Esthetic and medical tattooing: Part I: Tattooing techniques, implications, and adverse effects in healthy populations and special groups.

Tattooing, the introduction of exogenous pigments into the skin, has a rich history spanning thousands of years, with cultural, cosmetic, and medical significance. With the increasing prevalence of tattoos, understanding their potential complications and contraindications is of growing importance. The most common complications are hypersensitivity reactions, which may vary in morphology and timing. Infectious complications are often due to inadequate aseptic and hygienic practices during the tattooing process or healing period. Tattoo pigment can present diagnostic challenges, affecting cancer diagnosis and imaging. This CME article explores the history, cultural significance, epidemiology, chemistry, technique, contraindications, and complications of tattoos. Appreciating these factors can help individuals considering tattoos understand the safety and potential risks of their body art, and provide physicians with a thorough understanding of tattooing if consulted.

Laser tattoo removal strategies: Part II: A review of the methods, techniques, and complications involved in tattoo removal.

The rising global popularity of cosmetic and corrective tattoos has concurrently led to an increased demand for their removal. While in the past, methods like surgical excision, chemical destruction, and dermabrasion were employed, lasers have emerged as a reliable and effective tool for tattoo removal. Increasing technological options and combination treatment strategies have raised the importance of understanding the various approaches to laser tattoo removal along with their respective clinical impact. This CME aims to describe the multifaceted aspects of laser tattoo removal, including the method selection, application principles, and safety considerations. Furthermore, it addresses the factors considered when selecting the most suitable laser to achieve optimal treatment outcomes.

Treatment of Iron-Induced Cutaneous Hyperpigmentation With Energy-Based Devices.

OBJECTIVES: Iatrogenic cutaneous siderosis is a well-recognized dermatologic complication after parenteral iron infusion. The condition manifests as discrete, hyperpigmented patches near the site of injection. Most cases do not resolve spontaneously, leading to significant aesthetic and psychological distress to patients. A recent case of iatrogenic cutaneous siderosis at our institution prompted a systematic review of the efficacy of energy-based devices previously reported in the treatment of this condition. METHODS: PubMed and Cochrane databases were searched for all peer-reviewed articles published using the following search terms: "iron OR heme OR hemosiderosis OR siderosis" and "hyperpigmentation OR staining OR tattoo." Articles reporting on energy-based devices in the treatment of iron-induced hyperpigmentation were included. RESULTS: A total of seven articles and 54 total patients were included in this review. All patients, including the patient treated at our institution, were female, with an average age of 44 years. Hyperpigmentation was most commonly associated with intravenous iron infusion (48/54, 89%), on the arm or forearm (44/54, 81%), and used for the treatment of underlying iron deficiency anemia (54/54, 100%). The application of six different nanosecond or picosecond quality-switched laser systems was reported in the treatment of cutaneous siderosis, with wavelengths ranging from 532 to 1064 nm. Spot sizes varied between 2 and 7 mm, with energy fluences spanning 0.5-40 J/cm2 depending on both the device and spot size. Outcomes were measured after an average of 5.4 laser treatments and 10.4 months, with over half of all reported patients experiencing complete clearance (27/50, 54%). Our patient received treatment in three test areas with picosecond alexandrite 785 nm, nanosecond Nd:YAG 532 nm, and picosecond Nd:YAG 532 nm devices. The nanosecond Nd:YAG 532 nm treated area demonstrated the greatest improvement, and the entire arm was subsequently treated with this device. CONCLUSIONS: Despite the often intractable nature of iatrogenic cutaneous siderosis, laser surgery is a reasonable and safe treatment modality for patients seeking cosmetic improvement of this dyschromia. Dermatologists should be aware of this entity and the efficacy of the energy-based devices currently in our armamentarium. A combination approach may need to be utilized with different wavelengths and pulsed widths to target iron pigment in both dermal and subcutaneous layers.

Use of Optical Coherence Tomography to Assess Properties of Cutaneous Defects Following Radiofrequency Microneedling and Laser Treatment.

OBJECTIVES: To characterize the properties of cutaneous defects created by energy-based devices using optical coherence tomography. MATERIALS AND METHODS: Radiofrequency (RF) microneedling and non-ablative fractional laser (NAFL) treatment were performed in vivo with various parameters. Following treatment, optical coherence tomography (OCT) was used to image and measure cutaneous defects at multiple time points over a 24 h period. RESULTS: Channel-like cutaneous defects were visible with OCT following bipolar RF microneedling and NAFL treatment. Using a double pulse technique with RF microneedling yielded a greater number of defects visible with OCT, as well as defects that were deeper and more durable over time. Following treatment with 1927 nm thulium fiber laser, the average diameter of the defects was greater when the energy level was 20 mJ as compared to 10 mJ (0.33 mm vs. 0.27 mm, p < 0.01). CONCLUSIONS: Cutaneous defects were observed following both RF microneedling and NAFL treatment. Properties of the cutaneous defects varied based on device, treatment setting, and technique, which may be useful in guiding further study of device-assisted drug delivery.

Intradermal Delivery of Calcium Hydroxylapatite With Fractionated Ablation.

OBJECTIVES: The absorption of biostimulatory particulate matter following its application to fractional skin defects remains poorly understood, and even less is known about its in vivo impact in terms of tissue integration. The objectives of this study are twofold: (1) to evaluate the potential of calcium hydroxylapatite (CaHA) to penetrate through skin treated with a fractional laser; and (2) to assess the effectiveness of clinical laser scanning microscopy technologies in monitoring the effects of such treatment over time. METHODS: One area on a volunteer's arm was treated with a fractional erbium laser (Sciton Inc., Palo Alto, CA), while a second area received the same laser treatment followed by CaHA topical application. We used reflectance confocal microscopy (RCM) and multiphoton microscopy (MPM) to noninvasively image beneath the surface of the treated skin to study and monitor the effects of these treatments within 1 h of treatment and at four additional time points over a 6-week period. RESULTS: One hour posttreatment, at different depths beneath the skin surface, MPM and RCM provided similar visualizations of laser-induced channels. In skin treated by both laser and CaHA, these two imaging methods provided complementary information. RCM captured the lateral and depth distribution of CaHA microspheres and were seen as bright spheres as they became incorporated into the healing tissue. MPM, meanwhile, visualized the CaHA microparticles as dark shadow spheres within the laser-induced channels and encroaching healing tissue. Furthermore, MPM provided critical information about collagen regeneration around the microspheres, with the collagen visually marked by its distinct second harmonic generation (SHG) signal. CONCLUSIONS: This observational pilot study demonstrates that CaHA, a collagen stimulator used as a dermal filler, can not only be inserted into the dermis after fractional laser treatment but remains in the healing skin for at least 6 weeks posttreatment. The noninvasive imaging techniques RCM and MPM successfully captured the presence of CaHA microspheres mid-dermis during the healing phase. They also demonstrated new collagen production around the microspheres, highlighting the effectiveness of these imaging approaches in monitoring such treatment over time.

Sentinel lymph node biopsy is unreliable in predicting melanoma mortality for both younger and older patients.

BACKGROUND: Melanoma disease patterns vary with patient age. AIM: To evaluate sentinel lymph node biopsy (SLNB) in managing melanoma at differing patient ages. METHODS: Online prediction tools were applied to compare SLNB positivity (SLNB+) and survival risk at patient ages 20-80. Tübingen melanoma data were used to determine variations in the hazard ratio of SLNB+ for mortality at different patient ages. RESULTS: Regardless of tumour thickness, predicted SLNB+ rates were markedly higher than mortality rates for 20-year-old patients. For 80-year-old patients, it is the opposite. DISCUSSION: If 1000 20-year-olds with a 0.4 mm thickness non-ulcerated melanoma underwent SLNB, 100 would likely be positive. If all 100 were to be offered adjuvant drug therapy (ADT), fewer than three more melanoma deaths in those 1000 patients would be avoided. In total, 97 patients would have received medication they may never have needed. If 1000 80-year-olds with a 3 mm thickness non-ulcerated melanoma underwent SLNB, only 40 would likely be positive. In total, 274 patients would be predicted to die of melanoma, 245 being SLNB negative and 29 SLNB+. ADT linked to SLNB+ could deny treatment to 89% of these high-risk patients. LIMITATIONS: The authors relied on published risk data. CONCLUSION: SLNB has poor specificity at predicting mortality in young melanoma patients and poor sensitivity in older patients. SLNB is not indicated in managing cutaneous melanoma for patients under 40 or over 60 years of age. Many such patients could be managed with wide local excision alone in their clinician's office-based practice. For all cutaneous melanoma patients at all ages, linking ADT to BAUSSS biomarker, (an algorithm of Breslow thickness, age, ulceration, subtype, sex and Site) rather than SLNB+ is likely more appropriate. BAUSSS provides a more accurate melanoma-specific mortality risk assessment for patients without burdening them with added surgery, hospitalization, costs or morbidity risk.

Analysis of port-wine birthmark vascular characteristics by location: Utility of optical coherence tomography mapping.

INTRODUCTION: Port-wine birthmarks (PWBs) are congenital capillary malformations that can be located on any area of the body. Vascular features include vessel size, depth, and density, which can greatly differ between patients, individual lesions, and even sites within the same lesion. Previous studies have determined that the location of PWB lesions has impacted their clinical response to laser treatment. OBJECTIVE: We utilized dynamic optical coherence tomography (D-OCT) to measure in vivo vessel diameter, density, and superficial plexus depth in patients of all ages with PWB on various sites of the body. We hypothesized that these vascular characteristics would differ according to body location. MATERIALS AND METHODS: Patients who had a PWB and presented to clinic at three sites for treatment with the pulsed dye laser (PDL) were enrolled into the study. A D-OCT scanner was utilized for noninvasive, in vivo imaging of PWB lesions. The depth of the top portion of the superficial vascular plexus was estimated as the depth at which the vessel density reaches 50% of the maximum. Vessel diameter and density were calculated by incorporated software algorithm. RESULTS: A total of 108 patients were enrolled into the study. There was a total of 204 measurements of PWB lesions. Of all patients, 56.5% (n = 61) reported having a previous treatment with PDL. Of all D-OCT scans, 62.3% (n = 127) were located on the head, 14.2% (n = 29) the upper extremities, 8.3% (n = 17) the lower extremities, 7.8% (n = 16) the trunk, and 7.8% (n = 15) the neck. All locations were compared for each vascular characteristic. For superficial plexus depth, lesions on the head were significantly shallower than those on the upper extremities (217 vs. 284 µm; p < 0.001) and lower extremities (217 vs. 309 µm; p < 0.001). For vessel diameter, lesions on the head had significantly larger vessels than those on the upper extremities (100 vs. 72 µm; p = 0.001). For vessel density, lesions on the head had significantly denser vessels than those on the trunk (19% vs. 9.6%; p = 0.039) and upper extremities (19% vs. 9.3%; p < 0.001) CONCLUSIONS: PWB lesions have distinct vascular characteristics, which can be associated with their body location. This includes superficial vascular plexus depth as well as vessel diameter and density.

Evaluation of Device-Based Cutaneous Channels Using Optical Coherence Tomography: Impact for Topical Drug Delivery.

BACKGROUND: Topical medications play a large role in the management of cutaneous diseases, but penetration is limited. Device-assisted drug delivery using mechanical destruction, lasers, and other energy-based modalities can increase penetration and absorption through creation of transcutaneous channels. OBJECTIVE: To examine real-time, in vivo cutaneous changes in response to various devices used to improve topical drug delivery through optical coherence tomography (OCT) imaging. METHODS AND MATERIALS: Treatment was performed with 8 medical devices, including mechanical destruction, lasers, and other energy-based modalities. Optical coherence tomography was used for real-time, noninvasive, in vivo imaging. RESULTS: Using OCT, microneedling and radiofrequency microneedling demonstrated no cutaneous channels. Both low-energy, low-density, fractional nonablative lasers produced transient channels, which closed within hours. The fractional nonablative 1,927-nm thulium fiber and 1,550-nm erbium fiber lasers created channels with epidermal debris within, which were still closing at 24 hours. The fractional thermomechanical ablative device and the fractional ablative CO2 laser produced channels that were still open at 24 hours. CO2 laser channels had thick rims of coagulated tissue and remained open for longer. CONCLUSION: Demonstrable differences among the devices were seen, and only some can produce observable channels, the characteristics of which vary with each technology.

Vascular characteristics of port wine birthmarks as measured by dynamic optical coherence tomography.

BACKGROUND: Port wine birthmarks (PWBs) are congenital capillary malformations. Vessel characteristics, such as diameter and depth, may impact presentation and outcomes. They can be imaged using dynamic optical coherence tomography, a high-resolution, noninvasive imaging method. PURPOSE: We conducted a cross-sectional observational study to measure in vivo vascular characteristics as a function of PWB color. METHODS: Patients undergoing treatment for PWB were recruited from 3 sites. PWBs were classified by color. Dynamic optical coherence tomography images with calculations were obtained. RESULTS: One hundred eight patients were enrolled. Mean age correlated with PWB color, with birthmarks being lighter in younger patients and darker in older patients (P < .01). Mean superficial plexus depth was significantly shallower in purple PWBs than in pink PWBs. Color was not associated with significant differences in mean superficial vessel density or diameter. Among pink PWBs, each 10-year increase in age was associated with a 10.6-µm increase in superficial plexus depth. Among purple PWBs, each 10-year increase in age was associated with a 16.2-µm reduction in superficial plexus depth. In lesions without prior treatment, vessel density was 12.7% lower in purple PWBs than in pink PWBs. CONCLUSION: Superficial vessels of purple PWBs were significantly closer to the epidermis than those of pink PWBs, which might impact optimal laser parameters.

Assessing the Outcomes of Focused Heating of the Skin by a Long-Pulsed 1064 nm Laser with an Integrated Scanner, Infrared Thermal Guidance, and Optical Coherence Tomography.

BACKGROUND AND OBJECTIVE: Long-term benefits can be predicted by the incorporation of more intelligent systems in lasers and other devices. Such systems can produce more reliable zones of thermal injury when used in association with non-invasive monitoring and precise laser energy delivery. The more classical endpoint of tumor destruction with radiofrequency or long-pulsed (LP) 1064 nm laser is the non-specific appearance of tissue graying and tissue contraction. Herein we discuss combining non-invasive LP 1064 nm Nd:YAG treatment with the assistance of optical coherence tomography (OCT) and the forward-looking infrared (FLIR) thermal camera while testing literature-based formulae for thermal destruction. STUDY DESIGN/MATERIALS AND METHODS: The skin on the forearm and back of two consenting volunteers was marked and anesthetized with lidocaine with epinephrine. The parameters of a scanner-equipped LP 1064 nm Nd:YAG laser were adjusted to achieve an epidermal/superficial dermal heating of between 50°C and 60°C over a specified time course. Experimental single treatments examined various adjusted parameters including, fluence, pulse overlap, pulse duration, scan size, and pulse rate. A FLIR camera was used to record skin temperature. Outcome measures included skin temperature, post-treatment appearance, and OCT assessment of skin and vascular damage. The clinical response of each treatment was followed daily for 4 weeks. RESULTS: Optimal protocols initially raised the skin temperature to between 55°C and 60°C, which was carefully maintained using subsequent laser passes over a 60-second time course. Immediately post laser, clinical responses included erythema, edema, and blistering. Immediate OCT revealed increased vascularity with intact, dilated blood vessels. Prolonged exposure above 60°C resulted in sub-epidermal blistering and an absence of blood flow in the treatment area with prolonged healing. CONCLUSION: The LP 1064 nm laser can be used to achieve heat-related tissue injury, though the narrow parameters necessary for the desired endpoint require the assistance of IR thermal regulation to avoid unacceptable outcomes. The use of the laser scanner ensures precise energy delivery over a defined treatment area. Future studies might explore this as a selective hyperthermic method for the treatment of non-melanoma skin cancer. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Clinical Study Demonstrates that Electromagnetic Muscle Stimulation Does Not Cause Injury to Fat Cells.

BACKGROUND AND OBJECTIVES: A previous pre-clinical study on electromagnetic muscle stimulation (EMMS) suggested that fat cell apoptosis occurs following treatment in a porcine model. While EMMS can induce changes in muscle, the effect on fat tissue is not established. This clinical study sought to assess adipose tissue response to EMMS in comparison to cryolipolysis treatment. STUDY DESIGN/MATERIALS AND METHODS: Study subjects were recruited prior to abdominoplasty to receive body contouring treatments and subsequently to obtain tissue for histological analysis. Non-invasive abdominal treatments were delivered using a commercially available (n = 6) or prototype (n = 3) EMMS system or a cryolipolysis system (n = 2). Subjects received a single EMMS treatment (100% intensity for 30 minutes) or a single cryolipolysis treatment (-11°C for 35 minutes) to the abdomen. Superficial and deep (i.e., adjacent to muscle layer) subcutaneous adipose tissue was harvested at set timepoints post-treatment. The presence or absence of an inflammatory response was evaluated using standard hematoxylin and eosin (H&E) staining. As adipocytes that are destined to become apoptotic cannot be distinguished by traditional H&E staining during the early phases of injury, irreversible fat cell injury was assessed using perilipin immunofluorescence. RESULTS: Following H&E histological analysis at 3, 10, 11, and 17 days post-treatment, no EMMS-treated samples showed an inflammatory response in either the superficial or deep subcutaneous adipose tissue. For the cryolipolysis-treated adipose tissue, however, the H&E staining revealed a marked inflammatory response with an influx of neutrophils, lymphocytes, and macrophages at timepoints consistent with previous histological studies. Further, loss of perilipin staining provided clear visual evidence of irreversible fat cell injury in the cryolipolysis-treated adipose tissue. In contrast, the electromagnetic muscle stimulation-treated samples showed persistence of perilipin staining of adipose tissue indicating that all fat cells were viable. CONCLUSION: This study failed to demonstrate either fat cell injury or inflammatory response following EMMS treatment. While electromagnetic muscle stimulation may non-invasively induce muscle changes, this clinical study found no evidence of an impact injurious or otherwise on subcutaneous fat. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

Skin Preparation for Photodynamic Therapy, Chemexfoliation, and Ablative Laser Resurfacing: a Systematic Literature Review.

BACKGROUND: Photodynamic therapy, chemexfoliation, and ablative laser resurfacing are common practices for dermatologists, yet no formal protocols exist regarding preprocedural skin preparation. OBJECTIVE: To review and summarize the skin preparation protocols for photodynamic therapy, chemexfoliation, and ablative laser resurfacing available in the literature. METHODS: Data Sources A systematic review of English and non-English articles using the PubMed database was performed. A manual search of bibliographies from relevant articles was also performed to collect additional studies. Study Selection Only articles in the English language with full texts available that pertained to skin preparation for photodynamic therapy, chemexfoliation, and ablative laser resurfacing were included. Data Extraction Article selection was performed by one author, and relevant sources were verified by other authors using predefined inclusion and exclusion criteria. RESULTS: There is a paucity of scientific research regarding efficacy and safety of dermatologic preprocedural skin preparation agents. Only 2 studies have compared various cleansing agents for these measures. Yet, strong statements regarding the importance of degreasing are published without supportive data. CONCLUSION: Consensus guidelines for preprocedural protocols are lacking for photodynamic therapy, chemexfoliation, and ablative laser resurfacing. Further studies are warranted to explore the efficacy and safety of various preprocedural cleansing agents.

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.

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.

Laser Plume From Human Papillomavirus-Infected Tissue: A Systematic Review.

BACKGROUND: Laser procedures are becoming more prevalent across multiple medical specialties for a variety of indications. The plumes created by these lasers have raised concern for the dissemination of an infectious material. OBJECTIVE: To review and summarize the information on viral dissemination in laser plumes available in the literature. MATERIALS AND METHODS: Data Sources A systematic review was performed on English and non-English articles using the PubMed and the Cochrane databases. A manual search of bibliographies from relevant articles was also performed to collect additional studies. STUDY SELECTION: Only articles in the English language with full texts available that pertained to viral particles in laser plumes were included. Data Extraction Two authors performed independent article selections using predefined inclusion and exclusion criteria. RESULTS: There have been case reports of possible transmission of human papillomavirus (HPV) by inhalation of laser-produced aerosols. Multiple investigators have attempted to recreate this scenario in the laboratory to qualify this risk. Others have conducted clinical experiments to determine the presence of HPV in laser plumes. CONCLUSION: The current body of the literature suggests that laser surgeons are at a risk for HPV exposure by inhalation of laser-derived aerosols. We offer best practice recommendations for laser operators.

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.

The readability of online patient information about laser resurfacing therapy.

Because there are important distinctions between ablative and non-ablative laser resurfacing, accurate and effective patient education is paramount. However, as more patients use the internet as a resource for medical information, little is known about the content and readability of these sources. Thus, we sought to evaluate the readability of major online resources about laser resurfacing while recognizing the recommendations by the American Medical Association and National Institutes of Health. An internet search for the term "Laser Resurfacing" was performed. The first 9 results were identified, patient information from each of these 9 sites were downloaded, and a total of 25 articles were examined. Readability was analyzed using 7 different established tests. Analysis demonstrated an average grade level of at least 9th grade, with all articles exceeding the recommended 6th grade reading level, emphasizing that these resources are too challenging for many patients to read and comprehend. Such materials may hamper appropriate decision-making in patients considering the use of a laser for their dermatologic conditions. The potential detrimental effect on the opinion, participation, and satisfaction of laser resurfacing should spur dermatologists to be more critical of online patient materials and motivated to produce more appropriate resources.

Use of 5-Aminolevulinic Acid and Daylight Photodynamic Therapy for the Treatment of Actinic Keratoses.

BACKGROUND: Photodynamic therapy (PDT) is an effective modality for the treatment of actinic keratoses (AKs). The use of methyl aminolevulinate with daylight PDT (D-PDT) has quickly gained popularity internationally because of its tolerability and high levels of safety and efficacy. However, there is a paucity of studies on the use of D-PDT with 5-aminolevulinic acid (ALA). OBJECTIVE: To study the safety and efficacy of D-PDT in treating AKs on the face and scalp using ALA. MATERIALS AND METHODS: Thirty patients were recruited for this prospective, uncontrolled study. Patients were treated with topical ALA on either the scalp or face, incubated for 30 minutes, and then sat at home in a shady area for 2 hours. Weather conditions, lux measurements, and AK counts at 3 and 6 months were measured. RESULTS: Daylight PDT led to a median of 75% reduction in AK count at 6 months, with no significant adverse effects. Ninety-six percentage of patients were either moderately or very satisfied with the treatment, and the median peak pain score during treatment was 1. There was no correlation between weather or average lux received during treatment and 6-month outcomes. CONCLUSION: Daylight PDT with ALA is a safe and effective treatment modality for AKs on the head.