Josiane Helou

Fractional laser for vitiligo treated by 10,600 nm ablative fractional carbon dioxide laser followed by sun exposure.

Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo.

Evaluation of Nd:YAG laser device efficacy on onychomycosis: a case series of 30 patients

Until recently, pharmacologic molecules have been the only available treatments for onychomycosis. Laser treatments were introduced for recurrent or resistant cases or in patients in whom oral treatments are contra‐indicated. Some devices were approved by the Food and Drug Administration (FDA). Neodymium yttrium aluminium garnet (Nd:YAG) is used for onychomycosis as a short‐pulse or a long‐pulse system. We aim to evaluate the efficacy of the short‐pulse Nd:YAG in treating onychomycosis, its side effects, cure rates, and 12‐month recurrence rates. Efficacy was evaluated based on a subjective measure of patient satisfaction on a scale from 1 to 10, and an objective measure based on the results of the mycologic cultures. Medical records of 30 patients were reviewed. Ages ranged from 22 to 85, with a mean of 44. Mycologic cure at 12 months was not achieved in 5 patients (16.67%) who had received laser treatment. None of these patients showed any signs of clinical improvement. Twenty patients (66.67%) were completely cured at 12 months, with corroborating negative mycologic cultures. The remaining five patients (16.67%) had discordance between their clinical cure status and their mycologic cultures. Side effects were reported by 7 patients out of 30 (33%): pain within 48 hours of the treatment session, burning sensation in the treated nail bed area. Our primary end point of negative mycologic cultures at 12 months was seen in 24 out of 30 (80%) of our patients. Similar culture cure rates have not been reported before, not even with systemic treatments with oral antifungals. However, few limitations should warrant us (False‐negative results in fungal cultures; time limitation; sample size…). Still, we propose that this alternative should be offered for patients in whom antifungals are contraindicated or for patients previously treated, but not cured by oral antifungals, and in elderly and polymedicated patients.

Diabetic neuropathy and Nd-YAG (1064 nm) laser for onychomycosis: be careful

purpuric papules, nodules and plaques. Laboratory tests: serum albumin 27.3 g/L (40–55); urine analysis, protein1+; Bence Jones proteinuria, weak positive; Quantitative immunoglobulins, IgA 25 g/L (0.82–4.53) and IgM 0.45 g/L (0.46–3.04); Serum protein electrophoresis, albumin 41.5% (46.6–62.6), c-globulin 34.8% (11.6–24.4); Serum immunofixation, light chain amyloid with Kappa and Lambda were positive. Additional examination: Cardiac ultrasonography showed expansion of both atrium, LADi (Left atrial diameter)39 (50 9 44) mm/m. The left ventricle was thickened and there was an enhanced myocardial echo. Aortic valve had degenerative diseases. A small area of pericardial effusion was found, and the sonogram showed a dark liquid area. Scrotum ultrasonography revealed that the scrotal wall was thickened with the depth of 2.15 cm, and there was an enhanced strip echo. A dark liquid area could be found in the scrotum, which suggested a small area of biateral hydrocoele effusion. Bone marrow aspirate and biopsy revealed plasmacytosis of 12% (<2%). Skin biopsy was performed, which showed amorphic acidophilic material in superficial and deep dermis (Fig. 2). PSA leading to a high mortality rate and the median survival is less than 6 months for symptomatic patients without specific treatment. Prognosis is determined by the presence and severity of heart involvement and response to therapy. Left atrial enlargement was an independent predictor of total long-term survival, with an almost 2.5-fold increase in the risk of overall mortality, even after adjusting for other important and independent predictors of mortality in this high-risk population. Our patient presented with multiorgan affected, pathological examination led eventually to the diagnosis. Analysis of his laboratory measurements and additional examination especially the cardiac parameter, we identify that the patient with the highest risk of early mortality. Until we reported this case, at least 13 months after the initial diagnosis, the patient was still alive without treatment, but presented with generalized oedema and poor condition.

Nicolau livedoid dermatitis occurring after sclerotherapy

A 53-year-old woman presented with a lesion within the left popliteal fossa 2 weeks following varicose vein sclerotherapy. Two days following the sclerotherapy (polidocanol 1%), she complained of pain within the injection site that did not respond to anti-inflammatory or analgesic medications. Clinical examination illustrated a livedoid lesion with geographic margins and a necrotic center at the site of injection of polidocanol (Panel). A duplex ultrasound documented occlusion of a small saphenous vein (SSV) tributary and incompetence within the proximal portion of the SSV proper. A diagnosis of Nicolau livedoid dermatitis (NLD) was rendered. Treatment included low-molecular weight heparin (LMWH; enoxaparin 40 mg/day), a class IV topical corticosteroid (clobetasol propionate), and a gradient compression stocking. The pain abated over several days and 10 days later the lesion resolved. NLD is a rare cutaneous reaction at subcutaneous or intramuscular injection sites characterized by intense pain followed by a violaceous livedoid plaque that may evolve to skin necrosis. It often occurs in weak areas (e.g. inguinal folds, popliteal fossa) and is due to direct arterial embolism, ischemia after perivascular compression of the injected product, and/or reflex arterial vasospasm due to para-neural or para-arterial injection. The latter mechanism was thought to underlie the pathogenesis of NLD in our subject. Until recently, it has been rarely reported with varicose vein sclerotherapy.1–4 Treatment of NLD is not well specified. Usual therapy relies on anticoagulants and prednisone.2 We used LWMH and a local potent corticosteroid, not prednisone as is the usual practice,1–4 with an excellent result. Thus, an appropriate topical glucocorticoid agent could replace systemic steroid therapy when treating a focal lesion of NLD. Images in Vascular Medicine

Laser treatment of onychomycosis: beware of ring block anesthesia!

Laser treatment of onychomycosis is a novel treatment modality that improves the cosmetic appearance of the nails. Although no study has yet proved the efficacy of this treatment for onychomycosis, and although it is still not cleared by the FDA for this indication, it has emerged as a safe and effective technique that might enable from prescribing antifungal therapies, thus preventing potential drug interactions and systemic effects. Reported adverse effects ranged from a mild burning sensation to a complete nail loss due to overheating. Most patients only reported mild or no discomfort. In our practice, we experienced two situations of burning after a single laser session. A 57-year-old patient who received a treatment session for his toenail onychomycosis using a novel 0.65-ms pulsed Nd-YAG 1064-nm laser (PinPointe FootLaser, pulse duration 450 μs, PAV 6 W, fluence 200 mJ, frequency 30 Hz). He insisted on having a ring block anesthesia for the toenail to avoid any pain even though it is not recommended in our daily practice. The following day, he presented with excruciating pain, edema, oozing, erythema and a burning sensation (Fig. 1). Similar findings were noted in the second patient. Laser treatment of onychomycosis is based on photothermolysis [1, 2] which relies on a specific wavelength of light to target a precise tissue. The light absorbed by the target area generates sufficient energy to damage the target area while sparing the surrounding area [1]. It is known that fungi are heat sensitive above 55 °C which inhibits their growth and causes cell damage and death [3, 4]. The aim of laser treatment of onychomycosis is to heat the nail bed to temperatures required to disrupt fungal growth (approximately 40– 60 °C) and at the same time avoid pain and necrosis to surrounding tissues [1]. However, overheating could result in nail loss. Therefore, it is recommended to avoid anesthesia so that the patient can feel the increased heat and pain, forcing the operator to pause for some seconds and allowing the heat to dissipate [5]. Our two reported cases demonstrate the value of this recommendation. To reduce pain and avoid cutaneous damage, laser energy format should be either pulsed to allow the dissipation of heat by the tissue through its superior thermal conduction or delivered at a moderate energetic level to prevent tissue damage [2]. Patients should be aware of this rising concern as well as clinicians who should learn how to minimize the risk of adverse effects, sparing the patient possible and irreversible nail damage. Further studies are needed to define the safest and most effective treatment parameters. * Roger Haber roger.haber@net.usj.edu.lb

Depilatory laser: a potential causative factor for inguinal hyperhidrosis: Report of three cases

Abstract Hyperhidrosis has recently been described as a novel adverse effect of laser-assisted hair removal in the axillary area. Inguinal Hyperhidrosis (IH) is a localized and, typically, a primary form of hyperhidrosis affecting the groin area in individuals before age 25. IH has been reported in the literature after traumas and as a dysfunction of the central sympathetic nervous system. To the best of our knowledge, IH has never been reported as secondary to laser-assisted hair removal. Herein, we report three cases of IH following depilatory laser of the inguinal zone. Three female patients with no relevant medical history presented with the complaint of excessive sweating in the inguinal area after undergoing full bikini depilatory laser sessions. Although never described before, depilatory laser seems to trigger the occurrence of hyperhidrosis in the inguinal zone.

Fractional CO2 laser treatment for a skin graft.

Skin grafts are widely used in reconstructive and plastic surgery, leaving an inevitable scar appearance on the body, affecting the quality of life of the patients. Fractional ablative lasers have become a leading procedure for the treatment of acne and burn scars. We report a case of a skin graft showing excellent improvement in overall appearance after three sessions of fractional CO2 laser. The undamaged tissue left between the microthermal treatment zones is responsible of collagen formation and reepithelialization. Remodeling and collagen formation are observed even 6 months after a fractional CO2 laser session.

Intractable Localized Inguinal Pruritus as a Sign of Primary Hyperparathyroidism

Generalized pruritus is a well-known complication of primary hyperparathyroidism. We present the first case of primary hyperparathyroidism presenting as a severe localized inguinal pruritus. Pruritus completely resolved after subtotal parathyroidectomy suggesting that intractable cutaneous symptoms like pruritus might be added to the current approved indications of parathyroidectomy in primary hyperparathyroidism. This study also discusses the pathophysiology of pruritus in hyperparathyroidism.

Less Pain, More Gain: Lip Augmentation With Insulin Syringes

In addition, the relatively large size of the cannulas and proprietary filler needles can cause postoperative edema and bruising. Lip augmentation is a very delicate procedure that requires injection of small volumes of hyaluronic acid in the vermilion border and in the lip body. Accurate estimation of the amount injected can be difficult resulting in asymmetrical lips. Insulin syringes have been previously used for filler injection with good cosmetic results and a favorable safety profile.

A case of generalized bromhidrosis following whole-body depilatory laser.

Background: Laser treatment is a widespread method for hair removal. Despite its very common use, side effects remain relatively rare and transient. Objective: Axillary hyperhidrosis and bromhidrosis have already been reported in the literature after depilatory lasers. We report here a novel side effect of total body bromhidrosis following hair removal laser. Results: A 27-year-old man, phototype 3 underwent four sessions of total body depilatory laser, combining pulsed alexandrite and pulsed diode lasers. A few days afterwards, a generalized foul odor was noted and was resistant to regular deodorants and Aluminum chloride based antiperspirants. Possible mechanisms include the activation of dormant bacteria in the skin flora, sweat gland dysfunction, altered skin flora, sweat gland hormone receptor disturbances, and genetic factors. Conclusion: Total body bromhidrosis and hyperhidrosis are potential complications of total body laser hair removal.