Aesthetic Dermatology

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Anew patient-oriented Web site,"Explore Your Skin," is designed to provide general educational materials for patients about how skin diseases occur and how cosmetic procedures are performed. The interactive site is available in both English and Spanish. The Web site does not contain promotional messages. For more information, visit www.exploreyourskin.com

Anew patient-oriented Web site,"Explore Your Skin," is designed to provide general educational materials for patients about how skin diseases occur and how cosmetic procedures are performed. The interactive site is available in both English and Spanish. The Web site does not contain promotional messages. For more information, visit www.exploreyourskin.com

Anew patient-oriented Web site,"Explore Your Skin," is designed to provide general educational materials for patients about how skin diseases occur and how cosmetic procedures are performed. The interactive site is available in both English and Spanish. The Web site does not contain promotional messages. For more information, visit www.exploreyourskin.com

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

AUSTIN, TEX. — A new microfoam in trials in the United States holds promise for sclerotherapy, said Dr. Girish Munavalli, who also discussed other techniques currently available for addressing varicose veins.

It is important to address these veins, as they are indicative of venous insufficiency and saphenous reflux, Dr. Munavalli of Charlotte, N.C., said at the annual meeting of the American College of Mohs Surgery.

Some 60% of the U.S. population has varicose veins, and the frequency increases with age. Approximately 6 million workdays are lost annually because of complications from varicose veins, which can include venous leg ulcers, he said. Current treatment options include surgery (ligation and stripping); endovenous heat ablation; sclerotherapy; and a newer device, called ClosureFAST (VNUS Medical Technologies), which ablates the veins with a radiofrequency catheter. He said that he tends not to use lasers for sclerotherapy.

Dr. Munavalli is currently investigating the new microfoam, which is being used in Europe. It "is a really interesting technique. Hopefully, we'll get [Food and Drug Administration] approval soon," he said.

The product is contained in a can that holds air, but with less nitrogen than room air. When the sclerosant is pumped through the can, it creates much smaller bubbles, which increases the surface area of contact. The microfoam is thicker, compared with a sclerosant that's mixed with room air, said Dr. Munavalli. It still should be administered with ultrasound guidance.

In addition to being an investigator for the microfoam, Dr. Munavalli disclosed that he is on the speakers bureau and is a consultant for DUSA Pharmaceuticals.

AUSTIN, TEX. — A new microfoam in trials in the United States holds promise for sclerotherapy, said Dr. Girish Munavalli, who also discussed other techniques currently available for addressing varicose veins.

It is important to address these veins, as they are indicative of venous insufficiency and saphenous reflux, Dr. Munavalli of Charlotte, N.C., said at the annual meeting of the American College of Mohs Surgery.

Some 60% of the U.S. population has varicose veins, and the frequency increases with age. Approximately 6 million workdays are lost annually because of complications from varicose veins, which can include venous leg ulcers, he said. Current treatment options include surgery (ligation and stripping); endovenous heat ablation; sclerotherapy; and a newer device, called ClosureFAST (VNUS Medical Technologies), which ablates the veins with a radiofrequency catheter. He said that he tends not to use lasers for sclerotherapy.

Dr. Munavalli is currently investigating the new microfoam, which is being used in Europe. It "is a really interesting technique. Hopefully, we'll get [Food and Drug Administration] approval soon," he said.

The product is contained in a can that holds air, but with less nitrogen than room air. When the sclerosant is pumped through the can, it creates much smaller bubbles, which increases the surface area of contact. The microfoam is thicker, compared with a sclerosant that's mixed with room air, said Dr. Munavalli. It still should be administered with ultrasound guidance.

In addition to being an investigator for the microfoam, Dr. Munavalli disclosed that he is on the speakers bureau and is a consultant for DUSA Pharmaceuticals.

AUSTIN, TEX. — A new microfoam in trials in the United States holds promise for sclerotherapy, said Dr. Girish Munavalli, who also discussed other techniques currently available for addressing varicose veins.

It is important to address these veins, as they are indicative of venous insufficiency and saphenous reflux, Dr. Munavalli of Charlotte, N.C., said at the annual meeting of the American College of Mohs Surgery.

Some 60% of the U.S. population has varicose veins, and the frequency increases with age. Approximately 6 million workdays are lost annually because of complications from varicose veins, which can include venous leg ulcers, he said. Current treatment options include surgery (ligation and stripping); endovenous heat ablation; sclerotherapy; and a newer device, called ClosureFAST (VNUS Medical Technologies), which ablates the veins with a radiofrequency catheter. He said that he tends not to use lasers for sclerotherapy.

Dr. Munavalli is currently investigating the new microfoam, which is being used in Europe. It "is a really interesting technique. Hopefully, we'll get [Food and Drug Administration] approval soon," he said.

The product is contained in a can that holds air, but with less nitrogen than room air. When the sclerosant is pumped through the can, it creates much smaller bubbles, which increases the surface area of contact. The microfoam is thicker, compared with a sclerosant that's mixed with room air, said Dr. Munavalli. It still should be administered with ultrasound guidance.

In addition to being an investigator for the microfoam, Dr. Munavalli disclosed that he is on the speakers bureau and is a consultant for DUSA Pharmaceuticals.

SANTA MONICA, CALIF. — The ideal device for treating pigmentation disorders would reduce wrinkles, pigment, and redness in one pass with a low amount of pain and give patients a fast, easy recovery, according to Dr. E. Victor Ross.

"There's no device that does all those things, but the devices that actually selectively target blood and melanin are possibly the closest thing to it," Dr. Ross said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Ross of the Scripps Clinic in San Diego discussed the pros and cons of using intense pulsed light (IPL) devices, pulsed dye lasers (PDL), and potassium-titanyl-phosphate (KTP) lasers for treating pigmentation disorders.

Both pigmentation and vascular disorders can be treated in one pass using IPL therapy and KTP lasers, he said. The PDL was the first "boutique laser" to treat vascular lesions, he noted. Next came the KTP laser to treat isolated vessels. When IPL treatment entered the scene, it displaced the other devices because of its versatility, but all three approaches have a role in treating blood and pigment lesions. "My favorite on a daily basis is the KTP laser," he acknowledged.

PDL treatment is fast, and if a patient doesn't mind the resulting purpura, the PDL is probably the best device for improvement of redness in a single treatment, said Dr. Ross.

The PDL remains the standard for treating port wine stains. Nevertheless, it is not possible to reduce both red and brown facial lesions with this laser, and it cannot, in one pass, treat both blood and pigment lesions.

KTP lasers can treat both small and large spots. The spot-size reduction allows for safer treatment of darker-skinned (skin types IV and V) patients with telangiectasias. In addition, the device has a good vascular-to-pigment damage ratio. When a 1- to 5-mm spot size is used, vessel reduction can be seen in real time.

"It is nice to see a blood vessel disappear as you see it, which you can't do with the IPL," said Dr. Ross. "It's just fun to do." The handpiece is also light and easy to use.

KTP therapy has higher costs, however, and tends to cause more pain than IPL treatment. After KTP treatment, edema can be severe, and overtreatment can cause pitting.

IPL therapy is raising the bar for treating pigmentation. Filtration is better with an IPL device, lamp pumping is smoother, cooling has been added to the device, and the radio frequency has been improved. Most importantly, it is safe, he said.

One of IPL's drawbacks is that the divergence of the beam means the handpiece must be held close to the skin, which may compress vessels. Also, the nonlaser properties of IPL make it difficult to focus on small spots, so it can be challenging to use on discrete lesions. Finally, with large spot treatment capability comes the potential for big side effects, Dr. Ross noted.

He disclosed being a consultant for, and receiving research grants from, Palomar. Dr. Ross also has received research support from Cutera Inc., Lumenis, Candela Corp., Ulthera Inc., and Sciton Inc.

SDEF and this news organization are both owned by Elsevier.

My favorite laser on a daily basis for treating pigmentation disorders is the KTP. DR. ROSS

SANTA MONICA, CALIF. — The ideal device for treating pigmentation disorders would reduce wrinkles, pigment, and redness in one pass with a low amount of pain and give patients a fast, easy recovery, according to Dr. E. Victor Ross.

"There's no device that does all those things, but the devices that actually selectively target blood and melanin are possibly the closest thing to it," Dr. Ross said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Ross of the Scripps Clinic in San Diego discussed the pros and cons of using intense pulsed light (IPL) devices, pulsed dye lasers (PDL), and potassium-titanyl-phosphate (KTP) lasers for treating pigmentation disorders.

Both pigmentation and vascular disorders can be treated in one pass using IPL therapy and KTP lasers, he said. The PDL was the first "boutique laser" to treat vascular lesions, he noted. Next came the KTP laser to treat isolated vessels. When IPL treatment entered the scene, it displaced the other devices because of its versatility, but all three approaches have a role in treating blood and pigment lesions. "My favorite on a daily basis is the KTP laser," he acknowledged.

PDL treatment is fast, and if a patient doesn't mind the resulting purpura, the PDL is probably the best device for improvement of redness in a single treatment, said Dr. Ross.

The PDL remains the standard for treating port wine stains. Nevertheless, it is not possible to reduce both red and brown facial lesions with this laser, and it cannot, in one pass, treat both blood and pigment lesions.

KTP lasers can treat both small and large spots. The spot-size reduction allows for safer treatment of darker-skinned (skin types IV and V) patients with telangiectasias. In addition, the device has a good vascular-to-pigment damage ratio. When a 1- to 5-mm spot size is used, vessel reduction can be seen in real time.

"It is nice to see a blood vessel disappear as you see it, which you can't do with the IPL," said Dr. Ross. "It's just fun to do." The handpiece is also light and easy to use.

KTP therapy has higher costs, however, and tends to cause more pain than IPL treatment. After KTP treatment, edema can be severe, and overtreatment can cause pitting.

IPL therapy is raising the bar for treating pigmentation. Filtration is better with an IPL device, lamp pumping is smoother, cooling has been added to the device, and the radio frequency has been improved. Most importantly, it is safe, he said.

One of IPL's drawbacks is that the divergence of the beam means the handpiece must be held close to the skin, which may compress vessels. Also, the nonlaser properties of IPL make it difficult to focus on small spots, so it can be challenging to use on discrete lesions. Finally, with large spot treatment capability comes the potential for big side effects, Dr. Ross noted.

He disclosed being a consultant for, and receiving research grants from, Palomar. Dr. Ross also has received research support from Cutera Inc., Lumenis, Candela Corp., Ulthera Inc., and Sciton Inc.

SDEF and this news organization are both owned by Elsevier.

My favorite laser on a daily basis for treating pigmentation disorders is the KTP. DR. ROSS

SANTA MONICA, CALIF. — The ideal device for treating pigmentation disorders would reduce wrinkles, pigment, and redness in one pass with a low amount of pain and give patients a fast, easy recovery, according to Dr. E. Victor Ross.

"There's no device that does all those things, but the devices that actually selectively target blood and melanin are possibly the closest thing to it," Dr. Ross said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Ross of the Scripps Clinic in San Diego discussed the pros and cons of using intense pulsed light (IPL) devices, pulsed dye lasers (PDL), and potassium-titanyl-phosphate (KTP) lasers for treating pigmentation disorders.

Both pigmentation and vascular disorders can be treated in one pass using IPL therapy and KTP lasers, he said. The PDL was the first "boutique laser" to treat vascular lesions, he noted. Next came the KTP laser to treat isolated vessels. When IPL treatment entered the scene, it displaced the other devices because of its versatility, but all three approaches have a role in treating blood and pigment lesions. "My favorite on a daily basis is the KTP laser," he acknowledged.

PDL treatment is fast, and if a patient doesn't mind the resulting purpura, the PDL is probably the best device for improvement of redness in a single treatment, said Dr. Ross.

The PDL remains the standard for treating port wine stains. Nevertheless, it is not possible to reduce both red and brown facial lesions with this laser, and it cannot, in one pass, treat both blood and pigment lesions.

KTP lasers can treat both small and large spots. The spot-size reduction allows for safer treatment of darker-skinned (skin types IV and V) patients with telangiectasias. In addition, the device has a good vascular-to-pigment damage ratio. When a 1- to 5-mm spot size is used, vessel reduction can be seen in real time.

"It is nice to see a blood vessel disappear as you see it, which you can't do with the IPL," said Dr. Ross. "It's just fun to do." The handpiece is also light and easy to use.

KTP therapy has higher costs, however, and tends to cause more pain than IPL treatment. After KTP treatment, edema can be severe, and overtreatment can cause pitting.

IPL therapy is raising the bar for treating pigmentation. Filtration is better with an IPL device, lamp pumping is smoother, cooling has been added to the device, and the radio frequency has been improved. Most importantly, it is safe, he said.

One of IPL's drawbacks is that the divergence of the beam means the handpiece must be held close to the skin, which may compress vessels. Also, the nonlaser properties of IPL make it difficult to focus on small spots, so it can be challenging to use on discrete lesions. Finally, with large spot treatment capability comes the potential for big side effects, Dr. Ross noted.

He disclosed being a consultant for, and receiving research grants from, Palomar. Dr. Ross also has received research support from Cutera Inc., Lumenis, Candela Corp., Ulthera Inc., and Sciton Inc.

SDEF and this news organization are both owned by Elsevier.

My favorite laser on a daily basis for treating pigmentation disorders is the KTP. DR. ROSS

SANTA MONICA, CALIF. — The key to treating pigmentary disorders is making an accurate diagnosis using a Wood's lamp and classifying the patient's condition, according to Dr. Anand Ganesan.

"One of the things that is easy to learn but is easily forgotten is how to really prepare your patients when they first walk in the door, and for you to assess how well they are going to respond to the treatments that you are offering," said Dr. Ganesan, who is a professor of dermatology at the University of California, Irvine.

Dr. Ganesan discussed the etiology, diagnosis, and treatment of pigmentary disorders, as well as the triaging of patients with these conditions, at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Melasma

About 75% of melasma patients are female, and the condition is common in darker-skinned patients, he said. The exact cause of melasma is unknown, but triggers may include sun exposure, family history, phenytoin exposure, oral contraceptives, pregnancy, and increased estrogen.

The Wood's lamp is used to determine the classification of melasma: epidermal, dermal, or mixed. "If you can categorize your patients, you can actually predict very nicely how well they are going to respond to your treatment," he said.

In white and Hispanic patients, melasma appears as a reflected darker image. In patients with skin types V or VI the color will appear a little reddish, but a change can be seen over the pigmented area.

Melasma that has an epidermal component will respond well to almost any treatment. Dermal melasma tends to respond better to laser therapies. Darker-skinned patients will respond best to hydroquinone, while lighter skin responds best to peels and lasers.

Patients with melasma need to use a broad-spectrum sunscreen (UVA and UVB coverage with an SPF of 30 or more) every day, regardless of sun exposure, because fluorescent lighting emits some UVA rays, said Dr. Ganesan.

Birth control pills, cosmetic products, and phototoxic drugs should be discontinued if they appear to help cause the melasma.

Combining topical products is more effective than using tretinoin, hydroquinone, or steroids alone, he said, adding that it is important to balance an agent's potential for irritation with its strength because increased inflammation will result in poor clinical outcomes.

For patients who cannot tolerate hydroquinone, there are some less effective alternatives: kojic acid, which can be more irritating than hydroquinone; azelaic acid; mequinol, which has been shown to have some depigmenting activity and is less effective than hydroquinone; arbutin, which is a botanically related compound that can cause depigmentation; and licorice extract, available in Ayurvedic and other commercial preparations.

Chemical peels are not effective as single agents for treating melasma but may be slightly synergistic when used with hydroquinone. Peels are operator dependent, said Dr. Ganesan, so if the clinician has extensive clinical experience with them they may be a treatment option.

Studies suggest that the Q-switched Nd:YAG and ruby lasers, used in conjunction with hydroquinone, may be effective in treating dermal or mixed melasma. Positive results also have been seen with Fraxel lasers.

Vitiligo

The underlying factor thought to cause vitiligo is melanocyte susceptibility to destruction.

As with melasma, the diagnosis should be made with a Wood's lamp, which can distinguish vitiligo from other hypopigmenting conditions. Biopsy, along with Fontana-Masson staining, can be helpful to determine if melanocytes are present, Dr. Ganesan said.

There are two types of vitiligo: segmental (unresponsive to light therapy) and generalized (responsive to light therapy). Treatment options include photo therapy, lasers, surgery, and topical solutions. Given the safety and tolerability of narrow-band UVB, it is favored over treatment with PUVA.

A 380-nm excimer laser can be used to treat small surface areas, such as those on the face, but is less effective on the hands. An excimer laser should be used aggressively with dose escalation for best treatment results, Dr. Ganesan said. Because aggressive dosing regimens can lead to increased burning, it is best for treating localized areas and for patients who seek rapid improvement.

Although the excimer laser should be avoided when treating underarms, the device works well on the eyelids, he continued. It produces less response on the hands and feet but is an option if narrow-band UVB has failed.

Surgical options for treating vitiligo include punch grafting and suction blister grafting. Punch grafting has been found very effective for treating nonactive segmental lesions. A side effect of punch grafting is cobblestoning, which can diminish over time.

Dr. Ganesan disclosed having no conflicts related to his presentation.

SDEF and this news organization are both owned by Elsevier.

'If you can categorize your patients, you can actually predict very nicely how well they are going to respond.' DR. GANESAN

Possible melasma triggers include sun exposure, phenytoin exposure, and oral contraceptives. Courtesy Dr. Wendy E. Roberts

SANTA MONICA, CALIF. — The key to treating pigmentary disorders is making an accurate diagnosis using a Wood's lamp and classifying the patient's condition, according to Dr. Anand Ganesan.

"One of the things that is easy to learn but is easily forgotten is how to really prepare your patients when they first walk in the door, and for you to assess how well they are going to respond to the treatments that you are offering," said Dr. Ganesan, who is a professor of dermatology at the University of California, Irvine.

Dr. Ganesan discussed the etiology, diagnosis, and treatment of pigmentary disorders, as well as the triaging of patients with these conditions, at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Melasma

About 75% of melasma patients are female, and the condition is common in darker-skinned patients, he said. The exact cause of melasma is unknown, but triggers may include sun exposure, family history, phenytoin exposure, oral contraceptives, pregnancy, and increased estrogen.

The Wood's lamp is used to determine the classification of melasma: epidermal, dermal, or mixed. "If you can categorize your patients, you can actually predict very nicely how well they are going to respond to your treatment," he said.

In white and Hispanic patients, melasma appears as a reflected darker image. In patients with skin types V or VI the color will appear a little reddish, but a change can be seen over the pigmented area.

Melasma that has an epidermal component will respond well to almost any treatment. Dermal melasma tends to respond better to laser therapies. Darker-skinned patients will respond best to hydroquinone, while lighter skin responds best to peels and lasers.

Patients with melasma need to use a broad-spectrum sunscreen (UVA and UVB coverage with an SPF of 30 or more) every day, regardless of sun exposure, because fluorescent lighting emits some UVA rays, said Dr. Ganesan.

Birth control pills, cosmetic products, and phototoxic drugs should be discontinued if they appear to help cause the melasma.

Combining topical products is more effective than using tretinoin, hydroquinone, or steroids alone, he said, adding that it is important to balance an agent's potential for irritation with its strength because increased inflammation will result in poor clinical outcomes.

For patients who cannot tolerate hydroquinone, there are some less effective alternatives: kojic acid, which can be more irritating than hydroquinone; azelaic acid; mequinol, which has been shown to have some depigmenting activity and is less effective than hydroquinone; arbutin, which is a botanically related compound that can cause depigmentation; and licorice extract, available in Ayurvedic and other commercial preparations.

Chemical peels are not effective as single agents for treating melasma but may be slightly synergistic when used with hydroquinone. Peels are operator dependent, said Dr. Ganesan, so if the clinician has extensive clinical experience with them they may be a treatment option.

Studies suggest that the Q-switched Nd:YAG and ruby lasers, used in conjunction with hydroquinone, may be effective in treating dermal or mixed melasma. Positive results also have been seen with Fraxel lasers.

Vitiligo

The underlying factor thought to cause vitiligo is melanocyte susceptibility to destruction.

As with melasma, the diagnosis should be made with a Wood's lamp, which can distinguish vitiligo from other hypopigmenting conditions. Biopsy, along with Fontana-Masson staining, can be helpful to determine if melanocytes are present, Dr. Ganesan said.

There are two types of vitiligo: segmental (unresponsive to light therapy) and generalized (responsive to light therapy). Treatment options include photo therapy, lasers, surgery, and topical solutions. Given the safety and tolerability of narrow-band UVB, it is favored over treatment with PUVA.

A 380-nm excimer laser can be used to treat small surface areas, such as those on the face, but is less effective on the hands. An excimer laser should be used aggressively with dose escalation for best treatment results, Dr. Ganesan said. Because aggressive dosing regimens can lead to increased burning, it is best for treating localized areas and for patients who seek rapid improvement.

Although the excimer laser should be avoided when treating underarms, the device works well on the eyelids, he continued. It produces less response on the hands and feet but is an option if narrow-band UVB has failed.

Surgical options for treating vitiligo include punch grafting and suction blister grafting. Punch grafting has been found very effective for treating nonactive segmental lesions. A side effect of punch grafting is cobblestoning, which can diminish over time.

Dr. Ganesan disclosed having no conflicts related to his presentation.

SDEF and this news organization are both owned by Elsevier.

'If you can categorize your patients, you can actually predict very nicely how well they are going to respond.' DR. GANESAN

Possible melasma triggers include sun exposure, phenytoin exposure, and oral contraceptives. Courtesy Dr. Wendy E. Roberts

SANTA MONICA, CALIF. — The key to treating pigmentary disorders is making an accurate diagnosis using a Wood's lamp and classifying the patient's condition, according to Dr. Anand Ganesan.

"One of the things that is easy to learn but is easily forgotten is how to really prepare your patients when they first walk in the door, and for you to assess how well they are going to respond to the treatments that you are offering," said Dr. Ganesan, who is a professor of dermatology at the University of California, Irvine.

Dr. Ganesan discussed the etiology, diagnosis, and treatment of pigmentary disorders, as well as the triaging of patients with these conditions, at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Melasma

About 75% of melasma patients are female, and the condition is common in darker-skinned patients, he said. The exact cause of melasma is unknown, but triggers may include sun exposure, family history, phenytoin exposure, oral contraceptives, pregnancy, and increased estrogen.

The Wood's lamp is used to determine the classification of melasma: epidermal, dermal, or mixed. "If you can categorize your patients, you can actually predict very nicely how well they are going to respond to your treatment," he said.

In white and Hispanic patients, melasma appears as a reflected darker image. In patients with skin types V or VI the color will appear a little reddish, but a change can be seen over the pigmented area.

Melasma that has an epidermal component will respond well to almost any treatment. Dermal melasma tends to respond better to laser therapies. Darker-skinned patients will respond best to hydroquinone, while lighter skin responds best to peels and lasers.

Patients with melasma need to use a broad-spectrum sunscreen (UVA and UVB coverage with an SPF of 30 or more) every day, regardless of sun exposure, because fluorescent lighting emits some UVA rays, said Dr. Ganesan.

Birth control pills, cosmetic products, and phototoxic drugs should be discontinued if they appear to help cause the melasma.

Combining topical products is more effective than using tretinoin, hydroquinone, or steroids alone, he said, adding that it is important to balance an agent's potential for irritation with its strength because increased inflammation will result in poor clinical outcomes.

For patients who cannot tolerate hydroquinone, there are some less effective alternatives: kojic acid, which can be more irritating than hydroquinone; azelaic acid; mequinol, which has been shown to have some depigmenting activity and is less effective than hydroquinone; arbutin, which is a botanically related compound that can cause depigmentation; and licorice extract, available in Ayurvedic and other commercial preparations.

Chemical peels are not effective as single agents for treating melasma but may be slightly synergistic when used with hydroquinone. Peels are operator dependent, said Dr. Ganesan, so if the clinician has extensive clinical experience with them they may be a treatment option.

Studies suggest that the Q-switched Nd:YAG and ruby lasers, used in conjunction with hydroquinone, may be effective in treating dermal or mixed melasma. Positive results also have been seen with Fraxel lasers.

Vitiligo

The underlying factor thought to cause vitiligo is melanocyte susceptibility to destruction.

As with melasma, the diagnosis should be made with a Wood's lamp, which can distinguish vitiligo from other hypopigmenting conditions. Biopsy, along with Fontana-Masson staining, can be helpful to determine if melanocytes are present, Dr. Ganesan said.

There are two types of vitiligo: segmental (unresponsive to light therapy) and generalized (responsive to light therapy). Treatment options include photo therapy, lasers, surgery, and topical solutions. Given the safety and tolerability of narrow-band UVB, it is favored over treatment with PUVA.

A 380-nm excimer laser can be used to treat small surface areas, such as those on the face, but is less effective on the hands. An excimer laser should be used aggressively with dose escalation for best treatment results, Dr. Ganesan said. Because aggressive dosing regimens can lead to increased burning, it is best for treating localized areas and for patients who seek rapid improvement.

Although the excimer laser should be avoided when treating underarms, the device works well on the eyelids, he continued. It produces less response on the hands and feet but is an option if narrow-band UVB has failed.

Surgical options for treating vitiligo include punch grafting and suction blister grafting. Punch grafting has been found very effective for treating nonactive segmental lesions. A side effect of punch grafting is cobblestoning, which can diminish over time.

Dr. Ganesan disclosed having no conflicts related to his presentation.

SDEF and this news organization are both owned by Elsevier.

'If you can categorize your patients, you can actually predict very nicely how well they are going to respond.' DR. GANESAN

Possible melasma triggers include sun exposure, phenytoin exposure, and oral contraceptives. Courtesy Dr. Wendy E. Roberts