Single‐pass CO2 laser skin resurfacing of light and dark skin: extended experience with 52 patients

BACKGROUND: Multiple‐pass carbon dioxide (CO₂) laser skin resurfacing has been a favored treatment modality for photodamaged and acne‐scarred skin over the past several years. Its association with numerous side effects and complications, particularly prolonged erythema and dyspigmentation, however, has dampened the initial enthusiasm reserved for its use. By reducing the laser‐associated tissue ablation depth and degree of thermal necrosis, it is possible that the incidence of these side effects can also be reduced.

PURPOSE: To evaluate the clinical efficacy and side effect profile of single‐pass CO₂ laser skin resurfacing in a large series of patients.

MATERIALS AND METHODS: A total of 52 consecutive patients (skin phototypes I–VI) with mild facial rhytides, atrophic scars, or infraorbital hyperpigmentation underwent single‐pass treatment with a high‐energy, pulsed CO₂ laser. Side effects to treatment were closely monitored and tabulated. Clinical improvement using a quartile grading scale was assessed independently by two masked medical evaluators at 1, 3, 6, and 12 months postoperatively.

RESULTS: Significant clinical improvement was seen in all patients, with peak improvement scores noted at 12 months. Greater clinical improvement was seen in patients with darker skin tones despite the near universal incidence of transient postoperative hyperpigmentation in these patients.

CONCLUSIONS: Single‐pass CO₂ laser skin resurfacing can improve the appearance of fine rhytides, mild atrophic scars, and infraorbital hyperpigmentation in all skin types. The severity and duration of side effects and complications are reduced with this technique (compared with multiple‐pass procedures) and may offer a possible solution to the problem of treating patients with darker complexions.     

A study of fractional CO₂ laser resurfacing: the best fluences through a clinical, histological, and ultrastructural evaluation

Background Fractional resurfacing is a laser treatment modality to create numerous microscopic thermal injury zones of controlled width, depth, and density that are surrounded by a reservoir of spared epidermal and dermal tissue, allowing rapid repair of laser‐induced thermal injury. Objective To evaluate the safety and efficacy of a fractional CO₂ laser system in the treatment of photo‐damaged skin with clinical, histological, and ultrastructural evaluation, with special attention to one of the parameters of this laser system: the fluences. Materials and methods Twelve patients with Fitzpatrick skin types II to III with photo‐damage skin underwent fractional laser treatment with one single‐pass superficial on the face and forearm. Clinical outcome and histological and ultrastructural changes were assessed. Results  Light microscopy of biopsies gave important information about skin changes at three different times after fractional treatment, especially revealing some differences between the fluences used in the three groups of patients. Conclusion Fractional resurfacing offers significant surgical advantages allowing to achieve excellent esthetic results in balance with the biological structure. Besides, our study shows already that with 2.07 and 2.77 J/cm², instead of 4.15 J/cm², it is possible to reach a biological response without scar formation.     

Locobase Repair ® cream following CO 2 laser skin resurfacing reduces interstitial fluid oozing

BACKGROUND: The cosmetic result after laser resurfacing depends not only on the type of laser and the technique used, but also on post-treatment care. The efficacy of Locobase Repair ® cream, which improves skin barrier function due to its content of natural skin analogue fats and cholesterol, was investigated. METHODS: A total of 18 Caucasian patients underwent resurfacing for acne scars. Laser treatment was performed with a Sharplan 1020 CO 2 laser and a Silk Touch scanner. Locobase Repair cream (a water-in-oil cream with 63% lipids including natural components of stratum corneum: cholesterol, ceramide and free fatty acids) was applied daily to one side of the face and petrolatum was applied to the other. In addition, both sides were treated with a 2% fusidic acid cream. RESULTS: There was a significant reduction of oozing during the first 2 days after CO 2 laser treatment on the sides treated with Locobase Repair cream ( p < 0.05), CO 2 laser while from day 3 to day 7 no differences were demonstrated between the Locobase Repair cream and petrolatum. For the other parameters scored (scaling, oedema, erythema and pain), no significant differences between Locobase Repair cream and petrolatum were found. Furthermore, no significant differences were found between the two creams regarding the duration of wound healing and final cosmetic outcome. In all, 62% of the patients preferred to use Locobase Repair cream during the postoperative period, and 11% preferred petrolatum. The remaining 27% expressed no preferences. CONCLUSION: The use of Locobase Repair cream as a post laser resurfacing treatment reduces tissue fluid oozing during the first 2 postoperative days, indicating a quick restoration of skin barrier and hence possibly a reduction in the incidence of wound infections as well as enhancing patient compliance due to less fluid oozing.     

Accelerated reduction of post‐skin‐resurfacing erythema and discomfort with a combination of non‐thermal blue and near infrared light

The prolonged crusting and erythematic phases following chemical and laser skin resurfacing create discomfort and aggravate patients. Depending on the aggressiveness of the procedure, post‐procedure erythema may last from three weeks to several months. iClearXL (CureLight Ltd) is a non‐contact, non‐thermal blue (405–420?nm)/near infrared (850–900?nm) dual‐band light source emitting up to 60?J/cm² on a 30?cm by 30?cm treatment area. The blue component of the light source has been proven to have a significant anti‐inflammatory effect, whereas the near infrared component enhances vascular circulation as well as lymphatic drainage in the thin, necrotized papillary layer.

Facial skin laser resurfacing was performed on twelve patients. Starting one day after resurfacing, six patients received a daily 20‐minute treatment of blue (405–420?nm)/near infrared (850–900?nm) light for six consecutive days, and six control patients were treated with the usual topical care protocol. Twelve days after the procedure, the treated group had a weighted average erythema score of 0.33 as compared to 1.33 in the control group. Two months after the procedure, the treated group had a weighted average erythema score of 0.16 as compared to 0.83 in the control group. Twelve days after the procedure, the treated group had a weighted average discomfort score of 0.33 as compared to 0.83 in the control group.

The tested combination of non‐thermal blue (405–420?nm)/near infrared (850–900?nm) dual‐band light was found to significantly shorten the duration of post‐laser‐resurfacing erythema and discomfort with no side effects.     

Treatment of atrophic facial acne scars with fractional Er:YAG laser in skin phototype III–IV: A pilot study

Background: Fractional ablative lasers have recently been used for the treatment of skin scars. The objective of this study was to assess the efficacy and safety of the fractional erbium-doped yttrium aluminum garnet (Er:YAG) laser (2940 nm) in the treatment of skin scars. Materials and methods: A total of 9 patients (8 female, 1 male) with Fitzpatrick skin types III and IV suffering from atrophic facial acne scars were treated with a fractional Er:YAG laser for 2–5 (mean 3.3) sessions 4–6 weeks apart. One independent investigator assessed the efficacy, using standardized photographs, before and 1 month after the last treatment. The patients’ satisfaction rate was also evaluated. Results: The treatment was well tolerated by all patients without any anesthesia. The downtime was 2–3 days. All patients showed improvement in scars: excellent in 1, good in 1, and fair in 7 patients. Six patients were highly satisfied and 3 were satisfied with treatment. No adverse effect was noted. Conclusion: A fractional Er:YAG laser can deliver an effective and minimally invasive treatment for acne scars.     

Measurement of home‐use laser and intense pulsed light systems for hair removal: Preliminary report

Background: Laser and intense pulsed light (IPL) devices are used routinely by healthcare professionals for hair removal, but laser and light technology devices intended for home use have so far had little impact in the consumer market. However, as multinational companies enter this market, there will be an explosion in the use of such devices by the consumer. Objectives: This investigation focuses on the technical performance of the devices tested and although no clinical data are presented, the measured parameters are those that will directly impact efficacy in hair reduction, efficient coverage of skin, and safety in terms of unintentional eye exposure to the light source or incorrect settings for a given skin type. Consumers will consult healthcare professionals with experience of light‐based therapies for guidance and this study provides useful reference information on available home‐use devices. Methods: Previously published standard test methods were used to evaluate the devices tested. Results: Some of the devices measured in this study showed significant discrepancies between claims made by the manufacturers and the parameters measured. Conclusions: There is an urgent need for early ratification of the draft international IEC 60601‐1 intense light standard, which will encompass manufacturing standards for both professional and home‐use hair removal devices.     

Treatment of ulcerated haemangiomas with a non‐coherent pulsed light source: Brief initial clinical report

Background: Ulceration is the most common complication of infantile haemangiomas and constitutes an authentic therapeutic challenge because of associated pain, infection, haemorrhage and subsequent scarring. Objective: To report our experience with an intense pulsed light (IPL) system in the treatment of ulcerated haemangiomas. Methods: Case 1: A 4‐month‐old girl, with haemangioma affecting the entire cutaneous surface of the left limb, developed four ulcerations on the inner aspect of this extremity. Two sessions with an IPL system using a triple pulse mode, a 570‐nm lower cut‐off filter and a fluence of 38?J/cm² were performed. Case 2: A 5‐month‐old girl with ulcerated labial haemangioma that previously failed to respond to intralesional corticoids was treated with an IPL system device. Three sessions using a triple pulse mode with a 570‐nm lower cut‐off filter and a fluence of 48?J/cm² were realized. Results: Good results were rapidly obtained after two and four sessions of IPL treatment, respectively. Pain was soon relieved and complete epithelization was obtained by between 1 and 2 months in both patients. Conclusion: Although our experience is rare, we believe that IPL devices may be an effective alternative treatment of ulcerated haemangiomas.     

Tazarotene versus tazarotene plus hydroquinone in the treatment of photodamaged facial skin: A multicenter,double‐blind,randomized study

Objectives: To compare the efficacy and tolerability of tazarotene plus hydroquinone versus tazarotene alone in the treatment of facial photodamage. Methods: Patients with facial mottled hyperpigmentation of at least moderate severity and an overall integrated assessment of photodamage score of at least moderate applied tazarotene 0.1% cream each evening and either hydroquinone 4% cream or placebo cream each morning for up to 24 weeks. Results: Among 131 patients enrolled, 114/124 (92%) with exit data completed. Both regimens were highly effective in reducing photodamage, with tazarotene plus hydroquinone showing superiority over tazarotene alone for some efficacy measures. The incidence of ?1‐grade improvement from baseline (on a scale of none, minimal, mild, moderate, or severe) was significantly greater with tazarotene plus hydroquinone than with tazarotene alone for lentigines (weeks 12–24, p?0.01) and mottled hyperpigmentation (week 16, p?0.05). The incidence of ?50% global improvement was also significantly superior with the combination regimen as early as week 8 (p?0.01). Both regimens were associated with good tolerability and high patient satisfaction (no significant between‐group differences). Conclusions: The adjunctive use of hydroquinone can enhance the efficacy of tazarotene in reducing dyspigmentation associated with photodamage.     

Tazarotene 0.1% cream versus tretinoin 0.05% emollient cream in the treatment of photodamaged facial skin: a multicenter,double‐blind,randomized, parallel‐group study

OBJECTIVES: To compare the efficacy and tolerability of tazarotene 0.1% cream and tretinoin 0.05% emollient cream in the treatment of photodamaged facial skin.

METHODS: Subjects were eligible to enroll in this multicenter, double‐blind, randomized, parallel‐group study if they had at least mild levels of facial fine wrinkling and mottled hyperpigmentation, and at least moderate levels of one of these. Subjects were randomly assigned to apply either tazarotene cream or tretinoin emollient cream to their faces once each evening for 24 weeks.

RESULTS: A total of 173 subjects were enrolled, of whom 157 completed. All significant between‐group differences in efficacy measures were in favor of tazarotene – for fine wrinkling at the study endpoint and, at earlier timepoints, for treatment success (≥50% global improvement), and the overall integrated assessment of photodamage, mottled hyperpigmentation, and coarse wrinkling. Both products were comparable in terms of cosmetic acceptability and tolerability except that tazarotene was associated with a transiently higher incidence of a burning sensation on the skin (in the first week of treatment but not thereafter).

CONCLUSIONS: Tazarotene 0.1% cream can offer superior efficacy over tretinoin 0.05% emollient cream in the treatment of facial photodamage, particularly with respect to the speed of improvement.     

CO2 laser desiccation of urethral hair post‐penoscrotal hypospadias repair

Background: Proximal urethral defects account for approximately 20% of hypospadiac urethras. Previous surgical interventions involved hair‐bearing genital skin which consequently resulted in a hairy urethra, which is seen mainly in older patients. Objective: To evaluate the safety and effectiveness of the CO₂ laser for urethra hair elimination. Methods: Four men aged 18–20 years with hairy urethras, who failed electrolysis treatment, were treated with CO₂ laser desiccation at low fluences (2–5?watts). The treatments were performed at 1‐month intervals. Treatment was continued until no hair was seen. Visual assessment of the hair reduction was recorded. Results: Patients received two to four treatment sessions (average 3.2). On clinical assessment 3 months after the last treatment, outcome was rated excellent (no hair) in all patients. Conclusions: CO₂ laser desiccation should be considered as a therapeutic modality for a hairy urethra, especially after the failure of electrolysis.     

The management of skin malignancy: to what extent should we rely on clinical diagnosis?

BACKGROUND: Cutaneous malignancy forms a major part of the dermatologist's workload. Clinical diagnosis is an important factor in facilitating the urgent excision of squamous cell carcinomas (SCC) and malignant melanomas. OBJECTIVES: To identify the numbers and types of malignant skin tumours managed in an NHS teaching hospital and to assess the diagnostic accuracy. METHODS: Data were collected on every histologically proven malignant skin lesion over a 6-month period. RESULTS: One thousand one hundred and ninety-five malignant skin tumours were identified: 78% were basal cell carcinomas, 14% were SCC, 6% were malignant melanomas and the remaining 2% included Merkel cell tumours, malignant adnexal tumours and lentigo maligna. Eighty-one per cent of the tumours were managed by dermatologists. The correct clinical diagnosis had been made by the secondary care clinician in 84% of cases but an incorrect clinical diagnosis was given in 32% of SCC. Of the 1195 tumours, 916 (77%) had a primary excision and 92% (843 of 916) of these were completely excised. CONCLUSIONS: The majority of skin malignancies (968 of 1195, 81%) were managed by dermatologists. Where primary excision was attempted, this was complete in 91% (767 of 916) of cases. The correct clinical diagnosis was made in 84% of all tumours, but 32% of SCC were not correctly diagnosed prior to surgery.     

Treatment of inflammatory facial acne vulgaris: Comparison of the 1450‐nm diode laser and conventional physical treatment

The efficacy of the 1450‐nm diode laser in the treatment of inflammatory facial acne was evaluated by comparing it with conventional physical treatment. Seventeen patients received laser treatment on the right side of the face and conventional physical treatment on the other side. The two modalities were compared through photographs, inflammatory acne lesion counts, and a patient questionnaire. Clinical response was evaluated in 16 patients. Evaluation of baseline and follow‐up photographs indicated that more improvement was obtained after laser treatment than by physical treatment in six patients. In two patients, physical treatment yielded better results than laser treatment. Equal effect was obtained in eight patients. All patients had a reduction in the inflammatory acne lesion count on the laser‐treated side, which was statistically significantly greater on the laser‐treated side compared with the side treated physically (p = 0.039, Wilcoxon signed ranks test). By the assessment of patient satisfaction, seven patients preferred laser treatment, two patients preferred physical treatment and three patients found laser treatment equal to physical treatment. Questionnaire details could not be obtained in 4 patients. This study indicates that the 1450‐nm diode laser is a new option for local treatment of acne.     

Intravenous vitamin C in the treatment of post‐laser hyperpigmentation for melasma: A short report

Melasma is difficult to treat. Vitamin C, topical and by iontophoresis, has been shown to be useful. When lasers are used, there is a significant incidence of post‐laser hyperpigmentation. There is no single established treatment for the latter. The case history of a 51‐year‐old Chinese woman is presented. Intravenous vitamin C appears to be useful in treating this complication.     

Examination of skin lesions for cancer: Which clinical decision aids and tools are available in general practice?

Background

While skin cancer incidence is rising throughout Europe, general practitioners (GP) feel unsure about their ability to diagnose skin malignancies.

Objectives

To evaluate whether the GP has sufficient validated clinical decision aids and tools for the examination of potentially malignant skin lesions.

Methods

We conducted a review searching Medline and the Cochrane Library. In addition, reference lists and personal archives were examined. Outcome measures were sensitivity and specificity but also the advantages and disadvantages of different clinical decision aids and tools.

Results

No clinical decision aids or tools for the examination of non-pigmented lesions are available. Clinical decision aids and tools for the examination of pigmented lesions have mostly been studied in secondary care and, in primary care, randomised clinical trials comparing the additional value of a clinical decision aid or tools to care are scarce.

Conclusion

Sufficiently validated clinical decision aids and tools for the examination of potentially malignant skin lesions are lacking in general practice. The clinical decision aids and tools available in primary care need to be studied.

     

Objective and subjective clinical effects of a Nd:YAG 532‐nm frequency‐doubled long‐pulsed diode pumped laser system on photoaging of the face: A retrospective study on color signs,texture and rhytids

BACKGROUND: Pulsed 532‐nm lasers have been widely used in the treatment of vascular and pigmented conditions of aged skin. In addition to lesion clearance, many patients report color and texture improvements to the skin. These improvements are often difficult to appreciate from photographic analysis alone, but are significant to the patient's impression of treatment success. OBJECTIVE: To grade and compare objective and subjective results of treatments with a 532‐nm frequency‐doubled pulsed Nd:YAG laser using criteria of skin color, skin texture, and wrinkles based on a blinded retrospective analysis of photographs compared with results from patient questionnaires. METHODS: Clinical before and after pictures from 20 patients (skin types I–IV) treated for diffuse vascular and pigmented lesions were selected for evaluation. A blinded grading was performed using criteria of skin color, skin texture, and wrinkles. Patients were asked by questionnaire to also grade improvement using the same criteria. The results of the blinded and patient grading were reported and compared using a chi‐squared analysis. RESULTS: Clinical improvements recorded by blinded photographic evaluation and patient evaluation agreed with no statistically significant differences. Both the blinded observers and patients recorded remarkable improvement in the color signs of photoaging, slight to moderate improvement in skin texture and fine wrinkles, and negligible improvement of medium depth and deep wrinkles. CONCLUSION: The 532‐nm pulsed laser is a safe and effective device for the treatment of the visible signs of photoaging of skin types I–III. In addition to improvements in color defects, objectively and subjectively significant improvements in texture and fine wrinkles can be expected. Little to no improvement in medium to deep wrinkles can be anticipated.     

Treatment of active acne with an Er:Glass (1.54 µm) laser: A 2‐year follow‐up study

Background: To investigate the effects of the 1.54 µm wavelength on active lesions of the face and of the back at the 2‐year follow‐up. Methods: A 1.54 µm erbium:glass laser (Aramis, Quantel Medical, France) was used in combination with contact cooling set at +5°C to treat acne on the face with the following parameters (3 ms, four pulses, 10 J/cm², 2 Hz, cumulative fluence: 40 J/cm²). The laser spots were adjacent (maximum overlap: 20%) and delivered in rows in order to cover the entire area. Four treatments were performed at 4‐week intervals in 25 patients with acne severity greater than 3 on the Burton scale. Acne lesion counts (papules, pustules, nodules, comedones) were performed prior to each treatment, and at 2, 4, 12, 18 and 24 months after the final treatment. Results: Among the 25 patients, three were lost to follow‐up, four were retreated. So, 18 patients had acne lesions counts 2 years after the fourth treatment. The mean percent reduction was 71% at the 6‐month follow‐up, 79% at the 1‐year follow‐up and 73% at the 2‐year follow‐up. No side effects were reported. All patients commented that their skin was less prone to oiliness. Biopsies taken after treatment showed progressive rarefaction and miniaturization of sebaceous glands and pilosebaceous follicles without morphologic damage to epidermal and dermal structures. Conclusion: Active acne can be successfully treated by selective dermal heating with a 1.54 µm erbium:glass laser coupled to contact cooling, with no related side effects. Furthermore, this longer follow‐up study demonstrates long‐term acne clearing. Combined treatments with medications (oral or topical) or light (targeting Propionibacterium acnes) may also improve acne clearance.     

Effects of Hydroxydecine(®) (10-hydroxy-2-decenoic acid) on skin barrier structure and function in vitro and clinical efficacy in the treatment of UV-induced xerosis

10-Hydroxy-2-decenoic acid, a natural fatty acid only found in royal jelly, may be of value in correcting skin barrier dysfunction. We evaluated the activity of Hydroxydecine(?), its synthetic counterpart, in vitro on the regulation of epidermal differentiation markers, ex vivo on the inflammatory response and restoration of skin barrier function, and in vivo on UV-induced xerosis in healthy human volunteers. In cultured normal human keratinocytes, Hydroxydecine(?) induced involucrin, transglutaminase-1 and filaggrin protein production. In topically Hydroxydecine(?)-treated skin equivalents, immunohistochemical analysis revealed an increase in involucrin, transglutaminase-1 and filaggrin staining. In a model of thymic stromal lymphopoietin (TSLP)-induced inflamed epidermis, a Hydroxydecine(?)-containing emulsion inhibited TSLP release. In a model of inflammation and barrier impairment involving human skin explants maintained alive, Hydroxydecine(?) balm restored stratum corneum cohesion and significantly increased filaggrin expression, as shown by immunohistochemistry. It also decreased pro-inflammatory cytokine secretion (IL-4, IL-5 and IL-13). In healthy volunteers with UV-induced xerosis, the hydration index increased by +28.8% (p<0.01) and +60.4% (p<0.001) after 7 and 21 days of treatment with Hydroxydecine(?) cream, respectively. Hydroxydecine(?) thus proved its efficacy in activating keratinocyte differentiation processes in vitro, restoring skin barrier function and reducing inflammation ex vivo, and hydrating dry skin in vivo.