Isotretinoin and dermatosurgical procedures.

Several early reports suggested that performance of dermatosurgical procedures in patients on oral isotretinoin is associated with abnormal skin healing, keloid or hypertrophic scar formation. However, this association has been recently questioned in some studies. This review examines this issue, analyzes the studies published and concludes that the recommendation made earlier about the need to avoid dermatosurgical procedures in patients on isotretinoin is based on inadequate and insufficient evidence and hence needs revision. The review also suggests that recent studies on the subject establish that performing such procedures is safe.

Pre- and perioperative aspects of dermatosurgery.

Dermatosurgery occupies an exceptional position among all surgical disciplines. Above all, this includes the fact that, with very few exceptions, the vast majority of surgical interventions can be performed under local or regional anesthesia, usually in smaller procedure rooms that are spatially separated from larger operating suites. Thus, peri- and postinterventional patient monitoring is the responsibility of the dermatosurgeon and his team. Though inherently smaller, this team still has to observe numerous perioperative requirements that - in larger surgical specialties - would be attended to by a host of various specialists working in concert. Said requirements include hygienic aspects, knowledge concerning pre- and intraoperative patient monitoring, managing surgical site infections, adequate postsurgical pain management, as well as detailed pharmacological knowledge with respect to common local anesthetics and the toxic and allergic reactions associated therewith. Not only does this require interdisciplinary collaboration and shared responsibility for the patient. It also necessitates the development and implementation of quality-oriented and evidence-based guidelines that, in the dermatosurgical setting, usually extend far beyond the scope of the specialty per se. The objective of the present CME article is the condensed presentation of interdisciplinary aspects relating to the most important perioperative issues.

Tool to visualize and evaluate operator proficiency in laser hair-removal treatments.

BACKGROUND: The uniform delivery of laser energy is particularly important for safe and effective laser hair removal (LHR) treatment. Although it is necessary to quantitatively assess the spatial distribution of the delivered laser, laser spots are difficult to trace owing to a lack of visual cues. This study proposes a novel preclinic tool to evaluate operator proficiency in LHR treatment and applies this tool to train novice operators and compare two different treatment techniques (sliding versus spot-by-spot). METHODS: A simulation bed is constructed to visualize the irradiated laser spots. Six novice operators are recruited to perform four sessions of simulation while changing the treatment techniques and the presence of feedback (sliding without feedback, sliding with feedback, spot-by-spot without feedback, and spot-by-spot with feedback). Laser distribution maps (LDMs) are reconstructed through a series of images processed from the recorded video for each simulation session. Then, an experienced dermatologist classifies the collected LDMs into three different performance groups, which are quantitatively analyzed in terms of four performance indices. RESULTS: The performance groups are characterized by using a combination of four proposed indices. The best-performing group exhibited the lowest amount of randomness in laser delivery and accurate estimation of mean spot distances. The training was only effective in the sliding treatment technique. After the training, omission errors decreased by 6.32% and better estimation of the mean spot distance of the actual size of the laser-emitting window was achieved. Gels required operators to be trained when the spot-by-spot technique was used, and imposed difficulties in maintaining regular laser delivery when the sliding technique was used. CONCLUSIONS: Because the proposed system is simple and highly affordable, it is expected to benefit many operators in clinics to train and maintain skilled performance in LHR treatment, which will eventually lead to accomplishing a uniform laser delivery for safe and effective LHR treatment.

Core measures: implications for plastic surgery.

BACKGROUND: Perioperative complications are a major source of morbidity, mortality, and expenditures in health care. Many of these complications are preventable with simple, cost-effective measures when implemented in a standardized manner. Surgical specialties are increasing efforts to implement standardized and easily monitored measures to reduce perioperative complications. METHODS: The recommendations provided by the U.S. Department of Health and Human Services and published by the Joint Commission on Accreditation of Healthcare Organizations were summarized as they pertain to plastic surgery. A review of recent plastic surgery literature was pursued to evaluate these recommendations as they pertain to the specialty. RESULTS: Measures exist to reduce the incidence of perioperative infection, venous thromboembolism, and mortality associated with cardiac events. These measures include type and timing of prophylactic antibiotics, maintenance of perioperative normothermia, appropriate hair removal, early discontinuation of urinary catheters, appropriate venous thromboembolism prophylaxis, and use of preoperative beta-blockers. CONCLUSIONS: As national quality measures are implemented across an increasing number of specialties, the expansions will likely affect plastic surgery. These measures are evidence based and validated across a diverse group of surgical specialties, resulting in improved measured outcomes. Plastic surgeons would benefit by actively providing leadership as these and similar measures are implemented.

Topical eflornithine hydrochloride improves the effectiveness of standard laser hair removal for treating pseudofolliculitis barbae: a randomized, double-blinded, placebo-controlled trial.

BACKGROUND: Pseudofolliculitis barbae (PFB) significantly impacts the military population, especially deployed personnel. OBJECTIVE: This study was designed to determine whether the addition of topical eflornithine to hair laser treatment would improve efficacy in treating PFB. METHODS: This was a randomized, double-blinded, placebo-controlled, paired (right and left neck) comparison study examining a combination of eflornithine and hair laser versus placebo and hair laser for the treatment of PFB. In all, 27 male patients with clinical PFB were treated with a long-pulsed neodymium:yttrium-aluminum-garnet laser with an energy fluence of 25 to 30 J/cm(2), a pulse duration of 20 to 30 milliseconds, and a 10-mm spot size to the entire bearded neck region. The laser treatment was performed every 4 weeks for a total of 16 weeks. Between laser treatments, patients applied eflornithine and placebo creams twice daily to opposite sides of the bearded neck region. The number of hairs and inflammatory papules were counted bilaterally at each visit. RESULTS: The eflornithine side had a statistically significant decrease in the number of hairs and inflammatory papules compared with the placebo side. At 16 weeks, the eflornithine side had a median hair reduction of 99.5% from baseline (range 48.5%-100.0%), whereas the placebo side had an 85.0% median hair reduction from baseline (range 50.5%-94.5%), P less than .001. LIMITATIONS: Patients were not followed up beyond 16 weeks. CONCLUSION: The addition of topical eflornithine to hair laser treatment decreased hairs and inflammatory papules faster when compared with hair laser therapy alone in the treatment of PFB.

Are home-use intense pulsed light (IPL) devices safe?

The domestic market for home-use hair removal devices is rapidly expanding and there are numerous intense pulsed light (IPL) products now available globally to consumers. Technological challenges for the design of such devices include the need to be cost-effective in mass production, easy to use without training, and most importantly, clinically effective while being eye-safe. However inexpensively these light-based systems are produced, they are designed to cause biological damage to follicular structures, so precautions to prevent both ocular and epidermal damage must be considered. At present, there are no dedicated international standards for IPL devices. This review directly compares three leading domestic IPL hair removal devices: iPulse Personal (CyDen, UK), Silk'n/SensEpil (Home Skinovations, Israel), and SatinLux/Lumea (Philips, Netherlands) for fluence, emitted wavelength spectrum, time-resolved footprint, and spatial distribution of energy. Although each device has a primary mechanical or electrical safety feature to ensure occlusion of the output aperture on the skin to prevent accidental eye exposure, the ocular hazard of each device has been measured to IEC TR 60825-9 standard using an Ocean Optics HR2000+ photo spectrometer for both potential corneal and retinal damage. Using established measurement methods, this review has shown that the measured output parameters were significantly different for the three systems. Using equipment traceable to national standards, one device was judged at its two highest settings to be hazardous for naked eye viewing. This investigation also reports on the significantly different pulse durations of the devices measured and considers the potential impact on safety and efficacy in the light of the theory of selective photothermolysis. Although these devices offer low-cost personal convenience of treatment in the privacy of the home, ocular safety may be inadequate in the event of primary safety mechanism failure.

Agent-based model of laser hair removal: a treatment optimization and patient education tool.

BACKGROUND: Tracking of various parameters associated with laser hair removal is tedious and time consuming. The currently available mathematical models are not simple enough for physicians to be used as a treatment optimization and patient education tool. AIM: The aim of the study was to develop a mathematical model for laser hair removal using agent-based modeling and to make a user-friendly simulation environment. METHODS: The model was created using NetLogo. The hairs were modeled as agents oscillating between anagen and telogen. The variables were assigned based on published data whenever possible and the various paths the agent could take were coded as conditional statements. The improvement was assessed using an arbitrary index which takes into account the mean diameter and pigmentation along with the number and length of hairs visible above the surface. Few of the commonly encountered scenarios were simulated using the model. RESULTS: The model is made freely available online (http://www.gulfdoctor.net/model/lhr.htm). Limited number of simulations performed indicated that an eight-week gap between laser sessions may be more effective than a four-week gap. CONCLUSIONS: The simulation provides a reliable tool for treatment optimization and patient education as obtaining relevant clinical data is slow and labor-intensive. Its visual interface and online availability makes it useful for everyday use.

Standard guidelines of care: laser and IPL hair reduction.

UNLABELLED: Laser-assisted hair removal, Laser hair removal, Laser and light-assisted hair removal, Laser and light-assisted, long-term hair reduction, IPL photodepilation, LHE photodepilation; all these are acceptable synonyms. Laser (Ruby, Nd Yag, Alexandrite, Diode), intense pulse light, light and heat energy system are the different light-/Laser-based systems used for hair removal; each have its advantages and disadvantages. The word "LONG-TERM HAIR REDUCTION" should be used rather than permanent hair removal. Patient counseling is essential about the need for multiple sessions. PHYSICIANS' QUALIFICATIONS: Laser hair removal may be practiced by any dermatologist, who has received adequate background training during postgraduation or later at a centre that provides education and training in Lasers or in focused workshops providing such training. The dermatologist should have adequate knowledge of the machines, the parameters and aftercare. The physician may allow the actual procedure to be performed under his/her direct supervision by a trained nurse assistant/junior doctor. However, the final responsibility for the procedure would lie with the physician. FACILITY: The procedure may be performed in the physician's minor procedure room. Investigations to rule out any underlying cause for hair growth are important; concurrent drug therapy may be needed. Laser parameters vary with area, type of hair, and the machine used. Full knowledge about the machine and cooling system is important. Future maintenance treatments may be needed.

Trichotillometry: the reliability and practicality of hair pluckability as a method of nutritional assessment.

BACKGROUND: A nutritional assessment method that is quick and easy to conduct would be extremely useful in a complex emergency, where currently there is no agreed practical and acceptable method. Hair pluckability has been suggested to be a useful method of assessing protein nutritional status. The aim was to investigate the reliability of the trichotillometer and to explore the effects of patient characteristics on hair epilation force. METHODS: Three observers plucked hair from twelve participants to investigate the within- and between-observer reliability. To investigate the effect of patient characteristics on hair pluckability, 12 black African and 12 white volunteers were recruited. Participants completed a short questionnaire to provide basic information on their characteristics and hair. RESULTS: Mean hair pluckability measurements for the 12 participants obtained by the three observers (39.5 g, 41.2 g and 32.7 g) were significantly different (p < 0.001). Significant variation between patients was also found (p < 0.001). None of the patient characteristics significantly affected hair pluckability, with the exception of age, although this relationship was not consistent. CONCLUSION: Due to significant variation in measurements, hair pluckability does not appear to be a reliable method for assessing adult nutritional status. Hair pluckability could be a useful method of nutritional assessment in complex humanitarian emergencies but only if the reliability was improved.

Use of image analysis techniques for objective quantification of the efficacy of different hair removal methods.

In the field of consumer-used cosmetics for hair removal and hair growth reduction, there is a need for improved quantitative methods to enable the evaluation of efficacy and claim support. Optimized study designs and investigated endpoints are lacking to compare the efficacy of standard methods, like shaving or plucking, with new methods and products, such as depilating instruments or hair-growth-reducing cosmetics. Non-invasive image analysis, using a high-performance microscope combined with an optimized image analysis tool, was investigated to assess hair growth. In one step, high-resolution macrophotographs of the legs of female volunteers after shaving and plucking with cold wax were compared to observe short-term hair regrowth. In a second step, images obtained after plucking with cold wax were taken over a long-term period to assess the time, after which depilated hairs reappeared on the skin surface. Using image analysis, parameters like hair length, hair width, and hair projection area were investigated. The projection area was found to be the parameter most independent of possible image artifacts such as irregularities in skin or low contrast due to hair color. Therefore, the hair projection area was the most appropriate parameter to determine the time of hair regrowth. This point of time is suitable to assess the efficacy of different hair removal methods or hair growth reduction treatments by comparing the endpoint after use of the hair removal method to be investigated to the endpoint after simple shaving. The closeness of hair removal and visible signs of skin irritation can be assessed as additional quantitative parameters from the same images. Discomfort and pain rating by the volunteers complete the set of parameters, which are required to benchmark a new hair removal method or hair-growth-reduction treatment. Image analysis combined with high-resolution imaging techniques is a powerful tool to objectively assess parameters like hair length, hair width, and projection area. To achieve reliable data and to reduce well known image-analysis artifacts, it was important to optimize the technical equipment for use on human skin and to improve image analysis by adaptation of the image-processing procedure to the different skin characteristics of individuals, like skin color, hair color, and skin structure.

Epilation today: physiology of the hair follicle and clinical photo-epilation.

Despite the variations of length and type of hair (vellus or terminal), the growth of human hair in all body sites is cyclic. Phases of active hair growth, or anagen, are separated by periods of quiescence, or telogen. The duration of both phases varies greatly depending on the body site. Whether hairs are in anagen/telogen at the time of hair removal is important because only anagen hairs are particularly sensible to physical insults. Photo-epilation is a technique for long-term removal of unwanted hair by thermal destruction of the hair follicle and its reproductive system (stems cells). As melanin is the main chromophor existing in hair follicles the corresponding wavelength spectrum would range from ultraviolet up to infrared light. Furthermore longer wavelengths are preferred as the cromophor lies deep in the skin and the penetration of light is increasing with the wavelength. Thus, in the range of 600-1100 nm melanin absorption may be used for selective photothermolysis of hair follicles. Yet to be resolved questions for permanent destruction are the location of the key follicular target and the possible influence of the hair growth cycle on photothermolysis-induced hair removal. An overview on the individual physiology of the hair follicle is given to discuss the latest strategies for photo-epilation.

Photo-epilation: guidelines for care from the European Society for Laser Dermatology (ESLD).

Laser- or flashlamp- (also called intense pulsed light source or IPLS) assisted hair removal is a well tolerated and effective technique for patients who desire permanent reduction of hair growth. Although laser and light sources are very popular because of their non-invasive nature and the speed at which they operate, practitioners and patients have to be cautious to avoid permanent side effects instead of permanent hair reduction. These guidelines focus on patient selection and treatment protocol in order to provide safe and effective treatment. The ideal patient for laser hair removal is light skin with black coarse hair. Blond, grey and white hair does not respond to treatment. Individuals with dark skin, and especially tanned patients, are at higher risk for pigmentary changes. Sunscreen before and after treatment will produce and maintain untanned skin. The type of laser or IPLS and their specific parameters must be adapted to the patient (hair thickness, pigment concentration, Fitzpatrick skin type). Treatments should start on a test patch and a treatment grid can improve accuracy. Pre-, parallel and post-cooling, as well as a reduction of the fluence, will prevent adverse effects such as pigment alteration and scar formation. Average rates of long-term hair reduction are reported at between 70% and 90% at 6 months follow-up. At least three repeated treatments should be done to achieve partly permanent epilation.

SOGC clinical practice guidelines. Hirsutism: evaluation and treatment.

OBJECTIVES: To review the etiology, evaluation, and treatment of hirsutism. EVALUATION: A thorough history and physical examination plus selected laboratory evaluations will confirm the diagnosis and direct treatment. TREATMENT: Pharmacologic interventions can suppress ovarian or adrenal androgen production and block androgen receptors in the hair follicle. Hair removal methods and lifestyle modifications may improve or hasten the therapeutic response. OUTCOMES: At least six to nine months of therapy are required to produce improvement in hirsutism. EVIDENCE: The quality of evidence reported in this guideline has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS: Hirsutism can be slowly but dramatically improved with a three-pronged approach to treatment: mechanical hair removal, suppression of androgen production, and androgen receptor blockade. Lifestyle changes including weight loss and exercise will lower serum androgen levels and improve self-esteem. The patient should be educated regarding associated health problems or long-term medical consequences of hyperandrogenism, including obesity, irregular menses, anovulation, infertility, pregnancy-induced hypertension, diabetes, hyperlipidemia, hypertension, and heart disease.