Use of cutaneous lasers and light sources: appropriate training and delegation.

In recent years, there has been increasing concern among physicians, patient advocacy groups, and media watchdogs that laser, light, and cosmetic surgery are being practiced by poorly trained professionals, with resulting preventable injuries to patients. In response, several professional organizations have developed guidelines for the delegation of laser services to nonphysician providers. These guidelines delineate appropriate qualifications for delegating physicians and nonphysician providers, and also describe the circumstances and settings in which delegation is appropriate.

[Lasers and aesthetic dermatology]. / Lasertherapie in der ästhetischen Dermatologie.

The improved understanding of laser-tissue interaction along with the latest advances of laser technology have led to the development of sophisticated, safe, and user-friendly laser systems that provide effective treatment for a variety of aesthetic skin conditions. The use of lasers and their tissue-specific capabilities in the treatment of pigmented and vascular lesions has been greatly expanded to include rhytides, photoaged skin, atrophic scars, and unwanted hair. In addition, laser techniques have been employed in traditional "rejuvenating" procedures of aged skin, e.g., face-lifting, blepharoplasty, and hair transplantation, decreasing the intra-operative time and limiting the recovery period. These advances have led to a wide acceptance of cutaneous laser surgery by the dermatologic community and have created an increasing popularity among the public. The purpose of this article is to review the applications of lasers in aesthetic dermatology and discuss their limitations and potential side effects.

Evaluation of a silicone occlusive dressing after laser skin resurfacing.

BACKGROUND: Closed dressings are thought to promote postoperative wound healing after laser skin resurfacing; however, quantitative data are lacking. OBJECTIVE: To compare postoperative healing after combination carbon dioxide and erbium:YAG full-face laser skin resurfacing in patients who were treated with a silicone occlusive dressing (Silon-TSR; Bio Med Sciences, Inc, Bethlehem, Pa) vs open-wound care consisting of soaks and ointment application. DESIGN: Thirty-five patients with closed dressings compared retrospectively with 35 control subjects with open-wound care. In a prospective evaluation, 27 patients with closed dressings were then compared with 27 historical controls matched by age, sex, skin type, and treatment technique. Erythema, crusting, swelling, pain, pruritus, purpura, long-term complications, and dressing comfort were evaluated. SETTING: Referral-based academic practice. RESULTS: Prospectively, closed-dressing and open-wound care groups differed significantly in maximum erythema severity (1.8 vs 2.0 on a scale of 0-3; P =.03), noticeable erythema duration (15.4 vs 31.1 days; P =.04), and time until complete erythema resolution (41.8 vs 96.1 days; P =.02). Swelling resolution was more rapid in the dressing group (12.1 vs 29.5 days; P =.02). Crusting was limited to uncovered areas in the dressing group, and crusting duration was shorter (5.0 vs 9.1 days; P<.001). Pain was more likely to be reported prospectively, but severity was mild, in the closed-dressing group. Other short- and long-term complications did not differ significantly. Subjective patient attitudes toward the dressing were positive. CONCLUSIONS: Occlusive silicone dressing application decreases immediate postoperative morbidity with significantly reduced severity and duration of erythema and decreased duration of swelling and crusting. Long-term results and complication rates remain unchanged.

Treatment of a café-au-lait macule with the erbium:YAG laser.

The erbium:YAG laser is a relatively new instrument for skin rejuvenation. We present a case of a "Q-switched laser-resistant" café-au-lait macule that was successfully treated with the erbium:YAG laser.

Accessibility and reliability of cutaneous laser surgery information on the World Wide Web.

The World Wide Web has provided the public with easy and affordable access to a vast range of information. However, claims may be unsubstantiated and misleading. The purpose of this study was to use cutaneous laser surgery as a model to assess the availability and reliability of Web sites and to evaluate this resource for the quality of patient and provider education. Three commercial methods of searching the Internet were used, identifying nearly 500,000 possible sites. The first 100 sites listed by each search engine (a total of 300 sites) were compared. Of these, 126 were listed repeatedly within a given retrieval method, whereas only 3 sites were identified by all 3 search engines. After elimination of duplicates, 40 sites were evaluated for content and currency of information. The most common features included postoperative care suggestions, options for pain management or anesthesia, a description of the way in which lasers work, and the types of lasers used for different procedures. Potential contraindications to laser procedures were described on fewer than 30% of the sites reviewed. None of the sites contained substantiation of claims or referrals to peer-reviewed publications or research. Because of duplication and the prioritization systems of search engines, the ease of finding sites did not correlate with the quality of the site's content. Our findings show that advertisements for services exceed useful information.

Top-cited dermatology authors publishing in 5 "high-impact" general medical journals.

BACKGROUND: In addition to publishing in the dermatologic literature, some dermatologists also publish articles in the general medical journals, which enjoy wide circulation and whose articles are often cited. OBJECTIVE: To identify articles and citations to these articles that the most frequently cited authors in the dermatologic literature published in highly cited general medical journals. DESIGN: We obtained a citation database from the Institute of Scientific Information, Philadelphia, Pa, that identified all articles published by the top-cited authors in the dermatologic literature in 5 "high-impact" general medical journals. SETTING: The 5 high-impact general medical journals with the historically highest impact factors. SUBJECTS: Two hundred top-cited authors in dermatology journals and their coauthors. MAIN OUTCOME MEASURE: Number of citations to articles published in 5 high-impact general medical journals. RESULTS: From 1981 to 1998, 120 of the 200 top-cited dermatology authors published a total of 674 papers in the 5 most highly cited general medical journals. Original articles published in these high-impact general medical journals were cited an average 7.5 times more often than articles published in dermatology journals. CONCLUSIONS: Top-cited authors in dermatology journals also frequently publish in the leading 5 high-impact general medical journals. Publications in these journals by dermatologists are often highly cited.

New approaches to the treatment of vascular lesions.

BACKGROUND AND OBJECTIVE: The pulsed dye laser was developed based on the concept of selective photothermolysis. By using a wavelength of light well absorbed by the target and pulse duration short enough to spatially confine thermal injury, specific vascular injury could be produced. STUDY DESIGN/MATERIALS AND METHODS: Although the pulsed dye laser revolutionized the treatment of port wine stains (PWS) and a variety of other vascular lesions, the ideal thermal relaxation time for the vessels in PWS is actually 1-10 ms, not 450 micros of the original pulsed dye laser machines. These original theoretical calculations recently have been proven correct in a study that used both an animal vessel model and in human PWS. RESULTS: Longer wavelengths of light, within the visible spectrum, penetrate more deeply into the skin and are more suitable for deeper vessels, whereas longer pulse durations are required for larger caliber vessels. CONCLUSION: A variety of lasers recently have been developed for the treatment of vascular lesions which incorporate these concepts into their design, including pulsed dye lasers at 1.5 ms, a filtered flash-lamp pulsed light source with pulse durations of 1-20 ms, several 532-nm pulsed lasers with pulse durations of 1 ms to as high as 100 ms, long pulsed alexandrite lasers at 755 nm with pulse durations up to 20 ms, pulsed diode lasers in the 800 to 900 nm range, and long pulsed 1064 Nd:YAG sources.

Lasers in skin resurfacing.

The development of short-pulse high-peak power and rapidly scanned focused beam carbon dioxide lasers and normal mode erbium:yttrium aluminum garnet lasers, which can remove photodamaged skin layer by layer in a precisely controlled manner while leaving behind a very narrow zone of thermal damage, has revolutionized skin rejuvenation and enhanced our ability to treat scars. This review highlights laser-tissue interactions; the laser used for resurfacing; preoperative, operative, and postoperative issues and how to choose a candidate for the procedure; uses of resurfacing; adverse effects and complications of the procedure; and new developments in the field.

Growth of international contributors to dermatologic literature.

BACKGROUND: In the past, authors from a few countries dominated the publication of articles in dermatologic journals that were cited. The growth of dermatology in many additional countries has set the stage for a broader national representation of the authorship of the most frequently cited dermatologic articles. OBJECTIVE: To quantify changes in the number and proportion of citations and articles credited to authors from various countries from 1981 to 1996. DESIGN: We obtained a citation database from the Institute for Scientific Information, Philadelphia, Pa. From this database, we quantified the average number of articles and citations according to the year of publication, journal, and the countries from which authors came. SETTING: Dermatology journals. SUBJECTS: All articles published in 24 dermatology journals between 1981 and 1996. MAIN OUTCOME MEASURES: Country of origin of articles and number of citations of these articles. RESULTS: Authors from 121 countries were credited in whole or in part with authorship of original articles. Ten countries accounted for 82% of all articles published as original articles and 87% of citations to these articles. From 1981 to 1996, the proportion of citations attributed to most western European except Scandinavian countries grew significantly (P<.05, t test), but the proportion credited to authors from the United States fell significantly (P<.05, t test). CONCLUSIONS: International representation of author-cited articles appearing in the dermatology literature is increasing. The growth of scholarly contributions has been especially great for authors from western Europe except Scandinavia.

Comparison of the 595 nm long-pulse (1.5 msec) and ultralong-pulse (4 msec) lasers in the treatment of leg veins.

BACKGROUND: Although several lasers and light sources are now available for vascular lesions, treatment of leg veins has not been very satisfactory. Lengthening the pulse width should theoretically result in improved response rates. OBJECTIVE: This study compared the efficacy and safety of 595 nm pulsed lasers at 1.5 msec and 4 msec in treating leg veins. METHODS: For group A, 27 healthy adult volunteers with leg veins measuring less than 1 mm in diameter were treated with a 2 mm x 7 mm elliptical handpiece. Each patient had three areas treated. The first two areas were treated with the 4 msec pulsed dye laser with fluences of 16 and 20 J/cm2, while the last area was treated with a 1.5 msec pulsed dye laser at fluences ranging from 14 to 16 J/cm2. For group B, 13 subjects were treated. Areas 1 and 2 were treated with the 4 msec pulsed dye laser using a 3 mm x 5 mm and 5 mm handpiece, respectively, while the third site was treated with a 1.5 msec laser using a 3 mm x 5 mm handpiece. Fluences ranging from 14 to 16 J/cm2 were used. Clinical evaluations were performed and photographs taken at 4-8 week intervals. RESULTS: Neither laser regularly induced satisfactory diminution or disappearance of these vessels after one treatment. In group A, more than 50% of patients had little to no improvement, while in group B little to no improvement was observed in 33% of patients following a single treatment. Although there was no significant difference in outcomes between the test sites, the 4 msec PDL with a 3 mm x 5 mm spot size appeared to be most effective. Transient hyperpigmentation was common following either treatment, while hypopigmentation was seen in group B subjects. No scarring was noted. CONCLUSION: Both the 4 and 1.5 msec flashlamp-pumped pulsed dye lasers were ineffective in treating leg telangiectasia following a single treatment.

Classic and near-classic articles in the dermatologic literature.

BACKGROUND: Only a small fraction of articles published in the dermatologic literature are cited frequently. Articles cited at least 100 times are known as "citation classics" and have been previously discussed. The nature of dermatologic articles cited fewer than 100 times but still much more frequently cited than average has not been clearly elucidated. OBJECTIVE: To identify the source, authorship, and citation history of original articles published in 24 dermatologic journals that were cited more than 25 times. DESIGN: We analyzed a citation database provided by the Institute for Scientific Information. We identified the journal of publication, authorship, and country of authorship for all original articles cited at least 25 times and published from 1982 to 1996 in 24 dermatologic journals. MAIN OUTCOME MEASURE: Source of most frequently cited dermatologic articles. RESULTS: Only 2139 (6.45%) of all original articles were cited more than 25 times. Articles published in 4 of 24 journals accounted for the most frequently cited articles. Only 18 (0.13%) of more than 13,500 first authors published at least 5 articles that were cited more than 25 times. CONCLUSIONS: Few articles are cited at least 25 times, and few persons are first authors of multiple articles in the dermatologic literature cited at least that frequently.

Keloids and hypertrophic scars: review and treatment strategies.

Keloids and hypertrophic scars represent exuberant forms of scar formation that frequently are pruritic, painful, and occasionally form strictures. As well, they may result in significant cosmetic disfigurement. Recent years have seen an increased understanding in the molecular and biological mechanisms of keloidal scar formation, allowing for the development of more specific therapeutic options for these lesions. Despite these developments, keloids and hypertrophic scars remain difficult to manage. Clinical, histopathological, and biochemical features of keloids and hypertrophic scars, as well as treatment guidelines, are discussed.

Diagnostic clues to dermatitis artefacta.

We report a case of dermatitis artefacta in a 36-year-old man who had progressive, nonhealing ulcers and swelling of his right arm. The lesions spared two tattoos. In addition, our patient had several of the classic features of dermatitis artefacta. We outline more than a dozen diagnostic clues that may help the clinician faced with this difficult problem.

A clinical and histologic prospective controlled comparative study of the picosecond titanium:sapphire (795 nm) laser versus the Q-switched alexandrite (752 nm) laser for removing tattoo pigment.

BACKGROUND: Theory predicts that picosecond lasers should be more effective than the currently available nanosecond lasers in removing tattoo ink. In addition to thermal confinement, such pulse widths cause optimal photomechanical disruption of the target. OBJECTIVE: This study compared the efficacy of the picosecond titanium:sapphire (795 nm, 500 psec) laser and the Q-switched alexandrite (752 nm, 50 nsec) laser in the treatment of tattooed guinea pigs. METHODS: Six albino guinea pigs, each with 6 uniformly 1 cm circular black tattoos, were treated. Three of the tattoos were divided into 2; one half was treated with the titanium:sapphire laser and the other half with the alexandrite laser. Fluences used for both lasers were 6.11, 4.24, and 2.39 J/cm2 with spot sizes of 1.25, 1.5, and 2 mm, respectively. The remaining spots served as control. Clinical evaluation and biopsies were performed at baseline and at 11 and 16 weeks after a single laser treatment. RESULTS: Greater clearance of tattoo was observed in titanium:sapphire laser-treated areas in 2 of the 4 surviving guinea pigs. In some areas total clearing was observed after the single titanium:sapphire laser treatment. Clearing improved with higher fluences. No scarring was present. Histologic results showed similar findings. CONCLUSION: Our findings suggest that the picosecond titanium:sapphire laser is more effective than the Q-switched alexandrite laser in removing tattoo pigment and may be of significant clinical utility.