Color Atlas of Cosmetic Dermatology, 2E [2 ed.] 9780071639750, 0071639756, 0071635033, 9780071635035

Table of contents :
Title page
Dedication
Contents
Preface
Acknowledgments
SECTION ONE: PHOTOAGING
Analysis of the Aging Face and Non-Facial Regions
Topical Treatment Options
Soft Tissue Augmentation
Botulinum Toxin
Chemical Peels
Nonablative Laser Resurfacing
Ablative Laser Resurfacing
Nonablative Fractional Laser Resurfacing
Ablative Fractional Laser Resurfacing
Tissue Tightening
Dermatochalasis
Poikiloderma of Civatte
SECTION TWO: DISORDERS OF SEBACEOUS GLANDS
Acne Vulgaris
Rosacea
Sebaceous Hyperplasia
SECTION THREE: DISORDERS OF ECCRINE GLANDS
Hyperhidrosis
SECTION FOUR: DISORDERS OF HAIR FOLLICLES
Hirsutism
Pseudofolliculitis
Male Pattern Hair Loss
Female Pattern Hair Loss
Low Level Light Therapy (LLLT) and Hair Loss
SECTION FIVE: DISORDERS OF PIGMENTATION
Cafe Au Lait Macule
Ephelides
Lentigines
Melasma
Nevus of Ota
Postinflammatory hyperpigmentation
Vitiligo
SECTION SIX: VASCULAR ALTERATIONS
Angiokeratoma
Cherry and Spider Angiomas
Granuloma Faciale
Infantile Hemangioma
Keratosis Pilaris Atrophicans
Port-wine Stains
Pyogenic Granuloma
Facial Telangiectasias
Lower Extremity Telangiectasias,Reticular and Varicose Veins
Venous Lakes
Warts
SECTION SEVEN: BENIGN GROWTHS
Angiofibroma
Becker's Nevus
Epidermal Inclusion Cyst
Epidermal Nevus
Lipoma
Milium
Neurofibroma
Seborrheic Keratosis
Syringoma
Dermatosis Papulosa Nigra
Xanthelasma
SECTION EIGHT: CUTANEOUS CARCINOMAS
Actinic Keratosis
Basal Cell Carcinoma
Squamous Cell Carcinoma
SECTION NINE: INFLAMMATORY DISORDERS
Lichen Planus
Morphea
Psoriasis
SECTION TEN: ADIPOSE TISSUE ALTERATIONS
Gynecomastia
Cellulite
HIV Lipodystrophy/Facial Lipoatrophy
Striae Distensae
SECTION ELEVEN: WOUND HEALING ALTERATIONS
Hypertrophic Scars, Keloids,and Acne Scars
SECTION TWELVE EXOGENOUS CUTANEOUS ALTERATIONS
Ear Piercing
Tattoo Removal
Torn Earlobe
Index

Citation preview

Color Atlas of •

�osme -.,

c

��erma o o ZEINA TANNOUS SANDY TSAO

I

I

MATHEW M. AVRAM

MARC R. AVRAM

___

Color Atlas of

Cosmetic Dermatology

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Color Atlas of

Cosmetic Dermatology Second Edition

Ze ina Tannous, M D Chief, Mohs/Dermatologi c Surgery, Boston VA Medical Center Massachusetts General Hospital, Dermatology Laser & Cosmetic Center Affiliate Faculty, Wellman Center for Photomedicine Faculty Director for Dermatopathology, Department of Dermatology, Harvard Medical School Assistant Professor in Dermatology, Harvard Medical School Boston, Massachusetts

Mathew M . Avram, M D, JD Director Massachusetts General Hospital, Dermatology Laser & Cosmetic Center Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School Affiliate Faculty, Wellman Center for Photomedicine Boston, Massachusetts

Sandy Tsao, M D Director of Procedural Dermatology Harvard Medical School Massachusetts General Hospital, Dermatology Laser & Cosmetic Center Boston, Massachusetts

Marc R . Avram, M D Clinical Professor of Dermatology Weill Cornell Medical School Private Practice-905 Fifth Avenue New York, New York

B Medical New York Mexico City

Milan

Chicago

San Francisco

New Delhi

San J uan

Lisbon Seoul

London

Madrid

Singapore

Sydney

Toronto

The McGrow·H/11 Companies

Copyright©

2011

-

by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of

1976,

no part of this

publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN:

978-0-07-163975-0

MinD : 0-07-163975-6 The material in this eBook also appears in the print version of this title: ISBN:

MinD : 0-07-163503-3.

978-0-07-163503-5,

All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occun·ence of a trademarked name, we use names in an editorial faslllon only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a representative please e-mail us at [email protected]. Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they clisclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to adntinister to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. ("McGrawHill") and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of

1976

and the right to store and retrieve one copy of the work, you may not decompile, disassemble,

reverse engineer, reproduce, moclify, create derivative works based upon, transntit, distribute, clisseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill's prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prolllbited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED "AS IS." McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or en·or free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/ or its licensors be liable for any indirect, incidental, special, punitive, consequential or s.irnilar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

D E D I CATI O N

I wou ld l i ke t o ded icate this book t o the memory of m y beloved father, who a l ways gave me h is u lti mate love a n d s u p port.

Zeina Tannous, MD

I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morre l l a n d M a ria Avra m . You have provided me u ncond itional love a n d end less s u p po rt s i n ce the day I was born . I love yo u .

Mathew M. Avram, MD, JD

To my h us ba n d , Hensi n . You a re my stre ngth a n d i n s p i ration. You r l ove, wisd o m a n d encou ragement h e l p m e rea l ize a nyth i n g is poss i b l e . You a re a wo n d e rfu l h us ba n d , father a n d best fri e n d . I wi l l love y o u a lways . To my sons, Se basti a n a n d H u nter. You r u nconditional love, enthusiasm a n d sense o f adventure h e l p me remem ber what is truly i m porta nt. Yo u brighten my days a n d fi l l my l ife with h a p p i n ess and love .

Sandy Tsao, MD

T h i s book is ded icated to my wife R o b i n a n d my two sons Robert a n d J a c o b . I tha n k t h e m f o r the love a n d s u p port t h a t they give me every day.

Marc R. Avram, MD

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CONTENTS ix

Preface

SECTION THREE: DISORDERS OF ECCRINE GLANDS

Chapter 16: Hyperhidrosis.... .... ... .. 86 .

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SECTION ONE: PHO TOAGING

Chapter 1: Analysis of the Aging Face and Non-Facial Regions . .

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SECTION FOUR: DISORDERS OF HAIR FOLLICLES

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Chapter 17: Hirsutism Chapter 2: Topical Treatment Options.

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7 Chapter 18: Pseudofolliculitis ....

Chapter 3: Soft Tissue Augmentation

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... 14 Chapter 19: Male Pattern Hair Loss .... .... 103 .

Chapter 4: Botulinum Toxin

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21 Chapter 20: Female Pattern Hair Loss

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Chapter 5: Chemical Peels .. ...... .. ... 29 .

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Chapter 6: Nonablative Laser Resurfacing

Chapter 7: Ablative Laser Resurfacing

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Chapter 21: Low Level Light Therapy (LLLT) and Hair Loss. . .. .. .

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SECTION FIVE: DISORDERS OF PIGMENTATION

Chapter 22: Cafe Au Lait Macule ... ...... 136 .

Chapter 8: Nonablative Fractional Laser Resurfacing .............. .... 52

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Chapter 23: Ephelides Chapter 9: Ablative Fractional Laser Resurfacing .

Chapter 10: Tissue Tightening

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Chapter 24: Lentigines

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Chapter 25: Melasma . .. ...

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Chapter 11: Dermatochalasis........

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Chapter 26: Nevus of Ota

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Chapter 12: Poikiloderma of Civatte

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Chapter 27: Postinflammatory hyperpigmentation ............ 158

Chapter 28: Vitiligo.... ....

SECTION TWO: DISORDERS OF SEBACEOUS

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GLANDS

Chapter 13: Acne Vulgaris ...... .. ... .. 72 .

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SECTION SIX: VASCULAR ALTERATIONS

Chapter 14: Rosacea

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Chapter 29: Angiokeratoma

Chapter 15: Sebaceous Hyperplasia ......... 81

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Chapter 30: Cherry and Spider Angiomas ....

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Chapter 31: Granuloma Faciale

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Chapter 32: Infantile Hemangioma

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Chapter 33: Keratosis Pilaris Atrophicans

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Chapter 34: Port-wine Stains

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Chapter 35: Pyogenic Granuloma

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192

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Chapter 39: Warts

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Chapter 41: Becker's Nevus

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Chapter 42: Epidermal Inclusion Cyst

Chapter 43: Epidermal Nevus

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Chapter 54: Lichen Planus

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Chapter 55: Morphea

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Chapter 56: Psoriasis

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Chapter 59: HIV Lipodystrophy/Facial Lipoatrophy

Chapter 60: Striae Distensae

SECTION TEN: ADIPOSE TISSUE ALTERATIONS

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SECTION NINE: INFLAMMATORY DISORDERS

Chapter 58: Cellulite

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Chapter 53: Squamous Cell Carcinoma

SECTION SEVEN: BENIGN GROWTHS .

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Chapter 52: Basal Cell Carcinoma

Chapter 57: Gynecomastia

Chapter 40: Angiofibroma

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Chapter 38: Venous Lakes

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Chapter 51: Actinic Keratosis

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Chapter 37: Lower Extremity Telangiectasias, Reticular and Varicose Veins

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SECTION EIGHT: CUTANEOUS CARCINOMAS

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Chapter 36: Facial Telangiectasias

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SECTION ELEVEN: WOUND HEALING ALTERATIONS

Chapter 44: Lipoma

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Chapter 61: Hypertrophic Scars, Keloids, and Acne Scars

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Chapter 63: Tattoo Removal.

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300

Chapter 64: Torn Earlobe

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308

Index

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311

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Chapter 45: Milium

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Chapter 47: Seborrheic Keratosis

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Chapter 48: Syringoma

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Chapter 49: Dermatosis Papulosa Nigra

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Chapter 50: Xanthelasma

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Chapter 46: Neurofibroma

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SECTION TWELVE EXOGENOUS CUTANEOUS ALTERATIONS

Chapter 62: Ear Piercing

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PREFACE There has been a revol ution in the treatment of med ical a n d cos­

go these proced u res. The decision as to when not to treat a patient

m etic d isord ers of the s ki n . I n la rge part, this is d u e to the ava i l ­

is perha ps the m ost i m porta nt i n this fie l d .

a b i l ity o f procedu res a n d tec h nologies t h a t prod uce clear, cosmet­

With t h i s i n m i n d , Color Atlas o f Cosmetic Dermatology, Second

ic benefit with few side effects a n d l ittle downti m e . With the advent

Edition seeks to provide a succ i n ct yet broad overview of cosmetic

of lasers and l ight sou rces over the past 20 yea rs, cosmetic

thera py. There a re a plethora i l l ustrations and gra phs to e l u c i date

i m prove ment is a m atter of q u ic k , relatively pa i n less proced u res.

consu ltati o n , management, treatment and side effects of n u m e r­

N on-laser treatments such as soft tissue fi l l ers, botu l i n u m tox i n

ous cos metic proced u res. Its pra ctica l format is gea red to the busy

i njections, sclerothera py, h a i r tra ns p l a n tation a n d others have a lso

practitioner or tra i nee who seeks a q u ic k , comprehensive refer­

d ra matica l ly expa nded the scope of this field . These procedu res

ence fo r a pproa c h i n g the cosmetic patient. It a lso e m p h asizes

coincide with the busy l ifestyle of many patients who seek a n

pitfa l l s of treatment in ord e r to ed ucate the reader as to potenti a l

i m prove ment i n a p pea ra nce that does n ot interfere with t h e i r pro­

p r o b l e m s w i t h certa i n treatments. It serves as a n i nva l ua ble

fessiona l , soc i a l or perso n a l obl igati o n s .

resource to both the experienced a n d novice.

These proced u res, however, a re n ot without potentia l side effects o r co m p l icati o n s . Physicians who perform these treatments

Zeina Ta n nous, M D

in the a bsence of tra i n i ng or ed u cation a re certa i n to encou nter

M athew M . Avra m , M D , J D

poor resu lts , c o m p l ications and i rate patie nts . Beca use patients

Sandy Tsao, M D

a re p u rs u i ng el ective treatments fo r cosmetic benefit, a ny worsen ­

M a rc R . Avra m , M D

i ng o f a p pea ra n c e wi l l u n d e rsta n d a bly a nger patients who u n d e r-

ix

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ACKNOWLEDG M E NTS

We wou l d l i ke to tha n k two people who provided sign ificant h e l p i n the prod uction of this textbook, D r. R ox Anderson a n d Dr. G a ry Lask. In add iti o n , we wo u l d l i ke t o tha n k t h e office staff at the M assa c h u setts Genera l H os pita l Dermato l ogy Laser & Cosmetic Center a n d the office staff of Dr. M a rc Avra m for their h a rd work a n d d ed ication i n o bta i n i ng high-q u a l ity photogra ph s .

F i n a l ly, w e wou l d l i ke t o tha n k the professiona l staff at M c G raw- H i l l for t h e i r great h e l p and d evotion in p rod u c i n g this book. Tha n k you for push i n g us to strive for the best possi ble Atlas.

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ONE Photoaging

2

I

Color Atlas of Cosmeti c Dermatology

CHAPT E R 1

A n a lysis of the Agi ng Face a nd No n-Facial R eg i o ns

The face is the foc a l point of h u m a n bea uty. Although va rious factors i nfluence fac i a l bea uty, the aging process is the m ost common as pect prom pt i n g non-s u rgica l a n d/or s u rgica l i n tervention. Agi ng is a dyna m i c a n d con­ tinual process . D iffe rent c u lt u ra l , eth n i c , a n d ge nder norms (Ta ble 1 . 1 ) of bea uty exist; however, there a re cer­ ta i n featu res w h i c h globa l ly tra nscend these d ifferences to d ete r m i n e what is perceptua l l y pleas i n g . H ered ity a n d environ mental fa ctors ( e g , s u n expos u re , w i n d , tra u ma ) a re t h e m a i n determ i n a nts o f aging. I n a d d ition , ciga rette smoking a n d estrogen loss ca n accelerate the aging process. As one ages, c h a nges c a n be o bse rved i n a l l fac i a l a n d non-fa c i a l a nato m i c a l com pa rtments, i n c l u d ­ i n g t h e ski n , s u bcuta neous fat, m uscle, a n d b o n y struc­ tu re . Use of a systematic a p proach i n the a n a lysis of fac i a l a n d n o n -fac i a l aging wi l l a l low for the selection of a p propriate, safe, a n d effective thera p ies.

TAB L E 1 . 1

Fac ial Age-Related Contour Cha nges

•

M a l a r c rescent Cheek d e p ression Nasola b i a l fold formation P rej owl s u l c u s P latys m a ! ba nds

A

J owl formation

ANATO M I C CO N S I D ERAT I O N S S uccessfu l

rej uve nation o f the face a nd

non-fa c i a l

regio n s req u i res a thorough u n d e rsta n d i n g o f age-related conto u r cha nges ( u nderlying soft tissue aging) a n d tex­ tu ra l cha nges (skin aging) (Ta bles 1 . 1 a n d 1 . 2 ) .

TAB L E 1 . 2

•

Age-Re lated Textura l Changes

S u perficia l a n d deep rhytides Pigmenta ry d istu r b a n ces Te la ngiectasia fo rmatio n Loss o f s k i n elastic ity Acti n ic ke ratoses

A youthfu l face can be d ivided i nto th ree facial zones: u p per, m id d le, and lower zones, as wel l as the u pper neck. The u p per face incl udes the forehead , tem ple, a n d peri­ orbita l region . Agi ng resu lts i n flatte n i ng of the brow a rc h , eyelid s k i n red u nda ncy, pseudo fat hern iation , a n d forma­ tion of dyna m i c rhytid es at the latera l canthus. Horizonta l forehead s k i n creases develop secondary t o sustai ned con­ traction of the fronta l is m uscle i n a su bconsc ious atte m pt to elevate the sagging brows. A ri m sulcus d eformity d evelops between the cheek and the eyelid with u p per cheek

B

Figure 1.1 A&B G/ogau type 1 photoaging. Minimal signs of aging present

Secti o n 1: Ph otoa g i n g

th i n n i ng. This sulcus is exacerbated by a preexisti ng tea r trough deform ity. Orbicula ris oc u l i m uscle ptosis can create a malar fu l l ness, referred to as a malar crescent. The m i d face i n c l u d es the cheekbones that form a s mooth conti nuous convexity fro m the eyeli d to the l i p . T h e m e l o l a b i a l fol d re prese nts a flat, smooth j u n ction between the lowe r cheek a n d the u p per lip. The aging face res u lts i n a downward m igration of the malar soft tis­ sue, accentuati ng skeleto n i zation of the orbital

ri m .

Centra l cheek fat ptos is c reates a fu l l n ess latera l to the melola b i a l fol d , refe rred to as nasola b i a l fo lds. The lower face possesses a wel l-defi ned mand i b u l a r bor­ der and a well-defi ned cervicomental a ngle. With aging, platysma! m uscle ptosis a nd cheek fat ptosis a long the mandi ble prod uce "jowls" overlyi ng the jawl ine. Soft tissue atrophy a nterior to the jowls creates a " prejowl sulcus" which accentuates the skeleton ized a ppea ra nce. P latysma! ptosis of the u pper neck blu nts the cervico-mental a ngle, creati ng platysma! ba nds or a "turkey neck" d eformity. Facial textu ra l cha nges i n c l u d e su perfi c i a l a nd deep rhytides, pigme nta ry d istu rba nces, telangiectasia forma­ tion, loss of s k i n elasticity, a n d acti n i c keratoses .

P R EOPERAT IVE EVALUAT I O N A n individual ized treatment plan designed to m i n i m ize sur­ gica l risk is essenti al . The goa l is a youthfu l and natura l post­ operative result. A strategy should be formu lated for eac h of the three facial zones as well as each ind ividual non-facial regio n , as each a natomic region req ui res a specific man­ agement which influences the rema i n i ng a natomic regions. A systematic eva l uation s h o u l d i n c l u d e the d egree of textura l c h a n ges, rhyti d format i o n , pigmenta ry c h a nges, loss of su bcuta neous fat, cha nges in fac ia l m usculature, c a rti lagi n o u s a n d bony structu res, a nd elastic ity l oss.

• G l oga u P h otoag i n g C l ass i f i c at i o n­

Wri n k l e Sca l e The G loga u P h otoagi ng Classification has been d evised w h i c h b road ly d efi nes the cha nges that may be seen at d ifferent ages with c u m u lative sun exposure.

Type 1 -"no wri nkl es" (Fig. 1 . 1 ) •

Ea rly photoaging - M i ld pigme nta ry cha nge - N o ke ratoses - M i n i m a l wri n kles

•

Patient age : twenties o r t h i rties

•

M i n i ma l or n o m a keu p use

Type 2-"wrinkles i n motion" (Fig. 1 .2) •

B

Ea rly to moderate photoaging

Figure 1.2 A&B Glogau type 2 photoaging. Fine lines barely visible.

- Ea rly se n i l e lentigines visi ble

Minimal pigmentary changes noted

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Color Atlas of Cosmeti c Dermatology

- Keratoses pa l pa ble but not visi b l e - Para l lel s m i l e l i nes begi n n i ng t o a ppea r •

Patient age : late t h i rties or forties

•

U s u a l l y wea rs some fou n dation

Type 3-"wrinkles at rest" (Fig. 1 .3) •

Adva nced photoaging - O bvious dysc h ro m i a , tela ngiectasia - Visi ble keratoses - Wrin kles eve n when n ot movi ng

•

Patient age: fifties o r older

•

Always wea rs heavy fo u ndation

Type 4-"on l y wrinkles" (Fig. 1 .4) •

Severe photoaging - Yel l ow-gray [A3l color of skin - Prior s k i n m a l igna nc ies - Wrin kled throughout, n o normal s k i n

•

Patient age : sixties or seventies

•

Ca n n ot wea r m a k e u p-" ca kes and cracks"

• P i g m e nta ry C h a n ges A vita l as pect of the patient eva l uation is the dete r m i n a ­

A

tion o f the patie nt's s k i n res ponse t o eryth ema-prod ucing d oses of u ltraviolet l ight. Fitz patrick's classifi cation of skin types prov i d e s a stro ng i n d i ca t i o n of t h e pote nt i a l f o r post- i nfla m mato ry h y p e r p i g m e n ta t i o n a n d hypopig­ m e n ta t i o n and pote n t i a l fo r d ysc h ro m i a u po n e p i d e r­ m a l a n d/or pa p i l l a ry d e r m a l i n j u ry ( Ta b l e 1 . 3 ) .

TAB LE 1 . 3 S k i n type

•

Fitzpatrick's Classification of Skin Types

Color

Reactio n to s u n Always b u r n s

I

Very wh ite or frec kled

II

Wh ite

U s u a l ly b u rns

Ill

Wh ite to ol ive

Someti mes b u rns

IV

B rown

R a rely bu rns

v

Dark brown

Very ra rely b u rns

VI

B la c k

N ever b u rns

A patient's treatment res ponse c a n be d ete rm i n ed by assess i ng both t h e d egree of p h otod a mage p resent and the p i g m e nta ry skin type. A proced u ra l risk­ benefit ratio wi l l d iffer, d e pe n d i ng on the patient's i n d i ­ vid u a l fi n d i n gs ( F igs . 1 . 5 a n d 1 . 6 ) . I n ge n e ra l , patie nts with Fitzpatrick s k i n types I -I I I can tolerate more e p i d e r­ m a l a n d d e r m a l i n j u ry with m i n i ma l risk of res i d u a l d ysc h ro m i a . Patie nts w i t h Fitz patrick s k i n types I V-V have a h igh risk of res i d u a l d ysc h ro m i a with i n c reased

B

s k i n i nj u ry that may p rec l u d e the use of m a n y treatm e n t

Figure 1.3 A&B G/ogau type 3 photoaging. Dyspigmentation and wrinkles

m od a l ities.

are evident

Secti o n 1 : Ph otoa g i n g

• S u b c u ta n e o u s Fat At ro p h y Agi ng resu lts i n a sign ifica nt d egree of loss or red istri bu­ tion of su bcuta neous fat, espec i a l ly of the forehea d , tem ­ pora l fossae , periora l a rea , c h i n , a n d pre m a l a r a reas. This leads to a skeleton ized a p pea ra nce. R estorati o n of vol u m e loss resu lts i n the res h a p i n g of the face for a fu l ler, ro u nder a p peara nc e .

• Fac i a l M u sc u l at u re C h a n ges Agi ng a l so res u lts i n m uscu l a r atrophy, contri buti ng to vol u m e loss. As wel l , dyna mic rhyti d es, which a re m uscu­ lar i n origi n , often create a n a ngry, t i re d , or aged a p pea r­ ance. Selective c h e m ical denervation provides ma rked relaxation of these l i nes.

• C h a n ges i n Ca rt i l age , B o n y

S t r u c t u res, a n d U n d e r l y i n g S u p po rt i ve S t r u c t u res Agi ng resu lts i n sagging and loss of res i l iency. Red ra pi ng, repositio n i ng, and j u d icious rem ova l of skin and soft tis­ sue assist i n the restoration of a youthfu l a p pea ra n c e . Once a syste m i c a p p roach has b e e n fol l owed , the fou r Rs of fac i a l rej uvenation-relax, refi l l , red ra pe, a n d res u r-

A

face-can be a ppl ied solely or in combi nation to h e l p restore a m ore youthfu l a p pea ra nce.

B I B L I OG RAPHY C h u ng J H , E u n H C . Angiogenesis i n s k i n a g i n g a n d pho­ toaging. J Dermatol. 2007 ;34(9) : 593-600 . Davis R E. Facelift and a n c i l l a ry facial cosmetic surgery pro­

Techniques in Dermatologic Surgery. Lond o n : Mosby; 2003, pp. 333-344.

ced u res. I n : Nouri K, Leai-Nouri S, eds.

Fitzpatrick T. The va l i d ity a n d practica l ity of sun-reactive ski n types I through V I . Arch Dermatol. 1 998 ; 1 24:869-87 1 . G l oga u R . Aesthetic a n d a nato m i c a na lys is of the aging ski n . Semin Cutan Med Surg 1 996; 1 5( 3 ) : 1 34- 138.

Epidermal and Dermal Histological Markers of Photodamaged Human Facial Skin. Shelto n , CT: R i c h a rdson-Vicks; 1 988. M ontagna W, Carlisle K, Kirchner S .

Paes EC, Teepen H J , Koop WA, et a l . Periora l wrin kles: H i stologic d iffere nces between men and wom e n . Aesthet

Surg J. 2009 ; 29(6) :467-472. S haw RB J r, Katzel E B , Koltz P F, et al. Agi ng of the m a n d i ble a n d its aesthetic i m pl ications. Plast Reconst

Surg 2010; 12 5 (9 1 ) :332-342 . B

Figure 1.4 A&B Glogau type 4 photoaging. Extensive wrinkles and prominent dyspigmentation

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Color Atlas of Cosmeti c Dermatology

Figure 1.5 Female patient who avoided sun exposure throughout her life.

Her skin reflects only minimal signs of photoaging

Figure 1.6 Female patient with a history of extensive sun exposure in her life. Her skin reflects extensive photodamage with dyspigmentation and extensive wrinkle formation

Secti o n 1 : Ph otoa g i n g

CHAPT E R 2

I

7

Topica l Treat m e nt Optio ns

M ECHAN I S M OF ACT I O N •

S u n sc reen - The u ltraviolet ( U V) wave lengths of l ight associated with c uta neous da m age a re UVB ( 290-320 n m ) a n d UVA (320-400 n m ) l ight. - UVB a bsorption by DNA res u l ts i n a p53 tumor s u p­ pressor ge ne m utation res u lting i n pyri m i d i ne d i mer fo rmatio n , w h i c h is m utage n i c a n d l i n ked to cuta­ neous carc i n ogenesis. - Acute UVB expos u re resu lts i n a s u n b u r n ( Fig. 2 . 1 ) . - Re peat ac ute UVB exposu res over t i m e have been assoc iated with the formation of basa l cell carc i noma a n d melanoma . - Chronic UVB exposure has been l i n ked to the develop­ ment of acti nic keratoses and squamous cell carcinoma. - UVA is u naffected by wi n d ow glass, a ltitude, time of d ay, or season and can prod uce a ta n and dyspig­ mentation without preced i n g eryt h e m a . - UVA l ight penetrates d eeply i n to the dermis, prod uc­ i n g m a ny of the c l i n ical fi n d i ngs associated with photo d a mage ( Fig. 2 . 2 ) . - UVA a bsorptio n b y D N A res u lts i n fo rmation o f oxy­ gen free rad icals, thought to contr i bute to ca rc i n o­ genesis. It c auses i m m u nosu ppress ion through the

Figure 2 . 1 Patient with an acute sunburn. There is marked swelling and redness present. The upper back scar is the site of a previous superficial spreading melanoma (Courtesy of Richard Johnson, MD)

d e pletion of La ngerhans' cells and red uced a ntigen prese nti ng cell activity. - UVA expos u re has been l i n ked to the d eve l o pment of melanoma in a n i ma l models. Chem ica l s u n sc reen (Ta ble 2 . 1 )-a bsorbs l ight i n the UV wave length of l ight ( UVB 290-320 nm) and UVA

TAB L E 2 . 1

•

Chemical Sunscreen: Active Ingred ients

Avobenzone C i n oxate Dioxybenzone H omosa late M ethyl a nt h ra n i late M exoryl SX M exoryl XL Octocrylene Octyl m ethoxyc i n n a mate Octyl sa l i cylate Oxybenzone Pad i mate 0 Pa ra-a m i nobenzoic acid ( PABA) Phenyl benzi m idazole su lfo n i c acid S u l isobenzone Tro la m i ne sa l i cylate

Figure 2 . 2 Patient with marked photodamage due to chronic sun exposure.

The patient was an avid golfer and reported only occasional sunscreen use

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Color Atlas of Cosmeti c Dermatology

320-400 n m ) , tra n sfo r m i n g this l ight i nto h a r m less long

First Generation (Nonaromatics)

wave rad iation and re-e m itti ng as heat en ergy. Physica l screen ( Ta b le 2 . 2 )-scatters or reflects UV heat.

TAB L E 2 . 2

Retinol

•

Physical Su nscreen: Active I ngredients

Tita n i u m d ioxide Zinc oxide

COOH

Tretinoin

S u n protective factor-opt i ma l ly a s u nscreen wo u l d p ro­ vide protection aga i n st the fu l l spectr u m of UV rad iation .

� �

CH20H

rad iati o n . C a n a l so a bsorb U V l ight and release it as

Isotretinoin

�

OOH

The s u n p rotective factor ( S P F ) is the only i nternationa l ly sta ndard ized measure of a sunsc reen's a bi l ity to filter UV

Second Generation (Mono-Aromatics)

rad iatio n . It is the ratio of the UV e nergy needed to prod uce a m i n i ma l erythema d ose ( M ED ) on su nscreen-protected skin to the UV energy req u i red to prod uce an M ED on c u rrently recom mends the d a i ly use of sunscreen with

� .l.Ql. -

u n protected ski n . The American Academy of Dermatology Etretinate

-

COOH

-

H3CO

-

S P F 30 o r greater. •

Antioxida nts-theoretica l ly work to red uce a n d neutra l ­ i z e free rad icals t h a t d a mage DNA, cytoskeleta l struc­ tu res, and cel l u l a r proteins. They a lso possess a nti-i nflammatory effects a n d m a n y play a role in pigment red ucti o n .

Acitretin

Third Generation (Poly-Aromatics)

- I n ord e r to be b i o l ogica l ly effective, th ese prod ucts m ust be a ble to penetrate i nto the s k i n a n d rema i n biologica l l y active l o n g enough t o exert t h e desired benefits . A majority of the c u rrently ava i la b l e a ntioxi­

Arotinoid

d a nt prod ucts a re very u n sta ble, with oxidation m a k­ i n g them c hem ically i n a ctive. M o l e c u l a r formation and packagi ng a re key factors i n the sta b i l izatio n of these prod u cts. - Antioxida nts may work synergistica l l y to provide thei r

Adapalene

greatest benefit.

�

.£) IAlf)( �

COOH

0

- Vita m i n C-the only a ntioxi d a nt to date to have prove n benefit for wri nkle i m p rovement due to its a b i l ity to i n c rease col lagen formation rather than its a ntioxidative effects . - Vita m i n E-d emo nstrated to i n h i b it UV-i nd uced ery­ thema a n d edema in a n i ma l s . It has h igh contact d e rmatitis risk.

rings has made third-generation retinoids more stable for more targeted therapy with less potential side effects. (Reproduced, with permission, from Baumann L. Cosmetic Dermatology: Principles and Practice, 2nd ed. New York: McGraw-Hill; 2009)

- Coenzyme Q l O-natu ra l l y occ u rring n utrient a d d ed to m a n y over-the-cou nter prod ucts . C u rrently t h ere a re no stud ies ava i la ble to docu m ent its long-te rm benefits on skin aging. - l d ebeno n e-synthetic a na l og of Coenzyme Q l O . •

Tazarotene

Figure 2 . 3 Chemical structures of retinoic acids. The addition of aromatic

Reti noic ac i d-reti noids a re natu ra l ly occ u rr i n g d e riva­ tives of I)-ca rotene and la beled as vita m i n A and its derivatives . I n cl uded a re reti n o l , reti n a l d ehyd e , reti nyl este rs, and retinoic acid ( Fig. 2.3). Its benefits a re both preve ntative a n d repa rative .

Secti o n 1 : Ph otoa g i n g

- UVB exposu re res u lts in the u p-regu lation of severa l col lagen-degra d i ng matrix meta l l o protei nases, includ­ ing col lagenase, gelatinase, and stromelys i n , which

TAB L E 2 . 3 •

Ski n Lighte n i n g Agents

Hyd roq u i none

cause collagen degradation. Reti noids act to i n h i bit the

Aloes in

i n d uction of th ese meta l lo p rote i n ases.

Arbuti n

- UVB exposu re a lso dec reases collagen prod ucti o n .

Ascorbic acid

Reti noids work t o i n h i bit t h i s loss o f pro-co l lagen syn­

Flavonoids

thesis.

Gentisic a c i d

- Tret i n o i n-a fi rst-ge neration reti n o i d which was the

H y d roxyco u m a r i n s

fi rst ava i l a b l e to pica l reti n o i d . I t is a nonsel ective

Koj ic acid

ret i n o i d , a ctiva t i n g a l l reti n o i c a c i d pathways . I t is

Licorice extract

n ot p h oto-sta b l e . I t is ava i l a b le i n a ge neric fo r m , as we l l as i n bra nd for m u lations s u c h as R e n ova a n d

M u l berry extract •

Avita . C u rre ntly R e n ova is F D A a p proved fo r p h o­

M e l a n ocyte tra nsfer i n h i bition Lec ith i n s

toa g i n g . Treti n o i n is a lso ava i l a b l e in com b i nation a s

N ia c i n a m i d e

treti n o i n 0 . 02 5 % w i t h c l i n d a myc i n f o r patie nts seek­

Soybea n/m i l k extracts

ing benefits fo r both acne and p h otoa g i n g and as

•

M e l a n ocyte cytotoxic agents

treti n o i n 0 . 2 5 % i n com b i nation with 4% hyd ro­

Azela i c acid

q u i none a n d

M eq u i nol

0 . 0 5 % f l u o c i n o l o n e aceto n i d e fo r

hyperpigme ntation .

M on o benzone

- Reti nol-this prod uct m u st be converted to reti na lde­ hyde a n d then to a l l -tra ns-retinoic acid with i n the ker­

•

Skin turnover acce l e ration G lyco l i c a c i d

atinocyte in order to become a ctive, t h u s d isplayi ng

La ctic a c i d

less activity than treti noi n . I t is thought to be a p p roxi­

Linoleic acid

mately 20% less potent than retinoic acid . It is not as

Reti noic a c i d

freq uently assoc iated with i rritation or e rythema . It is pri m a ri ly fo u n d i n over-the-cou nter prod u cts at va ri­ o u s concentratio ns. - Ad a pa l e n e-a t h i rd -ge neration reti noid wi t h selective affi nity for specific ret i n o i c a c i d rece ptors, w h i c h a l lows for m ore targeted benefit a n d red uction of potentia l si d e effects . It is m ore c h e m i c a l l y sta ble t h a n tret i n o i n a nd d oes not brea k d own i n the pres­ ence of l ight. C u rrently ava i la b l e as D ifferin in a 0. 1 % a n d a 0 . 3 % concentrati o n .

I t i s c u rrently FDA

a p proved for to pica l acne thera py. - Taza rotene-a t h i rd-ge neration retinoid with sel ective affi n ity for s pecific retinoic rece ptors for more tar­ geted benefit. Has been associated with sign ificantly h igher i rritati o n than othe r retinoids. I t is ava i l a ble in 0 . 1 % and 0.05% gels and in 0 . 1 % and 0.05% c rea m s . It is c u rrently FDA a p proved for topica l acne thera py a n d plaque psoriasis. •

•

Tyrosi nase i n h i bitors

Skin l ighte n i ng agents-these prod ucts act to i n h i bit one o r more ste ps in the mela n i n biosynthesis pathway. The m a i n target is tyrosi nase, wh i c h is the rate- l i m iting step i n mela n i n prod uction (Ta ble 2 . 3 ) . - Hyd roq u i none-phenolic c o m p o u n d fo u n d natu ra l ly in m a ny pla nts , coffee, tea , bea r, a n d w i n e . I n h i bits conversion o f tyrosi nase t o m e la n i n . Decreases tyrosi nase activity b y 90% . May i n h i b it D N A synthesis. M ay i n h i b it RNA synthesis.

I

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Color Atlas of Cosmetic Dermatology

Ca n be cytotoxi c to mela n ocytes prod u c i n g i rre­ vers i b l e cel l d a m age with monobenzyl ether of hyd roq u i none. Concern rega rd ing carci n ogen i c potentia l-cu rrently heavily regulated a n d/or ba n ned i n E u rope, As i a , a n d severa l African cou ntries. Ava i l a ble i n over-the-cou nter prod u cts up to 2% and by presc r i ption i n 3 % to 4% concentrations. Ca n be c o m p o u n d ed u p to 1 0 % concentration . C u rrently ava i l a ble

in

Table 2.4 • Use of the ''teaspoon rule" for su nscreen application can be benefi c i a l i n educating patients on the proper of amount of sunscreen that shou l d be appl ied with each appl ication. Use of m ore tha n h a lf a teaspoon each on: •

Head a n d neck region

•

R ight a rm

•

Left a r m

Use o f m ore than a teaspoon e a c h o n : •

Anterior torso

c o m b i nation with to pica l

•

Posterior torso

reti noid acid a n d to pical stero i d a n d with other s k i n

•

R ight leg

l ighte n i ng agents.

•

Left leg

- Reti noic a c i d

( Data from D raelos ZD. P roced u res i n Cosmetic Dermatology Cosmeceuticals.

Acce lerate e p i d e r m a l turnover res u l t i n g i n i n c re­ ased keratin ocyte s h ed d i n g lea d i ng to pigment loss May i n h i bit tyrosi nase i n d uction May res u l t in keratinocyte pigment d ispersion May i nterfere with kerati n ocyte pigment tra nsfer - Natu ra l cosmeceuticals Koj ic a c i d-d e rived from va rious fu nga l species suc h as Aspergillus and Penicillium. Primari ly used as a food preservative and to promote the redd e n ­ i n g o f u n r i pe strawberries . Genera l ly u s e d i n 1 % t o 4 % conce ntration . N oted t o have h igh sensitizi ng potentia l . Licorice extract-derived from the root of G/ycyrrhiza g/abra

I ts

linneva.

main

active

i ngred ient

is

gla brid i n . It i n h i bits tyros i nase activity with associ­ ated cytotoxicity. It has been shown to be 1 6 x m ore efficacious t h a n hyd roq u i none. Azelaic a c i d-d e rived from Pityros poru m ova l e . I ts mec h a n is m of action i n not fu l l y u nd e rstood . I t works best on active melanocytes. Aloes i n-d e rived from a l oe vera . I t a cts as a com­ petitive i n h i bitor o n DOPA oxidation and noncom­ petitive

i n h i bitor

on

tyros i n e .

When

used

in

c o m b i nation with a rbuti n , it has been demon­ strated to i n h i bit UV- i n d uced melanogenesis. Arbut i n -derived from the bea rbe rry. I t a cts to i n h i bit mela noso m a l tyrosi nase activity. Ava i l a ble as a mono treatment o r i n 1% conce ntration with other d e pigme nti ng agents. Paper m u l berry-derived from the roots of an orna­ mental tree, Broussonetia papyrifera. Soy-acts

to

phagocytosis,

i n h i bit th us

kerati nocyte red ucing

melanosome

m e la n i n

tra nsfer.

Cos meceutica l effect noted on ly with fresh soy m i l k . N ia c i n a m i d e-acts t o i n h i bit m e l a n ocyte tra n sfer. Also exh i bits anti- i nfla m matory a n d a nti-oxidant properties.

Saund ers, 2005 . )

Sect i o n 1 : Ph otoa g i n g

Ascorbic a c id-acts at va rious oxidative steps in mela n i n synth esis by i nteracting with copper ions at the tyros i nase a ctive site a nd red u c i n g d o pa­ q u i none. G lyco l i c acid-has a n epidermal d iscohesive effect, res u lti n g

in

i n c reased

epidermal

turnover

fo r

i n c reased shed d i ng of pigme nted kerati n ocytes. S h o u l d be used i n lower concentrations to avoid s k i n i rritation .

I N D I CAT I O N S •

Red uce t h e occu rrence o f acti n i c keratoses a n d nonmelanoma s k i n cancer

•

Red uce the formation of s k i n aging

•

R hytides

•

Ephelides

•

Lentigin es

•

Melasma

•

Postinfla m matory hyperpigme ntation

P R ET R EAT M E NT EVALUAT I O N •

Eva l uation of pre-existing a l lergies t o a n y active i ngred ient

•

Past prod u ct use a nd res ponse

I D EAL CAN D I DATE •

A l l patients benefit from the d a i ly a ppl ication of a topi­ cal s u nsc ree n , SPF 30 or greater

•

Patie nts with rea l istic expectations that topica l medica­ tions may provide preve ntative benefits a n d a re less l i kely to red uce moderate to d eep rhytides

LESS THAN I D EAL CAN D I DATE • •

U n real istic patient expectations Patients with ma rked ly d ry or sensitive ski n-topical treatments may exa cerbate cond ition

CONTRA I N D I CAT I O N S • •

P re-existing a l lergy t o active i ngred ient Use of topical treti n o i n , sa l i cyl i c acid, and s k i n l ighten­ i n g agents i n pregnant a n d lactati ng women

APPLI CAT I O N TECH N I QU ES •

A su nscreen shou ld be a p p l ied a m i n i m u m of 30 m i n ­ utes prior t o s u n expos u re .

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Color Atlas of Cosmetic Dermatology

A p p roxi m ate ly 35 m l is the average a m o u nt of s u n ­ screen t h a t s h o u l d be a ppl ied t o t h e average-sized a d u lt with each a p p l icati o n . T h i s tra nslates to a tea­ spoon ( a p proxi mately 6 mU of s u n screen to each leg, back, a n d chest a n d h a l f a teaspoon ( a pproxi mately 3 m l) a p pl ied to the a rms, face, a nd neck for fu l l cover­ age (Ta ble 2 . 4 ) .

•

Topical retinoic acid prod u cts s h o u l d b e a pp l ied spa r­ i ngly to treatment a reas 30 m i n utes after was h i n g to m i n i m ize pote ntia l for i rritation .

•

B l eac h i ng c rea ms s h o u l d

be a p p l ied to hyperpig­

mented treatment a reas on ly, with efforts made to avoid u n i nvolved ski n .

COM P L I CAT I ON$ •

Conta ct a l lergic dermatitis

•

Conta ct i rritant dermatitis

•

Ac ne fla re

•

S k i n pee l i ng

•

Xerosis

•

Erythema

•

P h otoa l lergic rea ction

•

Ph ototoxic reacti on

•

Theoreti c a l red uction i n vita m i n D a bsorption with s u n screen use

•

Hyperpigmentation with blea c h i ng crea m use

•

Exogenous ochro n osis with bleac h i ng crea m

•

Hypopigm entation with blea c h i ng c rea m

•

Potentia l carc i n oge n i c risk of hyd roq u i no n e use

POSTTREAT M E N T CAR E •

Strict photo protection s h o u l d b e fol l owed d a i ly, i n c l u d ­ i n g s u n avo i d a n ce as m u c h as possi ble, t h e u s e o f a d a i l y s u nscreen S P F 30 or greater, use of a wide­ bri m med hat, a n d s u n protective c l oth i n g

PEARLS FOR T R EATM ENT S U CCESS •

M i n i m ize the n u m ber o f prod ucts a ppl ied d a i ly t o avo i d the potentia l fo r i rritation .

•

Check the expi ration d ates of a l l prod u cts a p pl ied . Th i s is pa rti c u l a r k e y fo r s u n sc reens, as the active i ngred i­ ents may not provi d e benefit beyo nd the recommended d ate of use.

•

Topical retinoic a c i d prod u cts shou l d be d isconti n u ed 2 weeks prior to fac i a l proced u res such as wax in g or tweezi n g i n order to avo i d s k i n d esq ua mati o n .

Sect i o n 1 : Ph otoa g i n g

•

B leac h i n g agents s h o u l d be d i sconti n ued if red ness or i rritation d evelops, as they may worse n existing pig­ mentatio n .

•

I t is usefu l t o d isconti n ue t h e use o f a hyd roq u i none c rea m every 3 to 4 months to dec rease the risk of exogenous och ronosis a n d to preve nt s i de effects .

B I B L I OG RAPHY B ruce S . Cosmeceuticals for t h e atten uation o f extrinsic a n d i ntrinsic dermal aging. J Drugs Dermatol, 2008; 7(2 S u p p l ) : s 1 7-s22 . Colven R M , P i n n e l l S R . To pica l vita m i n C in aging. Clin Dermatol. 1 996; 1 4 : 227-234. Dreher F, M a i bach H. Protective effects of topica l antioxi­ da nts i n h u mans. Curr Probl Dermatol. 2000;29: 1 57- 1 64. Fisher GJ , Ta lwa r H S , Lin J, et al. M o l ec u l a r mechanisms of photoaging i n human s k i n i n vivo a n d their prevention by a l l -tra ns reti noic acid . Photochem Photobiol. 1 999;69 : 1 54- 1 5 7 . Gensler H L, Aickin M , Peng Y M , e t a l . I m porta nce o f the fo rm of to pica l vita m i n E for prevention of ph otoca rcino­ genesis. Nutr Cancer. 1 996;26 : 1 83- 1 9 1 . G u eva ra I L, Panda AG . Melasma treated with hyd ro­ q u i none, treti noin a n d a fluori nated steroid . lnt J Dermatol. 200 1 ;30: 2 1 2 -2 1 5 . Ka ng S , Voorhees J J . P h otoaging thera py with topica l treti n o i n :

An

eviden ce-based

a n a lysis.

J Am Acad

Dermatol. 1 998;39 : S 55-S6 1 . Kligman A M . The growi ng i m porta nce of topica l reti noids i n c l i n ic a l dermato l ogy: A retros pective a nd prospective a n a lysis. JAmAcad Dermatol. 1998;39:S2-S 7 . L i n HW,

N aylor M ,

H o n igma n n H , e t a l . America n

Aca demy of Dermato l ogy Consensus Confe rence on UVA protection of s u nscree ns, s u m m a ry a n d reco m menda­ tions. JAmAcad Dermatol. 2000;44: 505-508 . Naylor M , Boyd A, S m ith D, et a l . H igh s u n protection factor su nscreens i n the s u p pression of acti n i c neoplas i a . Arch Dermato/. 1995; 1 3 1 : 1 70- 1 7 5 . Ogden S , Sa m u e l M , G riffiths S E . A review o f taza rote ne i n the treatment of ph otoda maged s k i n . Clin lntervAging. 2008;3( 1 ) : 7 1 - 7 6 . P i ca rd M , Ca rrera M . N ew a n d experi menta l treatments of c h loasma a n d oth er hypermela noses. Dermatol Clin. 2007 ; 25 : 3 53-362 . Schneider J . The teaspoon rule of a p plying s u n sc ree n . Arch Dermatol. 2002; 138:838-839. Solano F, B riga nti S , Picard o M, et al. Hypopigmenti ng agents : An u pd ated review on biologica l , c h e m i c a l a n d c l i n ical as pects . Pigment Cell Res. 2006; 1 9 : 550-57 1 .

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Color Atlas of Cosmetic Dermatology

CHAPT E R 3

Soft Tissue Aug m e ntatio n

M ECHAN I S M OF ACT I O N Use of a synthetic or biologica l prod uct or s u rgical restruc­ turing for the replacement of vol u m e loss and en h a nce­ ment of derma l , su bcuta n eous, and m usc u l a r d eficiencies that resu lt from tra u m a , s u rgical defects, l i poatrophic con­ d itions, photoaging, or c h ronological aging.

I D EAL F I LLER (Table 3.1) •

B iocom pati b l e

•

N o n i m m u noge n i c

•

Noncarc i noge n i c , nonte ratogen i c

•

N o n resorba b l e

•

N o n m igratory

•

I nexpensive

•

Eas i l y o bta i n ed a n d stored

•

Easy to a d m i n ister

•

P rovid es re prod u c i ble cosmetica l ly benefi c i a l res u lts

•

FDA a p p roved if not a utologous

•

Demonstrates m u lt i p u rpose use

•

N o side effects

•

Easy to re m ove in the event of a poor cosmetic outcome

TAB L E 3 . 1

•

Com monly Used F i l l ing Agents

Name

Com position

FDA approval

Skin testing req u i red

Longevity

Adatos i l 5000 ( Dow-Cor n i ng, M i d l a n d , M l )

S i l icone

No

No

Permanent

Al loderm ( Life C e l l Cor p . , B ra n c h b u rg, N J ;

Ace l l u l a r processed h u ma n

Yes

No

1-2 yr

O baj i M e d i ca l , C h i cago, I L)

cadaveric dermal a l l ograft

Aq u a m i d (Contu ra I nternatio na l , Soe bora ,

Po ly-a c ryl a m i d e gel

No

No

Permanent

Artefi l l (Canderm P h a r m a , I n c . , Quebec,

Bovi n e col lagen with poly( methyl

No

Yes

Perma nent

Ca n a d a ; Medical I nternational BV, B red a ,

methacrylate) beads

No

No

4-6 mo

Den mark)

The N etherla nds) B elotero Soft; B e l otero Basic ( M e rz

Non-a n i m a l hya l u ro n i c a c i d d e rived

P h a rma , Fra n kfu rt, Germa ny)

from bacteria l fe rmentation

B i o-Aica m i d ( B ri n d is, Italy)

Poly-a c ryla m i d e

No

Yes

Perma nent

Ca pti que™ ( l named Corp, Sa nta

Non-a n i ma l-sta b i l ized hya l u ronic

Yes

No

4-6 m o

Monica, CA)

acid ( NASHA) d e rived from plant

Cosmoderm ™ , Cosmoplast ™ (AIIerga n ,

Recom b i na nt h u m a n col lagen

Yes

No

4-6 m o

No

4-6 m o

I rvine, CA) Cymetra Life Cell Corp. , B ra n c h b u rg, N J ;

Ace l l u l a r processed lyo p h i l ized

O baji M e d i ca l , C h icago, I L

h u m a n cadaveric tissue (continued)

Sect i o n 1 : Ph otoa g i n g

TAB L E 3 . 1

•

I

15

Commonly Used F i l l ing Agents (Continued)

Name

Com position

Fasc i a n ( Fascia B iomaterials, B everly

H u m a n cadaveric preserved

H i l ls, CAl

pa rticu late fascia lata

Fat, su bcuta neous

Auto logous

Hylaform ® ( B iomatrix I n c . , R i d gefi e l d , N J ;

H ya l u ro n i c acid derived from

! na med Corp . , Santa M o n i c a , CAl

dom estic fowl coxcom bs

l solagen ( l so l agen I n c . , H o u sto n , TXl

FDA approva l

Skin testing req u i red

Longevity

No

3-4 mo

N/A

No

9-1 2 m o

Yes

No

4-6 mo

Autologous f ibro blasts

Yes

No

1-2 y r

J uved erm ™ U ltra , U ltra XC, U ltra Pl us,

N on-a n i m a l-sta b i l ized hya l u ro n i c

Yes

No

6-9 mo

U ltra P l u s XC (AIIerga n , I n c . , I rvi n e , CAl

acid ( N AS HAl d erived from

Yes

No

4-6 mo

bacteria l fe rmentation . XC formu lations with 0.3% lidoca ine P reve l l e Silk ( M entor Corporat i o n , Sa nta

N o n -a n i ma l -derived hya l u ro n i c

B a r ba ra , CAl

a ci d w i t h 0. 3% l i d oc a i n e

Rad iesse™ ( B ioform Med ica l , San

Synthetic calci u m hyd roxyla patite

Yes

No

9- 1 2 m o

Non-a n i ma l-sta bil ized hya l u ro n i c

Yes

No

6- 9 mo

S i l i cone

No

No

Perma nent

G ore-Tex

N/A

No

Perma nent

Lyop h i l ized poly- L-Iactic acid

Yes

No

1-2 y r

Bovin e col lagen

Yes

Yes

3-4 mo

Mateo, CAl Restylane, Restylane-L, Perlane, Perlane L™ (Q-Med AB, Swed e n ;

a c i d ( N AS H A l derived fro m bacterial fe rmentation .

M e d i c i s , Phoenix, AZl

L form u l ations with 0 . 3 % l i d ocaine S i l i kone- 1 000, Adatos i l-5000 (Alcon La bs, I n c , Fo rt Wort h , TXl Softform ( McGhan Med ica l , Santa Barbara , CAl Scul ptra ™ ( B iotech I n d ustry, SA, Luxe m bo u rg; Derm i k , Berwy n , PAl Zyd erm ® , Zyplast® (AIIerga n , I rvi n e , CAl

P R EOPERAT IVE EVALUAT I O N •

I d entify the a ppropriate patient and treatment region - Sign ificant past medical h istory, i n c l u d i ng h istory of b l eed i ng or c l otti n g d isord e rs; keloid formation ; exist­ ing d rug a l l ergies; i m m u nocom p ro m i sed state - Cu rrent med ication use; past or c u rrent isotreti noin use - Past s u rgica l

i nterventions,

yea r,

and

treatment

res ponse - C l i n ic a l eva l u ation to d eterm i n e if the d esi red treat­ ment a reas a re a me n a b l e to correction; outl i ne base­ l i n e structu ra l i rregula rities - Discuss l i ne softe n i ng versus vol u m e re placement for fi l le r selection - Discuss med ications to avo i d 1 0 days p reoperatively when med ica l l y safe , i n c l u d i n g aspiri n , nonsteroid a l med icati ons, vita m i n E s u p plements, S t . J o h n 's Wort, a n d other herbal m e d i cations that have an a nticoagu­ lative effect

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Color Atlas of Cosmetic Dermatology

Disc uss the risks a n d benefits of the treatment - Al lergic reacti o n , loca l ized versus system i c - P roced u ra l a n d posto perative d iscomfort - Postoperative edema - Posto perative bru ising - Sca r formation - I nfection - Reactivation of herpes s i m plex virus - I n complete a ugme ntation - I rreg u l a r co nto u r/textu re

•

I d e ntify contra i n d ications to treatment - Active i nfection at the treatment site - Nond iste nsi ble, rigi d , or icepick sca rs - Extensive jowl formation, prom i nent folds, a n d furrows - U n d e rlying connective tissue d isord e r - I m m u nologic d isease - Prior a l le rgic reaction to fi l le r/re lated fi l l e r/positive s k i n test - Use of isotretinoin with i n the preced ing 6 to 12 m onths - Pregna n cy - U n real istic expectations

•

O utl i n e the pred icted outcome and l i m itations to the treatment - D u ration of co rrection - Posto perative recovery period - Tissue sou rce - Expense

Figure 3.1 Massager utilized during filler placement to minimize treat­

ment discomfort

S K I N TESTI N G (WH E N APP L I CAB LE) •

I n itial test d ose-two s k i n tests recom me n d ed - I nj ected in tu berc u l i n m a n n e r i nto vol a r forea rm - Fou r-week o bservation period for fi rst test - Re peat s k i n test placed in o pposite forea rm - Two-week o bservation period fo r second test

•

Retest d ose-si ngle test recommended - For new patients who have received treatment by a n other physic i a n or patients who have not received treatment for more than 1 yea r - Two-week o bservation period recom mended

•

Positive fi l l e r reaction - Swe l l i ng, i n d u rati o n , ten derness , o r erythema that pe rsists o r occ u rs 6 h o u rs or longer after test i m p l a n ­ tation - A pos itive s k i n test is a n a bsol ute contra i n d ication to fi l l e r use

Figure 3 . 2 Clinical findings after EMLA application to skin. Expected

blanching lasts approximately 2 to 3 hours after application

Sect i o n 1 : Ph otoa g i n g

I

17

AN ESTH ES I A •

I njection of soft tissue fil lers may b e pa i nfu l , espec ia l ly with treatment of the l i ps . M ost patients req u i re some form of a n esthesia to m i n i m ize treatment d iscomfort.

•

Epidermis

"Ta l kesthesia , " h a n d - h o l d i ng, v i b ratory massager nea r the treatment s ite a re usefu l for patient d istraction ( Fig. 3 . 1 ) .

•

Topica l a n esthesia ca n b e uti l ized fo r s m a l l treatment a reas .

Commonly

used

agents

include

Betaca i n e

E n h a n ced G e l ( C a n d e r m , Quebec, Canada ) , Betaca i n e P l us

( Ca n d e r m ,

Quebec,

Canada ) ,

L- M -X-4

and

5 ( Ferndale La bs, Fernd a l e , M l ) , E M LA (AstraZeneca, Boston , MA), and ice ( Fig. 3 . 2 ) . •

Lidoca i n e i ntegrated d i rectly i nto t h e fi l l e r m a y e l i m i­ nate the need fo r a lternate forms of a n esthesia .

•

Regiona l n e rve blocks a re eas i l y a d m i n istered prior to treatment. The patient s h o u l d avoid extremely hot or cold beverages a n d foods for 2 to 3 h o u rs after menta l a n d/or i nfraorbita l n e rve blocks t o avoid m u cosa l i nj u ry d ue to i n a b i l ity to d etect tem pe rature a cc u rate ly.

•

Loca l ized tumescent a n esth esia

is util ized fo r fat

Fat

Figure 3 . 3 Recommended filler injection depths. (A dapted from Keyvan

N, Susana L-K, eds. Techniques in Dermatologic Surgery. United Kingdom: Mosby; 2003.)

extraction with a utologous fat tra n sfer. •

I nfi ltrative a n esthesia is to be avo i ded to o bviate tissue d i sto rtion of the treatment site .

PROCEDU RAL M E D I CAT I O N S •

Va ltrex 500 mg B I D

x

5 t o 7 days i n itiated 1 day prior

to the proced u re for patients with a h i story of h erpes s i m plex virus in or nea r the treatment site •

Keflex 500 mg B I D

x

7 days i n itiated 1 day prior to the

proced u re for patients u n d e rgoi n g a uto l ogo us fat trans­ fe r o r Gore-Tex i m pla ntation •

D iazepa m 5 to 1 0 mg can be offe red to a nxious patients 30 m i n utes prior to the proced u re

A

LEVEL OF I NJ ECT I O N (Fig. 3.3) •

S u perfi c i a l dermis: fi ne l i nes; verm i l ion bord e r l i p a ugmentation

Zyd erm I,

I I ; Cosmoderm I, I I ; Restylane Fine L i n e ;

Hylaform F i n e L i n e •

M i d t o deep d e r m i s : s u perficial t o moderate rhyti des, sca rs, and d efects; lip a ugm entation

Ca ptiq ue;

Cosmoderm

II,

Cosmoplast;

Hylafo r m ;

J uved erm U ltra ; P reve l l e S i l k ; Restylane; Zyder m I I , Zyplast •

Deep dermis, s u bc uta neous fat, and m uscle: dee per, more su bsta ntia l defects a n d rhytides ( Fig. 3 . 4 )

Autologous

fat

tra n sfe r;

Gore-Tex;

Hylaform

J uved erm U ltra P l u s ; Perla ne; Rad iesse; S c u l ptra

B

Figure 3.4 (A) Prominent nasolabial folds prior to augmentation with P l us ;

hyaluronic acid. ( B ) Softening of folds after 3 c hyaluronic placed into treatment sites

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Color Atlas of Cosmetic Dermatology

Com bi nation

derm a l ,

s u bcuta neous,

and

m uscle:

defects with both a su perfi c i a l a n d a d ee p com ponent uti l ize both a su perfi c i a l and deep fixer for opti m a l a u g­ m entation ( Fig. 3 . 5 )

I NJ ECT I O N TECH N I QU E (Fig. 3.6) •

Seria l pu nctu re : c l osely spaced p u n ctu res created a long l i nes, folds ( Fig. 3 . 7 ) .

•

Li nea r t h rea d i ng: withd rawa l o f fi l l e r a long t h e length of the fac i a l d efect as a conti n uous th read of material ( Fig. 3 . 8 ) .

•

Fa n n i ng: s i m i l a r t o l i near threa d i ng. N eed le d i rection is conti n ua l ly cha nged without with d rawing the need le tip.

U sefu l for ora l com m issu res, u p per nasola bia l

A

folds. •

C ross-hatc h i ng: similar to l i near t h rea d i ng. M aterial is i nj ected at right a ngles to the fi rst i nj ecti ons. U sed for s h a p i n g fac i a l conto u rs .

DEG R E E O F COR R ECT I O N •

Dependent o n the fi l l e r used . I n ge nera l , ove rcorrection is not reco m m ended . The m ost com mon tec h n i q u e error is u n d e r-correctio n .

•

M u lti p l e treatment sessions a re genera l ly req u i red for vol u m e re placement agents, i n c l u d i ng s i l icone a n d poly-L-Iactic a c i d .

D U RAT I O N OF COR R ECT I O N Dependent on t h e material i m pl a nted , i m p la ntation tec h ­

B

n i q ue, a n d a m o u nt i m pl a nted , the type o f d efect a n d

Figure 3 . 5 (A) Facial lipoatrophy with "sunken cheek appearance " prior

mec h a n ical stresses at the i m p l a ntation sites.

to Cymetra treatment. ( B ) Improvement of cheek volume after Cymetra treatment, 2. 0 cc total volume

ADV E R S E R EACT I O N S • H y pe rse n s i t i ve • •

Prolonged e rythema a n d edema at i njection sites Cyst/a bscess formation-long-lasti ng; can persist for m ore than 2 to 3 yea rs

•

G ra n u loma formation

•

Ana phylaxis

• N o n - H y p e rse n s i t i ve •

B i ofi l m

•

B r u ising

•

I nfection-i n c l udes reactivation of h erpes s i m plex virus a n d bacteri a l i nfection

Sect i o n 1 : Ph otoa g i n g

•

I

19

Necrosis-d ue to vasc u l a r com pro m i se at the treat­ ment site

• •

N od u l e formation/bea d i ng Pa rtial vision loss-d ue to vasc u l a r comprom ise at the treatment site

•

U lceration

• Tec h n i q u e C o m p l i cat i o n s •

I rreg u l a r texture-d ue to u neven placement

•

Bea d i ng-d ue to too superficia l p lacement ( Fig. 3 . 9 )

•

I m p la nt rejectio n -d u e t o too s u perficia l placement

•

Necrosis-d u e to vasc u l a r i njection o r vasc u l a r com­ pression

PEARLS FOR T R EAT M ENT S UCCESS •

With fi l l e rs, the affected treatment sites should be fu l ly a ugme nted to ensu re an eve n , c o m p l ete a ugmentati o n . U n der-correction w i l l l e a d t o a n i nadeq uate a ugmenta­ tion a n d patient d issatisfaction . With m ost tem pora ry fi l lers, this is o bta i ned at the fi rst treatment. Permanent fi l lers req u i re repeat treatments fo r correctio n comple­ tio n .

•

With tem pora ry fi l lers, patie nts m u st u n d e rsta n d that the treatment res ponse is va riable and can last less t h a n or greater tha n the ave rage expected t i m e . Re peat treatment w i l l be req u i red over t i m e .

•

Figure 3 . 6 Injection techniques A . Linear threading technique B. Serial puncture technique. (Adapted from Keyvan N, Susana L-K, eds. Techniques in Dermatologic Surgery. United Kingdom: Mosby; 2003.)

Patient expectations m u st be tem pered t o m i n i m ize u n rea l istic expectations a bout fi l l e r benefits . Patie nts m ust be awa re that the treatment e n d point is a soften­ i n g of the affected a reas .

•

Posto perative bea d i ng is ge nera l ly responsive t o local­ ized massage over 5 to 7 days. Persiste nt bead i n g can be corrected by i njecting 2 mg/m l of tria mci nolone a ceto n i d e i nto the bead o r by 1 1 -blade i n cisional extraction of the fi l ler materi a l .

•

A thorough preoperative eva l uation is necessa ry to e n s u re that there a re no contra i nd i cations to fi l l e r use, espec i a l ly when using perm a nent fi l lers.

•

Conservative a ugm entation of the gla bel l a r region is c ritica l to avoid vasc u l a r necrosis.

B I B L I OG RAPHY B e e r K, S o l i c h N . H ya l u ron ics for soft tissue a ugmenta­ tion : Practical considerations and tec h n ical recom m e n ­ d a t i o n s . J Drugs Dermatol. 2009;8( 1 2 ) : 1 086- 1 09 1 . C l a rk D P, H a n ke CW, Swa nson N . Derma l i m p l a nts: Safety of prod ucts i nj ected for soft tissue a ugmentation . J

Am Acad Dermatol. 1 989;2 1 :992-998.

Figure 3 . 7 Serial puncture method of injection

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Color Atlas of Cosmetic Dermatology

Cohen J L. U n dersta n d i ng, avoid i ng a n d ma naging d er­ m a l fi l l e r c o m p l icati o n . Dermatol Surg. 2008; (34 S u ppl 1 ) : S92-S93 . Colem a n S R . Fac i a l reconto u ring with l i posc u l pture. Clin

Plast Surg. 1 997;24( 2 ) :347-367 . G l a i c h AS, Cohen J L, G o l d berg LH . I njection nec ros is of the gla bel l a : P rotocol for prevention a n d treatment after use of d e r m a l fi l lers. Dermatol Surg. 2006 ;32 ( 2 ) : 276281 . J ones D H . Sem i perman ent a nd perma nent i njecta ble fi l lers. Dermatol C!in. 2009;27(4) :433-444. Mata rasso S L . I njecta ble collagens: Lost but not forgot­ ten-a review of prod u cts, i n d ications a n d i njection tec h­ n i q ues.

Plast Reconstruct Surg. 2007; 1 20(6 S u p pl ) :

1 7S-26S . S c h u l l e r- Petrovic S. I m p rovi ng the aesthetic aspect of soft tissue defects on the face usi ng a utologous fat tra nsplan­

Figure 3.8 L inear threading method of injection

tation . Facial Plast Surg. 1997 ; 1 3 ( 2 ) : 1 9-24.

Figure 3.9 Filler beading due to too superficial placement

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 4

B otulinum Toxi n

PHARMACOLOGY Botu l i n u m tox i n is a prote i n prod uced by the bacteri u m Clostridium botulinum. Seven serotypes exist, designated as A, B, C 1 , D, E, F, a n d G. Eac h one of them is a pro­ tease with a l ight c h a i n l i n ked to a h eavy c h a i n by a d is u l ­ fide bond . Ea c h is a ntigen ica l ly d isti n ct. H owever, botu l i n u m tox i n A ( BTX-A) , B ( BTX-B ) , a n d F a re the on ly serotypes c u r­ rently ava i la b l e for c l i n ical use (Ta b le 4 . 1 ) .

TAB L E 4 . 1

•

Bot u l inum Toxin Preparations

Type

U n its toxi n/bottle

Dos i n g eq u iva le nts

D i l ution

Botox Cosmetic (AIIerga n I n c . , I rvine,

1 00 U lyo p h i l ized powder

1 U Botox

Average 1-4 mL in

=

4 U Dysport

CA)-type A

prese rvative-free or prese rved sa l i n e

R e l ax i n ( M edicis Esthetics, Scottsdale,

500 U i n lyo p h i l ized

AZ), Dys port ( I psen L i m ited , Berks h i re ,

powde r

1 U Botox

=

2 . 5-4 U

U K)-type A R e l oxi n/Dys port

Average 1-2 . 5 m L i n prese rvative-free o r prese rved sa l i n e

Myobloc (Soltice N e u rosciences, San

2 , 500, 5,000, a n d

N ot we l l esta bl ished for

M a y b e used as is or d i l ute

F ra n c i sco, CA)-type B

10,000 U/m L a q ueous

cosmetic use

with sa l i n e

solution Xeo m i n ( M erz P h a rmaceutica ls,

1 00 U via l

F ra n kfu rt, Germa ny)-type A N e u ro n ox ( M edy-Tox, I n c , Seo u l ,

1 00 U vial

South Korea )-type A P rosigne ( La nzhou I nstitute of B i ologica l

Reported 1 U B otox

=

1 U

N ot wel l esta bl ished

=

1 U

N ot wel l esta b l is hed

Xeo m i n Reported 1 U B otox N e u ronox 50 U vial a n d 100 U vial

P rod ucts, La nzhou, C h i n a )-type A

M ECHAN I S M OF ACT I O N I n h i bition of acetyl c h o l i n e release at the n e u rom uscu l a r j u n ction res u lting i n m usc u la r f l a c c i d pa ra lysis. Receptor site b i n d i n g is med iated by the h eavy c h a i n portion of the toxi n , is spec ific for the toxin serotype, and is i rrevers i b l e . O n c e bou n d , the recepto r-neu rotoxi n comp lex is i n ter­ n a l ized i nto the nerve term i n a l a n d the tox i n l ight c h a i n acts as a protease t o c l eave specific syn a ptic prote i n peptide bonds req u i red for acetylc h o l i n e formati o n . The ta rget of BTX-A is the syna ptasome-associated prote i n of 25 k Da , S N A P-25. BTX- B a n d B TX-E cleave the vesicle­ associated mem b ra n e prote i n , syna ptob rev i n .

N ot wel l esta b l ished

N ot we l l esta blished

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Color Atlas of Cosmetic Dermatology

DI LUTION Procerus m usc l e

BTX-A i s stored i n lyo p h i l ized vials. It ca n b e reconsti­ tuted in prese rved sa l i n e or preservative-free sa l i n e . D i l utions va ry accord i n g t o physicia n preference a n d expe rience with BTX . A d i l ution ra nges from 1 m l ( 1 0 U/0 . 1 cc) t o 4 m L ( 2 . 5 U/0 . 1 c c ) . Dysport d i l uted to 2 . 5 ml wi l l atta i n a conce ntration of 20 U/0 . 1 cc. The

N asal i s m usc l e -+++--=-==:..___;-

i njected vol u me m ust be sufficiently sma l l to provide a c c u rate toxin d e l ivery without a n excessive vo l u me effect or del ivery of tox i n to s u rro u n d i ng m u scles other tha n the targeted m uscles. The vo l u me m ust be suffi ­ c i ently l a rge to permit a cc u rate i njection i nto the targeted

Levator lab i i s u perioris alaeq ue nasi m uscle

�-+--- Zygomaticus major m u sc l e

m uscles.

CONTRA I N D I CAT I O N S I\

• A b so l u te •

Levator superioris muscle

U nderlying n e u rom usc u l a r cond ition s u ch as myasthen ia gravis or a myotro p h i c late ra l sclerosis

•

P regnan cy/breast-feed i n g-pregna ncy category C

•

Active i nfection in treatment a rea

•

U n rea l istic patient expectations

Figure 4.1 Anatomical illustration of the upper and midfacial muscula­

ture

• R e l at i ve •

Ca l c i u m c h a n n e l bloc kers use-may pote ntiate effect

•

A m i n oglycosi d e a nti b i otic use-may potentiate effect

•

Patie nts who a re d e pend ent on fac i a l expression for t h e i r l i ve l i hood (eg, actors)

•

P ro m i n e nt eye l i d ptosis, heavy b row or ectropion

P R EOPERATIVE EVALUAT I O N •

Patient expectations m u st b e d efi ned a n d matched with the expected treatment outcomes

•

Patient med ical h i story

•

Past treatment h i sto ry a n d outcome

•

C l i n ical eva l uation

•

Determ i n e location and extent of i nvolvement of the treatment site

•

Doc u ment asy m m etries n oted ; presence of ptosis/l i d

X

X

X

X

laxity/brow prom i nence

• Lowe r Eye l i d " S n a p B a c k " Test to

Assess Lower L i d Lax i ty

�

)

The m i d d l e of the lower l i d is grasped between the i n d ex fi nger a n d the th u m b a n d p u l led forwa rd a n d u pwa rd .

Figure 4.2 Approximate injection sites for the forehead to obtain a more

The l i d is then released a n d a l l owed to "sna p " back

horizontal brow. This pattern is most frequently used to create a more masculine brow

Sect i o n 1 : Ph otoa g i n g

aga i nst the globe. A q u ic k return to its norma l state i n d i ­ cates m i n i m a l laxity. Botu l i n u m toxin t o t h i s region c a n provide benefit. A slow return o f s k i n t o its nat u ra l posi ­ tion i n d icates sign ifica nt laxity. Botu l i n u m toxin s h o u l d not be u s e d i n these patients, as it may accentuate t h e l i nes present.

P ROCEDU R E • •

Patient consent o bta i ned P reope rative pictures ta ken at rest and with targeted m usc le grou ps contra cted

•

P retreatment with topica l a n esthetic or ice for pa i n

•

Patient placed u p right

•

Treatment a reas wi ped with a l cohol

red uction

•

A

I njections a d m i n istered . Use of 1 ml syri nges with a 30 to 32 ga uge need l e is freq uently u t il ized . Use of i nsu l i n syringes with a n i n tegrated 30-ga uge syri nge a n d a h u b less system may hel p to red uce toxin vol u m e loss

M U SCLE G RO U PS A thorough knowledge of the fac i a l m uscu latu re a n d fac i a l a natomy is req u i red for the proper u s e a n d place­ ment of botu l i n u m toxin ( Fig. 4. 1 ) .

• Fore h ea d - F ro n ta l i s M u sc l e

( F i gs .

4.2

and

4.3)

Insertion: Originates at fro nta l bone ga lea a poneurotica and i nserts i nto fibers of the procerus, corrugator, a n d orbic u l a ris oc u l i Function: O pposes depressor m uscles o f t h e g la be l l a r com plex a n d brows t o elevate the brow a n d fo rehead Lines noted: H o rizonta l l i nes ac ross the fo rehead Injection technique: 2 to 3 u n its ( U ) added at 1 . 5-cm i nterva ls ac ross the m idforehea d , a m i n i m u m of 2 e m a bove t h e u pper brow Dose injected: Average 12 to 20 U Avoid: •

Excess treatment of this m uscle; u n o pposed d e p ressor fu nction wi l l res u l t in loss of u pper fac i a l express i o n , a "ti red " a p pea ra nce, a n d risk of b row ptos is.

•

Treatment of this m uscle if the fronta l i s is s u p porting a ptotic u pper eye l i d or if the patient has low-set brows a n d/or excess u pper eye l i d s k i n .

•

I nject 1 e m a bove the eye b rows t o red uce t h e r i s k of b row ptos i s . Patient m ust be awa re that res i d u a l l i nes wi l l be present after the treatment if low fore head wrin­ kles a re present.

B

Figure 4.3 (A) Forehead lines prior to B TX-A treatment. (B) Forehead lines 1 month following B TX-A treatment

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Color Atlas of Cosmetic Dermatology

I njection too c l ose to the med i a l orbita l ri m ; toxin d iffu­

X

sion t h rough the orbital sept u m to the levator pa l pebrae su perioris a n d orbicula ris m uscles may lead to d i plopia .

X X

• G l a b e l l a r Co m p l ex-T h e C o r r u gator

S u p e rc i l i i , the Proce r u s , M ed i a l

�

O r b i c u l a r i s O c u l i , a n d F r o n ta l i s M u sc l es ( F i gs .

4.4

and

4. 5)

)

X

X

l

.·

A

Insertion: Originates a t the nasa l process of the fronta l bone a n d extends latera l l y a n d u pward to i nsert i nto the m id d le t h i rd of the eye b row

X

Function: O p poses el evator m uscles of the fronta l i s for

X

b row a d d uction a n d brow/s k i n d ownward a n d med i a l m ove ment Lines noted: Frown l i nes; "a ngry" or "worried " a p pea r­ a n ce Injection technique: Fema les have a rc hed eye brows ; ma les have flatter or horizonta l eyebrows ; tec h n i q ue ta i­ lored to match the b row sha pe; 3 to 1 0 U i nto the pro­ cerus; 4 to 6 U in the i nfe rior and s u perior bel l i es of the

B

Figure 4.4 Approximate injection sites for the glabellar frown lines. (A) Female brow. (B) Male brow

corrugators; 2 to 3 U i nto the medial orbic u l a ris oc u l i Dose injected: 1 5 t o 4 0 U ( d e pendent on m uscle mass) Avoid: • •

U nd e rtreatment of t h i s region Too low of a n i njection resu lting i n tox i n d iffusion i nto the orbital se ptu m a n d orbit with resu lta nt l i d ptos is. Pal pation of the su perior bony orbita l ri m with i nj ection 1 e m or more a bove this l a n d mark h e l ps to m i n i m ize t h i s risk

•

Con c u rrent treatment of the forehead if a heavy brow is noted

• Pe r i o r b i t a l R eg i o n-O rb i c u l a r i s Oc u I i

( F igs.

4.6

and

4. 7)

A

Insertion: Enc i rcles the periorbita l region a n d i nserts i nto the m e d i a l a n d latera l canthal te ndons as wel l as i nto the fibers of the fronta l , proce rus, a n d corrugator su perc i l i i m usc les Function: Forcefu l closure of the eyes a n d d e p ression of the brows a n d eye l i d s Lines noted: Late ra l c a n t h a l l i nes; " c rows feet" Injection technique: 3 to 5 U a re i njected i nto th ree poi nts in a vertica l l i n e 1 em from the latera l canth us; if a strong sna p test is n oted , 2 to 4 U c a n be placed 3 e m below the m i d p u p i l lary l i ne Dose injected: 22 to 38 U

B

Figure 4 . 5 (A) Glabellar complex before BTX-A injection and (B) 3 weeks

following B TX-A injection

Sect i o n 1 : Ph otoa g i n g

Avoid: •

I njecti on of the i nfraorbita l region if a d e layed s n a p test

N ��

is n ote d ; ectropion of the i njected l i d may d eve l o p •

Overtreatment o f this a rea ; i m proper eye c l os u re, brow

�

..

•

)

An i njection a i med too low at the lower periorbita l wrin­ kles. Wea ken i n g of the levator labii su perioris m uscles

X

with a n u p per l i p d roop and a bnorma l s m i l e may be

• U p p e r N a sa l R oot ( F i g .

, •'

.:···

observed

X

··.

ptosis, or l i d ptosis may ensue

t

X X

Figure 4.6 Approximate injection sites for periorbital lines

4 . 8)

Insertion: Encircles the periorbita l regio n a n d i nserts i nto the m e d i a l a n d latera l ca ntha l te ndons as wel l as i nto the fibers of the fronta l , proce rus, and corrugator su perc i l i i m usc les

Function: Nasa l wri n k l i ng Lines noted: U p per nose fa n n ing rhytides; " b u n n y l i nes" I njection tec h n iq u e : 2 to 4 U is i nj ected i nto each latera l nasa l wa l l i nto the be l l y of the u p per nasa l i s as it traverses the d o rs u m of the n ose

Dose injected: 4 to 8 U Avoid: I njection i nto the u p per nasofa c i a l groove may resu lt i n lip ptosis Use of botu l i n u m toxin i n the lowe r face is m i n i ma l ly benefi c i a l . Other treatment modal ities a re l i kely to be m ore benefic i a l with fewer potentia l side effects. A stro ng u ndersta n d i n g of the lower fa ce and neck a natomy is c rit­ ical for i njection placement ( Fig. 4 . 9 ) .

• N a so l a b i a l Fo l d ( F i gs .

4. 1 0

and

4. 1 1)

It is key to weigh the l i m ited benefit of BTX-A in t h i s region com pa red w i t h the i n c reased risk o f compl ica­

A

tions. F i l l i ng agents may provide greater benefit with fewer side effects.

Insertion: Result of s k i n laxity, gravitatio n a l ptosis, a n d su bc uta neous fat loss overlying t h e c uta neous atta ch ­ ment i n the zygomaticus m a jor a n d m i nor, levator la bi i su perioris, a n d

levator l a b i i s u perioris a laeq ue n a s i

m usc les

Function: Associated with mouth a n d l i p movement Lines noted: Pro m i nent c rease, med i a l c heek; " g u m m y show"

Injection technique: 1 to 2 U i njected i nto the u p per aspect of the nasola b i a l fold 2 to 3 m m latera l to its i n ser­ tion with the n ose

Dose injected: 2 to 4 U Avoid: •

Complete re laxation of this a rea ; u p per l i p ptosis c reat­ i n g a sad a p pea ra nce may occ u r

B

Figure 4.7 (A) Periorbital lines prior to treatment with B TX-A. (B) Periorbital lines 6 weeks following B TX-A treatment

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Color Atlas of Cosmetic Dermatology

U n even pa ra lysis; a n asy m m etric s m i l e or d ispro por­ tionate l i p may be seen

• Per i o ra l R eg i o n-O r b i c u l a r i s O r i s

w i t h C o n t r i b u t i n g F i bers f r o m t h e B u c c i n ator, C a n i n u s , a n d

·.

)

Tr i a n g u l a r i s M u sc l es ; D e p ressor A n g u l i O r i s ; M e n ta l i s M u sc l e ( F igs.

4. 1 2

and

X

4. 1 3)

l X

Figure 4.8 Approximate injection sites for upper nasal root rhytides

Insertion: O r b i c u l a ris oris origi nates fro m the maxi l l a ry a lveol a r bord e r ru n n i ng c i rc u mferentia l l y a ro u n d the mouth to the overlyi ng cuta n eous attach me nts; d epres­ sor a ngu l i oris ( DAOl a rises from the m a n d i b u la r o b l i q u e l i n e , i nserting i nto the a ngle o f t h e mouth . I t is conti n uous with the pl atysm a m uscle; menta l is m uscle origi nates from the m a n d i b u l a r i n c i sive fossa and d escends to a c uta neous i nsertion

Function: Op position a n d protrusion of the l i ps; mouth a ngle d e p ression; lower lip protrusion a n d chin d i m p l i ng

Lines noted: Deep a n d s u p e rfic i a l rhyt id es, u p per a n d lower l i p ; pro m i nent a n g u l a r folds, " s a d a p pea ra n c e " ; c h i n wri n kl i n g

Injection technique: 0 . 5 t o 1 . 0 U i njected 2 t o 3 m m a bove t h e verm i l i on bord er i n fou r a reas each for the u pper and lowe r lip; 1 to 2 U i njected at the i ntersection of a line d rawn from the naso l a b i a l fol d and a n a rea 1 e m a bove the jawl i n e a ngle; 5 t o 1 0 U i nto the i nfe rior m id­ chin

Dose injected: 4 t o 8 U for t h e u p per a n d lower l i ps ; 2 to 4 U for the DAO; 5 to 10 U for the menta l i s m usc le

Avoid: •

Overtreatment of this a rea ; s peech d iffi c u lties, a n asym metric s m i le, i n a b i l ity t o c l ose t h e m o u t h , d rooling a n d a ltered fac i a l expressions may ensue

•

Deep i nj ecti ons; i n c reased risk of side effects

•

Too h igh of an i nj ecti on for the DAO; i n a b i l ity to raise

A u r i c u l ar i s su perior m u sc le A u r i c u l a r i s anterior m usc le

the corner of the mouth may d evelop

• N ec k- P l atys m a M u sc l e Co m p l ex

( F ig.

4 . 1 4)

Insertion: Origi nates on the fascia of the u p per pectora l i s

su perioris muscle

-"71--'T-=-''-----T-+- 0 r b i c u l a r i s o r i s m usc l e :.dr!'J-f- Depressor angu l i oris m usc l e Depressor l a b i i i nferioris m uscle

major a n d de ltoid m uscles a n d proceeds u pwa rd a n d med ia l ly a long t h e s i d es o f t h e neck. Fi bers a re i n serted i nto the m a n d i ble, su bc uta neous tissue of the lower face, periora l m uscle, and s k i n

Function: Fac i a l a n i mati o n ; lower jaw depressio n ; lowe r l i p d e p ression

Lines noted: Neck wri n k l i ng; centra l ba nds

Figure 4.9 Anatomical illustration of the m usculature of the lower face and neck

Sect i o n 1 : Ph otoa g i n g

Injection technique: 2 to 5 U i njected from the s u perior to i nferior portion of each platys m a ! ba nd at 1 to 1 . 5 e m i nterva ls w i t h the patient's teeth c l e n c hed to contract t h e m usc le d u ri n g i njection Dose injected: 20 to 1 00 U Avoid: Too deep an i njection; neck wea kness, l a ryngea l m usc le wea kness, or dysphagia may d evelop

POSTOPERAT I V E CO N S I D E RAT I O N S •

I c e or cold compresses may b e a p plied to red uce pos­ s i b l e bruising a n d edema

•

Active co ntraction of the treated m uscles for 20 to 30 seco nds every 30 m i n utes for 4 h o u rs afte r treatment may exped ite tox i n u pta ke

•

Physical a ctivity s h o u l d be l i m ited for 4 h o u rs after

Figure 4. 1 0 Approximate injection sites for nasolabial folds

treatment to avoid the th eoretica l poss i b i l ity of u nto­ wa rd toxin d iffusion

CO M P L I CAT I O N S •

Tra nsi ent pa i n

•

Eye l i d ptosis

•

Eye brow ptosis

•

Bruising

•

Headache

•

I nc o m p l ete or asy m m etric chemical denervation

•

D i plo pia

•

D ry eyes

•

Ectro pion

•

Asym metrical s m i l e

•

Droo l i ng

•

Decreased p uc ke r

•

Dysphagia

•

P u n ctate keratitis

•

Mask- l i ke expression less face

•

Anti body resista nce

•

F l u - l i ke sym ptoms

Figure 4. 1 1 Approximate injection sites for the perioral muscles

T R EAT M E N T B E N E F I TS R ecovery from B TX-A paralysis gen e ra l ly begins at 3 to 4 months after i njection . Patients who routinely receive BTX-A may note the recovery time to exte nd to 4 to 6 months over ti m e . Side effects i n c l u d i ng eye l i d a n d eye b row ptos is a n d b r u i s i n g ge nera l ly resolve with i n 2 to 3 weeks of onset. Treatment benefits may be lengthened with concom ita nt conservative use of a fi l l e r fo r soft tissue

Figure 4. 1 2 Approximate injection sites for the depressor anguli oris

a ugme ntati o n .

muscle

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PEARLS FOR T R EATM ENT S U CCESS •

Patie nts w i t h known neutra l iz i ng a nti bod ies aga i nst Botox-A may res pond to Myo b l oc given the la ck of sig­ n ificant c ross reactivity between the two tox i n s .

•

O n l y F DA-a pproved botu l i n u m prod ucts s h o u l d be uti­ l i zed . U n l icensed botu l i n u m toxin may res u lt i n seve re, l ife-th reate n i ng bot u l i s m .

•

I n the eve nt of an eye l i d ptos is, use of (a.-ad re nergic agon ist eyed rops suc h as a p raclon i d i n e hyd roc h l oride 0.5% eyed rops ( l e p i d i n e , Alco n , Fort Wort h , TXl may be used to provide tem pora ry lid elevation .

•

Patie nts s h o u l d be i nformed that the maxi m u m benefit of Botox ca n ta ke up to 4 weeks to d eve l o p .

•

D e e p fu rrows w i l l o n l y pa rtia l l y respond to botu l i n u m

Figure 4 . 1 3 Approximate injection site for the mentalis muscle

treatment. C o m b i nation thera py with a filler su bsta nce may provide the best c l i n ical end poi nt. •

I t s h o u l d be em phasized to patients that a s i ngle botu­ l i n u m treatment wi l l not be c o m p l etely effective i n e l i m ­ i nating a l l treated l i nes a n d wri n kles. A s we l l , it s h o u l d be expla i ned t h a t s o m e res i d u a l m usc u l a r movement is the desired treatment end point.

B I B L I OG RAPHY Alam M , Dove r J S , Arndt KA . Pa i n associated with i njec­ tion of botu l i n u m A exotoxin reconstituted using isoto n i c sod i u m c h l o r i d e w i t h a n d without preservative: A dou ble­ blind,

ra n d o m i zed

control led

tria l . Arch

Dermatol.

2002; 1 38 : 5 1 0- 5 1 4 . Alste r T, L u pton , J . Botu l i n u m tox i n type B f o r dyna m i c glabel l a r rhyti d es refractory t o botu l i n u m tox i n type A . Dermatol Surg 2003 ; 29 ( 5 ) : 5 1 6- 5 1 8 . B l itze r A, B i n der WJ , Aviv J E, e t a l . The ma nagement of hyperfu nctional fac i a l l i nes with botu l i n u m tox i n . A col­ la borative study of 210 i njection sites in 1 62 patients . Arch Otolaryngol Head Neck Surg. 1 997 ; 1 23 : 389-392 . B ra n d t F S , Boeker A . Botu l i n u m tox i n for t h e treatment of neck l i nes a n d neck ba nds. Dermatol C l i n . 2004 ; 2 2 : 1 59166. Carruthers A, Bogie M , Carruthers JD, et al. A ra ndom­ ized , eva l u ator- b l i nded two-center stu dy of the safety and effect of vo l u me on the d iffusion a n d efficacy of botu­ l i n u m toxi n type A in the treatment of latera l orbita l rhytides. Dermatol Surg. 2007;33: 567-57 1 . Carruthers A , Kiene K, Carruthers J . Botu l i n u m A exo­ tox i n use in c l i n ical d ermato l ogy. J Am Acad Dermatol. 1 996;34: 788-797 . Carruthers J , Carruthers A . Botu l i n u m tox i n A i n t h e m i d a n d lowe r face a n d nec k . Dermatol Clin. 2004;22 : 1 5 1 1 58 .

Figure 4.1 4 Approximate injection sites for the platysma muscle complex

Sect i o n 1 : Ph otoa g i n g

Carruthers J , Mata rraso S ;

Botox Consensus G ro u p .

Consensus recom mendation on t h e u s e o f botu l i n u m tox i n type A i n fac i a l aesthetics. Plastic Reconstruct Surg. 2004; 1 1 4 : 1 S-22S. Chertow DS, Ta n ET, Masla n ka S E , et al. Botu l ism i n 4 a d u lts fol lowi ng cosmetic i njections with a n u n l icensed , h ighly

conce ntrated

botu l i n u m

prepa rati o n .

JAMA.

2006 ; 296:2476-2479. H s u TS, Dover J S , Arndt KA. Effect of vol u m e a n d con­ centration on the d iffusion of botu l i n u m exotoxi n . Arch Dermatol. 2004; 140: 135 1 - 1 354 . Lelouarn C. Botu l i n u m tox i n A a n d fac i a l l i nes: The va ri­ able concentratio n . Aesth Plast Surg. 200 1 ;2 5: 73-84. Z i m bler MS, Holds J B , Ko l oska MS, et a l . Effect of botu­ l i n u m tox i n p retreatment on laser res u rfa c i ng res u lts: A p rospective, ra nd o m ized , b l i nded tria l . Arch Facial Plast Surg. 200 1 ;3 : 1 6 5- 1 69 .

CHAPT E R 5

Che mical Peels

M ECHAN I S M O F ACT I O N T h e a ppl ication o f a wou n d i ng agent t o i n d uce epidermal a n d/or dermal slough i n g .

I N D I CAT I O N S • •

Epiderm a l d efects-e p h e l i des, melasma Epiderm a l a n d dermal defects-melasma, lentigi nes, post- i nfla m matory

hyperpigme ntati o n ,

acti n i c

ker­

atoses, s u perfi c i a l rhytides, acne vu lga ris •

Dermal d efects-deep rhytid es, acne sca rring, sca rs

P R EOPERAT IVE EVALUAT I O N Peel i n g agents a re selected based o n t h e patient's l i festyle, defect d e pth , s k i n cha racteristics, a n d defect location (Ta bles 5 . 1 -5 .3 ) . •

Past med ical h i story - Past rad iation h i story-decreased a d nexa l structu res l i kely - H i story of ora l herpes s i m p lex virus-rea ctivation may occ u r - Pregna ncy-peels contra i n d i cated with t h e exception of glyco l i c a c i d - H i story o f k e l o i d formation-moderate a n d d eep­ d e pth peels should be avoided

I

29

30

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Color Atlas of Cosmetic Dermatology

TAB L E 5 . 1

•

C l inical I n d ications and Peel Types

I n d i cation

Peel d e pth/treatment e n d po i n t

Peel type

A c n e vu lga ris

S u perficia l when active

Localized epidermal peel i n g req u i red ; lesion a l i m p rovement

Ephelides; lentigines

S u perfic i a l or m ed i u m

Tota l epidermal pee l i ng req u i red for com plete remova l ; l ighte n i ng

Post-i nflam matory i nfla m mation

S u perfi c i a l or med i u m

Tota l epidermal pee l i ng req u i red ; l ighte n i n g with either strength

Melasma

S u perficia l or m ed i u m

Tota l epidermal pee l i ng req u i red ; l ighte n i ng with either strengt h ;

S u perficial rhytides

S u perficia l

Loca l i zed e p i d e r m a l pee l i ng req u i red ; softe n i ng

with s u perfi c i a l a pp l ication

i nconsistent res ponse Moderate rhytid es

M ed i u m or deep

Tota l epiderma l a n d pa p i l l a ry d e r m a l peel ing req u i red ; softe n i ng

Deep rhytides

Deep

Tota l epidermal to reti c u l a r d e rma l peel req u i red ; softe n i ng

Acti n ic ke ratoses

M ed i u m

Tota l epidermal to pa p i l l a ry dermal pee l i n g req u i red ; lesio n a l cleara n ce

Depressed sca rs

M ed i u m o r deep

Les i o n a l ed ges targeted ; tota l epidermal a n d pa rtia l d e r m a l pee l i ng req u i red; l esional flatte n i ng; va riable res ponse

TAB L E 5 . 2

•

Woun d i ng Depth of Superfi c i a l , Medium-Depth, and Deep-Depth Strength Peels

S u perfic i a l peel

M ed i u m -d e pth peel

Deep peel

a- Hyd roxy a c i d

G lyco l i c acid a n d TCA

Ba ker's Gordon phenol , u n occ l u d ed

M od ified U n na 's resorc i n o l paste

J essner's and TCA

Ba ker's Gordon phenol , occ l uded

J essner's

Solid carbon d ioxide a n d TCA

Sal icyl ic acid

50% TCA

Solid carbon d ioxide s l u s h

Pyruvic a c i d

Treti n o i n

8 8 % F u l l -strength p h e n o l

1 0%-25% TCA; 35% va ria b l e

TAB L E 5 . 3

•

Pee l i ng Agent Characteristics Safe for

Peel type

Color end poi nt

G lyco l i c a c i d

Confl uent erythema

1-2 coats

1-2 h

A l l s k i n types

J essner

Pale wh ite

Coats a re a pp l ied singly a n d

4-5 d ; m i l d epidermal

A l l s k i n types

Appl ication

e n d point mon itored for

H ea l i n g time

d esq u a mation noted

3-4 m i n prior to repeat a p pl ication TCA (30% or greater)

Sol i d wh ite

Si ngle even a p pl icati o n ;

1 0-14 d ; severe

loca l i zed a p p l ications for

s u n b u rn - l i ke pee l i n g

l ighter wh ite a reas may

observed

I a n d I I ; caution with I l l and I V

be considered Phenol

G ray wh ite

S i ngle even a p p l icatio n ; can be conservatively rea p p l ied

•

Past s u rgica l h i story - Prior cosmetic proced u res-prior face l ift, blep h a ro­ plasty, carbon d ioxi d e resu rfa c i ng, o r derma b rasion may affect peel o utcome . I nc reased ectropion risk prese nt.

•

Medication use - Previous isotreti n o i n use and yea r - To pica l med ications such as tret i n o i n a n d a-hyd roxy acids may potentiate peel penetration - Couma d i n use

1 0-14 d ; su perfi c i a l b u r n a p pea ra n ce

I and I I

Sect i o n 1 : Ph otoa g i n g

•

I

31

Fitz patric k s k i n ph ototype - Skin p hototypes I-I I I patients respond to a l l peel types. - S k i n ph ototypes IV a n d V patients a lso respond to a l l peel types, b u t the risk o f post-treatment dyspigmen­ tation is greater. - A test site may be wa rra nted for d a rker s k i n types to eva l uate peel outco me .

•

Degree o f acti n i c d a mage a n d p h otoaging - A wh ite l i ne of d e m a rcation between peeled a n d u n peeled s k i n m a y b e pro m i nent i n t h e p resence of moderate to severe dermatohel iosis.

•

Wood's lamp eva l uation - H e l pfu l i n ascerta i n i ng pigmentation type p rese nt - Epiderm a l

origi n :

lesional

color

e n h a ncement

( Fig. 5. 1 ) - Dermal o r c o m b i nation epidermal a n d derma l : n o lesional color e n ha ncement to l ight - Exa m i nation d oes not acc u rately pred ict c l i n ical peel res ponse - Epidermal pigment may res pond better to pee l i ng agents com pared with d e r m a l or c o m b i nation p ig­ ment d e position •

Medical cleara n ce - A rece nt electroca rd iogra m is necessa ry to serve as a base l i n e for phenol peels in the event of ca rd i otoxicity. - Liver fu nction a n d ren a l function tests s h o u l d be eva l ­ uated t o e n s u re adequate he patorenal fu n ction fo r phenol pee ls.

I D EAL CAN D I DATE •

S k i n p h ototype I or I I

•

Acti n i c d a maged s k i n

•

Static rhytides associated w i t h s u n expos u re

LESS I D EAL CAN D I DATE •

Dyn a m i c rhyti d es-a c h i eved benefits a re tem pora ry i n natu re

•

Exte nsive gravitati o n a l folds a n d fu rrows- l i kely to req u i re s u rgica l i nterve ntion in conj u n ction with c h e m i ­ cal peels

•

Deep rhytides

•

Boxc a r a c n e o r mod erate d e pth atro p h i c sca rring

CONTRAI N D I CAT I O N S •

U n rea l i stic patient expectations

•

Patient u n a b l e to perform necessa ry postoperative ca re

Figure 5 . 1 Thirty-one-year-old female with melasma. Wood's lamp accen­

tuated her facial pigmen tation

32

•

I

Color Atlas of Cosmetic Dermatology

Patients with ice p i c k sca rs or d ee p atro p h i c sca rs

•

Patients with d i lated , la rge pore size

•

H i story of o ra l isotret i n o i n use with i n 1 yea r prior to p ro­ ced u re

• •

H i story of keloid formation Patient with u n d e rlying ca rd iac a rrhyth m ias (for deep peels)

•

Coumad i n use (for deep pee ls)

•

Skin p hototypes I l l-V I (fo r deep pee ls)

M E D I CAT I O N S •

P reo perative a ntivi ra l medications a re reco m m e n d ed . Va ltrex 500 mg B I D or Acyc lovir 400 mg T I D i n itiated o n the day of p roced u re and conti n ued for 5 to 1 4 days is a d m i n istered depend i n g on peel d e pt h .

•

Topical retinoic a c i d a n d a-hyd roxy a c i d prod ucts a re d isconti n ued 48 h o u rs prior to a glycol i c acid peel a n d 1 wee k prior t o a deeper peel a n d n ot rei n itiated for 1 week post treatment.

WOU N D DEPTH Determ i ned b y m u lt i p l e factors. • •

Anato m i c consid e rations Fac i a l skin d iffers from non-fa c i a l s k i n i n the relative n u m be r of p i l osebaceous u n its per cosmetic u n it a n d t h i c kness. P ro m i nent a d nexa l structu res a re req u i red to promote re-e pith e l i a l ization post treatment. - The nose a n d forehead have more sebaceo us g l a n d s t h a n d o the c h eeks or tem ples. - The face has m o re sebaceous glands tha n the n o n ­ fac i a l a reas i nc l u d i n g the neck. - M o re a cti n i c a l l y d a maged s k i n is t h i n n e r with fewer p i l osebaceous u n its prese nt. Body location and prese nce of acti n i c a l l y d a m aged

ski n sign ificantly affects the selection of the wo u n d i n g agent. The pee l i ng agent m a y be m o re d estru ctive i n a reas with fewer a d nexa l structu res a n d th i n ne r ski n ; therefore a less aggressive pee l i ng agent s h o u l d b e uti-

1 ized in these a reas. •

Prepeel s k i n d efatt i ng-use of acetone to d efat the treatment a rea res u lts i n a deeper penetrati ng peel

•

Wo u n d i ng agent strength-a n i n c reased stre ngth wi l l

•

A m o u nt o f agent a p pl ied-deeper s k i n penetration with

resu lt i n d eeper s k i n peel i n g each peel layer a p p l ied

A

Figure 5.2 (A) Epidermal melasma unresponsive to topical bleaching

creams.

Sect i o n 1 : Ph otoa g i n g

I

P E E L TYP ES •

S u perfi c i a l peels-pa rtia l o r complete epidermal i nj u ry; may exten d i nto the pa p i l l a ry dermis ( Fig. 5.2A a n d B)

•

M ed i u m-d e pth peels-i nj u ry exten d s i nto the pa p i l l a ry to u p pe r reti c u l a r dermis ( Fig. 5.3A a n d B )

•

Deep

peels-i nj u ry exte nds

i nto the

m id - reti c u l a r

dermis

PROCED U R E •

P reoperative written consent o bta i ned .

•

P reoperative p i ctu res ta ke n .

•

Patie nt's m a ke u p rem oved a nd face c l ea nsed with a n a n tise ptic wash (eg, c h lorhexid i n e ) .

•

Scru b t h e treatment a rea with a cetone on cotton ga uze for 2 to 3 m i n utes.

•

The pee l i ng agent s h o u l d be pou red i nto a glass c u p .

•

T h e pee l i ng agent is a p p l ied t o t h e treatment site . - A pai ntbrush or cotton ba l l may be used to a p ply gly­ colic a c i d . - A sa ble b r u s h is rec o m m e nded f o r J essner peel for i n c reased penetration . - Cotton-ti p ped a p p l icators or cotton ga uze may be used to a p ply tri c h l o roacetic a c i d

(TCA)

peel i n g

agents . - One or two s m a l l cotto n-ti p ped a p p l icators a re used fo r phenol a p p l icati o n . - A rou n d toot h p i c k or wood en porti on o f a broken cotton -ti p ped

a p p l icator

may

be

used

to

treat

i n d ivid u a l rhytides a n d icepick a cn e sca rs. - The n u m be r of a p p l icators used and the p ressu re a p plied to the treatment site with agent a ppl ication will affect solution del ivery a n d d e pth of penetration ( Figs. 5.4 a n d 5 . 5 ) . •

A fa n is req u i red t o h e l p red uce t h e associated patient d iscomfort.

•

P retreatment with J essner o r glyc o l i c acid prior to a TCA peel a l l ows for d ee per peel penetrati o n .

•

Feathering i nto t h e h a i r l i n e a n d at the jawl i n e con cea ls the poss i b l e line of d e m a rcati o n . Feathering s h o u l d a lso be performed when the periora l a rea is treated a lone to p reve nt l i nes of d e m a rcation ( Fig. 5 . 6 ) .

•

The periorbita l tissue s h o u l d b e treated fi rst with TCA peels, fol l owed by the n ose, c h eeks, peri o ra l a rea , a n d forehead for best patient tolera n c e . The u pper a n d lower eye l i d s m a y b e treated . Extension 2 t o 3 m m o nto the periora l verm i l l ion is benefi c i a l for rhytid es red uc­ tio n .

•

A sa l i n e syri nge s h o u l d b e ava i l a b l e i n t h e case o f i na d ­ verte nt i ntrod uction o f the pee l i ng agent i nto the eye .

B

Figure 5.2 (continued) (8) Mild improvement noted following two 50% glycolic acid peels

33

34

•

I

Color Atlas of Cosmetic Dermatology

The a pp l icator should be wrung out a n d sem i-d ried to p reve nt d ri p p i ng. The glass conta i ner s h o u l d be h e l d away from the patient to avoid d i rect s pi l l i ng o n t o t h e patient.

•

J essner

pee l ,

TCA,

and

phenol

peels

a re

self­

neutra l izi ng. G lycol i c a c i d pee ls m ust be neutra l ized with water o r bica rbonate solution . •

Cool was h c l oth is a p p l ied to the treated a reas.

•

Vase l i n e is a p plied to the treatment site fo r J essner, TCA, a n d phenol peels. G lyco l i c a ci d peels req u i re a I ight moistu rizer.

•

Deep peels have i n h erent card ia c , rena l , a n d h e patic toxicities. F u l l -face a p p l ication req u i res i ntravenous f lu ­ ids, sedation , cardiac mon itoring, p u lse oxi meter, a n d blood pressu re mon itoring.

COM P L I CAT I ON$ •

G reater d e pth of peel provided than expected ( Fig. 5 . 7 )

•

I nfection-vira l , bacteria l , funga l

•

Tem po ra ry o r perma nent hyperpigme ntation o r d e pig­ mentation

• •

Prolonged e rythema Sca rring-atro p h i c , hypertro p h i c , keloida l ; ectro p i o n , d e layed hea l i n g

•

Conta ct dermatitis

•

Text u ra l c h a n ges

•

Acne

A

•

M i l ia

Figure 5.3 (A) Pseudo-ochronosis. The pigmentary changes persisted

•

Cardiac a rrhyth m ias (deep phenol pee l )

despite discontinuation of the inciting medication.

•

La ryngea l edema ( d e e p p h e n o l pee l )

POSTOP E RAT I V E CAR E •

A l ight moistu rizer i s a p p l ied twice d a i l y for glyco l i c a c i d peels.

•

Vase l i n e is ke pt o n rou n d the clock with twice d a i ly c l ea n s i ng soa p a n d water, J essner, TCA, a n d phenol peels.

•

Strict photoprotection is stressed fo r a m i n i m u m of 1 month after a glycol i c acid peel and 2 to 3 months for the re m a i nd e r of peels.

•

Patie nts a re i n structed to a l low nat u ra l slough i n g of the treated ski n . The skin m ust n ot be m a n u a l ly removed .

PEARLS FOR T R EATM ENT S U CCESS •

Ca refu l patient selection a n d p e e l selection is n eces­ sa ry for treatment s uccess. I t is best to u nd e rtreat with a less potent peel i n g agent in non-fa c i a l a reas to m i n i­ m ize the risk of sca r formati o n .

Sect i o n 1 : Ph otoa g i n g

•

I

35

Patie nts m u st be awa re of the expected recovery time with each chemical peel a n d the n ecessa ry posto pera­ tive wou n d care they wi l l n eed to perform to exped ite hea l i ng . Although one deep peel may provide the great­ est benefit, l ifestyle or work constrai nts make seria l su perfi c i a l or med i u m -d e pth peels a bette r long-te rm goa l .

•

T h e m a rgi n o f safety is m u c h n a r rower a n d t h e risk of c o m p l ications

much

greate r

with

i n c reased

peel

strengths . •

Patients w i t h s k i n ph ototypes I l l a n d I V h a v e a greater risk of d eve l o p i n g pregna n cy- i n d uced hypertension after a chemical peel . Consideration of a test site is wa r­ ra nted for m ed i u m-depth pee l s .

•

C h e m i c a l pee ls w i l l n o t a lter pore s i z e a n d may i n fact i n c rease thei r size.

B I B L I OG RAPHY Ba ker TJ , Gordon H L, M osienko P, e t a l . Long-term h i sto­ logica l study of s k i n after c h e m i c a l fac i a l pee l i ng. Plast

Reconstr Surg 1 9 74;53: 522-52 5 . B rody HJ . M ed i u m-depth c h e m i c a l pee l i ng o f the s k i n : A va riation of su perfi c i a l che mosu rgery.

Adv Dermatol.

1 988; 3 : 205-220. G r i mes PE. Melasma : Etio l ogic and therapeutic consid e r­ ations. Arch Dermatol. 1 997; 1 3 1 : 1453-1457. G ross D . Ca rd iac a rrhyth m i a d u ri n g phenol face pee l i ng.

Plast Reconstr Surg 1 984; 73: 590-594.

8

Kligman A M , B a ker TJ , Gordon H L. Long-term h isto logic

Figure 5.3 (continued) (B) Marked pigment lightening after three Jessner 35% TCA peels

fo l l ow- u p of phenol face peels . Plast Reconstr Surg. 1 985 ; 7 5 : 652-659 . La n d a u M . Com bination of c h e m i c a l pee l i ngs with botu­ l i n u m toxi n i njections and

dermal fi l l ers . J Cosmet

Dermatol. 2006; 5(2 ) : 1 2 1 - 1 26. M a c Kee G M , Ka rp FL. The treatment of post-a c n e sca rs with p h e no l . Br J Dermatol. 1 9 52 ; 64( 1 2 ) :456-459 . Mata rasso SL, G loga u R G . C h e m i c a l face peels. Dermatol

C!in. 1 99 1 ;9 : 1 3 1 - 1 50. M o n h eit

G.

The J essner's-tric h l o roacetic

acid

pee l .

Dermatol Clin. 1995 ; 1 3 ( 2 ) : 2 77-283 . M u ra d H , S h a m b a n AT, Premo PS. The use of glycol i c acid as a pee l i ng agent. Dermatol Clin. 1995; 1 3 ( 2 ) : 285307 . Que SK, Bergstrom KG . Hyperpigmentati o n : O l d p roblem, new thera pies. J Drugs Derma tal. 2009;8(9 ) : 879-882 . R u l l a n P, Ka ra m A M . Chemical peels for d a rker skin types.

Facial Plast Surg Clin North Am. 2010; 1 8( 1 ) : 1 1 1- 1 3 1 . Szzc h owicz E H , Wright W K . Delayed hea l i ng after fu l l ­ face c h e m i c a l pee ls. Facial Plast Surg. 1 989;6( 1 ) :6- 1 3 .

36

I

Color Atlas of Cosmetic Dermatology

Figure 5.4 Fine white color immediately following a 20% salicylic acid

peel

Sect i o n 1 : Ph otoa g i n g

I

Figure 5 . 5 Pale white color immediately following a Jessner peel

Figure 5.6 Solid white color immediately following a Jessner/35% TCA

peel

37

38

I

Color Atlas of Cosmetic Dermatology

Figure 5.7 Patient with line of demarcation between the Jessner/35%

TCA peel treated perioral area and untreated skin. Patient appears hypopigmented in the treatment site. A subsequent medium-depth peel to the remainder of the face resulted in a more even facial appearance

Figure 5.8 Localized frosting following application of a 50% glycolic acid peel. The localized peel resulted in some mild desquamation for 3 days

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 6

I

No n a blative Lase r R esu rfaci n g

I N TRODUCT I O N There a re m u lti ple laser a n d l ight sou rce treatments for p h otoaging. These treatme nts ra nge in effi cacy a n d side effects . Typical ly, there is a trad e-off between c l i n ica l i m prove ment a n d a concom ita nt i n c rease i n s i de effects a n d d ownt i m e fro m work a n d soc i a l activities . Oth e r cha pte rs have foc used o n s u c h treatments as n o n a b l a ­ tive fra ctional resu rfaci ng, a blative fractional res u rfa c i ng, and tra d itional res u rfa c i ng. This c h a pter exa m i nes non­ a b lative laser resu rfa c i n g a n d , i n partic u la r, the use of m id-i nfra red lasers . Other d evices such as i ntense pu lsed l ight, n o n a b lative fractional res u rfa c i ng lasers, and vas­ c u l a r lasers a lso ach ieve n o n a b l ative benefits, a n d a re add ressed i n d eta i l i n oth er cha pters . P h otoaging encom passes a l l the cha nges prod uced by expos u re to u ltraviolet ( UV) rad iation, i n c l ud i ng tela ngiec­ tasias, rhyti d es, poor skin text u re, and tone as we l l as ski n laxity (see Dermatohel iosis c h a pter) . N o n a b l ative rej uve nation treats s u n -da maged s k i n by heati ng d e r m a l

Figure 6.1 Vesicles appeared 1 day after treatment with a 1 4 50-nm

col lagen w i t h the a i m o f sti m u lating n ew collagen growt h .

diode laser with a Fitzpatrick skin type 1 patient. These vesicles com­ pletely cleared without sequelae 3 days later

I t is a lso effective i n t h e treatment o f a c n e scars. Epiderma l cool i n g is p rovid ed to e n s u re that thermal heati ng is ta rgeti n g the dermis, a n d n ot the e p i d e r m i s . The best adva n tage o f nona b lative treatme nts is t h a t they req u i re l ittle, if a n y, d ownti me from work a n d soc i a l activ­ ities. This is i n contrast to a blative and fra ctional a b lative treatm ents . In s k i l led h a n d s , side effects a re typ i ca l ly m i l d a n d tem pora ry ( Fig. 6. 1 ) . Ofte n , they p rod uce s u btle o r m i l d ben efits , eve n after m u ltiple treatments. U nfort u nately, the p red icta b i l ity of i m prove ment is u ncerta i n . Some patients d o not experi­ ence a ny d iscern i b l e ben efit even after m u ltiple treat­ ments. In the past few yea rs, nona blative fractional lasers have p rod uced e n h a nced results from other forms of n o n a b l ative res u rfa c i ng, with m u ltiple treatments. Th ese lasers have a lso p roven to be safe in s k i l led h a n d s . With the advent of nona b lative fractional lasers, trad itio n a l n o n a b l ative laser res u rfa c i n g has decl i n ed i n popula rity. In add ition to i ntense p u l sed l ight sou rces a n d vasc u l a r lasers, there a re m a n y n o n a b lative devices t h a t util ize vis­ i b le, nea r- i nfra red , and m id - i nfra red wavelengths with e p i d e r m a l skin coo l i n g . These wavele ngths target the water that is a b u nda nt in dermal tiss u e. The skin cool i ng p rotects aga i n st epidermal da mage. T hese lasers p ro­ d uce d ee pe r dermal penetrati o n , greate r a bsorption , a n d d e r m a l therma l i nj u ry t h a n vasc u l a r lasers. F u rther, there is sign ifica ntly decreased risk of pigme nta ry c h a nges i n d a rker s k i n phototypes a t these wavelength s . W h i l e the best ca n d id ates for treatment a re those with m i ld to mod­ e rate static rhytides, the d egree of i m provement after treatment is d iffic u lt to q ua ntify.

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Color Atlas of Cosmetic Dermatology

N o n a b lative lasers •

Su btle i m provement of rhyti d es, pa rti c u l a rly when com­ pa red to a blative d evices - Best for patients with m i l d to moderate p h otod a m ­ age, s k i n laxity, a n d s k i n coa rseness

•

Req u i res m u ltiple treatments to p rovide m i l d i m p rove­ ment of s k i n text u re, tone, a n d rhytides

•

Little to no posto perative d ownti me compared to tra d i ­ t i o n a l a blative d evices

•

Patient can return to work o r soc i a l activities the sa me day as the proced u re

•

Ca n treat cosmetic u n its effective ly without l i nes of dema rcation

I N D I CAT I O N S •

A

I n d ications - M i l d rhyt id es - P h otoda mage, i n c l u d i n g s k i n texture a n d tone - Acne sca rs, i n c l u d i n g boxca r, atro p h i c , ro l l i n g sca rs - S u btle benefit - M i ld i m provement in s k i n laxity - N ot effective for dyna m ic or deeper rhyti des

P R EOPERATIVE EVALUAT I O N •

S k i n type (can treat d a rker s k i n types with m id-i nfra red lasers, but req u i res caution with s k i n coo l i ng)

•

Sun exposu re

B

•

H istory of ke loids

Figure 6 . 2 (A) Patient with EMLA under occlusion prior to treatment of

•

l sotret i n o i n use i n past 6 months

acne scars. (B) Treatment with 1 4 50-nm diode laser with DCD cooling

•

Patie nts with u n rea l istic expectations A consu ltation is req u i red before this treatment to

assess the patient as wel l as a p p ro p riately prepare the patient for the proced u re . The patient s h o u l d be fully educated as to the risks a n d benefits of the proced u re . I t is i m perative t h a t expectations a re s e t rea l i stica l ly i n te rms o f t h e m i l d d egree of i m provement that w i l l often be seen for rhytides . The patient s h o u l d a lso be i nfo rmed that the ben efits of rhytid treatment accrue 3 to 6 months after treatment.

PROPHYLAX I S/AN ESTH ES I A M a y i nc l u d e a n y o f t h e fol l owi ng: •

Antiviral prophylaxis

•

Topical a n esthetic - 23% Lidoca i n e!? % tetraca i n e - 7 % Lidoca i n e/7 % tetra ca i n e - Eutectic m ixtu re o f loca l a n esthetic ( E M LA)

Sect i o n 1 : Ph otoa g i n g

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41

Beca use some of m id-i nfra red laser treatme nts c a n be pa i n fu l , some form of a n esthesia is ofte n req u i red . It wi l l va ry accord i ng t o t h e aggressiveness o f treatment, the pa rti c u l a r suscepti b i l ities of the patient, a nd the physi­ c i a n 's comfort with va rious a n esthetic reg i m e n s .

• M i d - i n fra red Lasers The 1320- n m N d :YAG laser ( Coolto u c h I n c . , Rosevi l le , CAl featu res a t h e r m a l feed back system t h a t measu res e p i d e r m a l tem peratu re to more precisely ta rget dermal collage n . Thus, the laser s u rgeon can control h eati ng with more p recision . I t is theorized that n ew col lagen sti m u lation is caused by i nfla m matory cyto k i n es after

A

d e r m a l heati ng. The 1450-n m d iode laser ( S m ooth bea m , Candela Corp . , Wayl a n d , MAl a lso targets dermal water, while p rotecti ng the e p i d e r m i s with a c ryoge n s p ray d evice ( Fig. 6 . 2 ) . There is n o tem peratu re feed back device. With either device, aggressive coo l i ng can p rod uce tem pora ry pigmenta ry c h a nges.

LAS E R SAFETY •

Eye protection : m eta l eye goggles - All perso n n e l p resent at the time of treatment m ust wea r safety glasses/goggles to avoid

i nadverte nt

cornea l d a mage.

B

Figure 6.3 Pretreatment and immediate posttreatment photos of non­

ADV E R S E S I DE EFFECTS Adverse side effects: fa r less co m mo n than a blative pro­ ced u res, but do occ u r with h igher fl u e n ces as we l l as i nadvertent pu lse sta c k i n g ( ie, fi r i ng twice in ra p i d s u c­ cession over the sa me a real •

Sca rring

•

B u l lae ( Fig. 6 . 2 )

•

Posti nfla m matory

hyperpigme ntation

( us u a l l y

from

ove rly aggressive s k i n cool i ng)

• Posto perat i ve C a re ( F i g .

6. 1)

•

Little postp roced u re pa i n .

•

A n y e rythema i s m i l d a n d resolves sh ortly after treat­ ment.

•

There is no req u i rement for a fol l ow- u p visit afte r treat­ ment.

• •

N o posto perative c a re is req u i re d . Patient s h o u l d b e i nstru cted t o ca l l if erythema persists or if vesic les or b u l lae d evel o p ( Fig. 6 . 1 ) .

bruising pulsed dye laser treatments. There is mild erythema after treat­ ments. Many patients note an improvement in the texture and tone of skin after a series of treatments

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Color Atlas of Cosmetic Dermatology

Postoperative erythema resolves q u ic kly. Strict s u n avoidance is recom mended . The fol l owing practices a l l sign ifica ntly i n c rease the

risk of sca r: •

Aggressive treatments i n c rease risk of sca r

•

Poor tec h n iq u e, ie, excess ive overla p ( p u lse stacking) In sum, nona b lative laser resu rfa c i n g proced u res offer

the adva ntage of q u ic k , safe treatments that p rod uce m i l d i m provement of photoda maged ski n . U s u a l ly, they can be performed on the sa m e day as work a n d soc i a l o b l igation s. N o n etheless, the treatment has i t s d raw­ backs s u c h as •

Resu lts a re usua l ly modest.

•

D u ration of benefit, if a n y, is n ot known .

•

Best resu l ts often req u i re more m u ltiple treatments. Beca use the i m provement i s often s u btle and u n p re­

d icta b le, eve n after m u lt i p l e treatme nts, other proce­ d u res s u c h as nona blative fract i o n a l resu rfa c i ng have i n c reasingly s u p pla nted the a p pea l of trad iti o n a l nona bla­ tive p roced u res.

B I B L I OG RAPHY Ta nzi EL, W i l l i a m s C M , Alster TS. Treatment o f fac i a l rhytides with a nona b lative 1450- n m d iode laser: A con­ trol led c l i n ic a l a n d

h istologic study.

Dermatol Surg.

2003 ; 2 9 ( 2 ) : 1 24- 1 28 . Ta nzi E L , Alster TS. C o m pa rison o f a 1450- n m d iode laser and a 1320- n m N d :YAG laser i n the treatment of atro p h i c fa c i a l scars: A prospective c l i n ical and h isto logic stu d y. Dermatol Surg. 2004;30(2 Pt 1 ) : 1 52- 1 57 .

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 7

A b l ative Lase r R es u rfaci ng

M ECHAN I S M OF ACT I O N U t i l i z i n g t h e p r i n c i ples of selective photothermolysis, a b lative rem ova l of s k i n i n a precisely control led fas h i o n w i t h resu lta nt m i n i ma l s u rro u n d i n g t h e r m a l d a m age is ach ieved . The d e pth of tissue penetration is dependent on sel ective a bsorptio n of water. I m med iate tissue effects a re d e pendent on the s pot s ize a n d power uti l ized as we l l as t h e s peed o f treatment a d m i n istration . T h e ti me of laser-tissue i nteraction is the critical factor for res i d u a l thermal da mage. Epidermal o b l iteration a n d (or pa rtia l a b lation o r coagu lation o f t h e u pper d e r m i s is t h e en d­ point. Re-epith e l i a l ization resu lts fro m the m igration of cells that a rise from su rro u n d i ng fol l i c u l a r ad nexae . N o r m a l com pact col lagen a n d elastic fibers re place the a m orphous elastotic dermal com pone nts, a n d norma l , we l l-orga n ized epith e l i a l cells replace t h e d i sorga n ized p hotoda maged epidermis. Col lagen re mode l i n g is n oted both i ntraoperatively via therm a l s h r i n kage and contrac­ tion and postoperatively with i n the re mod e l i ng phase of wo u n d hea l i ng.

• C a r b o n D i ox i d e Laser

( C 0 2 R es u rfac i n g) Conti n uo u s

wave

( 10,600 n m ) ,

s u per- p u lsed ,

and

sca n ned C0 2 lasers a re util ized for res u rfa c i ng. A rela­ tively b l ood less su rgery with red uced swe l l i ng is a c h ieved via the p h otocoagu lative effect on blood vesse ls and lym­ phatics. The risk of sca rring, u n p red icta b l e level of th er­ mal d a mage, a n d d e layed hea l i ng of the conti n uous wave laser l i m it its c l i n ical use. The sca n n ed a n d p u lsed C0 2 lasers d e l iver high pea k fl u en ces in less tha n 0.001 sec­ onds to a c h i eve tissue va porizatio n of 20 to 30 1-1m per pass . Approxi mately 40 to 120 1-1m of res i d u a l thermal d a mage is n oted per pass ( Fig. 7 . 1 ) .

• E r b i u m : Ytt r i u m - A i u m i n u m G a r n et

Laser ( E r : YA G ) A laser o f wave length 2 ,490 n m i s uti l ized for more s u perfic i a l

resu rfa c i ng.

It

is

16x

m ore

selectively

a bsorbed by water. It a c h i eves tissue va porization of 1 to 5 1-1m per pass. It res u l ts in a na rrower zon e of res i d u a l t h e r m a l da mage ( 5-30 1-J m ) . A s a z o n e o f therm a l d a m ­ a g e o f 50 1-1 m o r greate r is req u i red f o r ph otocoagulati o n , Er:YAG treatment resu l ts i n a s l ightly b l oody s u rgica l fie l d . The t h e r m a l d a mage is a lso i n s ufficient t o prod uce i m med iate

c o l l agen

contra cti o n .

re model i ng is l i m ited ( Fig. 7 . 2 ) .

Long-term

col lagen

A

Figure 7 . 1 (A) A 58-year-old woman with extensive actinic damage.

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Color Atlas of Cosmetic Dermatology

I N D I CAT I O N S Ablative lasers have been util ized as a c utti ng too l a n d va poriz i n g tool t o treat epidermal a n d su perfi c i a l d e r m a l lesions. •

Cutting too l :

keloids, acne kelo i d a l i s n uchae, cyst

remova l , basa l carc i n o m a , b u r n , a n d u l ce r d e b ri d e­ ment; h a i r tra nspla ntat i o n ; b l e p h a ro p lasty; other i n c i ­ sional s u rgeries where control led hemostasis is desi red or where e p i n e p h r i n e is contra i nd icated or a pacer pre­ c l udes use of e l ectrosu rgery. •

Va porizi ng tool : treatment of n u merous cond itions i n c l u d i ng static and dyna m ic rhyt id es, boxca r, c rateri­ form and hypertro p h i c acne sca rs, pox scars, wa rts, lentigines, adenoma sebace u m , a ngi okeratomas, pyo­ gen i c

gra n u l o m a ,

lym pha ngioma

c i rc u mscri ptu m ,

Bowe n 's d i sease, eryt h roplasia o f Queyrat, o ra l florid pa p i l l om atosis, acti n i c c h e i l itis, acti n i c keratoses , epi­ d e r m a l n evi , syri ngomas, gra n u loma faciale, n e u rofi­ b romas, xa nthelasma , and tattoos. •

N ot i n d icated for the treatment of icepick acne sca rs .

P R EOPERATIVE EVALUAT I O N Sign ifi cant past med ical h istory i nc l udes a h istory o f her­ pes l a b ia l is; u n derlyi ng a uto i m m u ne d i sease or i m m u n e d eficiency; u nd e rlyi ng koe bnerizing/i nfectious cond itions i n c l u d i ng psoriasis, verrucae, and m o l l u sc u m ; h i story of keloid or hypertro p h i c sca r format i o n ; u n derlying card ia c o r p u l m o n a ry cond itions t h a t may be exacerbated by t h e u s e o f a n esthetic medications; existi ng d rug a l le rgies; tobacco use; a ctive acne vu lga r i s . Sign ifica nt past s u rgica l h i story i n c l udes prior s u rgica l treatments to the treatment sites, s u rgica l dates, a n d patient response. The patient m ust be awa re of the lengthy recovery period that w i l l req u i re extens ive h a n d s-on patient care for o pti m a l treatment resu lts . Re-epit h e l i a l ization req u i res 7 to 10 days with associated pa i n , ed e m a , a n d e rythe m a . Posto perative erythema resolves over a n ave rage period of 3 to 5 months. Strict sun avoida nce m u st be fol l owed for a m i n i m u m of 1 yea r posto peratively to avoid pigmen­ ta ry cha nges a n d p h otose nsitivity. Rea l istic expectations a re the m ost i m porta nt d ete r m i n a nts of treatment suc­ cess . The patient m ust be aware that the treatment wi l l i m prove b u t d oes n ot e l i m i nate a l l or even m ost rhytides or sca rs a n d that dyna m i c rhytides a re l i kely to rec u r with i n a few months postoperative ly. P roced u ra l

risks to em phasize i n c l u d e tem pora ry

a n d/or perma nent hyperpigme ntation a n d d e pigme nta­ t i o n , i nfection (vi ra l , bacteria l , yeast ) , a n d sca r (atro p h i c , hypertro p h i c , keloi d a l ) fo rmati o n ; a c n e fla re; eczema last i n g 1 to 2 months. Pred icta ble side effects i n c l u d e proced u ra l a n d posto perative d iscomfort; edema , oozi ng,

B

Figure 7.1 ( continuedJ (B) A marked reduction in rhytides and dyspig­

mentation is noted 2 months after full-face carbon dioxide resurfacing

Sect i o n 1 : Ph otoa g i n g

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45

a n d crusti ng lasting 1 to 2 weeks; e ryth em a , s k i n tight­ ness, a n d pruritus lasti ng u p to 3 to 4 months.

I D EAL LAS E R CAN D I DATE •

Fa i r s k i n type ( Fitzpatrick phototypes I-l l )

•

Laser-a menable lesions

•

M i n i ma l assoc iated dyspigme ntation of neck a n d c h est

•

Abl e to tole rate exte n d ed period of conva lesce nce post­ operatively

•

Able to fo l low and exec ute necessa ry posto perative s k i n ca re regi men

•

Rea l istic treatment expectations

LESS THAN I D EAL LAS E R CAN D I DATE •

Da rker s k i n type ( Fitzpatrick ph ototypes I l l , IV, a n d Vl; treat with cauti o n , d ue to sign ifica nt risk of tem po ra ry a n d/or permanent pigmenta ry a lterations

•

Moderate associated d ys p igme ntation of neck and c h est

•

U na b l e to fol low a n d execute necessa ry postoperative s k i n care regi m e n

• •

P r i o r fac i a l s u rgica l proced u res performed P ro m i nent fac i a l pore pattern-laser treatment may exacerbate the i r a ppea ra nce

ABSOLUTE CONTRA I N D I CATI O N S •

Use of o ra l treti n o i n with i n 1 yea r o f su rgery

•

S k i n p h ototypes V a n d V I

•

Active cuta neous i n fection

•

P reexisti ng ectropion

•

Poor patient c o m p l ia nce

•

U n re a l istic patient expectations

R E LAT IVE CO NTRA I N D I CAT I O N S •

Exte nsive u nderlying dyspigmentation of face a n d su rrou n d i n g neck a n d c h est-risk o f d e m a rcatio n l i ne/ d ifference in s k i n color of treated vers us u ntreated s k i n

•

S k i n p h ototypes I l l a n d I V

•

U n d erlying connective tissue

•

U n d erlying koebnerizing cond ition

•

U n d erlying i m m u nologic d i sease

•

P revious lower lid a n d/or blepha roplasty (for i nfraorbita l resu rfa c i ng)

A

Figure 7.2 (A) A 45-year-old woman with facial photoaging and mild acne scarring.

46

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Color Atlas of Cosmetic Dermatology

Previous ablative resurfacing, derma brasion, cryosu rgery; face l i ft or phenol peel

•

H i story of fac i a l rad iation treatment

M E D I CAT I O N S •

Anti bacterial thera py: t o avoid i m petigi n i zation a n d bacterial i nfection o f t h e treatment sites, prop hylactic a nti biotics a re i n itiated 1 day p reo peratively. - Dic loxa c i l l i n 500 mg PO B I D or Keflex 500 mg PO B I D for 1 0 to 14 days is presc ri bed . - I n pen i c i l l i n-a l lergic i n d ivi d ua ls, Ci profloxa c i n 500 mg PO B I D PO

x

x

10 to 14 d ays or azith romyc i n 500 mg

1 day fo l l owed by 250 mg d a i ly for 5 days is

reco m m e n d ed . •

Antiviral thera py: laser resu rfa c i n g may trigger a herpes s i m p l ex outbrea k that can spread to the treatment sites with an i n c reased risk of sca r fo rmation . - Prop hylactic a ntiviral medications a re i n itiated 1 day p reoperatively. - Va lacyc lov i r 500 mg PO B I D for 14 days or acyc l ovi r 400 mg PO T I D for 14 d ays is reco m m ended .

•

Topical treti n o i n - Use o f treti n o i n prior t o C02 l a s e r res u rfa c i n g h a s b e e n shown c l i n ica l ly a n d v i a b i o c h e m i c a l a na lysis to not provide e n h a n ced collage n formati o n , acceler­ ated re-e pithe l i a l izati o n , or q u icker resol ution of post­ operative erythema. - Use of this med ication is o ptiona l . - Use o f this medication postoperatively s h o u l d be postponed u n t i l a l l associated e rythema and i nfla m ­ mation have resolved .

•

B l eac h i ng c rea ms: no p u b l ished , control led trials have

Figure 7 . 2 ( continued) (B) Improvement of photoaging 3 weeks after full­

demonstrated the ben efits of preo perative bleac h i ng

face erbium treatment

c rea ms to red uce the risk of postinfl a m matory hyper­ pigme ntati o n . To possi bly red uce this risk, patients with skin p h ototypes I l l and I V a re presc ri bed a blea c h i ng c rea m to be a ppl ied twice d a i ly for 6 to 7 weeks prior to treatment. As we l l , strict s u n avo i d a n ce is m a n d atory.

AN ESTH ES I A •

Cold-a i r cool i n g ( Z i m mer) may b e a d eq uate for loca l ­ ized or si ngle-pass C0 2 treatment or Er:YAG treatment.

•

Topical a n esthesia may be adeq uate for loca l ized or si ngle-pass C0 2 treatment o r Er:YAG treatment.

•

B

Regio n a l n e rve b l oc ks with su pple menta l i nfi ltrative a n esth esia a re ge nera l ly a d m i n istered for m u lti ple- pass C0 2 treatment.

Sect i o n 1 : Ph otoa g i n g

I

- Site-dependent b l ocks i n c l u d e s u p raorbita l , s u p ra­ troc h lea r, i nfraorbita l , and menta l blocks. - Lid oca i ne (1 % ) with 1 : 1 00,000 o r 1 :200, 000 epi­ n e p h r i n e , a tota l of 0 . 5 to 1 . 0 ml is a d m i n istered per site . - S u p plementa l i nfi ltrative a n esthesia consisting o f a n eq u a l m ixtu re o f 1 % l idoca i n e , 0 . 5 % b u pivaca i n e , a n d 1 : 1 0 sod i u m bica rbonate is ge nera l ly req u i red , espec ia l ly for the jawl i n e , u pper eyel ids, a nd te m ples. - Hya l u ro n i dase (Wyd ase) 7 5 U for tissue d iffusion may be a d d ed to the i nfi ltrative a nesthes i a . - Treatment is delayed 1 0 t o 1 5 m i n utes to a l low for c o m plete a n esthetic effect. •

Conscious i ntravenous sed ation a n d gen e ra l a n esthesia have been e m p l oyed by tra i ned physicians i n ce rtified fac i l ities i n patients u n a b l e to tolerate the i njections or for la rger proced u res.

SAFETY M EAS U R ES •

Eye protection - One o r two d ro ps of 0 . 05% to pica l pro pa raca i n e (Aica i n e ) or 0.05% topica l tetra ca i n e ( Pontoca i n e ) a re placed i nto e a c h eye o f the patient, fol l owed by the a ppl ication of to pica l e ryth romyc i n oi ntment o r o p htha l m i c l u bricant ( e g , Lacri-Lu be) a n d non reflec­ tive m eta l l ic ocu l a r shields (eg,

Byron

Medica l ,

Tucso n , AZ; Ocu lo-Piasti k , M o ntrea l , Canad a ) . - A l l perso n n e l m ust wea r clea r p lastic safety glasses to avo i d i nadve rtent cornea l d a mage . •

Operative field - All reflective su rfaces and windows m ust be covered to avoid inadve rtent treatment of a reflective s u rface. - The treatment room door m u st be la beled properly to wa rn others not to enter d u ri n g laser treatm ent. - A l l fla m ma ble materials and a nesthetic gases m ust be kept away fro m the operative field . - Wet d ra pes a n d sponges a re pla ced a ro u n d the s u r­ gica l s ite to preve nt accide nta l i rrad iation of s u r­ ro u n d i ng s k i n a n d to m i n i m ize potentia l fi re risk. - A nonfla m m a b l e oi ntment (eg, S u rgi l u be; KY J e l ly) m ust be placed ove r the exposed h a i r l i n e and eye­ brows to avoid h a i r si nge i n g . S u rgi l u be s h o u l d not be used over the eyelas hes to avoid the risk of cornea l keratitis. - All s u rgica l tools uti l ized m ust possess a non reflective or ro ughened black coati ng to preve nt laser bea m d eflection . - A laser smoke evac uator that fi lters pa rticles as s m a l l as 0. 1 2 m i n d ia meter a n d laser-gra d e s u rgica l masks m ust be used to red uce potenti a l s p read of i nfectious pa rtic l es in the laser p l u m e .

A

Figure 7.3 (A) A female patient who was most bothered by her perioral rhytides, but was also noted to have moderate dermatoheliosis with n umerous lentigines and actinic damage of the remainder of her face.

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Color Atlas of Cosmetic Dermatology

- Use of H i biclens, isopropyl a lc o h o l , a n d acetone is proh i bited due to their fla m ma bl e nature. All m a keu p a n d h a i rs pray a re to be removed , as they a re poten ­ tia l ly fla m m a b l e . - The l a s e r s h o u l d be ke pt i n the sta n d by m o d e at a l l ti mes other than a ctive treatment t o avo i d accid ental fi ri ng. - Oxygen s h o u l d be avoid e d , but if need ed, s h o u l d be c l osely mon itored a n d o n ly used in conj u nction with a c l osed gas system that i n c l udes either en dotracheal i n t u bation of l a ryngea l mask a i rway.

PROCEDU R E •

A thorough review of the risks a n d benefits i s perform ed .

•

Patient written consent is o bta i n ed .

•

R e p rese ntative preoperative pictu res a re o bta i ned .

•

P retreatment preparation is performed.

•

The choice of laser and laser pa ra meters va ries, d e pend i ng on the c l i n ica l situation . - The C0 2 laser is prefe ra ble for d ee per l i nes a n d sca rring p rocesses a n d for fa i r-sk i n ned patients ( Fig. 7 . 1 ) . - The Er:YAG laser is beneficia l for s u perfic i a l l i nes a n d dyspigme ntation a n d for da rker s k i n ned patients ( Fig. 7 . 2 ) . - T h e patient's postope rative considerations a lso affect the choice of laser. The C02 laser wi l l have a n expected longer recovery c o m pa red with t h e Er:YAG laser.

•

I n ge nera l , treatment of a cosmetic u n it or fu l l face is best to m i n i m ize the risk of text u ra l mismatch between nontreated a n d treated a reas. I n an isolated treatment, one m ust treat the entire lesion or line to their end rather than rema i n with i n a cosmetic u n it .

•

The ve rm i l ion border can be treated conservatively t o m i n i m ize l i pstic k " bleed i n g . "

•

Treatment s h o u l d extend beyond the a nato m i c a l u n it being treated with a feathering tec h n i q u e (decreased fluence) e m p l oyed to blend i nto the untreated ski n .

•

For d e p ressed scars, a d d iti o n a l passes with a s m a l l e r s pot s i z e o n t h e d efect edge a l l ow for more sign ifica nt flatte n i ng of the sca r.

•

Sca r contraction wi l l occ u r with hea l i ng. To avo i d atro p h i c sca r formati o n , a d m i n iste r treatment to the l evel of nea r normal adjacent s k i n on ly.

•

Ab lative resu rfa c i n g of dyna m i c rhytides provides o n l y tem pora ry benefit. Consideration o f c o m b i nation ther­ a py with botu l i n u m toxi n or a fi l l e r su bsta nce s h o u l d be enterta i ned to a c h i eve maxi m u m benefit.

B

Figure 7 . 3 ( continuec!J (8) Same patient immediately after perioral

carbon dioxide laser resurfacing and a Jessner/35% trichloroacetic acid peel to the remainder of her face.

Sect i o n 1 : Ph otoa g i n g

•

I

M i n i m a l mechanical tra u ma tec h n i q u e : fewer C0 2 passes performed with reta i n ment of the last pass esc h a r to exped ite hea l i ng a n d m i n i m ize sca r risk a n d pigme nta ry cha nges. T h i s tec h n i q u e is o pti m a l for you nger patients with more s u perfic i a l lesions a n d fo r d a rker s k i n types.

•

With any treatment m od a l ity, the presence of l a rger col­ lagen b u n d les hera l d entry i nto the deep retic u l a r d e r­ m is a n d wa rn of the poss i b i l ity of scar formation . Treatment s h o u l d be d i sconti n ued i m med iately.

•

Res u rfa c i n g of nonfa c i a l rhyti d es is associated with a h igh risk for textura l a n d pigmenta ry cha nges d u e to the red uction in a d nexa l stru ctu res a n d poor vasc u l a rity in compa rison to the face. The C0 2 laser s h o u l d n ot be util ized for the treatment of nonfa c i a l rhyti d e s . The Er:YAG laser should be util ized with extre me caution .

•

Combi nation thera pies of ca rbon d i oxide res u rfa c i n g a n d c h e m i c a l pee ls, botu l i n u m tox i n , or soft tissue a ug­ mentation may p rovide the greatest benefit ( F ig. 7 . 3 ) .

POSTOPERAT I V E CAR E •

An open wou n d tech n i q u e or c l osed tec h n i q u e may be fo l l owed .

•

Posto perative d iscomfort is cha racterized by moderate b u r n i ng with i n the fi rst 24 h o u rs . T h i s is m i n i m ized with the use of an occ l usive d ressi ng. I t can genera l ly be controlled with ice pac ks , cold c o m p resses, a n d a ceta­ m i no p h e n , as we l l as freq uent wo u n d ca re.

•

Posto perative edema d evelops 24 to 48 h o u rs postop­ eratively and c a n be contro l l ed with ice packs and head e l evati o n . O ra l steroids a re e m ployed when ma rked swe l l i ng d eve lops i ntraoperatively or i m med iately post­ operative ly.

•

Re-epith e l i a l izati on occ u rs with i n 3 to 10 days a nd is d e pendent on the laser util ized , the n u m ber of laser passes exec uted , and the s u rgica l ca n d i d ate. You nger patients, patients who u nd e rgo Er:YAG treatment, a n d fewer passes show faste r h ea l i ng. Delayed h ea l i ng is observed i n older patie nts, sm okers, and i nc reased laser passes.

•

Topica l a nt i b i otics and Aq u a p h o r H ea l i ng O i ntment should be avoided d ue to the risk of a l lergic co ntact d e rmatitis.

•

C l ose fol l ow- u p is m a n d a tory to ensure p ro per care a n d

•

Prophylactic a ntibiotics a n d a ntivira l med ications a re

hea l i ng o f t h e treated sites ( Figs. 7 . 4 a n d 7 . 5 ) . conti n ued for 10 to 14 days posto pe rative ly to avoid infecti o n . •

Strict s u n avo i d a n ce is m a i nta i ned fo r 1 yea r postopera­ tively to avoid photose nsitivity and to m i n i m ize the risk of posti nfla m matory hyperpigmentation.

c

Figure 7.3 ( continued) (C) Same patient 6 months following her treat­

ment. A marked reduction in both her rhytides and dyspigmentation is appreciated.

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Color Atlas of Cosmetic Dermatology

P EARLS FOR T R EATM ENT S U CCESS •

P reoperative wou nd c a re i n structions a r e critica l for treatment su ccess. The patient a n d sign ificant others m ust be pre pa red fo r the exten sive ca re that w i l l be req u i red fo r exped ient a n d

safe

hea l i ng.

Patients

s h o u l d be shown postoperative pictures to prepare them for how they wi l l a p pea r. Posto perative s u p p l i es, i n c l u d i n g wo u n d ca re s u p p l ies and d esi red ca m ouflage fou ndation, s h o u l d be o bta i ned prior to the treatment date. Patie nts with you nger c h i l d re n m ust prepare them for the sign ificant c h a nges that wi l l be noted d u r­ i ng the hea l i ng period . Any posto perative assista nce the patient may req u i re should be a rra nged prior to treat­ ment if possi b l e . •

Patients req u i re freq uent postoperative eva l uation for the fi rst 14 d ays to e n s u re proper wo u n d ca re is being e m ployed , pred icted hea l i ng is noted , and no side effects s u c h as sca r formation or i nfection occ u r. Patients s h o u l d be eva l u ated on posto perative day 2 , posto perative d a y 5 t o 7 , a n d postoperative day 1 0 to 1 4 a n d a nyti m e the patient exp resses a concern of need for eva I uation .

•

Patie nts' expectations m ust be ta i l o red to the expected be nefits . Patients s h o u l d be i nfo rmed that the greatest benefits w i l l not be a p p reciated for 6 to 12 months posto peratively.

•

Strict ph otoprotection a n d s u n protection a re c ritical i n red u c i n g t h e occ u rrence o f posti nfla m m atory hyperpig­ m entation and s u n b u r n and should be fo l l owed for a m i n i m u m of 1 yea r after treatment.

•

Treated skin is sensitive to a majority of fac i a l prod u cts, perfu mes, a n d to pica l medications for an average of 1 2 weeks posttreatment. B l a n d p rod u cts, i n c l u d i ng a s u n block, a re recom mended d u ri n g this hea l i ng t i m e .

•

Persistent a reas o f erythema s h o u l d ra ise concern rega rd i ng sca r formation or i nfection . A c u lture is rec­ o m m ended to rule out bacterial or yeast i nfectio n . Use of a pote nt topical corticosteroid a n d/o r pu lsed dye laser is crucial with close fol low- u p to ensure resol ution .

B I B L I OG RAPHY Alster

TS. C uta neous resu rfa c i n g with C0 2 a n d erbi u m : VAG lasers : P reoperative, i ntraoperative a n d post­

operative

consid erations.

Plast

Reconstr

Surg.

1 999; 1 03 : 6 1 9-634. Anderson R R , Parrish JA. Selective photothermolysis: P recise m i c rosu rgery by selective a bsorption of p u l sed rad iatio n . Science. 1 983 ;220: 524-527 . Carruthers J , Carruthers A , Zelichowska A. T h e power of c o m b i ned thera pies: Botox a n d a blative laser res u rfac­ ing. Am J Cosmet Surg. 2000; 1 7 : 129- 1 3 1 .

Figure 7.4 Under aggressive wound care. A substantial amount o f crust­

ing is observed. Proper wound care was demonstrated in-office and with repeat written instructions reviewed

Sect i o n 1 : Ph otoa g i n g

I

David I, R u i z- Es pa rza J . Fast hea l i n g after laser s k i n resu rfa c i ng . The m i n i ma l mecha n ical tra u ma tec h n i q u e .

Dermatol Surg. 1997;23:359-36 1 . Dover J S , H ruza GJ , Arndt KA . Lasers i n s k i n resu rfa c i n g .

Semin Cutan Med Surg. 1 996; 1 5: 1 7 7 - 1 88 . D u ke D, G reve l i n k J M . Ca re before a n d a ft e r l a s e r s k i n resu rfa c i ng .

A s u rvey a n d

review o f the

l iterature.

Dermatol Surg. 1 998;24:201 -206. Fitz patrick RS, G o l d m a n M P, Sat u r N M , Tope WD. P u lsed ca rbon d i oxide laser resu rfa c i ng of p h otoaged fac i a l s ki n .

Arch Dermatol. 1996 ; 1 32 : 395-402. Fitzpatrick R E, To pe W D , Gold m a n M P, et al. P u lsed ca rbon d ioxid e laser, tric h l o roacetic a c i d , Backer-Gordon phenol and derma b rasi o n : A com pa rative c l i n ical a n d h istologic study o f cutaneous res u rfa c i n g i n a porc i n e model . Arch Dermatol. 1 996; 132:469-47 1 . N a n n i CA, Alster TS. Com pl ications of ca rbon d ioxi d e l a s e r res u rfa c i n g : An eva l uation o f 5 0 0 patients. Dermatol

Surg. 1 998;24: 3 1 5-320. Orringer JS, Ka ng S, J o h nson TM, et al. Treti n o i n treat­ ment before carbon-dioxide laser res u rfacing: A c l i n ica l and

biochemical

a n a lysis.

J

Am

Acad

Dermatol.

Decem ber 2004; 5 1 ( 6 ) : 940-946. R a u l i n C , G rema H. S i ngle-pass carbon d ioxid e laser s k i n resurfa c i ng com bined w i t h cold-a i r cool i ng: Efficacy a n d patient satisfaction o f a pros pective side-by-side study.

Arch Dermatol. 2004; 140( 1 1 ) : 1 333- 1336. R u iz-Esparza J, Ba rba G o m ez J M , Gomez de Ia To rre OL. Wou n d ca re after laser skin res u rfa c i ng. A combi nation of open a n d c l osed methods using a new polyethylene mask. Dermatol Surg. 1 998;24: 79-8 1 .

Figure 7 . 5 Postinf/ammatory hyperpigmentation 6 weeks after perioral carbon dioxide resurfacing. This pigmentation resolved with the use of 4 % hydroquinone twice daily for 2 months

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Color Atlas of Cosmetic Dermatology

CHAPT E R 8

N o n a b l at i ve F ract i o nal Lase r R esurfaci ng

M ECHAN I S M OF ACT I O N

Fract i o n a l p h otothermolysis

Nona blative fractio n a l res u rfa c i ng ( N A F R ) is a n ovel con­ cept of skin rej uvenation that ca n ta rget both e p i d ermal

Laser

---

I I I I I I

a n d d e r m a l cond iti ons. NAFR p rod uces a u n iq ue thermal

I I I

d a mage patte rn consisti ng of m u ltiple col u m n s of th er­

I I I

I I I I I I

m a l coagu lative da mage, refe rred to as m i c rothermal treatment zones ( M TZs) ( Fig. 8. 1 ) . N A F R c h a racteristi­

I I I I l l

Epidermis

c a l l y spares the tissue su rrou n d i n g each MTZ, thus a l l ow­

I I I

'fiN

i n g fast epidermal repa i r d u e to m ic rosco pic size of the wou nd s a n d short m igratory d ista nce fo r the via b l e ker­ atinocytes p resent at the MTZ epidermal m a rgins. On ly a fractio n of the s k i n of the s u rface a rea is treated .

D E R M ATOPAT H O LOGY M TZ revea ls homogen ized col u m ns of dermal matrix a n d t h e formation o f m i c roscopic e p i d e r m a l nec rotic d e bris ( M EN D ) ( Fig. 8 . 2 ) . M E N D formation is thought to re p re­ sent the p rocess of e l i m i nation of the therma l ly d a m aged

S u bc uta neous fat

--

Figure 8 . 1 Schematic of microscopic treatment zones (MTZJ created by

fractional resurfacing laser (note the characteristic sparing of the sur­ rounding tissue between the treatment zones)

epidermis conta i n i ng pigment by the ra p i d l y m igrati ng via ble kerat i n ocytes at the MTZ ma rgi ns. M E N D may a lso conta i n d e r m a l structu res s u ch as the elastic fi bers . Vesse ls i n t h e M T Z regions can be therm a l ly d estroyed i n a nonselective m a n ner. H igher energies res u l t i n deeper and wider MTZs. H igher energies resu l t i n deeper a n d wider M TZs. N A F R can b e hel pfu l i n t h e treatment o f epi­ d e r m a l pigmentation suc h as melasma a n d lentigi nes d ue to the process of M EN D formatio n . N A F R can a lso be h e l pfu l in i m p rovi ng rhytides and sca rring due to the p rocess of col lagen remod el i ng and n ew col lagen forma­ tion, i nd uced by the dermal thermal da mage.

I N D I CAT I O N S N A F R c a n b e a n effective treatment o f fine-to- moderate rhytides; acne scars, s u rgica l , tra u matic, a n d burn sca rs; melasm a ; dysc h ro m i a ; and d e rmatohel iosis ( Fig. 8 . 3) .

P R EOPERATIVE EVALUAT I O N •

Sign ificant past medical history i n c l udes h i story o f h e r­ pes l a b i a l is, keloid or hypertro p h i c scar formatio n , ora l treti n o i n i ntake (d ate last cou rse com pleted ) , to pical retinoid use, tobacco use, a n d k n own d rug a l lergies i n c l u d i n g l i doca ine a l lergy.

•

Sign ificant past s u rgica l h i story i n c l udes prior s u rgical treatments to the treatment sites, the dates of the p ro­ ced u res, the pati ent's res ponse, and the associated side effects.

Figure 8.2 H & E histology of microthermal treatment zone (MTZ) 1 day after fractional resurfacing treatment (note the microscopic epidermal necrotic debris (MEND) overlying a column of homogenized dermis)

Sect i o n 1 : Ph otoa g i n g

•

I

53

The patient s h o u l d be awa re of the fol lowi ng: - Proced u ra l d iscomfort. - S u n burn-l i ke sensation for severa l h o u rs after the proced u re. - S u n b urn- l i ke postoperative erythema that may per­ sist for 3 to 7 days ( Fig. 8.4 l . - Posto perative edema, ge nera l ly m i l d , that usually resolves with i n 2 to 3 days. - Posto perative bronzing that is ge nera l ly noted o n the t h i rd posto perative day and often persists for 3 to 4 days . - Posto perative su perfi c i a l pee l i ng t h a t is often m i l d a n d is noted t o sta rt o n the th i rd postoperative day a n d to persist for 3 to 4 days . - Rea l istic expectations f o r the proced ure: the patient s h o u l d be awa re that the treatment wi l l i m prove fine­ to-moderate wri n kles, pigmentati o n , a n d s u perficial sca rs

but d oes

not e l i m i nate

moderate-to-deep

rhytides. A modest benefit may be noted for d eeper

A

B

Figure 8.3 Periorbital rhytides (A) following one fractional resurfacing

treatment and (B) following four fractional resurfacing treatments. An appreciable softening is noted (Courtesy of R. Fitzpatrick, MDJ

wri n k l es. - Proced u ra l risks: a lthough these adverse eve nts a re u ncommon a n d a re m u c h less freq uent than those assoc iated with a blative resu rfa c i ng, they sti l l exist. They i n c l u d e te m pora ry posti nfla m mato ry hyperpig­ mentation

( Fig.

8.5),

b l i ste ri ng,

c rusti ng,

m i l ia

( Fig. 8 . 6 ) , acn eiform e r u ption , p i n po i nt hemorrhage ( Fig. 8 . 7 ) , herpes s i m plex reactivati o n , a n d ra rely hypertro p h i c sca rri ng. This is in a d d ition to the p re­ d icta b l e side effects that i nc l u d e proced u ra l d iscom­ fo rt, posto perative e rythema, bronzing, and edema . There is usua l l y no assoc iated oozing or c rusti ng u n l ess very h igh energies a n d/or h igh densities a re util ized . •

The i d ea l ca n d i d ate is a fa i r-s k i n patient ( Fitzpatrick p hototypes 1-1 1 1 ) . H owever, NAFR can be safe and effective i n d a rker s k i n types ( F itz patrick p h ototypes I V a n d V ) . I t is a lso safe t o u s e o n nonfa c i a l a reas i n c l u d ­ i n g the n e c k , tru n k , a n d extrem ities, provided that decreased fluences and d e nsities a re uti l i zed .

CO NTRAI N D I CAT I O N S •

Ora l treti n o i n use with i n 6 months t o 1 yea r o f su rgery

•

Active c uta neous i nfection

•

U n real istic patient expectations

•

P regnant or lactating wom a n

M ED I CAT I O N S •

Anti bacterial therapy: prophylactic a nti biotics a re gen ­ era l l y n o t req u i red

Figure 8.4 Mild sunburn-like erythema immediately following Fraxel laser

treatment with 6 to 8 mJ, 250 M TZ!cm2 , eight passes. This erythema may persist for 3 to 7 days

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Color Atlas of Cosmetic Dermatology

Antiviral thera py - Fracti o n a l resu rfac i ng may trigger reactivation of her­ pes s i m plex that ca n s p read to the treatment sites . - Prophylactic

a ntivi ra l

m ed i cations

a re

i n itiated

1 d a y prior to the proced u re . Va la cyc lovir 500 mg PO B I D o r acyc l ovi r 400 mg PO T I D fo r 7 d a ys is u s u a l l y recom m e n d ed . An a l ternative is va l acyc l ov i r 2 PO B I D f o r 1 d a y t o be sta rted t h e m o rn i ng o f t h e proced u re . •

Treti noi n : i t is advised t o d isconti n u e treti n o i n c rea m at severa l days before N A F R to preve nt s k i n i rritation at the treatment sites.

AN ESTH ES I A •

Cold-a i r cool i ng (Zi m mer) i s very effective i n decreasi n g the proced u ra l d iscomfort.

•

Topical a n esthesia (oil or crea m base) a ppl ied at least

Figure 8 . 5 Postinflammatory hyperpigmentation following fractional resurfacing treatment to the upper lip

1 hour before the proced u re is genera l ly adeq uate, espe­ cially in combi nation with cold-a i r cool ing ( Z i m mer) . •

Regio n a l n e rve blocks ca n be effective to red uce the d iscomfort for patients with low pa i n t h resholds, espe­ c i a l l y when uti l i z i n g higher fl u ences a n d d e nsities . I nfraorbita l a n d menta l b l oc ks can be h e l pful when treati ng periora l wrin kles, but a re usually not necessa ry.

P R EOPERATIVE P R E PARAT I O N •

Ex p l a i n t h e risks a n d benefits o f the proced u re .

•

O bta i n t h e patient's writte n consent.

•

Wash the a rea to be treated with soa p and water.

•

O bta i n preo perative pictu res .

•

A p p l y a t h i c k layer of topical a n esthetic i n an o i l or c rea m base to the treatment site .

•

Wa it at l east 6 0 m i n utes t o a c h i eve o pti m a l a nesthetic effect.

•

Wi pe off the to pical a n esthetic with a d a m p c l oth .

PROCEDU RAL T I PS •

The laser pa ra meters a re c h osen accord i n g to the c l i n i ­ cal ta rget. - For e p i derma l cond itions s u ch as p h otod a mage, lentigi nes, melasma, and dysc h ro m i a : lowe r f lu ences and h igher densities a re u s u a l l y uti l ized . - For deeper processes such a s rhytid es or a cn e sca r­ ring: h igher fl uences a re uti l ized .

•

Lower percent coverage of s k i n su rface a rea ; that is, lower d e nsities a re i n d icated i n d a rker s k i n types to avoid postinfl a m matory hyperpigme ntation .

Figure 8.6 Milia on the chin 1 day after NAFR

Sect i o n 1 : Ph otoa g i n g

•

I

55

Caution s h o u l d be exerted when treating s m a l l e r a reas s u c h as u p per l i p , nose, and tem ple in ord e r to avoid b u l k heating that can res u l t in bl istering and sca rri ng. - Al l ow adequate time between passes for the heat to d issi pate and the s k i n to cool d own before the next pass . - When treati ng the u pper l i p, a l ternate the treatment between the right side and the left side, and sta rt each pass from the sa m e point.

•

Th ree to six treatment sessions ( d e pe n d i ng o n the i n d i­ cation for treatment) a re a d m i n istered 3 to 4 weeks a pa rt . Longer period between treatments is a dvised i n d a rker-s k i n patients t o avo i d o r decrease t h e i nc i dence of posti nfla m m atory hyperpigmentation ( P I H ) .

POSTOPERAT I V E CAR E •

Posto perative d i scomfo rt is genera l ly m i l d a n d tra n ­ sient. The patient wi l l experience a s u n b u rn sensatio n for seve ra l h o u rs .

•

Patie nts may a p p ly m a ke u p i m med iately after the treat­ ment.

•

Patie nts a re encou raged to use m i ld moisturize rs fo r severa l days after the p roced u re .

•

Posto perative e d e m a is u s u a l l y m i n i ma l but can be controlled with ice packs a n d head elevatio n . I n ra re i n sta nces of ma rked swe l l i ng, o ra l p red n isone ca n be p resc ri bed for 3 to 7 days.

•

Sun avo i d a nce is m a i nta i ned for at least 4 to 6 weeks after the proced u re to m i n i m ize the risk of posti nfla m­ matory hyperpigmentation . S u n sc reens with a m i n i ­ m u m S P F of 30 a re reco m mended .

•

Typical ly, patie nts can retu rn to work on the fi rst post­ operative day.

PEA R LS FOR TREAT M ENT S UCCESS •

Patient selectio n is the key. Treating rhyti d es o r sca rs that a re too deep w i l l p rove d isa ppointing to the patient a n d physic ia n . The patient m u st be awa re of the need for m u ltiple treatments to o bta i n the d esi red c l i n ical benefit.

•

NAFR ca n res u lt i n serious side effects such as sca r­ ri ng when used at very h igh fl uenc ies by i n experien ced physicia ns o r health ca re workers. Caution s h o u l d be ta ken to stay with i n the recom m e nded pa ra meters a n d a p ply a p propriate

ove r l a p p i n g tec h n i q u e t o avoid

potentia l com p l i cations. •

Patients m ust be awa re that benefits may be s h o rt last­ i n g a n d may req u i re m a i nte na nce treatments for con­ t i n ued c l i n i c a l benefit.

Figure 8.7 A patient with rosacea who developed pinpoint hemorrhage

1 day after Fraxel Restore treatment. Pinpoint hemorrhage can occur with higher energies and usually resolves in few days with no sequelae

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Effective N A F R treatment i n patients with ski n ph oto­ types I l l to V c a n be a c h ieved . An i n c reased i n c i d e n ce of posti nfla m matory hyperpigmentation

is genera l ly

noted . Patients m u st be aware of the poss i b i l ity of P I H with each treatment. Decreasing t h e density o f treat­ ment red uces the risk of PI H .

DEV I CES The m ost c o m m o n l y used N A F R d evices t h a t a re ava i l ­ a b le i n t h e ma rket a re Fraxel R estore (Solta Medica l , I n c . , Haywa rd , C A ) , L u x 1 , 540 n m laser ( Pa l o m a r Medical Tech n ologies, B u rl i ngto n , M A ) , a n d Affi rm 1 ,440 nm N d : YAG laser ( Cynos u re, Westford , MAl (Ta ble 8. 1 ) . Fraxel R estore util izes the sca n n i ng tec h n o l ogy whereas Lux 1 , 540 nm and Affi rm 1 ,440 nm lasers uti l ize the sta m p i n g tec h nology and d o not usually req u i re to pical a n esthesia or d isposa ble tips.

TAB L E 8. 1

•

Nonab lative Fractiona l Lasers

Com pany

Laser d evice

Laser

M od e

wavelength ( n m )

Sa lta Medical

F raxel R estore

1 , 550

Sca n n i ng

Cynosure

Lux 1 , 540 Affi rm 1 ,440 N d : YAG

1 , 540 1 , 440

B I B L I OG RAPHY La u bach HJ , Ta n nous Z , Anderson R R , M a nste i n D . S k i n res ponses t o fra ctional photothermolysis. Lasers Surg

Med. 2006;38(2 ) : 142- 149 . M a nste i n D , H e rro n G S , S i n k R K , Ta n n e r H , And erson R R . F ractiona l ph otothermolysis: A new concept fo r c uta ­ neous remod e l i ng u s i n g m i c rosco pic patterns of thermal i nj u ry. Lasers Surg Med. 2004;34( 5) :426-438. N a r u rka r VA . N o n a b lative fracti o n a l laser resu rfa c i ng.

Dermatol Clin. 2009 ;27(4) :473-478, vi. Ta n n o u s Z . Fractio n a l res u rfa c i ng. Clin Dermatol. 2007; 2 5 ( 5 ) : 480-486 .

M a x energy/MTZ

d i a meter ( m m )

or m ic ro bea m ( mJ )

d e l ivered ( c m 2 )

7

70

1 2-4,000 ( 5-48% )

Density

15

( Fraxel SR 1 , 500)

Pa l o m a r

Ti p

Sta m ping Sta m ping

10

1 00

1 00

15

15

320

10

8 J/cm 2/pu lse

1 , 000

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 9

A b l ative Fract i o nal Lase r R esu rfaci ng

I N TRODUCT I O N Treatme nts for photoaging ra nge fro m nona blative laser resu rfa c i ng to a blative laser res u rfa c i n g . Both of these tec h n i q ues a re d escri bed in d eta i l in previous cha pters. Put s i m ply, the m ost effective lasers, carbon d ioxi d e a n d e r b i u m a blative res u rfa c i ng lasers , provid e the m ost d ra matic benefit for photoaging a n d other s k i n co n d i ­ t i o n s , but a lso ca rry t h e h ighest r i s k f o r adverse effects. They rema i n the gol d sta n d a rd treatment for photod a m ­ aged ski n . Dramatic res u l ts, however, ca n be seen with one treatment. Side effects i n c l u d e prolonged erythema (fo r months ) , perma nent hypopigmentat i o n , te m pora ry hyperpigmentat i o n ,

i nfect i o n ,

and

sca r.

Ad d itional ly,

d ownt i m e from work a n d soc i a l a ctivities is sign ifica nt. For this reaso n , the po p u l a rity of a blative lasers has decreased d ra matica l ly over the past seve ra l yea rs a mong patients a n d physicians. By contrast, nona blative lasers, with m u ltiple treatment sessions,

p rovide a safe method for provid i ng m i ld

i m prove ment of m i l d -to- moderate p h otoda mage with l it­ tle risk of si d e effects. U nfortu nate ly, the p red icta b i l ity of i m prove ment is u ncerta i n . Some patients do n ot experi­ ence a n y d iscern i b l e benefit even after m u ltiple treat­ ments. In the past 5 years, nona blative fractional lasers have prod uced e n h a nced results from other forms of n o n a b l ative res u rfaci ng with m u lt i p l e treatm e nts . These lasers have a lso p roven to be safe in s k i l led h a n d s . Sti l l , thei r efficacy is l i m ited , espec ia l ly w h e n c o m p a red to a b lative laser resu rfaci ng. M ore rece ntly, fractional a blative lasers, both carbon d ioxid e and erb i u m va riants, have been d evelo ped to pro­ vide e n h a nced res u l ts with relatively good safety. The concept is to provi d e the more aggressive tec h nology of a b lati o n , but to confi ne potential d ownt i m e a n d s i de effects b y e m p l oying a fra ctional pattern of tissue d a m ­ age, w h i c h encou rages more ra pid h ea l i ng t i m e s with fewer side effects. O n ly a fraction of the skin is a blated at each treatment, as o p posed to trad iti o n a l a b lative res u r­ fac i ng proced u res . F u rther, the d e pth of a blation is d ee pe r tha n with tra d iti o n a l a blative resu rfa c i n g proce­ d u res. Adva ntages of fractional a blative lasers a re as fo l l ows : •

Better i m provement of deeper rhyti des t h a n nona bla­ tive d evices

•

Sign ificant benefit with one treatment

•

Ca n provid e some i m p rovement for s k i n laxity, pig­

•

Sign ificant red uction i n posto perative d ownti m e com­

mented lesions, a n d vasc u l a r dysc h ro m i a as we l l pa red to tra d itio n a l a b lative devices

Figure 9 . 1 Immediate endpoint of pixilated damage pattern with an erbium fractional ablative device

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58

•

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Color Atlas of Cosmetic Dermatology

Ca n treat cosmetic u n its effective ly without l i nes of d e m a rcation often seen with trad itional a blative proce­ d u res, that is, perioral/periorbita l a reas

I N D I CAT I O N S •

R hytides, espec i a l ly moderate-to-severe periora l a n d periorbita l rhytid es

•

P h otoda m age, i nc l u d i ng s k i n text u re a n d tone

•

Acne sca rs, i n c l u d i ng boxca r, atro p h i c , ro l l i n g sca rs

•

S u rgical a n d b u r n sca rs

•

M i l d i m provement in s k i n laxity

•

N ot effective for dyna m i c rhytid es

P R EOPERATI V E EVALUAT I O N •

S k i n type ( I-I I I a re best ca n d i d ates )

•

S u n exposu re

•

H istory of ke loids

•

System ic i nfections

•

Prior plastic s u rgery, espec i a l ly neck l ifting p roced u res a n d face lifts

•

l sotret i n o i n use i n past 6 months

•

Patients with u n rea l istic expectations A consu ltati on is req u i red before this treatment to

assess the patient as wel l as a p p ro p riately prepa re the patient for the proced u re . The patient s h o u l d be fu l ly educated as to the risks a n d benefits of this proced u re. The patient m u st be awa re of the recove ry period of 4 to 7 days (on average ) . The patient should be shown post­ operative pictu res to prepa re them fo r h ow they w i l l a p pea r. Any posto perative assista nce the patient m a y req u i re s h o u l d be a rra nged prior t o treatment if poss i b l e . The patient s h o u l d a lso be i nformed t h a t the ben efits of the treatment accrue 3 to 6 months after treatment. A patient who is u n a ble to fol l ow a n d execute necessa ry postoperative s k i n ca re regi men s h o u l d n ot be treated .

PROPHYLAX I SIAN ESTH ES lA May include any of the fol lowi ng: •

Antiviral and a nti biotic prophylaxis

•

Topical a n esthetic - 23% Lidoca i n e/7 % tetra ca i ne

•

Oral pa i n med ication a n d a nxiolytic - Vicod i n/a ceta m i n o p hen/ativa n/not h i n g

•

N e rve blocks/1 M Torad o l

•

Genera l a n esth esia

Figure 9.2 Patient immediately after C0 ablative fractional resurfacing

2 treatment. Note erythema, edema, and pinpoint hemorrhage

Sect i o n 1 : Ph otoa g i n g

Beca use this proced u re is pa i nfu l , some form of a n esthesia is req u i red .

It wi l l va ry accord i ng to the

aggressiven ess of treatment, the pa rt i c u l a r suscepti b i l i ­ ties o f t h e patient, a n d the p hysi c ia n 's co mfort with va rious a n esthetic reg i me n s . R egio n a l nerve blocks with s u p plementa l i nfi ltrative a n esthesia a re ge n e ra l l y h e l pfu l . S ite-d ependent b l ocks i nc l u d e su praorbita l , i nfraorb ita l , a n d menta l b l ocks. Lid oca i ne ( 1 % ) with 1 : 1 00, 000 o r 1 : 200,000 e p i n e p h r i n e , at a tota l o f 0 . 5 to 1 .0 m l c a n b e i njected at eac h site .

LAS E R SAF ETY •

Eye protect i o n : m eta l eye s h ields - One o r two d ro ps of 0 . 05% to pica l p ropa raca i ne (Aica i n e ) or 0.05% topica l tetra ca i n e ( Po ntoca i n e ) a re placed i nto e a c h eye o f the patient, fol l owed by the a p pl ication of to pical e ryth romyc i n oi ntment o r ophth a l m i c l u bricant ( e g , Lacri-Lu be) a n d non reflec­ tive meta l oc u l a r s h ields. - A l l perso n n e l present at the treatment m ust wea r safety glasses/goggles to avo i d i nadverte nt cornea l d a mage . Due to the pa i n , bleed i ng, a n d pa i n med ications assoc i­

ated with this treatment, it is i m perative that the patient be acco m pa n ied by a friend , spouse or relative who can d rive or accompany the patient home after the proced u re .

• Posto p e rat i ve C a re ( F i g .

9. 1)

•

I nterestingly, l ittle postp roced u re pa i n ( Fig. 9 . 2 )

•

Best expla nati o n : heat release th rough a blated c h a n n e l s

•

I m perative t o give ora l a n d written wou n d care i nstruc­ tions to patient

• •

Ga uze soa ks and e m o l l ie nts i m med iately posto perative Room tem peratu re sterile water soa ks for 20 m i n utes, every 3 to 4 h o u rs fol l owed by Aq u a p horNase l i n e a pp l i ­ cation for 2 to 3 days

• Fo l l ow- u p at

( Fig.

9.3)

48

to

72

h o u rs

•

Re-epith e l i a l izati on i s usually com plete .

•

Eryt h e m a , edema, a n d resi d u a l p i n po i n t h e morrhagic crusting a re expected .

•

M i l i a a re com m o n a n d often clear with i n a few days .

•

Assess fo r vesicles, b u l la e , p ustu les.

•

E m o l l i ents twice d a i ly for 3 to 7 days.

•

I nstructions to ca l l if a n y concerns or cha nges i n wou n d hea l i ng . Postoperative e rythema

resolves over a

period of

wee ks. Strict s u n avo i d a n ce m u st be fol l owed fo r a

Figure 9.3 Patient at 72-hour follow-up. Note that hemorrhage is no

longer present, but edema and erythema persist

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Color Atlas of Cosmetic Dermatology

m i n i m u m of 3 mo nths postoperatively to avoid pigmen­ ta ry c h a nges and p h otosensitivity.

• Adve rse S i d e Effects •

Delayed onset hypopigmentation

•

Sca rring

•

Posti nfla m m atory hyperpigme ntation

•

Persistent erythema

•

I nfection The side effects for fractional a blative resu rfa c i ng a re

the same as those for trad itiona l a blative res u rfaci ng proced u res, a l beit fa r less freq uent or severe i n s k i l l ed hands.

As

with

nonablative

fractional

resu rfaci ng,

post-i nfla m matory hyperpigmentation ( P I H ) is more l i kely to occ u r with h igher treatment densities, pa rtic u l a rly in da rker ski n phototypes ( Fig. 9.4). Hypertrophic sca rring of the neck is a sign ifica nt a nd potentially permanent com­ p l ication of fractionated C0 2 laser res u rfacing ( Fig. 9 . 5 ) . Caution is req u i red for these proced u res . The fol l owing p ractices a l l sign ificantly i nc rease the

Figure 9.4 Test spot treatments with a C0 ablative fractional resurfacing

2 device in a young male with Fitzpatrick skin type 5. The test spots are not arranged in order of aggressiveness. The darker areas of PIH coincide with increased treatment density. Increasing pulse energies do little to worsen PIH

risk of sca r: •

Aggressive treatments i n c rease risk of sca r

•

Poor tec h n iq u e , that is, excessive overl a p

•

Postoperative wo u n d i nfection

•

H i story of face lift o r neck l ifti n g proced u res

•

Treatment of nonfa c i a l ski n , espec i a l l y the neck

• I n fect i o n ( F i g .

9.6)

The key to treating i nfection i s to recogn ize i t at its i n cep­ tion . I nfections a re d iagnosed c l i n i c a l ly. C u ltures can confi rm a d iagnosis. E m p i ric a nti biotics a n d c l ose c l i n ical fo l l ow- u p a re the keys to treatment. Persistent a reas of e rythema s h o u l d raise concern rega rd i ng sca r formation o r i nfection . A c u lture is rec o m m e n d ed to r u l e out bacte­ rial o r yeast i nfection . Do not perform these proced u res if you can n ot recogn ize a n d treat bacteria l , v i ra l , fu nga l i nfections.

• N o n fa c i a l S k i n Nonfa c i a l s k i n i s more v u l nera b l e to thermal energy d u e t o u n derprivileged wo u n d h ea l i ng c a pa b i l ities. Th ere a re fewer p i l osebaceous u n its on the neck a n d more l i m ited c uta neous vasc u latu re to s u p port wou nd h ea l i ng. T h i s is espec ia l ly true where there is a h i story of prior plastic su rgery. Face/neck l ifti ng proced u res place neck s k i n onto the face; t h u s , y o u may be treating " neck" s k i n o n the fa ce. If there is a h i story o f p r i o r plastic s u rgery, it i s best to treat at lowe r setti ngs . Beca use of the risks of serious side effects, it is strongly a dvised

that fractional

a blative

res u rfa c i ng

Figure 9 . 5 Hypertrophic scar after treatment with a C0 fractional abla­ 2 tive device

Sect i o n 1 : Ph otoa g i n g

I

61

s h o u l d only be performed by a n a p p ro p riately tra i ned phys i c i a n experien ced i n postoperative wou n d ca re fol­ lowi ng resu rfa c i n g p roced u res. In s u m , a b lative fractio n a l res u rfa c i n g p roced u res offer the adva ntage of good res u lts with one treatment as wel l as offering sign ifica nt i m p rovement where nonablative fra ctional a n d n onfractional d evices do not, such as mod­ e rate a n d severe rhytides. At the sa me time, it offers the flex i b i l ity of treati ng s m a l l e r a reas than tra d itional resu r­ faci ng p roced u res beca use it d oes not typica lly leave l i nes of d e m a rcati o n . Ad d itional ly, there is sign ifica ntly red uced c l i n ic a l and soc i a l d ownt i m e com pared to fu l l s u rface a b lative proced u res. N o n etheless, t h e treatment has its d rawba c ks s uc h as •

lighte n i n g is usual l y modest.

•

D u ration of benefits i s not known .

•

Best resu l ts often req u i re more than one treatment. - Espec i a l l y acne sca rs . - Req u i res 1 wee k away fro m w o r k a n d soc i a l activities. - Series nona blative treatments may be more tolera ble a n d practical for m a n y patients.

Figure 9.6 Localized minute pustules, edema, and erythema representing a localized pseudomonas infection in the setting of post-C0 fractional 2 ablative resurfacing for a burn scar. It cleared fully without sequelae after oval antibiotic treatment.

62

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Color Atlas of Cosmetic Dermatology

CHAPT E R 1 0

Tissue Tighte ning

There have been a va riety o f n o n i nvasive d evices that p u r port to l ift a n d tighten " l oose" necks, jawl i nes, a n d eyes . These d evices work b y del iveri ng monopolar, bi po­ l a r, or i nfra red energy to the d ee p dermis a n d su bc uta ­ neous tissue, resu lting in tighte n i ng a n d l ifti ng of s k i n a n d c reation o f new collage n . T h e c h ief o bstacle for th ese d evices has been i nconsistent c l i n ica l resu lts . Some patients have had d ra m atic res u l ts i n com pa rison to tra­ d itional i nvasive s u rgery a nd oth e rs have seen l ittle or no i m provement. Patients who u n d e rsta n d the risks before the proced u re a re ha ppy with excellent resu lts a n d not d isappoi nted by lack of i m p rovement.

M ECHAN I S M OF ACT I O N There a re d iffe rent rad i ofreq uency ( R F) tec h n o l ogy a n d i nfrared d evices that del iver vol u m etric h eat t o t h e deep dermis and s u bcuta neous tissue wh i c h tightens existi ng col lagen and h e l ps c reate new collage n .

CAN D I DATE S E LECT I O N A s with a l l proce d u res, ca n d i d ate selection i s vita l t o the success of the proced u re . These devices wi l l n ot treat epi­ dermal cha nges of aging such as lentigo, tela ngiectasia, or ro ugh ski n . Ca n d idates should have deep cuta neous signs of aging such as "saggi ng" skin in the neck, jaw, or around the eyes. Some physicians have re ported good success in treating a reas off the face i n c l ud i ng u pper arms, a bdomen , and b reasts . All patients m u st be awa re that the a m o u nt of c l i n ic a l i m prove ment is h ighly va riable not pred icta b l e before the proced u re. Patients that d o not u n d e rsta nd this should not u n d e rgo the proced u re .

A

Figure 10.1 (A) Prior to treatment skin laxity is observed in the jowl

region.

THE PROCEDU R E When fi rst i ntrod uced t h e c h ief c o m p l a i n t with

RF

d evices was i ntolera b l e pa i n . The proced u re was done with a single pass at h igh energy settings. Over the yea rs the trend has been towa rd more passes with lower fluen­ cies. T h i s has greatly red u ced the pa i n associated with the proced u re. M u ltiple passes, lowe r fl uenc ies, and d if­ fe rent s pot sizes have resu lted i n greater i m med iate tis­ sue tighte n i n g o bserved

in

patie nts

and

a

h igher

percentage of patients with i m provement after 6 months.

• P re p roced u re C h ec k l i st •

Remove a l l m a ke u p .

•

Remove a l l jewel ry.

Sect i o n 1 : Ph otoa g i n g

•

No pacema ker or d efi bri l lator.

•

A l l patients with fac i a l i m pla nts s h o u l d have the mater­

I

63

ial of the i m p l a n t i d e ntified before the proced u re . If it is u n kn own , d o not treat d i rectly over the i m p la nt. •

A p p l y thick layer of topica l a n esthetic 30 m i n utes before p roced u re .

• •

Determ i n e a p p ro priate s pot size a n d fl uence. Kee p the h a n d piece even with the s k i n t h roughout the p roced ure.

•

After the proced u re patie nts c a n res u m e reg u l a r a ctivi­ ties i m med iately.

•

Patie nts s h o u l d com m u n icate with their phys i c i a n i n case o f a n y q u estions or concerns.

•

I m provement occ u rs fo r u p to 6 months after the p ro­ ced u re .

S I DE EFFECTS The a m o u nt of serious side effects has been red uced ove r the yea rs as treatment protocols have been refi ned . With l ower fluences the risk of side effects has been s u b­ sta ntia l ly red uced .

• Pote n t i a l S i d e Effects •

Atro phoderma which may be tem pora ry or perm a nent

•

B u rn

•

Erosion/ulcer

•

Sca r

•

Dysc h ro m i a

•

N e rve da mage

B

•

Oc u l a r da mage

Figure 10. 1 (continued) (B) Six months after treatment appearance of the

CLI N I CAL PEARLS •

A l l patients s h o u l d be wa rned before a n y proced u re that the a m o u nt of c l i n ic a l i m provement va ries from person to person . I m prove ment can ra nge from d ra­ matic to N O i m provement at a l l . Any patient who d oes not u nd e rsta n d

the

potenti a l for n o i m prove ment

should not have the proced u re performed . •

W h i le treating each patient conti n u ously, observe the skin and ask the patient to inform the physici a n if there is a partic u l a r s pot with i n c reased pa i n or u n usual sym p­ toms. If a patient complains of u n usual pa i n or sym p­ toms, sto p the p roced u re a n d reeva l uate the setti ngs.

•

M a ke s u re a u n iform a m o u n t of energy is d e l ivered with each pu lse. This is done by usi ng the a p propriate spot size a n d a pplyi ng u n iform gentle but firm p ress u re to the ski n .

•

D o not perform t h e p roced u re o n a patient with a ctive s u n burn or ta n .

jowl and neck is improved slightly. (Reproduced, with permission, from Hirsch R, Sadick N, Cohen JL. Aesthetic Rejuvenation: A Regional Approach. New York: McGraw-Hill, 2009: 97. )

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Color Atlas of Cosmetic Dermatology

CHAPT E R 1 1

D e r m atochalasis

Dermatoc ha lasis is a cond ition cha racterized by u p per a n d/or lowe r eye l i d s k i n , m uscle red u n d a ncy a nd laxity, a n d fat pad hern iation . It is m a i n ly attri buta b l e to c h rono­ logica l aging a n d c h ro n i c s u n expos u re .

EPI D E M I O LOGY Incidence: ve ry c o m m o n Age: m ost freq uently o bserved i n i n d iv i d u a l s older tha n 50 yea rs

Sex: no pred i l ectio n Race: most common i n fa i r-s k i n ned i n d ivi d u a ls (skin

A

phototypes I a n d I I ) ; l ess common in da rker-s k i n ned i nd i vid u a l s (ski n p hototypes IV-V I )

Precipitating factors: c h ronologica l aging; c h ro n i c s u n expos u re ; thyroid d isease

PATHOG E N ES I S U p per a n d/o r lower eye l i d s k in a n d m uscle hypertro phy and prola pse; fat pad d escen s ion .

PHYS I CAL EXAM I NAT I O N Ea rly fi n d i ngs i n c l u d e a d o u b l e l i d c rease with o n l y mod­

B

est hood i ng. Severe fi n d i ngs i n c l u d e pro m i nent eye l i d

Figure 11.1 (A) A 59-year-old female concerned about her sunken eyes and forehead wrinkles. (B) Improvement of the blepharloptosis, sunken eyes, and forehead wrinkles 9 months following upper lid blepharop/asty and leavator aponeurotica advancement. (Reproduced, with permission, from Harue Suzuki, MD, Kyoto, Japan.)

h ood i n g w i t h u pper a n d latera l v i s u a l f i e l d obstruction . Coexisting b row ptosis may f u rther c o m p rom ise the peri phera l visio n . Tests for lower l i d laxity h e l p determ ine i f a l id-tighte n i ng proced u re is needed . Lower l i d horizonta l laxity is measu red by the d istrac­ tion test that req u i res p u l l i ng the lowe r lid a nteriorly away from the globe. A greater than 7-mm lid excu rsion i n d i ­ cates laxity. Orbic u l a ris oc u l i tone is measu red by the s n a p test that is performed by p u l l i ng the lowe r lid i nfe riorly. If the l i d d oes not sponta neously retu rn t o the n o r m a l position prior to the next b l i n k , the test is positive i nd icati ng l ower lid laxity.

D I F F E R E N T I A L D I AG N OS I S B l e p h a rochalasis ( recu rrent i d i o path ic eye l i d i nfla m ma­ tion with resu lta nt re laxation of the u p per lid ski n ) ; u p pe r eye l i d hood i n g seco ndary t o eye b row ptos is.

Sect i o n 1 : Ph otoa g i n g

D E R M ATOPAT H O LOGY Epidermal aca nthosis with flatte n i ng of the derma l­ e p i derma l j u ncti o n ; dermal col lagen brea kd own with fo rmation of a m orphous masses and i n c rease i n gly­ cosa m i noglyca ns.

CO U RS E •

C h ro n i c p rogressive cou rse ; visual eye fields may be affected .

KEY CO N S U LTAT I V E QU EST I O N S •

A n y assoc iated sym ptoms i n c l u d i n g visual o bstruction, d ry eyes, excessive tea ring

•

U nderlying medical cond itions, espec i a l l y eye d i sease a n d thyroid cond itions

•

Prior treatment and response

MANAG E M ENT •

P reventi o n : strict s u n avoida nce

•

Control u n derlying thyro i d d isease

TREATM ENT •

Topica l thera py: d a i ly su nscreen a pp l ication with UVB/ UVA coverage

•

S u rgical thera py - Coro n a l browlift-u pper face rej uvenation - Trichophytic browlift-u pper face rej uvenation - Blepha roplasty-u p per and lower eye l i d rej uve nation ( Fig. 1 1 . 1 )

•

Laser thera py - Placement of protective eye s h i e l d s prior to laser treatment if pa ra m o u nt. - Conservative treatment is necessa ry to avoid ectropion formation a n d/or sca r formatio n . - Carbon d i oxide laser resu rfa c i ng. - Erbi u m : YAG laser. - Fractionated a b lative carbon d ioxide laser resu rfacing.

P I T FALLS TO AVO I D •

A conservative a pproa c h to s u rgica l rem ova l of this s k in is vita l to prevent a " sta rtled " a ppea ra nce o r ectropion .

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Color Atlas of Cosmetic Dermatology

Retention of a l l or portions of a ny hern iated fat pads h e l ps m i n i m ize the skeleto n ized a p pea ra nce ofte n noted to d eve l o p with age a n d loss of fa c i a l vol u m e .

•

D i rect visual ization o f t h e i nferior o b l i q u e m uscle is vita l t o avoid m uscle i nj u ry.

•

Treatment with l u brica nts a n d ta p i n g l i d s may h e l p pre­ vent keratoconj u n ctivitis.

B I B L I OG RAPHY A n c o n a D , Katz B E . A p ros pective study o f the i m prove­ ment in periorbita l wrin kles a n d eye brow elevation with a n ovel fractiona l C0 2 laser-th e fractional eye l ift. J Drugs Dermatol. 20 10;90 ) : 1 6-2 1 . Ca rte r S , Seiff S, Chao P. Lower eye l i d C02 laser rej uvena­ A ra n d o m ized p rospective c l i n ic a l stu dy.

tion :

Ophthalmology. 200 1 ; 1 08:437-44 1 . Cod ner MA, Wo lfl i J N , Anza rut A . P r i m a ry transc uta­ neous lower b l e p h a roplasty with routi ne latera l canthal s u p po rt: A com prehensive 1 0-yea r review. Plast Reconst Surg. 2008; 1 2 1 : 1 24 1 - 1 250 . J u nzeker C M , We iss ET, Geron e m us R G . Fractionated C0 2 laser res u rfa c i ng: Our experience with m o re t h a n 2000 treatments. Aesthet Surg J. 2009 ; 29(4) : 3 1 7-32 2 . K o r n B S , Ki kkawa DO, Cohen S R . Tra nscuta n eous lower eye l i d

b l e p h a roplasty

with

orbitomala r

suspensio n :

Retros pective review o f 2 1 2 consecutive cases. Plast Reconstr Surg. 20 1 0 ; 12 5 ( 1 ) : 3 1 5-323 . Lee D, Law V. S u bbrow blepha roplasty for u p per eye l i d rej uve nation i n Asia n s . Aesthet Surg J . 2009 ;29(4): 284288 . Le m ke B N , Stasior OG . T h e a n atomy o f eye l i d ptosis. Arch Ophthalmol. 1 932 ; 1 00:981 -986 . Levine

MR.

Manual

of

Oculoplastic

Surgrery.

P h i la d e l p h i a : B utterworth H ei n em a n n ; 2003 . Shorr N , Enzer Y. Considerations i n aesthetic eye l i d su rgery. J Dermatol Surg Oneal. 1992 ; 1 : 1 08 1 - 1 09 5 .

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 1 2

J

Poi kilod e r m a of Civatte

Poi k i l oderma of Civatte ( POC) is a cond ition that is attri b­ uta ble to chronic sun expos u re of the neck and the c h est. The seve rity of fi n d i ngs is d e pend ent on the d u ration a n d i ntensity

of

sun

expos u re,

constitutive

skin

color

( Fitzpatrick s k i n type ) , and the capac ity to ta n .

EPI D E M I O LOGY Incidence: common Age: most freq uently o bserved i n persons older than 40 yea rs

Sex: sl ight fem a l e pred o m i na nce Race: m ost common in fa i r-s k i n ned i n d ivid u a l s ( s k i n p hototypes I a n d I l l ; rarely seen i n da rker-s k i n ned i n d i ­ vid u a l s (ski n p hototypes I V-V I )

Precipitating factors: c h ro n i c s u n expos u re i n c l u d i n g i ntentio n a l s u n exposu re s i n ce youth a n d occ u pationa l expos u re; tra u m a ; c h ronologica l aging

PATHOG E N ES I S U ltraviolet B ( U V B ) i s the m ost d a maging U V rad iati o n , with h igh d ose u ltraviolet A ( U VA) contri buting t o t h e n oted cha nges . I n a d d it i o n , vis i b l e a n d i nfra red ra d iations have been shown to a ugment the action of UVB .

PHYS I CAL EXA M I NAT I O N Te langiectases, m i l d atrophy, ret i c u l ated hyperpigmenta­ tion , a n d hypopigm entation affect i n g the late ra l a n d pos­ teri or as pect of the neck, a nterior c h est, a n d jawl i n e . S u b menta l neck is s pa re d . Perifo l l i c u l a r s p a r i n g noted ( Figs. 1 2 . 1 a n d 1 2 . 2 ) .

D E R M ATOPATHOLOGY Epiderma l a ca nthosis with flatte n i ng of the d e r m a l­ e p i d e r m a l j u ncti o n . Foca l i n c rease i n e pi d e r m a l basa l c e l l m e l a n ocytes; i rreg u l a r basa l c e l l hyperpigme ntati o n . Dermal c o l lagen brea kdown with fo rmation o f a m o r­ p h o u s m asses a n d i nc rease i n glycosa m i n oglyca ns. Te l a ngiectasia noted .

D I F F E R E N T I AL D I AG N OS I S R oth m u n d-Thomson syn d ro m e ; ra d iation dermatitis; Ki n d l e r

syn d ro m e ;

tela ngiectasi a .

B l oo m 's

syn d ro m e ;

Ataxia­

Figure 1 2 . 1 Poikiloderma of Civatte. Reticulated pigmentation, ery­

thema, and atrophy can be seen with characteristic sparing of the sub­ mental area. The erythematous component is more prominent in this patient. (Courtesy of Richard A. Johnson, MO. )

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Color Atlas of Cosmetic Dermatology

COU RS E C h ro n i c p rogressive cou rse with conti n u ed s u n expos u re .

KEY CO N S U LTAT I V E QU EST I O N S •

Past a n d c u rrent s u n expos u re h i story

•

Occu pation

•

H o b b i es/sporting activities

•

U nd e rlying medical cond itions

•

H/o rad iation thera py

•

Past treatments a n d response

MANAG E M E N T P revention : strict s u n avo i d a n ce .

Figure 1 2 . 2 Poikiloderma o f Civatte-the pigmented component is more prominent in this patient.

TREAT M ENT •

Topical

thera py:

d a i ly

su nscreen

a p p l ication

with

UVB/UVA cove rage . •

Laser thera py: great caution m ust be fo l l owed with a ny laser treatment a d m i n istered to m i n i m ize the risk of sca r formati o n , dyspigmentati o n , "finger- p r i nting" o r treatment s k i p a reas, a n d text u ra l cha nges. The neck i s pa rtic u l a rly p r o n e t o sca rring given fewer pi losebaceous u n its. A test site is recom mended . M u lt i p l e sess ions a re genera l ly req u i red . Laser fl ue nces should be lowered by a pproxi mately

25% to 30% of fac i a l pa ra m eters to avoid adve rse effects . - Pu lsed dye laser-low flue nces util ized (eg, Vbea m 595 n m , 0.45- 1 . 0 ms, � J/cm 2 , 7- 1 0-m m spot, DCD 30/20). I m p rovement in te langiectasia a n d atro­

A

phy see n . L i m ited benefit for dyspigmentatio n . - I ntense

p u lsed

l ight

(eg,

Sta rLux,

20-30

ms,

28-34 J/d m 2 , 1 0 % pass overla p )-i m provement of

a l l com pon ents may be poss i b l e . - Versa P u lse 532-n m laser-l ow fl ue nces necessary ( Fig. 1 2 . 3 ) . - Fractionated n o nab l ative a n d a blative laser-a l l com­ ponents may be targeted . Can be safely util ized in affected body a reas, though conservative laser pa ra­ meters a re req u i red to avoid potenti a l sca rring.

P I T FALLS TO AVO I D •

A conservative a p proac h m u st be fo l l owed with a ny treatment used for POC, given the sign ifica nt risk of u n even remova l of the pigmentation a n d e rythema res u lting i n a "footprint" - l i ke a p pearance ( Fig. 1 2 . 4 ) .

B

Figure 1 2 . 3 (A) Poikiloderma of Civatte pretreatmen t. (B) Poikiloderma of

Civatte following three VersaPulse 532-nm laser treatments. Marked reduction in erythematous component is observed.

Sect i o n 1 : Ph otoa g i n g

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69

T h i s m ottled a p pea ra nce can occ u r norma l ly d u ri ng the cou rse of treatment. The patient m ust be awa re of t h i s poss i b i l ity. Cont i n ued treatment t o the resid ua l lesions genera l ly res u l ts i n a resol ution of t h i s side effect. •

Patients m u st be awa re of the d ifficu lty in i m provin g t h i s condition. M u lt i p l e treatments a re expected for end point of l ighte n i ng. Textural c h a nges a re l i kely to per­ sist.

•

POC with a p r i m a ry e rythemato us com ponent typica l ly res ponds better than POC with a primarily hyperpig­ mented com ponent.

B I B L I OG RAPHY B a tta K, H i n d s o n C , Cotte r i l l J A , Fo u l d s I S . Trea t m e n t of poi k i l od e r m a o f C i va tte with t h e potass i u m tita nyl p h o s p hate ( KT P ) laser. Br J Dermatol. 1 999 ; 1 40( 6 ) : 1 19 1 - 1 192. Gero n e m u s R . Po i k i loderma o f Civatte . Arch Dermatol. 1 990; 1 26(4) : 547-548. Kato u l is AC, Stavria neas N G , Panayiotides J G , et a l . Poi k i loderma of Civatte : A h i stopathologica l a n d u ltra­ struct u ra l study. Dermatology. 2007 ; 2 14(2) : 1 7 7 - 1 82 . La nge l a n d J . Treatment o f poiki loderma o f Civatte with the p u lsed d ye laser: A series of seven cases. J Cutan

Laser Ther. 1 999; 1 (2 ) : 1 2 7 . R uscia n i A, Motta A, F i n o P, Men i c h i n i G . Treatment of poi k i l oderma of C ivatte u s i n g i ntense p u lsed l ight sou rce: 7 yea rs of experience. Dermatol Surg. 2008;34( 3 ) : 3 1 43 19 . Ti erney EP, H a n ke CW. Treatment o f poi k i loderma of Civatte

with

a b lative

fractional

laser

res u rfa c i ng :

P ros pective study a n d review o f the l i teratu re . J Drugs

Dermatol. 2009;8(6) : 527-534. Ti erney EP, Kou ba DJ , H a n ke CW. R eview of fractional photothermolysis: Treatment i n d ications a n d effi cacy.

Dermatol Surg. 2009 ;35( 1 0 ) : 1 445- 146 1 .

Figure 1 2 .4 "Footprinting" o f the anterior neck after a single intense pulsed light (!PL) source treatment for Poikiloderma of Civatte. This sub­ sequently resolved with continued IPL treatments

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TWO D isord e rs of S e baceo u s G l and s

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Color Atlas of Cosmetic Dermatology

CHAPT E R 1 3

Ac n e Vulga ris

Acne vu lga ris is a c h ro n i c i nfla m m atory d isease of the pi losebaceous u n it. Ac ne lesions favor the face, neck, u pper ba ck, c hest, a n d u pper arms. M u lti ple c l i n ical va ri­ a nts exist and they i nc l u d e comedonal acne, pa p u l opus­ tular acne, nod u l ocystic a c n e , a cn e conglobata , a n d a c n e fu l m i na n s .

EPI O E M I O LOGY Incidence and age: pred o m i n a ntly a d isord e r of adoles­ cence; affects 85% of i n d ivid u a l s between

12 a n d

2 4 yea rs o f age; m a y affect a l l age grou ps

Race: lowe r i nc i d e n ce in Africa n-America ns a n d Asi a n s Sex: more severe forms i n m a l es Precipitating factors: ge netic p red isposition, endocri ne d isord e rs, stress, mec h a n ical factors (fricti o n , p ress u re, occ l usion ) , contact with a cnege n i c materials ( o i l s , c h lori­ nated hyd roca rbons, cosmetics) , a n d d rugs (steroids, l ith i u m , a n d rogens, hyda ntoi n )

PATHOG E N E S I S Many patients with nod u locystic acne have a fi rst-degree relative with a history of severe acne. The primary patho­ physiology i nvolves a ltered fol l i c u l a r keratin ization resu lting i n o bstruction of sebaceous fol l ic les, increased seb u m pro­ d uction, hyperprol iferation of Propion i bacteri u m acnes, and i n c reased prod uction of chemotactic factors which resu lt i n i nfla m matio n .

PHYS I CAL EXAM I NAT I O N Comedones ( c l osed a n d open ) , erythematous pa p u les, p ustu les, nod u les, and cysts. May resolve with res i d u a l hyperpigmentation or sca rri ng.

D I F F E R E N T I A L D I AG N OS I S Ac n e

rosa cea ,

ste roid

acne,

acne

mecha n i c a ,

P ityros poru m fol l i c u l itis, a n d bacteria l fol l i c u l it i s .

LABORATORY DATA • E n d oc r i n e St u d i es No routi n e stu d i es a re needed . If h i story a n d physical exa m i nation ra ise concerns then consider ordering­ screen for free a n d tota l testosterone, d e hyd roe p ia n d ros­ terone,

and

fo l l ic l e

sti m u lating

hormone/l ute n i z i n g

Figure 13.1 An 1 8-year-old male with cystic acne being treated with

1 , 450-nm diode laser

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

I

73

hormone ( FS H/LH ) ratios to exc l u d e polycystic ova ry syn­ d rome or other hormonal a bnorma l ities espec i a l l y in wo men with mode rate-to-severe a c n e , h i rsutism , i rregu­ l a r menses, a n d weight ga i n . D i et may play a role i n fla res of a c n e . H igh glyce m i c d i ets may exacerbate a c n e . F u rther stu d ies a re need ed .

• D e r m at o p at h o l ogy Pathology of early lesion (comedone) revea ls o bstruction of the fol l i c u l a r i nfu n d i b u l u m by corn ified cells lead i ng to d i latation . Later lesions revea l fol l i c u l a r r u pt u re with lym­ p hocytes, neutro p h i l s , and macrophages . Sca rring may be see n .

COU RSE T h i s d isease dem onstrates a c h ro n i c cou rse a n d rem its s ponta n eously in the early-to-mid-th i rd decade in the majority of patients. However, a c n e may persist m u c h longer i n some patients .

MANAG E M ENT Ea rly treatment o f a c n e is essential for t h e preve ntion of

A

d ysc h ro m i a or assoc iated sca rring (see sca r treatment cha pter 6 1 ) . M a ny acne patients benefit from c o m b i n a ­ tion thera pies. A thorough h i story a n d physical exa m i na­ tion a re para m o u nt to a d m i n istering a maxi m a l ly effective p la n . T h i s s h o u l d i n c l u d e c u rrent cosmetics a n d s u n ­ screens, s k i n type, l ifestyle, occ u pati o n , medications, past treatments a n d res ponse, d i et, menstrua l and ora l contraceptive h i story.

• To p i c a l Treat m e n t To pical treatment may b e req u i red for the d u ration o f t h i s c o n d ition . To pical for m u l ations s h o u l d be a p pl ied t o the lesions as wel l as to the adjacent a c n e-prone c l i n ica l l y normal ski n . •

Reti noids: treti noi n , a d a pa l e n e , taza roten e

•

Anti bacterial agents: benzoyl peroxide, c l i n d a m yc i n , e ryt h romyc i n

•

Kerato lytic agents: sa l icyl i c a ci d , hyd roxy a c i d , aze l a i c a c i d , sod i u m su lfaceta m i d e , a n d s u lfu r

• Syste m i c Treat m e n t •

B

Ant i biotics: tetracyc l i ne , d oxycyc l i ne, m i nocyc l i n e a re m ost

commonly

used .

Alternatives

i n c l ude

e ry­

t h romyc i n , azith romyc i n , a n d a m oxic i l l i n . •

Hormones: o ra l contraceptives or spi ronolacto ne for women with persistent acn e on lowe r face, c h i n , a n d neck.

Figure 13.2 (A) Facial inflammatory acne vulgaris unresponsive to multi­ ple topical and oral treatment regimens. (B) Marked improvement of acne 6 months following five 1 , 450-nm diode laser treatments (Smoothbeam, Candela Corp. , Wayland, MA), 6-mm spot, 1 4 J/cm 2 , DCD 30 ms

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Color Atlas of Cosmetic Dermatology

l sotreti n oi n : fo r severe n od u l ocystic acne that has fa i l ed other to pical a n d syste m i c thera pies.

• S u rg i c a l Treat m e n t •

Comedone extraction : expression of kerati nous con­ tents of open comedones by a pplying the comedone extractor to the comedones and a pplying p ress u re . A n i c k m a y b e m a d e t o t h e overlyi ng s k i n with a # 1 1 - blade or 1 8-ga uge need le to ease in the extracti o n . The

Scham berg,

Unna,

and

Saalfi e l d

comedone

expressors a re m ost com m o n l y uti l i zed . Comedone extraction is contra i n d icated for i nfla m ed comedones or pustu les d ue to i n c reased sca r risk. •

l ntra l esional steroid i njection : tri a m c i nolone aceto n i d e ( 2-3 mg/m U is i njected i nto i nfla m ed cystic lesions using a 30-ga uge need l e . Maxi m u m d ose i njected s h o u l d not exceed 0 . 1 mL per lesion to avo i d atro phy. Patients s h o u l d be wa rned that atrophy from an i nflam­ m atory cystic lesion can occ u r with o r without an i ntra lesiona l steroid i nj ectio n .

•

Chemical pee l s : seri a l sa l i cyl ic a c i d peels, glyco l i c a c i d peels ( 20-70% ) , a n d tri c h loroacetic a c i d ( T C A ) peels ( 1 0-20) have been util ized to red uce the n u m ber of comed ones a n d i m prove posti nfl a m m atory hyperpigmentation a n d persistent erythema . Peels may be per-

A

formed every 2 to 4 weeks, with i n c reasing strengths and time a p p l ied as tol erated . M i ld i rritation may be o bserve d . Adj u nctive thera py is genera l ly necessa ry. •

M i c roderma b ras ion : this is prima rily effective for come­ donal acne. It is usua l ly performed every 2 to 3 weeks. M u lti ple treatments a re needed with va ria ble i m prove­ ment.

• L i g h t Trea t m e n t •

Lasers: lasers a n d l ight sou rces a re not the fi rst-l i n e thera py f o r a c n e b u t ca n b e a n effective a lternative o r adj uva nt t o m e d i c a l thera py when req u i red . - 1450- n m d i ode laser ( S m ooth bea m laser, Candela Corp . , Wayla n d , M A ) : treatment fl u en cies from 8 to 14 J/c m 2 , 6-m m s pot size, a n d dyna m i c cool i n g device setting o f 30-35 ms can res u lt i n m i ld t o d ra­ matic i m provement of i nflam matory tru n k a n d fa c i a l acne w i t h a sign ificant red uction i n l e s i o n count after an ave rage of t h ree, sepa rated by 4-to-6-week i nter­ va ls ( F igs. 1 3 . 1 a n d 1 3 . 2 ) . I t is i m porta nt to d e l iver nonoverla p p i n g pu lses to red uce the risk of side effects. To pical l i doca i ne c rea m a p p l ied prior to treat­ ment is needed to m i n i m ize the treatment-assoc iated pa i n . It is vita l to a p ply the c rea m over a l i m ited body

B

s u rface to l i m it a ny risk of l idoca i n e toxic ity.

Figure 13.3 (A) Severe acne before treatment. (B) A fter three treatments of photodynamic therapy with topical 5-aminolevulinic acid and pulsed dye laser, 7-mm spot, 6 J!cm 2 , 6-ms pulse duration (Courtesy of Mark Nestor, MD, PhD)

- Lower fl u e n c ies of 8 J/c m 2 with two fu l l-face passes versus a si ngle ful l-fa ce pass at h igher fluenc ies ( 1 0- 1 4 J/cm 2 ) have been used to red uce pa i n .

Sect i o n 2 : D i so rd e rs o f Sebaceous G l a n d s

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75

- P u lsed dye laser ( P D U : stu d i es exa m i n i ng the effi­ cacy of P D L for i nfla m mato ry acne have prod uced conflicti ng data . P u lsed dye laser alone or i n c o m b i ­ n a t i o n w i t h long p u lsed 1 , 064- n m YAG l a s e r h a s b e e n effective i n red u c i n g i nfla m matory a c n e . P D L can i m p rove postacne erythe m a . F l u ences o f 5 . 5 t o 7 J/c m 2 , 7-m m spot s i z e w i t h pu lse d u rations o f 3 t o 6 ms a re most c o m m o n l y em ployed . Severa l treat­ ments a re n eeded to ach ieve the greatest benefit. •

P h ototh era py:

m u lt i p l e

l ight

sou rces

have

been

A

reported to sign ifica ntly i m prove acne with m i n i ma l side

Figure 1 3 .4 (A) Facial inflammatory acne prior to photodynamic therapy.

effects. These sou rces i n c l u d e h igh-i ntensity narrow­

(8) Marked reduction of the inflammatory acne after three sessions of

ba nd b l u e l ight, h igh-i ntens ity meta l h a l i d e la m p, h igh­

photodynamic therapy (Courtesy of Mark Nestor, MD, PhD)

energy b road-s pect r u m b l u e l ight, as wel l as m ixed b l u e a n d red l ight. •

B

P h otodyna m ic thera py ( P DT ) : PDT uti lizing the topica l a d m i n istration of 5-a m i nolevu l i n i c acid (ALA, Levulan Kerastick, D U SA Pha rmaceutica ls, I nc . , W i l m i ngto n , M A ) activated b y l ight exposure is a n other potentia l l y effective modal ity t o treat acne ( Figs . 1 3 . 3 a n d 1 3 .4) . Short contact A LA- PDT ( 1 5-60- m i n ute d rug i n c u bati o n ) w a s c a p a b l e o f i m p roving acne sign ifica ntly i n a va riety of c l i nical stu d i es . Diffe rent l ight sou rces have been uti l ized i ncl u d i ng b l u e l ight (405-420 n m ) , red l ight (635 n m ) , long- p u lsed 595- n m pu lsed dye lasers, a n d i ntense pu lsed l ight (430- 1 200 n m ) ( Fig. 1 3 . 5 ) .

B I B L I OG RAPHY Bowe WP, J osh i SS, S h a l ita A R . D i et a n d a c n e . J Am

Acad Dermatol. 20 1 0 ; 63( 1 ) : 1 24- 14 1 .

A

Fried m a n P M , J i h M H , Ki mya i-Asa d i A , Gold berg LH . Treatment of i nflam matory fac i a l acne vu lga ris with the 1 450- n m d iode lase r : A pilot stu d y.

Dermatol Surg.

2004;30(2 pt 1 ) : 147- 1 5 1 . H a m i lton F L , C a r J , Lyons C , C a r M , Layton A , Majeed A . Laser a n d oth e r l ight thera pies for the treatment of a cn e vu lga ris: Systematic revi ew. Br J Dermatol. 2009 ; 1 60(6): 1 273- 1 285. Leheta TM. Role of the 585- n m p u lsed dye laser i n the treatm ent of a c n e in c o m pa rison with other topica l thera­ peutic modal ities. J Cosmet Laser Ther. 2009; 1 1 ( 2 ) : 1 1 8- 1 24 . P o l l o c k B , Tu rner D , Stringer M R , e t a l . Topical a m i n ole­ vu l i n i c acid-photodyna m i c thera py for the treatment of

B

acne vulga ris: A study of c l i n ical efficacy a n d mec h a n ism

Figure 1 3 . 5 (A) Mild acne scarring and dyschromia prior to Er: YAG laser

of acti o n . Br J Dermato/. 2004; 1 5 1 (3 ) : 6 1 6-62 2 . Yeu ng C K , S h e k SY, Yu CS, Ko no T, C h a n H H . Treatment of i nfla m matory fac i a l ac n e with 1 ,450- n m d iode laser in type I V to V Asia n skin using an o pti m a l c o m b i nation of laser pa ra meters . Dermatol Surg. 2009;35(4): 593-600.

resurfacing. (B) Four months after Er: YA G laser resurfacing utilizing a 5-mm spot at 1 J with four passes results in significant improvement (Reproduced, with permission, from Dover J, Arndt K, Geronemus R, et a!. Illustrated Cutaneous & Aesthetic Laser Surgery. McGraw-Hi//, Inc.; 2000)

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CHAPT E R 1 4

R osacea

A c n e rosacea is a c h ro n i c vasc u l a r a n d a c neiform d isor­ der of the p i l osebaceo us u n it that affects p red o m i n a ntly the centra l face i n c l u d i ng the centra l c h eeks, n ose, a n d c h i n . The eyes a n d the eye l i d s can occasiona l ly be i nvolved . Typical ly, there is an i n c reased reactivity of cap­ i l la ries to h eat, lead i n g to fl u s h i n g and u ltimately tela ng­ iectasia .

S u btypes of

rosacea

include

(1)

vasc u l a r

rosacea (erythematotela ngiectatic), ( 2 ) pa p u l o pust u l a r rosacea , (3) sebaceous hyperplasia ( phymatous rosacea ) i n c l u d i n g r h i nophyma ( nasa l sebaceous hyperplas i a ) , a n d ( 4 ) oc u l a r rosacea . G ra n u lomatous rosacea is a vari­ a nt of rosacea .

EPI O E M I O LOGY Incidence: common Age: 30 to 50 yea rs; pea k i nc i d e n ce between 40 and 50 yea rs

Sex: fe male pred i lect i o n ; m a l e pred o m i n a nce for r h i n o phyma

Race: m ost common in fa i r-s k i n ned i n d ivid uals (skin phototypes I and I I ) ; rarely seen i n da rker-ski n ned i nd i ­ vid u a l s (ski n p hototypes IV-V I )

Precipitating factors: excessive s u n exposu re, caffe i n e ,

A

s picy food s , h ot foods a n d beverages, heat, a lcohol, seb­ orrhea ,

topical

corticosteroid

use,

and

u n derlyi ng

Pa rkinso n 's d isease

PATHOG E N E S I S M u ltiple facto rs a re i nvolved i n the pathogenesis of rosacea i n c l u d i n g vasc u l a r hypera ctivity, Demodex fol ­ l i c u lorum m ites, H e l icobacter pyl ori, a n d hypersensitivity to Pro p i o n i bacteri u m acnes.

PHYS I CAL EXAM I NAT I O N Va riable c l i n ic a l featu res ca n b e p resent d e pen d i ng o n the severity a n d t h e s u btype o f rosacea . Ea rly featu res i n c l u d e tra nsient a n d nontra nsient f l u s h i ng, e rythema­ to us pa p u les, a n d p ustu les. N o comedones a re n oted . Late featu res i n c l u d e tela ngiectasias, sebaceous hyper­ plasia, nasa l t h i c k e n i n g and e n l a rge ment ( r h i nophym a ) , a n d lym phedema . Oc u l a r i nvolvement is freq ue ntly see n .

D I F F E R E N T I A L D I AG N OS I S Acne vu lga ris, seborrheic d e rmatitis, periora l dermatitis, steroi d

rosacea, system ic l u pus erythematosus, a n d

B l u pu s m i l ia ris d isse m i natus fac ie i .

B

Figure 14. 1 A&B Severe rhinophyma prior to electrosurgery (Courtesy of

Suzanne Olbricht, MD)

Sect i o n 2: D i so rd e rs of Sebaceous G l a n d s

J

D E R M ATOPAT H O LOGY Vasc u l a r ectasia as wel l as perifo l l i c u l a r and perivasc u l a r lym phoh istiocytic i nfi ltrates a re t h e most c o m m o n fi n d ­ i ngs. Demod ex fol l ic u l o r u m is usua l ly d etected i n the fol l i ­ c l es . N oncaseating epithelioid gra n u lomas a re seen i n t h e gra n u lo matous va riant. Sebaceous hype rplasia a n d fi b rosis a re seen i n rhi nophym a .

CO U RS E C h ro n i c with freq uent rec u rre nces. May sponta n eously resolve afte r several yea rs .

MANAG E M ENT P reventi o n , red u ctio n , or e l i m i nation o f exacerba nts ; s u n

c

avoida nce.

• To p i c a l T h e ra py M etro n idazole (0. 7 5%- 1 % ) once or twice d a i ly, 1 0 % sod i u m s u lfaceta m i d e w i t h 5 % sulfur o n ce d a i ly, a n d aze l a i c a c i d o n c e d a i ly, a l o n e or i n c o m b i nati o n , a re h e l p­ ful i n s u p p ressi n g the pa pu l o pustu l a r com ponent of rosacea .

• Syste m i c T h e ra py •

Tetracyc l i ne, 1 ,000 to 1 , 500 mg d a i ly in d ivided d oses, u nt i l clear; then ta per to a m a i nte n a n ce d ose of 250 to 500 mg d a i ly.

•

M i nocyc l i n e a n d d oxycyc l i n e , 50 to 1 00 mg twice d a i ly, with a ta peri ng to once d a i l y use.

•

Oral

isotret i n o i n

is

o

'-- - """""'

reserved for severe cases not

res pond i ng to o ra l a nti biotics and req u i res c l ose fol low­ u p . A low-dose regi men may be effective .

• S u rg i c a l T h e ra py

Rh i nophyma M u ltiple s u rgica l mod a l ities have been used to correct the hypertro p h i c c h a nges of r h i nophyma . It is i m porta nt to exa m i n e a ph otogra ph of the patient prior to the onset of the r h i n o phymatous c h a nge in order to h e l p g u i d e the s u rgeon i n the re mod e l i ng of the nose . A regional nerve block with a d d itiona l loca l a n esthesia is suffic i ent in the majority of cases fo r perioperative pa i n m a n agement. D i rect i nj ection of a n esthesia req u i res m u lt i p l e i nfi ltra­ tions a n d is less effective and fa r more pa i nfu l . •

Electrosu rgery: electrosection (cutti ng) is very effective in d e b u l k i ng a n d reconto u r i n g the r h i n o p hymatous nose with the added adva n tage of a relatively b l ood less fie l d . It is s i m i l a r in efficacy to C0 2 laser treatment a n d less expensive ( Fig. 14. 1 ) .

E

Figure 14. 1 ( continued) C, D,&E Debulking and recontouring of the rhinophymatous nose in a relatively bloodless field utilizing large wire loop electrosurgery Impressive flattening of the rhinophymatous nose after electrosurgery. The wound is left to heal by secondary intention (Courtesy of Suzanne Olbricht, MDJ

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Color Atlas of Cosmetic Dermatology

The hypertro p h ied tissue is re moved with care to pre­ serve the p i l osebaceous u n its .

•

Overcorrection wi l l prod uce sca rring a n d contractu res . Wou n d contractu re with hea l i ng may p u l l the nasa l t i p u pwa rd .

•

Perma n e nt d e pigmentation may res u l t from overvigo r­ ous treatment. - The El l m a n S u rgitron can be used with a la rge wi re loop in

blended waveform "fu l l y rectifi ed" mode

which provides c utti ng with hem ostasis, at a powe r control between 4 a n d 5 . - A vac u u m evac uator s h o u l d be u t i l ized for e l i m i nat­ ing p l u mes of smoke. - Any rem a i n i ng b l eed i ng poi nts ca n be coagu lated at

A

t h e end of the proced u re by switc h i ng to t h e coagu l a tion " pa rtia l ly rectified " m o d e . - The wo u n d is a l l owed to heal b y seco n d a ry i nte ntio n . - The patients a re i n structed to kee p t h e wo u n d moist by m u lt i p l e a p pl ications of petro l e u m j e l l y d a i l y u nt i l re-epith e l i a l ization is com plete a p p roximately 2 weeks postop . •

Exc ision b y t h e fa r- i nfra red lasers ( i e , C0 2 o r Er:YA G ) fol l owed b y va porization is a lso ve ry effective w i t h a relatively blood less s u rgica l fie l d . A sca n n ed C0 2 laser is t h e o pti m a l d evice given the need to d e b u l k la rge, t h i c k a reas o f ski n . The pu lsed C0 2 laser can a lso b e used i n t h e conti n u o u s wave mode t o rem ove t h e b u l k o f the r h i n o phyma a n d i n t h e p u lsed mode to scu l pt and resu rface t h e rem a i n d e r of the nose.

8

Te langi ectasias Laser a n d flash la m p treatments based on selective l ight a bsorption by he mogl o b i n a re usua l ly very effective for re movi ng tela ngiectasias a n d pa rtia l ly effective in i n h i bit­ ing f l u s h i n g . Patie nts m ust be awa re that over time they a re l i kely to deve l o p more tela ngiectasias a n d back­ grou n d erythema . •

Laser treatment: m u lt i p l e effective o ptions a re ava i l ­ a ble. - P u lsed d y e lasers ( P O L) a re the treatment o f c h o i c e for fac i a l telangiectasias. The tra d itiona l P O L with a short pu lse d u ration of 0.45 or 1 . 5 ms provides the m ost effective treat­ ment for fac i a l te la ngiectasias. H owever, posttreat­ ment p u r p u ra occ u rs w h i c h ge nera l ly lasts 1 0 to 14 days.

c

A va ria ble-pu lse POL ( 59 5 n m , Candela V-bea m , Wayla n d , M A ) with stuttered pu lse d u rations ( i e , 0.45, 1 . 5, 3, 6, 10, 20, 30, 40 ms) can provide a red uced p u r p u ra t reatm ent of fac i a l tela ngiec­ tasias, b u t is somewhat less effective and usua l ly req u i res m u lti ple treatments.

-

Figure 14.2 (A, B, C) Prominent facial erythema prior to treatment with

/PL .

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

J

79

0 C o m m o n ly, s u b p u rp u ric fl uences of less t h a n 1 0 J/cm 2 at pu lse d u ration of 1 0 ms wit h a 7 - m m spot s i z e a re util ized .

0 Better efficacy of the va riable-pu lse P D L i n treat­ ing fac i a l telangiectasias can be a c h ieved by uti­ l iz i n g p u r p u ri c fl uences or with a p u lse sta c k i n g o f s u b p u r p u ric pu lses (sta c ked 2-4 s u b p u rpuric p u l ses at a 1 . 5- H z repetition rate, 7.5 J/c m 2 , 1 0-ms pu lse d u rati o n , 1 0- m m spot size, D C D of 30/20).

0 Facial edema, eryth em a , a n d d isco mfort c a n occ u r after exte nsive treatment w i t h the p u r p u ra ­ free va ria ble-pu lse P D L. H owever, these u nde­ si red effects a re ge nera l l y better tolerated when compared to a p u r p u ra- i n d u c i ng laser treatment.

D

- I ntense pu lsed l ight ( I PL) can be h ighly effective in treating backgro u n d erythema while P O Ls work bet­ te r for i n d ivid u a l telangiectasia . I P L fl uenc ies of 30 to 40 J/c m 2 with a 20 msec p u lse d u ration a re usua l ly effective ( Sta r l u x Lux G h a n d piece, Pa lomar Med ical Tec h n o logies, B u r l i ngton , M A J . The treatment end­ point is i m med iate vessel clearance or selective ves­ sel d a rke n i ng. M u lt i p l e treatments may be req u i red fo r the greatest treatment benefit. - The va riable pu lse width 1 , 064- n m N d : YAG laser has proven to be effective i n the treatm ent of fac i a l te la ngiectasias. S h o rter p u lse widths with h igher f lu ­ en ces m ight be n ecessa ry for effective treatment of s m a l l e r vessels but have a n increased risk of b l i ster and sca r formatio n . - Freq uency-d o u bled 532 n m N d : YAG laser, a lso cal led potass i u m-tita nyl-phosphate ( KT P ) laser, pro­

E

vides effective a bsorptio n of hemogl o b i n with a pu lse d u ration of 1 to 50 m s m a k i ng it idea l ly su ited to treat su perfi c i a l vessels without p u r p u ra formati o n . Tra c i n g o f i n d iv i d u a l vessels is a usefu l tec h n iq ue for patients with a cou nta b l e n u m be r of d iscrete , visi ble vesse ls. •

Flashla m p

( p u lsed

l ight)

treatment:

IPL

provides

a n othe r effective, p u r p u ra-free method for red ucing fa c i a l tel a ngiectasias a n d erythema ( Figs . 1 4 . 2 and 14.3 ) .

B I B L I OG RAPHY Afe rzon M , M i l l ma n B . Exc ision o f r h i n o phyma with h igh­ freq u ency electrosu rgery. Dermatol Surg. 2002 ; 28(8 ) : 735-738. Alam M, Dover JS, Arndt KA. Treatment of fac i a l telang­

F

iectasia

Figure 14.2 (continued) (0, E, F) Reduction of the facial erythema after

with

va r i a b l e- p u lse

h igh-fl uence

pu lsed-dye

laser: Com pa rison of efficacy with fl uences i m med iately a bove and below the p u r p u ra t h reshold . Dermatol Surg. 2003 ; 29 ( 7 ) : 68 1 -684 . D iscussion 685 .

two treatments with /PL, Starlux L ux G handpiece

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Color Atlas of Cosmetic Dermatology

Bernste i n EF, Kligm a n A. R osacea treatment using the new-gen eratio n , d u ration

h igh-energy,

p u l sed-dye laser.

595

nm,

long

pu lse­

Lasers Surg Med. 2008;

40(4): 233-239 . Del Rosso J Q . Anti-i nfla m matory d ose d oxycyc l i n e in the treatment of rosacea . J Drugs Dermatol. 2009 ; 8( 7 ) : 664-668 . J a s i m Z F, Woo WK, H a n d ley J M . Long-p u lsed (6-ms) d ye laser

treatment

of

rosacea-associated

te la ngiectasia

using s u b p u rp u ric c l i n ica l t h reshold . Dermatol Surg. 2004;30( 1 ) : 37-40 . Mark KA, S pa racio R M , Voigt A, M a re n u s K, Sa rnoff D S . O bjective a n d

q u a ntitative i m prove ment o f rosacea­

assoc iated erythema after i ntense p u l sed l ight treatment.

Dermatol

Surg.

2003 ; 29(6) : 600-604;

1 63- 1 6 7 .

Discussion 1 6 7 . N e u h a u s I M , Za ne LT, Tope W D . Comparative efficacy of n o n p u r p u rage n i c p u l sed dye laser a n d i ntense p u lsed l ight fo r erythematotela ngiectatic rosacea . Dermatol Surg. 2009 ;35(6):920-928. Sa rradet DM,

H ussa i n M , Gold berg DJ .

M i l l isecond

1 064- n m neodym i u m : YAG laser treatment of fa c i a l tela ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58. T h i boutot D M , Fleisc h e r AB, Del Rosso JQ, R i c h P. Re lated Articles 7: A m u lticenter study of topical aze l a i c

A

a c i d 1 5% gel i n c o m b i nation with ora l d oxycyc l i n e as i n i t i a l th era py a n d azela ic a c i d 1 5 % g e l as m a i nte nance monothera py. J Drugs Dermatol. 2009;8( 7 ) : 639-648.

B

Figure 14.3 (A) Prominent facial telangiectasias prior to treatment with

/PL . (B) Posttreatmen t erythema immediately after IPL treatment

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

CHAPT E R 1 5

Se baceous H ype rp l a s i a

Sebaceous hyperplasia a p pea rs a s 1 -to-3-m m ye l l ow u m bi l icated pa pu les with overlying te la ngiectasias on the face of m id d le-aged i n d iv i du a ls ( Fig. 1 5 . 1 ) . They re p re­ sent a benign prol iferation of sebaceous glands. The lesions a re someti mes m i sta ken for basa l cell carc i n o m a .

E P I D E M I O LOGY Incidence: very common Age: m ost c o m m o n l y middle age a n d elderly but can a p pea r i n you ng i n d ivid u a l s as wel l Race: more common in Caucasians Sex: eq ual Precipitating factors: orga n tra nspla ntation is a ra re p re­ c i pita nt

PATH OG E N ES I S U n known .

PATHOLOGY I nc reased n u m bers of l a rge, matu re sebaceous l o b u les a re c l u stered a ro u n d a centra l d u ct in the u p per d e r m i s . The lobu les l i e closer tha n normal t o the e p i d e r m i s .

PHYS I CAL LES I ON S There a re si ngle or m u lti p l e 1 -to-3-m m ye l low u m b i l i ­ cated pa p u les with overlying telangiectasias t h a t a p pea r on the face. The forehea d , c h eeks, a n d nose a re the m ost common locatio ns. I t can rarely present on the a reo l a .

D I FFERENTIAL D I AG N OS I S M ost c o m m o n l y m ista ken for basa l cel l carci n o m a .

LABO RATORY EXA M I NAT I O N N o n e i s i n d icated . B i o psy i f consideri ng basa l cell carci­ noma.

CO U RS E Ben ign , but d o not regress o r resolve without thera py.

KEY CO N S U LTAT I V E QU EST I O N S Any h i story of the lesion bleed i ng.

Figure 1 5 . 1 Large sebaceous hyperplasia on the forehead

J

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Color Atlas of Cosmetic Dermatology

MANAG E M ENT There i s no me d i c al i n d ication t o treat sebaceo us hyper­ plasia . Sti l l , some i n d ivid u a l s a re sign ifica ntly bothe red by its a p pea ra nce a n d req uest re mova l , pa rticula rly in the c i rc u msta nce of m u ltiple lesions. Treatme nts i n c l u d e o ra l , destructive, laser, a n d photodyna m ic thera p ies. Eac h has its side effects and risk of rec u rrence.

TREAT M ENTS A l l patie nts s h o u l d be i nformed before a ny treatment modal ity that i m prove ment is va ria b l e and i n the futu re new lesions may a rise req u i ri n g fol low- u p treatme nts.

• Dest r u ct i ve M o d a l i t i es •

" Light" c ryothera py a n d electrosu rgery a re q u ic k , i n ex­

A

pens ive means of treating sebaceo us hyperplasia .

• Laser T h era py •

The

1 ,450- n m

d iode

laser has

been stu d i ed

in

1 0 patients for the treatment of sebaceous hyperplasia ( Figs. 1 5 .2 and 1 5 . 3 ) . - Ea c h patient was treated 1 t o 5 times. - F l u e n ces of 1 6 to 17 J/c m 2 were em ployed , with cooli n g d u rations of 40 to 50 ms. - After two to th ree treatm ents with the d iode laser, 84% of lesions d ec reased in size greate r t h a n 50%, a n d 70% decreased greate r tha n 75%. Patient a n d phys i c i a n satisfaction was h igh . - Side effects i n c l uded one case of a n atro p h i c sca r a n d one case of hyperpigme ntati o n . •

Pu lsed d y e laser ( P D U ( 585 n m ) h a s been shown to i m prove sebaceous hyperplasia . - Su ccessful treatment has been shown with t h ree­ sta c ked 5-mm p u lses at fl u e n ces of 7 a n d 7 . 5 J/cm 2 . - M ost lesions respond after one treatment with flatten­ i ng, s h r i n k i ng, o r resol ution . - Seve n percent of lesions rec u rred com p l ete ly. - One study s h owed cleara n ce i n two patients treated with the P D L at 585 n m , 6 . 5 to 8 J/cm2 , a n d a p u lse width of 300 to 450 seconds. Two to t h ree treatments were performed .

•

Erbi u m : YAG or C0 2 laser a b lation c a n a lso i m p rove sebaceo u s hyperplasia .

•

Laser-assisted photodyna m i c thera py with topica l 20% 5-a m i no l evu l i n ic acid and PDL i rrad iation (595 n m ) , b l u e l ight or i ntense p u lse l ight; 1 t o 4 treatme nts a re needed with va ria b l e i m provement a n d futu re recu r­ rence a c h i eved m ore effective i m provem e nt of seba­ ceous hyperplasia than P D L a l one.

B

Figure 1 5 . 2 (A) Patient with sebaceous hyperplasia on the right temple

and forehead. (8) Improvement 1 month after treatment with 1 , 4 50-nm diode laser (Smoothbeam, Candela Corp., Wayland, MA) utilizing a 6-mm spot with a f/uence of 1 4 J/cm 2 and a pulse duration of 35 ms

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

J

- Treatme nts were performed at 1 -to-6-week i nterva l s . - B o t h thera pies showed greater i m provement t h a n no thera py at a l l . There were no long-term res u lts. - Side effects were l i m ited to m i l d tem po ra ry red ness, edema, and crusting.

P I T FALLS TO AVO I D/O UTCO M E EXPECTAT I O N S/CO M P L I CAT I O N S/ MANAG E M ENT •

Patie nts should b e i nfo rmed that com p l ete resol ution i s d iffic u lt a n d n ot a l ways permanent.

•

Destructive modal ities su ch as c ryothera py a n d electrod es iccation can prod uce pigmenta ry c h a n ges a n d eve n sca rring if done too aggressively. Recu rrences a re

A

co m m o n . •

Loca l exc ision leaves a sca r.

•

Ora l thera py with isotret i n o i n is clearly an a lte rnative treatment a n d is n ot as efficacious as other mod a l ities and ca rries with it the risk of sign ifica nt side effects s u c h as teratogen icity, d ry s k i n a nd m ucous mem­ b ra n es,

h igh

skeleta l

hyperostosis,

triglycerides and l iver

c h oleste ro l ,

fu nction

d iffuse

a bnormal ities,

red uced n ight vision, pse u d otu m o r cere b r i , l e u ko pe n i a , possi ble d e p ress i o n , a n d s u i c i d a l i d eati o n . To pical treti n o i n can p rod uce s k i n i rritation . •

Laser thera py m ust be used with caution, especially i n dark s k i n phototypes, given t h e risk o f hyperpigmentatio n .

•

There ca n be sca rri ng, red ness, e d e m a , a n d c rusti ng, as shown i n Figure 1 5 . 3 . Recu rrence is n ot u ncom m o n .

B

Figure 1 5.3 (A) Sebaceous hyperplasia-before. (8) Improvement one

B I B L I OG RAPHY Aghassi D, Gonza l ez E, And erson R R , R ajad hya ksha M , Go nza lez S . E l u c i d ati ng t h e p u lsed -dye laser treatment of sebaceous hyperplasia in vivo with rea l-ti me confoca l sca n n i ng laser m ic roscopy. J Am Acad Dermatol. 2000; 43 ( 1 pt 1 ) :49-53 . Alste r TS, Ta nzi EL. P hotodyna m i c thera py with topical a m i nolevu l i n ic acid and pu lsed dye laser i rra d iation for sebaceous hyperplas i a . J Drugs Dermatol. 2003 ; 2 ( 5 ) : 50 1 - 504. Kim SK, Do J E, Ka ng H Y, Lee ES, Kim YC. Combi nation of topica l 5-a m i nolevu l i n ic a c i d - photodyna m i c thera py with carbon d ioxi d e laser for sebaceous hyperplasia. J Am

Acad Dermatol. 2007 ; 56(3 ) : 523-524. R i c hey D F. A m i n o l evu l i n ic acid photodyna m i c thera py for sebaceous gla nd hyperplasia . Dermatol Clin. 2007 ;25( 1 ) : 59-65. Review. Schonermark M P, Sc h m id t C , Ra u l i n C. Treatment of sebaceous gland hyperplasia with the p u lsed dye laser.

Lasers Surg Med. 1997 ; 2 1 (4) :3 13-3 1 6 .

month after treatment with 1 450 nm diode laser 1 4 . 5 J/cm 2 , 35 ms cooling, single pulse per lesion

83

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TH RE E D isord e rs of Ecc rine G l and s

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Color Atlas of Cosmetic Dermatology

CHAPT E R 1 6

H ype rhid ros is

Hyperh i d rosis is t h e secretion o f excessive a m o u nts of sweat from the ecc ri ne sweat glands at rest a n d at normal room tem peratu re . It pro d u ces both physica l a n d soc i a l d iscomfort. The m ost com m o n l y affected a reas a re the axi l lae, pa l m s , a n d pla nta r feet. I t can present i n a b i lat­ eral o r sym m etric fas h i o n . The m ost c o m m o n cause of hyper h i d rosis is i d i o path i c .

EPI DEM I O LOGY Incidence: no good e p i d e m i ologic stu d i es of p reva lence. Age: pa l mo p l a nta r: b i rt h ; axi l l a ry: p u be rty. Race: no rac i a l pred i l ection . Sex: eq ua l . Precipitating factors: i d i o path ic, emotiona l , centra l nervous system injury/d isease, d rug, s u rgica l i nj u ry a re the most common ca uses. In most cases, there is a fa m i ly h i story.

Figure 1 6 . 1 An example of the starch-iodine test in the left axilla. Note

PATHOG E N E S I S Ecc rine glands a re primarily i n nervated b y sym pathetic fibers that a re c h o l i n ergic rather t h a n ad renergic in n e u ra l response.

PHYS I CAL F I N D I N G S •

Pa l m o pla nta r: excessive sweat a n d sweat d roplets p ro­ d uc i n g a moist a p pea ra n ce a n d c l a m m y feel

•

Axi l l a ry: sta i n i ng of s h i rts i n the u nd e ra r m a rea

D I F F E R E N T I A L D I AG N OS I S C l i n ical a p pea ra nce d oes n ot s u ggest other d isord ers .

LABORATORY EXAM I NAT I O N Sta rch-iod i n e or n i n hyd rin test a re usefu l i n d efi n i ng a reas of sweati ng ( Fig. 1 6 . 1 ) .

D E R M ATOPAT H O LOGY N o c h a racteristic fi n d i ngs . B i o psy plays no ro le i n m a n ­ agement.

COU RS E Does n ot remit sponta neously; may i m p rove sl ightly with age .

the prominent dark blue-black discoloration at sites of hyperhidrosis

Sect i o n 3 : D i so rd e rs of Ecc ri n e G l a n d s

KEY CO N S U LTAT I V E QU EST I O N S •

Med ication h i story

•

Past treatments a n d response

•

Assess fo r syste m i c a bnormal ity

•

Recent s u rgery

HYPERHIDROSIS

Antipersp i rant Botox M e d i cation

Antipersp i ra nt •

F i rst l i n e t reatment

•

A l u m i n u m c h l or i d e (20%-25%)

S u rgery

a p p l ied in the eve n i ng 2-4 t i m es per week

MANAG E M ENT

•

Effective for many patie nts

•

Dryness and i rritat i o n are m a i n s i d e effects

Botox

T h e goa l o f the treat m e n t is t o s u bsta ntia l l y d e c rease sweat p rod u c t i o n to i m p rove p h ys i ca l a n d soc i a l d i s­

o

Botu l i n u m tox i n type A ( Botox)

most com m o n l y used .

co mfort, n ot c o m p l ete e l i m i nati o n . T h e re a re m u lt i p l e

•

Average dose, 50- 1 00 u n i ts per axi l l a

o

Safe, h i g h l y effect ive 3-9 months

treat m e nts fo r h y pe r h i d ros i s ( F i g .

o

Expensive if not covered by i n surance

1 6 . 2 ) . Botu l i n u m

tox i n A i s a very effective treat m e n t p rov i d i ng tem po­ ra ry red uction in sweati n g . To p i c a l a n d ora l m e d i c a ­ t i o n s a re o n l y m o d estly effective . S u rg i c a l t h e ra py, i n c l u d i ng l i pos u c ti o n , is m o re effective tha n to p i ca l t h e ra py.

M e d i cati ons •

Com pensatory hyperh id rosis sec o n d a ry to sym pathec­

Antich o l i nergics; h igh

i n c i d e nce of side effects

tomy l i m its its use at present except as a fi n a l therapeutic modal ity.

. . . . .. . . . . . . . . ..

TOP I CAL M E D I CATI O N S •

A l u m i n u m c h loride hexahyd rate .

hyd rate solution in etha nol with o r without occ l usion to u nshaven sk i n for 6 to 8 h o u rs n ightly for 3 to 4 days ca n be benefi c i a l but is com pl icated by loca l i rritati o n . R etreatment once or twice wee kly for m a i n ­ tenance is reco m m e n d e d . Treated s k i n s h o u l d b e washed t h e fol lowi ng m o r n i n g . - I n the axillae, it is a p pl ied at n ight to u nshaven s k i n a n d washed off i n t h e morn i n g . - Freq u ency o f a p pl ication d i m i n ishes w i t h i m p rove­ ment. Ta p water iontophoresis can be effective. - The proced u re req u i res conti n u a l a p p l i cation for 1 5 t o 2 0 m i n utes 2 t o 3 ti m es per wee k . - B l istering a n d b u r n i ng have been reported as s i d e effects. - Contra i nd ications i n c l u d e p regnancy, ca rd iac pace­ m a kers, and m etal i m pl a nts.

ORAL M E D I CATI O N S Oral a ntichol i n e rgics i n c l u d i ng born a p r i n e , glycopyrro­ nium

brom i d e ,

propa nth e l i ne,

and

metha ntha l i ne

b rom ide a re of l i m ited efficacy. They prod uce d ose­ related a ntichol i n ergic side effects.

•

Consider if a l l other t h e ra py fa i l s

•

E n d osco p i c thora c i c sympath ecto my; m ost

effect ive for pa l mar or fac i a l hyper h i d rosis

- Appl ication of 1 0 % to 30% a l u m i n u m c h loride hexa­

•

S u rgery

•

H ig h l y effect ive proced u re w h e n performed by a

s k i l l ed spec i a l i st

Figure 16.2 Hyperhidrosis treatment diagram

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S U RG E RY

N o r m a l i n n ervat i o n Eccr i n e

S u rgica l proced u res i nc l u d e the fol lowi ng: •

Endoscopic

or

c l assic

sym path ecto my

Sympathet i c n erve

is

Acety l c h o l i n e

usua l ly

sweat gland

reserved as a fi n a l therapeutic option for pa l m a r hyper­ h i d rosis. S u rgery p rovides long-lasting control . Genera l a n esth esia is req u i red . S i d e effects i n c l u d e bleed i ng,

I n nervat i o n b l oc ked by Botox

sca r formatio n , i n fectio n , reaction to a n esthes i a , com­ pensatory hyperh i d rosis, gustatory sweating,

pneu­

moth orax, a n d Horner's syn d ro m e . •

Li posuction for axi l l a ry hyperh id rosis i n volves su bder­

Acety l c h o l i n e

--+ X

Selective g l a n d rem ova l is reserved f o r axi l l a ry hyper­ h i d rosis.

•

--•IIII X Sym pathet i c n e rve

Figure 16.3 Mechanism of action of Botox in hyperhidrosis. Blocking acetylcholine release from cholinergic presynaptic vesicles

m a l l i posucti on . The l i posuction ca n n u la is held with the bevel side up at the s u bdermal level for sucti o n i ng of this regi o n .

BOTU L I N U M TOX I N A Botu l i n u m tox i n A provides tem pora ry effective treatment fo r this cond ition . I t is a bacterial tox i n that dec reases sweating by i rrevers i bly blocking a cetyl c h o l i n e release from c h o l i n e rgic p resyna ptic vesicles ( F ig. 1 6 . 3 ) .

• A n e st h es i a •

Topical a n esthetic c rea m a nd/or ice ge nera l ly ca n p ro­ vide sufficient a n esthetic effect.

•

Sti l l , nerve blocks s h o u l d be considered prior to pla nta r a n d pa l m a r treatme nts to m i n i m ize the associated pa i n . - P l a nta r: s u ra l a n d posterior ti b i a l nerves - Pa l m a r : u l n a r a n d med i a n nerves

• Treat m e n t •

A sta rc h - i od i n e test perfo rmed prior t o treatment can h e l p d e l i n eate the a reas to be injected . Iodine is placed on the affected a rea , fol l owed by the a pp l ication of cornsta rch p rod u c i n g a pro m i nent d a rk bl u e- bla ck d is­ colorat i o n . The sta rch-iod i ne paste s h o u l d be washed off prior to Botox i njections.

•

Effective Botox d i l utions va ry. A Botox A ( 1 00 U/via l ) d i l ution o f 2 . 0 U/0 . 1 c c i s effective .

•

t

I njecti ons a re performed at 1 to 2 em i nterva ls i ntra d e r­ m a l l y t h roughout the affected a rea ( Figs. 1 6.4, 1 6 . 5 a n d 1 6 . 6 ) . Two u n its s h o u l d b e i njected p e r site .

•

A tota l d ose ra nging from 50 t o 1 00 U/axi l l a , pa l m , o r s o l e can be i njected , for a tota l d ose o f 1 00 t o 200 U for both treatment sites. A decreased d ose can be used for l oca l i zed hype r h i d rosi s.

•

Tem po ra ry h a n d a n d fi nger m uscle wea kness may be a

Figure 1 6.4 Appropriate injection sites of botulinum toxin A for

c o m p l ication of pa l m a r botu l i n u m tox i n A i njections,

treatment of (A) palmar hyperhidrosis and (B) axillary hyperhidrosis. Each injection should be approximately 1 to 2 em apart

especia l ly with i n c reasi n g d osages . Patie nts should use

Sect i o n 3: D i so rd e rs of Ecc ri n e G l a n d s

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caution when ho l d i ng c u ps a n d other o bj ects s u p­ ported by the thenar m uscle w h i l e the wea kness is p re­ sent. T h i s wea kness ge nera l ly d issi pates with i n 3 to 4 weeks . •

Decreased sweati n g is o bserved with i n 1 to 2 weeks .

•

Side effects may i n c l u d e loca l m uscle wea kness for pal­

Benefits ge nera l ly a re n oted between 3 a n d 9 months. m a r i njections, bru isi ng, a nti body resista nce, a n d ra rely an a n a phylactic reactio n . •

T h e efficacy o f botu l i n u m tox i n i njections is not affected by laser h a i r rem ova l in the sa me a rea of treatment.

• M ed i c at i o n s •

Antichol i ne rgics; h igh i n c i d ence of s i de effects

P I T FALLS TO AVO I D •

Figure 16.5 Injection sites marked on right axilla of a male prior to botu­

Tem porary h a n d a n d fi nge r m usc l e wea kness may be a c o m p l ication of pa l m a r i njections of botu l i n u m tox i n A, espec i a l ly with i n c reasing d osages .

•

Botox i nj ecti ons are contra i n d i cated i n patients with u n d erlyi ng n e u ro m u sc u l a r cond itions as wel l as in p regna nt and lactating patie nts.

•

Decreased d oses s h o u l d be consid ered fo r patients on a ngiotensin-converting enzyme (ACE) i n h i bitors, wh i c h ca n potentiate Botox effects.

•

It is i m porta nt to cou nsel that the benefits of Botox a re te m po ra ry a n d req u i re repeat treatments.

•

None of the thera pies is u n iversa l ly efficacious. The patient m u st be awa re that the treatm ent end point is a red uction i n sweating a n d n ot c o m p l ete e l i m i nation .

•

Treatment side effects may be considera ble d e pend i n g on the treatment c h ose n , a n d m ust b e revi ewed a t d e pth with t h e patient prior t o a n y treatment i n itiati o n .

B I B L I OG RAPHY Ca m panati A, Laga lla G , P e n n a L, Gesu ita R , Offi d a n i A . Loc a l n e u ra l block at t h e wrist for treatment o f pa l m a r hyperh id rosis with botu l i n u m toxi n : Tec h n ical i m prove­ ments . J Am Acad Dermatol. 2004 ; 5 1 (3) :345-348. G laser

DA.

Treatment

of

axi l l a ry

hyperh i d rosis

by

c h e modenervation of sweat gla nds using botu l i n u m tox i n type A . J Drugs Dermatol. 2004;3 ( 6 ) : 627-63 1 . G o h C L . A l u m i n u m c h l oride hexa hyd rate versus pa l m a r hyper h i d rosis. lnt J Dermatol. 1 990;29:368-370. G regoriou S , R igo pou los D, M a kris M , et al. Effects of bot­ u l i n u m toxi n-a thera py for pa l m a r hyperhid ros is in p l a n ­ ta r

sweat

496-498.

prod uctio n .

Dermatol Surg.

201 0;36(4) :

linum toxin A injection

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Color Atlas of Cosmetic Dermatology

H a m m H . The place of botu l i n u m tox i n type A in the treatment

of

foca l

hyperh i d rosis.

Br

J

Dermatol.

2004; 1 5 1 (6) : 1 1 1 5- 1 1 2 2 . Heckma n n

M,

Ceba l l os- Ba u m a n

AO,

Plewig

G.

Bot u l i n u m tox i n A f o r axi l l a ry hyperh i d rosis (excessive sweat i n g ) . N Eng/ J Med. 200 1 ;344:488-493. H erbst F, Plas EG, Fuggo R, F ritsch A . Endoscop i c tho­ racic sym pathectomy for pri m a ry hyperh i d rosis of the u pper l i m bs : A critical a na lysis and long-term res u lts in 480 operations. Ann Surg. 1 994;220: 86-90. Lowe N, Ca m pa nati A, Bodokh I, et a l . The use of topical glycopyrrolate i n the treatment of hyperh id rosis. Clin Exp Dermatol. 1998;23: 204-205. Pa u l A, Kra nz G, Sc h i n d l A, Kra n z G S , Auff E, Syc ha T. Diode laser h a i r rem ova l d oes not i nterfere with botu­ l i n u m tox i n A treatment aga i n st axi l l a ry hyperh i d rosis. Lasers Surg Med. 2010;42(3 ) : 2 1 1 -2 1 4. R e i n a uer S , N uesser A, Schauf G , H olzle E . I o ntophoresis with a lternati ng c u rrent and d i rect c u rrent offset (A/C ion­ to phoresis): A n ew a p p roac h fo r treatment of hype r h i d ro­ sis. Br J Dermatol. 1993 ; 1 29 : 1 66- 1 69 .

Figure 1 6 . 6 The sites of hyperhidrosis

FOUR D isord e rs of H air Fo l l ic l es

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CHAPT E R 1 7

Hirsutis m

H i rsutism rep rese nts a male pattern overgrowth of term i­ n a l a n d vel l us h a i rs i n women . Fa r fro m be i n g solely a cosmetic concern , h i rsutism can be a n i m porta nt m a n i­ festation of an u nderlying endocrine d isord e r a rising from i n c reased a n d roge n i c activity. Ofte n , it res u l ts from a n ove rprod uction of a d re n a l a n d ova ri a n hormones a n d m a y acco m pa ny oth e r s i g n s o f v i r i l izatio n . I ts a ppea ra nce prod u ces soc i a l a nxiety,

d i stress,

and

ostracism

in

affected patients. I t a l so merits a n a p pro p riate med ical work u p . By contrast, hypertrichosis feat u res fi ne h a i rs in a n d roge n-sens itive as wel l as a n d rogen-i nsensitive a reas. Normal ra c i a l and eth n i c va riations may cause confusion with these d isord ers .

EPI O E M I O LOGY Incidence: com m o n . Age: u s u a l l y postpu berta l b u t age o f o nset ca n va ry i n t h e setti ng o f med icati o n , t u m o r, or endocrine a b normal ity.

Race: rac i a l a n d c u ltura l factors affect the perception of what constitutes a bnormal h a i r growt h . S k i n type affects treatment options as wel l .

Sex: fe m a l e . Precipitating factors: h i rsutism is ca used b y a h ost of endocrine

a bnorma l ities.

Ad rena l

ca uses

include

C u s h i ng's d isease, ecto pic ad renocorticotropic hormone (ACT H J prod ucti o n , p r i m a ry a n d rogen-prod u c i n g neo­

Figure 1 7 . 1 Spot size, 8 mm versus 1 5 mm. Larger spot sizes penetrate

plasms, and congen ita l a d re n a l hyperplasia . Ova r i a n

deeper and allow quicker treatments

causes can be related to polycystic ova ri a n synd rome a n d p r i m a ry t u m o rs a m o ng oth e r causes. F i n a l ly, med­ ications

suc h

as

o ra l

contrace ptive

pills,

a n a bo l i c

steroids, a n d a n d roge ns may ca use h i rsutis m .

PHYS I CAL EXAM I NAT I O N There i s a n overgrowth o f h a i r i n a n d rogen-sensitive h a i r fo l l icles. C o m m o n sites i n c l u d e t h e bea rd a rea o f the face, c h i n , prea u ri c u l a r face, l i nea a l ba , pe r i a reola r a rea , a n d c hest. Depend i ng on the severity of the cond ition , other signs of v i r i l ization such as i nc reased m uscle mass, deep vo ice, male pattern h a i r loss, and c l itora l e n l a rge­ ment may be prese nt.

D I F F E R E N T I A L D I AG N OS I S W h i l e both h i rsutism a nd hypertric h osis featu re h a i r over­ growt h , these conditions ca n be d iffe re ntiated by the location and q u a l ity of the hair growth . H i rsutism is c h a r­ a cterized

by term i n a l

h a i r overgrowth

i n a n d rogen­

d e pendent a reas, wh i l e hypertrichosis featu res fi ne h a i rs

Figure 1 7 . 2 Hair trimmed prior to treatment

Sect i o n 4 : D i so rd e rs o f H a i r Fo l l i c l es

in a n d roge n-sensitive as wel l as a n d rogen-i nsensitive a reas. Normal rac i a l a n d eth n i c va riations may cause confusion with these d isorders.

LABO RATORY TESTS The la boratory workup should be gu ided by the patient's c l i n ical fi n d i ngs as wel l as by a deta i l ed patient h istory. Testing ca n hel p esta blish if there is an a d renal or ova ria n sou rce of the h a i r growth . Ova ria n , a d re n a l , a n d pitu ita ry tu mors should be ruled out in cases of ra pid onset by a n endocri n ologist a n d/or a gynecologist. Tota l testosterone levels, dehyd roepiand rosterone su lfate levels, u r i n a ry free cortisol levels, d exa methasone s u ppression test, prolacti n levels,

ACTH

sti m u lation,

l ute i n izing

hormone/foll icle­

sti m u lating hormone ( LH/FS H ) ratio, 1 7- hyd roxy proges­ terone levels, a n d pelvic u ltrasou n d may a l l present i m por­ ta nt com ponents of a thorough endocri nologic work u p .

CO U RS E Cou rse i s dependent o n t h e etiology o f t h e h i rsutism .

KEY CO N S U LTAT I V E QU EST I O N S •

Menstru a l h istory-reg u l a r or i rreg u l a r

•

Med ication h i story

•

O nset a n d p rogression of sym pto ms

•

Fa m i ly h i story of i nfla m m atory cystic acne and h a i r loss

•

H istory of endocrine a bnorma l ities

Figure 17.3 Laser light firing

MANAG E M ENT T h e pri m a ry goa l o f t h e treatment is t o d eterm i n e the u nderlying cause of h i rsutism a nd treat. After d eterm i n ­ i n g t h e ca use a n d e n s u r i n g a pp ropriate med ical thera py, the goa l ca n tra n s ition to reversi n g the a bn o r m a l h a i r growth . There a re m u lti ple mea ns b y w h i c h tem po ra ry a n d perma nent h a i r rem ova l can be ach ieved .

• C o n s u l t at i o n w i t h E n d oc r i n o l ogy I n cases of h i rsutism, the fi rst priority is to u n cove r the sou rce of the a be rra nt hair growth . N u merous la boratory i n vestigatio n s, as d eta i led a bove,

may be req u i red .

Consu ltation a nd referra l to a n en docri n ologist is stro ngly recom men d ed as pa rt of such a worku p .

• N o n l a ser T h e ra p i es There a re severa l tem pora ry means to con cea l h a i r ove r­ growth . They i n c l u d e m a ke u p , b l ea c h es, a n d hyd roge n perox i d e . S havi ng a lso c a n te m pora ri l y h id e h a i r growt h .

Figure 1 7.4 Characteristic posttreatment perifollicular erythema

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H a i r remova l can be ach ieved with d e p i lati o n , e p i l a ­ t i o n , l a s e r thera py, e l ectrolysis, a n d to pical eflorn ith i n e .

Depi lation Depi lation is the process of removing pa rt of the h a i r shaft. Its effects a re tem pora ry. There a re c h e m i c a l a n d mec h a n ical methods o f d e p i lati o n . C h e m i c a l depi latories, such as th ioglycolate sa lts and su lfides of a l ka l i m eta ls, d issolve hair shafts. They can prod uce loca l ized i rritati on at the site of treatment. Mecha n i c a l depi lation c a n be q u ite crude i n c l u d i ng shaving of h a i r as we l l as r u b b i n g h a i r w i t h a p u m ice stone.

E p i lation Epi lation is the process of removing the enti re hair shaft. I t provides more longevity tha n d e p i lation but is not per­ manent. It i n c l udes waxi ng, p l u c k i ng, t h rea d i ng, a n d e l ectrical d evices t h a t re move t h e h a i r shaft. Eac h of th ese o ptions is relatively i n expensive but can prod uce pa i n and irritation as side effects . P l u c k i n g can res u lt in loca l ized i nfection , i ngrown h a i rs, and even sca rring. Eac h of these treatm ents can be used i n com bi nation with topical eflorn ith i n e on the face of wo m e n .

Top i c a l eflorn i th i ne (Va n i qa) To pical eflorn ith i n e twice d a i ly has been a p proved by the U . S . Food a n d Drug Ad m i n istration ( F DA) for tem pora ry h a i r remova l on the face of wome n . It s h o u l d o n l y be used on the face a n d not on other pa rts of the body. It decreases the rate of hair growth by i n h i biti ng ornith i n e d eca r boxylase . I t s h o u l d be used i n conj u nction with other h a i r remova l methods, such as shaving, waxing, or p l u c k i ng.

Patie nts

should

use the

med ications for

Figure 1 7 . 5 Bizarre growth of back hair on a male due to poor technique

8 weeks to j u dge its efficacy. If there is n o i m provement after 8 weeks, the med ication should be d isconti n ued . If the

med i cation

works,

it

should

be

conti n ued .

Disconti n uation of treatment resu l ts in a res u m ption of h a i r growt h . S i d e effects i n c l u d e loca l irritation . It s h o u l d n ot be used d u ri n g pregnancy.

• E l ectro l ys i s • •

Remova l can be permanent. El ectrolys i s uses d i rect e l ectrica l c u rrent to d estroy the dermal pa p i l l a of t h e h a i r fo l l ic l e . A fi ne need le placed d i rectly i nto the h a i r fo l l i c l e d e l ivers the e l ectri c a l c u rrent to the fo l l i c l e's b a s e w i t h o u t p rod u c i ng sca r­ r i n g . T h e site of treatment is shaved severa l d ays prior to thera py and to pica l a n esthetic c rea m ca n be used 1 hour prior to the p roced u re to red uce pa i n . Side effects i n c l u d e sca r, hy po-/hyperpigmentat i o n , and i nfecti o n . I t i s m ost a p p ro p r i ate fo r s m a l l a reas of treatment.

•

Need for m u lt i p l e treatm ents for l i m ited treatment zon e .

•

G reater r i s k o f side effects, pa i nfu l .

•

N ot practical fo r la rge a reas o f the body.

Figure 1 7 . 6 Extensive dyschromia secondary to inappropriate fluence and pulse duration

Sect i o n 4 : D i so rd e rs of H a i r Fo l l i c l es

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• Laser h a i r re m ova l Lasers a re the treatment of choice for permanent red uc­ tion of u nwa nted , pigmented term i n a l hair fol l icles. Laser h a i r remova l is q u ic k , relatively n o n pa i nfu l , espec i a l l y compared to e l ectrolysis. Fu rthermore, it ca n cover a fa r m ore exte nsive a rea of affected s k i n with less pa i n in less ( i e , i m proper spaci ng and overla p) time. An average of five to seven treatments a re needed for greater tha n 50% red ucti o n .

Mechan ism of a cti on Lasers a re based on the selective p h otothermo lysis. The l ight is a bsorbed

by the

pigment i n

hair fol l i c les.

Therefore, if h a i r fol l i c l es have no pigment ( ie , blond or gray h a i r ) , lasers d o n ot work. Lasers work best o n t h i c ke r h a i r fol l ic l es .

A

.._______________________....,

• Pat i e n t Co n s u l tat i o n •

H a i r color.

•

S k i n type-a l l s k i n types ca n benefit from laser h a i r remova l .

•

Past med ical h i story.

•

Med ications.

•

Past treatments .

•

E m p hasize the n e e d for five t o seven treatments on a n average t o re move t h e majority o f u nwa nted h a i r.

• •

•

I m provement is va r i a b l e . Low risk o f no i m p rove ment or i n c reased h a i r (es pe­

B

c i a l ly in fe ma les of Med iterra nea n he ritage ) .

Figure 1 7 . 7 (A) Appearance of skin prior to laser hair removal. (B) Hair on

R isk o f hyper- or hypopigme ntation that m a y last

lateral cheeks

months; rarely perma nent. • •

Sca rring is ra re. Like l i hood of at l east some pa i n ; the a m o u nt of pa i n assoc iated with t h e proced u re is a refl ection o f t h e cal­ i be r a n d d e nsity of hair i n the treated regio n .

•

Ideal ca n d idate h a s d a r k cou rse h a i r a n d l ight s k i n phototype.

• •

Average ca n d i d ate-fi ne/l ight brown h a i r Poor ca n d i date-blond/gray h a i r s h o u l d n ot b e treated with

a

8 1 0-n m

d iode

laser

with

c u r rent

lasers .

Ad d itional ly, pati ents with u n rea l i stic expectations or med ic a l contra i n d i cations should not be treated .

• Pat i e n t Co n s u ltat i o n P r i o r to

Treat m e n t •

S u n avoidance is crucia l . If a patient is ta n ned , t h e pro­ ced u re s h o u l d be postponed u nt i l the ta n com pletely

Figure 17.8 Appropriate clinical endpoint of perifollicular erythema in

fa des. If the proced u re is performed on ta n ned ski n ,

this 24-year-old female with type VI skin and polycystic ovarian syndrome treated with the long-pulsed 1 , 064-nm Nd: YA G laser

t h e risk o f dysc h ro m i a i s ma rked l y i n c rease d .

I

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Color Atlas of Cosmetic Dermatology

Shave h a i r prior to a rrivi ng i n the offi ce. Alte rnatively, the h a i r can be tri m m ed in the office with a moustache tri m mer. T h i s w i l l foc us the majority of energy to the pigme nted hair fol l i c l es i n the ski n .

•

A topica l a n esthetic crea m ca n b e a p p l ied 1 h o u r prior to thera py to decrease the pa i n d u ri n g the proced u re . I t is i m porta nt t o advise the pati ent t o a p ply to pical a nes­ thetic over a l i m ited s u rface of the s k i n to avoid a ny risk of l i doca i ne toxicity.

•

H a i r waxing s h o u l d not be performed 2 to 3 weeks before treatment.

•

If there is a h i story of recu rrent herpes s i m plex vi rus, prophylaxis should

be

provided

before

laser

hair

remova l on face. •

P regnancy: there a re no clear stud ies dem onstrating safety or risk. I t is i m porta nt to edu cate pregn a n t patients desi ri ng h a i r re mova l as t o this uncerta i nty. M ost physicians wi l l not treat patients w h i l e pregna nt. If treatment is p u rs ued , it is recommended to treat only l i m ited a reas d u ri n g t h i rd tri meste r after m e d i ca l clear­ a nce from an o bstetric ia n .

• J u st P r i o r to Treat m e n t •

Written consent

•

Ph otogra phy

•

Tri m h a i r

• Laser H a i r R e m ova l Tec h n i q u e

( F igs.

1 7 . 1 - 1 7 . 8)

(Ta b l e

17. 1)

Key concepts for o pti m a l resu lts a re as fo l l ows : •

For s k i n types I to I l l , use relatively h igh energy with a shorter pu lse d u ration for o pti m a l resu lts.

TAB L E 1 7 . 1

•

Laser Hair Remova l Technique

Laser type R u by

Safest s k i n type I-I I I

Wavelength ( n m l 694

P u lse d u rati o n

Energy (J/cm 2 l

1-20 ms

1 0-40 J/c m 2

Comments Fi rst laser used for h a i r rem ova l ; slower to use

Al exa nd rite

I-I I I

755

Skin types I-I I I 3 ms; skin types I l l and I V

Diode

1-V

810

S k i n types I-I I I 20-25 J/cm 2 ; s k i n

1 0-20 ms

type I V 1 5-20 J/cm 2

3- 100 ms

30-40 J/cm 2

3 ms and 1 0-20 ms pu lse d u ration demonstrate eq u a l efficacy Longer p u lse d u ration for treatment of s k i n types IV and V

N d : YAG

I-V I

1 064

S k i n types I-I I I 1 0-20 ms; ski n types IV-VI 25-100 ms

I ntense p u lsed I ight-noncoherent l ight

I-I V

550- 1 200

1 . 5-3 . 5 ms

Skin types I-I I I 30-50 J/c m 2 ; skin types

Safest d evice for rem ovi ng h a i r i n s k i n

I l l-V I 25-35 J/c m 2

types I V-V I

25-50 J/cm 2

M ost va riable resu lts

LAS E R SAFETY Hazard: o c u l a r Da ngers

E n h a n c e Safety

Cornea , ret i n a , or lens

Base l i ne eye exam

can oc c u r f r o m d i r e c t exposure re f lec t ed beams, I . e .

equ a l to or greater t h a n

can be da m aged

Laser goggle optrcal

Damage

densrty (00) shou ld be 7 (c h ec k gogg l es)

or

I nspect goggles for vrsible damage or

pat ien t jewel ry, watches

degradation of t h e f i l ler med ia

Q-sw itc hed lasers are

Always c heck that appropriate gogg l es for

most hazardous, can

wavelength are used

cause b l i n d ness

Remove, e bon ize or cove r any ref lect iVe

� �

)

r cornea Lens

surfaces in laser room , i .e . m i r rors, meta l l ic garbage cans Remove pat ient jewe l ry, watches

H a z a r d : fire Dangers All lasers c a n pote n t i a l l y

cause fire hazards

su rfaces i n l a se r room , i.e. m irrors, metal l ic

Most common ly seen w i t h C02

E n h a n c e Safety R emove . ebonrze. or cover any relfectrve

lasers

garbage cans Avoi d alcohol or ensure that it i s f u l ly vapori zed prior to st a rt of

Damage can oc c u r f r o m d i rec t exposure or ref lected beams

treatment

Drape treatment srte wrth wet Remove a l l f lamm a b l e

t owe l s,

d rapes

gauze or

items, i . e .

dry

towe l s

gauze,

Coat exposed harr w i t h water-based j e l l y Decrease F i02 t o

40%

e ndotrac heal t u bes

H a z a r d : p l ume,

sp l att e r, infection

Dangers

E n h a n c e Safety

I n tact v i r rons and viral

Use mask

D N A such as

when treat r ng near

H PV

B

may

be present rn the p l u m e of COz l asers

Smoke

evac uator

nssue part i c les can splatter a n d aerosol ize with Q·switched lasers

Hazard: el ectrocution Dangers

E n h a n c e Safety

Even

O n l y q u a l i f ied laser tec h n r c rans should

with power off,

ca n ca use shock/

e l ec t rocu t i o n

open l ase rs

Check for water s p i l ls, hose ruptures or condensations

H a z a r d : general Dangers A n t i c i pate da ngers

E n h a n c e Safety Always r m mcd iatcly put laser on standby

mode when not treat rng pa t ren t E n s u re proper srgn rs on the door of laser room Ed ucate staff members as to laser safety

Figure 17.9 Laser safety. It is important to emphasize that lasers present special safety concerns for physicians, staff, and patients. Among the risks are ocular injury, fire, electrocution, and dissemination of infectious disease. No lasers should be operated in the absence of a detailed knowledge of laser safety issues between the physician and the staff. Educating staff members is an essential component of safe laser practices. Periodic laser safety training is required by many hospitals and remains good practice for private physician offices as well. (A) Patient and all personnel are wearing protective eyewear. Note gauze is moist to reduce the risk of fire. (8) Smoke evacuator. (C) Safety sign placed outside appropriate laser room to ensure proper warning of laser use

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•

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Color Atlas of Cosmetic Dermatology

S k i n types IV to VI m u st use l onger pu lse a n d lo nger wavele ngth such as a 1 064- n m YAG .

•

If u n certa i n as to treatment pa ra m eters, perfo rm test

LASER A N D EYE INJ U R I E S

sites with va ria ble fluencies a n d p u lse d u rations. •

gen , contact coo l i ng, or ge l . •

Opti m a l cool i n g setti ngs m ust b e util ized to lower the risk of d ysc h ro m i a .

•

Wavel ength ( n ml Lasers

Use l a rger s pot s izes for d eeper penetration a n d m o re Safety goggles for patient a n d med ical tea m .

•

Use the la rgest spot size possi ble for ta rget region .

•

Overla p laser p u lses 1 0 % over the enti re treatment regi o n .

• Postt reat m e n t I n st r u ct i o n s to Pat i e n t •

Ex pect red ness fo r u p t o severa l h o u rs afte r treatment.

•

If red ness o r pa i n persists for m o re than 1 2 h o u rs, ca l l t h e office. If there a re a n y c uta neous cha nges i n the s k i n the day afte r the p roced u re o r beyo n d , the patient m ust be to ld to conta ct the treati ng physic i a n .

•

O n c e red ness fades, patient may conti n ue t o wea r m a ke u p .

• •

Avoi d s u n for 4 8 h o u rs; no ta n n i ng. Hair remova l is not entirely i m med iate . Some hair wi l l fa l l o u t 1 t o 3 d ays after treatment.

•

Do not worry if some hair persists after treatment.

•

Ca l l the office if d iscoloration develops i n the treated sites.

•

Ca l l the office with q u esti ons or concerns.

P I T FALLS TO AVO I D/CO M PL I CATI O N S/ MANAG E M E N T ( F igs . 1 7 . 5-17 . 6) •

There is no effective mecha n is m for laser remova l of l ight or blond ha i r.

•

Excess ive fluenc ies or i ncorrect pu lse d u ration may prod uce epidermal d a mage and dysc h ro m i a . These effects a re typica l ly te m po ra ry but can be permanent. If there is a n y d o u bt rega rd i ng laser pa ra m eters, pe rfo rm a test site .

•

•

30().. 4 00 Exc 1 mer (308 n m )

yes

: yes

400-600 Argon (488 nm)

: yes

:

KTP

( 532 m n )

yes

Flash of the

em1 tted wavelength

fol l owed by

aften mage of a

complementary color

: yes

Pu lsed dye

laser

: yes

( 585-

600 nml

600- as N d : VAG 1 000 ( 532 n m )

: yes

as R u by

: yes

A lexa ndrite

: yes

D1ode

:

(694 n m )

(755 nm) (810 nm)

yes

detected as reh na lacks pam f i bers

a-switc hed lasers have h ighest pote n t i a l to

c a u se b l i n d ness

May produce a popping

sou nd, then v1sual

: yes

N d : VAG

: yes

D1ode

:

( 1 320 n m ) ( 1 4 50 n m ) yes

yes CO:! ( 1 0,600 n m )

yes

B u r n mg pam at the site of

exposure on the cornea o r sclera

Figure 1 7 . 1 0 Lasers and eye injuries

Coincident tattoos and lentigi nes may expe rience l ight­

(http:!lwww. eyesafety. 4ursafety. com/laser-eye-safety. h tm l)

A lways kee p contact coo l i ng aga i nst the s k i n to avo i d Overla p ( 10 % ) i n the treated zo n e . Do not leave "ga ps" that can c reate biza rre h a i r growth patte rns as h a i r regrows .

be

d i sorientation

1 000- as Nd: VAG 1 400 ( 1 064 n m )

1 4DO- Er: VAG 1 0000 (2940 n m )

Damage from a a-switc hed

N d : VAG l a se r m a y n o t

S k i n types IV to VI req u i re longer p u lse d u rations a n d

b u r n i ng. •

yes

fe ma les Precipitating factors: shaving in any region of the body

PATH OG E N ES I S T h i s d isord e r i s i n d u ced by shavi ng. Shaving sha rpens c u rled h a i r. Sha rpened , tightly c u rled h a i rs pierce i nto the ski n adjacent to the hair fo l l ic l e and i nvad e i nto the der­ mis prod u c i ng a n i nfla m matory reactio n . I t c a n a lso fol­ low hair p l u c k i ng, espec i a l ly i n fe m a l es with h i rsuti s m .

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Color Atlas of Cosmetic Dermatology

D E R M ATOPAT H O LOGY H a i r pe netration resu lts i n e p i d e r m a l i nvagi nation with associated m i c roa bscess , m i xed i nfla m m atory i nfi ltrate, and foreign body giant reaction at the tip of the i nvad i n g h a i r. Dermal fi brosis m a y b e o bserved .

PHYS I CAL LES I O N S M ost c o m m o n ly, i t presents with fol l i c u l a r pa p u les, pus­ tu les, and posti nfla m matory hyperpigme ntation in the bea rd a rea and a nterolatera l neck of ma les and u n d er­ a rms a n d biki n i a reas of fe males. Pa p u les can d eve lop i nto cysts. Sca r formation may be o bserved . The u p per c uta neous lip is typica l ly spared .

A

D I F F E R E N T I A L D I AG N OS I S Acne vu lga ris, fol l i c u l itis.

LABORATORY EXAM I NAT I O N None.

COU RS E Begi n s with shaving o r p l u c k i n g a n d conti n ues u nt i l cessation o r mod ification i n the h a i r rem ova l tec h n i q ue .

B

MANAG E M ENT

Figure 18. 1 (A) A young male with type VI skin phototype and pseudofol­

T h e goa l o f t h e treatment is t o prevent t h e formation of the pa p u les, pustu les, sca rring, a n d posti nfla m matory hyperpigmentation associated with this d isord e r. There a re m u ltiple treatment options ava i la ble to acco m p l ish this goa l . Cessation of shaving or p l u c k i ng is the m ost successful treatment but it is i m p ractica l a n d u ndesira b le fo r many patients . Laser thera py is h ighly effective with h igh patient satisfactio n .

TREAT M ENT • S h a v i n g Cessat i o n The most s i m ple, i nexpensive, a n d effective treatment for pseu d ofo l l i c u l itis is the cessation of shaving.

Many

patients w i l l fi nd this o p t i o n u nd es i ra b l e o r i m practica l .

• M o d i f i c at i o n of S h a v i n g Tec h n i q u e A proper shaving tec h n i q u e may preve nt o r sign ificantly decrease the risk of pse u d ofo l l i c u l itis. Among these prac­ tices a re l ifti ng, n ot p l u c k i n g i ngrown h a i rs, thoroughly

liculitis barbae prior to treatment. (B) Same patient 3 months later after several treatments with long-pulsed 1, 064-nm Nd: YAG laser. (Courtesy of E. Victor Ross, MD)

Sect i o n 4 : D i so rd e rs o f H a i r Fol l i c les

wetti ng the a rea prior to a pplying shaving c rea m , using a sharp razor, shaving i n the d i rection of the h a i r growth, a n d avo i d i ng shaving i n more t h a n one d i rection i n the sa m e a rea . The B u m p Fighter Razor p revents the shaved h a i r from being cut too short . Additional ly, c utting the h a i r twice d a i l y with h a i r c l i p pers p revents h a i rs from piercing i nto the skin.

• To p i c a l Treat m e n t To pical a nti biotics a re effective i n treati ng the i nfla m ma­ tion and occasional i m petigi n ization assoc iated with this conditi o n . To pical treti noi n , benzoyl peroxide, and gly­ colic acids can be h e l pfu l a dj u n cts.

• Laser H a i r R e m ova l ( F i g s .

and •

1 8.2)

18. 1

Laser h a i r remova l i s a safe, h ighly effective treatment modal ity for short and long-te rm i m provement.

•

S k i n types I to I l l - The long-pu lsed a lexa n d rite laser ( 755 n m ) , d iode laser (810 n m ) , i ntense pu lse l ight ( 590-1 00 n m ) ,

Figure 18.2 Pseudofolliculitis-laser therapy: pigmented versus

a n d long- p u lsed N d : YAG ( 1 064 n m ) laser have the

unpigmented hair follicle

a p pro p riate wavele ngths to selectively ta rget the c h ro m o p h ore mela n i n fou n d in the hair b u l b . - M u ltiple treatme nts (average o f 5- 1 0 ) every 4 t o 8 weeks ach ieve a n average of 50% to 75% perma nent red uction of fol l i c u l a r pa p u l es/pust u l es . •

S k i n types I V to V I - The long-pu lsed 1 , 064-n m N d : YAG l a s e r is the treat­ ment of choice in s k i n p h ototypes IV to V I . It is safe a n d effective . Long pu lse d u rations a re necessa ry fo r epidermal p rotection . P u lse d u rations of 30 to 1 00 ms a re genera lly recom m ended . O pti m a l flue nces

ra nge from 20 to 40 J/cm 2 . Treatment is performed

with nonoverla p p i ng p u lses uti l i z i n g coo l i ng to the epidermis via c ryoge n , contact coo l i ng, or gel . - N ewer ge neration d iode lasers with longer p u lse d u rations up to 400 ms can a lso be util ized with ca u ­ tion i n d a rker s k i n types. - Typical ly, 5 to 1 0 treatments spaced every 4 to 8 weeks a re needed for 50% to 75% perma nent red uctio n .

P I T FALLS TO AVO I D/O UTCO M E EXPECTAT I O N S/CO M P L I CAT I O N S/ MANAG E M ENT •

Ta n ned patients s h o u l d not b e treated with laser h a i r remova l . O n ce the ta n/i nfl a m mation su bsides, h a i r remova l can beg i n .

•

Do not p l u c k or wax h a i r prior t o o r d u ri ng t h e cou rse of laser h a i r remova l .

Figure 18.3 Etiology of pseudofolliculitis

I

101

1 02

•

I

Color Atlas of Cosmetic Dermatology

Patients with u n pigme nted h a i r ( b l o n d , gray, red ) wi l l not benefit from laser h a i r rem ova l a n d s h o u l d n ot be treated .

•

There is the risk of tra nsient a n d long-te rm hyperpig­ m entation and hypopigmentatio n . Tra nsient erythema, sca b b i ng, and risk of sca r formation also exist.

•

A majority of patients wi l l see 75% i m p rovement. A sma l l m i n ority w i l l see l ittle or no i m provement .

• •

Futu re m a i ntena nce treatments may be needed . A s m a l l m i nority of patients w i l l experience a paradoxi­ cal i n c rease i n hair growth, pa rt i c u l a rly fe ma les of Med iterra nean descent.

•

Treatment may n ot benefit p reexisting hyperpigme nta­ tion and wi l l n ot i m p rove sca rs.

•

A

I t is i m porta nt to i nform patients that side effects a re often delayed in s k i n p hototypes IV to VI a n d may not be o bserved for 1 to 2 weeks after treatment. Test s pot is a dvised fo r these patients ( Figs . 1 8 . 3 a n d 1 8 . 4 ) .

B I B L I OG RAPHY Battle EF J r, H o b bs LM . Laser-assisted h a i r remova l for d a rker s k i n types. Dermatol Ther. 2004; 1 7 (2 ) : 1 77 - 1 83 . B ridgema n-Shah S . T h e med ical a n d s u rgica l thera py of pseu d ofo l l i c u l itis barbae. Dermatol Ther. 2004; 1 7 ( 2 ) : 1 58- 163. Haedersd a l M , Wulf HC. Evi d e nce- based review of ha i r remova l u s i n g lasers a n d l ight sou rces. J Eur Acad

Dermatol Venereal. 2006;20( 1 ) :9-20.

B

Kontoes P, Vlachos S , Konsta nti nos M, Anastasia L, M yrta

Figure 18.4 (A) Test spot treatment under chin and on cheek is advised for darker skin phototypes before treating pseudofolliculitis. (B) Two weeks after test spot treatment, some hair removal is achieved with no pigmentary changes

S. H a i r i n d uction after laser-assi sted h a i r re m ova l a n d its treatment. J Am Acad Dermatol. 2006; 54( 1 ) :64-67. R oss EV, Cooke L M , Ti m ko AL, Overstreet KA, G ra h a m B S , Barnette DJ . Treatment o f pse udofo l l i c u l itis ba rbae i n s k i n types IV, V, a n d V I with a long-pu lsed neodym i u m : Yttr i u m a l u m i n u m ga rnet laser. J Am Acad Dermatol. 2002 ;47 ( 2 ) : 888-893.

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

CHAPT E R 1 9

I

M a l e Patte r n H ai r Loss

M a l e pattern h a i r loss c lassica l ly presents with bite m pora l

I

IV

II

IVa

II a

v

Ilia

Va

III

VI

III vertex

VII

h a i r loss that progresses t o t h e loss o f h a i r o n t h e vertex, fro nta l , a n d te m pora l sca l p . Parieta l a n d occi p ita l h a i rs a re usually u naffected . It is a no nsca rring forrn of a l o pe­ cia that occ u rs in gen etica l l y suscepti ble males. The gra d u a l involuntary loss of hair d oes cha nge the natura l fra m e h a i r provides a ro u n d o u r face. T h e gra d u a l loss of h a i r resulting in an i nvol u nta ry cha nge in a ppea ra nce c reates varyi ng d egree of emotional a nd psyc hologica l stress. M a ny men seek treatment fo r m a l e patte rn h a i r loss because o f u n ha ppi ness with its cosmetic a p pea r­ a n ce a n d association with aging.

E P I D E M I O LOGY Incidence: 30% of ma les older than 30 yea rs; more t h a n h a l f of m a l es o l d e r than 50 yea rs .

Age: begi ns after p u be rty. Precipitating factors: polygenetic i n herited pred is positio n . N o d iagnostic tests exist t o d eterm i ne t h e etio l ogy a n d natura l progression .

PATH OG E N ES I S The prec ise pathophysiology rema i n s u n k n own . This process is bel ieved to res u lt from both a polygenetic i n h erited suscepti b i l ity as we l l as a nd roge n i c sti m u lati o n . T h e m ost i m porta nt a n d rogen i n t h i s process is d i hy­ d rotestoste ron e . There is a d i m i n ution i n the size o f affected term i n a l fo l l i c les that regress t o become vei l u s fo l l icles that even­ tua l l y d isa p pea r. There is a n i n c rease i n telogen h a i rs and a decrease i n a nagen h a i rs .

PHYS I CAL EXAM I NAT I O N AN D NATU RAL PROG R ES S I O N Typica l ly, fronta l a n d tem pora l h a i r loss/th i n n i ng is pre­ sent first. T h i s beg i ns in pu berty a n d progresses ove r d ecades. The rate a n d extent of h a i r loss va ries from i n d i ­ vid u a l t o i n d ivid u a l . S o m e progress t o co m plete ba l d n ess in early 20s a n d others grad u a l l y t h i n over decades.

D I F F E R E N T I AL D I AG N OS I S I n ma les, the pattern of h a i r loss i s c h a racteristic s u ggest­ i n g no other d iagnoses.

Figure 19. 1 Norwood classification of the natural progression of male pattern hair loss

1 03

1 04

I

Color Atlas of Cosmetic Dermatology

TAB L E 1 9 . 1

•

M i noxi d i l and Finasteride-The Only Two FDA-Approved Medications for Male Pattern Hair Loss

M ec h a n is m of action

Fi nasteride

M i n oxi d i l

5-a red uctase type II i n h i bitor blocking the conversion of

U n known

testostero ne to d i hyd rotestosterone Key to success

E m p hasize m a i ntena nce ove r regrowth of h a i r and c o m p l i a n ce fo r at least 6-8 months to see ben efit

E m p hasize m a i ntena nce over regrowth of h a i r and com p l i a nce 6-8 months to see benefit

2% of men expe rience sex u a l d ysfu ncti o n . Revers i b l e with i n

S i d e effects

days i f d iscont i n ued

D ryness and pru ritus of the sca l p . R a re a l lergic reacti on

N o a l lergic reactions, bl ood m o n itori ng o r d rug i nteractions. P re m e n o pa use of fe ma les should never h a n d le or take medicati o n . Women may have some benefit C l i n ical onset of action

6-8 months

6-8 months

Dose

1 mg q d with o r without food

Two to fou r d rops one to two t i m es d a i ly to fronta l a n d vertex of sca l p

Ca n d i d ate selection N o rwood I I- IV

H ighly effective

H igh l y effective

N o rwood IV-V I I

Somewhat effective

Somewhat effective

LABORATORY EXAM I NAT I O N I n ma les, no laboratory work u p i s typica l l y req u i red .

M E D I CAL TH ERAPY • K ey C o n s u l tat i ve Q u est i o n s •

Age of onset

•

Rate of h a i r loss

•

Past med ical h istory

•

Med ications used to date a n d success of thera py

•

Patient expectation of a ny med ical or s u rgical thera py

• F DA-A p p roved M ed i c a l T h e ra py

(Ta b l e

19. 1)

M i noxid i l a n d fi nasteride a re the on ly two medications for male pattern h a i r loss a p p roved by the U . S . Food & Drug Ad m i n istration ( F DA).

HAI R TRA N S P LA N TAT I O N • Def i n i t i o n All patients s h o u l d expect consistently natu ra l a p pea ri ng tra nspla nted h a i r. Based on the theory of donor d o m i ­ na nce, h a i r fol l ic l es m a i nta i n t h e i r genetic d esti ny wher­ ever they grow on o u r sca l p . H a i r tra nspla nted from the posterior sca l p will grow fo r as long as it was ge netica l ly progra m med to grow. For the vast majority of m e n , tra n s­ pla nted h a i r wi l l grow for d ecades.

Figure 19.2 Unnatural "pluggy" hairline using 1 0 to 25 hair grafts.

Should never happen in twenty-first century

Sect i o n 4 : D i so rd e rs of H a i r Fol l i c les

I

1 05

H a i r nat u ra l ly grows in 1 to 4 h a i r fol l i c u l a r b u n d les. Contem pora ry hair tra nspla ntation uti l izes a la rge n u m ­ b e r o f 1 t o 4 h a i r fol l i c u l a r gro u p i ngs . The res u lt is consis­ tently nat u ra l a p pea r i n g tra nspla nted h a i r fo r men a n d wo m e n .

THE CON S U LT • K ey Q u est i o n s •

H ow long h ave you n oticed h a i r loss?

•

Rate of h a i r loss?

•

W h i c h m e d i cations, wheth er p rescri ption or a lternative,

•

Expectations?

have been tried and for h ow long?

• P h ys i c a l Exa m i n at i o n •

N o rwood stage ( F ig. 1 9 . 1 )

•

Donor density

•

Ca l i ber of h a i r fol l i c les - I d ea l c a n d i d ate : h igh donor density, t h i c k ca l i be r h a i r fo l l icle, rea l i stic expectation ( Figs . 1 9 . 3 a n d 1 9 .4) - Poor ca n d idate: poor donor den sity, below average h a i r ca l i ber, u n rea l istic ex pectations

• Key P o i nts to E m p h a s i ze B efore H a i r

Tra n s p l a ntat i o n •

Figure 19.3 Realistic expectations using 1 to 4 hair grafts. Before

N et perce ived dens ity fro m a h a i r tra ns p l a nt

=

the

Norwood V

n u m be r of hair fol l icles tra nspla nted-{)ngo i ng hair loss. •

F i n e hair fol l icles will c reate th i n natu ra l coverage , a n d t h i c k ca l i ber fol l icles wi l l c reate more perceived density.

•

O ngoi ng h a i r l oss w i l l affect the cosmetic a p pea ra nce of a tra nspla nt.

•

Visible donor sca r o r sca rs if h a i r is shaved o r c l osely c rop ped i n poste rior sca l p .

•

L i m ited d o n o r s u pply! Key to success: phys i c i a n and pati ent have s i m i l a r

expectations o f what t h e proced u re w i l l a n d wi l l not ach ieve over the short ( 1-3 yea rs) and

long term

( 1 0-20 yea rs ) .

• M ed i c at i o n a n d Tra n s p l a n tat i o n Med ication to m a i nta i n existi ng h a i r wi l l maxim ize the density from a tra ns p l a nt but med ications should a l ways rema i n elective . H a i r l i ne design a n d d istri bution of rec i pi­ ent sites should a lways ass u m e ongoin g hair loss.

Figure 19.4 Realistic expectations using 1 to 4 hair grafts. A fter 1 , 1 00

1 to 4 hair grafts

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Color Atlas of Cosmetic Dermatology

S U RG I CAL PROCED U R E • P reo p e rat i ve I n st r u ct i o n s •

N o s pecific b l ood tests

•

Medical clearance if a p p ropriate

•

Ph otogra phs

•

I nformed written consent sent to the patient for review at least 1 week before the p roced u re

• Day of P roced u re •

Written consent with postoperative i nstructions reviewed

•

I ntrod uce h a i r tra ns p l a nt tea m

•

Review p roced u re a n d goa ls with patient

Figure 19.5 Trim donor region with moustache trimmer, and tape hair up so donor suture will not be visible in the postoperative period

• D o n o r R eg i o n -O n l y L i m i t i n g Factor

i n H a i r Tra n s p l a ntat i o n ( F i g s . and

1 9 . 1 0)

19.5

An esth esia in donor region •

1 % Lidoca i n e w i t h 1 : 200, 000 e p i n e p h r i n e

•

30 t o 6 0 cc sa l i n e Sa l i ne i n d o n o r region p rovides •

a nesthesia

•

hemostasis

•

less tra nsection of hair fol l i c les

•

less l i kely to tra nsect the occi pita l a rteries

Donor harvesting tec h ni ques (Ta b l es 1 9. 2 a n d 1 9.3) •

El l i ptica l str i p h a rvesting: >95% of patients

•

Fol l i c u l a r u n it extractio n : 1 em have an increased risk of creating a hypertrophic scar

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

TAB L E 1 9 . 3

•

Fol l i c u l a r u n it extraction

M i n i m a l tra nsection of donor h a i r

Yes

No

N u m ber o f 1-4 grafts safely ha rvested p e r proced u re

1 , 500-2, 000

200-500

Ti me to ha rvest donor h a i r

1 5-20 m i n

1-2 h

Visi b l e d o n o r sca r with h a i r length > 1 e m

No

No

Visi b l e d o n o r sca r with h a i r length 95%

m a les ( 9 : 1 ) Precipitating factors: pregna ncy, ora l contraceptive p i l ls , s u n expos u re, hormone rep lacement thera py

PATHOG E N ES I S U n k nown .

D E R M ATOPAT H O LOGY In epidermal melasma, there is i n c reased mela n i n d e po­ sition in the epiderm is, pa rti c u l a rly in the basa l a n d su pra basa l layers . I n d e r m a l melasma, there a re perivas­ c u l a r m e l a n i n-conta i n i ng macrophages i n the su perfi c i a l a n d m iddermis. M ixed-type m e l a s m a exh i b its featu res of each of the a bove fi nd i ngs.

PHYS I CAL L ES I ON S Patients p rese nt with wel l -d e m a rcated l ight b rown to d a r k b rown sym m etric m a c u l a r hyperpigmentati o n . I n a p p roxi mately two-th i rd s of pat i e n ts i t a p pea rs o n the centra l fa ce i n c l u d i n g t h e fo rehead , n o s e , u p per c uta neous l i p, and c h i n . I t presents less freq u e n t l y o n the m a l a r a reas a n d jawl i n e . M o re ra rely, it a p pea rs o n t h e d o rsa l forea r m s . Derm a l m e l a s m a h a s m ore of a b l u e-gray h u e . M i xed-type m e l a s m a has a brown-gray c o l o rat i o n .

Figure 25. 1 Female with extensive melasma recalcitrant to m ultiple

topical regimens for several years

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Color Atlas of Cosmetic Dermatology

D I F F E R E N T I A L D I AG N OS I S Postinfl a m matory hyperpigmentation, exogenous och rono­ sis, d rug- i n d u ced/photo-hyperpigmentati o n , nevus of Ota , erythema dysc h ro m i c u m persta ns.

LABORATORY EXAM I NAT I O N Wood 's la m p exa m i nation accentuates the i n c reased ep i­ d e r m a l pigmentation i n me l a s m a but d oes not h ig h l ight its dermal com ponent.

COU RS E T h e p i g m e ntat i o n p rese nts over a period of weeks. I t occ u rs m ost co m m o n ly i n s u m m e rti m e , with

h igh

estroge n states , d u ri ng preg n a n cy, and p r i o r to men­ struat i o n . I t may fa d e c o m p letely months after d e l ivery or afte r d i sconti n u ation of o ra l co ntrace ptive p i l l s . It may rea p pea r in s u bseq u e n t preg n a n c ies a nd/o r s u n expos u re .

KEY CON S U LTAT I V E QU EST I O N S •

Med ication h i story

•

P regna n cy

•

S u n exposu re

•

Ti m e of onset

•

P revious treatments

MANAG E M E N T There

is

no

med ica l

i n d ication t o treat

melasma .

N evertheless, many patie nts u n dersta nd a bly a re d is­ tressed by its a ppea ra nce a n d desire treatment. The goa l of the treatment is to l ighte n or rem ove the pigmentati o n . Treating melasma can b e q u ite frustrati ng. P r i o r t o i n itiat­ ing thera py, it is esse nti a l for the physicia n to expla i n melasma a n d its treatment i n d eta i l t o the patient. W h i l e there a re many treatments for m e l a s m a , it s h o u l d b e stressed t h a t many a re often only p a rti a l ly effective. Recu rrences a re very c o mmo n . I t is a lso i m porta nt t o d eterm i n e which fo rm of melasma is being treated, that is, epidermal versus m ixed -type versus d e r m a l melasma ( Fig. 2 5 . 2 ) . There a re

m u lt i p l e

topica l

and

laser

thera pies

ava i l a b l e

( Fig. 2 5 . 3 ) . Treatment is frustrating a n d ofte n i n effective . There is a h igh rate of rec u rrence. Derm a l a n d m ixed ­ type melasma a re least responsive to thera py. I n a l l melasma patients, strict s u n avo i d a n ce is cr u cia l with a s u n sc reen with UVNUVB protection a n d/or a physical block suc h as tita n i u m d ioxide o r z i n c oxide d u ri n g and after any treatment regi m e n .

A

Figure 25.2 (A) A female patient with therapy-resistant melasma.

(Courtesy of Howard Conn)

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

I

151

TOP I CAL TREAT M ENT (Table 2 5 . 1) There a re a h ost of to pica l treatme nts for melasma . •

N u merous for m u lations conta i n i ng blea c h i n g agents s u c h as 4% hyd roq u i none a re effective treatments to l ighten or resolve pigme ntation. They a re most effective if used ove r a period of weeks to a few months. If the skin becomes sign ificantly i rritated from treatm e nt, d is­ conti n u e its use to avoid posti nfla m mato ry hyperpig­ mentation . Prolonged usage of hyd roq u i none can res u lt in a c h a racteristic s k i n d i scoloration k nown as pse udo­ ochronosis.

•

Reti noids s u c h as topical 0 . 1 % treti n o i n a ppl ied once d a i ly fo r 40 weeks has been shown to be effective, but less effective tha n hyd roq u i none.

•

Com b i nation thera py of 0.05% treti noi n , 4% hyd ro­ q u i none, a n d 0.0 1 % fluocinolone acetonide, that is, Tri l u ma , prod uces favorable c l i n ica l resu lts for melasma and postinflam matory hyperpigmentation with decreased irritatio n . Treatment d u ration is l i m ited by side effects of prolonged topical steroid use i nc l u d i ng skin atrophy and acne.

•

Aze l a i c acid has also been shown to prod uce i m p rove­ ment.

CH EM I CAL P E E LS Chem ica l peels a re often effective for melasma . •

I n one study, there was no d ifference i n resu lts when comparing J ess ner's solution versus 70% glycol i c a c i d peels after perfo r m i n g th ree peels 1 m o n t h a pa rt on

•

each side of the face.

B

G lyco l i c a c i d peels performed every 3 weeks i n co m b i ­

Figure 25.2 (B) ( Continued) Marked resolution in the melasma after four

nation with

treatment sessions with Fraxel laser. (Courtesy of Howard Conn)

TAB L E 2 5 . 1

•

d a i ly s u n sc reen

and

a

c o m b i nation

Treatment o f Pigmented Lesions o n the Face

Melasma

Ret i n o i d/hyd roq u i none

G lyco l i c a c i d peels

Q-switc hed laser

A blative res u rfa c i ng

Fractional resu rfa c i ng

Va r i a b l e i m provement

M u ltiple l ight pee ls in

No

Yes; but ca refu l

Yes in s k i n

conj u n ction with

patient selection

types 1-1 1 1 ;

su nscreen a n d

a n d l o n g postlaser

caution s k i n

topica l ret i n oid/

recovery

type IV

hyd roq u i none Posti nfl a m matory hyperpigmentation

Yes ; weeks to months

Va ria b l e i m prove ment

No

No

No

M i n i m a l/moderate

Yes; one to two

Yes;

M i l d/moderate

to see c l i n ica l i m provement

Lentigo

M i n i m a l/mod erate i m provement afte r

c h a nge with th ree

treatments a re

post-i nfla m matory

months of use

to fo u r peels

h igh ly s uccessfu l

erythema c h ief o bstacle

N evus of Ota

None

Non e

Yes; m u lti ple treatments res u lt in i m provement

No

No

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Color Atlas of Cosmetic Dermatology

glyco l i c a c id/hyd roq u i no n e c rea m has been shown to be effective . •

Seria l su perfic i a l c h e m i c a l peels s u ch as sa l icyl ic a c i d a n d glyco l i c acid pee ls a re the safest peels i n d a rker skin phototypes. Caution is req u i red for d a rker skin phototypes to avo i d

hyperpigmentati o n .

LAS ERS • Q-Sw i t c h e d Lasers a-switched laser treatment for melasma is not recom­ mended given its h igh i ncid ence of posti nflam matory hyperpigmentation . Add itiona l ly, it is not d ra matica l ly effec­ tive except in some cases of su perficial melasm a .

A • A b l at i ve Laser I n cases refractory t o topica l crea ms and chem ica l peels, erbium :YAG laser prod uced sign ificant, tem porary i m prove­ ment in 10 patients in one study but was com p l i cated by su bseq uent posti nfla m mato ry hyperpigme ntation in a l l 1 0 patie nts.

• N o n -A b l a t i ve Fract i o n a l R e s u rfac i n g N o n -A blative Fracti o n a l res u rfacing can be su ccessful for some cases of melasma , espec i a l ly epidermal types ( Fig. 2 5 . 2 ) . •

Long-term data a re lacking.

•

Treatment is ge nera l ly performed at su perfic i a l d e pth

•

Treatment is genera l ly performed at h igher densities.

relative to treatments for rhytid es and acne sca rs .

I t is m ost successfu l i n patients with l ighter skin p h o­ totypes, suc h as s k i n types I a n d I I . I m provement is less p red i cta b l e in sk i n type I l l , but is often a c h i eved . S k i n ph ototypes IV a n d V often do not respond favor­ a b ly to fra ctional resu rfa c i ng. Postinflam mato ry hyper­ pigme ntation is a high risk. •

P re- a n d posttreatment use of hyd roq u i none a n d l onger i nterva ls between treatments may red uce postinflam­ matory hyperpigme ntation i n d a rker s k i n phototypes.

P I T FALLS TO AVO I D/ COM P L I CAT I O N S/MANAG E M ENTI O U TCO M E EXPECTAT I O N S •

A l l forms o f melasma a re d iffic u lt a n d frustrating to treat. Recu rrence is co m m o n .

•

Derm a l melasma is pa rticula rly d iffic u lt.

•

Patie nts should be a p prised of the reca lc itra nt nature of t h i s condition in some cases .

B

Figure 25.3 (A) Young female with melasma. (B) Characteristic darkening of melasma 1 -day post intense pulsed light treatment

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

•

Postpa rtu m state a n d d isconti n ua n ce of oral contra­

Phys i c a l Exam

ce ptive p i l ls a re freq uently s uccessfu l thera pies . •

Some treatme nts worse n its a p pea ra n c e .

•

Strict s u n avo i d a n ce is c r u cia l w i t h a su nscreen with

•

S u n exposed a rea-face more often t h a n arms

•

D i st r i b ut i on-cheeks, l ower face , med i a l face,

in any com b i nation Wood 's Light to determ i n e e p i dermal vs.

•

d e r m a l d i stri b u t i o n of pigment

UVNUVB protection a nd/o r a physical block such as tita n i u m d ioxide o r z i n c oxi d e d u ri n g a n d after a ny treatment regi men .

I

C l i n ical

D ifferential Diagnosis

approach to diagnosing

•

Post- i nf l a m matory hyperpigme ntat i o n

melasma

•

M e d i cation i n d uced hyperpigme ntat ion

B I B L I OG RAPHY Risk Factors

F i n ke l U , D itre C M , H a m i lton TA, E l l is C N , Voorhees J J . To pica l treti n o i n ( reti noic a c i d ) i m proves melasm a . A veh i c l e-contro l l ed , c l i n i c a l tria l . Br J Dermatol. 1 993 ; 129: 4 1 5-42 1 . G r i mes P E . M a nagement of hyperpigme ntation i n d a rker

•

Pregnancy

•

Oral contracepti ves

•

I ncreased p igme ntat i o n w i t h s u n expos ure

Figure 25.4 Clinical approach to diagnosing melasma

rac i a l eth n i c grou ps. Semin Cutan Med Surg. 2009 ; 28( 2 ) : 77-85. Lawre nce N, Cox S E , B rody HJ . Treatment of melasma with J essner's sol ution versus glycol i c acid : A com pa rison of c l i n ic a l efficacy and eva l uation of the pred ictive a bi l ity of Wood 's l ight exa m i nati o n . J Am Acad Dermatol. 1997;36: 589-593 . Lee H S , Won C H , Lee D H , et a l . Treatment of melasma i n As i a n s k i n using a fractional 1 , 550 n m laser: An open c l i n ical study. Dermatol Surg. 2009;35( 1 0 ) : 1499 - 1 504 . M a n a loto R M , Alser T M . Erb i u m :YAG laser resu rfa c i n g

MELASMA

f o r refractory melas m a . Dermatol Surg. 1999 ; 25 : 1 2 1 -

Vig i l a nt sunscreen is cruc ial

123.

S P F30 before , d u r i ng a n d after any therapy

R o k h s a r C K , Fitzpatrick R E. The treatment o f melasma

I m provem e n t i s var i a b l e a n d rec u rrence i s common

with fractional p h otothermo lysis: A p i lot study. Dermatol

Surg. 2005;3 1 ( 1 2 ) : 1 645- 1 650. To ro k

HM,

J ones T,

Rich

P, S m ith

S,

Tschen

E.

Top i c a l

Mechanical

Lasers

•

H yd roq u i n o n e

•

Ret i n o i d s

to n i de 0 . 0 1 % : A safe a n d efficacious 1 2-month treat­

•

S u perf i c i a l pee l s

•

A b l at i ve resorfa c i n g

ment for melasma . Cutis. 2005 ; 7 5( 1 } ; 57-62 .

•

Koj i c a c i d

•

Q-switched

•

Aze l a i c a c i d

lasers

•

Licorice extracts

Hyd roq u i none 4 % , treti n o i n 0 . 0 5 % , fl uocinolone ace­

Vera l lo- Rowe l l V M , Ve ra lo V, G ra u pe K, Lo pez-V i l lafuerte L, G a rcia Lopez M . Double- b l i n d com parison of azeleic acid and hyd roq u i none i n the treatment of melasma .

•

M i crodermabras i o n

•

Fract i o n a l

photothermolysis

I

+

+

Acta Derm Venereal. 1 989 ; 143: 58-6 1 .

A com b i n at i o n of a topical s u c h as

Victor FC, G e l ber J , Rao B . Melasma : A revi ew. J Cutan

m i crodermabrasion for 6 months is a n

Med Surg. 2004; 8(2) :97- 1 02 .

effect ive a n d safe com b i n at i o n t h erapy

hyd roq u i n o n e , w i t h month ly pee l s a n d/or

+ •

Laser/l ight sou rces s h o u l d be u sed o n l y after c o m b i nation of topicals

a n d pee l s m i crodermabrasion fa i l •

R i sk of post- i n f l a m matory hyperpigme ntat i o n from a n y l aser

( m ay persist for months) •

Fract i o n a l photothermolysis has fewer s i d e effects a n d l ess down­

time t h a n a b l at i ve lasers •

A b l at i ve resorfa c i n g o n l y for t h e m ost refractory cases in patie nts

who can tolerate months of post i nf l a m m atory c h a n ges •

Q-switched l asers a re ofte n not effect ive a n d often worsen m e l asma

Figure 25.5 Melasma treatment protocol

1 53

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Color Atlas of Cosmetic Dermatology

CHAPT E R 2 6

Nevus of Ota

N evus of Ota , a lso known as nevus fuscoceru leus oph ­ tha l momaxi l l a ris, represents a ben ign pa rtia l ly confl uent mac u l a r

b rown- b l u e

pigme ntation

of the ski n

and

m ucous mem bra nes i n t h e d istri bution o f the fi rst a n d second b ra n c hes o f t h e trige m i n a l nerve. It may b e u n i ­ late ra l o r bi latera l . The i psi latera l scl era is freq ue ntly i nvolved .

E P I D E M I O LOGY Incidence: 0.4% to 0.8% of J a pa nese dermatology patients Age: b i modal d istri bution at birth a n d p u berty Race: m ore common in Asia ns a n d b l a c ks than wh ites Sex: m ore fema les t h a n ma les seek treatment for this cond ition ; u n known if there is a sex p red i lection

Precipitating factors: spora d i c , not a n i n h e rited d isord er

PATHOG E N E S I S Hyperpigme ntation

a rises

as

a

res u l t

of

dermal

melan ocytes t h a t have n o t m igrated to the epid erm i s .

PATHOLOGY H eavily pigme nted , e l ongated , d e n d ritic melan ocytes a re located a mong the reti c u l a r dermal collage n . Most typi­ c a l l y, these mela nocytes a re fo u n d i n the u p per one-t h i rd of the reticu l a r dermis but a re a lso seen in the pa p i l l a ry d e r m i s i n s o m e lesions.

A

PHYS I CAL LES I O N S I t presents a s confl uent o r pa rtia l ly co nfl uent b rown- b l u e patches i n the d istri bution o f the fi rst a n d second b ra n c h es of the trige m i n a l n e rve . G ray, black, and p u r p l e coloration may be p resent i n s o m e lesions as wel l . I t can be u n i latera l o r bi latera l . The magnitude of i nvolvement can va ry fro m loca l perioc u l a r i nvolvement to much of the side of the face. A p p roxi mately two-th i rd s of patie nts fea­ t u re i psi latera l sclera l i nvolvement.

D I FFERENTIAL D I AG N OS I S Melasma, cafe a u I ai t m a c u l e , H o ri's macule b l u e nevus, bru ising, och ronosis, a rgyria ,

p h otod ermatoses, fixed

d rug eru ption, a n d other m ed ication-related eru ptions should be considered i n the proper c l i n ical setting.

B Figure 26. 1 (A) Nevus of Ota prior to treatment with Q-switched ruby laser. (8) Significant clearance after serial treatments with Q-switched ruby laser

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

I

1 55

LABO RATORY EXA M I NAT I O N B i o psy m a y b e i n d icated i f t h e d iagnosis i s i n q u estio n o r t o exc l u d e the ra re case o f melanoma a rising i n this lesion .

CO U RS E There i s a b i modal d istri bution fo r n evus o f Ota , b i rth a n d p u be rty. It rema i n s relatively s i m i l a r i n a p pearance after i n itia l presentatio n .

KEY CO N S U LTAT I V E QU EST I O N S •

O nset o f eru ption

•

Med ication h i story

MANAG E M ENT There is no medical i n d ication t o treat nevus o f Ota . Cosmetic a p pea ra n ce, however, is d istressi n g to patients. W h i l e c ryothera py and topica l b l ea c h i n g treatments have been util ized , the treatment of c h oice is Q-switc hed laser treatment.

TOP I CAL T R EATM ENT M a k e u p can camouflage o r assist i n ca mo uflag i n g nevus of Ota . To pica l med ications a re less effective than laser.

Figure 26.2 Nevus of Ota. Periorbital blue-gray pigmentation with scleral

involvement (Kay K, Jen R, Richard J, et at eds. Color Atlas & Synopsis of Pediatric Dermatology. McGraw-Hill, Inc. ; 2002)

T R EAT M E N T •

N u merous stu d ies have s hown that nevus o f Ota i s a m e n a b l e t o su ccessfu l reso l ution with Q-switc hed laser

thera pies

i n c l u d i ng

the

Q-switched

ru by

( 694 n m ) , the a l exa n d rite (755 n m ) , a n d the N d :YAG ( 1 , 064 n m ) lasers ( Figs . 2 6 . 2 a n d 26 . 3 ) . • •

Test s pot ca n be performed prior t o treatment. The Q-switc hed r u by laser has been shown to be effec­

NEVUS OF OTA

tive at prod u c i n g 7 5 % or greater c l ea ra nce at fl uences of 5 to 7 J/c m 2 , 4-m m s pot size, a n d a 30-ns pu lse width at 3-to-4- month treatment i nterva ls. - I n a study of 46 c h i l d ren a n d 107 a d u lts with nevus of Ota , treatments were more s uccessfu l i n c h i l d ren

Topica l

Mechanical

Lasers

Camouflage may be h e l pfu l for some patients

M i croderma b rasi o n s h o u l d not b e performed • H igh risk of dysc h rom i a a n d/or scarr i ng

• Q-switched l asers are the t reat ment of choice • A b l a t i ve-no

•

t h a n i n a d u lts.

•

- The mean n u m be r of treatment sess ions to a c h ieve sign ifica nt cleari ng or better was 3 . 5 for the younger

•

age gro u p and 5.9 fo r the older age gro u p . - Ad d itional ly, com p l i cations we re lowe r i n t h e c h i l d ren t h a n ad u lts, that is, 4.8% as com pa red to 22.4% . - One

retros pective study exa m i ned

101

M u l t i p l e t reatments with Q-switched l asers are needed I m p rovement moderate to dramatic after m u lt i p l e treatments • Q-switched l aser treatment of lesions that arise in i nfancy may respond better to l aser t h erapy than l ater in l ife • If a Q-switched VAG l aser is u sed a com b i n a t i o n of 532 n m/ 1 064 n m m a y res u l t i n better c l i n i cal i m provement t h a n 1 064 n m a l o n e •

pati ents

1 yea r after treatment with Q-switc hed r u by laser a n d

Figure 26.3 Treatment of nevus of Ota algorithm

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Color Atlas of Cosmetic Dermatology

fo u n d that 1 6 .8% d is played hypopigme ntation a n d 5 . 9 % showed hyperpigmentatio n . One patient w h o had com plete resol ution d eve loped rec u rrence. •

The Q-switched a lexa nd rite laser is a lso effective for the treatment of nevus of Ota . Dermal white n i n g is the key c l i n ica l end point when treati ng nevus of Ota with Q-switc hed lasers . - One gro u p reported the su ccessful treatm e nt o f nevus

of

Ota

with

fractional

p h otothermo lysis.

N o n etheless, Q-switc hed laser is the treatment of choice.

• To p i c a l •

Ca mouflage may be hel pf u l fo r some patients .

• M ec h a n i c a l •

M i c roderma b rasion s h o u l d not be performed .

•

H igh risk of dysc h ro m i a a n d/o r sca rring.

• Lasers •

Q-switched lasers a re the treatment of choice.

•

Ablative-no.

•

M u lt i p l e treatme nts with Q-switc hed lasers a re need e d .

•

I m provement moderate t o d ra matic after m u ltiple treat­ ments.

•

Q-switched laser treatment of lesions that a rise i n i nfa ncy may respond better t o laser thera py t h a n later in l ife .

•

If a Q-switc hed YAG laser is use d , a c o m b i nation of 532 n m/ 1 , 064 nm may res u l t in better c l i n ical i m prove­ ment tha n 1 , 064 nm a l o n e . - One study treated 1 3 patients at fl uen ces ra ngi ng between 6 a n d 8 J/c m 2 at 8-week i n terva ls. T h e mea n

n u m ber o f treatments w a s a pproxi mately

seve n . Seve n patients ach ieved 75% or bette r l ight­ e n i ng, th ree patie nts a c h ieved between 5 1 % a n d 7 5 % i m prove ment, one a c h ieved between 2 5 % a n d 5 0 % i m p rovement, a n d a noth e r a c h i eved less tha n 25% i m provement. - Two patie nts experienced tra nsient hyperpigme nta­ t i o n ; one ex perienced tra nsient hypopigme ntatio n . •

T h e Q-switc hed N d : YAG ( 1 ,064 n m ) laser h a s a lso prove n to be effective. - Sl ightly less effective than other Q-switc hed lasers. - I t is safer for use in dark skin types . - Less risk of hypopigme ntatio n .

Secti o n 5: D i so rd e rs of Pigmenta t i o n

P I T FALLS TO AVO I D/O UTCO M E EXPECTAT I O N S/CO M P L I CAT I O N S/ MANAG E M ENT •

Laser treatment for nevus o f Ota is freq uently successfu l .

•

G iven t h e h igh proportio n o f patients with d a r k s k i n phototypes, there is the r i s k o f hypo- a n d hyperpigmen­ tatio n .

•

The r i s k o f suc h a n a dverse reaction s h o u l d be d is­

•

Add itiona l ly, a test site can be treated before perform­

•

Q-switc hed l a s e r treatment can be associated w i t h tra n ­

cussed with the patient prior to thera py. i n g fu l l treatment of a n y les i o n . sient hyperpigme ntation . •

Recu rrence after treatment is i n freq uent.

B I B L I OG RAPHY C h a n H H , Le u n g R S , Ying SY, e t a l . A retrospective a n a ly­ sis of compl ications in the treatment of n evus of Ota with the Q-switc hed a l exa n d rite and

Q-switched

N d : YAG

lasers . Dermato/ Surg. 2000;26( 1 1 ): 1 000- 1 006. Chan H H , Ying SY, Ho WS, Kono T, King WW. An i n vivo trial c o m pa ri ng the c l i n ic a l efficacy and c o m p l icati ons of Q-switc hed 755 nm a lexa nd rite a n d Q-switched 1 064 n m N d :YAG lasers i n t h e treatm e nt o f nevus o f Ota . Dermatol Surg. 2000;26( 1 0 ) : 9 1 9-92 2 . Ko no T , C h a n H H , Ercocen A R , e t a l . Use o f Q-switc hed r u by laser in the treatment of nevus of Ota i n d i ffe rent age gro u ps . Lasers Surg Med. 2003;32(5) :39 1 -395. Ko no T, N oza ki M, Chan H H , M i ka s h i m a Y. A retrospec­ tive study looking at the long-term com pl ications of Q-switc hed r u by laser in the treatment of nevus of Ota . Lasers Surg Med. 200 1 ;29(2) : 1 56 - 1 5 9 . Ko u ba DJ , F i n c h e r EF, M oy R L. N e v u s o f Ota successfu l ly treated by fractio n a l p h otothermo lysis u s i ng a fra ction­ ated

1440- n m N d :YAG laser. Arch Dermatol. 2008;

144( 2 ) : 1 56- 1 58 . R a d m a n esh M . Naevus o f Ota treatment w i t h c ryother­ a py. J Dermatol Treat. 200 1 ; 1 2 (4) : 205-209 .

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Color Atlas of Cosmetic Dermatology

CHAPT E R 2 7

Posti nfl a m mato ry hype rpig m e ntatio n

Posti nfla m matory hyperpigmentation ( P I H ) is a c o m m o n seq uela o f i nfla m matory dermatoses or i nj u ry t o the ski n . It

occ u rs

most

commonly

in

d a rker

skin

types .

Depend i n g on the etiology of the hyperpigmentation , p ig­ ment may be de posited in the dermis o r epidermis with i m porta nt i m p l ications for treati ng the pigment c h a nges . It is a c o m m o n seq uela of laser treatment, pa rti c u l a rly i n d a rker s k i n p hototypes ( Fig. 27 . 1 ) .

EPI D E M I O LOGY Incidence: com m o n , espec i a l ly in d a rker skin types Age: a l l ages Race: m ore common in d a rker s k i n types

Figure 27. 1 PI H seen after a series of treatments with nonablative

Sex: none

fractional resurfacing for a scar. The PIH resolved on its own within 3 weeks

Precipitating factors: a ny i nfla m m atory d isorder o r i nj u ry to the ski n can p rod uce hyperpigmentatio n . It may a lso res u lt from laser thera py, derma b rasi o n , c ryothera py, or c h e m i ca l peels. I t p rese nts more exu bera ntly a n d with a greate r d u ration i n d a rker s k i n ph ototypes

PATHOG E N ES I S U n known .

D E R M ATOPAT H O LOGY Basa l cel l layer pigme ntatio n and dermal mela n o p hages a re see n .

PHYS I CAL LES I O N S I n epidermal P I H , patients d isplay i n d isti nct ta n t o d a rk b rown m a c u l es at s ites of previous s k in i nfla m mation . I n d e r m a l P I H , there i s m o re of a brown-gray h u e .

D I F F E R E N T I A L D I AG N OS I S M astocytosis, m a c u l a r a myloidosis, m i noc i n hyperpig­ mentatio n , exogenous oc h ronosis, melasma, and ery­ thema dysc h ro m i c u m persta n s .

LABORATORY EXAM I NAT I O N None.

A

_____

Figure 27.2 (A) Pseudo-ochronosis seen after years of hydroquinone

treatment.

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

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1 59

CO U RS E P I H d oes not worse n i n the a bsence o f further i ns u lt o r i nfla m mation a t the affected site . P I H usually resolves ove r a period of a few months. In the case of dermal hyperpigmentati o n , th ere may n ot be i m provement.

KEY CO N S U LTAT I V E QU EST I O N S •

S u n expos u re, s u nscreen use

•

lime of onset

•

Recent rashes, i nj u ry, or treatment of s k i n

•

Med ication use

8

MANAG E M ENT W h i l e there is no medical i n d ication to treat P I H , m a n y patients a re as bothered by P I H as t h ey a re by t h e

Figure 27.2 (B) ( Continued) Significan t improvement after treatment with

a-switched laser

p rocesses that prod uced it i n itial ly. F u rthermore, P I H c a n end u re fa r longer tha n the origi n a l e r u ptio n . There a re m u ltiple treatments i n c l u d i ng to pica l , laser, a n d c h e m ical peels ( Ta ble 2 7 . 1 ) . I t is essentia l to fi rst dete r m i n e the cause of the hyperpigmentation . C u l prits ra nge from hemosiderin to pigment to vasc u l a r. Without d eterm i n i ng the etio l ogy correctly, treatment w i l l , at best, provide no i m provement, o r worsen the P I H . Freq ue ntly, the safest a n d most effective treatment is ti m e . Atte m pted treat­ ment of P I H , espec ia l ly in da rker s k in ph ototypes, c a n often worsen a n d prolong hyperpigmentatio n . N o r m a l ly, e p i d e r m a l P I H w i l l resolve on its own ove r a period of months. Thera peutic o ptions i n c l u d e topical reti noids, bleach­ i n g crea ms, chemical pee ls ( i nc l u d i ng glycol i c a c i d peels,

TAB L E 27. 1

•

Post- i nflammatory Hyperpigmentation treatment Fractio n a l

Thera peutic

R eti n oid/

Peels/

o ptions

hyd roq u i none

m i c roderm a b rasion

Q-switc hed laser

Ablative lasers

resu rfa c i ng

Post-i nfla m m atory

N eeds to be used

20-70% glycol i c acid

No

No

No

hyperpigmentation

for weeks to

peels, jessner peels,

months for

c o m b i nation j essner

i m prove ment

TCNpee ls and Sa l ic i lyc acid peels a n d/or m ic roderma brasion may h e l p i m prove m ore q u ickly

Fa ce/u pper body

R i s k of pa rad oxic a l l y

i m proves more

m a k i ng posti nfla m matory

q u ickly t h a n lower

c h a nges worse if too

ha If of the body

m u c h i nf la m mation is c reated

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Color Atlas of Cosmetic Dermatology

J essner peels, c o m b i nation J essnerfTCA pee ls, a n d sa l i­ cyl i c a c i d pee l s ), a n d fractional laser treatment. There is a risk of paradoxica l ly m a k i n g post- i nfla m matory c h a nges

worse if too m uc h i nfla m mation is created .

S U N P ROTECT I O N S u n b l oc ks a n d s u n sc reens used d a i ly a re c r u c i a l t o pre­ vent worse n i ng, as is sun avoid a n c e . Without their use, other thera pies w i l l n ot be effective . If a patient d oes n ot avoid s u n expos u re , P I H wi l l worsen . S u n avo i d a n ce i n c l udes avoid i ng pea k s u n h o u rs , wea r i n g a hat out d oors to protect the face from s u n exposu re a n d a n awa re ness t h a t UVA rays pen etrates through w i n d ows w h i l e d riving, w h i l e at work a n d wh i l e at home.

TOP I CAL T R EATM ENTS T here a re a h ost of topical treatments fo r P I H that pro­ d uce m i l d i m provement and may exped ite reso l ution . •

Hyd roq u i none form u lations, pa rticu larly with su nscreens - Hyd roq u i none ( 2 %-4% ) c rea ms a re effective, fi rst­ l i n e treatment. - Prolonged usage of hyd roq u i none can res u lt i n a

A

c h a ra cteristic s k i n d iscol oration known as pse udo­ och ronosis ( Fig. 2 7 . 2 ) . - B lea c h i ng c rea ms a re contra i n d i cated i n pregnant a n d lactat i n g wo m e n . •

Reti noids - Solage ( 2 % meq u i nol a n d 0 . 0 1 % treti n o i n ) and Tri l u ma ( 0 .0 1 % fluoc i nolone aceto n i d e , 4% hyd ro­ q u i none, a n d 0.05% treti n o i n ) provide an exfol iative benefit. - Tri l u m a s h o u l d n ot be used i n defi n itely d ue to its cor­ ticosteroid content and risk for atrophy.

•

Aze l a i c ac i d ( 20% ) c rea m a p pl ied twice d a i ly provides slow l ighte n i ng of pigmentati o n .

•

Koj ic a c i d ( 1 %-2 . 5 % ) c rea m . - The exact conce ntratio n of koj i c a c i d needed for effective res u lts is u n known .

•

If any of these to picals prod uces sign ifi ca nt i nfla m ma ­ tion or i rritati o n , it is i m porta nt t o d isconti n u e its use to avoid worse n i ng of P I H .

C H EM I CAL P E E LS Chem ica l peels a re an effective treatment option for the red uction of P I H . •

Over-the-cou nter a-hyd roxy a c i d peels a re a benefi c i a l adj u nct to phys i c i a n -strength c h e m i c a l

pee ls. The

conti n u a l exfoliation ach ieved from cons iste nt use of the peels may res u l t i n m i l d l ighte n i ng.

B

Figure 27.3 (A) Hyperpigmentation on left side of face before treatment. (8) Improvement after a series of salicylic acid peels and topical applica­

tion of 4 % hydroquinone (Courtesy of Pearl E. Grimes, MDJ

Secti o n 5: D i so rd e rs of Pigmenta t i o n

•

I

1 61

G lyco l i c a c i d pee ls (20%-70% ) a re a d m i n istered every 2 to 3 weeks utilizing i n c reasing strengths as tole rated . - The treatment end poi nt is m i ld confl uent e rythe m a . - Treated a reas m ust b e f u l l y ne utra l ized with sod i u m b i ca rbonate or wate r a t t h e com pletion o f t h e pee l . - Lighte n i ng o f su perfi c i a l P I H m a y b e o bserved after fo u r to six peels. - Strict photoprotection for 1 m o nth is essential and m u st be stressed .

•

J essner peels ( resorc i n o l , lactic acid , a n d sa l icyl ic a c i d ) a re a d m i n i stered every 6 t o 8 weeks. - Treatment end point is a l ight white n i ng of the ski n . - Strict photo protection for 2 t o 3 months i s advised . - M u ltiple treatments a re reco m m e nded . - Contra i n d icated i n p regnant a n d lactating women .

•

Com bi nation J essner/10% tri c h loroacetic (TCA) peels

A

may a lso be em ployed in a s i m i l a r fas h i o n as the J essne r pee l . The J ess ner peel res u l ts i n exfo l iation a l lowi ng for greater penetration of the TCA pee l . - M u ltiple peels a re ge nera l ly needed . - Contra i nd icated in p regnant a n d lactating wom e n . - Deeper pee ls a re ra re ly e m ployed given t h e r i s k of P I H exacerbation with h ea l i ng. •

Caution m u st be used i n treating s k i n phototypes I l l to VI, pa rti c u l a rly with med i u m-depth pee l s . Sa l i cyl ic a c i d peels a re safest for d a r k s k i n phototypes ( Fig. 2 7 . 3 ) .

LAS ERS Trad itiona l ly, laser treatment for P I H d oes n ot p rod uce re l i a b l e i m provement and is n ot fi rst- l i n e thera py. In fa ct, laser thera py may exacerbate P I H . In genera l , it is n ot reco m m e n d ed . F racti o n a l phototh ermolysis ( F P ) ca n , however, provide i m prove ment of P I H ( Fig. 27 .4) . T h i s is espec i a l l y true for patients with l ighter s k i n p h ototypes. I n d a rker s k i n types, P I H often worsen s . I t s h o u l d not be recom m e nd ed as a fi rst- l i n e thera py. Rather, blea c h i ng c reams a n d c h e m i c a l p e e l s provide more consistent, reprod u c i ble resu lts. Typical ly, F P treatments s h o u l d be d i rected toward s u perfic i a l s k i n d e pth a n d avoid higher treatment densi­ ties.

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M E NTIOUTCO M E EXPECTAT I O N S •

I t is i m porta nt t o reassu re patie nts that P I H w i l l resolve on its own with t i m e , except if it is a dermal process .

•

Laser treatment is u n re l i a b l e a n d may prod uce worsen­ i n g . It is u s u a l l y not reco m m e n d ed .

B

Figure 27.4 (A) Hyperpigmentation after a series of Q-switched laser tat­

too treatments. (B) Improvement of PIH after two nonablative fractional resurfacing treatments utilizing superficial depth and lower treatment densities

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Color Atlas of Cosmetic Dermatology

It is i m porta nt to d isconti n u e a n y to pical m ed i cations that prod uce i nfla m mation or i rritation to avoid wo rsen­ i ng P I H .

•

C h e m i c a l peels a re l i kely to only l i ghten a n d not f u l l y e l i m i nate the P I H . C a u t i o n s h o u l d be ta ken i n d a r ker s k i n phototypes.

•

I t is bette r and safe r to uti l ize seri a l s u perfi c i a l peels rather tha n a si ngle deeper peel to m i n i m ize the risk of PI H .

•

P I H may not i m prove d espite seria l c h e m i c a l peel use. P I H res u lt i n g from hemosiderin (ie, leg vei n treatme nts) w i l l not res pond to lasers, pee ls, a nd bleac h i ng c rea ms. In fact, treatment w i l l l i kely worsen the P I H .

B I B L I OG RAPHY K i l mer S L . Laser erad ication o f pigme nted lesions a n d tattoos . Dermatol. Clin. 2002;20( 1 ) :37-53. M is h i m a Y, Ohyama Y, S h i bata T, et a l . I n h i b itory action of koj ic acid on m e l a n ogenesis and its therapeutic effect for va rious h u m a n hyperpigme ntation d isorders. Skin Res. 1 994;36( 2 ) : 1 34- 1 50 . N a kagawa M , Kawa i K . Conta ct a l le rgy t o koj i c a c i d i n s k i n c a re prod ucts . Contact Dermatitis. 1995;3 1 ( 1 ) :9- 1 3 . Ngujen Q H , B u i T P. Azel a ic a c i d : Pha rmacoki netic a n d pha rmacodyn a m i c properties a n d its therapeutic role i n hyperpigmenta ry d isorders a n d a c n e . lnt J Dermatol. 1995;34( 2 ) : 75-84 .

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

CHAPT E R 28

Vitiligo

Viti l igo is an acq u i red i d i o path ic cond ition that prod u ces sym metric d e pigm ented patc hes of the ski n . It is pa rtic u ­ larly d istress i n g a n d c l i n i ca l ly a p pa rent i n patients with d a rker skin p h ototypes.

EPI D E M I O LOGY Incidence: a p p roxi mately 2% of the world popu lation Age: can present at a ny age but most commonly presents in the second to fou rt h decade

Race: eq u a l Sex: eq ual Precipitating factors: i n h erita nce, tra u m a , i l l ness, emo­ tional states

PATHOG EN ES I S U n k nown .

D E R M ATOPATHOLOGY There a re no melanocytes i n basa l cel l layer.

PHYS I CAL LES I ON S Patients

d isplay

wel l-demarcated ,

sym metric,

depig­

mented , chal k-wh ite macules. Common locations include el bows, knees, sacra l a rea , pen is, periora l a reas, a n d neck. H a i r may also lose pigmentation ( Figs . 28. 1 and 28.2 ) .

D I F F E R E N T I AL D I AG N OS I S Chem ical leukoderma, postinfl a m matory hypopigme nta­ tion, nevus depigmentosus, nevus a nemicus, pityriasis a l ba , l u pus erythe matos us, leprosy, and genodermatoses.

LABO RATORY EXA M I NAT I O N Wood 's l a m p exa m i nation i s h e l pfu l i n m a k i n g the d iag­ nosis. In cases of u ncerta i nty, b i o psy s h o u l d be per­ fo rmed of both lesiona l a n d n o n lesional s k i n in order to d eter m i n e if there is an a bsence of melan ocytes in the affected s ki n . Check thyro i d-st i m u lating hormone (TS H ) fo r hypothyro i d i s m .

CO U RS E Viti l igo c a n p u rsue a va ria ble cou rse . After a n i n itial ra pid p resentati o n , it te nds to sta bi l ize. Typical ly, it is a c h ro n i c

Figure 28. 1 Vitiligo on the trunk and neck of a young patient

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Color Atlas of Cosmetic Dermatology

d isease with periods of pa rt i a l re pigmentation but not res­ ol ution . It may i m p rove in the s u m merti m e . I n some cases, depigmentation beco mes extensive.

KEY CO N S U LTAT I V E QU EST I O N S •

Age o f patient

•

Time of onset

•

Fa m i ly h i story

•

Occu pation

•

Chemical exposu res

MANAG E M ENT There a re m u ltiple treatment modal ities for viti ligo. U n fo rtu nately, treatment is frustrating a n d often i n effec­ tive .

Patie nts u nd e rsta n d a bly a re d istressed

by the

a p pearance of viti l igo and desi re treatment. In exte ns ive cases, it p rod u ces a stri ki ng a ppea ra nce, pa rti c u l a rly for patients with darker s k i n ph ototypes .

P R EV E N T I O N S u nscreens a n d s u n avoida nce protect viti l iginous s k in from b u rn i ng a n d a re a n i m porta nt com ponent of ther­ a py. F u rther, ta n n i ng u naffected s k i n wi l l accentuate the contrast between normal a n d viti l iginous ski n , worse n i ng the cosmetic a ppea ra nce of the d i sease .

TOP I CAL T R EAT M E N T There a re a host o f topical treatments for viti l i go . T h ey include •

Corticosteroids - To pica l - l ntra lesi o n a l

• •

Ca l c i n e u r i n i n h i bitors: tac ro l i m us, pi mecrol i m us Monobenzylether of hyd roq u i none - Prod u ces permanent d e pigmentation - Twice d a i l y ove r 1-yea r period - Permanent d e p igmentation is prod uced in less t h a n 50% o f patie nts - Poor or no depigmentation in nearly h a lf of patients - Caution prior to p u rs u i n g this permanent treatment - Side effects i n c l u d e contact d ermatitis, e ryt h e m a , a n d pru ritus - He ightened risk of s u n burn after this perma nent treatment

•

Cam ouflaging m a ke u p and self-ta n n i ng agents to h i d e depigmented m a c u l es

Figure 28.2 White forelock in the same patient

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

I

1 65

PH OTOTH E RAPY P h otothera py is a m a i nstay of viti l igo treatment. •

Psora len and u ltravio l et A ( P UVA) with topical o r o ra l 5-methoxypsora len or 8-methoxypsora len

•

N a rrow- ba n d UVB

ORAL T H E RAPY Oral thera pies i n c l u d e •

Ora l 5- or 8-methoxypsora len i n c o m b i nation w i t h gra d ­ u a l , l i m ited s u n exposu re

•

P u lse thera py with corticosteroi d s

A

S U RG I CAL TREATM ENTS Autologous s k i n grafti n g can be a h e l pf u l treatment for viti l igo reca lc itra nt to other thera p ies. I t is not a fi rst- or seco n d - l i n e treatment. S p l it-t h i c k n ess grafts, epidermal bl iste r grafts, c u ltu red melanocyte grafts, si ngle hair grafts, a nd noncu ltu red epidermal suspension grafts have a l l been exa m i n ed . Pa i n after graft p roced u res is com m o n , pa rti c u l a rly at the ha rvest site ( Fig. 28. 3 ) . •

A majority o f patients e m p loying t h e epidermal suction graft tec h n i q u e sh owed i m prove ment.

•

S p l it-thi c k ness grafting and derma brasion have a lso a c h i eved re pigmentation with i n an ave rage of 6 months i n one stu dy of 22 patients .

•

Si ngle h a i r grafts a re m ost effective i n loca l ized or seg­ mental viti l igo . Success in genera l i zed viti l igo is poor.

•

Both c u ltured p u re melanocyte suspension as wel l as c u ltured epidermal grafting after treatment with C0 2 laser have been shown to be successful in treating viti l igo . - Resu lts were best i n loca l ized cases of viti l igo.

LAS ER T H E RAPY • Exc i m e r Laser An exci mer laser em its UVB ra nge l ight a t 308 n m , close to the wavelength of na rrow-ba nd UVB thera py that has been used to successfu lly treat viti l igo. Begi n n i ng with a starting

d ose of 1 00 mJ/cm 2 , with i n c reasing d oses i n sta ndard photothera py increments , there was good i m provement i n reca lc itra nt viti l igo after 30 weeks o f treatments. •

Acra l lesions were m ost refractory to treatment.

•

Few adverse effects.

•

Best res u l ts a re p rod uced on the face > neck, extre m i ­ ties, tru n k , a n d gen ita l i a > hands, feet.

•

M ore

expensive

tha n

m a ny

trad itiona l

thera pies.

Co m bi nation treatment with tacro l i m u s 0 . 1 % is more effective than treatment with exc i m e r laser a l o n e .

B Figure 28.3 (A) Depigmented patch of skin on right mandible. (B) Significan t improvement after m ultiple 1 -mm punch grafts (Courtesy

of Pearl E. Grimes, MD)

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P I T FALLS TO AVO I D/CO M PL I CAT I O N S/ MANAG E M E N T/O UTCO M E EXPECTAT I O N S •

Viti l igo is a d i ffi c u lt d isease to treat.

•

There a re m u ltiple fi rst- a n d secon d - l i n e therapies that should be e m p loyed before seeking s u rgica l o r laser treatments.

•

I t is es pec i a l ly d iffi c u lt to p rod uce long-term sign ifica nt cosmetic i m provement i n extensive cases.

•

Freq ue ntly, re pigmentation may be confi ned to perifol­ l i c u l a r a reas c reating a "spotty" a ppea ra n c e .

•

Patients n eed to be e d u cated t h a t a n y thera py m a y not succeed .

•

The exc i m e r laser is not widely ava i la b l e , ma king its use pa rtic u la rly d iffi c u lt.

B I B L I OG RAPHY Chen Y F, Ya ng PY, H u D N , Kuo FS, H u ng CS, H u ng C M . Treatment o f viti l igo by tra nspla ntation o f c u l t u red p u re melanocyte suspensi o n : Ana lysis of 1 20 cases . J Am Acad Dermato/. 2004; 5 1 ( 1 ) : 68-74. H a d i S M , Spencer J M , Lebwo h l M . The use of the 308nm exc i m e r laser fo r the treatment of viti l igo . Dermatol Surg. 2004;30 ( 7 ) :983-986 . Koga M . Epidermal grafting u s i ng the tops of s uction b l is­ te rs

in

the

treatment

of

viti l igo.

Arch

Dermatol.

1 988; 1 24( 1 1 ) : 1 656- 1 658. Na GY, Seo SK, Choi SK. Single hair grafting for the treat­ ment of viti l igo . JAmAcad Dermatol. 1 998;38(4): 580-584. Ozd e m i r M, Ceti n ka l e 0, Wolf R, et a l . Com parison of two s u rgica l a p proa c hes for treati ng viti l igo: A pre l i m i n a ry study. lnt J Dermatol. 2002 ;4 1 ( 3 ) : 135-138. Passeron T, Ostova ri

N,

Zakaria W, et al.

To pical

tacrol i m us a n d the 308 n m exc i m e r laser: A synergistic c o m b i nation for the treatment of viti l igo. Arch Dermatol. 2004; 140(9 ) : 1 065- 1 069 . Ta neja A, Tre h a n M , Taylor C R . 308- n m exc i m e r laser for the

treatment of

loca l ized

viti l igo .

tnt J Dermatol.

2003 ;42(8) : 658-662 . To riya ma K, Ka mei Y, Kazeto T, et a l . Combi nation of s h o rt- p u l sed C02 laser resu rfa c i n g a n d c u l t u red epid er­ mal sheet a utografting in the treatm e nt of vitil igo: A prel i m i n a ry report. Ann Plast Surg. 2004 ; 53 ( 2 ) : 1 78- 1 80 . va n G e e l N , Ongenae K, De M i l M , Haeghen YV, Vervaet C, N aeyaert J M. Dou ble-b l i n d placebo-controlled stu dy of a utologous tra nsplanted epidermal c e l l suspensions for re pigmenting viti ligo. Arch Dermatol. 1 203- 1 208.

2004; 140( 1 0 ) :

S IX Vasc u l a r A l te rat i o n s

1 68

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Color Atlas of Cosmetic Dermatology

CHAPT E R 29

Angio ke rato m a

Angioke ratomas a re te la ngiectasias with keratotic ele­ ments . They present i n d i ffe rent c l i n ical scena rios i n c l u d ­ i n g ( a ) solitary or m u lt i p l e a ngioke ratomas occ urring p red o m i n a ntly on lower extre m ities; ( b) a ngiokeratoma of Fordyce affecti n g the sc rotu m a n d the vu lva ; ( c ) a ngiok­ e ratom a of M i be l l i , a n a utoso m a l d o m i n a nt d isorder affecti n g d o rs u m of h a n d s a n d feet, e l bows, a n d knees; (d) a ngiokerato ma corporis d iffus u m associated with Fa bry's d isease, an X- l i n ked recessive d isord e r c h a rac­ terized by a.-ga lactosidase-A d eficie ncy and affecting the lowe r a bd o m e n , buttoc ks, a n d ge n ita l ia ; a n d ( e ) a ngioke ratoma c i rc u mscri ptu m usua l ly grou ped on one extre m ity.

E P I D E M I O LOGY Age: solita ry o r m u ltiple a ngiokeratomas u s u a l l y affect you n g a d u lts , a ngiokeratomas of Fordyce affect m i d d le­ aged and elderly i n d ivid u a l s . Angioke ratoma of M i be l l i a n d a ngioke rato ma c i rc u msc r i ptu m a re u s u a l l y d iag­ n osed in c h i l d h ood .

Sex: a ngiokeratoma of M i be l l i a nd a ngioke ratoma c i r­ c u mscri pt u m exh i bit fem a l e pred o m i na nce. Otherwise, there is no sex pred is position .

PHYS I CAL EXAM I NAT I O N R ed t o violaceous, we l l - c i rc u m sc r i bed hyperke ratotic pa p u les a n d p l a q ue s .

A

D I F F E R E N T I A L D I AG N OS ES Sol ita ry lesions ca n be m ista ken for mela noma , a cq u i red hemangioma, lym p ha ngio m a , seborrheic ke ratos is, a n d wa rts .

LABORATORY DATA • D e r m atopat h o l ogy M a rked d i lated , t h i n -wa l l ed blood vesse ls in the pa p i l l a ry d e r m i s , associated with an overlying acanthotic hyperker­ atotic epidermis.

COU RS E MANAG E M ENT

B

M a nagement o f a ngiokeratomas rema i ns a c h a l lenge.

Figure 29. 1 (A) Angiokeratomas on the abdomen of a young patient.

M a n y m od a l ities have been reported i n the l iterature with

(B) Angiokeratoma imaged through an epiluminescence microscope

va riable s uccess . Treatment m od a l ities i n c l u d e

(DermLite)

Sect i o n 6 : Va sc u l a r A l te rat i o n s

•

I

1 69

Lasers : a ngiokeratomas have occasionally been treated successfu lly with lasers. - The p u lsed dye laser ( P OL) is an effective d evice for the i m provement of the vasc u l a r component of a ngiokeratomas,

but

freq uently

some

keratosis

rema i n s . The target c h romophore is hemogl o b i n . P O L has proven successful a t 595 n m , 5-to-7- m m

spot, 9 t o 1 1 J/c m 2 , O C O 30/20. Cove ring the a ngiok­ e rato m a with a glass s l i d e , that is, d iascopy, is h e l p­

fu l . The end point is lesional p u r p u ra . H ea l i ng occ u rs in more than 10 to 14 days. M u lt i p l e treatments may be req u i red ( Fig. 29 . 3 ) . - Res u rfacing lasers s u c h as C0 2 and Er:YAG lasers ca n be uti l ized for lesiona l va porizatio n . Patients genera l ly req u i re local i nfi ltration with 1 % l id oca i n e with or with­ out epinephrine prior to treatment. The U ltra Pu lse C0 2 ( Lu men is, Sa nta Clara, CAl is employed using a 3-m m col l i mated hand piece, with an energy of 300 to 500 mJ with nonoverlapping pu lses . The va rious sca n ned C0 2 lasers such as the Sharplan FeatherTouch a re

Figure 29.2 Angiokeratoma on the left thigh resistant to m ultiple treat­

ments with pulsed dye laser

em ployed using the 1 25-m m hand piece, 3-m m sca n size at 14 to 40 W. The treatment end point is a blation to

achieve

lesional

flattening

and

opalescence.

Treatment sites should be clea nsed with sa l i ne soa ked ga uze

between

laser

passes.

Postoperative

care

req u i res twice d a i ly wash i ng with soa p and water a n d a ppl ication o f a n a nti biotic oi ntment. Hea l ing occ u rs i n more t h a n 2 t o 6 weeks. A s with a l l a blative proced u res, sca rring may be observed . - Other lasers that have been used i n the past with va riable success i n c l u d e potass i u m -tita nyl-phosphate laser, a rgon laser, a n d copper va por lase r. Long­ pu lsed N d : YAG ( 1 , 064 n m ) laser has been shown to be effective in i m prov i n g a ngioke ratomas d u e to its selectivity a nd its deeper penetration i nto the ski n . Successfu l treatment with a d ua l -wave length laser

A

system (595 a n d reported

1 , 064 n m ) has been rece ntly ( Cynergy with M u lti plex™ , Cynosu re,

Westford , MA, U S A ) . •

O t h e r s u rgical treatments i n c l u d e excision , electro­ ca utery, electrofu lgu ratio n , or c ryosu rgery.

P I T FALLS TO AVO I D •

Patients s h o u l d be advised that the P O L treatment wi l l cause o bvious b r u i s i n g for u p t o 14 days.

•

Keratotic

featu res

may

persist

after

treatment.

I m provement is often el usive.

B I B L I OG RAPHY Gorse SJ , J a mes W , M u rison M S . S u ccessful treatment of a ngioke ratoma with potass i u m tita nyl phosphate laser. Br J Dermatol. 2004; 1 50 ( 3 ) : 620-622.

B

Figure 29.3 (A) Biopsy-proven angiokeratoma on the thigh of a young

child. (B) Some resolution after one treatment with pulsed dye laser at a wavelength of 595 nm with a 1 0-mm spot, pulse duration of 1 . 5 ms, a fluence of 7. 5 J/cm2 , and DCD 30120

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La pi ns J , Emtesta m L, M a rcusson J A . Angiokeratomas i n Fa bry's d isease a n d Fordyce's d i sease : Successful treat­ ment with copper va pour laser. Acta Derm Venereal. 1 993; 73 ( 2 ) : 1 33- 1 3 5 . Occella C , B l e i d l D , R a m p i n i P, Schiazza L, R a m p i n i E. Argon laser treatment of c uta neous m u lt i p l e a ngioker­ atomas. Dermatol Surg. 1995;2 1 ( 2 ) : 1 70- 1 7 2 . Ozd e m i r M , Baysa l I , Engi n B , Ozd e m i r S . Treatment of a ngiokeratoma of Fordyce with long- p u lse neodym i u m­ d o ped ytt r i u m a l u m i n i u m garnet laser. Dermatol Surg. 2009;35( 1 ) : 92-97 . Pfi rrma n n G , R a u l i n C , Ka rsa i S . Angioke rato ma o f the lower extre m ities: Successfu l treatment with a d ua l ­ wavele ngth laser system ( 595 a n d 1 064 n m ) . Eur Acad Dermatol Venereal. 2009;23( 2 ) : 1 86- 187. Sommer S , M e rc h a nt WJ , Shee h a n - Da re R . Severe p re­ d o m i n a ntly acra l va riant of angiokeratoma of M i be l l i : Response t o long-pu lse N d : YAG ( 1 064 n m ) laser treat­ ment. JAmAcad Dermatol. 200 1 ;45 ( 5 ) : 764-766 .

CHAPT E R 3 0

Che r ry a nd Spid e r Angio mas

Cherry a ngiomas, a lso known a s r u by spots, se n i l e hema ngiomas,

a cq u i red

ca p i l lary

hemangioma,

and

Ca m p bell d e Morga n spots a re very c o m m o n benign vas­ c u l a r lesions that pred o m i n a ntly affect the tru n k . Spider a ngiomas, a lso known as nevus a ra n eus, spider telangiec­ tasia, a rteri a l spid er, and vasc u l a r spid er, re present loca l­ ized

telangiectasias

rad iating

from

centra l

feed ing

a rterioles. They a re common vasc u l a r lesions that pre­ d o m i n a ntly affect the face, u pper tru n k , a rms, and hands.

EPI OEM I O LOGY Incidence: very common Age: cherry a ngiomas-m i d d l e-aged a n d elderly peo ple; s p i d e r a ngiomas-a l l ages Sex: more common in fema les Precipitating factors: cherry a ngiomas can e r u pt d u ri n g p regnancy or w i t h h e patic d i sease. S pider a ngiomas a re strongly associated with pregna n cy, i nta ke of ora l contra­ ceptive p i l ls, a n d h e patoce l l u l a r d isease

PATHOG EN ES I S U n known for both . Assoc iation with pregna n cy, o ra l con­ traceptive use, a n d l iver d isease suggest a hormona l ly med iated a ngioge n i c mecha n is m .

Sect i o n 6: Va sc u l a r A l te rat i o n s

I

171

PHYS I CAL EXAM I NAT I O N Cherry a ngioma prese nts as a 1 -to-3-m m bright red to violaceous,

s mooth ,

d o m e-sha ped

pa p u l e .

Spider

a ngioma d is plays a network o f d i l ated ca p i l l a ries rad iati ng from a ce ntra l vessel . B oth may bleed when tra u matized .

PATHOLOGY Che rry a ngiomas show loss of rete ridges as we l l as con­ gested and ectatic ca p i l l a ries a n d postca p i l l a ry ven u les in the pa p i l la ry dermis. S p i d e r a ngiomas revea l a centra l asce n d i ng a rte riole that b ra nc hes a n d co m m u n icates with m u lt i p l e d i lated c a p i l l a ries.

D I F F E R E N T I AL D I AG N OS ES Cherry a ngiomas ca n be m ista ken for angiokerato m a , glomeruloid

hema ngioma ,

pyoge n i c

gra n u l o m a ,

and

n od u l a r mela noma . S p i d e r a ngiomas can be m i sta ken for genera l i zed essentia l te langi ectasias a n d h ered ita ry h em ­ orrhagic tela ngiectasia .

CO U RS E Che rry a nd spider a ngiomas a ri s i n g d u ri n g pregnancy may regress postpa rt u m . S p i d e r a ngiomas a rising i n c h i l d hood m a y a lso resolve sponta neous ly. Otherwise, both lesions ten d to persist.

A

MANAG E M ENT Although

med ica l l y

i nsign ifica nt,

c h e rry a n d

spider

a ngiomas a re freq u e ntly treated for cosmetic p u r poses . M u ltiple

effective

s u rgica l

treatment

o ptions

exist.

Depend i ng on the proced u re selected , the cost to the patient

may

va ry

sign ificantly.

Che rry

and

spider

a ngiomas that present d u ri ng pregnancy s h o u l d n ot be treated u ntil seve ra l months after d e l ivery as they may resolve on their own . •

El ectrosu rgery - El ectrod essication with coagulation ( monopolar set­ ti ng, 1-2 W fol l owed by gentle c u rettage with end­ point of lesional flatte n i ng a n d h em ostas is) has been the trad itiona l treatment m od a l ity for th ese lesions. - I t is effective and easi l y a ccess i b l e . - The potential f o r sca r formation m ust b e considered .

•

Laser su rgery : d ifferent lasers have been used su ccess­ fu l ly in treatment of c h e rry a n d spider angiomas.

B

- P u l sed dye laser ( P OL) is the treatm e nt of c h oice. A

Figure 30. 1 (A) Spider angioma, right nose. (B) Full resolution of spider angioma after a single pulsed dye laser treatment to central vessel and surrounding skin

s pot size s h o u l d be selected that matc h es d ia meter of the a ngioma . With spider a ngiomas, the ce ntra l

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Color Atlas of Cosmetic Dermatology

feed i n g vessel as we l l as the s u r ro u n d i n g vessels s h o u l d be treated . It is best to com press the lesion with a m i c roscope s l i d e to b l a n c h all but the centra l fee d i n g vesse l . A p u r p u r i c laser pu lse s h o u l d be d e l ivered . The m i c roscope s l i d e shou ld be rem oved to a l low for coo l i n g of the a rea . S u bseq uently, a p u r­ p u r i c laser p u lse ca n be e m p l oyed to target the te la ngiectasias rad iating from the feed i n g vesse l . The p u r p u ric treatment end point re presents coagu lation of the targeted vessels ( Figs . 30. 1 and 3 0 . 2 ) . - The potass i u m -tita nyl-phosphate ( KT P ) 532-n m laser prod u ces a favora b l e res ponse. S pot size s h o u l d match the lesion d i a m eter. The vessels shou l d b e traced out c o m p l etely for m ost effective treatment. Treatment end point is lesional cleara nce or su perfi­ c i a l white n i ng. E rythema ca n be expected posttreat­ ment, last i n g 24 to 48 h o u rs .

A

- Ca rbon d ioxid e laser ( U itra P u lse 3-m m co l l i m ated h a n d piece,

300-400

mJ/pu lse,

nonoverlapping

p u l ses; Sharplan FeatherTou ch 1 25- m m h a n d piece, 14-40 W, 3-mm sca n size, nonoverla p p i n g p u lses) has been e m p l oyed as secon d-l i n e thera py with su ccess . Treatment e n d po i n t is lesional flatte n i n g . Potentia l sca r formation m ust be consid ered . •

Light thera py - I ntense p u l sed l ight ( I P L) has a lso been e m p l oyed with some su ccess. As coagu lation is needed fo r lesional reso l ut i o n , h igher fluences may be req u i red for treatm ent efficacy.

•

S u rgical exc ision - Excision should be reserved for lesions that a re resis­ ta nt to other treatments. A posto perative sca r is expected w h i c h may be less cosmetically pleasing t h a n the a ngioma .

P I T FALLS TO AVO I D •

B

Figure 30.2 (A) Cherry angiomas on the trunk in a middle-aged female. (B) The appropriate endpoint is purpura obtained after pulsed dye laser

treatment (wavelength of 595 nm, 7-mm spot. 1 . 5-ms pulse duration, f/uence of 1 2 J/cm 2 , DCD 30120)

Patie nts need to be cou nseled as to the l i ke l i h ood of o bvious p u r p u ra fo l l owi n g treatment with P D L that may persist for 1 0 to 14 d ays , espec i a l l y off the face. Lesions a re less l i kely to be com pletely treated at s u b p u r p u ric fluences.

•

S i m ple electrocautery may be j u st as effective as P D L at a red uced cost t o t h e patient.

•

Com press i n g the lesion with a glass slide d u ri n g PDL o r K T P treatment is h e l pful t o m i n i mize its s i z e a n d a l low­ i ng for greate r laser penetrati o n . This red u ces the tota l energy needed for coagu lation a n d i n c reases the treat­ ment success rate .

•

M u lt i p l e treatme nts may be req u i red , in pa rti c u l a r for la rge spider a ngiomas.

A

Figure 30.3 (A) Cherry angioma, chest.

Sect i o n 6 : Va sc u l a r A l te rat i o n s

I

1 73

B I B L I OG RAPHY Dawn G , G u pta G . Com pa rison o f potass i u m tita nyl p h os­ p hate vasc u l a r laser a n d hyfrecato r in the treatment of vasc u l a r

spiders

and

che rry

a ngiomas.

Clin

Exp

Dermatol. 2003 ; 28(6) : 58 1 -583 . Fod or L, R a m o n Y, Fodo r A, Ca r m i N , Peled I J , U l l ma n n Y. A side- by-side pros pective study o f i ntense p u l sed l ight and N d : YAG laser treatment fo r vasc u l a r lesions. Ann

Plast Surg. 2006; 56(2 } : 1 64- 1 70 .

B

c

D

Figure 30.3 (ContinuedJ (B) Pulsed dye laser treatment to cherry angioma

utilizing diascopy (C) Purpura immediately post pulsed dye laser treat­ ment. (D) Complete resolution of cherry angioma after one pulsed dye laser treatment

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Color Atlas of Cosmetic Dermatology

CHAPT E R 3 1

G ra nu l o m a Facia l e

G ra n u loma fac i a l e ( G F ) was fi rst d escri bed by Wigley i n 1 945 w h o la beled t h e d i sease "eos i n o p h i l ic gra n u l o ma . " P i n kus re n a m ed this d isorder gra n u loma fac i a l e i n 1952. G F is a n i d i o pathic c h ro n i c c uta neous d isorder that usu­ a l ly i nvolves the face, pa rt i c u l a rly the nose . It ca n prese nt with a si ngle lesion or m u ltiple lesions.

E P I D E M I O LOGY Incidence: u n c o m m o n Age: 30 t o 50 yea rs Race: pri m a ri ly seen in Caucasians Sex: ma les > fem a l es

Figure 3 1 . 1 Granuloma faciale on the scalp

PATH OG E N ES I S U n k nown , but may b e mediated b y i m m u ne c o m p lex d e position .

PHYS I CAL EXAM I NAT I O N Si ngle i n d u rated facial brown ish-red pa pule o r plaque. Some lesions may have telangiectasia . M u ltiple lesions may be present. Extrafacial sites rarely observed . Lesions may vary in size from m i l l i meters to centimeters ( Fig. 3 1 . 1 ) .

D I FFERENTIAL D I AG N OS ES Cutaneous l u pus erythematos us, sa rco idosis, lym p h o m a , pseudolym phoma , c uta neous T-ce l l

lym p h o m a , fixed

d ru g e r u pti o n , rosacea .

D E R M ATOPATHOLOGY Dense, polymorphous i nflam matory cell i nfi ltrate i n the u pper two-t h i rds of the dermis. The i nfi ltrate is com posed of n u merous eosinoph i ls, neutrophi ls, lym phocytes, a n d h istiocytes . A pro m i nent grenz zone is c h a racteristica lly present. Leu kocytoclastic vasc u l itis is freq uently observed .

CO U RS E The lesions of G F a re usua l ly c h ro n i c a n d o n l y occasion­ a l ly resolve s ponta neously.

Sect i o n 6 : Va sc u l a r A l te rat i o n s

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1 75

MANAG E M ENT Difficu lt t o treat with a ny modal ity. A n y s uccessfu l treat­ ment often leaves sca rring.

• To p i c a l Treat m e n t •

Corticosteroids: topica l , i ntra lesio n a l

•

Tac ro l i m u s o i ntment (0. 1 % )

• Syste m i c Treat m e n t •

Da psone

•

Anti m a l a ri a l s

•

Colc h ic i n e

•

Cl ofaz i m i n e

•

G o l d i nj ecti ons

A

S U RG I CAL TREAT M E N T •

C ryos u rgery:

m u ltiple

reports

i n d icati ng su ccessful

c l ea ra n c e . Resu lts a re u n pred icta ble ( Fig. 3 1 . 2 ) . •

S u rgical excision .

•

Derm a b rasion .

•

El ectrosu rgery.

• L i g h t Treat m e n t •

Topica l psora len a n d u l traviolet A ( P UVA) rad iation thera py

•

Laser thera py: d ifferent lasers have been used in the treatment of GF with p ro m i s in g resu lts, either as an a b lative thera py with ca rbon d i oxid e laser o r as a selec­ tive thera py ta rget i n g the prom i n ent vasc u latu re in G F lesions using the Q-switc hed a rgon laser, p u lsed dye, d i ode laser, and potass i u m tita nyl phosphate ( KT P ) 532-nm l a s e r ( F ig. 3 1 .3 ) .

P I T FALLS T O AVO I D •

G F is often reca lc itra nt to thera py. Patie nts s h o u l d be cou nseled that successfu l treatment is often el usive.

B I B L I OG RAPHY A m m i rati CT, H ruza GJ . Treatment o f gra n u l o m a fac i a l e w i t h the 585- n m p u l sed d y e laser.

Arch Dermatol.

1 999; 135(8) :903-905. Apfel berg DB, Dru ker D , Maser M R , Las h H, S pence B J r, Denea u D. G ra n u l o m a fac i a l e . Treatment with the a rgon laser. Arch Dermatol. 1 983 ; 1 1 9 ( 7 ) : 573-576.

B

Figure 3 1 .2 (A) Multiple lesions of granuloma faciale on the face. (8) No significant improvement detected after one treatment with cryotherapy on a 4-month follow-up visit

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Chatrath V, R o h rer TE. G ra n u loma fac i a l e successfu l l y treated w i t h long-pu lsed t u n a b l e d y e laser. Dermatol

Surg. 2002 ;28( 6 ) : 527-529 . Elston O M . Treatment of gra n u loma fac i a l e with the p u l sed dye laser. Cutis. 2000;65(2 ) : 9 7-98. Khaled A , J ones M, Zerma n i R, et a l . G ra n u loma fac i a l e .

Pathologica. 2007 ;99( 5 ) : 306-308. M a i l l a rd H, G rogna rd C , Toled a n o C, J a n V, Mac het L, Va i l la nt L. G ra n u l o m a fac i a l e : Efficacy of c ryosu rgery i n 2 cases. Ann Dermatol Venereal. 2000; 1 2 7 0 ) : 77-79 . To mson N , Ste rl i ng J C , Sa lva ry I . G ra n u loma fac i a l e treated successfu l l y w i t h topica l tac ro l i m us . Clin Exp

Dermatol. 2009;34(3) :424-42 5 . Wheela nd R G , Ash l ey J R , S m ith O A , E l l i s O L, Wheela n d O N . Ca rbon d ioxid e l a s e r treatment o f gra n u loma fac i a l e .

J Dermatol Surg Oneal. 1 984; 1 0 ( 9 ) : 730-733 .

A

B

Figure 3 1 .3 (A) Indurated brownish-red plaque on the left cheek of a middle-aged female with granuloma facia/e. (B) Two-year follow-up show­ ing resolution of granuloma faciale after m ultiple pulsed dye laser treat­ ments

Sect i o n 6: Va sc u l a r A l te rat i o n s

CHAPT E R 3 2

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1 77

I nfa ntile H e m a ngio m a

I nfa nti le hema ngioma ( I H l , a lso known as strawberry, ca p i l l a ry,

or

cavernous

hema ngiom a ,

is

a

benign

e n d oth e l i a l prol iferation that re presents the most com­ mon tumor i n i nfa ncy. I t ca n be c lassified i nto su perfic i a l hema ngioma ( S H , 55% o f cases ) , deep hema ngioma ( D H , 30% of cases ) , and m ixed su perfi c i a l and deep hema ngioma ( M H , 1 5% of cases ) . They occ u r m ost com­ m o n ly o n head a n d neck a reas .

EPI D E M I O LOGY Incidence: 1% to 3 % a re p resent at b i rt h , 10% to 1 2 % a re p resent b y 1 yea r o f age

Age: majority (80 % ) become a p pa rent between 2 a n d 5 weeks o f age; 2 0 % a re n oted at b i rt h .

Sex: fe ma les a re affected two t o fou r ti mes more t h a n m a l es

A

Precipitating factors: prematu re i nfa nts a re more com­ monly affected

PHYS I CAL EXA M I NAT I O N The a p pearance depends o n t h e d e pth o f the heman­ gioma a n d the phase of evol utio n . S H p resents as bright red -colored p l a q u e . D H presents as a soft dermal o r s u b­ c uta neous nod u l e with a b l u ish- p u r p l e col or. M H shows featu res of both SH a n d D H . M u lt i p l e truncal heman­ giomas

may

be

o bserved .

I nvol uting

hema ngiomas

demonstrate a flatter su rfa ce with a grayis h - p u r p l e h u e t h a t begi ns ce ntra l l y a n d expa n d s outwa rd . The h e m a n ­ giomas

m ight

become

u lcerated

and

he morrhag i c .

Resi d u a l fatty tissue, atrop hy, tela ngiecta s i a , s c a r forma­ tion , and hypertrophy may be observed .

B

D I F F E R E N T I AL D I AG N OS ES Congen ita l hema ngiomas ca n be confused with a vasc u ­ lar

ma lformation

such

as

port-wi n e sta i n

at

b i rt h .

H ema ngiomas a re ge nera l ly present after b i rth versus vasc u l a r ma lformations, which a re genera l l y present at b i rth .

LABO RATORY TESTS • D e r m at o p at h o l ogy Prol iferations of p l u m p e n d oth e l i a l cel ls that may exte n d fro m the su perfi c i a l d e r m i s t o the deep su bcuta neous tiss u e , d e pen d i ng o n the hem a ngioma s u btype.

Figure 32. 1 (A) Left upper eyelid hemangioma in its early growth phase, a lesion that may threaten the child 's vision. (B) Marked lightening and flattening of the hemangioma after m ultiple pulsed dye laser treatments

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Color Atlas of Cosmetic Dermatology

• A n c i l l a ry Tests •

A n a bd o m i n a l u ltraso u n d s h o u l d be o bta i ned if m o re t h a n fo u r tru ncal hema ngiomas a re noted prior to 4 months of age .

•

An electroca rd iogra m ( ECG) a n d a ca rd iac EC H O should be considered for a n y concern of h igh ca rd iac output.

COU RS E H ema ngiomas c h a racteristica l l y exh i bit th ree phases of evol ution : ( a ) prol iferative phase, ( b ) i nvol uting phase, and (c) i nvo l uted phase. The prol iferati ng phase is c h a r­ a cterized by a ra p i d growth p hase that starts at 1 to 2 m o nths of age a n d lasts u nt i l 6 to 9 months of age. This growth phase is fol l owed by the i nvol uting phase that usua l l y starts i n the second yea r of l i fe a n d persists for

A

severa l yea rs. M ore than 90% of u ntreated hema ngiomas i nvol ute, that is, atta i n maxi m a l regression by 9 yea rs of age. U p to 30% of hema ngiomas leave posti nvol ution cha nges i n c l u d ing hypopigme ntati o n , sca rring, tela ngiectasi a , and fi b rofatty tiss u e .

COM P L I CAT I O N S B leed i n g a n d u lceratio n with seco n d a ry i nfection a n d sca rring, espec ia l ly i n hema ngiomas i nvolvi ng t h e d i a pe r a rea , a re c o m m o n l y see n . Oth er serious com pl ications i n c l u d e orbital o bstruction and a m b lyo pia with periorbita l hema ngiomas, u pper a i rway o bstruction with h e m a n ­ g i o m a s i n the bea rd d istri bution , s p i n a l a bnorma l ities with l u m bosacra l hema ngiomas, posterior fossa ma lfor­ mation in la rge fac i a l hema ngioma ( P H A C E syn d rome) , a n d h igh output c a rd ia c fa i l u re with m u lt i p l e c uta neous hema ngiomas assoc iated with viscera l i nvolvement.

B

Figure 32.2 (A) Hemangioma on the left fifth toe pad, a location that

in terfered with the child's ability to ambulate. (B) Significant clearing and near resolution of the hemangioma after multiple pulsed dye laser treat­ ments

KEY CO N S U LTAT I V E QU EST I O N S •

Onset o f lesion

•

N u m ber of lesions noted

•

U l ceration n oted

•

B l eed i ng noted

•

Prior treatm ents a n d res ponse

MANAG E M E N T T h e treatment o f I H s is controve rsia l . G iven t h e natu ra l cou rse o f I H with sponta neous reso l ution, m a n y physi­ cians c h oose to ca refu l ly o bserve the a rea with no i ntervention, espec i a l l y i n nonfacia l , sma l l , a n d u ncom­ p l icated

hema ngiomas.

Ea rly i ntervention

is recom­

m e n d ed for ( a ) all I H s that i nterfere with the function of vita l

orga ns

(eg,

periorbita l

hema ngiomas,

a i rway

o bstruction with hema ngiomas i n the bea rd d istr i b ution,

Sect i o n 6 : Va sc u l a r A l te rat i o n s

I

1 79

h igh-output cardiac fa i l u re ) ; ( b ) la rge facia l hema ngiomas that usua l ly i nvo l ute with permanent d i sfiguri ng; (c) u l cer­ ated hema ngiomas; and (d) hema ngiomas in the d ia per a rea that a re very l i kely to u lcerate causing severe pa i n . •

Medica l treatment - Steroids i n c l u d i ng topica l steroid a pp l i cation ( c lass 1 corticoste roid a p pl ied twice d a i ly with mon itoring every 2 wee ks) , i ntra lesiona l steroids (tria m c i nolone a ceto n i d e 1 0 mg!m L a d m i n istered monthly), and oral steroids ( 1 . 5-2 mg/kg/d of pred n isone) a re the m a i n ­ stay o f treatment. Patie nts m ust be mon itored c l osely, espec ia l ly with oral steroid use given the risk of sys­ temic com p l ications i nc l u d i ng growth reta rdation a n d g l u cose a lterations. Loca l ized side effects i n c l u d e atrophy a n d yeast infect i o n . - Other treatment options i nc l u d e to pica l i m i q u i mod ( a p p l ied d a i ly ) , i nterferon-a (3 m i l l ion u n its/m 2/d ,

A

S C ) , a nd v i n c ristine (0.05 mg/kg/d if less than 10 kg, IV ), espec ia l ly in steroid-resista nt I H . As i nterferon-a is associated with spastic d i plegi a , patients m u st be mon itored c l osely. •

P ro p ra nolol at a d ose of 2 mg/kg/d has been recently reported to be ve ry effective i n treating severe I H s , even in steroid-resista nt I H s . T h i s treatment is proposed to re place ora l or i ntravenous steroids that a re associated with sign ifica nt side effects. H owever, patients on p ro­ pra n olol s h o u l d be c l osely m o n itored for bradyca rd i a , hypotension , a n d hypoglycemia espec ia l ly a t the o nset of the treatment.

•

Laser treatment - P u lsed dye laser ( P D U treatment i n d u ces sign ifi­ ca ntly faster regression of the I H . Fl u e nces lower than those of PWS a re effective and a re assoc iated with lowe r risk of laser- i n d u ced sca rri ng ( Figs . 3 2 . 1 , 3 2 . 2 a n d 3 2 . 3 ) . P D L has been used exte nsively i n

B

the treatment of I H i n th ree c l i n ical scena rios:

Figure 32.3 {A) Segmental hemangioma in volving the hand of a 1 -year­

1. U l cerated hema ngiomas res pond effectively to P D L. PDL ma rked ly dec reases the associated pa i n a n d i n d uces ra pid hea l i ng of the u l ceration (75% with i n 2 weeks) ( Fig. 32.4) . Res i d u a l sca r fo rmation from the u l ce ration is expected . 2. S H s c a n respond wel l to P D L if sta rted either before

or

early

in

the

prol ife rative

phase.

M u ltiple treatments, every 4 to 6 weeks, a re req u i red in the prol iferative phase. T h e o n ly exception is a ra pid ly prol ife rating fa c i a l hema n­ gioma . P D L treatment may i n d uce u lceratio n of these va ria nts so treatm ent s h o u l d be avoided . I H with deeper components ( M H , D H J res pond less effectively to PDL beca use of the l i m itation of penetration of PDL to 1 . 2 mm i n the ski n . 3 . P D L ca n h e l p treat the res i d u a l erythema a n d tela ngiectasias o n hemangiomas.

the

s u rface o f i nvol uted

old girl. {B) Complete resolution of the hemangioma after four treatments with 595-nm pulsed dye laser at low fluences

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Color Atlas of Cosmetic Dermatology

- Long-pu lsed N d : YAG lasers a re usefu l for photocoagu­ lation of D H s but have a h igher incidence of sca rring. •

Other

interventions

include

s u rgical

debulking

and

em bol ization . The risks and benefits of each s u rgica l a pproach should be considered ca refu l ly before i nterven­ tion since the sca r from spontaneous regression is usua l ly better than the surgica l scar. Em bol ization is uti l ized in hema ngiomas associated with h igh-output ca rd iac fa i l u re.

P I T FALLS TO AVO I D •

Use of excessive P O L fluences without s k i n coo l i ng ca n cause sca r.

•

Pa rents a re u nd ersta n d a bly a nxious a bout their c h i l d 's hema ngioma . A f u l l d iscussion of the natu ra l c o u rse of

A

hema ngiomas is m a ndatory prior to sta rt i n g thera py. The option of foregoi n g treatm ent a n d c l i n ica l l y m o n i ­ toring a patient s h o u l d b e reviewed ca refu l ly p r i o r to sta rt i n g treatment. •

Pa rents s h o u l d a lso have a rea l i stic idea of the l i m ita­ tions of thera py. La rge hema ngiomas res pond less suc­ cessfu l ly

to

o ra l ,

s u rgica l ,

and

laser

thera py.

C o m p l icated hema ngiomas that may i n te rfere with the c h i l d 's health s h o u l d be referred to an a p p ropriate ped iatric spec i a l i st. P a re nts m ust be awa re that treat­ ment wi l l provide an i m provement but may n ot res u lt i n fu l l resol ution o f t h e h e m a ngioma . •

Parents n eed to be ed ucated on proper wou n d care, espec i a l ly for u lcerated hema ngiomas, i n order to i m prove the c h i l d 's q u a l ity of l ife .

•

F i b rofatty c h a n ges a re ofte n a seq uela of resolved hema ngiomas.

Such

c h a nges

can

be

B

i m p roved

sign ificantly with n o n a b l ative a n d a blative fract i o n a l resu rfa c i ng.

B I B L I OG RAPHY Batta K, G oodyea r H M , M oss C, Wi l l i a m s H C , H i l ler L, Waters R. R a n d o m ised control led study of early p u lsed dye laser treatment of u ncompl icated c h i l d hood haeman­ giomas: Resu lts of a 1 -yea r a na lysis.

Lancet 2002 ;

360(9332 ) : 5 2 1 -527 . Lea ute-La breze C, Du mas de Ia Roq ue E, H u biche T, Bora levi F, Tha m bo J - B , Ta·leb A. Propranolol for severe hema ngiomas of i n fa n cy. N Eng! J Med. 2008;358: 2649265 1 .

c

L i YC, McCa h a n E , R owe N A , M a rt i n PA, Wilcsek G A ,

Figure 32.4 (A) Ulcerated hemangioma, isolated nodular type, extremely painful and hemorrhaging, treated twice with pulsed dye laser 6 Jlcm 2 , 7-mm spot size, 590 nm. (B) At 2 months ' follow-up, significant healing of the ulceration after a single treatment with pulsed dye laser. (C) Four months after initial pulsed dye laser treatment and 2 months after second pulsed dye laser treatment, there is complete healing of the ulceration

M a rt i n FJ . S uccessfu l treatment o f i nfa nti le h a e m a n ­ g i o m a s o f the o r b i t w i t h pro p ra n olol . Clin Experiment

Ophthalmol. 2010;38(6): 5 54-559 . More l l i J G , Ta n OT, Yoh n J J , Weston WL. Treatment of u l cerated hema ngiomas i nfa n cy. Arch Pediatr Ado/esc

Med. 1 994; 148( 1 0) : 1 1 04- 1 1 0 5 .

Sect i o n 6: Va sc u l a r A l te rat i o n s

CHAPT E R 33

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1 81

Ke ratosis Pi l a ris At rophica ns

Ke ratosis p i l a ris atro p h ica ns ( K PA) is a gro u p o f i n he rited d i so rd e rs with th ree su btypes i n c l u d i ng (a) keratosis p i l a ris atro p h i ca n s fac i e i ( KPAF ) , (b) atrophoderma ver­ m ic u latu m (AV ) , a n d (c) ke ratosis fo l l i c u l a ris s p i n u losa d ecalva n s ( KFS D ) . KPA F a n d AV present m a i n ly on the face with K FS D often a p pea r i n g o n the eye b row a n d AV m ost com m o n l y seen on the c heeks, sparing the eye­ brows a n d sca l p . KFSD can affect the face, sca l p , a n d tru n k . I n herita nce pattern can b e a utosom a l d o m i na nt ( KPAF, AV) , recessive (AV ) , or X-l i n ked ( KFS D ) .

EPI D E M I O LOGY Incidence: very ra re; KPAF is the m ost c o m m o n su btype Age: KPAF a n d KFSD in i nfa ncy; AV in c h i l d h ood Sex: ma les a re more seve rely affected in KFSD

Figure 33. 1 Keratosis pilaris: fine, sandpaper-like follicular papules on

PATH OG E N ES I S

the arm of a young man

Abnormal fol l i c u l a r keratin ization of the u pper sectio n of the h a i r fol l icle that may later res u lt in atro p h i c fo l l i c u l a r sca rring.

PHYS I CAL EXAM I NAT I O N Fol l i c u l a r

pl u gging

with

erythema

in

early

stages

( Figu re 33. 1 ) . Atro p h i c fol l i c u l a r sca r fo rmation with assoc iated a lopecia in later stages .

D I FFERENTIAL D I AG N OS I S Ke ratos is p i l a ris, keratosis pila ris ru b ra , seborrheic der­ matitis ( KPA F ) , atopic d e rmatitis ( KFS D ) , other etiologies of sca rring a l o pecia ( KFS D ) , acne sca rri ng (AV), Rom bo syn d rome (AV ) , a n d K I D syn d rome ( K FS D ) .

D E R M ATOPAT H O LOGY D i lated fo l l ic l es with fo l l i c u l a r hyperkeratosis and i nfla m ­ m a t i o n i n e a r l y stages . Fol l i c u l a r fi brosis a n d atrophy i n later stages .

CO U RS E The cou rse i s c h ro n i c with n o sponta n eous reso l ution . With t i m e , the e ryt h e m ato u s fo l l i c u l a r hyperkeratotic pa p u les i nvol u te i nto d e p ressed atro p h i c fo l l i c u l a r sca rs with a l opec i a .

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Color Atlas of Cosmetic Dermatology

MANAG E M ENT There is n o com pletely effective treatment for KPA. M u ltiple treatment options have been tried with only va ri­ a b le s uccess . Patients should be cou nseled that thera py may not be effective. •

Topical thera py may, at best, prod uce modest benefit. - Lactic acid a n d a-hyd roxy acid lotions ( 1 0 %- 1 2 % ) a p plied twice d a i ly may i m p rove the text u ra l ro ugh­ ness. H owever, they may p rod uce i rritatio n . - R eti n o i d s (taza rote n e , reti n-A) a p p l ied n i ghtly may i m p rove text u r a l ro ugh ness. T h ey may prod uce i rri­ tati o n . - Corticosteroids a p p l ied s pa ri ngly m a y show i m provement. R i s k of fac i a l atro ph y l i m its their use.

•

A

System i c thera py - Other o ptions that have p rovided va ria ble su ccess i n c l u d e o ra l reti noids a n d d a pso n e . - They a re m ost h e l pfu l fo r the i nfla m m atory stage of KPA, but provide m i n i m a l i m prove ment in the fol l ic u ­ l a r hyperkeratos is. - They req u i re ca refu l mon itoring for potentia l side effects.

•

Laser thera py - P u lsed dye laser ( 59 5 n m , 7-m m spot, 7-1 0 J/cm 2 , D C D 40/20, p u lse d u ration of 1 . 5-3 ms) c a n be effective in the treatment of the assoc iated e rythema of KPAF but will not sign ifica ntly i m prove the text u ra l rough n ess o f KPA ( Fig. 33 . 2A , B ) . - Laser-assisted h a i r remova l with long- p u lsed n o n ­ Q-switc hed ru by l a s e r may be a n effective treatment i n patients with KFS D .

P I T FALLS T O AVO I D Pati ent expectations a re ge nera l ly very h i g h . They m ust be cou nseled as to the c h ro n i c natu re of the cond ition and m i n i m a l res ponse to ava i la ble thera pies.

B I B L I OG RAPHY Baden H P, Byers H R . C l i n i c a l fi n d i ngs, c uta neous pathol­ ogy, and response to therapy i n 21 patients with keratosis p i l a ris atro p h ica n s . Arch Dermatol. 1 994; 130(4):469475. C h u i CT, B e rger TG , P rice VH, Za c h a ry CB. R eca lcitra nt sca rring fol l ic u l a r d isord e rs treated by laser-assisted h a i r re mova l : A prel i m i na ry report. Dermatol Surg. 1 999 ; 25( 1 ) : 34-3 7 . C l a rk S M , M i l l s C M , La n iga n SW. Treatment o f keratosis p i l a ris atro p h i c a n s with the p u lsed tunable dye laser. J

Cutan Laser Ther. 2000 ; 2 (3 ) : 1 5 1 - 1 56.

B

Figure 33.2 (A) Keratosis pilaris atrophicans. Patient is emotionally both­ ered by persistent erythema. (8) Marked lightening of erythema 2 years following three pulsed dye laser treatments

Sect i o n 6: Va sc u l a r A l te rat i o n s

Ka u n e K M , Haas E, E m m e rt S, Schon M P, Z utt M . Successfu l treatment of severe keratos is p i l a ris ru bra with a 595- n m pu lsed dye laser. Dermatol Surg. 2009 ; 3 5 : 1 592- 1 595. M a rq ue l i ng AL, G i l l ia m AE, P rend ivi l l e J, et al. Keratosis p i l a ris ru b ra : A c o m m o n but u n d errecogn ized conditi o n . Arch Dermatol. 2006; 142( 1 2 ) : 1 6 1 1 - 1 6 1 6 . R i c h a rd

G,

H a rth W . Keratosis fol l ic u l a ris s p i n u losa

d ecalva n s . T he ra py with isotret i n o i n and etreti nate in the i nfla m matory stage. Hautarzt. 1 993;44(8) : 529-534.

CHAPT E R 34

Po rt-wi n e Stains

Port-wine sta i n s ( PWS) a re low-flow ca p i l lary m a lforma­ tions. They represent the m ost common type of vasc u l a r ma lformations. Any a rea o f t h e body can b e affected . H owever, the head a n d neck a reas a re m ost co m mo n ly affected .

EPI D E M I O LOGY Incidence: 3 per 1 , 000 newborns Age: prese nt at b i rt h i n the majo rity of patients ; rarely a p pea r i n adolesce nce o r a d u lthood Sex: no sex pred i l ection Race: less common i n Asi a n s a n d African Americans Associated syndromes: PWS can be a m a n ifestation of severa l synd romes i n c l u d i n g Stu rge-We ber syn d rome, K l i ppel-Tre n a u nay synd ro m e , P rote us syn d rome, and pha komatos is pigmentovasc u la ris

P H YS I CAL EXA M I NAT I O N PWS prese nts a t b i rth a s l ight p i n k , we l l-dema rcated m a c u l a r lesions a n d patc hes usua l l y in a segmenta l d is­ tri butio n . They ca n tra n sform with age i nto hypertro p h i c d a r k r e d a n d/or p u r p u ric pla q u es w i t h nod u l a rity. PWS i nvolves the face m ost c o m m o n l y a l ong the trigem i n a l n e rve d istri bution : ophtha l m i c b ra n c h V 1 ( u pper eye l i d a n d forehea d ) , maxi l l a ry b ra n c h V2 ( u pper l i p , cheek, lower eye l id ) , a n d m a n d i b u l a r b ra n c h V3 .

D I FFERENTIAL D I AG N OS I S PWS exh i bits c h a racteristic c l i n i cal featu res a n d i s sel­ d o m m isd iagnosed . I t can be confused with the mac u l a r stage o f h e m a ngioma at b i rth .

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D E R M ATOPAT H O LOGY M u ltiple d i lated t h i n -wa l led vesse ls in the pa p i l l a ry a n d reti c u l a r d e r m i s .

A N C I LLARY TESTS •

The pa rents s h o u l d be cou nseled rega rd i n g the possi­ b i l ity of Stu rge-We ber synd rome (SWS) i n lesions l ocated i n a fac i a l Vl o r V2 dermatom a l d istri bution . SWS is cha racterized by the prese nce of fac i a l PWS with i psi latera l o c u l a r a n d lepto m e n i ngea l a n o m a l ies. Ten to fifteen percent of pati ents with PWS i n the V l d istr i b ution wi l l have SWS . Patients w i t h b i latera l PWS h ave even a h igher risk of SWS . An ophthal mologic exa m i nation to ru l e out gla ucoma a nd cata ract forma­ tion with conti n ued fo l lowu p is necessa ry for these patients . A head c o m p uted tomogra phy ( CT) or mag-

A

netic reson a n ce i maging ( M R I ) s h o u l d be o bta i ned to r u l e out b ra i n i nvolvement that could affect menta l development a n d res u l t i n sei z u res. •

PWS overlyi ng the s p i n e ca n be associated with s p i n a l a n o m a l y s u c h as s p i n a l dysra p h i s m o r tethered s p i n a l cord . N e u ro l ogic eva l uation a n d a p p ro priate i maging stu d ies a re recom m e n d ed .

•

Large extremity PWS should ra ise the consideration of Kl i ppel-Trenau nay syn d rome, cha racterized by capillary­ venous ma lformations or ca pil lary-lym phatic-venous mal­ formations with hypertrophy of the affected extrem ity. Leg girth and length should be measu red and followed over time.

COU RS E PWS grows proporti o n a l l y with the patient a n d gra d ua l ly t h i c kens a n d d a rkens i n color from p i n k to d a r k red to

B

deep p u rple. Eleven percent may d eve l o p n od u l a rity a n d 2 4 % may d eve l o p pyoge n i c gra n u lomas. PWS may b e associated with hypertro phy o f u n derlying soft tissue a n d bone,

pa rtic u l a rly

in

Stu rge-We ber

syn d rome

and

K l i ppel-Tre n a u nay syn d ro m e .

KEY CO N S U LTAT I V E QU EST I O N S •

On set o f lesion

•

Assoc iated c l i nical fi n d i ngs

•

Is the c h i l d m eeti ng d eve l o pmenta l m i lestones?

•

Has the c h i l d had an eye exa m i nation?

•

Has the c h i l d had a head M R I or CT?

•

Past treatments a n d response

•

B l eed i ng

•

B l ebs

(B) Significant lightening of the PWS after a single POL treatment.

•

G rowth of PWS

(C) Complete resolution of the PWS after POL treatments

c

Figure 34. 1 (A) PWS on the right inner thigh of an infant girl.

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MANAG E M ENT PWS d e m o nstrates progressive vasc u l a r d i latation a n d hypertrophy with age, t h u s m a k i ng treatment d u ri ng ea rly i nfa ncy esse ntial for a bette r res ponse. Treatment ca n be sta rted as ea rly as 2 weeks of age . Treatment p ro­ vides a red uction in the n u m be r of vessels a n d d oes n ot c o m p l ete ly rem ove the enti re lesio n . T h e refore , the PWS may exh i bit some d a rke n i n g a n d t h i c ke n i ng over t i m e despite

i n terventio n .

G e n e ra l

a n esthesia

m ight

be

needed for treati ng la rge PWS i n c h i ld re n . •

Laser treatm e n t ( F igs . 34. 1-34. 5 ) . P u lsed dye laser ( P O L) rema i n s the gol d sta n d a rd for

the treatment of PWS . Effective P O L pa ra meters i n c l u d e wavele ngths o f 5 8 5 t o 600 n m , flue nces o f 6 t o 1 5 J/c m 2 , p u l se d u rations of 0.45 or 1 . 5 ms with cryogen spray

A

cool i n g (CSC). Fou r to twe lve laser sessions with 4-to-8week i nterva ls a re u s u a l l y req u i red in order to ach ieve sign ificant b la n c h i n g of the PWS . Lower fl uen ces a re i n itia l ly uti l i zed for PWS off the face a n d in d a rker s k i n types . The use o f e s c concom ita ntly d u ri n g P O L treatment sign ificantly dec reases the pa i n associated with the proced u re a n d the i n c i d ence of bl istering. esc protects the epidermis a n d a l l ows for d e l ivery of h igher flu ences, resulting in more effective b l a n c h i ng of the PWS . P O L treatm ent is fo l l owed b y tem pora ry p u r p u ra that usua l ly resolves in 7 to 14 days. Complete l ighte n i ng of PWS with POL treatment is a c h i eved i n l ess than 20% of PWS . Resista nce to

P O L treatment

is

more freq ue ntly

encou nte red in deeper and hypertro p h i c PWS . H e l pful m a n e u ve rs to potentiate the efficacy of P O L i n c l u d e i n c reasi n g t h e fl u e n ces with adeq uate c ryogen cool i n g to p rotect the epidermis a n d i n c reas i n g the wavelength u p to 600 n m to ta rget deeper vesse ls. A pi lot study demon­ strated that PWS that a re treated with to pica l imiquimod once d a i ly for 1 month after P O L exposu re m a n ifest su perior b l a n c h i ng res ponse over time as compared to P O L a l o n e . Another re port i n vestigated the c o m b i ned use of POL and a topica l a n giogenesis i n h i bitor, rapamycin, using the in vivo rodent wi n d ow c ha m ber mode l . There was no reformation a n d reperfusion of blood vessels after treatment with P O L fol l owed by topical ra pamyc i n for 14 d ays, i n contrast to P O L a l o n e . With extreme ca ution to avo i d sca rring and dyspigmentatio n , it is poss i b l e to treat P O L-resista nt PWS and deeper or hypertro p h i c a d u lt P W S su ccessfu l ly w i t h longer wavele ngth lasers that a l low d eeper penetration i nto the skin such as l ongp u l sed a l exa n d rite (755 n m ) laser, long-pu lsed N d :YAG ( 1 , 064 n m ) laser, and d u a l 595- n m P O L a n d 1 ,064- n m N d :YAG laser cou pled w i t h adeq uate coo l i ng. U s e o f t h e N d :YAG laser can be treac h e rous as there is a narrow thera peutic ra nge. R isk of sca r ca n be sign ificant. •

Light treatment: i ntense pu lsed l ight ( I P L ) may be effec­ tive in treatment of PWS , i n c l u d i n g P O L- resista nt PWS . A green-ye l l ow waveband a n d lowest ava i l a ble p u lse

B Figure 34.2 (A) Extensive port-wine stain on the right face and forehead

of an infant male. (8) Significant resolution after multiple treatments with pulsed dye laser

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d u ration s h o u l d be used , with s k i n coo l i ng. A recent ra ndom ized c l i n ical tria l com pa r i ng P O L a n d I P L side by side revea led a better efficacy a n d h igher patient preference after POL treatment. P h otodyna m ic thera py may a lso prove to be an a lternative efficacious treat­ ment for PWS . •

Other treatment modal ities for PWS that can be effec­ tive i n c l u d e tattooing a n d cosmetic m a keu p .

P I T FALLS TO AVO I D •

Patients s h o u l d be cou nseled that PWS d isplay a va ri­ a b le response to treatment. M o re extens ive and th icker lesions respond less wel l when com pa red to su perfi c i a l lesions. Fac i a l PWS responds best. P W S treatment effi-

A

cacy decreases as one d escends from face to feet, with the lower extre m ities d isplaying the least treatment benefit. •

M u lt i p l e treatment sessions may be req u i red . B r u i s i n g is a necessa ry side effect t o o bta i n efficacious thera py.

•

Laser treatment may prod uce "footpri nti ng" or o n ly pa r­ tial i m p rovement.

•

Treatme nts should be ceased when the patient is satis­ fied with l ighte n i ng, o r when n o fu rther benefit has been noted , that is, afte r two su bseq uent treatments.

B I B L I OG RAPHY Alste r TS, Ta nzi EL. C o m b i ned 595- n m a n d 1 , 064- n m laser i rrad iation o f rec a l c itra nt a n d hypertro p h i c port­ wine sta i n s in

c h i l d ren a n d a d u lts.

Dermatol Surg.

2009 ; 3 5 ( 5 ) : 8 1 3-8 1 5 . C h a n g CJ , Hsiao Y C , M i h m M C J r, N elson J S . P i lot stu d y

B

Figure 34.3 (A) Extensive port-wine stain on the right neck of a young

female. (B) Marked resolution of the port-wine stain after multiple treatments with pulsed dye laser

exa m i n i ng the com b i ned u s e o f p u lsed d y e l a s e r a n d topical l m i q u i mod versus laser a l o n e for treatment of port wine sta i n b i rt h m a rks. Lasers Surg Med. 2008;40(9 ) : 605-6 1 0 . C h a pas A M , Eickhorst K, G e ron e m u s R G . Efficacy of early treatment of fac i a l port w i n e sta i n s in newborns: A review of 49 cases. Lasers Surg Med. 2007;39 ( 7 ) : 563568 . C h i u C H , C h a n H H , H o WS , Ye u ng C K , N e lson J S . P ros pective stu d y o f p u l sed d ye laser i n conj u nction with c ryogen s p ray coo l i n g fo r treatment of port wine sta i ns i n C h i n ese patients. Dermatol Surg. 2003;29(9):909-9 1 5 . Discussion 9 1 5 . Fa u rsc h o u A , Togsverd- B o K , Zachariae C , Haedersdal M. P u lsed dye laser vs . i ntense p u lsed l ight for po rt-wine sta i ns : A ra nd o m ized side-by-side tria l with b l i n ded res ponse eva l uati o n . Br J Dermatol. 2009 ; 1 60(2) :359-

�.

A

Figure 34.4 (A) Port-wine stain on the lower mucosal and cutaneous lip.

Sect i o n 6: Va sc u l a r A l te rat i o n s

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Ho WS, Ying SY, C h a n PC, C h a n H H . Treatment of port wine sta i n s with i ntense pu lsed l ight: A prospective study.

Dermatol Surg. 2004;30(6):887-890. H u i keshoven M, Koste r P H , d e B orgie CA, Beek J F, va n Gernert M J , va n d e r H o rst C M . Reda rken i n g of port-wine sta i n s 1 0 years after p u l sed-dye-laser treatment. N Eng! J

Med 2007;356( 1 2 ) : 1 235- 1 240. Li L, Kon o T, G roff WF, C h a n H H , Kitazawa Y, N oza ki M . Com parison study of a long-pu lse p u lsed dye laser a n d a long-pu lse p u lsed a lexa nd rite laser in the treatment of port w i n e sta i ns . J Cosmet Laser Ther. 2008; 1 0( 1 ) :

12-15. P h u ng T L , O ble D A , J ia W , B enja m i n L E , M i h m M C J r, N elson J S . Can the wo u n d hea l i ng res ponse of h u ma n s k i n b e mod u l ated afte r laser treatment a n d t h e effects of exposu re exte nded? I m pl ications on the c o m b i ned use of the p u l sed dye laser a n d a topical a ngioge nesis i n h i bitor

B

fo r treatment of port wine sta i n b i rth ma rks . Lasers Surg

Figure 34.4 (Continued) (B) Significant lightening of port-wine stain after

Med. 2008;40( 1 ) : 1-5. Se l i m M M , Ke l l y K M , N e lson J S, We nd elsc hafe r-Cra b b G , Ke n n edy WR , Z e l i c kson B D. Confocal m i c roscopy stu d y

three treatments with a combination of pulsed dye laser to the cutaneous lip and vermilion and long-pulsed 1 , 064-nm Nd: YAG laser to the inner mucosa/ lip and vermillion

o f nerves a n d blood vessels i n u ntreated a n d treated portwine sta i ns : Pre l i m i n a ry o bservati ons. Dermatol Surg.

2004;30:892-897. Ya ng M , Ya roslavsky A , Fari n e l l i , e t a l .

Long-pu lsed

neodym i u m : Yttri u m -a l u m i n u m -ga rnet laser treatment for port-wi ne sta i n s . J Am Acad Dermatol. 2005 ; 52(3):

480-490.

Figure 34.5 Hypopigmentation, which can be permanen t, after aggres­ sive treatment of a PWS in an A frican-American patient

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CHAPT E R 3 5

Pyoge nic G ra n ulo m a

Pyoge n i c gra n u l o m a ( PG ) c a n be rega rded a s a benign vasc u l a r tu m o r o r a s a reactive vasc u l a r process a risi ng at sites of prev i o u s tra u m a or i rritat i o n . PG is a lso k n own as l o b u l a r ca p i l l a ry h e m a n g i o m a , gra n u l o m a tela ng­ iectatic u m , a n d gra n u lo m a gravi d a r u m when p rese nting o n t h e gi ngiva of preg n a n t wo m e n . I t commonly occ u rs i n a reas of tra u ma i n c l u d i n g the face a n d finge rs .

EPI D E M I O LOGY Incidence: c o m m o n Age: most common i n c h i l d ren a n d yo u ng a d u lts Precipitating factors: m i nor tra u ma , pregna n cy, laser treat­ ment of port-wi ne sta ins, isotretinoin

Figure 35. 1 Classic hemorrhagic pyogenic granuloma

PATHOG E N E S I S Reactive neovasc u l a rization suggested b y c o m m o n asso­ c iation with preexisting tra u m a o r i rritation a n d l i m ited growth ca pac ity.

PHYS I CAL EXAM I NAT I O N Red t o violaceous, d o me-sha ped , friable

pa p u l e or

nod u le , 0.5 to 1 . 5 e m i n size, with s m ooth surfa ce that freq uently ulcerates ( Figs. 35. 1 , 3 5 . 2 and 3 5 . 3 ) .

D I F F E R E N T I A L D I AG N OS ES N od u l a r a me l a n otic m e l a n o m a , glomus tumor, h e m a n ­ gioma , sq u a m o us c e l l carci noma ( S C C ) ( F ig. 3 5 . 4 ) , nod u la r basa l cel l carc i n o m a , wa rt, bac i l l a ry a ngiomato­ sis, Ka posi 's sa rco m a , and m etastatic cancer.

D E R M ATOPAT H O LOGY Wel l -circ u mscri bed exo phytic l o b u l a r pro l i feration of ca p­ i l l a ries with flattened a n d someti mes e roded overlyi n g epidermis w i t h pe r i p hera l epidermal "colla rettes . "

COU RS E P G u s u a l l y grows ra p i d ly over the cou rse of weeks o r months a n d then sta b i l izes. It b l eeds freq u e ntly with m i nor tra u ma and ca n persist i n d efin itely if n ot treated .

Figure 35.2 Pyogenic granuloma on the palm of a pregnant woman, bleeding frequently

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MANAG E M ENT •

Laser treatment - Pu lsed dye laser (585--600 n m , 0.45- 1 . 5 ms, 7-10 m m , 6-- 1 5 J/cm 2, O C O 20-40/20 with or without d iascopy) is a safe and effective device for the treatment of small lesions and for ped iatric patients. Seria l treatments are usua l ly req uired . Treatment is wel l tolerated without anesthesia. A recent report suggested shave excision followed by immed iate pu lse dye laser ( P OLl for larger lesions. POL has been also reported to be effective i n gi ngival PG. Nd:YAG laser c a n also be effective. - Carbon d ioxi d e is effective . Lesional flatte n i ng is the c l i n ica l end point. l ntra l esional l i doca i n e 1% is neces­ sa ry prior to treatment. Postoperative ca re req u i res twice d a i ly cleansing with soa p a n d water a n d a p p l i ­ cation o f a nt i b i otic oi ntment over a 2 t o 6 wee ks heal­ i n g t i m e . Sca r formation is l i kely. A low rec u rrence rate is noted .

•

S u rgical treatment: a l l treatments may res u lt in sca r for­

Figure 35.3 Pyogenic granuloma overlying a dermal nevus

mati o n . - Shave exc ision fol l owed b y electrod essication o f t h e base is t h e proced u re most c o m m o n l y e m p loyed . Recu rrence is common ( Figs . 3 5 . 5 a n d 3 5 . 6 ) - El l i ptica l exc ision c a n be pe rformed w i t h l o w rec u r­ rence but wi l l leave a sca r - Ligation of the base - C ryos u rgery •

Alternative treatment options i n c l ud e - l m iq u i m od 5 % c rea m h a s been recently reported to be effective in ped iatric patients a n d in patients with recu rrent PG - l ntralesional i njection of a bsol ute etha nol - Scleroth erapy with monoetha nola m i n e oleate - To pica l a l itreti n o i n (9- cis-ret i n oic c i d ) ge l , a d rug that is used for the treatment of Ka pos i 's sa rcoma

P I T FALLS TO AVO I D •

Patients s h o u l d be awa re that rec u rre nce is common after treatment.

•

Patie nts s h o u l d be i nformed that all treatments may result i n sca rring.

•

Amela notic melanoma as wel l as SCC and other skin can­ cers can m i mic PG . A biopsy should be performed for any suspicious lesions in the a ppropriate c l i nical setti ng.

B I B L I OG RAPHY B o u rguignon

R,

Paq uet

P,

P i e ra rd - F ra n c h i mont

C,

P i e ra rd G E . Treatment o f pyogen ic gra n u lomas with t h e N d-YAG laser. J Dermatolog Treat. 2006; 1 7(4) : 247-249 .

Figure 35.4 Pyogenic granuloma mimicking a squamous cell carcinoma

on the left lower mucosa/ lip of a patient with multiple nonmelanoma skin cancers

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Fa l l a h H , Fisc h e r G , Zaga re l l a S. Pyoge n i c gra n u loma i n c h i ld re n : Treatment with to pical i m i q u i m od . A ustralas J

Dermatol. 2007;48(4) : 2 1 7-220 Kha n d p u r S , Sharma VK. S u ccessfu l treatment of m u lti­ p l e gi ngiva l pyoge n i c gra n u lomas with p u lsed-dye laser.

Indian J Dermatol Venereal Lepra/. 2008; 74( 3 ) : 275-27 7 . M a loney D M , S c h m idt J D , D u v i c M . A l itreti n o i n g e l to treat pyoge n i c gra n u loma . J Am Acad Dermatol. 2002 ; 47( 6 ) : 969-970. Mats u m oto K, N a ka n is h i H, Seike T, Koiz u m i Y, M i h a ra K, Ku bo Y. Treatment of pyogen i c gra n u loma with a scleros­ ing agent. Dermatol Surg. 200 1 ;27(6) : 52 1 -523 . R a u l i n C, G reve B , H a m mes S. The combi ned conti n u ­ ouswave( pu I sed carbon d ioxide laser for treatment o f pyo­ gen i c gra n u lo m a . Arch Dermatol. 2002 ; 138( 1 ) :33-3 7 . S u d A R , Ta n ST.

Pyoge n i c gra n u loma c o m p l icating

p u lsed -dye laser thera py for c h e rry a ngioma . J Plast

Reconstr Aesthet Surg. 2010;63(8) : 1 364- 1368.

A

B

Figure 35.5 (A) Shaving a hemorrhagic and painful pyogenic granuloma on the plantar foot with # 1 5 blade. The specimen was sent for histological confirmation. (B) Electrodessication of the residual pyogenic granuloma

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A

B

Figure 3 5 . 6 (A) Biopsy-proven pyogenic granuloma on the right chin of a young female. (8) Shave excision of pyogenic granuloma with Derma Blade (Personna Medical, Verona, VA)

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CHAPT E R 3 6 Fac i a l

Facial Te l a ngiectasias

tela ngiectasias a re d i lated

vesse ls a p pea ring

su perfi c i a l l y i n the dermis m ostly on the a l a e nas i . Te la ngiectasias a re a lso c o m m o n i n sca rs a n d va rious s k i n lesions .

EPI O E M I O LOGY Incidence: very common Age: most common i n a d u lts and elderly peop le Sex, race: n o se x o r ra ce pred isposition Prec i p itati ng facto rs: c h ro n i c a cti n i c d a mage, rosacea, and topical steroid use a re the m ost common preci pitat­ ing factors. Other less c o m m o n etiologies i n c l u d e hered i ta ry hemorrhagic telengiectasia , Cockayne synd ro m e , ataxia telengiectasia ,

B l oo m 's syn d ro m e ,

A

Roth m u nd­

Thomson synd rome, sclerod erma, C R EST syn d rome, l u pus, a n d ra d iation dermatitis

PHYS I CAL EXAM I NAT I O N Te la ngiectasias consist o f fi n e , tiny, e rythe matous l i n ea r vessels, typica l ly 0 . 2 t o 2 m m i n d ia m eter, c o u rs i n g a l ong the s u rface o f the ski n , w h i c h b l a n c h ea s ily u po n press u re .

D E R M ATOPAT H O LOGY D i lated , t h i n-wa lled vessels i n the u p per d e r m i s .

B

COU RS E Fac i a l telangiectasias a re usua l ly c h ro n i c i n natu re with no sponta neous resol ution .

MANAG E M E N T Fac i a l tela ngiectasias a re freq uently treated for cosmetic p u r poses . M u ltiple effective treatment opti ons exist. •

Laser treatment: m u lt i p l e effective options a re ava i l ­ a b l e . Patients m u st b e awa re that ove r t i m e they a re l i kely to d eve l o p more te la ngiectas ias. - Pu lsed dye lasers ( P D U a re the treatment of choice for fac i a l telangiectasias ( Figs. 36 . 1-36 . 5) . The trad itional P D L with a short pu lse d u ration of 0.45 or 1 . 5 ms provides the most effective treatment for fac i al tela ngiectasias. However, posttreatment p u r p u ra occ u rs which genera l ly lasts 7 to 14 days

c

Figure 36. 1 (A) Middle-aged male with multiple facial telangiectasias. (B) Purpura observed immediately after pulsed dye laser treatment. (C) Significan t reduction in telangiectasias after a single-pulsed dye

laser treatment

Sect i o n 6 : Va sc u l a r A l te rat i o n s

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N ewer generation 595- n m P D L ( i e , V- bea m or V- bea m Perfecta lasers, Ca ndela Corp . , Wayl a n d , M A l with va ria b l e pu lse d u rations ( 0 .45, 1 . 5, 3, 6, 10, 20, 30, 40 msl can provide a red u ced p u r p u ra treatment of fac i a l tela ngi ectasias when longer p u l se d u rations a re util ized , but is somewhat less effective and u s u a l l y req u i res m u lt i p l e treatme nts

0 C o m m o n ly, s u b p u r p u ric fluences of less t h a n 1 0 J/c m 2 at pu lse d u ration o f 1 0 m s , with a 7-mm spot size a re util ized .

0 Better efficacy of the va riable-pu lse P D L i n treat­ ing fac i a l tela ngi ectasias can be a c h ieved by uti­ l iz i n g p u r p u ric fl ue n ces o r by pu lse sta c k i n g with s u b p u rpuric pu lses (stac ked 2-4 s u b p u p u ric p u lses at a 1 . 5- H z repetition rate, 7 . 5 J/cm 2 , 1 0-ms p u lse d u rati o n , 1 0- m m spot size, D C D of

A

30/20l or by perfo r m i n g m u ltiple passes d u ri n g the sa m e session .

0 La rger t h icker l i near vessels can be treated with the newest ge neration 595- n m long- P O L (V- bea m Perfecta , Candela Corp . , Wayla n d , MAl using a 3

x

10 mm e l l i ptical spot size, 40- ms pu lse d u ra­

tio n , 1 5 to 1 7 J/cm 2 , a n d DCD 30 to 40/20. The end point is tra nsient b l u ish d a rke n i ng of the vessel fol l owed by vessel b l a n c h i n g ( Figs . 36.4 and 36. 5 l . T h is treatment may res u lt in m i ld p u r p u ra in a ro u n d 23% of patients . Fac i a l edema , eryt h e m a , a n d d iscomfort c a n occ u r after exte nsive treatment with the p u r p u ra-free va ri­ a ble-pu lse PDL. H owever, these u nd es i red effects a re ge nera l ly better tolerated when c o m pa red to a

B

p u r p u ra-i n d u c i ng laser treatment - The va riable pu lse width 1 ,064-n m N d : YAG laser has prove n to be effective i n the treatment of fac i a l telangiectasias. S h o rter pu lse w i d t h s w i t h h igher fl u ­ en ces m ight be n ecessa ry for effective treatment of s m a l l e r vessels but have an i n c reased risk of bl ister and scar formati o n . The seq uential d e l ivery of 595and 1 , 064- n m wavelength has been re ported to be more effective than a single wavelength treatment. - Freq u e ncy-d o u bled

532- n m

N d :YAG

laser

a lso

cal led potass i u m-tita nyl-p hosphate ( KT P l laser pro­ vides effective a bsorptio n of hemogl o b i n with a pu lse d u ration of 1 to 50 m s m a k i ng it idea l ly su ited to treat su perfi c i a l vesse ls without p u r p u ra formati o n . Tra c i n g o f i n d ivid u a l vessels is a usefu l tec h n i q u e for patients with a counta b le n u m be r of d iscrete , visi ble vesse ls. •

Flashla m p ( i ntense pu lsed l ight [ I P Ll l treatment - I P L provi des a n other effective, p u r p u ra-free method fo r red ucing fac i a l tel a ngiectasias and

e rythema ( Fig. 36.6l . For exa m ple, fluences of 30 to 40 J/c m 2

with 20-ms pu lse d u ration a re effective with the Starlux Lux G handpiece ( Palomar Medical Tech nologies,

c

Figure 36.2 (A) Telangiectasias prior to pulsed dye laser treatment. The setting was 1 0-mm spot, 595 nm, 8 J!cm2 , 6-ms pulse duration. (B) Immediately posttreatment. (C) Ten days after pulsed dye laser treatment

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B u rl i ngton, M A l . The treatment end poi nt is i m med iate vessel cleara nce or selective vessel d a rken i ng. M u ltiple treatments may be req u i red for the greatest treatment benefit. •

Other

treatment

options

include

electrosu rgery,

c ryothera py, a n d i nfi ltration of scleros i n g agents. These a re less selective, often less effective, a n d more l i kely to resu lt in sca rring than laser or I P L treatment

P I T FALLS TO AVO I D • •

Treatment typica l l y is wel l tolerated O bvious posttreatment p u r p u ra for 7 to 1 4 days with p u r p u r i c setti ngs is expected

•

P u r p u ra ca n be avoided by uti l iz i n g non pu rpu ric set­

A

ti ngs at the expense of dec reased efficacy •

Fac ia l edema, erythema , a nd d isco mfort can occ u r after extens ive treatment with the p u r p u ra-free va riable-pu lse POL

•

Tela ngiectasias w i l l rec u r over yea rs

•

Caution in da rker s k i n types

B I B L I OG RAPHY Bernste i n EF, Kligm a n A . R osacea treatment u s i n g the new-generation , h igh-energy, 595 nm, long p u lse-d u ra ­ tion p u lsed -dye laser. Lasers Surg Med. 2008;40(4) : 233239 . J 0rgensen G F, Hedel u nd L, Haedersda l M . Lo ng-pu lsed

B

dye laser versus i ntense pu lsed l ight for ph otodamaged ski n : A ra n d o m ized spl it-face trial with b l i n d ed res ponse eva l uation . Lasers Surg Med. 2008;40 ( 5 ) : 293-299. Ka rsa i S , R oos S, R a u l i n C . Treatment of fac i a l te la ngiectasia using a d ua l -wavelength laser system ( 59 5 a n d 1 , 064 n m ) : A ra n d o m ized control led tri a l w i t h b l i nded res ponse eva l uati o n . Dermatol Surg. 2008;34( 5 ) : 702708 . R o h re r TE, C hatrath V, Iyenga r V . Does p u lse stacking i m prove the res u lts of treatment with va ria ble-pu lse p u l sed -dye lase rs? Dermatol Surg. 2004;30(2, pt 1 ) : 1 631 6 7 . Disc ussion 1 6 7 . 6 . R oss EV, U e bel hoer N S , Doman kevitz Y . U s e o f a novel p u lse d ye laser for ra pid s i ngle- pass p u r p u ra -free treatment of te la ngiectases. Dermatol Surg. 2007 ;33( 1 2 ) : 1 466- 1469 . Sa rradet D M , 1 064- n m

H ussa i n

M , Gold berg DJ .

neodym i u m :YAG

M i l l isecond

laser treatment of fa c i a l

te la ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58.

c Figure 36.3 (A) Female with centrofacial telangiectasias and erythema prior to pulsed dye laser therapy (B) Pulsed dye laser treatment at a wavelength of 595 nm, 1 O-ms pulse duration, 7 J/cm 2 , 7-mm spot size. (C) Appropriate clinical endpoint of erythema and slight edema at sites of

treatment. No purpura was produced

Sect i o n 6: Va sc u l a r A l te rat i o n s

I

1 95

A

B

c Figure 36.4 Telangiectasias prior to long pulse-duration pulsed dye laser

treatment. The settings were 40-ms pulse duration, 7-mm spot, 595 nm, 1 2J!cm2 . (B) Note the transient vasoconstriction with almost complete disappearance of the telangiectasias immediately posttreatment. (C) Slight decrease in diameter of the telangiectasias 1 month after one treatment

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Color Atlas of Cosmetic Dermatology

A

B Figure 36.5 (A) Large caliber nasal telangiectasias on the nose prior to

long-pulse duration pulsed dye laser treatment. (B) Decrease in the diam­ eter of the telangiectasias after six treatments with PDL using long pulse duration of 40 ms, 7-mm spot size, and f/uences up to 1 1 . 5 J/cm 2 .

Sect i o n 6: Va sc u l a r A l te rat i o n s

I

1 97

c Figure 36.5 ( Continued) {C) Marked resolution of the telangiectasias after

an additional four POL treatments utilizing short pulse duration of 1 . 5 ms, 7-mm spot size, and 1 2Jicm 2

Figure 36.6 Intense pulsed treatment with Starlux (Palomar Inc. ,

Burlington, MAJ of facial telangiectasias. The handpiece is in full contact with the skin

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CHAPT E R 3 7

Lowe r Extre mity Tela ngiectasias , R eticula r a nd Va ricose Veins

Lower extrem ity telangiectasias, ret i c u l a r a n d va ricose ve i n s d eve l o p as a res u lt of ve nous system i m pa i rment.

E P I D E M I O LOGY Incidence: very common and the i n c idence i n c reases with age . R eti c u l a r vei n s can occ u r in up to 10% of c h i l ­ d ren 1 0 t o 1 2 yea rs old . The i n c id e nce o f va ricose vei ns in the seventh d ecade is 72% i n wo men a n d 43 % in men

Age: m ore common i n a d u lts a n d e l d erly Sex: more common i n wom e n Precipitating factors: fa m i l ia l pred i s position, p reg n a n cy, static gravitational p ressu res, dyna m i c m uscu l a r forces, hormonal i nfl ue n ces

PATHOPHYS I OLOGY Venous

pathology d evelops when

venous

ret u r n

is

i m pa i red for a n y reason . I t can d evelop from venous o bstruction (thro m botic o r

A

nonthro m botic ) o r from ve nous va lvu l a r i n com petence.

PHYS I CAL EXAM I NAT I O N Lower extrem ity te la ngiectasias a re red t o violaceous i n color a n d u p t o 2 m m i n d i a m eter. R eti c u l a r ve i n s a re b l u e to b l u e-green in color a n d u p to 4 m m in d i a meter. Va ricose vei ns a re b l u e to b l u e-gree n in color with a d ia meter greater than 3 to 4 m m .

LABORATORY DATA • D e r m at o p at h o l ogy D i lated vasc u l a r c h a n nels in the d e r m i s .

• Vasc u l a r St u d i es Doppler u ltraso u n d a n d/or d u plex sca n n i ng a re i n d i cated in the fol l owing c l i n ical scenarios: •

Asym ptomatic va ricosity greater tha n 4 mm i n d i a meter

•

Sym ptomatic vei n s

•

Reti c u l a r, perforati ng, a n d/or va ricose ve i n s

•

S i g n s o f ve nous i nsufficiency o r stasis c h a nges

•

Prior h istory of deep vei n throm bosis or t h rom boph leb itis

•

Prior h i story of sclerothera py with rec u rrences or bad outcome

B

Figure 37. 1 (A) Sclerotherapy of spider veins. The needle is bent at a 45-degree angle and the vessel is canalized. (B) Immediate vessel blanching seen after injecting the sclerosant agent

Sect i o n 6 : Va sc u l a r A l te rat i o n s

I

1 99

MANAG E M ENT • S c l e rot h e ra py ( F i gs .

37 1 37 3) .

-

.

Sclerotherapy i s the treatment of c h oice fo r lowe r leg tela ngiectasias a n d reti c u l a r ve i n s . It s h o u l d be repeated at 6 to 8 week i nterva l s . Patients may req u i re two to six scleroth e ra py sess ions to ach i eve the greatest treatment benefit.

S c l erosi n g agents An ideal sclerosing agent ca uses complete local endothe­ l i a l d estruction of the vesse l wa l l with seco n d a ry fibrosis and

l u men

obl iteratio n ,

with

no

system i c

toxicity.

Sclerosing agents a re classified i nto th ree gro u ps depend­ i ng on their mecha nism of action of i n d ucing endoth e l i a l i nj u ry. These i n c l u d e hyperosmotic agents, d etergents,

A

and chem ical i rrita nts (Ta bles 37 . 1 and 3 7 . 2 ) . The most commonly used sclerosa nt agents in the U n ited States a re hype rto n i c sa l i n e ( HS) a n d sod i u m tetradecyl su lfate (STS ) . Both HS a n d STS a re FDA a p p roved a n d have low­ est i n c idence of a l lergen i city. Sod i u m morrhuate a nd poli­ d oca nol a re a lso FDA a p p roved .

S c l erothera py tec h n i q u e for te langiectasias a n d reticular v e i ns •

Fi l l the sclerosa nt agent i nto 3 c m 3 d isposa ble syri nges with d isposa ble 30-ga uge h a lf i n c h need les.

•

Swa b the site to be treated with a lcohol to better visual­ ize the vesse l s .

•

Treat l a rger vessels fi rst.

•

Bend the need le at a 30-d egree a ngle to 45-d egree a ngle.

Figure 37.2 (A) Spider veins, prior to treatment with sclerotherapy.

•

Stretc h the s k i n overlying the vessels being treated .

(B) Marked resolution of the spider veins after sclerotherapy treatment

•

I nsert the need le slowly in the vessel wa l l . Yo u may use the a i r bo l u s tec h n i q u e by i njecti ng less than 0.5 c m 3 of a i r in the vessel o r the p u nctu re-fi l l tec h n i q u e relyi ng on the feel associated with vessel wa l l perforation w h i l e i nj ecti ng. The em pty vei n tec h n i q u e , performed b y e l e­ vati ng the leg a n d gently knead i n g the vei n prior to i nj ecti o n , a l lows for thro m b u s red uction a n d need fo r s m a l l e r sclerosa nt vo l u mes. When treat i n g reti c u l a r a n d va ricose vei n s , aspirate a sma l l a m o u nt o f blood t o con­ firm i ntravasc u l a r locati o n .

•

I nject the sclerosa nt very slowly t o ensu re sufficient co ntact of the sclerosa nt with the vessel endoth e l i a l wa l l a n d t o preve nt d i stention a n d r u pture. I nject less t h a n 0 . 5 c m 3 per i njection at 3-cm i nterva ls.

•

Apply small circular band a i d s , ta ped cotton ba l ls o r ro l l s at the i njection sites f o r com pression .

Foa m sclerotherapy A treatment mod ification can be made for la rge r vesse ls by vigorously foa m i ng a n a i r-sc l e rosa nt solution j ust prior to i njection to i n d uce a solution that d isplaces b l ood a n d re m a i n s for a n extended t i m e i n t h e ta rget vessel without

B

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Color Atlas of Cosmetic Dermatology

being fl ushed . Theoretical ly, lowe r sclerosa nt conce ntra­ tions can be used with a lower i n c i d e nce of pigmentation and matti ng (Ta b les 37.2 and 3 7 . 3 ) . The foa m i ng d eter­ gent of either sotradechol or po l i d oca nol is prepa red by m ixing the d etergent with a i r ( usua l ly 1 :4 ml ratio of d eterge nt to a i r) i n a back a n d forth motion using a th ree­ way sto p lock u n t i l a foa med e m u lsion is c reated . The foa m sclerosa nt is i nj ected i n a m a n ner s i m i l a r to that with other scl erothera py tec h n i q u es .

Postop erative care •

Com pression i n c reases the efficacy of sclerothera py a n d decreases the i nc i d ence of hyperpigme ntatio n .

A

Elastic com p ression stoc k i ngs ( 1 5-60 mm Hg) a re h ighly recommended i m med iately fol lowi ng sclerothera py a n d u p to 2 to 3 wee ks after the proced u re , espec i a l l y posttreatment of la rger ca l i be r vesse ls. Fas h i o n hose ( 1 5- 1 8 m m Hg) a n d Class I h ose (20-30 m m H g ) a re the m ost commonly u s e d grad uated com pression h ose used postsc leroth erapy of te la ngiectasias and reti c u l a r vei n s . •

Encou rage wa l k i n g to avoid thromboe m bo l i c d iseases .

•

Avo i d s u n exposu re to m i n i m ize posttreatment hyper­ pigme ntation .

C o m p l i cati ons (Ta b l e 37 .3) •

B

Postsc lerothera py hyperpigme ntatio n ( PS H ) : The i nci­

Figure 37.3 (A) Lower leg telangiectasias at baseline. (B) Marked resolu­

dence of PSH can be u p to 30% d e pe n d i ng on the

tion of the telangiectasias 1 month after one sclerotherapy treatment. Note the development of slight telangiectatic matting superior to the treated area

tec h n i q u e used , the size of the treated vessels, the type of sclerosi n g agent, a n d the solution conce ntratio n . Postsc lerothera py c o m p ress ion decreases t h e i nc i ­ dence o f PS H . P S H is caused b y perivasc u l a r d e posi­ tion of hemosiderin rather than mela n i n and fol l ows the

TABLE 3 7 . 1

•

Sclerosi ng Agents

Sclerosa nt c lass Hyperosmotic agents

Sclerosa nt types

Mecha n ism

Hyperto n i c sa l i ne ( 1 0-30 % )

Dehyd ration

Hyperto n i c sa l i ne ( 1 0 % ) d extrose ( 2 5 % ) (Sclerodex) Detergents

Sod i u m tetrad ecyl s u l fate (Sotradechol, Thromboinject)

S u rface tension c h a nge

Polid oca nol (Aethoxysc lero l , Aetoxisc l e ro l , Sclerove i n ) Sod i u m morrh uate (Scleromate) Etha n o l a m i n e oleate C h e m i c a l i rrita nts

Polyiod ide iod i d e (Va rigloba n , Va rigl o b i n , Sclerod i n e )

Corrosives

G lyceri n ( 7 2 % ) w i t h 8% c h rom i u m potass i u m a l u m ( C h ro m ex)

TAB L E 37.2

•

Recommended Sclerosa nt Concentration

Sclerosa nt/rec o m m e nded concentratio n

Te la ngiectasias

Reti c u l a r vei n s

Va ricose ve i n s

Dose l i m itatio n

Hyperto n i c sa l i ne

1 1 . 7-23.4%

23.4%

N ot commonly used

6-1 0 m L o f 18-30%

Sod i u m tetrad ecyl su lfate

0 . 1 -0 . 5 %

0.3-0 . 5 % , 0 . 1 -0 . 2 5 % foa m

0 . 5-3 % , 0 . 5- 1 % foa m

1 0 ml of 3 % sol ution

solution

Sect i o n 6: Va sc u l a r A l te rat i o n s

TAB L E 3 7 . 3

•

I

Com p l ications of Sclerotherapy

Sclerosa nt

Al lerge n i city

Hyperto n i c sa l i ne

C ra m pi n g

Pa i n

Hyperpigmentati on

Te la ngiectatic matting

S k i n necrosis

+

+

+

+

+

+

+

+

+

+ An a p hylaxis

Sod i u m tetrad ecyl s u l fate

( ra re, < 0.01 % )

cou rse of the treated site. The pigme ntation usua l ly resolves in 6 to 12 months. It can i m prove with the use of i ntense pu lsed l ight ( I P U . •

Tel a n giectatic matting (TM ) : T h e i nc i d e n ce o f T M can be up to 16%. It consists of a network of b l u s h - l i ke, fine ( m a l es ( 2 : l l Precipitating factors: strongly associated with fa m i ly history Figure 49 . 1 Dermatosis papulos nigra on the forehead of an A frican American female

PATH OG E N ES I S U n known .

PATHOLOGY D P N s featu re hyperkeratosis, pa p i l lo matosis, and acan­ thosis as seen i n seborrheic keratoses . N o sq ua mous edd ies a re present.

PHYS I CAL LES I ON S They present i n a sym m etric fas h i o n as s m a l l brown s mooth sess i l e pa pu les o n the face, neck, a n d u p per tru n k of African America ns and Asia n s . They range from 1 to 5 mm in d ia meter and a re often ped u n c u lated .

D I FFERENTIAL D I AG N OS I S Seborrheic

ke ratosis,

lentigo,

ve rruca ,

acrochord o n ,

m e l a n ocytic nevus, a n giofi bro m a , a n d ad nexa l tumors a re a l l in the d iffe rential d iagnosis.

LABO RATORY EXAM I NAT I O N None.

CO U RS E They present d u ri ng teenage yea rs . Over t i m e , they become la rger and m ore n u m erou s , pea king i n m id d l e age. They d o n ot regress sponta neously.

24 1

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Color Atlas of Cosmetic Dermatology

KEY CON S U LTAT I V E QU EST I O N S Fa m i ly h i story o f D P N s .

MANAG E M E N T There is no med ical i n d i cation t o treat D P N s , u n less they a re i rritated . Sti l l , the cosmetic a p peara n ce bothers m a n y patients pa rti c u l a rly when n u mero u s . Th ere a re m u lti p l e modal ities f o r treating D P N s i n c l u d i ng c ryothera py, elec­ trodessicatio n , gra d l e scissor remova l , c u rettage, a n d a b lative laser thera py. P r i m a ry consideration befo re treat­ ment s h o u l d be the effective remova l of the D P N s without prod u c i n g pigmenta ry cha nge .

TREAT M ENTS •

Shave or gra d l e scissor excision c a n effectively re move DPNs - Local i nfi ltration with loca l a n esthesia fol l owed b y gra­ dle scissor rem ova l is safe, fast and has the lowest risk of posti nfla m m atory dysc h ro m i a

•

C ryothera py - Light c ryothera py is a q u ic k , i nexpensive, s l i ghtly pa i nfu l , and effective method of treating D P N s - Cautio n : cryothera py can p rod uce hypopigmentation by d estroyi ng m e l a n ocytes. Hyperpigme ntation ca n a lso occu r

•

Light electrodesiccation a n d c u rettage - Light electrod esiccation of D P N s is a n other q u ic k a n d effective m ethod o f treatment. There is a r i s k of posti nfla m matory dysc h ro m ia - With l ight electrodesiccati o n , the lesion w i l l turn wh ite

•

O n ly l ight e l ectrod esiccation s h o u l d be e m p l oyed to decrease the risk of pigme nta ry cha nges

LAS E R T R EAT M E NTS •

M e la n i n ta rgeting lasers fo r t h i n D P N s - Q-switched ru by (694 n m ) a n d Q-switc hed a l exa n ­ d rite ( 7 5 5 n m ) c a n someti mes effectively treat t h i n ­ ner D P N s . - S pot size s h o u l d b e l ess tha n the size o f the lesion . - R e peat treatme nts may be req u i red . - R isk of hypopigmentation a n d hyperpigme ntation should be exp l a i ned ca refu l l y to patient. - Expensive com pa red to tra d it i o n a l thera p ies.

•

Ab lative lasers - C0 2 , fractional a blative a n d erbi u m :YAG lase rs can a b late these epidermal lesions.

Sect i o n 7 : B e n ign G rowt h s

- Expensive compared to tra d itional thera p ies. - R isk of hypopigmentation and

hyperpigmentation

should be exp l a i n ed ca refu l ly to the patient.

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M ENTIOUTCO M E EXPECTAT I O N S •

A n y thera py h a s poss i b l e adverse effects s u ch a s pig­ menta ry c h a n ges, sca rring, a n d rec u rre nce. G ra d l e scissor remova l has the lowest r i s k o f dysc h ro m i a .

•

D P N s ca n be treated with a n u m ber o f d iffe rent a n d effective moda l ities.

•

Tra d iti o n a l thera p i es such as scissor excision, c u rettage, or l ight c ryothera py a re s i m ple, q u ick, a n d effective.

•

Laser thera py is more expensive a nd ca rries a h igher potential for hyper- o r hypopigmentation . Test spot may be a p p ropriate.

B I B L I OG RAPHY K i l m e r S L . Laser eradication o f pigme nted lesions a n d tattoos. Dermatol Clin. 2002 ;20( 1 ) :37-53. Sc hweiger ES , Kwa s n i a k L, Ai res OJ . Treatment of d e r­ matosis pa p u l osa n igra with a 1 064 nm N d : YAG laser: Report of two cases. J Cosmet Laser Ther. 2008; 1 0(2 ) : 1 20- 1 2 2 .

CHAPTE R 50

Xa n t h elas m a

Xanthelasmas, a lso referred to as xa nthelasma pa l pe­ b ra r u m , a re pla n e xa nthomas, occ u rring on the eye l i d s .

E P I D E M I O LOGY Incidence: relatively com mon Age: m id d le-aged a d u lts Precipitating factors: hyperl i p i d e m i a prese nt in 50% of patients with xa nthelasmas, fa m i ly h i story of hyperl i ped­ i m a , and xa nthelsma . Yo u nger a d u lts who p resent with xa nthelasma a re more l i kely to have l i pid a bnormal ities

PATHOG E N ES I S Abnorma l ities of a po l i poprote i n E phen otypes o r oth e r l i poprote i n s .

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PHYS I CAL EXAM I NAT I O N Xanthelasmas commonly present a s m u ltiple soft sym met­ rical ova l yel l owish pa pu les a n d pla q u es on the eyelids.

D I F F E R E N T I A L D I AG N OS ES Syri ngomas, sebaceo us neoplasms, m i l i a , necrobiotic xa nthogra n u l o m a .

D E R M ATOPAT H O LOGY Col lections of foa m cells i n the superfi c i a l d e r m i s .

COU RS E

A

T hey a re ge n e ra l l y perma nent with tendency t o i n c rease in n u m be r a n d coa lesce with t i m e .

MANAG E M ENT Xa nthelasmas often

rec u r after treatment with a ny

modal ity.

• S u rg i c a l Exc i s i o n S u rgica l excision i s the treatment of choice fo r xa nthelas­ mas. The lesion is l ifted and then exc ised using a blade o r a G ra d l e scissor. The d efect is either left to heal by second i ntentio n o r sutu red using silk o r eth i l o n sutu res ( Fig. 50. 1 ) . This proced u re u s u a l l y res u lts in a ve ry cos­ metica l l y acce pta ble outco m e .

• Loca l i zed Ti ss u e Dest r u ct i o n C02 o r erb i u m laser va porization, tric h l o roacetic a c i d , el ectrosu rgery, o r c ryothera py.

P I T FALLS TO AVO I D •

Although

50%

of patients with xa nthelasmas a re

normoli p e mi c , it is c r u c i a l to screen new patients with xa nthelasmas fo r the p resence of hyperl i p i d e m i a . This is pa rti c u l a rly i m porta nt i n you nger patie nts who pre­ sent with xa nthelasma s i n c e they a re more l i kely to have assoc iated l i p i d a bnorma l ities. •

Patie nts m ust be made awa re that complete remova l of the xa nthelasmas d oes not preve nt futu re d evelopment of new lesions.

•

Extre me caution should be exerted when operati ng o n the eye l i d s i n o r d e r t o avoid eye i nj u ry.

B

Figure 50. 1 Xanthelasma on the left upper medial eyelid in a middle­ aged woman. (B) The resulting defect is sutured using ethilon sutures. This procedure produced a very good cosmetic result

Sect i o n 7: B e n ign G rowt h s

B I B L I OG RAPHY Eedy DJ . Treatment o f xa nthelasma b y excision with sec­ o n d a ry i nte ntion h ea l i ng. Clin Exp Dermatol. 1 996;2 1 : 273-27 5 . G h osh YK, Pra d h a n E, A h l uwa l ia H S . Exc ision o f xa nthe­ lasm ata-c la m p , shave, and suture. lnt J Dermatol. 2009 ;48 ( 2 ) : 1 8 1 - 18 3 . Hawk J L. C ryothera py ma y be effective f or eyel i d xa nthe­ las m a . Clin Exp Dermatol. 2000;25:35 1 . M a n n i no G ,

Pa pa le A , D e Bella

F, et a l .

Use of

erbi u m : YAG laser in the treatment of pa l pe b ra l xa nthelas­ mas. Ophthalmic Surg Lasers. 200 1 ;32: 129-133. N a has T R , M a rq u es J C , N i coletti A, Cunha M, N is h iwa ki­ Da ntas M C , Filho JV. Treatment of eye l i d xa nthelasma with 70% tri c h l o roacetic a c i d . Ophtha/ P/ast Reconstr Surg. 2009;25(4): 280-283 . U l l m a n n Y, H a r-Shai Y, Peled IJ . The use of C0 2 laser fo r the treatment of xa nthelasma pa l pe b ra r u m . Ann Plast Surg. 1 993;3 1 : 504-507

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E I GH T C utaneo u s Ca rcino mas

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Color Atlas of Cosmetic Dermatology

CHAPT E R 5 1

Acti nic Ke ratosis

Acti n ic keratos is (AK) present as si ngle or m u ltiple d is­ c rete, sca ly lesions, fou n d m ost freq uently in ha bitua l ly s u n-exposed sk i n of ad u lts .

E P I D E M I O LOGY Age: m ost c o m m o n l y noted i n m id d le age, occasionally occ u rs i n patients u n d e r 30 yea rs

Sex: more common in m a les Incidence: very c o m m o n ; i n Austra l i a 1 : 1 ,000 persons

Race: s k i n phototypes I-I I I , rarely seen i n s k i n phototypes I V-V I Occupation: outdoor workers (eg, fa rmer, ra ncher, sa i lor) and outdoor sports (golf, te n n is, sa i l i ng)

A

PATHOG E N E S I S Prolonged a n d re peated s u n expos u re i n suscepti ble per­ sons resu lts in c u m u lative kerati n ocyte d a mage. The p r i n c i p l e sun d a m age is secondary to u ltravoi l et B ( UV B ) ( 290-320 n m l l ight.

PHYS I CAL EXAM I NAT I O N AKs present as s i ngle o r m u ltiple ski n-colored , e rythema­ to us, o r b rown sca ly patc hes. There is a pred i lection for s u n-exposed a reas i n c l u d i ng the fa ce, ears, neck, fore­ a rms, and dorsa l h a n d s . A Ks may become t h i c kened, fo rm i n g a cuta neous horn . M o re easily pa l pated t h a n see n . They a re genera l ly asym ptomatic but may be ten­

B

d e r o r pru riti c . Act i n i c c h e i l itis d eve lops o n the verm i l i o n bord e r as d iffuse sca l i ng o r d ryn ess . Associated tela ng­ iectasia, so l a r elastosis, and lentigi nes a re freq uently o bse rved .

D E R M ATOPAT H O LOGY Epidermal pro l iferation with m i l d -to- moderate bas i l a r ker­ atinocyte pleomorph i s m , pa ra ke ratosi s , and dyskeratotic keratinocytes. Cytologica l ly, atypical kerati n ocytes a re usua l l y confi ned to the epidermal basa l laye r.

D I F F E R E N T I A L D I AG N OS I S •

Eczematous d e rmatitis

•

Extra m a m m a ry Paget's

•

Sq u a m o u s cell ca rc i n o m a

•

Basa l cell carc i noma

c

Figure 5 1 . 1 (A) Numerous facial actinic keratosis pre-Aidara treatment. (B) Expected erythema and crusting during A ldara treatment. (C) Facial

actinic keratosis post-Aidara treatment applied twice weekly for 4 weeks (Courtesy of Richard Johnson, MDJ

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

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249

CO U RS E A Ks ca n self-resolve, b u t genera l l y a re persistent i n natu re . T h e progress ion t o s k i n cancer with i n preexist i n g A Ks is u n known but is estimated at less t h a n 1 % o f i n d i­ vid u a l lesion s . B i o psy wa rra nted for pigme nted A Ks ( s u perfi c i a l

pigme nted a cti n i c

ke ratosis)

or

nod u la r

ke ratosi s .

KEY CO N S U LTAT I V E QU EST I O N S •

D u ration o f lesion(s)

•

Lesiona l rate of growth

•

Prior treatment for lesions a nd response

•

Perso n a l and fa m i ly h i story of prior s k i n ca n ce rs

•

H i story of prior rad iation treatment to the a rea

•

Cu rrent med ica l h i story

•

Med ication use

•

Evidence of i m m u n os u ppression

•

P red ispos i n g synd romes

A

MANAG E M ENT Assess ment o f t h e n u m be r, size, location, freq uency of deve l opment, a n d any u nderlying i m m u nosu ppressed state s h o u l d be o bta i n ed . A b i o psy should be o bta i ned of any

lesion

that

is

suspicious

for

skin

c a n cers .

Consideration m a y t h e n b e given t o treatment o f i n d ivid­ ual or m u lt i p l e lesions, prophylactic thera py, and deter­ m i nation of the n eed for c l i n ical fol low- u p .

B

Figure 5 1 .2 (A) Actinic cheilitis, lower lip. Patient complained of fre­

quent peeling that was poorly responsive to cryosurgery and efudex.

T R EATM ENT •

(8) Reduction in actinic damage following carbon dioxide resurfacing.

Patient reported complete resolution of peeling

P reve ntion - A p p l ication of da i ly s u n s creen with U VN U V B pro­ tectio n - To pica l treti n o i n a pp l ied n ightly

•

Topica l - Once d a i ly ( Ca ra c ) or twice d a i ly ( Efudex) a p pl ication of 5-fl u o ro u ra c i l fo r 3 to 4 weeks - Twice weekly o r every th i rd

day a p p l ication

of

i m i q u i nod (Aida ra 3M St. Pa u l , M N ) for 4 weeks ( Fig. 52 . 1 ) - D i c l ofenac (Sola raze) 3% sod i u m topica l gel twice d a i ly for 2 to 3 m o nths - l ngenol mebutate a p p l ied on 2 su bseq uent days or twice 1 week a pa rt •

Gentle c ryosu rgery with a si ngle freeze-thaw cyc l e . B l ister formation poss i b l e . R e peat treatment may b e req u i red . R isk o f tempora ry hyperpigmentation a n d

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Color Atlas of Cosmetic Dermatology

permanent depigme ntation m ust be a d d ressed with the patient. T hi s modal ity is best for isolated n u m ber of lesions •

System ic - Long-te rm low-dose oral retinoid has been used , t h i s treatment req u i res c l ose fol low- u p to avo i d pote ntial side effects. Benefi c i a l o n l y while on m ed i cation - O ra l vita m i n A has been used , req u i res close fol l ow­ up to avoid potentia l side effects. Benefi c i a l o n l y w h i l e on med ication

•

S u rgica l - Photodyna mic thera py with topical a m i nolevu linic acid ( Levu len , Dusa Pharmaceutica ls, I nc . , Wilmi ngton, MAl has been successfu lly uti l ized . The pu lsed dye laser 595 nm, blue l ight 415 n m , nea r-infrared 830 n m , i ntense pu lsed light sou rce, a n d l ight-em itting d iode have been e m ployed for del ivery of treatment. M ulti ple treatments a re usually req u i red . Topica l levu lan appl ied 1

hour

prior

to

l ight treatment

may

be

used .

Photosensitivity posttreatment promi nent - C h e m i c a l pee ls-seria l med i u m-depth peels i n c l u d ­ i n g J essner/10% t o 35% tri c h loroacetic a ci d peels a re

h ig hl y

beneficia l

Postoperative

in

red u c i n g

lesion

cou nt.

pee l i ng may last u p to 2 weeks

d e pe nd i ng on the strength util ized - Fractionated a b l ative carbon d i oxi d e laser-seria l treatments may be req u i red to reac h treatment e n d ­ point o f lesio n a l red uction - P u lsed ca rbon d ioxide laser-h ighly effective i n m a n ­ agement o f acti n i c c h e i l itis ( Fig. 5 2 . 2 ) . The ve rm i l io n bord e r is outl i n ed p r i o r t o the ad m i n istration o f m e n ­ ta l block a n d/or loca l ized i nfi ltrative a n esthesia with 1% l i d oca i n e with 1 : 100,000 e p i n e p h ri n e . Passes a re performed u nt i l remova l of epidermis is o bse rved . Area wi ped with sa l i ne soa ked spo nges between the passes . Posto perative care req u i res soa king the treat­ ment site with water a n d a clean wash c l oth to rem ove a n y crusti n g a n d a p pl icati o n of vase l i n e th ree to fou r ti mes a day. R i s k of sca r formation a n d i nfection m ust be consid ered

P I T FALLS TO AVO I D •

With acti n i c c h e i l itis, it is esse ntia l to avo i d vaporiza­ ti on of the verm i l io n

bord e r to p reve n t sca rring.

D e l i n eati n g the bord e r prior to a d m i n istration of a n es­ thesia is h e l pfu l . •

Patients m u st b e awa re that a ny treatment a d m i n istered d oes not e l i m i nate the d evelopment of fut u re pre m a l ig­ nant a nd m a l igna nt growths. Strict photoprotection a n d s u n avoida nce is m a n d atory.

•

Patients uti lizing to pica l treatments m ust be made awa re of the expected erythema, crusti ng, a n d d iscomfort that

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

w i l l persist d u ri ng the d u ration of treatment a nd for 1 to 2 weeks posttreatment. A m i ld topica l corticosteroid may be prescri bed posttreatment completion to assist i n the resol ution of these fi ndi ngs.

B I B L I OG RAPHY A l be rts D , Ra nger- M oore J , Einspa h r J , e t a l . Safety a n d efficacy o f d ose-i ntens ive o ra l vita m i n A i n s u bjects with su n-da maged ski n . Clin Cancer Res. 2004; 10(6) : 1 8751 880 . Ericson

MB,

Sand berg

C,

Stenq u ist

B,

et

al.

P h otodyna m i c thera py o f acti n i c keratosis a t va ry i n g flu­ ence rates : Assessment of photo b l ea c h i ng, pa i n a n d pri­ m a ry c l i n i cal outcome. Br J Dermatol. 2004; 1 5 1 (6 ) : 1 204- 1 2 1 2 . H a d ley G , Derry S , M oore R A . l m iq u i m od for acti n c ker­ atosis: Syste m i c review a nd

meta-a na lysis. J Invest

Dermatol. 2006; 1 26(6) : 1 2 5 1 - 1 255 J a rvis B , Figgitt D P. To pical 3 % d i c l ofenac i n 2 . 5 % hya l u ro n i c ac i d ge l : A review o f its u s e i n patients with acti n i c ke ratosis. Am J Clin Dermatol. 2003 ;4( 3 ) : 2032 13 . J orizzo J , Weiss J , F u rst K, Va n d e Pol C . Effect o f a 1 -wee k treatment with 0 . 5 % to pical fl uoro u ra c i l o n occu rrence o f acti n i c keratosis afate r c ryos u rgery: A ra n­ d o m ized , veh i c le-contro l l ed c l i n ical tria l . Arch Dermatol. 2004; 140( 7 ) : 8 1 3-8 1 6 . Rolf-Ma rkus S , M atheson R , Davis S , e t a l . To pica l methyl a m i nolevu l i nate photodyna m i c thera py using red ! l ight­ emitting d iode l ight for m u lt i p l e a cti n i c ke ratosis: A ra n ­ d o m ized study. J Dermatol Surg. 2009 ;35(4): 586-59 2 . S i l le r G , G e ba ue r K, Wel b u rn P , Katsa mas J , Ogbo u rn e S M . P EP005 ( i ngenol me b utate) ge l , a n ovel agent fo r the treatment of acti n i c keratosis: Resu lts of a ra ndom­ ized , d o u ble- bl i n d , ve h icle-control led , m u l tice ntre phase l l a study. Australas J Dermatol. 2009 ; 50( 1 ) : 1 6-22. Thai KE, Ferg i n P, F ree m a n M, et a l . A pros pective stu dy of the use of c ryosu rgery fo r the treatment of acti n i c ker­ atosis. lnt J Dermatol. 2004;43 ( 9 ) : 687-69 2 .

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Color Atlas of Cosmetic Dermatology

CHAPT E R 5 2

B asal Cell Ca rci n o m a

Basa l cel l carc i noma ( BCC) i s a slow-growing m a l ignant skin tumor that presents i n d isti nct h isto l ogica l s u btypes i n c l u d i ng nod u l a r, su perfi c i a l , m i c ronod u la r, i nfi ltrati ng, and morpheafo r m . N od u la r BCC is the most common type occ u rring pred o m i n a ntly on the head a n d neck regions.

EPI OEM I O LOGY Incidence: the m ost com mon skin cancer i n Ca ucasia ns with a p proxi mately 800,000 cases/year d i agnosed i n the U n ited States

Age: most common in patients over 40 yea rs Race: m ost c o m m o n in Caucasians Sex: h igher i n c idence i n ma les Precipitating factors: c h ro n i c u lt raviolet ra d iation a n d fa i r s k i n a re t h e m ost s i g n ificant p red isposing fa ctors . Oth e r fa ctors i n c l u d e i o n i z i n g ra d i ati o n , a rs e n i c expo­ s u re , i m m u n os u p p ress i o n , P U VA , and ge netic p red is­ positi o n .

PATHOG E N E S I S T h e m ost c o m m o n a ltered gene i n B C C i s t h e PTCH tumor

s u ppressor

ge ne

with

a

res u lta n t

a ltered

H edgehog signa l i ng pathway lea d i ng to u n reg u lated cel l prolife ration a n d a l te red c e l l d ifferentiatio n . M u tations i n t h e p53 t u m o r s u p p ressor gene a re a lso freq uently o bserved lea d i ng to cel l u l a r i m m o rta l ity a n d resista nce to a po ptos i s .

PHYS I CAL EXAM I NAT I O N P i n k , e rythematous, pea rly tra nsl ucent pa p u l e , nod u l e , o r pla q u e with a ro l led bord e r a n d overlying tela ngiec­ tasias ( Fig. 52 . 1 ) . S u perfi c i a l B CC p resents as a p i n k or e rythematous thin sca ly plaq u e . The center may become u l cerated and covered by a c rust, that is, " rodent u lcer. " Morpheaform B C C exh i bits a scar- l i ke a p pea ra nce with i l l-defi ned borders. They m ost commonly present in pho­ tod istri buted a reas.

D I F F E R E N T I A L D I AG N OS ES Dermal m e l a n ocytic nevi , sebaceous hyperplasia, sq ua­ mous cel l c a rc i noma (SCC).

Figure 52. 1 Large BCC on the face. Note the characteristic rolled bor­ ders, overlying telangiectasias, and the central ulceration

Secti o n 8: C u ta n eo u s Ca rc i n o m a s

I

253

LABO RATORY DATA • D e r m at o p at h o l ogy Lo b u les, nests, or cords of neoplastic basa loid cells with peri phera l pa l isa d i ng, c lefti ng, and m u ci n o u s stroma .

CO U RS E Loca l ly i nvasive a n d slow growi ng over m o nths a n d even yea rs. M etastasis is an exceed i ngly ra re occ u rre nce.

KEY CO N S U LTAT I V E QU EST I O N S Excessive s u n expos u re a n d other pred ispos i n g factors, prior h istory of BCC or SCC, perso n a l a n d fa m i ly h i story of s k i n cancer, i m m u nos u p pressio n .

MANAG E M ENT

A

There a re m u lti ple methods for treating B C C . Treatment selectio n should be based u po n the age, hea lth, a n d prefe rences o f t h e patient after a fu l l d iscussion o f treat­ ment options, risks, a n d benefits. G iven the loca l ly d estructive nature of B C C, h istologica l confi rmation of com plete remova l is o pti m a l . S u rgica l excision a n d h i sto­ logical eva l uation rem a i n the treatment of choice in most cases. Tu m o rs fixed to u nd e rlying bone, espec i a l ly the sca l p , merit rad io l ogica l work u p prior to s u rgica l excision o r M o h s m i c rogra ph i c su rgery. Topical thera pies req u i re c l ose fo l l ow- u p for a n y evidence of treatment fa i l u re or recu rrence. Patient ed ucation rega rd i n g the benefits of sun avoida nce, s u n sc reen use, and reg u l a r self-exa m i na­ tions a re i m porta nt preventive measures.

• F i rst- l i n e T h e ra p i es •

Exc isional s u rgery: ge n e ra l ly with 4-m m m a rgins is the treatment of choice for nonsu perficia l BCC that d o n ot meet the criteria of Mohs m i c rogra p h i c s u rgery

•

Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice for h igh-risk a nato m i c a l locations (ie, " mask" a rea of the face), locations where tissue conservati o n is c r u c i a l for fu n ctional o r cosmetic reasons, rec u rrent tu mors, i l l ­ d efi ned c l i n ical m a rgi ns, h i stologica l l y aggressive s u b­

B

types , t u m o rs in i m m u nosu ppressed patients, t u m o rs

Figure 52.2 (A) BCC on the nose with very ill-defined clinical margins.

la rge r than 2 e m , i rrad iated ski n , a n d peri n e u ra l i nva­

(B) Large defect after Mohs micrographic surgery. Mohs micrographic surgery is the ideal treatment for this type of skin cancer providing the highest cure rate among all other treatment modalities

sion on biopsy ( Figs . 52 . 2-52.4) . M o hs m i c rogra ph i c su rgery has the h ighest c u re rate o f a n y treatm ent of BCC •

El ectrodessication a n d c u rettage

•

Cryothera py

254

•

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Color Atlas of Cosmetic Dermatology

Rad iation thera py is a nother treatment option espe­ c i a l ly when su rgery i s not feasible or contra i n d icated . It can a lso be used as a n adj uva nt thera py when per­ i n e u ra l i nvasion is i d e ntified

• A l te r n ate T h e ra p i es •

Topical i m i q u i mod , a p p l ied five t i m es a week for a tota l d u ration of 6 wee ks . It is FDA a pproved for treatment of su perfi c i a l B C C .

Recu rrence

rates a re sign ifica ntly

h igher than s u rgica l excision . •

Topical 5-fl uoro u ra c i l is primarily reserved for treatment of su perfi c i a l B C C . H owever, rec u rrence rates a re h i g h .

•

P h otodyn a m i c

thera py

prod u ces

a

p h otoc h e m i c a l

reaction t h a t req u i res the prese nce o f a p h otosensitiz­ i ng agent, tissue oxyge n , a n d l ight with ph otoactivating wavelength . The m ost common to pical photosens itizer is 5-a m i nolevu l i n i c acid (5-ALA ) . 5-ALA is a precu rsor of the i ntri nsic i ntrace l l u l a r hemebiosynthetic pathway, w h i c h resu l ts in the prod uction of a photoactive porphyri n , protoporphyri n IX. The m ethyl d e rivative of 5ALA, methyl a m i nolevu l i n ic acid ( M AL) is a lso very

A

c o m m o n l y used a n d demonstrates a bette r sel ectivity for m a l igna nt cells. The l ight sou rces a re usua l ly in the visi ble l ight ra nge and they i n c l u d e laser (coherent) l ight sou rces (eg, pu lsed dye lasers) or noncoherent l ight sou rces ( red, blue l ight) . Red l ight provides the dee pest penetration of these l ight based treatment modal ities. PDT ca n provide 76% to 97% clearance rates for su perficia l BCC. I t is pa rticula rly useful i n patients who a re poor s u rgica l ca n d i d ates or those who h ave m u ltiple BCCs that req u i re m u ltiple s u rge ries. C l ose c l i n ical fol l ow- u p after treatment is req u i red for a n y evidence of rec u rrence or i ncom plete remova l •

l ntra lesi o n a l i n te rfe ron is ra re ly performed

•

Carbon d ioxi d e laser-may be effective for s u perfi cia l B C C a n d patients w i th m u lt i p l e s h a l l ow tumors s u c h as i n basa l cell nevus synd rome

P I T FALLS TO AVO I D - I nfecti o n , bleed ing, pa i n , nerve da mage, poor cosme­ sis fo l lowi ng surgical repa i r, hypertro p h i c or atrophic sca rring, a n d rec u rrence a re all com mon pitfa l ls of BCC s u rgica l thera py a n d should be fu l ly d iscussed with the patient prior to treatment. - Nonsurgica l thera pies may provide better cosmesis but sign ificantly h igher rates of recu rrence. Fu rthermore, nonsurgical i nterventions d o not provide the opportu­ n ity for h istological confi rmation of complete remova l . They a re best for patients w h o have n u merous BCCs and i n those who a re poor surgica l candidates.

8

Figure 52.3 (A) Surgical defect after Mohs micrographic surgery of BCC on the right forehead. (B) Repair of the defect with an A to T advance­ ment flap. Notice that the horizontal incision line is hidden within the eyebrow hairs for a better cosmetic outcome

Secti o n 8: C u ta n eo u s Ca rc i n o m a s

I

B I B L I OG RAPHY Atti l i S K, Lesa r A, M c N e i l l A , e t a l . An o p e n pilot study of a m bu latory photodyn a m i c thera py u s i ng a wea ra ble low­ i rrad ia nce orga n i c l ight-e m itti ng d iode l ight sou rce in the treatment of n o n m e l a noma s k i n cancer. Br J Dermatol.

2009 . M u ller

FM,

Dawe

RS,

M oseley

H,

Fleming

CJ .

R a n d om ized com pa rison of mohs m ic rogra p h i c s u rgery a n d s u rgica l excision fo r s m a l l nod u la r basa l c e l l carci­ n o m a : Tissue-sparing o utco m e. Dermatol Surg. 2009 . R owe D E , Carro l l RJ , Day CL J r. Long term rec u rrence rates in previously u ntreated ( pr i m a ry) basa l ce l l carci­ n o m a : I m pl ications for patient fol l ow- u p . J Dermatol Surg

Oneal. 1989; 1 5 : 3 1 5-328 .

A

Ti erney E, Ba rker A, Ahdout J , H a n ke CW, M oy R L, Ko u ba DJ . P h otodyna m i c thera py for the treatment of c uta neous neoplasia , i nfla m matory d isord e rs , a n d p h o­ toaging. Dermatol Surg. 2009;35(5): 725-746. Wolf DJ , Zite l l i JA. S u rgica l m a rg i n s for basa l cel l carci­ noma. Arch dermatol. 1987 ; 1 23 : 340-344 .

B

c

Figure 52.4 (A) Nodular basal cell carcinoma on the left preauricular

area. (B) Clearance of basal cell carcinoma after Mohs surgery. (C) Primary closure of the Mohs defect with dog-ear repair

255

256

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Color Atlas of Cosmetic Dermatology

CHAPT E R 53

Sq u a m ous Cell Ca rci n o m a

S q u a m ous cell c a rc i noma (SCC) m ost c o m m o n l y origi­ nates from kerati nocytes i n su n-da maged skin either d e novo or from a preexisting a cti n i c keratosis o r sec i n situ (a lso known as Bowe n 's d isease ) , predom i na ntly affect­ ing the h ea d , neck, a n d a r m s . I t can a l so a rise in non­ su n-exposed s k i n most commonly from c h ro n i c leg u l ce rs a n d b u rn sca rs .

EPI DEM I O LOGY Incidence: it is the seco n d most common skin cancer in Caucasians and the most common skin cancer i n d a rkly pigmented s ki n . A p proxi mately 1 50,000 cases/year a re d iagnosed in the U n ited States

Age: most common in patients over 55 yea rs Race: m a i n ly affects Caucasians Sex: h igher i n c idence i n ma les Precipitating factors: c h ro n i c u ltravio l et rad iation and fa i r

Figure 53 . 1 Invasive squamous cell carcinoma on the right neck

s k i n a re the most significant pred ispos i n g factors . Other factors i n c l u d e i m m u nos u p press i o n , h u ma n pa p i l loma virus

i n fection ,

ge netic

ionizing

d isord e rs

ra d iati o n , a rse n i c expos u re ,

(epidermodysplasia

verruc iform is,

a l b i n i s m , xerod erma pigmentos u m , epid ermolysis bul­ losa ) , P U VA expos u re, smoki ng, a n d c h ro n i c i nfla m m a ­ t i o n ( u lcers, b u rn scars, d iscoid l u pus)

PATHOG E N E S I S The most common a ltered gene i n SCC i s the p53 tu mor s u p p resso r gene, res u lting i n keratinocyte i m m orta l iza­ tion and u n reg u l ated c e l l prol ife ratio n .

PHYS I CAL EXAM I NAT I O N Hyperkeratotic ski n-col ored t o erythematous

pa p u l e ,

p l a q u e , or nod u le ( Figs . 53 . 1 a n d 53 . 2 ) . I t can b e u l ce r­ ated , fria ble, or exo p hyti c . It m ost commonly presents with i n su n-da maged ski n .

D I F F E R E N T I A L D I AG N OS ES Keratoacanthoma ( F ig. 53 . 3 ) , hypertro p h i c acti n ic ker­ atosis, basa l cell carc i n o m a ( B C C ) , i nfla med seborrh eic keratosis.

Figure 53.2 Recurrent squamous cell carcinoma on the chest of an

elderly woman

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257

LABO RATORY DATA • D e r m at o p at h o l ogy Prol iferation of atypical kerati nocytes with va ria b l e d iffer­ entiation of the epidermis a n d va riably sized n ests a n d islands i nvad i ng t h e d e r m i s . Foci o f kerat i n izatio n a re n oted i n we l l-diffe rentiated va ria nts . Peri n e u ra l i nvolve­ ment may be o bse rved .

CO U RS E SCC tends t o b e more aggressive t h a n B CC, with a reported

2%

to

3%

i nc i d e n ce

of

metastasis.

M ucocuta neous SCC has a h igher rate of m etastasis, as h igh as 1 1 % . M ore aggress ive forms of SCC a re o bserved in i m m u n os u p p ressed patients o r sec that a rises with i n previously i rrad i ated sites, sca rs, b u rns, a n d a reas of i nfla m mati o n . There is a h igher m etastatic potential for

sec a rising on the ea r a n d the l i p.

Figure 53.3 Giant keratoacanthoma on the chest. Many authors regard

keratoacanthomas as variants of well-differentiated squamous cell carcinoma

KEY CO N S U LTAT I V E QU EST I O N S Eva l uate fo r past h i story o f bl istering s u n b u rns a n d c h ro n i c s u n expos u re . Determine i f other pred ispos in g factors a re present s u c h as perso n a l a n d fa m i ly h istory of ski n cancer a n d i m m u n os u p pression , especia l ly orga n tra nspla ntatio n .

MANAG E M ENT P reventative measu res, s u c h as s u n avoi da nce a n d d a i l y s u n sc reen u s e , a re c ritica l for lo ng-term preventio n . Treatment selection s h o u l d be based u pon the age, hea lth , and preferences of the patient after a fu l l d iscus­ sion of treatment options, risks, and benefits . G iven the m etastatic potentia l of sec, h i stologica l confi rmation of complete remova l is a l ways advised . S u rgica l excision and

h i stological eva l uation

rema i n the treatment of

choice i n m ost cases . Tu m o rs fixed to u nderlying bone, espec ia l ly the sca l p, merit ra d iological work u p prior to s u rgica l excision o r Mohs m i c rogra p h i c su rgery. Prior to treatment, lym p h node pa l pation is a p propriate for la rge

sec, sec in i m m u n osu p pressed patients, a n d h igh-risk SCCs. To pica l thera pies req u i re c l ose fol l ow- u p fo r any evidence of treatment fa i l u re o r rec u rrence.

• F i rst- L i n e T h e ra p i es •

Exc isional s u rgery: 4-m m m a rgins a re ge nera l ly recom­

•

Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice

A

for high-risk a nato m i c a l locations (ie, " mask" a rea of

Figure 53.4 (A) Defect on the ear after Mohs excision of a squamous cell

the face ), locations where tissue conservation is c r u c i a l

carcinoma.

mended

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Color Atlas of Cosmetic Dermatology

for fu nctional or cosmetic reasons, rec u r rent t u m o rs, i l l­ defined c l i n i cal m a rgins, h i stologica lly aggressive s u b­ types, t u m o rs in i m m u n osu ppressed patients, t u mo rs la rge r than 2 e m , i rrad iated ski n , a n d per i n e u ra l i nva­ sion on biopsy ( Figs. 53.4 a n d 53 . 5 ) . C u re rates of SCC depend o n size, h isto l ogica l gra d e, peri n e u ra l i nvasion, a n d i m m u nos u p pressi o n . La rge r lesions, less d iffe renti­ ated va ria nts with per i n e u ra l i nvolvement, and lesions i n i m m u noco m p ro m ised patie nts demonstrate lowe r c u re rates •

Electrodessication a n d c u rettage ( usua l ly not recom­ mended d u e to lack of h i stologic confi rmation of remova l )

•

C ryothera py ( u s ua l ly not reco m m e nded d u e t o l a c k of h isto l ogica l confi rmation of remova l )

•

Rad i othera py ( a p p ropriate for poor s u rgical ca n d i d ates)

B

Figure 5 3 . 4 ( Continued) {8) The Mohs defect is repaired with a

• A l te r n ate T h e ra p i es

full-thickness skin graft

•

Topical 5-fl uorouraci is l i m ited to SCC in situ

•

Topical i m i q u i m od is l i m ited to SCC i n situ

•

l ntra lesional i n terfe ron

•

P h otodyn a m i c thera py ( P DT) u s i n g topica l o r syste m i c photosensitize rs with lasers or noncoh erent red l ight a re m ost effective for SCC in situ . Clearance rates ra nge from 72% to 94% . PDT can act as an a lternative treat­ ment for la rge lesions, espec i a l l y for those patients who a re poor s u rgica l c a n d i d ates. It can serve as a n a lterna­ tive treatment i n patients with m u ltiple SCCs. For these patients, P DT and c l ose c l i n ical fol l ow- u p may o bviate the need for m u lti p l e s u rgeries. P DT is a lso effective for decreasing the n u m ber of acti n i c keratosis, t h us acting as a preventative of future sec development

•

Carbon d ioxide laser is h ighly effective fo r a cti n i c chei l i ­ t i s . It can a l so b e used t o treat S C C i n situ

P I T FALLS TO AVO I D I nfection , bleed i ng, ne rve d a mage, pa i n , hypertro p h i c sca rring, p o o r cosmesis fol lowi n g s u rgica l repa i r, a n d recu rrence a re a l l c o m m o n pitfa l ls o f S C C treatm ent a n d s h o u l d b e fu l l y d iscussed with the patient p r i o r t o treat­ ment. Nonsu rgica l thera pies may provide better cosme­ sis

but

sign ifica ntly

h igher

rates

of

rec u rre nce.

F u rthermore, nonsu rgica l i nterve ntions d o not provide the o p portu n ity for h i sto logica l confi rmation of complete remova l . T h i s is pa rti c u l a rly cr u cia l given the potential of metastatic s p read with SCC. T h u s , sta n d a rd or Mohs m ic rogra p h i c s u rgica l exc ision with h istologica l confi rma­ tion of clear m a rg i n s is a l ways the treatment of choice for

sec.

A

Figure 53.5 {A) Surgical defect after Mohs micrographic surgery of an sec on the left cheek.

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

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259

B I B L I OG RAPHY Covadonga M a rtinez-G onza lez M , d e l Pozo J , Paradela S , Fernandez-J orge B , Fern a n dez-Torres R , Fonseca E . Bowe n 's d i sease treated b y ca rbon d i oxide laser. A series of 44 patients. J Dermatolog Treat. 2008; 1 9 ( 5 ) : 293-299 . M orton CA, McKenna KE, R hodes LE. B ritish Assoc iation of

Dermatologists

Thera py

G u i d e l i nes

and

Aud it

S u bcomm ittee and the B ritish P hotod ermatology G rou p . G u i d e l i nes for to pical p h otodyna m i c thera py : Update. Br

J Dermatol. 2008; 1 59 ( 6) : 1 245- 1 246. P reston DS, Ste rn RS. N o n melanoma cancers of the ski n .

N Eng/ J Med. 1 992;327 : 1 649- 1 662. R owe D E , Carro l l RJ , Day C L J r. P rognostic factors for loca l rec u rre nce, m etastasis, a n d s u rviva l rates in sq ua­ mous cel l carc i n o m a of the skin, ear, a n d l i p. I m p l ications fo r treatment m od a l ity selecti o n . J Am Acad Dermatol. 1992;26:976-990.

B

c

Figure 5 3 . 5 (Continued) (B) The Mohs defect is repaired with a transposi­

tion flap. (C) A fter suture removal 1 week later

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NINE I nf l a m matory Disord e rs

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CHAPT E R 54

Liche n Pla nus

Lichen p l a n u s ( LP ) is a c o m m o n i nfla m m atory d isease i nvo lvi ng the s k i n a n d m u cous m e m b ra nes. M a n y c l i n ical va ria nts exist that include atro p h i c , u lcerative, b u l lous, a n n u la r, l i nea r, i nverse , hypertro p h i c , l i c h e n pla n o p i l a ris, acti n i c LP and LP pigme ntos u s .

EPI D E M I O LOGY Incidence: About 0 . 5 % Age: 30 t o 6 0 yea rs Race: A l l races a re affected eq u a l ly i n m ost va riants Sex: H igher i n c i d e n ce in fe ma les Precipitating Factors: M ost c o m m o n l y i d iopath ic medica­ tions may i nd uce a LP- I i ke e r u ption

PATHOG E N E S I S Primari ly, a T- hel per cell-med iated reaction

PHYS I CAL EXAM I NAT I O N Most common ly, primary lesions consist of m u ltiple viola­ ceous,

polygo n a l ,

flat-topped ,

grou ped

pa pu les,

and

plaq ues that a re usually pru ritic. T h e i r su rface is s h iny o r tra nspa rent a n d m a y exh i b it small gray-white punctae o r reticular fine wh ite li nes known as Wickha m 's striae . T h e lesions favor t h e oropharynx, flexural wrists, dorsa l hands, med i a l th ighs, s h i ns, tru n k , a n d gen ita l i a . Posti nfla m matory hyperpigmentation is com mo n . Acti nic LP a n d LP pigmen­ tosus can present with melasma - l i ke hyperpigmented patc hes on the forehead and the face ( Figs. 54. 1-54.3) .

D I F F E R E NT I A L D I AG N OS I S Psoriasis, l ic h e n s i m plex, l ic h en oid graft-versus-host d is­ ease, c h ro n ic c uta neous l u pus e rythe matos us, l i chenoid d rug e r u ptio n , melasm a .

LABORATORY DATA G iven the association with h e patitis B a n d C , h e patitis serologies can be i nvestigated .

• D e r m at o p at h o l ogy Pathology reveals l i chenoid i nterface dermatitis, hyperk­ e ratosis, hypergra n u losis, saw-tooth aca nthosis, associ­ ated with colloid o r civatte bodies.

Figure 54. 1 Actinic LP on the forehead, temples, and lateral cheek, mimicking melasma

Secti o n 9 : I nfla m m atory D i so rd e rs

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263

CO U RS E S ponta neous re m ission of cuta n eous L P occ u rs with i n 1 yea r o f onset i n t h e majority o f patients. O ra l LP persists for many yea rs . Sq u a m o u s ce l l carc i noma may a rise from these

lesions,

pred o m i n a ntly from

the

oral

va riant

( Fig. 54.4).

MANAG E M ENT • To p i c a l Treat m e n t •

Corticosteroids, topica l , i ntra lesi o n a l

•

l m m u n omod u lators, s u c h as tac rol i m us

•

Cyc losporine retention mouthwash for o ra l LP

• Syste m i c Treat m e n t • •

Corticoste roids

Figure 54.2 Generalized lichen planus in a patient with skin type 1 V-V

in volving the trunk and buttocks with postinflammatory hyperpigmentation

Reti n o i d s : isotret i n o i n a n d acitreti n . Acitret i n is the only syste m i c treatment that has been eva l uated i n a d o u b l e - b l i n d , p l a cebo-contro l led study

•

G riseofu lvi n , metro n i d azole, a ntima l a ri a l s , m ethotrex­ ate, cyc l ospori ne, a n d mycophenolate m ofet i l

• L i g h t Treat m e n t •

N a rrow B a n d UVB

•

P U VA

•

308- n m UVB exc i mer laser for o ra l LP

•

C0 2 laser for o ra l L P : va ria b l e resu lts with i n c reased risks of side effects

•

Extracorporea l photophoresis

B I B L I OG RAPHY Da m m a k A , Masmoud i A , Bou daya S , Bouassida S , M a rrekc h i S , Tu rki H . C h i l d h ood acti n i c l i c h e n pla n u s ( 6 cases) [ p u b l ished o n l i ne a head o f p r i n t J a n u a ry 18, 2008] . Arch Pediatr. 2008; 1 5( 2 ) : 1 1 1 - 1 14. La u rberg G , Geiger J M , Hjorth N , et al. Treatment of l i c h e n p l a n us with a c itreti n . A d o u ble-bl i n d , place bo­ contro l l ed study in 65 patients. J Am Acad Dermatol 1 99 1 ; 24(3):434-437 . Tre h a n M , Taylor C R . Low-dose exc i mer 308- n m laser for the treatment of o ra l l i c h e n pla n us . Arch Dermatol 2004; 140(4) :41 5-420. va n der Hem PS, Egges M, va n der Wa l J E, Rooden b u rg J L. C0 2 laser eva poration of oral l i c h e n p l a n u s . tnt J Oral Maxillofac Surg. 2008; 3 7 ( 7 ) : 630-633.

Figure 54.3 Hypertrophic lichen planus on the legs of 4 years duration

resistant to topical and intralesional steroid therapy. The patient improved markedly after 1 month treatment with acetretin

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Color Atlas of Cosmetic Dermatology

A

B

Figure 54.4 (A) Ora/ lichen planus at baseline. (B) Two month follow-up after 1 8 treatments with excimer laser administered weekly (Courtesy of Charles Taylor, MDJ

Secti o n 9 : I nfla m m atory D i so rd e rs

CHAPT E R 5 5

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265

M o rphea

M orphea is l oca l ized scleroderma confi ned t o the ski n . It m ost commonly affects the tru n k but a lso occ u rs on the face and extre m ities. The fo u r c l i n ical va ria nts i n c l u de p l a q u e-type morphea, gen e ra l ized morphea, l i near mor­ phea (en cou p de sabre), a n d pa nsclerotic morphea of c h i l d re n ( morphea profu n d a ) .

E P I D E M I O LOGY Incidence: ra re Age: m ost com m o n l y occ u rs i n the seco n d to fifth d eca d e . Li nea r scleroderma a nd morphea profu nda a re more c o m m o n i n c h i l d ren

A

Race: sl ightly more common in Caucasians Sex: fe ma les more than ma les (2-3 : 1 ) Precipitating factors: Borrelia c a n trigger morphea i n some cases, pred o m i n a ntly i n E u ro pe

PATHOG EN ES I S Overprod uction of col lagen (types I , I I , I l l ) a n d gly­ cosa m i noglyca ns by s k i n fi broblasts a nd vasc u l a r d a m ­ age. Proba ble T-cell med iated phenomeno n .

PHYS I CAL EXAM I NAT I O N I l l-d efi ned p i n k t o violaceous, i nd u rated 2 - t o 1 5-cm plaq ues that tra n sform to sm ooth sclerotic ivory-colored plaq ues with a l ight violaceous bord e r a n d a s h i n y s u r­ face. Posti nfla m matory hyperpigmentation is p reva lent ( Fig. 55. 1 ) . Linear morphea presents with a l i nea r e rythe­ matous i nfla m matory streak that may progress to form a sca r- l i ke ba n d i nvolvi ng u n d e rlying fasc i a , m usc le, a n d te ndons.

D I F F E R E N T I A L D I AG N OS ES Acrod ermatitis c h ron ica atro p h icans, eos i n o p h i l i c fasc i­ itis, l i c h e n sclerosus et atro p h i c u s , sclered e m a , sc l e­ ro myxed e m a , a n d n e p h roge n i c system i c fi b rosis.

LABO RATO RY DATA • S e ro l ogy Check for Borre l i a a n t i bodies.

B

Figure 5 5 . 1 (A) Early morphea on the left leg presenting as an erythema­

tous plaque. (B) Same patient with late stage morphea on the right leg presenting as linear depressed yellowish to white hard plaques with ery­ thematous margins

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• D e r m atopat h o l ogy H omogen ization a n d thickening of derma l col lagen b u n ­ d l es, tra p ped a n d atro p h i c eccrine glands, perivasc u l a r mononuclear i nfi ltrate o f lym p h ocytes a n d plasma cells with normal o r atro p h i c overlying epidermis. U n d erlying su bcuta neous fat may a lso be i nvolved with sclerosis in adva n ced cases.

COU RS E Cou rse i s va ria b l e . M a ny patients re m it s ponta n eously but others have a p rogress ive cou rse.

A

MANAG E M ENT Treatment for t h i s cond ition ca n b e frustrating d ue t o fre­ q uent treatment fa i l u re . Patients s h o u l d be cou nseled that thera py may not be effective . •

Topical treatment - Corticosteroids - Calci potriene

•

System i c treatment - Corticosteroids, D-penicillami ne, vitamin 03, methotrexate

•

Light treatment - U ltraviolet A l photothera py - P u lsed dye laser ( 585 n m , 5 J/cm 2 twice monthly), reported to be effective i n s i ngle case report

•

S u bc i s io n : s u bcision with a N okor 18G need le may

B

help to elevate the b o u n d -down ski n . It is m ost effec­

Figure 5 5 . 2 (A) Morphea with significant epidermal, dermal, and subcu­

tive

taneous atrophy. (8) Elevation of the atrophic plaque of morphea after a single autologous fat transfer. The associated telangiectasias were subse­ quently treated with the pulsed dye laser with substantial improvement

for

l i nea r

m o r phea

and

fa c i a l

h e m iatro p h y.

S u bc i s i o n is performed u n d e r loca l i nfi ltrative a n esthe­ sia

to the affected

s ite with

1%

l i d oca i n e with

1 : 1 00,000 e p i n e p h ri n e . The Nokor need le is i ntro­ d uced at a 45-degree a ngle i nto the skin uti l i z i n g a swee p i n g

motion

to

release

a ny tethered

a reas.

M u lt i p l e entra nce sites should be performed fo r opti­ m a l benefit. F i r m press u re is a p pl ied to the treatment sites fo r h e m ostasis •

Soft tissue a ugmentatio n : va rious fi l lers have been e m ployed with va riable s uccess to a ugment the scle­ rotic sites . They a re m ost com monly uti l i zed for l i near morphea a n d fac i a l h e m i atrophy. Te m pora ry fi l l e rs c u r­ rently rec o m m e n d ed given the u n p red i cta ble c o u rse of morphea . Autologous fat tra n sfer can provi d e sign ifi­ cant a ugme ntation of the affected sites ( Fig. 5 5 . 2 ) . R e peat i njections genera l ly req u i red . En bloc a u tolo­ gous dermal fat graft re ported to be effective i n one case re port.

Secti o n 9: I nfla m m atory D i so rd e rs

P I T FALL TO AVO I D Patients must be awa re of the u n pred icta ble natu re of mor­ phea, therefore the u n pred icta ble nature of the treatment.

B I B L I OG RAPHY Eisen D , Alster TS. U s e o f 5 8 5 n m p u lsed dye laser fo r the treatment of morphea . Dermatol Surg. 2002 ; 28( 7 ) : 6 1 5-6 1 6 . La piere J C , Aasi S , Cook B , M onta lvo A . S u ccessful cor­ rection of d e p ressed sca rs of the forehead seco n da ry to tra u ma a n d morphea e n cou p de sa b re by en b l oc a utol­ ogous d e r m a l fat graft. Dermatol Surg. 2000 ; 26(8) : 793797. N i stico

S P,

Saraceno

R,

Sc h i pa n i

C,

Costa nzo

A,

C h i menti S . Differe nt a p pl ications o f m on oc h romatic exc i mer l ight i n skin d iseases. Photomed Laser Surg. 2009 ; 27(4) : 647-654 .

CHAPTER 56

Pso riasis

Psoriasis is a c o m m o n c h ron i c i nfla m m atory d isease of the s ki n . They a re sym metric in d istri bution a n d favor e l bows, knees, sca l p , retroa u r i c u l a r ski n , and i nte rtrigi­ nous a reas. Many c l i n ical va riants exist and i n c l u d e p l a q u e psoriasis, pustu l a r psoriasis, guttate psoriasis, i nve rse psoriasis, and eryth rod ermic psoriasis, with the plaque va riant bei ng the m ost common type ( Figs . 56. 1 and

56 . 2 ) .

N a i ls a n d

m ucous mem bra n es can

be

affected . Psoriasis is associated with psoriatic a rth ritis i n a t least 5 % o f patients .

EPI DEM I O LOGY Incidence: About 1 . 5 % to 2 % of the wor l d 's population Age: can occ u r at a n y age. Two pea ks of onset, the sec­ ond

and sixth decades. Onset is ea rlier in wo m e n .

U ncom m o n ly affects c h i l d ren

Race: lower i n c idence i n African Ame rica n s , Native America ns, a n d Asians

Sex: eq ual Precipitating factors: bacterial i nfections, especia l ly strepto­ cocca l i nfection (guttate psoriasis), tra u m a ( Koebner p he­ nomenon ) , stress, ge netic pred isposition, a nd med ication use ( m ost com monly l it h i u m , beta blockers, antimalarials) . Rapid corticosteroid ta pers may ind uce pustu lar psoriasis

Figure 56. 1 Classic psoriatic plaques on the knees

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PATHOG E N E S I S Polyge n i c d i sease with a 4 1 % risk for a c h i l d to d evelop psoriasis if both the pa rents a re affected . The p r i m a ry pathophysiology i nvolves hyperprol iferation a n d a b nor­ m a l d ifferentiation of epidermal kerati nocytes as well as a b normal cel l u la r i m m u n e res ponse.

PHYS I CAL EXAM I NAT I O N P l a q u e va riant with we l l-demarcated , p i n k t o erythema­ to us pa pu les a n d plaq ues with overlyi ng s ilvery-wh ite sca l e . P i n po i n t bleed i n g o bserved with sca le re mova l (Ausp itz sign ) . G uttate va riant with tea r d rop-sha ped lesions. Erythe mato u s genera l ized pustu les a re seen with p ustu l a r pso riasis.

D I F F E R E N T I A L D I AG N OS ES

Figure 56.2 Psoriatic plaques koebnerizing vitiligo patches

Ti nea corporis, seborrheic d e rmatitis, eczematous d er­ matitis, mycosis fu ngoides, pa ra pso riasis, l i c h e n s i m plex c h ro n i c us ,

p ityriasis

ru bra

pila ris,

Reiter's

d isease,

Bowe n 's d isease.

LABORATORY DATA • S e ro l ogy Antistrepto lys i n O(ASO) titer for guttate psoriasis.

• D e r m at o p at h o l ogy Regu l a r psoriasiform epidermal hyperplasia with a bsent gra n u la r cell layer and th i n n i ng a bove the dermal pa p i l ­ l a e . Othe r c h a racteristic featu res i n c l u d e col lections of ne utro p h i l s in epidermis as wel l as tortuous blood vessels i n the pa p i l l a ry d e r m i s .

COU RS E T h i s d isease d e mo nstrates a c h ro n i c cou rse with m u ltiple exacerbations a n d re m issions, w h i c h ca n be season a l or related to stress.

MANAG E M ENT There a re m u lt i p l e thera peutic options for treatm e nt of psoriasis. C hoos i n g an a p pro p riate thera py d e pen ds o n the a g e , h e a l t h , a n d prefe ren ces o f the patient. It a lso d e pends on the exte nt of the psoriasis. The costs of ther­ a py va ry d ra m atically as we l l . Alternative thera pies a re m ost a pprop riate in refractory cases. Assessing the side­ effect profi le of treatments is a n other cruc i a l com ponent

Secti o n 9: I nfla m m atory D i so rd e rs

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269

of thera py. Com bi nation thera p i es a re gen e ra l ly m ost effective to decrease inflam mation a n d red uce sca le p ro­ d ucti o n . •

Topica l Treatment - Corticosteroids, to pical a n d i ntra l es i o n a l - Calci potriene - Taza rotene - Coa l ta r - Anthra l i n - Sa l icyl ic acid

•

System i c Treatment - M ethorexate - Reti noids, p red o m i n a n etly a c itret i n - Cyc lospori ne - B i o logics suc h as a l efa cept, eta ne rcept, efa l uz i m a b , a n d i nfl ixi m a b

•

Laser a n d Light Treatme nts - Psora len with U ltraviolet A ( P UVAJ - U l travio l et B ( U V B ) , 3 1 1 - n m na rrowba nd-UVB ( N BUVBJ - 308- n m UVB exc i m e r laser An a lternative fo r treatment of m i ld-to- moderate psoriasis, where m o re conventi o n a l t h era pies have fa i led . It is espec i a l l y h e l pfu l for loca l i zed refractory p l a q u e psoriasis Stu d i es have demonstrated that this local ized UVB treatm ent provides much lowe r c u m u lative d oses of UVB to i n d uce cleara n ce of psoriatic plaq u es com­ pa red to N B-UVB thera py The exc i mer laser m ight a lso prod uce longer re m is­ sion periods, with m i n i m ization of UVB expos u re to healthy su rrou n d i ng s k i n Exc i m e r l a s e r has proved t o be effective a n d safe i n treating refractory sca l p psoriasis D rawbacks of exc i m e r laser in psoriasis treatment i n c l u d e l i m ited ava i l a b i l ity, treatment expense and exte ns ive treatment time n eeded per session

•

Ph otodyna m i c thera py has been shown to i m prove pso­ riasis

in

m u lt i p l e stud ies.

The

major side effects

i n c l uded pa i n a n d b u r n i n g sensation associated with PDT •

Pu lsed dye laser (0.45- 1 . 5 m s , 7-mm s pot, 7-9 J/c m 2 , D C D 30-40/20) has been e m p l oyed to ta rget the vas­ c u la rity assoc iated with psoriatic lesions with noted benefit. I n a recent study, P D L p roved to be effective i n t h e treatment o f n a i l psoriasis ( Fig. 56.3)

•

In a recent study, N d : YAG laser ( 1 ,064 nm) fa i led to i m prove loca l ized p l a q u e type psoriasis

T Figure 56.3 Improvement in treated psoriatic plaque 3 months after pulsed dye laser treatment (585 nm, 1 0-mm spot size, 5 J/cm 2 , no cool­ ing, 0. 45-ms pulse duration), as compared to the control site (Reproduced, with permission, from Brian Zelickson, MD)

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P I T FALLS •

Patients s h o u l d be cou nseled t h a t psoriasis is a c h ro n i c cond ition with fla res a n d re m issions. Laser th era py, such as the exc i m e r laser, is an a l ternative treatment that should o n ly be considered afte r a pati ent has fa i led m u ltiple other treatment reg im en s .

•

Patients s h o u l d be awa re t h a t any treatment a d m i n is­ tered , it may res u l t in s p read of the psoriasis ( Koebner phenomenon ) . They should a lso be awa re that s u rgica l treatments performed for a ny reason may a lso res u lt i n si m i l a r s p rea d .

B I B L I OG RAPHY Ferna n dez-G u a r i n o

M,

H a rto A ,

Sanc hez- Ronco

M,

Ga rcfa - M o ra les I , J a e n P. P u lsed dye laser vs . p h otody­ n a m i c therapy in the treatm e nt of refractory n a i l pso ria­ sis: A comparative p i lot study. J Eur Acad Dermatal Venereal. 2009 ; 23(8) : 89 1 -895 . Gattu S , R a s h i d R M , Wu JJ . 308- n m exci mer laser i n psoriasis vu lga ris, sca l p psoriasis, a n d pa l m o p l a nta r pso­ riasis. J EurAcad Dermatal Venereal. 2009; 23( 1 ) :36-4 1 . N o borio

R,

Ku rokawa

M,

Kobaya s h i

K,

Morita

A.

Eva l uation o f t h e c l i nica l a n d i m m u n o h istologica l efficacy of the 585- n m p u lsed dye laser in the treatment of psori­ asis. J Eur Acad Dermatal Venereal. 2009 ;23(4) :420424 . S m its T, Klei n pe n n i ng M M , va n Erp P E , va n de Ke rkhof P C , Ge rritsen

MJ .

A placebo-controlled

ra n dom ized

study on the c l i n ic a l effectiveness, i m m u noh istoc h em ica l cha nges a n d p rotoporphyri n I X accu m u lation i n fraction­ ated 5-a m i nolaevu l i n i c a c i d - p hotodyn a m i c th era py in patients with psoriasis. Br J Dermatal. 2006; 1 55 ( 2 ) :429436 Taylor C R , Racette AL. A 308- n m exc i m e r laser for the treatment

of

sca l p

psoriasis.

Lasers

Surg

Med.

2004;34(2) : 1 36- 140. Va n Li ngen RG, d e J ong EM, va n Erp P E , va n M eeteren WS, va n De Kerkhof PC, Seyger M M . N d : YAG laser ( 1 , 064 n m ) fa i l s to i m prove loca l ized p l a q u e type psoria­ sis: A c l i n ic a l and i m m u n oh i stoc h e m i c a l pi lot study [ p u b l ished o n l i n e a h ead of p r i nt Octo ber 2 7 , 2008] . Eur J Derma tal. 2008; 18(6) :67 1 -676.

TE N Ad i pose Ti ss u e A l te ratio n s

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CHAPT E R 5 7

G y n eco m astia

Gynecomastia is the i nc reased p resence of benign gla n­ d u l a r tissue, i n the form of a firm mass, a r o u n d the n i pple i n m a l es ( Fig. 5 7 . 1 ) . I t is accom pa n i ed by i n c reased fat d e position . I n contrast, i nc reased fat de position a lone, i n the a bsence of gla n d u l a r prol ife ratio n , i s known as pseudogyn ecomasti a . It ca n be b i l atera l or u n i latera l . I t is common at b i rt h , p u berty, m id d l e age, a n d i n elderly a d u lts. M a ny cases a re i d i o path i c . M u ltiple prec i pitat i n g factors exist i n c l u d i n g hormonal a bn or m a lities, m ed ica­ tion , c i rrhosis, hypogo n a d i s m , test i c u l a r t u m o rs, hyper­ thyro i d i s m , a n d c h ro n i c re n a l i n s uffi c i e n cy.

For t h i s

reason , i n the a p p ropriate c l i n ical setting, the a ppea r­ a n ce of gynecomastia d e m a n d s a med ical work u p .

A

E P I D E M I O LOGY Incidence: most common i n newborns but a lso c o m m o n i n p u berty a n d o l d e r ma les

Age: b i rth (0-3 weeks ) , p u be rty ( 1 0- 1 7 yea rs) , m i dd le­ aged and elderly age gro u ps ( 50-80 yea rs)

Race: none Sex: ma les Precipitating factors: hormonal i m ba l a nces, hormonal thera py for prostate ca ncer, d rugs s u c h as, finasteride, c i rrhosis, hypogonad i s m , testic u l a r tu mors, hyperthy­ roid i s m , c h ro n i c re n a l i n s ufficiency. About one-q u a rter of cases a re id iopath ic

PATHOG E N E S I S I n cases of hormonal

B i m ba l a n ces, the fu n d a m enta l

defect is a decrease in a n d rogen levels with a concomi­ ta nt i n c rease i n estroge n levels.

PHYS I CAL LES I O N S A fi rm su bcuta neous n o d u l e extends con centrica l ly from the n i p pl e . It may be u n i latera l or bi latera l . I n pse u d ogy­ necomastia, the exa m i ned a rea is less firm as there is no excess gla n d u l a r tissue.

D I F F E R E N T I A L D I AG N OS I S B reast ca ncer, pse ud ogynecom asti a , b reast hypertrophy.

LABORATORY EXAM I NAT I O N Seru m h C G , L H , testosteron e , estra d i o l leve ls s h o u l d be i n vestigated in the setti n g of pa i n , tenderness, o r recent

Figure 57. 1 Characteristic appearance of gynecomastia in a middle-aged

male

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

onset or c l i n ica l suspicion of endocrine a b normal ities. F u rther worku p i s i n d icated i n the eve nt of u n i latera l b reast e n l a rgement.

CO U RS E T h i s depends on t h e etio l ogy. N ewborn gynecomastia persists for a few weeks. In tee nagers, it may last a few yea rs .

D i sconti n u a nce of med ication w i l l a m e l io rate

sym ptom s in d rug- i n d u ced cases. In cases of hormonal i m ba la n ce, k i d n ey d isease, a n d hyperthyroid ism , correc­ tion of the u n d e rlying i l l ness w i l l prod uce i m provement.

KEY CO N S U LTAT I V E QU EST I O N S •

Medication h i story

•

Hormonal c h a nges

•

R e n a l or thyroid d i sease

•

Hormonal thera py for prostate cancer

•

Assoc iated sym pto ms

•

U n i latera l or b i latera l

MANAG E M ENT M ost gynecomastia is tem pora ry a n d wi l l resolve without thera py. If it is related to p u be rty, c l i n i ca l o bservation and fo l l ow- u p wi l l l i kely be all that is needed . Disconti n uation of a n offe n d i ng med i cation is typi c a l l y a l l that is req u i red to treat d rug- i n d uced gynecomastia . U n i latera l gyneco­ m astia req u i res a m a m mogra m with a p propriate fo l low­ u p as needed . Med ica l a n d s u rgica l opti ons a re ava i la ble for patients who have persistent gynecomastia i nto late p u be rty p rod ucing e m otional d istress, pa i n , or tend er­ ness . Ben ign psued ogynecomastia is the m ost c o m m o n cause o f m a l e b reast e n l a rgement.

T R EATM ENT • O ra l M e d i cat i o n s Medical thera py for gynecomastia i s beyond the scope of this textbook. It is best performed by a physician who is tra i ned in internal med icine or endocri nology. Med ications include androgens, a ntiestrogens, and aromatase i n h i bitors .

• P ro p h y l ax i s i n P rostate C a n c e r B reast rad iation c a n b e performed prophylactica l ly i n pati ents u n d e rgoing a ntiand rogen thera py or orch iec­ tomy for prostate c a ncer. Concom ita nt ta m oxifen a d m i n ­ istration with f i nasteride/fl uta m i d e thera py ca n a lso be prophylactic for gynecomastia .

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• S u rge ry I n the event of medical treatment fa i l u re , s u rgica l thera py is the next o pti o n . It is reserved for pati ents with refra c­ tory gyn eco mastia that has fa i led medical thera py. The treatments depend on the exte nt of gyn ecomastia . A few options a re descri bed bel ow. •

S u rgical excision i n c l u d i ng sta n d a rd el l i ptical excision as we l l as s u bcuta neous mastectomy.

•

Conventiona l a n d u ltraso u n d -assisted l i posucti o n , that is, l oca l ized rem ova l of gla n d u l a r tissue a n d/o r excess fat . T h i s is part i c u l a rly successfu l in early stage a n d l i m ited gyn ecomastia . - Li posuction is performed th rough s m a l l incisions i n t h e axilla a n d ste rn u m t o m i n i m ize sca rring - Li posuction is less effective i n longsta n d i ng a n d s u b­ sta ntial gynecomastia - In prostate cancer patie nts, ea r l i e r i nte rvention is more efficacious - Resid u a l pe ri areola r fat may be n oted postl i pos uction that can be i m p roved with local ized d issection of fat via a s m a l l peria reo l a r i n cision - Postproced u re s k i n laxity may be n oted

•

Com bi nation of s u rgica l excision a n d t u m escent l i po­ sucti o n . T h i s i nvolves l i posuctio n , open excision , a n d s k i n red uction for laxity. Li posuction h a s a lso been c o m b i ned with su bcuta neous mastectomy.

•

S u rgical excision with plastic s u rgica l repa i r, p a rticu­ la rly i n the event of b reast tissue sagging. Excessive fat, gla n d u l a r tiss u e , and loose skin a re exc ised via e l l i ptica l excision ,

i n c l u d i ng

the

ni pple

and

a reola.

The

n i p ple/a reola co m pl ex is then p laced i n the a p p ro priate a nato m i c position as a fu l l t h i c k n ess s k i n graft after the excess gla n d u l a r tissue is re m oved . •

Psuedogynecomastia c a n be treated with l i posuction . M a l e b reast fat tends to be re latively fi b rous, a n d t h us more d ifficult to treat. F u rther, ca re m ust be ta ken to avoid i nj u ry to the pectora lis m uscle. I n true gynecos­ m asti a , excess gla n d u l a r tissue ren ders the p roced u re eve n more c h a l lenging.

•

W h i l e tra d itiona l l i posuction a n d t u m escent l i posuction have d o m i nated l i posuction treatment of gynecomastia and pse u d ogynecomast i a , laser-assisted l i posuction is a recent a d d ition to this fie l d . Th ere is no evidence to show that laser-assisted l i posuction is su perior to either of these forms of I i posucti o n .

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M E N T/O UTCO M E EXPECTAT I O N S •

I t is i m porta nt t o recogn ize that gyn ecomastia h a s m u l ­ t i p l e etio l ogies before atte m pting t o treat it.

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

• •

I n most cases, watc hfu l wa iti ng is the best thera py. I n cases of a n u nd e rlying syste m i c ca use, referral to the a p propriate spec i a l ist is m a n dated .

•

I n cases of d rug- i n d uced gyn ecomasti a , d isconti n ua­ tion of the med ication is the best ma nagement.

•

In cases of refractory to medical manage ment, there a re severa l s u rgica l options. C o m p l i cations from these pro­ ced u res i n c l ude a poor cosmetic res u lt, posto perative sca rring, i ncom plete re mova l , postproced u re s k in laxity, perma nent n u m bness i n the a rea , a n d he matoma for­ mation .

B I B L I OG RAPHY As i a n G , Tu n ca l i D , Te rziogl u A, B i ng u l F . Peria reolar­ tra nsa reol a r-perithe l i a l i n cision for the s u rgica l treatment of gyn eco mastia . Ann Plast Surg. 2005; 54( 2 ) : 1 30-134. B e m bo SA, Ca rlson H E. Gynecomasti a : I ts features, and when a n d h ow to treat it. Cleve Clin J Med. 2004; 7 1 (6 ) : 51 1-517. G a b ra

HO,

M o ra bito

A,

Bianchi

A,

B owen

J.

Gynaecomastia i n t h e adolescent: A surgica lly releva nt cond ition . Eur J Pediatr Surg. 2004; 1 4( 1 ) :3-6. Gaspero n i C , Sa lgare l l o M, Gaspero n i P. Tec h n ic a l refi ne­ ments in the s u rgica l treatment of gyn ecomasti a . Ann Plast Surg. 2000;44(4) :455-458 lwuagwu OC, Calvey TA, l lsley D, D rew PJ . U ltraso u n d g u ided m i n i m a l ly i nvasive breast s u rgery ( U M I BS ) : A s u perior tec h n i q u e for gynecom asti a . Ann P/ast Surg. 2004 ; 52( 2 ) : 1 3 1 - 1 3 3 . R o h rich

RJ ,

Classificatio n

Ha

RY,

and

Ken kel

JM,

ma nagement

Ad a m s of

WP

J r.

gynecomasti a :

Defi n i ng the ro le o f u ltraso u n d -assisted l i posucti o n . Plast Reconstr Surg 2003 ; 1 1 1 ( 2 ) : 909-923. G raf R, Auersva ld A, Da masio R C , R i ppel R, d e Ara ujo LR, B iga re l l i LH, F ra n c k CL. U ltraso u n d-assisted l i posuc­ tion : An a na lysis of 348 cases. Aesthetic Plast Surg. 2003 ; 2 7 ( 2 ) : 146- 1 53 . Z e l i c kson B D , Dresse l T D . Discussion o f laser-assisted l i pos u ction . Lasers Surg Med. 2009;4 1 ( 1 0 ) : 709-9 1 3 .

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CHAPT E R 58

Cellulite

Cel l u l ite d escri bes an orange peel type d i m pl i ng of s k i n i n t h e u p per poste rior th ighs a n d buttoc ks ( Fig. 58. 1 ) . Although there i s n o assoc iated morbid ity o r morta l ity, i t is a mong the m ost common cosmetic com p l a i nts a mong fe male patients . I t is present i n nearly all post p u berta l fe males, rega rd less of weight. It is best thought of as a fe male

seco n d a ry sexua l

cha racteristic .

I m po rta ntly,

treatments for fat remova l a n d cel l u l ite s h o u l d be consid­ e red d isti nct. Effective treatments fo r fat remova l typica l ly have no benefit for cel l u l ite .

EPI D E M I O LOGY Incidence: 85% to 98% of postpu be rta l fe ma les, fa r less c o m m o n in ma les

Age: begins in fem a l es after p u be rty Race: m ore common in Caucasians Sex: fa r more c o m m o n i n fem a les, ra re i n m a l es Precipitating factors: fe m a l e ge nder, a n d roge n deficiency in m a les ( ra re)

PATHOG E N E S I S U n known .

PHYS I CAL LES I O N S There is a n ora nge peel o r cottage c h eese type d i m p l i n g o f t h e u p per a n d outer th ighs a n d buttoc ks. Other com­ mon locations i n c l u d e the breasts, lowe r a bd o m e n , u pper a rms, a n d n a pe o f neck.

D I F F E R E N T I A L D I AG N OS I S None.

LABORATORY EXAM I NAT I O N None i n d icated a s the c l i n ic a l a p pea ra nce is class i c .

COU RS E Begi ns i n p u berty i n fe males a n d persists t h roughout l ife . I n m a l es with a n d rogen d eficienc ies, the c l i n i c a l a p pea r­ a n ce worsens as the a n d rogen d eficie ncy becom es m o re severe . It may p resent de novo in m a l es u n d e rgoing hor­ m o n a l thera py for prostate cancer.

Figure 58. 1 Classic appearance of cellulite

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

KEY CO N S U LTAT I V E QU EST I O N S I n m a l es, i n q u i re a s t o a n y poss i b i l ity o f endocrine a b n or­ m a l ities. T hi s is a very rare assoc iation of cel l u l ite i n males.

MANAG E M ENT There is no med ica l i n d ication t o treat cel l u l ite. Sti l l , many patients req uest thera py. C u rrently, there a re n u merous p u r ported thera pies, none of which have proven to be very effective . I nteresti ngly, despite the lack of sci entific evi dence of i m provement, many patients report su bjective i m provement a n d satisfaction with thera py.

T R EATM ENTS • D i et •

We ight has o n l y a m i nor association with ce l l u l ite

•

I t is c o m m o n in t h i n fe m a l es a n d ra re in o bese m a l es

•

There is no d ata to s h ow that d i et a n d exe rcise a re effective treatme nts

• To p i c a l Treat m e nts •

A m i nophyl l i ne, reti noids, lactic a c i d , xa nth i n es, a n d many others have a l l b e e n used w i t h l ittle evi d e nce o f efficacy

• •

Some c rea m s may prod uce more harm t h a n benefit In fact, one study i n d icated 25% of cel l u l ite c rea ms exa m i ned conta i ned known contact a l l erge ns

• I n t e rve n t i o n a I Treat m e nts

Liposucti o n •

There a re a few pu bl ished re ports o f i m prove ment;

•

I n some cases, it accentuates the a p pea ra nce of cel­

however, typica l l y it d oes n ot i m p rove ce l l u l ite l u l ite •

Prior to perfo r m i n g a l i posuction proced u re, it is usefu l to i n form patients that their cel l u l ite wi l l not reso lve . T h i s wi l l protect aga i n st postproced u re d is a p poi ntment

Endermologie •

Endermologie is a n FDA cleared device to i m prove the a p peara nce of cel l u l ite

• •

S k i n is kneaded by a h a n d held m a c h i n e I t is rol led over affected a reas o f the body t h a t a re cov­ ered by a nylon s u it

•

It p u r ports to i m prove blood a n d lym phatic flow as wel l as s k i n a rc h itect u re

Figure 58.2 VelaSmooth laser treatment of thigh of young female

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Color Atlas of Cosmetic Dermatology

Twice wee kly treatm e nts of 10 to 45 m i n utes each a re reco m m e n d ed

•

There is a l ittle evi d e nce to s u p po rt its efficacy

Subcision • •

Req u i res l o c a l a n esthesia U s i n g a sca l pel or special 1 6-ga uge need le, the fat septae a re cut i n the deep s u bcuta n eous fat

•

Side effects i n c l u d e pa i n , bruisi ng, sca r, a n d puckering

•

Little d ata to su pport tem pora ry effi cacy

M esotherapy P h os p h ati d y l c h o l i n e i njecti o n s : n ot a reco m m e n ded t h e ra py. •

I njecti on of c o m b i nations of i ngredie nts d i rectly i nto su bc uta neous fat

•

P h osp hatidylchol i ne a n d d eoxycho late prepa rati ons a re most c o m m o n ly used - Deoxyc holate is the a ctive i ngred ient

•

N o p u b l ished d ata to show efficacy

Laser •

Ve laSmooth system (Syneron

I nc.,

R i c h m on d

Hill,

O nta rio, C a n a d a ) com b i n es near-i nfra red l ight a t a wavele ngth of 700 to 2 , 000 n m , conti n u o u s-wave rad io freq u ency, a n d mecha n ic a l suction ( Fig. 58 . 2 ) - Twice wee kly treatments fo r a tota l o f eight t o t e n ses­ sions have been recommended - Th ere a re no long-term d ata to su pport its efficacy i n patients •

The TriActive Laserdermology (Cynosure, I nc, Chel msford, Massachusetts) combi nes six near-infrared d iode lasers at a wavelength of 810 nm, loca l ized cooling, and mechani­ ca l massage - Th ree wee kly treatments fo r 2 weeks a n d then b iweekly treatme nts for 5 weeks a re suggested - Th ere a re no long-term d ata to s u p po rt its effi cacy i n patients

•

Other FDA clea red devices include a u n i polar rad i ofre­ quency device (Alma Accent, Alma, I n c . , B uffa l o G rove, I l l . ) a n d a d ua l wavelength laser system (SmoothSha pes, Eleme Med ica l , I nc . , Merri mack, N ew H a m ps h i re)

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M E N T/O UTCO M E EXPECTAT I O N S Patients s h o u l d b e i nformed that there a re no truly effec­ tive treatments fo r cel l u l ite. It is a lso i m porta nt to d isti n­ guish treatments for body conto u r i n g and fat re m ova l from those of cel l u l ite. M ost of the positive resu lts relati ng to ce l l u l ite treatment a re a n ecd ota l or reported i n sma l l ,

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

u nscientific stud ies . M a n y of the thera p i es a re expensive, espec ia l ly given the i r lack of efficacy. Some may even prod uce more harm than benefit. There may be a more p ro m ising futu re for laser a n d l ight sou rce treatments.

B I B L I OG RAPHY Avra m M M . Cel l u l ite; A review o f i t s physiology a n d treat­ ment. J Cosmet Laser Ther. 2005 ; 7 : 1 -5 . Gold berg DJ , Faze l i A , Berl i n AL. C l i n ica l , la boratory, a n d MRI

a n a lysis o f cel l u l ite treatment with a

u n i po l a r

rad i ofreq uency device. Dermatol Surg. 2008;34( 2 ) : 204209 . K i n ney B M . Cel l u l ite treatment: A myth or rea l ity: a p rospective ra ndom ized , controlled tria l of two thera pies, endermologie a nd a m i nophyl l i n e c rea m . Plast Reconstr

Surg. 1999 ; 1 04: 1 1 1 5- 1 1 1 7 . Lis-Ba l c h i n M . Pa ra l lel-placebo-control led c l i n ica l study of a m ixtu re of herbs sold as a remedy for cel l u l ite.

Phytother Res. 1999 ; 1 3 : 627-629 . P i era rd-Fra n c h i mont C , P i era rd G E, H e n ry F, Vroome V, Ca uwen bergh G . A ra ndom ized , place bo-control led tria l of topical reti n a l in the treatment of cel l u l ite . Am J Clin

Derma to/. 2000; 1 :369-37 4 . Rao J , Gold M H , G o l d m a n M P. A two-center, dou ble­ b l i nded , ra n d o m ized tria l testi ng the to lera b i l ity a n d effi­ cacy of a novel thera peutic agent for cel l u l ite red ucti o n .

J Cosmet Dermatol. 2005;4(2) :93- 1 02 R ossi A R , Vergna n i n i A L . Cel l u l ite: A review. J Eur Acad

Dermatol Venereal. 2000; 14:25 1 -262 . va n V l i et M , O rtiz A, Avra m M M , Ya m a u c h i PS. An assessm e nt of traditional a n d n ovel thera p ies fo r cel l u l ite.

J Cosmet Laser Ther. 2005; 7 ( 1 ) : 7- 1 0 . Wa n ne r M , Avra m M M . An evi d ence-based assessment of treatments fo r cel l u l ite . J Drugs Dermatol. 2008 ; 7 (4) : 341 -345

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CHAPT E R 59

H IV Lipod ystrophy/Facia l Lipoatrophy

H IV l i podystrophy d escri bes a conste l lation of cha nges i n su bcuta neous a n d viscera l fat d istri bution i n patients on a nti retrovira l

thera py.

In

d isti nction

to

" l i poatrophy"

(wh ich descri bes local fat loss ) , l i podystro phy refers to both the acc u m u lation of fat as wel l as the loss of fat in other a reas. I n H I V l i postro phy, the fi n d i ngs i n c l u d e s u b­ cuta n eous fat loss in the m a l a r a n d b u cca l fat pads, ie, fa cial l i poatrophy, as wel l as o n the extre m ities. It a l so fea­ tu res fat a cc u m u lation on the d o rsocervica l fat pad , ( Fig 59 . 1 ) ie, buffa l o h u m p, b reasts, a n d i ntra-a bdom i n a l cavity. Its c h a racteristic a p pearance is sign ificant, i n t h a t i t red uces patient com plia nce with a nti retrov i ra l thera py a n d d e prives patients of H I V status privacy, pa rti c u l a rly i n com m u n ities where H IV rates a re h ig h . T h i s d isord er is a lso associated with a host of meta bol ic d isord e rs with long-term i m pa ct on health hyperl i pi d e m i a ,

and

i n c l u d i ng hyperglyc e m i a ,

hypertriglycerid e m i a .

A

Treatments

va ry accord i n g to the c l i n ical fi n d i ngs.

E P I D E M I O LOGY Incidence: 25% to 83 % of patients treated with a nti retro­ virals depend i ng on c riteria used

Age: A l l ages , but older age is p red i ctive of severity Race: N o n e Sex: Eq u a l , severe fi n d i ngs m ore freq uent i n fem a les

P R EC I P I TAT I NG FACTORS Anti retrov i ra l thera pies a re the prec i p itating factor. It a lso presents i n freq ue ntly in H IV patients na'lve to H I V ther­ a py. Typical ly, pati ents a re on com b i nation thera pies.

PATHOG E N ES I S Path oge nesis rem a i ns u n known . I t i s a m u ltifactorial d is­ order that va ries a ccord i ng to the med ications ta ke n .

D E R M ATOPAT H O LOGY Com p l ete or nea r complete loss of fat. J uxta position of the dermis a n d fascia may be see n . Ad i pocytes a re ma rked ly red uced in n u m be r a n d size.

PHYS I CAL LES I O N S Fat a cc u m u lation a n d fat loss a re d isplayed . •

Fat acc u m u lation

8

Figure 59. 1 (A) "Buffalo h ump " in dorsocervical back of HIV-infected

male. (8) Substantial reduction in size of buffalo h ump after liposuction procedure

Sect i o n 10: Ad i pose Tissue Alterati o n s

- Dorsocervica l fat pa d , ie, buffa l o h u m p - B reasts - I ntra-a bdo m i n a l cavity, ie, Crix bel ly •

Fat loss - M a l a r a n d bucca l fat pads - Extrem ities and buttocks

D I F F E R E N T I A L D I AG N OS I S Other l i podystrop h i es fac i a l l i poatrophy from aging, H IV wasting synd rome, C u s h i ng's d i sease, m a l n utrition states, a n o rexia nervosa , meta bolic X synd ro m e , cachexia sec­ o n d a ry to cancer, m a l a bsorptio n synd romes, thyrotoxico­ sis, and m u lt i p l e sym metric l i pomatosis.

LABO RATORY EXAM I NAT I O N B i o psy i s not usefu l . T h e c l i n ical fi n d i ngs a re sufficient to make a d iagnosis. La boratory work u p s h o u l d i n c l u d e assessm e nt o f blood g l u cose, l i pids, a n d triglycerides. If C u s h i ng's is c l i n ica l ly suspected , la boratory exa m i nation should be performed .

CO U RS E H I V l i podystro phy d oes n ot sponta neously regress i n the a bsence of treatment or medication cha nge .

KEY CO N S U LTAT I V E QU EST I O N S M ed ication use Com p l i a nce H I V status D u ration of l i podystoprhy Associated hyperglycem i a , hyperl i p i d e m i a , a n d hyper­ triglycerid e m i a

P R EV E N T I O N Once a patient h a s been treated fo r t h e H IV virus, there i s no prevention o f H IV l i podystro phy.

MANAG E M ENT Cosmetic i m provement ca n b e essentia l t o promoting a patient's ad herence to their H IV med ication regimen. There a re several means by which the cosmetic a ppea ra nce of H IV l i pcdystrophy ca n be i m proved . These include medica­ tion cha nges, filler su bsta nces, and l i posu ctio n . Diet and exercise can be helpfu l both for cosmesis a n d meta bolic

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dera ngements. Treating the meta bolic derangements is best referred to physicians skilled in treating hyperl i pi­ demia, hypertriglyceridemia, and i nsu l i n resista nce.

T R EAT M E NTS There a re severa l treatme nts that can

i m p rove the

cosmetic a p pea ra n ce of these d isord ers . They ca n be d ivided i nto two sections: treatment of l i poatrophy a n d treatment o f fat accu m u lati o n . Ad d itional ly, cha nges i n med ications c a n b e p u rsued . T h i s i s best entrusted t o a p hysic i a n who spec i a l i zes in the care of patients with H I V.

• O ra l M e d i cat i o n s A l l c h a n ges to a n a nti retrov i ra l reg i m e n a re best h a n d led by physic i ans who spec i a l ize i n H I V treatment. These cha nges can i m prove the a p pea ra nce of H I V l i podystro­ p hy. Med ication cha nges i n c l u d e •

D isconti n ua n ce o f a nti retrovira l thera py - O bvious risks of d i sconti n u i ng med ications for a l ife t h reate n i n g i l l ness

•

Cha nge H IV medications - Other H IV med ications prod uce the sa me cond ition - Some a ntiretrov i ra ls have a

lower i n c id e nce of

l i podysto phy

• Treat m e n t of Fac i a l L i poatro p h y

Tempora ry fi l l ers •

Poly-L-Iactic a c i d , Scu l ptra , is FDA cleared for the treat­ ment of H IV fac i a l l i poatro phy - Synthetic, biodegra d a b l e polymer The materi a l used i n Vicry l sutures - Seve ra l treatme nts a re req u i red , d e pend i ng on sever­ ity of l i poatrophy Benefits a re n ot seen u nt i l weeks after each treat­ ment - 18 to 24 month d u ration of fi l l e r material - N o n eed for a l lergy testing

•

Ca l c i u m hyd roxyla patite, Rad iesee , is FDA cleared for the treatment of H IV fac i a l l i poatro phy - I m med iate correction - D u ration up to 1 8 months - N o need for a l lergy testing

Perma nent fi l l ers •

S i l icone

•

A h ighly pu rified 1 , 000-cSt s i l icon o i l has been exa m ­

- N ot FDA c l ea red i n ed i n 77 patients

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

•

The data showed that the n u m be r of treatments a n d a m o u n t o f s i l icone req u i red for fu l l treatment was corre­ lated to the i n itia l seve rity of fa c i a l l i poatrophy

•

The i n vestigato rs n oted no adverse events but cau­ tioned that long-term effi cacy a n d safety a re yet to be determ i ned

• Treat m e n t of Fat Acc u m u l a t i o n

L i p osucti o n/l i pectomy •

Loca l ized l i posuction/li pectomy uses tu mescent loca l­ ized a n esthesia rather t h a n ge nera l a n esthesia

• •

U ltraso u n d assisted l i posuction has a lso been em ployed It is effective in rem ovi ng excess fat in the d o rsocervical regi o n , that is, buffa lo h u m p

P I T FALLS T O AVO I D/CO M PL I CAT I O N S/ MANAG E M ENTIOUTCO M E EXPECTAT I O N S It is i m porta nt t o m a ke certa i n that t h e m u ltiple med ica l issues

a re

being

mon itored

a p p ropriately

in

th ese

patients. It is a lso i m porta nt to e m p hasize the l i m ited a b i l ity of th ese treatments in the fa ce of exte nsive H I V l i podystro phy. General ly, however, patients a re ve ry eager to see i m p rovement and gratefu l for the h e l p they receive. F i l lers can be very effective for i m proving fac i a l l i poat­ rophy. Tem pora ry fi l l e rs, s u c h as Scul ptra or R a d i esse, have the adva ntage of FDA clearance and stu d i es docu­ menting the i r efficacy.

F u rt h er, thei r

non permanent

nature a l lows for tem pora ry side effects i n the eve nt of poor resu lts or gra n u l oma fo rmatio n . U nfortu nately, tem­ pora ry fi l l e rs req u i re perpetua l treatment sessions a n d expense . Permanent fi l l ers such as s i l icone a re attractive i n these patients because t h e i r d isord e r is perm a nent. Data a re pro m i s i ng, but fu rthe r lo ng-term stud ies a re n eeded to assess lo ng-term efficacy and safety concerns. After a series of i njections, fu rther treatment a n d expense is n ot req u i red . U nfo rtunately, poor tec h n i q u e a n d gra n u loma formation a re haza rds . W h i l e gra n u lomas a re i nfreq uent side effects, they prod uce o bvious cosmetic d isfigu re­ ment. Th e re is the potenti a l of gra n u loma formation m a ny years afte r i n itial treatment as wel l . These gra n u lomas do n ot resolve with the relative ra pid ity of n o n perm a nent fi l l e r s u bsta nces.

F u rthermore,

s i l icone

is

n ot

F DA

cleared for the treatment of H IV l i podystro phy. Li posuction can be very effective in patients with buf­ fa lo h u m ps . Local ized l i posu ction/l i pectomy uses t um es­ cent loca l ized a n esthesia rather t h a n ge nera l a n esthes i a , w h i c h dec reases the possi b i l ity o f s e r i o u s adverse eve nts. Sti l l , l i posuction can be expensive and

res u lts va ry

accord i ng to the experience of the p ractitioner.

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Fac i a l plastic s u rgica l proced u res ca n be effective, but req u i re major i nvasive s u rgery with its atte n d a n t risks of morbid ity. There is also i n c reased d own t i m e , pa i n , a n d t h e r i s k o f ge neral a n esthes i a .

B I B L I OG RAPHY B o i x V . Polylactic acid i m p l a nts . A n e w s m i l e f o r l i poat­ ro p h i c faces? AIDS. 2003 ; 1 7 ( 1 7 ) : 2533-253 5 . Carruthers A , Ca rruthers J . Eva l uation o f i nj ecta ble c a l ­ c i u m hyd roxyla patite f o r the treatment o f fac i a l l i poatro­ phy associated with h u m a n i m m u n od efi ciency virus. Dermatol Surg 2008;34( 1 1 ) : 1486- 1 499 . Carruthers A, Liebeskind M , Carruthers J , Fo rster B B . Rad iogra p h i c a n d com puted tomogra p h i c stud ies of cal­ cium hyd roxyla patite for treatment of H IV-associated fac i a l l i poatro phy a n d correction of naso l a b i a l fol d s . Dermatol Surg 2008;34( S u p p l 1 l : S 78-S84 Con nolly N , M a n d e rs E, R id d ler S. Sh ort com m u n icati o n : S uctio n -assisted l i pectomy for l i podystro phy. AIDS Res Hum Retroviruses. 2004;20(8 ) : 8 13-8 1 5 . H a d iga n C , Yawetz S , Thomas A , Havers F, Sax P E , G r i nspoon S . Meta bo l i c effects o f rosigl itazo ne i n H IV l i podystro phy; A ra ndom ized , control led tria l . Ann Intern Med. 2004; 786-794. J ones D H , Carruthers A , O rentrei ch D, et a l . H ig h ly p u r i ­ f i e d 1 000 est s i l icon o i l f o r treatment o f h u ma n i m m u n ­ odeficiency virus-assoc iated fac i a l l i poatro phy: A n open p i l ot tria l . Dermatol Surg 2004;30( 1 0) : 1 279-1 286 . Koutkia P, Canava n B, B reu J , Torria n i M , Kissko J , G r i nspoon S . G rowth hormone-releasing h o r m o n r i n H I V­ i n fected m e n with l i podystro phy: A ra n d om ized con­ trol led tria l . JAMA. 2004;292 ( 2 ) : 2 1 0-2 1 8 . Levy R M , Red bord KP, H a n ke CW. Treatment o f H IV l i poatro phy a n d l i poatro phy of aging with poly-L-Iactic a c i d : a prospective 3-yea r fol l ow- u p study. J Am Acad Dermatol. 2008;59( 6 ) : 923-933. P i lero PJ , H u bbard M , King J, Fa ragon J J . Use of u ltra­ sonogra phy-assisted

l i posuction for the treatment of

h u m a n i m m u n odefi c i ency vi rus-assoc iated e n l a rgement of the d o rsocervica l fat pad . Clin Infect Dis. 2003 ; 3 7 : 1374- 1 3 7 7 . Vl egga a r D ,

Bauer U.

Fac i a l e n h a ncement a n d the

E u ropean experience with Scu l ptra ( poly-L-Iactic a cid ) . J Drugs Dermatol. 2004;3 ( 5 ) : 542-547 .

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

CHAPT E R 60

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Str i a e Diste nsa e

Striae d istensae, m ore com m o n l y known as " stretch marks, " a re atro p h i c l i nea r ba nds of skin that a p pear after certa i n p rec i p itati ng factors such as pregna ncy, steroid use, a n d d ra matic cha nges i n weight or m uscle mass ( F ig. 60. 1 ) . At prese ntatio n , they feature a pu rple or p i n k color (striae ru bra) that fad es to a pa ler wh ite (striae a l ba ) over time. They a re most common in a d u lt women .

E P I D E M I O LOGY Incidence: common Age: pu berty, pregna ncy Race: more common in Ca ucasians Sex: fe males > ma les (associated with pu berty a n d preg­ na ncy)

Precipitating factors: to pical

and

o ra l

ste roid

use,

A

C u s h i ng's synd rome, p regna ncy, b reast-feed i ng, pu berty, genetic col lagen d efects,

and

d ra matic c h a nges

in

weight, height, or m uscle mass

PATHOG E N ES I S There a re cha nges i n the extrace l l u l a r dermal matrix i n c l u d i ng fi b ri l l i n , elasti n , a nd collage n , resulting from p rolonged stretc h i ng of the s ki n .

PATHOLOGY There a re sca r- l i ke featu res . Typica l ly, there is an atro p h i c epidermis w i t h na rrow col lagen b u n d l es a rra nged pa ra l lel to the ski n s u rface. The rete ridges a re effaced . I n early striae, there is a s u perficia l , deep, a nd i nterstitia l lym p h o­ cytic perivasc u l a r i nfi ltrate a n d occasional eos i n o p h i l s . The i nfi ltrate fades i n older lesions.

PHYS I CAL L ES I ON S M u ltiple sym metric l i nea r ba nd-l i ke plaq ues o f atro p h i c ski n t h a t present most commonly i n the outer thighs, b reasts, a n d buttocks of wo men a long the l i nes of cleav­ age. They p resent with a p i n k/purple h ue (striae ru bra ) a n d become pa ler with fi ne wri n kl i n g over time (striae a l ba ) . Striae a re la rgest a n d m ost a b u nd a nt i n pati ents with C u s h i ng's d isease. I n preg n a ncy, striae a re m ost a b u n d a nt on the a bd o m e n . In weight l ifters, they a re m ost p ro m i nent on the s h o u l d ers. To pical corticoste roid use most c o m m o n l y produces striae on the face, ge n i ­ ta l i a , flex u ra l a reas, a n d body folds.

B

Figure 60. 1 (A) Striae alba at baseline. (B) Striae alba at 1 1 months

follow-up after four treatments with a 1 450-nm diode laser (Smoothbeam, Candela Corp., Wayland, MAJ at energy settings of 1 3 to 1 4 J!cni2 , using a 6-mm spot size with a pulse duration of 30 ms. Treatment was performed at intervals of 2 to 3 months

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D I F F E R E NT I A L D I AG N OS I S Linear foca l elastosis.

LABORATORY EXAM I NAT I O N T h e c h a ra cteristic c l i n i c a l a p pea ra n c e of striae n egates a ny n eed fo r s k i n b i o psy. Ad d itional la boratory work u p to rule out C u s h i ng's d i sease is i n d icated in the a p p rop riate c l i n ica l setting.

COU RS E Striae beg i n a s p i n k o r pu rple atro p h i c lesions that becom e pa ler and less o bvious ove r t i m e .

A

KEY CO N S U LTAT I V E QU EST I O N S •

D u ration

•

S k i n phototype

•

P regna n cy

•

Assess for sym ptoms of Cush i ng's d isease

•

Use of corticostero i d s

•

H istory o f weight cha nge

•

H istory of weight l ifti n g

MANAG E M E N T There is no medical i n d ication t o treat stria e . Sti l l , ma ny i n d ivi d u a ls a re sign ifica ntly bothered by the i r a p pea ra nce and req u est treatment. There a re n u m e rous options to treat stria e . U nfort u n ately, none of the treatments is com­ p l etely successfu l . In fact, m ost treatme nts provide mod­ est or no benefit. Thus, prior to treatment, patie nts' expectations n eed to be tem pered . C o m b i nation treat­ ment i nvolving laser and

topical regimens s u c h as

treti n o i n is often a hel pfu l method of treatment. More recently, nona blative a nd a b lative fractional treatm ents have emerged . Fort u nately, the a p pea ra nce, parti c u la rly the color of striae, i m proves with t i m e . Patients with s k i n phototypes 1-1 1 1 respond better t h a n those w i t h types I V-VI to laser thera py. Test sites prior to thera py a re rec­ om mended . There is some data to show that treatments i m prove striae over n o n i nterventio n . The fi rst priority is to esta bl ish whether stria r u b ra or stria a l ba a re be i n g treated , as the i r treatments d iffe r sign ifica ntly.

TREAT M ENT (Fig. 6 0 . 2) •

Stria ru bra : the pu lsed dye laser (585 n m ) with a 7- or 10mm spot size and 2 to 4 J/cm 2 fluence has been shown to i m prove the erythema of striae, but is associated with

B

Figure 60.2 (A) White striae, axilla. Prominent atrophy, textural changes, and depigmentation are observed. (B) White striae, axilla, following three fractional resurfacing laser treatments. Mild improvement of the atrophy and textural changes are noted. Mild post-inflammatory hyperpigmenta­ tion is observed, which resolved 3 weeks after the last laser treatment

Sect i o n 10: Ad i pose Ti s s u e Alterati o n s

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287

the risk of hyperpigmentation in da rker skin phototypes. A c l i n ica l end point of deep erythema o r l ight purpura is o pti m a l . In o u r experience, lower fluences a re more suc­ cessful than h igher fluences ( Fig. 60. 3 ) . - P u lsed d y e l a s e r treatments d o l ittle, if a nyth i ng, to i m prove the textu re a n d atro phy of striae. - I m p rovement ca n be seen even i n cases of poor i n i ­ ti al res ponse 6 months afte r treatment. - Stu d ies recom mend aga i n st treating s k in phototypes V-V I . - Some d ata casts d o u bt on the effectiveness of pu lsed dye laser. •

Stria a l ba : nona blative fractional resurfa c i ng has been s h own to provide some benefit for striae a l ba e . Stud i es show a ra nge of efficacy with these treatments. There is l ittle data to suggest whether deep d e pth , h igh

A

coverage treatme nts a re more effective t h a n lower d e pt h , lower coverage treatme nts.

I n o u r experience, m ost

patients see a modest benefit from treatment. A m i no rity sees more sign ificant resu lts . •

S hort- p u l sed erbi u m :YAG a n d C0 2 lasers can be mod­ estly effective but a re no lo nger commonly used due to s u c h side effects as prolonged , d iffic u lt h ea l i ng and pigme nta ry a lte rat i o n . They a re n ot reco m mended .

•

The exc i m e r laser (308 n m ) has been exa m i ned for treatment of striae a l ba

and

sca rs in

31

a d u lts .

Treatme nts bega n at t h e M i n i ma l Erythema Dose ( M ED l m i n us 50 mJ/cm 2 to affected a reas a n d were performed biweekly for 1 0 weeks. An i m prove m ent i n coloratio n , b y visual i n s pection ( 60-70% ) a n d colorimetric a na lysis ( 1 00% ) , was n oted and correlated strongly with the n u m ber of treatme nts performed . The pigment correctio n , h owever, retu rned c l ose to base l i n e after a 6-month fol l ow- u p . N o bl iste r i ng or pigmenta ry

B

d istu r ba nces were noted .

Figure 60.3 (A) Numerous striae rubra and alba on the abdomen of a young woman . (8) Immediate endpoint of purpura following low energy, short pulse duration treatment with a pulsed dye laser

TOP I CAL T R EATM ENT •

Ea rly striae - Tre n i n o i n (0. 1 %) crea m can i m prove the a ppea ra nce of striae, partic u l a rly early stria e , wh i l e decreasi ng t h e i r length a n d width .

•

Matu re striae - Treti n o i n (0.05 % ) and 20% glyco l i c acid ca n i m prove striae. - G lyco l i c a c i d (20 % ) a n d 10% L-ascorbic acid can i m prove striae.

M I CRODERMABRAS I O N M icrod erma brasion ca n

prod uce sma l l

i m provement

after six to ten treatments . M ic roderma brasion ca n also

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Color Atlas of Cosmetic Dermatology

be used i n assoc iation with laser thera py given its fa irly benign sid e-effect profi l e .

P I T FALLS TO AVO I D/O UTCO M E EXPECTAT I O N S/CO M P L I CAT I O N S/ MANAG E M ENT •

Patients s h o u l d b e i nformed that com p l ete resol ution i s not rea l isti c . Rather, m i l d-to-moderate benefit is most rea l istic . Thus, h ighly motivated patients with rea l istic expectations a re the best ca n d i dates for treatment.

•

Laser thera py m ust be used with caution i n dark s k i n phototypes given the r i s k o f hyperpigme ntati o n .

•

Topical treti n o i n can prod uce s k i n i rritati o n .

B I B L I OG RAPHY Alexiades-Arme n a kas M R , Bernste i n U , Fried m a n P M , Gero n e m u s R G . The safety a nd efficacy o f t h e 308- n m exc i mer laser for pigment correctio n o f hypopigme nted sca rs a n d striae a l ba . Arch Dermatol. 2004; 1 40(8) : 955960. Ash K, Lord J, Z u kows ki M, M c Da n iel D H . Comparison of to pical thera py fo r striae a l ba (20% glycol i c a c id/0.05% treti n o i n versus 20% glyc o l i c acid/10% L-ascorbic a cid ) . Dermatol Surg 1 998;24( 8 ) : 849-856. Bak H, Kim BJ , Lee WJ , et a l . Treatment of striae d i sten ­ s a e w i t h fractional

phototherm olysis.

Dermatol Surg.

2009 ; 3 5 ( 5 ) : 826-83 2 . Gold berg OJ , Sa rradet D , H ussa i n M . 308- n m Exc i m e r laser treatment o f mature hypo pigmented striae. Dermatol Surg. 2003 ;29(6): 596-598. Discussion 598-599. J i menez G P,

Flores

F,

Berman

B,

G u nja-S m ith

Z.

Treatment of striae ru bra and striae a l ba with the 585-n m p u l sed-dye laser. Dermatol Surg. 2003 ;29(4) :362-365 . M c D a n iel D H , Ash K, Z u kowski M . Treatment of stretc h ma rks with the 585- n m flash la m p- p u m ped pu lsed dye laser. Dermatol Surg 1 996;22(4) :332-33 7 . Nehal

K S , Lichte nste i n

DA,

Ka m i no

H,

Levi n e VJ ,

As h i n off R . Treatment of matu re striae with the p u lsed dye laser. J Cutan Laser Ther. 1 999; 1 ( 1 ) : 4 1 -44. N o u ri K, R o magosa R, C h a rtier T, Bowes L, Spencer J M . Com parison of the 585 n m pu lse dye laser a n d the short p u l sed C02 laser i n the treatment of striae d istensae in s k i n types IV a n d VI. Dermatol Surg. 1 999 ; 2 5 ( 5 ) : 368370. Stotla n d M, Cha pas AM, B rightm a n L, et al. The safety a n d effi cacy of fra ctional p h otothermolysis for the correc­ tion of striae d i stensae. J Drugs Dermatol. 2008; 7 ( 9 ) : 857-86 1 .

E L EVE N Wo und H ea l ing A l te rations

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CHAPT E R 6 1

H ype rtrop hic Sca rs , Ke l oids , a nd Ac n e Sca rs

I NTRODUCT I O N Hypertro p h i c sca rs a n d keloids a re both c h a ra cte rized by excess fibrous tissue at a site of i nj u ry in the s ki n . Hypertro p h i c sca rs a re confi ned t o t h e origi n a l wou n d site, whereas keloids, b y contrast, exten d beyond the origi n a l wou n d site (Ta b l e 6 1 . 1 ) . Both a re common a n d freq u e ntly d istu r b patients greatly, both as a n u n s ightly sca r as wel l as a rem i nd e r of p revious tra u ma o r s u rgery. Acne sca rs res u l t from the loss of u n d erlying col lage n a n d elastic tissue from d e r m a l i nflam mation assoc iated with a c n e , pa rti c u larly cystic acne. Ac ne sca rs a re a lso very c o m m o n a n d a sou rce of d istress to the patient, both fo r thei r obvious a p pea ra nce o n the face as wel l as a re m i nder of p revious a c n e .

HYPERTROPH I C SCARS AND KELO I DS : PHYS I CAL EXAM I NAT I O N Hypertro p h i c sca rs prese nt as thick, firm l i nea r plaq ues at the site of tra u m a . I n itial ly, they may be erythematous

Figure 6 1 . 1 Dermal injection of hypertrophic scar that resulted from a

shave biopsy

but often become s k i n -colored with time. Ke loids a re fi r m , fibrous p l a q u es that exte nd outside the s ite of i nj u ry with claw- l i ke projectio ns.

D I F F E R E NT I A L D I AG N OS I S Dermatofi broma , sca r sarco i d , d ermatofi b rosa rcoma pro­ tu bera ns, gra n u lo m a .

LABORATORY EXAM I NAT I O N N o n e . If, however, a keloid i s u n res ponsive t o m u lti p l e thera pies, s k i n b i o psy t o rule out d e rmatofi b rosa rcoma protu bera ns is i n d icated .

TABLE 6 1 . 1

•

Hypertrophic Scars Versus Keloids

Defi n ition

Ke loid

Hypertro p h i c sca r

Excess fibrous tissue formation i n a wo u n d that

Excess fi brous tissue formation in a wo u n d that

exte nds beyon d the orig i n a l wou n d site

re m a i n s with i n the origi n a l wo u n d site

Cou rse

Does n ot sponta neously regress May a rise weeks or months afte r i nj u ry

U s u a l l y a rise with i n weeks of i nj u ry

Prec i p itati ng factors

Fa m i ly h i story, s u rgery, tra u m a , b u r n , a c n e , earlobe

Fa m i l y history, su rgery, tra u m a , b u r n , acne; may

pierc i ng; most common in skin types I V-V I ,

Often sponta neous regression months after the i nj u ry

a rise in a n y patient at all ages

but may a rise in a l l s k i n types a n d a l l ages I n cidence

Co m mo n ; M a les = fe ma les

Com m o n ; M a les = fe ma les

Ste rn u m : most c o m m o n location

Ste rn u m : most common location

Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s

I

29 1

MANAG E M ENT There a re

m u ltiple thera pies that a re effective for

decreasing the u nsightly a p peara n ce of ke loids a n d hypertro p h i c sca rs . N o n e is complete ly satisfactory a n d n o n e ca n be designated as a treatment o f choice. Patients s h o u l d be ed ucated as to the refractory natu re of keloids a n d hypertro p h i c sca rs a n d that m u ltiple treat­ ments ove r months a re typ ica l l y req u i red for effi cacy. Ke loids tend to be more resista nt to thera py than hyper­ tro p h i c scars. These treatment opti ons i n c l u d e i ntra l es i o n a l tri a m c i ­ n o l o n e aceto n i d e , i ntra lesiona l 5-fl uoro u ra c i l ( 5- F U ) , s i l icone s h eeti ng, i m i q u i m od , rad iati o n , e l l i ptical exc i­ sion, fractio n a l res u rfa c i ng, a n d p u lsed dye laser ( P D U ( 59 5 n m ) . These treatme nts provide d iffe rent ben efits. Some red uce eryth e m a , others flatten lesions, a n d some perform both the functions. M ost ofte n , i ntra l esio n a l

Figure 6 1 .2 Mild purpura after pulsed dye laser treatment of keloidal

stero ids a re a good i n itia l th era py t h a t ca n b e com bi ned

acne on back of a teenager. lntralesional kenalog was also used to produce eventual clinical improvement after a series of treatments

with o r fol l owed by oth e r thera pies. Treatments can be b roa d ly d ivided i nto laser and non laser thera p i es (Ta b l e 6 1 . 2 ) .

TAB L E 6 1 . 2

•

Non laser Treatment Options

l ntra les ional 1 tri a m c i nolone

Dose

I nterva l of time

Hypertro p h i c sca r

Keloids

Com ments

5-40 mg!m l

Every 2-6 weeks

For m ost scars,

Va ria ble su ccess; m ost

Effective, safe,

(site dependent)

aceto n i d e

moderate to d ra matic

successful with

i nexpensive; ca re

i m prove ment

early i ntervention

to avoid atrophy

( Fig. 6 1 . 1 ) I ntra lesional

50 mg/m l

5-fl u o ro u rac i l

1 -3 ti mes wee kly for t h e fi rst

Ca n be effective;

Va riable success

No clea r adva ntage ove r tria m c i nolone

secon d - l i n e thera py

1-2 wee ks;

aceto n i d e

then every 2-5 weeks 1 2 h o u rs per

S i l icone sheeti ng

Va ria b l e i m provement

Va riable i m p rovement

Safe

N ot stud ied

Study showed no

N o lo ng-term

day for 1 2 weeks l m i q u i mod

I n d u ces t u m o r

N ightly

necrosis facto r

a p pl ication for

recu rrences u p to

stud ies for

a l pha a n d

6- 8 weeks

6 months; risk

rec u rre nce rates

i n terfero n a l pha

sta rti n g the

hyper pigmentation

and ga m m a

d a y o f su rgery

i n sca r. F u rther study needed to confi rm these results

Excision s u rgical

M ostly u n s u ccessfu l ,

Very high rec u rre nce

I m med iate

n ot recom mended

rate without adj u n ct

gratification but

without adj uva nt

thera py. All patie nts

i nc reased risk of

thera py

m ust be awa re

rec u rrence

rec u rrent keloid may be worse than original

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LAS E R P D L ( 595 n m lhas e me rged as a n i m porta nt adjuvant for treatment of ke loids a n d hype rtro p h i c sca rs ( Fig. 6 1 . 2 ) . G ive n its selective ta rgeting o f su perfi c i a l b l ood vessels, PDL can d ra matica l l y i m prove the erythema assoc iated with

hypertro p h i c

sca rs

and

keloids

(Ta ble

6 1 .3).

I nteresti ngly, lowe r fluence treatments at short pu lse d u rations te n d to be more successfu l than higher fl uence treatments. It has a lso been shown h e l p to flatten lesions as wel l . Ab lative a n d n o n a blative fractio n a l res u rfa c i n g res u r­ fac i ng has been shown to provide moderate i m provement for acne, s u rgica l , hypertro p h i c , a n d b u r n sca rs . It is sti l l u n k n own wh eth er h igh-d e nsity treatments a re m o re effective than re m od e l i ng

low-density treatments. Typical ly, sca r

with

nona blative

fra ctional

A

res u rfa c i n g

req u i res six t o eight treatments t o a c h i eve a bout 50% benefit ( Fig. 6 1 .3) . S ig n ificant i m prove ment is seen with one to two treatments with a b lative fractio n a l resu rfa c i n g . C0 2 l a s e r treatment o f these lesions, w h i l e reported successful in some of the l iteratu re, is not reco m me n d ed d ue to a h igh rate of rec u rre nce. l ntra l esional corticos­ teroids a re a h e l pf u l adjuva n t to laser thera py to h e l p flat­ ten lesions and red uce pru ritus.

STU D I ES •

One study exa m i ned the effect of a flash la m p p u m ped P D L at 585 nm o r a flash l a m p P D L at 5 1 0 nm o n 1 5 patients with red hypertro p h i c scars. After a n aver­ age of nea rly two treatme nts, 77% i m provement was noted . After th ree treatm e nts, 7 of the 1 5 patients had complete reso l ut i o n .

•

Another stu d y u s i n g the 585- n m P D L treated one h a lf

B

Figure 6 1 .3 (A) Pre- and (B) postappearance of a traumatic scar after a series of fractional resurfacing treatments. There is some m ild residual PIH that faded within 1 to 2 weeks

of m e d i a n ste rnotomy hypertro p h i c sca rs/ke loids i n 1 6 patients a n d l eft t h e other s i de u ntreated . Patients received two treatm ents every 6 to 8 weeks a n d we re exa m i ned after 6 months. B l i nded o bserve rs a nd pho­ togra phy revea led "significant i m p rovement" in red­ ness, sca r height, skin s u rface texture , and pru ritis i n laser-treated sca r a reas after 6 m onths .

TAB LE 6 1 .3 • Pu lsed Dye Laser for Hypertrophic Scars/Keloids Mecha n is m of action

U n k n own

Expectation

I m proves erythema , t h i c kness, a n d p l ia b i l ity by u p to 30-90%

PDL setti ngs

3-7 J/cm 2 , 7 or 1 0-m m spot, 0.45- or 1 . 5-ms p u lse d u ration

Average n u m ber of treatments

4-6; but may req u i re fa r m ore

A

Figure 6 1 .4 (A) Erythematous deep acne scars.

Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s

I

293

C L I N I CAL EXPER I E NCE •

Avo id elective su rgery i n patie nts with a h istory of

•

Consider begi n n i ng therapy at the t i m e of su rgery o r at

keloids/hypertro p h i c sca rring. suture remova l . •

Keloids a re more d iffi c u lt t o treat a n d more u n pre­ d i cta b l e in the i r res ponse tha n hypertro p h i c sca rs.

•

Hypertro p h i c sca rs often i m prove with no treatment i n 6 months. P O L a n d fractional res u rfa c i ng lasers a re effective in

i m proving hypertro p h i c sca rs, F ra ctio n a l res u rfa c i ng can i m prove the text u re a n d a p pearance o f s u rgica l a nd b u r n sca rs

AC N E SCARS Acne sca rring is a co m mon seq uela of severe i nfla m ma ­ tory o r cystic a c n e . It can present i n a m i ld o r cosmeti­ ca l ly d i sfigu ri ng fo rm . The best prevention of acne sca rring is aggressive treatment of a c n e vu lga ris at the time

of

presentati o n ,

i n c l u d i ng,

when

a p propriate,

isotretinoi n . Acne sca rs have severa l va rieties i n c l u d i ng atro p h i c , ice-pick, ro l l i ng, a n d boxca r sca rs. Treatme nts va ry accord i ng to the type of sca r being treated . I n fact, a c o m b i nation of treatments is ofte n m erited , that is, P O L fo r sca r erythema a n d s u bseq u e nt n o n a b l ative fractional resu rfa c i ng for a c n e sca rs ( Fig. 6 1 .4) They a lso va ry in terms of d u ration of efficacy a n d expe nse. Prior to s u rgical o r a blative thera py, it is i m porta nt to e l icit a ny recent

B

h istory of Acc uta ne use with i n the previous 6 months as we l l as a h istory of hypertro p h i c or keloida l sca rring to avo id poor wou n d hea l i ng a n d sca rring after thera py.

• P h ys i c a l Les i o n s •

Atro phic sca rs a re d e p ressed from the s k i n s u rface a n d result from loca l loss o f tissue from i nfla m mati o n , i ntra lesi o n a l stero ids, s k i n s u rgery, weight loss, or ra pid growth (Ta ble 6 1 . 4 ) .

•

Ice-pick sca rs a re na rrow, d e e p , vertica l , cyl i n d rica l de pressions at the site of the i n fu n d i bu l u m . G iven t h e i r d e pth , they a re more resista nt t o l a s e r thera py. P u n c h excisions, fol l owed b y nona b lative fractional resu rfac­ i ng, can be h e l pfu l ( Fig. 6 1 . 5 ) .

•

R ol l i ng sca rs a re s h a l low de pressions that a re best a p preciated with a c h a nge in surface l ighti ng. They c a n va ry i n s i z e a n d often coa l esce w i t h n e i g h b o r i n g rol l i n g sca rs . They a re w i d e r tha n

ice-pick sca rs. T h e i r

de pressed a p pearance reflects a n u n d erlyi ng fi b rosis of the d e r m i s a n d su bcuta neous fat. •

Boxc a r sca rs a re wider than ice-pick sca rs but less deep. They have a wel l-defi ned c i rc u l a r o r ova l s h a pe .

c

Figure 6 1 .4 (Continued) (8) Improvement in acne scar erythema after a series of pulsed dye laser treatments. (C) Further improvement with acne scars with subsequent nonablative fractional resurfacing

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Color Atlas of Cosmetic Dermatology

TAB L E 6 1 .4

•

Treatment Options for Atroph ic Scars

Thera py

Type of thera py

Cou rse

C o m m ents

To pical

Tret i n o i n 0 . 0 5-1 % n ightly

Sl ight i m provement after

S l ight i m provement as monothera py. M ost

6-- 1 2 months

effective as an a dj u nct with other modal ities. If i n it i a l i rritation , a p ply every other n ight u nti l better tolerated

Laser

1 ,450-n m d iode: 1 2- 13 J/c m 2 ,

1 0-30% i m p rovement

M i l d i m provement

6-m m s pot size 30-40-ms c ryogen coo l i ng spray, th ree to fou r treatments over 4-6 months; treats active acne as we l l Safe in a l l s k i n types R isk of transito ry hyperpigmentatio n ; postlaser erythema weeks to months; may cause acne fla re Fractional resu rfa c i ng: five t o six

N o n a b l ative : moderate

treatments; d eeper d e pth of

i m provement afte r five to six

treatment is more effective,

treatm ents

u nclear if h igher or lower density of treatment is m ore effective

S i d e effects i n c l u d e tem po ra ry erythema, edema, crusti ng, a n d mild pa i n

A blative: moderate i m provement after two treatme nts Some m a y d evelop bronzing a n d m i ld fla k i n g at 5-7 days H igher i n c idence of hyperpigmentation i n d a rker s k i n p hototypes Low risk for lo ng-term adve rse side effects; except that scarri ng may occ u r with a blative fractional d evices

U ltra p u lsed pu lse carbon d ioxide laser

40---{)0 % i m provement; m ore effective than nona blative

M o re d ownti m e a n d side effects t h a n nona blative laser

laser Postlaser erythema lasting weeks to months; risk of hyperpigmentatio n , i n fect i o n , sca r, a n d permanent hypopigmentation Best for s h a l l ow, wide sca rs such as boxcar sca rs Antivi ra ls for patients with history of H SV F i l l e rs

R estylane ( h ya l u ro n i c a c i d )

D ra matic i m provement

Te m po ra ry

6--8 months Low-risk a l lergy, gra n uloma; do not overcorrect sca rs F i l l e rs

Auto logous fat

D ra matic i m provement a n d

Longer d u ration

longer d u ration t h a n other fi l lers N o risk of a l lergy, gra n u loma M ore d iffic u lt to master effective tec h n i q u e F i l l e rs

Bovine collage n : Zyd erm I , Zyd erm I I , Zyplast

Good , tem pora ry i m provement

Req u i res test site for a l l e rgy

fo r 2-3 months H igher risk of a l lergy ( ie , 1-3 % ) Tec h n i q ue: overcorrect sca rs Easier proced u re for i nexpe rienced practitioners t h a n other fi l le rs Adverse effects: s h o rter d u ration

F i l l e rs

H u ma n col lagen

Good , tem pora ry i m provement fo r 2-3 months

Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s

TAB L E 6 1 .4

I

295

Treatment Options for Atrophic Scars ( Continued)

•

Thera py

Type of thera py

Cou rse

C o m m e nts

Mecha n ical/

M icoderma b rasi o n , glyco l i c a n d

M i ld i m p rovement

M ic rod e r m a b rasion/glyc o l i c a c i d peels a re safe;

chem ical

sa l icyl ic acid pee ls safe in s k i n types I V-V I ;

sa l i cyl ic acid peels ( Fig. 6 1 .4)

derma brasion s h o u l d n ot be performed

TCA peels; derma b rasion

except i n extremely expe rienced h a n d s S u rgica l

S u bcision ( i ncision i nto dermis with

M i l d i m p rovement

Safe

Good i m provement

Ti me cons u m i ng. M u ltiple treatme nts. Better

mec h a n ical tra u ma i n d u c i n g fi b rosis) S u rgica l

P u n c h exc ision Fig. 6 1 . 6 ) , p u n c h grafting, p u n c h a utografti ng,

for ice- p i c k sca rs

punch elevation

• K ey P o i nts i n Treat i n g Ac n e S c a rs •

Em phasize i m provement rather tha n complete reso l u ­ tion as a n o bta i n a bl e res u lt .

•

D iscuss a l l treatment o ptio n s . A l l o ptions have adva n ­ tages a n d d isadva ntages .

•

M a n y patients w i l l benefit from a com bination of ther­ a py.

•

O bta i n com plete medical h i sto ry a n d med ication use, that is, Accuta ne with i n 6 months of a ny s u rgica l/a bla­ tive treatment.

•

M a ke s u re a c n e is being o r has been treated to p revent futu re sca rs .

B I B L I OG RAPHY Alste r T S , W i l l ia m s C M . Treatment o f kel o i d sternotomy

A

sca rs with 585 nm flash la m p-pu m ped p u l sed -dye laser.

Lancet. 1 995;345(8959) : 1 1 98- 1 200 . Avra m M M , Tope W D , Yu T, Szacowicz E, Nelson J S . Hypertro p h i c sca rring o f the neck fo l l owi n g a blative fra c­ tional carbon d ioxide laser res u rfa c i n g . Lasers Surg Med. 2009 ; 4 1 ( 3 ) : 185-188. Berma n B , Ka ufm a n J. P i lot study of the effect of posto p­ e rative i m i q u i mod 5% c ream on the rec u rre nce rate of exc ised keloids. J Am Acad Dermatol. 2002;47(su ppl 4 ) : S209-S2 1 1 . Berma n B, Via l l A. l m iq u i mod 5% c rea m fo r keloid m a n ­ agement. Dermatol Surg. 2003 ;29( 1 0) : 1 050- 1 05 1 . C h u a S H , Ang P, Khoo LS , Goh C L . N o n a b lative 1450 n m d iode laser i n treatment o f fac i a l atro p h i c a c n e sca rs i n type IV Asian ski n . Dermatol Surg. 2004 ; ( 1 0) : 1 287- 1 29 1 . Fitzpatrick R E. Treatment of i nfla med hypertro p h i c sca rs using i ntra lesi o n a l 5 - F U . Dermatol Surg. 1 999 ; 2 5 ( 3 ) : 224-23 2 .

B

Figure 6 1 . 5 (A) Ice pick scars prior to punch excisions. (8) Improvement

of ice pick scars 1 week after suture removal. Further improvement was achieved with nonab/ative fractional resurfacing

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G l a i c h AS,

R a h m a n Z, Gold berg L H , Fried m a n P M .

Fracti o n a l resurfa c i ng for the treatment of hypopig­ mented sca rs: A p i lot stu dy. Dermatol Surg. 2007;33 ( 3 ) : 289-294 . Haedersd a l

M,

M o rea u

KE,

Beyer D M ,

Nyma n n P,

Alsbjorn B . Fractional nona blative 1 540 n m laser resu r­ fac i ng or thermal b u r n scars: A ra ndom ized control led tri a l . Lasers Surg Med. 2009 ;4 1 ( 3 ) : 1 89 - 1 9 5 . Jacob C l , Dover J S , Ka m i n e r M S . Ac ne sca rring: A c lassi­ fication system and review of treatment o ptio n s . J Am

Acad Dermato/. 200 1 ;45( 1 ) : 1 09- 1 1 8 . N iwa A B , M e l l o AP, Toreza n L A , Oso rio N . Fractional p h o ­ tothermolysis for the treatment o f hypertro p h i c sca rs: C l i n ical experience of eight cases. Dermatol Surg. 2009 ; 35( 5 ) : 773- 7 7 7 . N o u ri K, J i menez G P, Ha rriso n - B a l estra C , Elga rt GW. 585 nm p u l sed d ye laser in treatment of s u rgical sca rs sta rti ng on suture remova l day. Dermatol Surg. 2003 ; 29( 1 ) : 65-73 Wa i bel J, Beer K. Fractional laser resu rfa c i n g fo r thermal

Figure 6 1 .6 Patient after numerous punch excisions. Sutures are removed 5 to 7 days after the procedure

burns. J Drugs Dermatol. 2008; 7 ( 1 ) : 59-6 1 .

TAB L E 6 1 . 5

•

I ce-Pick/Boxcar Scar Adva ntage

P u n c h h a rvesting and suture or punch ha rvest a n d i m p l a nt full­ thickness graft

Low cost, potentia l d ra m atic i m p rovement; best fo r na rrow, deep sca rs s u c h as

D isdva ntage U n p red i cta b l e , risk of m a k i ng cosmetic a p pea ra nce worse; time consu m i ng

ice-pick sca rs or deep boxcar sca rs; p u n c h exc ision ca n b e fo l l owed b y a blative or nona b lative fractional resurfa c i ng treatments

Ablative C0 2/Erbi u m : YAG

Potentia l 40-60% long-term i m provement; best for s h a l l ow boxcar sca rs

Postlaser erythema weeks to months; risk of hyperpigmentati o n , i n fectio n , sca r, and permanent hypopigmentation

Q u i c k , sign ificant i m p rovement Antivi ra ls for patients with history of H SV No perma nent i m p rovement

F i l l e rs, ie, R estylane, collage n , etc . (see Ta ble 6 1 .4) Low risk

N eed to repeat at least twice a n n ua l ly

Lasts 4-8 m o nths N o n a b lative laser ie, 1 ,450- n m d iode 1 2- 1 3 J/c m 2 (one pass) l ower fl uenc ies (two passes) m u ltiple monthly treatme nts

Low risk of serious side effects No d ownti m e Treats a ny a ctive a cn e

I m prove ment 1 0-30 %

TWE LVE Exogeno u s C utaneo u s A l te rat i ons

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CHAPT E R 62

Ea r P i e rei ng

Ea r pierc i ng i s performed t o fac i l itate a n i n d ivid u a l 's desire to wea r earri ngs. By having the proced u re per­ formed in a medical fac i l ity by a physic i a n , the patient is reassu red that the proced u re is being performed i n a safe , control led environment.

KEY CO N S U LTAT I V E QU EST I O N S •

Contact a l le rge ns t o meta ls

•

H istorY of ke loids or hypertro p h i c sca rri ng

•

Desi red site of pierc i ng

PHYS I CAL EXAM I NAT I O N Assess the thickness of ea rlobes.

MANAG E M ENT There a re two common methods for ea r pierc i n g . It c a n b e performed with a need le b y h a n d or with t h e h e l p of an a utomatic ea r-pierc i n g g u n ( Fig. 62 . 1 ) . Before per­ fo rm i n g either proced u re , it is i m porta nt to m a ke certa i n that the correct location for pierc i ng h a s been selected . Sym metrY with the contra late ra l ear is esse ntia l for a good cosmetic a ppea ra n c e . The patient s h o u l d review the sites using a m i rror prior to treatment.

TREAT M E N T •

Steril ize a l l i n stru me nts

•

Ste r i l ize a n d a nesthetize both ea r lobu les

•

Identify the exact sites to be pierced with a marking pen on the a nterior and posterior portions of the ear lobule. Confirm proper placement with patient before proceed ing

•

U s i n g slow press u re, adva n ce a 1 4- to 18-ga uge need le t h rough the poste rior lobule i nto the a nterior l o b u l e

•

If a n a utomatic ea r-pierc i n g g u n is used , the g u n is advanced from the a nterior l o b u l e towa rd the poste rior lobule

•

Use a steril ized ea rring w i t h a sta i n l ess steel post

•

A n ickel-free post of the ea rring is adva n ced with the needle a n d the tip is p u l led back t h rough the ea r

• •

The clasp is put on the posterior post Leave the ea rring in place for a pproxi mately 14 days u ntil re-epithe l i a l ization of the tra c k

•

C l e a n t h e site with hyd rogen peroxide a n d topical a nti biotic oi ntment twice d a i ly

Figure 62. 1 Ear-piercing gun being used on earlobe of a young female

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

P I T FALLS TO AVO I D/CO M P L I CATI O N S/ MANAG E M ENT/O UTCO M E EXPECTAT I O N S • •

T h i n ea rlo bes m a y spl it, espec ia l ly with heavier earri ngs P lace earri ngs o n the sa m e level horizonta l ly to assu re sym metry

•

A good clean steri l e tec h n iq u e c a n avoid postproced u re i nfections

•

I t is i m porta nt to el icit a n y h i story of hypertro p h i c scars or ke loids i n these patients ( Fig. 62 . 2 ) . Ea r pierc i ng s h o u l d not be performed on th ese patients

•

Any h i story of n i c kel or other m eta l a l lergens s h o u l d be e l i c ited prior to a ny proced u re as wel l

•

Ed u cate patients as t o wou n d care a n d t h e need to co ntact you in the event of i nfection

•

In the event of co ntact dermatitis or a l le rgy, topical steroids a re the m a i nstay of treatment

Figure 62.2 Keloid on posterior earlobe secondary to ear piercing

(Courtesy of Tomi Panda/fino, MD)

B I B L I OG RAPHY Atk i n D H , Lask G P. E a r pierc i n g a n d s u rgica l repa i r o f the earlobe .

In:

Lask G P, M oy R L, ed s .

Principles and

Techniques of Cutaneous Surgery. N ew York: M c G raw­ H i l l , I n c ; 1 996.

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CHAPT E R 63

Tattoo R e m ova l

Tens of m i l l ions of Am erica ns have tattoos . Over t i m e , many d e c i d e t h a t they wa nt the tattoo t o be re moved . Qual ity-switched

( Q-switc hed ) lasers a re effective i n

re movi ng most tattoo pigme nts safe ly ( Figs . 63 . 1-63 . 3 ) . T h e a p propriate laser wave length is determ i ned b y the tattoo i n k's a bsorption s pectru m . It is bel i eved that laser p u l ses in the n a n osecond range target tattoo pigments a n d brea k them i nto s m a l l e r pa rticles, there by fac i l itati ng remova l

of

the

pigment

tra nse piderma l l y

or

via

macro phages and loca l scave nger cells. In order to treat m u lticol ored tattoos, seve ra l Q-switched

laser wave­

lengths m ust be e m p l oyed .

A

KEY CO N S U LTAT I V E QU EST I O N S •

Was the tattoo placed b y a n a mate u r or a profess ional tattoo a rtist?

•

Was the tattoo placed for the p u rpose of rad iation thera py?

•

Is the tattoo the res u l t of tra u m a or i nj u ry?

•

What colors a re conta i ned with i n the tattoo? (Ta ble 63 . 1 )

•

P revious treatments

•

Use of isotret i n o i n with i n 6 months

•

H istory of keloids/hypertro p h i c sca rs

•

D u ration of tattoo

•

S k i n p hototype

•

H istory of H SV at site of treatment

•

H istory of a l le rgic or gra n u l omatous reactio n to tattoo pigment

TABLE 63 . 1

B Figure 63 . 1 (A) Tattoo on left earlobe prior to therapy. (8) Resolution after six treatments with 1 , 064-nm Q-switched Nd: YA G laser

•

Laser Therapy by Tattoo Color

Tattoo pigment

Light s pectrum

M ost effective lasers

Comment

Red

G reen

Freq uency-d ou bled Q-switc hed N d :YAG

May cause pigment a lteration i n da rker s k i n

( 532 n m ) Ye l l ow

G reen

Freq ue ncy-d ou bled Q-switc hed N d :YAG

G reen

Red/nea r i nfra red

Q-switc hed ru by ( 694 n m )

Least pa i nfu l o f Q-switc hed lasers N ot very effective

( 532 n m ) May ca use hypopigme ntation in da rker s k i n

Q-switc hed a l exa nd rite ( 7 5 5 n m ) Light b l ue

Red/nea r i nfra red

Q-switc hed ru by (694 n m )

May ca use hypopigme ntation i n da rker s k i n

Q-switc hed a l exa nd rite ( 7 5 5 n m ) Dark blue

Red/nea r i nfra red

a-switc hed ru by (694 n m ) : l ight s k i n types o n l y

B la c k

Q-switc hed a l exa nd rite (755 n m ) : l ight skin types on ly Q-switc hed N d : YAG ( 1 , 064 n m ) : a l l s k in types

Q-switched N d : YAG ( 1 ,064 n m ) safe i n a l l s k i n types. Less p i g m e n t loss

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•

I

30 1

Is the tattoo placed over or covering a nother tattoo?

•

H i story of go ld i n gestion

•

Does the tattoo conta i n rust-col ored o r wh ite pigment?

MANAG E M ENT It is i m porta nt t o a s k t h e patient w h o placed t h e tattoo . P rofessional tattoo pigments a re denser a n d placed d ee per in the dermis than most a mate u r tattoos. This re nders these tattoos m o re refractory to treatment, partic­ u l a rly those that a re m u lticolored and conta i n meta l l ic pigments . It is i m porta nt to i nform the patient prior to treatment that c o m p l ete resol ution is not a l ways fea s i b l e . It is a lso i m porta nt to cou nsel t h a t m u ltiple treatments ove r 1 to 2 yea rs may be req u i red for maxi m a l i m prove­ ment. There is no fixed a n swer as to the n u m be r of treat­ ments for tattoo rem ova l .

A

P R ET R EAT M E NT ASS ESS M E NT •

Patients w i t h da rker s k i n types a re m o re l i kely t o suffer pigme nta ry cha nges

•

Professional tattoos req u i re more treatm ents than a ma ­ te u r tattoos

• •

O l d e r tattoos res pond m o re favora bly than new tattoos B la c k a n d d a r k b l u e tattoos res pond more effectively t h a n yel l ow tattoos

•

Assess for s u nta n . If patient is ta n ned , delay treatment u nt i l ta n resolves

•

M u lticolored tattoos a re more d ifficult to su ccessfu lly clear than si ngle-color tattoos. D u ri ng treatment, some patients may be frustrated at the n o n u n iform i m p rove-

B

ment of these tattoos •

Assess for sca rring with i n the tattoo . If p resent, s how the patient a n d doc u ment prior to treating

N U M B E R OF T R EAT M E NTS •

Professional tattoos req u i re a bout 6 to 20 treatments prior to rem ova l ; not i nfreq ue ntly, more than 20 treat­ ments a re needed for max i m a l i m p rovement

•

Amate u r tattoos conta i n less dense pigment particles a n d usua l ly req u i re a bout fou r to six treatments

•

Rad iation tattoos a n d tra u matic tattoos a re more su per­ ficia l and less de nse than professiona l tattoos, req u i ri n g o n l y a few treatments for resol ution ( Fig. 63 .4)

•

•

In genera l , rad iation tattoos can be removed i n one to th ree treatme nts. Someti mes, they req u i re a d d itional

c

treatments

Figure 63.2 (A) Tattoo on arm with underlying port-wine stain. (B) Note

Lower fluences a n d la rger s pot sizes can be as effective

the selective removal of the tattoo, while the port-wine stain persists.

as s m a l ler spot s izes a n d i n c reased f l u ences

(C) Tattoo clearance

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Color Atlas of Cosmetic Dermatology

Test spot may be a p pro priate i n d a rker s k i n phototypes if concern i n g

•

Test spots a re c l ea rly i n d icated f o r cosmetic tattoos , rust-colored tattoos, a n d wh ite tattoos

TATTOO TREATM E NT •

Ph otogra ph of tattoo prior to treatment

•

Topical a n esthesia o r 1% l i d oca i n e, i n the form of l oca l i njection or nerve block, w i l l m a ke the treatment more comforta ble for the patient

•

Treat the affected a reas with the a p propriate a-switc hed

•

The c l i n ica l e n d po i n t is i m med iate tissue wh iten i ng. For

laser a l lowi ng for up to a 10% overlap (Ta ble 63 .2)

A

the 1 ,064-n m a-switc hed N d :YAG , i n a d d ition to tissue white n i ng there may be a sma l l a m o u nt of p i n point bleed i n g at the site of treatment ( Figs. 63 . 5 a n d 63 .6) •

Tissue "splatter" (ie, epid erma l/dermal d isruption a n d bleed i ng) m a y prod uce sca rring. If this occ u rs, decrease the fluence

•

If the tattoo is m u lticolored , treat the red pigment fi rst. E rythema a n d i nfl a m mation from other treated sites may o bsc u re vis u a l ization of red tattoo pigment

•

Apply to pical hyd rated petrolatu m a n d a nonad herent d ressing after completing the treatment

•

Counsel s u nscreen a n d sun avoi da nce to the treatment a rea

B Figure 63.3 (A) Left shoulder tattoo with inferior scar resulting from prior

POSTTREAT M E N T CAR E •

S u n avoida nce, s u n sc reens

•

Telfa d ress i n g and hyd rated petrolatu m o i ntment with

treatment with dermabrasion. (B) Improvement after six treatments with 1 , 064-nm Q-switched Nd: YA G laser. While improvement is not complete, the cosmetic result is far superior to that of dermabrasion

paper ta pe •

If tattoo is located in belt-l i n e a rea o r a bove a n kles, cau­ tion patients from wea ring tight belts o r boots that may prod uce friction aga i nst the treated a rea

•

Retu rn for treatment in 6 to 8 weeks

TAB L E 63.2

•

Laser Therapy by Qual ity-Switched Lasers

Laser

I n itial setti ngs

Effective aga i n st th ese tattoo i n ks

Freq uency d o u b l ed a-switc hed N d : YAG (532 n m )

1 . 5-5 .0 J , 4 . 0-8 . 0 mm spot size

Red , orange, ye l l ow

a-switc hed r u by (694 n m )

3 . 0-8 . 0 J, 6.5 mm s pot size

G ree n , b l u e , black

a-switc hed a lexa nd rite ( 7 5 5 n m )

5 . 0-6 . 5 J, 2 . 0-4. 0 mm spot size

G reen , blue, b l a c k

a-switc hed N d : YAG ( 1 , 064 n m )

3 . 0- 1 2 . 0 J, 2 .0-8. 0 mm s pot size

B l ue , b l a c k (safest i n d a rk s k i n types)

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

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303

ADV E R S E EFFECTS/PR ECAUT I O N S • •

Pigmenta ry a lterati o n B l iste r i ng ( es pec i a l ly, Q-switc hed a l exa n d rite a n d r u by) ( Fig. 63 . 7 )

• •

Sca rring ( Fig. 63.8) In a patient with a n a l lergic reaction to tattoo ink i n the past ( Fig. 63 . 9 ) , th ere is the poss i b i l ity of a rec u rre nce seco nd ary to the re lease of tattoo ink fol lowi ng laser thera py. A l l e rgic p reca utions s h o u l d be ta ke n . Syste m i c a l lergic reactions c a n occ u r with Q-switc hed lasers ( u n l ike d estructive modal ities-derma brasion, etc . )

•

R u st-co lored a n d wh ite tattoos s h o u l d b e treated ca re­ fu l l y as wel l as red a n d flesh-colored cosmetic tattoos, for exa m ple, l i p l i ner. Someti mes wh ite i n k is m ixed with other pigme nts ( Fig. 63 . 1 0) - The tattoo may d a rken as a result of oxidation of i ron o r tita n i u m oxi d e pigment with i n the tattoo - A test site can be performed 4 to 8 weeks prior to

Figure 63.4 Traumatic tattoo on knee of a female that has persisted 30 years after childhood bicycle fall. a-switched 1 , 064-nm Nd: YA G cleared the tattoo i n three treatments

treatment for possible d a rke n i ng - This d a rken i n g ca n someti mes be treated with lasers or may req u i re excision - They respond slowly to laser thera py •

Perform a test s pot prior to treating patie nts with h i story of gold salt i n gestio n . C h rys iasis, m a n i fested as da rk­ b l u e pigmentation , can res u lt fro m treatment with Q­ switc hed lasers

•

Ra rely, patients w i l l experience a tra nsient i m m u n e res ponse fol l owi ng a

laser tattoo treatment. S u c h

responses i n c l u d e fl u - l i ke sym ptoms a n d e n l a rged lym ph nodes

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M ENT/O UTCO M E EXPECTAT I O N S •

Response t o tattoo treatment is dependent u pon the d e pth of pigment, the color of pigment, and the size of pigment pa rticles. I t c a n va ry d ra matica l l y fro m one to tattoo to a nother

•

Effective treatment for a professional tattoo may req u i re u p to a 20 or more treatment sessions over a period of 1 to 2 yea rs . F u rt h e rmore, complete remova l is often not fea s i b l e

•

A su ccessful treatment often leaves s o m e res i d u a l tat­ too pigment. T hi s can be i m proved with n o n a b l ative fractiona l res u rfa c i n g

•

Physicians s h o u l d c o u n s e l patients t h a t sign ifica nt l ighte n i ng may be the best feasible c l i n ical resu l t

•

Tattoo treatment can prod uce hyper- a n d hypopigmen­ tation i n a ny patient, espec i a l l y those with da rker skin types

Figure 63.5 Tissue whitening after treatment with the 532-nm frequency­

doubled a-switched Nd: YAG and 694-nm a-switched ruby laser. Tissue whitening is the appropriate endpoint when treating tattoos with a­ switched lasers. Pinpoint bleeding resulted from injection of lidocaine with epinephrine prior to treatment

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Color Atlas of Cosmetic Dermatology

Treatment of tattoos in a reas of h a i r growth ( i e , eye­

•

b rows ) may prod uce tem porary h a i r remova l The freq uency-dou bled Q-switc hed N d : YAG , Q-switc hed

•

ru by, and Q-switched a l exa nd rite lasers a re more l i kely to ca use d u ra ble pigmenta ry cha nges than the Q-switc hed N d : YAG ( 1 ,064 n m ) M ost freq uently,

•

pigment

a l teration

is

te m pora ry.

Hyperpigme ntation typ i ca l ly resolves more q u i c kly Lower fl uences and a d d itio n a l time between treatments

•

s h o u l d be e m ployed i n da rker s k i n p h ototypes

B I B L I OG RAPHY Alster T . Q-switched a l exa n d rite laser ( 7 5 5 n m ) treatment of

professiona l

a nd

a mate u r

tattoos .

J Am Acad

Dermatol. 1 995;33 : 69-73. Ferguson J E, August PJ . Eva l uation of the Nd/YAG laser

Figure 63.6 Purpura immediately after treatment of an eyebrow tattoo

fo r treatment of a m ateu r and profess iona l tattoos. Br J

with a Q-switched Nd: YAG laser

Dermatol. 1996; 135(4) : 586-59 1 . F itzpatri ck R E, G o l d m a n M P. Tattoo re m ova l using the a l exa n d rite laser. Arch Dermatol. 1994 ; 1 30 : 1 508- 1 5 14. G reve l i n k J M ,

M u las

MW,

Hata

TR,

Goldman

M P,

F itzpatrick R E, G reve l i n k J M . Laser treatment of tattoos i n d a rkly pigme nted patients : Efficacy a n d side effects .

J Am Acad Dermatol. 1 996;34: 653-656. l z i kson

L,

Avra m

MM,

Anderson

RR.

Tra nsient

i m m u noreactivity after laser tattoo remova l : Re port of two cases. Lasers Surg Med. 2008;40(4) :23 1 -232. K i l mer S L, Anderson R R . C l i n ical use of the Q-switc hed r u by and the Q-switc hed N d : YAG ( 1 064 nm and 532 n m ) lasers fo r treatment o f tattoos . J Dermatol Surg Oneal. 1 993; 1 9 (4) : 330-338. Levine VJ , Gero n e m u s RG. Tattoo remova l with the Q­ switc hed r u by laser and the Q-switc hed N d : YAG laser: A comparative study. Cutis. 1 995; 55:29 1 -296.

Figure 63.7 Blistering after tattoo treatment. This reaction is common and usually resolves completely within a week with routine topical skin care

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

Figure 63.8 Scarring after treatment with a Q-switched ruby laser

(Courtesy of Teresa Soriano, MD)

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A

B Figure 63.9 (A) Allergic hypersensitivity reaction to tattoo (see elevated

portions of tattoo). (B) To avoid systemic allergic reaction with traditional Q-switched laser treatment of the entire tattoo, focal treatment with an ablative fractional erbium laser was performed. Note focal improvement after several treatments

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

I

307

A

B Figure 63. 1 0 (A) Tattoo prior to test spot treatment. (B) Test spot treat­

ment of tattoo with a 694-nm Q-switched ruby laser produces discol­ oration. Tattoo ink combined blue and white inks

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CHAPT E R 64

To r n Ea rl o be

Torn earlobe a n d e n l a rged p ierced earlobe canals a re a c o m m o n conseq u e n ce of wea ring heavy earri ngs for a pro l onged pe riod of t i m e ( F ig. 64 . 1 ) as we l l as other fac­ tors such as tra u ma , heavy earri ngs, i nfecti o n , low place­ ment of pierc i ng, pressu re necrosis, etc . It occ u rs most easi ly in t h i n ear l o b u les. D roo p i n g or easily torn ea rlobes may also be secondary to a congen ita l d efect o r tra u m a .

K E Y CO N S U LTAT I V E QU EST I O N S •

P rec i pitating event of earlobe tea r

•

H istory of ke loids or hypertro p h i c sca rri ng

•

Does patient desire to wea r ea rri ngs aga i n after the repa i r?

MANAG E M ENT

A

There a re n u merous s u rgica l methods t o repa i r com­ p l etely a n d pa rti a l ly torn earlo bes. D iffe rent tec h n i q ues a re su ited for d iffe re nt tea rs. Partial tea rs a re m o re easily treated a n d c a n be corrected via sid e-to-s ide closure as we l l as punch exc ision and repa i r.

T R EAT M E NTS ( Figs . 64 . 1-64 . 3) Com plete tea rs a re m ore d iffic u lt to treat tha n pa rtial tea rs . There a re n u merous d iffe rent tec h n i q ues that ca n be successfu l . M ost c o m m o n ly, the Z-plasty repa i r o r i nterloc k i n g L s repa i r prod uce the best res u lt . •

Sterile pre paration a n d tec h n i q u e

•

Loca l a n esthesia s h o u l d be i njected i nto t h e repa i r site

•

The epidermis of the opposing edges of the tea r wo u n d

•

s h o u l d b e exc ised

B

- Sca l pel

Figure 64. 1 (A) Female with large tear defect of earlobe at the site of

- Scissors

heavy earring. (B) Torn earlobe reconstructed by primary repair

I nterru pted 6-0 epidermal sutures a pproxi mate a n d eve rt t h e wou n d edges o f t h e a nte rior a n d posterior lobe - Be certa i n to a p prox i mate the wou n d ed ges of the i nferior r i m of the ea r ca refu l ly to avoid d istortion o r m isa l ignment - The wo u n d edges s h o u l d be u n d e r m i n i ma l tension

•

N o su bcuta n eous sutu res a re used

•

Z-plasty re pa i r ( Fig. 64 . 2 ) or i nterloc k i n g Ls repa i r on the rim wi l l prod uce tissue a p p roxi mation wh i l e pre­ venting the d i m pl i ng of the i nferior rim of the earlobe

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

•

I

309

Patients should be cou nseled to refra i n from wea ring earrings for 3 months fol l owi n g the repa i r

A

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M ENTIOUTCO M E EXPECTAT I O N S •

M eti c u lous attention t o a p p roximating t h e wou n d edges a n d the i nfe rior r i m of the ea r a re esse ntia l for a satis­ fa ctory resu lt. N otc h i ng of the i nfe rior rim of the earlobe

b

ca n occ u r easi ly, sign ifica ntly compromising a esthetic a p pea ra nce •

Caution i n a patient with a h i story of keloids or hyper­ tro p h i c sca rs

•

B

Patient s h o u l d n ot wea r earrings for 2 to 3 m o nths after s u rgery

•

Wou n d strength is less than the origi nal strength of the lobe. Avoid wea ring heavy earri ngs to prevent rec u rrence

B I B L I OG RAPHY Ti pton J B . A s i m ple tec h n iq u e for red uction o f the ea r­ lobe. Plast Reconstr Surg. 1 980;66: 630-63 2 .

Figure 64.2 Repair of complete earlobe tear utilizing a Z-plasty to pre­

vent dimpling of the inferior aspect of earlobe

31 0

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Color Atlas of Cosmetic Dermatology

A

8

c

Figure 64.3 One stage preauricular flap to repair earlobe deformities

INDEX N ote : I n this i ndex, the letters "f" and "t" denote figu res and ta bles, respectively.

pathogenesis, 72

1, 450-nm diode laser, 82, 82f, 83f

physical exa m i nation, 72

5-a m inolevu l i n i c acid (5-ALA), 75, 254 5-fl uorouraci l , 207, 224, 229

Acq u i red ca p i l l a ry hema ngioma, 1 70-1 73

1320-nm N d : YAG laser, 4 1 1 450- n m diode laser, 4 1 , 74

Acra l amela notic melanoma, 206 Acti n i c c h e i l itis, 248 Actinic keratosis (AK), 248 consu ltative q uestions, 249

A

cou rse, 249

Ablative fractional laser resu rfaci ng, 39, 57

dermatopathology, 248

adva ntages of, 57 ind ications, 58

d ifferential d iagnosis, 248 epidemiology, 248

laser safety, 59

ma nagement, 249

adverse side effects, 60, 601

pathoge nesis, 248

fol low- u p , 59-60, 59f

physical exa m i nation, 248

i nfectio n , 60, 6 1 1

pitfa l l s , 250-2 5 1

nonfacial skin, 60-6 1 postoperative care, 57f, 58f, 59

treatment, 249-250 Acti n i c keratoses vs. wa rts, 206

preoperative eva l uation, 58

Acyclovir, 32, 46, 54

prophylaxis/a nesth esia, 58-59 Ablative laser res u rfacing, 1 5 11, 1 52

Ada palene, 9, 73

a bsol ute contra i nd ications, 45

Adatosil 5000, 14t, 1 5t

a n esthesi a , 46-47 for Becker's nevus, 2 1 8

Adenoma sebaceu m , 2 1 2 Affirm 1 , 440 n m N d : YAG laser, 56, 56t

for epidermal nevus, 224

Age-related textural cha nges, 2t

ideal laser candidate, 45

Agi ng, 2

i n d ications, 44

Aging face and non-facial regions, a na lysis of

less than ideal laser cand idate, 45

a natomic consid erations, 2-3 , 2t

mecha n ism of action, 43 ca rbon d i oxide laser, 43, 43f, 44f

preoperative eva l uation, 3 ca rti lage, bony structures, and s u p portive structures,

Er:YAG, 43, 45f

cha nges in, 5

medications, 46

facial m uscu lature cha nges, 5

for m i l ia , 230

G l oga u Photoaging Classification, 2f, 3-4, 3f, 4f, 5f

postoperative care, 49, 501, 5 1 1

pigmenta ry cha nges, 4, 6f

preoperative eva l uation, 44-45 proced ure, 48-49, 49f

su bcuta neous fat atrophy, 5 AK. See Acti nic keratosis

relative contra ind ications, 45-46

A LA . See 5-a m i n olevu l i n i c acid

safety mea s u res, 47-48

Alca i ne. See Topica l proparaca ine

for seborrheic keratosis, 236

Alcon, 28

treatment pearls, 50 ACE i n h i bito rs . See Angiotensi n-converting enzyme (ACE) i n h i bitors

Alcon La bs, 1 5t Al lerga n , 1 4t, 1 5t, 2 1 1

Aceta m i nophen, 58

Allergic reactions

Acetone, 48

to sclerothera py, 20 1 Al loderm , 14t

Acne scars, 290, 293

Aloe vera , 10

physica l lesions, 293-295 treatment, 295 Acne vu lga ris, 72, 76, 1 00

Aloesi n , 9t, 10 a-hyd roxy acid, 32 lotions, 182

vs. angiofi broma, 2 1 2

for posti nfl a m matory hyperpigmentation, 1 60

cou rse, 73 d ifferential d iagnosis, 72

peels, 1 4 1

epidemiology, 72

A l u m i n u m c h l oride hexa hydrate, 8 7

la boratory data dermatopathology, 73

A m b u latory phle bectomy, 202 American Academy of Dermatology, 8

endocrine stud ies, 72-73

Amoxici l l i n , 73

ma nagement, 73

Amyotro phic latera l sclerosis, 22

l ight treatment, 72f, 73f, 74-75, 75f

Anesthesia , 88

s u rgica l treatment, 74

for a blative fractional laser resu rfaci ng,

systemic treatment, 73-74 topical treatment, 73

58-59 for a blative laser resu rfaci ng, 46-47

31 1

31 2

I

I ndex

for a ngiofi broma, 2 1 3 for l i poma treatment, 227 for neurofi broma, 236 for nonablative fractional laser resu rfaci ng, 54 for nonablative laser resu rfa c i ng, 40 m i d - i nfrared lasers, 40f, 4 1 for soft tissue augmentation, 1 6f, 1 7 for wa rt remova l , 207t, 208 Angiofi broma, 2 1 2-2 1 5 consu ltative q uestions, 2 1 3 cou rse, 2 1 3 , 2 1 3f de rmatopathology, 2 1 2 d ifferenti a l d iagnosis, 2 1 2 epidemiology, 2 1 2 laboratory data , 2 1 3 ma nagement, 2 1 3-2 14, 2 1 4f, 2 1 5f pathogenesis, 2 1 2 physical exa m i nation, 2 1 2 , 2 1 2f pitfa l l s , 2 1 4 Angiokeratoma, 1 68 vs. angiomas, 1 7 1

cou rse ma nagement, 1 68-1 69, 1 69f de rmatopathology, 1 68 differentia l d i agnoses, 1 68 epidemiology, 1 68 physical exa m i nation, 1 68 pitfa l l s to avo i d , 1 69 Angio l i poma, 226 Angiomas, cherry and spider, 170 cou rse, 1 7 1 differentia l d i agnoses, 1 7 1 epidemiology, 1 70 ma nagement, 1 7 1 - 1 7 2 pathogenesis, 1 70 pathology, 1 7 1 physical exa m i nation, 1 7 1 pitfa l l s to avo i d , 1 7 2 Angiotensi n-converti ng enzyme (ACE) i n h i bitors, 89 Anth ra l i n , 224 Anti bacterial agents, 73 Anti bacteria l thera py, 46, 53 Anti biotics, 73 Antima la ria ls, 1 75 Antioxida nts, 8 Anti pers p i ra nt, 89 Antivira l med ications, 49 Antivira l thera py, 46, 54 Apraclo n i d i n e hydrochloride, 28 Aq ua m i d , 1 4t Aquaphor H ea l ing O i ntment, 49 Arbuti n , 9t, 1 0 Artefi l l , 1 4t Arterial spider, 1 70- 1 73 Ascorbic acid , 9t, 1 1

B B l u pu s m i l iaris d isse m i natus faciei, 76

B - H C G . See � - H u m a n chorionic gonadotropin B a n naya n-Zonana synd rome, 226 Basa l cell carci noma ( BCC), 81, 252-254 epidermal nevus a n d , 222, 223 consu ltative q uestions, 253 cou rse, 253 de rmatopathology, 252 d ifferential d iagnoses, 252 epidemiology, 252 la boratory data, 253 ma nagement, 253-254, 253f, 254f, 255f pathogenesis, 252 physical exa m i nation, 252, 252f pitfa l l s , 254 B ea rberry, 1 0 B ecker's nevus, 2 1 6--2 1 8 consu ltative q uestions, 2 1 7 cou rse, 2 1 7 d ifferential d iagnosis, 2 1 6 epidemiology, 2 1 6 la boratory exa m i nation, 2 1 6 ma nagement, 2 1 7-2 18, 2 1 7f pathogenesis, 2 1 6 pathology, 2 1 6 physical exa m i nation, 2 1 6, 2 1 6f pitfa l l s , 2 1 8 B e l otero Basic, 1 4t B e l otero Soft, 14t Benign growths a ngiofi broma, 2 1 2-2 1 5 Becker's nevus, 2 1 6--2 1 8 epidermal i nclusion cyst, 2 1 9-22 1 epidermal nevus, 222-225 Benzoyl peroxide, 73

�- H u ma n

chorionic gonadotropin ( B- H C G )

Betaca ine Enha nced Gel, 1 7 B etaca ine P l u s , 1 7 B io-Aica m i d , 14t B i oform M e d i ca l , 1 5t B iomatrix I nc . , 1 5t B i o psies epidermal i nclusion cysts, 220 epidermal nevus a n d , 223 l i poma, 227 neurofi broma, 232 seborrheic keratosis, 235 B i otech I n d u stry, 1 5t B laschke, l i nes of, 222 B leac h i n g crea ms, 46 B l e p h a rochalasis, 64 B loom's synd rome, 67, 136 Bornaprine, 87

Ash leaf macule, 2 1 2, 2 1 3f

Botox, 89 . See also Botu l i n u m toxin A

Aspergillus, 1 0 AstraZeneca , 1 7

Botu l i n u m toxin

Botox Cosmetic, 2 1!

Ataxiatela ngiectasia, 67

com pl ications, 27

Ativa n , 58

contra i n d ications

Atro p h i c scars, 294-295 Atrophoderma verm iculatu m (AV), 1 8 1

a bsol ute, 22 relative, 22

Avila , 9 Avobenzone, 7t

d i l ution, 22

Azelaic a c i d , 9t, 10, 73, 77, 1 4 1 , 1 5 1 , 1 60

m uscle gro u ps, 22f, 23

Azit h romyc i n , 46, 73

mecha nism of action, 21 forehea d , 22f, 23-24, 23f

I n d ex

gla bellar com plex, 24, 24f

Cavernous hemangioma, 1 77-1 80

nasolabial fol d , 25--2 6, 27f

Cel l u l ite, 276-279, 276f

neck, 26-27, 28f

consu ltative q uestions, 277

periora l region, 26, 27f, 28f periorbital regio n , 24-25, 25f

course, 276

u pper nasal root, 25, 26f

epidemiology, 276 la boratory exa m i nation, 276

pharmacology, 2 1 , 2 1 !

ma nagement, 277

postoperative considerations, 27

physical lesions, 276

preoperative eva l uatio n , 22

pitfa l l s , 278--279

lower eyelid snap back test, 22-23 prepa rations, 2 lt

treatments, 277-278, 277f

proced u re, 23

Centrofacial te la ngiectasias, 194f Chem ical peels, 30, 74, 1 4 1

treatment benefits, 27

compl ications, 3 4 , 38f

treatment pearls, 28

contra i n d ications, 3 1-32

B otu l i n u m toxin A ( BTX-Al , 2 1 , 22, 87, 88, 88f a n esthesi a , 88 antipers p i ra nt, 89

ideal ca n d i d ate, 3 1 less ideal ca n d idate, 3 1 med ications, 32

Botox, 89

peel types, 33

hyperh i d rosis, mechanism of action i n , 88f

postoperative care, 34

i njection sites of, 88f, 89f

proced ure, 33-34, 36f, 37f

med ications, 89

treatment pearls, 34-35

su rgery, 89 treatment, 88-89, 88f, 89f

wou n d depth, 32 Chem ical su nscreen, 7-8, 7t

Botu l i n u m toxin B ( BTX- B l , 2 1

Cherry a ngiomas, 1 70-- 1 73 , 1 72f

B otu l i n u m toxin E ( BTX-E), 2 1

Cinoxate, 7t

B r i n d is, 14t

C i p rofloxa c i n , 46

Broussonetia papyrifera, 1 0

C l i ndamyc i n , 73

B ucci nator, 2 6 , 27f, 28f

Clofazimine, 1 7 5

c

C02 l a s e r a b lation, 82 C02 resu rfacing. See Carbon d ioxide (C02 ) laser Coenzyme Q10, 8

Clostridium botulinum, 2 1

Cafe au lait macu les (CALMs), 136 vs. B ecker's nevus, 2 1 6 consu ltative q uestions, 137

Colchicine, 1 7 5

cou rse, 137

Col lagen, i n a ngiofi broma, 2 1 2 Col lagenase, 9

d ifferential d iagnosis, 136

Comedone extractio n , 74

epidemiology, 136

Common wa rts, 206-209

la boratory exa m i nation, 136 laser treatment, 1 37-138

Compression stocki ngs, 200

ma nagement, 137

Complete tea rs, 308

vs. neurofi bromas, 232

Congen ital ad renal hyperplasia, 92 Congen ita l hema ngiomas, 1 7 7

pathogenesis, 136

Congen ita l nevus, 2 1 6

pathology, 136

Contu ra I nternationa l , 1 4t

physica l lesions, 136 pitfa l ls, 138

Cooltouch I n c . , 4 1

topical treatment, 138

Corrugator s u perc i l i i , 24, 24f Corticosteroids, 1 64, 1 75

Calci potriol, 224

Corrective h a i r transplant su rgery, 1 10, 1 1 0t

Campbell de Morga n spots, 1 70--1 73

for epidermal nevi , 224

Candela Corp . , 4 1

for epidermal i ncl usion cysts, 22 1

Canderm, 1 7 Canderm Pharma, I n c . , 1 4t Ca n i n us, 26, 27f, 28f

for m i l ia , 229 Cosmod ermrM , 14t

Cantharone, 207

Cosmoplas(TM , 14t Cross-hatch ing, 18

Ca p i l l a ry, 1 77

Cryogen spray coo l i n g (CSC ) , 185

Ca ptiq uerM , 1 4t

Cryosu rgery, 175

Carbon d ioxide (C02 ) laser, 43, 43f, 48, 49, 57, 1 7 2 , 239 Carbon d ioxide laser resu rfacing

Cryothera py

for a ngiofi broma, 213, 2 1 4-2 1 5f for a ngiomas, 1 72

for de rmatosis pa pu losa n igra , 242 for ephelides, 142 for epidermal nevus, 224

for basa l cell ca rcinoma, 254

for lentigines, 146

for epidermal nevus, 224 for neu rofi broma, 232

for sebaceous hyperplasia, 83

for seborrheic keratosis, 236

for sq uamous cell carcinoma, 258

for sq uamous cell carcinoma, 258 for venous la kes, 208

for venous lakes, 204 for wart remova l , 209

for wa rts, 207t, 208

for seborrheic keratosis, 236, 237, 237f

for seborrheic keratosis, 236

I

313

314

I

I ndex

C u rettage

Dyschromia

for epidermal nevus, 224 for wa rt remova l , 209

from wart remova l , 207t, 208, 209 Dysport, 2 lt

Cushi ng's d isease, 92, 285 Cutting tool , 44 Cymetra Life Cell Corp., 14t

E

Cynosure, 56, 56t

Ea r piercing, 298

Cyproterone acetate, 1 28 Cysts

consu ltative q uestions, 298 ma nagement, 298, 298f

epidermal incl usion cysts, 2 1 9-2 2 1

physical exa m i nation, 298

h o r n , 235 m i l i a , 229-230

pitfa l l s , 299, 299f

pilar cysts, 220

treatment, 298 Ectopic ad renocorticotropic hormone prod uction, 92 Electroca utery, 239 for epidermal nevus, 224 Electrodesiccation, 83

D

for a ngiofi bromas, 2 1 3

DAO. See Depressor angu l i oris

for seborrheic keratoses, 236

Dapsone, 1 75 Deep-depth strength peels, 30t, 33

Electrolysis, 94, 2 1 7 Electrosection, 7 7

Deep hema ngioma ( D H ) , 1 7 7

Electrosu rgery, 76f, 7 7 , 77f, 8 2 , 1 7 5

Deep vei n throm bosis, 198

for venous lakes, 204

Demodex fol l ic u l o ru m , 77

El l i ptical excision, 2 1 3 , 2 1 9f, 227, 2 132

Depilation, 94

El l i ptical strip h a rvesti ng, 1 06

Depressor angu l i oris ( DAO), 26, 27f, 28f Derc u m 's d i sease, 226

vs. fol l i c u l a r unit extraction ( F U E) , 107, 107t E l l m a n S u rgitro n , 78

Derma brasion , 1 75

Em bol ization, 180

for epidermal nevus, 224 for a ngiofi broma, 2 1 4

Endermologie for cel l u l ite, 277-278

Derm a l melasma, 149

Endocrine stud ies, of acne v ulgaris, 72-73

Dermatochalasis, 64 consu ltative q uestions, 65

Endocrinology, consu ltation with, 93 End osco pic/classic sym pathectomy, 88

cou rse, 65

Eosi noph i l ic gra n u loma, 1 74

de rmatopathology, 65

Ephelides, 139

differentia l d iagnosis, 64

consu ltative q uestions, 1 40

epidemiology, 64

course, 140

ma nagement, 65 pathogenesis, 64

d ifferential d iagnosis, 1 40 epidemiology, 1 39

physical exa m i nation, 64

la boratory exa m i nation, 140

pitfa l ls, 65-66

ma nagement, 140

treatment, 65 Dermatosis pa pu losa n i gra ( D P N s ) ,

pathogenesis, 139 pathology, 140

24 1 , 24lf consu ltative q uestions, 242

physical lesions, 140 vs. solar lentigo, 1 45t

cou rse, 24 1

treatments

differentia l d iagnosis, 241

chemical peels, 14 1-142

epidemiology, 241

cryothera py, 1 42

laboratory exa m i nation, 241

laser thera py, 1 42- 143

laser treatments, 242-243 ma nagement, 242

pitfa l l s to avoid/com plications/ma nagement, 143 topical treatment, 1 40- 1 4 1

pathogenesis, 241

E p i d e r m a l acanthosis, 6 5 , 6 7

pathology, 24 1

E p i d e r m a l inclusion cysts ( EI C ) , 2 1 9-22 1

physical lesions, 241

consu ltative q uestions, 220

pitfa l ls, 243

cou rse, 220

Derm ik, 1 5t Destructive modal ities, 83 of sebaceous hyperplasia Diazepa m , 17

d ifferential d iagnosis, 220 epidemiology, 2 1 9 la boratory data, 220 ma nagement, 220

Dicloxa c i l l i n , 46

pathogenesis, 2 1 9

Diode laser treatments

pathology, 2 1 9

for Becker's nevus, 2 1 8 for venous la kes, 204 Dioxybenzone, 7t

physical exa m i nation, 2 1 9, 2 19f pitfa l l s , 22 1 treatment, 220-22 1 , 2 1 9f, 220f

Dow-Corn ing, 1 4t

Epidermal melasma, 32f, 1 49

Doxycyc l i ne, 73, 77

Epidermal nevus ( E N ) , 222

D P N s . See Dermatosis pa pu losa n igra

vs. Becker's nevus, 2 1 6

I n d ex

consu ltative q uestions, 223

medical thera py, 1 27-1 28

course, 223

non-FDA a p p roved medications, 1 28

d ifferentia l d iagnosis, 223

pathogenesis, 1 26

epidemiology, 222 la boratory data, 223

physical exa m i nation, 1 26, 1 28-129 su rgery, 128

pathogenesis, 222

Female s u rgica l pla n n i ng, 129

pathology, 222

postoperative i n structions, 130

physica l exa m i nation, 223

postoperative period , 130- 1 3 1

pitfa l ls, 225 vs. seborrheic keratosis, 223, 235

treatment, 224-225 Epidermis a n d epidermal i n c l usion cysts, 2 1 9

preoperative i n structions, 1 3 0 Fern d a l e La bs, 1 7 Fi brous pa pu les, 2 1 2 F i l iform wa rts, 206 F i l lers permanent, 282-283

i n l i poma, 226 Epidermoid cyst, 2 1 9 E pi l u m i nescence microscopy ( E L M ) , 203 Epinephrine, 59

tem porary, 282 Finasteride, 104, 104t, 1 28, 1 33 Fitzpatrick skin phototype, 3 1

Er:YAG . See Erbi u m : Yttr i u m-Al u m i n u m Ga rnet Laser

Fitzpatrick's classificatio n , of skin types, 4t

Erbi u m ablative resu rfacing lasers, 57

Flash l a m p , 78f, 79, 79f, 801

Erbi u m : Yttriu m-Ai u m i n u m Garnet ( Er:YAG) laser

treatment, 193

and a blative laser resu rfacing, 43, 451, 48, 49

Flavonoids, 9t

a n d epidermal nevus, 224 and seborrheic keratos is, 236

Foam sclerothera py, 199-200 Follicular i nfu n d i b u l u m , 2 1 9

Erythematotela ngiectatic rosacea . See Vasc u l a r rosacea

Follicular u n it extraction ( FU El , 1 06t, 1 0 7 , 1 08! vs. e l l i ptica l strip ha rvesting, 1 07t

Eryth romyc i n , 73 Eutectic m i xture of loca l a n esthetic (EM LA), 17, 40

Fo l l i c u l itis, 1 00

Exci mer laser, 1 65, 287

Forehea d , 22f, 23-24, 24f

Excision su rgica l , 253, 257, 29 1 , 29 11 Eye i nj u ries

m i l i a , 229-230 Fractional photothermolysis ( F P )

and lasers, 981

Fractional res u rfaci ng, 1 5 11, 152, 1 53f Fraxel Restore, 56, 56! Freckles. See Ephel ides Fronta l i s m u scle, 221, 23-24, 23f

F Facial age-related conto u r changes, 2t

Fronta l i s m u scles, 24, 24f F U E . See Follicular u n it extraction

Facia l m uscu lature changes, 5 Facial telangiectasias, 192, 192f cou rse, 192 dermatopathology, 192

G

epidemiology, 192

Gelatinase, 9

ma nagement, 192-194 physica l exa m i nation, 192

Genita l wa rts, 206-209 Gentisic acid , 9t

pitfa l l s to avo i d , 194

G l a be l l a r com p l ex, 24, 24f

prior to long p u l se-d u ration pu lsed dye laser

G la brid i n , 1 0

treatment, 1 951 prior to p u l sed dye laser treatment, 1 931 Fa n n i ng, 18 Fascia B iomateria ls, 1 5t Fascia n, 1 5t Fat accu m u lation treatment of, 283

G l oga u Photoaging Classification, 2f, 3 -4 , 3f, 4f, 51 G lycolic acid , 9t, 30! G lycolic acid pee l , 32, 331, 74, 1 60 and e p h i l ides, 1 4 1 and melasma, 1 5 1 , 1 5 1 t G lycopyrro n i u m bromide, 8 7 G/ycyrrhiza g/abra linneva, 1 0

F DA-a pproved med ications, for male pattern h a i r loss, 104, 1 04t

G o l d i njections, 1 7 5

Female pattern h a i r loss, 126, 1 26f. See also M a l e pattern hair loss c h i ef com pla i nt, 1 3 1

G rafts, s k i n , 2251 G ra n u loma faciale, 1 74, 1 741, 1 76f

consult, 1 3 1-132

cou rse, 1 74

consu ltative q u estions, 1 26

de rmatopathology, 17 4

course, 126

d ifferential d iagnoses, 1 74

d ifferentia l d iagnosis, 1 2 7

epidemiology, 1 74

epidemiology, 1 26 female hair transplantation, 1 3 1

l ight treatment, 1 75 ma nagement, 175

t o correct a ltered tem pora l h a i r l i ne, from l ifting proced u re, 1 3 1 female surgica l pla n n i ng, 129 postoperative i n structions, 130 postoperative period , 130- 1 3 1 preoperative i n structions, 1 30 vs. male pattern h a i r loss, 1 29, 1 29t, 1 3 1 1

m u ltiple lesions of, 1 75f pathogenesis, 1 74 physical exa m i nation, 1 74 pitfa l l s to avoid, 1 7 5 syste m i c treatment, 1 75 topical treatment, 1 7 5

I

31 5

31 6

I

I ndex

G ra n u loma gravida r u m , 1 88- 1 9 1

botu l i n u m toxin A, 88, 88f

G ra n u loma tela ngiectaticu m , 188- 1 9 1

anesthesi a , 88

G ra n u lomatous rosacea , 7 6

antipers p i ra nt, 89

Gynecomastia, 2 72-275, 272f consu ltative q u estions, 273

botox, 89 medications, 89

cou rse, 273

su rgery, 89

differentia l d iagnosis, 272

treatment, 88-89, 88f, 89f

epidemiology, 272

consu ltative q uestions, 87

laboratory exa m i nation, 272-273

cou rse, 86

ma nagement, 273 pathogenesis, 272

de rmatopathology, 86 d ifferential d iagnosis, 86

physical lesions, 272

epidemiology, 86

pitfa l ls/com p l ications/outcome expectations, 274-275

la boratory exa m i nation, 86, 86f

treatment, 273-274

ma nagement, 87, 87f ora l med ications, 87 pathogenesis, 86 physica l fi ndi ngs, 86

H H a i r loss. See Female pattern h a i r loss; M a l e pattern h a i r loss H a i r remova l , 2 1 7 H a i r tra nspla ntation, 1 04-1 05 H a i r l i n e design , 1 08 H a rn a rto rna , 2 16, 222 Hemangioma, segmenta l , 1 80f Hemangioma, u l cerated , 1 79f Herna ngiornas, 1 7 7 H i bernoma, 226 H i biclens, 48 H i rsutism, 92 consu ltative q u estions, 93 cou rse, 93 differentia l d iagnosis, 92-93 epidern iology, 92 laboratory tests, 93 ma nagement, 93 electrolysis, 94 endocrinology, consultation with , 93 j ust prior to treatment, 96 laser h a i r remova l tech n i q ue, 95, 96-98 non laser thera p ies, 93-94 patient consu ltation, 95-96 posttreatment i n structions to patient, 98 physical exa m i nation, 92

pitfa l l s , 89-90 su rgery, 88 topical med ications, 87 Hyperh i d rosis sites of, 90f treatment d iagra m , 87f Hyperpigrnentation a n d cryotherapy, 209 and post-sclerothera py, 200 Hype rsensitive rea ctions, of soft tissue augmentation , 18 Hypertonic sa l i n e , 199, 200t, 201t Hypertrichosis, 2 1 6, 2 1 7 Hypertrophic sca rs, 290 c l i n ical experience, 293 d ifferential d iagnosis, 290 vs. keloids, 290! la boratory exa m i nation, 290

laser, 29lf, 292, 292f ma nagement, 291 physica l exa m i nation, 290 pu I sed dye laser, 292t stud ies, 292 Hypopigmentation, 67, 187f and cryothera py, 209 , 236 and laser treatments, 2 1 8

pitfa l l s , 94f, 98-99 H IV l i podystrophy/facial l i poatrophy, 280-284 consu ltative q u estions, 281 cou rse, 28 1

Ice-Pick/Boxcar Sca r

dermatopathol ogy, 280 differentia l d iagnosis, 281

lcod i n , 58 l d e benone, 8

epidemiology, 280

l m i q u imod , 1 79 , 207, 29 1 , 29 1 T

laboratory exa m i nation, 281

l named Corp, 14t

ma nagement, 281-282

l named Corp. , 1 5t

pathogenesis, 280 physical lesions, 280-281

I nfa nti le hemangioma ( I H ) , 1 7 7 , 1 7 7f, 1 78f

pitfa l ls, 283-284

a n c i l l a ry tests, 1 78 com pl ications, 1 78

prec i pitating factors, 280

course, 1 78

prevention, 28 1

de rmatopathology, 1 7 7

treatments, 282-283 Homosalate, 7t Hormones, 73

d ifferential d iagnoses, 1 7 7 epidem i ology, 1 7 7

H u ma n pa pil lomavirus ( H PV), 206-209

la boratory tests, 1 77 ma nagement, 1 78-180

Hya l u ronidase, 47

physical exa m i nation, 1 7 7

Hyd roq u i none, 9 , 9t, 13, 140, 146, 15 1!, 160, Hyd roxy acid, 73 Hyd roxycou marins, 9t Hylaform ® , 1 5t Hyperhid rosis, 86

pitfa l l s t o avo i d , 180 I ntense pu lsed l ight lasers for pseudofo l l i c u l itis, 1 0 1 for Becker's nevus, 2 1 8 for cherry and spider a ngiomas, 1 72

I n d ex

for port-wine sta i ns, 185

and h i rsutism , 95

for postsclerothera py hyperpigmentatio n , 201-202, 20lf, 202f

and pseudofolliculitis, 1 001, 1 0 1 , 1 0 l f

for venous lakes, 204

tech niq ue, 9&-98

I nterferon-a, 179

Laser l ight firing, 93f

I nterlocking Ls repa ir, 308 l ntra lesional 5-fl uoro u racil (5-FU ) , 29 1 , 29 lt

Laser safety, 97f

l ntra lesional steroid i njection, 74

nona b lative laser resu rfaci ng, 41 for a blative fractional laser resurfaci ng, 59

l ntra lesional tria mcinolone acetonides, 29 1 , 29 lt

adve rse side effects, 60, 601

l o p i d i n e , 28

fol low- u p , 59-60, 59f

I PL. See I ntense pulsed l ight

i nfection, 60, 6 1 f

I psen L i mited, 2 1 t lsolage n , 1 5t

nonfacial ski n, 60-6 1

Isopropyl a lcohol , 48 lsotreti n o i n , 40, 58, 74, 77

I

postoperative care, 57f, 58f, 59 Laser thera py for d ermatochalasis, 65 for gra n u loma faciale, 1 75 for Poiki loderma of Civatte, 68, 68f

J

for sebaceous hyperplasia, 82--83, 82f, 83f

J essner, 30t, 35f

Laser-assisted photodynamic thera py, 82

J essner peels, 14 1 , 160

Lasers, 74

J uvedermrM , 1 5t

Lecithins, 9t Lentigines, 144 chem ical peels, 146 consu ltative q uestions, 1 45-146

K Keflex, 1 7 , 46 Keloids d ifferential d iagnosis, 290 vs. hypertrophic scars, 29ot vs. keloids, 290t

laboratory exa m i nation, 290 laser, 29lf, 292, 292f ma nagement, 29 1 physica l exa m i nation, 290 pulsed dye laser, 292t stud ies, 292 Keratinocytes, 1 40, 222 Keratolytic agents, 73 Keratoses seborrheic, 223 Keratosis fol liculari s s p i n u losa deca lva ns ( KFSD), 1 8 1 Keratosis p i l a r i s atroph ica ns ( KPA), 1 8 1 , 1 8lf, 1 82f cou rse, 1 8 1 dermatopathology, 1 8 1 d ifferential d iagnosis, 1 8 1 epidemiology, 1 8 1 ma nagement, 1 8 2 pathogenesis, 1 8 1 physica l exa m i nation, 1 8 1 pitfa l l s t o avoid , 182 Keratosis pila ris atroph ica ns faciei ( KPA F ) , 181 Keratoses actinic, 206 seborrheic, 206, 234-237 Kindler synd rome, 67 Koenen's tumor, 2 1 2 Koj ic acid , 9t, 1 0 , 1 4 1 KTP laser. See Potass i u m -tita nyl-phosphate laser

cou rse, 1 45 cryothera py, 146 d ifferential d iagnosis, 145 epidemiology, 144 la boratory exa m i nation, 145 laser and l ight sou rce treatment, 146-147 ma nagement, 1 45 pathogenesis, 1 44 pathology, 144 physical lesions, 144 pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations, 147-148 vs. seborrheic keratosis, 235

topical med ications, 1 45-146 Lentigo sim plex, 144 LEOPA R D synd rome, 1 44 Lichen planus ( L P ) , 262-264 course, 263, 264f de rmatopathology, 262 d ifferential d iagnosis, 262 epidemiology, 262 la boratory data , 262 ma nagement, 263 pathogenesis, 262 physical exa m i nation, 262, 262f, 263f Lichen striatus, 223 Licorice extract, 9t, 10 Lidoca i ne, 47, 59, 107 for wart removal , 208 Life Cell Corp. , 1 4t Light treatment, of acne vu lgaris, 72f, 73f, 74-75, 75f Light cryothera py, 82 Linear foca l elastosis. Linear th readi ng, 1 8 Linoleic acid, 9t

L L- M -X-4 a n d 5, 1 7

Li pectomy, 283 Lipoma, 22&-228 consu ltative q uestions, 227

Lactic acid, 182

cou rse, 227

Lactic acid, 9t

d ifferentia l d iagnosis, 226 epidemiology, 226

LAM B synd rome, 1 44 La nzhou I nstitute of B iologica l Prod ucts, 2 1t Laser h a i r remova l

la boratory data , 227 pathology, 226

31 7

31 8

I

I ndex

physical exa m i nation, 226, 226f, 227f, 228f pitfa l l s , 228 treatment, 227-228, 227f, 228f

Melanin i n post-sclerothera py hyperpigmentation , 200 in seborrheic keratosis, 236

Li posa rcom a , 226

M ela nocyte cytotoxic agents, 9t

Li posucti o n , 88 for cel l u l ite, 277

Melanoma

Melanocyte tra nsfer i n h i bition, 9t

for gynecomasti a , 274

vs. seborrheic keratosis, 235

for HIV l i podystrophy/facial l i poatrophy, 283

venous la kes a n d , 203

for l i poma, 227

warts a n d , 206

Liver s pots. See Solar lentigos

M elanophages, 1 44

LLLT. See Low level l ight laser therapy Lob u l a r ca p i l l a ry hemangioma, 188-- 1 9 1

M elasma, 1 4 9 , 1 49f a blative laser, 152

Long- p u lsed alexa nd rite laser, 1 0 1

chemical peels, 1 5 1- 152

Long- p ulsed N d : YAG laser, 1 0 1

consu ltative q uestions, 1 50

Low level l ight laser thera py ( LLLT), 1 33, 1 33f, 1 34f

cou rse, 1 50 de rmatopathology, 149

mecha nism of action , 133 pea rls of wisd o m , 1 33 use of, 1 33

d ifferential d iagnosis, 1 50 epidemiology, 149

Lower extremity telangiectasias, 198--202

fractional resu rfaci ng, 1 52 , 1 53f

Lower eye l i d snap back test, 22-23

la boratory exa m i nation, 1 50

Lower face, 3

ma nagement, 1 50, 1 50f, 1 5 11, 1 52f

Lower lid horizonta l laxity, 64 LP. See Lichen planus

pathogenesis, 1 49

Lux 1 , 540 n m laser, 56, 56t

pitfa l l s , 1 52-153

physical lesions, 149 Q-switched laser, 1 52 topical treatment, 1 5 1 , 1 5 lt

M

M EN D . See M icroscopic epidermal necrotic debris

Macu les, 2 1 6, 223 Madelu ng's d i sease, 226

M enta l i s m uscle, 26, 27f, 28f

Male pattern hair loss, 1 03 . See also Female

M eq u i n o l , 9t

pattern hair l oss consult, 105 d ifferential d iagnosis, 1 03

Mentor Corporation, 1 5t M e rz Pharma, 1 4t, 2 lt M esothera py for cel l u l ite, 278

epidemiology, 1 03 vs. fem a l e pattern h a i r loss, 129, 1 29t, 1 3 1 1

M ethanthel i u m bromide, 87

h a i r transpla ntation, 1 04- 1 05

M ethyl a nthra n i late, 7t

laboratory exa m i nation, 104

M etron idazole, 77 M exoryl SX, 7t

medica l thera py, 1 04, 1 04t

M ethyl a m i nolevu l i nic acid ( MAL), 254

natural progression, 1 03

M exoryl XL, 7t

pathogenesis, 103 physical exa m i nation, 1 03 , 1 03f, 1 05f

M icroderma brasion, 74, 229, 287

s u rgica l proced u re

M icroth ermal treatment zones ( MTZs ) , 52

M icrosco pic epidermal necrotic debris ( M E N D ) , 52

corrective h a i r transplant su rgery, 1 10, 1 10t

M idface, 3

day of proced u re, 1 06

M id-i nfrared lasers, 401, 4 1

donor h a rvesti ng tec h n i q ues, 1 06, 1 06f, 106t, 107t

M i ld atrophy, 67

donor regi o n , a n esthesia i n , 1 06 fol l i c u l a r unit extraction ( F U E) , 107, 107t

M i l i a , 229-230 consu ltative q uestions, 230

graft creation, 107

cou rse, 230

graft placement, 108--1 09, 1 13f

epidemiology, 229

h a i r l i n e design , 1 08

pathogenesis, 229

post h a i r tra n splant side effects, 109

pathology, 229

postoperative period , 109 postsu rgica l period after sutu res/sta ples

physica l exa m i nation, 229, 229f, 2301

removed , 1 09-1 1 0

treatment, 230, 2301

preoperative i n structions, 1 06

pitfa l l s , 230 M i n i m a l erythema d ose ( M ED ) , 8

ra re side effects, 1 09

M i nocyc l i ne, 73, 77

reci pient region, anesthesia i n , 1 08

M i noxid i l , 104, 1 04t, 1 2 7-1 28, 1 2 7t, 1 3 1 , 133

reci pient site creation, 1 08, 1 12f McCune-A l bright syndrome, 136 M c G h a n Medica l , 1 5t

M ixed dermal melasma, 149 M ixed su perficial a n d deep hema ngioma ( M H ) , 177 Mohs microgra p h i c surgery, 254, 257-258

M ED. See M i n i m a l erythema d ose

M onobenzone, 9t

Medial orbicularis ocu l i , 24, 24f

Morphea, 265--267

M ed icis, 1 5t

cou rse, 266

Medicis Esthetics, 2 l t M ed i u m -d e pth pee l , 30t, 3 3 , 34f, 35f

de rmatopathology, 266

M edy-Tox, Inc, 2 l t

epidemiology, 265

d ifferential d iagnosis, 265

I n d ex

la boratory data, 265-266

med ications, 53-54

ma nagement, 266, 266f

postoperative care, 55

pathogenesis, 265

preoperative eva l uation, 52-53, 53f, 54f

physica l exa m i nation, 265, 265f pitfa l l , 267

preoperative pre paratio n , 54

M TZs. See M icrothermal treatment zones

proced ura l tips, 54-55 treatment pearls, 55-56

M u l berry extract, 9t

Nonablative fractional lasers, 57

M uscle grou ps, 23

Nonablative fractional resu rfacing, 39, 60

forehea d , 23-24

Nonablative laser resurfaci ng, 39, 39f

glabellar com p l ex, 24, 24f nasola bial fol d , 25-26, 27f

adve rse side effects, 4, 4 1 f l

neck, 26-27 , 28f

postoperative care, 4 1 -42 i n d ications, 40

periora l region, 26, 27f, 28f

laser safety, 4 1

periorbita l regio n , 24-25, 25f

preoperative eva l uation, 40

u pper nasal root, 25, 26f

prophylaxis/a nesthesia , 40

M yasthenia gravis, 22 Myobloc, 2 l t

m i d - i nfra red lasers, 40f, 4 1 N onfacial s k i n , 60--6 1 N o n - F DA approved med ications, for fe male pattern h a i r loss, 128 Non-hypersensitive reactions, of soft tissue augmentation, 18-19

N

Non laser thera py, 93

N A F R . See Nona blative fractional laser res u rfacing Nasal sebaceous hyperp lasia . See R h i nophyma Nasolabial fol d , 25-26, 27f N d :YAG laser, 99, 1 93 for seborrheic keratosis, 236

depi lati o n , 94 topical eflorn ith i n e , 94 Norwood classification, 103f

N eck, 26-27 , 28f

0

N e u rofi bromas ( N F) , 23 1-234

Octocrylene, 7t

consu ltative q uestions, 232 cou rse, 232 d ifferential d iagnosis, 23 1 epidemiology, 2 3 1 la boratory data, 232

Octyl methoxycinna mate, 7t Octyl sa l i cylate, 7t Ocular rosacea , 76 Oral medications i n hyperh i d rosis, 87

ma nagement, 232

Oral thera py, 1 65

pathogenesis, 231

Orbicularis ocu l i , 24-25, 25f

pathology, 23 1 physica l exa m i nation, 23 1 , 23lf pitfa l ls, 223-224

Orbicularis ocu l i tone, 64 Orbicularis oris, 26, 27f, 28f Oxybenzone, 7t

treatment, 232-233, 232f N e u rofi bromatosis, 136 N e u ronox, 2 l t N e v u s a ra neus, 1 70- 1 73 N evus, Becker's, 2 1 6-2 1 8 N evus, epiderma l , 222-225, 235

p rf>3 tumor suppressor gene,

252

PABA. See Pa ra-a m i n o benzoic acid Padi mate 0, 7t

Nevus fuscoceruleus ophtha l momaxilla ris, 1 54

Palmoplanta r warts , 206-209

Nevus of Ota , 1 54

Palomar Medical Tec h nologies, 56, 56t, 79 Paper m u l berry, 1 0

consu ltative q uestions, 1 55 cou rse, 155 d ifferential d iagnosis, 1 54 epidemiology, 1 54 la boratory exa m i nation, 155 ma nagement, 1 55 pathogenesis, 1 54 pathology, 1 54 physical lesions, 1 54 pitfa l ls, 1 57 topical treatment, 155 treatment, 1 55- 1 56

Papu les in angiofi bromas, 2 1 2 i n epidermal nevus, 223 i n warts, 206 Papu lopustular rosacea, 76 Pa ra-a m i n o benzoic acid ( PABA), 7t Partial tears, 308 Patient consu ltation, 95 prior to treatment, 95-96 P D L. See Pu lsed d ye laser P DT. See Photodyna mic thera py

Nevus sebaceous, 223

Pearly pen ile pa p u l es, 2 1 2

N ia c i n a m i d e , 9t, 10 Nonablative fractional laser resu rfacing ( N A F R )

Peel types, 33 and c l i n ica l i n d ications, 30t

a n esthesia, 54

Pee l i ng agent characteristics, 30t

contra i n d i cations, 53 dermatopathology, 52, 52f

Penici l l i u m , 1 0 Perifo l l i c u l a r erythema, cha racteristic posttreatment, 93f

devices, 56, 56t

Periora l dermatitis, 76

i n d ications, 52 mecha nism of action, 52, 52f

Periorbita l region, 24-25, 25f, 26, 27f, 28f Periorbita I rhyti d es, 55f

I

31 9

320

I

I ndex

Peri u ngua l fibromas, 2 1 2

pathogenesis, 1 58

Perlane, 1 5t

physica l lesions, 1 58

Perla ne LrM , 1 5t

pitfa l l s to avoid/co m p l ications/ma nagem ent/outcome

Peutz-Jeghers syndrome, 144 P H A G E synd rome, 1 78 Phenol, 30!

expectations, 1 6 1 s u n p rotection, 1 59 topical treatment, 1 60

Phenyl benz i m i d azole su lfonic acid , 7t

Postsclerotherapy hyperpigmentation ( P S H ) , 200

Photodyn a m i c thera py ( P DT ) , 75

Potass i u m -tita nyl-phosphate laser, 79, 193

Photodyn a m i c thera py, 254, 258, 269

Pred nisone, 130, 1 79

Photothera py, 75, 1 65 P hymatous rosacea . See Sebaceous hyperplasia

Pregna ncy

P hysical screen , 8, 8t

and telangiectasias, 1 98, 201 Pregna ncy-ind uced hypertension ( P I H ) , 60

Pigmentary cha nges, i n face, 4, 6f

Prevelle s i l k , 1 5t

P I H. See Posti nflam matory hyperpigmentati o n ; Pregna ncy-ind uced hypertension

Primary and rogen-prod ucing neoplasms, 92 Procerus, 24, 24f

Pilar cysts, 220, 226 P i mecro l i m u s, 1 64

Propanth e l i ne, 87 Prophylactic anti biotics, 49 , 53

P ityros poru m ova l e , 1 0

Propranolol, 1 79

P l a n e warts, 206--209

Prosigne , 2 1 !

Pla ntar wa rts, 206

Prostate cancer

Plaques in a ngiofi broma, 2 1 2 i n Becker's nevus, 2 1 6 i n seborrheic keratosis, 235 P latysma m uscle co m p l ex, 26--27, 28f

prophylaxis in, 273 Proteus syn d rome, 226 Pseudofollicul itis, 99 course, 100 de rmatopathology, 100

POC. See Poiki loderma of Civatte

d ifferentia l d iagnosis, 1 00

Podophyl l i n , 224

epidemiology, 99

Podophyllotox i n , 207 Poiki loderma of Civatte ( POC), 67

la boratory exa m i nation, 100 ma nagement, 1 00

consu ltative q uestions, 68

pathogenesis, 99

course, 68

physical lesions, 100

de rmato pathology, 67

pitfa l l s , 1 0 1-102, 1 0 11, 1 02f

differentia l d iagnosis, 67 epidemiology, 67

treatment

ma nagement, 68

laser hair remova l , lOOt, 1 0 1 , 1 0 1 1 shaving cessation, 100

pathogenesis, 67

shaving tech n i q ue , mod ification of, 10(}- 1 0 1

physical exa m i nation, 67, 67f, 68f

topical treatment, 1 0 1

pitfa l ls, 68-69, 69f pretreatment, 68f treatment, 68, 68f

Pseudofo l l i c u l itis, a n d etrology, 1 0 1 1 Pseudogynecomasti a , 272

Polidoca n o l , 199, 200, 200!

Pseudo-och ronosis, 34, 1 59f Psora len a n d ultraviolet A ( P UVA ) , 1 65, 1 75

Poly-L-Iactic acid, 1 8

Psoriasis, 267-270, 267f, 268f

Pontoca i n e . See Topica l tetraca ine Port-wine sta i n s ( PWS), 1 83 , 1 84f, 1 85f, 1 86f ancil lary tests, 1 83 course, 183

course, 268 d ifferential d iagnosis, 268 epidemiology, 267

dermatopathology, 183

la boratory data, 268 ma nagement, 268-269, 269f

differentia l d iagnosis, 1 83

pathogenesis, 268

epidemiology, 183

physica l exa m i nation, 268

ma nagement, 1 83 physical exa m i nation, 1 83 pitfa l l s to avo i d , 183 Post hair tra nsplant side effects, 109 Post i nfla m matory erythema a n d cu rettage, 237f Post i nfla mmatory hyperpigmentation ( P I H ) , 1 58, 1 58f chemical peels, 1 6(}- 1 6 1 consu ltative q uestions, 1 59

pitfa l l s , 270 Psuedogynecomastia, 274 P u l sed carbon d i oxide laser, 250 Pu lsed dye laser ( P OL) for acne vulga ris, 75 for a ngiofi broma, 2 1 3 for a ngiokeratomas, 1 69 for cherry and spider a ngiomas, 1 7 1 for facial telangiectasia, 203, 203f, 205f

course, 1 59

for facial tela ngiectasias, 192

dermato pathology, 1 58

for hypertrophic scars/ke loids, 292t

differentia l d iagnosis, 1 58

for i nfa ntile hema ngiomas, 1 79

epidemiology, 1 58

for keratosis pila ris atrophicans, 182

laboratory exa m i nation, 1 58 lasers, 1 6 1

for m orphea , 266 for Poiki loderma of Civatte, 68

treatment, 2 18, 233 ma nagement, 1 59

for port-wine sta ins, 185 for psorias, 269

I n d ex

for pyogenic gra n u lo m a , 189

Rete ridges in epidermal nevus, 222

for rosacea , 78 for sebacious hyperplasia, 82 for striae d i ste nsae, 287 for telangiectasias, 201

Reticular veins, 198-202 Reticulated hyperpigmentation , 67

for venous la kes, 203, 205f

Reti n-A, 1 82 Reti naldehyde, 8, 9

for warts, 206f, 208, 208f, 209f

Reti noic acid, 8-9, 9t, 10, 1 2 chemical structu res of, Sf

for warts, 208 P u n c h excision, 2 1 3

Reti noids, 73, 1 4 1 , 1 5 1 , 1 5 1!, 1 60, 182

Pu rpura, 204, 208 PUVA. See Psora len a n d u ltraviolet A

Reti n o l , 8

Pyogenic gra n u loma ( PG ) , 1 88, 188f, 1 89f

I

Retinyl esters, 8 R F technology. See Radiofreq uency ( R F) tech nology

biopsy-proven , 1 9 l f

R h i nophyma, 76, 76f, 77-78

cou rse, 188

R hytides, 58

dermatopathology, 1 88

R osacea , 76 cou rse, 77 de rmatopathology, 77

d ifferential d iagnoses, 1 88 epidemiology, 188 laser treatment, 1 89

d ifferential d iagnosis, 76

ma nagement, 1 89

epidemiology, 76

pathogenesis, 1 88

ma nagement, 77

physica l exa m i nation, 1 88

surgica l thera py, 77-79

pitfa l l s to avo i d , 189 s u rgica l treatment, 189

systemic thera py, 77 topical thera py, 77 pathogenesis, 76

vs. venous la kes, 203

physical exa m i nation, 76 Roth m u nd-Thomson synd rome, 67

Q

R u by spot, 1 70-1 73 . See also Cherry a ngiomas

Q-M ed AB, 1 5t Q-switched lasers, 1 52

R ussell-Silver synd rome, 1 36

alexa nd rite for Becker's nevus, 2 1 7, 2 1 8f

s

for cafe au Ia it macules, 1 3 7 , 138

Sa l icyl ic acid , 73, 207

for dermatosis pa pu losa n igra , 242 for epidermal nevus, 225

Sa l i n e

for nevus of Ota , 1 55, 1 56 for seborrheic keratosis, 236 a rgon and gra n u loma faciale, 1 75 N d :YAG for Becker's nevus, 2 1 7, 2 1 8f

a n d warts, 2 0 7 , 208 and tela ngiectasias, 201 Scarring from a n giofi broma treatment, 2 1 4 from surgica l i ncision, 224, 228 from wart remova l , 207t, 208, 209

for cafe au Ia it macules, 1 3 7 , 138

SCC . See Squamous cell carcinoma Sclerothera py, 199-20 1 , 1 98f, 1 99f, 200f, 200t, 201t, 204

a n d e p h i l ides, 142

Scoliosis, 232

a n d lentigines, 1 46

Sc u l ptra TM , 1 5t

for nevus of Ota , 155

Se baceo us cyst, 2 19

for tattoo remova l , 300!, 302 r u by for Becker's nevus, 2 1 7, 2 1 8f

Se baceo us hyperplasia, 76, 77, 8 1 , 8lf consu ltative q uestions, 81 cou rse, 8 1

for dermatosis pa p u l osa n igra , 242

d ifferential d iagnosis, 8 1

for e p h i l ides, 1 42

epidemiology, 8 1

for lentigines, 1 46, 1 47

for seborrheic keratosis, 236f

for nevus of Ota , 155 for seborrheic keratosis, 236 for tattoo remova l , 300!, 302t

la boratory exa m i nation, 81 ma nagement, 82 pathogenesis, 81 pathology, 8 1

R Rad iation dermatitis, 67 Rad iation thera py, 2 54 Radiesse TM , 1 5t

physical lesions, 8 1 pitfa l l s , 83 treatments, 82 destructive modal ities, 82 laser thera py, 82-83, 82f, 83f

Radiofreq uency ( R F) tech nology, 62

Seborrheic dermatitis, 76

Rad iothera py, 258

Seborrheic keratosis, 234--2 37. See also Dermatosis pa pulosa n igra

R e-epithe l i a l ization, 49

consu ltative q uestions, 235

Relaxi n , 2 1 !

cou rse, 235

Renova , 9 R estylane, 1 5t

d ifferential d iagnosis, 235 epidemiology, 234

R estyla ne-L, 1 5t

vs. epidermal nevus, 223, 235

32 1

322

I

I ndex

ma nagement, 235-236

de rmatopathology, 257

pathology, 235

d ifferential d iagnosis, 256, 257f

physical exa m i nation, 235

epidemiology, 256

pitfa l l s , 237 treatment, 236

vs. epidermal nevus, 223 la boratory data , 257

vs. wa rts, 206

ma nagement, 257-258, 258f, 259f

Segmenta l hemangioma, 1801

pathogenesis, 256

Senile hema ngiomas, 1 70-1 73

physical exa m i nation, 256, 256f

Seria l p u n ctu re, 18

pitfa l l s , 258

Seria l sa l icylic acid peels, 74 Sharplan FeatherTouch, 1 69

vs. seborrheic keratosis, 235

Shave biopsies a n d excisions

vs. wa rts, 206, 207

Sta rch-iod ine test, 88

for a ngiofi bromas, 2 1 3

Sta rlux Lux G hand piece, 79

for epidermal nevus, 224

Steroid rosacea , 76

for l i poma, 227, 227f

Stockings, elastic com pression, 200

for n e u rofi bromas, 236 for seborrheic keratosis, 236

Strawberry, 1 77- 1 80 Stretch marks. See Striae d i stensae

Shaving cessation, 100

Stria a l ba , 287

Shaving tech n i q u e , mod ification of, 1 00-1 0 1

Stria ru bra , 286-287, 287f

Short-pu lsed erbi u m , 287

Striae d i stensae, 285, 285f

S i l icone, 18

consu ltative q uestions, 286

S i l icone sheeti ng, 29 1 , 29 lt S i l i kone- 1 000, 1 5t

cou rse, 286 d ifferential d iagnosis, 286

Skin grafts, 225f

epidemiology, 285

Skin l ightening agents, 9-1 1

la boratory exa m i nation, 286

Skin testi ng, 1 6

ma nagement, 286

Skin turnover acceleration, 9t

m icroderma brasion , 287

Skin types a n d Becker's nevus, 2 1 8

pathogenesis, 285 pathology, 285

Smooth bea m , 4 1

physica l lesions, 285

SNAP-25, 2 1

pitfa l l s , 288

Sod i u m morrh uate, 199

topical treatment, 287

Sod i u m sulfaceta mide, 73, 77 Sod i u m tetradecyl su lfate, 199, 200t, 20lt Soft tissue a ugmentation adve rse reactions

treatment, 286-287 Stromelysi n , 9 Stu rge-Weber syndrome (SWS) , 184 S u bcision, 278

hypersensitive, 18

Su bcuta neous fat, i n l i poma, 226

non-hypersensitive, 1 8- 1 9

Su bcuta neous fat, 1 5t

tec h n i q u e compl ications, 1 9 a n esthesia, 1 6f, 1 7

Su bcuta neous fat atro phy, 5 Su lfu r, 73

degree o f correction, 1 8

S u l isobenzone, 7t

d u ration o f correction, 18

S u n expos ure

ideal fil ler, 14, 14t- 1 5t i njection tech n i q ue, 18, 1 8f, 19f level of i njection, 1 7- 18, 1 7f, 18f mecha n ism of action , 14

and sclerothera py, 200 and venous lakes, 203 Sun protective factor ( S P F ) , 8 Su nscreen , 7-8, 7f, 7t

preoperative eva l uation, 1 5- 1 6

Su perficial hemangioma ( S H ) , 1 77 , 1 79

proced ura l medications, 1 7

Su perficial pee l , 30t, 32f, 33, 33f

skin testi ng, 1 6

Su rgery

treatment pearls, 19 Softform, 1 5t Solar le ntigo vs. ephel i d , 145t Solar le ntigos, 144

in hyperhidrosis, 88 S u rgica l excision, 1 75 S u rgica l proced u re, for hair tra nsplantation corrective hair tra nsplant su rgery, 1 10, 1 10t

Solta Medica l , I n c . , 56, 56t

day of proced u re, 1 06

Soltice Neu rosciences, 2 lt

donor h a rvesti ng tec h n i q ues, 1 06, 1 06f, 106t, 107t

Sotradechol, 200

donor region, a nesthesia i n , 1 06

Soy, 1 0 Soybea n/m i l k extracts, 9t

fol l i c u l a r u n it extraction ( F U E) , 107, 107t graft creation, 107

S P F. See S u n protective factor

graft placement, 108-1 09, 1 1 3f

Spider a ngiomas, 1 70-173, 1 7 11

hairline design , 1 08

Spider tela ngiectasia, 1 70-1 73

post h a i r tra n s plant side effects, 109

S p i n a l dysra p h i s m , 227

postoperative period , 109

Spi ronolactone, 73, 1 28 Squamous cell carcinoma (SCC), 256-258

postsu rgica l period after sutu res/sta ples removed , 1 09-1 1 0

consu ltative q uestions, 257

preoperative i n structions, 1 06

cou rse, 257

rare side effects, 1 09

I n d ex

checkl ist, 62-63 side effects, 63

S u rgica l thera py of acne vu lgaris, 74

for Dermatochalasis, 64f, 65

Topica l 5-fl uorou raci l , 254 Topica l eflorn ith ine, 94 Topica l i m iq u i m od , 254 Topica l med ications, in hyperh i d rosis, 87

for epidermal i ncl usion cysts, 220

Topica l proparaca ine, 47, 59

for epidermal nevus , 224

Topica l retinoic acid , 32

for l i poma, 227, 227f, 228f

Topica l tetraca ine, 47, 59 Topica l thera py

for neu rofi broma, 232-233, 232f of Rosacea , 76f, 77-79 , 79f, 80f

of acne vu lgaris, 73

for venous lakes, 204

for dermatochalasis, 65

for wa rt remova l , 207-209

for Poiki loderma of Civatte, 68 of pseudofo l l i c u l itis, 1 0 1

Syri ngoma, 238, 238f consu ltative q uestions, 239 cou rse, 239

o f Rosacea , 77 Topica l treatment options

d ifferential d iagnosis, 238

a p p l ication tec h n i q ues, 1 1- 1 2

epidemiology, 238

com pl ications, 1 2

laboratory exa m i nation, 238

contra i n d icatio ns, 1 1

ma nagement, 239

ideal ca ndidate, 1 1

pathogenesis, 238 pathology, 238

i nd ications, 1 1 less than ideal ca ndidate, 1 1

physica l lesions, 238, 238f

mecha nism of action , 7-1 1

pitfa l ls, 239f, 240, 240f

posttreatment care, 1 2

treatment, 239-240 System i c l u pus erythematosus, 76 System i c thera py of acne vu lgaris, 73-74

323

proced ure, 62

reci pient region, a nesthesia i n , 1 08 reci pient site creation, 1 08, 1 12f

for a ngiofi broma, 2 1 3 for Becker's nevus, 2 1 7

I

pretreatment eva l uation, 1 1 treatment pearls, 12-13 Topica l treti n o i n , 46, 146 Torn earlobe, 308

of Rosacea , 77

key consu ltative q uestions, 308 ma nagement, 308 pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations, 309

T Tacro l i m us, 1 64

treatments, 308-309, 308f, 309f, 3 1 0f Trad ition a l P D L, 78

Tacro l i m u s oi ntment, 1 75

Trad ition a l resu rfaci ng, 39

Ta l kesthesia, 1 7

Tretinoi n , 9, 46, 54, 73

Ta p water iontophoresis, 87

and epidermal nevus, 224

Tattoo remova l , 300, 300f

and m i l i u m , 230

adverse effects/preca utions, 303, 304f, 305f, 306, 307f consu ltative q uestions, 300-301

TriActive Laserd ermology, 278 Tria mci nolone aceton ide, 1 79

laser thera py, 300t

Triangula ris m uscles, 26, 27f, 28f

ma nagement, 301

Trich l o racetic acid (TCA) peels, 301, 74

pitfa l ls, 303-304

for wart removal , 207

posttreatment care, 302

Tri l u ma , 1 46

pretreatment assessment, 30 1 tattoo treatment, 302, 302t, 303f, 304f

Trola m i n e sa l i cylate, 7t TS H . See Thyroid-sti m u lating hormone

treatment, 30 1-302, 303f

Tu berous sclerosis, 136

Tazarotene, 9, 73, 1 82

Tu berous sclerosis, 213, 2 1 3f

TCA peels. See Trichloroacetic acid peels

Tu rnors, 220

Telangiectases, 67

Tylenol, 109

Tela ngiectasias, 78-79, 78f, 79f, 80f lower extremity, 198-202

Tyrosinase, 9 Tyrosi nase i n h i b itors, 9t

epidemiology, 198 laboratory data, 198 ma nagement, 199-202, 1 98f, 1 99f, 200f pathophysiology, 198 physical exa m i nati o n , 198 Telangiectatic matting rM , 201

u U l cerated hemangioma, 1 79f U ltra , 1 5t U ltra P l u s , 1 5t

Telogen effl uvi u m , 1 29, 130-13 1

U ltra P l u s XC, 1 5t

Tetracycl i ne, 73, 77

U ltra XC, 1 5t

T h ro m boph lebitis, 198

U ltrasou n d , 198 U ltraviolet A ( U VA), 67

Thyroid-sti m u lating hormone (TS H ) , 1 63 Tissue tighte n i ng, 62 ca n d idate selection, 62 c l i n ical pea rls, 63 mecha n ism of action, 62

U ltraviolet B ( U V B ) , 67 U p per a n d m idfacial m uscu latu re, a natom ical i l l u stration of, 22f U p per face, 2-3

324

I

I ndex

U p per nasal root, 25, 26f

la boratory exa m i nation, 1 63

U .S . Food a n d Drug Ad m i n istration, 94

laser thera py exci mer laser, 1 65

UVA. See U ltraviolet A UVB exposu re, 9

ma nagement, 1 64

U V B . See U ltraviolet B

oral thera py, 1 65 pathoge nesis, 1 63

v

physical lesions, 1 63

photothera py, 165 pitfa l l s to avoid/co m p l ications/managem ent!

Valacyclovir, 46

outcome expectations, 1 66

Valacyclovir, 54

preventi o n , 1 64 s u rgica l treatments, 1 65

Valtrex, 1 7 , 32 Va n iqa . See Topica l eflorn ith i n e

topical treatment, 1 64

Va porizi ng tool , 44 Variable-pu lse P D L, 78 Varicose veins, 198-202 Vascular a lterations lower extremity telangiectasias, 198-202 reticular and va ricose veins, 198-202

w Warts, 206-209 cou rse, 207

venous lakes, 203-205

de rmatopathology, 206

warts, 206-209

differentia l d iagnosis, 206 epidemiology, 206

Vascular a lterations

pathogenesis, 206

venous lakes, 203-205

physica l exa m i nation, 206

warts, 206-209 Vasc u l a r ectasia, 77

pitfa l l s , 209 treatment, 207-209, 206f, 207f, 205f, 209f

Vascular lasers, 39 Vascular rosa cea , 76 Vascular spid er, 1 70- 1 73

Watson's syndrome, 136 Westerhof's syndrome, 136

Vaseli ne, 34

Wickha m 's striae, 262

Vei ns, reticular a n d varicose, 198-202 VelaSmooth system , 278

Wood's l a m p eva l uation, 3 1 , 3 1 1, 1 63 Wydase. See Hya l u ron idase

Venous lakes, 203-205 cou rse, 203 de rmato pathology, 203 d ifferenti a l d iagnosis, 203 epidemiology, 203 e p i l u m i n escence m i c roscopy ( EL M ) , 203

X Xa nthelasma pa l pebraru m . See Xa nthelasrnas Xa nthelasmas, 243 cou rse, 244

ma nagement, 203-204, 203f, 204f, 205f

de rmatopathology, 244

physical exa m i nation, 203

differentia l d iagnosis, 244

pitfa l ls, 204

epidemiology, 243 ma nagement, 244

Venous o bstruction, 198 Venous va lvular incom petence, 198 Verruca , 223, 235

pathoge nesis, 243 physica l exa m i nation, 244

Vincristine, 1 79 Vita m i n C, 8 Vita m i n E, 8

pitfa l l s , 244 Xeom i n , 2 1 !

Vitiligo, 1 63 consu ltative q uestions, 1 64 cou rse, 1 63-1 64 dermato pat hology, 1 63

z

d ifferential d iagnosis, 1 63

Z-plasty repa i r, 308 Zyd erm ® , 1 5t

epidemiology, 1 63

Zyplast® , 1 5t