Aesthetic Dermatology

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Thrombolytic therapy has resulted in limb salvage among 18 patients with severe frostbite treated at one Minnesota hospital in the last few years.

Thrombolytic therapy has been available for management of frostbite for 10 years and has the potential to reduce amputations, but its use has not extended to the rural northern areas where most cases of frostbite occur.

Severe frostbite results in ischemia and blistering with subsequent demarcation and loss of tissue. Prostaglandins and other chemical mediators are released locally, resulting in intense spasm and blistering. Arterial thrombosis results from injury to endothelial cells that retract to expose subintimal collagen, subsequently triggering acute thrombosis after rewarming, according to Dr. George R. Edmonson of St. Paul (Minn.) Radiology.

Traditional treatment has simply been to rewarm the affected extremity, wait to see how much tissue recovers, then amputate the rest, but over the last couple of decades, investigators have been experimenting with intra-arterial infusion of various thrombolytic and vasodilating agents to dissolve clots and relieve arterial spasm in attempts to preserve more tissue.

At the annual meeting of the Society of Interventional Radiology, Dr. Edmonson described the process used at Regions Hospital, also in St. Paul. Patients are admitted to the burn unit, where the the affected limb is assessed. Diagnostic arteriography is done to assess small vessel occlusion and loss of "distal tuft blush" at the tips of digits. Catheters are positioned for simultaneous infusion of treatment drugs into each affected limb.

Since the mid-1990s, Dr. Edmonson and his associates have been treating frostbite of the extremities with a variety of combined antithrombotic, antiplatelet, and vasodilating agents. Initially, they used urokinase along with heparin and papaverine, then switched to reteplase, and now have moved to using tenecteplase (TNK) because of its superior plasma stability and higher fibrin specificity compared with reteplase, he explained.

During three unusually mild Minnesota winters, six patients aged 18-65 years with severe frostbite who were at risk for amputation were treated for up to 72 hours with intra-arterial TNK infusions at 0.25 mg/hour per limb with coaxial papaverine at 30 mg/hour per limb and intravenous heparin at 500 mcg/hour.

Of the six patients, three who had 16 involved digits responded well and required no amputations. The other three (6 limbs, 30 digits) had incomplete angiographic responses. Of those, two (4 limbs, 20 involved digits) improved following TNK infusion but then developed infections and required partial amputations. One patient—who needed intubation for alcohol withdrawal—failed to respond and lost 8 fingers, but his thumbs were saved.

Those patients were compared with surviving patients (aged 14-77 years) of 12 treated with the same protocol using various doses of reteplase and papaverine over a 2-year period. Six of the patients recovered with no amputations, four had lost 31 digits at 45 days, and two had amputations but more distally than would have been anticipated without treatment.

Fingers with severe frostbite (left) can be saved from amputation with restored blood flow (right) after treatment with tenecteplase, papaverine, and heparin. Photos courtesy Dr. George R. Edmonson

WASHINGTON — Thrombolytic therapy has resulted in limb salvage among 18 patients with severe frostbite treated at one Minnesota hospital in the last few years.

Thrombolytic therapy has been available for management of frostbite for 10 years and has the potential to reduce amputations, but its use has not extended to the rural northern areas where most cases of frostbite occur.

Severe frostbite results in ischemia and blistering with subsequent demarcation and loss of tissue. Prostaglandins and other chemical mediators are released locally, resulting in intense spasm and blistering. Arterial thrombosis results from injury to endothelial cells that retract to expose subintimal collagen, subsequently triggering acute thrombosis after rewarming, according to Dr. George R. Edmonson of St. Paul (Minn.) Radiology.

Traditional treatment has simply been to rewarm the affected extremity, wait to see how much tissue recovers, then amputate the rest, but over the last couple of decades, investigators have been experimenting with intra-arterial infusion of various thrombolytic and vasodilating agents to dissolve clots and relieve arterial spasm in attempts to preserve more tissue.

At the annual meeting of the Society of Interventional Radiology, Dr. Edmonson described the process used at Regions Hospital, also in St. Paul. Patients are admitted to the burn unit, where the the affected limb is assessed. Diagnostic arteriography is done to assess small vessel occlusion and loss of "distal tuft blush" at the tips of digits. Catheters are positioned for simultaneous infusion of treatment drugs into each affected limb.

Since the mid-1990s, Dr. Edmonson and his associates have been treating frostbite of the extremities with a variety of combined antithrombotic, antiplatelet, and vasodilating agents. Initially, they used urokinase along with heparin and papaverine, then switched to reteplase, and now have moved to using tenecteplase (TNK) because of its superior plasma stability and higher fibrin specificity compared with reteplase, he explained.

During three unusually mild Minnesota winters, six patients aged 18-65 years with severe frostbite who were at risk for amputation were treated for up to 72 hours with intra-arterial TNK infusions at 0.25 mg/hour per limb with coaxial papaverine at 30 mg/hour per limb and intravenous heparin at 500 mcg/hour.

Of the six patients, three who had 16 involved digits responded well and required no amputations. The other three (6 limbs, 30 digits) had incomplete angiographic responses. Of those, two (4 limbs, 20 involved digits) improved following TNK infusion but then developed infections and required partial amputations. One patient—who needed intubation for alcohol withdrawal—failed to respond and lost 8 fingers, but his thumbs were saved.

Those patients were compared with surviving patients (aged 14-77 years) of 12 treated with the same protocol using various doses of reteplase and papaverine over a 2-year period. Six of the patients recovered with no amputations, four had lost 31 digits at 45 days, and two had amputations but more distally than would have been anticipated without treatment.

Fingers with severe frostbite (left) can be saved from amputation with restored blood flow (right) after treatment with tenecteplase, papaverine, and heparin. Photos courtesy Dr. George R. Edmonson

WASHINGTON — Thrombolytic therapy has resulted in limb salvage among 18 patients with severe frostbite treated at one Minnesota hospital in the last few years.

Thrombolytic therapy has been available for management of frostbite for 10 years and has the potential to reduce amputations, but its use has not extended to the rural northern areas where most cases of frostbite occur.

Severe frostbite results in ischemia and blistering with subsequent demarcation and loss of tissue. Prostaglandins and other chemical mediators are released locally, resulting in intense spasm and blistering. Arterial thrombosis results from injury to endothelial cells that retract to expose subintimal collagen, subsequently triggering acute thrombosis after rewarming, according to Dr. George R. Edmonson of St. Paul (Minn.) Radiology.

Traditional treatment has simply been to rewarm the affected extremity, wait to see how much tissue recovers, then amputate the rest, but over the last couple of decades, investigators have been experimenting with intra-arterial infusion of various thrombolytic and vasodilating agents to dissolve clots and relieve arterial spasm in attempts to preserve more tissue.

At the annual meeting of the Society of Interventional Radiology, Dr. Edmonson described the process used at Regions Hospital, also in St. Paul. Patients are admitted to the burn unit, where the the affected limb is assessed. Diagnostic arteriography is done to assess small vessel occlusion and loss of "distal tuft blush" at the tips of digits. Catheters are positioned for simultaneous infusion of treatment drugs into each affected limb.

Since the mid-1990s, Dr. Edmonson and his associates have been treating frostbite of the extremities with a variety of combined antithrombotic, antiplatelet, and vasodilating agents. Initially, they used urokinase along with heparin and papaverine, then switched to reteplase, and now have moved to using tenecteplase (TNK) because of its superior plasma stability and higher fibrin specificity compared with reteplase, he explained.

During three unusually mild Minnesota winters, six patients aged 18-65 years with severe frostbite who were at risk for amputation were treated for up to 72 hours with intra-arterial TNK infusions at 0.25 mg/hour per limb with coaxial papaverine at 30 mg/hour per limb and intravenous heparin at 500 mcg/hour.

Of the six patients, three who had 16 involved digits responded well and required no amputations. The other three (6 limbs, 30 digits) had incomplete angiographic responses. Of those, two (4 limbs, 20 involved digits) improved following TNK infusion but then developed infections and required partial amputations. One patient—who needed intubation for alcohol withdrawal—failed to respond and lost 8 fingers, but his thumbs were saved.

Those patients were compared with surviving patients (aged 14-77 years) of 12 treated with the same protocol using various doses of reteplase and papaverine over a 2-year period. Six of the patients recovered with no amputations, four had lost 31 digits at 45 days, and two had amputations but more distally than would have been anticipated without treatment.

Fingers with severe frostbite (left) can be saved from amputation with restored blood flow (right) after treatment with tenecteplase, papaverine, and heparin. Photos courtesy Dr. George R. Edmonson

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

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CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS

Polyalkylimide dermal fillers can produce delayed adverse immune effects, including chronic inflammatory and granulomatous reactions, investigators reported in the Archives of Dermatology.

This is the first report of histologic granulomas related to polyalkylimide implants (PAIs) described in the literature, according to Dr. Jaume Alijotas-Reig of Vall d'Hebron University Hospital, Barcelona, and associates.

"Considering the increased use of polyalkylimide fillers in European countries and the United States, physicians should be aware that … delayed effects can occur with polyalkylimide implants just as they can with collagen, polyacrylamide, polylactic acid, or methacrylate," the researchers wrote.

PAIs are used for a variety of facial defects, including anatomic or traumatic deformities as well as aesthetic defects. They also are being used increasingly in lipodystrophy related to antiretroviral therapy in patients with HIV.

According to manufacturers PAIs do not change over time, do not move or migrate, and will not be reabsorbed, unlike other dermal implant materials. However, recent reports refute these statements, according to the investigators.

A voluntary registry of patients with delayed adverse effects related to implants was designed jointly by the Spanish Society of Cosmetic Medicine and Surgery and Dr. Alijotas-Reig and associates at the hospital's clinical immunology unit.

The researchers reported on 25 patients in the registry who had delayed adverse effects related to PAIs. Of the three study patients who were HIV-positive, two were not undergoing treatment with antiretrovirals.

"Multiple inflammatory tender nodules of different sizes, facial edema and/or angioedema, and swelling and/or skin induration were the most frequent local and/or regional complaints. … In six cases, distant or systemic manifestations appeared," including Sjögren's syndrome, they reported (Arch. Dermatol. 2008;144:637-42).

Pseudoabscesses were also common. "Recovered material looks like pus, but bacterial cultures are usually negative for organisms," Dr. Alijotas-Reig and associates wrote.

The mean interval between implantation and symptom onset was 13 months (range, 1-60 months).

Other factors—such as smoking status, personal or family history of autoimmune disease, and "triggering" events such as infection or trauma—did not contribute to granulomatous reactions in these patients.

Of the 17 patients who had laboratory assessments, 12 had at least one abnormal result. These included elevated levels of C-reactive protein and fibrinogen in 11 of the 12, "so underlying inflammatory processes in different stages had to be present."

Five patients also showed elevated lactate dehydrogenase levels, which probably indicated lymphocyte or macrophage activation. Six patients had elevated levels of angiotensin-converting enzyme, which also might be secondary to macrophage and granulomatous immune responses.

Biopsy of facial and distant nodules was performed in three patients, and all showed nonspecific foreign-body granulomas.

All patients were treated with NSAIDs, and some also received hydroxychloroquine or low-dose prednisone. At least 15 had previously received antibiotics, which were ineffective.

After an average of 21 months of follow-up, 11 patients had achieved remission, 10 had recurrent or residual nodules, induration, or edema, and 4 were lost to follow-up.

"Although infrequent, delayed, moderate to severe immune-mediated adverse effects may be caused by PAIs, occasionally with systemic manifestations," the investigators concluded.

Polyalkylimide dermal fillers can produce delayed adverse immune effects, including chronic inflammatory and granulomatous reactions, investigators reported in the Archives of Dermatology.

This is the first report of histologic granulomas related to polyalkylimide implants (PAIs) described in the literature, according to Dr. Jaume Alijotas-Reig of Vall d'Hebron University Hospital, Barcelona, and associates.

"Considering the increased use of polyalkylimide fillers in European countries and the United States, physicians should be aware that … delayed effects can occur with polyalkylimide implants just as they can with collagen, polyacrylamide, polylactic acid, or methacrylate," the researchers wrote.

PAIs are used for a variety of facial defects, including anatomic or traumatic deformities as well as aesthetic defects. They also are being used increasingly in lipodystrophy related to antiretroviral therapy in patients with HIV.

According to manufacturers PAIs do not change over time, do not move or migrate, and will not be reabsorbed, unlike other dermal implant materials. However, recent reports refute these statements, according to the investigators.

A voluntary registry of patients with delayed adverse effects related to implants was designed jointly by the Spanish Society of Cosmetic Medicine and Surgery and Dr. Alijotas-Reig and associates at the hospital's clinical immunology unit.

The researchers reported on 25 patients in the registry who had delayed adverse effects related to PAIs. Of the three study patients who were HIV-positive, two were not undergoing treatment with antiretrovirals.

"Multiple inflammatory tender nodules of different sizes, facial edema and/or angioedema, and swelling and/or skin induration were the most frequent local and/or regional complaints. … In six cases, distant or systemic manifestations appeared," including Sjögren's syndrome, they reported (Arch. Dermatol. 2008;144:637-42).

Pseudoabscesses were also common. "Recovered material looks like pus, but bacterial cultures are usually negative for organisms," Dr. Alijotas-Reig and associates wrote.

The mean interval between implantation and symptom onset was 13 months (range, 1-60 months).

Other factors—such as smoking status, personal or family history of autoimmune disease, and "triggering" events such as infection or trauma—did not contribute to granulomatous reactions in these patients.

Of the 17 patients who had laboratory assessments, 12 had at least one abnormal result. These included elevated levels of C-reactive protein and fibrinogen in 11 of the 12, "so underlying inflammatory processes in different stages had to be present."

Five patients also showed elevated lactate dehydrogenase levels, which probably indicated lymphocyte or macrophage activation. Six patients had elevated levels of angiotensin-converting enzyme, which also might be secondary to macrophage and granulomatous immune responses.

Biopsy of facial and distant nodules was performed in three patients, and all showed nonspecific foreign-body granulomas.

All patients were treated with NSAIDs, and some also received hydroxychloroquine or low-dose prednisone. At least 15 had previously received antibiotics, which were ineffective.

After an average of 21 months of follow-up, 11 patients had achieved remission, 10 had recurrent or residual nodules, induration, or edema, and 4 were lost to follow-up.

"Although infrequent, delayed, moderate to severe immune-mediated adverse effects may be caused by PAIs, occasionally with systemic manifestations," the investigators concluded.

Polyalkylimide dermal fillers can produce delayed adverse immune effects, including chronic inflammatory and granulomatous reactions, investigators reported in the Archives of Dermatology.

This is the first report of histologic granulomas related to polyalkylimide implants (PAIs) described in the literature, according to Dr. Jaume Alijotas-Reig of Vall d'Hebron University Hospital, Barcelona, and associates.

"Considering the increased use of polyalkylimide fillers in European countries and the United States, physicians should be aware that … delayed effects can occur with polyalkylimide implants just as they can with collagen, polyacrylamide, polylactic acid, or methacrylate," the researchers wrote.

PAIs are used for a variety of facial defects, including anatomic or traumatic deformities as well as aesthetic defects. They also are being used increasingly in lipodystrophy related to antiretroviral therapy in patients with HIV.

According to manufacturers PAIs do not change over time, do not move or migrate, and will not be reabsorbed, unlike other dermal implant materials. However, recent reports refute these statements, according to the investigators.

A voluntary registry of patients with delayed adverse effects related to implants was designed jointly by the Spanish Society of Cosmetic Medicine and Surgery and Dr. Alijotas-Reig and associates at the hospital's clinical immunology unit.

The researchers reported on 25 patients in the registry who had delayed adverse effects related to PAIs. Of the three study patients who were HIV-positive, two were not undergoing treatment with antiretrovirals.

"Multiple inflammatory tender nodules of different sizes, facial edema and/or angioedema, and swelling and/or skin induration were the most frequent local and/or regional complaints. … In six cases, distant or systemic manifestations appeared," including Sjögren's syndrome, they reported (Arch. Dermatol. 2008;144:637-42).

Pseudoabscesses were also common. "Recovered material looks like pus, but bacterial cultures are usually negative for organisms," Dr. Alijotas-Reig and associates wrote.

The mean interval between implantation and symptom onset was 13 months (range, 1-60 months).

Other factors—such as smoking status, personal or family history of autoimmune disease, and "triggering" events such as infection or trauma—did not contribute to granulomatous reactions in these patients.

Of the 17 patients who had laboratory assessments, 12 had at least one abnormal result. These included elevated levels of C-reactive protein and fibrinogen in 11 of the 12, "so underlying inflammatory processes in different stages had to be present."

Five patients also showed elevated lactate dehydrogenase levels, which probably indicated lymphocyte or macrophage activation. Six patients had elevated levels of angiotensin-converting enzyme, which also might be secondary to macrophage and granulomatous immune responses.

Biopsy of facial and distant nodules was performed in three patients, and all showed nonspecific foreign-body granulomas.

All patients were treated with NSAIDs, and some also received hydroxychloroquine or low-dose prednisone. At least 15 had previously received antibiotics, which were ineffective.

After an average of 21 months of follow-up, 11 patients had achieved remission, 10 had recurrent or residual nodules, induration, or edema, and 4 were lost to follow-up.

"Although infrequent, delayed, moderate to severe immune-mediated adverse effects may be caused by PAIs, occasionally with systemic manifestations," the investigators concluded.

KISSIMMEE, FLA. — Dermal and epidermal pigmentary disorders in East Asian patients can be treated successfully in many cases without causing postinflammatory hyperpigmentation by carefully combining topical bleaching agents with either a Q-switched laser or intense pulsed light.

Careful attention to the device settings as well as the patient's skin type and any presence of melasma will help to ensure the best results with a low risk of postinflammatory hyperpigmentation (PIH), said Dr. Kei Negishi of Tokyo Women's Medical University.

To remove epidermal pigmentation that commonly occurs in East Asians, such as solar lentigines, freckles, melasma, PIH, and pigmented seborrheic keratoses, Dr. Negishi advised using a Q-switched laser, intense pulsed light (set to specific lesion parameters or full-face), and/or topical bleaching cream. Her patients are mainly Japanese, but she also sees some South Korean and Chinese patients.

If the treatment is for a small number of epidermal pigmentary lesions, she recommended using a Q-switched laser or intense pulsed light (IPL) set to a specific lesion parameter, combined with a topical bleaching cream such as hydroquinone or retinoic acid.

Q-switched lasers are the only devices that are capable of removing dermal pigment, such as nevus of Ota or acquired dermal melanocytosis, without scarring. Long-pulsed lasers and IPL would cause permanent scarring, Dr. Negishi said at the annual meeting of the American Society for Laser Medicine and Surgery.

Avoiding PIH

PIH has been reported to occur 1 month after treatment for solar lentigines with a Q-switched laser in 10%-25% of Chinese patients and 43%-44% of Japanese patients. In Dr. Negishi's own studies, she has found that the addition of a bleaching cream (composed of hydroquinone and retinoic acid) to Q-switched laser treatment plus a steroid and antibiotics could reduce the incidence of PIH by 20%-40%. There was a higher risk of PIH in her patients with skin types IV and V, and in those with melasma, she reported.

To minimize the incidence of PIH, Dr. Negishi suggested using minimum fluences within the window of efficacy for each device, and testing the laser in an inconspicuous area on a patient when it will be used for large or multiple areas. Posttreatment cooling, immediately after treatment, also sometimes helps, she said.

In patients at high risk for PIH, she advises using bleaching agents 2-4 weeks before Q-switched laser treatment, followed by steroid treatment for 7 days after treatment, and then an additional 3-4 weeks of bleaching cream. She also advises patients to use sunscreen every day during the treatment period.

To treat PIH with obvious erythema, she recommended using a steroid plus a mild bleaching agent, such as vitamin C derivatives. In cases without erythema, treatment with IPL at a mild setting can shorten the recovery period, in addition to 2% or 5% hydroquinone, 0.025% or 0.05% retinoic acid, and 0.025% dexamethasone, if it is tolerable.

IPL for Epidermal Pigmentation

The main advantage of using IPL to treat epidermal pigmentation is its reduced risk of causing PIH, Dr. Negishi said. IPL does not disrupt melanosomes, unlike Q-switched lasers, but instead affects melanin-rich keratinocytes, inducing the formation of a microcrust and a partial turnover of the epidermis. Multiple IPL treatments might be necessary to treat pigmentation, and IPLs with a shorter wavelength range have greater efficacy.

Dr. Negishi reported that after an IPL treatment, reflectance-mode confocal microscopy reveals the rapid migration of melanocytes to the basal layer. This suggests that in order to stimulate IPL's efficacy, patients should begin using bleaching cream immediately after the microcrust peels off, she said. With "Q-switched lasers, bleaching creams are used to prevent PIH, but with IPL, they are used to stimulate treatment efficacy," she said.

IPL also is a good choice for full-face skin rejuvenation and whitening in East Asians, Dr. Negishi said.

For each IPL treatment, Dr. Negishi first checks the patient for melasma and acquired dermal melanocytosis. She uses the UV light in a Wood's lamp to distinguish acquired dermal melanocytosis from subtle or hidden melasma rather than just to determine the area of melasma. She then uses a spectrophotometer to check the patient's skin color.

She uses a mild parameter setting for full-face irradiation, consisting of longer wavelengths at low fluences. For specific lesions, she increases the fluence, shortens the pulse width, or shortens the wavelength, using white paper to cover the area surrounding the lesion. The immediate reaction to full-face IPL should be very slight erythema in normally pigmented areas and a slight darkening of pigmented areas with pain remaining about 3-4 on a 10-point scale.

Particular attention should be paid when using IPL for full facial skin rejuvenation in patients with darker skin, such as those with type V skin or type IV plus sun damage, because of the risk of epidermal burning. For patients with darker skin or melasma, it is preferable to use a long wavelength/low fluence setting for second passes over specific lesions with white paper covering the surrounding area, she said.

In a study, Dr. Negishi and her coinvestigators used an ultraviolet filter to identify very subtle epidermal melasma in 63 (28%) of 223 East Asian patients who had previously not been diagnosed with melasma. The patients who did not use sunscreen had a significantly higher risk of the condition than those who did use it (Dermatol. Surg. 2004;30:881-6). "This type of pigmentation tends to worsen with aggressive IPL treatment," she said.

Melasma in East Asians is thought to be epidermal, caused by an increased number of melanocytes and increased activity of melanogenic enzymes, which leaves the skin at a high risk for PIH.

IPL treatment alone is not enough to remove melasma, so Dr. Negishi commonly uses topical agents (such as 2%-5% hydroquinone, 5%-10% vitamin C derivative, or 0.025%-0.4% tretinoin) or oral tranexamic acid as her first choice to use in combination with IPL.

Oral tranexamic acid has been used for treating melasma in East Asians for more than 20 years, according to Dr. Negishi. When telangiectasias are present concurrently with melasma, she uses a long-pulse 1,064-nm Nd:YAG laser to reduce the vascular lesions while also stimulating epidermal turnover.

Dr. Negishi reported that she conducted much of her research with equipment borrowed from Cutera Inc., Danish Dermatologic Development A/S, Lumenis Ltd., and Syneron Inc., but she has no financial interests with any of these companies.

KISSIMMEE, FLA. — Dermal and epidermal pigmentary disorders in East Asian patients can be treated successfully in many cases without causing postinflammatory hyperpigmentation by carefully combining topical bleaching agents with either a Q-switched laser or intense pulsed light.

Careful attention to the device settings as well as the patient's skin type and any presence of melasma will help to ensure the best results with a low risk of postinflammatory hyperpigmentation (PIH), said Dr. Kei Negishi of Tokyo Women's Medical University.

To remove epidermal pigmentation that commonly occurs in East Asians, such as solar lentigines, freckles, melasma, PIH, and pigmented seborrheic keratoses, Dr. Negishi advised using a Q-switched laser, intense pulsed light (set to specific lesion parameters or full-face), and/or topical bleaching cream. Her patients are mainly Japanese, but she also sees some South Korean and Chinese patients.

If the treatment is for a small number of epidermal pigmentary lesions, she recommended using a Q-switched laser or intense pulsed light (IPL) set to a specific lesion parameter, combined with a topical bleaching cream such as hydroquinone or retinoic acid.

Q-switched lasers are the only devices that are capable of removing dermal pigment, such as nevus of Ota or acquired dermal melanocytosis, without scarring. Long-pulsed lasers and IPL would cause permanent scarring, Dr. Negishi said at the annual meeting of the American Society for Laser Medicine and Surgery.

Avoiding PIH

PIH has been reported to occur 1 month after treatment for solar lentigines with a Q-switched laser in 10%-25% of Chinese patients and 43%-44% of Japanese patients. In Dr. Negishi's own studies, she has found that the addition of a bleaching cream (composed of hydroquinone and retinoic acid) to Q-switched laser treatment plus a steroid and antibiotics could reduce the incidence of PIH by 20%-40%. There was a higher risk of PIH in her patients with skin types IV and V, and in those with melasma, she reported.

To minimize the incidence of PIH, Dr. Negishi suggested using minimum fluences within the window of efficacy for each device, and testing the laser in an inconspicuous area on a patient when it will be used for large or multiple areas. Posttreatment cooling, immediately after treatment, also sometimes helps, she said.

In patients at high risk for PIH, she advises using bleaching agents 2-4 weeks before Q-switched laser treatment, followed by steroid treatment for 7 days after treatment, and then an additional 3-4 weeks of bleaching cream. She also advises patients to use sunscreen every day during the treatment period.

To treat PIH with obvious erythema, she recommended using a steroid plus a mild bleaching agent, such as vitamin C derivatives. In cases without erythema, treatment with IPL at a mild setting can shorten the recovery period, in addition to 2% or 5% hydroquinone, 0.025% or 0.05% retinoic acid, and 0.025% dexamethasone, if it is tolerable.

IPL for Epidermal Pigmentation

The main advantage of using IPL to treat epidermal pigmentation is its reduced risk of causing PIH, Dr. Negishi said. IPL does not disrupt melanosomes, unlike Q-switched lasers, but instead affects melanin-rich keratinocytes, inducing the formation of a microcrust and a partial turnover of the epidermis. Multiple IPL treatments might be necessary to treat pigmentation, and IPLs with a shorter wavelength range have greater efficacy.

Dr. Negishi reported that after an IPL treatment, reflectance-mode confocal microscopy reveals the rapid migration of melanocytes to the basal layer. This suggests that in order to stimulate IPL's efficacy, patients should begin using bleaching cream immediately after the microcrust peels off, she said. With "Q-switched lasers, bleaching creams are used to prevent PIH, but with IPL, they are used to stimulate treatment efficacy," she said.

IPL also is a good choice for full-face skin rejuvenation and whitening in East Asians, Dr. Negishi said.

For each IPL treatment, Dr. Negishi first checks the patient for melasma and acquired dermal melanocytosis. She uses the UV light in a Wood's lamp to distinguish acquired dermal melanocytosis from subtle or hidden melasma rather than just to determine the area of melasma. She then uses a spectrophotometer to check the patient's skin color.

She uses a mild parameter setting for full-face irradiation, consisting of longer wavelengths at low fluences. For specific lesions, she increases the fluence, shortens the pulse width, or shortens the wavelength, using white paper to cover the area surrounding the lesion. The immediate reaction to full-face IPL should be very slight erythema in normally pigmented areas and a slight darkening of pigmented areas with pain remaining about 3-4 on a 10-point scale.

Particular attention should be paid when using IPL for full facial skin rejuvenation in patients with darker skin, such as those with type V skin or type IV plus sun damage, because of the risk of epidermal burning. For patients with darker skin or melasma, it is preferable to use a long wavelength/low fluence setting for second passes over specific lesions with white paper covering the surrounding area, she said.

In a study, Dr. Negishi and her coinvestigators used an ultraviolet filter to identify very subtle epidermal melasma in 63 (28%) of 223 East Asian patients who had previously not been diagnosed with melasma. The patients who did not use sunscreen had a significantly higher risk of the condition than those who did use it (Dermatol. Surg. 2004;30:881-6). "This type of pigmentation tends to worsen with aggressive IPL treatment," she said.

Melasma in East Asians is thought to be epidermal, caused by an increased number of melanocytes and increased activity of melanogenic enzymes, which leaves the skin at a high risk for PIH.

IPL treatment alone is not enough to remove melasma, so Dr. Negishi commonly uses topical agents (such as 2%-5% hydroquinone, 5%-10% vitamin C derivative, or 0.025%-0.4% tretinoin) or oral tranexamic acid as her first choice to use in combination with IPL.

Oral tranexamic acid has been used for treating melasma in East Asians for more than 20 years, according to Dr. Negishi. When telangiectasias are present concurrently with melasma, she uses a long-pulse 1,064-nm Nd:YAG laser to reduce the vascular lesions while also stimulating epidermal turnover.

Dr. Negishi reported that she conducted much of her research with equipment borrowed from Cutera Inc., Danish Dermatologic Development A/S, Lumenis Ltd., and Syneron Inc., but she has no financial interests with any of these companies.

KISSIMMEE, FLA. — Dermal and epidermal pigmentary disorders in East Asian patients can be treated successfully in many cases without causing postinflammatory hyperpigmentation by carefully combining topical bleaching agents with either a Q-switched laser or intense pulsed light.

Careful attention to the device settings as well as the patient's skin type and any presence of melasma will help to ensure the best results with a low risk of postinflammatory hyperpigmentation (PIH), said Dr. Kei Negishi of Tokyo Women's Medical University.

To remove epidermal pigmentation that commonly occurs in East Asians, such as solar lentigines, freckles, melasma, PIH, and pigmented seborrheic keratoses, Dr. Negishi advised using a Q-switched laser, intense pulsed light (set to specific lesion parameters or full-face), and/or topical bleaching cream. Her patients are mainly Japanese, but she also sees some South Korean and Chinese patients.

If the treatment is for a small number of epidermal pigmentary lesions, she recommended using a Q-switched laser or intense pulsed light (IPL) set to a specific lesion parameter, combined with a topical bleaching cream such as hydroquinone or retinoic acid.

Q-switched lasers are the only devices that are capable of removing dermal pigment, such as nevus of Ota or acquired dermal melanocytosis, without scarring. Long-pulsed lasers and IPL would cause permanent scarring, Dr. Negishi said at the annual meeting of the American Society for Laser Medicine and Surgery.

Avoiding PIH

PIH has been reported to occur 1 month after treatment for solar lentigines with a Q-switched laser in 10%-25% of Chinese patients and 43%-44% of Japanese patients. In Dr. Negishi's own studies, she has found that the addition of a bleaching cream (composed of hydroquinone and retinoic acid) to Q-switched laser treatment plus a steroid and antibiotics could reduce the incidence of PIH by 20%-40%. There was a higher risk of PIH in her patients with skin types IV and V, and in those with melasma, she reported.

To minimize the incidence of PIH, Dr. Negishi suggested using minimum fluences within the window of efficacy for each device, and testing the laser in an inconspicuous area on a patient when it will be used for large or multiple areas. Posttreatment cooling, immediately after treatment, also sometimes helps, she said.

In patients at high risk for PIH, she advises using bleaching agents 2-4 weeks before Q-switched laser treatment, followed by steroid treatment for 7 days after treatment, and then an additional 3-4 weeks of bleaching cream. She also advises patients to use sunscreen every day during the treatment period.

To treat PIH with obvious erythema, she recommended using a steroid plus a mild bleaching agent, such as vitamin C derivatives. In cases without erythema, treatment with IPL at a mild setting can shorten the recovery period, in addition to 2% or 5% hydroquinone, 0.025% or 0.05% retinoic acid, and 0.025% dexamethasone, if it is tolerable.

IPL for Epidermal Pigmentation

The main advantage of using IPL to treat epidermal pigmentation is its reduced risk of causing PIH, Dr. Negishi said. IPL does not disrupt melanosomes, unlike Q-switched lasers, but instead affects melanin-rich keratinocytes, inducing the formation of a microcrust and a partial turnover of the epidermis. Multiple IPL treatments might be necessary to treat pigmentation, and IPLs with a shorter wavelength range have greater efficacy.

Dr. Negishi reported that after an IPL treatment, reflectance-mode confocal microscopy reveals the rapid migration of melanocytes to the basal layer. This suggests that in order to stimulate IPL's efficacy, patients should begin using bleaching cream immediately after the microcrust peels off, she said. With "Q-switched lasers, bleaching creams are used to prevent PIH, but with IPL, they are used to stimulate treatment efficacy," she said.

IPL also is a good choice for full-face skin rejuvenation and whitening in East Asians, Dr. Negishi said.

For each IPL treatment, Dr. Negishi first checks the patient for melasma and acquired dermal melanocytosis. She uses the UV light in a Wood's lamp to distinguish acquired dermal melanocytosis from subtle or hidden melasma rather than just to determine the area of melasma. She then uses a spectrophotometer to check the patient's skin color.

She uses a mild parameter setting for full-face irradiation, consisting of longer wavelengths at low fluences. For specific lesions, she increases the fluence, shortens the pulse width, or shortens the wavelength, using white paper to cover the area surrounding the lesion. The immediate reaction to full-face IPL should be very slight erythema in normally pigmented areas and a slight darkening of pigmented areas with pain remaining about 3-4 on a 10-point scale.

Particular attention should be paid when using IPL for full facial skin rejuvenation in patients with darker skin, such as those with type V skin or type IV plus sun damage, because of the risk of epidermal burning. For patients with darker skin or melasma, it is preferable to use a long wavelength/low fluence setting for second passes over specific lesions with white paper covering the surrounding area, she said.

In a study, Dr. Negishi and her coinvestigators used an ultraviolet filter to identify very subtle epidermal melasma in 63 (28%) of 223 East Asian patients who had previously not been diagnosed with melasma. The patients who did not use sunscreen had a significantly higher risk of the condition than those who did use it (Dermatol. Surg. 2004;30:881-6). "This type of pigmentation tends to worsen with aggressive IPL treatment," she said.

Melasma in East Asians is thought to be epidermal, caused by an increased number of melanocytes and increased activity of melanogenic enzymes, which leaves the skin at a high risk for PIH.

IPL treatment alone is not enough to remove melasma, so Dr. Negishi commonly uses topical agents (such as 2%-5% hydroquinone, 5%-10% vitamin C derivative, or 0.025%-0.4% tretinoin) or oral tranexamic acid as her first choice to use in combination with IPL.

Oral tranexamic acid has been used for treating melasma in East Asians for more than 20 years, according to Dr. Negishi. When telangiectasias are present concurrently with melasma, she uses a long-pulse 1,064-nm Nd:YAG laser to reduce the vascular lesions while also stimulating epidermal turnover.

Dr. Negishi reported that she conducted much of her research with equipment borrowed from Cutera Inc., Danish Dermatologic Development A/S, Lumenis Ltd., and Syneron Inc., but she has no financial interests with any of these companies.

KISSIMMEE, FLA. — Photopneumatic therapy is highly effective and nearly painless for the treatment of acne vulgaris, according to Dr. Michael Gold.

The recently approved Aesthera PPx laser system—which combines light energy and a vacuum apparatus to cleanse pores and destroy bacteria associated with acne vulgaris—was used to treat both pustular and comedonal acne in an open-label study involving 11 patients with mild to moderate acne, Dr. Gold said at the annual meeting of the American Society for Laser Medicine and Surgery.

Up to four treatments were provided at 3-week intervals, and all of the patients experienced significant and rapid clearing of their lesions, he reported.

Drying and flattening of the lesions were noted within 2 days of treatment in more than half of the patients, and most experienced sustained clearance at 3-month follow-up with a 78% reduction in inflammatory lesions, and up to a 70% reduction in noninflammatory lesions, Dr. Gold said.

Reported pain was minimal in more than 85% of patients, and 82% of patients said they were moderately or very satisfied with the outcomes.

Adverse events included only slight dryness post treatment, which was managed with application of a daily moisturizer, he said.

The findings are comparable with those from other studies of this device as reported in the literature, all of which have demonstrated its efficacy for the treatment of acne, said Dr. Gold of the Tennessee Clinical Research Center in Nashville.

Given that more than one-third of dermatology visits are associated with acne, this device—which is the only device that has been approved by the Food and Drug Administration to treat both comedonal and inflammatory acne, and which appears to be effective even in those patients who are nonresponders to traditional therapies—is a welcome addition to the acne treatment armamentarium, he concluded.

The study was sponsored by Aesthera Corp., which provided equipment, discounts, travel expenses, a research grant, and honoraria to Dr. Gold.

Photo at left shows a patient before treatment with the photopneumatic device. Photo at right shows improvement of the patient's acne after receiving four treatments over an interval of 3 weeks. Photos courtesty Dr. Michael Gold/Tennessee Clinical Research Center

KISSIMMEE, FLA. — Photopneumatic therapy is highly effective and nearly painless for the treatment of acne vulgaris, according to Dr. Michael Gold.

The recently approved Aesthera PPx laser system—which combines light energy and a vacuum apparatus to cleanse pores and destroy bacteria associated with acne vulgaris—was used to treat both pustular and comedonal acne in an open-label study involving 11 patients with mild to moderate acne, Dr. Gold said at the annual meeting of the American Society for Laser Medicine and Surgery.

Up to four treatments were provided at 3-week intervals, and all of the patients experienced significant and rapid clearing of their lesions, he reported.

Drying and flattening of the lesions were noted within 2 days of treatment in more than half of the patients, and most experienced sustained clearance at 3-month follow-up with a 78% reduction in inflammatory lesions, and up to a 70% reduction in noninflammatory lesions, Dr. Gold said.

Reported pain was minimal in more than 85% of patients, and 82% of patients said they were moderately or very satisfied with the outcomes.

Adverse events included only slight dryness post treatment, which was managed with application of a daily moisturizer, he said.

The findings are comparable with those from other studies of this device as reported in the literature, all of which have demonstrated its efficacy for the treatment of acne, said Dr. Gold of the Tennessee Clinical Research Center in Nashville.

Given that more than one-third of dermatology visits are associated with acne, this device—which is the only device that has been approved by the Food and Drug Administration to treat both comedonal and inflammatory acne, and which appears to be effective even in those patients who are nonresponders to traditional therapies—is a welcome addition to the acne treatment armamentarium, he concluded.

The study was sponsored by Aesthera Corp., which provided equipment, discounts, travel expenses, a research grant, and honoraria to Dr. Gold.

Photo at left shows a patient before treatment with the photopneumatic device. Photo at right shows improvement of the patient's acne after receiving four treatments over an interval of 3 weeks. Photos courtesty Dr. Michael Gold/Tennessee Clinical Research Center

KISSIMMEE, FLA. — Photopneumatic therapy is highly effective and nearly painless for the treatment of acne vulgaris, according to Dr. Michael Gold.

The recently approved Aesthera PPx laser system—which combines light energy and a vacuum apparatus to cleanse pores and destroy bacteria associated with acne vulgaris—was used to treat both pustular and comedonal acne in an open-label study involving 11 patients with mild to moderate acne, Dr. Gold said at the annual meeting of the American Society for Laser Medicine and Surgery.

Up to four treatments were provided at 3-week intervals, and all of the patients experienced significant and rapid clearing of their lesions, he reported.

Drying and flattening of the lesions were noted within 2 days of treatment in more than half of the patients, and most experienced sustained clearance at 3-month follow-up with a 78% reduction in inflammatory lesions, and up to a 70% reduction in noninflammatory lesions, Dr. Gold said.

Reported pain was minimal in more than 85% of patients, and 82% of patients said they were moderately or very satisfied with the outcomes.

Adverse events included only slight dryness post treatment, which was managed with application of a daily moisturizer, he said.

The findings are comparable with those from other studies of this device as reported in the literature, all of which have demonstrated its efficacy for the treatment of acne, said Dr. Gold of the Tennessee Clinical Research Center in Nashville.

Given that more than one-third of dermatology visits are associated with acne, this device—which is the only device that has been approved by the Food and Drug Administration to treat both comedonal and inflammatory acne, and which appears to be effective even in those patients who are nonresponders to traditional therapies—is a welcome addition to the acne treatment armamentarium, he concluded.

The study was sponsored by Aesthera Corp., which provided equipment, discounts, travel expenses, a research grant, and honoraria to Dr. Gold.

Photo at left shows a patient before treatment with the photopneumatic device. Photo at right shows improvement of the patient's acne after receiving four treatments over an interval of 3 weeks. Photos courtesty Dr. Michael Gold/Tennessee Clinical Research Center