Valerio Cervelli MD, Pietro Gentile MD, Diana Spallone MD, Fabio Nicoli MD, Stefano Verardi MD, Massimiliano Petrocelli MD, Alberto Balzani MD
Background and Objective: Scar management is a long-term process. A variety of modalities have been employed and, depending
on scar type, treatment may be invasive and/or conservative. The purpose of this study was to evaluate a new CO2 laser resurfacing
for post-traumatic and pathological scars and to compare this device with classic dermabrasion. The new fractionated ultrapulsed CO2
laser (Ultrapulse Encore, Lumenis Ltd., Santa Clara, CA) is equipped with two types of scanners: the first, ActiveFX, is non-sequential
while the second, DeepFX, is sequential and produces microspot.
Materials and Methods: From September 2008 to November 2008, a study on 60 patients was performed. The patients (average
age 47.3 years) enrolled in this study had severely scarred skin and were divided into two groups of 30 people. All patients were
Caucasian with skin type II or III. Each scar was photographed and scored by the authors using the Manchester Scar Scale (MSS).
Follow-up ranged from 12–15 months.
Results: Sixty patients were analyzed in two homogeneous groups. Significant improvement in skin tone, texture and appearance of
skin was noted in all patients treated with CO2 laser, lower improvement resulted with dermabrasion. Both subjects and investigators
noted similar aesthetic improvement. No major complications were found for both groups and minor complications included transient
erythema and edema.
Conclusion: Fractional ultrapulsed CO2 laser resurfacing has proven to be both safe and effective. The efficacy and favorable side effects
profile for this technology, with low incidence of pigmentary changes, make it a viable alternative for the treatment of moderateto-
Eric F. Bernstein MD MSE, Jay Bhawalkar PhD, Joan Clifford MPH, James Hsia PhD
Background: Multi-colored and even black tattoos often require more than one wavelength to remove the target pigment. The authors
report here a novel alexandrite laser with two Nd:YAG laser handpieces pumped by the alexandrite treatment beam enabling
the delivery of three wavelengths from a single device.
Objective: To describe and evaluate the effectiveness of a novel Q-switched laser-pumped laser for treating tattoos.
Materials and Methods: Twenty tattoos in 14 subjects were treated at four-week intervals using a combination of available wavelengths
(532, 755 and 1064 nm) as determined by the treating physician. Digital cross-polarized photographs were taken before treatment
and two months following the fourth and final treatment. Photographs were evaluated by three physician observers blinded
as to the treatment condition and rated for clearance by the following scale: 1=>95 percent, 2=76–95 percent, 3=51–75 percent,
4=26–50 percent and 5=0–25 percent clearance.
Results: The average clearance score was 3.1, in the 51–75 percent range, two months following four treatments. No scarring,
hyper- or hypopigmentation was noted on post-treatment photographs or by the treating physician.
Conclusion: The alexandrite and alexandrite-pumped 532 nm and 1064 nm Q-switched lasers are effective for removing decorative
tattoos, and represents the first commercial laser with laser-pumped, laser handpieces.
Sindy Hu MD MS and Michael H. Gold MD
Modalities for the treatment of atrophic facial acne scars have been studied extensively. One, an erbium:yttrium-aluminum garnet (Er:YAG) laser device that generates both short, ablative pulses of high fluence and long, coagulative pulses of low fluence, has been shown to achieve tissue contraction, control intraoperative bleeding and deliver energy quickly and uniformly. The investigators were able to achieve significant depth and ablation with repetitive pulses at the same site and remove the epidermis with a single pass. Subsequent studies showed that facial acne scars of patients with dark skin types could be treated with a similar device. This report reviews the development of the Er:YAG laser and the preliminary results of a study in which moderate-to-severe facial acne scars of 180 Asian patients (skin types III–IV) were treated successfully with a dual-mode Er:YAG laser device.
Robert Bissonnette MD, Catherine Maari MD, Simon Nigen MD, Nathalie Provost MD, Chantal Bolduc MD
Background: Photodynamic therapy (PDT) with methylaminolevulinate (MAL) under occlusion is effective for the treatment of acne
vulgaris but is associated with significant phototoxic side effects.
Objective: To evaluate the safety and efficacy of topical MAL with or without occlusion followed by red light exposure in patients
with facial acne vulgaris.
Patients/Methods: Forty-four patients with facial acne vulgaris were randomized to receive four MAL applications (80 mg/g) at twoweek
intervals with occlusion on either the right or left side followed 90 minutes later by either 25 or 37 J/cm2 of red light.
Results: At 18 weeks after the first MAL-PDT treatment, the percentage of inflammatory lesions was reduced by a median of 31.7,
59.4, 58.1 and 55.8 percent for patients randomized to 25 J/cm2 without occlusion, 25 J/cm2 with occlusion, 37 J/cm2 without occlusion
and 37 J/cm2 with occlusion respectively. MAL-PDT was, in general, well tolerated and only two patients discontinued their
participation due to adverse events.
Conclusion: PDT with MAL at 80 mg/g without occlusion reduces the number of inflammatory lesions in patients with facial
Frank Martiniuk PhD, Diona L. Damian PhD, John F. Thompson MD,Richard A. Scolyer MD, Kam-Meng Tchou-Wong PhD,f William R. Levis MD
The authors provide an update on a previously reported patient with in-transit metastatic melanoma of the scalp treated with
topical diphencyprone (DPCP). Molecular studies implicate the thymus-derived TH17 lymphocyte subset in a remarkable immunotherapeutic regression. The authors performed RT-PCR of total RNA from paraffin-embedded tissue before and after treatment with DPCP. Before treatment with DPCP, the authors found elevated expression of IL17C/D/E/F; after treatment there was no detectable expression. Conversely, increased expression of PLZF/CD27 and CTLA4 was seen after treatment with no expression before treatment. No expression of IL17A/B, CD7, RORgT and FoxP3 were before or after treatment. Conclusions are limited to only the time samples were obtained. Remarkable regression of an in-transit metastatic melanoma treated with the immunomodulatory agent DPCP showed gain and loss of gene expression of the TH17 pathway. Further study of this pathway from NK to NK-T to TH17 and TH1 cells both with and without accessory or dendritic cells will improve understanding of contact sensitizers as topical immunomodulators
Mohamed L. Elsaie MD MBA and Sonal Choudhary MD
Numerous treatment modalities are available for scar management depending upon scar characteristics, age and patient expectations. The focus of this article is to review commonly used nonsurgical methods of scar revision. These include topical applications (e.g., silicone, vitamin E, pressure dressing, herbal extracts), intralesional medication (e.g., steroids, antimitotics), soft-tissue augmentation
(e.g., collagen, fat), laser applications (e.g., 585-nm flashlamp-pumped pulsed dye, CO2), cryotherapy and make-up camouflage. Nonsurgical modalities can be used as prophylactic prevention of adverse scar formation, as definitive treatment, as intervening therapy until further surgical repair can be made, or as adjunctive treatment following surgical scar revision. There are several laser systems available that permit successful treatment of various types of scars. The 585-nm PDL remains the gold standard for laser treatment of hypertrophic scars and keloids. Although atrophic scars may best be treated with ablative CO2 and Er:YAG lasers, the intense interest in procedures with reduced morbidity profiles has increased the popularity of nonablative laser procedures. This paper will focus on the use of lasers for scar revision.
Donato Callegaro-Filho MD, Niraj Shrestha MS, Anne E. Burdick MD, Patrick A. J. Haslett MD
Lepromatous leprosy is a model of immune evasion wherein pathogen-specific IL-10-secreting T cells and concomitant failure of Th-1 immunity permit uncontrolled proliferation of the intracellular pathogen, Mycobacterium leprae (M. leprae). The mechanism of this immune escape is unknown. Here, the authors report that phenolic glycolipid-1 (PGL-1), a major and distinguishing feature of the M. leprae cell wall, is expressed in the cell membrane of M. leprae-infected human dendritic cells, where it can activate complement in human serum. The authors demonstrate that PGL-1 and the C3 component of complement colocalize in lipid rafts in the dendritic cell membrane, and enter the immune synapse upon co-culture of M. leprae-infected DCs and T cells. Hence, activated C3 is strategically located to costimulate naïve T cells via the complement regulatory protein, CD46, a process known to stimulate the differentiation of IL-10-secreting regulatory T cells. These observations suggest a potential novel mechanism of immune evasion, wherein M. leprae
may subvert host natural immunity to provoke an adaptive response that favors bacillary survival.
Autologous cellular immunotherapies have been used experimentally in humans to treat many types of cancer. These therapies are divided into two principal types: active cellular immunotherapies that rely on autologous dendritic cells or other antigen presenting cells; and adoptive T-cell therapies, in which large numbers of antigen-specific T lymphocytes are propagated ex vivo and then infused back into the patient. With the FDA approval of the antigen presenting cell vaccine sipuleucel-T for prostate cancer, active immunization has become an accepted approach for the treatment of established cancer.
Lawrence F. Eichenfield MD, Joseph L. Jorizzo MD, Thomas Dirschka MD, Amy Forman Taub MD, Charles Lynde MD,e Michael Graeber MD, Nabil Kerrouche MS
Acne vulgaris is a common disease in adolescents, and early treatment may minimize its physical and psychological effects. A fixeddose combination gel of adapalene 0.1% and benzoyl peroxide 2.5% (adapalene-BPO) is efficacious and safe in the treatment of acne patients aged 12 years or older, as demonstrated in three randomized and controlled studies. The current study is a subgroup analysis of the efficacy and safety of adapalene-BPO among 2,453 patients aged 12–17 years. After 12 weeks of treatment, significantly more patients in the adapalene-BPO group were “clear” or “almost clear” (30.9%, P<0.001) compared to the monotherapies and vehicle. The percentage reduction from baseline in total, inflammatory and non-inflammatory lesions was 56, 63 and 54.5 percent in
the adapalene-BPO group, respectively, significantly higher than in the monotherapy groups and vehicle (all P<0.001). Significantly earlier onset of effect was observed at week 1. Adapalene-BPO was also well tolerated, with the mean scores of dryness, erythema, scaling and stinging/burning less than 1 (mild) at all study visits. Overall, the adapalene-BPO combination gel provides significantly greater and synergistic efficacy and a fast onset of action compared to the monotherapies and vehicle in young acne patients aged 12–17 years.
Brad A. Yentzer MD and Alan B. Fleischer Jr. MD
Background: Rosacea is a chronic skin condition that requires lifelong treatment. Given the rise in antibiotic-resistant bacteria, many physicians are re-evaluating their use of antibiotics for long-term treatment of rosacea.
Purpose: To examine trends in the treatment of rosacea and the comorbidities associated with this skin condition.
Methods: From 2002–2006, the National Ambulatory Medical Care Survey queried drug mentions at rosacea visits and coexisting
diagnoses. Prescribing patterns of dermatologists were compared to other physicians’ patterns.
Results: Ten million physician visits had the diagnosis of rosacea; 74 percent were associated with co-morbidities. Metronidazole,
tetracyclines, azelaic acid and sodium sulfacetamide were the top medications mentioned at rosacea visits. Prescriptions increased
for azelaic acid and decreased for sodium sulfacetamide. Dermatologists decreased their prescribing of systemic medications.
Conclusion: Dermatologists are reducing their use of systemic antibiotics for rosacea and turning to therapies, such as azelaic acid,
that do not have potential to induce bacterial resistance.
A significant number of patients with moderate-to-severe inflammatory acne are candidates for oral antibiotic therapy. Use of tetracycline for acne has yielded to second-generation molecules doxycycline and minocycline, which are associated with numerous benefits over their predecessor, especially less frequent dosing and improved safety. Nonetheless, these agents are associated with certain potential side effects, including gastrointestinal (GI) concerns, staining of developing teeth in children, candidiasis, vestibular concerns and, somewhat more controversially, photosensitivity. Additionally, minocycline may be associated with the development of autoantibodies, including anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA) and anti-phospholipid antibodies with or without associated clinical symptoms. Given their similar efficacy for the management of moderate-to-severe acne vulgaris, the choice of doxycycline or minocycline may depend on specific clinical considerations, including patient satisfaction with
therapy, compliance and convenience. Data and clinical experience suggest that enteric-coated doxycycline, with its low rate of GI symptoms, may represent a more tolerable treatment option for many acne patients and therefore be associated with better likelihood of compliance.
Eric S. Schweiger MD, Olga Boychenko DO, Robert M. Bernstein MD
Androgenic alopecia (AGA), or pattern hair loss, is a common condition that affects both men and women has been gradually increasing. The discovery of the androgen receptor (AR) gene and related genes has expanded the knowledge on the genetics of hair loss. These basic science studies, combined with more recent clinical studies, have led to a better understanding of the pathogenesis of AGA in both men and women. These genetic advances have also led to the development of a new screening test for AGA. Recently, in addition to the two currently approved U.S. Food and Drug Administration (FDA) medications (minoxidil and finasteride), a novel device was FDA-approved for the treatment of hair loss, the laser hair comb. Further studies are needed to verify the accuracy and validity of the genetic screening test and the efficacy of the laser hair comb.
Clinical Trial Review is a JDD department designed to provide physicians with information on drugs undergoing clinical testing. It is our goal to inform the reader of the status of select drug trials relevant to the practice of dermatology before this information is available through standard channels. To participate in or learn more about these and additional trials, visit www.clinicaltrials.gov.
Kendra Gail Bergstrom, MD, FAAD
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Pipeline Previews brings to you information on the newest drugs and medical products as they become available to the dermatologic
community. This department may include additional information from the manufacturers, plus reports from physicians who wish to share
their clinical experience with these new products. In addition, we will inform our readers about the latest drugs receiving Food and Drug
Administration (FDA) approval. We trust you will find this information beneficial to your practice and research.