Use of cutaneous lasers and light sources: appropriate training and delegation.

In recent years, there has been increasing concern among physicians, patient advocacy groups, and media watchdogs that laser, light, and cosmetic surgery are being practiced by poorly trained professionals, with resulting preventable injuries to patients. In response, several professional organizations have developed guidelines for the delegation of laser services to nonphysician providers. These guidelines delineate appropriate qualifications for delegating physicians and nonphysician providers, and also describe the circumstances and settings in which delegation is appropriate.

Coal tar phototoxicity: characteristics of the smarting reaction.

We examined the properties and ultraviolet exposure parameters of tar smarts in an effort to elucidate the mechanisms involved. We showed that irradiation with 1 minimal smarting dose (MSD) of UVA immediately following tar removal lowered the MSD for 6 h, demonstrated by subsequent challenge with UVA. Following 3 MSDs this "memory" effect was demonstrable for 24 h. The smarting reaction was area dependent--smaller areas of exposure require higher doses of UVA to induce smarting. Smarting followed reciprocity over a 6-fold range of irradiances (2-12.5 mW/cm2) but higher irradiances required higher doses of UVA, perhaps due to a delay in the recognition and reporting of smarting. The smarting reaction and delayed erythema due to UVA and tar were equally blocked by sunscreen.

Cutaneous tissue repair following CO2 laser irradiation.

We studied the mechanism of repair following exposure of normal skin to the CO2 laser in a focused mode. Exposed areas were biopsied at 0, 24, 48 h; 1, 2 weeks; 1, 2 1/2 months (pulse width varying from 0.1 to 1.0 s) after irradiation. The initial pattern was a V-shaped zone of cauterized collagen with a central crevice, the depth of which correlated with the total energy applied. The epidermal changes consisted of transepidermal cauterization and basal vacuolar changes lateral to the site of impact. Over a period of 1 week, the wound crevice decreased in depth and width and the central margins of the zone of cauterized collagen approximated. The cauterized collagen was extruded and was noted in the epidermal crust; minimal granulation tissue was present. Biopsies at later time periods showed formation of granulation tissue and retention of small amounts of necrotic collagen; the process of collagen extrusion was largely prevented by suturing. These observations show that dermal contraction and necrotic collagen extrusion are important components of initial tissue repair following limited dermal destruction produced by CO2 irradiation.

Inhibition of cutaneous contact hypersensitivity in the mouse with systemic or topical spiperone: topical application of spiperone produces local immunosuppression without inducing systemic neuroleptic effects.

We tested the ability of the neuroleptic agent spiperone (8-[3-(p-fluorobenzoyl)propyl]-1-phenyl-1,3,8-triazaspiro-[4.5] decan-4- one) to influence the tissue swelling and leukocyte infiltration associated with T-cell--dependent immune responses, i.e., contact hypersensitivity reactions, in mice. Contact hypersensitivity reactions were elicited by applying the haptens oxazolone or dinitrofluorobenzene topically to one or both ears 5-8 d after epicutaneous sensitization. When spiperone was given subcutaneously at a dose of 30 or 150 mg/kg, 1 h after challenge with oxazolone, cutaneous contact hypersensitivity to this hapten was significantly diminished. When applied topically in concentrations as low as 0.08% (w/w), preparations of spiperone significantly suppressed both the tissue swelling and the leukocyte infiltration associated with the elicitation phase of contact hypersensitivity. Topical treatment with spiperone also suppressed the sensitization phase of contact sensitivity. However, mice treated topically with spiperone, unlike those treated systemically, exhibited no drowsiness or other evidence of central nervous system effects. Spiperone expresses both serotonin and dopamine receptor antagonist activity. However, unlike spiperone, the chemically unrelated serotonin antagonists, trazadone and mianserin, and the dopamine receptor antagonist, haloperidol, were not effective in suppressing contact hypersensitivity. Our results indicate that spiperone can have immunosuppressive effects on contact hypersensitivity reactions in the mouse, even when applied topically in doses that lack neuroleptic effects, and that the mechanism of action of spiperone on the immune response may be independent of its serotonin or dopamine receptor blocking properties.

Coal tar phototoxicity: kinetics and exposure parameters.

We examined two manifestations of coal tar phototoxicity: delayed erythema and skin pain (tar smarts) by quantifying the amount (dose) of UVA and exposure conditions required to induce these phenomena in normal human skin. The minimal UVA dose required to induce delayed erythema (minimal phototoxic dose or MPD) and the minimal UVA dose required to induce an immediate smarting reaction (minimal smarting dose or MSD) were recorded in 32 subjects in a variety of settings. A log-log dose-response model described the relation between the interval of time tar was left on the skin and lowering of MPD. We examined 4 different methods of tar removal and showed that several methods using more than water alone were equally effective--judging by resultant phototoxicity. The time between tar removal and UVA irradiation is important. Even 30 min was sufficient for the MPD to increase from 3.77 +/- 1.55 to 6.1 +/- 4.0 J/cm2 (p less than 0.02). The smarting reaction shows a similar dependence on the time interval between tar removal and exposure. The mean MSD was less than the mean MPD at all times tested. Both manifestations of coal tar phototoxicity, reduced delayed erythema threshold and susceptibility to the smarting reaction, persisted at least 30 h after tar removal.

Low-fluence CO2 laser irradiation: selective epidermal damage to human skin.

The interaction of normal human skin with low-fluence CO2 laser irradiation was studied using a three-phase approach. In phase one, freshly excised skin was observed immediately after impact. In phase two, skin irradiated 2 h prior to excision was studied. In phase three, human volunteers were irradiated and biopsied at time zero, 24 h and 48 h. Seventy-five sites were exposed and 60 biopsies were performed. The earliest histologic changes were observed in the 6-10 J/cm2 fluence (radiant exposure) range and these changes included spindle and vacuolar changes in the basal layer of the epidermis. Papillary dermal coagulation was present to a maximum of 0.03 mm. At fluences of 10-25 J/cm2, superficial dermal necrosis (0.06-0.08 mm) was observed. At fluences above 25 J/cm2, transepidermal necrosis was present with increasing papillary dermal necrosis that was in proportion to the energy density delivered. At 2h, basal vacuolar changes were accompanied by diffuse keratinocytic cell death where contact was maintained between the epidermis and dermis, while where separation occurred limited keratinocytic death was observed. The earliest changes occurred at lower threshold fluences (4-6 J/cm2). After 24 h, these doses resulted in extensive epidermal necrosis with focal acute inflammatory infiltrates. At 48 h, the degree of epidermal "slough" was proportional to the energy density delivered and was maximal with a fluence of 5.7 J/cm2 delivered whereas with a fluence of 3.8 J/cm2 thin slough (0.02 mm) was observed. These findings suggest that low-dose CO2 laser irradiation may provide a new approach to selectively damage the epidermis with minimal dermal damage.

In vivo spectrophotometric evaluation of normal, lesional, and laser-treated skin in patients with port-wine stains.

The influence of patient age and argon laser therapy on port-wine stains (PWS) was studied quantitatively in 16 patients aged 15-64 years using a spectrophotometer and computer graphics/statistics program. Normalized reflectance curves revealed a 10-20% decrease with age in the reflectance of normal skin from 400 nm to 650 nm, with an even more pronounced reflectance decrease in the region of peak deoxyhemoglobin absorption at approximately 555 nm. In each patient, PWS reflectance was less than that in the normal skin, as expected, and the average discrepancy increased with age from approximately 25% to 50%, with further reduction at 555 nm. The data suggest that with advancing age, both normal skin and PWS have a greater total hemoglobin content and an increased proportion of deoxyhemoglobin, consistent with increasing vascular dilation and tortuosity; and that the age-associated changes in PWS are an exaggeration of those in normal skin. Laser-treated PWS in both young and old patients had reflectance curves indistinguishable from those of untreated PWS in young patients. This implies, contrary to published clinical impressions, that in the absence of scarring the results of argon laser therapy are the same in young and old patients, but that only older patients experience a significant color shift in the lesion.

Failure of hypnotic suggestion to alter immune response to delayed-type hypersensitivity antigens.

The ability to alter delayed-type hypersensitivity via hypnotic suggestion was tested in 12 highly hypnotizable, untrained subjects and 30 nonhypnotized controls. Subjects were skin-tested bilaterally with a standardized panel of delayed hypersensitivity antigens and instructed either to enhance or suppress the skin test response unilaterally. Compared with results in controls, the skin test response reflected no effect of hypnotic suggestion with regard to either the area of induration or the degree of inflammation assessed histologically.

Information excess in medicine. Overview, relevance to dermatology, and strategies for coping.

BACKGROUND: The amount of biomedical information contained in scientific journals has grown to the point that complete coverage of this material is impossible. The number of articles and journals being published has been growing at an exponential rate since 1750. Thirty-four thousand references from 4000 journals are added each month to the National Library of Medicine MEDLINE database from among the more than 100,000 scientific journals now published. This increase in scientific literature reflects not greater productivity but simply a larger number of scientists at work. Most articles written are eventually published in the medical literature, but a large number of scientific articles are of less than optimal quality, and most scientific articles that are published are never cited. Articles of higher quality and usefulness cluster in a few journals that enjoy great use in medical libraries and high scores on bibliometric scores such as the Science Citation Index. OBSERVATIONS: To assess the reading habits of dermatologic trainees and evaluate how they cope with this information excess, a survey was distributed to 36 residents in three training programs. The average number of medical journal reading hours per month was 17; the number of hours devoted to reading issues of the Archives of Dermatology, the Journal of the American Academy of Dermatology, and the Journal of Investigative Dermatology were 3.2, 5.0, and 1.4, respectively; and the average resident read seven peer-reviewed journals, two to four dermatologic tabloids, and four peer-reviewed medical journals. CONCLUSIONS: Critically and consistently reading a limited number of high-quality peer-reviewed journals as well as taking advantage of information available through computer networks and bibliographic and full-text databases is the best approach to coping with the volume of medical literature. Translating this information into a change in attitude and modification of physician behavior is best accomplished when local role models incorporate new ideas into their practice and teaching. Modifications that would, in fact, bring about truly useful changes, such as decreasing the number of new publications, melding journals already present into smaller numbers of publications rather than instituting new journals, altering the "publish-or-perish" rules, and writing more comprehensive articles rather than multiple small contributions, all await fundamental alterations in long-accepted policies in medicine.

Top-cited dermatology authors publishing in 5 "high-impact" general medical journals.

BACKGROUND: In addition to publishing in the dermatologic literature, some dermatologists also publish articles in the general medical journals, which enjoy wide circulation and whose articles are often cited. OBJECTIVE: To identify articles and citations to these articles that the most frequently cited authors in the dermatologic literature published in highly cited general medical journals. DESIGN: We obtained a citation database from the Institute of Scientific Information, Philadelphia, Pa, that identified all articles published by the top-cited authors in the dermatologic literature in 5 "high-impact" general medical journals. SETTING: The 5 high-impact general medical journals with the historically highest impact factors. SUBJECTS: Two hundred top-cited authors in dermatology journals and their coauthors. MAIN OUTCOME MEASURE: Number of citations to articles published in 5 high-impact general medical journals. RESULTS: From 1981 to 1998, 120 of the 200 top-cited dermatology authors published a total of 674 papers in the 5 most highly cited general medical journals. Original articles published in these high-impact general medical journals were cited an average 7.5 times more often than articles published in dermatology journals. CONCLUSIONS: Top-cited authors in dermatology journals also frequently publish in the leading 5 high-impact general medical journals. Publications in these journals by dermatologists are often highly cited.

Organizational impact in the dermatologic literature.

We revisit our citation data derived from 58,201 articles published between 1981 and 1994 in the 17 top-ranked peer-reviewed international dermatology journals to identify the institutions that house the people who have made the greatest impact on the dermatologic literature during this period. Using these citation data, we estimate an institution's impact in 2 ways. First, institutions are ranked by the gross number of citations to articles from 1981 to 1994 accurred during this same period. To recognize institutions whose articles, on average, have received higher numbers of citations, we also rank institutions by the average number of citations received by each article published by a particular institution (blended impact factor).

The impact of dermatology journals.

As the scientific literature continues to burgeon, readers must develop strategies to efficiently glean important information from the thousands of journals published each month. Citation data can provide quantitative estimates of a journal's usefulness to the scientific community. Annually, Journal Citation Reports calculates and publishes impact factors for all the journals that are indexed by the Science Citation Index. The 1993 impact factors have been calculated by dividing 1993 citations to the 1991 and 1992 published items of a particular journal by the total number of published items in that journal from 1991 and 1992.

Growth of international contributors to dermatologic literature.

BACKGROUND: In the past, authors from a few countries dominated the publication of articles in dermatologic journals that were cited. The growth of dermatology in many additional countries has set the stage for a broader national representation of the authorship of the most frequently cited dermatologic articles. OBJECTIVE: To quantify changes in the number and proportion of citations and articles credited to authors from various countries from 1981 to 1996. DESIGN: We obtained a citation database from the Institute for Scientific Information, Philadelphia, Pa. From this database, we quantified the average number of articles and citations according to the year of publication, journal, and the countries from which authors came. SETTING: Dermatology journals. SUBJECTS: All articles published in 24 dermatology journals between 1981 and 1996. MAIN OUTCOME MEASURES: Country of origin of articles and number of citations of these articles. RESULTS: Authors from 121 countries were credited in whole or in part with authorship of original articles. Ten countries accounted for 82% of all articles published as original articles and 87% of citations to these articles. From 1981 to 1996, the proportion of citations attributed to most western European except Scandinavian countries grew significantly (P<.05, t test), but the proportion credited to authors from the United States fell significantly (P<.05, t test). CONCLUSIONS: International representation of author-cited articles appearing in the dermatology literature is increasing. The growth of scholarly contributions has been especially great for authors from western Europe except Scandinavia.

Top cited authors in dermatology: a citation study from 24 journals: 1982-1996.

BACKGROUND: One measure of the impact of a medical article is how often it is cited in other articles. Many authors of articles published in dermatologic journals are seldom, if ever, cited while other authors are often cited. OBJECTIVE: To identify the 25 authors whose publications in the dermatology literature were most often cited. DESIGN: We obtained a citation database from the Institute for Scientific Information. From this database we separately quantified the total number of citations for each author and the total number of citations to first authors of original articles. SETTING: Dermatology journals. SUBJECTS: All authors of papers published in 24 dermatology journals between 1981 and 1996. INTERVENTION: None. MAIN OUTCOME MEASURE: Number of citations. RESULTS: If all articles irrespective of the author's listing (eg, first or second) are counted, the top 25 cited authors in the dermatology literature from 1981 to 1996 were cited between 1480 and 4706 times. If only citations and articles of which an author was the first listed author are counted, the top 25 authors were cited between 400 and 813 times. Only 4 authors were among the top 25 cited authors by both criteria. CONCLUSIONS: A relatively small proportion of all authors account for a high proportion of all citations of the dermatologic literature. The most frequently cited first authors of original articles were different in 84% of cases from the most often cited authors of all papers irrespective of the individuals placement in the authorship listing.

Classic and near-classic articles in the dermatologic literature.

BACKGROUND: Only a small fraction of articles published in the dermatologic literature are cited frequently. Articles cited at least 100 times are known as "citation classics" and have been previously discussed. The nature of dermatologic articles cited fewer than 100 times but still much more frequently cited than average has not been clearly elucidated. OBJECTIVE: To identify the source, authorship, and citation history of original articles published in 24 dermatologic journals that were cited more than 25 times. DESIGN: We analyzed a citation database provided by the Institute for Scientific Information. We identified the journal of publication, authorship, and country of authorship for all original articles cited at least 25 times and published from 1982 to 1996 in 24 dermatologic journals. MAIN OUTCOME MEASURE: Source of most frequently cited dermatologic articles. RESULTS: Only 2139 (6.45%) of all original articles were cited more than 25 times. Articles published in 4 of 24 journals accounted for the most frequently cited articles. Only 18 (0.13%) of more than 13,500 first authors published at least 5 articles that were cited more than 25 times. CONCLUSIONS: Few articles are cited at least 25 times, and few persons are first authors of multiple articles in the dermatologic literature cited at least that frequently.

Citation classics in clinical dermatologic journals. Citation analysis, biomedical journals, and landmark articles, 1945-1990.

BACKGROUND AND DESIGN: Analysis of the most frequently cited dermatology articles and the journals in which they appear identifies and emphasizes the impact of works of colleagues and predecessors, recognizes key advances in cutaneous medicine and surgery, and adds useful data about historical developments in dermatology. Use of citation analysis to examine the dermatologic literature reveals quantitative information about authors, articles, and journals helpful in identifying classic works and high-impact journals. We analyze the characteristics of all dermatology articles cited 100 or more times in one of the 10 most highly ranked clinical dermatology journals as indicated by the Institute of Scientific Information (Philadelphia, Pa) database from 1945 through 1990 and also discuss the standard and, as well, more recently described bibliometric indexes for dermatologic journals. RESULTS: Thirty-one institutions located in 11 different countries produced 129 landmark articles. Ninety-two percent of the citation classics originated in the United States, United Kingdom, Sweden, and Germany. There were 16 authors with three or more top-cited articles. Fifty-two percent of the articles were of the clinical type, 22% were clinical review articles, and 26% discussed basic science topics. The mean number of authors has increased gradually over the past 80 years. The average classic article was published in 1969, peaked in popularity 9 years later with 26 peer citations, and received only 11 citations in 1990. CONCLUSIONS: Citation frequency and citation analysis reveal useful and interesting information about scientific communication. The data on citation classics we describe can be interpreted in many ways, but certainly reflects the attention that articles have received over the past 48 years. The half-life of the average citation classic of about 10 years reflects the rapid pace of advances in the science and practice of dermatology over the past several decades. This information, along with current bibliometric indexes, may assist physicians in optimizing the time they spend reading the medical literature.

Argon laser-port-wine stain interaction. Immediate effects.

Biopsy specimens from 11 patients with port-wine stains were examined by routine paraffin sections immediately after argon laser therapy, and the findings were correlated with those seen in 1-micron epoxy resin-embedded sections and with immunofluorescence microscopy studies localizing factor VIII-related antigen and type IV collagen. The histopathologic pattern was that of an arc-shaped injury to the papillary and upper reticular dermis, extending to a depth of 0.45 mm. Most of the abnormal vessels in the port-wine stain were encompassed in this zone and showed severe injury. Erythrocytes in these vessels displayed changes, ranging from near normal to complete fragmentation. Focally, vessels adjacent to the area of major injury contained clumped erythrocytes with tinctorial changes but intact walls. In two specimens, alterations in basement membrane and endothelial immunofluorescence staining patterns were present in the zones adjacent to the major cauterized areas, extending focally to a depth of 0.75 mm. This study suggests that, in addition to the major nonspecific destructive component of argon laser therapy, there is a smaller adjacent "specific" zone of damage in which collagenous stroma is maintained and chromophore content becomes important as a determinant of injury.

Port-wine stains. Morphologic variations and developmental lesions.

Studies have shown that port-wine stains (PWSs) probably represent a progressive ectasia of the superficial cutaneous vascular plexus. During examination of approximately 500 patients with PWSs, seven lesions were identified that could be categorized into two groups. In one group (two patients), the typical superficial PWS was accompanied by a proliferation and ectasia of thin-walled vessels in the deeper dermis, subcutaneous adipose tissue, and skeletal muscle (cavernous hemangioma). In the other group (five patients), single or multiple polypoid tumors arose that consisted of a proliferation of vessels with walls of varying thickness, and intervascular stroma (arteriovenous malformation). These tumors appear to arise in both young patients with flat lesions as well as the older patients with pronounced surface irregularities. Two patients were specifically chosen because they represented the typical PWS cobblestone pattern. This vascular abnormality represents a localized exaggeration of the ectasia process. We conclude that a small number of PWSs are associated with an underlying cavernous hemangioma. Furthermore, besides the surface irregularities that characterize the older PWS, de novo vascular tumors arise that can be categorized as arteriovenous malformations.

Complications of cutaneous laser surgery. A survey.

We surveyed a selected group of 139 dermatologists and plastic surgeons about their experience with the complications of cutaneous laser surgery. Reported complication rates varied from 0% to 35%, with means of 3.2% for dermatologists and 6.2% for plastic surgeons using the argon laser, and 4.2% for dermatologists and 2.8% for plastic surgeons using the carbon dioxide laser. Hypertrophic scarring was the complication noted most frequently; 69% of physicians using the argon laser and 64% of physicians using the carbon dioxide laser have seen at least one case of hypertrophic scarring. Complications noted less frequently include infection, pain, atrophic scarring, intraoperative or postoperative hemorrhage, and prolonged wound healing. Environmental accidents were few. No procedure-related deaths, ocular damage, or secondary cutaneous malignant neoplasms were reported. We conclude that cutaneous laser surgery has an acceptable risk profile but that complications are not uncommon.

Low-fluence carbon dioxide laser irradiation of lentigines.

Low-fluence carbon dioxide (CO2) laser irradiation of skin has previously been shown to induce damage limited primarily to the epidermis. To evaluate whether this technique was therapeutically effective for pigmented epidermal lesions, ten lentigines caused by methoxsalen and ultraviolet light therapy were treated in one patient using the CO2 laser at fluences ranging from 3.0 to 7.7 J/cm2 for 0.1-s exposures with 4.5-mm spot size. Based on substantial clearing in seven of ten lesions treated, 146 solar lentigines were treated in five patients at fluences of 3.0, 3.7, or 4.4 J/cm2. Biopsies were performed on a total of 30 lesions immediately and 24 hours, seven days, and six weeks after irradiation. Of 125 lesions followed up clinically for six weeks, 12 cleared completely, 81 lightened substantially, and 28 remained unchanged. Only two demonstrated atrophic change. Hyperpigmentation or hypopigmentation did not occur. All lesions that improved had been treated at 3.7 or 4.4 J/cm2. Immediate histologic injury consisted of vacuolar and spindly change and subsequent vesiculation limited to the basilar epidermis. Twenty-four hours later there was epidermal necrosis with regeneration, 0.1 mm of dermal basophilia and stromal condensation, and a mild inflammatory infiltrate. These alterations were dose-dependent, with near complete epidermal necrosis and superficial dermal involvement at the highest fluence, and only focal epidermal necrosis at the lowest. At seven days, epidermal regeneration was complete with traces of melanin remaining in keratinocytes. Melanophages first appeared at seven days and persisted at six weeks, by which time the inflammatory infiltrate had cleared. No lentiginous proliferation was evident and epidermal pigmentation had become normal. Low-fluence CO2 laser irradiation is an effective means of damaging the epidermis with only minimal dermal change. This mode of therapy is an effective way to lighten the pigmentation of lentigines without substantial scarring.