Laser-Assisted Photodynamic Therapy: Two Novel Protocols for Enhanced Treatment Results.

Photodynamic therapy (PDT) uses a topical photosensitizing agent which is activated by a light source to cause destruction of specific cells. Commonly used for the treatment of actinic keratoses and photodamage, PDT can also be used for other conditions including acne and sebaceous hyperplasia. Here we report our experience with two treatment protocols. The first protocol utilizes laser assisted delivery of topical 5-aminolevulinic acid for enhanced efficacy of blue light photodynamic therapy in the treatment of actinic keratoses and photodamage. The second protocol utilizes red light photodynamic therapy followed by pulsed dye laser to effectively target sebaceous glands in patients with extensive sebaceous hyperplasia.

J Drugs Dermatol. 2017;16(4):329-331.

The CRH1 antagonist GSK561679 increases human fear but not anxiety as assessed by startle.

Fear to predictable threat and anxiety to unpredictable threat reflect distinct processes mediated by different brain structures, the central nucleus of the amygdala and the bed nucleus of the stria terminalis (BNST), respectively. This study tested the hypothesis that the corticotropin-releasing factor (CRF1) antagonist GSK561679 differentially reduces anxiety but increases fear in humans. A total of 31 healthy females received each of four treatments: placebo, 50 mg GSK561679 (low-GSK), 400 mg GSK561679 (high-GSK), and 1 mg alprazolam in a crossover design. Participants were exposed to three conditions during each of the four treatments. The three conditions included one in which predictable aversive shocks were signaled by a cue, a second during which shocks were administered unpredictably, and a third condition without shock. Fear and anxiety were assessed using the acoustic startle reflex. High-GSK had no effect on startle potentiation during unpredictable threat (anxiety) but increased startle potentiation during the predictable condition (fear). Low-GSK did not affect startle potentiation across conditions. Consistent with previous findings, alprazolam reduced startle potentiation during unpredictable threat but not during predictable threat. The increased fear by high-GSK replicates animal findings and suggests a lift of the inhibitory effect of the BNST on the amygdala by the CRF1 antagonist.

Post-filler vascular occlusion: a cautionary tale and emphasis for early intervention.

We report a case of a 36-year-old female who experienced significant vascular occlusion after injection with hyaluronic acid into the nasolabial folds. The patient experienced immediate pain after the injection, however, the vascular compromise was not diagnosed and treated until 48 hours later. The patient suffered tissue damage despite treatment with hyaluronidase, hyperbaric oxygen, nitropaste, and aspirin. The case highlights the importance of proper injection technique by a qualified physician, as well as the need for immediate recognition and treatment of vascular occlusion should it occur.

A randomized controlled trial of a cognitive behavioural patient education intervention vs a traditional information leaflet to address the cardiovascular aspects of rheumatoid disease.

OBJECTIVES: Cardiovascular disease (CVD) is responsible for 50% of the excess mortality for patients with RA. This study aimed to evaluate a novel 8-week cognitive behavioural patient education intervention designed to effect behavioural change with regard to modifiable CVD risk factors in people with RA. METHODS: This was a non-blinded randomized controlled trial with a delayed intervention arm. Participants were randomly assigned to receive the cognitive behavioural education intervention or a control information leaflet at a ratio of 1:1. The primary outcome measure was patient's knowledge of CVD in RA; secondary measures were psychological measures relating to effecting behaviour change, actual behaviour changes and clinical risk factors. Data were collected at baseline, 2 and 6 months. RESULTS: A total of 110 participants consented (52 in the intervention group and 58 in the control group) to participate in the study. At 6 months, those in the intervention group had significantly higher knowledge scores (P < 0.001); improved behavioural intentions to increase exercise (P < 0.001), eat a low-fat diet (P = 0.01) and lose weight (P = 0.06); and lower mean diastolic blood pressure by 3.7 mmHg, whereas the control group's mean diastolic blood pressure increased by 0.8 mmHg. There was no difference between the groups on actual behaviours. CONCLUSIONS: Patient education has a significant role to play in CVD risk factor modification for patients with RA, and the detailed development of this programme probably contributed to its successful results. It is disappointing that behaviours, as we measured them, did not change. The challenge, as always, is how to translate behavioural intentions into action. Larger studies, powered specifically to look at behavioural changes, are required. Trial registration. National Institute for Health Research, UKCRN 4566.

Calcium hydroxylapatite nodule resolution after fractional carbon dioxide laser therapy.

BACKGROUND: Injection of calcium hydroxylapatite filler may result in nodule formation owing to superficial placement of the filler. Calcium hydroxylapatite nodules are difficult to reverse. Previously reported therapeutic options are limited and include intralesional triamcinolone, massage, needling, and excision, each with inconsistent results or potential for scarring. OBSERVATION: We have observed complete resolution of calcium hydroxylapatite nodules after a single treatment with fractional carbon dioxide laser. CONCLUSIONS: A single session of fractional carbon dioxide laser treatment may resolve selected cases of calcium hydroxylapatite nodules. The mechanism of action may involve conversion of the product into tricalcium phosphates which dissolve readily. This novel therapeutic technique may enhance treatment options for a difficult clinical problem.

Improvement in arm and post-partum abdominal and flank subcutaneous fat deposits and skin laxity using a bipolar radiofrequency, infrared, vacuum and mechanical massage device.

BACKGROUND AND OBJECTIVES: Skin laxity of the body is a growing cosmetic concern. Laxity can result from chronological or photoaging and changes in body dimensions during pregnancy or weight loss. The end result is loose, sagging skin, and localized fat deposits. Liposuction and abdominoplasty or brachioplasty are established approaches to these issues. Patient desire for alternatives to surgical correction has spawned the development of non-invasive body contouring devices. The combination of infrared light (IR), bipolar radiofrequency (RF), vacuum and mechanical massage (Velashape, Syneron Medical Ltd, Israel) has demonstrated efficacy in improving skin appearance and circumference of the thighs [Goldberg et al., Derm Surg 2008; 34:204-209; Fisher et al., Derm Surg 2005; 31:1237-1241; Arnoczky and Aksan, J Am Acad Orthop Surg 2000; 8:305-313; Alster and Tanzi, J Cosmetic Laser Therapy 2005; 7:81-85; Wanitphakdeedecha and Manuskiatti, J Cosmet Dermatol 2006; 5:284-288; Nootheti et al., Lasers Surg Med 2006; 38: 908-912], but only anecdotal evidence has supported its use on other anatomic locations. This study was designed to evaluate the efficacy and safety of Velashape on additional body sites and more rigorously examine the technology's impact on upper arm as well as abdominal and flank circumference. STUDY DESIGN AND METHODS: Subjects were 28-70 years old, skin types I-V. Nineteen subjects underwent 5 weekly treatments of the upper arms, and 10 subjects underwent 4 weekly treatments of the abdomen and flanks. Treatments were performed using Velashape. Circumference measurements, photographs, and subject weights were performed prior to treatment and at 1- and 3-month follow-ups. Subjects were asked to record their treatment satisfaction level. RESULTS: Change in arm circumference, at the 5th treatment was statistically significant with a mean loss of 0.625 cm. At 1- and 3-month follow-ups, mean loss was 0.71 and 0.597 cm respectively. Reduction of abdominal circumference at 3rd treatment was statistically significant with a 1.25 cm mean loss. At 1- and 3-month follow-ups, average loss was 1.43 and 1.82 cm respectively. CONCLUSIONS: This study demonstrates with statistical significance, sustainable reduction in circumference and improvement in appearance of arms and abdomen following treatment with Velashape.

Outcomes of childhood hemangiomas treated with the pulsed-dye laser with dynamic cooling: a retrospective chart analysis.

BACKGROUND: Laser treatment of childhood hemangiomas remains controversial. Previous studies have used outdated technology, resulting in a potential overrepresentation of adverse outcomes. OBJECTIVE: To evaluate outcomes of hemangiomas treated with the most current laser technology. METHODS: A retrospective chart analysis of 90 patients with a median age of 3.0 months and a total of 105 hemangiomas were enrolled over a 2.5-year period. All were treated with the 595-nm long-pulse pulsed-dye laser (LP-PDL) with dynamic epidermal cooling at 2- to 8-week intervals depending on the stage of growth. Exclusion criteria were previous laser, surgical, or corticosteroid treatment. Three reviewers assessed outcomes. RESULTS: Near-complete or complete clearance in color were achieved for 85 (81%) and in thickness for 67 (64%) hemangiomas. There was no scarring or atrophy. Ulceration occurred in one case and resolved during treatment. Hyperpigmentation and hypopigmentation occurred in 4% and 14% of hemangiomas, respectively. CONCLUSION: Early treatment of childhood hemangiomas with the 595-nm LP-PDL with dynamic cooling may reduce the proliferative phase and result in excellent rates of clearing and few adverse events.

Port wine stain progression: a potential consequence of delayed and inadequate treatment?

BACKGROUND AND OBJECTIVES: Port wine stains are congenital low-flow vascular malformations of the skin. Unlike hemangiomas, PWS do not involute with time, but rather if left untreated can hypertrophy and develop nodularity. Laser therapy of PWS particularly with pulsed-dye lasers, is a safe, well-established treatment that is successful in the majority of patients, especially for younger patients. Patients that fail to receive treatment early in life may subsequent develop lesions more likely to progress. STUDY DESIGN/PATIENTS AND METHODS: A case report and review of the literature are presented. We report a 43 year-old man born with a port-wine stain on the right side of his face that extended in the V2 distribution on his face. He had undergone several sessions with a pulsed-dye laser, the sequential dual-wavelength (595 nm and 1064 nm) laser and a CO2 resurfacing laser from the age of 26 but failed to follow through with a sufficient number of treatments to prevent hypertrophy. RESULTS: Due to an insufficient number and interval of treatments (with only 7 treatments over 16 years starting at age 26) with the various lasers, the patient's port wine stain continued to progress in color and development of nodularity. CONCLUSIONS: Patients born with port wine stains should have early laser treatment to achieve optimal results. Delay in treatment, as in this patient until age 26, may result in hard to treat PWS that can continue to progress in nodularity. This case illustrates the hypertrophy and nodularity that can occur due to progression of a PWS with failure to follow through with sufficient number of laser treatments.

The safety and efficacy of fractional photothermolysis for the correction of striae distensae.

BACKGROUND: Improving the appearance of striae distensae, particularly striae alba, has remained a challenge due to the limited availability of effective and low-risk treatment options. Fractional photothermolysis, a novel concept in skin rejuvenation, has been reported to be effective in the treatment of facial rhytides, acne scars, and surgical scars, but its use in the treatment of striae has not been well studied. OBJECTIVE: To determine the safety and efficacy of fractional photothermolysis treatment on striae alba and striae rubra. METHODS: Twenty female patients with striae rubra or striae alba on their abdomen, thighs, or buttocks were enrolled in the study. Lesions were randomized to receive treatment, with site-matched normal control areas. Patients received a total of 6 treatments using a 1550-nm, erbium-doped fiber laser with 2 to 3 weeks of elapsed time between treatments. Clinical response to treatment was assessed at each visit, and at 1-month, 2-month, and 3-month follow-up intervals by the patient and investigator. A comparison evaluation of 8 patients examining photographs of striae at baseline and at the 3-month follow-up evaluation which was assessed by 4 independent dermatologists using the quartile grading scale. RESULTS: The independent evaluators' assessments of improvement from photographs of 8 randomly selected patients showed an overall improvement of 26% to 50% in 63% (5/8) of patients. A less than 25% improvement in dyschromia was noted in 50% (4/8) of patients. An improvement in texture of 26% to 50% was observed in 50% (4/8) of patients. The clinical responses were independent of age, gender, and skin phototype. The treatments were tolerated well by all patients with a majority of patients experiencing transient posttreatment erythema and edema. CONCLUSION: Fractional photothermolysis can be effectively and safely used in the treatment of striae rubra and striae alba.