David H. McDaniel

Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser

BACKGROUND Striae, or stretch marks, are very common skin disorders that do not impair bodily function, but are of considerable cosmetic concern to many patients. Traditionally, treatment options have been very limited. This study examines the results of treating striae using the 585‐nm pulsed dye laser. Stimulation of a variety of wound healing processes has been attributed to low energy laser therapy. Clinically, improvement of hypertrophic and erythematous scars with the 585‐nm pulsed dye laser at energy densities of 6–7 J/cm2 is well established. Since striae are dermal scars, evaluation of this same therapy to treat striae was undertaken. OBJECTIVE To evaluate the effectiveness of the 585‐nm flashlamp‐pumped pulse dye laser in treating cutaneous striae. METHODS Thirty‐nine striae were treated with four treatment protocols. These treated striae were compared with untreated striae controls in the same patient. The patients ages ranged from 23 to 52 years, with an average age of 36 years. The average age of the treated striae prior to initial treatment was 14 years (range, 8 months to 32 years). Treatment parameters included spot sizes of 7 and 10 mm and fluences of 2.0, 2.5, 3.0, and 4.0 J/cm2. Response to therapy was evaluated through clinical grading, sequential photography, and optical profilometry at a blinded laboratory. Skin biopsies were also examined with light microscopy from two of the 39 striae that were treated. RESULTS Subjectively, striae appeared to return toward the appearance of normal skin with all protocols. However, the protocol with 10‐mm spot size using 3.0 J/cm2 fluence improved the appearance of striae better than the other treatment protocols. Objectively, shadow profilometry revealed that all treatment protocols reduced skin shadowing in striae. This result corresponds with surface patterns of striae returning to that closely resembling adjacent normal skin surface patterns. Histologically, using hematoxylin and eosin stains as well as elastin strains, striae treated with a low fluence pulsed dye laser treatment protocol regained normal appearing elastin content when compared with normal (non‐striae) skin adjacent to the treated striae. CONCLUSION Treatment with the 585‐nm pulsed dye laser at low energy densities was shown to improve the appearance of striae. Apparent increased dermal elastin was also observed 8 weeks posttherapy and possibly contributed to the improvement seen in the study patients.

Comparison of Topical Therapy for Striae Alba (20% Glycolic Acid/0.05% Tretinoin Versus 20% Glycolic Acid/ 10% L-Ascorbic Acid)

background. Topical treatment of striae rubra with 0.1% tretinoin and laser treatment of striae rubra and alba with the 585‐nnt pulsed dye laser are proven therapeutic options. However, little efficacy has been shown for treatment of striae alba topically, and the laser is currently not a suitable treatment option for darker ethnic skin types. objective. The purpose of this study was to demonstrate that selected commercial topical agents can improve the appearance of striae alba. methods. Ten patients of varying skin types (I‐V) having striae distensae alba on the abdomen or thighs were selected to evaluate the effectiveness of two topical treatment regimens. Patients were placed on daily topical application of 20% glycolic acid (MD Forte) to the entire treatment area. In addition, the patients applied 10% L‐ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine to half to the treatment area and 0.05% tretinoin emollient cream (Renova) to the other half of the treatment area. The creams were applied on a daily basis for 12 weeks. Improvement was evaluated at 4 and 12 weeks in an objective unblinded fashion at the follow‐up visits, a objective blinded fashion by visual grading at the conclusion of the study, and in an objective blinded fashion with profilometry. Additionally, histopathologic analysis was performed. results. Analysis of these data reveals: 1) both regimens can improve the appearance of stretch marks; 2) these topical therapy regimens are safe and effective in study patients with minimal irritation; 3) elastin content within the reticular and papillary dermis can increase with topical 20% glycolic acid combined with 0.05% tretinoin emollient cream therapy; 4) both regimens increased epidermal thickness and decreased papillary dermal thickness in treated stretch marks when compared with untreated stretch marks; 5) combined epidermal and papillary dermal thickness in stretch marks treated with either topical regimen approaches that of normal skin; and 6) profilometry can objectively measure differences in skin texture associated with striae treatments when compared to controls, however, it is not sensitive enough to justify comparison or quantitative improvements between similarly effective treatments.

Variable pulse erbium:YAG Laser skin resurfacing of perioral rhytides and side-by-side comparison with carbon dioxide Laser

Laser resurfacing of facial rhytides has become a popular treatment option for many patients with wrinkles, photoaging, and acne scarring. Laser wavelength/pulse duration options and new techniques continue to shorten the healing phase associated with laser skin resurfacing while maintaining clinical efficacy. Variable pulse erbium:YAG (Er:YAG) laser systems are now available that offer the surgeon the ability to vary the Er:YAG pulse duration from a pulse that is primarily ablative to one that is more thermal. The objective of this study was to evaluate the histologic effects created with a variable pulse Er:YAG laser. To study prospectively the clinical effects on upper lip rhytides with a variable pulse Er:YAG laser when compared side by side with pulsed carbon dioxide (CO2) laser resurfacing.

Laser therapy of stretch marks

Striae distensae, better known as stretch marks, are a common disfiguring skin disorder of significant cosmetic concern. Many sources have reported the use of lasers to diminish the appearance of striae. Controlled clinical studies of the various treatment modalities available for striae are relatively uncommon, and much of the clinical data are anecdotal. The use of lasers alone or in combination with other therapeutic modalities can provide a safe and effective reduction in the appearance of both red and white striae distensae. Many of these therapies require special measures for darker skin phototypes. This article reviews the historical use of laser therapy for this disorder and discusses current therapeutic options.

The erbium: YAG laser: a review and preliminary report on resurfacing of the face, neck, and hands.

The use of short-pulsed or flash-scanned CO(2) lasers to resurface skin has rapidly joined chemical peels and dermabrasion as an accepted procedure. The purpose of this study was to evaluate a mid-infrared pulsed Erbium: YAG laser prospectively to determine its clinical efficacy for resurfacing of the face, neck, and hands. Postoperative changes and recovery period were also evaluated. A total of 21 patients were evaluated on a prospective basis with Er: YAG laser resurfacing (12 crows feet, five upper lips, three hands, and one neck). Additional nonstudy clinical experience is also reported. Posttreatment crusting or scabbing lasted an average of 2.7 days, pain an average of 3 days, erythema an average of 5.2 days, and swelling an average of 3 days. Blinded subjective grading was performed 2 months postoperatively. This grading revealed a 52% combined improvement from all areas. The appearance of crows feet was improved by 58%; upper lip, 43%; dorsal hand, 48%; and neck, 44%. Overall the Er: YAG laser consistently produced reduction in rhytids and improvement in the appearance of sun-damaged skin. The times for reepithelialization and duration of erythema were strikingly shorter than those typically observed with current CO(2) laser resurfacing. This report details the study, reviews Er: YAG laser technology, and compares our findings with those observed with standard CO(2) laser resurfacing.

Antioxidants and the skin: Understanding formulation and efficacy

Antioxidants are molecules capable of inhibiting the oxidation of other molecules. Although oxidation reactions are essential for life, they can also be damaging. All living organisms maintain complex systems of multiple types of antioxidants to protect their cells from oxidative damage. Antioxidants can also act as pro‐oxidants, under certain circumstances. The efficacy and benefit of an antioxidant is, therefore, very much dependent on the delivery of the antioxidant to the organism. Topically applied antioxidants constitute an important group of pharmacologically active agents capable of preventing the occurrence and reducing the severity of UV‐induced skin damage and skin aging. Antioxidants protect skin cells against the damaging effects of reactive oxygen species (ROS), such as singlet oxygen, superoxide, peroxyl radicals, hydroxyl radicals, and peroxynitrite. ROS induced oxidative stress in the skin has been linked to cancer, aging, inflammation, and photodamage. This review focuses on antioxidants used in the cosmetic industry for protection of skin, formulation methods used to enhance their efficacy, and methods used to test the efficacy of antioxidants in topical formulations.

Multicenter, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing Proteins, in the Treatment of Glabellar Frown Lines

BACKGROUND Botulinum toxin type A is a proven, effective aesthetic treatment for glabellar frown lines. IncobotulinumtoxinA (NT 201, Xeomin/Xeomeen/Bocouture, Merz Pharmaceuticals GmbH, Frankfurt, Germany) is a 150‐kDa botulinum toxin type A free of complexing proteins. OBJECTIVE To assess the efficacy and safety of incobotulinumtoxinA in a randomized, double‐blind, placebo‐controlled, Phase III study in patients with moderate to severe glabellar frown lines. MATERIALS AND METHODS Two hundred seventy‐six patients were randomized 2:1 to receive a single injection of 20 U of incobotulinumtoxinA or placebo, respectively. Efficacy was assessed at day 30 using a Food and Drug Administration–mandated composite endpoint; a responder was defined as a patient with a 2‐point or greater improvement in glabellar frown lines on a 4‐point scale as assessed by investigator and patient. Safety was assessed periodically through Day 120. RESULTS Treatment with a single dose of incobotulinumtoxinA was significantly superior to placebo in the treatment of glabellar frown lines at Day 30 using the composite endpoint (p < .001), with investigators and patients assessing glabellar frown lines as significantly more improved after incobotulinumtoxinA injection than with placebo (p < .001). IncobotulinumtoxinA was well tolerated. CONCLUSION A single dose of 20 U of incobotulinumtoxinA demonstrated efficacy and safety in the treatment of glabellar frown lines using new Food and Drug Administration efficacy variables.

A randomized, placebo-controlled, double-blind phase III trial investigating the efficacy and safety of incobotulinumtoxinA in the treatment of glabellar frown lines using a stringent composite endpoint.

BACKGROUND A prospective, randomized, double‐blind, multicenter, Phase III trial of incobotulinumtoxinA using new Food and Drug Administration endpoints. OBJECTIVE To investigate the efficacy and safety of a single dose of incobotulinumtoxinA for the treatment of glabellar frown lines. MATERIALS AND METHODS Two hundred seventy‐one subjects with moderate to severe glabellar frown lines at maximum frown—as assessed by an investigator according to the facial wrinkle scale (FWS)—were randomized 2:1 to receive one treatment of 20 U of incobotulinumtoxinA or placebo, respectively, and assessed over 120 days. The primary efficacy variable was a composite endpoint consisting of patients who were 2‐point or more responders at maximum frown on Day 30 according to the investigators rating on the FWS, and 2‐point or more responders at maximum frown on Day 30 according to the patients assessment on a 4‐point scale. Safety analyses were performed throughout the study. RESULTS IncobotulinumtoxinA was statistically significantly more efficacious than placebo using a new rigorous composite endpoint (p < .0001). CONCLUSION A single dose of 20 U of incobotulinumtoxinA is superior to placebo in the treatment of glabellar frown lines at Day 30 and is well‐tolerated.

Accelerated Laser Resurfacing Wound Healing Using a Triad of Topical Antioxidants

background. The speed of wound healing and the duration of erythema are the primary complaints after laser skin resurfacing. Antioxidants have been shown to enhance the healing of wounds by reducing free radical damage. Reepithelialization is also enhanced by the moist environment produced by occlusive dressings. objective. This study was conducted to compare two occlusive agents: white petrolatum and “melting” petrolatum. Another arm of the study evaluated the use of melting petrolatum with and without a triad of topical antioxidants (TTA). results. Plain white petrolatum proved superior to melting petrolatum in time required for reepithelialization as well as in discomfort. Crusting and pain were decreased with white petrolatum but duration of erythema was equivalent. Wound healing was enhanced when TTA was added. Time for reepithelialization, duration of crusting and scabbing, pain, redness, and swelling were decreased when TTA was added to topical therapy. conclusion. TTA compound enhances and hastens wound healing. White petrolatum as a base occlusive vehicle shortens reepithelialization compared with “melting” petrolatum.

Hair removal using a long-pulsed alexandrite laser.

The use of lasers for hair depilation has become a common modality for physicians in the recent past. As new lasers are developed, the complex mechanisms affecting this form of treatment are now under close investigation. The long-pulsed alexandrite laser functioning at a wavelength of 755 nm has recently been added to the armamentarium of health care providers to assist patients with unwanted body hair. A review of the embryology and anatomy of the hair follicle are discussed, as well as the findings of recent studies using this form of laser therapy. Using the suggested treatment protocols offered laser assisted depilation may be effectively achieved. The degree and duration of reduction vary with anatomic site and improve with multiple treatments.