex vivo human skin.

BACKGROUND: A novel radio frequency multi-electrode surgical (MES) device has produced minimal residual thermal collagen damage (RTCD) and rapid healing in treating articular cartilage. OBJECTIVE: To assess the immediate tissue effects of the MES device on human skin. METHODS: Specimens of ex vivo human skin were subjected to 1 to 3 passes of the device at 3 voltage settings, then processed for routine and polarized light microscopy. The degree of tissue ablation, amount of RTCD, and level of follicular injury were assessed. RESULTS: Epidermal ablation did not occur; epidermal removal correlated with manual debridement after the first passes. Dermal ablation was not readily discernable even after 2 or 3 passes. The thickness of RTCD tended to increase with increased pass number. The mean thickness of this zone of damaged collagen measured 24-53 micro after 1, 63-83 micro after 2, and 80-97 micro after 3 passes, respectively. For a given number of passes, the thickness of the zone of RTCD did not consistently change with increasing voltage applied (86, 108, and 139 V). The small number of samples did not enable meaningful statistical analysis of these observations. In samples with pilosebaceous units, the electrosurgical keratinocyte injury extended down the follicular epithelium, but never beyond the level of the infundibulum. CONCLUSIONS: These findings suggest the MES device produces immediate tissue effects favorable for effective cutaneous resurfacing and rapid postoperative wound healing.

Ultrastructure of collagen thermally denatured by microsecond domain pulsed carbon dioxide laser.

BACKGROUND: Clinical improvement in photodamaged skin after carbon dioxide (CO2) laser resurfacing is thought to result in part from thermal collagen shrinkage. The presence of such collagen has not been unequivocally demonstrated. To identify and characterize the morphological features of collagen after CO2 laser exposure, we irradiated ex vivo human facial skin and bovine calcaneus tendon with microsecond domain pulsed CO2 laser energy and examined specimens for histopathological and ultrastructural changes in collagen. OBSERVATIONS: In dermis and tendon, 3 zones of collagen structure were apparent on electron microscopy. The first, most superficial zone demonstrated loss of collagen structure. The second zone consisted of admixed normal collagen fibers and thickened collagen fibers. Zone 3 consisted of normal-appearing collagen fibers. CONCLUSIONS: Ultrastructural examination of irradiated collagen revealed distinct morphological zones of denatured collagen fibers. Partially denatured fibers had an increased diameter consistent with lineal shrinkage. Zonal distinction was undetectable by light microscopy. Ultrastructurally, the zones of denatured collagen located above the normal fibers correlated with the zone of altered material seen on light microscopy. These findings suggest that collagen fiber shrinkage does occur after pulsed CO2 laser irradiation and that this phenomenon contributed, at least in part, to the immediate tissue contraction observed clinically.

Positive predictive value for presumptive diagnoses of skin cancer and compliance with follow-up among patients attending a community screening program.

BACKGROUND: There is an ongoing need for evaluating the effectiveness of skin cancer screening programs and barriers to obtaining definitive diagnoses and treatments among screen-positive patients. METHODS: We studied 132 patients who were given presumptive diagnoses of skin cancer while attending a free skin cancer screening program during May 1994 in San Diego, California (464 screened). We assessed compliance with recommendations to see a physician for definitive diagnostic workup. Logistic regression models included potential determinants of compliance: age, gender, health insurance, educational level, anatomic site, number of suspicious skin lesions, personal and family history of skin cancer, propensity to sunburn, and history of recent change in moles. The positive predictive value (PPV) of skin cancer diagnoses was defined conservatively as a range by inclusion then exclusion of patients not biopsied. RESULTS: Follow-up information was obtained for 115 patients, and 88 (77%) of these reported obtaining a definitive workup. The final regression model controlling for age showed that patients without a family history of skin cancer were less compliant than those with a history [OR for noncompliance 3.29, 95% confidence interval (CI) 1.10-9.83], and patients with only one presumptive skin cancer lesion were less compliant than those with additional cancer lesions (OR 5.31, 95% CI 1.07-26.43). Older patients were more compliant than younger. Among 82 patients under 65 years of age, the above factors were important only among men. Also, noncompliance was significantly higher among younger men without versus with health insurance (OR 5.14, 95% CI 1.23-20.68). Two melanomas, 1 squamous cell carcinoma, and 23 basal cell carcinomas were histopathologically confirmed. The PPV for melanoma was 6-15%, for squamous cell carcinoma 4-12%, and for basal cell carcinoma 32-85%. CONCLUSIONS: This study confirms the ability of skin cancer screening programs to successfully identify individuals with cutaneous malignancies. The significant association of noncompliance to seek recommended follow-up care with lack of health insurance for men too young to participate in Medicare suggests that approaches to definitive workup for uninsured patients be developed alongside free screening programs.

Protoporphyrin IX fluorescence induced in basal cell carcinoma by oral delta-aminolevulinic acid.

Limited depth of penetration significantly limits photodynamic therapy of nodular basal cell carcinoma (BCC) using topical delta (5)-aminolevulinic acid (ALA). To demonstrate safety and efficacy of orally administered ALA in inducing endogenous protoporphyrin IX (PpIX) production in BCC, 13 patients with BCC ingested ALA in a dose-escalation protocol. All dose ranges (10, 20 or 40 mg/kg single doses) resulted in formation of PpIX in human skin and BCC, measurable by in vivo fluorescence spectrophotometry. The PpIX fluorescence peaked in tumors before normal adjacent skin from 1 to 3 h after ALA ingestion. Gross fluorescence imaging of ex vivo specimens revealed greater PpIX fluorescence in tumor than normal skin only at the 40 mg/kg dose. Fluorescence microscopy confirmed this finding by showing distinct, full-thickness PpIX fluorescence in all subtypes of BCC only after ALA given at 40 mg/kg. Side effects were dose dependent and self limited. Photosensitivity lasting less than 24 h and nausea coinciding with peak skin PpIX fluorescence occurred at 20 and 40 mg/kg doses. After 40 mg/kg ALA, serum hepatic enzyme levels rose to a maximum within 24 h, then resolved over 1-3 weeks. Transient bilirubinuria occurred in two patients.

Surgical pearl: phlebectomy hook Norplant extraction.

PIP: Removal of Norplant contraceptive implants may be rendered difficult by the size of the capsules and variations in insertion technique. In the standard removal technique, a single transverse incision is made close to and below the distal ends of the capsules, and a mosquito forceps is used for extraction. Described, in this article, is a simple technique for the isolation and removal of Norplant with a Ramelot phlebectomy hook. After anesthesia with 1% lidocaine with 1:100,000 of epinephrine, a 5 mm horizontal stab incision with a Number 11 blade is made at the base of the implants. Using digital palpation for stabilization, each capsule is captured with the Ramelot hook and delivered through the incision. After the implant is grasped with a mosquito forceps, gentle traction and an oscillating motion dislodge the implant from the surrounding fibrous tissue. Incision sites are closed with plain gut sutures. Complications associated with this procedure include broken capsules, cutaneous infection, and contusion.^ieng

Pulsed carbon dioxide laser resurfacing of photo-aged facial skin.

BACKGROUND AND DESIGN: public demand for procedures to rejuvenate photoaged skin have stimulated the use of high-energy short-pulsed carbon dioxide lasers as a precise and predictable treatment modality. The purpose of this study was to determine the degree of clinical improvement achieved in treating perioral and periorbital wrinkles with a high-energy, microsecond-domain pulsed CO2 laser. Photodamaged skin in the perioral (n=73) and periorbital (n=38) regions was treated with multiple passes of confluent single pulses of CO2 laser energy (10 600 nm, 3-mm collimated beam, <1- millisecond pulse, 450 mJ per pulse, 2 to 5 W), with the tissue being cleansed and débrided with normal saline between passes. A nine-point clinical scoring system was devised for evaluation of the degree of wrinkling and photodamage present. Preoperative and postoperative photographs were independently scored by four ¿blinded¿ reviewers. The patients were observed postoperatively for 1 to 12 months for the course of healing, and adverse events were recorded. RESULTS: All three classes (mild, moderate, and severe) of photoaging of the skin responded equally well, showing an average wrinkling score reduction of 2.25 for the periorbital region and 2.34 for the perioral region, the most superficial wrinkles and photodamage being eliminated and the more severe being markedly improved. An unexpected finding was tightening of loose and folded skin. Side effects included transient erythemia and postinflammatory hyperpigmentation, and one instance of an isolated hypertrophic scar. CONCLUSIONS: Resurfacing of photoaged skin by means of a high-energy, microsecond-domain pulsed CO2 laser with a specific clinical treatment protocol results in predictable improvement in perioral and periorbital wrinkling and photodamage with minimal risks. Heat-induced collagen shrinkage appears to contribute to these results by tightening loose skin and folds.

Multimodal management of diffuse neonatal hemangiomatosis.

Diffuse neonatal hemangiomatosis is a rare, frequently fatal disorder. We describe the case of a neonate with numerous cutaneous and ocular hemangiomas. Hepatic hemangiomas were noted at 4 weeks of age, associated with congestive heart failure resulting from hepatic arteriovenous shunting. This condition was controlled by treatment with prednisone, interferon alfa-2b and hepatic embolization. Treatment of cutaneous hemangiomas with the tunable dye laser prevented hemorrhage, facilitated routine skin care, and allowed uninhibited intravenous access during hospitalization.