Emmy M. Graber

Side effects and complications of fractional laser photothermolysis: experience with 961 treatments.

BACKGROUND A novel 1,550-nm erbium-doped laser (Fraxel, Reliant Technologies Inc.) has been shown to be effective in the treatment of photodamaged skin and scars with minimal postoperative recovery; however, studies evaluating its side effects and complication rates have been limited. PURPOSE The purpose was to determine the frequency and range of side effects and complications associated with fractional photothermolysis treatment. METHODS A retrospective evaluation of 961 successive 1,550-nm erbium-doped laser treatments in patients of various skin phototypes (I–V) was conducted in a single center. Side effects and complications of treatment, including time of onset and duration, were identified and tabulated. Patient demographics and laser parameters were also assessed. RESULTS Seventy-three treatments (7.6%) resulted in development of complications. The most frequent complications were acneiform eruptions (1.87%) and herpes simplex virus outbreaks (1.77%). Side effects and complications were equally distributed across different ages, skin types, body locations, laser parameters, and underlying skin conditions, except for postinflammatory hyperpigmentation, which occurred with increased frequency in patients with darker skin phototypes. CONCLUSIONS Fractional laser skin treatment is associated with a relatively low complication rate. Side effects and complications observed in this study were temporary and did not result in long-term or significantly severe sequelae (e.g., scarring).

Guidelines of care for the management of acne vulgaris

Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

Laser Tattoo Removal: A Review

BACKGROUND Tattoos have played an important role in human culture for thousands of years, and they remain popular today. The development of quality‐switched (QS) lasers has revolutionized the removal of unwanted tattoos. OBJECTIVES To thoroughly review the literature on laser tattoo removal pertaining to its history, its theoretical basis, the various devices used, potential adverse effects, and future developments. MATERIAL AND METHODS An extensive literature review of publications related to tattoo removal was conducted. RESULTS Reports exist demonstrating the efficacy of laser removal of different tattoo types, including professional, amateur, traumatic, cosmetic, and medical. The literature supports the use of different QS lasers for removal of tattoos. Some colors have a more‐complete response using particular wavelengths. CONCLUSION QS lasers can effectively and safely remove different types of unwanted tattoos.

Collagenase Followed by Compression for the Treatment of Earlobe Keloids

BACKGROUND Many therapeutic options are available for treating keloids, but success rates vary widely, and the keloids often recur. The Food and Drug Administration has recently approved intralesional collagenase for the treatment of Dupuytrens contracture. This medication has not been explored for the treatment of earlobe keloids, a common problem. OBJECTIVE To evaluate the safety and clinical efficacy of intralesional collagenase followed by compression for the treatment of earlobe keloids. MATERIALS AND METHODS Six earlobe keloids in six patients were injected with a commercial collagenase preparation. Study participants were asked to use compression earrings daily thereafter. Patients were examined and photographed 1 day, 2 weeks, 4 weeks, 10 months, and 12 months after injection. Adverse events were assessed at each visit, and the keloids were measured and photographed. RESULTS All patients had a decrease in the size of their earlobe keloid by an average of 50% (p = .02). Three of the six participants chose to have their earlobe keloids surgically excised for cosmetic reasons 6, 8, and 11 months after enrollment, so measurements for data analysis for these patients were taken after only 1, 1 and 10 months. All participants returned for follow‐up at the last study visit 1 year after study commencement. The three patients who completed the study were pleased with the improvement of their earlobe keloid, although complete clearance was not achieved. Side effects included injection site swelling, tenderness, and one ulceration that spontaneously resolved within 2 weeks. CONCLUSION Intralesional collagenase followed by compression appears to be a safe and modestly effective treatment for earlobe keloids. This approach warrants further investigation in larger studies with longer follow‐up in motivated patients who decline surgical excision.

Lasers and Lights for Treating Pigmented Lesions

Pigmented lesions were initially treated with destructive non-selective lasers. Now pigment selective Q-switched lasers used. Pigmented skin lesions are exceedingly common. Selective destruction of pigmented lesions relies on the theory of selective photothermolysis. Melanin has a broad absorption spectrum with absorption steadily decreasing with increasing wavelength. Several Q-switched lasers fall within the melanin absorption spectrum. Their nanosecond pulse duration is effective since it is shorter than the thermal relaxation time of melanin.

Nonablative Fractional Resurfacing for the Treatment of Iatrogenic Hypopigmentation

Hyaluronic acid fillers are extremely popular because of their favorable safety profile and potential for dissolution with hyaluronidase. Because of the natural thinness of the skin below the eye, placement of filler in the tear trough should be deep, below the orbicularis oculi just above the bone. An experienced physician (NL) injected all of our patients, and product was placed deep to the orbicularis oculi muscle with a 30-G needle inferior to the orbital bone and massaged into proper position. No patients had a history of eyelid surgery, although patients 1 and 3 had had periorbital botulinum toxin injections intermittently. To the best of our knowledge, this is the first published case report of hyaluronic acid causing a delayed Tyndall effect due to migration of product superficially, years after implantation.

Body Dysmorphic Disorder: Effects of Aesthetic Treatments and Implications for the Dermatologist and Cosmetic Surgeon

The prevalence of body dysmorphic disorder (BDD) is higher among patients seeking dermatologic care than in the population at large. Patients with BDD frequently seek treatment in both general and cosmetic dermatology settings for perceived imperfections in their appearance. Dermatologists should therefore be aware of the condition and of potential consequences of treatment. This chapter reviews the literature concerning nonpsychiatric treatment of patients with BDD as well as other ramifications for treating physicians. Overall, patients with BDD are dissatisfied when they receive nonpsychiatric treatment. Even when satisfied with the treatment of a particular issue, their concerns about appearance shift to other body parts and overall BDD symptoms usually do not improve. Besides providing ineffective treatment, physicians who treat patients with BDD potentially expose themselves to harassment, litigation, and even violence. For this reason, nonpsychiatric treatment of manifestations of BDD is increasingly viewed as contraindicated. Dermatologists should therefore develop ways to screen patients with BDD and to appropriately refer psychiatric or multidisciplinary treatment.

Treatment of Truncal Acne Scarring

Acne vulgaris is a common condition with a lifetime incidence of over 80%. Acne scarring is an unfortunate, yet, frequent sequela of acne. Any type of acneiform lesion, including comedones, papules, pustules, or nodulocystic lesions, may result in scarring. Although it is impossible to pinpoint exactly which patients with acne will develop scarring, there are some factors that put a patient at higher risk. Acneiform lesions that have been manipulated are more likely to result in scarring. Truncal acne scarring is more common in males than females, and Asian and Black patients are especially prone to keloidal scarring. More severe acne and especially acne conglobata, (Fig. 8.1) has a higher risk of leading to scarring.