Julia Schwartz MDa and Adam J. Friedman MDa,b
The stratum corneum (SC) is the skin’s outermost layer and serves the primary function of acting as a shield to keep foreign matter out and to essential elements, such as moisture and water, in. Maintenance of this skin barrier is crucial to healthy functioning skin. A damaged or diseased skin barrier is vulnerable to infection, irritants, and allergens. The cornerstone of skin barrier regulation and repair is through the use of moisturizers. While healthcare providers and patients may underestimate the importance of moisturizers due to their lack of active ingredients, the benefit of a well-planned moisturizer regimen for skin barrier regulation should not be discounted. Dermatologists should be comfortable prescribing and educating about over-the-counter moisturizers to patients with skin barrier is- sues. A general understanding of basic moisturizer ingredients and formulations will aid the dermatologist in providing a personalized moisturizer regimen to their patients.
J Drugs Dermatol. 2016;15(11):1289-1294.
Douglas J. Key MD and Lauren Boudreaux DO
BACKGROUND: Laxity of the eyelid and periorbital area, a common manifestation of aging, is usually addressed via blepharoplasty and/ or fat transfer. Given the trend toward safer, less invasive treatments preferred by those patients reticent to undergo more invasive procedures, viable alternatives have been sought. Transcutaneous temperature controlled radiofrequency (TTCRF) integrates non- invasive super cial RF treatment with automatic temperature feedback control of energy deposition, as a stimulator of overall collagen remodeling; however, the globe of the eye is particularly sensitive to RF energy. The purpose of the study was to propose a method by which TTCRF and other non-ablative modalities could be used to treat eyelid and infrabrow laxity, with autoclavable opaque black haptic scleral contact lenses protecting the globe of the eye.
METHODS: Subjects (n=40, 36 women and 4 men, age range, 33-72) with mild to moderate laxity of the eyelid and infrabrow were treated with TTCRF using black plastic eye shields (Oculoplastik, Montreal, Quebec, Canada) to protect the globe of the eye from heat and RF energy. With the shields in place subjects were treated with the 10 mm small monopolar emitter of the ThermiSmooth device (Thermi, Irving, Tex.), using small circular looping motions to safely elevate the temperature of target tissue to the therapeutically rel- evant range for approximately 6 minutes; tissue temperature was measured in real time using the device’s forward-looking infrared imaging.
RESULTS: No major adverse events were recorded. Treatment was safe and tolerable for all subjects.
CONCLUSION: The use of autoclavable opaque black plastic eye shields provides a safe method of treating the upper eye lid and infrabrow using TTCRF.
J Drugs Dermatol. 2016;15(11):1302-1305.
Joel L. Cohen MD,a Steven F.Weiner MD,b Jason N. Pozner MD,c Omar A. Ibrahimi MD PhD,d David B.Vasily MD,e E.Victor Ross MD,f and Zena Gabriel MDg
In this multi-center pilot study, the safety pro le of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for safety in the treatment of the aging neck and face. A newly designed insulated microneedle system delivers a signi cant coagulative thermal injury into the dermis while sparing the epidermis from RF injury. Thirty- ve healthy subjects from seven aesthetic practices were evaluated, and data from each were incorporated in this case report. The subjects received a single treatment using settings that delivered the highest RF energies suggested from the new recommended protocols. The depth of thermal delivery was adjusted before each pass and all subjects received a minimum of two to three passes to the treated areas. Before and after photographs along with adverse effects were recorded. This case report demonstrates the ability to deliver significant RF thermal injury to several layers of the dermis with insulated microneedles safely with little injury to the epidermis and minimum downtime.
J Drugs Dermatol. 2016;15(11):1308-1312.
Joel L. Cohen MDa and Roy Geronemus MDb
BACKGROUND & OBJECTIVE: Surgical scars are an unwanted sequela following surgical procedures. Several different treatment modalities and approaches are currently being employed to improve the cosmesis of surgical scars with each having varying degrees of success. The objective of this study was to assess the ef cacy and safety pulsed dye laser treatment, CO2 ablative fractional resurfacing, and a combined treatment with these two modalities for the cosmetic improvement of surgical scarring that occurred following the surgical removal of skin cancer from different anatomic areas.
MATERIALS AND METHODS: Twenty-five patients with surgical scarring most frequently on the face following recent surgical excision of skin cancer with Mohs surgery were included in this multicenter, prospective clinical study. Patients were randomized into 4 treatment arms, namely, pulsed dye laser alone, CO2 laser alone, a combined treatment with these two modalities, and CO2 ablative fractional resurfacing on the same day of surgery to half of the scar, followed by a combined treatment with the two modalities to that half of the scar. Patients in each study arm received a total of 3-4 treatments, while those patients in Arm 4 underwent an additional treatment with CO2 laser immediately after surgery. Patients were followed up at 1 and 3 months after the final treatment session.
RESULTS: No adverse events were seen. Significant improvements in the appearance of scars were achieved in all study arms, as as- sessed by the Vancouver Scar Scale and Global Evaluation Response scales, with the best clinical outcomes seen in those scars that underwent a combination treatment. All patients reported very high satisfaction from treatment.
CONCLUSION: Both pulsed dye laser treatment and CO2 ablative fractional resurfacing, when used as a monotherapy, are safe and effective in the treatment and improvement of recent surgical scarring. When both of these modalities are used in combination, however, they appear to potentially have a synergistic effect and an accelerated outcome on the cosmesis of recent surgical scars.
J Drugs Dermatol. 2016;15(11):1315-1319.
Margit L.W. Juhasz MD,a,b Melissa K. Levin MD,a and Ellen S. Marmur MDa,c
“Fractionated photodynamic therapy (PDT)” is a new term being used by dermatologists to describe advances in PDT technology including fractionated light or the adjuvant use of fractional lasers. Although dermatologists have used PDT since the early 1990s for the treatment of photodamage and precancerous lesions, newer developments in technology have allowed for the treatment of non-melanoma skin cancers (NMSCs), in ammatory disorders, and even uses in the eld of anti-aging. Recent developments in fractionated light therapy have allowed for PDT with dark intervals and two-fold illumination schemes to increase cellular damage and apoptosis. Combining PDT with fractional laser technology has allowed for enhanced dermal penetration of topical photosensitizers including 5-aminolevulinic acid (ALA) and methyl aminolevulinate (MAL), as well as increased ef cacy of treatment. These advances in PDT technology will allow for increased convenience, decreased treatment time, only one application of topical photosensitizer, and decreased cost to the patient and dermatologist.
J Drugs Dermatol. 2016;15(11):1324-1328.
Erin Courtney RN BSN and David J. Goldberg MD JD
INTRODUCTION: Diode lasers are often considered as the gold standard preference for hair removal due to the deep penetration and ef- fective targeting of the hair follicle. A wide variety of diode lasers are available, which can differ in terms of their parameters (such as fluence, pulse duration, repetition rate, scanner, and cooling).
OBJECTIVE: The objective of the study was to evaluate the safety and ef cacy of hair removal with an 810 nm novel scanning diode laser, up to six months after last treatment.
METHODS: A scanning 810 nm diode laser was used for axillary hair removal of 14 female patients who received 3 treatments, 4-6 weeks apart. Follow-up on hair count was conducted 3 and 6 months after last treatment and compared to baseline hair count.
RESULTS: No unexpected or signi cant adverse events were recorded. An average hair count reduction of 72.8% after 3 months and 67.6% 6 months after the last treatment is demonstrated.
CONCLUSIONS: The examined 810 nm diode laser was proven to be safe and effective for hair removal. Results were sustained for 6 months after last treatment. Longer follow-up data are followed for further substantiation of the clinical effect. Scanning technology can provide for potentially faster and safer treatments.
J Drugs Dermatol. 2016;15(11):1330-1333.
Girish Munavalli MD MHS FAAD FACMS
Recent appreciation of the multifactorial pathophysiology of skin aging has led to increased use of parallel treatment regimens. This prospective, split-face, randomized study assessed the safety and efficacy of same-day sequential Q-switched Nd:YAG laser and 1565 nm non-ablative fractional laser (SST) facial rejuvenation treatment in comparison to fractional non-ablative laser (NAFL) treatment only. Seventeen patients underwent three treatment sessions, conducted at 4-6-week intervals, in which SST treatment was delivered on a randomly selected side of the face followed by NAFL treatment on the contralateral side immediately thereafter. Immediate skin responses were assessed within 30 minutes of treatment, while wrinkle/elastosis scores, and skin tone and texture were evaluated 1, 3, and 6 months following the final treatment session. While SST and NAFL proved equally safe, SST was associated with signi cantly lower pain scores in all three treatment sessions. Both treatment regimens yielded signi cant improvements in wrinkle/elastosis scores, which were maintained throughout the 6 months of follow up. Physician-evaluated skin tone and patient ratings of skin texture and overall improvement of the SST-treated side were consistently higher than the contralateral NAFL-treated side. Histological analysis suggested a broader effect, alongside sparing of the outermost epidermal layer with the SST versus NAFL treatment. Although the SST regimen failed to demonstrate statistically signi cant clinical superiority over the NAFL regimen, the significantly lower pain levels, consistently higher physician and patient ratings following SST may justify its regular use as a skin rejuvenation technique.
J Drugs Dermatol. 2016;15(11):1335-1342.
Derek Ho BS,a,b Farzad Fereidouni PhD,c Richard M. Levenson MD,c and Jared Jagdeo MD MSa,b,d
BACKGROUND: Skin care products make up the largest part (36%) of the cosmetic market globally, of which the United States plays the largest role. In 2015, approximately 115 billion USD was spent globally on skin care products. Skin care products, in contradistinction to pharmaceuticals, are not strictly regulated by the FDA. A key factor for evaluation of a skin care product or topical drug is skin barrier function and effect on super cial skin. Thus, it is critical to have quantitative and qualitative methods to study the effects of skin care products on skin barrier and the super cial skin. Currently, no imaging method exists that can evaluate and track super cial skin changes visually in real-time.
OBJECTIVE: To report using a novel imaging modality, Microscopy using Ultraviolet Surface Excitation (MUSE), to provide real-time, high- resolution, in vivo characterization of super cial skin and moisturizing properties of topical moisturizer, and to highlight key bene ts of using MUSE to visualize the super cial skin and serve as an excellent complementary tool to current quantitative methods.
METHODS AND MATERIALS: The methodology of MUSE is based upon two main principles inherent to ultraviolet (UV) light and uorescent staining agents. In this study, the author’s (JJ) index ngertip was imaged using the MUSE instrument without and with moisturizer.
RESULTS: Dermatoglyphics of the fingertip consists of ridges (cristae super ciales) and grooves (sulci super ciales) proved to be straightforward to visualize at high resolution. Desquamation of superficial corneocytes and opening of an acrosyringium (the most superficial portion of eccrine ducts) were visualized in high-resolution. Post-application of a moisturizer, a uniform layer of moisturizer could be seen superficial to the corneocytes along the ridges and CONCLUSIONS: Real-time, high-resolution, in vivo characterization of super cial skin and moisturizing properties of moisturizer using MUSE is feasible. Its utility can be enhanced with downstream quantification using imaging software.
J Drugs Dermatol. 2016;15(11):1344-1346.
Emil A.Tanghetti MDa and Danielle M.Tartar MD PhDb
INTRODUCTION: This study explored immediate heat signatures with different passing techniques and the delayed thermal data points with the picosecond Alexandrite laser with the 6mm at and fractional optic during and after treatment. We sought to clarify the im- mediate effects of heating and understand the thermal and short term clinical difference when using these optics.
RESULTS: There were no immediate differences or a signi cant temperature rise with different passing techniques using the at or the fractional optic. However, after treatments a signi cant temperature elevation over 24 hours with manageable erythema was noted with the fractional optic. Only faint redness was appreciated with the at optic.
CONCLUSION: The different passing methods with these optics did not result in a significant thermal change. However, the fractional optic produces a localized area of epidermal necrosis which results in a significant clinical and a delayed thermal effect. With multiple treatments over time, collagen, elastic tissue, and mucin is produced resulting in improvement of acne scars and photo-damaged skin. This process suggests that a well-placed epidermal injury can stimulate an inflammatory cascade with dermal remodeling.
J Drugs Dermatol. 2016;15(11):1347-1352.
Julius Few MD,a Michael Gold MD FAAD,b and Neil Sadick MD FACP FAACS FACPh FAADc
BACKGROUND: Increasing demand for non-invasive skin tightening and body contouring procedures has led to several technological in- novations in energy-based devices such as ultrasound, radiofrequency and cryolipolysis. An emerging trend in the eld is to evaluate whether combination therapies for skin laxity/body contouring using energy-based devices can deliver superior clinical results and patient satisfaction. As such, the objective of this prospective, internal-controlled, blind clinical study was to assess the safety and efficacy of cryolipolysis followed by multipolar radiofrequency with pulsed electromagnetic elds (PEMF) and adjustable pulsed suction for the treatment of skin laxity in the flanks.
METHODS: Ten subjects with focal adiposities in the anks were enrolled in the study. All subjects received one session of cryolipolysis treatment and after randomization received two sessions of radiofrequency with PEMF (spaced two weeks apart), followed by another two sessions of radiofrequency with PEMF and adjustable pulsed suction (spaced two weeks apart). Clinical photography was used to monitor the subject’s results at baseline, one week, three, and six months post treatment. Blinded reviewers and the treating inves- tigator assessed the clinical outcomes using the Global Aesthetic Improvement (GAI) scale. Side effects were recorded at every visit and patient satisfaction was noted at the one week, three and six-month follow-up using a 5-scale subject satisfaction assessment questionnaire.
RESULTS: Analysis of the blinded investigator ratings demonstrated statistical significant enhanced skin laxity mean improvement of 1 grade on the GAI scale in subject treated with the combination treatment (cryolipolysis+RF/PEMF/suction) compared with the cryolipolysis treatment alone. The unblinded investigator GAI ratings also showed enhanced (20%) mean improvement of laxity in the combination treated subjects versus those receiving cryolipolysis alone. Over half of the participants reported satisfaction with both treatment results, but there was a 10% statistically significant higher satisfaction rating of the outcomes in the flank treated with the combination treatment. Procedures were well tolerated, side effects were transient and self-resolving and no unexpected adverse effects were reported for the duration of the study.
CONCLUSION: The results of this study show that the combination of multipolar RF with PEMF/suction following cryolipolysis is a safe, effective, and painless approach to enhance skin tightening following fat reduction procedures in the flanks.
J Drugs Dermatol. 2016;15(11):1354-1358.
Yael Politi MD,a Assi Levi MD,b,c and Moshe Lapidoth MDa,b,c
INTRODUCTION: Acne scars are a common result of in ammatory acne, affecting many patients worldwide. Among which, atrophic scars are the most prevalent form, presenting as dermal depressions caused by inflammatory degeneration of dermal collagen. Mid-infrared laser skin interaction is characterized by its modest absorption in water and nite penetration to the mid-dermis. Since collagen is a desirable laser target, 1540-nm wavelength is amenable for collagen remodeling within the depressed area of atrophic scars.
OBJECTIVES: To evaluate the safety and efficacy of acne scars treatment using an integrated cooling-vacuum-assisted 1540 nm Erbium: Glass Laser.
PATIENTS AND METHODS: This interventional prospective study included 25 volunteers (10 men, 15 women) with post acne atrophic scars. Patients were treated with a mid-infrared non-fractional 1540 nm Er:Glass laser (Alma Lasers Ltd. Caesarea, Israel) with integrat- ed cooling- vacuum assisted technology. Acne scars were exposed to 3 stacked laser pulses (400-600 mJ/pulse, 4 mm spot size, frequency of 3 Hz). Patients underwent 3-6 treatment sessions with a 2-3 week interval and were followed-up 1 month and 3 months after the last treatment. Clinical photographs were taken by high resolution digital camera before and after treatment. Clinical evaluation was performed by two independent dermatologists and results were graded on a scale of 0 (exacerbation) to 4 (76%-100% improvement). Patients’ and physicians’ satisfaction were also recorded (on a 1-5 scale). Pain perception and adverse effects were evaluated as well.
RESULTS: Almost all patients (24/25) demonstrated a moderate to significant improvement. Average improvement was 3.9 and 4.1 points on the quartile scale used for outcome assessment 1 and 3 months following the last session, respectively. Patient satisfaction rate was 4.2. Side effects were minimal and transient: erythema, mild transient vesicles, and mild pain or inconvenience.
CONCLUSION Cooling-Vacuum-Assisted mid-infrared non-fractional Er:Glass 1540 nm laser is safe and effective in the treatment of atrophic acne scars.
J Drugs Dermatol. 2016;15(11):1359-1363.
Hilary Reich MD,a,b Irmina Wallander BA,a Lacie Schulte MS BA,a Molly Goodier BS,a and Brian Zelickson MDa
METHODS: In this split-face, evaluator-blinded study, 18 subjects were randomly assigned to receive either the SSR or NFL treatments on each side of the face. For the SSR facial sides subjects followed two morning-evening regimens. On the NFL sides subjects were treated 3 times with the 1927-nm laser at 4-week intervals. Three physician evaluators were asked to rate hyperpigmentation, global photoaging, and ne lines and wrinkles for each side of the face at baseline and at 3 months using a 5-point scale.
RESULTS: The SSR and NFL treatments provided comparable results for each skin attribute. Improvement from baseline was signi - cant in both treatment programs for each skin attribute. The greatest 3-month improvement for both programs was in hyperpigmen- tation. For global photoaging and ne lines and wrinkles, positive responses were slightly greater in the NFL than in the SSR facial sides. Subject preference for the SSR over the NFL was greatest for ne lines around the eyes, ne lines around the mouth, smooth texture, radiant complexion, and overall improvement while the NFL was preferred for skin rmness and evenness. When the study was completed5 of 18 split-face subjects decided to undergo NFR laser treatment on the non laser treated side along with using the SSR product and 13 of the 18 subjects continued to use the SSR products to their full face after the study.
CONCLUSION: The mass market skin care system of the present study provides improvement in hyperpigmentation, global photoaging, and ne lines and wrinkles comparable to that of a series of treatments with a non-ablative fractional laser.
J Drugs Dermatol. 2016;15(11):1366-1372.
Jill S.Waibel MD,a Ashley C. Rudnick,a Adam J.Wulkan MD,b and Jon D. Holmesc
BACKGROUND: In recent decades, a number of optimal diagnostic technologies have emerged to assist in tissue visualization. Real-time monitoring of skin during laser therapies will help optimize laser parameters for more ef cient therapies. One of these technologies, optimal coherence tomography (OCT), may be used to help visualize burn and traumatic scars. When lasing severe scars, lasers have tunable pulse energies, which are made proportional to the scar thickness as estimated by palpation and the physician eye. This has historically been estimated by the clinician with no objective data. OCT is an emerging non-invasive imaging technique that provides a cross-sectional image of tissue micro-architecture from a depth of 0.7 – 1.5 mm. The signal intensity is related to the tissue optical scattering properties, which in turn is related to tissue constituents such as collagen density. Thus, OCT may provide an objective non-invasive measurement of scar depth.
STUDY: Thirty burn and traumatic scars were imaged with quality, traceable, and veri able OCT data from burn and trauma patients both pre- and post- laser therapy. OCT was rapid and ef cient (approximately 2 minutes) to scan skin to visualize real-time scar tissue in different areas of heterogenous scars. The OCT image of the scar was compared to that of normal tissue in order to identify scar tissue and estimate its depth. Laser parameters were then dialed to treat full thickness of the scar.
RESULTS: Clinical and OCT correlation between atrophic versus hypertrophic scars was found. However, in most cases the clinicians underestimated the depth of the scar in the dermis.
CONCLUSION: The treatment of burn and traumatic scars for both civilian and wounded warriors can be challenging. As these scars are often very deep, OCT allows for non-invasive examination of the thickness of the scar allowing the physician better accuracy for laser settings in the treatment for the full thickness of the scar tissue.
J Drugs Dermatol. 2016;15(11):1375-1380.
BACKGROUND AND OBJECTIVE: A new 3-step protocol using broadband light allows patients with moderate to severe in ammatory acne to avoid potential side effects of systemic acne treatments and the risks and uncertainties associated with laser and light treatments to date. The protocol also addresses acne scarring and, with appropriate modi cations, all skin types.
METHODS: The protocol consists of 6 to 8 treatments performed with a single device that allows the user to select wavelength, spot size, uence, and pulse duration. Step 1 uses blue light with a large spot size and low uence to kill Propionibacterium acnes. Step 2 features red and yellow light with a smaller spot size and higher uence, which together exert anti-in ammatory effects and trigger neocollagenesis. Step 3 employs visible and infrared (IR) light with a high uence and 12-second pulse length, delivered with a constant motion technique, to enhance previous results while also targeting areas of frequent breakouts.
RESULTS: Challenging cases treated with the protocol include a young adult female with a nearly decade-long history of in ammatory and cystic acne. Her skin remained clear more than 6 months post-treatment. She reported her scarring reduction at 90%. Having treated more than 100 patients with the protocol, the author reports that approximately 80% of patients clear completely or achieve at least a 75% improvement in their in ammatory acne. Acne improvements start appearing 2 to 3 days after a treatment session. Red, purple, raised, or depressed acne scars less than 1 to 2 years old begin to fade 1 to 3 weeks post-treatment.
CONCLUSION: The 3-step protocol is safe and effective for patients with moderate to severe in ammatory acne and acne scarring.
J Drugs Dermatol. 2016;15(11):1382-1388.
Yiping Ge MD, Lifang Guo MD, Qiuju Wu MD, Mengli Zhang MD, Rong Zeng MD, and Tong Lin MD PhD
Background: A 755nm picosecond alexandrite laser with a diffractive lens array has been reported for the treatment of acne scar and photoaging with clinical ef cacy. In this study, we evaluated the application of the 755nm picosecond alexandrite laser with a diffractive lens array for facial photoaging in Chinese.
Materials and Methods: Ten subjects with moderate facial photoaging were enrolled in a prospective, evaluator-blinded, open-label, and split-face trial to assess the ef cacy and safety of the 755nm picosecond alexandrite laser with a diffractive lens array for facial photoaging. Each subject received a series of four treatment sessions on the right side of the face at two-week intervals. The left side of the face served as the control side. Blinded evaluation of baseline, pre-treatment, and two-month follow-up visit was performed by two independent dermatologists on a 5-point global photoaging scale (GPS) and a 6/8-point Asian photographic scale (APS). Adverse events and discomfort associated with the treatment were also assessed.
Results: Signi cant improvement in photoaged tissue was observed on the treated side of the face, with a mean GPS score decrease from 2.67 to 1.44 at the two-month follow-up visit. A greater improvement in wrinkles was observed (2.78 vs 1.89; P less than 0.05) when com- pared to the improvement in pigmentation (2.67 vs 2.11; P less than 0.05). No changes were observed on the control side. Treatment results improved gradually throughout the treatment program and continued to the two-month follow up. In addition, skin tightening was perceived in all subjects, and shallower nasolabial folds were observed in 60% of the subjects on the treated side of face. Moderate pain and transient erythema were observed as the two main discomforts associated with the treatment.
Conclusions: The 755nm picosecond alexandrite laser with a diffractive lens array is efficacious and safe for rejuvenation of photodamaged facial tissue in Chinese.
J Drugs Dermatol. 2016;15(11):1390-1396.
BACKGROUND: The diffractive optic coupled with a picosecond pulsed alexandrite laser has been shown to effectively minimize pigmen- tation while improving the appearance of textural irregularities and rhytides. We evaluated the safety and ef cacy of the diffractive optic laser treatment for off of the face applications including the hands and décolletage in a pico-toning technique.
STUDY: 20 healthy female patients (40-70 years of age) were treated with a picosecond pulsed alexandrite laser with a diffractive lens. 10 of the patients were enrolled in a prospective hand assessment study (20 hands) while the remaining 10 subjects were enrolled in an IRB approved study treating photodamage of the décolletage. Protocol for both groups included 4 treatments to the designated area with a picopulsed alexandrite laser with a diffractive lens on a 6mm handpiece delivering 0.71 j/cm2 with 10 hz repetition at 3 week intervals (+- 7 days) with follow up at 1 month and 3 months post fourth treatment using standardized digital photography.
RESULTS: Statistically signi cant improvement in the overall appearance of pigmentation, texture and rhytides were recorded at each sub- sequent visit and at 1 and 3 months post the nal laser treatment. Clinical photographs were evaluated from baseline to the final photo at 3 months post last laser treatment by the treating physician, patient, and an independent evaluator. All hand subjects and chest subjects showed improvement in all 3 areas which were found to be statistically signi cant. No adverse events occurred in either study group.
CONCLUSION: These study results show signi cant improvement in not only pigmentation, but in texture and rhytides in all subjects receiving pico-toning laser treatments to off of the face areas. The laser was well tolerated by all patients with no adverse effects. The use of a diffractive lens optic on a 6 mm xed spot size handpiece with a picopulsed alexandrite laser, in a pico-toning technique, provides a safe, low uence, yet effective treatment for not only pigment dyschromia but also textural irregularities and rhytides when treating the hands and décolletage.
J Drugs Dermatol. 2016;15(11):1398-1401.
Suneel Chilukuri MD FAAD FASDS and Gregory Mueller MD FACS
The demand for body contouring is increasing rapidly and has generated the need for a variety of non-invasive body contouring devices. This review concentrates on three popular “hands-free” body contouring devices and analyzes their mechanism of action, as well as their evidence of safety and ef cacy. It also addresses some issues of usability from both the operators’ and patients’ point of view.
J Drugs Dermatol. 2016;15(11):1402-1406.
João Carlos Pereira MD,a João Carlos Pereira Filho MD,b and João Pedro Cabrera Pereira MDc
A robotic system can select and remove individual hair follicles from the donor area with great precision and without fatigue. This report describes the use of the robotic system in a megasession for hair restoration. Patients were instructed to cut their hair to 1.0 to 1.2 mm before surgery. The robot selected and removed 600 to 800 grafts per hour so the follicular units (FU)s could be transplanted manually to recipient sites. The robot arm consists of a sharp inner punch and a blunt outer punch which together separate FUs from the sur- rounding tissue. Stereoscopic cameras controlled by image processing software allow the system to identify the angle and direction of hair growth. The physician and one assistant control the harvesting with a hand-held remote control and computer monitor while the patient is positioned in an adjustable chair. When the robot has harvested all the FUs they are removed by technicians with small forceps. Hairline design, creation of recipient sites, and graft placement are performed manually by the physician.
Clinical photographs before and after surgery show that patients experience excellent outcomes with the robotic megasession. Phy- sician fatigue during graft extraction is reduced because the robot performs the repetitive movements without fatigue. Variability of graft extraction is minimized because the robot’s optical system can be programmed to choose the best FUs. The transection rate is reduced because the robot’s graft extraction system uses two needles, a sharp one to piece the skin and a blunt needle to dissect the root without trauma. A robotic megasession for hair restoration is minimally invasive, does not result in linear scars in the donor area, and is associated with minimal fatigue and discomfort for both patient and physician. Healing is rapid and patients experience a high level of satisfaction with the results.
J Drugs Dermatol. 2016;15(11):1407-1412.
Lucija Kroepfl MBChBa and Jason J. Emer MDb
Acne is one of the most prevalent skin conditions seen by dermatologists. The cosmetic sequelae of severe acne, including scarring and pigmentation, have a profound psychological impact on those in icted. Topical (eg, retinoids, antibiotics, dapsone, hydroxyacids) and oral treatments (eg, antibiotics and/or spironolactone) are often bene cial to control acne or in the instance of oral isotretinoin use, rid the acne permanently; however, these treatments have very little affect on the ultimate cosmetic outcome of the acne scarring and skin texture that results. Given the variety of scar types that can form and the variability of responses seen in various skin types and textures, treatment options are vast without appropriate guidelines for pathways that dictate best timing, combinations, and options in given clinical scenarios. Current treatment options include solo or combina- tions of energy-based (eg, laser, radiofrequency), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and llers and/or fat injections. Most recently, fractional radiofrequency-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation. In severe cystic ares, scarring treatments are often postposed till the acne is under control and in many instances this can limit the dermatologists ability to affect future cosmetic treatments. Based on personal experience of various clinical scenarios in a busy laser practice that treats a signi cant number of patients with acne scarring, fractional radiofrequency is an excellent choice for treating all forms of acne scars with minimal risk to patients, even those on concurrent treatments such as isotretinoin. Additionally, fractional radiofrequency can be used in combination with all other treatment options to speed the time to clinical improvement appreciated by the patient. Here we present personal experiences of combination treatments for acne scarring, pigmentation and textural issues, and suggest that fractional radiofrequency be considered a “gold standard” treatment of acne scarring in those with dark or sensitive skin types or those on concurrent isotretinoin.
J Drugs Dermatol. 2016;15(11):1413-1419.
David E. Orbuch BS,c Lauren Penn MD MS,b Bradley S. Bloom MD,a,b Jeremy A. Brauer MD,a,b Daniel B. Shin MS PhD,d Joshua Greenbaum,a Leonard J. Bernstein MD,a,e Elliot T.Weiss MD,a,e Robert T. Anolik MD,a,b and Roy G. Geronemus MD1,2
BACKGROUND: Photodynamic therapy (PDT) is an FDA approved treatment for actinic keratoses (AK’s) although multiple off-label indi- cations are reported. Despite frequent use for AK’s, no clear consensus exists regarding protocols for overall treatment parameters.
METHODS: Retrospective chart review of 1,491 subjects who underwent PDT between 2007 and 2011 at a high volume laser surgery center. Demographic information, clinical history, treatment data, and subsequent diagnosis of skin cancers were recorded. An ex- ploratory subgroup analysis was performed for patients treated for AK and/or squamous cell carcinoma (SCC) that developed SCC or remained SCC-free one year after treatment.
RESULTS: The most common indications for PDT were actinic keratoses (n=1404, 94.9%) then NMSC (n=45, 3.0%) The most common treatment site was the head and neck (n=1274, 86.1%). Blue light activation (405-420nm) was used more frequently than red light and visible light. (73.8% vs. 22.8% vs. 6.8%). The most commonly used photosensitizer was aminolevulinic acid (ALA) (98.6%, n=1456). Topical application (97.7% n=1437) of photosensitizer was used more frequently than intralesional administration (2.0%, n=29). 580 patients met subgroup analysis criteria. 66 developed SCC at treatment site (11%). Factors associated with developing SCC were older age, SCC history, Fitzpatrick skin-type 1, and sixty-minute or less incubation times (P less than 0.05 for all factors). The SCC subgroup had a unique distribution of treatment sites (P less than.001). No statistically significant differences were observed for gender or wavelength.
CONCLUSION: There are differences in protocols based on indication and location of lesion. Blue light is preferable for superFIcial lesions and red light for deeper lesions. Intralesional delivery is used more commonly for NMSC. Extremities require longer incubation times. PDT may be more effective with younger patients and longer than sixty-minute incubation times. PDT chemoprevention is independent of light source used.
J Drugs Dermatol. 2016;15(11):1420-1426.
Marta I. Rendon MD FAADa and Sylvia Barkovic BAb
The bene ts of monotherapy with hydroquinone for melasma and retinoids for photodamaged skin is well established. Here we report results of a hydroquinone skincare regimen designed for melasma treatment combined with a cosmetic retinol cream on subjects presenting with both melasma and facial photodamage in a 24-week study. Improvement in melasma and photodamage ef cacy pa- rameters of melasma pigmentation intensity and melasma area and severity index (MASI), as well as overall photodamage and mottled hyperpigmentation were found by week 4, the rst post-baseline time point. By week 8 signi cant improvements were also found in melasma disease severity assessment, tactile roughness, ne wrinkles, crepiness, actinic lentigines, and laxity. By week 18 signi cant reduction in coarse wrinkles was evident. Bene ts persisted through the study end on the panel of 31 subjects, with over 3⁄4 of par- ticipants demonstrating improvements in 10 of the 11 graded attributes. For the remaining attribute, coarse wrinkling, approximately 50% of the panel showed improvement. The regimen produced an average of “marked improvement” in melasma severity (51-75% improvement). Results of tolerance evaluations documented overall treatment mildness for a majority of the study participants. Subject questionnaires concur with high ratings of the study regimen for tolerability, ef cacy perception, product aesthetics and overall treat- ment satisfaction in subjects of Fitzpatrick Skin Type III-VI classi cation with melasma and photodamage in mild-to-moderate severity.
J Drugs Dermatol. 2016;15(11):1435-1441.
Doru Alexandrescu MD,a Sabrina Fabi MD,b Lindsey C.Yeh MD MS, c Richard E. Fitzpatrick MD,b and Mitchel P. Goldman MDb
BACKGROUND: The pathogenesis of keloids involves a hyperproliferative state due to molecular abnormalities, cellular driving pathways, such as TGF, VEGF, and the inactivation of proapoptotic genes. We reviewed the literature and compared various treatment combina- tions in the treatment of keloids in a one patient observation.
METHODS AND MATERIALS: Treatment modalities consisted of: intralesional 5- uorouracil (5-FU)/triamcinolone (TMC), 5-FU/verapamil, enal- april alone, verapamil alone, and fractional carbon dioxide laser. Size, height, and softness of the keloid, pain, itching, and pain were assessed.
RESULTS: 5-FU based treatments proved to be more ef cacious than the other modalities. 5-FU + TMC demonstrated the largest reduc- tion in keloid height and rmness. The greatest degree of scar softening and average size reduction was achieved with 5-FU/ TMC (80% and 70% reduction, respectively), followed by 5-FU/verapamil (50% and 33% reduction, respectively). The same combinations led to the greatest reduction in scar height (70% and 33%, respectively). All treatments led to resolution of pain and itching in the keloid. CONCLUSION: The favorable effects of the 5-FU + verapamil combination are new and deserve further exploration.
J Drugs Dermatol. 2016;15(11):1442-1447.
Sushil T.Tahiliani MD and Harsh S.Tahiliani MD
Laser-based photoepilation of dark skin types demands a delicate combination of appropriate light wavelengths and spot size to achieve optimal epidermal-to-follicular energy absorption ratios. This prospective study assessed the axillary, arm, thigh, and back hair clearing ef cacy of the LightSheer In nity 1060 nm diode laser in 10 Fitzpatrick skin type IV-V patients. Each area was treated up to ve times, at 4-6-week intervals, after which immediate skin responses and adverse events were recorded. Hair count, color and coarseness were assessed before each treatment session, as well as 1, 3, and 6 months following the last session. Both patients and the treating physician rated the degree of improvement with time, and patients also ranked their satisfaction with the treatment outcome. Percent hair reduction from baseline gradually increased with treatment and peaked at 74.6%, 68.4%, and 65.7% for axillary, arm and thigh regions, respectively, 6 months following the last treatment session. Baseline hair growth patterns precluded effective selection of a representative area for hair counting. Patients satisfaction was consistently higher for axillary hair clearance rates, followed by thigh and arm responses. Throughout the follow-up period, the investigator rated 50-67% of the treated axillae as presenting “good” or “very good” hair clearance, and provided similar ratings for 67% of the treated thigh regions at both the 1 and 6 month follow-up sessions. Immediate responses to treatment were mild to moderate and short-lived and no incidents of brosis or scarring were reported. Taken together, the LightSheer In nity 1060 HS Handpiece provided for an ideal ef cacy-safety balance in treating dark-skinned patients, providing for long-term hair clearance with minimal downtime.
J Drugs Dermatol. 2016;15(11):1427-1434.