Aesthetic Dermatology

PALM BEACH, FLA. — Certain widely held beliefs among dermatologic surgeons are revealed as myths when subjected to scientific scrutiny, according to Dr. James M. Spencer.

"In surgery we do a lot of things just because a respected professor once told us to," said Dr. Spencer of Mount Sinai School of Medicine, New York.

An example Dr. Spencer cited is the dictum that one should never use epinephrine with lidocaine on the fingers, because the epinephrine is so vasoconstrictive that hypoxia and necrosis would result. This prohibition is included as dogma in textbooks—yet a literature review identified only 50 reported cases of digital gangrene following local anesthesia. All of these were early 20th century cases and multiple medications were involved, including cocaine and procaine, with nonstandardized techniques and methods of mixing, he said.

These early cases also included the inappropriate use of tourniquets and postoperative hot soaks (J. Am. Acad. Dermatol. 2004;51:755–9). There have been no reports of necrosis of the finger since commercial lidocaine with epinephrine was introduced in 1948, Dr. Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Another myth is that dog-ears must be completely removed at the time of surgery or they will be permanent. "I was taught 'thou shalt not leave dog-ears,' but this is clearly untrue," he said.

"When I had my first job at the University of Miami, the chairman of the department of plastic surgery would do primary repairs leaving patients with dog-ears. I wondered why no one had ever told him not to leave dog-ears, but then I thought, what are the chances of me being right and the chairman of plastic surgery being wrong? Zero," he said.

When this was studied prospectively, in 43 postexcision dog-ears in 26 patients, some degree of regression was seen in all 43. The dog-ears were measured immediately postoperatively and followed for up to 180 days. Complete regression was seen in 19 of the 43, over a mean of 132 days, and the probability of complete regression was greater in dog-ears of 8 mm in height or less (Dermatol. Surg. 2008;34:1070–6).

"I can tell you from experience that dog-ears on hands regress completely, those on arms and legs do pretty well, but those on the forehead not at all," he said.

"We also were all taught that nonabsorbable sutures are always preferred as outer, cuticular sutures because absorbable sutures are too inflammatory, they favor infection, and give an inferior cosmetic result," he said.

Patients, however, would prefer not to have to return for suture removal, so a group of emergency physicians performed a study in which they randomized pediatric patients with lacerations to treatment with absorbable plain gut sutures or nonabsorbable nylon sutures and evaluated them at 10 days and at 4–5 months.

At 10-day follow-up, there were no differences in wound outcome, including infection and dehiscence rates, and 4–5 months later, evaluation by a blinded plastic surgeon showed no difference in cosmetic outcome (Acad. Emerg. Med. 2004;11:730–5). "In fact, the plain gut sutures appeared to give a slightly better cosmetic result," said Dr. Spencer, who also is in private practice in St. Petersburg, Fla.

Another myth that has been perpetuated by dermatologists is that patients receive 80% of their lifetime sun exposure by age 18.

The 80% number was an extrapolation from a calculation in 1986 that sunscreen use by young people would reduce their lifetime risk of skin cancer by 78%. In fact, the original publication stated that the incidence of nonmelanoma skin cancer was related to the square of the ultraviolet dose—the actual dose was not calculated (Arch. Derm. 1986;122:537–45).

A more recent analysis determined that Americans actually receive less than 25% of their total exposure by age 18 (Photochem. Photobiol. 2003;77:453–7). "This, of course, means that sun protection is equally important in older and younger patients," he said.

Finally, it has been accepted that laser resurfacing is contraindicated while a patient is on isotretinoin, but there is very little evidence to support this, with only nine cases of keloid scarring having been reported. Six were from Dr. Henry Roenigk in Chicago, who has done thousands of cases of dermabrasion on patients with acne scars who were on isotretinoin or had only recently discontinued it (J. Am. Acad. Dermatol. 1986;15:280–5). The remaining three were patients from Great Britain who developed scarring after dermabrasion or argon laser while taking isotretinoin (Br. J. Dermatol. 1988;118:703–6).

"That's it. Nine patients in the world literature have become a medicolegal fact. Textbooks don't even reference it, they just state it like it's the 11th commandment."

Dr. Spencer disclosed having no conflicts of interest relevant to his presenation.

'I was taught "thou shalt not leave dog-ears," but this is clearly untrue.' DR. SPENCER

PALM BEACH, FLA. — Certain widely held beliefs among dermatologic surgeons are revealed as myths when subjected to scientific scrutiny, according to Dr. James M. Spencer.

"In surgery we do a lot of things just because a respected professor once told us to," said Dr. Spencer of Mount Sinai School of Medicine, New York.

An example Dr. Spencer cited is the dictum that one should never use epinephrine with lidocaine on the fingers, because the epinephrine is so vasoconstrictive that hypoxia and necrosis would result. This prohibition is included as dogma in textbooks—yet a literature review identified only 50 reported cases of digital gangrene following local anesthesia. All of these were early 20th century cases and multiple medications were involved, including cocaine and procaine, with nonstandardized techniques and methods of mixing, he said.

These early cases also included the inappropriate use of tourniquets and postoperative hot soaks (J. Am. Acad. Dermatol. 2004;51:755–9). There have been no reports of necrosis of the finger since commercial lidocaine with epinephrine was introduced in 1948, Dr. Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Another myth is that dog-ears must be completely removed at the time of surgery or they will be permanent. "I was taught 'thou shalt not leave dog-ears,' but this is clearly untrue," he said.

"When I had my first job at the University of Miami, the chairman of the department of plastic surgery would do primary repairs leaving patients with dog-ears. I wondered why no one had ever told him not to leave dog-ears, but then I thought, what are the chances of me being right and the chairman of plastic surgery being wrong? Zero," he said.

When this was studied prospectively, in 43 postexcision dog-ears in 26 patients, some degree of regression was seen in all 43. The dog-ears were measured immediately postoperatively and followed for up to 180 days. Complete regression was seen in 19 of the 43, over a mean of 132 days, and the probability of complete regression was greater in dog-ears of 8 mm in height or less (Dermatol. Surg. 2008;34:1070–6).

"I can tell you from experience that dog-ears on hands regress completely, those on arms and legs do pretty well, but those on the forehead not at all," he said.

"We also were all taught that nonabsorbable sutures are always preferred as outer, cuticular sutures because absorbable sutures are too inflammatory, they favor infection, and give an inferior cosmetic result," he said.

Patients, however, would prefer not to have to return for suture removal, so a group of emergency physicians performed a study in which they randomized pediatric patients with lacerations to treatment with absorbable plain gut sutures or nonabsorbable nylon sutures and evaluated them at 10 days and at 4–5 months.

At 10-day follow-up, there were no differences in wound outcome, including infection and dehiscence rates, and 4–5 months later, evaluation by a blinded plastic surgeon showed no difference in cosmetic outcome (Acad. Emerg. Med. 2004;11:730–5). "In fact, the plain gut sutures appeared to give a slightly better cosmetic result," said Dr. Spencer, who also is in private practice in St. Petersburg, Fla.

Another myth that has been perpetuated by dermatologists is that patients receive 80% of their lifetime sun exposure by age 18.

The 80% number was an extrapolation from a calculation in 1986 that sunscreen use by young people would reduce their lifetime risk of skin cancer by 78%. In fact, the original publication stated that the incidence of nonmelanoma skin cancer was related to the square of the ultraviolet dose—the actual dose was not calculated (Arch. Derm. 1986;122:537–45).

A more recent analysis determined that Americans actually receive less than 25% of their total exposure by age 18 (Photochem. Photobiol. 2003;77:453–7). "This, of course, means that sun protection is equally important in older and younger patients," he said.

Finally, it has been accepted that laser resurfacing is contraindicated while a patient is on isotretinoin, but there is very little evidence to support this, with only nine cases of keloid scarring having been reported. Six were from Dr. Henry Roenigk in Chicago, who has done thousands of cases of dermabrasion on patients with acne scars who were on isotretinoin or had only recently discontinued it (J. Am. Acad. Dermatol. 1986;15:280–5). The remaining three were patients from Great Britain who developed scarring after dermabrasion or argon laser while taking isotretinoin (Br. J. Dermatol. 1988;118:703–6).

"That's it. Nine patients in the world literature have become a medicolegal fact. Textbooks don't even reference it, they just state it like it's the 11th commandment."

Dr. Spencer disclosed having no conflicts of interest relevant to his presenation.

'I was taught "thou shalt not leave dog-ears," but this is clearly untrue.' DR. SPENCER

PALM BEACH, FLA. — Certain widely held beliefs among dermatologic surgeons are revealed as myths when subjected to scientific scrutiny, according to Dr. James M. Spencer.

"In surgery we do a lot of things just because a respected professor once told us to," said Dr. Spencer of Mount Sinai School of Medicine, New York.

An example Dr. Spencer cited is the dictum that one should never use epinephrine with lidocaine on the fingers, because the epinephrine is so vasoconstrictive that hypoxia and necrosis would result. This prohibition is included as dogma in textbooks—yet a literature review identified only 50 reported cases of digital gangrene following local anesthesia. All of these were early 20th century cases and multiple medications were involved, including cocaine and procaine, with nonstandardized techniques and methods of mixing, he said.

These early cases also included the inappropriate use of tourniquets and postoperative hot soaks (J. Am. Acad. Dermatol. 2004;51:755–9). There have been no reports of necrosis of the finger since commercial lidocaine with epinephrine was introduced in 1948, Dr. Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Another myth is that dog-ears must be completely removed at the time of surgery or they will be permanent. "I was taught 'thou shalt not leave dog-ears,' but this is clearly untrue," he said.

"When I had my first job at the University of Miami, the chairman of the department of plastic surgery would do primary repairs leaving patients with dog-ears. I wondered why no one had ever told him not to leave dog-ears, but then I thought, what are the chances of me being right and the chairman of plastic surgery being wrong? Zero," he said.

When this was studied prospectively, in 43 postexcision dog-ears in 26 patients, some degree of regression was seen in all 43. The dog-ears were measured immediately postoperatively and followed for up to 180 days. Complete regression was seen in 19 of the 43, over a mean of 132 days, and the probability of complete regression was greater in dog-ears of 8 mm in height or less (Dermatol. Surg. 2008;34:1070–6).

"I can tell you from experience that dog-ears on hands regress completely, those on arms and legs do pretty well, but those on the forehead not at all," he said.

"We also were all taught that nonabsorbable sutures are always preferred as outer, cuticular sutures because absorbable sutures are too inflammatory, they favor infection, and give an inferior cosmetic result," he said.

Patients, however, would prefer not to have to return for suture removal, so a group of emergency physicians performed a study in which they randomized pediatric patients with lacerations to treatment with absorbable plain gut sutures or nonabsorbable nylon sutures and evaluated them at 10 days and at 4–5 months.

At 10-day follow-up, there were no differences in wound outcome, including infection and dehiscence rates, and 4–5 months later, evaluation by a blinded plastic surgeon showed no difference in cosmetic outcome (Acad. Emerg. Med. 2004;11:730–5). "In fact, the plain gut sutures appeared to give a slightly better cosmetic result," said Dr. Spencer, who also is in private practice in St. Petersburg, Fla.

Another myth that has been perpetuated by dermatologists is that patients receive 80% of their lifetime sun exposure by age 18.

The 80% number was an extrapolation from a calculation in 1986 that sunscreen use by young people would reduce their lifetime risk of skin cancer by 78%. In fact, the original publication stated that the incidence of nonmelanoma skin cancer was related to the square of the ultraviolet dose—the actual dose was not calculated (Arch. Derm. 1986;122:537–45).

A more recent analysis determined that Americans actually receive less than 25% of their total exposure by age 18 (Photochem. Photobiol. 2003;77:453–7). "This, of course, means that sun protection is equally important in older and younger patients," he said.

Finally, it has been accepted that laser resurfacing is contraindicated while a patient is on isotretinoin, but there is very little evidence to support this, with only nine cases of keloid scarring having been reported. Six were from Dr. Henry Roenigk in Chicago, who has done thousands of cases of dermabrasion on patients with acne scars who were on isotretinoin or had only recently discontinued it (J. Am. Acad. Dermatol. 1986;15:280–5). The remaining three were patients from Great Britain who developed scarring after dermabrasion or argon laser while taking isotretinoin (Br. J. Dermatol. 1988;118:703–6).

"That's it. Nine patients in the world literature have become a medicolegal fact. Textbooks don't even reference it, they just state it like it's the 11th commandment."

Dr. Spencer disclosed having no conflicts of interest relevant to his presenation.

'I was taught "thou shalt not leave dog-ears," but this is clearly untrue.' DR. SPENCER

PALM BEACH, FLA. — Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.

This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Purse-string closure of defects after surgery for skin cancer—with sutures placed around the defect and the skin pulled together—is cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).

"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.

The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.

Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.

Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.

"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.

The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.

"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.

The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.

PALM BEACH, FLA. — Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.

This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Purse-string closure of defects after surgery for skin cancer—with sutures placed around the defect and the skin pulled together—is cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).

"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.

The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.

Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.

Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.

"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.

The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.

"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.

The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.

PALM BEACH, FLA. — Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.

This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Purse-string closure of defects after surgery for skin cancer—with sutures placed around the defect and the skin pulled together—is cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).

"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.

The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.

Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.

Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.

"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.

The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.

"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.

The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

Stretch marks, or striae distensae, are scar tissue in the skin's dermal layer that result from rapid growth or weight gain. These lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks, and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (from weight lifting, for example), and prolonged use of topical steroids.

In these instances or periods of growth, collagen and elastin are not produced fast enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks.

Initially, these dermal alterations present as pink, red, or purple lesions, known as striae rubra. If the lesions are untreated, they become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls and pregnant women are beset with striae distensae.

Dermatologists now have a number of options to tackle this cosmetically stressful condition, including novel laser treatments for striae alba, but the primary focus here is on topical and cosmeceutical options.

Prevention

There is no surefire method to prevent stretch marks per se, but avoidance of a rapid gain or loss of weight improves one's chances of not developing these lesions.

Several topical agents have demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing three or four times daily is recommended. Skin becomes more pliant and elastic when it is well hydrated. Moisturizers that contain cocoa butter, shea butter, or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, massage such formulations deeply into the affected areas. I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and C. asiatica, to my patients.

Treatment

Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple because the lesions are most likely to respond to at-home products and in-office peels at this stage. Once stretch marks are white, treatment becomes more difficult and less successful.

Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) lotions, most likely through the alpha-hydroxy acid's capacity to stimulate collagen synthesis. I recommend brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion.

Topical vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Supplementation with oral vitamin C 500 mg twice daily may also confer some benefit.

Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for its ability to increase elastic tissue, which may ameliorate stretch marks. Its efficacy is unconfirmed at this point.

Retinoids

In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks from various causes completed the study, 15 of whom exhibited significant clinical improvement (J. Dermatol. Surg. Oncol. 1990;16:267–70).

Retinoids promote the production of collagen and elastin. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade (Dermatol. Surg. 1998;24:849–56). Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant and breastfeeding women.

In a study evaluating commercial topical products for the treatment of striae alba, investigators tested two regimens on 10 patients who had abdominal striae alba with skin types ranging from I to V. Patients applied 20% glycolic acid (MD Forté) to the whole treatment area on a daily basis for 12 weeks. Patients also were directed to apply 0.05% tretinoin emollient cream (Renova) to half of the treatment area, and 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream to the other half.

Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented for both regimens. In addition, a comparison of treated striae alba with untreated lesions revealed that both regimens were effective in decreasing papillary dermal thickness and increasing epidermal thickness (Dermatol. Surg. 1998;24:849–56).

In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study, researchers observed marked improvement in all striae after 3 months, compared with baseline, with an average 20% reduction in the length of the target lesion. Despite the emergence in 11 patients of erythema and scaling, topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae (Adv. Ther. 2001;18:181–6).

I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A, Tazorac, and Differin are stronger and, therefore, may be more effective than retinol. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel.

In-Office Treatment

Glycolic acid can be administered in the office at higher doses than those contained in OTC products. After three or four visits, patients usually notice a slight change in the length, width, and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for people with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel.

Lasers

Since vascular lasers are designed to treat dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser.

In a recent study, investigators treated 20 patients with striae rubra using the 1,064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent), and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found this laser to be an effective option for treating striae rubra, with minimal side effects (Dermatol. Surg. 2008;34:686–91).

In another study, researchers evaluated the efficacy of the Therma Cool TC (Thermage Inc.), in combination with a 585-nm pulsed dye laser, for the treatment of striae distensae in people with darker skin types. Overall improvement was termed “good and very good” by 89% of the participants in the subjective evaluation. Skin biopsies of nine patients also revealed that the level of collagen fibers in each sample increased (Dermatol. Surg. 2007;33:29–34).

In a previous study of patients with dark skin types (IV-VI), researchers studied the effects of a nonablative 1,450-nm diode laser on striae distensae. Eleven Asian patients were treated with the laser with cryogen cooling spray on half of the body; the untreated half served as the control. The investigators concluded that, for patients with skin types IV-VI, the nonablative 1,450-nm diode laser is not a viable option for treating stretch marks (Lasers Surg. Med. 2006;38:196–9).

Intense Pulsed Light

In research on the efficacy of intense pulsed light (IPL), investigators treated 15 women with abdominal striae distensae. Their study was based on the reported efficacy of IPL in fostering the synthesis of collagen and the ordering of elastic fibers. Before-and-after photos and skin biopsies of all 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness (Dermatol. Surg. 2002;28:1124–30).

A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, was conducted on 10 patients who had striae distensae. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome, and few subjects observed improvement, but histologic assessment revealed improvement in epidermal and dermal condition. The researchers concluded that additional treatment sessions might afford better chances for desired cosmetic results, given the absence of side effects (Aesthetic Plast. Surg. 2008;32:523–30).

Fractional Photothermolysis

Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba.

Perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers aged 20–35 years using a 1,550-nm fractional photothermolysis laser.

Patients were followed for 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Investigators also noted that skin elasticity had become somewhat normalized (Am. J. Clin. Dermatol. 2008;9:33–7).

Conclusions

Although preventive measures can be used to reduce the likelihood of developing stretch marks, prevention is a challenge.

Treatment options are continually expanding. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures and OTC products. Vitamin C may also impart some benefit. In addition, lasers are emerging as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba.

Patients are advised to begin at-home treatment for stretch marks upon first noticing them and to schedule a dermatologic visit.

Stretch marks, or striae distensae, are scar tissue in the skin's dermal layer that result from rapid growth or weight gain. These lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks, and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (from weight lifting, for example), and prolonged use of topical steroids.

In these instances or periods of growth, collagen and elastin are not produced fast enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks.

Initially, these dermal alterations present as pink, red, or purple lesions, known as striae rubra. If the lesions are untreated, they become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls and pregnant women are beset with striae distensae.

Dermatologists now have a number of options to tackle this cosmetically stressful condition, including novel laser treatments for striae alba, but the primary focus here is on topical and cosmeceutical options.

Prevention

There is no surefire method to prevent stretch marks per se, but avoidance of a rapid gain or loss of weight improves one's chances of not developing these lesions.

Several topical agents have demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing three or four times daily is recommended. Skin becomes more pliant and elastic when it is well hydrated. Moisturizers that contain cocoa butter, shea butter, or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, massage such formulations deeply into the affected areas. I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and C. asiatica, to my patients.

Treatment

Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple because the lesions are most likely to respond to at-home products and in-office peels at this stage. Once stretch marks are white, treatment becomes more difficult and less successful.

Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) lotions, most likely through the alpha-hydroxy acid's capacity to stimulate collagen synthesis. I recommend brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion.

Topical vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Supplementation with oral vitamin C 500 mg twice daily may also confer some benefit.

Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for its ability to increase elastic tissue, which may ameliorate stretch marks. Its efficacy is unconfirmed at this point.

Retinoids

In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks from various causes completed the study, 15 of whom exhibited significant clinical improvement (J. Dermatol. Surg. Oncol. 1990;16:267–70).

Retinoids promote the production of collagen and elastin. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade (Dermatol. Surg. 1998;24:849–56). Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant and breastfeeding women.

In a study evaluating commercial topical products for the treatment of striae alba, investigators tested two regimens on 10 patients who had abdominal striae alba with skin types ranging from I to V. Patients applied 20% glycolic acid (MD Forté) to the whole treatment area on a daily basis for 12 weeks. Patients also were directed to apply 0.05% tretinoin emollient cream (Renova) to half of the treatment area, and 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream to the other half.

Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented for both regimens. In addition, a comparison of treated striae alba with untreated lesions revealed that both regimens were effective in decreasing papillary dermal thickness and increasing epidermal thickness (Dermatol. Surg. 1998;24:849–56).

In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study, researchers observed marked improvement in all striae after 3 months, compared with baseline, with an average 20% reduction in the length of the target lesion. Despite the emergence in 11 patients of erythema and scaling, topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae (Adv. Ther. 2001;18:181–6).

I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A, Tazorac, and Differin are stronger and, therefore, may be more effective than retinol. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel.

In-Office Treatment

Glycolic acid can be administered in the office at higher doses than those contained in OTC products. After three or four visits, patients usually notice a slight change in the length, width, and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for people with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel.

Lasers

Since vascular lasers are designed to treat dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser.

In a recent study, investigators treated 20 patients with striae rubra using the 1,064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent), and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found this laser to be an effective option for treating striae rubra, with minimal side effects (Dermatol. Surg. 2008;34:686–91).

In another study, researchers evaluated the efficacy of the Therma Cool TC (Thermage Inc.), in combination with a 585-nm pulsed dye laser, for the treatment of striae distensae in people with darker skin types. Overall improvement was termed “good and very good” by 89% of the participants in the subjective evaluation. Skin biopsies of nine patients also revealed that the level of collagen fibers in each sample increased (Dermatol. Surg. 2007;33:29–34).

In a previous study of patients with dark skin types (IV-VI), researchers studied the effects of a nonablative 1,450-nm diode laser on striae distensae. Eleven Asian patients were treated with the laser with cryogen cooling spray on half of the body; the untreated half served as the control. The investigators concluded that, for patients with skin types IV-VI, the nonablative 1,450-nm diode laser is not a viable option for treating stretch marks (Lasers Surg. Med. 2006;38:196–9).

Intense Pulsed Light

In research on the efficacy of intense pulsed light (IPL), investigators treated 15 women with abdominal striae distensae. Their study was based on the reported efficacy of IPL in fostering the synthesis of collagen and the ordering of elastic fibers. Before-and-after photos and skin biopsies of all 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness (Dermatol. Surg. 2002;28:1124–30).

A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, was conducted on 10 patients who had striae distensae. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome, and few subjects observed improvement, but histologic assessment revealed improvement in epidermal and dermal condition. The researchers concluded that additional treatment sessions might afford better chances for desired cosmetic results, given the absence of side effects (Aesthetic Plast. Surg. 2008;32:523–30).

Fractional Photothermolysis

Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba.

Perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers aged 20–35 years using a 1,550-nm fractional photothermolysis laser.

Patients were followed for 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Investigators also noted that skin elasticity had become somewhat normalized (Am. J. Clin. Dermatol. 2008;9:33–7).

Conclusions

Although preventive measures can be used to reduce the likelihood of developing stretch marks, prevention is a challenge.

Treatment options are continually expanding. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures and OTC products. Vitamin C may also impart some benefit. In addition, lasers are emerging as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba.

Patients are advised to begin at-home treatment for stretch marks upon first noticing them and to schedule a dermatologic visit.

Stretch marks, or striae distensae, are scar tissue in the skin's dermal layer that result from rapid growth or weight gain. These lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks, and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (from weight lifting, for example), and prolonged use of topical steroids.

In these instances or periods of growth, collagen and elastin are not produced fast enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks.

Initially, these dermal alterations present as pink, red, or purple lesions, known as striae rubra. If the lesions are untreated, they become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls and pregnant women are beset with striae distensae.

Dermatologists now have a number of options to tackle this cosmetically stressful condition, including novel laser treatments for striae alba, but the primary focus here is on topical and cosmeceutical options.

Prevention

There is no surefire method to prevent stretch marks per se, but avoidance of a rapid gain or loss of weight improves one's chances of not developing these lesions.

Several topical agents have demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing three or four times daily is recommended. Skin becomes more pliant and elastic when it is well hydrated. Moisturizers that contain cocoa butter, shea butter, or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, massage such formulations deeply into the affected areas. I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and C. asiatica, to my patients.

Treatment

Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple because the lesions are most likely to respond to at-home products and in-office peels at this stage. Once stretch marks are white, treatment becomes more difficult and less successful.

Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) lotions, most likely through the alpha-hydroxy acid's capacity to stimulate collagen synthesis. I recommend brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion.

Topical vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Supplementation with oral vitamin C 500 mg twice daily may also confer some benefit.

Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for its ability to increase elastic tissue, which may ameliorate stretch marks. Its efficacy is unconfirmed at this point.

Retinoids

In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks from various causes completed the study, 15 of whom exhibited significant clinical improvement (J. Dermatol. Surg. Oncol. 1990;16:267–70).

Retinoids promote the production of collagen and elastin. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade (Dermatol. Surg. 1998;24:849–56). Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant and breastfeeding women.

In a study evaluating commercial topical products for the treatment of striae alba, investigators tested two regimens on 10 patients who had abdominal striae alba with skin types ranging from I to V. Patients applied 20% glycolic acid (MD Forté) to the whole treatment area on a daily basis for 12 weeks. Patients also were directed to apply 0.05% tretinoin emollient cream (Renova) to half of the treatment area, and 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream to the other half.

Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented for both regimens. In addition, a comparison of treated striae alba with untreated lesions revealed that both regimens were effective in decreasing papillary dermal thickness and increasing epidermal thickness (Dermatol. Surg. 1998;24:849–56).

In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study, researchers observed marked improvement in all striae after 3 months, compared with baseline, with an average 20% reduction in the length of the target lesion. Despite the emergence in 11 patients of erythema and scaling, topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae (Adv. Ther. 2001;18:181–6).

I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A, Tazorac, and Differin are stronger and, therefore, may be more effective than retinol. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel.

In-Office Treatment

Glycolic acid can be administered in the office at higher doses than those contained in OTC products. After three or four visits, patients usually notice a slight change in the length, width, and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for people with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel.

Lasers

Since vascular lasers are designed to treat dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser.

In a recent study, investigators treated 20 patients with striae rubra using the 1,064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent), and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found this laser to be an effective option for treating striae rubra, with minimal side effects (Dermatol. Surg. 2008;34:686–91).

In another study, researchers evaluated the efficacy of the Therma Cool TC (Thermage Inc.), in combination with a 585-nm pulsed dye laser, for the treatment of striae distensae in people with darker skin types. Overall improvement was termed “good and very good” by 89% of the participants in the subjective evaluation. Skin biopsies of nine patients also revealed that the level of collagen fibers in each sample increased (Dermatol. Surg. 2007;33:29–34).

In a previous study of patients with dark skin types (IV-VI), researchers studied the effects of a nonablative 1,450-nm diode laser on striae distensae. Eleven Asian patients were treated with the laser with cryogen cooling spray on half of the body; the untreated half served as the control. The investigators concluded that, for patients with skin types IV-VI, the nonablative 1,450-nm diode laser is not a viable option for treating stretch marks (Lasers Surg. Med. 2006;38:196–9).

Intense Pulsed Light

In research on the efficacy of intense pulsed light (IPL), investigators treated 15 women with abdominal striae distensae. Their study was based on the reported efficacy of IPL in fostering the synthesis of collagen and the ordering of elastic fibers. Before-and-after photos and skin biopsies of all 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness (Dermatol. Surg. 2002;28:1124–30).

A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, was conducted on 10 patients who had striae distensae. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome, and few subjects observed improvement, but histologic assessment revealed improvement in epidermal and dermal condition. The researchers concluded that additional treatment sessions might afford better chances for desired cosmetic results, given the absence of side effects (Aesthetic Plast. Surg. 2008;32:523–30).

Fractional Photothermolysis

Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba.

Perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers aged 20–35 years using a 1,550-nm fractional photothermolysis laser.

Patients were followed for 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Investigators also noted that skin elasticity had become somewhat normalized (Am. J. Clin. Dermatol. 2008;9:33–7).

Conclusions

Although preventive measures can be used to reduce the likelihood of developing stretch marks, prevention is a challenge.

Treatment options are continually expanding. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures and OTC products. Vitamin C may also impart some benefit. In addition, lasers are emerging as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba.

Patients are advised to begin at-home treatment for stretch marks upon first noticing them and to schedule a dermatologic visit.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — A device that delivers supersonic pressure to the skin for rejuvenation is showing efficacy for several conditions, including facial wrinkles, solar keratoses, and acne scars.

The device, which was developed by a Russian rocket scientist, is called the JetPeel-3 and is manufactured by TavTech Ltd. It uses pressurized gas to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin at supersonic velocities.

The device was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

"It removes microscopic particles that are usually inaccessible, such as those between cells, in epidermal cracks, in sweat secretions, and in the depression of the hair follicle," Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery. "Supplements are penetrated through pressurized zones, which stretch skin-widening micro-canals inherent in the skin layers and create new ones. It's a simple, safe, painless, and effective device for skin rejuvenation."

He added that the JetPeel-3 restores a youthful-looking appearance by reducing cellular buildup, strengthening capillary respiration, removing metabolic waste from tissues, hydrating and oxygenating tissues, and energizing cell renewal and the wound-healing process.

The technology "is something I find fascinating," said Dr. Gold, who is a paid consultant of TavTech and uses the JetPeel-3 in his Nashville, Tenn., dermatology practice. At the meeting he showed several before and after pictures of cases that were successfully treated with the device for wrinkles above the lips, crow's feet, solar keratoses, and acne scars.

"Many times you see good results after just one treatment," he said. In his experience, most patients require two to four treatments for optimal correction.

While most studies of the device to date have focused on exfoliation with saline, current research is exploring its role in enhancing laser, intense pulsed light, and other treatments, and in the needleless delivery of mesotherapy products and vitamins. "You can personalize these things," he said.

Nutritional elements currently being used include hyaluronic acid, which enriches the skin's natural connective tissue; vitamin C, which improves the ability of skin cells to even out pigment; and vitamins A, B, and E, "which are important ingredients for the proper functioning of cells," he said.

In an interview at the meeting, Oren Gan, TavTech's vice president of sales and marketing, said that many patients achieve immediate results and their skin typically returns to its natural coloration within 30 minutes after treatment is completed.

"It's a true lunchtime procedure," he said, noting that the price of the JetPeel-3 is $22,900.

Dr. Gold disclosed that he is a consultant to, speaks on behalf of, and has performed research for many pharmaceutical and medical device companies, including TavTech.

'It's a simple, safe, painless, and effective device.' The technology is 'something I find fascinating.' DR. GOLD

LAS VEGAS — A device that delivers supersonic pressure to the skin for rejuvenation is showing efficacy for several conditions, including facial wrinkles, solar keratoses, and acne scars.

The device, which was developed by a Russian rocket scientist, is called the JetPeel-3 and is manufactured by TavTech Ltd. It uses pressurized gas to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin at supersonic velocities.

The device was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

"It removes microscopic particles that are usually inaccessible, such as those between cells, in epidermal cracks, in sweat secretions, and in the depression of the hair follicle," Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery. "Supplements are penetrated through pressurized zones, which stretch skin-widening micro-canals inherent in the skin layers and create new ones. It's a simple, safe, painless, and effective device for skin rejuvenation."

He added that the JetPeel-3 restores a youthful-looking appearance by reducing cellular buildup, strengthening capillary respiration, removing metabolic waste from tissues, hydrating and oxygenating tissues, and energizing cell renewal and the wound-healing process.

The technology "is something I find fascinating," said Dr. Gold, who is a paid consultant of TavTech and uses the JetPeel-3 in his Nashville, Tenn., dermatology practice. At the meeting he showed several before and after pictures of cases that were successfully treated with the device for wrinkles above the lips, crow's feet, solar keratoses, and acne scars.

"Many times you see good results after just one treatment," he said. In his experience, most patients require two to four treatments for optimal correction.

While most studies of the device to date have focused on exfoliation with saline, current research is exploring its role in enhancing laser, intense pulsed light, and other treatments, and in the needleless delivery of mesotherapy products and vitamins. "You can personalize these things," he said.

Nutritional elements currently being used include hyaluronic acid, which enriches the skin's natural connective tissue; vitamin C, which improves the ability of skin cells to even out pigment; and vitamins A, B, and E, "which are important ingredients for the proper functioning of cells," he said.

In an interview at the meeting, Oren Gan, TavTech's vice president of sales and marketing, said that many patients achieve immediate results and their skin typically returns to its natural coloration within 30 minutes after treatment is completed.

"It's a true lunchtime procedure," he said, noting that the price of the JetPeel-3 is $22,900.

Dr. Gold disclosed that he is a consultant to, speaks on behalf of, and has performed research for many pharmaceutical and medical device companies, including TavTech.

'It's a simple, safe, painless, and effective device.' The technology is 'something I find fascinating.' DR. GOLD

LAS VEGAS — A device that delivers supersonic pressure to the skin for rejuvenation is showing efficacy for several conditions, including facial wrinkles, solar keratoses, and acne scars.

The device, which was developed by a Russian rocket scientist, is called the JetPeel-3 and is manufactured by TavTech Ltd. It uses pressurized gas to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin at supersonic velocities.

The device was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

"It removes microscopic particles that are usually inaccessible, such as those between cells, in epidermal cracks, in sweat secretions, and in the depression of the hair follicle," Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery. "Supplements are penetrated through pressurized zones, which stretch skin-widening micro-canals inherent in the skin layers and create new ones. It's a simple, safe, painless, and effective device for skin rejuvenation."

He added that the JetPeel-3 restores a youthful-looking appearance by reducing cellular buildup, strengthening capillary respiration, removing metabolic waste from tissues, hydrating and oxygenating tissues, and energizing cell renewal and the wound-healing process.

The technology "is something I find fascinating," said Dr. Gold, who is a paid consultant of TavTech and uses the JetPeel-3 in his Nashville, Tenn., dermatology practice. At the meeting he showed several before and after pictures of cases that were successfully treated with the device for wrinkles above the lips, crow's feet, solar keratoses, and acne scars.

"Many times you see good results after just one treatment," he said. In his experience, most patients require two to four treatments for optimal correction.

While most studies of the device to date have focused on exfoliation with saline, current research is exploring its role in enhancing laser, intense pulsed light, and other treatments, and in the needleless delivery of mesotherapy products and vitamins. "You can personalize these things," he said.

Nutritional elements currently being used include hyaluronic acid, which enriches the skin's natural connective tissue; vitamin C, which improves the ability of skin cells to even out pigment; and vitamins A, B, and E, "which are important ingredients for the proper functioning of cells," he said.

In an interview at the meeting, Oren Gan, TavTech's vice president of sales and marketing, said that many patients achieve immediate results and their skin typically returns to its natural coloration within 30 minutes after treatment is completed.

"It's a true lunchtime procedure," he said, noting that the price of the JetPeel-3 is $22,900.

Dr. Gold disclosed that he is a consultant to, speaks on behalf of, and has performed research for many pharmaceutical and medical device companies, including TavTech.

'It's a simple, safe, painless, and effective device.' The technology is 'something I find fascinating.' DR. GOLD