Laser resurfacing: usual and unusual complications.

The use of the carbon dioxide laser for skin resurfacing was initially described in 1989. 1 Since that time, several reports have shown it to be highly effective in the treatment of photodamaged skin and acne scarring. 2,3,4,5 Advances in laser technology have simplified the procedure and minimized adverse sequelae. Laser skin resurfacing has become a very popular technique, and recently several patient series have been published on the use of different resurfacing lasers to treat photodamaged skin. 3,4 However, very little has been written about its complications. Adequate patient selection, sound medical judgement, proper training with experience and knowledge of skin physiology and wound care are important factors for successful outcomes. Interested physicians across a broad range of subspecialties have expressed concern about the rate of adverse outcomes and management of complications. We report seven representative cases of complications referred to our dermatology clinics from outside physicians, in the hope of educating clinicians regarding the usual and unusual side effects of this procedure.

Histological comparison of postoperative wound care regimens for laser resurfacing in a porcine model.

BACKGROUND: The use of short-pulsed CO2 lasers for skin resurfacing is routinely performed, but few studies have examined postsurgical care. OBJECTIVE: To determine which postoperative treatments are most beneficial in promoting optimal healing after laser resurfacing. METHODS: Four pigs received laser resurfacing. The laser sites were randomly left untreated or treated with petroleum-based ointment or dressed with 1 of the following occlusive dressings: hydrocolloid, hydrogel or foam. Biopsies were taken from each treatment group on Days 2, 3, 4, 5, 8, 12, and 19. All samples were stained with hematoxylin and eosin. Each histological slide was evaluated by a blinded investigator. RESULTS: Differences were observed between treatment groups in the amount of cellular infiltrate, presence of necrotic tissue, progression of the epidermal sheet, maturation of the epidermis, presence of rete ridges, and appearance of new collagen. CONCLUSION: Postoperative treatments after laser resurfacing vary in their ability to influence the quality of healing.

Solar-induced postinflammatory hyperpigmentation after laser hair removal.

BACKGROUND: Postinflammatory hyperpigmentation (PIHP) is a frequently encountered problem in many cosmetic procedures. The treatment of PIHP is difficult and remains a challenge. OBJECTIVE: To treat a patient who developed multiple hyperpigmented macules on her thighs due to sun exposure after treatment of unwanted hair using a normal-mode ruby pulse laser. METHODS: The patient was treated daily with tretinoin (Retin A) 0.1% cream, triamcinolone 0.1% cream, and hydroquinone 4% cream with sunscreen (Solaquin forte), and was to avoid sun exposure. Several sites received monthly treatment of 40% trichloroacetic acid (TCA). The degree of clinical improvement of the hyperpigmentation was assessed by both the physician and the patient. RESULTS: Cosmetic results were fair. The amount of hair in her thighs was reduced but the PIHP responded only slightly to therapy. CONCLUSION: To our knowledge this is the first case of solar-induced PIHP following laser hair removal. The treatment of PIHP is difficult because there are few therapeutic options that are consistently successful. Avoidance of exposure to ultraviolet light should be emphasized to all patients prior to laser therapy. We demonstrated that serial TCA peels provided an additional benefit compared to medical treatment.

Borderline tuberculoid Hansen's disease in AIDS.

We performed an immunohistochemical analysis of a skin lesion from a patient with AIDS who had borderline tuberculoid Hansen's disease. We also evaluated other laboratory features and performed peripheral blood flow cytometric analysis. The in situ immunologic response to Mycobacterium leprae was minimally affected by concomitant infection and immunosuppression by HIV. The skin demonstrated the typical characteristics of borderline tuberculoid lesions. These results indicate that although a patient with HIV infection may have laboratory evidence typical of the immunosuppression seen in AIDS, the immunologic response to M. leprae is essentially unchanged.

Porphyria cutanea tarda and human immunodeficiency virus infection.

Porphyria cutanea tarda (PCT), a relatively uncommon disease, has recently been reported in patients infected with the human immunodeficiency virus (HIV). Although PCT and HIV infection may co-exist by chance, the increasing number of reported cases suggest that HIV or an associated factor triggers the development of PCT in predisposed individuals. We report four additional cases of PCT in HIV seropositive patients and review the previously reported cases. The possible links between PCT and HIV are discussed. We believe the diagnosis of PCT should prompt investigation for HIV infection in all patients.

UVB phototherapy of the pruritic papular eruption of the acquired immunodeficiency syndrome.

BACKGROUND: Pruritic papular eruption (PPE) is a chronic dermatosis frequently seen in human immunodeficiency virus (HIV)-positive patients. UVB phototherapy has been successfully used to treat a similar inflammatory condition (Ofuji disease) as well as pruritus of systemic origin. OBJECTIVE: We describe the successful treatment with UVB of seven of eight patients with PPE. METHODS: Eight HIV-positive patients with PPE were treated. The number of papules in a specified area of skin and the intensity of pruritus were monitored before, during, and after UVB phototherapy given three times a week. Biopsy specimens were taken before and after therapy and systemic immune function was evaluated. RESULTS: Both the number of papules as well as pruritus decreased after UVB treatment in all but one patient. Immunoperoxidase staining showed a relative decrease in CD4+, CD8+, and CD2+ cells in all samples studied except for the patient noted to be unresponsive to the therapy. CONCLUSION: UVB phototherapy is effective in the treatment of patients with PPE. This is associated with a significant decrease in inflammation and number of T cells from various subsets within the dermis, thereby implicating these cells in the pathogenesis of this disorder.

Pityriasis rubra pilaris and HIV infection.

Many cutaneous diseases have been reported in patients with human immunodeficiency virus infection. We report two patients with pityriasis rubra pilaris and human immunodeficiency virus infection. In one patient, the onset of pityriasis rubra pilaris preceded the discovery of human immunodeficiency virus infection. In the second patient, the onset of pityriasis rubra pilaris occurred shortly after the patient tested positive for human immunodeficiency virus infection. Both patients had a severe form of pityriasis rubra pilaris, and both had a minimal therapeutic response to etretinate.

Location of basement membrane type IV collagen beneath subepidermal bullous diseases.

Using standard immunohistochemical methods, routinely processed sections, and a polyclonal antibody to Type IV collagen, we have determined the location of Type IV collagen, a substance located in the lamina densa of basement membrane, in a spectrum of acquired subepidermal bullous diseases. Type IV collagen was attached to the blister roof in five cases of well-established epidermolysis bullosa acquisita and to the blister base in 25 cases of bullous pemphigoid, four cases of dermatitis herpetiformis and 12 cases of porphyria cutanea tarda. Immunohistochemical localization of Type IV collagen in epidermal-dermal basement membrane is a simple, rapid and reliable technique which can be utilized to exclude and possibly to confirm the diagnosis of epidermolysis bullosa acquisita in routinely fixed paraffin-embedded tissues.

Studies of immunoglobulin and T cell receptor gene rearrangement in cutaneous B and T cell lymphomas.

We report two patients with cutaneous B and T cell lymphomas, respectively, in which DNA rearrangement studies were instrumental in establishing a diagnosis. In each case clinical, histopathologic, and immunologic criteria were not sufficient to establish a definitive tissue classification. The use of DNA gene rearrangement studies in the analysis of cutaneous lymphomas is discussed.

Leg ulcers following subcutaneous injection of a liquid silicone preparation.

We present an unusual case of leg ulcers occurring 23 years after the patient had received large-volume subcutaneous injections of a liquid silicone preparation into her legs for cosmetic reasons. Light microscopy of a biopsy specimen from the edge of the ulcer showed optically clear vacuoles in the dermis, together with a mixed cellular infiltrate. Scanning electron microscopic studies revealed amorphous spherules within the vacuoles, and energy-dispersive spectroscopy established the presence of silicon in these spherules. Nearby tissue not containing spherules did not show a silicon peak. This case adds to the growing documentation of morbidity associated with injections of silicone of uncertain purity.

Alveolar rhabdomyosarcoma arising in the nasal cavity of a 3-year-old child.

A 3-year-old girl had a large exophytic mass protruding from the nares, of seven months' duration. Routine microscopic studies demonstrated a tumor composed of solid sheets of small cells, with scattered foci lining alveola-like spaces. Immunohistochemical studies demonstrated the presence of desmin and myoglobin, and the absence of prekeratin, neuron-specific enolase, and leukocyte common antigen. These observations are consistent with the diagnosis of alveolar rhabdomyosarcoma.

Hypertrophic lichen planus and light sensitivity in an HIV-positive patient.

A 40-year-old black man who was HIV positive developed generalized hypertrophic lichen planus in areas previously affected by a photosensitivity eruption. After unsuccessful attempts to induce remission of his lichen planus with conventional therapies, etretinate produced a dramatic response.

Immunoelectron microscopic localization of relaxin in endometrial gland cells of the pregnant guinea pig.

Endometrial gland cells in uteri from late-pregnant guinea pigs (day 60 to parturition) resembled typical protein-secreting cells. Extensive rough endoplasmic reticulum and well-developed Golgi complexes were evident. The most striking features of endometrial gland cells were accumulations of large (approximately equal to 0.5 micron in diameter), dense, membrane-bounded granules. The granules were located in the supranuclear region of the cell and frequently occurred in close proximity to the plasma membrane adjacent to the lumen of the gland. Thin sections of endometrial gland cells treated with relaxin antiserum and either colloidal gold-protein A or colloidal gold-goat antirabbit IgG demonstrated that the granules contained relaxin. These studies provide additional evidence that the uterus of the guinea pig produces relaxin and support the hypothesis that uterin relaxin may play an important role in pregnancy and parturition in the guinea pig.

Localization of relaxin in endometrial gland cells of pregnant, lactating, and ovariectomized hormone-treated guinea pigs.

Uteri taken from guinea pigs in different stages of pregnancy and during lactation, as well as animals that had been ovariectomized and treated with hormones, were examined for relaxin with the peroxidase-antiperoxidase (PAP) technique employing an antiserum produced against porcine relaxin. While relaxin was not detected in uteri of day 15 pregnant animals, small amounts were noted in a few endometrial glands in day 30 pregnant animals. Uteri from day 45, day 60, and late-pregnant animals exhibited heavy amounts of relaxin; however, endometrial gland cells from lactating animals contained very little or no relaxin. Injections of estrogen and progesterone that brought a relaxation of the pelvic ligaments in ovariectomized guinea pigs also induced an accumulation of relaxin in the endometrial glands. Relaxin was not detected in nonendometrial portions of the uterus, endometrial stromal components, luminal surface epithelium, or uterine cervical glands. Extracts prepared from uteri of day 45, day 60, and late-pregnant animals showed positive responses for relaxin in the mouse uterus bioassay.