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Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities.To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method.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.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.FP is a safe and effective treatment for refractory melasma, with long-term remission.

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.

BACKGROUND AND OBJECTIVES Acne scars affect the entire population, causing significant distress and concern. Previous treatments for acne scars have yielded varying degrees of success and associated side effects. Fractional photothermolysis has been shown to improve scars, including surgical scars, hypopigmented scars, and atrophic acne scars. The newest system has the option of increased fluences for greater depth of penetration and variable treatment coverage. Our aim was to determine the efficacy and safety of the second-generation erbium-doped 1,550-nm fractional photothermolysis laser (1,550nm Fraxel SR laser, Reliant Technologies Inc.) in the treatment of all types of acne scars and of all severities. STUDY DESIGN/MATERIALS AND METHODS Twenty-nine patients (20 females and 9 males, ages 15–65 years), Fitzpatrick Skin Types I to V, were treated with two to six treatments with the second-generation erbium-doped 1,550-nm fractional photothermolysis laser at 1-month intervals. Fluences ranged from 35 to 40mJ/microthermal zone. Treatment levels varied from 7 to 10 and ‘‘Advanced Level 1,’’ corresponding to treatment coverage of 20% to 35%. Patients were graded on a 4-point scale by three independent physicians using digital photography. RESULTS The majority of patients achieved a 50% to 75% improvement in facial and back acne scarring (18 of 29 patients). Five patients had an improvement of greater than 75% in acne scarring, 5 patients had a 25% to 50% improvement in acne scarring, and 1 patient had less than a 25% response to treatment. The patients’ degree of satisfaction paralleled the physicians’ assessment. Side effects were minimal and no posttreatment pigmentary changes were noted. CONCLUSION Fractional photothermolysis is a safe and efficacious treatment modality for the treatment of all types of acne scars of all severities. No adverse effects were noted, including in patients with Fitzpatrick Skin Types III to V. The authors have indicated no significant interest with commercial supporters.

The 1450-nm diode laser has been known to thermally alter sebaceous glands and has been found to be effective for the treatment of inflammatory facial acne.Our aim was to evaluate the dose response of a 1450-nm diode laser for treatment of facial acne, sebum production, and acne scarring utilizing two laser fluences and to determine long-term remission after laser treatment.Twenty patients (Fitzpatrick skin phototypes II-VI) received 3 treatments using the 1450 nm diode laser (3-4 week intervals). Split face comparisons were performed by randomizing patients to one of two fluences (14 or 16 J/cm(2)) on the right or left side of the face. Clinical photographs, lesion counts, and sebum measurements were obtained at baseline and after each treatment. Investigators' and patients' subjective evaluations of response to treatment were assessed.Percentage reductions in mean acne lesion counts from baseline were 42.9% (14 J/cm(2)) and 33.9% (16 J/cm(2)) after one treatment and 75.1% (14 J/cm(2)) and 70.6% (16 J/cm(2)) after 3 treatments. There was persistent reduction of 76.1% (14 J/cm(2)) and 70.5% (16 J/cm(2)) at the 12-month follow-up (P.01). Both objective and subjective improvements in acne scarring and sebum production were noted. Treatment-related pain was well tolerated, and adverse effects were limited to transient erythema and edema at treatment sites.This was a small study and comparison was limited to two laser fluences.The 1450-nm diode laser reduced inflammatory facial acne lesions even in Fitzpatrick skin phototypes IV-VI with minimal side effects. Significant improvement in acne lesion counts were noted after the first treatment and was maintained 12 months after the third treatment, indicating significant long-term clinical remission after laser treatment.

BACKGROUNDInjection of filler materials into the dermis is well tolerated with few mild and transient side effects. Injection necrosis is a rare but clinically important potential complication caused by interruption of the vascular supply to the area by compression, injury, and/or obstruction of the

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm with microscopic similarities to non-cutaneous lymphoepitheliomatous malignancies, particularly undifferentiated carcinoma of the nasopharynx. It can be clinically and histologically confused with other benign and malignant tumors. If not adequately treated, recurrence and distant metastasis are probable. We present two cases of LELCS treated surgically with complete microscopic margin control (one by the Mohs method and the other with en face permanent sections) and review the literature.

BIBLIOGRAPHY Feldmeyer L, Mevorah B, Grzeschik KH, Huber M, Hohl D. Clinical variation in X-linked dominant chondrodysplasia punctata (X-linked dominant ichthyosis). Br J Dermatol 2006;154:766-9. Happle R. X-linked dominant chondrodysplasia punctata. Hum Genet 1979;53:65-73. Happle R. Cataracts as a marker of genetic heterogeneity in chondrodysplasia punctata. Clin Genet 1981;19:64-6. Kolb-Maurer A, Grzeschik KH, Haas D, Brocker D, Brocker EB, Hamm H. Conradi-Hunerman-Happle syndrome (X-linked dominant condrodyspasia punctata) confirmed by plasma sterol and mutation analysis. Acta Derm Venereol 2008;88:47-51. Steijlen PM, van Geel M, Vreeburg M, Marcus-Soekarman D, Spaapen LJM, Castelijns FCM, et al. Novel EBP gene mutations in Conrad-Hunermann-Happle syndrome. Br J Dermatol 2007; 157:1225-9. J AM ACAD DERMATOL SEPTEMBER 2009 544 JAAD grand rounds

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.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.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 patient's degree of satisfaction paralleled the physician's assessment of improvement. Side effects were limited to mild pain during treatment and mild, transient post-treatment erythema and edema.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.

Kaposi sarcoma is a neoplasm commonly seen in HIV patients. Cutaneous lesions may vary in presentation between patients. In AIDS-associated Kaposi sarcoma, small red papules or nodules initially present on the face, especially on the nose, and the trunk, that then rapidly spread to other areas. We present an unusual case of AIDS-associated Kaposi sarcoma mimicking nephrogenic systemic fibrosis.

Kaposi sarcoma is a neoplasm commonly seen in HIV patients. Cutaneous lesions may vary in presentation between patients. In AIDS-associated Kaposi sarcoma, small red papules or nodules initially present on the face, especially on the nose, and the trunk, that then rapidly spread to other areas. We present an unusual case of AIDS-associated Kaposi sarcoma mimicking nephrogenic systemic fibrosis.

Acne scars affect the entire population, causing significant distress and concern. Previous treatments for acne scars have yielded varying degrees of success and associated side effects. Fractional photothermolysis has been shown to improve scars, including surgical scars, hypopigmented scars, and atrophic acne scars. The newest system has the option of increased fluences for greater depth of penetration and variable treatment coverage. Our aim was to determine the efficacy and safety of the second-generation erbium-doped 1,550-nm fractional photothermolysis laser (1,550-nm Fraxel SR laser, Reliant Technologies Inc.) in the treatment of all types of acne scars and of all severities.Twenty-nine patients (20 females and 9 males, ages 15-65 years), Fitzpatrick Skin Types I to V, were treated with two to six treatments with the second-generation erbium-doped 1,550-nm fractional photothermolysis laser at 1-month intervals. Fluences ranged from 35 to 40 mJ/microthermal zone. Treatment levels varied from 7 to 10 and "Advanced Level 1," corresponding to treatment coverage of 20% to 35%. Patients were graded on a 4-point scale by three independent physicians using digital photography.The majority of patients achieved a 50% to 75% improvement in facial and back acne scarring (18 of 29 patients). Five patients had an improvement of greater than 75% in acne scarring, 5 patients had a 25% to 50% improvement in acne scarring, and 1 patient had less than a 25% response to treatment. The patients' degree of satisfaction paralleled the physicians' assessment. Side effects were minimal and no posttreatment pigmentary changes were noted.Fractional photothermolysis is a safe and efficacious treatment modality for the treatment of all types of acne scars of all severities. No adverse effects were noted, including in patients with Fitzpatrick Skin Types III to V.

Unlike selective photothermolysis, which produces bulk thermal injury to specific targets in the skin, fractional photothermolysis (Fraxel, Reliant Technologies, Inc., Mountain View, CA) creates hundreds of microthermal treatment zones (MTZs) while sparing the surrounding tissue. We report marked improvement of postinflammatory erythema after the resolution of inflammatory acne vulgaris in two patients after one treatment session with fractional photothermolysis.

BACKGROUND Treatments for hypopigmented scars have shown limited efficacy and variable safety profiles. OBJECTIVE This study evaluated the safety and efficacy of fractional resurfacing (1,550-nm Fraxel SR laser, Reliant Technologies, Mountain View, CA) for the treatment of hypopigmented scars on the face in seven patients. MATERIALS AND METHODS Seven patients with hypopigmented scars on the face received between two and four successive treatments at 4-week intervals with the 1,550-nm Fraxel SR laser. Energy settings ranged from 7 to 20 mJ and a total density of 1,000 to 2,500 microthermal zones per square centimeter. Digital photographs were taken before each treatment and at 4 weeks after the last treatment. Independent physician clinical assessments were performed. RESULTS Independent physician clinical assessment 4 weeks after the final Fraxel SR laser treatment revealed improvements of 51% to 75% in hypopigmentation in six of seven patients. One patient had only 26% to 50% improvement in hypopigmentation. Additionally, clinical improvements were noted in the overall texture of the treated skin. The patient's degree of satisfaction paralleled the physician's assessment of improvement. All patients reported improvement in hypopigmentation lasting greater than 3 months after the last treatment. Side effects were limited to mild pain during the treatment and mild posttreatment erythema and edema, which resolved in 2 to 4 days. CONCLUSION Fractional resurfacing is a potentially effective modality for the treatment of hypopigmented scarring on the face. No adverse effects were observed.

Injection of filler materials into the dermis is well tolerated, with few mild and transient side effects. Injection necrosis is a rare but clinically important potential complication caused by interruption of the vascular supply to the area by compression, injury, and/or obstruction of the vessel(s). The glabella is a particular danger zone for injection necrosis regardless of the type of filler used.We recommend a protocol that may be used to help prevent and treat injection necrosis of the glabella after injection with dermal fillers.Injection necrosis in the glabellar region may be prevented by knowledge of the local anatomy and an understanding of its pathophysiology and treated by a suggested protocol.

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm with microscopic similarities to non-cutaneous lymphoepitheliomatous malignancies, particularly undifferentiated carcinoma of the nasopharynx. It can be clinically and histologically confused with other benign and malignant tumors. If not adequately treated, recurrence and distant metastasis are probable. We present two cases of LELCS treated surgically with complete microscopic margin control (one by the Mohs method and the other with en face permanent sections) and review the literature.

Background and Objectives The 585-nm pulsed-dye laser and the 1,450-nm diode laser have been found effective for the treatment of mild-to-moderate inflammatory facial acne. This study was designed to evaluate the efficacy and safety of the combined treatment with the 595-nm pulsed-dye laser and the 1,450-nm diode laser for inflammatory facial acne. Study Design/Materials and Methods Fifteen patients with inflammatory facial acne were treated with a combination of the 595-nm pulsed-dye laser and the 1,450-nm diode laser. Patients' subjective response to treatment was evaluated regarding improvement in acne, acne scarring, oiliness, and redness of the skin. Results All patients had reductions in acne lesion counts. Mean lesion counts decreased 52% (P