Jennifer D. Peterson

Rejuvenation of the Aging Chest: A Review and Our Experience

BACKGROUND Photo‐damaged skin of the chest is characterized by skin laxity, lines and wrinkles, hyperpigmentation, erythema, tactile roughness, atrophy, and telangiectasias. STUDY DESIGN A Medline search was performed on rejuvenation of the chest from 1960 to 2010. Practical applications to these procedures are also provided. RESULTS Chest‐based reports of injectable poly‐l‐lactic acid (PLLA), botulinum toxin, sclerotherapy, and chemical peels, along with lasers and light therapies such as intense pulsed light (IPL), photodynamic therapy (PDT), nonablative fractionated lasers, and ablative fractionated lasers were identified. CONCLUSION Review of the literature revealed that options for minimally invasive treatment options for rejuvenation of the skin of the chest include injectable PLLA, botulinum toxin, sclerotherapy, and chemical peels, along with lasers and light therapies such as IPL, PDT, and nonablative fractionated lasers. For more dramatic results, ablative fractional lasers can be safely used, although longer healing times and potential adverse effects are to be expected. Adverse events are often due to the thinness of the dermis and epidermis and the lower concentration of pilosebaceous units. If treatments are tailored to the skin of the chest, the incidence of adverse events is lower, and patients can be safely treated. The authors have declared no conflicts in regards to this article.

The adverse events of deep fractional CO2: A retrospective study of 490 treatments in 374 patients

Fractionated carbon dioxide CO2 laser resurfacing unites the idea of fractional photothermolysis with an ablative 10,600‐nm wavelength. This technology permits effective treatment of deeper rhytides, photodamaged skin, and scars, with shorter recovery and a decreased side effect profile as compared to traditional CO2 laser resurfacing.

Evaluation of the Effect of Fractional Laser with Radiofrequency and Fractionated Radiofrequency on the Improvement of Acne Scars

BACKGROUND Options for acne scar reduction include peels, subcision, fillers, lasers, dermabrasion, and surgical excision, although not all are applicable in darker skin types. A novel device with a handpiece combining optical and radiofrequency (RF) energies along with a fractionated RF handpiece is available for nonablative resurfacing. OBJECTIVES Our primary objective was to evaluate the improvement in acne scars and skin texture. Secondary objectives were determination of patient satisfaction and comfort and evaluation of scar pigmentation improvement. Patients received five treatments at 30‐day intervals. Post‐treatment follow‐up visits were performed 30 and 90 days after the last treatment. RESULTS A 72.3% decrease (p<.001) was observed on the acne scar scale from day 1 to 210. From day 30 to 210, investigator‐rated changes in scarring, texture, and pigmentation improved 68.2% (p<.001), 66.7% (p<.001), and 13.3% (p=.05), respectively. Patient satisfaction scores showed no significant change over time, although patient‐evaluated overall improved scores increased 60% over baseline (p=.02). CONCLUSION This technology may be a useful, nonablative resurfacing treatment for acne scarring. Scarring, texture, and pigmentation improved significantly according to investigator‐rated assessment parameters. Although patient satisfaction scores did not improve, overall improvement scores did. The study was supported by Syneron.

An Investigation into the Influence of Various Gases and Concentrations of Sclerosants on Foam Stability

BACKGROUND Foam sclerotherapy is an increasingly popular modality in varicose vein treatment. Our previous work showed that the half‐life of room air foam varied according to the percentage and type of sclerosant solution. MATERIALS AND METHODS A plastic connector was used to create foam made from a combination of 0.25%, 0.50%, and 1% sodium tetradecyl sulfate (STS) and room air, carbon dioxide (CO2), oxygen (O2), or a mixture of CO2 and O2. To measure foam stability, the foam half‐life was defined as the time it took for half the original volume of sclerosing solution to settle. RESULTS Half‐life varied according to sclerosant concentration when room air, O2, or a mixture of CO2 and O2 was used for foam creation but not when CO2 was used. Room air foam is more than 3 times as stable as CO2 foam and 1.5 times as stable as a mixture of CO2 and O2. CONCLUSIONS CO2 foam half‐life did not vary according to sclerosant solution concentration, though room air, O2, and CO2/O2 did. The half‐life of room air foam is more than 3 times as long as that of CO2 and 1.5 times as long as that of a mixture of CO2 and O2. Foam half‐life for room air and O2 are similar at low concentrations of STS but differ at higher concentrations. Portable Medical Devices, Inc., North Fort Myers, Florida, provided CO2mmander for testing.

The Progression of Inflammation Parallels the Dermal Angiogenesis in a Keratin 14 IL-4-Transgenic Model of Atopic Dermatitis

The role angiogenesis plays in atopic dermatitis is not well understood. The authors previously demonstrated ultrastructurally dermal microvascular angiogenesis in the IL‐4‐transgenic mouse model of atopic dermatitis. Here, they determine the angiogenic factors involved in dermal microvascular angiogenesis, regulatory function of inflammatory cytokines on the VEGF‐A production, and microvascular permeability in this model. Computer‐assisted photometric analyses for immunofluorescence‐labeled CD31 demonstrated a progressive increase in blood vessel number, diameter, and percent dermal areas occupied by CD31+ vessels as the disease evolves in transgenic mice from before disease onset through early and late skin lesions. Similar findings were documented for VEGR2+ vessels. Quantification of skin angiogenic factor mRNAs showed progressive increase of transcripts of VEGF‐A, but not VEGF‐B, VEGF‐C, or VEGF‐D. ELISA showed a similar increase of VEGF‐A in the serum and skin of transgenic mice. IL‐6 and IFN‐γ stimulated VEGF‐A mRNA production in the skin and in primary keratinocytes of transgenic mice. Other skin angiogenic factors that increased included Ang‐1, Ang‐2, GBP‐1, and VE‐cadherin. Microvascular leakage began in the transgenic mouse skin before disease onset and peaked in the late stage. In conclusion, IL‐6 and IFN‐γ may play important roles in upregulation of VEGF‐A, along with other pro‐angiogenic factors, to induce dermal microvascular angiogenesis.

Effectiveness and side effects of anti-CD20 therapy for autoantibody-mediated blistering skin diseases: A comprehensive survey of 71 consecutive patients from the Initial use to 2007.

In order to examine the efficacy and side effects of the monoclonal antibody anti-CD20 (rituximab) on autoimmune blistering skin diseases, we performed a comprehensive survey of 71 consecutive patients from initial use up to 2007, using the PubMed database. A heterogeneous group of patients, including 51 patients with pemphigus vulgaris, one with pemphigus vegetans, nine with pemphigus foliaceus, five with paraneoplastic pemphigus, four with epidermolysis bullosa acquisita, and one with both bullous pemphigoid and graft vs host disease was included in this survey. Overall the monoclonal antibody seems to be effective in that 69% of patients showed complete response, 25% of patients showed partial response, whereas 6% of patients showed progressive disease. Six deaths occurred in association with the treatment, with four of these deaths in patients with paraneoplastic pemphigus, a disease characteristically resistant to conventional medication and with a high mortality rate. Of note, 11 patients who received combined rituximab and intravenous immune globulin treatments had the best outcome: complete response without any serious side effects. Therefore further investigation on rituximab with controlled clinical trial is a worthy pursuit.

Treatment of Reticular and Telangiectatic Leg Veins: Double-Blind, Prospective Comparative Trial of Polidocanol and Hypertonic Saline

Background Sixty‐three subjects’ legs were randomized to receive treatment with polidocanol (POL) or hypertonic saline (HS) for telangiectasias and reticular leg veins. Objective To compare the safety and efficacy of two sclerosing agents in three dermatologic surgery practices. Methods After exclusion of saphenofemoral junction incompetence, each subjects veins were categorized (telangiectasias <1 mm and reticular veins 1–3 mm) and randomized. Telangiectasias were treated with POL 0.5% or 11.7% HS and reticular veins with POL 1% or 23.4% HS. An independent, blinded physician determined efficacy and adverse events. Subject satisfaction questionnaires were administered and global clinical improvement assessments performed. Results All patients completed four visits at 0, 1, 4, and 12 weeks. Patients reported significantly greater pain during treatment with HS (2.42) than POL (1.03) (p < .001). There were no significant differences in physician‐assessed improvement of reticular leg veins or telangiectasias; subject‐ or physician‐assessed overall improvement; or physician‐assessed phlebitis, pigmentation, edema, or matting in either of the three practices or the entire cohort. Two subjects developed ulcerations with HS. No ulcerations or allergic reactions developed after POL injections. Conclusion Both agents provided effective treatment, but HS caused 2.35 times as much pain during injections and resulted in two episodes of tissue necrosis.

Autoimmunity to type VII collagen in SKH1 mice is independent of regulatory T cells

Epidermolysis bullosa acquisita is an autoimmune blistering disease characterized by circulating and skin basement membrane‐bound IgG autoantibodies to type VII collagen, a major structural protein of the dermal–epidermal junction. Regulatory T cells (Treg) suppress self antigen‐mediated autoimmune responses. To investigate the role of Treg in the the autoimmune response to type VII collagen in a mouse model, a monoclonal antibody against mouse CD25 was used to deplete Treg. A recombinant mouse type VII collagen NC1 domain protein and mouse albumin were used as antigens. SKH1 mice were used as a testing host. Group 1 mice received NC1 immunization and were functionally depleted of Treg; group 2 mice received NC1 immunization and rat isotype control; and group 3 mice received albumin immunization and were functionally depleted of Treg. Results demonstrated that anti‐NC1 IgG autoantibodies with high titres, as determined by enzyme‐linked immunosorbent assay and Western blotting, developed in all mice immunized with NC1 (groups 1 and 2), but were undetected in group 3 mice. The predominant subclasses of anti‐NC1 autoantibodies were IgG1, IgG2a and IgG2b; furthermore, these antibodies carried only the kappa light chain. IgG autoantibodies in the sera of NC1‐immunized mice reacted with mouse skin basement membrane in vitro and deposited in skin basement membrane in vivo as detected by indirect and direct immunofluorescence microscopy, respectively. Our data suggest that the development of autoimmunity against type VII collagen in mice is independent of Treg function and the autoimmune response is mediated by both Th1 and Th2 cells. We speculate that the basement membrane deposition of IgG may eventually lead to blister development.

An Investigation of Coagulation Cascade Activation and Induction of Fibrinolysis Using Foam Sclerotherapy of Reticular Veins

Background Coagulation parameters have not been investigated when foam sclerotherapy is used to treat reticular leg veins. Objective To evaluate the effect of foam bubbles on coagulation and fibrinolysis by measuring platelet count and concentrations of clotting factors and fibrinogen after foam sclerotherapy with sodium tetradecyl sulfate (STS) mixed with room air. Materials and Methods Patients with reticular veins received treatment with up to 30 mL of foam sclerotherapy prepared with STS and room air in a 1:4 ratio (1 mL STS, 4 mL room air) using the double‐syringe technique. Venous blood was drawn immediately beforesclerotherapy and 15 minutes after the procedure. Pre‐ and post‐treatment laboratory values were compared. Results Subjects treated with up to 30 mL of foam (30 mL foam = 6 mL sclerosing solution and 24 mL air) showed no statistically significant difference in coagulation or fibrinolysis, as measured according to platelet count and concentrations of clotting factors and fibrinogen, after foam sclerotherapy with STS mixed with room air. Conclusion STS foam made with room air, up to 30 mL, when injected into reticular veins does not affect coagulation parameters.

Laser, Light, and Energy Devices for Cellulite and Lipodystrophy

Cellulite affects all races, and it is estimated that 85% of women older than 20 years have some degree of cellulite. Many currently accepted cellulite therapies target deficiencies in lymphatic drainage and microvascular circulation. Devices using radiofrequency, laser, and light-based energies, alone or in combination and coupled frequently with tissue manipulation, are available for improving cellulite. Laser assisted liposuction may improve cellulite appearance. Although improvement using these devices is temporary, it may last several months. Patients who want smoother skin with less visible cellulite can undergo a series of treatments and then return for additional treatments as necessary.