Paul M. Friedman

Microcystic adnexal carcinoma: Collaborative series review and update

BACKGROUND Microcystic adnexal carcinoma (MAC) is a malignant appendageal tumor first described in 1982. It can be clinically and histologically confused with other malignant and benign cutaneous neoplasms, leading to inadequate initial treatment. This neoplasm is locally aggressive and deeply infiltrating, characterized by high morbidity and frequent recurrence. Mohs micrographic surgery has been used to conserve tissue and improve the likelihood for cure. OBJECTIVE We report our experience using Mohs micrographic surgery for the treatment of MAC and compare with earlier reports in the literature. In addition, we review the epidemiology, clinical and histologic characteristics, and optimal treatment of this rare neoplasm. We also describe a 15-year-old white male patient with MAC on the scalp occurring only 7 years after radiation exposure. METHODS The medical records of 11 patients with MAC who were treated by Mohs micrographic surgery were reviewed at both departments, and follow-up data were obtained. RESULTS In all patients treated with Mohs micrographic surgery, there were no recurrences after a mean follow-up of 5 years. CONCLUSION Mohs technique enables the detection of clinically unrecognizable tumor spread and perineural invasion often encountered with MAC. Aggressive initial treatment by microscopically controlled excision appears to offer the greatest likelihood of cure for this neoplasm, while providing conservation of normal tissue. In addition, we describe the second youngest patient with MAC and readdress the issue of previous radiotherapy as an important predisposing factor.

Fractional photothermolysis for the treatment of surgical scars: A case report

Background. Surgical scars are a challenging condition to treat. Fractional photothermolysis provides a promising new modality for treatment. Case report. A 55‐year‐old white female patient with a surgical scar on the chin was treated with fractional photothermolysis (1550 nm FraxelTM SR laser). A single treatment session was performed at pulse energy of 8 mJ (MTZ) and a final density of 2000 MTZ/cm2. The treatment response was assessed by comparing pre‐ and 2‐week post‐treatment clinical photography. Results. A greater than 75% clinical improvement of scarring was achieved at 2 weeks after a single treatment based on independent physician assessment. No significant adverse effects were noted. The improvement was persistent at 1‐month follow‐up. Conclusion. Fractional photothermolysis offers a new, effective, and safe modality for the treatment of surgical scars.

Laser eradication of pigmented lesions: a review.

BACKGROUND Pigmented lesions include solar lentigines, seborrheic keratoses, dermatosis papulosa nigra, ephelides, café‐au‐lait macules, nevus spilus, Beckers nevus, postinflammatory hyperpigmentation, melasma, nevocellular nevi, congenital nevi, junctional and compound melanocytic nevi, nevus of Ota and Ito, Horis nevus, and blue nevi. Advances in laser technology have resulted in the ability to treat pigmented lesions with greater safety and efficacy. OBJECTIVE To review the literature on the use of cutaneous laser treatments for pigmented lesions using Medline. RESULTS The literature cited the use of various lasers to treat pigmented lesions, including argon, carbon dioxide, erbium‐doped yttrium aluminum garnet, Q‐switched, long‐pulsed ruby, alexandrite, diode, and fractional lasers. For each lesion, we describe the efficacy of laser treatments, treatment intervals, and settings used for a variety of diagnoses. CONCLUSION The treatment of pigmented lesions continues to evolve as new laser technology emerges and improvements in existing devices are made. The ability to treat pigmented lesions with greater efficacy and safety has resulted from recent advances in laser technology. The authors have indicated no significant interest with commercial supporters.

Treatment of melasma using fractional photothermolysis: a report of eight cases with long-term follow-up.

BACKGROUND Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities. OBJECTIVES To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method. MATERIALS AND METHODS Eight female patients (Fitzpatrick skin type II–IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3‐ to 8‐week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8–10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow‐up visit 7 to 36 months (mean 13.5 months) after the last treatment session. RESULTS At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow‐up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted. CONCLUSIONS FP is a safe and effective treatment for refractory melasma, with long‐term remission. The authors have indicated no significant interest with commercial supporters.

Fractional Photothermolysis for the Treatment of Postinflammatory Hyperpigmentation

Postinflammatory hyperpigmentation (PIH) is an acquired hypermelanosis of the skin. Development of PIH can occur after any type of inflammation of the skin but is typically seen in association with acne, folliculitis, eczema, and trauma and as a complication of laser resurfacing. Other diseases that may produce this change are lichen planus, lichenoid drug reaction, lupus erythematosus, fixed drug reaction, pityriasis rosea, herpes zoster, insect bite reactions, contact dermatitis, and superficial burns. It is thought that inflammatory interruption of the epidermal–dermal junction is responsible for the development of PIH and that the degree of inflammation and disruption of the epidermal–dermal junction affects the severity of the PIH. Arachidonic acid metabolites and histamine, found in large amounts in inflamed skin, may play a role in the initiation of the development of PIH. Histopathology reveals high levels of epidermal melanin, with melanophages present in the superficial dermis. Lymphohistiocytes are variably present around superficial blood vessels in the dermal papillae. Clinically, lesions appear as irregularly shaped, darkly pigmented macules that coalesce and may persist for months or become permanent. PIH is more commonly seen in people with darker skin types and is found equally in men and women. PIH can occur anywhere on the body and at any age. Resulting cosmetic disfigurement may lead to problems with self-esteem, social interactions and to distress. Treatments for PIH include topical agents such as retinoids, hydroquinone bleaching creams, corticosteroids, dermabrasion, and chemical peels. 6 These treatment modalities have been used with varying success. Topical hydroquinones have been associated with undesirable depigmentation, irritant dermatitis, and ochronosis. Chemical peels and microdermabrasion may cause dyspigmentation and hypertrophic scarring. The Q-switched ruby laser has been used for the treatment of PIH with variable results and for postsclerotherapy hyperpigmentation. Owing to the success of fractional photothermolysis in treating epidermal and dermal pigmented lesions and conditions, it was conjectured that PIH could also be treated with this technology.

Nonablative Fractional Photothermolysis for the Treatment of Striae Rubra

Fractional photothermolysis has proven to be an effective treatment modality for hypopigmented and acne scars. Striae distensae may be considered to be a form of dermal scarring. It was hypothesized that fractional photothermolysis with the 1,550-nm erbium-doped fiber fractionated laser (Fraxel, Reliant Technologies Inc., Mountain View, CA) may be an effective treatment modality for this type of dermal scarring. In the early stages of the condition, changes are more inflammatory in nature, appear purple to red, and are called striae rubra. More advanced lesions, called striae alba, are hypopigmented and atrophic. We report the successful treatment of striae rubra using fractional photothermolysis. To our knowledge, these are the first reported cases of fractional photothermolysis for the treatment of striae rubra.

Eruptive Keratoacanthomas on the Legs After Fractional Photothermolysis: Report of Two Cases

These changes often occur gradually asa person ages but can develop earlier if extensive UVexposure and photodamage have taken place. Whenpatients present early with photodamage, their con-cerns are often cosmetic, inquiring about treatmentsfor rhytides, skin roughness, laxity, and mottledappearance.

Fractional photothermolysis for the treatment of telangiectatic matting: A case report

Background: Recent reports have demonstrated clinical and histologic evidence of the potential benefit of fractional photothermolysis (1550 nm Fraxel SR™ laser) for the treatment of dermal vascular lesions. This report evaluated the potential efficacy of fractional photothermolysis for the treatment of matted telangiectasias. Methods: A 62‐year‐old female, Fitzpatrick skin type III, with matted telangiectasias on her right medial thigh underwent five successive treatments at monthly intervals with the 1550 nm Fraxel SR laser. Digital photographs were taken prior to each treatment and at 6 months after the last treatment. Clinical assessments were performed by a non‐treating physician. Results: Clinical assessment 6 months after the last treatment with the Fraxel SR laser revealed marked improvement in the clinical appearance of the matted telangiectasias. The patients degree of satisfaction paralleled the physicians assessment of improvement. Side effects were limited to mild pain during treatment and mild, transient post‐treatment erythema and edema. Conclusion: Fractional photothermolysis is a potentially effective modality for the treatment of matted telangiectasias and warrants further studies. No long‐term adverse events were noted and the safety profile appears to be fairly broad.

Paradoxical adipose hyperplasia secondary to cryolipolysis: An underreported entity?

Cryolipolysis is a non‐invasive, safe, and effective treatment for localized fat reduction. Paradoxical adipose hyperplasia (PAH) is a rare adverse effect in which patients develop painless, firm, and well‐demarcated tissue masses in the treatment areas approximately 3–6 months following cryolipolysis. The incidence of PAH has been estimated at 0.0051% or 1 in 20,000 treated patients. We report two cases of PAH seen in our practice, which may suggest the incidence is greater than previously reported.

595-nm long pulsed dye laser and 1450-nm diode laser in combination with intralesional triamcinolone/5-fluorouracil for hypertrophic scarring following a phenol peel

Hypertrophic scars and keloids are a therapeutic challenge because of the low response to treatment and recurrences after treatment. A variety of treatment regimens have been used with different degrees of success, with no universally accepted treatment protocol resulting in their complete and permanent resolution. We offer this case to demonstrate a combination approach for the treatment of hypertrophic scarring. A 75-year-old woman (with Fitzpatrick skin type II) presented with a 4-month history of scarring, which had developed following a phenol peel for perioral rhytides. The patient underwent 10 treatment sessions with the 595-nm long-pulsed dye laser followed immediately by the 1450-nm diode laser in combination with intralesional triamcinolone and 5-fluorouracil. After the fifth treatment session, about 90% improvement was noted; at the last treatment session, greater than 95% overall improvement was noted. Two and a half years after the last treatment session, the patient and treating physician noted no regression. A limitation of this therapy is that the combination approach makes it difficult to determine what individual contributions each treatment modality had on the final result. We have illustrated a successful multifaceted treatment regimen for hypertrophic scars and keloids using a combination approach.