Treatments of Periorbital Hyperpigmentation: A Systematic Review.

BACKGROUND: Periorbital hyperpigmentation (POH) is an aesthetic concern for patients. Etiologies of the condition include pigmentary, structural, vascular, and mixed causes. OBJECTIVE: To systematically review the current literature for treatment of POH. METHODS: A systematic literature review was performed on PubMed. Search terms included "infraorbital dark circles," "dark circles," "periorbital hyperpigmentation," "idiopathic hyperchromia AND orbital," "under-eye circles," "ICHOR (idiopathic cutaneous hyperchromia of the orbital region)," "dark circles" AND "treatment," and "filler" AND "dark circles." RESULTS: A total of 39 studies were included. Effective treatments for POH include lasers, topical creams and serums, fillers, chemical peels, carboxytherapy, plasma-rich platelet injections, blepharoplasty, and normobaric oxygen. CONCLUSION: Soft tissue fillers and autologous fat grafting are most effective in treating dark circles due to volume loss. Blepharoplasty surgery is best when excessive skin laxity is the underlying cause. Various topical creams and chemical peels are useful in treating pigment-based POH, whereas lasers are mildly to moderately beneficial for both vascular and pigment types. Given the scarcity of high-quality evidence supporting these results, recommendations should be interpreted selectively. Additional randomized clinical trials studying POH will be helpful.

Skewed Distribution of Medical Spas and Aesthetic Physician Practices: A Cross-Sectional Market Analysis.

BACKGROUND: Medical spas have experienced a recent rise in popularity by consumers. Their regulations vary from state to state, especially concerning oversight and credentialing. A majority of aesthetic physicians were shown to have a medical spa within 5 minutes of their workplace. OBJECTIVE: Our study investigated the current market distribution of medical spas and physician practices in the aesthetic field. MATERIALS AND METHODS: For the 30 most populous cities, data were collected for medical spas and aesthetic physicians. Descriptive ratios were calculated, and various local factors were examined. RESULTS: The cities with the greatest number of medical spas were New York (374), Houston (297), and Los Angeles (227). The cities with the greatest number of aesthetic physicians were New York (365), Houston (135), and Chicago (122). Population size had significant relationships with number of medical spas (p < .000001) and aesthetic physicians (p < .000001). For ratio of medical spas to aesthetic physicians, the top cities were Las Vegas (9.17), Denver (3.86), and San Jose (3.65). In total, 73.3% of cities had more medical spas than aesthetic physicians. CONCLUSION: Certain cities have experienced an unequal distribution of medical spas. Further research should examine how this affects consumer decision-making for the selection of practice settings.

Hyperhidrosis and Aesthetics.

When one considers the avalanche of new indications and uses for botulinum toxins, it is truly surprising that this has all happened in such a short time. And the safety and dependability of these products are profound, when used appropriately. There is still much to be discovered about the potential of this agent when you contemplate the profound non-cosmetic benefits reported by clinicians and scientists from around the world. The mechanism of action has been studied in depth, and yet the benefits appreciated by people with chronic migraine or major depressive disorder, for instance, are unlikely to be explained by our current mechanistic understanding. Given that these toxins control acetylcholine at the motor end plates, and given that acetylcholine is central to practically every cell in the body, it will not be surprising to find that botulinum toxin researchers will be enjoying many decades of fruitful studies. The advent of the non-surgical aesthetic physician has helped push the clinical utilization of botulinum toxins well beyond its original adoption by oculoplastic surgeons in their patients with blepharospasm. We can expect that the next edition of this book to have a dozen or more new indications which will surprise us all.

Treatment Modalities for Cherry Angiomas: A Systematic Review.

BACKGROUND: Cherry angiomas are benign vascular proliferations of endothelial cells associated with aging. Currently, no mainstay of treatment for these vascular anomalies exists. OBJECTIVE: To review existing evidence-based therapies for the treatment of cherry angiomas. METHODS: A literature search in May 2019 was performed with PubMed Database and Cochrane Library using the following terms: "cherry angioma," "senile hemangioma," "senile angioma," "cherry hemangioma," and "Campbell de Morgan spots." RESULTS: Ten studies included in this systematic review reported laser therapy and nonlaser therapy as efficacious treatments for cherry angiomas. Among the laser therapies, pulsed dye laser (PDL) was preferred over potassium-titanyl-phosphate (KTP) and electrodessication (ED), based on decreased procedure-related pain. The neodymium-doped yttrium aluminum garnet (Nd:YAG) laser 1064 nm produced less pigmentary complications, whereas KTP and PDL risked pigmentary changes in darker-skinned individuals. Nonlaser therapies included cryotherapy, sclerotherapy, electrosurgery (i.e., ED, electrocoagulation), and radiofrequency ablation. No therapy proved to be superior. CONCLUSION: A variety of therapeutic modalities exist for the treatment of cherry angiomas. However, a limited number of high-quality studies explored the efficacy of treatments and compared treatment modalities. Light-based methods such as argon, KTP, Nd:YAG, intense pulsed light, and PDL, along with non-light-based interventions such as cryotherapy, electrosurgery, and sclerotherapy effectively treated cherry angiomas.

Experiences With Counterfeit Aesthetic Medical Devices and Injectables: A National Survey.

BACKGROUND: Counterfeit medical devices and injectables have recently garnered interest in the field of aesthetics. Unlike their original counterparts, these counterfeit products have neither been tested nor verified using certified quality control measures. OBJECTIVE: Our study investigated the pervasiveness of counterfeit products in the field as well as the experiences and attitudes of practitioners. MATERIALS AND METHODS: An online survey was distributed to current members of the American Society for Dermatologic Surgery (ASDS) and the American Society for Laser Medicine and Surgery (ASLMS). RESULTS: For medical devices, 37.4% have encountered counterfeits and 20.1% have experienced patients with adverse events from them. For injectables, 41.1% have encountered counterfeits and 39.7% have experienced patients with adverse events from them. Compared with their original, most respondents believe that counterfeits are worse in terms of reliability, safety, and effectiveness. The majority also believe that counterfeits are either very or extremely endangering to patient safety. CONCLUSION: Counterfeit medical devices and injectables are not uncommonly encountered. Overall, practitioners believe counterfeits are endangering patient safety and result in adverse events and think that either stricter rules and regulations or better enforcement of existing regulations is necessary.

Experiences With Medical Spas and Associated Complications: A Survey of Aesthetic Practitioners.

BACKGROUND: Medical spas have experienced a recent rise in popularity. However, rules and regulations vary nationwide. Given the number of complications attributable to medical spas, questions remain about currently regulatory practices and whether they are sufficient to protect patients from harm. OBJECTIVE: Our study investigated the current state of medical spas and their associated patient complications in the aesthetic field as well as the experiences and attitudes of practitioners. MATERIALS AND METHODS: A survey was distributed to current members of the American Society for Dermatologic Surgery. RESULTS: Of all cosmetic complications encountered in the past 2 years, the majority reported that the percentage of complications seen in their practice attributable to medical spas ranged from 61% to 100%. The most commonly cited complications from medical spas were burn, discoloration, and misplacement of product, whereas the most commonly cited treatments resulting in complications were fillers, intense pulsed light, and laser hair removal. For safety and outcomes, medical spas were rated as inferior to physician-based practices. CONCLUSION: Patient complications associated with medical spas are not uncommon. Overall, practitioners believe medical spas are endangering to patient safety, think that stricter rules and regulations are necessary, and request more support from the specialty medical societies.

Utility of Preinjection Aspiration for Hyaluronic Fillers: A Novel In Vivo Human Evaluation.

BACKGROUND: Hyaluronic acid (HA) fillers have increased in popularity. While complications are rare, practitioners should focus on their prevention. Preinjection aspiration remains controversial as an effective safety checkpoint. OBJECTIVES: Our study investigated the utility of preinjection aspiration as a safety checkpoint for HA fillers through comparison of physiochemical and rheological properties in a novel in vivo human model. METHODS: An in vivo human model consisted of a cannula inserted into a peripheral vein. Preinjection aspiration was evaluated using syringes of 10 commonly used HA fillers. The time required to visualize a flash was recorded. RESULTS: Using a multivariable regression model, needle gauge, HA concentration, elastic modulus (G'), viscous modulus (G″), and complex modulus (G*) had significant relationships with time to flash, whereas pullback volume did not. However, when comparing pullback volume using a more appropriate paired analysis, 0.5 cc pullback volume had a significantly decreased time to flash than 0.2 cc. CONCLUSIONS: Preinjection aspiration for HA fillers has utility as a safety checkpoint. The times to visualize flashback decreased when using a human peripheral vein model compared to a previous in vitro model, suggesting that there may be real-time clinical utility of preinjection aspiration. Waiting times to visualize flashback may be affected by physiochemical and rheological properties. Additional studies would help to validate our results.

Public social media consultations for dermatologic conditions: an online survey.

The use of social media in medicine has been increasingly studied in recent years, especially concerning its role in patient outreach, education, diagnosis, and management. Dermatology is a unique field in that patients can post photographs of their skin ailments when seeking online medical advice and information. This study examines the role of public social media consultations for dermatologic conditions. A large portion of patients utilize social media for dermatologic consultations and many do not seek care from a dermatologist afterward. Future studies should trend this phenomenon, especially as the use of social media continues to expand.

Evolution of the Picosecond Laser: A Review of Literature.

BACKGROUND: Picosecond pulse duration lasers (PS) have altered the field of dermatology. PS were initially used in tattoo removal, to optimize efficacy and reduce side effects with nanosecond domain lasers. More recently, they have been demonstrated to be effective in the treatment of pigmentary disorders, acne scarring, and photoaging. OBJECTIVE: In this article, we critically analyze the published data on the many uses of picosecond lasers in dermatology. MATERIALS AND METHODS: A systematic review of PubMed was conducted using the following search terms: "picosecond," "picosecond laser," "picosecond laser dermatology," "picosecond laser pigment/pigmentation," and "picosecond laser tattoo removal." Articles ranged from 1988 until 2017. RESULTS: Forty-one articles were identified, and 27 met inclusion criteria for review. Indications for the PS included a variety of dermatologic applications include tattoo removal, benign pigmented lesions/pigmentary disorders, acne scarring, and photoaging. Most studies demonstrated safe and effective treatment. CONCLUSION: The development of the picosecond pulse duration is a breakthrough innovation in laser technology, changing the scope of laser treatment. Encouraging findings in tattoo pigment clearance spurred the use of PS in a wider array of dermatologic issues. The increasingly positive results and low incidence of adverse effects further substantiates PS efficacy for a variety of dermatologic uses.

Laser Treatment of Skin of Color for Medical and Aesthetic Uses With a New 650-Microsecond Nd:YAG 1064nm Laser

Individuals with skin of color are a rapidly growing portion of the cosmetic procedures market. There are unique challenges to treating skin conditions in skin of color patients. This article and roundtable discussion focus on the use of energy-based modalities, particularly a 650-microsecond 1064nm laser that delivers energy in a collimated beam. Alone or in combination with other therapies, the 650-microsecond 1064nm laser has been used successfully to treat melasma, acne, postinflammatory hyperpigmentation, pseudofolliculitis barbae, hair removal, acne keloidalis nuchae, and aging skin in skin of color. J Drugs Dermatol. 2019;18(4 Suppl 1):s135-137.

Practical Applications for Medical and Aesthetic Treatment of Skin of Color With a New 650-Microsecond Laser

The following roundtable is edited from discussion between the authors concerning treatment with the 650-microsecond 1064nm Nd:YAG laser. These dermatologist experts share their expertise, experience, and treatment pearls regarding the device for medical and aesthetic use, and in treatment of skin of color (SOC).

Treatment of pseudoxanthoma elasticum-like papillary dermal elastolysis with nonablative fractional resurfacing laser resulting in clinical and histologic improvement in elastin and collagen.

OBJECTIVE: Pseudoxanthoma elasticum-like papillary dermal elastolysis (PXE-PDE) is a rare skin condition seen predominantly in elderly females. These asymptomatic lesions are brought to the dermatologist's attention due to patient's displeasure in their appearance. We report a case of a 28-year-old female with PXE-PDE on the right neck treated with nonablative fractional resurfacing (NAFR). CASE: The patient on examination had yellow-to-skin-colored papules that coalesced into a cobblestone-appearing plaque on her lateral neck. The area was treated with NAFR to improve texture and cosmesis. After three treatments, the patient noted at least a 50% improvement of appearance and texture in the affected skin. Adverse effects were mild without development of serious side effects, such as scarring and/or permanent dyspigmenation. CONCLUSION: Established therapies for elastin disorders like PXE-PDE have yielded unsatisfactory results by patient and clinician standards. Positive results with NAFR, illustrated in our PXE-PDE case, further provides a role for NAFR in elastin disorders.

Vaginal rejuvenation: whose turf?

Many medical conditions can cross over the territories of various specialties. These conditions may benefit from, or even require, a multidisciplinary approach. While ideally this leads to a collaborative and coveted patient-centered care model, it can also give rise to competitive turf wars. A popular topic that has entered the turf wars is vaginal rejuvenation. Vaginal rejuvenation through light- and energy-based devices is a rapidly expanding field, quickly gaining the attention of dermatologists and gynecologists alike. Dermatology has the most experience and expertise with lasers and energy-based devices for rejuvenation, whereas gynecology has the advanced knowledge of the vaginal anatomy, tissue structure, and function. We herein argue that a collaborative effort between dermatology and gynecology is most appropriate for proper care of our patients and for the advancement of this growing niche.

Striae Distensae: Preventative and Therapeutic Modalities to Improve Aesthetic Appearance.

BACKGROUND: Striae distensae (SD) are aesthetically troublesome to patients and therapeutically challenging. OBJECTIVE: Herein, the authors comprehensively review the literature pertaining to the history, pathogenesis, clinical presentation, clinical rating scales, and laboratory, imaging, and histologic features of SD. METHODS AND MATERIALS: A review of PubMed, MEDLINE, Scopus, Embase, and Google scholar was conducted, including literature published from 1773 to August 6, 2016. RESULTS: The authors identified 68 articles that met inclusion and exclusion criteria. CONCLUSION: There are few randomized controlled trials evaluating the long-term efficacy and safety of various topical and energy-based devices. Based on clinical and anecdotal experience, both nonablative and ablative fractionated lasers have shown modest SD improvement compared with other treatment modalities (including Excimer laser, CuBr laser, pulsed dye laser, and 1,064-nm Nd:YAG laser). In the authors' experience, 1,540-nm nonablative fractionated laser is a worthy first-line modality for the treatment of SD. Future researchers may consider greater focus on enhanced study design, including larger, long-term split-body, or split-SD head-to-head randomized comparative trials with objective outcome measures and end points, such as biopsy and molecular studies demonstrating increased collagen and elastic fibers that correlate to clinical improvement.

1060 nm Diode Hyperthermic Laser Lipolysis:The Latest in Non-Invasive Body Contouring.

Non-invasive body contouring is becoming increasingly popular in the United States. Using the 1060 nm diode laser to achieve hyperthermic temperatures within the adipose tissue with subsequent lipolysis is one of the most recent advancements in this field and is the first of its kind. This wavelength was carefully chosen to effectively target the unwanted adipocytes while sparing the overlying skin and adnexae. Appreciable results are achieved after a single treatment, and these results are comparable to other non-invasive technologies. The 25-minute procedure is well tolerated among patients, with no downtime required. This versatile system allows for treatment of multiple body sites, which can be customized for a particular patient's needs. Herein, we discuss in detail the mechanism of action, efficacy, and safety of 1060 nm diode hyperthermic laser lipolysis. Amongst the various body contouring modalities available today, the 1060 nm diode hyperthermic laser is a worthy addition providing a safe, quick, and effective non-invasive fat reduction option for patients. J Drugs Dermatol. 2017;16(1):48-52..

Advances in fractional technology for skin rejuvenation, skin tightening, drug delivery, and treating scars and skin defects.

The development of fractional photothermolysis has revolutionized the treatment of skin scarring, rejuvenation, and tightening. By creating targeted microthermal zones and leaving surrounding tissue intact, this concept has provided the field with efficacious results, with less downtime and a better safety profile. This has started to change the paradigm of what is considered first-line treatment for scarring and rejuvenation. While originally applied to nonablative lasers, fractionation has now been employed in ablative, quality-switched, picosecond, and novel hybrid fractional lasers. Furthermore, other energy-based technologies, such as radiofrequency, have adopted the concept of fractionation in an attempt to optimize the balance of efficacy, downtime, and side effects. Herein, we describe how the ever-expanding repertoire of fractional devices is applied to the treatment of scarring, skin rejuvenation, and tightening. In addition, newer applications, such as transdermal drug delivery, are being developed by using fractional devices. Growing experience with these devices has broadened their relevance to more skin types and body sites than ever. Ultimately, the knowledge of appropriate treatment parameters is paramount and allows for the safe and effective treatment of a variety of patients with numerous devices.

Non-ablative fractional resurfacing in the treatment of scar contracture.

BACKGROUND AND OBJECTIVES: A 28-year-old female presented with extensive scarring after a traumatic injury to her right lower extremity. She had been hit by a vehicle one year prior to presentation and had several open fractures with extensive overlying cutaneous damage, which required multiple surgeries and skin grafts. She had limited range of motion of the affected limb secondary to scar contracture. STUDY DESIGN/MATERIALS AND METHODS: The patient received 6 treatments with a non-ablative fractional resurfacing (NAFR) device with two wavelengths (Fraxel DUAL, Solta Medical, Hayward, CA) spaced 4-8 weeks apart. The patient received two treatments with the 1927 nm NAFR thulium laser (10 mJ, 30% density, 8 passes) and two treatments with the 1550 nm NAFR laser (40 mJ, 17-26% density, 8 passes). Before and after treatment photographs were taken, as well as range of motion measurements with respect to her right ankle. RESULTS: The patient had 50-75% improvement in the texture and discoloration. There was both subjective and objective improvement in the range of motion of her right lower extremity. The patient experienced mild erythema and edema, both of which resolved after 7-10 days. CONCLUSION: Recent studies have shown great functional improvement in scar contractures with ablative fractional laser treatments; however, these treatments are accompanied by significant downtime along with risk of further scarring and infection. NAFR is an accessible treatment with a low side effect profile and to our knowledge has not been reported as efficacious in the treatment of scar contracture. This case report is novel in its demonstration of the utility of a dual wavelength NAFR in the treatment of scar contracture and functional impairment.

Port wine stain treated with a combination of pulsed dye laser and topical rapamycin ointment.

BACKGROUND AND OBJECTIVE: A port wine stain (PWS) is a type of capillary vascular malformation composed of malformed, dilated blood vessels within the papillary and reticular dermis. Currently, pulsed dye laser (PDL) is considered the therapeutic gold standard, although greater than 90% of lesions may be refractory to treatment. Studies have shown that a delay in treatment results in a higher proportion of patients who develop hypertrophy and nodularity within lesions that become more resistant to therapy. Therapeutic resistance is multifactorial, but is believed to be largely due to revascularization after laser treatment. Oral sirolimus and topical imiquimod have shown promise as adjunctive therapies to minimize post-laser revascularization, but both have significant side effects. We wish to demonstrate the utility of adjunct topical sirolimus to reduce revascularization after PDL treatment. STUDY DESIGN/PATIENTS AND METHODS: This is a single patient case report of a 56-year-old male patient with an extensive PWS. After seeing initial improvement with PDL alone, he began to experience thickening and nodularity of his PWS necessitating surgical debulking. Since this procedure, topical sirolimus 0.5% ointment has been added to his treatment regimen as an adjunct to PDL. The patient is being treated with PDL (Vbeam Perfecta, Candela/Syneron, Wayland, MA) every 4-6 weeks at varied settings with the following laser parameters: fluence 9-11 J/cm(2), pulse duration 0.45-1.5 ms, focal spot size 7 mm, cooling 30/20. Sirolimus 0.5% ointment is applied to the area twice daily. RESULTS: The patient showed significant improvement in color and texture of his PWS. Compared to the initial therapy of PDL alone, topical sirolimus ointment in conjunction with PDL demonstrated greater improvement and maintenance of therapeutic results with fewer overall laser treatments. CONCLUSION: Topical sirolimus 0.5% ointment is a safe and effective adjunct to PDL in the treatment of PWS.

Evaluation of a 1540-nm and a 1410-nm Nonablative Fractionated Laser for the Treatment of Striae.

BACKGROUND: Aesthetically, striae distensae (SD) are a source of great concern. No treatment modality is currently considered the gold standard. However, studies of nonablative fractionated lasers (NAFLs) have been promising. OBJECTIVE: To evaluate and compare the clinical and histopathologic efficacy and safety of a 1540-nm NAFL and a 1410-nm NAFL for the treatment of SD. METHODS AND MATERIALS: Nine patients with abdominal striae were treated for 6 sessions-half of the abdomen was treated with a 1540-nm NAFL whereas the other half was treated with a 1410-nm NAFL. Photographs were taken at baseline and at the 3-month follow-up visit, when subjects were given a questionnaire. Two blinded dermatologists scored the photographs using a pre-established clinical scale. Biopsies were taken from 2 subjects and graded by 2 dermatopathologists using a pre-established pathology scale. RESULTS: All 9 subjects demonstrated clinical improvement bilaterally after treatment. Skin biopsies after treatment showed an increase in epidermal thickness, dermal thickness, and collagen and elastin density when compared with baseline. Clinical and histopathological differences between the 2 lasers were not statistically significant. CONCLUSION: Treatment with both the 1540-nm and the 1410-nm NAFL was shown to improve SD clinically and histopathologically. Further studies are needed to optimize treatment parameters.