David M. Ozog

Laser Assisted Drug Delivery: A Review of An Evolving Technology

Topically applied drugs have a relatively low cutaneous bioavailability.

Randomized Control Trial for the Treatment of Hidradenitis Suppurativa with a Neodymium‐Doped Yttrium Aluminium Garnet Laser

BACKGROUND Hidradenitis suppurativa (HS) is a chronic suppurative condition for which there is limited efficacy of medical and surgical treatments. OBJECTIVE To assess whether the 1,064‐nm neodymium‐doped yttrium aluminium garnet (Nd:YAG) laser is an effective treatment for HS. MATERIALS AND METHODS Prospective, randomized, controlled study for patients with stage II to III HS disease (n=22). A series of 3 monthly laser sessions were performed. Treatment response was measured before each laser session and 1 month after the completion of laser treatment (HS Lesion, Area, and Severity Index (HS‐LASI) scale). A modification was made to include symptoms (erythema, edema, pain, and purulent discharge; modified HS‐LASI, 0‐3 scale). RESULTS The percentage change in HS severity after 3 months of treatment was –65.3% over all anatomic sites, −73.4% inguinal, −62.0% axillary, and −53.1% inframammary. For all anatomic sites combined and each individual anatomic site, the change in HS severity from baseline to month 3 was statistically significant at the treated sites (p<.02 for modified HS‐LASI and HS‐LASI) but not at the control sites (p>.05 for modified HS‐LASI and HS‐LASI). CONCLUSIONS The long‐pulse Nd:YAG laser is effective for treatment of HS. The effectiveness of Nd:YAG laser, a hair epilation device, supports the primary follicular pathogenesis of the condition. The authors have indicated no significant interest with commercial supporters.

Clinical and molecular effects on mature burn scars after treatment with a fractional CO2 laser

There have been several case reports of improvement in the appearance of mature burn scars following treatment with fractional CO2 lasers. However, the biochemical mechanisms responsible for these improvements have not been elucidated.

Safety and efficacy of erbium-doped yttrium aluminum garnet fractionated laser for treatment of acne scars in type IV to VI skin.

BACKGROUND Ablative resurfacing lasers are effective for treatment of acne scars, but they have a high risk of complications. Fractional lasers have less severe side effects but more moderate efficacy than ablative devices. Studies were performed in individuals with Fitzpatrick skin type I to VI. OBJECTIVE To determine the efficacy and safety of an erbium 1,550‐nm fractional laser in the treatment of facial acne scars in Fitzpatrick skin types IV to VI. METHODS We conducted a prospective, single‐blind, randomized trial in patients with acne scars (n=15), skin type IV to VI, with a 1,550‐nm erbium fractionated laser. Patients were divided into two groups; one was treated with 10 mJ and the other with 40 mJ. Five monthly laser sessions were performed. A patient questionnaire was distributed. RESULTS There was a significant improvement in the acne scarring and overall appearance (p<.001). No significant difference was found between 10 and 40 mJ. Patients were highly satisfied with their results. Significant postinflammatory hyperpigmentation was seen; pain was significantly higher in darker skin. CONCLUSIONS Fractional photothermolysis is effective for the treatment of acne scars, but practition‐ers should be aware of the higher incidence of pain and postinflammatory hyperpigmentation in individuals with skin types IV to VI. The study was funded by Reliant Technologies, Inc., which participated in the study design. Galderma (Ft. Worth, TX) provided Tri‐luma cream and GlaxoSmithKline (Research Triangle Park, NC) provided valacyclovir (Valtrex).

Photodynamic therapy for actinic keratoses: Survey of patient perceptions of treatment satisfaction and outcomes

Background: While there are many available treatments for actinic keratoses (AKs), patient‐preferred treatment options remain undefined. Objective: To quantify patient perceptions and preferences in the management of AKs, including comparison of photodynamic therapy (PDT) with other therapies. Methods: A self‐administered questionnaire was mailed to 45 patients who had received PDT for AKs in 2005–2006 in the Henry Ford Health System. A series of indicators for each treatment were surveyed, including: recovery time, cosmetic appearance, patient cost, effectiveness, patient satisfaction, treatment option preference, and perceived burden of treatment. Results: A total of 39 of the 45 patients participated (86.7%). A patients reported recovery time was significantly more likely to be 1 week or less for PDT when compared with cryotherapy (p = 0.02) and surgical excision (p = 0.02). Borderline significance was found for the improved cosmetic outcome in PDT vs. surgical excision (p = 0.058) and for patient satisfaction with PDT compared with 5‐fluorouracil (p = 0.058). Patients significantly preferred PDT to 5‐fluorouracil (p<0.001) or imiquimod (p = 0.031). Conclusion: While the effectiveness of lesion clearance with PDT for AKs has been well proven in the literature, this is the first study to evaluate patient perception of the effectiveness, side‐effect profile and benefits of PDT relative to several standard treatment approaches for AKs. PDT was found to have equivalent or improved recovery times, cosmetic outcomes, patient satisfaction and preference as a treatment for AKs by patients compared with other options.

Current Methods Employed in the Prevention and Minimization of Surgical Scars

BACKGROUND Postsurgical scars are of significant concern to patients and surgeons. Many studies have focused on different treatment options for established surgical scars. The prevention and minimization of such aberrant healing responses is more likely to yield better outcomes and require less time and expense. OBJECTIVE AND METHOD A review of the literature on various forms of prophylactic treatments intended to prevent or minimize the development of prominent postsurgical scars was performed using the Pubmed database over a period from 1987 to 2010. Search terms included “scar prevention,” “scar minimization,” “post‐surgical scar management,” and “surgical scars.” RESULTS Various over‐the‐counter topical products commonly used by patients have failed to demonstrate any significant benefits in improving final scar outcomes. Numerous interventions performed around the time of surgery, including botulinum toxin, lasers, and intradermal injectable products, have shown effectiveness in minimizing eventual scar appearance. CONCLUSIONS Patient education on proper wound care is a simple method of improving the cosmetic appearance of surgical scars. At the other end of the spectrum, our knowledge of the complex mechanisms of wound healing has allowed for the development of new, effective treatment modalities, including lasers, botulinum toxin, cytokines, and stem cells.

Melanocyte-keratinocyte transplantation procedure in the treatment of vitiligo: The experience of an academic medical center in the United States

BACKGROUND Vitiligo is a disfiguring disease with limited treatment options. Surgical treatment is underused in the United States because of perceived risk of infection, costs, and difficulty of the procedure. OBJECTIVE We sought to determine the efficacy and safety of the melanocyte-keratinocyte transplantation procedure (MKTP) in an academic dermatology department in the United States. METHODS This prospective, uncontrolled, open-label study enrolled patients aged 18 years or older with a self-reported history of vitiligo and no new or expanding lesions for at least 6 months before surgery. Patients with a history of koebnerization or keloid formation were excluded. Patients underwent autologous MKTP. Repigmentation during a 3- to 6-month follow-up period was assessed categorically and by modified Vitiligo Area Scoring Index. Safety was assessed by frequency of adverse events. RESULTS Of the 28 patients who underwent 36 procedures, 23 patients who underwent 29 procedures completed the 3- to 6-month follow-up period. Data for these 29 procedures show excellent repigmentation (ie, 95%-100%) after the MKTP in 17%, and good repigmentation (ie, 65%-94%) in 31%. Fair (64%-25%) and poor (24%-0%) repigmentation were achieved in 10% and 41% of patients, respectively. Average percent change in Vitiligo Area Scoring Index was -45% (95% confidence interval -64% to -26%), signifying an improvement in pigmentation. LIMITATIONS Limitations include small sample size and lack of a control group. CONCLUSIONS The MKTP is an effective and well-tolerated procedure based upon categorical and Vitiligo Area Scoring Index assessments of repigmentation.

Recommendations and current practices for the reconstitution and storage of botulinum toxin type A

BACKGROUND Current guidelines from the Centers for Disease Control and Prevention (CDC) regarding the reconstitution and storage of botulinum toxin type A (BT-A) differ from those of the Centers for Medicare and Medicaid Services and current clinical practice. CDC guidelines require single-patient use of BT-A vials. Strict adherence to these guidelines creates waste and a significant financial impediment, and does not confer increased protection from infection, assuming standard safe injection practices are followed. OBJECTIVE This study examines current clinical practices and provides expert consensus recommendations regarding the reconstitution and storage of BT-A. A review of the literature on the sterility and efficacy of BT-A stored beyond the recommended time period of 4 hours is also presented. METHODS An Internet-based survey was used to analyze the current practices of physician members of the American Society for Dermatologic Surgery who administer botulinum type A toxins. RESULTS After reconstitution, the majority of physicians (68.6%) routinely store BT-A for a period of greater than 1 week and safely use each toxin vial for more than one patient. Not a single case of infection was observed. LIMITATIONS This was a single survey with a 32.2% response rate. CONCLUSION A single vial of BT-A can be safely administered to multiple patients, assuming standard safe injection techniques are followed. After reconstitution, Our data suggest that BT-A can be stored beyond the recommended time period of 4 hours.

Photodynamic Therapy: A Clinical Consensus Guide.

BACKGROUND The American Society of Dermatologic Surgery (ASDS) periodically develops consensus documents for its members concerning various aspects of dermatologic surgery. Advances in photodynamic therapy (PDT) have been many and PDT use has been established in a variety of skin conditions. OBJECTIVE The ASDS board of directors proposed a committee of experts in the field to develop consensus documents on different treatments. An expert panel reviewed the literature on PDT and discussed the findings. The consensus was reached with evidence-based recommendations on different clinical applications for PDT. PATIENTS AND METHODS This consensus document includes discussions regarding PDT, including different photosensitizers and various light source activators, historical perspective, mechanism of action, various therapeutic indications and expected outcomes, pre- and post-care, and management of adverse outcomes. RESULTS Photodynamic therapy is highly effective for pre-cancerous lesions, superficial nonmelanoma skin cancers, inflammatory acne vulgaris and other conditions. New protocols including laser mediated PDT significantly improve results for several indications. CONCLUSION The ASDS consensus document on PDT will be helpful for educating members on safe and effective PDT for a variety of indications.

A Randomized Split-Scar Study of Intraoperative Treatment of Surgical Wound Edges to Minimize Scarring

Kang, Bahadoran, Lacour, and Ortonne. Statistical analysis: Fontas. Obtained funding: Passeron and Ortonne. Administrative, technical, and material support: Lacour and Ortonne. Study supervision: Passeron. Financial Disclosure: Galderma provided the TCC used in the study. Funding/Support: This study was supported by the Nice University Hospital (CHU Nice) and the Association Niçoise pour l’Etude de la Dermatologie (ANED). Role of the Sponsors: The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; or in the preparation, review, or approval of the manuscript. Trial Registration: clinicaltrials.gov Identifier: NCT00863178 Previous Presentation: This research was presented at the 18th Congress of the European Academy of Dermatology and Venereology; October 2009; Berlin, Germany. Additional Contributions: Charlotte Sakarowitch, provided valuable help in the statistical analysis review.