Medical and aesthetic improvement of photodamaged skin by the combination of intense pulsed light and photodynamic therapy with 10% aminolevulinic acid hydrochloride gel.

OBJECTIVE: To evaluate the efficacy and safety of photodynamic therapy (PDT) with the novel 10% aminolevulinic acid (ALA) hydrochloride gel (10% ALA gel) and BF-RhodoLED® light (635 nm; 37 J/cm2 ) in combination with intense pulsed light (IPL) to augment the medical and aesthetic improvement of photodamaged skin of the décolleté. METHODS: This was a single-site prospective, randomized, intraindividual split chest pilot study with 20 female subjects with moderate to severe photodamage of the décolleté. Subjects were randomized to ALA-PDT + IPL to one split-side of the chest and ALA-PDT only to the contralateral side. Three blinded raters assessed aesthetic improvement using the global aesthetic improvement scale (GAIS). RESULTS: Eighteen subjects completed the study. Superior GAIS results were achieved on the ALA-PDT + IPL treatment side than on the ALA-PDT only treatment side (p < 0.001) after 24 weeks of follow-up. CONCLUSIONS: ALA-PDT using 10% ALA hydrochloride gel and BF-RhodoLED® light had superior rejuvenation effects on the décolleté when combined with IPL compared to ALA-PDT alone.

Prospective study of intense pulsed light versus pulsed dye laser with or without blue light in the activation of PDT for the treatment of actinic keratosis and photodamage.

BACKGROUND: Exposure to ultraviolet (UV) light from the sun is known to have a deleterious effect on the skin. Repeated insults to the dermal matrix from UV radiation result in the clinical signs of photodamage, including changes in skin elasticity, color, and texture. UV radiation also leads to the accumulation of DNA mutations and promotes tumor development, resulting in the formation of cutaneous precancerous and cancerous lesions. Continuous-wave incoherent blue light, intense pulsed light (IPL), and pulsed dye laser (PDL) are safe and efficacious light sources commonly used for aminolevulinic acid photodynamic therapy (PDT). The aim of this study was to prospectively evaluate the efficacy of PDT for the treatment of photodamage and actinic keratoses using four different combinations of light sources: PDL, PDL + blue light, IPL, and IPL + blue light. STUDY: A total of 220 patients with either photodamage or actinic keratosis (AK) were recruited from the Miami Dermatology Laser Institute (Miami, FL) and were assigned prospectively to undergo one PDT treatment with one of the four light options: PDL, PDL + blue light, IPL or IPL + blue light. Of the 220 patients enrolled in treatment groups, 214 patients completed the study. Of the 214 patients, 88 received treatment for AK, and 126 received treatment for photodamage. All patients gave their consent to participate in the study and to allow their photographs to be utilized for the purpose of scientific presentations. RESULTS: Treatment with IPL resulted in a 70.8% reduction of actinic keratoses at a 1-month follow-up. Treatment with IPL and blue light 84.4% reduction of actinic keratoses at 1 month follow up. Treatment with PDL 70.5% reduction of actinic keratoses at 1 month follow up. Treatment with PDL and blue light 69.3% reduction of actinic keratoses at 1 month follow up. Treatment with IPL resulted in an improvement score of 2.9. Treatment with IPL and blue light resulted in an improvement score of 3.0. Treatment PDL resulted in an improvement score of 1.5. Treatment with PDL and blue light resulted in an improvement score of 1.8. CONCLUSION: Although all four treatment groups led to some improvement in signs of photoaging, IPL + blue light again demonstrated increased efficacy when compared to IPL, PDL, and PDL + blue light treatment groups. Results from our study were limited by an unequal distribution between treatment groups and a lack of follow-up beyond a 1-month period and warrant further research.

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.

1,550 nm Erbium-Doped and 1,927 nm Thulium Nonablative Fractional Laser System: Best Practices and Treatment Setting Recommendations.

BACKGROUND: The Fraxel Dual laser system (Solta Medical, Inc., Bothell, WA) contains a 1,550 and 1,927 nm wavelength single handpiece with different indications for each wavelength. OBJECTIVE: To discuss treatment setting recommendations and best practices for select on-label and investigational applications of the 1,550 and 1,927 nm dual laser system. MATERIALS AND METHODS: Eight board-certified dermatologists with 10 or more years of experience with the 1,550 and 1,927 nm laser system completed an online survey about their clinical experience with the system and then participated in a roundtable to share clinical perspectives and best practices for using the laser system. RESULTS: For all Fitzpatrick skin types, treatment recommendations were described for selected approved indications for the 1,550 and 1,927 nm laser system, including both lasers in combination. Treatment recommendations were also reached for investigational applications with the 1,550 nm laser and 1,927 nm laser. Best practices for using the lasers during the treatment session to achieve optimal outcomes and decrease the post-treatment recovery time were compiled. CONCLUSION: The 1,550 and 1,927 nm dual laser system is effective for a wide range of aesthetic and therapeutic applications, on and off the face and across all Fitzpatrick skin types.

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.

Randomized, Controlled Early Intervention of Dynamic Mode Fractional Ablative CO2 Laser on Acute Burn Injuries for Prevention of Pathological Scarring.

BACKGROUND AND OBJECTIVES: This study challenges the currently accepted treatment parameters of waiting 1 year following burn injury to treat the resultant scarring. It assesses the impact of treating burn and trauma wounds at less than 3 months of injury on scar formation, providing a new temporal paradigm to patients in the prevention and minimization of scar formation. STUDY DESIGN/MATERIALS AND METHODS: This randomized clinical trial included 19 patients with moderate-to-severe acute burn injuries less than 3 months from injury. The treatment areas underwent three fractional ablative CO2 laser treatments at 8-week intervals. The primary outcomes were improvement in the Manchester Scar Scale (MSS) and photography. Secondary outcomes were optical coherence tomography (OCT), treatment time, immediate post-treatment response, and histology. RESULTS: Upon blinded evaluation, 100% of treatment areas were correctly identified when compared with control. MSS scores before and after treatment were totaled with an averaged sum of 13.33 per scar at baseline to 8.39 after treatment, a 63% average improvement versus control (P < 0.001). Histology and OCT demonstrated a re-organization of the underlying skin structure. The average treatment time was 18 minutes. Immediate post-treatment responses were limited to mild-to-moderate erythema. CONCLUSIONS: Early intervention with ablative fractional laser on acute traumatic wounds resulted in significant decrease of scar formation compared with untreated areas on the same wounds, providing an impactful new time course to treat severe burn and trauma injuries. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Treatment of Hypertrophic Burn and Traumatic Scars With a 2,940-nm Fractional Ablative Erbium-doped Yttrium Aluminium Garnet Laser: A Pilot Study.

BACKGROUND: In recent years, fractional ablative lasers at low density have proven to be the centerpiece in a multimodality approach to treating hypertrophic burn scars. OBJECTIVE: To determine the safety and efficacy of fractional ablative erbium-doped yttrium aluminium garnet (Er:YAG) laser in the treatment of hypertrophic burn scars. METHODS: Eleven patients received 3 fractional ablative Er:YAG laser to hypertrophic burn scars at 400 to 800 µm, density 11%, no coagulation, and single pass at 4-week intervals. RESULTS: Overall, average improvement was noted to be 2.27 of 3 as determined by blinded observers. A significant improvement was noted in all measured parameters including dyschromia, atrophy hypertrophy, vascularity, and texture. CONCLUSION: This is a pilot study showing the safety and efficacy of fractional ablative Er:YAG laser treatment is a safe and effective treatment modality in the treatment of hypertrophic scars.

Treatment of Hypertrophic Scars Using Laser-Assisted Corticosteroid Versus Laser-Assisted 5-Fluorouracil Delivery.

BACKGROUND: As the mortality of individuals suffering severe cutaneous injuries decreases, there is an increased need to improve the methods by which physicians treat the resultant scars. Fractional lasers, which create zones of ablation at variable depths, provide a powerful tool in the management of scar complications and deformities. After disruption of the normal skin barrier, these zones may be used to deliver drugs that may enhance scar resolution. OBJECTIVE: To determine the differences in clinical outcome for hypertrophic scars treated with laser-assisted corticosteroid delivery, as compared to laser-assisted 5-fluorouracil delivery. METHODS: In this prospective, double-blinded, single-subject study of 20 individuals with hypertrophic scars, subjects underwent 3 treatment sessions at 1-month intervals consisting of fractional ablative laser treatment, followed by postoperative application of either topical triamcinolone acetonide (20 mg/mL) or topical 5-fluorouracil (50 mg/mL). RESULTS: Three sessions of laser-assisted triamcinolone acetonide and 5-fluorouracil delivery both produced reductions in overall scar area. When compared with one another, there were no statistically significant differences in area reduction between the 2 modalities (p = .603). However, scars treated with 5-fluorouracil were not associated with side effects seen with corticosteroid therapy, such as dermal atrophy or telangiectasia formation. CONCLUSION: As 5-fluorouracil was associated with fewer adverse events, these findings support the use of a nonsteroidal agent in the management of traumatic scars by laser-assisted therapy.

Re-pigmentation of Hypopigmentation: Fractional Lasers vs Laser-Assisted Delivery of Bimatoprost vs Epidermal Melanocyte Harvesting System

Background: Hypopigmentation is a common cutaneous manifestation that frequently poses a therapeutic challenge for dermatologists. Current treatments have varying efficacies and rarely provide patients with long-term results. However, new treatments are emerging, and head-to-head studies comparing these treatments are warranted. Methods & Materials: In this prospective, Institutional Review Board (IRB)-approved, double-blinded study, 40 subjects with moderate to severe hypopigmentation were randomized into 1 of 4 treatment arms; non-ablative fractional laser, ablative fractional laser, ablative fractional laser with laser-assisted delivered bimatoprost, and an epidermal harvesting system. Results: All patients in this study showed improvement regardless of the treatment modality. The average improvement score was calculated on a 0 to 4 scale, and Group 3 (fractional ablative laser and bimatoprost) was found to have a significantly higher average improvement than all other treatments, with 76% of the patients exhibiting at least a grade 3 (over 50%) improvement over the treatment course. Group 1 (non-ablative fractional) also had a significantly higher average score compared with group 2 (fractional ablative laser). Conclusion: New and emerging therapies have shown promise in helping re-pigmentation of cutaneous hypopigmentation. In this head-to-head trial, it was shown that laser-assisted delivery of bimatoprost had a greater statistically significant improvement compared with 3 possible treatment modalities for stimulation of pigment in medical and cosmetic hypopigmentation. J Drugs Dermatol. 2019;18(11):1090-1096.

Angiographic optical coherence tomography imaging of hemangiomas and port wine birthmarks.

OBJECTIVES: A current therapeutic challenge of vascular lesions is that they do not always respond effectively to laser treatment. Information on targeted vessels could potentially be used to guide laser treatments. Optical coherence tomography (OCT) is a useful tool for the non-invasive imaging of tissues, including skin hemangiomas and port wine birthmarks. Dynamic OCT is able to rapidly characterize cutaneous blood vessels. The primary goal of this study was to demonstrate the ability of bedside OCT to image (i) overall vessel pattern; (ii) individual vessel morphology, diameter and depth; and (iii) total vessel density as a function of depth in infantile hemangiomas and port wine birthmarks (PWB). MATERIALS AND METHODS: This IRB approved, observational clinical trial was performed among healthy volunteers ages 3 months-73 years old. All patients presented for laser treatment of either infantile hemangiomas or PWB with skin types ranging from Fitzpatrick I-V. OCT imaging of 49 hemangioma and PWB scans were performed pre- and post-treatment. The diameter and depth of the blood vessels making up the vascular lesions were measured. In addition, normal skin was scanned for comparison. Five datasets for infantile hemangiomas and five for PWB that were without motion artifacts were analyzed. RESULTS: Scanned lesions exhibited variable and highly heterogeneous blood vessel patterns with vessel diameters ranging from 20 to 160 µm, suggesting that the laser treatment with single pulse durations may not be optimal. The largest blood vessel diameter observed (160 µm) may not be adequately treated by commonly used pulsed dye laser pulse durations. CONCLUSION: OCT allowed rapid, non-invasive characterization of the diameter and depth of blood vessels in individual vascular lesions. Imaged lesions consisted of a heterogeneous population of vessel sizes, morphologies, and depth. Future studies could utilize this information to assist development of individualized treatment protocols in an effort to improve vascular birthmark removal. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

The Role of IL-17 in the Human Immune System and Its Blockage as a Treatment of Rheumatoid Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis.

Interleukin 17 (IL-17) functions as a bridge between the innate and adaptive immunity. In addition to being a crucial defense mechanism against extracellular pathogens, it plays a significant role in inflammation, therefore considered a decisive factor in inflammatory conditions; hence the importance of its understanding for the treatment of autoimmune diseases. Animal models have demonstrated that blockage of the IL-17 receptor (IL-17R) may prevent these pathologies. For instance, there is evidence that IL-17R-deficient mice may be protected against the development of collagen-induced arthritis (CIA) and experimental autoimmune encephalitis (EAE). Furthermore; inflammatory disorders such as rheumatoid arthritis (RA), psoriasis, psoriatic arthritis (PSA), and ankylosing spondylitis (AS) have been associated with IL-17, and therapeutically targeting this inflammatory pathway could improve patients' outcomes. The discovery and subsequent studies of this interleukin have aided in the understanding of the immune system, and its potential therapeutic blockage provokes optimism for the treatment of these distressing conditions. J Drugs Dermatol. 2018;17(5):539-542.

Laser-assisted delivery of vitamin C, vitamin E, and ferulic acid formula serum decreases fractional laser postoperative recovery by increased beta fibroblast growth factor expression.

BACKGROUND AND OBJECTIVE: Laser-assisted drug delivery is an emerging technology to achieve greater penetration by existing topical medications to reach desired targets in the tissue. The objective of this research was to study whether laser-assisted delivery of Vitamin C, E, and Ferulic immediately postoperatively of fractional ablative laser could improve wound healing. Secondary objectives were to evaluate the potential molecular markers involved in this wound-healing process. STUDY DESIGN/MATERIAL AND METHODS: A double blinded, prospective, single center, randomized split face trial of Vitamin C, E, and Ferulic topical formula #740019 to decrease postoperative recovery time in fractional ablative laser resurfacing for photo damage. Fifteen healthy men and women of ages 30-55 years were treated with the Vitamin C, E, and Ferulic acid serum to one side of face and vehicle to the other side of face, within 2 minutes immediately after fractional ablative CO2 laser surgery and daily during the healing process. Patients were evaluated daily on days 1-7 using photographs, patient questionnaires, and molecular evaluation. RESULTS: Clinically, postoperative Vitamin C, E, and Ferulic delivery resulted in decreased edema versus vehicle on postoperative day 7 and decreased erythema versus vehicle on postoperative days 3 and 5. Molecularly, the expression of basic fibroblast growth factor (bFGF) was significantly increased at day 5 on the lesion treated with Vitamin C, E, and Ferulic acid serum compared to vehicle control on the other side. CONCLUSION: This is first study to show that Vitamin C, E, and Ferulic acid correlate with more rapid wound healing post-fractional ablative laser. Elevated bFGF could be involved in the Vitamin C, E, and Ferulic acid-induced rapid wound healing.

Fractional Ablative Laser Followed by Transdermal Acoustic Pressure Wave Device to Enhance the Drug Delivery of Aminolevulinic Acid: In Vivo Fluorescence Microscopy Study.

BACKGROUND: Topical drug delivery is the foundation of all dermatological therapy. Laser-assisted drug delivery (LAD) using fractional ablative laser is an evolving modality that may allow for a greater precise depth of penetration by existing topical medications, as well as more efficient transcutaneous delivery of large drug molecules. Additional studies need to be performed using energy-driven methods that may enhance drug delivery in a synergistic manner. Processes such as iontophoresis, electroporation, sonophoresis, and the use of photomechanical waves aid in penetration. This study evaluated in vivo if there is increased efficacy of fractional CO2 ablative laser with immediate acoustic pressure wave device. METHODS: Five patients were treated and biopsied at 4 treatment sites: 1) topically applied aminolevulinic acid (ALA) alone; 2) fractional ablative CO2 laser and topical ALA alone; 3) fractional ablative CO2 laser and transdermal acoustic pressure wave device delivery system; and 4) topical ALA with transdermal delivery system. The comparison of the difference in the magnitude of diffusion with both lateral spread of ALA and depth diffusion of ALA was measured by fluorescence microscopy. RESULTS: For fractional ablative CO2 laser, ALA, and transdermal acoustic pressure wave device, the protoporphyrin IX lateral fluorescence was 0.024 mm on average vs 0.0084 mm for fractional ablative CO2 laser and ALA alone. The diffusion for the acoustic pressure wave device was an order of magnitude greater. CONCLUSION: We found that our combined approach of fractional ablative CO2 laser paired with the transdermal acoustic pressure wave device increased the depth of penetration of ALA.

The Diagnostic Role of Optical Coherence Tomography (OCT) in Measuring the Depth of Burn and Traumatic Scars for More Accurate Laser Dosimetry: Pilot Study.

BACKGROUND: In recent decades, a number of optimal diagnostic technologies have emerged to assist in tissue visualization. Real-time monitoring of skin during laser therapies will help optimize laser parameters for more ef cient therapies. One of these technologies, optimal coherence tomography (OCT), may be used to help visualize burn and traumatic scars. When lasing severe scars, lasers have tunable pulse energies, which are made proportional to the scar thickness as estimated by palpation and the physician eye. This has historically been estimated by the clinician with no objective data. OCT is an emerging non-invasive imaging technique that provides a cross-sectional image of tissue micro-architecture from a depth of 0.7 - 1.5 mm. The signal intensity is related to the tissue optical scattering properties, which in turn is related to tissue constituents such as collagen density. Thus, OCT may provide an objective non-invasive measurement of scar depth. STUDY: Thirty burn and traumatic scars were imaged with quality, traceable, and veri able OCT data from burn and trauma patients both pre- and post- laser therapy. OCT was rapid and ef cient (approximately 2 minutes) to scan skin to visualize real-time scar tissue in different areas of heterogenous scars. The OCT image of the scar was compared to that of normal tissue in order to identify scar tissue and estimate its depth. Laser parameters were then dialed to treat full thickness of the scar. RESULTS: Clinical and OCT correlation between atrophic versus hypertrophic scars was found. However, in most cases the clinicians underestimated the depth of the scar in the dermis. CONCLUSION: The treatment of burn and traumatic scars for both civilian and wounded warriors can be challenging. As these scars are often very deep, OCT allows for non-invasive examination of the thickness of the scar allowing the physician better accuracy for laser settings in the treatment for the full thickness of the scar tissue. J Drugs Dermatol. 2016;15(11):1375-1380..

Current trends and future considerations in scar treatment.

The goal of scar therapy is the restoration of the patient to their preinjury state. A combination of injected antimetabolites, surgery, laser, and laser-assisted delivery of drugs is needed for minimally invasive surgical correction of scars. As a result, laser therapy is emerging as an essential treatment element. It has been noted that fractional lasers normalize both the clinical and histological appearance of scars. Laser- and light-based therapies complement existing approaches of surgery and physical therapy, resulting in significant gains with minimal associated morbidity. Emerging and future laser technologies are creating a new paradigm in the management of scar rehabilitation.

Laser assisted drug delivery: a review of an evolving technology.

BACKGROUND: Topically applied drugs have a relatively low cutaneous bioavailability. OBJECTIVE: This article reviews the existing applications of laser assisted drug delivery, a means by which the permeation of topically applied agents can be enhanced into the skin. RESULTS: The existing literature suggests that lasers are a safe and effective means of enhancing the delivery of topically applied agents through the skin. The types of lasers most commonly studied in regards to drug delivery are the carbon dioxide (CO2 ) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers. Both conventional ablative and fractional ablative modalities have been utilized and are summarized herein. LIMITATIONS: The majority of the existing studies on laser assisted drug delivery have been performed on animal models and additional human studies are needed. CONCLUSIONS: Laser assisted drug delivery is an evolving technology with potentially broad clinical applications. Multiple studies demonstrate that laser pretreatment of the skin can increase the permeability and depth of penetration of topically applied drug molecules for both local cutaneous and systemic applications.

Treatment of atrophic scars with fractionated CO2 laser facilitating delivery of topically applied poly-L-lactic acid.

BACKGROUND: Atrophic scars represent a loss of collagen and a challenging reconstructive dilemma with disappointing traditional treatments. OBJECTIVE: To study the safety and efficacy of the treatment of atrophic scars using an ablative fractionated CO2 laser and topical poly-L-lactic acid (PLLA) immediately after to improve atrophic scars. MATERIALS AND METHODS: This was an uncontrolled, institutional review board-approved, prospective study evaluating the treatment of atrophic scars. Four blinded dermatologists evaluated a total of 20 photographs taken at baseline and 3 months after the laser and PLLA treatments using the Modified Manchester Scar Scale. Four criteria were evaluated: (1) overall improvement, (2) improvement in scar atrophy, (3) improvement in scar color/dyschromia mismatch, and (4) improvement in scar contour. RESULTS: All 4 observers accurately identified 76 of the 80 "before" and "after" photographs. Therefore, the blinded evaluating physicians agreed that at the 3-month follow-up visit, 95% of the scars had improved. Each criterion demonstrated an average improvement of at least 33%. CONCLUSION: The combination of using an ablative fractional CO2 laser and PLLA in the treatment of atrophic scars has a synergistic effect on their inherent properties in up-regulating new collagen synthesis to improve atrophic scars.

Merkel cell carcinoma.

A 92-year-old man presented for evaluation with a 1-month history of a rapidly growing asymptomatic pink nodule on his forearm. Biopsy results of the lesion demonstrated pathology consistent with Merkel cell carcinoma (MCC). Immunohistochemical studies displayed positive cytoplasmic staining for cytokeratin AE1/AE3, positive dot-like perinuclear staining for cytokeratin-20, diffuse cytoplasmic staining for neuron specific enolase, and no significant staining for S-100. Subsequent positron emission tomography did not reveal evidence of metastatic disease. Wide excision of the lesion was performed along with a sentinel node biopsy of his left axilla. The sentinel nodes were negative for MCC. Adjuvant radiation treatment of the tumor site was provided because the pathologist noted MCC within 2 mm of the deep margin.

Treatment of hypertrophic scars using laser and laser assisted corticosteroid delivery.

BACKGROUND AND OBJECTIVES: Hypertrophic scars and contractures are common following various types of trauma and procedures despite skilled surgical and wound care. Following ample time for healing and scar maturation, many millions of patients are burdened with persistent symptoms and functional impairments. Cutaneous scars can be complex and thus the approach to therapy is often multimodal. Intralesional corticosteroids have long been a staple in the treatment of hypertrophic and restrictive scars. Recent advances in laser technology and applications now provide additional options for improvements in function, symptoms, and cosmesis. Fractional ablative lasers create zones of ablation at variable depths of the skin with the subsequent induction of a wound healing and collagen remodeling response. Recent reports suggest these ablative zones may also be used in the immediate post-operative period to enhance delivery of drugs and other substances. We present a case series evaluating the efficacy of a novel combination therapy that incorporates the use of an ablative fractional laser with topically applied triamcinolone acetonide suspension in the immediate post-operative period. METHODS: This is a prospective case series including 15 consecutive subjects with hypertrophic scars resulting from burns, surgery or traumatic injuries. Subjects were treated according to typical institutional protocol with three to five treatment sessions at 2- to 3-month intervals consisting of fractional ablative laser treatment and immediate post-operative topical application of triamcinolone acetonide suspension at a concentration of 10 or 20 mg/ml. Three blinded observers evaluated photographs taken at baseline and six months after the final treatment session. Scores were assigned using a modified Manchester quartile score to evaluate enhancements in dyschromia, hypertrophy, texture, and overall improvement. LIMITATIONS: Small sample size and lack of a control arm. RESULTS: Combination same session laser therapy and immediate post-operative corticosteroid delivery resulted in average overall improvement of 2.73/3.0. Dyschromia showed the least amount of improvement while texture showed the most improvement. CONCLUSION: Combination same-session therapy with ablative fractional laser-assisted delivery of triamcinolone acetonide potentially offers an efficient, safe and effective combination therapy for challenging hypertrophic and restrictive cutaneous scars.

Scar Therapy of Skin.

Scar therapy is truly important in medicine. Patients experience great loss in quality of life with scars. There are many treatment modalities that help treat scars, including topical, intralesional, surgical, and energy-based devices. In addition, early intervention can help mitigate scar formation. Lasers represent a major innovation in the treatment of all types of scars. Treating scars is a multimodal and multispecialty endeavor. This article highlights the use of many therapies to treat scars and scar symptoms including pruritus, pain, and range of motion. This also highlights key literature including multiple recent consensus guidelines in treating scars.