Nonablative 1,064-nm Nd:YAG Laser for Treating Atrophic Facial Acne Scars: Histologic and Clinical Analysis

BACKGROUND Non-ablative methods have been attempted in treating atrophic facial scars, but the histologic findings do not always coincide with the clinical results and patient satisfaction.
OBJECTIVE To study the effects and safety of the Nd:YAG laser for treating atrophic facial scars.
MATERIAL AND METHODS Twelve subjects (skin phototypes II-V) with mild to moderate atrophic facial acne scars received five monthly treatments with 1,064 nm Nd:YAG laser and were photographed before, in the middle of, and 6 months after the last treatment. Histologic evaluations were performed on skin biopsies obtained before treatment and 1 month after the last session. Collagen quantification per area, before and after the treatment, was performed by morphometry, with computerized image analysis. Patient satisfaction and clinical condition were assessed using standard grading scales.
RESULTS Mild to moderate clinical improvement was observed in most patients. Photographic assessment of scars found visible cosmetic improvement in eleven patients. All patients were satisfied. There were statistically significant collagen increases in the dermis following the treatment. Side effects were limited to mild transient erythema and increased skin sensitivity after the procedure.
CONCLUSIONS The 1,064 nm Nd:YAG laser is a safe and effective nonablative method for improving atrophic scars, even in darker skin.     

Effect of Pretreatment on the Incidence of Hyperpigmentation Following Cutaneous CO2 Laser Resurfacing

Background. Transient hyperpigmentation is the most common complication seen following cutaneous carbon dioxide (CO₂) laser resurfacing.
Objective. The purpose of this study was to determine whether the use of a topical skin lightening regimen prior to cutaneous laser resurfacing reduces the incidence of post-laser resurfacing hyperpigmentation.
Methods. One hundred consecutive CO₂ laser resurfacing patients (skin types I–III) were randomized to receive preoperative treatment with 10% glycolic acid cream twice daily (n = 25), hydroquinone 4% cream qHS and tretinoin 0.025% cream twice daily (n = 25) or no pretreatment (n = 50, control) for at least 2 weeks. Clinical and photographic assessments were performed prior to laser resurfacing and at 4 and 12 weeks following treatment.
Results. There was no significant difference in the incidence of post-CO₂ laser resurfacing hyperpigmentation between subjects who received pretreatment with either topical glycolic acid cream or combination tretinoin/hydroquinone creams and those who received no pretreatment regimen.
Conclusion. It is postulated that reepithelialization after cutaneous laser resurfacing includes follicular melanocytes that have not been affected by topical pretreatment. When instituted as a component of the skin care regimen postoperatively, topical hydroquinone, tretinoin and/or glycolic acid preparations may be helpful in reducing post-laser resurfacing hyperpigmentation.     

A prospective study of the safety and efficacy of a combined bipolar radiofrequency,intense pulsed light,and infrared diode laser treatment for global facial photoaging

The clinical features of photoaging include: skin texture changes, laxity, rhytides, pigmentary changes, and vascular changes such as erythema and telangiectasias. In order to meet patients’ increasing demands for improving all aspects of photoaging at one office visit, employing a multi-modality treatment for all aspects of photoaging has become increasingly desirable for the physician and patient alike. We examine a novel device that employs bipolar radiofrequency (RF), intense pulsed light (IPL), and infrared diode laser. These laser and light source treatments are performed sequentially. This study aims to evaluate the clinical efficacy and safety of this device (i.e., ELOS Triniti?). Twenty-six subjects received four ELOS Triniti? treatments at 1-month intervals. They were followed up 1, 3, and 6 months after completing the treatments. Two blinded dermatologists used a comprehensive grading scale to evaluate the degree of the photoaging in terms of rhytides, laxity, dyschromia, erythema, telangiectasias, and texture. Subjects used a 0–10 grading scale for self-assessment of photoaging. Additionally, we measured the Erythema Index (EI), Melanin Index (MI), transepidermal water loss scores (TEWL), stratum corneum moisture scores (SC), and dermis moisture scores (D) before treatment and 1, 3, and 6 months after treatment. There was a statistically significant improvement in all five aspects of the comprehensive grading scale. Overall, it had excellent efficacy for improving erythema, telangiectasias, and skin texture. It also had a relatively long effect on improving skin laxity; however, it had only a limited ability to improve rhytides and dyschromia. It can mildly to moderately improve the global photoaging. This global effect can be noted 1 month after treatment and becomes most clinically apparent 3 months after treatment. This is maintained at least 6 months after treatment. MI index and SC and D values increased while EI index and TEWL values decreased after the treatment. The subjects’ self-assessment improved by 2.7 ± 1.2 points. The overall satisfaction rate was 88%. The degree of pain measured 2.5 ± 1.9 points on average. There was no downtime and no severe side effects reported. The sequential implementation of bipolar radiofrequency based optical combination devices (IPL, IR, diode laser) is effective and safe for global facial photoaging.     

Improvement of Neck and Cheek Laxity With a Nonablative Radiofrequency Device: A Lifting Experience

Objective. Laxity of cheek and neck skin is a common cosmetic complaint of patients as they age. Improvement of skin laxity can be difficult to achieve without invasive surgical lifting procedures. The object of this study was to evaluate the safety and efficacy of a novel nonablative radiofrequency device in the treatment of cheek and neck laxity.
Methods. Fifty patients (skin phototypes I to IV) with mild-to-moderate cheek laxity (n=30) or neck laxity (n=20) received one treatment with a radiofrequency device (ThermaCool; Thermage Corp., Hayward, CA). Topical anesthetic cream was applied under occlusion for 60 minutes before treatment of the skin extending laterally and inferiorly from the nasolabial folds to the preauricular regions and mandibular ridge for treatment of the cheeks and from the mandible to mid neck for treatment of the neck. Clinical improvement of treatment areas was independently determined by three masked assessors' evaluations of comparative photographs at baseline, immediately after treatment, at 1 week, and at 1, 3, and 6 months after treatment using a quartile grading scale (0=less than 25%, 1=25% to 50%, 2=51% to 75%, 3=more than 75% improvement). Patient satisfaction surveys were also obtained at each follow-up visit.
Results. Significant improvement in cheek and neck skin laxity was observed in the majority of patients. Patient satisfaction scores paralleled the clinical improvements observed. Side effects were mild and limited to transient erythema, edema, and rare dysesthesia. No scarring or pigmentary alteration was seen.
Conclusions. Noninvasive radiofrequency bulk dermal heating of skin can achieve safe and effective tissue tightening of the cheeks and neck. Although tightening continued to be evident 6 months after a single treatment, the longevity of clinical results has yet to be determined.     

Tretinoin Peeling

BACKGROUND: Topical tretinoin has been used for a long time to improve photoaged skin, but this therapy takes quite a few months to show some clinical changes. Because of that, we think tretinoin peeling would be an excellent choice for improvement of photoaged skin. OBECTIVE: Our objective was to show the clinical and histologic modifications of the skin after five sessions of tretinoin peeling. METHODS: The authors studied the clinical and histologic modification that occurred in 15 female patients after conducting tretinoin peeling procedures twice a week in concentrations of 1-5%. Conventional sectioning of punch biopsy specimens was conducted before and after the treatment. RESULTS: Clinical improvement was observed in the skin texture and appearance. Through histologic examinations, a decrease in the corneous layer and an increase in the epidermal thickness were noticed, inducing an improvement of its stratification, as well as the formation of cristae cutis. CONCLUSION: It was concluded that the peeling conducted with serial tretinoin showed good clinical and histologic results, especially for the treatment of photoaged skins I and II, melasma, ephelis, and acne degree I, as well as being practical, quick, and easily accomplished with no side effects.     

Endovenous Laser Treatment of the Small Saphenous Vein with a 980-nm Diode Laser: Early Results

BACKGROUND Whereas numerous studies have been conducted regarding the outcome of the treatment of the great saphenous vein, few studies have been conducted on the small saphenous vein (SSV), especially concerning endovenous laser treatment.
OBJECTIVE The objective was to evaluate the safety and efficacy of the 980-nm diode laser for the treatment of SSV reflux caused by saphenopopliteal junction (SPJ) incompetence.
MATERIALS AND METHODS From October 2003 to April 2006, 390 SSVs in 344 subjects with varicose veins were treated with 980-nm diode laser energy delivered percutaneously into the SSV. Tumescent anesthesia (70–220 mL of 0.1% lidocaine) was delivered perivenously under ultrasound (US) guidance. The patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and thereafter to assess the efficacy of the treatment and the adverse reactions of the patients to it.
RESULTS Successful occlusion of the SSV, defined as the absence of flow on color Doppler imaging, was noted in 389 of the 390 SSVs (99.7%) after the initial treatment. The remaining 1 SSV was closed after the repeat treatment. Of 108 SSVs, 102 (94.4%) remained closed throughout the 12th-month follow-up. Bruising and tightness along the course of the treated vein was present in almost all the patients, but these disappeared in 1 to 2 weeks. Seven patients (2%) noted localized skin paresthesia, but there were no major complications like skin burns and deep vein thrombosis.
CONCLUSION Taking into account the high failure rates of incompetent SSV surgery and the anatomic complexity of SPJ, the endovenous 980-nm diode laser surgery is a safe and effective, cosmetically preferential procedure while a long-term follow-up is being awaited.     

Nonablative Dermal Remodeling With a 585-nm, 350-μsec, Flashlamp Pulsed Dye Laser: Clinical and Ultrastructural Analysis

BACKGROUND.   A nonablative 350-μsec, 585-nm, flashlamp pulsed dye laser is currently being used for the treatment of rhytides.
OBJECTIVE.   To analyze both clinical rhytid improvement and electron microscopic evidence of ultrastructural changes after treatment with a nonablative 350-μsec, 585-nm, flashlamp pulsed dye laser.
RESULTS.   At 6 months after two treatments, 40% of the treated subjects noted mild improvement in rhytid appearance. Nontreating physician evaluation revealed some degree of improvement in 50% of the treated subjects. Mild improvement in quality and texture of the skin was also reported by 50% of the subjects. Electron microscopic evaluation showed ultrastructural changes that are consistent with new collagen formation.
CONCLUSION.   Treatment with a nonablative 350-μsec, 585-nm, flashlamp pulsed dye laser can lead to both clinical and electron microscopic evidence of improvement in photo-damaged skin.     

A Split-face,Controlled Study to Assess the Compatibility of Tretinoin 0.05% Acne Lotion with Facial Foundation Makeup

OBJECTIVE: This study was conducted to assess compatibility of tretinoin 0.05% acne lotion with foundation makeup. DESIGN: This was a single-center, evaluator-blinded, randomized, controlled clinical trial. Participants were randomized to apply tretinoin 0.05% lotion to either the right or left side of the face before applying full-face foundation makeup. SETTING: Participants were enrolled at a single center in the United States. PARTICIPANTS: Female individuals aged 18 to 50 years who used facial foundation makeup ≥5 days per week were included. MEASUREMENTS: Investigator-assessed grading for foundation coverage and participant evaluations of makeup appearance were conducted at post-makeup application (Post-Makeup) and Hour 6 (6H) timepoints. Antera 3D® images were taken for skin texture roughness analysis and tolerability evaluations were performed at baseline, post-tretinoin application, Post-Makeup, and 6H timepoints. RESULTS: A total of 30 participants were enrolled and 29 completed the study. There were no significant differences between tretinoin treated and untreated sides for any outcomes of investigator-assessed grading of foundation (percentage coverage, blotchiness, overall coverage, skin tone evenness, visual smoothness). There was a small but statistically significant worsening in percent coverage at 6H versus Post-Makeup on the untreated side, but not the treated side. As rated by participants, even/full coverage and skin smoothness were significantly better on the tretinoin-lotion treated versus the untreated side. Three-dimensional imaging showed there were no significant differences in skin roughness between the treated and untreated sides. Participants reported overall satisfaction with the tretinoin lotion-treated side. CONCLUSION: Tretinoin 0.05% lotion did not interfere with facial makeup application or wearability and was well tolerated.     

Shrinking Upper and Lower Eyelid Skin with a Novel Radiofrequency Tip

BACKGROUND Many subjects wish to have tightening of eyelid skin but are reluctant to undergo aesthetic blepharoplasty surgery. We wanted to perform a small pilot study to test the efficacy and safety of a 0.25-cm² monopolar radiofrequency tip in a prospective noncomparative study as a novel nonsurgical method to safely tighten upper and lower eyelid skin in subjects of differing ethnicity and sex.
METHODS Twenty adult subjects were enrolled in this prospective pilot study. All received symmetrical monopolar radiofrequency treatments in multiple passes to the pretarsal, preseptal, and lateral orbital skin. All subjects wore a protective plastic haptic contact lens to protect their vision during the radiofrequency treatment. (Haptic contact lenses fit over the entire anterior surface of the globe from superior to inferior and medial to lateral fornix. The purpose of using such a large contact lens was to protect the globe itself from radiofrequency energy.) Standardized color digital photography with eyes both open and closed was taken on each visit. Treatment efficacy was evaluated by both the expert observer and the subject at each visit.
RESULTS At 6-month follow-up, according to the expert observer, 26 upper lids (87%) showed 25% or more tightening. Twenty lower lids (67%) showed 25% or more tightening. Two subjects (3.33%) had 51% to 75% upper lid tightening at 6 months. There were no adverse events beyond one subject with minimal corneal epithelial punctate defects on the treatment day. These resolved over several hours.
CONCLUSIONS The use of this new tip was shown to be safe. Effectiveness at shrinking eyelid skin was at best mild to moderate.     

Clinical, Laboratory, and MRI Analysis of Cellulite Treatment with a Unipolar Radiofrequency Device

BACKGROUND Cellulite is seen in more than 85% of postpubertal women. Recent studies show that bipolar radiofrequency and low-level laser devices can produce mild skin tightening of cellulite.
OBJECTIVE The primary objective was to determine if a novel unipolar, more deeply penetrating, radiofrequency device can promote better skin tightening with fewer treatments than is seen with previously described devices. The secondary objective was to determine if such a deeply penetrating device produced undesired effects on lipid metabolism.
METHODS Thirty subjects, with Nurnberger-Muller Scale III–IV upper thigh cellulite, were entered into the study. All were treated, every other week, with a unipolar radiofrequency device for a total of six treatments. Subjects were evaluated before and 6 months after treatment with clinical photographs, clinical measurements, biopsies, MRIs, and blood lipid evaluations.
RESULTS Twenty-seven subjects showed evidence of clinical improvement. The mean decrease in leg circumference was 2.45 cm. Histologic changes showed dermal fibrosis of the upper dermis. No MRI or lipid abnormalities were noted.
CONCLUSION Upper thigh skin cellulite can be improved with a new unipolar radiofrequency device. Histologic changes suggest skin tightening as the method of improvement. No undesired complications of the skin or lipid metabolism were noted.     

Absence of Degradation of Tretinoin When Benzoyl Peroxide is Combined with an Optimized Formulation of Tretinoin Gel (0.05%)

Background: Clinicians have been reluctant to prescribe benzoyl peroxide concurrently with topical tretinoin due to a belief that the benzoyl peroxide may cause oxidation and degradation of the tretinoin molecule, thereby reducing its effectiveness. However, benzoyl peroxide-induced degradation of tretinoin may not necessarily apply to all topical tretinoin formulations. Objective: To evaluate the potential for benzoyl peroxide-induced degradation of an optimized aqueous gel formulation of tretinoin (0.05%). Methods: Tretinoin gel (0.05%) and benzoyl peroxide gel (6.26% premix concentration to produce 5% benzoyl peroxide in a fixed combination clindamycin product) were mixed together (1:1) at 32oC and samples assayed after 1, 2, 3, 5, and 7 hours. Each sample was analyzed for tretinoin (expressed as % tretinoin remaining) and its degradation product content. Results: No loss of tretinoin was observed over the seven-hour time period. When tretinoin gel (0.05%) was combined with benzoyl peroxide, 100 percent of the initial tretinoin concentration remained after seven hours. There was no increase in the degradation products of tretinoin. Conclusions: There was no benzoyl peroxide-induced degradation of tretinoin when the optimized formulation of tretinoin gel (0.05%) was admixed with benzoyl peroxide gel (6.26%). Although the direct clinical significance of these results is unknown, clinicians may feel comfortable using this particular combination concurrently without concerns about tretinoin oxidation and degradation.     

Five-Year Safety and Efficacy of a Novel Polymethylmethacrylate Aesthetic Soft Tissue Filler for the Correction of Nasolabial Folds

BACKGROUND A novel soft tissue filler composed of polymethylmethacrylate (PMMA) microspheres suspended in a collagen gel matrix containing 0.3% lidocaine (ArteFill, Artes Medical, Inc.) was recently approved by the Food and Drug Administration for the correction of nasolabial folds. A randomized, multicenter, controlled pivotal trial performed in the United States established the safety and efficacy of this medical device throughout a 12-month study period.
OBJECTIVE The objective was to substantiate the long-term 5-year safety and efficacy of this novel soft tissue PMMA filler.
METHODS AND MATERIALS Attempts were made to contact all subjects treated with the PMMA filler that were enrolled in the original pivotal study. Safety was assessed by standard adverse event reporting methods. Efficacy was determined using a validated six-point facial fold assessment photometric grading scale using blinded observers' assessment of standardized photographs.
RESULTS Subjects ( n =119) demonstrated significant improvement in nasolabial folds comparing baseline (before any treatment) to 5 years after their last treatment ( p <.001). Notably, subjects also demonstrated continued improvement between 6 months after their last treatment and Year 5 ( p =.002). No serious unanticipated device-related adverse events were reported.
CONCLUSION This PMMA filler is the first soft tissue filler to demonstrate continued improvement and persistence of correction over a 5-year period posttreatment.     

Immunogenicity Studies of Cosmetically Administered Nonanimal-Stabilized Hyaluronic Acid Particles

BACKGROUND Hypersensitivity resulting from humoral or cellular immunologic mechanisms is the least well-documented of adverse events associated with dermal fillers.
OBJECTIVE Humoral and cellular immunogenicity of nonanimal-stabilized hyaluronic acid (NASHA) was studied in prospective clinical trials involving nasolabial fold augmentation.
METHODS In two randomized clinical studies, 150 (10 centers) and 283 (17 centers) subjects received NASHA as Restylane and/or Perlane (both QMed, Uppsala, Sweden; mean, 69 mg) for dermal augumentation. Serum immunoglobulin (Ig)E and IgG anti-NASHA were measured by immunoassay at 0, 6, and 24 weeks and IgE anti-NASHA by intradermal skin testing (ID-ST) at 0 and 24 weeks. The 24-week ID-ST site was biopsied 3 days later for histopathologic evidence of cell-mediated immunity.
RESULTS Of 433 subjects, 42 systemic adverse experiences were reported by 37 participants; all but 1 were judged by investigators to be unrelated to NASHA administration. All ID-STs and IgE anti-NASHA results were negative, indicating no IgE sensitization. Serologically, 91.8% of 425 subjects were negative for IgG anti-NASHA (<1.5 μg/mL) at all time points, whereas 7.8% had positive enrollment IgG anti-NASHA (range, 1.5–18.5 μg/mL) that remained essentially unchanged over the study period. The 24-week ID-ST biopsies showed no histological evidence for NASHA-induced cell mediated lymphocytic inflammatory reactions (Type IV hypersensitivity) or superficial dermal edema (Type 1 hypersensitivity).
CONCLUSION NASHA administration does not elicit clinical/laboratory evidence for cellular or humoral immune responses in 98% of individuals, supporting the conclusion that Restylane and/or Perlane are not commonly immunogenic or allergenic.     

Clindamycin 1.2% Tretinoin 0.025% Gel versus Clindamycin Gel Treatment in Acne Patients: A Focus on Fitzpatrick Skin Types

Background: Acne vulgaris affects individuals of all races and ethnicities. Understanding the safety and efficacy of topical agents benefits the practicing clinician when treating patients with skin of color. Purpose: To report observations in acne patients representing all six Fitzpatrick skin types based on a Phase 3 study that evaluated the efficacy and safety of a clindamycin phosphate 1.2% tretinoin 0.025% gel versus a clindamycin phosphate 1.2% gel alone. Methods: The two treatments were compared in a randomized, double-blind, multicenter, parallel, 12-week study employing a total of 2,010 patients with moderate-to-severe acne. Primary efficacy endpoints were 1) treatment success defined as percentage of patients who were clear or almost clear or achieved at least a 2-grade improvement in Evaluators Global Severity Scores at Week 12 and 2) percent change from baseline versus 12-week scores for noninflamed, inflamed, and total lesions. Results: The 12-week, 37.8-percent Evaluators Global Severity Scores treatment success for clindamycin phosphate 1.2% tretinoin 0.025% gel was greater than the 31.7 percent observed for clindamycin phosphate 1.2% gel alone (P = 0.002). Percent changes from baseline versus 12-week scores for noninflamed, inflamed, and total lesions obtained with clindamycin phosphate 1.2% tretinoin 0.025% gel (49.8, 60.9, and 54.5%, respectively) were significantly greater than those observed for clindamycin phosphate 1.2% gel alone (41.3, 54.8, and 46.9%, respectively); all comparisons P<0.001. Conclusion: Use of clindamycin phosphate 1.2% tretinoin 0.025% gel resulted in greater percent reductions of Evaluators Global Severity Scores treatment success scores and acne lesions in patients with all six Fitzpatrick skin types combined than clindamycin phosphate 1.2% gel alone. Both products were well tolerated, with no hypo- or hyperpigmentation noted. Side effects observed were similar to those previously reported for the individual ingredients.     

维A酸乳膏联合健脾消痤汤治疗脾虚湿热型痤疮的临床效果

目的 评估维A酸乳膏联合健脾消痤汤治疗脾虚湿热型痤疮的效果。方法 选取我院2021年 1月-2024年1月收治的80例脾虚湿热型痤疮患者为研究对象,采用随机数字表法分为对照组和联合组,各 40例。对照组予以维A酸乳膏治疗,联合组在对照组基础上加用健脾消痤汤治疗,比较两组中医证候积 分、皮损情况、临床疗效及复发情况。结果 两组治疗后中医证候积分低于治疗前,且联合组低于对照组 （P ＜0.05）;两组治疗后皮损情况评分低于治疗前,且联合组低于对照组（P ＜0.05）;联合组治疗 总有效率为95.00%,高于对照组的77.50%（P ＜0.05）;联合组复发率为5.00%,低于对照组的25.00% （P ＜0.05）。结论 维A酸乳膏与健脾消痤汤联合治疗脾虚湿热型痤疮可有效提高治疗效果,改善患者皮 损情况,减轻临床症状,降低近期复发风险。     

Efficacy and Safety of Clindamycin Phosphate 1.2% and Tretinoin 0.025% Gel for the Treatment of Acne and Acne-induced Post-inflammatory Hyperpigmentation in Patients with Skin of Color

Objective: To assess the efficacy and safety of a topical gel containing clindamycin 1.2% and tretinoin 0.025% for the treatment of acne and acne-induced postinflammatory hyperpigmentation (PIH) in darker skinned patients. Design: Randomized, double-blind, placebo-controlled study. Setting: Two United States clinical sites. Participants: Thirty-three patients 12 years of age or older with skin types IV to VI, mild-to-moderate facial acne, and PIH were enrolled. Measurements: Patients applied clindamycin phosphate/tretinoin gel or a nonmedicated vehicle each evening and a sun protection factor 30 sunscreen daily. Changes in skin erythema and hyperpigmentation were measured using a chromameter and photographic images. Efficacy was assessed using the Evaluators Global Acne Severity Scale, lesion counts, Post-inflammatory Hyperpigmentation Severity Scales and Patient's Global Assessment Scale. Safety and tolerability were assessed by adverse event reports and a Safety Assessment Scale. Results: The mean (SD) baseline inflammatory lesion count was 11.9 (11.1) in clindamycin/tretinoin-treated patients, decreasing by 5.5 (6.56) after 12 weeks while the mean baseline inflammatory lesion count was 13.6 (11.15) in placebo-treated patients, decreasing by 4.1 (11.36) (p=0.05 for change from baseline, clindamycin/tretinoin vs. placebo). Clindamycin/tretinoin-treated patients generally demonstrated superior efficacy versus placebo treatment. The clindamycin/tretinoin topical gel was well tolerated, causing little or no irritation, although one patient withdrew due to periorbital edema of moderate severity possibly related to clindamycin/tretinoin gel. Conclusion: Although limited by small sample size, the results of this pilot study suggest clindamycin phosphate 1.2% and tretinoin 0.025% topical gel is a safe and effective option for treating mild-to-moderate acne in patients with skin of color.     

Tretinoin Peels versus Glycolic Acid Peels in the Treatment of Melasma in Dark-Skinned Patients

BACKGROUND: Chemical peels have become a popular method for treating melasma. Although daily topical 0.05 and 0.1% tretinoin have been used for melasma, the therapy takes at least 4 to 6 months to produce clinically significant lightening. In a recent trial, 1% tretinoin peel has shown good clinical and histologic results after biweekly applications in 2.5 weeks only in the treatment of melasma. OBJECTIVE: Because there is a paucity of studies evaluating the efficacy and safety of 1% tretinoin peel in the treatment of melasma in dark-skinned Asian population, we conducted a pilot study to evaluate the efficacy and side effects of this potentially new peeling agent versus a standard peeling agent, 70% glycolic acid, in the treatment of melasma in Indian women. METHODS: Ten female patients of melasma, after written consent, were taken up for an open left-right comparison pilot study of 12 weeks. One percent tretinoin peel was applied on one-half of the face, whereas 70% glycolic acid was applied on the other at weekly intervals. The results were evaluated by a clinical investigator by using the modified Melasma Area and Severity Index and with photographs at baseline and 6 and 12 weeks. RESULTS: A significant decrease in the modified Melasma Area and Severity Index from baseline to 6 weeks and then from 6 to 12 weeks was observed on both facial sides (p<0.001). Nevertheless, there was no statistically significant difference between the right and the left sides. Side effects were minimal and 1% tretinoin peel appeared to be well tolerated by the patients. CONCLUSIONS: It was concluded from the present trial that serial 1% tretinoin peel is a well tolerated and as effective a therapy for melasma in dark-skinned individuals as a standard and well-tried chemical peel, 70% glycolic acid, although larger trials over longer periods may be necessary to substantiate such findings.     

Clinical Trial of Bleaching Treatment With 10% All-Trans Retinol Gel

BACKGROUND: Although an aggressive use of tretinoin along with hydroquinone enables an efficient treatment of hyperpigmented skin lesions, irritant dermatitis remains to be solved. OBJECTIVE: To evaluate the efficiency and adverse effects of 10% all-trans retinol (ROL) gel for improvement of skin hyperpigmentation. METHODS: Ten-percent ROL gel was used instead of 0.1% tretinoin gel in our two-phased bleaching protocol (bleaching and healing phases); 5% hydroquinone and 7% lactic acid ointment were used along with ROL gel in the bleaching phase (2 to 6 weeks). Five-percent hydroquinone and 7% ascorbic acid ointment were used alone during the healing phase (4 to 6 weeks). Twenty-one Japanese patients with hyperpigmented lesions on the face were enrolled in this study, and 18 patients who were followed for more than 10 weeks were analyzed. RESULTS: Improvement of pigmentation was seen in 16 of 18 patients after an average treatment period of 11.3 weeks, and in 6 patients, pigmentation was almost eliminated after treatment. Erythema and scaling were seen, however, during the bleaching phase as well as the bleaching treatment with tretinoin gel. CONCLUSION: ROL can improve skin hyperpigmentation to a similar extent to tretinoin when used at high concentration, whereas it induces irritant dermatitis as well.     

Pulse oximeter perfusion index as an early indicator of sympathectomy after epidural anesthesia

Background: The pulse oximeter perfusion index (PI) has been used to indicate sympathectomy-induced vasodilatation. We hypothesized that pulse oximeter PI provides an earlier and clearer indication of sympathectomy following epidural anesthesia than skin temperature and arterial pressure.
Methods: Forty patients received lumbar epidural catheters. Patients were randomized to receive either 10 ml 0.5% bupivacaine or 10 ml 0.25% bupivacaine. PI in the toe, mean arterial pressure (MAP) and toe temperature were all assessed at baseline and at 5, 10 and 20 min following epidural anesthesia. The effect of epidural anesthesia over time was assessed by repeated measures analysis of variance. Additionally, we defined clinically evident sympathectomy criteria (a 100% increase in the PI, a 15% decrease in MAP and a 1 °C increase in toe temperature). The numbers of patients demonstrating these changes for each test were compared using the McNemar test for each time point.
Results: Twenty-nine subjects had photoplethysmography signals that met a priori signal quality criteria for analysis. By 20 min, PI increased by 326%, compared with a 10% decrease and a 3% increase in MAP and toe temperature, respectively. For PI 15/29, 26/29 and 29/29 of the subjects met the sympathectomy criteria at 5, 10 and 20 min, respectively, compared with 4/29, 6/29 and 18/29 for MAP changes and 3/29, 8/29 and 14/29 for toe temperature changes.
Conclusions: PI was an earlier, clearer and more sensitive indicator of the development of epidural-induced sympathectomy than either skin temperature or MAP.