Expert opinion about laser and intense pulsed light (IPL)-induced leukoderma or vitiligo: a cross-sectional survey study.

Vitiligo patients may desire laser hair removal, skin rejuvenation, vascular treatments, and other laser or intense pulsed light (IPL) assisted treatments. However, there is a risk of inducing new depigmented patches (Koebner phenomenon). In absence of guidelines on the safe use of laser or IPL in vitiligo patients, dermatologists tend to be reluctant to administer these treatments. The aim of this survey study was to provide an estimation of the occurrence and related risk factors of laser/IPL-induced leukoderma or vitiligo. A cross-sectional survey study was performed among 15 vitiligo experts from 11 countries, with 14 questions about affected patients, involved laser/IPL treatments and the physicians' approach. In a total of 11,300 vitiligo patients, laser/IPL-induced leukoderma or vitiligo was reported in 30 patients (0.27%). Of these, 12 (40%) patients had a medical history of vitiligo and seven (58%) of these patients had stable (> 12 months) vitiligo before the treatment. Most frequently reported were hair removal procedures and localization of the face and legs. Side effects like blistering, crusting, and erosions occurred in 56.7% of the cases. These vitiligo experts based their advice on the risk of the laser treatment on stability of the vitiligo (43%) and activity signs (50%), and 50% discuss the risks before starting a laser treatment. Relevant activity signs are the Koebner phenomenon (57.1%), confetti-like lesions (57.1%) and hypochromic borders (50%). Laser-induced leukoderma or vitiligo is an uncommon phenomenon. Remarkably, a minority had a medical history of vitiligo of which 58% were stable. Consequently, most cases could not have been prevented by not treating vitiligo patients. However, a majority had laser/IPL-induced skin damage. Therefore, caution is advised with aggressive settings and test-spots prior to the treatment are recommended. This study showed significant variation in the current recommendations and approach of vitiligo experts regarding laser/IPL-induced leukoderma or vitiligo.

Prevalence of Hypopigmentary Disorders in Primary School Children in Zagazig City, Sharkia Governorate, Egypt.

BACKGROUND: Epidemiologic data derived from population-based studies are very important to understand human diseases and their implications. Highlighting skin problems by identifying their incidence and prevalence is vital to direct suitable medical attention toward them. AIM: The aim of the study was to detect the prevalence and most common causes of hypopigmentation in primary school children in Zagazig City. METHODS: Cross-sectional study on 185 students selected from two schools. Data were collected by filling a questionnaire, clinical examination, and Wood's light examination to detect hypopigmented skin disorders. RESULTS: The prevalence of hypopigmentation among studied population was 45.4%; the commonest cause was pityriasis alba 58.3%, followed by pityriasis versicolor 17.9%, postinflammatory hypopigmentation 10.7%, hypopigmented nevus 9.5%, and finally 3.6% vitiligo. CONCLUSION: Hypopigmented skin disorders are important and easy to diagnosis skin diseases that need medical attention.

Laser Treatment for Non-Melanoma Skin Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Surgery is the mainstay of treatment for non-melanoma skin cancer. Lasers are an additional option. OBJECTIVE: The objective of this study was to review the literature on the efficacy and safety of lasers for the treatment of non-melanoma skin cancer. METHODS: A systematic review and meta-analysis of laser treatment for non-melanoma skin cancer was performed. The primary outcome was recurrence rate (RR). RESULTS: The review included 32 studies (six randomized controlled trials and 26 cohort studies): 27 evaluated basal cell carcinomas (BCCs), three squamous cell carcinomas, and two both, for a total of 4755 BCCs and 214 squamous cell carcinoas. Most BCCs were low risk. The Nd:YAG laser (seven studies, 3286 BCCs) had a 3.1% RR (95% confidence interval [CI] 1.4-6.4%) during a mean follow-up of 7.9 years, with a low rate (< 20%) of scarring and dyspigmentation. The CO2 laser (ten studies, 904 BCCs) had a 9.4% RR (95% CI 4.1-20) during a mean follow-up of 2.1 years, with a low rate of side effects. The pulsed dye laser (eight studies, 206 BCCs) had a 38% RR (95% CI 24-55). In two studies, the Nd:YAG laser demonstrated a RR of 10% (95% CI 2-31) for Bowen's disease, and in three studies, the CO2 laser demonstrated a RR of 22% (95% CI 5-61) for squamous cell carcinoma. CONCLUSIONS: Based on cohort studies, the Nd:YAG laser is a safe and efficacious modality for the treatment of low-risk BCC. Based on settings applied in prior studies in the literature, the CO2 laser is less efficacious than the Nd:YAG laser, thus it cannot be recommended for BCC treatment. Insufficient data preclude conclusions regarding laser treatment for squamous cell carcinoma. REGISTRATION: PROSPERO registration number CRD42019129717.

Cutaneous side effects in a cohort of patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors: General description and further characterization, correlation with photoexposition and study of hypopigmentation as treatment's prognostic factor.

Cutaneous adverse effects (AE) related to tyrosine-kinase inhibitor (TKI) drugs have been mainly described as case reports. We have characterized their appearance and correlation with patient's photoexposition habits and, further, with treatment response, in 61 patients with chronic myelogenous leukemia (CML) treated with TKI drugs. We have found hypopigmentation in 49.2% of the cases and a statistically significant association with interferon (IFN) intake. Eyelid edema's frequency was 45.4%. Mean photo-exposure was 1.95 h/day and only 8.3% of the patients used sunscreen daily. 44.3% of the patients reported a lighter skin color with the treatment and a statistically significant relationship with conjunctival hemorrhage was also found. Concordance between patients and dermatologist was moderate (kappa index 0.41). We found xerosis (21.3%), eczematous eruptions (21.3%), melasma (4.9%) and other isolated skin problems (ie, granulomatous panniculitis) in up to 16.4% of cases. Appearance of hypopigmented macules is associated to vascular conjunctival fragility and these patients need a slightly longer time to reach a complete molecular response, but without additional changes in survival or relapse frequency. We have stablished a specific dermatologic diagnosis in all the cases and we have not found the previously published as maculopapular rashes. Hypopigmentation, the more frequent AE, was not perceived as a relevant side effect. Photosensitivity, in our cases, was not reported, although imatinib-treated patients avoided sun-exposure. In addition, we identified some nonpreviously described dermatologic conditions in patients taking TKI drugs, like granulomatous panniculitis tufted folliculitis or oral spindle cell lipoma.

Defining dose constraints for catheter insertion sites to minimize toxicity after interstitial breast brachytherapy.

PURPOSE: The purpose of this study was to define dose constraints for catheter insertion sites to minimize probability of prominent post-therapy skin marks after interstitial breast brachytherapy. METHODS AND MATERIALS: Forty patients who had undergone interstitial breast brachytherapy were studied at followup at least 2 years after the procedure. Their implant marks were compared with background skin and areola and scored as Gr0 = invisible (same color as surrounding skin), Gr1 = darker than surrounding skin but lighter than areola or hypopigmentation, and Gr2 = same color as areola or darker. Highest point doses received in each plane of implant and their corresponding closest distances from clinical target volume, 85% isodose, and closest catheter dwell point were used for analysis. A logistic regression was performed to ascertain effects of various dosimetric parameters on the probability of Gr2 marks. Receiver operating characteristic curve was generated to derive cutoffs. RESULTS: A total of 280 dose points were studied. Median values for various parameters were 1.4 Gy (0.24-3.74) for Dose max and 1.6 cm, 1.5 cm, and 1.0 cm for Dist CTV min, Dist Iso min, and Dist Dwell min, respectively. On logistic regression, increasing Dose max alone was associated with an increased likelihood of developing Gr2 marks. Each unit increase of Dose max increased probability of development of Gr2 skin marks by 5.0% (2.391-10.328). Receiver operating characteristic analysis also showed greatest odd ratio (8.0), sensitivity (74.8%), and specificity (73%) for Dose max. CONCLUSIONS: It seems prudent to restrict dose to catheter insertion sites for better cosmesis.

Treatment of Laser-Responsive Dermal Pigmentary Conditions in Type III-IV Asian Skin With a 755-nm Picosecond Pulse Duration Laser: A Retrospective Review of Its Efficacy and Safety.

BACKGROUND: Picosecond lasers have become very popular in the treatment of hyperpigmentation. OBJECTIVE: Evaluating the efficacy and safety of picosecond 755-nm laser in treatment of nevi of Ota (NO) and Hori's nevi (HN) in Asians with Fitzpatrick skin Types III/IV. METHODS: A retrospective review of patient records at the National Skin Center, Singapore, from 2015 to 2017. Three independent blinded dermatologists assessed pre-and-post treatment photographs using the physician's global assessment (PGA) score (0-clear, 1-almost clear, 2-mild, 3-moderate, and 4-severe). RESULTS: There were 18 cases of NO and 11 cases of HN. Mean treatment sessions were 2.22 (NO; range 1-6) and 3.82 (HN; range 1-6). In the NO group, mean pre-and-post treatment PGA scores were 3.1 and 1.3, respectively (1.8 point change, p-value 0.0002), and average fluence used was 2.02 J/cm (range: 1.02-2.38). In the HN group, mean pre-and-post treatment PGA scores were 2.6 and 1.1, respectively (1.5 point change, p-value 0.004), and average fluence was 2.08 J/cm (range: 1.98-3.40). Eleven patients (37.9%) experienced postlaser erythema, and 1 (3.4%) patient developed transient postlaser hypopigmentation. No permanent hyper/hypopigmentation was seen. CONCLUSION: The picosecond 755-nm laser is effective in the treatment of dermal pigmentary conditions in Asians with Fitzpatrick skin Types III/IV, with minimal risk of postlaser complications, and compared with the center's past experience with the Q-switched nanosecond 1064-nm laser, results in faster and more effective pigment clearance.

Comparison of a picosecond alexandrite laser versus a Q-switched alexandrite laser for the treatment of nevus of Ota: A randomized, split-lesion, controlled trial.

BACKGROUND: Novel picosecond lasers have been available for various pigmentary disorders. However, there are limited data directly comparing picosecond lasers and Q-switched lasers for treatment of nevus of Ota. OBJECTIVE: To compare the efficacy and safety of a picosecond alexandrite laser (PSAL) with a Q-switched alexandrite laser (QSAL) for the treatment of nevus of Ota. METHODS: Each lesion of 56 enrolled participants was split into 2 parts and randomly assigned to either the PSAL or QSAL treatment arm. Each lesion was treated in up to 6 sessions in 12-week intervals. Efficacy and safety were determined using blinded visual evaluation and self-report at each follow-up visit. RESULTS: The PSAL arm achieved a significantly better clearance (5-point scale, PSAL 4.53 vs QSAL 4.0) with fewer sessions (PSAL 5.26 vs QSAL 5.87) and less severe pain (Visual Analog Scale, PSAL 5.61 vs QSAL 6.40). Patients were more satisfied with PSAL than QSAL (Likert scale, 4.5 vs 4.0). Occurrences of postinflammatory hyperpigmentation (PSAL 26% vs QSAL 34%) and hypopigmentation (PSAL 21% vs QSAL 47%) were also lower in PSAL than QSAL arm. LIMITATIONS: Lack of objective assessments and outcome measures. CONCLUSION: PSAL demonstrated better clinical results and fewer adverse events than QSAL for the treatment of nevus of Ota.

Evaluation of different concentrations of hydrogen peroxide solution (3% and 6%) as a potential new therapeutic option of nongenital warts: A randomized controlled triple-blinded clinical trial.

BACKGROUND: Warts are common viral skin infections caused by human papillomavirus. None of the available treatment modalities fulfills the criteria of an ideal treatment option. OBJECTIVES: To evaluate the efficacy and safety of hydrogen peroxide (HP) 3% and 6% solution as a topical treatment of nongenital warts. METHODS: This prospective randomized controlled study included 145 patients with nongenital warts. They were divided into three groups. Group 1 used topical hydrogen peroxide 6% solution under occlusion with a plastic tape for one hour daily for 6 weeks, group 2 used hydrogen peroxide 3% solution, and group 3 used normal saline 0.9% as a placebo. Patients were evaluated at the third and sixth weeks of treatment and 12 weeks after treatment completion. RESULTS: Treatment responses were significantly better in groups 1 and 2 than in group 3 with a better overall responses in group 1 than in group 2 (P = 0.0001*). Apart from mild hypopigmentation which was detected in only two patients in groups 1 and 2, no other side effects could be detected. Three months after treatment completion, no recurrence was observed. CONCLUSION: Hydrogen peroxide solution (3% and 6%) is an effective, safe, and cheap treatment modality for nongenital warts which can be used simply at home. Since the overall response was better with the 6% concentration, it should be the better therapeutic option.

Survival and prognosis of individuals receiving programmed cell death 1 inhibitor with and without immunologic cutaneous adverse events.

BACKGROUND: The treatment response to new immunotherapy in advanced melanoma patients remains varied between individuals. Immune-related cutaneous side effects might have prognostic value. OBJECTIVE: To determine whether development of ≥1 of the 3 immune-mediated cutaneous events (eczema, lichenoid reaction, or vitiligo-like depigmentation) is associated with improved progression-free survival. METHODS: A cohort study of adults with stage IIIC-IV melanoma treated with pembrolizumab or nivolumab during May 1, 2012-February 1, 2018, at Westmead Hospital, Sydney, Australia. Treatment response was based on iRECIST version 1.1. RESULTS: In total, 82 patients of an average age of 59.9 years were included. Median follow-up was 40.7 months; 33 patients had ≥1 target skin reaction. Skin reactions developed in one-third of individuals by 6 months. At any given time, the instantaneous risk of disease progression and death was lower for individuals who had ≥1 cutaneous adverse event (CAE) develop. Compared with individuals with no CAE, the hazard ratio for disease progression and death for individuals who had ≥1 CAE develop was 0.46 (95% confidence interval 0.23-0.91; P = .025) by the time-dependent Cox proportional hazards model. LIMITATIONS: Single-center study. CONCLUSION: This study demonstrates an association between the development of ≥1 of 3 CAEs and improved progression-free survival in this cohort of patients.

Outcomes and prognostic factors in African American and black patients with mycosis fungoides/Sézary syndrome: Retrospective analysis of 157 patients from a referral cancer center.

BACKGROUND: The prevalence of mycosis fungoides/Sézary syndrome (MF/SS) is higher in the black population than in the white population in the United States and worse outcomes have been observed in black patients. OBJECTIVE: To describe the outcomes and to identify prognostic factors in African American and black patients with MF/SS. METHODS: Clinical features and follow-up data were analyzed in 157 self-identified African American or black patients seen during 1994-2018. RESULTS: We included 122 patients with early stage MF and 35 patients with advanced-stage disease (median follow-up of 25 months). Overall, >80% of the patients who died from disease or progressed had erythema or hyperpigmentation without hypopigmentation. Patients with hypopigmentation, either as the sole manifestation or in combination with other lesions, had better overall survival (P = .002) and progression-free survival (P = .014). Clinical stage, TNMB classification, plaque disease, and elevated serum lactate dehydrogenase were also significantly associated with outcomes. Demographic and socioeconomic parameters were not associated with prognosis. LIMITATIONS: A retrospective study at a single cancer center. CONCLUSION: MF/SS manifestations and outcomes in African American and black patients are heterogeneous. Demographic and socioeconomic factors do not seem to have a prognostic role, while clinical characteristics might help in the stratification of risk of progression and shorter survival, allowing for individually tailored therapeutic interventions.

Patterned cutaneous hypopigmentation phenotype characterization: A retrospective study in 106 children.

BACKGROUND: Cutaneous patterned hypopigmentation's phenotype is highly variable and may be associated with extracutaneous anomalies. OBJECTIVE: We evaluated the phenotypic and clinical characteristics of patients with cutaneous patterned hypopigmentation to determine whether certain patterns were more likely to be associated with underlying anomalies. METHODS: The charts of 106 children with cutaneous patterned hypopigmentation were reviewed retrospectively (2007-2018) at Sainte-Justine University Hospital Centre, in Montreal, Canada. Retrieved information included sex, age at diagnosis, phototype, pattern, and distribution of the cutaneous lesions and the presence of extracutaneous findings. Data were recorded on a software tool which collects and analyzes phenotypic information. RESULTS: The predominant types of cutaneous patterned hypopigmentation were along Blaschko's lines in narrow (38.7%) and broad bands (53.8%). Mixed patterns were observed in 22.5% of children. The anterior trunk and posterior trunk were most frequently affected (69% and 56%, respectively). Extracutaneous involvement, especially neurological and developmental, was present in 28.3% of patients and was significantly associated with ≥ 4 involved body sites. CONCLUSION: Distribution and types of cutaneous patterned hypopigmentation were not predictive of extracutaneous findings, with the exception of multiple sites involvement and possibly centrofacial location and blocklike lesions. Follow-up until school entry should help identify subtler associated extracutaneous anomalies.

Nevus depigmentosus: review of a mark of distinction.

Nevus depigmentosus (ND), also known as nevus achromicus or achromic nevus, is an uncommon congenital hypomelanosis of the skin that is often characterized as being nonprogressive and having serrated borders. It needs to be distinguished from other hypopigmented skin conditions such as nevus anemicus, hypomelanosis of Ito, Fitzpatrick patches (ash leaf spots) of tuberous sclerosis, vitiligo, indeterminate leprosy, and pigment demarcation lines. Treatment may be desired for aesthetic and possible psychosocial considerations. We review and update knowledge about ND and its simulants.

Pigmentation Disorders in the Elderly.

Aging skin is subject to morphological change due to both intrinsic (skin tone, genetics, endogenous hormones) and extrinsic (chronic sun exposure, medications, exogenous pigments) factors. The broad spectrum of transformation includes both hypo- and hyperpigmentation. Although cutaneous pigmentary disorders are common in younger individuals, certain disorders are more prevalent in the geriatric population. This article reviews the epidemiology, pathophysiology, clinical appearance, treatment, and prognosis of pigmentary lesions that are predominant in the elderly.

Fractional Carbon Dioxide Laser in Patients with Skin Phototypes III to VI and Facial Burn Sequelae: 1-Year Follow-Up.

BACKGROUND: Fractional carbon dioxide laser treatment in postburn scars is safe and effective, but high rates of hypochromia (35 percent) have been described in patients with skin phototypes V and VI after 2 months. The authors evaluated the efficacy and safety of fractional carbon dioxide laser treatment of burn scars in skin phototypes III to VI after 1 year, focusing on the incidence of hypochromia. METHODS: A case series of 20 patients had skin phototypes III to VI with facial burn sequelae. They underwent three sessions of fractional laser. Laser fluence was increased in patients with no hypochromia and reepithelialization time of less than 15 days. Scars were evaluated after 2 months and 1 year by a five-item scale: color, hydration, surface irregularities, volume, and distensibility. RESULTS: The mean time for reepithelialization was 13.3 days (range, 2 to 40 days). The average final score of the scale increased from 4.4 before treatment to 7.33 after 1 year for physicians, and from 5.35 to 7.5 for patients. There was also an increase in the subjective score, which patients used to assess their skin. Two months after treatment, 60 percent of patients presented with punctate hypochromia. After 1 year, only 15 percent of patients still had mild hypochromia; all of them had skin phototypes V and VI. Nevertheless, they were satisfied with overall bleaching of the skin. CONCLUSIONS: Fractional carbon dioxide laser improved skin quality. Late punctate hypopigmentation should be considered a possible complication in patients with skin phototypes V and VI. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Scalp as a donor site in children: Is it really the best option?

BACKGROUND: Since 2003 we have used the scalp as a donor site for split skin grafts (SSGs) in major burns when there was a shortage of conventional donor areas. However, we seen a high incidence of complications, contrary to international experience. OBJECTIVE: The aim of this study was to analyze the results and complications related to the scalp as a donor site and to determine whether there is an association between our specific patient population and the complications encountered. METHODS: A retrospective review of our scalp donor site outcomes over a 12-year period was conducted. The cohort included 25 patients, 15 of black African descent, nine of mixed race and one Caucasian. The various hair types were identified based on ethnicity and classified into eight types. Most of our patients had hair types VI-VIII. None of these patients had scalp burns and all received standard burn treatment. The SSGs were taken with an electric dermatome with a standard micrometric setting of 0.2mm. Complications were categorized into short- or long-term, with a mean follow-up time of 1.59years. RESULTS: The mean age of the 25 children was 5.7years. Nineteen sustained flame burns and 6 sustained hot water burns, with a mean total body surface area of 44.9%. A total of 43 scalp procurements were performed in the 25 patients studied. The group of 15 black African patients (hair types VI-VIII) had a total of 22 procurements, the nine patients of mixed race (hair types III-V) had 18 procurements and the single Caucasian patient (hair types II-III) had two procurements. The median healing time was 15days, 11.8days and 8.5days, respectively, per group. Significant complications were encountered, including folliculitis 44%, non-healing wounds 52%, alopecia 16% and visible, hypopigmented scars 3%. One patient had a hypertrophic scar and no hair transfers to the recipient areas were observed. The various hair types correlated with the complications encountered. Five children, with an average burn size of 65.2% (range: 40-85%) died of sepsis. Due to the small sample size, the only statistically significant findings were related to the total body surface area of the burn and the number of times skin was harvested from the scalp, with a p-value of 0.005. The p-values for the healing times related to the first, second and third croppings, were p=0.022, p=0.00032 and p<0.001 respectively. CONCLUSION: Our study suggests that in pediatric patients of black African descent (hair types VI-VIII) the scalp is not an ideal donor area, due to the unacceptably high incidence of complications. Hence, every precaution should be taken when it becomes necessary to harvest donor skin from the scalp.

Hypopigmented mycosis fungoides: a 20-case retrospective series.

BACKGROUND: Hypopigmented mycosis fungoides (hMF) is a rare subtype of mycosis fungoides. The aim of this study was to identify the clinical-epidemiological profile of our patient group and also to provide additional information about treatment responses and prognosis. METHODS: This is a cross-sectional retrospective observational study, with exploratory analysis. The outcome variables were disease progression and related death. RESULTS: Twenty patients with hMF were selected from a group of 102 patients diagnosed with MF. There was no gender difference (10 females and 10 males). Mean age at diagnosis was 43.85 years, and most patients had mixed or black skin color. The mean time between the onset of the lesions and the diagnosis was 66.75 months. Patients were equally distributed in stages IA (50%) and IB (50%). Photochemotherapy (psoralen and ultraviolet A) was the predominant therapeutic modality. The mean follow-up time was 7.25 years. In 10%, disease progression was observed. Death related to the disease occurred in one patient. CONCLUSIONS: The clinical and epidemiological profile of patients with hypopigmented MF found in our sample is in agreement with what is described in the literature, with the exception of the age at diagnosis, higher than expected. Diagnostic delay time, despite long, is also consistent with the medical literature; however, in this sample, we had two cases of disease progression, with death of one patient, despite the treatment, which is extremely important since hypopigmented MF is usually associated with good prognosis.

Distinct Patterns and Aetiology of Chromonychia.

Abnormal colouring of the nails may be a sign of underlying systemic or local disorders. This study investigated the prevalence and causes of chromonychia as a whole, as well as of each subtype. Among 163 patients with chromonychia, trauma was the pathogenesis in up to 20.9% (34/163) of cases. The most common subtype was melanonychia (54.0%; 88/163), followed by leukonychia (23.9%), red (8.6%), green (6.7%), yellow (4.9%) and blue (1.8%) nails. Nail matrix naevus (33.3%; 29/88) was the most common cause of melanonychia, while skin diseases (41.0%; 16/39), such as psoriasis (75%, 12/16) and alopecia areata (18.8%; 3/16), in addition to systemic diseases (33.3%; 13/39) including anaemia (38.5%, 5/13) and chronic renal failure (15.4%; 2/13) were the dominant causes of leukonychia. As chromonychia may be the first or only sign of an underlying disorder, it should alert physicians and patients to the need for a prompt and thorough evaluation.

Pediatric disorders of pigmentation commonly seen in skin of color.

There are certain disorders of hyper- and hypopigmentation that are more common in children with skin of color. It is imperative that practitioners can swiftly and accurately diagnose these pigmentary disorders to prevent delay in treatment and enhance quality of life. Pigmentary disorders have many etiologies and may present similarly in the clinical setting; however treatment varies widely and is dependent on accurate diagnosis. Herein, we present a review of common disorders of hyperpigmentation and hypopigmentation in children with skin of color. We aim to provide physicians with information that can enhance clinical detection of common pigmentary disorders in this vulnerable population.