Evidence-Based Clinical Practice Guidelines for Laser-Assisted Drug Delivery.

Importance: Laser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD. Objective: To develop recommendations for the safe and effective use of LADD. Evidence Review: A systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved. Findings: Of the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline's 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections. Conclusions and Relevance: This systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.

Combined Treatment of Rolling Acne Scars in Ethnic Skin Using Extensive Subcision, Trichloracetic Acid Peel, and Fractional Ablative Erbium Laser.

BACKGROUND: Successful treatment of acne scars in ethnic skin requires procedures that are safe and effective with a low incidence of hyper or hypopigmentation postoperatively. OBJECTIVE: In this study, the safety and efficacy of a combined treatment protocol including tumescent anesthesia, subcision, trichloracetic acid peel, and fractional erbium laser resurfacing was evaluated. METHODS: This is a retrospective study of 56 patients (22 women and 34 men) with predominantly rolling acne scars and Fitzpatrick skin Types IV-VI who were treated using a combination of tumescent anesthesia, extensive subcision, fractional ablative erbium laser, and a blending 20% trichloracetic acid (TCA) peel. RESULTS: The mean improvement after a single treatment, assessed by 3 independent evaluators (2 dermatologist and 1 dermatology physician assistant), was 2.52 (SD = 1.04) on a scale of 1 to 4. CONCLUSION: The combination of tumescent anesthesia, extensive subcision, fractional ablative erbium laser resurfacing, and a blending 20% TCA peel (combined procedure) is both safe and effective in the treatment of rolling acne scars in ethnic skin types with acceptable temporary adverse effects.

Treatment of Sebaceous Hyperplasia by Laser Modalities: A Review of the Literature and Presentation of Our Experience With Erbium-doped Yttrium Aluminium Garnet (Er:YAG).

INTRODUCTION: Sebaceous hyperplasia (SH) is a common skin presentation in adults. Due to their unwanted yellow papular appearance, patients may desire their removal. Although several treatment modalities have been reported, the full range and efficacy of options are unclear. OBJECTIVE: To determine the efficacy of laser modalities in the treatment of SH. The authors will also specifically assess the efficacy, recurrence rate and side effect profile of SH treatment with Er:YAG wavelength using a variable long pulsed (VLP) Er:YAG laser (SP Dynamis Fotona laser, Ljubljana, Slovenia) Methods & Materials: A comprehensive literature search was performed through PubMed, EMBASE, and Web of Science, using the search terms [(sebaceous hyperplasia)] and [(laser[s], Er:Yag, Er:Glass, Fraxel, CO2, PDL, Pulse dye laser, Diode, Xe-Cl, Excimer, Argon, KTP, Ruby, Alexandrite or Nd:YAG)]. The search yielded a total of 119 results and 8 were identified as relevant to this reviewResults: Pulse dye laser (PDL) provides a wide range of treatment results from complete reduction to flattening of the SH without significant adverse events; recurrence rates were unreported. Short PDL showed faster treatment response than long PDL. CO2 laser can produce considerable positive cosmetic outcomes with marked clinical improvement without any recurrence, but significant adverse effects have been reported. The 1450-nm diode laser has been described to produce good (75%) clinical improvement and lesion shrinkage ranging from 50% to greater than 75% without lasting adverse effects. In our clinic, Er:YAG has provided very significant cosmetic outcomes with a low recurrence rate and minimal adverse effects. CONCLUSIONS: Laser modalities can provide satisfactory results for removing SH. It is crucial that the laser is being used by an expert who is familiar with the device as well as understand the laser tissue interaction to minimize patient adverse effects while providing the best cosmetic outcome. In our experience, Er:YAG laser can provide a safe and highly effective solution for SH.

Sound levels and safety in cosmetic laser surgery.

OBJECTIVES: Measure the sound levels produced by various lasers commonly used during routine outpatient cosmetic surgery to determine whether or not their use exceeds exposure levels set forth by the US National Institute for Occupational Safety and Health (NIOSH) and the US Occupational Safety and Health Administration (OSHA). MATERIALS AND METHODS: Using two different meters, the sound levels of lasers commonly used in cosmetic surgery were recorded during various procedures for several indications: tattoo removal, treatment of lentigines and pigmented lesions, facial erythema and vascular lesions, hair removal and resurfacing of acne scars, and photoaging. RESULTS: All but five lasers had a maximum sound level below 85 dBA, the limit proposed by NIOSH. The loudest laser examined was a fully ablative 2,940 nm Er:YAG during facial resurfacing, with an average maximum sound level of 101.5 decibels (dBA). Two other lasers used for resurfacing exceeded 85 dBA including a fractional ablative 1064 Nd:YAG with an average maximum of 97.8 and a different fully ablative 2,940 nm Er:YAG which had an average maximum of 96.3 nm. The two other lasers that exceeded 85 dBA were picosecond lasers used to treat black tattoos, including a 1,064 nm Nd:YAG with an average maximum of 93.7 dBA and a 755 nm alexandrite with an average maximum of 93.6 dBA. CONCLUSION: Although some lasers in cosmetic surgery may be perceived as being quite loud, they remain safe. Even the loudest laser studied would have to be used for nearly 2 hours before exceeding the OSHA recommended exposure limit. Even physicians who spend a large amount of time using lasers in clinical practice should be reassured that these devices are not likely to produce noise-induced hearing loss (NIHL) hearing loss. Lasers Surg. Med. 51:491-494, 2019. © 2019 Wiley Periodicals, Inc.

Single Session Treatment of Rolling Acne Scars Using Tumescent Anesthesia, 20% Trichloracetic Acid Extensive Subcision, and Fractional CO2 Laser.

BACKGROUND: Successful treatment of acne scars is challenging. Many modalities have been used with marginal success. OBJECTIVE: The authors describe a combination of a superficial chemical peel, subcision, and fractional carbon dioxide (CO2) laser resurfacing in a single-treatment session as a novel treatment approach for rolling acne scars. METHODS: A total of 114 patients (75 women and 39 men) with predominantly rolling acne scars were treated with a 20% trichloracetic acid chemical peel, subcision with a novel dissecting instrument, and the CO2 laser under tumescent anesthesia. This was a retrospective, uncontrolled, unblinded study. RESULTS: The mean improvement after a single treatment was 2.9 on a scale of 1 to 4 with few complications. Ninety percent of the patients were satisfied with their final result and desired no additional treatment. CONCLUSION: The combination of a trichloracetic acid 20% chemical peel, subcision, and fractional CO2 laser resurfacing combined with tumescent anesthesia is both safe and effective in the treatment of rolling acne scars.

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.

Successful short-term and long-term treatment of melasma and postinflammatory hyperpigmentation using vitamin C with a full-face iontophoresis mask and a mandelic/malic acid skin care regimen.

BACKGROUND: Treatment of melasma and postinflammatory hyperpigmentation is often challenging. No ideal short-term and long-term treatment is available. Vitamin C alone and in combination with iontophoresis has been studied and found to be useful; however, no long-term studies have been published. METHODS: In this study, 35 patients (34 female, 1 male) were treated with a novel full-face iontophoresis mask (FFIM) and a proprietary vitamin C (ascorbyl glucoside) preparation. Patients received one in-office treatment and 12 to 24 at-home treatments over 1 to 2 months in conjunction with a strict maintenance regimen consisting of a mandelic/malic acid skin care regimen, broad-spectrum ultraviolet A/ultraviolet B sunblock, a wide-brimmed hat, and sun-avoidance behavior. Follow-up after the initial in-office treatment ranged from 1 to 54 months (mean, 26 months). Four independent observers graded improvement of melasma and PIH using a 4-point scale. Before the study, high-performance liquid chromatography was used to verify iontophoretic penetration of vitamin C into the skin to a level of 0.2 cm in healthy volunteers (2 male, 2 female). RESULTS: A mean 73% improvement in abnormal pigmentation was observed at the end of FFIM/vitamin C treatment. Greater than 25% improvement was observed in 32 of 35 patients, and greater than 50% improvement in 22 of 35 patients. Melasma Area and Severity Index scores demonstrated substantial improvement from baseline for all patients, with a mean improvement of 15.7. CONCLUSIONS: Full-face iontophoresis of vitamin C appears to be an effective short-term treatment for melasma and postinflammatory hyperpigmentation. A protocol of strict sun avoidance in combination with a mandelic/malic acid skin care regimen appears to be useful in maintaining the improvement.

Porokeratotic eccrine ostial and dermal duct nevus treated with a combination erbium/CO2 laser: a case and brief review.

Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is an uncommon disease that presents early in childhood and is characterized by keratotic papules, often in a linear configuration. We describe a 12-year-old girl with characteristic lesions of PEODDN and describe her response to treatment with a combination CO2/Erbium laser. We also briefly review the literature on PEODDN.

Diffuse osteopenia and myelopathy in a puppy fed a diet composed of an organic premix and raw ground beef.

CASE DESCRIPTION: An 8-month-old Shetland Sheepdog was evaluated because of the sudden onset of signs of neck pain, collapse, and inability to rise. A cursory diet history indicated that the dog had been fed a raw meat-based diet. CLINICAL FINDINGS: Initial evaluation of the dog revealed small physical stature, thin body condition, and signs of cranial cervical myelopathy. Radiographically, diffuse osteopenia of all skeletal regions was identified; polyostotic deformities associated with fracture remodeling were observed in weight-bearing bones, along with an apparent floating dental arcade. Hypocalcemia and hypophosphatemia were detected via serum biochemical analyses. The dog's diet was imbalanced in macronutrients and macrominerals. TREATMENT AND OUTCOME: The dog received supportive care and treatment of medical complications; neurologic abnormalities improved rapidly without intervention. Dietary changes were implemented during hospitalization, and a long-term feeding regimen was established. Following discharge from the hospital, exercise restriction was continued at home. Serial follow-up evaluations, including quantitative bone density measurements, revealed that dietary changes were effective. After 7 months, the dog was clinically normal. CLINICAL RELEVANCE: In the dog of this report, vitamin D-dependent rickets type I and suspected nutritional secondary hyperparathyroidism developed following intake of a nutritionally incomplete and unbalanced diet. The raw meat-based, home-prepared diet fed to the dog was not feed-trial tested for any life stage by the Association of American Feed Control Officials, and its gross nutrient imbalance induced severe metabolic, orthopedic, and neurologic abnormalities. Inadvertent malnutrition can be avoided through proper diet assessment and by matching nutrient profiles with patients' nutritional needs.

Predominance of subtype 3 among Blastocystis isolates from a major hospital in Singapore.

Blastocystis is an enteric protozoan parasite commonly found in humans and animals. Phylogenetic and genotypic analyses have shown that Blastocystis exhibits extreme genetic diversity, and humans are host to a number of zoonotic isolates. In the present study, the prevalence of Blastocystis in 276 stool samples from a hospital in Singapore was examined, and for the first time, riboprinting using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to determine the genetic diversity of the Blastocystis isolated from the Singapore population. The prevalence rate was determined to be 3.3% (9/276), and Blastocystis displaying two main ribotypes were isolated. As a comparison, we performed PCR-RFLP using two different published methodologies, and both methods allowed the isolates to be divided into two distinct groups based on their riboprint patterns. According to a recently proposed classification scheme, 78% (7/9) of the isolates were of subtype 3, while 22% (2/9) were subtype 1. The predominance of subtype 3 in an urbanized city state such as Singapore is in agreement with the idea that subtype 3 is a genotype of human origin.

Split-face comparison of radiofrequency versus long-pulse Nd-YAG treatment of facial laxity.

BACKGROUND AND OBJECTIVE: To improve photoaging skin with laser treatment, multiple sessions have been considered necessary to achieve results comparable with one radiofrequency (RF) treatment. We compared single-treatment improvements obtained by the long-pulse 1064 nm Nd:YAG laser and RF device. STUDY DESIGN/MATERIALS AND METHODS: In a split-face study, patients with sagging skin were treated once with laser (left side) and once with RF (right side) energy. RESULTS: Improvement judged by six blinded observers was greater for wrinkles and laxity (30% median) on the laser-treated side and essentially the same with both modalities (15% median) for texture, pores, and pigmentation. Improvement was maintained for at least 2-6 months on both facial sides without adverse effects. CONCLUSION: With a single treatment, both the long-pulse 1064 nm Nd:YAG laser and ThermaCool RF device provide a modest degree of improvement in both wrinkles and laxity of facial skin and similar improvement in texture, pores, and pigmentation.

Intermedilysin release by Streptococcus intermedius: effects of various antibacterial drugs at sub-MIC levels.

Intermedilysin is a cytolytic toxin produced by Streptococcus intermedius, a pathogen of humans. In vitro studies showed that exposure of S. intermedius to sub-minimum inhibitory concentration (MIC) levels (1/2 MIC) of protein-inhibiting antibiotics and nucleic acid-inhibiting antibiotics decreased intermedilysin release by S. intermedius. The most potent antibiotic was clindamycin. On the other hand, exposure to cell wall-inhibiting antibiotics generally showed insignificant changes in intermedilysin release at sub-MIC concentrations. Investigations into possible mechanisms underlying this sub-MIC effect with clindamycin showed that there was selective decrease in biosynthesis and release of toxin after exposure to 1/2 MIC condition. However, no significant differences in the mRNA levels of the intermedilysin gene were observed.

Chlamydia pneumoniae IgG seropositivity and clinical history of ischemic heart disease in Singapore.

There is still substantial uncertainty concerning the association between Chlamydia pneumoniae and ischemic heart disease. This may partly be explained by the adjustment for potential confounders in different population studies. This is the first study in Singapore to look at the association of C. pneumoniae seropositivity with ischemic heart disease in a multivariate analysis. A random sample of 714 persons aged between 35 and 69 years was selected from the participants of the Singapore National Health Survey conducted in 1998. Data on clinical measurements and conditions were collected using biochemical tests and interviewer-based questionnaires. Ischemic heart disease was defined by the Rose questionnaire and included history suggestive of angina and/or myocardial infarction. Immunoglobulin G antibodies for C. pneumoniae were detected using an indirect microimmunofluorescence test, and seropositivity was defined as IgG titers > or = 1:16. There were no statistically significant differences in the prevalence rates of seropositivity to C. pneumoniae among the three ethnic groups, that is, Chinese (80.4%), Malays (74.0%), and Asian Indians (73.2%). There was no association between seropositivity and ischemic heart disease after adjustment for age alone (OR 1.00, 95% CI 0.54-1.83) or for age, sex, and other risk factors of atherosclerosis (OR 0.99, 95% CI 0.53-1.84). C. pneumoniae Immunoglobulin G seropositivity was not associated with an increased risk of ischemic heart disease as defined by the Rose angina questionnaire in Singapore.

Seroprevalence of IgG antibodies against Chlamydia pneumoniae in Chinese, Malays and Asian Indians in Singapore.

BACKGROUND: Chlamydia pneumoniae, a bacterium that causes respiratory infections, is probably under-diagnosed. There is also interest in its possible role in the aetiology of coronary heart disease. This is the first population-based seroprevalence survey of C. pneumoniae infection in Singapore. METHODS: A random sample of 1,068 people aged 18-69 years was selected from the participants of the Singapore National Health Survey conducted in 1998. Sera and data on certain clinical measurements and conditions had been collected. IgG antibodies for C. pneumoniae were detected using an indirect microimmunofluorescence test and positivity graded. Seropositivity was defined as IgG titre >/=1:16. RESULTS: There were no statistically significant differences in the prevalence rates of seropositivity to C. pneumoniae for age group 18-69 years among the three ethnic groups, i.e. Chinese (males 76.7%, females 68.3%), Malays (males 75.4%, females 59.1%), and Asian Indians (males 74.6%, females 59.4%). The seropositivity rate for people aged 18-69 years in Singapore was 75.0% for males and 65.5% for females (difference of 9.5%, P < 0.001). In both genders combined, seropositivity increased from 46.5% in the age group 18-29 to reach a plateau of 78.9% in the age group 40-49, which remained stable to 60-69 years. There was no association of seropositivity with smoking, diabetes mellitus, hypertension or body mass index after adjustment for age and gender. CONCLUSION: The high prevalence rates in our study population and the higher rate in males compared to females are consistent with studies from other parts of the world. No significant difference in prevalence rates was observed among Chinese, Malays and Indians. The pattern of rising and levelling off of seropositivity with age suggests that C. pneumoniae infection occurs early in life, and in older ages the high level of seropositivity is probably maintained by re-infections or chronic infections. Chlamydia pneumoniae infection was not found to be associated with the cardiovascular risk factors examined.

Fatal case of pneumonia caused by a nonhemolytic strain of Streptococcus pyogenes.

We report a case of pneumonia with a fatal outcome caused by a nonhemolytic strain of Streptococcus pyogenes. This strain was isolated in pure growth from blood cultures and was fully identified biochemically. Such strains will be difficult to recognize and isolate from sites with heavy growth of normal flora. This phenomenon has been reported sporadically before, and it is unknown how common such strains may be in pharyngeal samples.