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Importance Lasers are gaining interest as a treatment option for postinflammatory hyperpigmentation (PIH) but can pose a clinical dilemma given the risk for laser-induced or exacerbated PIH. Objective To assess the clinical evidence for the use of lasers in the treatment of PIH. Evidence Review A systematic review was performed by searching PubMed databases from January 1, 1990, through May 31, 2016. Included studies involved laser treatment for PIH with the degree of pigmentation as a measure of outcome. The search was filtered to include only clinical studies written in the English language. Study methods were analyzed and the reproducibility of the studies was graded. Outcome measures varied from study to study and included concentration of melanin and hemoglobin, patient satisfaction questionnaires, clinical photography, subjective clinical improvement, light microscopy, melanin index, reflectance spectroscopy, and/or skin biopsy evaluated by a blinded dermatopathologist. Findings Of 1295 results, 20 unique studies with 224 patients met the inclusion criteria. These studies included 1 randomized clinical observer-blinded study (6 patients), 4 nonrandomized clinical trials (133 patients), 1 cohort study (34 patients), 7 case series (44 patients), and 7 case reports (7 patients). Multiple lasers were studied; however, most of the studies were not methodologically rigorous. Some studies showed no improvement or worsening of PIH after laser treatment. The most extensively studied device was the Q-switched Nd:YAG laser, which has shown promising results based on multiple outcome measures as listed above. Conclusions and Relevance Some lasers may be beneficial in the treatment of PIH. The evidence suggests that additional studies would be required to determine the benefit of laser treatment of PIH.

Importance Facial lipoatrophy (FLA) is associated with human immunodeficiency virus (HIV) disease and the use of highly active antiretroviral therapy. The condition is primarily characterized by facial volume loss that affects the contours of the cheeks, temples, and orbits and may negatively affect patients’ adherence to highly active antiretroviral therapy, psychological health, and quality of life. A single treatment of hyaluronic acid (HA) filler, 20 mg/mL, may provide an immediate, natural-appearing facial enhancement outcome. Objective To evaluate the safety and efficacy of an HA filler for treatment of HIV-associated FLA during a 12-month follow-up. Design, Setting, and Participants Open-label, safety and efficacy study in patients with HIV-associated FLA, a Carruthers Lipoatrophy Severity Scale (CLSS) grade of 2 or greater (range, 1-4, with higher scores indicating greater severity), and no previous treatment for FLA during the past year received 1 treatment and an optional touch-up. Twenty patients were treated and followed up at the Sacramento Veterans Affairs Medical Center, Mather, California, from March 5, 2015, to May 17, 2016. Interventions Midface (cheeks and temples) volumization was performed using the “smile-and-fill,” fanning, and depot technique with an optional touch-up at the 2-week follow-up. Main Outcomes and Measures Patients underwent evaluation at the initial visit and follow-up at 2 weeks and 3, 6, 9, and 12 months. Main outcome measures included safety (rate of treatment-related adverse events), CLSS grade, and Global Aesthetic Improvement Scale rating (5-point scale, ranging from worse to very much improved). Results Nineteen of the 20 patients (all men; mean [SD] age, 57 [10] years) completed all study visits. Baseline HIV-associated FLA severity was CLSS grade 2 in 16 patients; grade 3, in 3 patients; and grade 4, in 1 patient. The total mean (SD) volume of HA used was 6.1 (3.1) mL for grade 2 FLA; 9.3 (4.2) mL for grade 3 FLA; and 26.0 (0) mL for grade 4 FLA (1 mL equals 1 syringe of HA filler). All 19 patients maintained a significant improvement of CLSS (grade 1) and Global Aesthetic Improvement Scale rating (very much improved) with no treatment-related adverse events at 12 months. Conclusions and Relevance This study reports excellent safety and efficacy and supports use of this HA filler for treatment of HIV-associated FLA with durable results at 12 months. Future multicenter, randomized clinical trials with blinded independent investigators are needed to demonstrate the long-term safety, efficacy, and durability of this HA filler for treatment of HIV-associated FLA.