Vicki J. Levine

Adverse effects associated with the 577- and 585-nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: A study of 500 patients

BACKGROUND The flashlamp-pumped pulsed dye laser has been used in the treatment of cutaneous vascular disorders since 1986. Although this laser is now widely used for the treatment of port-wine stains, telangiectases, and hemangiomas, the incidence of adverse reactions has not been clearly defined in a large series of patients. OBJECTIVE We assessed the incidence of adverse effects associated with the use of the pulsed dye laser in the treatment of vascular lesions. METHODS We studied 500 patients undergoing pulsed dye laser treatments for port-wine stains, telangiectases, and hemangiomas. All patients were examined during the course of their treatment to assess the incidence of adverse effects associated with the use of the pulsed dye laser. RESULTS There were no cases of hypertrophic scarring. The incidence of atrophic scarring was less than 0.1%. A spongiotic dermatitis was seen in 11 of 297 patients (0.04%) after multiple treatments of port-wine stains. Hyperpigmentation was seen in five of 500 patients (1%), whereas transient hypopigmentation was seen in 13 (2.6%). CONCLUSION These findings demonstrate that the flashlamp-pumped pulsed dye laser is safe for the treatment of port-wine stains, telangiectases, and hemangiomas in children and adults.

Allergic Reactions to Tattoo Pigment after Laser Treatment

BACKGROUND Cutaneous allergic reactions to pigments found in tattoos are not infrequent. Cinnabar (mercuric sulfide) is the most common cause of allergic reactions in tattoos and is probably related to a cell‐mediated (delayed) hypersensitivity reaction. OBJECTIVE The purpose of these case presentations is to describe a previously unreported complication of tattoo removal with two Q‐switched lasers. RESULTS Two patients without prior histories of skin disease experienced localized as well as widespread allergic reactions after treatment of their tattoos with two Q‐switched lasers. CONCLUSION The Q‐switched ruby and neodymium:yttrium‐aluminum‐garnet lasers target intracellular tattoo pigment, causing rapid thermal expansion that fragments pigment‐containing cells and causes the pigment to become extracellular. This extracellular pigment is then recognized by the immune system as foreign.

Laser Removal of Tattoos

Tattoos are placed for different reasons. A technique for tattoo removal which produces selective removal of each tattoo pigment, with minimal risk of scarring, is needed. Nonspecific methods have a high incidence of scarring, textural, and pigmentary alterations compared with the use of Q-switched lasers. With new advances in Q-switched laser technology, tattoo removal can be achieved with minimal risk of scarring and permanent pigmentary alteration.There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic. Amateur tattoos require less treatment sessions than professional multicolored tattoos. Other factors to consider when evaluating tattoos for removal are: location, age and the skin type of the patient.Treatment should begin by obtaining a pre-operative history. Since treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anaesthesia cream may be used prior to laser treatment. Topical broad-spectrum antibacterial ointment is applied immediately following the procedure.Three types of lasers are currently used for tattoo removal: Q-switched ruby laser (694nm), Q-switched Nd:YAG laser (532nm, 1064nm), and Q-switched alexandrite laser (755nm). The Q-switched ruby and alexandrite lasers are useful for removing black, blue and green pigments. The Q-switched 532nm Nd:YAG laser can be used to remove red pigments and the 1064nm Nd:YAG laser is used for removal of black and blue pigments.The most common adverse effects following laser tattoo treatment with the Q-switched ruby laser include textural change, scarring, and pigmentary alteration. Transient hypopigmentation and textural changes have been reported in up to 50 and 12%, respectively, of patients treated with the Q-switched alexandrite laser. Hyperpigmentation and textural changes are infrequent adverse effects of the Q-switched Nd:YAG laser and the incidence of hypopigmentary changes is much lower than with the ruby laser. The development of localized and generalized allergic reactions is an unusual complication following tattoo removal with the Q-switched ruby and Nd:YAG lasers.Since many wavelengths are needed to treat multicolored tattoos, not one laser system can be used alone to remove all the available inks and combination of inks. While laser tattoo removal is not perfect, we have come a long way since the advent of Q-switched lasers. Current research is focusing on newer picosecond lasers, which may be more successful than the Q-switched lasers in the removal of the new vibrant tattoo inks.

Er:YAG Laser for the Treatment of Actinic Keratoses

Background. There is no single optimal treatment for multiple facial actinic keratoses. The existing therapies such as topical 5‐fluorouracil, chemical peels, cryotherapy, dermabrasion, and CO2 laser resurfacing can produce prolonged recovery time or are often operator dependent. Objective. The purpose of this study was to investigate another therapeutic modality which provides a shorter recovery time with uniform results. We performed a prospective pilot study investigating the use of the Er:YAG laser for the treatment of multiple facial actinic keratoses. Methods. Five patients with multiple facial actinic keratoses were treated with two to three passes of Er:YAG laser. Anesthesia was achieved in all cases by topical application and local infiltration when indicated. All patients were treated with 2.0 J, 5 mm spot size, and a fluence of 10 J/cm2. Clinical and histologic evaluations were performed both pre‐ and postoperatively. Results. All patients showed a decrease in the total number of clinical actinic keratoses on the face ranging from 86 to 96%. In addition to the reversal of actinic damage in the epidermis, histologic evidence revealed increased fibroplasia and decreased superficial solar elastosis 3 months after the laser resurfacing. Reepithelialization occurred in 5–8 days, and erythema lasted for about 3–6 weeks after the procedure. There was no evidence of scarring or pigmentary changes in any of the patients during the follow‐up period. Conclusion. Er:YAG laser skin resurfacing is a safe and effective treatment for multiple facial actinic keratoses. Histologic data suggest a new zone of collagen deposition occurs in the superficial papillary dermis. Under our current parameters, Er:YAG laser skin resurfacing has a relatively short recovery period and a low risk of scarring. Unlike the CO2 laser, Er:YAG laser skin resurfacing can be performed with topical anesthesia alone.

Short-pulse carbon dioxide laser resurfacing in the treatment of rhytides and scars : A clinical and histopathological study

background. Previous studies have shown the efficacy of short‐pulse carbon dioxide (CO2) lasers in the treatment of rhytides and scars. To date, there have been few studies examining the histological aspects of these treatments. objective. The purpose of this study was to perform a prospective clinical and histopathological study of CO2 laser resurfacing for improvement of facial rhytides and scars. methods. A total of 23 patients were studied. Clinical improvement was evaluated both pre‐ and postoperatively using photographs and optical profilometry. Skin biopsies of rhytides were also obtained. results. Postoperatively, rhytides and scars both demonstrated significant increases in clinical improvement scores. Results from optical profilometry studies reflected these results. Skin biopsies from rhytides posttreatment demonstrated increases in collagen layer thickness. Improvement was sustained as late as 1 year following treatment. conclusions. Histopathological studies suggest improvement of rhytides and scars by CO2 laser resurfacing may be attributed to new collagen formation following treatment.

Procedural dermatology training during dermatology residency: A survey of third-year dermatology residents

BACKGROUND Given the expanding role of multiple surgical procedures in dermatology, resident training in procedural dermatology must be continually assessed to keep pace with changes in the specialty. OBJECTIVE We sought to assess the third-year resident experience in procedural dermatology during residency training. METHODS This survey study was mailed to third-year dermatology residents at 107 Accreditation Council for Graduate Medical Education (ACGME)-approved dermatology residency programs in 2009. RESULTS A total of 240 residents responded (66%), representing 89% of programs surveyed. Residents assume the role of primary surgeon most commonly in excisional surgery (95%) and flap and graft reconstruction (49%) and least often in Mohs micrographic surgery (18%). In laser and cosmetic procedures, the resident role varies greatly. Residents believed they were most prepared in excisional surgery, botulinum toxin, and laser surgery. Residents believed it was sufficient to have only knowledge of less commonly performed procedures such as hair transplantation, tumescent liposuction, and ambulatory phlebectomy. Of responding residents, 55% were very satisfied with their procedural dermatology training during residency. LIMITATIONS Individual responses from residents may be biased. Neither residency program nor dermatologic surgery directors were surveyed. CONCLUSION This survey confirms dermatology residents received broad training in procedural dermatology in 2009, in keeping with ACGME/Residency Review Committee program guidelines. The results provide feedback to dermatology residency programs and are an invaluable tool for assessing, modifying, and strengthening the current procedural dermatology curriculum.

A clinical and histologic evaluation of two medium-depth peels : Glycolic acid versus Jessner's trichloroacetic acid

BACKGROUND. Chemical peels using alpha hydroxy acids have become one of the most frequently requested dermaiologic procedures. The use of glycolic acid in superficial chemical peels is now well established. However, the role of glycolic add in medium‐depth chemical peels has yet to be elucidated. OBJECTIVE. We performed a clinical and histologic comparison of 70% glycolic acid versus fessners solution as part of a medium‐depth chemical peel using 35% trichloroacetic acid (TCA). METHODS. Thirteen patients with actinic keratoses, solar lentigines, and fine wrinkling were evaluated praspectively. Each patient was treated with 70% glycolic acid plus 35% TCA (GA‐TCA) to the right face and Jessners solution plus 35% TCA (JS‐TCA) to the left face. Clinical and histologic changes were evaluated at 7, 30, and 60 days postoperatively. RESULTS. Clinically, the GA‐TCA peel was effective in treating photodamaged skin. The GA‐TCA peel was slightly more efficacious in removing actinic keratoses (clinical response score = 1.5) than the JS‐TCA peel (clinical response score = 1.0). His‐tologically, the GA‐TCA peel caused the formation of a slightly thicker Grenz zone (mean = 0.053 mm) 60 days postpeel than the JS‐TCA peel (mean = 0.048 mm) (not statistically significant). The GA‐TCA peel caused more neoelastagenesis than the JS‐TCA peel, while the JS‐TCA peel resulted in more papillary dermal fibrosis and neavascularization than the GA‐TCA peel. CONCLUSION. The GA‐TCA peel is a new medium‐depth chemical peel that is effective in treating photodamaged skin.

Laser treatment of congenital and acquired vascular lesions. A review.

Several quasi-continuous-wave and pulsed lasers can effectively treat a variety of vascular lesions. The pulsed dye laser and its newer variants were specifically designed to target hemoglobin and, by increasing their wavelengths slightly, have successfully achieved greater depths of penetration. When used in to compliance with the theory of selective photothermolysis, these systems have been shown to be safe and to have a low incidence of adverse sequelae. With the concomitant use of epidermal cooling systems, side-effect profiles have been further reduced. Although great progress has been made in the laser treatment of leg telangiectasias, even the newest laser systems have failed to meet patient expectations. Continuing advances in laser technology, however, will probably lead to enhanced clinical results, decreased side-effect profiles, improved hardware, and reduced costs.

Comparison of high-energy pulsed carbon dioxide laser resurfacing and dermabrasion in the revision of surgical scars.

background. Both dermabrasion and high‐energy pulsed carbon dioxide (CO2) laser resurfacing can improve the appearance of surgical scars. Although the results of these two procedures have been compared using historical data, a prospective evaluation has never been performed in humans. objective. To prospectively compare the clinical effects of dermabrasion and high‐energy pulsed CO2 laser resurfacing in the revision of surgical scars. methods. Facial surgical scars in four patients were prospectively revised using a split scar model. One half of the scar was dermabraded and the other half was resurfaced with the high‐energy pulsed CO2 laser. Comparisons of the two treatment modalities were performed through clinical assessment, photographic evaluation, and textural analysis of the scars. results. The high‐energy pulsed CO2 laser‐resurfaced halves of the scar were bloodless with less postoperative crusting in comparison with the dermabraded halves. Reepithelialization time and degree and duration of postoperative erythema were similar for both treatment halves. Photographic evaluation and textural analysis showed comparable improvement in the clinical appearance and surface texture of the scars with both treatment modalities. conclusions. Both the high‐energy pulsed CO2 laser and dermabrasion can achieve comparable clinical improvement in the revision of surgical scars. The high‐energy pulsed CO2 laser offers the advantage of a bloodless field and a more precise method of tissue ablation. Postoperative erythema, however, is an expected finding with both treatment modalities.

LASER TREATMENT OF ACQUIRED VASCULAR LESIONS

Several quasi-continuous wave and pulsed lasers can effectively treat a variety of vascular lesions. The PDL follows the theory of selective photothermolysis, is safe for infants and children, and has a low incidence of side effects. It is successful in treating telangiectasias, spider and cherry angiomas, pyogenic granulomas, venous lakes, and poikiloderma of Civatte, as well as small leg telangiectasias. Quasi-continuous wave lasers such as the APTDL, copper vapor, krypton, and KTP lasers can be used to treat telangiectasias and other vascular lesions as well. Although they carry a higher risk of complications, they may prove more useful in treating larger caliber vessels. Although the PDL often produces superior clinical results than the quasi-continuous wave lasers, some patients may prefer these latter lasers because of the lack of post-operative purpura. Lastly, newer lasers, as well as noncoherent light sources, are being developed for the treatment of leg telangiectasias. Continuing advances in laser technology will enhance results, decrease side effects, improve equipment, and reduce costs, with great benefit to an increasing patient population.