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BACKGROUND Non-ablative fractional laser is an effective modality for the treatment of periorbital wrinkling, one of the earliest signs of skin aging. Thermo-mechanical fractional injury (TMFI) therapy (Tixel®, Novoxel®, Israel) is an innovative technology that is now being used for facial skin rejuvenation. Our study compares the clinical results, side effects, and downtime profile between TMFI treatment and non-ablative fractional 1565 nm laser (ResurFX®, Luminis, Israel). METHODS This was a prospective study of 68 patients (64 women, 4 men) with skin types I-VI in two medical centers (34 from Israel, 34 from the USA) that were randomized to receive either TMFI or NAFL treatment for periorbital wrinkling. Patients received 3-5 treatments, 3-5 weeks apart. Six months after the last treatment, the change in Fitzpatrick Wrinkling Classification System (FWCS) was calculated by three non-involved physicians and compared to pretreatment results. Side effects and downtime profiles were assessed in each group (including VAS pain assessment, time required to refrain from work and social activity, and time required for the resolution of redness, edema, and crusts.) RESULTS: A moderate improvement in periorbital wrinkling was demonstrated in both groups, with an average improvement of 1.6 ± 0.6 in FWCS in the TMFI group and an average improvement of 1.7 ± 0.8 in the NAFL group (p

Objective A 730 nm picosecond-domain laser was developed to improve the clearance of pigmented lesion and reduce adverse events. This study assessed the safety and efficacy of this system for the clearance of lentigines and explores how the short picosecond pulses interact with tissue via histology. Study design and methods Twenty subjects with Fitzpatrick skin types II-IV were enrolled in this prospective, IRB-approved study. Four treatments were administered using a 730 nm picosecond-domain laser. Pre- and posttreatment photos were assessed by blinded reviewers at 4- and 12-week follow-up visits, using a 5-point clearance scale. Subject satisfaction was measured using a 5-point scale. Investigator Global Improvement Score (IGIS) was performed at the 4- and 12-week follow-up visits, using an 11-point clearance scale. Subject pain level was measured using an 11-point scale (no pain [0], extreme pain [10]). Histology of 730 and 532 nm picosecond pulses was compared with 755 and 532 nm nanosecond pulses. Results Sixteen subjects with a total of 118 discontinuous treatment areas, each comprised of 1-20 lesions, completed all study visits. Thirty body regions were studied, including arms (6), hands (16), scalp (1), forehead (2), face (3), and back (2). Spot sizes ranging from 2 to 5 mm diameters were used with fluences ranging from 0.8 to 4.0 J/cm2 . Mean pain score was 3.6 of 10 for all four treatments. Ninety-nine percent of randomly paired 4-week posttreatment images and 100% of 12-week posttreatment images were correctly identified from their respective baseline images by three blinded reviewers. Mean IGIS demonstrated scores of 6.7 and 7.0 at 4- and 12-week follow-up visits, respectively. At the 4- and 12-week follow-up visits, 76% and 73% of subjects, respectively, were satisfied to highly satisfied. The mean clearance score for all 118 treatment areas was 3 of 4 in follow-up visits. At 12-week follow-up, 36% of 118 treatment areas had a clearance score of 4, and 38% had a clearance score of 3. Post treatment, there was typical erythema, edema, dryness, crusting, and itching but negligible purpura, no pinpoint bleeding, blistering or scarring, and no significant hyperpigmentation or hypopigmentation. Histology showed diffuse, focal epidermal vacuolization ~5-10 µm in diameter and mild extravasation of erythrocytes with 730 nm picosecond pulses, while diffuse epidermal vacuolization was observed with coalescence of vacuoles (~20-100 µm), junctional clefting and mild extravasation of erythrocytes with 755 nm nanosecond pulses. Picosecond pulses of the wavelength of 532 nm produced diffuse, focal epidermal vacuolization and larger dermal vacuoles to depths of 500 µm, while 532 nm nanosecond pulses produced diffuse epidermal vacuolization with coalescence of vacuoles and marked dermal hemorrhage. Conclusion This study demonstrated the potential of a new 730 nm picosecond-domain laser for the clearance of lentigines. The results showed good clearance with no adverse events and good subject satisfaction in patients with skin type II-III. Additional studies need to be conducted on darker skin types. The histopathologic findings demonstrate that the picosecond 730 nm laser produces excellent selectivity for pigment with minimal disruption of the dermal-epidermal junction and may therefore reduce healing times and the risk of adverse events.

Background Ultrasound energy has been used for cutaneous rejuvenation, including treatment of fine lines and wrinkles. Ultrasound waves of high intensity can induce thermal injury in the dermis, which causes tissue coagulation and remodeling. Objective To examine the safety and utility of a novel ultrasound device that uses high-intensity, high-frequency, parallel ultrasound beams to improve fine lines and wrinkles of the face and neck. Materials and methods A prospective, multicenter, clinical study investigated the utility of this novel ultrasound device to improve fine lines and wrinkles. Sixty subjects were enrolled for single treatment to the face and neck. Results Fifty-eight subjects completed the study. The mean age was 58 years, and 87.9% were women. Fitzpatrick skin Types I to VI were represented. Assessments compared 12-week follow-up with baseline. Two blinded reviewers agreed in identifying pretreatment and post-treatment photographs for 78% of subjects. There was significant improvement of 1 to 3 Fitzpatrick Wrinkle and Elastosis Scale units in 86% of subjects. For investigator global improvement scores, 88% of subjects had improvement. Overall, 72% of subjects noted improvement, and the majority were satisfied. There were no device-related adverse events. Conclusion Treatment with a novel ultrasound device that uses high-intensity, high-frequency, parallel ultrasound beams safely improved the clinical appearance of fine lines and wrinkles of the face and neck.

Background and objectives This paper describes the laser techniques available for the treatment of surgical and trauma scars and develops recommendations for an algorithmic-based treatment approach based on extensive clinical experience and published data. Study design/materials and methods We reviewed the literature regarding laser treatment of surgical and traumatic scars and incorporated the clinical experience of the authors to develop an algorithm for the treatment of surgical and trauma scars. Results In order to develop treatment recommendations, scars were differentiated based on their clinical characteristics. Specific scar characteristics aid in determining the appropriate treatment strategy for different types of complex surgical and trauma scars. Conclusion Laser therapy is first-line therapy for traumatic and surgical scars. The treatment approach should be guided by scar characteristics (e.g., anatomic location, type of injury, color, thickness, tension, scar age, and activity) and involves choosing the appropriate laser type and determining the benefit of combination therapy with surgical and nonsurgical treatment modalities to optimize treatment responses. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

BACKGROUND Picosecond-domain laser pulses improve the photomechanical disruption of tattoos. OBJECTIVE This study evaluates the efficacy and safety of a novel, dual-wavelength, 1,064/532-nm, picosecond-domain laser for tattoo clearance. MATERIALS AND METHODS This was a prospective, self-controlled, clinical study of 34 subjects with 39 tattoos treated at 2 sites with an interval of 4.8 ± 1.6 weeks and up to 10 treatments (mean, 7.5). Blinded evaluation and investigator assessment of serial digital images was performed to evaluate treatment efficacy in the 36 tattoos that received at least 3 treatments. Investigators also assessed efficacy before each treatment visit up to 10 treatments. Safety and tolerability was evaluated for all 39 tattoos that underwent at least 1 treatment. RESULTS Blinded evaluation demonstrated that lightening of tattoos was achieved in all subjects, with 86% (31 of 36 tattoos) showing at least a 50% clearance after 3 treatments. Adverse events were few and transient in nature. Patient satisfaction and treatment tolerability were high. CONCLUSION Treatment of single-colored and multicolored tattoos with this novel 1,064/532-nm picosecond laser is highly safe and effective.

Lentigines are benign, pigmented macules that are frequently a cosmetic concern for patients. Solar lentigines are an early sign of dermatoheliosis and are common in lighter skinned individuals. Procedures used alone or in combination to treat solar lentigines include topical creams, cryotherapy, microdermabrasion, chemical peels, intense pulsed light, and lasers. Nanosecond domain lasers and intense pulsed light sources are the workhorse modalities for treatment of lentigines, and experience is growing with picosecond lasers. Other methods include cryotherapy, millisecond domain long-pulsed lasers, non-ablative fractional lasers, and lightening creams, which can be used alone or in combination. Treatment approaches are tailored for each patient based on the skin and lesion color, as well as tolerance for downtime and multiple treatment sessions. Test treatments can help the clinician find the treatment with the most efficacy and the least side effects. Most treatment modalities are extremely well tolerated without significant adverse events. Strict sun protection is required to prevent post-inflammatory pigment alteration and lesion recurrence.

Background and Objective Non-ablative fractional lasers (NAFL) generate microscopic non-contiguous columns of thermal injury in the dermis, resulting in collagen remodeling. This manuscript details our experience with a novel 1,565 nm scanned, erbium-doped fiber NAFL for the treatment of facial photodamage. Study Design/Materials and Methods A prospective, open-label clinical trial was conducted at two clinical sites in the United States on 16 female subjects with a mean age of 49.6 years, Fitzpatrick skin types II to IV, and a baseline Fitzpatrick–Goldman Wrinkle and Elastosis Score (FGWES) of 3–6. Each subject received three treatments at 4–5 week intervals with follow-up assessments at 1, 3, and 6 months after the last treatment. Results The mean FGWES demonstrated a statistically significant decrease from baseline both at 3 months (−0.58 ± 0.23, P = 0.02) and 6 months (−0.66 ± 0.22, P = 0.008) after the last treatment. Fifty percent (95%CI [24.21%, 68.49%]) of subjects showed a significant (at least 1 grade) improvement in FGWES from baseline at 3-month follow-up. At least 72% of subjects perceived the results as “moderate” to “very good” at 3 months post-treatment, with comparable satisfaction rates. Treatments were not associated with a high level of pain or discomfort and typical downtime was less than 2 days. No unexpected adverse events or serious adverse events were reported. Conclusion The 1,565 nm erbium-doped scanned NAFL is an effective treatment for facial wrinkles with a favorable recovery and side effect profile. Lasers Surg. Med. 48:174–180, 2016. © 2015 Wiley Periodicals, Inc.

Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in the United States. Cutaneous squamous cell carcinoma has an estimated incidence of more than 700,000 new cases per year and a 5% risk of metastasis.To provide clinicians with guidelines for the management of cSCC based on evidence from a comprehensive literature review and consensus among the authors.The authors conducted an extensive review of the medical literature on treatment methods for cSCC, taking into consideration cure rates, recurrence and metastatic rates, aesthetic and functional outcomes, and cost effectiveness of the procedures.Surgical treatments provide the best outcomes for cSCC. Mohs micrographic surgery is a cost-effective procedure that affords the highest cure rate, maximal tissue preservation, and superior cosmetic outcomes. Nonsurgical methods may be used as a primary treatment for low-risk squamous cell carcinomas, but the cure rates are lower.The cure rate remains the most important consideration in choosing the treatment method, but additional factors, such as the patient's general medical condition, psychosocial circumstances, the location of the tumor and cost effectiveness of the therapy should be considered. Mohs micrographic surgery remains the preferred treatment for high-risk tumors and tumors located in cosmetically sensitive areas.

Background Basal cell carcinoma (BCC) is the most common cancer in the US population affecting approximately 2.8 million people per year. Basal cell carcinomas are usually slow-growing and rarely metastasize, but they do cause localized tissue destruction, compromised function, and cosmetic disfigurement. Objective To provide clinicians with guidelines for the management of BCC based on evidence from a comprehensive literature review, and consensus among the authors. Materials and methods An extensive review of the medical literature was conducted to evaluate the optimal treatment methods for cutaneous BCC, taking into consideration cure rates, recurrence rates, aesthetic and functional outcomes, and cost-effectiveness of the procedures. Results Surgical approaches provide the best outcomes for BCCs. Mohs micrographic surgery provides the highest cure rates while maximizing tissue preservation, maintenance of function, and cosmesis. Conclusion Mohs micrographic surgery is an efficient and cost-effective procedure and remains the treatment of choice for high-risk BCCs and for those in cosmetically sensitive locations. Nonsurgical modalities may be used for low-risk BCCs when surgery is contraindicated or impractical, but the cure rates are lower.

Background Fractional photothermolysis, an approach to laser skin resurfacing that creates microscopic thermal wounds in skin separated by islands of spared tissue, was developed to overcome the high incidence of adverse events and prolonged healing times associated with full coverage ablative laser procedures. Objective To examine whether fractional nonablative laser resurfacing induces skin tightening. Materials and methods A literature review was performed to evaluate the clinical and histologic effects of fractional nonablative laser resurfacing and full coverage ablative resurfacing procedures. Results Fractional nonablative lasers produce excellent outcomes with minimal risk and morbidity for a variety of clinical conditions, including photodamaged skin, atrophic scars, surgical and burn scars. Efforts to induce robust fibroplasia in histologic specimens and skin tightening in the clinical setting have yielded inconsistent results. Conclusion A better understanding of the histology of fractional laser resurfacing will help to optimize clinical outcomes.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Melasma is an acquired disorder of pigmentation that commonly affects women with phototypes III-V, and it has a negative impact on the quality of life in affected individuals. It presents clinically as symmetric tan or brown patches on the face, most often involving the forehead, cheeks, perioral region, and periorbital region. On histologic examination, there is increased melanin in the epidermis and/or an increased number of melanosomes in the dermis, with a normal number of highly melanized and dendritic melanocytes. The mainstay of treatment is the use of sunscreen along with topical medications that suppress melanogenesis. Clearance is usually incomplete and recurrences or exacerbations are frequent, probably because of the poor efficacy in clearing dermal melanosomes. Treatment with high-energy pigment-specific lasers, ablative resurfacing lasers, and fractional lasers results in an unacceptably high rate of postinflammatory hyper- and hypopigmentation and rebound melasma. Recently, promising results have been achieved with low-fluence Q-switched neodymium-doped yttrium aluminium garnet laser treatment, which can selectively target dermal melanosomes without producing inflammation or epidermal damage, in all skin phototypes. This article reviews the current treatment modalities for melasma, the rationale for using and the clinical results of combination therapy with low-fluence Q-switched neodymium-doped yttrium aluminium garnet lasers.

Background and Objective A common, disfiguring problem in women, melasma is often refractory to treatment, and long-term remissions are difficult to achieve. This study assessed the safety and effectiveness of a procedure combining microdermabrasion, a topical regimen, and low fluence Q-switched Nd:YAG laser treatment. Materials and Methods In this observational study of 27 female subjects, phototypes II–V, referred for treatment of mixed-type melasma refractory to previous therapies, low-fluence QS Nd:YAG laser treatment of 1.6–2 J/cm2 with 5 or 6 mm spot was administered immediately following microdermabrasion. Daily application of a broad-spectrum sunscreen began immediately; subjects used a topical skin care regimen of hydroquinone with tretinoin or vitamin C. Treatments were repeated at 4-week intervals. Follow-up assessment was done 3–12 months after the last treatment. Adverse effects were recorded at each visit. Standardized digital photographs obtained before each treatment session and at follow-up visits were objectively assessed by blinded comparison using a quartile grading system. Results Treatment was successful in all skin types, deemed painless by all subjects, and required no anesthesia. Average number of treatments was 2.6. Twenty-two subjects (81%) had >75% clearance of melasma; 11 subjects (40%) achieved >95% clearance. Most subjects showed >50% clearance of their melasma 1 month after the first treatment. Side effects were limited to mild post-treatment erythema, which developed after the microdermabrasion and lasted approximately 30–60 minutes. Four subjects noted temporary exacerbation of melasma after inadvertent sun exposure, but this resolved within several weeks of resuming the topical skin care regime. Remission lasted at least 6 months. Conclusion Microdermabrasion plus low-fluence QS Nd:YAG laser treatment is a simple, non-invasive procedure with minimal risk, no recovery time, and long-lasting remission. Treatment works on all skin phototypes in just two to three treatment sessions. Subject compliance with skin care was excellent, probably due to the dramatic improvement observed within 4 weeks. Lasers Surg. Med. 44:117–124, 2012. © 2012 Wiley Periodicals, Inc.

The pathophysiology of acne vulgaris depends on active sebaceous glands, implying that selective destruction of sebaceous glands could be an effective treatment. We hypothesized that light-absorbing microparticles could be delivered into sebaceous glands, enabling local injury by optical pulses. A suspension of topically applied gold-coated silica microparticles exhibiting plasmon resonance with strong absorption at 800 nm was delivered into human pre-auricular and swine sebaceous glands in vivo, using mechanical vibration. After exposure to 10-50 J cm(-2), 30 milliseconds, 800 nm diode laser pulses, microscopy revealed preferential thermal injury to sebaceous follicles and glands, consistent with predictions from a computational model. Inflammation was mild; gold particles were not retained in swine skin 1 month after treatment, and uptake in other organs was negligible. Two independent prospective randomized controlled clinical trials were performed for treatment of moderate-to-severe facial acne, using unblinded and blinded assessments of disease severity. Each trial showed clinically and statistically significant improvement of inflammatory acne following three treatments given 1-2 weeks apart. In Trial 2, inflammatory lesions were significantly reduced at 12 weeks (P=0.015) and 16 weeks (P=0.04) compared with sham treatments. Optical microparticles enable selective photothermolysis of sebaceous glands. This appears to be a well-tolerated, effective treatment for acne vulgaris.

Background and Objectives The pulsed dye laser set the standard of care for the treatment of vascular lesions, and recent modifications have enabled improved efficacy with fewer side effects. An investigational high energy, variable pulse duration pulsed dye laser has been modified to treat both vascular and pigmented lesions associated with photoaging. Each laser pulse is comprised of a sequence of eight uniform micropulses, which evenly distribute the pulse energy, effectively increasing the purpura threshold at any given fluence. Pigmented lesions are treated with a compression handpiece (CHP) that removes competing vascular target from the field, and helps to prevent purpura. This pilot study was undertaken to determine the optimum laser settings, and to investigate the ability of this device to improve vascular and pigmented lesions associated with photoaging. Study Design/Materials and Methods Twenty-four patients with photoaged skin and phototype I–III were enrolled in the study. Thirteen received treatment for vascular and pigmented lesions, and 11 subjects were treated for pigmented lesions alone. Subjects received one to three treatments at 3–4 weeks intervals, and underwent 3- and 12-week follow-up evaluation. The degree of improvement was assessed by subject evaluation as well as comparison of standardized digital photographs by three independent dermatologists. Background erythema was treated with a 12-mm spot size, at a fluence of 7 J/cm2, and a pulse width of 10 ms. The cryogen cooling was set at 30 mseconds with a 30 ms delay. Individual telangiectasias were treated with a 5- or 7-mm spot size at fluences of 9–14 J/cm2 and pulse widths of 6–20 mseconds. Pigmented lesions were treated using a 5- or 7-mm spot size, with energy of 9–15 J/cm2 and a pulse width of 1.5–10 ms without cooling. The CHP had a 7-mm spot size, and fluences of 9–16 J/cm2, and pulse widths of 1.5 or 3 ms were used in the treatment of pigmented lesions. Results The treatment was well tolerated without the use of topical anesthetic. All subjects noted improvement in the both vascular and pigmented lesions, and were satisfied with their outcomes. Objectively, there was moderate improvement in background erythema, telangiectasia, and pigmented lesions. Three subjects who were treated with sun tans developed transient hypopigmentation and two subjects developed a transient textural change following pulse stacking for the treatment of pigmented lesions with the conventional handpiece. Purpura was noted in all patients treated for pigment with the conventional handpiece at pulsewidths less than 6 mseconds, as compared to only one that was treated with the CHP. Three patients treated in rapid succession for vascular, and then pigmented lesions with the CHP exhibited purpura, which was prevented in future treatments with 1–2 minutes of topical ice cooling between passes. Conclusions This novel 595-nm pulsed dye laser, with a modified pulse sequence and CHP, now has the versatility to safely treat both pigment and vascular changes associated with photoaging. Lasers Surg. Med. 38:808–813, 2006. © 2006 Wiley-Liss, Inc.

Recent advances in nanotechnology have provided numerous opportunities to transform medical therapies for the treatment of diseases including cancer, atherosclerosis, and thrombosis. Here, we report, through in vitro studies and in vivo human pilot clinical studies, the use of inert, inorganic silica-gold nanoshells for the treatment of a widely prevalent and researched, yet poorly treated disease of acne. We use ~150nm silica-gold nanoshells, tuned to absorb near-IR light and near-IR laser irradiation to thermally disrupt overactive sebaceous glands in the skin which define the etiology of acne-related problems. Low-frequency ultrasound was used to facilitate deep glandular penetration of the nanoshells. Upon delivery of the nanoshells into the follicles and glands, followed by wiping of superficial nanoshells from skin surface and exposure of skin to near-infrared laser, nanoshells localized in the follicles absorb light, get heated, and induce focal thermolysis of sebaceous glands. Pilot human clinical studies confirmed the efficacy of ultrasonically-delivered silica-gold nanoshells in inducing photothermal disruption of sebaceous glands without damaging collateral skin.

The development of lasers using deeper-penetrating, near-infrared wavelengths with millisecond pulse durations and skin-cooling methods has produced safer and more predictable results for the treatment of leg veins less than 1 mm in diameter and depth. Recent prospective studies of the near-infrared lasers show comparable efficacy and side effect profiles to those observed with sclerotherapy. Treatment of reticular and varicose veins is effective with these wavelengths but is limited by patient discomfort when compared with sclerotherapy. Visible light lasers (such as the pulsed dye and KTP) and intense pulsed-light sources are reproducibly effective only for superficial, nonarborizing pink-to-red telangiectasia, in the absence of points of proximal reflux. Because most lower-extremity vascular ectasias comprise a heterogeneous group of vessel sizes and depths, many patients achieve the best results using a combination of techniques. This article reviews the fundamentals of laser tissue interactions for the treatment of leg veins and details the recent clinical experience with the newer near-infrared devices.

BACKGROUND. New char-free carbon dioxide lasers are capable of precise tissue vaporization with minimal residual thermal damage. These lasers operate either by producing high energy, rapid pulses or by scanning a highly focused continuous mode beam. OBJECTIVE. To determine the depth of ablation and the depth of residual thermal injury produced with one to three passes of the pulsed and scanned systems. METHODS. The distal ends of preauricular donor skin from 12 patients requiring full-thickness skin grafts following Mohs micrographic surgery were treated with zero to three passes of each of the lasers, and fixed for histopathological analysis. RESULTS. The three lasers tested produced vaporization of thin (20-50 μm) layers of tissue and narrow (20-150 μm) zones of thermal injury following one, two, or three passes on intact skin. CONCLUSION. The pulsed and scanned technologies are capable of producing char-free tissue ablation with minimal residual thermal damage.

BACKGROUND Approximately 50–75% lightening of port-wine stains is achieved within two to three treatments with pulsed dye laser therapy, but the incidence of complete clearing is variable. OBJECTIVE This study was designed to: 1) assess the ability of continued repetitive pulsed dye laser treatments to further lighten persistent port-wine stains; 2) evaluate the factors contributing to the resistance of port-wine stains to laser therapy; and 3) determine the relative risk of adverse effects following repetitive treatments to the same area. METHODS A retrospective photographic analysis was performed of 69 patients that failed to achieve greater than 75% lesional lightening within nine treatment sessions. The percentage improvement was assessed by comparing the degree of lightening at the last treatment to that of the midway point of treatment. RESULTS Significant improvement in port-wine stain lightening, from the midway to last treatment, was seen in patients who had 10–25 repetitive treatments. CONCLUSION Repetitive treatments with the pulsed dye laser can lead to improvement in the overall lightening of persistent port-wine stains without an increased risk of adverse effects.

Before the development of laser technology, unacceptable cosmetic outcomes often resulted when conventional surgical or destructive methods were used to treat a variety of cutaneous vascular disorders. Treatment of port wine stains, hemangiomas, telangiectases, hypertrophic scars, and warts has been revolutionized by dramatic advances in laser technology and an improved understanding of laser-tissue interaction. These vascular lesions can now be safely and effectively treated in infants, children, and adults with a minimal risk of scarring. The evolution of continuous-wave and pulsed vascular lesion lasers and their clinical applications are discussed in this article.

Lasers and light-based therapy have been used to treat port-wine stains and hemangiomas for the past two decades.Laser treatment produces dramatic clearing of port-wine stains with minimal scarring or epidermal damage, minimizes hypertrophy of lesions, decreases the risk of bleeding from pyogenic granlomas, and reduces the associated psychosocial morbidity. Lasers are used to halt the proliferation of the superficial component of hemangiomas, reduce the mass of the lesions, and to treat the vascular ectasia as well as the atrophic scarring that develops following involution.Laser therapy provides a safe and effective modality with low morbidity for cutaneous vascular anomalies.

Background: Millisecond-pulsed Nd:YAG lasers have been developed for the treatment of reticular leg veins. Objective: We evaluated the effectiveness of a single treatment with a 50 millisecond 1064 nm Nd:YAG laser in the treatment of reticular veins of the lower extremity. Methods: Twenty patients with reticular veins measuring 1.0 to 3.0 mm in diameter received one treatment with a 1064 nm Nd:YAG laser (Coolglide, Altus, Burlingame, Calif) at fluences of 100 J/cm 2 and 50 millisecond pulse duration. Symmetric matched areas that were left untreated served as the control. Eleven patients were pretreated with a topical anesthetic cream for 1 hour before treatment and wore compression stockings for 5 days after treatment. Nine patients were treated without topical anesthesia and did not wear compression stockings. Percent clearing and side effects were determined by 3 nontreating physicians (at each respective site) comparing projected Kodachrome images 1 month and 3 months after treatment. Patients also performed a self-assessment of their results. Results: Two-thirds of vessels measuring 1 to 3 mm in diameter cleared more than 75% with one treatment. Larger vessels appeared to improve more than smaller vessels. Immediate treatment discomfort was tolerable. Side effects were minimal and included superficial thrombosis, delayed bruising, hyperpigmentation, and matting. Conclusion: Millisecond-pulsed Nd:YAG lasers used with 50 millisecond pulses are effective in the treatment of reticular leg veins. (J Am Acad Dermatol 2003;48:76-81.)

Nonanimal hyaluronic acid gel was recently developed for soft tissue augmentation and volume expansion and has been shown to offer several advantages in comparison to other augmentation materials. There are rare reports of adverse events believed to be secondary to trace amounts of proteins in the hyaluronic acid raw material.To determine the safety profile of nonanimal stabilized hyaluronic acid gel (Restylane, Perlane, Restylane Fine Lines, Q-Med AB, Uppsala, Sweden) for soft tissue augmentation using a retrospective review of all adverse events data from Europe, Canada, Australia, South American, and Asia from 1999 and 2000.Data from an estimated 144,000 patients treated in 1999 indicated the major reaction to injectable hyaluronic acid was localized hypersensitivity reactions, occurring in approximately 1 of every 1400 patients treated. In 1999 there was an adverse event reported for 1 of every 650 patients (0.15%) treated. These were temporary events that included redness, swelling, localized granulomatous reactions, bacterial infection, as well as acneiform and cystic lesions. For 2000 there was an estimated 262,000 patients treated with hyaluronic acid gel. The total number of adverse events was 144, corresponding to one adverse event for every 1800 patients (0.06%) treated. The major adverse event was again hypersensitivity, occurring in 1 of every 5000 patients treated.According to the reported worldwide adverse events data, hypersensitivity to nonanimal hyaluronic acid gel is the major adverse event and is most likely secondary to impurities of bacterial fermentation. According to data from 2000, the incidence of hypersensitivity appears to be declining after the introduction of a more purified hyaluronic acid raw material.

background. The treatment of inverse psoriasis can be both challenging and frustrating. Conventional topical and systemic treatments can be limited in terms of efficacy, acceptability and safety. The 308 nm excimer laser has been shown to be effective in the treatment of psoriatic plaques. methods. A patient with chronic inverse psoriasis was treated with 308 nm excimer laser using a 3.5 cm spot, a dosage of 2 minimal erythema doses and a pulse width of 30 ns. results. Complete clearance of the psoriatic lesions was obtained after 3 weeks of treatment. Remission duration was at least 6 months. conclusion. The 308 nm excimer laser is safe and effective for the treatment of inverse psoriasis. Treatments are well tolerated with minimal side effects. Numerous topical and systemic options exist for the treatment of psoriasis, but disease limited to intertriginous areas poses a special therapeutic challenge. The treatments can be inconvenient, impractical, and unpleasant. The clinical response to these treatments is frequently inconsistent and transient. The risks and costs of systemic immunosuppressive, immunomodulatory, and retinoid compounds usually outweigh the benefits for conditions with a limited distribution. Avoidance of retinoids in women of childbearing age is yet another consideration when choosing appropriate therapy. The challenge was to provide a safe, effective, and longer-lasting therapeutic alternative for the treatment of inverse psoriasis in this patient. Case Report A 26-year-old Caucasian woman presented with a 1.5-year history of red scaly plaques limited to the axilla, groin, and posterior nuchal areas. She denied any current medications, medical problems, or family history of skin disease. A biopsy obtained at the initial presentation confirmed the diagnosis of inverse psoriasis. The lesions initially responded to treatment with topical corticosteroids (class II), but relapses occurred off therapy. Other topical treatments such as calcipotriene, tar, and anthralin were not helpful and poorly tolerated. The patient refused oral medications to treat her skin lesions, given the limited extent of her condition. The psoriatic lesions were noted to improve during the summer months and after sun exposure. However, she had never been treated with either phototherapy or photochemotherapy.

background. A new method for treating facial rhytides and acne scars with nonablative laser and light source techniques has recently been introduced. Given the inherent limitations of photographic and clinical evaluation to assess subtle changes in rhytides and surface topography, a new noninvasive objective assessment is required to accurately assess the outcomes of these procedures. objective. The purpose of this study was to measure and objectively quantify facial skin using a novel, noninvasive, In-vivo method for assessing three-dimensional topography. This device was used to quantify the efficacy of five treatment sessions with the 1064 nm QS Nd:YAG laser for rhytides and acne scarring, for up to six months following laser treatment. methods. Two subjects undergoing facial rejuvenation procedures were analyzed before and after therapy using a 30-mm, three-dimensional microtopography imaging system (PRIMOS, GFM, Teltow, Germany). The imaging system projects light on to a specific surface of the skin using a Digital Micromirror Device (DMD™ Texas Instruments, Irving, TX) and records the image with a CCD camera. Skin Surface microtopography is reconstructed using temporal phase shift algorithms to generate three-dimensional images. Measurements were taken at baseline, at various times during the treatment protocol, and then at three and six-month follow-up visits. Silicone skin replicas (FLEXICO, Herts, England) were also made before and after the laser treatment protocol for comparison to In-vivo acquisition. results. Skin roughness decreased by 11% from baseline after three treatment sessions in the wrinkles subject, while a 26% improvement of skin roughness was recorded by 3D In-vivo assessment six months following the fifth treatment session. The subject with acne scarring demonstrated a 33% decrease in roughness analysis after three treatment sessions by 3D In-vivo assessment. A 61% improvement in surface topography was recorded 3-months following the fifth treatment session, which was maintained at the 6-month follow-up. conclusion. Three-dimensional In-vivo optical skin imaging provided a rapid and quantitative assessment of surface topography and facial fine lines following multiple treatment sessions with a 1064-nm QS Nd:YAG laser, correlating with clinical and subjective responses. This imaging technique provided objective verification and technical understanding of nonablative laser technology. Wrinkle depth and skin roughness decreased at the three and six-month follow-up evaluations by 3D In-vivo assessment, indicating ongoing dermal collagen remodeling after the laser treatment protocol. Future applications may include comparison of nonablative laser technology, optimization of treatment regimens, and objective evaluation of other aesthetic procedures performed by dermatologists.

New developments in laser technology have enabled improved therapy of small and large leg telangiectasia. While sclerotherapy remains the gold standard of treatment, laser therapy should be considered a first line approach for isolated, superficial, fine-caliber, nonarborizing telangiectasia and postsclerotherapy telangiectatic matting. Laser therapy is an excellent option for patients who are fearful of needles or have demonstrated a poor response to sclerotherapy injections. Recent studies have demonstrated good clearance of leg telangiectasia and reticular veins using a variety of laser systems with deeper penetrating, near-infrared wavelengths and higher fluences in conjunction with various epidermal cooling methods. As with sclerotherapy, optimal results are achieved with lasers when larger feeding vessels are treated first using appropriate modalities.

Objective To examine the safety and efficacy of a pulsed alexandrite laser for treatment of leg telangiectasia and reticular veins. Design Observational study. Setting Laser and Skin Surgery Center of New York, New York, NY. Subjects Twenty women with skin phototypes I to III and with 54 patches of leg veins measuring 0.3 to 2.0 mm in diameter. Interventions Each patch was treated once using 1 to 3 passes of a 755-mm, 3-millisecond alexandrite laser. An 8-mm spot and fluences of 60 to 80 J/cm 2 were used, with dynamic epidermal cooling. Main Outcome Measures Subjects underwent evaluation at 4 and 12 weeks for degree of clearance, based on a quartile grading system, and incidence of adverse effects. Results At the 4-week follow-up, 17 (35%) of 48 treatment sites showed greater than 75% clearance and an additional 16 (33%) showed greater than 50% clearance. By 12 weeks, 33 (65%) of 51 treatment sites showed greater than 75% clearance, and there was greater than 50% clearance in an additional 11 (22%). Hyperpigmentation was observed in 18 (35%) of 51 treatment sites. Conclusion A single treatment with a 755-nm, 3-millisecond alexandrite laser at high fluence in conjunction with cryogen skin cooling produced excellent clearance of telangiectasia and reticular veins of the leg with minimal adverse effects.

Background Pseudofolliculitis barbae is a common disorder in individuals with thick, curly hairs, and treatment options are limited. Objective To evaluate the effectiveness of a diode laser in the treatment of pseudofolliculitis barbae. Design Observational study. Setting Laser and Skin Surgery Center of New York, New York, NY. Patients Ten consecutive patients with long-standing pseudofolliculitis barbae and skin phototypes I to IV. Interventions Treatment was performed using an 810-nm diode laser (20- to 30-millisecond pulse duration) at fluences of 30 to 40 J/cm 2 . Three treatments were performed at 6- to 8-week intervals, and subjects underwent evaluation for improvement in the pseudofolliculitis and the degree of hair reduction. Main Outcome Measures Patients were assessed at 6- to 8-week intervals for the degree of hair-count reduction, improvements in papule and pustule formation, and adverse effects. Results Complete hair-growth delays of 3 to 8 weeks' duration were produced, and a decrease in hair density of greater than 50% was noted in all subjects 6 to 8 weeks after the last laser treatment. All patients exhibited greater than 50% improvement in the signs of pseudofolliculitis. Preexisting pigmentary changes improved with therapy. Conclusion Diode laser treatment is a safe and effective method for improving pseudofolliculitis barbae in patients with skin phototypes I to IV.

Author(s): Waldorf, HA; Alster, TS; McMillan, K; Kauvar, AN; Geronemus, RG; Nelson, JS | Abstract: Background and objectiveThe objective of this study was to determine the effectiveness of a dynamic cooling device (DCD), spraying the skin with a brief spurt of cryogen prior to the laser pulse, in reducing transient pain associated with 585-nm pulsed dye laser (PDL) treatment of port-wine stains (PWS), and reducing epidermal damage (hypo/hyperpigmentation) caused by this laser during PWS treatment.Materials and methodsMatched treatment sites were compared with and without the use of the cryogen spray in 47 patients at two investigational sites. Pain ratings, clearance of the PWS, and pigmentation changes were assessed. The results were analyzed by skin type and patient age.ResultsA statistically significant reduction in pain ratings was found in all patient groups using the DCD without changing the efficacy of PWS clearance. Pain reduction was most remarkable in patients with darker skin types. Dynamic cooling prevented the occurrence of epidermal damage or pigmentation change in most cases.ConclusionsThis study suggests that dynamic cooling can dramatically diminish pain during PWS treatment with the 585-nm PDL without reducing treatment efficacy. The absence of epidermal damage in most patients suggests that precooling with the DCD may allow the use of higher laser fluences to expedite clearance without inducing epidermal change. Dynamic cooling has potential use with other lasers and different lesions where discomfort and epidermal effects limit therapy.

Until recently, standard therapies for rejuvenating photoaged skin or recontouring facial scarring included mechanical skin abrasion and chemical exfoliation. An inability to precisely control tissue removal with either of these methods resulted in a high risk of adverse effects including scarring, depigmentation, and textural change. The development of novel technology carbon dioxide lasers has enabled the precise removal of thin layers of tissue and the potential for a safer and more effective means of skin resurfacing. Histologic studies of the effects of CO 2 lasers on tissue have been useful in predicting which systems are capable of thin-layer tissue ablation and providing a framework for appropriate use of each device.

background Carton dioxide (CO2) laser resurfacing has become a very popular method of rhytide and scar removal in the recent past. Preliminary studies have been published describing the method, histology, and clinical results of CO2 laser resurfacing. However, none of these studies has dealt with long-term follow-up results. objective To review all side effects resulting from CO2 laser resurfacing with regard to both short- and long-term effects. method Retrospective analysis of 104 patients who have undergone CO2 laser resurfacing for either facial rhytides and/or scarring with follow-up periods of 4-23 months (average, 8.2 months). results The incidence of side effects are generally very low for CO2 laser resurfacing, including scarring, postinflammatory hyperpigmentation, and infection. However, there is a significant and previously unreported risk of hypopigmentation in an area of the population who often seek improvement in the appearance. conclusions CO2 laser resurfacing of facial rhytides and acne scars can be a very safe procedure by an experienced laser operator. However, careful patient selection, thorough patient instruction, and proper aesthetic analysis of treatment sites must be followed to insure the most favorable outcomes with CO2 laser resurfacing.

Cutaneous laser resurfacing is already proving to be a highly effective tool for improving photodamaged or scarred skin. The clinical and histological effects of the new high-energy, pulsed carbon dioxide (CO2) systems compare favorably with other treatments such as dermabrasion and chemical peels. The tissue-tightening effect noted after laser treatment may account for the claims of superior clinical improvement and needs further investigation.

BACKGROUND. Recent advances in carbon dioxide (CO 2 ) laser technology have resulted in the development of lasers that can precisely remove thin layers of skin with minimal thermal damage to the surrounding tissue. These lasers rely on rapid pulsing or scanning of the laser beam. The effects of these lasers are predictable and reproducible, making them ideal for skin resurfacing. Clinical results have been promising, however, to date, no published series exist. OBJECTIVE. To evaluate the effectiveness and side effect profile of laser resurfacing utilizing a CO 2 laser with a scanning device, and make recommendations for patient selection and treatment protocol. METHODS. Patients with perioral, periorbital, and glabellar rhytides were treated with a CO 2 laser with a scanning device. Utilizing chart review and photographic evaluation, patients treated between November 1994 and April 1995 were retrospectively evaluated for effectiveness of therapy, healing time, and complication rates. RESULTS. A total of 47 patients were evaluated. Photographic evaluation or chart review revealed good to excellent cosmetic results in all anatomic areas studied. All patients experienced posttreatment erythema lasting 1-6 months. Other minor complications were limited to contact dermatitis to topical preparations, transient postinflammatory hyperpigmentation, and milia formation. One patient experienced a primary herpes simplex virus infection during reepithelialization and required intravenous therapy. Minor focal atrophy was seen in one patient. No hypertrophic scarring or permanent pigmentation changes were seen. CONCLUSION. A CO 2 laser system with a scanning beam can effectively and safely improve or remove glabellar, perioral, and periorbital rhytides.

T he increased availability of cosmetic tattoo procedures has also led to an increase in the demand for cosmetic tattoo removal. Undesired appearance of the tattoo either shortly after its application or, after a change in color over time, are common reasons given by patients who request removal of their cosmetic tattoos. Traditionally, Qswitched lasers, such as the ruby, Nd:YAG, and alexandrite, are effective for black, green, red, orange, and purple colors.1,2 However, it is best to avoid using these lasers to remove tattoo pigments suspected of containing metallic oxides. Paradoxical darkening of the tattoo pigments may occur after treatment with any Q-switched lasers that can be permanent and disfiguring.3 The change in iron oxidation states from ferric to ferrous oxide is believed to be responsible for the darkening of the tattoo. Ferric oxide-containing pigments are often found in red, pink, and flesh-colored tattoos. A 44-year-old woman was dissatisfied with the appearance of her pinkish-red cosmetic lip-liner tattoo and requested removal. Cosmetic tattoos of this color typically contain iron oxide. Both the upper and lower lip margins had been outlined with tattoo ink 2 months earlier (Fig 1). No prior treatments had been attempted. The patient denied a history of oral herpes simplex and was determined to have Fitzpatrick skin type II. Before each procedure, local anesthetic with lidocaine, epinephrine, and sodium bicarbonate was infiltrated into the upper and lower lip margins. Prophylactic antibiotic (dicloxacillin) and antiviral medications (acyclovir) were given orally 1 day before each procedure and continued for 1 week postoperatively. The pulsed carbon dioxide laser, with a computer pattern generator (Coherent Laser, Santa Clara, Calif) was used at 10,600 nm, 300 mJ, 60 W. A linear scan pattern was used with a scan density of 6. The entire tattoo was resurfaced in 1 pass. The overlying vaporized tissue was wiped away with a moistened gauze leaving clinically apparent tattoo present. Bacitracin ointment was subsequently applied to the wound. Complete healing of the treated area took place after 4 days. The procedure was repeated at 1-month intervals. After 6 treatments, removal of the tattoo was essentially complete (Fig 2). No scarring or pigmentary change was evident. This report demonstrates safe and effective removal of a tattoo that likely contained iron oxide and that was at risk for paradoxical darkening from use of any of the Q-switched lasers. As with other tattoo laser procedures, complete response required multiple treatments with gradual clearing noted after each treatment. Q-switched lasers target the pigment located in tattoos through selective photothermolysis.4 The target of the pulsed carbon dioxide laser is water, leading to superficial tissue vaporization. Repetitive, conservative treatment sessions were performed by design to minimize the chance of hyperFrom the Laser & Skin Surgery Center of New York. Reprint requests: Roy G. Geronemus, MD, Laser & Skin Surgery Center of New York, 317 E 34th St, Suite 11 North, New York, NY 10016. E-mail: rgeroneumus@hotmail.com. J Am Acad Dermatol 2003;48:271-2. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 0 doi:10.1067/mjd.2003.29 . Fig 1. Red lip-liner tattoo present at the vermillon border before treatment with the pulsed carbon dioxide laser.

Background: The Q-switched ruby laser has been used successfully to treat a variety of benign pigmented lesions. In this study, congenital nevi (diameter, ≤5 cm) in 18 prepubertal children were treated with the Q-switched ruby laser. Observations: Photographic evaluation revealed an average of 57% clearance of pigmentation in all treated nevi by the fourth treatment session and an average maximum clearance of 76% after approximately eight sessions. Greater than 90% clearance of pigment was attained in five patients. Partial repigmentation was seen in all patients who were followed up after discontinuation of therapy. Findings from histopathologic studies, obtained from one patient, revealed a reduction of nevus cells in the papillary dermis and upper reticular dermis that correlated with clinical lightening. There was no such reduction in the lower reticular dermis. Side effects were limited to transient erythema and hypopigmentation. Conclusions: The Q-switched ruby laser effectively lightens and may clear pigmentation and eliminate superficial nevus cells from small and medium congenital nevi safely without scarring. However, these results are not permanent. The Q-switched ruby laser may be a viable alternative for providing cosmetic improvement for unresectable lesions, but it should not be considered definitive treatment. Additional studies are needed to address the long-term results of this therapy. (Arch Dermatol. 1996;132:301-304)