The Rise and Fall of the Pale Puffy Lower Eyelid Pillow.

This case series demonstrates an exaggerated form of the clinical presentation of a known distressing late complication of retained hyaluronic acid filler – the “pale puffy pillow.” This presentation is often, unfortunately for the patient, misdiagnosed as festoons. However, the correction with liberal hyaluronidase is simple. Additionally, we have demonstrated that ablative fractional carbon dioxide laser resurfacing is an excellent tool that may be utilized after hyaluronidase to correct the residual skin laxity.J Drugs Dermatol. 20(4):475-476. doi:10.36849/JDD.5509.

Safety Profile of Combined Same-Day Treatment for Botulinum Toxin With Full Face Nonablative Fractionated Laser Resurfacing.

BACKGROUND: Spread of botulinum toxin outside the treated muscle is a concern, when energy-based device treatment is performed on the same day as toxin injection. OBJECTIVE: We assessed the frequency of eyelid ptosis after the glabella/periorbital botulinum toxin injection and nonablative fractionated laser performed at the same session. METHODS AND MATERIALS: This single-center, retrospective study identified treatments consisting of glabella and/or periorbital botulinum toxin injection and nonablative fractionated laser treatment to full face from 2017 to 2019 and eyelid ptosis determined by documentation of the complication at a follow-up encounter, or prescription of apraclonidine. RESULTS: Six hundred sixteen treatments of glabella/periorbital botulinum toxin injection and full-face nonablative fractionated laser on the same day on 393 individuals were identified. Five hundred eighty treatments (94%) included botulinum toxin injected in the glabella, 541 (88%) in the periorbital areas, and 508 (82%) in the forehead. Nonablative fractionated lasers used to treat the cohort were a 1,927-nm thulium and a 1,550-nm er:glass laser. Eyelid ptosis complication was documented in one case (0.2%) following the combined laser and toxin treatment. CONCLUSION: The risk of spread of glabella/periorbital botulinum toxin to an unintended muscle was minimal in the setting of the concomitant full-face nonablative fractionated laser.

The Male Aesthetic Patient: Facial Anatomy, Concepts of Attractiveness, and Treatment Patterns.

BACKGROUND: The number of nonsurgical aesthetic procedures performed in men is growing rapidly. However, there are limited data on treatment principles and goals for the male aesthetic patient.

OBJECTIVE: To review the objective data available on male aging and aesthetics and to synthesize with expert opinion on treatment considerations specific to male patients.

METHODS: Expert advisors met to discuss anatomical differences in male versus female facial anatomy related to aging, facial treatment preferences in aesthetically oriented men, and current dosing data for facial injectable treatments in male versus female patients.

RESULTS: Symmetry, averageness, sexual dimorphism, and youthfulness are generally accepted as factors that contribute to the perception of attractiveness. There are differences between men and women in facial anatomy, concepts of attractiveness in the context of masculinity and femininity, and treatment objectives. A communication gap exists for men, as evidenced by the lack of information available online or by word of mouth about injectable treatments.

CONCLUSIONS: Approaches to aesthetic consultation and treatment should differ between men and women based on the fundamental dissimilarities between the sexes. Educating men about available aesthetic treatments and about the safety and side effects associated with each treatment, as well as addressing concerns about their treatment results looking natural, are key considerations.

J Drugs Dermatol. 2018;17(1):19-28.

Signs of Facial Aging in Men in a Diverse, Multinational Study: Timing and Preventive Behaviors.

BACKGROUND: Men are a growing patient population in aesthetic medicine and are increasingly seeking minimally invasive cosmetic procedures. OBJECTIVE: To examine differences in the timing of facial aging and in the prevalence of preventive facial aging behaviors in men by race/ethnicity. METHODS: Men aged 18 to 75 years in the United States, Canada, United Kingdom, and Australia rated their features using photonumeric rating scales for 10 facial aging characteristics. Impact of race/ethnicity (Caucasian, black, Asian, Hispanic) on severity of each feature was assessed. Subjects also reported the frequency of dermatologic facial product use. RESULTS: The study included 819 men. Glabellar lines, crow's feet lines, and nasolabial folds showed the greatest change with age. Caucasian men reported more severe signs of aging and earlier onset, by 10 to 20 years, compared with Asian, Hispanic, and, particularly, black men. In all racial/ethnic groups, most men did not regularly engage in basic, antiaging preventive behaviors, such as use of sunscreen. CONCLUSION: Findings from this study conducted in a globally diverse sample may guide clinical discussions with men about the prevention and treatment of signs of facial aging, to help men of all races/ethnicities achieve their desired aesthetic outcomes.

The Photodynamic Therapy Experience of a High Volume Laser and Dermatologic Surgery Center.

BACKGROUND: Photodynamic therapy (PDT) is an FDA approved treatment for actinic keratoses (AK's) although multiple off-label indi- cations are reported. Despite frequent use for AK's, no clear consensus exists regarding protocols for overall treatment parameters. METHODS: Retrospective chart review of 1,491 subjects who underwent PDT between 2007 and 2011 at a high volume laser surgery center. Demographic information, clinical history, treatment data, and subsequent diagnosis of skin cancers were recorded. An ex- ploratory subgroup analysis was performed for patients treated for AK and/or squamous cell carcinoma (SCC) that developed SCC or remained SCC-free one year after treatment. RESULTS: The most common indications for PDT were actinic keratoses (n=1404, 94.9%) then NMSC (n=45, 3.0%) The most common treatment site was the head and neck (n=1274, 86.1%). Blue light activation (405-420nm) was used more frequently than red light and visible light. (73.8% vs. 22.8% vs. 6.8%). The most commonly used photosensitizer was aminolevulinic acid (ALA) (98.6%, n=1456). Topical application (97.7% n=1437) of photosensitizer was used more frequently than intralesional administration (2.0%, n=29). 580 patients met subgroup analysis criteria. 66 developed SCC at treatment site (11%). Factors associated with developing SCC were older age, SCC history, Fitzpatrick skin-type 1, and sixty-minute or less incubation times (P less than 0.05 for all factors). The SCC subgroup had a unique distribution of treatment sites (P less than.001). No statistically significant differences were observed for gender or wavelength. CONCLUSION: There are differences in protocols based on indication and location of lesion. Blue light is preferable for superFIcial lesions and red light for deeper lesions. Intralesional delivery is used more commonly for NMSC. Extremities require longer incubation times. PDT may be more effective with younger patients and longer than sixty-minute incubation times. PDT chemoprevention is independent of light source used. J Drugs Dermatol. 2016;15(11):1420-1426..

Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring.

IMPORTANCE: Fractional laser technology is routinely used in the treatment of acne scarring, with thermal injury resulting in collagen synthesis and remodeling. Use of a picosecond pulse duration with a diffractive lens array may be a new technologic advancement in the treatment of acne scarring. OBJECTIVE: To investigate the safety and efficacy of a 755-nm alexandrite picosecond pulse duration laser with diffractive lens array for the treatment of facial acne scarring. DESIGN, SETTING, AND PARTICIPANTS: This single-center, prospective study performed in a private practice with a dedicated research department included patients with clinically diagnosed scarring secondary to inflammatory or cystic acne. INTERVENTIONS: Patients received 6 treatments with a 755-nm picosecond laser with a spot size of 6 mm, fluence of 0.71 J/cm2, repetition rate of 5 Hz, and pulse width of 750 picoseconds in combination with a diffractive lens array, allowing for greater surface area and pattern density per pulse. MAIN OUTCOMES AND MEASURES: The pain and satisfaction scores for overall appearance and texture were recorded. Masked assessment of clinical photographs and analysis of 3-dimensional volumetric data were performed. Biopsy specimens were obtained for independent histologic evaluation by 2 investigators at baseline and at 3 months after last treatment. RESULTS: Fifteen women and 5 men (mean age, 44 years; age range, 27-61 years) with Fitzpatrick skin types I through V and facial acne scarring were enrolled. The mean pain score was 2.83 of 10. Patients were satisfied to extremely satisfied with improvement in appearance and texture at their final treatment and follow-up visits. The masked assessment scores of 17 patients were 1.5 of 3 and 1.4 of 3 at 1 and 3 months, respectively (a score of 0 indicates 0%-25% improvement and a score of 3 indicates >75% improvement). A 3-dimensional analysis revealed a mean 24.3% improvement in scar volume, maintained at 1 (24.0%) and 3 (27.2%) months after treatment. Histologic analysis revealed elongation and increased density of elastic fibers, with an increase in dermal collagen and mucin. CONCLUSIONS AND RELEVANCE: Treatment of facial acne scars with a diffractive lens array and 755-nm picosecond laser produced improvement in appearance and texture at 3 months after the last treatment, with objective findings similar to those published for a series of fractional ablative laser treatments. Histologic findings suggest that improvement in scarring from this treatment goes beyond remodeling of collagen.

Patient initiation and persistence with allergen immunotherapy.

BACKGROUND: Allergen immunotherapy (AIT) is advised for patients with allergic rhinitis who remain symptomatic despite the use of pharmacotherapy and allergen avoidance. Several factors influence the decision to initiate and complete the AIT regimen. OBJECTIVE: To evaluate patient initiation and persistence with subcutaneous and sublingual immunotherapies (SCIT and SLIT) according to physician recommendation. METHODS: A retrospective review of electronic health records of patients with allergic rhinitis for whom AIT was recommended was conducted in a large private allergy practice in Pennsylvania. RESULTS: Of 8,790 patients advised to consider AIT, 36.2% initiated AIT (57% adults, 43% children); 78% chose SCIT and 22% chose SLIT drops. Election of AIT was significantly associated with select comorbidities, specifically chronic sinusitis (8.1% for AIT vs 10% for no AIT), allergic conjunctivitis (12.5% for AIT vs 18.5% for no AIT), and asthma (33.8% for AIT vs 37.4% for no AIT; P < .05). Choice of SCIT vs SLIT drops was significantly associated with older age, female sex, select comorbidities, and more allergy medications at initiation (P < .05). Of adults, 30.2% completed at least 3 years of recommended treatment. Median time on treatment was longer for adults on SCIT vs SLIT drops (3 vs 1.6 years). Similarly, 35.4% of children completed treatment, with a longer median time on treatment for SCIT (4.7 years) vs SLIT drops (3.5 years). CONCLUSION: A minority of patients initiated AIT according to allergist recommendation and a subset of these patients completed therapy. AIT might be an underused option that could benefit patients unable to manage allergic rhinitis symptoms by other means. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01549340.

Retrospective study of the treatment of infantile hemangiomas using a combination of propranolol and pulsed dye laser.

BACKGROUND: Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone. OBJECTIVES: To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated with propranolol alone. MATERIALS AND METHODS: Retrospective review of facial-segmental IH treated with propranolol and PDL and controls treated with propranolol was conducted. Blinded physicians used patient photographs to select clearance level and the earliest date of near-complete clearance. Days of propranolol, PDL sessions, and propranolol dose, each until date of near-complete clearance; total days of propranolol; and total propranolol dose were recorded. RESULTS: Infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance (6/12) more often than IH treated with propranolol followed by PDL (2/5) or IH treated with propranolol alone (1/8; difference in clearance scores p = .01) and achieved near-complete clearance after fewer days of propranolol (mean 92 days for concurrent propranolol and PDL vs 288 days for propranolol; p < .001). Cumulative propranolol dose until near-complete clearance was lowest in the concurrent propranolol and PDL group (149.16 vs. 401.25 mg/kg for propranolol; p < .001). CONCLUSION: Facial-segmental IH treated with propranolol and PDL displayed morerapid and complete clearance and required a lower cumulative propranolol dose to achieve near-complete clearance.

Treatment of port-wine stains with a short pulse width 532-nm Nd:YAG laser.

BACKGROUND AND OBJECTIVE: Pulsed dye laser treatment often results in port-wine stain (PWS) improvement; however, results vary. A frequency-doubled neodymium-doped yttrium aluminum garnet (Nd:YAG) laser that allows for shorter pulse widths along with large spot sizes and high fluences has been developed for the treatment of cutaneous vascular lesions. STUDY DESIGN: A prospective, controlled study was performed in 5 adults with PWS using a frequency-doubled Nd:YAG laser (Excel V; Cutera Inc, Brisbane, CA) in 4 quadrants, using spot sizes of 6 to 10 mm, fluences of 4.8 to 9 J/cm2, and pulse durations of 3 to 6 ms. An adjacent control area was not treated. Each was assessed immediately posttreatment for purpura and edema and at 1 month for PWS color, size, texture, and thickness. Skin biopsies obtained immediately after and at 1 month posttreatment were evaluated. RESULTS: All treatment quadrants displayed purpura. At 1-month follow-up, all treatment quadrants showed at least 1 grade of color improvement, from a minimum of 1% to 25% to a maximum of 51% to 75% improvement (12/20 quadrants with 1%-25% improvement, 3/20 with 26%-50%, 5/20 with 51%-75%, and 0/20 with 76%-100%). Histologic evaluation of treatment quadrants revealed vascular changes ranging 0.35 to 4 mm in depth. Immediately posttreatment, thrombi and extravasated red blood cells were observed in treatment quadrants. Histology at 1 month revealed decreased number and diameter of vessels in treatment quadrants (superficial vessels decreased by mean 1.1 vessels per section [13%], and diameter by 3.0 µm [47%], midlevel vessels decreased in number by 2.3 [20%], diameter by 2.42 µm [25%], and deep vessels decreased in number by 1.5 [83%], and diameter by 7.44 µm [88%]). CONCLUSIONS: A single treatment with a short pulse width, frequency-doubled Nd:YAG laser resulted in safe and effective improvement of PWS, with up to 75% improvement in color observed at 1 month. Histologic evaluation demonstrated vascular injury at depths of 0.35 to 4 mm with a reduction in vessel number and size at multiple dermal levels.

1927-nm fractional resurfacing of facial actinic keratoses: a promising new therapeutic option.

BACKGROUND: Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. OBJECTIVE: We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. METHODS: This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. RESULTS: At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. LIMITATIONS: This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. CONCLUSION: The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option.

Topical perfluorodecalin resolves immediate whitening reactions and allows rapid effective multiple pass treatment of tattoos.

BACKGROUND AND OBJECTIVE: Laser tattoo removal using multiple passes per session, with each pass delivered after spontaneous resolution of whitening, improves tattoo fading in a 60-minute treatment time. Our objective was to evaluate the safety and efficacy of topical perfluorodecalin (PFD) in facilitating rapid effective multiple-pass tattoo removal. STUDY DESIGN: In a randomized, controlled study using Q-switched ruby or Nd:YAG laser, 22 previously treated tattoos were treated with 3 passes using PFD to resolve whitening after each pass ("R0 method"). In previously untreated symmetric tattoos, seven were treated over half of the tattoo with the R20 method, and the opposite half with 4 passes using PFD (R0 method); two were treated over half with a single pass and the opposite half with 4 passes using PFD (R0 method); and six treated over half with a single pass followed by PFD and the opposite half with a single pass alone. Blinded dermatologists rated tattoo fading at 1-3 months. Optical coherence tomography (OCT) imaging of whitening was performed in two tattoos. RESULTS: Topical PFD clinically resolved immediate whitening reactions within a mean 5 seconds (range 3-10 seconds). Tattoos treated with the R0 method demonstrated excellent fading in an average total treatment time of 5 minutes. Tattoo areas treated with the R0 method demonstrated equal fading compared to the R20 method, and improved fading compared to a single pass method. OCT imaging of whitening demonstrated epidermal and dermal hyper-reflective "bubbles" that dissipated until absent at 9-10 minutes after PFD application, and at 20 minutes without intervention. CONCLUSIONS: Multiple-pass tattoo removal using PFD to deliver rapid sequential passes (R0 method) appears equally effective as the R20 method, in a total treatment time averaging 5 minutes, and more effective than single pass treatment. OCT-visualized whitening-associated "bubbles," upon treatment with PFD, resolve twice as rapidly as spontaneous resolution.

Ablative fractional resurfacing for involuted hemangioma residuum.

BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

Successful and rapid treatment of blue and green tattoo pigment with a novel picosecond laser.

BACKGROUND: While the understanding and technology of laser tattoo removal has advanced much over the last 5 decades, treatments and results remain far from perfect. With currently available devices, treatment courses are often painful and prolonged with mixed results. We describe the successful and rapid treatment of 12 tattoos containing blue and/or green pigment with a novel, picosecond, 755-nm alexandrite laser. OBSERVATIONS: All previously untreated multicolored tattoos as well as tattoos recalcitrant to treatment demonstrated at least 75% clearance of blue and green pigment after 1 or 2 treatments with a novel, picosecond, 755-nm alexandrite laser. More than two-thirds of these tattoos approached closer to 100% clearance. CONCLUSIONS: While additional future studies are needed, we believe that this new technology is more effective in targeting blue and green pigment, resulting in expedited clearance with less collateral injury to surrounding tissue.

The CHOICE survey: high rates of persistent and uncontrolled asthma in the United States.

BACKGROUND: Surveys have consistently shown that many patients with asthma do not have their disease well controlled. OBJECTIVES: The CHOICE (Comprehensive Survey of Healthcare Professionals and Asthma Patients Offering Insight on Current Treatment Gaps and Emerging Device Options) survey was designed to evaluate the current status of inhalation devices used in asthma treatment, but questions also were included about asthma severity and control. METHODS: A total of 1,000 patients with asthma were interviewed about their use of inhalation devices and asthma-related burden, medication use, and hospital/emergency care. Based on the responses to these questions, asthma severity and control were categorized using methods established in the Expert Panel Report III (EPR 3). RESULTS: Almost half (490) of the patients with asthma participating in the CHOICE survey were not using controller medications. Most of those not using controllers (79%) had persistent asthma; 47% had either mild or moderate persistent asthma. Of those on controllers (510), only 14.3% were well controlled. Acute care utilization was greater for patients with persistent asthma than those with intermittent asthma and for patients with not well and poorly controlled asthma than those with well-controlled asthma. CONCLUSION: The CHOICE survey is particularly pertinent clinically, because it demonstrates for the first time, using EPR 3 methods, the current extent of poor asthma control in the United States. This situation falls far short of national asthma management targets.

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.

Investigation into optimal treatment intervals of facial port-wine stains using the pulsed dye laser.

BACKGROUND: Port-wine stains (PWS) affect 0.3% to 0.5% of newborns and pulsed dye laser (PDL) remains the treatment of choice. Optimal treatment intervals have not been established. OBJECTIVE: We sought to validate the optimal treatment intervals for the management of facial PWS with PDL. METHODS: In all, 24 infants with facial PWS who received at least 5 treatments with the PDL at 2-, 3-, and 4-week intervals at a private laser and skin surgery center from 2009 to 2010 were identified by a retrospective chart review. Safety and efficacy were compared by blinded investigators. RESULTS: Side effects were equivalent in all interval groups and included only expected short-term erythema, edema, purpura, and mild postinflammatory hyperpigmentation. No patient developed hypopigmentation, scarring, or infection. All interval groups showed 50% to 100% clearance of their PWS after 5 treatments. Complete or near-complete clearance was seen in 6 of 8 (75%) and 7 of 8 (87.5%) patients in the 2- and 3-week interval groups, respectively, as compared with 3 of 8 (37.5%) patients in the 4-week interval group. LIMITATIONS: This was a retrospective chart review from a single institution. Long-term side effects and recurrence rates were not assessed. CONCLUSION: We conclude that PDL treatments at 2-, 3-, and 4-week intervals are effective for the management of facial PWS in infants with minimal short-term side effects. Shorter treatment intervals may allow for relatively more rapid and more effective treatment.