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The uptake of topical formulations can be enhanced through laser pretreatments. Newer technologies, such as non-ablative fractional lasers (NAFLs), can target dermal tissues and spare the stratum corneum (SC), which can mitigate common side effects associated with ablative laser treatment.To discuss the parameters of 2 NAFL pretreatment systems (1440-nm/1927-nm diode system or 1550-nm erbium-doped glass/1927-nm thulium system), which can be paired with topicals to improve their cutaneous uptake.The parameters of the 1440-nm/1927-nm diode system and 1550-nm erbium-doped glass/1927-nm thulium system were reviewed, as well as in vivo experiments using both laser systems.Multiple parameters should be optimized to enhance the uptake of various topical formulations and minimize side effects, including wavelength, spot size, density, pulse duration, thermal properties, and topical formulation. Chosen therapeutic parameters must account for patient-specific factors, such as treatment indication, therapeutic area, and Fitzpatrick skin type. In vivo experiments have demonstrated that both laser systems are effective in enhancing the uptake of various topical therapies relative to untreated controls.Individualization of laser system parameters increases efficiency and minimizes risk.

A port-wine stain (PWS) is a vascular birthmark present in 0.3% to 0.5% of newborns. If untreated, this erythematous patch will grow proportionally with the child to thicken and darken with age. PWSs have implications for the child’s quality of life for many years, with cosmetic, medical, and psychosocial disability. Controversy exists in many aspects surrounding laser treatment of these birthmarks in the pediatric population. We have reviewed the clinical features as well as the historic and current laser treatment of PWS. We have also examined the current hot topics of debate surrounding the treatment of PWS in the pediatric population. These controversies include the patient age of treatment initiation, the long-term psychologic impact, the use of general anesthesia, the application of eye shields, and alternative treatments for recalcitrant PWS. We have concluded with a discussion on the future directions of management and treatment.

BackgroundPort wine birthmarks (PWBs) are congenital capillary malformations. Vessel characteristics, such as diameter and depth, may impact presentation and outcomes. They can be imaged using dynamic optical coherence tomography, a high-resolution, noninvasive imaging method.PurposeWe conducted a cross-sectional observational study to measure invivo vascular characteristics as a function of PWB color.MethodsPatients undergoing treatment for PWB were recruited from 3 sites. PWBs were classified by color. Dynamic optical coherence tomography images with calculations were obtained.ResultsOne hundred eight patients were enrolled. Mean age correlated with PWB color, with birthmarks being lighter in younger patients and darker in older patients (P&nbsp

Topical medications play a large role in the management of cutaneous diseases, but penetration is limited. Device-assisted drug delivery using mechanical destruction, lasers, and other energy-based modalities can increase penetration and absorption through creation of transcutaneous channels.To examine real-time, in vivo cutaneous changes in response to various devices used to improve topical drug delivery through optical coherence tomography (OCT) imaging.Treatment was performed with 8 medical devices, including mechanical destruction, lasers, and other energy-based modalities. Optical coherence tomography was used for real-time, noninvasive, in vivo imaging.Using OCT, microneedling and radiofrequency microneedling demonstrated no cutaneous channels. Both low-energy, low-density, fractional nonablative lasers produced transient channels, which closed within hours. The fractional nonablative 1,927-nm thulium fiber and 1,550-nm erbium fiber lasers created channels with epidermal debris within, which were still closing at 24 hours. The fractional thermomechanical ablative device and the fractional ablative CO2 laser produced channels that were still open at 24 hours. CO2 laser channels had thick rims of coagulated tissue and remained open for longer.Demonstrable differences among the devices were seen, and only some can produce observable channels, the characteristics of which vary with each technology.

Melasma is a chronic cutaneous condition that not only affects the appearance of patients but also has an immense psychosocial impact on patient quality of life. Although many treatment options are currently available, there is no single universal treatment regimen that works for all patients. Significant attention has been recently focused on the development and use of topical treatments that can lighten the dark patches associated with melasma. One such ingredient that has received growing attention in recent years is cysteamine. It works through several mechanisms to influence the melanogenesis pathway. This commentary reviews the information on this topical ingredient and offers relevant clinical insights. (

Laser pretreatment with cosmeceutical topicals is growing in popularity. However, lasers may also enhance the uptake of medical topicals that treat dermatologic conditions, such as vitiligo, alopecia, and cancerous and precancerous lesions. Permeation of these topicals must be quantified to optimize treatment protocols.To analyze transdermal uptake of 3 topicals after nonablative fractional 1,550-nm erbium-doped glass or 1,927-nm thulium fiber laser pretreatment.Human donor tissue was pretreated with a nonablative fractional 1,550-nm erbium-doped glass or 1,927-nm thulium fiber laser followed by application of 0.03% bimatoprost, 0.5% 5-fluorouracil, or 5% minoxidil. Permeation and retention were measured over 24 hours (bimatoprost and 5-fluorouracil) or 90 minutes (minoxidil), and uptake was calculated.Pretreatment with 1,927-nm thulium laser (500 MTZ/cm2; 5 mJ; 5 W) enhanced uptake and retention of bimatoprost versus untreated control at 24 hours post-treatment. Pretreatment with 1,550-nm erbium-doped glass laser (2,000 MTZ/cm2; 10 mJ; 30 W) enhanced permeation, uptake, and retention of 5-fluorouracil at 24 hours post-treatment and enhanced permeation and uptake of minoxidil at 90 minutes post-treatment.Nonablative laser pretreatment may enhance topical treatment of dermatologic conditions. Device settings must be optimized to maximize topical permeation while minimizing laser-associated thermal side effects.

The effect of multiple general anesthesia (mGA) procedures administered in early life is a critical theme and has led the Food and Drug Administration (FDA) to issue an alert. This systematic review seeks to explore the potential effects on neurodevelopment of mGA on patients under 4 years. The Medline, Embase and Web of Science databases were searched for publications up to 31 March 2021. The databases were searched for publications regarding “children multiple general anesthesia OR pediatric multiple general anesthesia”. Case reports, animal studies and expert opinions were excluded. Systematic reviews were not included, but they were screened to identify any possible additional information. A total of 3156 studies were identified. After removing the duplicates, screening the remaining records and analyzing the systematic reviews’ bibliography, 10 studies were considered suitable for inclusion. Comprehensively, a total cohort of 264.759 unexposed children and 11.027 exposed children were assessed for neurodevelopmental outcomes. Only one paper did not find any statistically significant difference between exposed and unexposed children in terms of neurodevelopmental alterations. Controlled studies on mGA administered before 4 years of age support that there might be a greater risk of neurodevelopmental delay in children receiving mGA, warranting the need for careful risk/benefit considerations.

This commentary examines the utility of arnica in cosmetic dermatology. For many years, arnica has been used to reduce the morbidity associated with various procedures, including surgeries and treatments with lasers and other energy-based devices. Arnica is a traditional homeopathic remedy that can reduce post-procedural edema and bruising. Although it has been used clinically by many physicians and is widely and readily available to patients, the available data is limited and often conflicting. We reviewed the relevant information on arnica and offer our own insights into its use in order to shed more light on its periprocedural utility.

This commentary evaluates trends in the factors influencing consumer decision‐making for cosmetic dermatologic procedures during the COVID‐19 pandemic in the United States. This is a follow‐up national survey to one that was published 1 year ago. This study compares the data from Summer 2020 to early Summer 2021, which presents a stark contrast. Our results demonstrate that consumers are now more interested in cosmetic dermatologic procedures compared to 1 year prior. Additionally, they still value the overall safety of the clinic, so physicians should ensure that certain safety measures remain in place despite any decreasing rates of COVID‐19 positivity. Our survey sheds more light on current consumer perspectives, which may in turn help physicians adjust their practices to meet current demand. It is important for physicians to be knowledgeable regarding the patterns of consumer decision‐making in order to deliver appropriate patient education and provide proper patient outreach during the COVID‐19 pandemic.

To evaluate the temporal trends in diversity within the ASLMS board of directions from 1996 to 2021.A list of Board of Directors from 1996 to 2021 was obtained from ASLMS headquarters. Using a composite of publicly available resources through internet searches, board director characteristics, such as age, gender, race/ethnicity, terminal degrees, specialties/field of expertise, and current full-time affiliations, were recorded.One hundred forty-six unique individuals held 628 ALSMS board member positions from the years 1996-2021. The median age of the board members started with a median age of 43.0 years old in 1996 to 54.5 years old in 2021. The age spread between first and third quartiles (interquartile range) in each year in more recent years (2014-2019) was 17.0, 20.0, 18.8, 18.8, 18.0, and 15.3 years, respectively. Female representation started with 10.5% in 1996 to 30.8% in 2021. Diversity, by racial/ethnicity measures, has more representation of Asian (average across 1996-2010: 2.3% to 2010-2022: 19.0%) and Hispanic (average 1996-2010: 0.7% to 2010-2022: 4.4%) board members. No African American has held a position across these decades. MD holders (average 66.5%) and other degree holders (average 33.5%) have been relatively consistent across all years observed. From 2016 to 2021, dermatologists held board member seats at an average rate of 56.5% across these years, while prior, from 1996 to 2015, 67.3% of board member seats on average were held by members of other expertises. Most board members have full-time affiliations in private practice across most years observed (average 43.7% across all years observed).After analyzing the diversity trends across board members in ASLMS across 1996-2020, we have noticed overall trends of increased diversity over time that reflect a greater chance of bringing in new ideas and experiences to grow ASLMS. Although the leadership of ASLMS has become significantly more diverse over time, there remain opportunities to increase diversity further, including women, underrepresented ethnic minorities, and other experts of specialties other than dermatology.

Although the stratum corneum limits transdermal absorption of topicals, laser devices can enhance topical uptake by disrupting the skin barrier. Nonablative lasers are commonly used, but their effects on topical uptake should be quantified to optimize outcomes.The objective of this study is to analyze transdermal uptake of 4 topicals after nonablative fractional diode laser pretreatment.Human donor tissue was pretreated ex vivo with a nonablative fractional diode laser (1,927 nm or 1,440 nm, at varying treatment densities, powers, and peak energies) followed by application of either 2% salicylic acid, 10% ascorbic acid, over-the-counter mineral eye serum, or 4% hydroquinone. Topical uptake was quantified over 24 hours.Despite lower power settings, pretreatment with the 1,927 nm wavelength was associated with greater uptake of 10% ascorbic acid, mineral eye serum, and 4% hydroquinone than the 1,440 nm wavelength. In addition, 1,440-nm laser pretreatment with higher density (320 microscopic treatment zones [MTZ]/cm 2 ) and peak power (3 W) was associated with similar uptake but greater retention of 2% salicylic acid and greater uptake of 10% ascorbic acid than that with lower density (80 MTZ/cm 2 ) and peak power (1.2 W).When using laser pretreatment, device settings should be adjusted to balance outcomes with potential side effects.

A role for addiction psychiatry in aesthetic treatment-seeking behavior has been evidenced for ultraviolet light tanning.We aim to demonstrate an initial proof of concept for the presence of addictive behaviors in cosmetic procedure use.Adults visiting a cosmetic dermatology practice with history of at least 1 cosmetic procedure and consideration of at least 1 cosmetic procedure in the past 12 months were included. Two previously validated instruments in the detection of alcohol use disorder, the Cut Down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria were modified to evaluate participants for a substance-related disorder (SRD) in cosmetic procedures.Of 153 adults, 34 (22.2%) met modified CAGE criteria, and 40 (26.1%) met modified DSM-V criteria. Results from both instruments were significantly associated (P .0002). Significant differences in consideration and use of cosmetic treatments were found in SRD positive versus negative groups (P .0001 and P = .009, respectively).Preliminary criteria for SRD in cosmetic procedure use in this study has not yet been validated.A type of SRD involving cosmetic procedures may exist, and qualifying individuals may have increased cosmetic treatment use. Future efforts to rigorously validate an instrument for SRD detection in cosmetic procedures use are warranted for future research and clinical application.

Background and objectives Melasma may be related to aberrant blood vessels, but there has been no report on the utility of dynamic optical coherence tomography (D-OCT) in studying vessel characteristics in melasma. We studied the characteristics of cutaneous blood vessels in melasma and the effects of oral tranexamic acid (TXA) with D-OCT. Study design/materials and methods Six patients with moderate to severe melasma had a D-OCT scanning of the areas on the face affected by melasma and not affected by it. Three of them had scans within 3 months after starting oral TXA and at a follow-up visit. Blood flow at different depths of the skin and vessel diameter were compared between the melasma and normal skin. For those taking oral TXA, we compared the percent change of blood flow and diameter between the melasma and normal skin. Results Dermal blood flow and vessel diameter were greater in the melasma skin than in the normal skin. Oral TXA reduced dermal blood flow in both the melasma and normal skin, but the reduction was more dramatic in the lesional melasma skin. Conclusions D-OCT findings that (i) dermal blood vessels in melasma are increased in size and flow and (ii) oral TXA reduced the vessel size and flow, providing evidence supporting the relationship between melasma and cutaneous blood vessels. D-OCT may be utilized in measuring response to treatments targeting melasma. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Background and objectives Fractional ablative 10,600-nm carbon dioxide (CO2 ) laser has well-demonstrated safety and efficacy in resurfacing treatment of scars in the adult population and in the treatment of pediatric burn scars. However, there is a paucity of literature regarding laser resurfacing of traumatic and surgical scars for cosmetic benefit in the pediatric population, and in majority of cases previously reported, this was done under general anesthesia. Study design/materials and methods This was a retrospective chart review of pediatric patients under the age of 18 who underwent fractional ablative CO2 laser resurfacing (FALR) of traumatic or surgical scars at a single center between 2018 and 2019, inclusive. Primary endpoints included safety and tolerance. Results A total of 31 FALR treatments were performed in 10 patients with traumatic and surgical scars located on the face (age 4-14 years, Fitzpatrick skin type [FST] I-IV, 60% female). Settings ranged from total energy per session 0.02-0.33 kJ, with a 7-mm tip and 30-50% coverage. Nine patients had two or more treatments (average 3, maximum 8) spaced at least 4 weeks apart. All resurfacing treatments were well-tolerated with local infiltration of 1% lidocaine with epinephrine (1:100,000). Six (67%) patients were treated with additional measures including pulsed dye laser, 1927-nm fractional non-ablative low-energy, low-density laser, or intralesional agents (5-fluorouracil, triamcinolone, botulinum toxin). At follow-up (of varied intervals), short-term erythema, as expected, was seen in six patients, and hyperpigmentation in one case (FST IV), both treated with aforementioned alternate devices. Although gradual, improvement in scar appearance and texture was seen with FALR treatments. No additional scarring, infection, or hypopigmentation was seen. Conclusions Treatment with fractional ablative laser resurfacing is safe and well-tolerated in the pediatric population in an outpatient setting with local anesthesia. Traumatic scars may cause significant distress to children and parents alike. Multimodal therapy may lead to optimal cosmesis. Given the excellent tolerability, the authors recommend consideration of laser resurfacing in pediatric patients with traumatic or surgical scars when bothersome, either cosmetically or psychologically. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

IntroductionPort-wine birthmarks (PWBs) are congenital capillary malformations that can be located on any area of the body. Vascular features include vessel size, depth, and density, which can greatly differ between patients, individual lesions, and even sites within the same lesion. Previous studies have determined that the location of PWB lesions has impacted their clinical response to laser treatment.ObjectiveWe utilized dynamic optical coherence tomography (D-OCT) to measure in vivo vessel diameter, density, and superficial plexus depth in patients of all ages with PWB on various sites of the body. We hypothesized that these vascular characteristics would differ according to body location.Materials and methodsPatients who had a PWB and presented to clinic at three sites for treatment with the pulsed dye laser (PDL) were enrolled into the study. A D-OCT scanner was utilized for noninvasive, in vivo imaging of PWB lesions. The depth of the top portion of the superficial vascular plexus was estimated as the depth at which the vessel density reaches 50% of the maximum. Vessel diameter and density were calculated by incorporated software algorithm.ResultsA total of 108 patients were enrolled into the study. There was a total of 204 measurements of PWB lesions. Of all patients, 56.5% (n = 61) reported having a previous treatment with PDL. Of all D-OCT scans, 62.3% (n = 127) were located on the head, 14.2% (n = 29) the upper extremities, 8.3% (n = 17) the lower extremities, 7.8% (n = 16) the trunk, and 7.8% (n = 15) the neck. All locations were compared for each vascular characteristic. For superficial plexus depth, lesions on the head were significantly shallower than those on the upper extremities (217 vs. 284 µm; p

Microneedling and soft-tissue filler injections have been used independently to improve acne scarring. The effectiveness of a combined approach using microneedling followed by polymethylmethacrylate (PMMA)-collagen gel has not been carefully studied.The goal of this study was to assess the effectiveness and safety of microneedling alone versus microneedling followed by injection of PMMA-collagen gel filler for correction of atrophic facial acne scars.We conducted a multicenter, open-label, randomized, prospective study on subjects with distensible atrophic acne scars in the face to determine whether microneedling with PMMA-collagen gel is a superior acne scar treatment over microneedling alone. Forty-four subjects received 3 microneedling treatments over a 12-week period followed by randomization to treatments with PMMA-collagen gel (treatment group) or no further treatment (control group).At 24 weeks, the treatment group achieved a statistically significant improvement in acne scores over microneedling alone. The improvement continued at 36 weeks. At 24 weeks, the treatment group showed a strong trend in improvement on the Physician Global Aesthetic Improvement Scale compared with microneedling alone.

Consumer interest in aesthetic procedures continues to grow. Through savvy marketing, affordable pricing, and minimal wait times, medical spas have grown in number to where they now outnumber physician-based cosmetic practices in 73% of major U.S. cities. In order to staff these facilities, owners frequently turn to non-physician operators who have variable levels of training in dermatology and cosmetics. There has been a lack of uniform standardization of training and oversight, which may contribute to adverse events, such as burns, pigmentary alterations, and scarring. As the market for non-invasive and minimally invasive cosmetic procedures continues to grow, physicians should be informed about the current cosmetic landscape in which they practice in order to improve patient awareness, education, and safety.

Background:. We introduce an innovative and novel technology that achieves scarless skin removal without the use of thermal energy. Microcoring technology (MCT) uses a modified, hollow hypodermic needle to remove skin safely and without a scar. This method is advantageous compared to other fractional devices, given that it has the same benefits as energy-based devices (removal of skin cores without a scar), with the added value of immediate closure along the relaxed skin tension lines, with significantly less thermal energy. Methods:. Three prospective clinical safety trials analyzing MCT treatment on abdominal and facial skin (short- and long-term) are described. Results:. MCT treatment of human skin resulted in scarless skin removal that was well tolerated by patients. Healing occurred rapidly, with limited side effects. Skin area reduction (skin tightening) and increase in skin thickness were observed long term. Conclusions:. MCT treatment of human skin is safe and well tolerated. Although further studies on efficacy are required to evaluate the full potential of MCT in skin rejuvenation, early findings such as skin tightening and increase in skin thickness are encouraging.

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.

This commentary examines the seasonality of various procedures in dermatology. With the rising demand of cosmetic procedures, it is important for physicians to understand seasonal trends of their services, which can offer insights to better forecast patient demand and optimize practice management. Although it has been anecdotally reported that the popularity of dermatologic procedures may peak during specific times of the year, available data on consumer behavior is limited. Our data fills this gap in the literature by examining the seasonality of dermatologic procedures and discussing the potential reasons for these findings. Physicians can utilize this information to optimize marketing strategies for particular procedures in order to capture greater market share and potentially increase practice revenues.

ImportanceLaser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD.ObjectiveTo develop recommendations for the safe and effective use of LADD.Evidence ReviewA systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved.FindingsOf the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline’s 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections.Conclusions and RelevanceThis systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.

BACKGROUND Performing multiple cosmetic treatments in a single session to target different aspects of facial rejuvenation is an effective regimen. Picosecond lasers with a fractionated handpiece can target fine lines, which can supplement submental fat reduction procedures. However, limited data exist on the safety and efficacy of single-session treatment strategies. AIMS To assess the safety and utility of paired facial treatment with 755 nm picosecond laser with diffractive lens array (DLA) and 1060 nm laser lipolysis of the submentum. PATIENTS/METHODS A prospective clinical study investigated the utility of paired facial treatment with 755 nm picosecond laser with DLA and 1060 nm diode laser lipolysis of the submentum. Subjects received treatments during the same session. Subjects were enrolled to receive up to 3 picosecond laser and 2 lipolysis treatments at 2-8-week intervals. RESULTS Eleven subjects completed the study. Mean age was 52.1 years, and 81.8% were female. Fitzpatrick skin types II-VI were represented. For investigator global aesthetics improvement scores (GAIS), 63.6%, 81.8%, and 85.7% had improvement from baseline at 30-, 90-, and 180-day follow-up, respectively. At 180-day follow-up, 100% maintained improvement from 90-day follow-up. At 90-day follow-up, calculations for neck laxity showed a significant improvement of 11.7% from baseline (p