The Use of a Fractional Ablative Micro-Plasma Radiofrequency Device in Treatment of Striae.

OBJECTIVE: To evaluate the efficacy of a fractional ablative micro-plasma radiofrequency (RF) device in the reduction of the appearance of abdominal striae. METHODS: Five female patients (age range, 30-60) with abdomen striae alba (n=4) and striae rubra (n=1) were enrolled in the study. Skin type distribution among the 5 patients was two type II, one type III, and two type IVs. The device (Accent XL, Alma Lasers Inc.) is a radiofrequency fractional platform (40.68 MhZ) that deploys multiple conical pin electrodes on a moving handheld 6 cogs roller. Four treatments were performed every two weeks with settings based on test spots performed two weeks prior to a full treatment session. Assessment of striae was based on clinical severity of the lesions on a 1-4 scale, with "4" being the most severe. A questionnaire was administered to patients with possible subjective responses ranging from 0-4, with 0 being no improvement and quartiles from 1-4 (1= mild improvement, 2= fair improvement, 3= moderate improvement, and 4= marked improvement, respectively). RESULTS: Three months after 4 treatments, a mean improvement of 20% was achieved (mean severity score changed from 2.9 to 2.5). Micro-wounds were approximately 200 µm wide on the surface, initially presenting as small gray "dots" and evolving into black dots lasting about 2 weeks. Mean pain was 2/10. Erythema and edema persisted for about one day. No pigmentation abnormalities were observed at the final evaluation. The results from the patient questionnaire revealed a mean score of 2.4/4, thus falling in the range of good to very good. CONCLUSION: A fractional ablative micro-plasma RF roller device can improve improvement in the appearance of abdomen striae.

Analysis of Depth of Ablation,Thermal Damage, Wound Healing, and Wound Contraction With Erbium YAG Laser in a Yorkshire Pig Model.

BACKGROUND AND OBJECTIVES: The erbium YAG laser is commonly used for skin resurfacing. It is known that varying the pulse duration can influence residual thermal damage and wound healing. Our study used a porcine model to evaluate a broad range of settings in a comparison of depth of ablation, depth of residual thermal damage (RTD), and wound contraction employing both a full coverage and fractional hand piece with an erbium YAG laser. MATERIALS AND METHODS: The laser delivered an ablative pulse followed by a heating pulse of variable duration using either the full coverage or fractional hand piece. Pulse durations for specific coagulation depths were selected based on existing heat transfer models. The bilateral flanks of a single Yorkshire pig were irradiated. There were 14 treatment groups. 3 sites were treated per group for a total of 42 sites. Two of the 3 sites were for observational assessments and the 3rd site served as a reservoir for biopsies. Biopsy specimens were collected on days 0, 1, 3, 7, 14, and 28. Bleeding, erythema, wound healing, and wound contraction (in the fractional hand piece groups) were assessed. CONCLUSION: Wound healing is faster for fractional laser skin resurfacing compared with traditional contiguous resurfacing as demonstrated by textural changes and degree of erythema. The laser operator can be confident that the depth of ablation displayed on this system accurately reflects what is occurring in vivo for both confluent and fractional modes. Likewise, the measured degree of coagulation was consistent with panel display settings for the confluent mode. However, the degree of coagulation, as measured by the thickness of residual thermal damage, did not vary significantly between the fractional groups. In other words, the pulse duration of the second (heating) pulse did not impact the degree of coagulation in the fractional mode. There was a 2.3% wound contraction between some groups and a 6.5% wound contraction between other groups. A two way analysis of variance found a statistically significant difference in wound contraction based on ablation depth ( P = 0.012) but the degree of coagulation did not prove to be statistically significant for wound contraction (P = 0.66).

A split face study to document the safety and efficacy of clearance of melasma with a 5 ns q switched Nd YAG laser versus a 50 ns q switched Nd YAG laser.

BACKGROUND AND OBJECTIVES: To determine the safety and efficacy of a 50 ns Q switched Nd YAG laser vs. a 5 ns Q switched Nd YAG laser for clearance of melasma. To compare subject satisfaction, efficacy, and comfort level between the two lasers. STUDY DESIGN/MATERIALS AND METHODS: This is a prospective, randomized split face clinical study. The study was approved by the Scripps IRB. Ten healthy female subjects with moderate to severe melasma were enrolled. Each subject had three laser treatments one month apart. Patients were followed up approximately 1 month, 3 months, and 6 months after the final laser treatment. A treatment session consisted of a microdermabrasion, 1064 nm QS laser, and topicals. Subjects were asked to rate treatment pain based on a numerical scale range 0-10 (0 = no pain and 10 = worst pain). A melasma area and severity index (MASI) grading system was applied. Also, melanin measurements were acquired by a reflectance spectrophotometer. Side effects were documented during the study including post treatment erythema. RESULTS: Eight patients completed the study. Subjects showed improvement on both sides of the face. From baseline to 1 month post the final laser treatment, the average MASI scores showed a 16% reduction for the 50 ns QS 1064 nm laser vs. a 27% reduction for the 5 ns QS 1064 nm laser (both significant versus baseline pigment, P < 0.05). This difference in MASI scores between the two lasers was not statistically significant (P = 0.87930). Laser treatments displayed mild erythema that resolved after one day. The melanin meter measurements showed a reduction in pigment readings on both sides. Three months after the final treatment there was some relapse in the melasma, as the mean pigment reduction fell to 12% for the 50 ns laser and 11% for the 5 ns laser. By 3 months pigment reduction was not statistically significant for either laser, and no significant differences in pigment reduction were noted between the two pulse durations. There was a statistically significant difference (P < 0.05) in pain scores reported by the subjects (scale 0-10), the mean pain score for 50 ns QS 1064 nm laser was 1.2 and for the 5 ns QS 2.9 the score was 2.9. CONCLUSIONS: In this study, we showed that a combination of microdermabrasion, QS1064 nm laser, and topicals decreased the MASI and meter scores without clinically significant side effects. Moreover, the longer pulsed Q switched 1064 nm laser i.e. (50 ns) was associated with less pain than its shorter pulse width counterpart.

Periocular hyperpigmentation: a review of etiology and current treatment options.

BACKGROUND: Periocular "dark circles" fall among the most difficult chief complaints to address. In most cases, we have little information regarding etiology and no gold-standard treatment option. The extent of the problem is reflected in the sheer number of products on the market advertised to either lighten or cover the pigmentation. OBJECTIVE/METHODS: To present dermatologists with a complete review of the literature with regard to anatomy, definition, etiology, and treatment of periocular hyperpigmentation. CONCLUSIONS: Our understanding of the causes and treatment of periocular hyperpigmentation continues to advance. Nevertheless, we are in need of additional controlled clinical trials and novel therapeutic options. Individual patients will likely benefit most from a combination of approaches. Although more randomized clinical studies are necessary, Pfaffia paniculata/Ptychopetalum olacoides B./Lilium candidum L.-associated compound cream seems to be a promising option, with 90% improvement. For patients with increased melanin deposition, quality-switched ruby laser therapy could offer a better treatment option. In the hands of experienced professionals, a surgical option might be suitable, either by autologous fat transplantation or hyaluronic acid filler.

Upper limb motor function in young adults with spina bifida and hydrocephalus.

OBJECTIVE: The objective of the study was to measure upper limb motor function in young adults with spina bifida meningomyelocele (SBM) and typically developing age peers. METHOD: Participants were 26 young adults with SBM, with a Verbal or Performance IQ score of at least 70 on the Wechsler scales, and 27 age- and gender-matched controls. Four upper limb motor function tasks were performed under four different visual and cognitive challenge conditions. Motor independence was assessed by questionnaire. RESULTS: Fewer SBM than control participants obtained perfect posture and rebound scores. The SBM group performed less accurately and was more disrupted by cognitive challenge than controls on limb dysmetria tasks. The SBM group was slower than controls on the diadochokinesis task. Adaptive motor independence was related to one upper limb motor task, arm posture, and upper rather than lower spinal lesions were associated with less motor independence. CONCLUSIONS: Young adults with SBM have significant limitations in upper limb function and are more disrupted by some challenges while performing upper limb motor tasks. Within the group of young adults with SBM, upper spinal lesions compromise motor independence more than lower spinal lesions.

Should children with Bell's palsy be treated with corticosteroids? A systematic review.

The objective of this study was to evaluate the effect of corticosteroids in the treatment of pediatric Bell's palsy. A systematic review of trials that included pediatric (< 16 years old) cases with Bell's palsy and involved the use of steroids was conducted. Eight trials were identified, five of which were randomized, and prednisone was used in six trials, whereas corticotropin was used in the other two. The methods of randomization and allocation concealment of the treatments used were rarely reported. Only one trial was done exclusively in children; none of the other seven trials analyzed the pediatric cases separately. Four trials reported some benefit from steroids. The pediatric trial did not provide evidence for benefit from corticosteroids. There was substantial heterogeneity in the population and interventions used; hence a meta-analysis was not done. Based on this systematic review, we do not recommend the routine use of steroids in children with Bell's palsy.

Idiopathic "benign" intracranial hypertension: case series and review.

Idiopathic "benign" intracranial hypertension is an uncommon but important cause of headache that can lead to visual loss. This study was undertaken to review our experience in the diagnosis and management of idiopathic intracranial hypertension, giving special attention to treatments used. A retrospective chart review was conducted on 32 patients diagnosed with idiopathic intracranial hypertension between 1984 and 1995. Subjects included 23 females and ranged in age from 2 to 17.5 years. Headache was the most common symptom, followed by nausea and vomiting, double vision, and visual loss. Papilledema was the most common sign. Others were VIth cranial nerve palsy and compromised visual acuity at or within 3 months of presentation. Management included administration of acetazolamide or corticosteroids, lumboperitoneal shunt, optic nerve fenestration, and repeat lumbar puncture. Treatment combinations were used in 40% of cases. During follow-up, headache, papilledema, and decreased visual acuity persisted for longer than 10 months in a significant number of patients. We conclude that idiopathic intracranial hypertension causes significant short- and long-term morbidity with no proven effective treatment available. A prospective study is needed to establish the indications for treatment and the efficacy of the treatments used.

Migraine and sickle-cell disorders: is there a cause for concern?

Migraine and sickle-cell disease are common diseases, and may coexist in the same individual. Such a chance association is potentially dangerous because the two disorders may act synergistically to cause major neurological complications which may be permanent and contribute to the well-known mortality of sickle-cell disease. In theory, it is possible to minimize the risk of adverse sequelae of this combination of common maladies.

Benign intracranial hypertension or communicating hydrocephalus: factors in pathogenesis.

Benign intracranial hypertension and communicating hydrocephalus are uncommon but important disorders that affect cerebrospinal fluid dynamics. They have clinical similarities but their management is usually different. The factors determining which of the two disorders will develop include brain compliance, the state of the cranial sutures, the nature of the insult and its magnitude. I propose that the time course of the pathological events leading to presentation may be a further factor to consider in the pathogenesis and management of these disorders.

Is the prophylactic use of antiepileptic drugs in Sturge-Weber syndrome justified?

Sturge-Weber syndrome (SWS) is a rare neurocutaneous syndrome. Epilepsy is one of its most common features and is usually the first neurological manifestation. Adequate control of epilepsy assumes major importance in SWS as the early onset of seizures and severe seizures are associated with developmental regression and hemiparesis. Recent advances in neuroimaging have helped in making preclinical and early diagnosis in SWS. The author proposes treating newly diagnosed patients with severe SWS with antiepileptic drugs (AEDs) before the onset of epilepsy. This may help prevent the development of hemiplegia and the developmental problems that may ensue.

Saccades in children with spina bifida and Chiari type II malformation.

BACKGROUND: Saccades are essential for optimal visual function. Chiari type II malformation (CII) is a congenital anomaly of the cerebellum and brainstem, associated with spina bifida. OBJECTIVE: To investigate the effects of CII on saccades and correlate saccadic parameters with brain MRI measurements. METHODS: Saccades were recorded in 21 participants with CII, aged 8 to 19, using an infrared eye tracker. Thirty-nine typically developing children served as controls. Participants made saccades to horizontal and vertical target steps. Nineteen participants with CII had MRI. Regression analyses were used to investigate the effects of spinal lesion level, number of shunt revisions, presence of nystagmus, and midsagittal MRI measurements on saccades. RESULTS: Saccadic amplitude gains, asymptotic peak velocities, and latencies did not differ between the control and CII groups (p > 0.01). No significant differences were found between saccadic gains, asymptotic peak velocities or latencies, and spinal lesion level, number of shunt revisions, presence of nystagmus, or MRI measurements. CONCLUSIONS: Saccades were normal in most participants with Chiari II malformation (CII). Neural coding of saccades is robust and is typically not affected by the anatomic deformity of CII.

Peripheral and autonomic nervous system involvement in chronic GM2-gangliosidosis.

GM2-gangliosidosis (McKusick 268800 and 272800) is a rare hereditary, progressive disorder of ganglioside metabolism caused by deficiency of lysosomal beta-hexosaminidase (EC 3.2.1.52) activity. It is characterized by severe central nervous system involvement. Involvement of the peripheral and autonomic nervous system has been suspected but rarely documented in published case reports in the chronic form of the disease. Four patients, aged 24-29 years, with chronic GM2-gangliosidosis were examined prospectively for evidence of peripheral and autonomic nervous system dysfunction. All had nerve conduction studies, sympathetic skin responses and cardiac monitoring during the head tilt-table test. Three patients had objective evidence of autonomic dysfunction with abnormal sympathetic nervous skin responses and axonal sensorimotor polyneuropathy. None of the patients had evidence of significant cardiovascular autonomic dysfunction on the head tilt-table test. The peripheral and autonomic nervous system may be involved in patients with chronic GM2-gangliosidosis. In some cases, this may be clinically significant. On the other hand, cardiovascular autonomic instability is apparently not a significant problem in young adult patients with the disease.