Nd:YAG laser combined with IPL treatment improves clinical results in non‐ablative photorejuvenation

BACKGROUND: Intense pulsed light (IPL) sources have been reported in non‐ablative photorejuvenation, but the excellent histological findings do not always coincide with the clinical results and patient satisfaction index (SI).

METHODS: Ten female patients (two forehead, four periocular and four perioral), ages ranging from 28 to 46 years, skin types II–IV, wrinkle types I–III, participated in the study. The IPL system was applied with the yellow (570?nm) cut‐off filter, 30?J/cm², single pulse, followed by the Nd:YAG at 120?J/cm², double pulse (7?ms per shot with 20?ms between pulses) on the wrinkled areas only. Three sessions were given at monthly intervals, and an assessment was made 1 and 6 months after the third session. Biopsies were taken from four consenting patients as a cross‐section before the first treatment and then 1 and 6 months after the third session. For clinical control and contrast of tissue results, a group of 10 patients (two forehead, four periocular and four perioral; ages ranging from 27 to 47 years, skin types II–IV, wrinkle types I–III) was treated only with IPL, using the same parameters and sessions. Histologies were taken from four consenting patients.

RESULTS: The histology showed thickening of the epidermis with good dermal collagen organization in both groups. However, the combined treatment showed more dramatic changes in histological tissue condition, and ectatic blood vessels were seen in the deeper dermis. The patient SI values, related to the results, were lower when IPL was used alone. All patients completed the study. In the combined treatment group, overall SIs of 8 (80%) and 8 (80%) were obtained at the control points of 1 and 6 months, respectively, after session 3, compared with SIs of 6 (60%) and 4 (40%) scored by patients in the IPL group at the same points. Discomfort and side effects were minimal in both groups.

CONCLUSIONS: The addition of the Nd:YAG laser to the IPL regimen in non‐ablative skin rejuvenation gave very good histological results, which were echoed by stronger patient satisfaction than in the control group treated only with IPL. Visible improvement in the skin condition of both groups was achieved, but was better in the combined treatment group.     

Pilot study to determine the efficacy of ALA‐PDT photorejuvenation for the treatment of facial ageing

Objective. The study was divided into two parts. The objective of the preliminary study was to evaluate the optimum dose and tolerance of 5‐aminolaevulinic acid (5‐ALA) compared to a placebo cream with a 633‐nm LED light in normal, healthy, volunteer forearm skin. The second study was to establish if ALA‐PDT treatments improve the signs of ageing.

Results. Threshold photosensitization was observed using 5% 5‐ALA under plastic occlusion for 30?minutes following a dose response study of forearm skin. Mild improvement was observed, using this concentration and time, for periorbital skin aging. Other anecdotal positive results of photorejuvenation are reported for facial and chest areas.     

What is nonablative photorejuvenation of human skin?

Nonablative photorejuvenation has become an integral procedure in the emerging discipline of laser dermatologic surgery. The objective is to confine selectively, without any epidermal damage, thermal injury to the papillary, and upper reticular dermis leading to fibroblast activation and synthesis of new collagen and extracellular matrix material. The procedure results in minimal patient morbidity, no interference with lifestyle, and a low risk of complications, while providing a satisfying degree of rhytides reduction. Multiple devices have been studied and marketed for nonablative photorejuvenation of human skin. However, currently, nonablative photorejuvenation should not be considered an alternative to laser skin resurfacing. The skin surface is not removed or modified. What really occurs may be more accurately referred to as dermal "remodeling" or "toning" as a wound healing response is initiated and collagen regenerated. The narrow "therapeutic window" of laser-induced dermal heating and epidermal cooling must still be optimized so that effective treatments can be obtained routinely. Clinical verification of effective treatment parameters (irradiation wavelength, pulse structure, radiant exposure, cooling time) will be obtained through further human studies. Most importantly, understanding the relationship between the degree of dermal thermal injury and synthesis of new collagen and extracellular matrix material will be fundamental to predicting the clinical efficacy and limitations of nonablative photorejuvenation.     

Long‐term results of acitretin therapy for hidradenitis suppurativa. Is acne inversa also a misnomer?

Background Hidradenitis suppurativa (HS) is a distressing chronic inflammatory skin disorder which affects predominantly the groins and axillae. In analogy to acne, oral isotretinoin has been considered in the treatment of HS, although there are strong indications that this drug has only a very limited therapeutic effect. During the past 25 years scattered case reports have described promising results of treatment with acitretin. Objectives To evaluate the long‐term efficacy of acitretin monotherapy. Methods A retrospective study in 12 patients with severe, recalcitrant HS who were treated with acitretin for 9–12 months at one Dermatology Centre in the Netherlands between 2005 and 2007 and were followed up to 4 years. The patients were men and infertile women. The efficacy of the treatment was rated by the patients on global maximum pain of nodules and abscesses on a visual analogue scale (VAS) as well as by physician global assessment. Results All 12 patients achieved remission and experienced a significant decrease in pain as assessed by VAS. In nine patients long‐lasting improvement was observed, with no recurrence of lesions after 6 months (n = 1), 1 year (n = 3), > 2 years (n = 2), > 3 years (n = 2) and > 4 years (n = 1). Conclusions Acitretin appears to be an effective treatment for refractory HS, leading to reduction of pain from painful nodules and reducing the extent of the disease for a prolonged period.     

Photometric and clinical assessment of localized UVB phototherapy systems for the high‐dosage treatment of stable plaque psoriasis

BACKGROUND: Ultraviolet‐B (UVB) light sources are widely used for the safe and effective treatment of inflammatory skin conditions. The recent commercial introduction of fiber‐coupled UVB phototherapy systems facilitates the selective exposure and treatment of localized psoriasis plaques while permitting the safe use of high‐dosage treatments.

OBJECTIVE: In this study, the performance characteristics and clinical outcome of psoriasis treatments were assessed when using two technologically distinct sources of high‐intensity, fiber‐optically delivered therapeutic UVB.

METHODS: A pulsed, monochromatic 308?nm excimer laser and a continuous‐wave, incoherent UVB light source were compared using photosensitive recording papers, images captured with a CCD camera, and on the healthy and lesional skin of ten psoriasis patients.

RESULTS: Beam profile analyses and minimal erythema dose (MED) test spots revealed distinct energy distribution patterns from the two devices. The Guassian‐type laser beam energy distribution complicated MED determinations, whereas skin exposed to light from the incoherent UVB system developed a more uniform erythema. Both systems cleared the treated psoriasis plaques equivalently, requiring no more than two to five weeks of high‐dose treatments.

CONCLUSION: When used at equally erythemogenic high doses, both systems produced rapid plaque clearance with minimal side effects. Unlike conventional phototherapy, localized UVB minimizes exposure to the healthy skin, making it suitable for patients with mild to moderate psoriasis, individuals with recalcitrant plaques and for the successful treatment of lesions occurring on most body sites.     

Non‐sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin: Preliminary clinical report

This study evaluates results, adverse side effects and downtime of the protocol ‘ActiveFX’ for photodamaged facial skin. A non‐sequential fractional ultrapulsed CO₂ laser with specific settings is used in addition to a new computer pattern generator (CPG). From September 2006 to March 2007, 55 patients underwent this new ‘soft’ single‐session, single‐pass and full‐face ablative fractional treatment. The patients were evaluated at baseline and 1 and 3 months after the treatment using a five‐point scale. Seven aspects of photodamaged skin were recorded: global score, fine lines, mottled pigmentation, sallow complexion, tactile roughness, coarse wrinkles and telangiectasias. The results were compared with a non‐parametric statistical test, the Wilcoxon's exact test. Eight patients received a double‐pass treatment on the crow's feet regions and the improvement of the coarse wrinkles was analyzed with a quartile grading scale. Significant differences (p<0.05) between baseline and 1 and 3 months post‐treatment were observed for all features except telangiectasias. Coarse wrinkles presented a good improvement only in the regions submitted to a double‐pass. Minimal and isolated adverse side effects were noted and the downtime was very low. Non‐sequential fractional ultrapulsed CO₂ light treatment (‘ActiveFX’) can be considered an excellent alternative for photodamaged facial skin.     

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.     

Intense pulsed light (IPL) treatment for the skin in the eye area – clinical and cutometric analysis

Objective: The aim of the research was to establish the influence of IPL treatment on skin ageing in the eye area. Material and methods: This study included 24 women, aged 38–63 years (mean age was 48.04) with Fitzpatrick skin type II and III who underwent five successive treatment sessions with an IPL in two-week intervals. The Cutometer (Courage + Khazaka electronic) reference test was an objective method for the assessment of the biomechanical properties of the skin. The measurements were made in three places around the eye. The photo documentation was used to compare state of skin before and after three months of treatments. Additionally, patients filled in a questionnaire, which contained questions concerning self-assessment of the procedure effects. Results: Cutometric analysis showed significant improvement of skin elasticity (statistical significance level is mostly < 0.0001). The comparison of clinical changes in the therapy, based on photo documentation, showed a 25% improvement. Conclusions: This treatment was used in order to improve skin elasticity and decrease the amount and depth of wrinkles. It is a non-invasive treatment, with low risk of complications.     

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.     

The inherent capacitance of moisturising creams: A source of false positive results?

The capacitance is a frequently used measurement of skin hydration in vivo, therefore any potential for false capacitance results is of importance. This in vitro study is to investigate the capacities of moisturizing creams to cause false positive results. Adding different volumes of demineralised water and saline on dry clean plastic-backed tissue paper and measuring the capacitance values, the standard relation curve of capacitance value and volume of water was established. Four moisturizing creams, petrolatum, a protective cream and a gel were then applied to the same kind of tissue paper in constant volumes, and were measured for weights and capacitance values over a 1-hour period allowing the gradual evaporation of water and volatile elements. A positive linear relationship was found between volume of water and capacitance value. All the creams had inherent capacitance that correlated with their water content. The inherent capacitance of creams decreased over time and ultimately reached comparable low values. The decrease in capacitance correlated significantly with weight reduction, except for petrolatum, which showed negligible inherent capacitance and weight reduction. The rates of decrease in capacitance value versus cream weight were significantly different for different creams. The results assured that capacitance value correlates to water content, and the inherent capacitance of creams may contribute to false positive skin capacitance in vivo if measured before water and other volatile elements of creams evaporate from the skin surface. In addition, the inherent capacitance and its durability may be relevant characteristics for further comparative studies of moisturizers and their clinical efficacy.     

Comparison of histopathologic and clinical evaluations of pathergy test in Behçet's disease

Background The pathergy test, an important test in the diagnosis of Behçet’s disease, is currently applied with disposable/sharp needles and evaluated only clinically (no histopathologic evaluation). In this study, the usefulness of the pathergy test conducted intradermally and intravenously with disposable/sharp needles in the diagnosis and determination of the activation of the disease is studied in comparison with the test conducted with nondisposable/blunt needles. In addition, histopathologic evaluation of the pathergy test is compared with the clinical evaluation. Methods The study group consists of 43 Behçet’s disease patients together with 15 patients with dermatosis as the control group. The pathergy test was applied to the Behçet’s disease patients and the control group intradermally and intravenously with disposable/sharp and nondisposable/blunt needles. Results The results of the pathergy test on the patients and the control group were evaluated clinically and histopathologically. Conclusions Clinical evaluation of the pathergy test conducted intradermally with nondisposable/blunt needles is sufficient for both the diagnosis and determination of the activation of Behçet’s disease. Histopathologic evaluation of the test is not found to be more sensitive than the clinical evaluation.     

Comparison of effectiveness of 1,064-nm Nd:YAG laser and Nd:YAG laser–IPL combination treatments in hand skin rejuvenation

Objective: Evaluation of the efficacy and side effects of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and Nd:YAG laser–intense pulsed light (IPL) combination treatments in photorejuvenations of skin of the hand, and determining their impacts on patient satisfaction. Materials and Methods: Thirty-five female patients with signs of photoaging on the skin of their hands were included in the study. Three sessions of IPL and four sessions of Nd:YAG laser treatment were applied to the right hand in total with 2-week intervals between each session, whereas six sessions of Nd:YAG laser treatment were applied to the left hand of patients with 2-week intervals between each session. Results: The patients’ ages ranged between 31 and 78, and mean age was 60.77 ± 9.48. While there was no difference in pigment distribution, fine wrinkles, coarse wrinkles, and global scores between the right and left hand prior to treatment (p > 0.05), average pigment tone score was higher in the right hand with a statistically significant difference (p < 0.05). There was greater improvement in scores of pigment distribution, fine wrinkles, sallowness, pigment tone parameters, and global score on the right hand compared to left hand, which was statistically significant (p <0.001). Conclusion: In rejuvenation of photoaged dorsal skin of the hand, IPL–Nd:YAG laser combination treatment surpasses Nd:YAG laser treatment.     

Can text messaging results reduce time to treatment of Chlamydia trachomatis?

We assessed the impact of text messaging as the preferred method of communicating positive Chlamydia trachomatis test results in an urban sexual health clinic. Following the introduction of a text messaging service to communicate positive C trachomatis test results to patients, the time between test and treatment in 293 consecutive patients was compared with 303 historic controls. No significant difference was found in either median time to treatment for all patients (3 days in 2005; 4 days in 2007) or median time to treatment (both 7 days) for those not treated immediately. There was no significant difference in time to treatment between those using a landline or mobile phone. Mobile phone use was significantly higher in 2007. Overall, we treated more cases within 4 weeks in 2007 (98.6% cf 96%). The lack of difference in time to treatment showed the use of this technology is as effective as more traditional means of communication. The increase in cases of C trachomatis treated within 4 weeks may reflect the significant increase in mobile phone use and improved ability to contact people rather than simply the introduction of text messaging.     

The clinical spectrum of dermatomyositis and the new autoantibodies – with regard to two clinical cases with distinct associations

Dermatomyositis is a rare idiopathic inflammatory myopathy associated with different autoantibodies (anti-MDA5, anti-TIF1-γ) which are linked with typical and distinct phenotypes of dermatomyositis. We describe two cases that illustrate these diverse cutaneous and systemic manifestations.     

Birt-Hogg-Dubé syndrome: clinical and genetic studies of 20 families

Birt-Hogg-Dubé syndrome (BHD) is an autosomal-dominant genodermatosis characterized by skin fibrofolliculomas and an increased risk of spontaneous pneumothorax, renal and possibly other tumors. A causative gene (FLCN) on chromosome 17p has recently been identified. We here report clinical and genetic studies of 20 BHD families ascertained by the presence of multiple fibrofolliculomas or trichodiscomas in the proband. Pathogenic FLCN germline mutations were found in 11 (69%) of 16 probands tested and in 14 family members. Six different FLCN germline mutations were detected, four of which have not been reported previously. The clinical features were variable. None and less than 10 skin lesions were observed in two mutation carriers at the age of 67 and 29 years, respectively. Spontaneous pneumothorax was reported in four and renal carcinoma of mixed histological types in two of 36 BHD-affected individuals and/or FLCN mutation carriers. Both the prevalence of spontaneous pneumothorax and renal tumors appeared to be relatively low compared with previously reported data. Various other extracutaneous tumors were observed in 11 of 36 BHD-affected individuals and/or FLCN mutation carriers. This study of the second largest cohort to date contributes to the expanding data on the variable phenotype and underlying gene defects in BHD.     

Review of the chronology of clinical manifestations in 60 patients with Behçet's disease

BACKGROUND: The natural course of Beh?et's disease is not fully known. OBJECTIVE: The aim of the present study was to determine the occurrence of the symptoms retrospectively in chronologic order in patients with Beh?et's disease, diagnosed according to the criteria of the International Study Group for Beh?et's Disease. METHODS: A total of 60 consecutive patients (29 male and 31 female; aged 35.87 +/- 9.84 years) were involved in the study. The symptoms of the disease were retrospectively recorded in the time order of the manifestations per patient. RESULTS: Oral ulcer was the most commonly observed onset manifestation (51 of 60 patients: 85%), followed by genital ulcer (13 of 60 patients: 21.7%) and articular symptoms (10 of 60 patients: 16.7%). The duration between the oral ulcer and the fulfillment of diagnostic criteria was calculated to be 3.77 +/- 4.43 years. The same duration was 2.50 +/- 4.74 and 2.11 +/- 3.44 years for genital ulcer and articular symptoms, respectively. The duration between the time point of fulfillment of diagnostic criteria and the diagnosis (2.83 +/- 2.3 years) was found to be longer in female patients (3.2 +/- 2.5 years). The duration was also longer in patients having only mucocutaneous lesions (3.18 +/- 2.5 years) than in patients having serious organ involvement such as eye disease (1.63 +/- 0.7 years; p < 0.05). CONCLUSION: Our study indicates that oral ulcer is the onset manifestation in the majority of the patients and the disease is often diagnosed with a delay of several years after the appearance of the onset sign.