Cutaneous interaction with visible light: What do we know?

Visible light has been used therapeutically in dermatology for years for a variety of cosmetic and medical indications, including skin rejuvenation and the treatment of inflammatory and neoplastic conditions, among others. Until recently, visible light was thought to be relatively inert compared to its spectral neighbors, ultraviolet and infrared radiation. However, recent literature has described the ability of visible light to cause erythema in light skin and pigmentary changes in individuals with darker skin types. Concern surrounding its potentially damaging cutaneous effects has been raised in both the medical community and social media outlets. In this article, we provide an evidenced-based review describing what is currently known about visible light, focusing on its role in dermatologic diseases including disorders of hyperpigmentation such as melasma and postinflammatory hyperpigmentation.

Emerging topical therapies to treat pigmentary disorders: an evidence-based approach.

BACKGROUND: Hyperpigmentation disorders are commonly encountered in dermatology clinics. The use of prescription-grade and over-the-counter topical lightening agents has increased in popularity, leading to a substantial growth of research over the past decade. OBJECTIVE: We seek to review clinical studies evaluating the use of different Rx-grade and OTC ingredients in treating hyperpigmentation. METHODS AND MATERIALS: A comprehensive search on PubMed was conducted to identify patient-based evidence on the most common ingredients used as topical lightening agents: arbutin, ascorbic acid, cysteamine, hydroquinone, kojic acid, niacinamide, retinoids, and triple-combination therapy. The topicals were classified as either prescription-grade or over-the-counter. RESULTS: Varying levels of evidence support the use of topicals in treating hyperpigmentation. There were more clinical trials examining Rx-grade products than OTC products. Mild but tolerated side effects are noted in many of these agents. CONCLUSION: Careful monitoring and adjustment of doses will be needed to maximize skin lightening benefits and minimize side effects.

Indoor tanning: Evidence surrounding advertised health claims.

Indoor tanning continues to remain common, despite evidence of an increased risk of skin cancer from artificial ultraviolet (UV) radiation. In the hopes of gaining customers, the tanning bed industry has marketed health benefits of indoor tanning such as increased vitamin D production, development of a base tan, enhanced mood, and treatment of certain dermatologic conditions. To better educate their patients, providers need a comprehensive reference reviewing the evidence that support or oppose these claims. In this work, we conducted an evidence-based review of the literature to identify and grade studies that investigate health claims related to UV exposure. Results indicate that there is little evidence to support each of these proposed health benefits. Tanning beds emit primarily UVA radiation, which is relatively ineffective at activating vitamin D or mood enhancing pathways, and the effects are minimal in regard to tanning beds generating a protective base tan or treating dermatologic conditions compared with the increased risk of skin cancer. Health care providers must continue to warn and educate patients about the misleading information propagated by the tanning bed industry as well as about the dangers of artificial UV radiation.

Increased Tattoo Fading in a Single Laser Tattoo Removal Session Enabled by a Rapid Acoustic Pulse Device: A Prospective Clinical Trial.

BACKGROUND AND OBJECTIVES: The ability to provide improved tattoo fading using multiple laser passes in a single office laser tattoo removal session is limited. In part, this is due to the loss of laser effectiveness caused by epidermal and dermal vacuole "whitening" generated during the initial laser pass at the tattoo site. The Rapid Acoustic Pulse (RAP) device generates acoustic shock wave pulses that clear epidermal and dermal vacuoles to enable multiple laser passes in a single office laser tattoo removal session. The objectives of this study were to determine if the RAP device, when used as an accessory to the 1064 nm Nd:YAG Q-switched (QS) laser can enable delivery of multiple laser passes in a single office laser tattoo removal session, and therefore result in increased tattoo fading compared to the clinical standard single-pass QS laser tattoo removal session. STUDY DESIGN/MATERIALS AND METHODS: The RAP device was evaluated in a single-center (SkinCare Physicians), prospective, IRB approved study. A total of 32 black ink tattoos, from 21 participants, were divided into three zones and treated with either multiple QS laser passes, each followed by 1 minute of RAP device application (Laser + RAP) in zone one and single-pass QS laser treatment (Laser-Only) in zone two, separated by an untreated control zone. The treatment sites were assessed for the number of laser passes and adverse events immediately, 6 weeks, and 12 weeks following the treatment session. Photographs of the treatment sites were assessed for percent fading at 12 weeks post-treatment by three blinded reviewers. RESULTS: When the RAP device was applied as an accessory to the QS laser in a multi-pass laser tattoo removal treatment, an average of 4.2 laser passes were delivered in a single session, with no unexpected or serious RAP device-related adverse events. At the 12-week follow-up, tattoos treated with Laser + RAP showed a statistically significant increase in average fading (44.2%) compared with tattoos treated with Laser-Only (24.8%) (P < 0.01). Additionally, a significantly higher overall proportion of tattoos treated with Laser + RAP (37.5%) had a response of >50% fading compared with tattoos treated with QS Laser-Only (9.4%) (P < 0.01) as well as a response of >75% fading from Laser + RAP treatment (21.9%) compared with Laser-Only treatment (3.1%) (P < 0.05). CONCLUSIONS: The RAP device, applied as an accessory to the 1064 nm Nd:YAG QS laser, safely enables multiple QS laser treatments in a single office laser tattoo removal session by clearing the whitening caused by the previous QS laser pass. Enabling multiple QS laser passes results in a statistically significant increase in tattoo fading in a single office laser tattoo removal session compared to the clinical standard single-pass QS laser tattoo removal session. © 2019 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Delayed-Onset Nodules to Differentially Crosslinked Hyaluronic Acids: Comparative Incidence and Risk Assessment.

BACKGROUND: Robust and long-term data on true incidence of delayed-onset nodules and immune tolerance of hyaluronic acid (HA) fillers are lacking. OBJECTIVE: To characterize the incidence of delayed nodules in Vycross (VYC) HA fillers compared with previously reported FDA and non-FDA data of all HA fillers. METHODS AND MATERIALS: The incidence of delayed nodules in all patients who had received VYC fillers in a 12-month period was assessed through a retrospective chart review. Nodule incidence for currently approved nonanimal-stabilized hyaluronic acid (NASHA) fillers was assessed using the FDA Summary of Safety and Effectiveness Data. RESULTS: Overall, 1,029 patients received 1,250 VYC filler treatments. Five patients developed delayed nodules to VOB, with an incidence of 1.0% per patient and 0.8% per syringe. No nodules were observed in patients who received VLR or VOL. All nodules were treated successfully using a combination of intralesional triamcinolone and hyaluronidase. Compared with other currently approved NASHA fillers, VOB is associated with a higher incidence of nodule formation. CONCLUSION: The introduction of VYC HAs has introduced a new variable that may be changing the immune tolerance of these substances, resulting in a higher incidence of delayed nodules than previously expected.

Setting appropriate pain expectations: Lessons learned from a clinical trial.

OBJECTIVE: This retrospective study compares subject-reported pain levels and expectations set forth by industry and treating physicians during a clinical trial of an energy based device. The physiologic and emotional aspects of pain expectations are discussed and recommendations are made for strategic patient counseling. MATERIALS AND METHODS: Average and mode pain scores were collected from the records of a previously conducted clinical trial investigating a radiofrequency microneedling device at three different settings. The trial protocol and device manual were reviewed to ascertain language regarding procedural pain. Treating physicians were asked how they learned about procedural pain and how they described it to subjects. Subject-reported pain scores and verbal pain descriptors from the device manual and trial protocol were translated onto validated pain scales, the Numerical Rating Scale (NRS), and the Verbal Rating Scale (VRS), for comparison. RESULTS: A total of 90 procedural pain scores were collected from 30 subject charts. The average procedural pain scores for three different device settings were 5.3, 6.7, and 4.6 out of 10 and the mode pain score was 6 out of 10. This translated to a 5-6 and 7-8 on the NRS, respectively and classification as "painful but bearable" and "considerable pain" on the VRS. Industry sourced pain levels translated to a 2-4 on the NRS and classification as "little pain" on the VRS. CONCLUSION: Subject-reported pain scores were higher than those set forth by industry materials and personnel. Physicians should be wary of manufacturer materials or anecdotal evidence that might mislead patients and cause undue physiological or emotional stress. Lasers Surg. Med. 9999:XX-XX, 2018. © 2018 Wiley Periodicals, Inc.

Patient Positioning and Skin Sequelae: Ischemic Epidermal Necrosis from Tight Padding During Cardiac Surgery.

Careful positioning and padding of pressure points during surgery are recommended to prevent pressure ulcers, vascular injury, and nerve damage in an immobilized patient. However, overpadding may have unintended consequences. We report a case of ischemia-induced full-thickness epidermal necrosis secondary to tight foam padding during a cardiac surgery.

Dilated lymphatic vessels in tufted angioma: a potential source of diagnostic confusion.

Tufted angioma (TA), an uncommon benign vascular tumor, has a variable clinical presentation, and histopathologic findings are a key component of diagnosis. The presence of lymphatic vessels suggestive of lymphangioma can occasionally be the predominant finding and cause diagnostic confusion. Nine biopsies from 7 cases of TA were studied to assess the frequency and distribution of lymphangioma-like areas. Specimens were also stained with D2-40, VEGF-A, GLUT-1, and HHV-8. In one biopsy, lymphangioma-like vessels were the main finding. In all other cases of TA, lymphatics were present in the stroma but were often overshadowed by tufts of capillaries. D2-40 highlighted the stromal lymphatics and partially stained the capillaries within tufts. VEGF-A showed diffuse nonspecific staining of epidermis and endothelial cells in all specimens. GLUT1 and HHV-8 staining were uniformly negative in all 9 specimens. Accurate diagnosis of TA has important clinical implications given its occasional association with Kasabach-Merritt phenomenon, and the presence of lymphangioma-like vessels in biopsies of vascular lesions is entirely compatible with TA.

A close call: the role of screening mammography in the fight against breast cancer: health and medicine for women: a multidisciplinary, evidence-based review of mid-life health concerns.

A multidisciplinary panel debated the role of screening mammography in fighting breast cancer during the Health and Medicine for Women continuing medical education (CME) conference at Yale Medical School in September 2010. Different guidelines from professional societies have presented conflicting recommendations for patients regarding both the benefits of mammography and the appropriate age and frequency of screening. In addition, a recent longitudinal study argues that screening mammography may only offer a modest benefit in terms of reducing cancer mortality. In light of these considerations, the panel debated whether mammography should be an informed decision that must be discussed and individualized for each patient based on the context of risk factors such as family history, age, and genetic dispositions.