Ashish C. Bhatia

Topical Methyl Aminolevulinate Photodynamic Therapy Using Red Light‐Emitting Diode Light for Multiple Actinic Keratoses: A Randomized Study

BACKGROUND Photodynamic therapy (PDT) is an effective treatment for actinic keratoses (AKs). Light‐emitting diodes (LEDs) offer practical advantages when treating multiple lesions. OBJECTIVE To evaluate the efficacy and tolerability of PDT using a LED and topical methyl aminolevulinate (MAL) for treatment of multiple AKs. METHODS AND MATERIALS One hundred thirty‐one patients with four to 10 non‐pigmented, previously untreated thin or moderately thick AKs on the face or scalp were enrolled in this multicenter, double‐blind, randomized, placebo‐controlled study. MAL or matching placebo cream was applied to the débrided lesion surface for 3 hours before illumination with noncoherent red light (630 nm, light dose 37 J/cm2). Treatment was repeated 1 week later. RESULTS Efficacy was evaluated in 57 patients with 418 lesions treated with MAL PDT and 58 with 414 lesions treated with placebo PDT. Sixteen patients were excluded as protocol violators (not randomized). MAL PDT was superior (p<.001) to placebo PDT in lesion complete response rates (83.3%, 95% confidence interval (CI)=79.3–86.7%, vs 28.7%, 95% CI=24.4–33.4%) and patient complete response rates (all lesions showing complete response; 68.4%, 95% CI=54.8–80.1% vs 6.9%, 95% CI=1.9–16.7%). CONCLUSIONS Topical MAL PDT using a LED is an effective treatment for multiple AKs. This study was supported by Photocure, ASA.

Paradoxical Hypertrichosis After Laser Therapy: A Review

BACKGROUND Laser hair removal is a safe and effective procedure for the treatment of unwanted body hair but is not exempt from side effects. A rare but significant adverse effect with this treatment modality is paradoxical hypertrichosis. OBJECTIVE To evaluate the potential etiologies, risk factors, related laser types, and treatment options for the development of excess hair after laser therapy. MATERIALS AND METHODS An analysis of previously published case studies and review articles along with our own experience was used to gather information regarding this phenomenon. RESULTS Paradoxical hypertrichosis has a low incidence, ranging from 0.6% to 10%, and most commonly occurs on the face and neck. All laser and light sources have the potential to cause hair induction, especially in individuals with darker skin types (III–VI); with dark, thick hair; and with underlying hormonal conditions. Possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Treatment for paradoxical hypertrichosis is laser therapy of the affected area. CONCLUSIONS Paradoxical hypertrichosis is a rare side effect of laser hair removal; the pathogenesis of this event remains widely unknown. We recommend further large‐scale studies to investigate this effect. The authors have indicated no significant interest with commercial supporters.

Review of the efficacy, durability, and safety data of two nonanimal stabilized hyaluronic acid fillers from a prospective, randomized, comparative, multicenter study.

BACKGROUND Nonanimal stabilized hyaluronic acid (NASHA)‐based fillers are currently the criterion standard for cosmetic soft tissue augmentation. OBJECTIVE To report the efficacy, durability, and safety data of a large‐particle NASHA filler and a small‐particle NASHA filler. METHODS & MATERIALS A blinded, prospective, randomized subject and evaluator study was conducted at 17 sites in the United States with 248 subjects enrolled. One of the two products was injected into both nasolabial folds and, if deemed necessary, the oral commissures of each subject. A 2‐week touch‐up injection was provided if necessary. Subjects returned for follow‐up visits 2, 6, 12, and 24 weeks after receiving their last injection. Assessments were done using a subject diary, blinded investigators Wrinkle Severity Rating Score (WSRS), and palpability of product. RESULTS Both products demonstrated similar efficacy, durability, and safety profiles. CONCLUSION Although both NASHA fillers demonstrated similar efficacy, durability, and safety, the fanning injection technique, and a faster rate of injection played a key role in the increase in incidence of adverse experiences. Furthermore, the safety of each NASHA product was demonstrated at volumes well beyond the volume range listed on the product inserts. The authors have indicated no significant interest with commercial supporters.

Patient perception on the usage of smartphones for medical photography and for reference in dermatology.

BACKGROUND With increasing use of smartphones in the practice and delivery of dermatologic care, little is known on patient perceptions regarding its applications in the clinical setting. OBJECTIVE To survey patient viewpoints regarding medical photography and the usage of smartphone applications during a medical encounter. MATERIALS AND METHODS Cross-sectional survey of adult patients in urban academic and private practice clinics. Patients responded to questionnaires tailored to identify respondent characteristics, preferences of photographing procedure and smartphone uses, and concerns regarding smartphone camera use. RESULTS Of the 300 patients surveyed, the majority preferred a hospital-owned camera (97.7%) over the use of personal photographing equipment including a physicians digital camera (27.5%) or a physicians smartphone camera (27.2%). The majority found personal smartphones to be an acceptable reference tool (69.7%) and means to provide information to the patient (75.3%). CONCLUSION Patients appear to have clear preferences in the equipment used for medical photography and acceptable applications of smartphones, highlighting the importance of feedback in shaping patient–physician interactions. In light of patient opinions on camera preferences, it may be prudent to make a conscientious effort to refrain from using smartphones as a camera in the clinical setting until patient concerns regarding its use can be addressed.

Association Between Number of Stages in Mohs Micrographic Surgery and Surgeon-, Patient-, and Tumor-Specific Features: A Cross-Sectional Study of Practice Patterns of 20 Early- and Mid-Career Mohs Surgeons

OBJECTIVE To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early‐ to mid‐career Mohs surgeons and to assess other factors affecting number of stages. METHODS Statistical analysis of MMS logs of 20 representative early‐ to mid‐career surgeons. RESULTS There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS Early‐ and mid‐career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. &NA; The authors have indicated no significant interest with commercial supporters.

YouTube and the Expanding Role of Videos in Dermatologic Surgery Education

Video is an excellent medium for medical education, both for clinicians and for the public. YouTube has emerged as one of the largest sources of freely accessible content. It is our intent to provide a preliminary discussion of the growing role of videos in medical education, sources of this video content, and the format of surgical video content on YouTube. Additionally, we will highlight the limitations and pitfalls that clinicians and the public should be aware of when viewing online video content. Several sources of both patient- and clinician-directed videos are easily accessible from the Internet and DVDs today. Medical professionals, students, and patients now have mobiles and instantaneous access to a growing collection of video content. A brief list of online video sources to view and learn dermatologic surgical techniques is provided. Given the increasing ease of creating and posting high-quality video content, this list will continue to grow, providing dermatologic surgeons with an ever-increasing wealth of visual knowledge. Although YouTube is a dominant source of publicly accessible videos, clinicians and consumers should be aware of the source and intent of the video content before accepting the content. Although it is easy to post content on YouTube, it is difficult to verify sources and the credentials of the people posting the videos. Therefore, the viewer should filter content with a discerning eye, embracing the concept of caveat emptor--or buyer beware.

Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations.

Importance The notion that systemic isotretinoin taken within 6 to 12 months of cutaneous surgery contributes to abnormal scarring or delayed wound healing is widely taught and practiced; however, it is based on 3 small case series from the mid-1980s. Objective To evaluate the body of literature to provide evidence-based recommendations regarding the safety of procedural interventions performed either concurrently with, or immediately following the cessation of systemic isotretinoin therapy. Evidence Review A panel of national experts in pediatric dermatology, procedural/cosmetic dermatology, plastic surgery, scars, wound healing, acne, and isotretinoin was convened. A systematic PubMed review of English-language articles published from 1982 to 2017 was performed using the following search terms: isotretinoin, 13-cis-retinoic acid, Accutane, retinoids, acitretin, surgery, surgical, laser, ablative laser, nonablative laser, laser hair removal, chemical peel, dermabrasion, wound healing, safety, scarring, hypertrophic scar, and keloid. Evidence was graded, and expert consensus was obtained. Findings Thirty-two relevant publications reported 1485 procedures. There was insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures for patients currently receiving or having recently completed isotretinoin therapy. Based on the available literature, mechanical dermabrasion and fully ablative laser are not recommended in the setting of systemic isotretinoin treatment. Conclusions and Relevance Physicians and patients may have an evidence-based discussion regarding the known risk of cutaneous surgical procedures in the setting of systemic isotretinoin therapy. For some patients and some conditions, an informed decision may lead to earlier and potentially more effective interventions.

Expanding the role of the iPad and tablet devices to cosmetic patient consultations.

The iPad is a useful reference tool for patient education in cosmetic consultations. In this article, we plan to (1) discuss how the iPad can be implemented and used by patients and physicians in consultations, (2) compare the advantages and disadvantages of the iPad with other forms of technology, (3) discuss the optimal way of using the iPad for patient care, (4) see how this tool complies with privacy regulations, and (5) look at other uses of the iPad in the patient care setting. There has been positive feedback from both patients and physicians regarding the addition of the tablet computer during consultations. In addition to showing patients pictures of cosmetic procedures, the iPad also has various multimedia capabilities such as videos and drawing tools that are useful in optimizing patient satisfaction, increasing clinical efficacy, and improving the overall patient experience.

Protection of Patients’ Right to Privacy in Clinical Photographs, Video, and Detailed Case Descriptions

Dermatology, one of the most visually oriented fields of medicine, relies on inspection of the skin by a physician trained to perceive and interpret the skin clues to be able to make a diagnosis and demonstrate response to treatment. Clinical photographs are the way records are kept; clinical processes are compared over time, and communication occurs with our colleagues to teach about dermatologic processes and obtain consultations. Such communication needs to be mindful of protecting the patients’ right to privacy. Collecting information about patients in the course of conducting research can present unique concerns about maintaining patient privacy and anonymity. While these concerns about research are usually mitigated by submission of research protocols and amendments to those protocols to the institutional review board with the requirement of deidentification of data, case reports and observations do not come under the purview of the institutional review board; thus, it is important for clinicians to understand how to protect the privacy of their patients when publishing case reports. While identifying information can easily be removed from self-reported surveys, laboratory tests, and pathology data, photographs and videos of patients are not easily deidentified, and often detailed descriptions of patients are needed for reports to be scientifically complete, clinically meaningful, and educational. Photographs that include an ear, eye, facial hair, or skin lesion may not seem to reveal the person’s identity to the reader, but the test of anonymity is whether the patient could recognize his or her own image. This can be a difficult test to pass. Even a birthmark, tattoo, jewelry, clothing, nail polish, or unique mole included in a photograph might reveal the patient’s identity. The Figure shows 3 examples of images that required patient permission to publish.1-3 In the past, attempts at concealing the identity of patients included masking, which consists of placing bars over the eyes or pixelating the areas over the eyes. Masking of facial images was abandoned at least 2 decades ago.4-6 Now the standard is careful cropping to remove identifying features while attempting to preserve the elements of the clinical process that is being conveyed. This can prove to be challenging if the image is not properly staged and framed. In situations in which patient anonymity cannot be guaranteed, authors must abandon attempts to deidentify clinical photographs and related text description and ask permission from the patient to publish their likeness and other identifying information. In 1995, the International Committee of Medical Journal Editors released a position paper stating that identifying information, such as photographs, should not be published unless the publication is necessary for scientific purposes and the patient has granted informed consent.7 Proper staging and framing of a patient prior to taking a photograph or recording video is key. The physician should have the patient remove identifying and visually distracting jewelry and clothing.8 If certain articles cannot be easily removed, they may be draped with a solid-colored drape such as a surgical towel, paper drape, or photography bib. Written informed consent needs to be obtained prior to taking any patient photographs, even if the intention is not to publish the images. As part of this consent, the patient should be asked to give permission to have the image published in a medical journal. The permission should give the patient the right to review the manuscript or waive the right to review the manuscript, which should include any photographs or videos. JAMA Dermatology, JAMA, and the other JAMA Network journals require patients to sign a JAMA Network informed consent form prior to publication for any patients who are identifiable in text descriptions or photographs.6 Since authors may not be able to predict which journal a manuscript will be submitted to at the time the initial informed consent is obtained, the need for patient consent may be perceived as an unnecessary burden. If the author chooses to wait until the manuscript is completed, it may be difficult to locate and contact patients to obtain informed consent after the fact. Furthermore, if the patient dies, then the next of kin will need to be asked to sign the release, which can be difficult for the physician. While authors may wish to rely on standard institutional informed consent forms, such as those used for surgical procedures, with a few incorporated sentences regarding photographs, the editorial staff of JAMA Dermatology frequently note omissions on these standard permission forms. To summarize the key points, all patients identifiable by their photographs, detailed case descriptions, or pedigrees in a manuscript should be given the opportunity to review the manuscript and materials in which they are included or waive their right to do so. In addition, the permission form must include provisions for the publication of the material on the Internet, and this permission must be irrevocable. Obviously, once an article about a patient is published, the identifying information and material cannot be unpublished. Whenever a physician has a question about the need to obtain informed consent for publication of photographs, video, or descriptive text of a patient, the physician should act conservatively and strive to preserve the patient’s privacy and anonymity. If identifying information is essential to the clinical message or scientific importance of the article, permission from Opinion

Improved sensation in a palmar hand burn scar with fractional CO(2) laser treatments.

Each year in the United States there are approximately 450,000 people who seek medical attention for burns. Regardless of the cause, burns can leave devastating sequelae, like scars and contractures that affect a person’s psyche and function. The care of burn scars is an evolving field and fractional CO2 lasers are becoming an important component. They can improve texture and appearance of scars, and there may be potential for improvement of function in scar contractures. Our case report focuses on the treatment of burn scars with the fractional CO2 laser, including the first report of an additional potential benefit—the restoration of sensation in a scar. Our patient is a 73-year-old Caucasian male with Fitzpatrick skin type I who presented to our clinic for treatment of burn scars 30 years after a methane gas explosion left him with 54% total body surface area (TBSA) burns. He had undergone multiple debridement and skin grafting procedures for burns to the trunk, face, and upper extremities. After some discussion, we decided to treat the burn scar on his left palmar hand, which was his primary concern due to the development of severe flexion contractures and loss of sensation to the fourth and fifth digits. On exam, the patient had hypopigmented, hyperkeratotic scars to the dorsal and palmar aspects of his hand. Prior to treatment, the patient was evaluated by an orthopedist who ruled out the presence of any fractures, dislocations, or ossification of the bone. He was further evaluated by an occupational therapy hand specialist, who established a baseline examination. The patient was noted to have a 45-degree flexion contracture at the proximal interphalangeal (PIP) joint of left fourth finger and a 30-degree flexion contracture at the distal interphalangeal (DIP) joint of the left fifth finger. Over a course of 2 months, the patient received a total of three treatments with a fractional CO2 laser (Mixto SX, Lasering USA, San Ramon, CA). Prior to each treatment, the patient’s hands were anesthetized with topical benzocaine/lidocaine/ tetracaine mixture and ice packs. The patient did not report any discomfort with the treatments. The sites were cleansed with 70% isopropyl alcohol and the patient was administered acetaminophen pre-treatment. Each treatment was performed using a 180 mm microspot hand piece with a density of 10% (two passes with 5% density) and 2.5 millisecond pulse duration in the fractional mode. The energy level used was increased incrementally with each treatment from 20 W to 25 W to 28 W. These correlate with depths of penetration ranging from approximately 750 to 1100 mm. Following each session, polysporin was applied and the treated site was dressed with Xeroform, nonadherent pads, and wrapped with an ace bandage. Home care included the application of Biafine Emulsion Cream (Valeant Pharmaceuticals International Incorporated, Montreal, Quebec, Canada) daily and the use of a full hand splint. The patient also began physical therapy 2 days after his first treatment with the fractional CO2 laser and continued to attend regularly throughout his treatments. After the first treatment, the patient noticed that the skin involved was more pliable and softer in