A 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial.

BACKGROUND: Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines. METHODS: A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale. RESULTS: Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted. CONCLUSION: A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

The Differences in the Practice of Cosmetic Dermatologic Procedures Between Physicians and Nonphysicians.

BACKGROUND: With a rise in demand for cosmetic dermatologic procedures comes an increase in nonphysician providers performing such procedures. However, little is known about the practice of cosmetic procedures performed by nonphysicians. OBJECTIVE: To assess the differences in the practice of cosmetic procedures provided by physicians and nonphysicians. MATERIALS AND METHODS: A cross-sectional analysis was performed using participant ( n = 4,062) responses to an 18-point, web-based survey about previous cosmetic procedures. RESULTS: In total, 1,328 participants reported having previous cosmetic procedures done by a physician ( n = 828), a nonphysician ( n = 413), or an unknown provider ( n = 87). Respondents of all age ranges and male respondents ( p < .001) tended to choose physicians over nonphysician providers when choosing a practice. Moderate adverse events were more frequently seen when nonphysician providers completed cosmetic procedures ( p < .001). Despite a higher frequency (73.3% vs 51.8%) of more moderate complications seen in procedures done by nonphysician providers, over 70% of respondents believe that nonphysician providers are qualified enough to continue performing cosmetic procedures. CONCLUSION: People should be encouraged to make an informed decision when choosing a provider because cosmetic procedures are still considered medical procedures.

Phenol-Croton Oil Chemical Peeling Induces Durable Improvement of Constitutional Periorbital Dark Circles.

BACKGROUND: Constitutional periorbital dark circles (PDC) are common in skin of color and represent a therapeutic challenge. OBJECTIVE: To summarize the experience of the International Peeling Society on the safety and effectiveness of deep chemical peeling in the treatment of constitutional PDC. MATERIALS AND METHODS: Multi-institutional, retrospective case series (1990-2020) of constitutional PDC treated by deep chemical peeling. Descriptive analysis by age, sex, Fitzpatrick phototype, phenol-croton formula, degree and durability of improvement, and complications. RESULTS: Fifty-five phenol-croton oil peels were performed in 52 patients: 3 patients received a second peel for periorbital rhytids 72 to 84 months after the first peel. 92% (48/52) of patients were women; the median age was 46 years (range, 23-68 years). 89% (46/52) of patients were Fitzpatrick III-IV. Most common formula included phenol 60% to 65% and croton oil 0.6% to 0.7%. 89% (49/55) of peels demonstrated >50% clinical improvement. The median duration of improvement was 24 months (range, 1.5-168 months), and 69% (36/52) of patients demonstrated ongoing improvement at the last follow-up. 4% (2/55) of peels exhibited complications of persistent erythema that resolved without scarring. CONCLUSION: Based on its safety and effectiveness, deep chemical peels are a treatment of choice for constitutional PDC.

Skin of color representation in cosmetic clinical trials: A literature review.

Despite cosmetic procedures being on the rise in the US in all demographics, cosmetic procedures remain heavily skewed towards non-skin of color patients. Cosmetic clinical trials in the United States must be representative of the ever-increasing diversity of the US population. We sought to analyze published cosmetic randomized controlled trials, both industry-sponsored and investigator-initiated, to characterize and assess representation of skin of color participants over the past three decades. Our study shows that industry sponsorship correlates with poor study participant ethnic/racial diversity in aesthetic randomized controlled trials, and should serve as a call to action for industries to increase the inclusion of skin of color participants in their studies.

Fractional Ablative Laser Therapy is an Effective Treatment for Hypertrophic Burn Scars: A Prospective Study of Objective and Subjective Outcomes.

OBJECTIVE: The aim of this study is to determine objective and subjective changes in mature hypertrophic burn scars treated with a fractional ablative carbon dioxide (CO2) laser. BACKGROUND: Fractional CO2 laser treatment has been reported to improve burn scars, with increasing clinical use despite a paucity of controlled, prospective clinical studies using objective measures of improvement. METHODS: A multicenter, site-controlled, prospective open-label study was conducted from 2013 to 2016. Objective and patient-reported outcome measures were documented at baseline, at each monthly laser treatment, and 6 months after treatment. Objective measurements employed were: mechanical skin torque to measure viscoelastic properties; ultrasonic imaging to measure scar thickness; and reflectometry to measure erythema and pigmentation. Subjective measures included health-related quality of life, patient and investigator scar assessment scales, and blinded scoring of before and after photographs. Subjects aged 11 years or older with hypertrophic burn scars were recruited. Each subject received 3 monthly treatment sessions with an ablative fractionated CO2 laser. RESULTS: Twenty-nine subjects were enrolled, of whom 26 received at least 1 fractional CO2 laser treatment and 22 received 3 treatments. Mean age of those completing all 3 treatments was 28 years. Statistically significant objective improvements in elastic stretch (P < 0.01), elastic recovery (P < 0.01), extensibility (P < 0.01), and thickness (P < 0.01) were noted. Patient- and physician-reported scar appearance and pain/pruritus were significantly improved (P < 0.01). There was no regression of improvement for at least 6 months after treatment. CONCLUSIONS: Fractional ablative laser treatment provides significant, sustained improvement of elasticity, thickness, appearance, and symptoms of mature hypertrophic burn scars.

Chemical Peels as Field Therapy for Actinic Keratoses: A Systematic Review.

BACKGROUND: Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs. OBJECTIVE: This review systematically analyzes the use of chemical peels for treatment of AKs. MATERIALS AND METHODS: A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs. RESULTS: Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas. CONCLUSION: Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.

Differences in pediatric versus adult clinical trial characteristics for atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a growing burden in all ages. The aim of this study was to compare trial characteristics between pediatric and adult AD trials. METHODS: Data were collected from ClinicalTrials.gov on AD therapeutic trials completed between 2003 and 2019. The trials were classified as pediatrics (mean or median age <18 years of the experimental group participants) or adults. The trials with and without results on ClinicalTrials.gov were searched on PubMed for further data collection. RESULTS: Of 210 trials, 50 (24%) were pediatric trials [mean age: 8.2 ± 4.3 years (SD)] and 160 (76%) were adult trials [mean age 35.2 ± 5.7 years (SD)]. Pediatric and adult trials were equally likely to be randomized controlled trials; however, pediatric trials were more likely to be open-label trials (P < .001) and have no comparator (P < .001). Adult trials were more likely to be industry-funded (95% vs. 80%, P = .001). Any evaluation of drug safety was more likely present in adult trials (83% vs. 60%, P = .001). In trials examining AD severity as an outcome, the Eczema Area and Severity Index (EASI) predominated in adult trials (51% vs. 29%, P < .05) and Scoring Atopic Dermatitis (SCORAD) in pediatric trials (25% vs. 10%, P < .05). CONCLUSION: The results highlight differences in trial design between pediatric and adult AD trials and show a lack of standardization in trial design.

Use of Extranasal Bilobed Transposition Flaps in Cutaneous Reconstructive Surgery at 2 Institutions.

BACKGROUND: Bilobed transposition flaps are versatile random pattern flaps used in nasal and extranasal reconstruction as they preserve free margins, access distal tissue reservoirs, and reliably repair dynamic defects. OBJECTIVE: We highlight the utility of extranasal bilobed flaps to encourage surgeons to consider these flaps for Mohs micrographic surgery defects. METHODS: A two-institution retrospective chart review of patients reconstructed using an extranasal bilobed flap after Mohs micrographic surgery was performed. A validated scar scale was applied to postoperative photographs. Statistical analyses of the patient and surgery characteristics including patient co-morbidities, anatomic distribution, flap dimensions, and postprocedural events, including revisions, were conducted. RESULTS: Forty-eight patients were identified. Site-specific flap dimensions were obtained with the cheek/lower eyelid requiring greater tissue mobilization with a higher final to primary defect ratio when compared with other sites. Postoperative events (complications, erythema, flap fullness, dehiscence, infection, etc.) were minimal. No major complications were noted. Nine cases of flap fullness or swelling were identified. Neither flap fullness nor dehiscence compromised flap integrity or cosmetic outcome. Independent flap cosmetic outcome review was good using a validated photographic scar scale. CONCLUSION: Bilobed transposition flaps are versatile repairs for extranasal reconstruction with a favorable safety and outcome profile.

Depth Map for Face and Neck Deep Chemical Peel Resurfacing.

BACKGROUND: Chemical peels are applied to the face and neck to improve rhytides and the photoaged appearance of the skin. Peels can be applied to different skin depths depending on the types of chemicals, the volume of solution, and the amount of pressure or friction applied. If a peel is applied too superficially, rhytides will not be removed. If a peel is applied too deeply, scarring or hypopigmentation could occur. OBJECTIVE: To create face and neck depth maps for chemical peeling, which can guide safety when removing rhytides and improving the skin's appearance. MATERIALS AND METHODS: A multicenter retrospective review of records was conducted of patients who underwent phenol-croton oil peeling, from January 1, 2018, to December 31, 2018. Information was collected on facial and neck cosmetic units peeled, peel formula and strength used, outcomes, and complications. RESULTS: A total of 410 patients received deep peels. Two depth maps were created that corresponded to the most common patterns of deep chemical peel applications. CONCLUSION: Different areas of the face and neck are treated with different chemical peel application depths to safely improve rhytides and appearance. Depth maps are created to balance safety and efficacy.

Advanced chemical peels: Phenol-croton oil peel.

Once considered the standard for deep facial resurfacing, the classical Baker-Gordon phenol-croton oil peel has largely been replaced by formulas with lower concentrations of phenol and croton oil. The improved safety profile of deep peels has ushered in a new era in chemical peeling. Wrinkles can be improved and skin can be tightened with more subtle and natural results. No longer does a deep peel denote "alabaster white" facial depigmentation with complete effacement of wrinkles. Gregory Hetter's research showed that the strength and corresponding depth of penetration of the phenol-croton oil peel can be modified by varying the concentration of croton oil. This second article in this continuing medical education series focuses on the main historical, scientific, and procedural considerations in phenol-croton oil peels.

Basic chemical peeling: Superficial and medium-depth peels.

Chemical peeling, or chemexfoliation, has been used for centuries to improve signs of ultraviolet light-induced sun damage. Over the last 30 years, the science behind chemical peeling has evolved, increasing our understanding of the role of peeling ingredients and treatment indications. The depth of peels is directly related to improved results and to the number of complications that can occur. Key principles for superficial and medium depth peeling are discussed, as well as appropriate indications for these treatments.

Cosmetic Dermatology Training During Residency: Outcomes of a Resident-Reported Survey.

BACKGROUND: As the demand for cosmetic treatments increases, it is important for dermatology residents to be educated about and achieve proficiency in dermatologic cosmetic procedures. OBJECTIVE: To assess dermatology residents' educational exposure to cosmetic dermatology. MATERIALS AND METHODS: An anonymous 18-question survey was sent electronically to 1,266 dermatology residents requesting information about cosmetic dermatology training during residency. RESULTS: Two hundred sixty-eight residents responded to the survey (21% response rate). Most residents receive didactic instruction (94%) and hands-on training (91%) on cosmetic dermatology topics during residency. Survey participants in residency programs perceived as supportive of cosmetic dermatology training are more frequently provided lectures (70% vs 31%, p < .001) and procedural training (100% vs 69%, p < .001) in cosmetic dermatology as compared to residents in unsupportive programs. Eighty-nine percent of respondents reported hands-on training as the most effective method for developing proficiency in cosmetic procedures. CONCLUSION: Providing safe and competent patient care should serve as the impetus for expanding cosmetic dermatology education and training for residents.

Variation among pathologists' treatment suggestions for melanocytic lesions: A survey of pathologists.

BACKGROUND: The extent of variability in treatment suggestions for melanocytic lesions made by pathologists is unknown. OBJECTIVE: We investigated how often pathologists rendered suggestions, reasons for providing suggestions, and concordance with national guidelines. METHODS: We conducted a cross-sectional survey of pathologists. Data included physician characteristics, experience, and treatment recommendation practices. RESULTS: Of 301 pathologists, 207 (69%) from 10 states (California, Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New Jersey, New Mexico, Utah, and Washington) enrolled. In all, 15% and 7% reported never and always including suggestions, respectively. Reasons for offering suggestions included improved care (79%), clarification (68%), and legal liability (39%). Reasons for not offering suggestions included referring physician preference (48%), lack of clinical information (44%), and expertise (29%). Training and caseload were associated with offering suggestions (P < .05). Physician suggestions were most consistent for mild/moderate dysplastic nevi and melanoma. For melanoma in situ, 18 (9%) and 32 (15%) pathologists made suggestions that undertreated or overtreated lesions based on National Comprehensive Cancer Network (NCCN) guidelines, respectively. For invasive melanoma, 14 (7%) pathologists made treatment suggestions that undertreated lesions based on NCCN guidelines. LIMITATIONS: Treatment suggestions were self-reported. CONCLUSIONS: Pathologists made recommendations ranging in consistency. These findings may inform efforts to reduce treatment variability and optimize patterns of care delivery for patients.

The utilization of spitz-related nomenclature in the histological interpretation of cutaneous melanocytic lesions by practicing pathologists: results from the M-Path study.

BACKGROUND: Spitz nevi, atypical Spitz tumors and spitzoid melanomas ('spitzoid lesions') represent controversial and poorly understood cutaneous melanocytic lesions that are difficult to diagnose histologically. It is unknown how these terms are used by pathologists. METHODS: We describe use of Spitz-related terminology using data from the Melanoma Pathology (M-Path) study database comprising pathologists' interpretations of biopsy slides, a nation-wide study evaluating practicing US pathologists' (N = 187) diagnoses of melanocytic lesions (8976 independent diagnostic assessments on 240 total test cases, with 1 slide per case). RESULTS: Most pathologists (90%) used the Spitz-related terminology. However, significant variation exists in which specific lesions were diagnosed as spitzoid and in the corresponding treatment recommendations. Recommendations ranged from 'no further treatment' to 'wide excision of 10 mm or greater' with no category capturing more than 50% of responses. For spitzoid melanoma diagnoses, 90% of pathologists recommended excision with ≥10 mm margin. Pathologists report less confidence in diagnosing these lesions compared with other melanocytic proliferations and are more likely to request second opinions and additional clinical information (all p < 0.05). CONCLUSIONS: Spitzoid lesions are often not classified in any standardized way, evoke uncertainty in diagnosis by pathologists, and elicit variability in treatment recommendations.

Occupational exposures and determinants of ultrafine particle concentrations during laser hair removal procedures.

BACKGROUND: Occupational exposures to ultrafine particles in the plume generated during laser hair removal procedures, the most commonly performed light based cosmetic procedure, have not been thoroughly characterized. Acute and chronic exposures to ambient ultrafine particles have been associated with a number of negative respiratory and cardiovascular health effects. Thus, the aim of this study was to measure airborne concentrations of particles in a diameter size range of 10 nm to 1 µm in procedure rooms during laser hair removal procedures. METHODS: TSI Model 3007 Condensation Particle Counters were used to quantify the particle count concentrations in the waiting and procedure rooms of a dermatology office. Particle concentrations were sampled before, during, and after laser hair removal procedures, and characteristics of each procedure were noted by the performing dermatologist. RESULTS: Twelve procedures were sampled over 4 days. Mean ultrafine particle concentrations in the waiting and procedure rooms were 14,957.4 particles/cm3 and 22,916.8 particles/cm3 (p < 0.0001), respectively. Compared to background ultrafine particle concentrations before the procedure, the mean concentration in the procedure room was 2.89 times greater during the procedure (p = 0.009) and 2.09 times greater after the procedure (p = 0.007). Duration of procedure (p = 0.006), body part (p = 0.013), and the use of pre-laser lotion/type of laser (p = 0.039), were the most important predictors of ultrafine particle concentrations. Use of a smoke evacuator (a recommended form of local exhaust ventilation) positioned at 30.5 cm from the source, as opposed to the recommended 1-2 in., lowered particle concentrations, but was not a statistically significant predictor (p = 0.49). CONCLUSIONS: Laser hair removal procedures can generate high exposures to ultrafine particles for dermatologists and other individuals performing laser hair removal, with exposure varying based on multiple determinants.