Aesthetic Dermatology

SAN DIEGO — If you recommend Mohs surgery for a melanoma patient, remember that you are one point along a spectrum of medical and emotional care for that person, Duane C. Whitaker, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

Consider yourself part of a multiphysician treatment team that may include a pathologist, oncologist, surgical oncologist, and a primary care physician.

More important than proficiency in the technical details of Mohs surgery "is the ability to properly evaluate, prognosticate, follow the patient, educate the patient, and have consultations," said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. "Working with high-risk melanoma as part of a team is key."

He said dermatologists can consider Mohs surgery for melanoma when:

▸ The adequate surgical margin of a tumor is unknown.

▸ The tumor can be evaluated properly by microscopy and frozen section.

▸ The tumor is accessible to a staged surgical approach.

▸ Local tumor growth is thought to be contiguous.

The benefits of Mohs surgery include tissue sparing, precise margin determination, immediate reconstruction, minimal wound and repair, and the opportunity to initiate other therapies immediately.

"There is no evidence that patients who have undergone Mohs surgery are at higher risk for metastasis or have increased local recurrence, but it is evident that less surgical morbidity is a benefit in certain cases," Dr. Whitaker said.

A prospective study of 553 primary melanomas treated with Mohs found local or distant recurrence equivalent to or better than historical controls (J. Am. Acad. Dermatol. 1997;37:236–45). Clear margins were achieved in 85% of patients with a 6-mm margin.

In another study, investigators who used Mohs for treating both lentigo maligna melanoma and lentigo maligna found that no predetermined excisional margin could be established (Arch. Dermatol. 2004; 140:1087–92). They employed frozen section margin control and found 2% recurrence at a mean follow-up of 38 months.

A more recent study found that melanomas of the head and neck commonly have subclinical extension (J. Am. Acad. Dermatol. 2005;52:92–100). Mohs surgery achieved 5-year disease-free rates equivalent to or better than historical data.

Physicians should consider these factors before recommending Mohs surgery:

▸ Surgical experience. "I do not advocate Mohs surgery for melanoma across the board," Dr. Whitaker said. "I think the physician's knowledge of the disease, experience with Mohs surgery, and comfort with reading frozen sections are key."

▸ Facial or critical anatomy where the benefit of tissue conservation is substantial. Examples include melanomas of the foot, hand, or genital areas.

▸ Patient and consultant comprehension. "The patient needs to understand what you're doing," he noted. "There is not a huge body of literature to support the idea of Mohs surgery for melanoma. You may be criticized for performing it, but if it's looked at in the whole of the treatment plan, I think there is a rationale for it."

▸ Review of alternatives and adjunctive therapy. Any time you make a diagnosis as serious as melanoma, "it's part of your obligation to tell the patient what every option is in terms of evaluation, treatment, and what the known benefits are," he said. "If the patient has an in situ melanoma or a thin melanoma, Mohs surgery with good assessment and evaluation may be the only treatment that needs to be done."

Mohs surgery "will continue to be employed in the management of melanoma when the managing physician identifies benefits for the patients and has something to offer that would be hard to equal in any other way," he concluded.

SAN DIEGO — If you recommend Mohs surgery for a melanoma patient, remember that you are one point along a spectrum of medical and emotional care for that person, Duane C. Whitaker, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

Consider yourself part of a multiphysician treatment team that may include a pathologist, oncologist, surgical oncologist, and a primary care physician.

More important than proficiency in the technical details of Mohs surgery "is the ability to properly evaluate, prognosticate, follow the patient, educate the patient, and have consultations," said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. "Working with high-risk melanoma as part of a team is key."

He said dermatologists can consider Mohs surgery for melanoma when:

▸ The adequate surgical margin of a tumor is unknown.

▸ The tumor can be evaluated properly by microscopy and frozen section.

▸ The tumor is accessible to a staged surgical approach.

▸ Local tumor growth is thought to be contiguous.

The benefits of Mohs surgery include tissue sparing, precise margin determination, immediate reconstruction, minimal wound and repair, and the opportunity to initiate other therapies immediately.

"There is no evidence that patients who have undergone Mohs surgery are at higher risk for metastasis or have increased local recurrence, but it is evident that less surgical morbidity is a benefit in certain cases," Dr. Whitaker said.

A prospective study of 553 primary melanomas treated with Mohs found local or distant recurrence equivalent to or better than historical controls (J. Am. Acad. Dermatol. 1997;37:236–45). Clear margins were achieved in 85% of patients with a 6-mm margin.

In another study, investigators who used Mohs for treating both lentigo maligna melanoma and lentigo maligna found that no predetermined excisional margin could be established (Arch. Dermatol. 2004; 140:1087–92). They employed frozen section margin control and found 2% recurrence at a mean follow-up of 38 months.

A more recent study found that melanomas of the head and neck commonly have subclinical extension (J. Am. Acad. Dermatol. 2005;52:92–100). Mohs surgery achieved 5-year disease-free rates equivalent to or better than historical data.

Physicians should consider these factors before recommending Mohs surgery:

▸ Surgical experience. "I do not advocate Mohs surgery for melanoma across the board," Dr. Whitaker said. "I think the physician's knowledge of the disease, experience with Mohs surgery, and comfort with reading frozen sections are key."

▸ Facial or critical anatomy where the benefit of tissue conservation is substantial. Examples include melanomas of the foot, hand, or genital areas.

▸ Patient and consultant comprehension. "The patient needs to understand what you're doing," he noted. "There is not a huge body of literature to support the idea of Mohs surgery for melanoma. You may be criticized for performing it, but if it's looked at in the whole of the treatment plan, I think there is a rationale for it."

▸ Review of alternatives and adjunctive therapy. Any time you make a diagnosis as serious as melanoma, "it's part of your obligation to tell the patient what every option is in terms of evaluation, treatment, and what the known benefits are," he said. "If the patient has an in situ melanoma or a thin melanoma, Mohs surgery with good assessment and evaluation may be the only treatment that needs to be done."

Mohs surgery "will continue to be employed in the management of melanoma when the managing physician identifies benefits for the patients and has something to offer that would be hard to equal in any other way," he concluded.

SAN DIEGO — If you recommend Mohs surgery for a melanoma patient, remember that you are one point along a spectrum of medical and emotional care for that person, Duane C. Whitaker, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

Consider yourself part of a multiphysician treatment team that may include a pathologist, oncologist, surgical oncologist, and a primary care physician.

More important than proficiency in the technical details of Mohs surgery "is the ability to properly evaluate, prognosticate, follow the patient, educate the patient, and have consultations," said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. "Working with high-risk melanoma as part of a team is key."

He said dermatologists can consider Mohs surgery for melanoma when:

▸ The adequate surgical margin of a tumor is unknown.

▸ The tumor can be evaluated properly by microscopy and frozen section.

▸ The tumor is accessible to a staged surgical approach.

▸ Local tumor growth is thought to be contiguous.

The benefits of Mohs surgery include tissue sparing, precise margin determination, immediate reconstruction, minimal wound and repair, and the opportunity to initiate other therapies immediately.

"There is no evidence that patients who have undergone Mohs surgery are at higher risk for metastasis or have increased local recurrence, but it is evident that less surgical morbidity is a benefit in certain cases," Dr. Whitaker said.

A prospective study of 553 primary melanomas treated with Mohs found local or distant recurrence equivalent to or better than historical controls (J. Am. Acad. Dermatol. 1997;37:236–45). Clear margins were achieved in 85% of patients with a 6-mm margin.

In another study, investigators who used Mohs for treating both lentigo maligna melanoma and lentigo maligna found that no predetermined excisional margin could be established (Arch. Dermatol. 2004; 140:1087–92). They employed frozen section margin control and found 2% recurrence at a mean follow-up of 38 months.

A more recent study found that melanomas of the head and neck commonly have subclinical extension (J. Am. Acad. Dermatol. 2005;52:92–100). Mohs surgery achieved 5-year disease-free rates equivalent to or better than historical data.

Physicians should consider these factors before recommending Mohs surgery:

▸ Surgical experience. "I do not advocate Mohs surgery for melanoma across the board," Dr. Whitaker said. "I think the physician's knowledge of the disease, experience with Mohs surgery, and comfort with reading frozen sections are key."

▸ Facial or critical anatomy where the benefit of tissue conservation is substantial. Examples include melanomas of the foot, hand, or genital areas.

▸ Patient and consultant comprehension. "The patient needs to understand what you're doing," he noted. "There is not a huge body of literature to support the idea of Mohs surgery for melanoma. You may be criticized for performing it, but if it's looked at in the whole of the treatment plan, I think there is a rationale for it."

▸ Review of alternatives and adjunctive therapy. Any time you make a diagnosis as serious as melanoma, "it's part of your obligation to tell the patient what every option is in terms of evaluation, treatment, and what the known benefits are," he said. "If the patient has an in situ melanoma or a thin melanoma, Mohs surgery with good assessment and evaluation may be the only treatment that needs to be done."

Mohs surgery "will continue to be employed in the management of melanoma when the managing physician identifies benefits for the patients and has something to offer that would be hard to equal in any other way," he concluded.

LAKE BUENA VISTA, FLA. — The adjunctive use of aminolevulinic acid with intense pulsed light treatment appears to be more effective than the light therapy alone for the treatment of photoaging, said Ashish Bhatia, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Aminolevulinic acid (ALA) 20% topical solution is currently approved for the treatment of actinic keratoses of the face and scalp. "Many studies have suggested that the adjunctive use of ALA with intense pulsed light [IPL] can enhance the therapeutic effects of IPL used for photoaging," said Dr. Bhatia, a dermatologist in Naperville, Ill.

In a prospective study, 20 patients received treatment with ALA and IPL on one side of the face and IPL alone on the other. The trial was conducted at the facilities of SkinCare Physicians of Chestnut Hill in Boston.

Materials, equipment, and funding for the study were provided by DUSA Pharmaceuticals Inc., maker of Levulan Kerastick (ALA).

Patients underwent five treatments 3 weeks apart. The first three treatments were split face. For the ALA treatment, patients first underwent a vigorous acetone scrub. Once the ALA was applied, it remained in contact with the face for 30–60 minutes before being washed off. Both sides of the face were then treated with IPL. The final two treatments consisted of IPL alone.

A blinded investigator evaluated patients for five photodamage parameters—global photodamage, fine lines, mottled pigmentation, tactile roughness, and sallowness—prior to every treatment and 1 month of follow-up. Each parameter was rated on a 0–4 scale. Each patient also rated satisfaction for each side of the face at the end of the study. A blinded investigator was also asked to perform cosmetic evaluations at the end of the study.

Pretreatment with ALA resulted in significant improvement in global photodamage scores and in mottled pigmentation. Treatment with ALA resulted in significantly greater reductions of mottled pigmentation and fine lines (to low or imperceptible levels) than IPL alone.

Patient satisfaction was greater for the ALA combination treatment than it was for IPL alone. Likewise, the blinded investigator cosmetic evaluation was greater for the combination treatment than for IPL alone.

Both treatments were well tolerated, with very little difference between the two in terms of adverse effects, Dr. Bhatia said.

LAKE BUENA VISTA, FLA. — The adjunctive use of aminolevulinic acid with intense pulsed light treatment appears to be more effective than the light therapy alone for the treatment of photoaging, said Ashish Bhatia, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Aminolevulinic acid (ALA) 20% topical solution is currently approved for the treatment of actinic keratoses of the face and scalp. "Many studies have suggested that the adjunctive use of ALA with intense pulsed light [IPL] can enhance the therapeutic effects of IPL used for photoaging," said Dr. Bhatia, a dermatologist in Naperville, Ill.

In a prospective study, 20 patients received treatment with ALA and IPL on one side of the face and IPL alone on the other. The trial was conducted at the facilities of SkinCare Physicians of Chestnut Hill in Boston.

Materials, equipment, and funding for the study were provided by DUSA Pharmaceuticals Inc., maker of Levulan Kerastick (ALA).

Patients underwent five treatments 3 weeks apart. The first three treatments were split face. For the ALA treatment, patients first underwent a vigorous acetone scrub. Once the ALA was applied, it remained in contact with the face for 30–60 minutes before being washed off. Both sides of the face were then treated with IPL. The final two treatments consisted of IPL alone.

A blinded investigator evaluated patients for five photodamage parameters—global photodamage, fine lines, mottled pigmentation, tactile roughness, and sallowness—prior to every treatment and 1 month of follow-up. Each parameter was rated on a 0–4 scale. Each patient also rated satisfaction for each side of the face at the end of the study. A blinded investigator was also asked to perform cosmetic evaluations at the end of the study.

Pretreatment with ALA resulted in significant improvement in global photodamage scores and in mottled pigmentation. Treatment with ALA resulted in significantly greater reductions of mottled pigmentation and fine lines (to low or imperceptible levels) than IPL alone.

Patient satisfaction was greater for the ALA combination treatment than it was for IPL alone. Likewise, the blinded investigator cosmetic evaluation was greater for the combination treatment than for IPL alone.

Both treatments were well tolerated, with very little difference between the two in terms of adverse effects, Dr. Bhatia said.

LAKE BUENA VISTA, FLA. — The adjunctive use of aminolevulinic acid with intense pulsed light treatment appears to be more effective than the light therapy alone for the treatment of photoaging, said Ashish Bhatia, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Aminolevulinic acid (ALA) 20% topical solution is currently approved for the treatment of actinic keratoses of the face and scalp. "Many studies have suggested that the adjunctive use of ALA with intense pulsed light [IPL] can enhance the therapeutic effects of IPL used for photoaging," said Dr. Bhatia, a dermatologist in Naperville, Ill.

In a prospective study, 20 patients received treatment with ALA and IPL on one side of the face and IPL alone on the other. The trial was conducted at the facilities of SkinCare Physicians of Chestnut Hill in Boston.

Materials, equipment, and funding for the study were provided by DUSA Pharmaceuticals Inc., maker of Levulan Kerastick (ALA).

Patients underwent five treatments 3 weeks apart. The first three treatments were split face. For the ALA treatment, patients first underwent a vigorous acetone scrub. Once the ALA was applied, it remained in contact with the face for 30–60 minutes before being washed off. Both sides of the face were then treated with IPL. The final two treatments consisted of IPL alone.

A blinded investigator evaluated patients for five photodamage parameters—global photodamage, fine lines, mottled pigmentation, tactile roughness, and sallowness—prior to every treatment and 1 month of follow-up. Each parameter was rated on a 0–4 scale. Each patient also rated satisfaction for each side of the face at the end of the study. A blinded investigator was also asked to perform cosmetic evaluations at the end of the study.

Pretreatment with ALA resulted in significant improvement in global photodamage scores and in mottled pigmentation. Treatment with ALA resulted in significantly greater reductions of mottled pigmentation and fine lines (to low or imperceptible levels) than IPL alone.

Patient satisfaction was greater for the ALA combination treatment than it was for IPL alone. Likewise, the blinded investigator cosmetic evaluation was greater for the combination treatment than for IPL alone.

Both treatments were well tolerated, with very little difference between the two in terms of adverse effects, Dr. Bhatia said.

ORLANDO, FLA. — Topical application of a special agent to improve the optical properties of darker skin types appears to significantly improve the efficacy of laser-assisted hair removal with fewer epidermal side effects, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

By using an optical clearing agent to improve laser light penetration at the skin surface, "we believe that in darker skin types … types I-V … we can definitely improve laser hair removal," said Misbah Khan, M.D., a laser surgery fellow at the Beckman Laser Institute at the University of California, Irvine.

The optical clearing agent—a polypropylene and polyethylene glycol mixture—decreases dermal scattering of light, thereby increasing laser light penetration. Once the optical clearing agent is applied to the skin, it is easier to see the dermal portion of the hair shaft, which led the researchers to suspect that it might also be easier to treat the hair.

In the study, the optical clearing agent was applied to one of each of 13 volunteers' underarms at least 2 hours prior to a single treatment with an alexandrite laser (GentleLase by Candela Corp.) in combination with cryogen spray cooling. The other side was treated with laser alone. Laser treatment was performed at various fluences depending on the volunteer's skin type, but both underarms of a single patient received the same fluence.

Hair counts in each area were performed before and 2 months after the procedure. Representative hairs also were clipped at the widest point of the base before and 2 months after treatment to determine hair diameter. In addition, the researchers assessed the areas for hyperpigmentation, hypopigmentation, and scarring.

"We were able to achieve more than a 70% reduction [in hair count] in a single treatment with the help of the optical clearing agent," said Dr. Khan. However, there was no significant difference in diameter between areas receiving the optical clearing agent and those receiving laser treatment alone.

In addition, with the use of the optical clearing agent, "we were able to substantially increase the depth and the extent of the thermal damage, and the immediate side effects of the laser-assisted hair removal were minimized to the degree that we didn't really see any," Dr. Khan said. A few volunteers required topical steroids for a day or 2 after the procedure on the side that did not receive the optical clearing agent.

Biopsies also were collected for histologic analysis. Cell viability stains were performed to assess the amount of thermal damage to the hair follicle. Hair follicles in areas treated with the optical clearing agent had much more evidence of thermal damage than did those in areas treated with laser alone.

The results are promising because even though several hair removal options are available for those who are considered to be good candidates, "there are limited treatment options available for people who are not good candidates, for example people with darker skin types and who also have dark hair," Dr. Khan said.

Longer wavelengths of laser light are one option because these do penetrate deeper. They are not well absorbed, though. Using shorter wavelengths instead typically leads to epidermal burns. The researchers believe that the optical clearing agent improves laser hair removal in patients with darker skin by allowing the use of shorter wavelengths while still avoiding dermal injury.

ORLANDO, FLA. — Topical application of a special agent to improve the optical properties of darker skin types appears to significantly improve the efficacy of laser-assisted hair removal with fewer epidermal side effects, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

By using an optical clearing agent to improve laser light penetration at the skin surface, "we believe that in darker skin types … types I-V … we can definitely improve laser hair removal," said Misbah Khan, M.D., a laser surgery fellow at the Beckman Laser Institute at the University of California, Irvine.

The optical clearing agent—a polypropylene and polyethylene glycol mixture—decreases dermal scattering of light, thereby increasing laser light penetration. Once the optical clearing agent is applied to the skin, it is easier to see the dermal portion of the hair shaft, which led the researchers to suspect that it might also be easier to treat the hair.

In the study, the optical clearing agent was applied to one of each of 13 volunteers' underarms at least 2 hours prior to a single treatment with an alexandrite laser (GentleLase by Candela Corp.) in combination with cryogen spray cooling. The other side was treated with laser alone. Laser treatment was performed at various fluences depending on the volunteer's skin type, but both underarms of a single patient received the same fluence.

Hair counts in each area were performed before and 2 months after the procedure. Representative hairs also were clipped at the widest point of the base before and 2 months after treatment to determine hair diameter. In addition, the researchers assessed the areas for hyperpigmentation, hypopigmentation, and scarring.

"We were able to achieve more than a 70% reduction [in hair count] in a single treatment with the help of the optical clearing agent," said Dr. Khan. However, there was no significant difference in diameter between areas receiving the optical clearing agent and those receiving laser treatment alone.

In addition, with the use of the optical clearing agent, "we were able to substantially increase the depth and the extent of the thermal damage, and the immediate side effects of the laser-assisted hair removal were minimized to the degree that we didn't really see any," Dr. Khan said. A few volunteers required topical steroids for a day or 2 after the procedure on the side that did not receive the optical clearing agent.

Biopsies also were collected for histologic analysis. Cell viability stains were performed to assess the amount of thermal damage to the hair follicle. Hair follicles in areas treated with the optical clearing agent had much more evidence of thermal damage than did those in areas treated with laser alone.

The results are promising because even though several hair removal options are available for those who are considered to be good candidates, "there are limited treatment options available for people who are not good candidates, for example people with darker skin types and who also have dark hair," Dr. Khan said.

Longer wavelengths of laser light are one option because these do penetrate deeper. They are not well absorbed, though. Using shorter wavelengths instead typically leads to epidermal burns. The researchers believe that the optical clearing agent improves laser hair removal in patients with darker skin by allowing the use of shorter wavelengths while still avoiding dermal injury.

ORLANDO, FLA. — Topical application of a special agent to improve the optical properties of darker skin types appears to significantly improve the efficacy of laser-assisted hair removal with fewer epidermal side effects, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

By using an optical clearing agent to improve laser light penetration at the skin surface, "we believe that in darker skin types … types I-V … we can definitely improve laser hair removal," said Misbah Khan, M.D., a laser surgery fellow at the Beckman Laser Institute at the University of California, Irvine.

The optical clearing agent—a polypropylene and polyethylene glycol mixture—decreases dermal scattering of light, thereby increasing laser light penetration. Once the optical clearing agent is applied to the skin, it is easier to see the dermal portion of the hair shaft, which led the researchers to suspect that it might also be easier to treat the hair.

In the study, the optical clearing agent was applied to one of each of 13 volunteers' underarms at least 2 hours prior to a single treatment with an alexandrite laser (GentleLase by Candela Corp.) in combination with cryogen spray cooling. The other side was treated with laser alone. Laser treatment was performed at various fluences depending on the volunteer's skin type, but both underarms of a single patient received the same fluence.

Hair counts in each area were performed before and 2 months after the procedure. Representative hairs also were clipped at the widest point of the base before and 2 months after treatment to determine hair diameter. In addition, the researchers assessed the areas for hyperpigmentation, hypopigmentation, and scarring.

"We were able to achieve more than a 70% reduction [in hair count] in a single treatment with the help of the optical clearing agent," said Dr. Khan. However, there was no significant difference in diameter between areas receiving the optical clearing agent and those receiving laser treatment alone.

In addition, with the use of the optical clearing agent, "we were able to substantially increase the depth and the extent of the thermal damage, and the immediate side effects of the laser-assisted hair removal were minimized to the degree that we didn't really see any," Dr. Khan said. A few volunteers required topical steroids for a day or 2 after the procedure on the side that did not receive the optical clearing agent.

Biopsies also were collected for histologic analysis. Cell viability stains were performed to assess the amount of thermal damage to the hair follicle. Hair follicles in areas treated with the optical clearing agent had much more evidence of thermal damage than did those in areas treated with laser alone.

The results are promising because even though several hair removal options are available for those who are considered to be good candidates, "there are limited treatment options available for people who are not good candidates, for example people with darker skin types and who also have dark hair," Dr. Khan said.

Longer wavelengths of laser light are one option because these do penetrate deeper. They are not well absorbed, though. Using shorter wavelengths instead typically leads to epidermal burns. The researchers believe that the optical clearing agent improves laser hair removal in patients with darker skin by allowing the use of shorter wavelengths while still avoiding dermal injury.

PHOENIX, ARIZ. — Adding Botox therapy to cosmetic dermatologic treatments can "extend the results for virtually everything we do," Jean Carruthers, M.D., said at a clinical dermatology conference sponsored by Medicis.

Clinical studies have already shown that combining botulinum toxin type A with broadband light therapy and with nonanimal stabilized hyaluronic acid can produce better results than a single therapy, reported Dr. Carruthers, an ophthalmology professor at the University of British Columbia, Vancouver.

"It makes so much sense to use them together," she said of Botox and Restylane, a nonanimal stabilized hyaluronic acid filler approved for use in the United States. "Botox halts active frown, and Restylane helps the dermis."

Dr. Carruthers cited a prospective study she conducted with her husband Alaistair Carruthers, B.M., of the same university. They randomized 38 adult females with moderate to severe glabellar wrinkles into two cohorts for a comparison of Restylane therapy alone with Restylane plus Botox.

The investigators reported that the women given both treatments "showed a better response both at rest and on maximal frown." The combination treatment also lasted longer. Median time to preinjection furrow status was 32 weeks for the combination patients, compared with 18 weeks for those treated only with the filler (Dermatol. Surg. 2003;29:802–9).

In another study, they randomized 30 women with moderate to severe crow's feet to two groups: one treated only with broadband light therapy and the other to light therapy plus Botox treatment. For this experiment they used Intense Pulsed Light from Lumenis Ltd. of Yokneam, Israel.

The Carruthers reported that all patients showed improvement when their faces were at rest and smiling, but the patients given both treatments improved more. Skin biopsies revealed an increase in dermal collagen for both groups. The researchers also reported improvements in lentigines, telangiectasia, and skin texture (Dermatol. Surg. 2004;30:355–6).

Dr. Carruthers called the synergy with the light system exciting. "Does IPL [intense pulsed light] stimulate new dermal collagen deposition?" she asked. "Does Botox stimulate new collagen formation in the dermis? Is it just IPL, or is Botox additive?"

Dr. Carruthers' commercial disclosures include Allergan, maker of Botox; Medicis Pharmaceuticals, distributor of Restylane; and Lumenis. She said she is a consultant to and investor in Allergan.

PHOENIX, ARIZ. — Adding Botox therapy to cosmetic dermatologic treatments can "extend the results for virtually everything we do," Jean Carruthers, M.D., said at a clinical dermatology conference sponsored by Medicis.

Clinical studies have already shown that combining botulinum toxin type A with broadband light therapy and with nonanimal stabilized hyaluronic acid can produce better results than a single therapy, reported Dr. Carruthers, an ophthalmology professor at the University of British Columbia, Vancouver.

"It makes so much sense to use them together," she said of Botox and Restylane, a nonanimal stabilized hyaluronic acid filler approved for use in the United States. "Botox halts active frown, and Restylane helps the dermis."

Dr. Carruthers cited a prospective study she conducted with her husband Alaistair Carruthers, B.M., of the same university. They randomized 38 adult females with moderate to severe glabellar wrinkles into two cohorts for a comparison of Restylane therapy alone with Restylane plus Botox.

The investigators reported that the women given both treatments "showed a better response both at rest and on maximal frown." The combination treatment also lasted longer. Median time to preinjection furrow status was 32 weeks for the combination patients, compared with 18 weeks for those treated only with the filler (Dermatol. Surg. 2003;29:802–9).

In another study, they randomized 30 women with moderate to severe crow's feet to two groups: one treated only with broadband light therapy and the other to light therapy plus Botox treatment. For this experiment they used Intense Pulsed Light from Lumenis Ltd. of Yokneam, Israel.

The Carruthers reported that all patients showed improvement when their faces were at rest and smiling, but the patients given both treatments improved more. Skin biopsies revealed an increase in dermal collagen for both groups. The researchers also reported improvements in lentigines, telangiectasia, and skin texture (Dermatol. Surg. 2004;30:355–6).

Dr. Carruthers called the synergy with the light system exciting. "Does IPL [intense pulsed light] stimulate new dermal collagen deposition?" she asked. "Does Botox stimulate new collagen formation in the dermis? Is it just IPL, or is Botox additive?"

Dr. Carruthers' commercial disclosures include Allergan, maker of Botox; Medicis Pharmaceuticals, distributor of Restylane; and Lumenis. She said she is a consultant to and investor in Allergan.

PHOENIX, ARIZ. — Adding Botox therapy to cosmetic dermatologic treatments can "extend the results for virtually everything we do," Jean Carruthers, M.D., said at a clinical dermatology conference sponsored by Medicis.

Clinical studies have already shown that combining botulinum toxin type A with broadband light therapy and with nonanimal stabilized hyaluronic acid can produce better results than a single therapy, reported Dr. Carruthers, an ophthalmology professor at the University of British Columbia, Vancouver.

"It makes so much sense to use them together," she said of Botox and Restylane, a nonanimal stabilized hyaluronic acid filler approved for use in the United States. "Botox halts active frown, and Restylane helps the dermis."

Dr. Carruthers cited a prospective study she conducted with her husband Alaistair Carruthers, B.M., of the same university. They randomized 38 adult females with moderate to severe glabellar wrinkles into two cohorts for a comparison of Restylane therapy alone with Restylane plus Botox.

The investigators reported that the women given both treatments "showed a better response both at rest and on maximal frown." The combination treatment also lasted longer. Median time to preinjection furrow status was 32 weeks for the combination patients, compared with 18 weeks for those treated only with the filler (Dermatol. Surg. 2003;29:802–9).

In another study, they randomized 30 women with moderate to severe crow's feet to two groups: one treated only with broadband light therapy and the other to light therapy plus Botox treatment. For this experiment they used Intense Pulsed Light from Lumenis Ltd. of Yokneam, Israel.

The Carruthers reported that all patients showed improvement when their faces were at rest and smiling, but the patients given both treatments improved more. Skin biopsies revealed an increase in dermal collagen for both groups. The researchers also reported improvements in lentigines, telangiectasia, and skin texture (Dermatol. Surg. 2004;30:355–6).

Dr. Carruthers called the synergy with the light system exciting. "Does IPL [intense pulsed light] stimulate new dermal collagen deposition?" she asked. "Does Botox stimulate new collagen formation in the dermis? Is it just IPL, or is Botox additive?"

Dr. Carruthers' commercial disclosures include Allergan, maker of Botox; Medicis Pharmaceuticals, distributor of Restylane; and Lumenis. She said she is a consultant to and investor in Allergan.

LAKE BUENA VISTA, FLA. — Plasma skin resurfacing reduces acne scars and fine lines while minimizing downtime and adverse events, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

"Plasma skin regeneration provides an effective long-term facial rejuvenation for acne scarring and fine lines," said M. Potter, M.D., of RAFT Institute of Plastic Surgery in London.

The plasma device works by passing ultrahigh energy through nitrogen gas, generating plasma used to treat scars and lines with short pulses.

In this study, Dr. Potter treated a total of 11 patients (10 women)—3 for acne scars, 7 for fine lines, and 1 patient for both. The treatment was performed under anesthesia. Energy varied between 1 and 4 J.

All patients were assessed at 10 days and 3 and 6 months post treatment. "A precise measure of skin irregularity was recorded using silicon molds. … Wrinkle depth was assessed using a light microscope technique to give an accurate measurement," Dr. Potter said.

In patients with fine lines, the mean pretreatment wrinkle depth was 0.25 mm. At 10 days, there was a mean improvement in wrinkle depth of 39%. At 6 months, mean improvement was 24%. "Acne is always difficult to treat, but these patients had an improvement of 35% at 10 days and 23% at 6 months," Dr. Potter said.

LAKE BUENA VISTA, FLA. — Plasma skin resurfacing reduces acne scars and fine lines while minimizing downtime and adverse events, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

"Plasma skin regeneration provides an effective long-term facial rejuvenation for acne scarring and fine lines," said M. Potter, M.D., of RAFT Institute of Plastic Surgery in London.

The plasma device works by passing ultrahigh energy through nitrogen gas, generating plasma used to treat scars and lines with short pulses.

In this study, Dr. Potter treated a total of 11 patients (10 women)—3 for acne scars, 7 for fine lines, and 1 patient for both. The treatment was performed under anesthesia. Energy varied between 1 and 4 J.

All patients were assessed at 10 days and 3 and 6 months post treatment. "A precise measure of skin irregularity was recorded using silicon molds. … Wrinkle depth was assessed using a light microscope technique to give an accurate measurement," Dr. Potter said.

In patients with fine lines, the mean pretreatment wrinkle depth was 0.25 mm. At 10 days, there was a mean improvement in wrinkle depth of 39%. At 6 months, mean improvement was 24%. "Acne is always difficult to treat, but these patients had an improvement of 35% at 10 days and 23% at 6 months," Dr. Potter said.

LAKE BUENA VISTA, FLA. — Plasma skin resurfacing reduces acne scars and fine lines while minimizing downtime and adverse events, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

"Plasma skin regeneration provides an effective long-term facial rejuvenation for acne scarring and fine lines," said M. Potter, M.D., of RAFT Institute of Plastic Surgery in London.

The plasma device works by passing ultrahigh energy through nitrogen gas, generating plasma used to treat scars and lines with short pulses.

In this study, Dr. Potter treated a total of 11 patients (10 women)—3 for acne scars, 7 for fine lines, and 1 patient for both. The treatment was performed under anesthesia. Energy varied between 1 and 4 J.

All patients were assessed at 10 days and 3 and 6 months post treatment. "A precise measure of skin irregularity was recorded using silicon molds. … Wrinkle depth was assessed using a light microscope technique to give an accurate measurement," Dr. Potter said.

In patients with fine lines, the mean pretreatment wrinkle depth was 0.25 mm. At 10 days, there was a mean improvement in wrinkle depth of 39%. At 6 months, mean improvement was 24%. "Acne is always difficult to treat, but these patients had an improvement of 35% at 10 days and 23% at 6 months," Dr. Potter said.

PHOENIX, ARIZ. — The lip that is enhanced with filler should meet definable proportions and yet retain its individuality, Arnold W. Klein, M.D., said at a clinical dermatology conference sponsored by Medicis.

"Lips are about volume but more importantly shape. Any enhancement must be undetectable," said Dr. Klein, who holds a dermatology chair in his name at the University of California, Los Angeles' David Geffen School of Medicine.

Lip augmentation requires fillers to increase facial volume in a subtle and aesthetically pleasing manner, he said. It is not about "simply eradicating lines."

The lower third of the aging face, including the lip, is the area least amenable to plastic surgery. Along with the thinning of both lips, he cited prominent labial mandibular grooves, the ends of the upper lips hanging down, loss of bone support from dentition and from the mandible, and decreased vertical support, he said.

According to Dr. Klein's formulation of the aesthetic lip: "The length of the closed, relaxed mouth should equal the distance between the medial aspect of the irises in the well-proportioned face." In addition, the ratio of the upper lip to the lower lip should be 1:1.6.

When the head is photographed in a postural position with a relaxed mouth, an interpupillary line drawn horizontally across the eyes should be parallel to a horizontal commissural line drawn where the lips meet.

Dr. Klein cited other characteristic facial landmarks including curvature of the dorsum and angulation of the nose. He said the base of the nose should be 18–20 mm above the upper lip, whereas the recommended distance between the lower lip and the chin is 36 mm.

Looking at the postural head position in profile, the physician should make sure both lips touch the "Steiner line," he said.

When seen in profile, the nasolabial angle should be about 84–105 degrees, he continued: "You want a good nasolabial angle."

To illustrate this, he showed a photograph in which one extended line connected the base of the nose to the tip of the nose. A second line from the base of the nose touched the "Glogau-Klein point" at the center edge of the upper lip. The angle is formed where the two lines intersect.

The G-K point describes the "ski slope" shape of the lip in profile as you move from the skin above the lip down onto the pink vermillion. There is always a little upturn, a point of reflection, which becomes lost as one ages, Richard G. Glogau, M.D., told SKIN & ALLERGY NEWS.

The cosmetic implication is that you have to recreate this shape with fillers used in the border of the lip to make the lip young and attractive. Also, if you use too much Botox on the upper lip, the orbicularis muscle flattens and makes an older looking lip. Therefore, it is generally a good idea to combine fillers with the Botox if you are trying to reestablish a youthful looking upper lip, said Dr. Glogau, who is a consultant to Allergan Inc., Medicis, and Inamed Aesthetics.

Dr. Klein cited a study of 100 women which showed that aging lips lose height (Dermatology 2004;208:307–13). He said the most important aspect of lip augmentation involves building buttresses to restore the lost height and the ends of the lips.

"You want flying buttresses to hold up the lips because of the loss of dentition," he said. "You want to restore the ends and build buttresses to support the lip. That's really important."

The choice of filling agent is less important than the physician's skill in using it, according to Dr. Klein, who disclosed ties as a consultant and/or investigator for Allergan Inc., Genzyme, Inamed Aesthetics, Anika Inc., Medicis, SkinMedica, and OrthoNeutrogena.

"It is not what you use. It is how you use it," he said, recommending physicians become really skilled in one or two products rather than plow through what he described as a delicatessen menu of filling agents on the market.

Except for correction of scars, Dr. Klein opposes the use of permanent fillers. He warned that these agents could become increasingly visible or create an unnatural appearance as facial contours change over time. "For aesthetic indications I believe permanent fillers are a formula for disaster," he said.

The Glogau-Klein point shows dimensions of the aesthetic lip. Courtesy Dr. Richard G. Glogau and Dr. Arnold W. Klein

PHOENIX, ARIZ. — The lip that is enhanced with filler should meet definable proportions and yet retain its individuality, Arnold W. Klein, M.D., said at a clinical dermatology conference sponsored by Medicis.

"Lips are about volume but more importantly shape. Any enhancement must be undetectable," said Dr. Klein, who holds a dermatology chair in his name at the University of California, Los Angeles' David Geffen School of Medicine.

Lip augmentation requires fillers to increase facial volume in a subtle and aesthetically pleasing manner, he said. It is not about "simply eradicating lines."

The lower third of the aging face, including the lip, is the area least amenable to plastic surgery. Along with the thinning of both lips, he cited prominent labial mandibular grooves, the ends of the upper lips hanging down, loss of bone support from dentition and from the mandible, and decreased vertical support, he said.

According to Dr. Klein's formulation of the aesthetic lip: "The length of the closed, relaxed mouth should equal the distance between the medial aspect of the irises in the well-proportioned face." In addition, the ratio of the upper lip to the lower lip should be 1:1.6.

When the head is photographed in a postural position with a relaxed mouth, an interpupillary line drawn horizontally across the eyes should be parallel to a horizontal commissural line drawn where the lips meet.

Dr. Klein cited other characteristic facial landmarks including curvature of the dorsum and angulation of the nose. He said the base of the nose should be 18–20 mm above the upper lip, whereas the recommended distance between the lower lip and the chin is 36 mm.

Looking at the postural head position in profile, the physician should make sure both lips touch the "Steiner line," he said.

When seen in profile, the nasolabial angle should be about 84–105 degrees, he continued: "You want a good nasolabial angle."

To illustrate this, he showed a photograph in which one extended line connected the base of the nose to the tip of the nose. A second line from the base of the nose touched the "Glogau-Klein point" at the center edge of the upper lip. The angle is formed where the two lines intersect.

The G-K point describes the "ski slope" shape of the lip in profile as you move from the skin above the lip down onto the pink vermillion. There is always a little upturn, a point of reflection, which becomes lost as one ages, Richard G. Glogau, M.D., told SKIN & ALLERGY NEWS.

The cosmetic implication is that you have to recreate this shape with fillers used in the border of the lip to make the lip young and attractive. Also, if you use too much Botox on the upper lip, the orbicularis muscle flattens and makes an older looking lip. Therefore, it is generally a good idea to combine fillers with the Botox if you are trying to reestablish a youthful looking upper lip, said Dr. Glogau, who is a consultant to Allergan Inc., Medicis, and Inamed Aesthetics.

Dr. Klein cited a study of 100 women which showed that aging lips lose height (Dermatology 2004;208:307–13). He said the most important aspect of lip augmentation involves building buttresses to restore the lost height and the ends of the lips.

"You want flying buttresses to hold up the lips because of the loss of dentition," he said. "You want to restore the ends and build buttresses to support the lip. That's really important."

The choice of filling agent is less important than the physician's skill in using it, according to Dr. Klein, who disclosed ties as a consultant and/or investigator for Allergan Inc., Genzyme, Inamed Aesthetics, Anika Inc., Medicis, SkinMedica, and OrthoNeutrogena.

"It is not what you use. It is how you use it," he said, recommending physicians become really skilled in one or two products rather than plow through what he described as a delicatessen menu of filling agents on the market.

Except for correction of scars, Dr. Klein opposes the use of permanent fillers. He warned that these agents could become increasingly visible or create an unnatural appearance as facial contours change over time. "For aesthetic indications I believe permanent fillers are a formula for disaster," he said.

The Glogau-Klein point shows dimensions of the aesthetic lip. Courtesy Dr. Richard G. Glogau and Dr. Arnold W. Klein

PHOENIX, ARIZ. — The lip that is enhanced with filler should meet definable proportions and yet retain its individuality, Arnold W. Klein, M.D., said at a clinical dermatology conference sponsored by Medicis.

"Lips are about volume but more importantly shape. Any enhancement must be undetectable," said Dr. Klein, who holds a dermatology chair in his name at the University of California, Los Angeles' David Geffen School of Medicine.

Lip augmentation requires fillers to increase facial volume in a subtle and aesthetically pleasing manner, he said. It is not about "simply eradicating lines."

The lower third of the aging face, including the lip, is the area least amenable to plastic surgery. Along with the thinning of both lips, he cited prominent labial mandibular grooves, the ends of the upper lips hanging down, loss of bone support from dentition and from the mandible, and decreased vertical support, he said.

According to Dr. Klein's formulation of the aesthetic lip: "The length of the closed, relaxed mouth should equal the distance between the medial aspect of the irises in the well-proportioned face." In addition, the ratio of the upper lip to the lower lip should be 1:1.6.

When the head is photographed in a postural position with a relaxed mouth, an interpupillary line drawn horizontally across the eyes should be parallel to a horizontal commissural line drawn where the lips meet.

Dr. Klein cited other characteristic facial landmarks including curvature of the dorsum and angulation of the nose. He said the base of the nose should be 18–20 mm above the upper lip, whereas the recommended distance between the lower lip and the chin is 36 mm.

Looking at the postural head position in profile, the physician should make sure both lips touch the "Steiner line," he said.

When seen in profile, the nasolabial angle should be about 84–105 degrees, he continued: "You want a good nasolabial angle."

To illustrate this, he showed a photograph in which one extended line connected the base of the nose to the tip of the nose. A second line from the base of the nose touched the "Glogau-Klein point" at the center edge of the upper lip. The angle is formed where the two lines intersect.

The G-K point describes the "ski slope" shape of the lip in profile as you move from the skin above the lip down onto the pink vermillion. There is always a little upturn, a point of reflection, which becomes lost as one ages, Richard G. Glogau, M.D., told SKIN & ALLERGY NEWS.

The cosmetic implication is that you have to recreate this shape with fillers used in the border of the lip to make the lip young and attractive. Also, if you use too much Botox on the upper lip, the orbicularis muscle flattens and makes an older looking lip. Therefore, it is generally a good idea to combine fillers with the Botox if you are trying to reestablish a youthful looking upper lip, said Dr. Glogau, who is a consultant to Allergan Inc., Medicis, and Inamed Aesthetics.

Dr. Klein cited a study of 100 women which showed that aging lips lose height (Dermatology 2004;208:307–13). He said the most important aspect of lip augmentation involves building buttresses to restore the lost height and the ends of the lips.

"You want flying buttresses to hold up the lips because of the loss of dentition," he said. "You want to restore the ends and build buttresses to support the lip. That's really important."

The choice of filling agent is less important than the physician's skill in using it, according to Dr. Klein, who disclosed ties as a consultant and/or investigator for Allergan Inc., Genzyme, Inamed Aesthetics, Anika Inc., Medicis, SkinMedica, and OrthoNeutrogena.

"It is not what you use. It is how you use it," he said, recommending physicians become really skilled in one or two products rather than plow through what he described as a delicatessen menu of filling agents on the market.

Except for correction of scars, Dr. Klein opposes the use of permanent fillers. He warned that these agents could become increasingly visible or create an unnatural appearance as facial contours change over time. "For aesthetic indications I believe permanent fillers are a formula for disaster," he said.

The Glogau-Klein point shows dimensions of the aesthetic lip. Courtesy Dr. Richard G. Glogau and Dr. Arnold W. Klein

SAN DIEGO — Dermoscopy can help you reliably diagnose melanomas as small as 3 mm, James W. Steger, M.D., said at a melanoma update sponsored by the Scripps Clinic.

"The best method of diagnosis is not your naked eye by itself or dermoscopy by itself, but using your clinical judgment and both of those things," said Dr. Steger, who chairs the department of dermatology at Naval Medical Center San Diego.

Dermoscopy is a technique of subsurface imaging of color and structures using magnification and either an optical clearing medium such as oil, alcohol, or water, or polarized light. The technique is widely used in Italy, Germany, and Austria, but only about 20% of dermatologists in the United States use it.

In a prospective study of 349 patients with 375 pigmented lesions that required biopsy for diagnosis, 161 of the lesions ranged in size from 1 to 6 mm. Of these, 13 (8%) were melanomas (Eur. J. Dermatol. 2002;12:573–6).

Clinical diagnosis alone detected 10 of 13 melanomas correctly, for a sensitivity of 77% and specificity of 74%. Dermoscopy alone also detected 10 of 13 melanomas correctly, for a sensitivity of 77% and a specificity of 72%.

Another challenging area for dermatologists is diagnosing early-stage nodular melanomas. Dr. Steger explained that nodular melanomas grow relatively fast and differ clinically from superficial spreading malignant melanomas. Small nodular melanomas are usually symmetrical and of a single color.

"They tend to be elevated and dome shaped. And they tend to be firm because of all the cellularity in those tumors," he explained. "When they get mature, they start to weep, encrust, and ulcerate."

Consequently, he added, the ABCD rule for the diagnosis of superficial spreading malignant melanomas does not apply to nodular melanomas. Instead, consider the EFG rule, where E means the lesion is elevated, F means the lesion is firm, and G means it's been growing progressively for 1 month. The G "is of primary importance" according to the new rule's originator, John W. Kelly, M.D., Director, Victorian Melanoma Service, Alfred Hospital, Melbourne (The Melanoma Letter 2004;22:2).

Dr. Steger added that on dermoscopy, "some clinically amelanotic lesions may show areas of light or medium brown pigmentation. Atypical vascular patterns may also be seen."

If you plan to learn dermoscopy, the easiest screening algorithms to use include the three-color test and the three-criteria checklist, Dr. Steger said.

In a study of the three-color test, the presence of three or more colors seen in the lesion on dermoscopy yielded sensitivity for melanoma that ranged from 92% to 97% (Br. J. Dermatol. 2002;146:481–4). However, melanoma was wrongly diagnosed about 50% of the time.

"So you'll be biopsying more benign lesions [with the three-color test], but that's OK," Dr. Steger added.

The three-criteria checklist includes asymmetry of color of dermoscopic structures, atypical pigment network, and any blue or white colors that appear on dermoscopy.

When used by six clinicians who were new to dermoscopy, the checklist yielded a sensitivity of 96% and a specificity of 33% (Dermatology 2004;208:27–31).

"The value of both of these algorithms is in screening," he said. "These are good techniques that all of us can use. When in doubt, biopsy."

To get started in dermoscopy, Dr. Steger recommends reading dermatology literature on the topic and taking one of the introductory courses offered by the American Academy of Dermatology and other organizations.

He also recommends "Dermoscopy: The Essentials," by Robert H. Johr, M.D., et al. (Philadelphia: Mosby, 2004).

SAN DIEGO — Dermoscopy can help you reliably diagnose melanomas as small as 3 mm, James W. Steger, M.D., said at a melanoma update sponsored by the Scripps Clinic.

"The best method of diagnosis is not your naked eye by itself or dermoscopy by itself, but using your clinical judgment and both of those things," said Dr. Steger, who chairs the department of dermatology at Naval Medical Center San Diego.

Dermoscopy is a technique of subsurface imaging of color and structures using magnification and either an optical clearing medium such as oil, alcohol, or water, or polarized light. The technique is widely used in Italy, Germany, and Austria, but only about 20% of dermatologists in the United States use it.

In a prospective study of 349 patients with 375 pigmented lesions that required biopsy for diagnosis, 161 of the lesions ranged in size from 1 to 6 mm. Of these, 13 (8%) were melanomas (Eur. J. Dermatol. 2002;12:573–6).

Clinical diagnosis alone detected 10 of 13 melanomas correctly, for a sensitivity of 77% and specificity of 74%. Dermoscopy alone also detected 10 of 13 melanomas correctly, for a sensitivity of 77% and a specificity of 72%.

Another challenging area for dermatologists is diagnosing early-stage nodular melanomas. Dr. Steger explained that nodular melanomas grow relatively fast and differ clinically from superficial spreading malignant melanomas. Small nodular melanomas are usually symmetrical and of a single color.

"They tend to be elevated and dome shaped. And they tend to be firm because of all the cellularity in those tumors," he explained. "When they get mature, they start to weep, encrust, and ulcerate."

Consequently, he added, the ABCD rule for the diagnosis of superficial spreading malignant melanomas does not apply to nodular melanomas. Instead, consider the EFG rule, where E means the lesion is elevated, F means the lesion is firm, and G means it's been growing progressively for 1 month. The G "is of primary importance" according to the new rule's originator, John W. Kelly, M.D., Director, Victorian Melanoma Service, Alfred Hospital, Melbourne (The Melanoma Letter 2004;22:2).

Dr. Steger added that on dermoscopy, "some clinically amelanotic lesions may show areas of light or medium brown pigmentation. Atypical vascular patterns may also be seen."

If you plan to learn dermoscopy, the easiest screening algorithms to use include the three-color test and the three-criteria checklist, Dr. Steger said.

In a study of the three-color test, the presence of three or more colors seen in the lesion on dermoscopy yielded sensitivity for melanoma that ranged from 92% to 97% (Br. J. Dermatol. 2002;146:481–4). However, melanoma was wrongly diagnosed about 50% of the time.

"So you'll be biopsying more benign lesions [with the three-color test], but that's OK," Dr. Steger added.

The three-criteria checklist includes asymmetry of color of dermoscopic structures, atypical pigment network, and any blue or white colors that appear on dermoscopy.

When used by six clinicians who were new to dermoscopy, the checklist yielded a sensitivity of 96% and a specificity of 33% (Dermatology 2004;208:27–31).

"The value of both of these algorithms is in screening," he said. "These are good techniques that all of us can use. When in doubt, biopsy."

To get started in dermoscopy, Dr. Steger recommends reading dermatology literature on the topic and taking one of the introductory courses offered by the American Academy of Dermatology and other organizations.

He also recommends "Dermoscopy: The Essentials," by Robert H. Johr, M.D., et al. (Philadelphia: Mosby, 2004).

SAN DIEGO — Dermoscopy can help you reliably diagnose melanomas as small as 3 mm, James W. Steger, M.D., said at a melanoma update sponsored by the Scripps Clinic.

"The best method of diagnosis is not your naked eye by itself or dermoscopy by itself, but using your clinical judgment and both of those things," said Dr. Steger, who chairs the department of dermatology at Naval Medical Center San Diego.

Dermoscopy is a technique of subsurface imaging of color and structures using magnification and either an optical clearing medium such as oil, alcohol, or water, or polarized light. The technique is widely used in Italy, Germany, and Austria, but only about 20% of dermatologists in the United States use it.

In a prospective study of 349 patients with 375 pigmented lesions that required biopsy for diagnosis, 161 of the lesions ranged in size from 1 to 6 mm. Of these, 13 (8%) were melanomas (Eur. J. Dermatol. 2002;12:573–6).

Clinical diagnosis alone detected 10 of 13 melanomas correctly, for a sensitivity of 77% and specificity of 74%. Dermoscopy alone also detected 10 of 13 melanomas correctly, for a sensitivity of 77% and a specificity of 72%.

Another challenging area for dermatologists is diagnosing early-stage nodular melanomas. Dr. Steger explained that nodular melanomas grow relatively fast and differ clinically from superficial spreading malignant melanomas. Small nodular melanomas are usually symmetrical and of a single color.

"They tend to be elevated and dome shaped. And they tend to be firm because of all the cellularity in those tumors," he explained. "When they get mature, they start to weep, encrust, and ulcerate."

Consequently, he added, the ABCD rule for the diagnosis of superficial spreading malignant melanomas does not apply to nodular melanomas. Instead, consider the EFG rule, where E means the lesion is elevated, F means the lesion is firm, and G means it's been growing progressively for 1 month. The G "is of primary importance" according to the new rule's originator, John W. Kelly, M.D., Director, Victorian Melanoma Service, Alfred Hospital, Melbourne (The Melanoma Letter 2004;22:2).

Dr. Steger added that on dermoscopy, "some clinically amelanotic lesions may show areas of light or medium brown pigmentation. Atypical vascular patterns may also be seen."

If you plan to learn dermoscopy, the easiest screening algorithms to use include the three-color test and the three-criteria checklist, Dr. Steger said.

In a study of the three-color test, the presence of three or more colors seen in the lesion on dermoscopy yielded sensitivity for melanoma that ranged from 92% to 97% (Br. J. Dermatol. 2002;146:481–4). However, melanoma was wrongly diagnosed about 50% of the time.

"So you'll be biopsying more benign lesions [with the three-color test], but that's OK," Dr. Steger added.

The three-criteria checklist includes asymmetry of color of dermoscopic structures, atypical pigment network, and any blue or white colors that appear on dermoscopy.

When used by six clinicians who were new to dermoscopy, the checklist yielded a sensitivity of 96% and a specificity of 33% (Dermatology 2004;208:27–31).

"The value of both of these algorithms is in screening," he said. "These are good techniques that all of us can use. When in doubt, biopsy."

To get started in dermoscopy, Dr. Steger recommends reading dermatology literature on the topic and taking one of the introductory courses offered by the American Academy of Dermatology and other organizations.

He also recommends "Dermoscopy: The Essentials," by Robert H. Johr, M.D., et al. (Philadelphia: Mosby, 2004).

VIENNA — Successful Mohs micrographic surgery depends on two things: that the tumor is contiguous and that 100% of the surgical margins are examined histologically, Stuart J. Salasche, M.D., said at the 10th World Congress on Cancers of the Skin.

"Recurrences do happen, and if you're doing 1,000, 2,000 cases a year then even small percentages add up to numbers, and each number represents an individual patient who put [himself or herself] in your hands," Dr. Salasche said.

Some recurrences are caused by "housekeeping errors" such as inadequate slide preparation, mapping errors, and poor tissue samples, and can be reduced with repetition and good staff training, he said.

Large tumors in general, and particularly those on the ear or medial canthus of the eye, can be difficult to map, and should be marked carefully with scalpel hatch marks that correspond to color-coded maps for more accurate orientation.

Poor slide preparation can result in false negative margins because of missing epidermis or holes and folds in the tissue where tumor can exist.

False-negative margin situations are frequently caused by noncontiguous tumors. Common culprits are recurrent tumors where residual tumor was left in multiple foci of which only one became clinically apparent. This applies particularly in immunosuppressed patients, he said. Some tumors may inherently have skip areas such as those seen in sebaceous carcinoma and Merkel cell carcinoma.

"The ones that we see most often and cause us the most trouble are tumors that have already been operated on or previously treated," said Dr. Salasche of the Arizona Cancer Center at the University of Arizona in Tucson.

When evaluating recurrent tumors, consider the original treatment modality, the type of repair used, the time from original surgery to clinical recurrence, the aggressiveness of the tumor histology, and whether the area was covered with a graft, he said at the meeting, cosponsored by the Skin Cancer Foundation.

In the approach to a recurrence, all visual tumor and the entire scar should be resected, as if the scar were part of the original tumor. Pay particular attention to squamous cell carcinomas or lesions on the scalp, temple, or forehead, most notably in organ transplant patients, he said.

Inflammation can also mask tumors and is common in elderly populations with chronic lymphocytic leukemia. Tumor masked by the inflammation may go unrecognized by the surgeon, or result in the surgeon chasing the inflammation or subclinical extensions as they track along nerves for great distances, he said. Immunostaining is helpful in these cases.

Another problem is recognizing that basal cell carcinomas probably originate from stem cells that reside in the outer root sheath of the hair follicle, and result in subtle buds of tumor coming off the follicle that can be misread as hair follicles, he said.

VIENNA — Successful Mohs micrographic surgery depends on two things: that the tumor is contiguous and that 100% of the surgical margins are examined histologically, Stuart J. Salasche, M.D., said at the 10th World Congress on Cancers of the Skin.

"Recurrences do happen, and if you're doing 1,000, 2,000 cases a year then even small percentages add up to numbers, and each number represents an individual patient who put [himself or herself] in your hands," Dr. Salasche said.

Some recurrences are caused by "housekeeping errors" such as inadequate slide preparation, mapping errors, and poor tissue samples, and can be reduced with repetition and good staff training, he said.

Large tumors in general, and particularly those on the ear or medial canthus of the eye, can be difficult to map, and should be marked carefully with scalpel hatch marks that correspond to color-coded maps for more accurate orientation.

Poor slide preparation can result in false negative margins because of missing epidermis or holes and folds in the tissue where tumor can exist.

False-negative margin situations are frequently caused by noncontiguous tumors. Common culprits are recurrent tumors where residual tumor was left in multiple foci of which only one became clinically apparent. This applies particularly in immunosuppressed patients, he said. Some tumors may inherently have skip areas such as those seen in sebaceous carcinoma and Merkel cell carcinoma.

"The ones that we see most often and cause us the most trouble are tumors that have already been operated on or previously treated," said Dr. Salasche of the Arizona Cancer Center at the University of Arizona in Tucson.

When evaluating recurrent tumors, consider the original treatment modality, the type of repair used, the time from original surgery to clinical recurrence, the aggressiveness of the tumor histology, and whether the area was covered with a graft, he said at the meeting, cosponsored by the Skin Cancer Foundation.

In the approach to a recurrence, all visual tumor and the entire scar should be resected, as if the scar were part of the original tumor. Pay particular attention to squamous cell carcinomas or lesions on the scalp, temple, or forehead, most notably in organ transplant patients, he said.

Inflammation can also mask tumors and is common in elderly populations with chronic lymphocytic leukemia. Tumor masked by the inflammation may go unrecognized by the surgeon, or result in the surgeon chasing the inflammation or subclinical extensions as they track along nerves for great distances, he said. Immunostaining is helpful in these cases.

Another problem is recognizing that basal cell carcinomas probably originate from stem cells that reside in the outer root sheath of the hair follicle, and result in subtle buds of tumor coming off the follicle that can be misread as hair follicles, he said.

VIENNA — Successful Mohs micrographic surgery depends on two things: that the tumor is contiguous and that 100% of the surgical margins are examined histologically, Stuart J. Salasche, M.D., said at the 10th World Congress on Cancers of the Skin.

"Recurrences do happen, and if you're doing 1,000, 2,000 cases a year then even small percentages add up to numbers, and each number represents an individual patient who put [himself or herself] in your hands," Dr. Salasche said.

Some recurrences are caused by "housekeeping errors" such as inadequate slide preparation, mapping errors, and poor tissue samples, and can be reduced with repetition and good staff training, he said.

Large tumors in general, and particularly those on the ear or medial canthus of the eye, can be difficult to map, and should be marked carefully with scalpel hatch marks that correspond to color-coded maps for more accurate orientation.

Poor slide preparation can result in false negative margins because of missing epidermis or holes and folds in the tissue where tumor can exist.

False-negative margin situations are frequently caused by noncontiguous tumors. Common culprits are recurrent tumors where residual tumor was left in multiple foci of which only one became clinically apparent. This applies particularly in immunosuppressed patients, he said. Some tumors may inherently have skip areas such as those seen in sebaceous carcinoma and Merkel cell carcinoma.

"The ones that we see most often and cause us the most trouble are tumors that have already been operated on or previously treated," said Dr. Salasche of the Arizona Cancer Center at the University of Arizona in Tucson.

When evaluating recurrent tumors, consider the original treatment modality, the type of repair used, the time from original surgery to clinical recurrence, the aggressiveness of the tumor histology, and whether the area was covered with a graft, he said at the meeting, cosponsored by the Skin Cancer Foundation.

In the approach to a recurrence, all visual tumor and the entire scar should be resected, as if the scar were part of the original tumor. Pay particular attention to squamous cell carcinomas or lesions on the scalp, temple, or forehead, most notably in organ transplant patients, he said.

Inflammation can also mask tumors and is common in elderly populations with chronic lymphocytic leukemia. Tumor masked by the inflammation may go unrecognized by the surgeon, or result in the surgeon chasing the inflammation or subclinical extensions as they track along nerves for great distances, he said. Immunostaining is helpful in these cases.

Another problem is recognizing that basal cell carcinomas probably originate from stem cells that reside in the outer root sheath of the hair follicle, and result in subtle buds of tumor coming off the follicle that can be misread as hair follicles, he said.

VIENNA — For skin cancers on the nose, Mohs micrographic surgery is associated with low recurrence rates and spares a maximal amount of healthy tissue, Abel R. González, M.D., reported at the 10th World Congress on Cancers of the Skin.

"Some patients just want a healed wound, but others have a high aesthetic standard," said Dr. González of the Institute of Oncology Angel H. Roffo at the University of Buenos Aires. "They wish a nose restored to normal, no matter how much time or effort it takes" to accomplish the results.

Of the 2,648 Mohs surgeries performed between 1990 and 2004 at the Institute, 780 (29%) tumors were located on the nose. A review of 758 cases shows 322 (42%) of cases were managed with secondary-intention healing, 306 (40%) with flaps, 111 (15%) with grafts, and 19 (2%) with primary closure.

Secondary-intention healing is simple, complications are rare, and it saves time and cost associated with reconstruction, Dr. González said, at the meeting cosponsored by the Skin Cancer Foundation.

For procedures that require nasal reconstruction, skin quality is an important variable.

The upper two-thirds of the nose and the columella are covered by thin, nonsebaceous and slightly mobile skin. Here, local flaps rotate easily and are a good choice for small defects. Grafts blend well into the smooth and shiny surfaces of the dorsum and sidewalls, Dr. González said.

On the tip or ala, the skin is sebaceous and adherent to underlying tissues. Single lobe flaps rotate poorly, but bilobed or nasolabial flaps can overcome these problems. Grafts are a poor choice as they create a patch of shiny skin in the thick, pitted skin of the area, he said.

For superficial defects, a full-thickness skin graft can be performed. When using grafts, the preference is for delayed, full-thickness skin grafts because bleeding or exudation diminishes when a graft is delayed rather than performed immediately. This also results in a well-vascularized bed, which increases graft survival.

When bone or cartilage is exposed, a flap will be necessary.

When nasal support is missing, and a framework needs to be restored, a distant flap will prevent tension that could distort cartilage reconstruction. A distant flap also is needed when repairing defects larger than 1.5 cm.

Incisions placed strategically in the joins that separate the subunits of the nose—the tip, ala, paired sidewalls, dorsum, soft triangles, and columella—will be perceived as a normal fold or contour line.

If more than 50% of a subunit is lost, the guiding principle is that replacing the entire unit usually gives a better result than just patching the defect.

The forehead flap is an excellent option in nasal reconstruction because the forehead skin matches nasal skin almost exactly and has superb perfusion. The forehead flap should always be vertically oriented because of perfusion, and narrow, paramedian flaps allow easier rotation. It should never reconstruct the cheek.

The final defect after five stages of Mohs surgery is shown.

Photos courtesy Dr. Abel R. González

VIENNA — For skin cancers on the nose, Mohs micrographic surgery is associated with low recurrence rates and spares a maximal amount of healthy tissue, Abel R. González, M.D., reported at the 10th World Congress on Cancers of the Skin.

"Some patients just want a healed wound, but others have a high aesthetic standard," said Dr. González of the Institute of Oncology Angel H. Roffo at the University of Buenos Aires. "They wish a nose restored to normal, no matter how much time or effort it takes" to accomplish the results.

Of the 2,648 Mohs surgeries performed between 1990 and 2004 at the Institute, 780 (29%) tumors were located on the nose. A review of 758 cases shows 322 (42%) of cases were managed with secondary-intention healing, 306 (40%) with flaps, 111 (15%) with grafts, and 19 (2%) with primary closure.

Secondary-intention healing is simple, complications are rare, and it saves time and cost associated with reconstruction, Dr. González said, at the meeting cosponsored by the Skin Cancer Foundation.

For procedures that require nasal reconstruction, skin quality is an important variable.

The upper two-thirds of the nose and the columella are covered by thin, nonsebaceous and slightly mobile skin. Here, local flaps rotate easily and are a good choice for small defects. Grafts blend well into the smooth and shiny surfaces of the dorsum and sidewalls, Dr. González said.

On the tip or ala, the skin is sebaceous and adherent to underlying tissues. Single lobe flaps rotate poorly, but bilobed or nasolabial flaps can overcome these problems. Grafts are a poor choice as they create a patch of shiny skin in the thick, pitted skin of the area, he said.

For superficial defects, a full-thickness skin graft can be performed. When using grafts, the preference is for delayed, full-thickness skin grafts because bleeding or exudation diminishes when a graft is delayed rather than performed immediately. This also results in a well-vascularized bed, which increases graft survival.

When bone or cartilage is exposed, a flap will be necessary.

When nasal support is missing, and a framework needs to be restored, a distant flap will prevent tension that could distort cartilage reconstruction. A distant flap also is needed when repairing defects larger than 1.5 cm.

Incisions placed strategically in the joins that separate the subunits of the nose—the tip, ala, paired sidewalls, dorsum, soft triangles, and columella—will be perceived as a normal fold or contour line.

If more than 50% of a subunit is lost, the guiding principle is that replacing the entire unit usually gives a better result than just patching the defect.

The forehead flap is an excellent option in nasal reconstruction because the forehead skin matches nasal skin almost exactly and has superb perfusion. The forehead flap should always be vertically oriented because of perfusion, and narrow, paramedian flaps allow easier rotation. It should never reconstruct the cheek.

The final defect after five stages of Mohs surgery is shown.

Photos courtesy Dr. Abel R. González

VIENNA — For skin cancers on the nose, Mohs micrographic surgery is associated with low recurrence rates and spares a maximal amount of healthy tissue, Abel R. González, M.D., reported at the 10th World Congress on Cancers of the Skin.

"Some patients just want a healed wound, but others have a high aesthetic standard," said Dr. González of the Institute of Oncology Angel H. Roffo at the University of Buenos Aires. "They wish a nose restored to normal, no matter how much time or effort it takes" to accomplish the results.

Of the 2,648 Mohs surgeries performed between 1990 and 2004 at the Institute, 780 (29%) tumors were located on the nose. A review of 758 cases shows 322 (42%) of cases were managed with secondary-intention healing, 306 (40%) with flaps, 111 (15%) with grafts, and 19 (2%) with primary closure.

Secondary-intention healing is simple, complications are rare, and it saves time and cost associated with reconstruction, Dr. González said, at the meeting cosponsored by the Skin Cancer Foundation.

For procedures that require nasal reconstruction, skin quality is an important variable.

The upper two-thirds of the nose and the columella are covered by thin, nonsebaceous and slightly mobile skin. Here, local flaps rotate easily and are a good choice for small defects. Grafts blend well into the smooth and shiny surfaces of the dorsum and sidewalls, Dr. González said.

On the tip or ala, the skin is sebaceous and adherent to underlying tissues. Single lobe flaps rotate poorly, but bilobed or nasolabial flaps can overcome these problems. Grafts are a poor choice as they create a patch of shiny skin in the thick, pitted skin of the area, he said.

For superficial defects, a full-thickness skin graft can be performed. When using grafts, the preference is for delayed, full-thickness skin grafts because bleeding or exudation diminishes when a graft is delayed rather than performed immediately. This also results in a well-vascularized bed, which increases graft survival.

When bone or cartilage is exposed, a flap will be necessary.

When nasal support is missing, and a framework needs to be restored, a distant flap will prevent tension that could distort cartilage reconstruction. A distant flap also is needed when repairing defects larger than 1.5 cm.

Incisions placed strategically in the joins that separate the subunits of the nose—the tip, ala, paired sidewalls, dorsum, soft triangles, and columella—will be perceived as a normal fold or contour line.

If more than 50% of a subunit is lost, the guiding principle is that replacing the entire unit usually gives a better result than just patching the defect.

The forehead flap is an excellent option in nasal reconstruction because the forehead skin matches nasal skin almost exactly and has superb perfusion. The forehead flap should always be vertically oriented because of perfusion, and narrow, paramedian flaps allow easier rotation. It should never reconstruct the cheek.

The final defect after five stages of Mohs surgery is shown.

Photos courtesy Dr. Abel R. González