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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.

The present report documents 6 patients who developed distinctive hyperpigmented skin lesions after bleomycin sclerotherapy for vascular malformations of the face, neck, and extremities. The patients ranged in age from 2 to 65 years and included both black and white and male and female patients. The bleomycin treatment dose varied from 15 to 45 U, with 5 of the 6 patients receiving foamed bleomycin. The hyperpigmented lesions were near the patient's vascular anomaly and attributable to postprocedural cutaneous pressure (eg, electrocardiographic [ECG] leads or tape). Hyperpigmentation faded slowly over time but was visible up to 3 years after the procedure.

Background Melasma can be associated with immense psychosocial stress, which can impact quality of life. One theory suggests that ultraviolet light can increase plasmin activity in keratinocytes, which has led to the investigation of tranexamic acid for treating melasma, since it possesses anti-plasmin properties. The use of laser-assisted drug delivery can also increase the uptake of topical medications. Aims A prospective pilot study was performed to assess the utility of combination treatment with low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid for melasma. Patients/methods A total of 10 subjects were enrolled. Each received 5 treatments to the full face with a low-energy, low-density 1927 nm fractional thulium fiber laser. Immediately following treatment, topical tranexamic acid was applied, and subjects were instructed to apply it twice daily for 7 days. Clinical measures, quality of life, and patient satisfaction were assessed. Results Mean improvements in Melasma Area and Severity Index (MASI) scores were 1.1 (P = .0899), 3.5 (P = .0395), and 2.5 (P = .2429) at 30-, 90-, and 180-day follow-up, respectively. Maximum improvement occurred at 90-day follow-up. The mean improvement of Melasma Quality of Life Scale (MELASQOL) score was 9.6 (P = .0024) at 30-day follow-up. In addition to changes in pigmentation, subjects also believed their skin felt better, looked more radiant, and had improvements in skin texture and tone. Conclusion Combination of low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid improved clinical outcomes and quality of life associated with melasma. This combination treatment was safe, well-tolerated, and well-liked by subjects.

Background Topical adjuncts have been investigated to improve clinical outcomes associated with laser resurfacing for photodamage and cutaneous aging. One such product is a tripeptide/hexapeptide serum, which has been shown to increase dermal collagen and elastin as well as improve postprocedural recovery following treatments. Aims A randomized, blinded, split-face, comparative trial was performed to assess the utility of a tripeptide/hexapeptide serum as a peri-procedural adjunct to nonablative fractional laser resurfacing. Patients/methods A total of 20 subjects were enrolled. Each hemiface was randomized to either tripeptide/hexapeptide serum or bland moisturizer for twice daily application starting 14 days prior to first laser treatment and continuing until 60 days after. All subjects received 2 treatments to entire face approximately 1 month apart with 1927 nm thulium nonablative fractional laser. Clinical measures and immediate postprocedural recovery were assessed. Results For each hemiface, scores improved for all measures, including global photodamage, lentigines, pores, radiance, texture, and tone at 30 and 60 days. The tripeptide/hexapeptide serum had greater improvements for all measures at both time points, except for radiance at 60 days, which was equal. In cases where clinical ratings differed between sides, tripeptide/hexapeptide serum more frequently had the superior outcome. Overall, subjects were satisfied with tripeptide/hexapeptide serum. No significant adverse events were observed. Conclusion Addition of tripeptide/hexapeptide serum as a peri-procedural adjunct to nonablative fractional laser resurfacing improved various clinical measures of photodamage and cutaneous aging and the immediate postprocedural recovery. The tripeptide/hexapeptide serum was demonstrated to be safe, well-tolerated, and well-liked by subjects.

OBJECTIVE Nevus of Ota represents congenital dermal melanocytosis in a trigeminal distribution, most commonly occurring in Asian individuals and other individuals with skin of color. Evidence suggests early treatment is beneficial. Multiple reports have shown efficacy and safety of Q-switched laser treatment in adults. There is little data on children and in non-Asian skin types. This series was done to demonstrate safe and effective use of Q-switched laser therapy in children of multiple skin types. STUDY DESIGN Retrospective case series. METHODS This was a chart review of patients under 18 years old who presented to our practice from 2002 to 2015 with a clinical diagnosis of nevus of Ota who were treated with Q-switched lasers (694 and 1,064 nm). Patients were treated without the use of general anesthesia or sedation, and corneal shields were used in appropriate cases. Percentage of improvement as well as side effects were rated by five physicians independently. Improvement, when present, was rated in quartiles (1-25%, 26-50%, 51-75%, and 76-100% improvement). RESULTS Twenty-four children were included. The average age at the start of treatment was 3.9 years old (range of 3 months to 12.4 years), and patients had Fitzpatrick skin types IV through VI. The mean number of treatments was 9.3. Assessment revealed excellent response (76-100% improvement) in 70% of patients and good to excellent response (51-100% improvement) in 86%. Two patients (8%) had post-inflammatory hyperpigmentation, one of whom also had focal hypopigmentation. CONCLUSION Treatment of nevus of Ota with Q-switched lasers in children with skin of color, without general anesthesia or sedation, is safe and effective. Early intervention should be encouraged for better efficacy and to prevent psychosocial distress in later childhood and adulthood. Lasers Surg. Med. 50:56-60, 2018. © 2017 Wiley Periodicals, Inc.

Nevus of Ota represents congenital dermal melanocytosis in a trigeminal distribution, most commonly occurring in Asian individuals and other individuals with skin of color. Evidence suggests early treatment is beneficial. Multiple reports have shown efficacy and safety of Q-switched laser treatment in adults. There is little data on children and in non-Asian skin types. This series was done to demonstrate safe and effective use of Q-switched laser therapy in children of multiple skin types.Retrospective case series.This was a chart review of patients under 18 years old who presented to our practice from 2002 to 2015 with a clinical diagnosis of nevus of Ota who were treated with Q-switched lasers (694 and 1,064 nm). Patients were treated without the use of general anesthesia or sedation, and corneal shields were used in appropriate cases. Percentage of improvement as well as side effects were rated by five physicians independently. Improvement, when present, was rated in quartiles (1-25%, 26-50%, 51-75%, and 76-100% improvement).Twenty-four children were included. The average age at the start of treatment was 3.9 years old (range of 3 months to 12.4 years), and patients had Fitzpatrick skin types IV through VI. The mean number of treatments was 9.3. Assessment revealed excellent response (76-100% improvement) in 70% of patients and good to excellent response (51-100% improvement) in 86%. Two patients (8%) had post-inflammatory hyperpigmentation, one of whom also had focal hypopigmentation.Treatment of nevus of Ota with Q-switched lasers in children with skin of color, without general anesthesia or sedation, is safe and effective. Early intervention should be encouraged for better efficacy and to prevent psychosocial distress in later childhood and adulthood. Lasers Surg. Med. 50:56-60, 2018. © 2017 Wiley Periodicals, Inc.

Importance Response to laser treatment for cafe au lait macules (CALMs) is inconsistent and difficult to predict. Objective To test the hypothesis that irregularly bordered CALMs of the “coast of Maine” subtype respond better to treatment than those of the smooth-bordered “coast of California” subtype. Design, Setting, and Participants This retrospective case series included patients from 2 multiple-clinician US practices treated from 2005 through 2016. All patients had a clinical diagnosis of CALM and were treated with a Q-switched or picosecond laser. A total of 51 consecutive patients were eligible, 6 of whom were excluded owing to ambiguous lesion subtype. Observers were blinded to final patient groupings. Exposures Treatment with 755-nm alexandrite picosecond laser, Q-switched ruby laser, Q-switched alexandrite laser, or Q-switched 1064-nm Nd:YAG laser. Main Outcomes and Measures Main outcome was grade in a visual analog scale (VAS) consisting of 4 levels of treatment response: poor (grade 1, 0%-25% improvement), fair (grade 2, 26%-50% improvement), good (grade 3, 51%-75% improvement), and excellent (grade 4, 76%-100% improvement). Results Forty-five patients were included in the series, 19 with smooth-bordered lesions and 26 with irregularly bordered lesions. Thirty-four (76%) of the participants were female; 33 (73%) were white; and the mean age at the time of laser treatment was 14.5 years (range, 0-44 years). Smooth-bordered lesions received a mean VAS score of 1.76, corresponding to a fair response on average (26%-50% pigmentary clearance). Irregularly bordered lesions received a mean VAS score of 3.67, corresponding to an excellent response on average (76%-100% clearance) (P Conclusions and Relevance CALMs with jagged or ill-defined borders of the coast of Maine subtype tend to respond well to laser treatment, whereas those with smooth and well-defined borders of the coast of California subtype tend to have poor response. Clinicians using Q-switched or picosecond lasers to treat CALMs can use morphologic characteristics to help predict response and more effectively manage patient expectations.

We report a case of successful treatment of a traumatic tattoo in a 2-year-old patient. He presented with a green discoloration on the left infraorbital region after his sister accidentally hit him with a face paint brush while playing together. A single treatment with an alexandrite picosecond laser resulted in a complete clearance without any side effects for this disfiguring condition.

Laser therapy is an important treatment modality in pediatric dermatology, and its efficacy relies on the provider's proper use of the laser device. We describe a simple yet effective teaching tool that can be used to train dermatology residents prior to their using lasers on actual patients.

The current study examined the effects of institutionalization on the discrimination of facial expressions of emotion in 3 groups of 42-month-old children. One group consisted of children abandoned at birth who were randomly assigned to Care as Usual (institutional care) following a baseline assessment. Another group consisted of children abandoned at birth who were randomly assigned to high-quality foster care following a baseline assessment. A third group consisted of never-institutionalized children who were reared by their biological parents. All children were familiarized to happy, sad, fearful, and neutral facial expressions and tested on their ability to discriminate familiar versus novel facial expressions. Contrary to our prediction, all three groups of children were equally able to discriminate among the different expressions. Furthermore, in contrast to findings at 13-30 months of age, these same children showed familiarity rather than novelty preferences toward different expressions. There were also asymmetries in children's discrimination of facial expressions depending on which facial expression served as the familiar versus the novel stimulus. Collectively, early institutionalization appears not to impact the development of the ability to discriminate facial expressions of emotion, at least when preferential looking serves as the dependent measure. These findings are discussed in the context of the myriad domains that are affected by early institutionalization.

BACKGROUND It is a common practice to biopsy clinically atypical nevi, which may signify an individual's increased risk of developing melanoma. There is no consensus in the current literature, however, as to what the best method is to manage biopsy-proven atypical nevi. OBJECTIVE The objective was to compare margin clearance rates between reshave excision and full-thickness surgical excision performed to manage biopsy-proven atypical nevi. MATERIALS AND METHODS In this retrospective observational study, histopathology specimens from 201 patients whose atypical nevi were surgically removed were analyzed. RESULTS For the majority (76%-79%) of the atypical nevi studied, all atypical melanocytes were removed by the initial shave biopsy. Of those atypical nevi with positive margins, shave re-excision was shown to have a lower clearance rate (76.2%) when compared with surgical excision (87.5%). CONCLUSION This study shows that in most cases, no residual atypical melanocytes are left after the initial shave biopsy. However, of the lesions where margins are not clear, full-thickness surgical excision may have a higher rate of success at eventual clearance than reshave excision.

The current study examined the effects of institutionalization on the discrimination of facial expressions of emotion in 3 groups of 42-month-old children. One group consisted of children abandoned at birth who were randomly assigned to Care as Usual (institutional care) following a baseline assessment. Another group consisted of children abandoned at birth who were randomly assigned to high-quality foster care following a baseline assessment. A third group consisted of never-institutionalized children who were reared by their biological parents. All children were familiarized to happy, sad, fearful, and neutral facial expressions and tested on their ability to discriminate familiar versus novel facial expressions. Contrary to our prediction, all three groups of children were equally able to discriminate among the different expressions. Furthermore, in contrast to findings at 13–30 months of age, these same children showed familiarity rather than novelty preferences toward different expressions. There were also asymmetries in children’s discrimination of facial expressions depending on which facial expression served as the familiar versus the novel stimulus. Collectively, early institutionalization appears not to impact the development of the ability to discriminate facial expressions of emotion, at least when preferential looking serves as the dependent measure. These findings are discussed in the context of the myriad domains that are affected by early institutionalization.

Porocarcinoma is a rare malignant neoplasm that arises from the intraepidermal ductal portion of the eccrine sweat glands. This neoplasm most often presents in elderly individuals on the lower extremities. We present an unusual case of porocarcinoma arising on the scalp of a young patient. To the best of our knowledge, there have been fewer than 20 cases of porocarcinomas arising at this site reported in the literature.

As the largest organ in the body, the skin may reveal the first manifestations of internal disease. The astute clinician can often use dermatologic findings to diagnose an underlying systemic disease. This chapter outlines some of the most important skin manifestations of internal disease. Common yet clinically important systemic diseases will be reviewed, and their most notable skin findings will be delineated.

Background Complete and accurate excision of cancer is guided by the examination of histopathology. However, preparation of histopathology is labor intensive and slow, leading to insufficient sampling of tissue and incomplete and/or inaccurate excision of margins. We demonstrate the potential utility of multimodal confocal mosaicing microscopy for rapid screening of cancer margins, directly in fresh surgical excisions, without the need for conventional embedding, sectioning, or processing. Materials and methods A multimodal confocal mosaicing microscope was developed to image basal cell carcinoma margins in surgical skin excisions, with the resolution that shows nuclear detail. Multimodal contrast is with fluorescence for imaging nuclei and reflectance for cellular cytoplasm and dermal collagen. Thirty-five excisions of basal cell carcinomas from Mohs surgery were imaged, and the mosaics analyzed by comparison with the corresponding frozen pathology. Results Confocal mosaics are produced in about 9 min, displaying tissue in fields of view of 12 mm with ×2 magnification. A digital staining algorithm transforms black and white contrast to purple and pink, which simulates the appearance of standard histopathology. Mosaicing enables rapid digital screening, which mimics the examination of histopathology. Conclusions Multimodal confocal mosaicing microscopy offers a technology platform to potentially enable real-time pathology at the bedside. The imaging may serve as an adjunct to conventional histopathology to expedite screening of margins and guide surgery toward more complete and accurate excision of cancer.

Acquired perforating dermatosis (APD) is a type of perforating disorder that is traditionally thought to be associated with diabetes, chronic renal failure, or occasionally liver disease. We report a case of APD in a patient with stage IV colon cancer with hepatic metastases. Although rare, APD associated with colon cancer is an important entity to consider; APD may be associated with a broader range of systemic diseases than previously recognized.

Morphea, also known as localized scleroderma, is characterized by idiopathic fibrosis of the skin and adjacent structures. Patients with morphea classically present with skin lesions without any associated symptoms and the lesions usually regress spontaneously over time. We describe a patient with morphea who presented with debilitating pain in her skin plaque. She failed topical therapy and required systemic methotrexate to control her disease. We titrated the methotrexate dose with the goal of pain relief. Although unusual, pain associated with morphea can be debilitating. Physicians should assess for pain in patients with morphea and prescribe treatments accordingly. We propose using pain, when present, in addition to physical examination as a guide for titrating morphea therapy.

Acquired perforating dermatosis (APD) is a type of perforating disorder that is traditionally thought to be associated with diabetes, chronic renal failure, or occasionally liver disease. We report a case of APD in a patient with stage IV colon cancer with hepatic metastases. Although rare, APD associated with colon cancer is an important entity to consider; APD may be associated with a broader range of systemic diseases than previously recognized.