Dermatologic Surgery

In recent years, chemical peels have become increasingly popular in the treatment of melasma. However, postpeel hyperpigmentation is a frequently encountered side effect, especially in dark-skinned individuals. The role of priming agents in preventing this complication has not been adequately evaluated. Hence, we studied the effect of hydroquinone versus tretinoin as priming agents in minimizing the incidence of this side effect in a double-blind, randomized clinical trial of 50 patients with melasma. Of a total of 50 patients, 25 patients each with a similar skin phototype, the nature and severity of melasma were assigned to groups I and II. The patients were primed with 2% hydroquinone in group I, and in group II with 0.025% tretinoin once daily (night time) 2 weeks before starting trichloroacetic acid peels. Subsequently, all of them received trichloroacetic acid peels at intervals of 2 weeks for 12 weeks, followed by monthly peels for next 12 weeks during the follow-up period. Patients continued to use a sunscreen with an SPF of greater than 15 and the recommended priming agent during the follow-up. Final assessment was made at 6 months, based on the impression of the patient, clinical examination by the physician, and photographic analysis. A total of 50 patients (25 in each group) participated in the study. The predominant Fitzpatrick skin type observed among them was type IV (56%), and the type of melasma was mixed (44%). The final results at 12 weeks were comparable in two groups. However, a significant difference was seen in the two groups during the follow-up period, with continued improvement in 24% and worsening in 28% of patients in group I and continued improvement in only 16% and worsening in 40% in group II patients. Hydroquinone is superior to tretinoin as a priming agent in maintaining the results achieved with peels and in decreasing the incidence of postpeel reactive hyperpigmentation.

Chemical peels have become a popular modality in the treatment of melasma. The most disturbing side effect of this procedure is postinflammatory hyperpigmentation. This may be minimized with the help of priming agents. Because there is a paucity of such studies, this study was taken up to evaluate the beneficial effects of hydroquinone versus tretinoin as priming agents in treatment of melasma with glycolic acid peels. Sixty patients of melasma were randomly assigned in three groups of 20 patients each in a single-blind study. Group I received only glycolic acid peels while Groups II and III were primed with 0.025% tretinoin and 2% hydroquinone, respectively, for 2 weeks before peeling. The patients received serial glycolic acid peels fortnightly for the first 3 months and then monthly for the next 3 months and were then followed up for the next 3 months when peeling was stopped. Clinical and photographic evaluation was done at 3, 6, and 9 months, and subjective improvement was noted. There was an overall decrease in MASI from baseline to 6 months in all three groups but it was highly significant between Groups I and III (p<.001) at 6 and 9 months and significant between Groups II and III (p<.01) at 9 months. Results are better with hydroquinone as priming agent compared to tretinoin in enhancing the results with glycolic acid peels in melasma and in decreasing postpeel postinflammatory hyperpigmentation.

The authors have indicated no significant interest with commercial supporters.

Ocularly applied bimatoprost 0.03% is associated with increased eyelash growth. To assess the safety, efficacy, and subjective experience of using dermal application of bimatoprost 0.03% for the growth of natural eyelashes. Prospective, open-label study of subjects who desired longer, thicker (fuller), and darker natural eyelashes. Bimatoprost was applied to the upper lid margin once daily for 12 weeks. Adverse events and intraocular pressure were assessed, and subjects completed health outcomes questionnaires. Eyelash growth and darkening were scored using photographs taken at weeks 1 and 12. All subjects were female (N=28). No serious or unexpected adverse events were reported. The mean change from baseline intraocular pressure was less than 1 mmHg at each time point, but was statistically significant at weeks 1 and 4 (p< or =.047). At week 12, all subjects had noticed significant growth or darkening. Post hoc analysis of photographs corroborated these reports (p<.001). Bimatoprost was found safe for eyelid application and was associated with enhanced eyelash growth. All subjects noticed favorable changes in the appearance of their eyelashes.

Topical treatment of striae rubra with 0.1% tretinoin and laser treatment of striae rubra and alba with the 585-nm pulsed dye laser are proven therapeutic options. However, little efficacy has been shown for treatment of striae alba topically, and the laser is currently not a suitable treatment option for darker ethnic skin types. The purpose of this study was to demonstrate that selected commercial topical agents can improve the appearance of striae alba. Ten patients of varying skin types (I-V) having straie distensae alba on the abdomen or thighs were selected to evaluate the effectiveness of two topical treatment regimens. Patients were placed on daily topical application of 20% glycolic acid (MD Forte) to the entire treatment area. In addition, the patients applied 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine to half to the treatment area and 0.05% tretinoin emollient cream (Renova) to the other half of the treatment area. The creams were applied on a daily basis for 12 weeks. Improvement was evaluated at 4 and 12 weeks in an objective unblinded fashion at the follow-up visits, a objective blinded fashion by visual grading at the conclusion of the study, and in an objective blinded fashion with profilometry. Additionally, histopathologic analysis was performed. Analysis of these data reveals: 1) both regimens can improve the appearance of stretch marks; 2) these topical therapy regimens are safe and effective in study patients with minimal irritation; 3) elastin content within the reticular and papillary dermis can increase with topical 20% glycolic acid combined with 0.05% tretinoin emollient cream therapy; 4) both regimens increased epidermal thickness and decreased papillary dermal thickness in treated stretch marks when compared with untreated stretch marks; 5) combined epidermal and papillary dermal thickness in stretch marks treated with either topical regimen approaches that of normal skin; and 6) profilometry can objectively measure differences in skin texture associated with striae treatments when compared to controls, however, it is not sensitive enough to justify comparison or quantitative improvements between similarly effective treatments.

Mild to moderately photodamaged skin is characterized by dyspigmentation, fine wrinkles, and tactile roughness. An optimal approach to the topical treatment of photoaging would simultaneously address all appearance issues. This study was undertaken to evaluate the effect of 4% hydroquinone and 0.3% retinol in photoaging. A 16-week study was designed to evaluate the efficacy and tolerance of a single cream containing prescription topical 4% hydroquinone for dyspigmentation and the cosmeceutical 0.3% retinol for fine wrinkles in an emollient vehicle for tactile roughness. This novel formulation was compared with 0.05% tretinoin emollient cream, the standard against which all other topical photoaging treatments are compared. Investigator assessments, subject assessments, and photography represented the evaluation end points. The cosmeceutical emollient 4% hydroquinone/0.3% retinol cream more effectively diminished the collective signs of photodamage than 0.05% tretinoin emollient cream in terms of dyspigmentation, fine wrinkles, and tactile roughness in 16 weeks. Combination therapy of hydroquinone and retinol may improve photoaging-associated hyperpigmentation.

The authors have indicated no significant interest with commercial supporters.

It is commonly requested that perioral and lateral canthal rhytides, which result from extrinsic and intrinsic factors, be rejuvenated. To valuate the safety and efficacy of and patient satisfaction with injectable hyaluronic acid (HA) with 0.3% lidocaine hydrochloride in reducing superficial, vertical perioral wrinkles and superficial, horizontal, lateral canthal rhytides. This was a two-center, evaluator-masked, 180-day study in which 40 patients with moderate to severe superficial, vertical perioral lines or superficial, horizontal, lateral canthal lines were treated at their baseline visit with up to three 0.9-mL syringes of HA (5.5 mg/mL) with 0.3% lidocaine hydrochloride. The investigator and a blinded evaluator assessed patients 7 days after treatment and then every 30 days after the initial treatment session for 180 days. Subjects experienced statistically significant improvement in their superficial, vertical perioral lines and superficial, horizontal, lateral canthal lines and maintained those results for 180 and 120 days, respectively. Three patients experienced delayed-onset periocular nodule formation associated with swelling and erythema at sites of injection, which were histologically consistent with a granulomatous reaction to the product. Injectable HA with a particle size of 350 μm was efficacious and resulted in high patient improvement scores in improving moderate to severe superficial, vertical perioral lines and superficial, horizontal, lateral canthal lines. Three of the 40 enrolled patients demonstrated granuloma formation.

Dermicol-P35 27G, an advanced collagen dermal filler, is effective for nasolabial fold (NLF) correction. To compare the efficacy and tolerance of Dermicol-P35 27G premixed with lidocaine with that of Dermicol-P35 27G injected after topical anesthesia for NLF correction. In a split-face protocol, 10 patients were injected with Dermicol-P35 27G/topical anest:esia or Dermicol-P35 27G/0.3% lidocaine. Patients were monitored for adverse events and for pain using the Thermometer Pain Scale (TPS) and a visual analog scale (VAS). Efficacy was measured using the Modified Fitzpatrick Wrinkle Scale and the Global Aesthetic Improvement Scale. Patients experienced significantly less pain with Dermicol-P35 27G/0.3% lidocaine than with Dermicol-P35 27G/topical anesthesia (mean clinician-assessed TPS scores +/- standard deviation: 2.0 +/- 0.8 and 5.2 +/- 2.1, respectively, p<.001). Patients reported less discomfort with Dermicol-P35 27G/0.3% lidocaine than with Dermicol-P35 27G/topical anesthesia (mean VAS scores: 2.0 +/- 1.0 and 6.3 +/- 2.0, respectively, p<.001; TPS scores: 2.3 +/- 0.6 and 5.4 +/- 1.2, respectively, p<.001). Both treatments yielded similar efficacy scores and were well tolerated. Adverse events were mild. Dermicol-P35 27G/0.3% lidocaine resulted in less pain than Dermicol-P35 27G/topical anesthesia, with no observed reduction in efficacy.

Laser and intense pulsed light device treatments of leg veins have generally yielded disappointing results. Use of longer wavelengths, longer pulse widths, and better cooling devices have recently sparked renewed interests in these methods. To prospectively compare, side by side, a 3-msec cryogen spray-equipped 755 nm alexandrite, a sapphire window cooled super-long-pulse 810 nm diode, and a variable pulse width, cryogen spray-equipped 1064 nm Nd:YAG laser for the treatment of 0.3-3mm leg veins. Thirty female volunteers, skin types I-V, age 32-67 years with comparable sets of leg veins were treated with the Nd:YAG laser and either the diode laser, alexandrite laser, or both. In most patients two to three sets of comparable sites were treated. Treatment parameters varied with each laser and according to the size of veins being treated. Patients were examined 1 week after each treatment and at 1, 2, and 3 months after the last treatment. Pre- and posttreatment 35mm photographs were taken. Improvement was judged by two experienced physicians both visually on patients and by comparison of pre- and posttreatment photographs. Results were graded as percent resolution, in five groups, 0%, 0-25%, 25-50%, 50-75%, and 75-100%. In the 22 patients completing the study, 36 leg vein sites were treated with the Nd:YAG laser, 18 leg vein sites were treated with the diode laser, and 12 leg vein sites were treated with the alexandrite laser. Greater than 75% improvement was observed at 88% of the Nd:YAG laser-treated sites, 29% of the diode laser-treated sites, and 33% of the alexandrite laser-treated sites. Greater than 50% improvement was observed at 94% of the Nd:YAG laser-treated sites, 33% of the diode laser-treated sites, and 58% of the alexandrite laser-treated sites. Less than 25% improvement was observed at 6% of the Nd:YAG laser-treated sites, 39% of the diode laser-treated sites, and 33% of the alexandrite laser-treated sites. Pain during treatment was variably perceived by patients, but occasionally sufficient for patients to decline further treatment. Posttreatment purpura and telangiectatic matting were a significant drawback for the alexandrite laser. Transient hemosiderin pigmentation, as seen with sclerotherapy, was common with larger vessels. The cryogen spray-equipped 1064 nm Nd:YAG laser was remarkably effective and safe for the treatment of 0.3-3 mm leg veins. The use of topical anesthesia may be needed for some patients. The super-long-pulse 810 nm diode laser gave unpredictable results. Additional refinements of fluence and pulse width could improve its performance. The 3-msec, 755 nm alexandrite laser at fluences of 60-70 J/cm2 and an 8 mm spot can be effective, but inflammatory response, purpura, and matting limit its usefulness. Longer pulse widths might decrease these problems. For leg vein treatment, the 1064 nm wavelength is very safe for type V skin, the 810 nm wavelength at super-long pulse widths of 400-1000 msec is very safe for type IV and marginal for type V skin, and the 755 nm wavelength is limited to nontanned type I-III skin.

Liposome used in spray form to encapsulate and deliver 5-aminolevulinic acid (5-ALA) into the pilosebaceous unit lowers the concentration of 5-ALA to 0.5% in photodynamic therapy (PDT) for acne, with low post-treatment photosensitivity. To investigate the clinical outcome and side effects of PDT using intense pulsed light (IPL) and 0.5% 5-ALA spray for inflammatory facial acne in Asian skin. Twelve subjects (skin types IV-V) with facial acne received full-face treatment at 3-week intervals with IPL 1 hour after being sprayed with 5-ALA. Lesion counts were assessed using serial standardized photographs taken up to 6 months after treatment. Serial sebum measurement and subjective assessment was conducted. There were mean reductions in inflammatory lesions of 52% at 1 month (p=.02) and 65% at 6 months (p=.04) after treatment. Mean subjective acne score decreased from 6.6 to 4.5 (on a scale from 1 to 10) 1 month after treatment. Significant reduction in sebum production was noted only on the forehead. No significant side effects, including postinflammatory hyperpigmentation and phototoxicity, were observed. Use of 0.5% liposome-encapsulated 5-ALA spray with IPL reduced inflammatory facial acne in Asians, with a low risk of persistent phototoxic effects after PDT in this pilot study.

Laser resurfacing has become less popular because of its long recovery time, significant discomfort, and potential risks. Microsurfacing employs the use of single-pass erbium:YAG (Er:YAG) "mini peels," which may be performed serially. The purpose of this study was to evaluate the efficacy and patient acceptance of microresurfacing Er:YAG peels in treating facial photodamage. The variable-pulse Er:YAG system was used and was allowed a comparison of the 0.5- and 4-ms pulse widths. Six female patients underwent eight microresurfacing peels in a split-face fashion using the 0.5- and 4.0-ms pulse durations of a variable-pulse Er:YAG laser. Patients returned at postoperative Days 3 to 4 and 7 for clinical evaluation and Mexameter measurements. There were no significant differences in healing or postoperative erythema between the 0.5- and 4-ms pulse durations on postoperative Day 7. The average time to reepithelialization was 3.6 days. In a 1-year postoperative interview, four of six patients said that they would undergo the peel again periodically, and five of six stated they had maintained some level of improvement. Microresurfacing is an effective and well-tolerated procedure. Benefits include its tolerability under topical anesthesia, limited down time, and high patient satisfaction.

The author has no conflicts to disclose.

There are no previously published reports focusing exclusively on the use of 1,000-centistoke purified polydimethylsiloxane (PDMS-1000) for cosmetic soft-tissue augmentation. To provide clinical experience with its cosmetic use, solely and in conjunction with other nonpermanent fillers, in a private practice setting. A retrospective chart review was conducted for patients treated by the author over 6 years, beginning in 2003. Treatments were tabulated according to facial region and arbitrarily designated as rhytides, acne scars, lips, infraorbital, nasolabial, and general contour. Therefore, up to six treatments were possible with any visit. Concomitant treatment with nonpermanent fillers, as well as any significant adverse events, was noted as well. Nine hundred sixteen patients were treated (816 (89%) female, 100 (11%) male). There were 5,246 treatments over 3,307 visits, with an average of 3.5 visits per patient and 1.6 treatments per visit. Adverse events were limited to overcorrection in 11 patients (1%). Of the 916 patients, 257 (28%) were also treated with other (nonpermanent) fillers without incident. Over the 6-year period, PDMS-1000 was found to be effective and safe in the cosmetic practice setting. Other (nonpermanent) fillers were also used without incident.

Short-scar rhytidectomies offer patients with mild to moderate facial aging an alternative to traditional face-lift surgery. Advantages of decreased recovery time, diminished risk, and decreased cost make this an attractive procedure to add to a cosmetic surgery practice. This study is a review of 1,000 consecutive short-scar rhytidectomies performed over 36 months with at least 6 months of follow-up. All patients underwent short-scar rhytidectomy with SMAS suspension. Outcome parameters examined included complications or adverse events and any interventions necessary. The most common complication was suture extrusion, observed in 148 patients (14.8%). Ten patients had hematomas (1%), while postauricular nodules were observed in 8 patients (0.8%). Eight patients (0.8%) required liposuction under local anesthesia to address asymmetry due to under removal of fat in the submental region. Revision rhytidectomy was required in 5 patients (0.5%). Five patients (0.5%) had hypertrophic scarring, while 1 patient (0.1%) developed hyperpigmentation. There were no cases of nerve injury, infection, skin flap necrosis, skin puckering or depression, hair loss, or parotid injury. Short-scar rhytidectomy is an excellent procedure for good candidates with mild to moderate aging of the face. It has a very low complication rate and can be done safely in an office environment.

Clinical classification (C) of patients suffering from chronic venous disorders according to the Clinical, Etiology, Anatomy, and Pathophysiology Classification takes into account signs and symptoms, but the C3 (venous edema) class has been identified as poorly specific. Patients in whom physicians fail to observe significant edema (sign) frequently report a feeling of swelling (symptom). Previous studies of venoactive drugs have demonstrated significant reduction in leg volume, but the correlation with a clinical improvement was lacking. To describe the clinical status of a sample of Argentinean patients presenting with venous symptoms and signs. To demonstrate the relationship between the reduction of leg swelling and the improvement of symptoms of chronic venous disorders (CVDs) and quality of life (QoL) in patients with CVD. One thousand thirty-six patients were included prospectively and submitted to medical interrogation and examination and specific and generic self-questionnaires. Patients included were reassessed using the same tools after phlebotropic treatment (Ruscus+hesperidin+ascorbic acid), the prescription of which was expected to induce variations in clinical status. Significant correlations were observed between ankle circumference reduction and improvement of all symptoms in C2 to C3 patients: heaviness, pain, paraesthesia, and cramps. Such correlations were found in C0 to C1 patients. There was a correlation between improvement attained in QoL and the physical dimension of the Chronic Venous Insufficiency Questionnaire. Our results demonstrate the relevance of moderate ankle swelling, which is not usually described clinically as edema and is probably a typical symptom of chronic venous disorders. Future studies should focus on this insufficiently analyzed clinical feature and put to better use more specific QoL questionnaires.

The authors have indicated no significant interest with commercial supporters.

BACKGROUND Onychomycosis is difficult to cure. Systemic and topical treatments, including the 1,064-nm Nd:YAG laser, are not very effective when used individually.OBJECTIVE To compare the efficacy and safety of combined treatment with a long-pulsed 1,064-nm Nd:YAG laser and oral terbinafine with those of either treatment alone.METHODS We randomly divided 53 patients with a total of 90 infected nails into 3 treatment groups: the T group received oral terbinafine, the L group received long-pulsed Nd:YAG laser treatment, and the T + L group received both treatments. We evaluated the mycological clearance rate (MCR) and the clinical clearance rate (CCR) of the 3 groups at Weeks 4, 8, 12, 16, and 24.RESULTSThe MCR and CCR increased in all 3 groups in a time-dependent manner. The MCR and CCR of the T + L group were significantly higher than those of the T group and the L group at Weeks 8, 12, 16, and 24 (p < .05).CONCLUSION These data indicate that 12 weeks of combined treatment with a long-pulsed Nd:YAG laser and oral terbinafine produce more rapid and effective mycological and clinical clearance in patients with onychomycosis than either treatment alone, without any obvious side effects.