Will nonablative rejuvenation replace ablative lasers? Facts and controversies.

Since the early 1980s, the field of skin rejuvenation has evolved rapidly. Traditional ablative resurfacing with carbon dioxide and Er:YAG lasers offered dramatic improvement of the skin tone and texture, but prolonged postoperative period and an increased risk for side effects and complications were unacceptable for the majority of patients. It prompted the development of nonablative lasers and non-laser systems, which stimulate dermal neocollagenesis without epidermal disruption, and therefore, produce less adverse effects with little or no healing time. Recently, fractional nonablative and ablative lasers have been introduced, employing a completely new concept of fractional photothermolysis, which ensures high efficacy and fewer risks. Ablative laser resurfacing still remains the gold standard for treating advanced and severe photoaging providing excellent results in experienced hands. Alternatively, ablative fractional resurfacing can be used, with the results, which are comparable to fully ablative lasers with better standard of safety. Nonablative resurfacing is ideal for patients under the age of 50 years with minimal facial sagging, and for those who are unwilling to undergo expensive and demanding ablative procedures. It can be concluded that the key of therapeutic success is in proper patient selection, setting appropriate expectations and combining different rejuvenation technologies with other therapeutic modalities, such as botulinum toxin and fillers.

Dermatologic lasers in the treatment of aging skin.

Skin aging includes intrinsic aging, a universal and inevitable process attributable to the passage of the time alone; and photoaging, changes attributable to chronic sun exposure, which are neither universal nor inevitable. The major clinical features of aging skin include xerosis, laxity, wrinkles, slackness, and the occurrence of benign neoplasms such as seborrheic keratoses and cherry angiomas. Photoaging is characterized by dryness (roughness), actinic keratoses, irregular pigmentation (freckling, lentigines, guttate hypomelanosis, persistent hyperpigmentation), wrinkling, stellate pseudoscars, elastosis (fine nodularity and/or coarseness), inelasticity, telangiectasia, venous lakes, purpura (easy bruising), comedones (maladie de Favre et Racouchot) and sebaceous hyperplasia. Current antiaging therapy consists of lasers, intense pulsed light as well as fillers, neurotoxins, radiofrequency, microdermabrasion and chemical peeling. Over the last 50 years, lasers applications in dermatology have become more specific and often irreplaceable. In this manuscript laser resurfacing and laser therapy of vascular and pigmented lesions of aging skin will be overviewed. Current trends show an increase in the number of nonablative and fractional resurfacing procedures because they are followed by less intense side effects and faster recovery rates compared to ablative laser rejuvenation, although producing mild improvement.

Laser therapy of pigmented lesions: pro and contra.

Although frequently performed, laser removal of pigmented lesions still contains certain controversial issues. Epidermal pigmented lesions include solar lentigines, ephelides, café au lait macules and seborrheic keratoses. Dermal lesions include melanocytic nevi, blue nevi, drug induced hyperpigmentation and nevus of Ota and Ito. Some lesions exhibit both an epidermal and dermal component like Becker's nevus, postinflammatory hyperpigmentations, melasma and nevus spilus. Due to the wide absorption spectrum of melanin (500-1100 nm), several laser systems are effective in removal of pigmented lesions. These lasers include the pigmented lesion pulsed dye laser (510 nm), the Q-switched ruby laser (694 nm), the Q-switched alexandrite laser (755 nm) and the Q-switched Nd:YAG laser (1064 nm), which can be frequency-doubled to produce visible green light with a wavelength of 532 nm. The results of laser therapy are usually successful. However, there are still many controversies regarding the use of lasers in treating certain pigmented lesions. Actually, the essential question in removing pigmented lesions with lasers is whether the lesion has atypical features or has a malignant potential. Dermoscopy, used as a routine first-level diagnostic technique, is helpful in most cases. If there is any doubt whether the lesion is benign, then a biopsy for histologic evaluation is obligatory.

Could anti IL12/23 therapy replace anti-TNF biologics?

Biologic therapies improved dramatically the outcome of psoriatic arthritis and moderate to severe chronic plaque psoriasis. Anti-TNF agents were developed approximately one decade ago by rheumatologists and today represent one of the most effective classes of drugs in severe psoriasis resistant to 2 out of 3 "classic" systemic therapies (methotrexate, cyclosporine, and PUVA). Recent studies on psoriasis pathogenesis were focused on early steps of the inflammatory cascade, i.e. activation of T cells with a recently described phenotype Th17 and consequent expression of interleukins (IL) 12 and 23. IL12 and IL23 have a common p40 subunit that is a target of a new therapeutic class, fully human monoclonal antibodies anti IL12/23: ustekinumab and ABT-874. Randomized, placebo-controlled clinical trials in patients with moderate to severe chronic plaque psoriasis using ustekinumab and ABT-874 showed PASI 75 achievements at week 12 in 80% and 93% of patients, respectively. Larger studies are ongoing in order to assess the safety profile of this new therapy. As anti-TNF drugs represent an important and effective treatment of psoriatic arthritis and moderate to severe plaque psoriasis, comparative studies are needed to assess the advantages, the safety and the place of anti-IL12/23 in the era of biologic therapy.

Ancient medicine--a review.

Different aspects of medicine and/or healing in several societies are presented. In the ancient times as well as today medicine has been closely related to magic, science and religion. Various ancient societies and cultures had developed different views of medicine. It was believed that a human being has two bodies: a visible body that belongs to the earth and an invisible body of heaven. In the earliest prehistoric days, a different kind of medicine was practiced in countries such as Egypt, Greece, Rome, Mesopotamia, India, Tibet, China, and others. In those countries, "medicine people" practiced medicine from the magic to modern physical practices. Medicine was magical and mythological, and diseases were attributed mostly to the supernatural forces. The foundation of modern medicine can be traced back to ancient Greeks. Tibetan culture, for instance, even today, combines spiritual and practical medicine. Chinese medicine developed as a concept of yin and yang, acupuncture and acupressure, and it has even been used in the modern medicine. During medieval Europe, major universities and medical schools were established. In the ancient time, before hospitals had developed, patients were treated mostly in temples.

Influence of PUVA and UVB radiation on expression of ICAM-1 and VCAM-1 molecules in psoriasis vulgaris.

The expression of adhesion molecules Intercellular adhesion molecule-1 (ICAM-1) and Vascular cell adhesion molecule-1 (VCAM-1) is increased in lesional and in non-lesional skin of psoriatic patients, and play role in pathogenesis of the disease. PUVA and UVB therapy are important treatments of psoriasis vulgaris. It has been demonstrated that UVA and UVB therapies reduce expression of these molecules. In this investigation, phototherapy was used to treat psoriatic patients. The expression of these molecules was examined by immunohistochemical method in lesional and non-lesional skin of 10 patients with psoriasis vulgaris before and after treatment. Results showed increased expression of ICAM-1 molecules in keratinocytes, in perivascular infiltrate--lymphocytes, and in endothelial cells. The expression of VCAM-1 molecules was also increased, although with less intensity then ICAM-1. After therapy, the expression of the adhesion molecules decreased together with a marked improvement of the disease. In conclusion, study demonstrated that phototherapy improves psoriasis vulgaris probably through mechanisms acting on the adhesions molecules. Adverse reactions due to intense or long lasting UVA (PUVA) and UVB therapies are immunosuppression and damage of DNA which can lead to development of non-melanocytic skin tumors like basal cell carcinoma and squamous cell carcinoma, as well as melanoma.

[Topical corticosteroids and corticosteroid sparing therapy in psoriasis management]. / Lokalni kortikosteroidi i postedna kortikosteroidna terapija u lijecenju psorijaze.

Psoriasis is a chronic, recurrent, genetically determined, inflammatory dermatosis that affects the skin, scalp and joints. Psoriasis is caused by various triggers (infections, drugs, physical and emotional factors). It ranges in severity from mild to severe, and patients with moderate to severe disease suffer significant deterioration in the quality of life. Clinical types of psoriasis are psoriasis guttata, nummular psoriasis, plaque, generalized and erythrodermic psoriasis. Skin changes affect intertriginous regions (inverse psoriasis), and there also are special forms of pustular psoriasis and arthropathic psoriasis. The goals of psoriasis treatment are to gain initial and rapid control of the disease; to decrease plaque lesions and percentage of body surface area involved, to achieve long-term remission; and to minimize adverse events. Topical treatment for mild psoriasis includes topical corticosteroids, calcipotriene, tazarotene, topical tars, anthralin and keratolytics, and immunomodulators (pimecrolimus, tacrolimus). The treatment of moderate to severe psoriasis includes systemic therapies such as methotrexate, acitretin, cyclosporine, hydroxurea and biologicals. Topical treatment can be effective using combination, rotational or sequential regimens for patients with more severe disease. The aim of successful treatment of psoriasis is fast control of the disease and regression of lesions in a short period, prolonged remission and minimal adverse reaction. Local therapy with various topicals is administered for mild and localized forms of the disease, with or without phototherapy (UVB). Topical corticosteroids are used in a variety of formulations, with a potential ranging from superpotent to least potent (class 1-7), which decrease symptoms in tne first two weeks of treatment with improvement in subsequent weeks; D3 vitamin analog (effective in 6-8 weeks), retinoids (effective in 1-2 weeks), tars (2-4 weeks), anthralin (2-4 weeks), and keratolytics (most effective in combination with corticosteroids. Topical corticosteroids have been the first choice in the treatment of and inflammatory dermatoses since 1952 to the present. Corticosteroids are effective as monotherapy or in combination for sequential or rotational treatment. They are effective in short time, simple for use and inexpensive. Psoriasis is a chronic skin disease that requires long-term therapy. For patients with mild to moderate form, intermittent corticosteroid therapy is the most effective treatment. Every-other-day or weekend-only application may be effective in chronic stage. Calcipotriene and tazarotene are more effective in combination with corticosteroids in the initial weeks of therapy. Tar preparations, anthralin and keratolytics may be used with ultraviolet light and corticosteroids. Topical immunomodulators are effective on the face and intertriginous psoriatic lesions.

Atopic dermatitis: an update and review of the literature.

Atopic eczema/dermatitis from the aspects of immunologic background, genetics, skin barrier dysfunction, IgE receptors, and triggers of AD (including allergens, microorganisms, and autoantigens) is described. Also reviewed are diagnostic procedures, treatment modalities with topical treatment (emollients, topical corticosteroids, topical calcineurin inhibitors, wet wrap therapy, and topical antimicrobial therapy), systemic management (antimicrobials, systemic corticosteroids, cyclosporine A, azathioprine, antihistamines), and phototherapy. Primary and secondary prevention are discussed and the role of the different cell receptors and their up-and down-regulation in this setting are emphasized.

Antiproliferative, antiangiogenic and apoptotic effect of photochemotherapy (PUVA) in psoriasis patients.

The aim of the study was to investigate the antiproliferative, antiangiogenic and apoptotic effect of photochemotherapy (PUVA) in psoriatic patients, and to compare it with a control group of psoriatics treated with local corticosteroid therapy. The study included 60 psoriasis patients, 30 of them allocated to PUVA therapy and local corticosteroid each. Immunohistochemical methods of staining with Ki-67, F-8 and bcl-2 antibodies were used to determine proliferative keratinocyte count, to visualize the number of blood vessels in the dermis, and to determine the number of cells exhibiting expression of the antiapoptotic oncoprotein bcl-2, respectively. In all study patients, the values of Ki-67, F-8, bcl-2 and PUVA score were recorded pre- and at six weeks post-therapeutically. Study results showed a statistically significant decrease in the epidermal proliferative keratinocyte count and dermal number of blood vessels after both therapeutic modalities (p < 0.001 both). The value of bcl-2 showed a statistically significant increase in the group of patients treated with PUVA therapy (p = 0.001) and an increase in the control group, demonstrating enhanced keratinocyte apoptosis after treatment. Accordingly, study results demonstrated the antiproliferative, antiangiogenic and apoptotic effect of both PUVA and local corticosteroids. These very mechanisms appear to play a key role in the action of most antipsoriatic therapies.

Topical management of psoriasis - corticosteroids and sparing corticosteroid therapy.

Psoriasis is a complex disease that requires safe, long-term treatment. Topical steroid therapy, topical non-steroid therapy only, and a combination of various topical therapies in the treatment of mild to moderate forms of psoriasis are presented. Topical therapy includes corticosteroids, vitamin D3 analogs, retinoids, tars, anthralin, keratolytics, and topical immunomodulators. While most medications are approved for use as a single agent in the treatment of psoriasis, some of these drugs are most effective when used in combination with topical corticosteroids. Topical therapy is generally administered for mild and localized forms of psoriasis, whereas phototherapy and systemic therapy are reserved for extensive lesions and more severe forms of the disease. Individual approach is absolutely necessary in each patient with psoriasis.

Laser therapy for solar lentigines: review of the literature and case report.

Solar lentigines are benign, brownish lesions that occur on light exposed skin surfaces from age 30 onwards, as a sign of photoaging. As they are of cosmetic importance to many patients, different therapeutic modalities have been tried to remove these unwanted spots. The recent development of short-pulsed, pigment-specific lasers has enabled physicians to selectively destroy the pigment within the solar lentigo lesions with significant clinical improvement, low risk of adverse effects, and high patient acceptance. Therefore this therapeutic option is superior to traditional treatment modalities and represents the treatment of choice in the management of solar lentigines. A case is reported of the successful use of Q-switched ruby laser in the treatment of solar lentigo on the face.

Treatment of childhood psoriasis.

Psoriasis is a common disease in children and adolescents. Because of the chronic course of the disease, appropriate choice of therapy in particular stage of the disease, so-called rotation therapy, is of paramount importance. This article provides a review of therapeutic options for childhood psoriasis. Local therapy for psoriasis in children consists of corticosteroid preparations, calcipotriol, tars and dithranol, local retinoids, and local immunomodulators. Phototherapy (narrow band UVB, photochemotherapy PUVA baths) is now a part of psoriasis therapy in children. Systemic therapy retinoids (acitretin) methotrexate, cyclosporine is only used in severe forms of the disease such as erythrodermic, pustular and arthritic psoriasis. All these therapeutic options can be used as monotherapy or in various combinations.

Phototherapy in pediatric patients.

The treatment of children with psoriasis, atopic dermatitis (AD), pityriasis lichenoides, and scleroderma poses a therapeutic problem because all therapeutic options are associated with numerous side effects. Therefore ultraviolet A and B (UVA and UVB) phototherapy is presented as a possible alternative to some of these therapies, primarily topical and systemic corticosteroids, in children. Our results in treating children with phototherapy and psoralen plus UVA (PUVA) bath phototherapy over the past 5 years are reported. UVB therapy (TL01) was used in 20 psoriatic children (6 boys, 14 girls; ages 6-14 years) during the stage of disease exacerbation and in 9 children (3 boys, 6 girls; ages 8-16 years) with pityriasis lichenoides. Combined UVA/UVB phototherapy was applied in 21 AD children (7 boys, 14 girls; ages 4-15 years). Photochemotherapy with local application of a PUVA bath was used in six children (2 boys, 4 girls; ages 9-16 years) with circumscribed scleroderma and in one girl with systemic scleroderma. All children received short courses of phototherapy with either no maintenance or short maintenance. All three therapeutic protocols resulted in a certain degree of improvement in most of the study patients. None of the patients exhibited any early phototherapy side effects. We conclude that phototherapy and PUVA bath are valuable and safe therapeutic options for selected children who do not respond to other treatments.