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Background: Severe keloids are difficult to treat. Corticosteroid injections with needles are painful and associated with frequent recurrences. Therefore, more effective, safe and patient-friendly alternative treatments are urgently needed., Objectives: To assess the efficacy, tolerability and patient satisfaction of intralesional bleomycin treatment using a needle-free electronic pneumatic jet injector (EPI) in severe keloids., Methods: Patients with severe keloids were included in this double-blind, randomized, placebo-controlled trial with split-lesion design. Three EPI treatments with bleomycin or saline were administered every 4 weeks in the intervention and control sides. Outcome measures were change in scar volume assessed by three-dimensional imaging, Patient and Observer Scar Assessment Scale (POSAS), skin perfusion with laser speckle contrast imaging (LSCI), spilled volume, procedure-related pain, adverse events and patient satisfaction., Results: Fourteen patients (nine female, five male) were included. The estimated mean keloid volume was significantly reduced by 20% after EPI-assisted bleomycin, compared with a slight increase of 3% in the control side (P < 0.01). The estimated mean POSAS patient and observer scores decreased by respectively 28% and 20% (P = 0.03 and P = 0.001). LSCI showed no significant change in perfusion. EPI treatment was preferred over previous needle injections in 85% of patients. The estimated mean spilled volume after EPI was around 50%, and numerical rating scale pain scores were moderate. Adverse events included bruising, hyperpigmentation and transient superficial necrosis., Conclusions: A course of three EPI-assisted bleomycin injections is efficacious and well tolerated in severe keloids. Moreover, EPI was preferred by most patients and may serve as a patient-friendly alternative treatment., Competing Interests: Conflicts of interest V.Z.B., K.M.Z., L.B., W.T.V., P.A., F.O., R.B., E.P.P., R.R. and M.B.A.vD. declare no conflicts of interest. M.H. declares no conflicts of interests related to this work and declares the following conflicts of interest outside of this work: Cherry Imaging (Equipment), Cynosure (Equipment), Galderma (lectures, teaching, research), GME Medical (equipment), LEO Pharma (research grant), L’Oréal/La Roche Posay (research grant, consulting), Lutronic (equipment), MiraDry (equipment), Procter & Gamble (consulting) and Venus Concept (research grant, equipment)., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Association of Dermatologists. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Competing Interests: Conflicts of interest: J.R.Z. is a paid consultant to Coegin Pharma AB; A.C.M. is an employee of Studies&Me A/S; I.M. is a paid consultant to Studies&Me A/S; J.R.Z. and A.D.A. are previous employees of Studies&Me A/S; M.H. has received a research grant from Studies&Me A/S.

Background: Kidney transplant recipients (KTRs) have increased risk of human papillomavirus (HPV)-related anogenital (pre)cancers, including anal high-grade intraepithelial lesions and cancer. Previous studies on anal high-risk HPV (hrHPV) among KTRs are sparse., Methods: In a cross-sectional study, we included 247 KTRs and 248 controls from a dermatology department and 5 nephrology departments in Denmark during 2016-2017. All participants provided an anal cytobrush sample that was tested for HPV DNA. Participants completed a questionnaire on lifestyle and sexual habits. We used logistic regression to estimate odds ratios (ORs) of anal hrHPV in KTRs compared with controls and risk factors for anal hrHPV in KTRs., Results: The anal hrHPV prevalence was higher in female KTRs (45.5%) than in controls (27.2%). Female KTRs had almost 3-fold higher adjusted odds of anal hrHPV than controls (adjusted OR, 2.87 [95% confidence interval, 1.57-5.22]). In contrast, among men we did not observe increased prevalence or odds of anal hrHPV in KTRs compared with controls (prevalence, 19.4% vs 23.6%; adjusted OR, 0.85 [95% 95% confidence interval, .44-1.64]). Among hrHPV-positive KTRs, 63% and 52% of men and women, respectively, were infected with hrHPV types covered by the nonavalent HPV vaccine (type 16, 18, 31, 33, 45, 52, or 58). Current smoking, >10 lifetime sexual partners, history of genital warts, and among men having had receptive anal sex were risk factors for anal hrHPV in KTRs., Conclusions: Female KTRs had an increased risk of anal hrHPV compared with immunocompetent controls. Our findings indicate that pretransplant HPV vaccination should be considered to prevent anal high-grade intraepithelial lesions and cancer caused by anal hrHPV infection in KTRs., Clinical Trials Registration: NCT03018327., Competing Interests: Potential conflicts of interest. H. K. L. has received lecture and conference registration fees from LEO Pharma. S. K. K. has received a lecture fee from Merck and a research grant from Merck through her institution. M. H. reports research grants, unrelated to this work, from LEO Pharma, Lutronic, Mirai Medical, Studies&Me, and Venus Concept; lecture payments from Galderma Nordic; and reports receipt of equipment from Cherry Imaging, Cynosure, Lutronic, Venus Concept, PerfAction Technologies, MiraDry, Sientra, and Mirai Medical. J. H. B. has received honoraria from Hologic, Qiagen, and BD Diagnostics Systems for lectures and reports a leadership role in the Danish National Board of Health as an appointed expert on HPV (public health appointment), a National Board of Health appointed member, and a member of the National Cervical Screening Steering Committee (public health appointment). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed, (© The Author(s) 2022. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: There is limited evidence on the best available treatment options for capillary malformations (CMs), mainly due to the absence of uniform outcome measures in trials on therapies. A core outcome set (COS) enables standard reporting of trial outcomes, which facilitates comparison of treatment results., Objectives: To develop a core outcome domain set (CDS), as part of a core outcome set (COS), for clinical research on CMs., Methods: Sixty-seven potentially relevant outcome subdomains were recognized based on the literature, focus group sessions, and input from the COSCAM working group. These outcome subdomains were presented in an online Delphi study to CM experts (medical specialists and authors of relevant literature) and (parents of) patients with CM (international patient associations). During three e-Delphi study rounds, the participants repeatedly scored the importance of these outcome subdomains on a seven-point Likert scale. Participants could also propose other relevant outcome subdomains. Consensus was defined as ≥ 80% agreement as to the importance of an outcome subdomain among both stakeholder groups. The CDS was finalized during an online consensus meeting., Results: In total 269 participants from 45 countries participated in the first e-Delphi study round. Of these, 106 were CM experts from 32 countries, made up predominantly of dermatologists (59%) and plastic surgeons (18%). Moreover, 163 (parents of) patients with CM from 28 countries participated, of whom 58% had Sturge-Weber syndrome. During the two subsequent e-Delphi study rounds, 189 and 148 participants participated, respectively. After the entire consensus process, consensus was reached on 11 outcome subdomains: colour/redness, thickness, noticeability, distortion of anatomical structures, glaucoma, overall health-related quality of life, emotional functioning, social functioning, tolerability of intervention, patient satisfaction with treatment results, and recurrence., Conclusions: We recommend the CDS to be used as a minimum reporting standard in all future trials of CM therapy. Our next step will be to select suitable outcome measurement instruments to score the core outcome subdomains. What is already known about this topic? Besides physical and functional sequelae, capillary malformations (CMs) often cause emotional and social burden. The lack of uniform outcome measures obstructs proper evaluation and comparison of treatment strategies. As a result, there is limited evidence on the best available treatment options. The development of a core outcome set (COS) may improve standardized reporting of trial outcomes. What does this study add? A core outcome domain set (CDS), as part of a COS, was developed for clinical research on CMs. International consensus was reached on the recommended core outcome subdomains to be measured in CM trials: colour/redness, thickness, noticeability, distortion of anatomical structures, glaucoma, overall health-related quality of life, emotional functioning, social functioning, tolerability of intervention, patient satisfaction with treatment results, and recurrence. This CDS enables the next step in the development of a COS, namely to reach consensus on the core outcome measurement instruments to score the core outcome subdomains. What are the clinical implications of this work? The obtained CDS will facilitate standardized reporting of treatment outcomes, thereby enabling proper comparison of treatment results. This comparison is likely to provide more reliable information for patients about the best available treatment options., (© 2022 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Objectives: Nailfold video capillaroscopy (NVC) and angiographic optical coherence tomography (OCTA) have potential in diagnosing PsA and differentiating it from psoriasis vulgaris (PsO) and hand OA. We aimed to assess the diagnostic properties of NVC and OCTA in patients with PsA compared with patients with PsO and hand OA based on nailfold capillary patterns., Methods: Patients with DIP joint PsA and nail involvement ( n = 50), PsO with nail involvement ( n = 12) and OA ( n = 13) were included in this cross-sectional study. Capillaries were evaluated semi-quantitatively and qualitatively. Differences in capillary findings between groups were assessed using mixed linear models. Binary logistic regression analyses were performed to determine the probability for PsA diagnosis based on capillaroscopy findings., Results: Below mean capillary density and reduced nailfold blood flow in OCTA images distinguished PsA from both PsO ( P = 0.004 and P = 0.052, respectively) and OA ( P = 0.024 and P < 0.001, respectively). Qualitative analysis revealed that glomerular capillaries were found in only 3% of PsA patients but in 13% of PsO patients ( P = 0.003). Furthermore, crossed vessels were seen in only 55% of PsA patients and 71% of PsO patients ( P = 0.043). NVC microhaemorrhage was dominant in PsA patients (13%) and significantly different from OA patients ( P <0.05). No capillary pattern was associated with an increased probability of the PsA diagnosis., Conclusion: A pathognomonic pattern for PsA diagnosis was not identified; however, we demonstrated some characteristic capillaroscopy findings for PsA, such as decreased capillary density, reduced blood flow and fewer crossed vessels in OCTA and presence of NVC microhaemorrhages., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: Renal transplant recipients (RTRs) have increased risk of human papillomavirus (HPV)-related cancers, including anal cancer. We investigated the prevalence of anal high-grade intraepithelial lesions (HSILs) in RTRs compared with immunocompetent controls and risk factors for anal HSIL in RTRs., Methods: We included 247 RTRs and 248 controls in this cross-sectional study. We obtained anal samples for HPV testing with INNO-LiPA and performed high-resolution anoscopy on all participants. The participants completed a questionnaire on lifestyle and sexual habits. We used logistic regression to estimate odds ratios (ORs) of histologically confirmed anal HSIL in RTRs vs controls and risk factors for anal HSIL in RTRs, stratified by sex and anal high-risk (hr) HPV status, adjusting for age, smoking, lifetime sexual partners, and receptive anal sex., Results: RTRs had higher anal HSIL prevalence than controls, both among men (6.5% vs 0.8%; adjusted OR [aOR], 11.21 [95% confidence interval {CI}, 1.46-291.17]) and women (15.4% vs 4.0%; aOR, 6.41 [95% CI, 2.14-24.10]). Among those with anal hrHPV, RTRs had higher anal HSIL prevalence than controls (33.8% vs 9.5%; aOR, 6.06 [95% CI, 2.16-20.27]). Having had receptive anal sex (aOR, 6.23 [95% CI, 2.23-19.08]) or genital warts (aOR, 4.21 [95% CI, 1.53-11.48]) were risk factors for anal HSIL in RTRs. All HSIL cases occurred in individuals with anal hrHPV., Conclusions: RTRs had increased risk of anal HSIL compared with immunocompetent controls, with particularly high prevalence in female RTRs. Receptive anal sex, previous genital warts, and anal hrHPV infection were risk factors for anal HSIL in RTRs. Screening for anal HSIL in RTRs should be considered., Clinical Trials Registration: NCT03018927., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Physical pretreatments can potentiate the efficacy of daylight photodynamic therapy (dPDT), but clinical comparative studies remain limited., Objectives: Performed in large skin areas with actinic keratoses (AKs) and photodamage, this blinded, randomized clinical trial compared the efficacy and safety of dPDT after tailored skin pretreatment using ablative fractional laser (AFL) or microdermabrasion (MD)., Methods: Two ≥ 50-cm 2 side-by-side skin areas were randomized to receive a single treatment with AFL-dPDT or MD-dPDT. Pretreatment parameters were tailored according to AK grade and skin constitution to ensure standardized immediate end points. Subsequently, methyl aminolaevulinate was applied, followed by 2-h daylight exposure. The primary outcome comprised blinded assessment of AK clearance at the 3-month follow-up., Results: In 18 patients with 832 AKs, AFL-dPDT provided significantly higher AK clearance (81% vs. 60%, P < 0·001), led to fewer new AKs (P < 0·001) and showed superior improvement in dyspigmentation (P = 0·003) and skin texture (P = 0·001) vs. MD-dPDT. Peaking at days 3-6, AFL-PDT induced more intensified local skin responses (P = 0·004), including instances of Staphylococcus aureus infection (n = 3). Patients nonetheless preferred AFL-dPDT (P = 0·077), due to lower pretreatment-related pain (P = 0·002) and superior cosmesis (P = 0·035) and efficacy compared with MD-dPDT., Conclusions: AFL-dPDT is an effective treatment for patients with AK with extensive field cancerization, although AFL pretreatment is associated with intensified local skin reactions., (© 2018 British Association of Dermatologists.)

Background: In recent years, various lasers have increasingly been applied during wound healing to minimize scar formation. However, no consensus regarding treatment procedures exists., Objectives: To assess scar formation clinically after three nonablative fractional laser (NAFL) exposures, targeting the inflammation, proliferation and remodelling wound healing phases in patients vs. untreated controls., Methods: A randomized controlled trial was performed using a split-wound design to assess excisional wound halves treated with 1540-nm NAFL vs. no laser treatment. Three NAFL exposures were provided: immediately before surgery, at suture removal and 6 weeks after surgery. NAFL exposures were applied using two handpieces, sequentially distributing energy deeply and more superficially in the skin (40-50 mJ per microbeam). Evaluated at 3 months of follow-up, the primary outcome was blinded, on-site evaluation using the Patient Observer Scar Assessment Scale (POSAS total; range from 6, normal skin to 60, worst imaginable scar). Secondary outcomes comprised blinded evaluation on the Vancouver Scar Scale (VSS) and standardized assessment comparing scar sides, carried out by blinded on-site, photo and patient assessments. This trial was registered with ClinicalTrials.gov (NCT03253484)., Results: Thirty of 32 patients completed the trial. At the 3-month follow-up, the NAFL-treated scar halves showed improvement compared with the untreated control halves on POSAS total: NAFL treated, median 11, interquartile range (IQR) 9-12 vs. control, median 12, IQR 10-16; P = 0·001. The POSAS subitems showed that the NAFL-treated halves were significantly less red and more pliable, and presented with smoother relief than the untreated controls. VSS total correspondingly revealed enhanced appearance in the NAFL-treated halves: median 2, IQR 1-2·5 vs. control, median 2, IQR 1·75-3, P = 0·007. The standardized assessment comparing appearance of scar halves demonstrated a low degree of correspondence between on-site, photo and patient assessments. NAFL-treated scars were rated as superior to untreated scars by 21 of 29 patients., Conclusions: NAFL-treated scars showed subtle improvement compared with untreated control scars., (© 2018 British Association of Dermatologists.)

Background: Topical photodynamic therapy (PDT) is an approved treatment for actinic keratosis (AK). To enhance the efficacy of PDT for AKs, physical and chemical pretreatments have been suggested., Objectives: To compare the efficacy and safety of the combination of topical calcipotriol (CAL) before methyl aminolaevulinate (MAL)-PDT for AKs of the scalp vs. conventional MAL-PDT in a randomized controlled clinical trial., Methods: Twenty patients with multiple AKs on the scalp were randomized to receive conventional MAL-PDT with previous curettage on one side of the scalp and CAL-assisted MAL-PDT once a day for 15 days before illumination on the other side. After 3 months, patients were evaluated for clearance of AKs, side-effects and histopathology before and after the procedure. Protoporphyrin IX (PpIX) fluorescence was measured before and after illumination on both sides., Results: All 20 patients completed the study. Overall AK clearance rates were 92·1% and 82·0% for CAL-PDT and conventional PDT, respectively (P < 0·001). Grade 1 AKs showed similar response rates for both sides (P = 0·055). However, grade II AKs showed more improvement on the CAL-PDT side (90%) than on the MAL-PDT side (63%) (P < 0·001). Before illumination, PpIX fluorescence intensity was higher on the CAL-assisted side (P = 0·048). The treatment was more painful on the CAL-PDT side, although well tolerated. The mean visual analogue scale score was 5·4 ± 1·4 on the CAL-PDT side and 4·0 ± 0·69 on the conventional MAL-PDT side (P = 0·001). Side-effects such as erythema (P = 0·019), oedema (P = 0·002) and crusts (P < 0·001) were more pronounced on the CAL-assisted side. Histopathological analyses were obtained from five patients and both sides showed improved keratinocyte atypia following PDT, with slightly more improvement on the CAL-assisted side., Conclusions: CAL-assisted PDT proved to be safe and more effective than conventional MAL-PDT for the treatment of AKs on the scalp. CAL pretreatment increased PpIX accumulation within the skin and may have enhanced the efficacy in this first human trial., (© 2018 British Association of Dermatologists.)

Background: Actinic keratoses (AKs) in solid organ transplant recipients (OTRs) are difficult-to-treat premalignancies and comparison of topical therapies is therefore warranted., Objectives: In an intraindividual study to compare the efficacy and safety of field treatment with methyl aminolaevulinate photodynamic therapy (MAL-PDT) and imiquimod (IMIQ) for AKs in OTRs., Methods: OTRs (n = 35) with 572 AKs (grade I-III) in two similar areas on the face, scalp, dorsal hands or forearms were included. All patients received one MAL-PDT and one IMIQ session (three applications per week for 4 weeks) in each study area according to randomization. Treatments were repeated after 2 months (IMIQ) and 3 months (PDT) in skin with incomplete AK response. Outcome measures were complete lesion response (CR), skin reactions, laboratory results and treatment preference., Results: The majority of study areas received two treatment sessions (PDT n = 25 patients; IMIQ n = 29 patients). At 3 months after two treatments, skin treated with PDT achieved a higher rate of CR (AK I-III median 78%; range 50-100) compared with IMIQ-treated skin areas (median 61%, range 33-100; P < 0·001). Fewer emergent AKs were seen in PDT-treated skin vs. IMIQ-treated skin (0·7 vs. 1·5 AKs, P = 0·04). Patients developed more intense inflammatory skin reactions following PDT, which resolved more rapidly compared with IMIQ (median 10 days vs. 18 days, P < 0·01). Patient preference (P = 0·47) and cosmesis (P > 0·30) were similar for PDT and IMIQ., Conclusions: Compared with IMIQ, PDT treatment obtained a higher rate of AK clearance at 3-month follow-up and achieved shorter-lasting, but more intense, short-term skin reactions., (© 2017 British Association of Dermatologists.)

Background: Topical photodynamic therapy (PDT) for actinic keratoses (AK) is hampered by pain during illumination and inferior efficacy in organ-transplant recipients (OTR)., Objectives: We assessed ablative fractional laser (AFL)-assisted daylight photodynamic therapy (PDT) (AFL-dPDT) compared with daylight PDT (dPDT), conventional PDT (cPDT) and AFL alone (AFL) in field treatment of AK in OTR., Methods: In each patient, four areas in the same region were randomized to one treatment with AFL-dPDT, dPDT, cPDT and AFL. AFL was delivered with a 2940-nm AFL at 2·3 mJ per pulse, 1·15 W, two stacks, 50-μs pulse-duration, 2·4% density. In dPDT and AFL-dPDT, methyl aminolaevulinate (MAL) was applied for 2·5 h without occlusion during daylight exposure. For cPDT, MAL was occluded for 3 h followed by red-light (630 nm) irradiation at 37 J cm(-2). The primary end-point was complete response (CR) 3 months post-treatment., Results: Sixteen patients with 542 AK (grades I-III) in field-cancerized skin of the scalp, chest and extremities were treated during August and September 2012. After 3 months, CR (AK I-III) rates were 74% after AFL-dPDT, 46% after dPDT, 50% after cPDT and 5% after AFL (P < 0·001). CR rates in AFL-dPDT, dPDT and cPDT were also significantly different (P = 0·004). Median maximal pain scores differed significantly during AFL-dPDT (0), dPDT (0), AFL (0) and cPDT (5) (P < 0·001). Erythema and crusting were more intense following AFL-dPDT than dPDT and cPDT, but only transient hypopigmentation was observed., Conclusions: AFL-dPDT is a novel PDT modality that enhances CR with excellent tolerability compared with dPDT and cPDT in difficult-to-treat AK in OTR., (© 2014 British Association of Dermatologists.)

Background: At-home laser and intense pulsed-light hair removal continues to grow in popularity and availability. A relatively limited body of evidence is available on the course of hair growth during and after low-fluence laser usage., Objectives: To assess growing hair counts, thickness and colour quantitatively during and after cessation of low-fluence laser treatment., Methods: Thirty-six women with skin phototypes I-IV and light to dark-brown axillary hairs were included. Entire axillary regions were randomized to zero or eight self-administered weekly treatments with an 810-nm home-use laser at 5·0-6·4 J cm(-2). Standardized clinical photographs were taken before each treatment and up to 3 months after the final treatment for computer-aided quantification of growing hair counts, thickness and colour., Results: Thirty-two women completed the study protocol. During sustained treatment, there was a reduction in growing hair that reached a plateau of up to 59%, while remaining hairs became up to 38% thinner and 5% lighter (P < 0·001). The majority of subjects (77%) reported 'moderately' to 'much less hair' in treated than untreated axilla, and assessed remaining hairs as thinner and lighter (≥ 60%). After treatment cessation, hair growth gradually returned to baseline levels, and 3 months after the final treatment the count and thickness of actively growing hair exceeded pretreatment values by 29% and 7%, respectively (P ≤ 0·04)., Conclusions: Sustained usage of low-fluence laser induced a stable reduction of growing hair counts, thickness and colour. The reduction was reversible and hairs regrew beyond baseline values after cessation of usage. Computer-aided image analysis was qualified for quantification of hair counts, thickness and colour after laser epilation., (© 2014 British Association of Dermatologists.)

Background: Photodynamic therapy (PDT) is approved for selected nodular basal cell carcinomas (nBCC) but efficacy is reduced for large and thick tumours. Ablative fractional lasers (AFXL) facilitate uptake of methyl aminolaevulinate (MAL) and may thus improve PDT outcome., Objectives: To evaluate efficacy and safety of AFXL-mediated PDT (AFXL-PDT) compared with conventional PDT of high-risk nBCC., Methods: Patients with histologically verified facial nBCC (n = 32) defined as high-risk tumours were included; diameter > 15 mm, tumours located in high-risk zones, or on severely sun-damaged skin. Tumours were debulked and patients randomized to either AFXL-PDT (n = 16) or PDT (n = 16). Fractional CO2 laser treatment was applied at 5% density and 1000 μm (80 mJ) ablation depth. MAL was applied under occlusion for 3 h and illuminated with a 633-nm light-emitting diode source, 37 J cm(-2) . Clinical assessments were performed at 3, 6, 9 and 12 months and biopsies were taken at 12 months., Results: Clinical cure rates at 3 months were 100% (16 of 16 AFXL-PDT) and 88% (14 of 16 PDT, P = 0·484). Recurrences tended to occur later and in lower numbers after AFXL-PDT at 6, 9 and 12 months (6%, 19%, 19%) than PDT (25%, 38%, 44%) (P = 0·114). Histology at 12 months documented equal tumour clearance after AFXL-PDT (63%, 10 of 16) and PDT (56%, 9 of 16). Cosmetic outcomes were highly satisfactory after both treatments (P > 0·090)., Conclusions: Long-term efficacy was similar after PDT and AFXL-PDT with a trend for a favourable short-term cure rate after AFXL-PDT. AFXL-PDT needs further refinement for nBCC and at present is not recommended over PDT., (© 2014 British Association of Dermatologists.)

Background: Photodynamic therapy (PDT) is a well-documented treatment for actinic keratosis (AK), but achieves inferior efficacy in organ transplant recipients (OTRs), particularly in acral regions. Ablative fractional laser (AFXL) intensifies the PDT response and may improve the efficacy of AK clearance when used as monotherapy., Objectives: To compare the efficacy of a single treatment with AFXL-assisted PDT vs. AFXL alone for difficult-to-treat AKs and wart-like lesions (WLLs) in OTRs., Methods: Ten OTRs were included with a total of 680 AKs (severity grade I-III) and 409 WLLs on the dorsal hands. Both hands were initially treated with targeted fractional ablation of thick keratotic lesions followed by AFXL field treatment. Treatment regions were then randomized to (i) PDT (AFXL-PDT) or (ii) no further treatment (AFXL). The primary end point was complete response (CR) at 4 months after treatment; secondary end points were improvement of AK severity grade, overall patient assessment of efficacy and tolerability of treatments., Results: CR of AKs was significantly higher for AFXL-PDT (73%) compared with AFXL alone (31%) (P = 0·002). AFXL-PDT improved 82% of AKs to lower lesion grades compared with 52% after AFXL alone (P = 0.008). For WLLs, the rate of CR was 37% for AFXL-PDT compared with 14% for AFXL (P = 0·02). Overall assessment showed a preference for AFXL-PDT compared with AFXL (AFXL-PDT, n = 8; AFXL, n = 0; equal, n = 2). Mild pigment changes were observed in four patients (AFXL-PDT, n = 3; AFXL, n = 1). No scarring was observed., Conclusions: AFXL-PDT is more effective than AFXL in the treatment of acral AKs and WLLs in OTRs., (© 2013 British Association of Dermatologists.)

Background: Photodynamic therapy (PDT) is an attractive therapy for nonmelanoma skin cancers and actinic keratoses (AKs). Daylight-mediated PDT is a simple and tolerable treatment procedure for PDT. Methyl aminolaevulinate (MAL)-PDT is approved for the treatment of thin or nonhyperkeratotic AKs on the face and scalp. However, thick AK lesions are often treated as well when present in the field-cancerized treatment area., Objectives: In a randomized multicentre study to evaluate efficacy of daylight-mediated PDT for different severity grades of AKs., Methods: One hundred and forty-five patients with a total of 2768 AKs (severity grades I-III) of the face and scalp were randomized to either 1½ or 2½ h exposure groups. After application of a sunscreen (sun protection factor 20) and gentle lesion preparation, MAL was applied to the entire treatment area. Patients left the clinic immediately after application and exposed themselves to daylight according to randomization. Daylight exposure was monitored with a wrist-borne dosimeter., Results: No difference in lesion response was found between the 1½ and 2½ h exposure group. The mean lesion response rate was significantly higher in grade I lesions (75·9%) than in grade II (61·2%) and grade III (49·1%) lesions (P < 0·0001). Most grade II (86%) and III AKs (94%) were in complete response or reduced to a lower lesion grade at follow-up. Large variations in response rate of grade II and III AKs were found between centres. No association was found between response rate and light dose in patients who received an effective light dose of > 3·5 J cm(-2)., Conclusions: Daylight-mediated PDT of moderate to thick AKs was less effective than daylight-mediated PDT of thin AKs especially in some centres. However, nearly all thicker lesions (grades II and III) were reduced to a lower lesion grade at 3 months after a single treatment of daylight-mediated PDT., (© 2012 The Authors. BJD © 2012 British Association of Dermatologists.)

Background: Photodynamic therapy (PDT) with methyl aminolaevulinate (MAL) is effective for thin actinic keratoses (AKs) in field-cancerized skin. Ablative fractional laser resurfacing (AFXL) creates vertical channels that facilitate MAL uptake and may improve PDT efficacy., Objectives: To evaluate efficacy and safety of AFXL-assisted PDT (AFXL-PDT) compared with conventional PDT in field-directed treatment of AK., Methods: Fifteen patients with a total of 212 AKs (severity grade I-III) in field-cancerized skin of the face and scalp were randomized to one treatment with PDT and one treatment with AFXL-PDT in two symmetrical areas. Following curettage of both treatment areas, AFXL was applied to one area using 10 mJ per pulse, 0·12 mm spot, 5% density, single pulse (UltraPulse(®), DeepFx handpiece; Lumenis Inc., Santa Clara, CA, U.S.A.). MAL cream was then applied under occlusion for 3 h and illuminated with red light-emitting diode light at 37 J cm(-2). Fluorescence photography quantified protoporphyrin IX (PpIX) before and after illumination., Results: At 3-month follow-up, AFXL-PDT was significantly more effective than PDT for all AK grades. Complete lesion response of grade II-III AK was 88% after AFXL-PDT compared with 59% after PDT (P = 0·02). In grade I AK, 100% of lesions cleared after AFXL-PDT compared with 80% after PDT (P = 0·04). AFXL-PDT-treated skin responded with significantly fewer new AK lesions (AFXL-PDT n = 3, PDT n = 11; P = 0·04) and more improved photoageing (moderate vs. minor improvement, P = 0·007) than PDT-treated skin. Pain scores during illumination (6·5 vs. 5·4; P = 0·02), erythema and crusting were more intense, and long-term pigmentary changes more frequent from AFXL-PDT than PDT (P = not significant). PpIX fluorescence was higher in AFXL-pretreated skin [7528 vs. 12,816 arbitrary units (AU); P = 0·003] and photobleached to equal intensities after illumination (AFXL-PDT 595 AU, PDT 454 AU; P = 0·59)., Conclusions: AFXL-PDT is more effective than conventional PDT for treatment of AK in field-cancerized skin., (© 2012 The Authors. BJD © 2012 British Association of Dermatologists.)

Light-based hair removal (LHR) is one of the fastest growing, nonsurgical aesthetic cosmetic procedures in the United States and Europe. A variety of light sources including lasers, e.g. alexandrite laser (755 nm), pulsed diode lasers (800, 810 nm), Nd:YAG laser (1064 nm) and broad-spectrum intense pulsed light (IPL, 590-1200 nm), are available and used widely for such procedures in dermatological/clinical settings under proper supervision. Patient selection and appropriate fluence settings are managed by professionals to maximize efficacy while minimizing adverse events. In the past 5 years, LHR devices have been sold directly to consumers for treatment in the home. In this review, we outline the principles underlying laser and IPL technologies and undertake an evidence-based assessment of the short- and long-term efficacy of the different devices available to the practising dermatologist and discuss the efficacy and human safety implications of home-use devices., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Background: Actinic keratoses (AKs) are common dysplastic skin lesions that may differentiate into invasive squamous cell carcinomas. Although a superior cosmetic outcome of photodynamic therapy (PDT) is advantageous compared with equally effective treatments such as cryotherapy and curettage, the inconvenience of clinic attendance and discomfort during therapy are significant drawbacks. Daylight-mediated PDT could potentially reduce these and may serve as an alternative to conventional PDT., Objectives: To compare the efficacy of methyl aminolaevulinate (MAL)-PDT with 1½ vs. 2½ h of daylight exposure in a randomized multicentre study., Methods: One hundred and twenty patients with a total of 1572 thin AKs of the face and scalp were randomized to either 1½- or 2½-h exposure groups. After gentle lesion preparation and application of a sunscreen of sun protection factor 20, MAL was applied to the entire treatment area. Immediately after, patients left the clinic and exposed themselves to daylight according to the randomization. Daylight exposure was monitored with a wristwatch dosimeter and patients scored their pain sensation during treatment., Results: The mean lesion response rate at 3 months was 77% in the 1½-h group and 75% in the 2½-h group (P = 0·57). The mean duration of daylight exposure was 131 and 187 min in the two groups. The mean overall effective light dose was 9·4 J cm(-2) (range 0·2-28·3). Response rate was not associated with effective daylight dose, exposure duration, treatment centre, time of day or time of year during which the treatment was performed. Treatment was well tolerated, with a mean ± SD maximal pain score of 1·3 ± 1·5., Conclusions: Daylight-mediated MAL-PDT is an effective, convenient and nearly pain-free treatment for patients with multiple thin AKs. Daylight-mediated PDT procedures were easily performed and 2 h of daylight exposure resulted in uniformly high response rates when conducted in the period from June to October in Nordic countries., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Background: Hirsutism is a common disorder in women of reproductive age, and androgen disturbances may aggravate the condition. Limited evidence exists regarding efficacy of hair removal in this specific population and no data are available for patients with verified normal testosterone levels., Objectives: To compare efficacy and safety of intense pulsed light (IPL) vs. long-pulsed diode laser (LPDL) in a well-defined group of hirsute women with normal testosterone levels., Methods: Thirty-one hirsute women received six allocated split-face treatments with IPL (525-1200 nm; Palomar Starlux IPL system) and LPDL (810 nm; Asclepion MeDioStar XT diode laser). Testosterone levels were measured three times during the study period. Patients with intrinsically normal or medically normalized testosterone levels throughout the study were included in efficacy assessments (n = 23). Endpoints were reduction in hair counts assessed by blinded photoevaluations at baseline and 1, 3 and 6 months after final treatment, patient-evaluated reduction in hairiness, patient satisfaction, treatment-related pain and adverse effects., Results: IPL and LPDL reduced hair counts significantly, with median reductions from baseline of 77%, 53% and 40% for IPL and 68%, 60% and 34% for LDPL at 1, 3 and 6 months, respectively. At 6 months follow-up, there was no significant difference between treatments in terms of hair reduction (P = 0·427), patient assessment of hairiness (P = 0·250) and patient satisfaction (P = 0·125). Pain scores were consistently higher for IPL [median 6, interquartile range (IQR) 4-7] than LPDL (median 3, IQR 2-5) (P < 0·001)., Conclusion: Hirsute women with normal or medically normalized testosterone levels responded equally well to IPL and LPDL treatments of facial hairiness, but the efficacy declined over 6 months., (© 2010 The Authors. BJD © 2010 British Association of Dermatologists.)

Background: Individuals are recommended to wait for 20 min following sunscreen application before dressing. However, this is probably seldom done in daily life, and therefore we investigated how dressing earlier than 20 min after application affected the sun protection factor (SPF)., Objectives: To determine the SPF of a sunscreen applied at different amounts at 4, 8 and 20 min before dressing., Methods: An organic sunscreen was used on the backs of 22 healthy volunteers. Before SPF testing, participants wore a cotton T-shirt for 60 min after the test areas had been uncovered for 4, 8 or 20 min after sunscreen application. The SPF was also tested on unclothed skin., Results: The median SPF was 11.7 (2 mg cm(-2)), 5.7 (1 mg cm(-2)) and 3.3 (0.5 mg cm(-2)) for unclothed skin, and 8.1 (2 mg cm(-2)), 4.8 (1 mg cm(-2)) and 2.2 (0.5 mg cm(-2)) following an interval of 8 min before dressing. The SPF was similar for time intervals of 20 and 8 min when the amount was 1 mg cm(-2) (P = 0.48) and 2 mg cm(-2) (P = 0.56). For 0.5 mg cm(-2) there was no difference between skin clothed after 20 min and unclothed skin (P = 0.19), nor between skin clothed after 4 min and after 8 min (P = 0.28)., Conclusions: When sunscreens are applied at amounts of 1 and 2 mg cm(-2) the time between sunscreen application and dressing can be as little as 8 min. When less sunscreen is used the SPF is insensitive to the length of time between application and dressing.

Background: Photodynamic therapy (PDT) is an effective but time-consuming and often painful treatment for actinic keratosis (AK). Home-based daylight-PDT has the potential to facilitate treatment procedure and to reduce associated pain due to continuous activation of small amounts of porphyrins. Moreover, a reduced methyl aminolaevulinate (MAL) concentration may reduce associated inflammation, making the treatment more tolerable for the patients., Objectives: To compare response rates and adverse effects after PDT using conventional 16% and 8% MAL with home-based daylight exposure in treatment of AK., Methods: Thirty patients with mostly thin-grade AK of the face or scalp were treated with 16% and 8% MAL-PDT in two symmetrical areas after application of sunscreen. Immediately after, patients left the hospital with instructions to spend the remaining day outside at home in daylight. Patients scored pain during treatment and light exposure was monitored with an electronic wristwatch dosimeter., Results: The complete response rate after 3 months was 76.9% for 16% MAL and 79.5% for 8% MAL (P = 0.37). Patients spent a mean of 244 min outdoors and received a mean effective light dose of 30 J cm(-2). Light doses of 8-70 J cm(-2) induced similar response rates (P = 0.25). Patients experienced mild to moderate pain during daylight exposure (mean maximal pain score of 3.7). No differences in pain scores and erythema were seen between the areas treated with 16% MAL and with 8% MAL., Conclusions: Home-based daylight-mediated MAL-PDT was an effective and well-tolerated treatment for AK. No differences in response rates or adverse events were found between the areas treated with 16% MAL and with 8% MAL.

Background: Chronic radiodermatitis is a common sequela of treatment for breast cancer and potentially a psychologically distressing factor for the affected women., Objectives: To evaluate the efficacy and adverse effects of treatments with a long-pulsed dye laser (LPDL) vs. intense pulsed light (IPL) in a randomized split-lesion trial., Methods: Thirteen female volunteers with radiodermatitis and Fitzpatrick skin types II-III were included in the study. Subjects received a series of three treatments at 6-week intervals with half-lesion LPDL (V-beam Perfecta, 595 nm) and half-lesion IPL (Ellipse Flex); the interventions were randomly assigned to left/right or upper/lower halves. Primary end-points were reduction in telangiectasia, patient satisfaction and preferred treatment. Secondary end-points were pain and adverse effects. Efficacy was registered by blinded photographic evaluations 3 months after the final treatment., Results: Eleven patients completed the study. Telangiectasia cleared with both treatments but the efficacy of LPDL was superior. Blinded photographic evaluations showed median vessel clearances of 90% (LPDL) and 50% (IPL) (P = 0.01). LPDL treatments were associated with lower pain scores than IPL treatments [median visual analogue scale (VAS) score 4.3 and 6.0, respectively, P < 0.01]. Patients were slightly more satisfied with LPDL (median VAS score 8) than IPL treatments (median VAS score 7; P < 0.05) and more preferred LPDL (n = 9) to IPL (n = 2) (P < 0.01). Two patients withdrew from the study because of hypopigmentation of the IPL treated areas, which slowly repigmented within 1 year., Conclusions: This study was based on two specific laser and IPL devices, and found the LPDL treatment to be advantageous compared with IPL due to superior vessel clearance and less pain.

Background: Pulsed dye lasers (PDLs) are considered the treatment of choice for port-wine stains (PWS). Studies have suggested broadband intense pulsed light (IPL) to be efficient as well. So far, no studies have directly compared the PDL with IPL in a randomized clinical trial., Objectives: To compare efficacy and adverse events of PDL and IPL in an intraindividual randomized clinical trial., Methods: Twenty patients with PWS (face, trunk, extremities; pink, red and purple colours; skin types I-III) received one side-by-side treatment with PDL (V-beam Perfecta, 595 nm, 0.45-1.5 ms; Candela Laser Corporation, Wayland, MA, U.S.A.) and IPL (StarLux, Lux G prototype handpiece, 500-670 and 870-1400 nm, 5-10 ms; Palomar Medical Technologies, Burlington, MA, U.S.A.). Settings depended on the preoperative lesional colour. Treatment outcome was evaluated by blinded, clinical evaluations and by skin reflectance measurements., Results: Both PDL and IPL lightened PWS. Median clinical improvements were significantly better for PDL (65%) than IPL (30%) (P = 0.0004). A higher proportion of patients obtained good or excellent clearance rates with the PDL (75%) compared with IPL (30%) (P = 0.0104). Skin reflectance also documented better results after PDL (33% lightening) than IPL (12% lightening) (P = 0.002). Eighteen of 20 patients preferred to receive continued treatments with PDL (P = 0.0004). No adverse events were observed with PDL or IPL., Conclusions: Both the specific PDL and IPL types of equipment used in this study lightened PWS and both were safe with no adverse events. However, the PDL conveyed the advantages of better efficacy and higher patient preference.

The aim of this study was to establish a simple guinea pig model for the purpose of evaluating diagnostic principles and treatment modalities for dermatophytic infections. The following variables were evaluated; pre-treatment of the skin by shaving versus tape stripping, Microsporum canis or Trichophyton mentagrophytes test strains as etiologic agents, differences in inoculum concentrations, and inoculation with and without occlusion. The course of infection was evaluated clinically by redness and lesion scores and mycologically by microscopy, culture, and histopathology. The applicability of the model was evaluated with a recently developed diagnostic pan-dermatophyte PCR and antifungal treatment was tested with an oral solution of itraconazole, 10 mg/kg, once daily during days 3-14 of the test period. Pre-treatment of the skin with a manual razor was for practical reasons preferable to tape stripping. Inoculation under occlusion showed no advantage in the establishment of experimental infections. Infection severity showed some association with the inoculum concentration and subtype of T. mentagrophytes but not in studies involving M. canis. The establishment of dermatophytosis was confirmed by histopathology. Surprisingly, microscopy was found to be less sensitive than culture and the latter was as sensitive as pan-dermatophyte PCR. Itraconazole significantly reduced lesion and redness score, with M. canis infections responding better to itraconazole treatment than those caused by T. mentagrophytes. In conclusion, we established a dermatophytosis animal model, which was proven useful for evaluating diagnostic methods and antifungal susceptibility testing.

Background: Photodynamic therapy (PDT) is a highly effective treatment for actinic keratoses (AK); however, it is time consuming and often painful for the patient. Daylight-PDT would make the treatment independent of the clinic and less painful due to the continuous activation of small amounts of porphyrins during its formation., Objectives: The objective of this randomized controlled study was to compare response rates and adverse effects after methyl aminolevulinate (MAL)-PDT using conventional red light-emitting diode (LED) light vs. daylight., Patients/methods: Twenty-nine patients with AK of the face and scalp were treated with MAL-PDT in two symmetrical areas. One area was illuminated by red LED light (37 J cm(-2)) after 3-h incubation with MAL under occlusive dressing. The other area was treated with daylight for 2.5 h after the MAL cream had been under occlusion for half an hour., Results: We found no significant difference in the treatment effect between the two treatments (P = 0.13), with a reduction of AK lesions of 79% in the daylight area compared with 71% in the LED area. Treatment response in the daylight area did not depend on the intensity of the daylight. Illumination with LED was more painful than daylight (P < 0.0001). Erythema and crusting occurred after both treatments and were similar in the two areas., Conclusions: PDT of AK by continuous activation of porphyrins by daylight proved to be as effective as conventional PDT. PDT using daylight activation will make the treatment of these extremely common premalignant tumours more time and cost effective, and more convenient for the patient.