Kavitha K. Reddy

Successful and Rapid Treatment of Blue and Green Tattoo Pigment With a Novel Picosecond Laser

BACKGROUND While the understanding and technology of laser tattoo removal has advanced much over the last 5 decades, treatments and results remain far from perfect. With currently available devices, treatment courses are often painful and prolonged with mixed results. We describe the successful and rapid treatment of 12 tattoos containing blue and/or green pigment with a novel, picosecond, 755-nm alexandrite laser. OBSERVATIONS All previously untreated multicolored tattoos as well as tattoos recalcitrant to treatment demonstrated at least 75% clearance of blue and green pigment after 1 or 2 treatments with a novel, picosecond, 755-nm alexandrite laser. More than two-thirds of these tattoos approached closer to 100% clearance. CONCLUSIONS While additional future studies are needed, we believe that this new technology is more effective in targeting blue and green pigment, resulting in expedited clearance with less collateral injury to surrounding tissue.

Laser treatment of port-wine stains

Port-wine stains are a type of capillary malformation affecting 0.3% to 0.5% of the population. Port-wine stains present at birth as pink to erythematous patches on the skin and/or mucosa. Without treatment, the patches typically darken with age and may eventually develop nodular thickening or associated pyogenic granuloma. Laser and light treatments provide improvement through selective destruction of vasculature. A variety of vascular-selective lasers may be employed, with the pulsed dye laser being the most common and well studied. Early treatment produces more optimal results. Advances in imaging and laser treatment technologies demonstrate potential to further improve clinical outcomes.

Histologic mimickers of mycosis fungoides: a review

Abstract:  Mycosis fungoides (MF) is a rare type of non‐Hodgkin’s lymphoma affecting the skin. Because MF develops slowly over several years and may have a variety of clinical presentations, including itchy patches, plaques or tumors that may be confused with common benign conditions such as eczema and psoriasis, the disease presents a diagnostic challenge. The average time to diagnosis varies but is frequently as long as 3 to 6 years. Skin biopsies frequently reveal non‐specific features of several dermatoses; thus, histologic evaluation of the disease is also challenging. Importantly, various significant and/or benign conditions may mimic MF histologically and result in a misdiagnosis of MF. Here we review the reported histologic mimickers of MF and discuss both similar and differentiating features of each, in order to aid in more accurate interpretation of diagnostically challenging skin biopsies. Clinicopathologic correlation is ultimately essential to make accurate diagnosis of MF and its histologic mimickers.

Atypical (Dysplastic) Nevi: Outcomes of Surgical Excision and Association With Melanoma

OBJECTIVE To evaluate the effect of surgical excision, performed after biopsy diagnosis of dysplastic nevus, on final diagnosis, melanoma prevention, and melanoma detection. DESIGN, SETTING, AND PARTICIPANTS Outcome study using retrospective review conducted in an academic dermatopathology practice (Boston Medical Center Skin Pathology Laboratory) that receives specimens from community and academic practices across the United States. Consecutive patient pathology samples of dysplastic nevi and cutaneous melanomas evaluated between September 1, 1999 and March 1, 2011, and identified using systematized nomenclature of medicine codes were included. MAIN OUTCOMES AND MEASURES In dysplastic nevi cases, the rate of clinically significant change in diagnosis and the rate of melanoma detection as a result of excision. In melanoma cases, the rate and characteristics of association with dysplastic nevus. RESULTS Of dysplastic nevi, 196 of 580 (34%) showed a positive biopsy margin, increasing with grade of atypia (P < .001); 127 of 196 with positive biopsy margin received excision (65%), performed more often as grade of atypia increased (P < .001). Two excisions (2 of 127, 1.6%) resulted in a clinically significant change in diagnosis, from biopsy-diagnosed moderately-to-severely dysplastic nevi before excision to melanoma in situ after excision. In melanomas (n = 216), in situ and superficial spreading subtypes were more often associated with dysplastic nevi (20% and 18%, respectively) (P = .002), most often of moderate-to-severe or severe grade. CONCLUSIONS AND RELEVANCE Excision of biopsy-diagnosed mildly or moderately dysplastic nevi is unlikely to result in a clinically significant change in diagnosis, and risk of transformation to melanoma appears very low. Moderately-to-severely and severely dysplastic nevi are more often associated with melanoma, and excision may be beneficial for melanoma detection or prevention.

Common complementary and alternative therapies with potential use in dermatologic surgery: Risks and benefits

BACKGROUND Ambulatory surgery patients often use complementary and alternative medicine (CAM) therapies. CAM therapies may create beneficial and detrimental perioperative conditions. OBJECTIVE We sought to improve knowledge of CAM effects in dermatologic surgery, allowing dermatologists to potentially capitalize on therapeutic actions and to mitigate complications. METHODS PubMed literature search of CAM therapies in dermatologic and surgical settings was performed. Common CAM therapies with possible effects on dermatologic surgery were selected. Beneficial and detri-mental effects were reviewed. RESULTS A myriad of products may be used perioperatively by the patient. Therapies appearing to have some evidence for potential benefit include bromelain, honey, propolis, arnica, vitamin C and bioflavonoids, chamomile, aloe vera gel, grape seed extract, zinc, turmeric, calendula, chlorella, lavender oil, and gotu kola. Potential complications vary according to product and include platelet inhibition, contact dermatitis and, in rare cases, systemic toxicity. LIMITATIONS This review focuses on CAM having significant published studies evaluating efficacy for wound healing, anti-inflammatory, antipurpuric, or perioperative-related use. Most published studies have been small and often have design flaws. The scope of CAM is large and not all therapies are discussed. CONCLUSION Selected CAM therapies have been reported to promote wound healing, reduce edema or purpura, and provide anti-inflammatory effects. Because of high rates of CAM use, surgeons should familiarize themselves with common uses, potential benefits, and complications. Further study of effects in the dermatologic surgery setting may improve the patient-doctor relationship and enhance outcomes.

Retrospective Study of the Treatment of Infantile Hemangiomas Using a Combination of Propranolol and Pulsed Dye Laser

BACKGROUND Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone. OBJECTIVES To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated with propranolol alone. MATERIALS AND METHODS Retrospective review of facial‐segmental IH treated with propranolol and PDL and controls treated with propranolol was conducted. Blinded physicians used patient photographs to select clearance level and the earliest date of near‐complete clearance. Days of propranolol, PDL sessions, and propranolol dose, each until date of near‐complete clearance; total days of propranolol; and total propranolol dose were recorded. RESULTS Infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance (6/12) more often than IH treated with propranolol followed by PDL (2/5) or IH treated with propranolol alone (1/8; difference in clearance scores p = .01) and achieved near‐complete clearance after fewer days of propranolol (mean 92 days for concurrent propranolol and PDL vs 288 days for propranolol; p < .001). Cumulative propranolol dose until near‐complete clearance was lowest in the concurrent propranolol and PDL group (149.16 vs 401.25 mg/kg for propranolol; p < .001). CONCLUSION Facial‐segmental IH treated with propranolol and PDL displayed morerapid and complete clearance and required a lower cumulative propranolol dose to achieve near‐complete clearance.

1927-nm Fractional resurfacing of facial actinic keratoses: A promising new therapeutic option

BACKGROUND Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. OBJECTIVE We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. METHODS This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. RESULTS At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. LIMITATIONS This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. CONCLUSION The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option.

Ablative Fractional Resurfacing for Involuted Hemangioma Residuum

BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

Calcium Hydroxylapatite Nodule Resolution After Fractional Carbon Dioxide Laser Therapy

BACKGROUND Injection of calcium hydroxylapatite filler may result in nodule formation owing to superficial placement of the filler. Calcium hydroxylapatite nodules are difficult to reverse. Previously reported therapeutic options are limited and include intralesional triamcinolone, massage, needling, and excision, each with inconsistent results or potential for scarring. OBSERVATION We have observed complete resolution of calcium hydroxylapatite nodules after a single treatment with fractional carbon dioxide laser. CONCLUSIONS A single session of fractional carbon dioxide laser treatment may resolve selected cases of calcium hydroxylapatite nodules. The mechanism of action may involve conversion of the product into tricalcium phosphates which dissolve readily. This novel therapeutic technique may enhance treatment options for a difficult clinical problem.

Topical perfluorodecalin resolves immediate whitening reactions and allows rapid effective multiple pass treatment of tattoos.

Laser tattoo removal using multiple passes per session, with each pass delivered after spontaneous resolution of whitening, improves tattoo fading in a 60‐minute treatment time. Our objective was to evaluate the safety and efficacy of topical perfluorodecalin (PFD) in facilitating rapid effective multiple‐pass tattoo removal.