Autofluorescence Excitation Imaging of Nonmelanoma Skin Cancer for Margin Assessment Before Mohs Micrographic Surgery: A Pilot Study.

BACKGROUND: Autofluorescence photography can detect specific light-tissue interactions and record important pathophysiological changes associated with nonmelanoma skin cancer (NMSC), which has been ascribed to the fluorescence of an aromatic amino acid, tryptophan. OBJECTIVE: To assess the impact of a novel, autofluorescence imaging (AFI) device on margin control for NMSCs before Mohs micrographic surgery (MMS) in an effort to decrease overall operating time. METHODS: Before the initial stage of MMS, NMSCs were measured with a 2-mm margin as standard of care (normal margin). The tumor was then imaged with the AFI device. A 2-mm margin was drawn around the fluorescent area captured by the AFI device and was referred to as the camera margin. The tumor was excised based on the normal margin and evaluated on frozen histological section. RESULTS: Imaging based on the AFI device resulted in appropriate recommendations for margin control in 8 of 11 tumors. Four of these tumors did not fluoresce and demonstrated a lack of tumor residuum on stage I specimen, as anticipated. There were no side effects from the AFI device. CONCLUSION: This is an initial pilot study that supports the use of a novel, noninvasive imaging device to help with margin assessment before MMS. On optimization, this device has potential to extend applicability to surgical excisions for tumors that do not fulfill criteria for MMS.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Efficacy and Safety of the 532-nm KTP and Long-Pulsed 1064-nm Neodymium-doped Yttrium Aluminum Garnet Laser for Treatment of Vascular Malformations.

BACKGROUND: Pulsed dye lasers (PDLs) are well-established for treatment of capillary malformations but are unable to penetrate the depth needed to treat deeper vascular lesions. A combined approach using a deeper penetrating wavelength with a "superficial" wavelength could more comprehensively treat vascular malformations than PDL alone. OBJECTIVE: To evaluate the safety and efficacy of the long-pulsed 1064-nm neodymium:yttrium-aluminum-garnet (LP 1064-nm Nd:YAG) in conjunction with the 532-nm potassium titanyl phosphate (532-nm KTP) laser wavelengths for treatment of capillary venous and venous malformations. METHODS: In this retrospective single-center study, we queried patient records who underwent treatment with the 532-nm KTP and LP 1064-nm Nd:YAG laser wavelengths. A blinded panel of 3 physicians evaluated improvement in lesion color, elevation, texture, and overall architecture on a four-point scale: 0% to 25%; 26% to 50%, 51% to 75%, and 76% to 100%. RESULTS: Our cohort consisted of 23 cases. Sixteen cases had sufficient information for clinical assessment. Treatment number and parameters varied depending on lesion, skin type, and end point. Clinical assessment of treatment effectiveness revealed average scores of 51% to 75% improvement for color, elevation, texture, and overall architecture. CONCLUSION: This study illustrates that 2 wavelengths, 532-nm KTP to target superficial components and LP 1064-nm Nd:YAG for deeper components, can safely and effectively treat both capillary venous and venous malformations.

The Evolving Story of Laser Therapeutics for Basal Cell Carcinoma.

BACKGROUND: The increasing burden from basal cell carcinoma (BCC) has stimulated the development of alternative treatments for these tumors. OBJECTIVE: This review focuses on upcoming laser treatments for BCC and highlights the limitations of these therapies. METHODS: A PUBMED search was conducted for articles on laser therapy of BCC. Key studies involving lasers to treat BCC were reviewed. Novel approaches to BCC are also described. RESULTS: Vascular-specific laser therapy has increasingly been studied as an addition in the therapeutic armamentarium of BCC. Although these studies demonstrate efficacy for nonaggressive BCC, optimization of this technique is ongoing to minimize scarring. A more targeted approach to the treatment of BCC, such as immunized photothermal therapy or laser-assisted chemotherapeutic delivery, may result in less scarring, while maintaining efficacy similar to that of lasers targeting tumor vasculature. CONCLUSION: Vascular-specific laser therapies show promise in treating low-risk BCC; however, scarring is not an uncommon adverse event. Although only animal studies have been performed to date, laser-activated gold nanoparticle therapy and laser-assisted drug delivery of vismodegib are potential therapies that theoretically confer a more selective approach. Laser modalities demonstrate promise in the treatment of nonaggressive BCC, although long-term studies have yet to be published.

Analysis of U.S. Food and Drug Administration Data on Soft-Tissue Filler Complications.

BACKGROUND: With the rising popularity of dermal fillers, the number of complications associated with fillers has increased. OBJECTIVE: To identify and review reports of adverse events involving cosmetic injectable soft-tissue fillers from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from June 1993 to August 2014. MATERIALS AND METHODS: The authors conducted a search of adverse events within the U.S. Food and Drug Administration database that involved injectable dermal fillers for soft-tissue augmentation from June 1993 to August 2014. Search terms included generic and trade names of commercially available soft-tissue fillers. RESULTS: Three thousand seven hundred eighty-two complications involving dermal fillers were identified in the MAUDE database. Forty-four percent of complications implicated hyaluronic acid fillers, 40% involved poly-L-lactic acid fillers, 15% complications included calcium hydroxylapatite fillers, and <1% complications arose from polymethylmethacrylate fillers. Common adverse events included lumps, infection, allergic reaction, ischemia, and swelling. Rare events included trigger of autoimmune reactions, visual disturbances, and stroke. CONCLUSION: Although complications with dermal fillers are infrequent in comparison with the growing number of filler procedures being performed in the United States every year, this study underscores the importance of appropriate skill and training when administering dermal fillers. Physicians using injectable dermal fillers should be trained to recognize potential complications and know how to appropriately manage them.

Treatment of benign pigmented lesions using a novel Dermal Cooling System.

Benign pigmented lesions are among the most common dermatologic diagnoses that patients seek treatments for. Treatment modalities range from cryotherapy to light and laser-based technologies. These treatments have been shown to be effective, yet may lead to dyschromia or significant downtime. Therefore, we report the first clinical experience with a novel Dermal Cooling System that provides localized and controlled freezing to benign pigmented lesions. Twenty patients seeking treatment for benign pigmented lesions were treated with the Dermal Cooling System at the laser and cosmetic dermatology clinic at the University of California, San Diego. Photographs were captured at baseline and follow-up visits. Two blinded investigators reviewed and graded the photographs. Most patients experienced improvement after 1 month following the first treatment. Macular or slightly raised lesions responded best. Treatment side effects were transient, lasted a maximum of 3 days, and included erythema, swelling, itching, and darkening. There was no observed long-term dyschromia. The novel Dermal Cooling System shows promise in the treatment of flat to slightly raised benign pigmented lesions with little-to-no downtime. Further clinical experience is necessary to continue to optimize treatment parameters. Lasers Surg. Med. 51:59-61, 2019. © 2018 Wiley Periodicals, Inc.

Outcomes of long-pulsed 1064 nm Nd:YAG laser treatment of basal cell carcinoma: A retrospective review.

BACKGROUND AND OBJECTIVE: Recent prospective trials have supported treatment of nonfacial BCC with long-pulsed 1064 nm Nd:YAG laser based on short-term histologic clearance rates. Studies have yet to identify the long-term clinical clearance rates of this specific laser therapy for BCC. STUDY DESIGN/MATERIAL AND METHODS: This is a retrospective review of BCC treated with long-pulsed 1064 nm Nd:YAG laser, which have been clinically monitored for at least 6 months, to assess for recurrence and cosmetic outcomes of the treated area. RESULTS: 16 BCC lesions (11 subjects) treated with 1064 nm Nd:YAG laser were enrolled. Our analysis revealed 100% clearance rate in all subjects (16 of 16 BCC) treated with long-pulsed Nd:YAG laser based on mean follow-up of 9 months (range 6-15 months). Minimal scarring and no long-term adverse events were noted. CONCLUSIONS: This study supports the use of 1064 nm Nd:YAG laser as a therapeutic modality for BCC based on the absence of clinical recurrence upon a mean follow-up of 9 months. As studies progress, we are beginning to observe a potential role for laser as an alternative to patients who refuse surgery, have multiple co-morbidities, or decline non-surgical therapies. Laser treatment with 1064 nm Nd:YAG is an evolving, promising story that we continue to investigate to optimize parameters. Lasers Surg. Med. 51:34-39, 2019. © 2018 Wiley Periodicals, Inc.

Lasers and energy-based devices marketed for vaginal rejuvenation: A cross-sectional analysis of the MAUDE database.

INTRODUCTION: The FDA issued a statement on July 30, 2018, expressing concern over the marketing of lasers and energy-based devices to promote "vaginal rejuvenation." The FDA stated that there is insufficient data to recommend this modality for optimization of sexual function and alleviation of genitourinary syndrome of menopause (GSM)-related symptoms in postmenopausal or postpartum women. This analysis aims to characterize the mandatory and voluntary reports concerning laser and energy-based procedures marketed for vaginal rejuvenation. METHODS: Cross-sectional analysis of the FDA database, Manufacturer and User Facility Device Experience (MAUDE), for events related to laser and energy-based devices for vaginal rejuvenation. RESULTS: Between October 2015 and January 2019, 45 distinct events describing 46 patients were recorded and reviewed. The most commonly reported adverse event related to the procedure was pain (vulvar, bladder, urethral, or unspecified) (n = 19). The majority of patients sought medical care for their injuries, which included evaluation by urgent care, urology, gynecology, neurology, gastroenterology, pelvic floor therapy, primary care providers, and the device operator. Thirty-three patients indicated chronicity of their injury, which included long-term pain, numbness, burning, bladder disturbances, infections, scarring, dyspareunia, worsening symptoms, aggravation of lichen sclerosis, and disfigurement. CONCLUSIONS: A variety of adverse events associated with the use of laser and energy-based devices for "vaginal rejuvenation" was reported to the MAUDE database. Although the circumstances surrounding these events were unclear, these reports signify the importance of clinical trials that investigate the efficacy and safety profile of laser and energy-based devices for optimization of sexual function and treatment of GSM-related symptoms. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Airborne particulate concentration during laser hair removal: A comparison between cold sapphire with aqueous gel and cryogen skin cooling.

BACKGROUND: High concentrations of sub-micron nanoparticles have been shown to be released during laser hair removal (LHR) procedures. These emissions pose a potential biohazard to healthcare workers that have prolonged exposure to LHR plume. OBJECTIVE: We sought to demonstrate that cold sapphire skin cooling done in contact mode might suppress plume dispersion during LHR. METHODS: A total of 11 patients were recruited for laser hair removal. They were treated on the legs and axilla with a 755 or 1064 nm millisecond-domain laser equipped with either (i) cryogen spray (CSC); (ii) refrigerated air (RA); or (iii) contact cooling with sapphire (CC). Concentration of ultrafine nanoparticles <1 µm were measured just before and during LHR with the three respective cooling methods. RESULTS: For contact cooling (CC), counts remained at baseline levels, below 3,500 parts per cubic centimeter (ppc) for all treatments. In contrast, the CSC system produced large levels of plume, peaking at times to over 400,000 ppc. The CA cooled system produced intermediate levels of plume, about 35,000 ppc (or about 10× baseline). CONCLUSIONS: Cold Sapphire Skin cooling with gel suppresses plume during laser hair removal, potentially eliminating the need for smoke evacuators, custom ventilation systems, and respirators during LHR. Lasers Surg. Med. 50:280-283, 2018. © 2017 Wiley Periodicals, Inc.

An expanded study of long-pulsed 1064 nm Nd:YAG laser treatment of basal cell carcinoma.

BACKGROUND AND OBJECTIVE: Basal cell carcinoma (BCC) is an indolent form of skin cancer that is rarely life threatening, but can cause significant cosmetic and functional morbidity. Surgical treatments often result in disfiguring scars, while topical therapies frequently result in recurrence. The need for a more effective nonsurgical alternative has led to the investigation of laser treatment of BCC. We have previously conducted a pilot study which showed 100% histologic clearance at high fluences. Treatments were well tolerated with no significant adverse events. The objective of this larger study was to confirm preliminary results that the 1064 nm Nd:YAG laser is a safe and effective method for treating non-facial BCC. DESIGN: This is an IRB-approved, prospective, multi-center study evaluating the safety and efficacy of the 1064 nm Nd:YAG laser for the treatment of BCC on the trunk and extremities. Thirty-three subjects seeking treatment for biopsy-proven BCC that did not meet the criteria for Mohs surgery were recruited. Subjects on current anticoagulation therapy, or with a history of immunosuppression were excluded. Subjects received one treatment with the 1064 nm Nd:YAG laser as follows: 5-6 mm spot, fluence of 125-140 J/cm2 and a pulse duration of 7-10 ms. Standard excision with 5 mm clinical margins was performed at 30 days after laser treatment to evaluate clinical and histologic clearance of BCC. Standardized photographs and adverse assessments were taken at the baseline visit, immediately after laser treatment and on the day of excision. RESULTS: Thirty-one subjects completed the study. BCC tumors had a 90% (28 of 31 BCC tumors) histologic clearance rate after one treatment with the long-pulsed 1064 nm Nd:YAG laser. Treatments were generally well tolerated without any anesthesia. Immediate side effects included edema and erythema. At 1-month follow-up, some patients had residual crusting. No significant adverse events occurred. CONCLUSION: The 1064 nm long-pulsed Nd:YAG laser is an alternative for treating non-facial BCC for those that are poor surgical candidates. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

A Combination Approach to Surgical Scars.

BACKGROUND: Scar formation from surgical procedures is an unavoidable risk. Despite measures taken by both the surgeon and patient during the perioperative and postoperative periods to maximize cosmesis, some patients will wish to pursue surgical or laser scar revision. OBJECTIVE: The authors propose a treatment algorithm to assist in approaching surgical scar revision with combination treatments. MATERIALS AND METHODS: A PubMed search was performed on various surgical scar revision techniques. The authors augment these findings with their own personal experiences. RESULTS: Reports of surgical excision, intralesional corticosteroid injection, intralesional 5-fluorouracil injection, pulse dye laser treatment, nonablative fractional laser resurfacing, ablative fractional laser resurfacing, and microneedling and fractional needle radiofrequency, used in isolation or combination, were found. The authors also provide clinical photographs documenting improvement in appearance of surgical scars using these treatments. CONCLUSION: Surgical scars are best treated with a combination approach to address various features of the scar. The authors propose a treatment algorithm with multiple treatment options and how to combine them safely and effectively.

ASDS Cosmetic Dermatologic Surgery Fellowship Milestones.

BACKGROUND: The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE: To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS: An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS: Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION: Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

1064 nm long-pulsed Nd:YAG laser treatment of basal cell carcinoma.

BACKGROUND AND OBJECTIVE: Standard surgical and destructive treatments for basal cell carcinoma (BCC) can result in significant morbidity and scarring, stimulating the investigation of alternative non-surgical options. The objective of this study was to determine the safety, clinical, and histological efficacy of pulsed, high-fluence 1064 nm Nd:YAG laser therapy for the treatment of BCC on the trunk and extremities. STUDY DESIGN/MATERIALS AND METHODS: This was a prospective, non-randomized, open-label clinical trial. Ten subjects with a biopsy-proven BCC less than 1.5 cm in diameter on the trunk or extremities received one treatment with a 10 milliseconds pulsed 1064 nm Nd:YAG laser. Standard excision was performed 1 month after laser treatment to confirm histologic clearance. RESULTS: The laser treatment was quick and well tolerated. There was complete histologic clearance after one treatment in 92% of the BCC tumors, overall. At higher fluences, there was 100% histologic clearance after one treatment. No significant adverse events were seen, including scarring. CONCLUSIONS: The 1064 nm long-pulsed Nd:YAG laser may offer a safe alternative for treating BCC off the face. A larger study is highly warranted to confirm these preliminary results. Lasers Surg. Med. 47:106-110, 2015. © 2015 Wiley Periodicals, Inc.

Generalized basaloid follicular hamartoma syndrome: a case report and review of the literature.

Basaloid follicular hamartoma (BFH) is a rare, generally benign lesion of importance because of its clinical and histopathological similarity to infundibulocystic basal cell carcinoma. Autosomal dominant generalized BFH syndrome is 1 of the 5 clinical forms of BFH that has been described in the literature. We report a case of BFH syndrome in a 47-year-old Hispanic female who presented with an increasing number of small 1- to 2-mm tan to brown smooth facial papules, few palmar pits, and cobblestoning of the tongue. Her mother had similar lesions on her face. A biopsy of one of the patient's facial lesions confirmed the diagnosis of BFH. Of note, this patient later presented with rapid growth of one of her facial lesions, and a subsequent biopsy confirmed the development of a basal cell carcinoma arising within one of her BFH lesions. Although BFH is classically stable for years and does not require immediate surgical removal, our case highlights the importance of continual monitoring of these patients, given the potential for malignant transformation of these lesions.

Noninvasive body contouring: cryolipolysis and ultrasound.

Over the past 5 years, there has been a paradigm shift in the treatment of fat. The clear trend is toward noninvasive fat removal technologies over more traditional forms of fat removal such as liposuction. While these devices do not yet approach the results seen with liposuction, noninvasive treatments are gaining popularity due to their ability to safely and effectively reduce fat with little downtime and typically no need for anesthesia. The optimal candidate is relatively fit with localized areas of adiposity, rather than an obese patient. It is important to note that there are numerous noninvasive fat devices including low-level light, radiofrequency, laser, cryolipolysis, and ultrasound. Some of these technologies have more robust data to support their efficacy than others. This review will focus on only 2 noninvasive fat technologies: cryolipolysis and ultrasound.

A review of lasers and light for the treatment of onychomycosis.

BACKGROUND AND OBJECTIVE: Onychomycosis is a common fungal infection that affects many individuals. Systemic therapies are effective, but are limited by their side effects and potential for hepatotoxicity. Topical therapies have less serious side effects, yet provide only limited efficacy due to their inability to penetrate the nail plate. These limitations have led to the investigation of laser and light-based modalities as alternative treatment options for onychomycosis. This article will provide an overview and critical assessment of the field of laser and other energy-based treatments for onychomycosis. STUDY DESIGN/MATERIALS AND METHODS: A literature search was conducted on laser and light-based treatments for onychomycosis. RESULTS: Early data are promising, however, many of these studies are small or poorly designed. CONCLUSION: Further evaluation and larger studies are needed to determine the optimal light source, pulse duration, and treatment schedule for long-term success.

Ablative CO2 lasers for skin tightening: traditional versus fractional.

BACKGROUND: With patients more resistant to invasive treatments and those that result in significant downtime, there has been a rise in using lasers to improve skin laxity and induce tissue tightening as an alternative to surgery. Traditional and fractional ablative resurfacing induces skin tightening through precise dermal heating and a wound-healing effect. OBJECTIVE: The purpose of this review was to discuss the mechanism of action of using ablative lasers to induce skin tightening and compare traditional versus fractional technologies. MATERIALS AND METHODS: A review of the literature was performed. RESULTS: The authors discuss traditional and fractional ablative lasers for achieving skin tightening. CONCLUSION: Neocollagenesis and dermal remodeling seen after ablative resurfacing contributes to the clinical improvement seen in tissue tightening. Fractional photothermolysis may enhance tissue tightening effects of ablative lasers because of its ability to ablate deeper into the reticular dermis without significant risk for scarring.

A 1,320-nm Nd: YAG laser for improving the appearance of onychomycosis.

BACKGROUND: Onychomycosis is a therapeutic challenge because of the toxicities of systemic medications. This has led to the investigation of light-based technologies for safe and effective alternative treatment modalities. OBJECTIVE: The purpose of this study was to determine the safety and efficacy of 4 treatments with a 1,320-nm neodymium:yttrium aluminum garnet (Nd:YAG) laser in improving the appearance of onychomycosis. MATERIALS AND METHODS: This study was a 24-week, single-center randomized placebo-controlled study. Ten subjects were enrolled with culture-proven, bilateral great toenail onychomycosis. The subjects received 4 treatments with the 1,320-nm Nd:YAG laser to the treatment toenail on Days 1, 7, 14, and 60. The control toenail received a sham treatment of cryogen cooling only. Mycologic cultures were obtained at 3-month follow-up visits. RESULTS: Fifty percent of mycologic cultures were negative at the 3-month follow-up after 4 laser treatments. Toenails had improvement in subungual debris, hypertrophy, and yellowing. Patient satisfaction was upheld as assessed by the Nail Quality of Life Questionnaire. CONCLUSION: The 1,320-nm Nd:YAG laser may be a safe and effective therapy for improving the appearance of onychomycosis. Additional therapy may be necessary to enhance long-term results. Further investigation needs to explore the optimal treatment settings and the most effective treatment schedule.

Rising concern over cosmetic tattoos.

BACKGROUND: A rise in popularity of cosmetic tattoos has led to an increase in adverse reactions. Due to more pressing concerns, the Food and Drug Administration (FDA) has not traditionally enforced its authority over tattoo inks. OBJECTIVE: To raise awareness of the dangers of cosmetic tattoos. MATERIALS AND METHODS: We reviewed FDA policies regarding tattoo ink, different ink components, adverse reactions, and various treatment options for cosmetic tattoo removal. RESULTS AND CONCLUSION: An increase in consumer complaints has prompted FDA investigation into tattoo inks and their safety. It is important that further complications be reported to the FDA to promote regulation of cosmetic tattoo inks.

Port-wine stain laser treatments and novel approaches.

BACKGROUND AND OBJECTIVES: Port-wine stains (PWSs) are capillary vascular malformations that are commonly resistant to treatment. Currently, the pulsed dye laser (PDL) is the treatment of choice. Multiple treatments are required and complete blanching after laser irradiation is rarely achieved. We review current therapeutic modalities for PWSs and recent developments for enhanced clearance. STUDY DESIGN/MATERIALS AND METHODS: Relevant literature was reviewed including PDL modifications for improved efficacy, alternative laser devices for treatment-resistant PWSs, and the addition of agents to modulate the wound-healing response after laser irradiation. RESULTS: Although PDL is the treatment of choice for PWSs, increased understanding of interactions between PWSs and PDL has led to improvements in therapeutic outcome in terms of lesion blanching. CONCLUSIONS: Preliminary evidence of combination therapy using antiangiogenic agents after laser irradiation appears promising and could lead to the development of a new standard of care for PWSs.