Tarnish tattoos - localised cutaneous argyria from sterling silver in fresh piercings: a case series.

Tarnish tattoo is a form of localised cutaneous argyria resulting from the deposition of silver into the skin following exposure to silver jewellery in fresh piercings. This report presents the clinical presentation, diagnosis, and management of 4 female patients with tarnish tattoos on the nose and ear from wearing silver jewellery. All four patients wore silver studs or rings immediately following the piercing. Two of the four patients underwent treatment with nanosecond Q-switched 1064nm Neodymium: Yttrium Garnet laser (QS Nd: YAG) and Q-switched Alexandrite 755nm lasers with minimal improvement. Tarnish tattoos are an under-recognized side-effect of wearing silver jewellery in fresh piercings. The grey-blue discolouration from tarnish tattoos can be challenging to treat with nanosecond QS lasers.

The NHS two week wait skin cancer referral pathway: analysis and recommendations for process improvement.

BACKGROUND: While pressures on the National Health Service skin cancer services have predated the COVID pandemic, the two -week-wait (2WW) skin cancer standards have deteriorated post-pandemic. METHODS: The 2WW skin cancer pathway is analysed in this report utilising 4V typology and volume-variety matrix. Performance matrix of the 2WW skin cancer pathway and SIPOC analysis are also examined. Recommendations are provided following analysis and redesign of the process map of the pathway. RESULTS: Process analysis has enabled identification of some of the limitations of the 2WW skin cancer pathway. This has led to recommendations including lesion assessment using artificial intelligence, single lesion assessment clinics and direct access skin surgery, all of which aim to expedite patient care and increase capacity in 2WW clinics. CONCLUSIONS: Process analysis of the 2WW skin cancer pathway provides useful insights and helps identify bottlenecks in the system. Recommendations following remapping the process offer potential solutions to help reducing time to referral and increasing capacity. These recommendations should help reduce waiting times for patients receiving initial diagnosis and subsequent definitive treatment for suspected skin cancers.

The Role of Lasers in Connective Tissue and Inflammatory Dermatoses: A 10-Year Retrospective Review of 60 Patients in a UK Tertiary Laser Clinic.

Introduction: The role of lasers in the treatment of standard therapy-resistant inflammatory dermatoses and connective tissue disorders has been controversial and evidence supporting the role of lasers in this setting is scarce. Objective: To assess the efficacy of lasers in the management of inflammatory dermatoses and connective tissue disorders (CTD). Materials and Methods: A retrospective case review of all inflammatory dermatoses/connective tissue diseases treated in a tertiary laser clinic between March 2010 and 2020 was undertaken. Results: A total of 60 cases (48 = female) were included and the average age was 51 years (range 21 to 74). The following conditions were treated: scleroderma n = 22 (37%), granuloma faciale n = 10 (17%), sarcoidosis n = 8 (13%), discoid lupus erythematosus n = 7 (12%), and systemic lupus erythematosus n = 2 (3%). Other diagnoses included necrobiosis lipoidica, pyoderma vegetans, hypertrophic lichen planus, and dermatomyositis. The most common type of laser used was pulsed dye laser (PDL) in n = 41 (68%) cases. Eight (13%) patients received treatment with the carbon dioxide (CO2) laser. The most common site treated was the face. A good response with a marked reduction of signs was seen in 62% of patients while 10% of the patients did not respond to laser treatment. Self-limiting complications included purpura and hyperpigmentation. Limitations: Lack of objective assessment and outcome measures. Conclusions: This is the largest cohort of patients to have undergone laser treatment for inflammatory dermatoses/connective tissue disease. Based on this retrospective review, we conclude that lasers can be a useful adjunct in the management of otherwise difficult-to-treat selected inflammatory and connective tissue diseases.

Symmetric Idiopathic MicroPapular Facial Eruption or SIMPLE - Description of a New Entity Featuring Facial Vellus Hair Lichen Planopilaris in the Absence of Frontal Fibrosing Alopecia.

Patients with frontal fibrosing alopecia (FFA) can present with facial micropapules which histologically represent vellus hair lichen planopilaris (LPP). Noninflammatory vellus hair LPP in the absence of FFA is rarely reported. The report describes noninflammatory vellus hair LPP presenting as symmetrical facial micropapules in the absence of clinical signs of FFA.

Prevalence of wound complications following Mohs micrographic surgery (MMS): a cross-sectional study of 1000 patients undergoing MMS and wound repair in a UK teaching hospital.

BACKGROUND: Mohs micrographic surgery (MMS) for nonmelanoma skin cancer is often quoted as having an excellent safety profile. AIM: To determine the complication rate of patients undergoing MMS in a large UK Mohs unit and subdivide complication rates into mild/intermediate and major, and to identify potential risk factors necessitating a clinical intervention. METHODS: This was a single-centre, cross-sectional study of 1000 consecutive cases of MMS performed with in-house repair. Notes from the postsurgical dressing clinics were reviewed at Visit 1 (Days 7-14) and Visit 2 (approximately Week 6). Based upon the intervention required and effect on cosmetic/functional outcome, complications were classified as minor, intermediate or major. Logistic regression modelling was used to identify risk factors associated with a complication that needed a clinical intervention (i.e. intermediate or major). RESULTS: In total, 1000 Mohs surgeries were performed on 803 patients, resulting in 1067 excisions. Complication rates in our cohort were low (minor 3.6%, intermediate 3.1% and major 0.8%) Potential risk factors for developing a complication included skin graft (unadjusted OR = 4.89, 95% CI 1.93-12.39; fully adjusted OR = 7.13, 95% CI 2.26-22.45) and patients undergoing surgery on the forehead (unadjusted OR = 3.32, 95% CI 0.95-11.58; fully adjusted OR = 5.34, 95% CI 1.40-20.42). Patients whose wounds were allowed to heal by secondary intention healing (6.8%) exhibited no complications. CONCLUSION: We advocate that patients should be informed during the consent procedure that less than 1 in every 100 patients (0.75%) undergoing MMS will have a serious adverse event (major complication) affecting their cosmetic or functional outcome.

Idiopathic Guttate Hypomelanosis Treated with 308-nm Excimer Light and Topical Bimatoprost.

Idiopathic guttate hypomelanosis (IGH) is an acquired pigmentary disorder that is characterized by the presence of multiple hypopigmented macules on the shins and forearms. Albeit asymptomatic, it can cause considerable cosmetic anxiety. The pathogenesis is not fully understood and to date, there have been no successful treatments. We report a case of a 48-year-old female who presented with an 8-year history of multiple hypopigmented macules on both legs, typical of IGH. She previously failed to respond to topical pimecrolimus. She received targeted phototherapy with an excimer lamp (308 nm, 250-480 mJ), and a small patch was treated once daily with topical bimatoprost, in addition to the excimer lamp. After five sessions, better improvement was noted on the combination treatment patch; she received combination treatments for further six sessions. Good repigmentation has been achieved on the smaller macules. The larger depigmented macules continue to improve with further treatments. A combination of excimer light with topical bimatoprost appears to be a promising potential treatment option for IGH, a condition where management options are otherwise limited.

Resumption of laser/IPL skin services post COVID-19 lockdown-British Medical Laser Association (BMLA) guidance document.

The COVID-19 pandemic has had a significant negative impact on the global health economies. As health care resources have been prioritised to cater for patients affected by COVID-19, routine health care services have remained suspended. In an effort to slow the spread of SARS-CoV-2 virus, the UK introduced a country-wide lockdown which came into effect on the 23rd March 2020. Since then, clinics offering laser and intense pulsed light services have remained closed for business. As the rate of COVID-19 infection slows, the UK government has issued guidance for lifting of the lockdown in a cautious and phased manner. With this in view and to facilitate safe resumption of laser and intense pulsed light services, the British Medical Laser Services has issued this guidance document, based on best available and current scientific evidence.

Carbon dioxide laser ablation of dermatosis papulosa nigra: high satisfaction and few complications in patients with pigmented skin.

Dermatosis papulosa nigra (DPN) is a common condition of pigmented skin. Whilst lesions are benign, they may be symptomatic or cosmetically disfiguring. Ablative lasers have previously been reported as a useful therapeutic modality in DPN. We report the largest case series to date of patients with DPN ablated with the carbon dioxide (CO2) laser. A retrospective case note review was conducted of all patients with DPN treated in our laser clinic in the last five years, and a post-treatment telephone survey was undertaken to assess patient satisfaction. Forty-five patients were identified, with a median age of 41 years (range 25-74 years), of whom 37 (82%) were female. The median number of treatments undertaken was three (range 1-10). Of the 18 respondents to the telephone survey, when asked to grade their satisfaction with the procedure out of 10, median response was 9.5 (range 6-10) with nine patients citing the maximum score of 10. All patients replied that their confidence had improved following the procedure and that they would recommend the treatment to other patients. Five respondents (28%) reported recurrence of a few lesions following CO2 laser ablation; the remaining 13 respondents (72%) reported no recurrence of DPN. No respondents reported any other post-procedural complications (including scarring, hypopigmentation and hyperpigmentation). We advocate use of the CO2 laser as a safe, convenient means of treating DPN, with a high degree of patient satisfaction, low recurrence rate and few complications.

Papular Acne Scars of the Nose and Chin: An Under-recognised Variant of Acne Scarring.

BACKGROUND: Scarring following acne vulgaris is common and can be of profound psychosocial consequence. AIMS AND OBJECTIVES: We have clinically noted a variant of acne scarring, overlooked by previous categorisation schemes, which we have denominated as papular acne scars of the nose and chin. We sought to characterise these novel entities further. MATERIALS AND METHODS: Initially, we identified 14 patients with papular acne scars of the nose and chin in a cosmetic dermatology clinic, of whom two were female and rest were male. We then prospectively evaluated 100 consecutive patients attending our tertiary referral acne isotretinoin clinic and 49 patients attending a general dermatology clinic. RESULTS: Amongst 149 patients, from a general dermatology and tertiary acne clinic, soft papular scars were noted in four patients, distributed on the nose and chin. Three of the four patients were male, three patients had additional acne scars and the median age was 23.5. CONCLUSIONS: We have identified 18 patients with papular acne scars of the nose and chin and propose that this new category should be added to acne scarring classification schemes. Future work should be directed at corroborating the epidemiology of such lesions and describing effective treatment modalities.

Comparative Efficacy and Patient Preference of Topical Anaesthetics in Dermatological Laser Treatments and Skin Microneedling.

BACKGROUND: Topical anaesthetics are effective for patients undergoing superficial dermatological and laser procedures. Our objective was to compare the efficacy and patient preference of three commonly used topical anaesthetics: (2.5% lidocaine/2.5% prilocaine cream (EMLA(®)), 4% tetracaine gel (Ametop™) and 4% liposomal lidocaine gel (LMX4(®))) in patients undergoing laser procedures and skin microneedling. SETTINGS AND DESIGN: This was a prospective, double-blind study of patients undergoing laser and skin microneedling procedures at a laser unit in a tertiary referral dermatology centre. MATERIALS AND METHODS: All 29 patients had three topical anaesthetics applied under occlusion for 1 hour prior to the procedure, at different treatment sites within the same anatomical zone. A self-assessment numerical pain rating scale was given to each patient to rate the pain during the procedure and each patient was asked to specify their preferred choice of topical anaesthetic at the end of the procedure. STATISTICAL ANALYSIS: Parametric data (mean pain scores and frequency of topical anaesthetic agent of choice) were compared using the paired samples t-test. A P-value of ≤0.05 was considered as statistically significant. RESULTS AND CONCLUSIONS: Patients reported a mean (±SD; 95% confidence interval) pain score of 5 (±2.58; 3.66-6.46) with Ametop™, 4.38 (±2.53; 2.64-4.89) with EMLA(®) and 3.91 (±1.95; 2.65-4.76) with LMX4(®). There was no statistically significant difference in pain scores between the different topical anaesthetics. The majority of patients preferred LMX4(®) as their choice of topical anaesthetic for dermatological laser and skin microneedling procedures.

Facial fat necrosis following autologous fat transfer and its management.

Autologous fat transfer (AFT) is an increasingly popular cosmetic procedure practiced by dermatologic surgeons worldwide. As this is an office based procedure performed under local or tumescent anaesthesia with fat transferred within the same individual and limited associated down time its is considered relatively safe and risk free in the cosmetic surgery arena. We describe a case of AFT related fat necrosis causing significant facial dysmorphia and psychosocial distress. We also discuss the benefits and risks of AFT highlighting common causes of fat graft failure.

Carbon dioxide laser perforation and extirpation of steatocystoma multiplex.

BACKGROUND: Steatocystoma multiplex (SM) is a rare condition that presents as multiple dermal cysts, the appearance of which can have a significant impact on the patients' quality of life. Treatment options for SM are limited to surgical excision. OBJECTIVE: To present our experience of treating 8 SM cases using a novel approach that uses the carbon dioxide (CO2) laser and to explore patients' views about the treatment. METHODS: Patients were identified from our records. All patients had multiple lesions treated using the CO2 laser in the super pulse mode that punctured the cyst. This was followed by extirpating the cyst wall and its contents using a small Volkmann's spoon. Treatment efficacy was assessed clinically and feedback from the patients was sought through a telephone interview. RESULTS: All patients showed significant clinical improvement with minimal scarring and low recurrence rates. High levels of patient satisfaction, which helped to significantly improve their quality of life, were reported with the CO2 laser treatment. CONCLUSION: CO2 laser perforation and extirpation is a successful approach for managing SM that results in high patient satisfaction.

Carbon dioxide laser treatment of cutaneous neurofibromas.

INTRODUCTION: Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder, with multisystem involvement, including cutaneous manifestations of hyperpigmentation and neurofibromas. Multiple cutaneous lesions are often disfiguring and lead to emotional distress and social isolation. Treatment of NF1 is predominantly surgical but alternative treatments should be considered for patients with large numbers of lesions as cold steel excision of multiple lesions can be cumbersome and may not be practical. The authors report a series of patients with multiple neurofibromas successfully treated using a CO(2) laser. METHODS: Data on CO(2) laser treatments, follow-up, and recurrence following treatment was collected retrospectively. A post-treatment telephone survey was carried out to assess patient satisfaction using a standardized set of questions and a scoring tool. RESULTS: Five of seven patients who underwent CO(2) laser treatment of their multiple neurofibromas responded to the post-treatment survey. All five patients (age range 36-56 years, mean age 45.2 years, three men:two women) had multiple variable-sized neurofibromas. The mean number of lesions per patient was 114 (range 20-200 lesions). The mean number of treatment sessions was 2.2 (range 1-4 sessions) and mean follow-up was 14.4 months (range 6-24 months). Three patients (60%) reported no recurrence up to 2 years post-laser treatment. Two patients (40%) had recurrences of a few lesions (≤10% of treated lesions per patient). The mean patient satisfaction score was 9.2 out of 10 (range 8-10). All patients mentioned that they would recommend CO(2) laser treatment to others with multiple neurofibromas. Hypopigmentation or depigmentation at treatment sites were the only reported adverse effects. CONCLUSION: Based on current results, the authors feel that CO(2) laser treatment achieves a high level of patient satisfaction with a low recurrence of treated lesions.