Aesthetic Dermatology

While advances in technology have made lasers more effective as a treatment for spider veins, sclerotherapy remains the standard for treatment, according to Dr. Margaret W. Mann.

While there have been significant advances in laser technology that make them an option for some spider veins, most telangiectases respond best to the more traditional treatment, said Dr. Mann, codirector of the dermatologic surgery and laser center at the University of California, Irvine.

"The majority of the time, I tend to reserve lasers for treating spider veins under a few circumstances," Dr. Mann said in an interview. They are best used for superficial vessels with a diameter of 1 mm or less, especially isolated telangiectases or those around the ankles. Patients with telangiectatic matting may also be candidates for laser treatment. Lasers might also be considered for a patient with needle phobia, or someone who has had a poor response to prior sclerotherapy, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Outside of those circumstances, I tend to use sclerotherapy, which provides more reproducible results with less discomfort and fewer complications."

Different laser types have specific applications when treating spider veins. The potassium-titanyl-phosphate (KTP) and pulsed dye lasers are usually reserved for small vessels with a diameter of up to 1.5 mm. Melanin tends to absorb the energy from these lasers, which can result in hyperpigmentation.

"The majority of the time, I use the 1064-nm Nd:YAG, because it has a lower risk of pigmentary changes and because the advances in cooling devices associated with the Nd:YAG make overheating less likely," Dr. Mann said.

In contrast to telangiectases on the face, which are best treated with lasers, spider veins on the legs do not uniformly respond to lasers. The homogenous nature of facial telangiectases, both in diameter and depth, makes them easier targets than leg veins. "Telangiectases in the legs are a more heterogenous group; they tend to be different sizes and different depths, so it is harder to uniformly target them than it is the facial vessels."

She recommended an ultrasound evaluation for patients who may have more complicated vessel disease, including those with vessels larger than 5 mm in diameter, palpable varicosities, or classic corona phlebectasia—a clustering of spider veins along the medial malleolus.

Patients who have not responded to multiple sessions with sclerotherapy or lasers should undergo an ultrasound evaluation. "These are all indications of larger vessel disease, such as greater saphenous vein insufficiency." If the ultrasound confirms these findings, treatment with endovenous ablation or microphlebectomy should precede any further sclerotherapy or laser treatments.

Endovenous ablation can be performed in the office with tumescent anesthesia, she said. It requires only a small incision in which a laser fiber is threaded under ultrasound guidance within the vein. The laser is activated and withdrawn, which gently heats the lining of the vein and seals it shut.

Ambulatory microphlebectomy is also a safe, effective option for isolated varicosities. The procedure involves making multiple tiny incisions (1–3 mm) through which the varicose veins are removed. A compression dressing is necessary for 24 hours after the procedure, after which the patient can resume normal activity while wearing compression hose for 3 weeks.

Dr. Mann reported no financial conflicts regarding her presentation.

SDEF and this news organization are owned by Elsevier.

Sclerotherapy 'provides more reproducible results withless discomfort and fewer complications.' DR. MANN

While advances in technology have made lasers more effective as a treatment for spider veins, sclerotherapy remains the standard for treatment, according to Dr. Margaret W. Mann.

While there have been significant advances in laser technology that make them an option for some spider veins, most telangiectases respond best to the more traditional treatment, said Dr. Mann, codirector of the dermatologic surgery and laser center at the University of California, Irvine.

"The majority of the time, I tend to reserve lasers for treating spider veins under a few circumstances," Dr. Mann said in an interview. They are best used for superficial vessels with a diameter of 1 mm or less, especially isolated telangiectases or those around the ankles. Patients with telangiectatic matting may also be candidates for laser treatment. Lasers might also be considered for a patient with needle phobia, or someone who has had a poor response to prior sclerotherapy, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Outside of those circumstances, I tend to use sclerotherapy, which provides more reproducible results with less discomfort and fewer complications."

Different laser types have specific applications when treating spider veins. The potassium-titanyl-phosphate (KTP) and pulsed dye lasers are usually reserved for small vessels with a diameter of up to 1.5 mm. Melanin tends to absorb the energy from these lasers, which can result in hyperpigmentation.

"The majority of the time, I use the 1064-nm Nd:YAG, because it has a lower risk of pigmentary changes and because the advances in cooling devices associated with the Nd:YAG make overheating less likely," Dr. Mann said.

In contrast to telangiectases on the face, which are best treated with lasers, spider veins on the legs do not uniformly respond to lasers. The homogenous nature of facial telangiectases, both in diameter and depth, makes them easier targets than leg veins. "Telangiectases in the legs are a more heterogenous group; they tend to be different sizes and different depths, so it is harder to uniformly target them than it is the facial vessels."

She recommended an ultrasound evaluation for patients who may have more complicated vessel disease, including those with vessels larger than 5 mm in diameter, palpable varicosities, or classic corona phlebectasia—a clustering of spider veins along the medial malleolus.

Patients who have not responded to multiple sessions with sclerotherapy or lasers should undergo an ultrasound evaluation. "These are all indications of larger vessel disease, such as greater saphenous vein insufficiency." If the ultrasound confirms these findings, treatment with endovenous ablation or microphlebectomy should precede any further sclerotherapy or laser treatments.

Endovenous ablation can be performed in the office with tumescent anesthesia, she said. It requires only a small incision in which a laser fiber is threaded under ultrasound guidance within the vein. The laser is activated and withdrawn, which gently heats the lining of the vein and seals it shut.

Ambulatory microphlebectomy is also a safe, effective option for isolated varicosities. The procedure involves making multiple tiny incisions (1–3 mm) through which the varicose veins are removed. A compression dressing is necessary for 24 hours after the procedure, after which the patient can resume normal activity while wearing compression hose for 3 weeks.

Dr. Mann reported no financial conflicts regarding her presentation.

SDEF and this news organization are owned by Elsevier.

Sclerotherapy 'provides more reproducible results withless discomfort and fewer complications.' DR. MANN

While advances in technology have made lasers more effective as a treatment for spider veins, sclerotherapy remains the standard for treatment, according to Dr. Margaret W. Mann.

While there have been significant advances in laser technology that make them an option for some spider veins, most telangiectases respond best to the more traditional treatment, said Dr. Mann, codirector of the dermatologic surgery and laser center at the University of California, Irvine.

"The majority of the time, I tend to reserve lasers for treating spider veins under a few circumstances," Dr. Mann said in an interview. They are best used for superficial vessels with a diameter of 1 mm or less, especially isolated telangiectases or those around the ankles. Patients with telangiectatic matting may also be candidates for laser treatment. Lasers might also be considered for a patient with needle phobia, or someone who has had a poor response to prior sclerotherapy, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Outside of those circumstances, I tend to use sclerotherapy, which provides more reproducible results with less discomfort and fewer complications."

Different laser types have specific applications when treating spider veins. The potassium-titanyl-phosphate (KTP) and pulsed dye lasers are usually reserved for small vessels with a diameter of up to 1.5 mm. Melanin tends to absorb the energy from these lasers, which can result in hyperpigmentation.

"The majority of the time, I use the 1064-nm Nd:YAG, because it has a lower risk of pigmentary changes and because the advances in cooling devices associated with the Nd:YAG make overheating less likely," Dr. Mann said.

In contrast to telangiectases on the face, which are best treated with lasers, spider veins on the legs do not uniformly respond to lasers. The homogenous nature of facial telangiectases, both in diameter and depth, makes them easier targets than leg veins. "Telangiectases in the legs are a more heterogenous group; they tend to be different sizes and different depths, so it is harder to uniformly target them than it is the facial vessels."

She recommended an ultrasound evaluation for patients who may have more complicated vessel disease, including those with vessels larger than 5 mm in diameter, palpable varicosities, or classic corona phlebectasia—a clustering of spider veins along the medial malleolus.

Patients who have not responded to multiple sessions with sclerotherapy or lasers should undergo an ultrasound evaluation. "These are all indications of larger vessel disease, such as greater saphenous vein insufficiency." If the ultrasound confirms these findings, treatment with endovenous ablation or microphlebectomy should precede any further sclerotherapy or laser treatments.

Endovenous ablation can be performed in the office with tumescent anesthesia, she said. It requires only a small incision in which a laser fiber is threaded under ultrasound guidance within the vein. The laser is activated and withdrawn, which gently heats the lining of the vein and seals it shut.

Ambulatory microphlebectomy is also a safe, effective option for isolated varicosities. The procedure involves making multiple tiny incisions (1–3 mm) through which the varicose veins are removed. A compression dressing is necessary for 24 hours after the procedure, after which the patient can resume normal activity while wearing compression hose for 3 weeks.

Dr. Mann reported no financial conflicts regarding her presentation.

SDEF and this news organization are owned by Elsevier.

Sclerotherapy 'provides more reproducible results withless discomfort and fewer complications.' DR. MANN

Lily Talakoub, MD and Naissan O. Wesley, MD

The United States has become progressively more multicultural, with the ethnic population growing at record rates. The US Census Bureau projects that, by the year 2056, greater than 50% of the US population will be of non-Caucasian descent. Ethnic patients have different cosmetic concerns and natural features that are unique. The cosmetic concerns of ethnic patients also differ as the result of differences in skin pathophysiology, mechanisms of aging, and unique anatomic structure. There is no longer a single standard of beauty. We must now adapt to the more diverse population and understand how to accommodate the diversity of beauty in the United States. Ethnic patients do not necessarily want a Westernized look because what constitutes beauty is determined by racial, cultural, and environmental influences. We as leaders in skin care must understand these differences and adapt our practices accordingly. This article will focus on the differences in aging in different ethnic populations and highlight procedures unique to skin of color.

*For a PDF of the full article, click on the link to the left of this introduction.

Lily Talakoub, MD and Naissan O. Wesley, MD

The United States has become progressively more multicultural, with the ethnic population growing at record rates. The US Census Bureau projects that, by the year 2056, greater than 50% of the US population will be of non-Caucasian descent. Ethnic patients have different cosmetic concerns and natural features that are unique. The cosmetic concerns of ethnic patients also differ as the result of differences in skin pathophysiology, mechanisms of aging, and unique anatomic structure. There is no longer a single standard of beauty. We must now adapt to the more diverse population and understand how to accommodate the diversity of beauty in the United States. Ethnic patients do not necessarily want a Westernized look because what constitutes beauty is determined by racial, cultural, and environmental influences. We as leaders in skin care must understand these differences and adapt our practices accordingly. This article will focus on the differences in aging in different ethnic populations and highlight procedures unique to skin of color.

*For a PDF of the full article, click on the link to the left of this introduction.

Lily Talakoub, MD and Naissan O. Wesley, MD

The United States has become progressively more multicultural, with the ethnic population growing at record rates. The US Census Bureau projects that, by the year 2056, greater than 50% of the US population will be of non-Caucasian descent. Ethnic patients have different cosmetic concerns and natural features that are unique. The cosmetic concerns of ethnic patients also differ as the result of differences in skin pathophysiology, mechanisms of aging, and unique anatomic structure. There is no longer a single standard of beauty. We must now adapt to the more diverse population and understand how to accommodate the diversity of beauty in the United States. Ethnic patients do not necessarily want a Westernized look because what constitutes beauty is determined by racial, cultural, and environmental influences. We as leaders in skin care must understand these differences and adapt our practices accordingly. This article will focus on the differences in aging in different ethnic populations and highlight procedures unique to skin of color.

*For a PDF of the full article, click on the link to the left of this introduction.

Eliot F. Battle, Jr, MD and Cylburn E. Soden, Jr, MD, MA

The demographics of the US population continue to change at an extremely rapid pace. As of 2008, Asians, Hispanics, and African Americans accounted for 31% of the US population, and it is estimated that by the year 2050 half of the population of America will be represented by darker ethnic skin types. With the increase in the total number of individuals of skin of color, the demand for safe and effective laser therapy in darker skin types continues to increase. However, despite the increase in demand, the current literature regarding the use of lasers in darker skin remains limited. Most of the treatment parameters defined for laser platforms have been established primarily through extensive testing on skin phototypes I to III, and those studies that have been conducted on darker skin phototypes have been overwhelmingly conducted on Asian skin. Nevertheless, it has become clear that effective cutaneous laser surgery in darker skin types can be accomplished despite a relative overall greater risk for complications. Therefore, as the diversity of America continues to grow, the laser surgeon needs to maintain a clear understanding of the complexities associated with treating ethnic skin and remain mindful of the current, and ever-changing, therapeutic modalities available. This will allow the conscientious physician to maximize outcome and minimize risk when performing laser surgery on darker skin types.

*For a PDF of the full article, click on the link to the left of this introduction.

Eliot F. Battle, Jr, MD and Cylburn E. Soden, Jr, MD, MA

The demographics of the US population continue to change at an extremely rapid pace. As of 2008, Asians, Hispanics, and African Americans accounted for 31% of the US population, and it is estimated that by the year 2050 half of the population of America will be represented by darker ethnic skin types. With the increase in the total number of individuals of skin of color, the demand for safe and effective laser therapy in darker skin types continues to increase. However, despite the increase in demand, the current literature regarding the use of lasers in darker skin remains limited. Most of the treatment parameters defined for laser platforms have been established primarily through extensive testing on skin phototypes I to III, and those studies that have been conducted on darker skin phototypes have been overwhelmingly conducted on Asian skin. Nevertheless, it has become clear that effective cutaneous laser surgery in darker skin types can be accomplished despite a relative overall greater risk for complications. Therefore, as the diversity of America continues to grow, the laser surgeon needs to maintain a clear understanding of the complexities associated with treating ethnic skin and remain mindful of the current, and ever-changing, therapeutic modalities available. This will allow the conscientious physician to maximize outcome and minimize risk when performing laser surgery on darker skin types.

*For a PDF of the full article, click on the link to the left of this introduction.

Eliot F. Battle, Jr, MD and Cylburn E. Soden, Jr, MD, MA

The demographics of the US population continue to change at an extremely rapid pace. As of 2008, Asians, Hispanics, and African Americans accounted for 31% of the US population, and it is estimated that by the year 2050 half of the population of America will be represented by darker ethnic skin types. With the increase in the total number of individuals of skin of color, the demand for safe and effective laser therapy in darker skin types continues to increase. However, despite the increase in demand, the current literature regarding the use of lasers in darker skin remains limited. Most of the treatment parameters defined for laser platforms have been established primarily through extensive testing on skin phototypes I to III, and those studies that have been conducted on darker skin phototypes have been overwhelmingly conducted on Asian skin. Nevertheless, it has become clear that effective cutaneous laser surgery in darker skin types can be accomplished despite a relative overall greater risk for complications. Therefore, as the diversity of America continues to grow, the laser surgeon needs to maintain a clear understanding of the complexities associated with treating ethnic skin and remain mindful of the current, and ever-changing, therapeutic modalities available. This will allow the conscientious physician to maximize outcome and minimize risk when performing laser surgery on darker skin types.

*For a PDF of the full article, click on the link to the left of this introduction.

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.