Cosmetic Considerations in Dark-Skinned Patients.

For dermatologists, diversities of human races result in an opportunity to encounter patients with various skin types. Cosmetic procedures have gained more popularity and become more accessible over the past decades. Thus, the selection of appropriate treatment protocol for each patient becomes inevitable. This review will focus on basic knowledge and key points in performing safe cosmetic-related procedures in patients with dark-complexioned skin. In terms of structure and function of the skin, people of color have equal epidermal thickness, corneocyte size and melanocyte number. However, they have more stratum corneum compaction, melanosome dispersion and melanocyte activity than fair skin individuals. Data regarding drug penetration and cutaneous irritation showed conflicting results. Superficial chemical peels and microdermabrasion can be done safely in dark-skinned patients. Medium-depth peel should be used with extreme caution. While deep-depth peel should be avoided at all times due to pigmentary and textural complications. Prolonged treatment interval, use of priming agents and sun protection are recommended. Injectable materials including botulinum toxin and soft tissue augmentation by hyaluronic acid filler can be done harmlessly in dark-skinned patients. Lasers and energy-based devices should be done with caution. Higher melanin dispersion and melanocyte activity acts as competitive chromophore. Pigmentary or textural changes can occur after aggressive treatment protocol. High energy setting, pulse stacking, short wavelength lasers and short treatment interval should be avoided in dark-skinned patients.

The effect of combined hyaluronic acid filler injection and radiofrequency treatment: A clinic histological analysis.

BACKGROUND: Hyaluronic acid (HA) filler injections have increased in popularity. They are usually performed in combination with other treatment modalities, including lasers and energy-based devices, to enhance cosmetic results. Theoretically, HA and other filler injections should be performed after laser- or energy-based device treatments. In some instances, however, practitioners are asked to administer laser- or energy-based device treatment after HA dermal filler injection. There is a concerning possibility of HA filler degradation as a result of bulk heating generated by lasers or energy-based devices, especially radiofrequency (RF). AIM: To evaluate the effect of RF treatment at different time points on HA degradation in vivo, using clinicohistological analysis. PATIENTS/METHODS: Fourteen volunteers were recruited and received intradermal HA filler injections in four sites on the abdomen. One site served as the control, and the other three sites were treated with monopolar RF on the same day after injection, at 14 and 28 days post-injection. Skin biopsies were performed at baseline and 56 days after HA injection. Histopathological sections were reviewed for residual filler in the tissue. RESULTS: The results showed that HA grading scores decreased in five (35.71%), one (7.14%), and one (7.14%) participants when RF was performed immediately, 14 and 28 days after injection, respectively. CONCLUSION: In conclusion, RF treatment after HA filler injection may affect the integrity of the HA filler in the tissue, especially if RF treatment was performed on the same day after HA injection.

Rumpel-Leede Phenomenon Associated with Pneumatic Compression: A Case Report.

Rumpel-Leede phenomenon is a rarely reported condition with an unknown prevalence. It is characterized by the acute development of non-blanchable purpuric macules resulting from dermal capillary rupture caused by compressive forces. We report a case of Rumpel-Leede phenomenon in both feet following the application of pneumatic compression in a 49-year-old woman who underwent en bloc spondylectomy for a giant cell tumor of the spine. The condition appeared after the application of pneumatic compression on both legs for venous thromboembolism prophylaxis, and the lesions spontaneously resolved after discontinuation of compression. Currently, most cases are reported in patients with a history of diabetes mellitus, hypertension, or thrombocytopenia. We report a case of Rumpel-Leede phenomenon in a patient without underlying medical conditions. In our patient, capillary fragility combined with increased intracapillary pressure was hypothesized as the underlying mechanism.

A Comparative Study of Dermatoscopic Features of Acne-related Postinflammatory Hyperpigmentation in Facial and Nonfacial Areas in Asian Patients.

Background: Postinflammatory hyperpigmentation (PIH) is a common problem, especially in patients with darker skin tones. It can occur on any area of the body following external injuries or intense inflammatory conditions. However, there is limited evidence regarding the differences in dermatoscopic patterns between facial acne-related PIH and nonfacial acne-related PIH. Objective: We sought to determine the dermatoscopic features of acne-related PIH in facial and nonfacial areas in an Asian population. Methods: Patients with acne-related PIH in both facial and nonfacial areas were enrolled. Baseline demographic data, location, and duration of PIH were recorded. Dermatoscopic and clinical pictures of each patient were taken from the darkest PIH lesions of both areas. Differences in dermatoscopic patterns were analyzed. Results: Fifty patients were enrolled. The mean age was 26.74 (+ 6.75) years, and the Fitzpatrick Skin Types were III (66%) and IV (34%). In terms of morphological patterns of melanin, nonfacial PIH showed a significantly more regular pigment network than facial PIH (100% vs. 20%, p<0.05), while facial PIH exhibited a more pseudoreticular pigment network than nonfacial PIH (70% vs. 0%, p<0.05). In terms of vascularity, facial PIH demonstrated more telangiectasia and an increased vascular component compared to nonfacial PIH (56% vs. 16%, p<0.05). Moreover, hypopigmentation within the PIH lesion was demonstrated in both facial and nonfacial lesions (42% vs. 50%, p=0.541). Conclusion: Acne-related PIH in facial and nonfacial areas showed different morphological pigment patterns and degrees of vascularity. Dermatoscopic examination should be performed before treatment initiation.

Incobotulinum Toxin Type A for Treatment of Ultraviolet-B-Induced Hyperpigmentation: A Prospective, Randomized, Controlled Trial.

Incobotulinum toxin A (IncoBoNT-A) is effective in preventing ultraviolet B (UVB)-induced hyperpigmentation. This prospective, randomized, controlled study aimed to evaluate the effect of IncoBoNT-A on the treatment of UVB-induced hyperpigmentation in 15 volunteers. Five hyperpigmentation squares (2 × 2 cm) were induced by local UVB on the abdomen at baseline. At Day 7, each site was randomized to receive no treatment (control), normal saline, or intradermal IncoBoNT-A injection with 1:2.5, 1:5, and 1:7.5 dilutions (12, 6, and 4 units, respectively). The mean lightness index (L*), hyperpigmentation improvement score evaluated by blinded dermatologists, and participant satisfaction scores were obtained at Days 21, 28, and 35. At Day 21, improvements in mean L* of 1:2.5, 1:5, and 1:7.5 IncoBoNT-A-treated, saline-treated, and control sites were 14.30%, 12.28%, 6.62%, 0.32%, and 4.98%, respectively (p = 0.86). At Day 28, the improvement in mean L* in IncoBoNT-A-treated groups was superior to that in the other groups. In terms of the hyperpigmentation improvement score, 12 participants (80%) experienced better outcomes with the IncoBoNT-A-injected site compared with the other sites. IncoBoNT-A, especially at higher concentrations, showed some positive effects on the treatment of UVB-induced hyperpigmentation. This may serve as an adjuvant treatment for hyperpigmentary conditions that are aggravated by UVB.

Study of botulinum toxin type A for the treatment of ultraviolet B-induced hyperpigmentation: A prospective, randomized, controlled trial.

BACKGROUND: Botulinum toxin type A (BTX-A) has been used experimentally under various dermatological conditions. Recent studies have revealed a preventive effect of BTX-A against ultraviolet B (UVB)-induced skin hyperpigmentation. OBJECTIVE: We examined the effect of BTX-A for the treatment of UVB-induced hyperpigmentation in humans. MATERIAL AND METHODS: A prospective, double-blind, randomized controlled trial was conducted. UVB irradiation induced five separate hyperpigmented squares on the abdomen. Seven days after irradiation, all squares were randomly assigned to five intervention groups: control, 0.9% normal saline injection, 12 units (1:2.5), 6 units (1:5), and 4 units (1:7.5) of onabotulinum toxin injections. The lightness index (L*), hyperpigmentation improvement score rated by a blinded physician, and participant satisfaction scores were obtained at 14, 21, and 28 days after injection. RESULTS: Fifteen participants (mean age 36.9 years, Fitzpatrick skin types III-IV) completed the study. The BTX-A (1:2.5)-treated site had a lower degree of hyperpigmentation at all time points, as measured by mean L* and hyperpigmentation improvement scores. However, there were no statistically significant differences between the groups. Participants were most satisfied with the control site. CONCLUSION: Intradermal BTX-A injection had no therapeutic effect on UVB-induced hyperpigmentation. However, the role of BTX-A injections in the treatment of other hyperpigmentary conditions requires further elucidation.

Randomized, evaluator-blinded comparative study of a potassium titanyl phosphate (KTP) 532-nm picosecond laser and an alexandrite 755-nm picosecond laser for the treatment of solar lentigines in Asians.

BACKGROUND: Various pigment-specific lasers can be used to treat solar lentigines. However, the most effective treatment options remain to be explored to reduce complications, such as postinflammatory hyperpigmentation, especially in dark-skinned patients. OBJECTIVES: This study aims to compare the efficacy and safety between the KTP 532-nm picosecond laser and the alexandrite 755-nm picosecond laser for the treatment of solar lentigines in Asians. MATERIALS AND METHODS: Thirty patients who had at least two solar lentigines on their arms were enrolled. A total of 30 paired lentiginous lesions were randomly selected for a single treatment with either a KTP 532-nm picosecond laser or an alexandrite 755-nm picosecond laser. Mean luminance score (L*) was evaluated at baseline and at 6 and 12 weeks to determine treatment efficacy. Improvement was assessed by a blinded physician using a 5-point score. Satisfaction was rated by patients using a visual analog scale. All adverse events were documented. RESULTS: All 30 patients completed the study. Both lasers showed significant improvement in mean L* from baseline (p < 0.001). With the parameter settings employed, lesions treated with the alexandrite 755-nm picosecond laser showed greater improvement in mean L* when compared with treatment with the KTP 532-nm picosecond laser at 12 weeks follow-up (p = 0.002). According to physician scoring, more than 50% improvement was observed in 25 and 19 lesions of the alexandrite 755-nm picosecond laser group and the KTP 532-nm picosecond laser group, respectively. Adverse events did not differ between groups. A significantly higher satisfaction score was observed with the alexandrite 755-nm picosecond laser at the last visit (p = 0.038). CONCLUSION: Both types of picosecond laser may be used to treat solar lentigines. Proper treatment settings and endpoint observation are the most important factor to achieve a successful outcome.

Dermal Pathology in Melasma: An Update Review.

BACKGROUND: Melasma is a complex and multipathophysiological condition that is challenging to treat. The roles of each element in the dermis were highlighted in this recent year due to targeting it with emerging therapies. Although some studies have demonstrated abnormal findings in the dermis of melasma lesions, there are no integrated data regarding these findings. PURPOSE: This article aims to discuss each finding in the dermis of melasma lesions and to provide some ideas about treatment options. METHODS: An Internet search was completed using the MEDLINE, Embase, Scopus, and Google Scholar databases for relevant literature through June 2021 and reference lists of respective articles. Only the articles published in English language were included. RESULTS: Several studies have focused on the dermal changes in melasma. Common findings included basement membrane disruption, pendulous melanocytes, marked solar elastosis, increased melanophages, increased mast cells, and neovascularization. In addition, each of them had the specified mechanism that may relate with the others. CONCLUSION: Several changes in the dermis of melasma lesion may be connected with pathological changes in the epidermis. This may serve as a potential target treatment for melasma, which requires a multimodal approach.

A single-blinded, randomized, controlled trial comparing efficacy between low-fluence alexandrite 755-nm picosecond laser and low-fluence neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064-nm picosecond laser for the treatment of ultraviolet B-induced hyperpigmentation.

BACKGROUND: Hyperpigmentation is a common concern of patients in dermatology clinics. Although there are many treatment options, lasers are considered a promising therapy for various hyperpigmentary conditions. OBJECTIVES: This study aims to evaluate the efficacy of alexandrite 755-nm picosecond and neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064-nm picosecond lasers for the treatment of ultraviolet B (UVB)-induced hyperpigmentation in Asians. MATERIALS AND METHODS: A randomized, single-blinded study was conducted. UVB-induced hyperpigmentation was performed in three spots by narrowband UVB. After 2 weeks, these three spots were allocated into 755-treated, 1064-treated, and control sites. Patients received weekly laser treatments for five sessions. Follow-ups were scheduled at 1 and 2 months after the last session. RESULTS: Twenty patients attended the study. Overall, 755-nm and 1064-nm picosecond lasers showed a significant improvement in the mean lightness index (L*) compared to the control site, which started at Day 49 and Day 77, respectively. The mean L* of the 755-nm-treated site was also higher than that of the 1064-nm-treated site at Day 105 (p ≤ 0.001). Initially, the mean L*, physician's visual analog scale (VAS), and patient satisfaction with the 1064-nm picosecond laser were better than those with the 755-nm picosecond laser. Nevertheless, an inversion of the mean L* and VAS was noted at Day 49, whereas the mean patient satisfaction was noted at Day 77. In the subgroup analysis, a 755-nm picosecond laser effectively treated Fitzpatrick skin types (FPTs) III and IV. However, the mean L* of the 1064-nm picosecond laser was not significantly different from that of the control for FPT4. CONCLUSION: The alexandrite 755-nm picosecond and Nd:YAG 1064-nm picosecond lasers appear to be effective and safe modalities for treating UVB-induced hyperpigmentation. With the setting employed in this study, the outcome after the 755-nm picosecond laser treatment seemed superior to that of the 1064-nm picosecond laser treatment, especially for FPT4.

A study of combined microfocused ultrasound and hyaluronic acid dermal filler in the treatment of enlarged facial pores in Asians.

BACKGROUND: Enlarged facial pores are a common cosmetic complaint in practice. Microfocused ultrasound with visualization (MFU-V) and low-degree crosslinked hyaluronic acid filler (L-HA) injection has recently become a popular procedure for skin rejuvenation. The effectiveness of the combined MFU-V and L-HA injection in the treatment of enlarged pores has not been evaluated. OBJECTIVES: To compare the efficacy of MFU-V monotherapy (single technique) and MFU-V combined with L-HA injection (combined technique) for the treatment of enlarged facial pores in Asians. METHODS: We conducted a randomized, single-blinded, split-face study on participants with enlarged facial pores. Each side of the face was randomly assigned to treatment with one session of single technique or combined technique. Pore volume was objectively measured by an Antera 3D® system. Subjective assessment was evaluated by one-blinded physician using a pore grading score (0-4). Patients rated the improvement in terms of satisfaction using the visual analog scale (VAS, 0-10). RESULTS: Forty-six participants completed the study. The mean pore volume of both sides declined with statistical significance at every visit compared to baseline, with the lowest mean at 4 months post-treatment. The combined technique showed a lower mean pore volume than single technique throughout the follow-ups. Physician's subjective evaluation showed no statistically significant difference between the two techniques. The patient satisfaction score showed a similar trend to the mean pore volume, with a statistically significant difference at 4 and 6 months post-treatment. CONCLUSIONS: Both techniques are effectively minimize enlarged facial pores. The combined technique resulted in more patient satisfaction.

A Study of Botulinum Toxin A for Ultraviolet-Induced Hyperpigmentation: A Randomized Controlled Trial.

BACKGROUND: Ultraviolet (UV) exposure contributes to skin hyperpigmentation. Recently, botulinum neurotoxin type A (BoNT-A) showed a promising protective effect on UVB-induced hyperpigmentation in both in vitro and animal models. OBJECTIVE: The study aimed to investigate the preventive effect of BoNT-A against UVB-induced hyperpigmentation in human subjects. MATERIALS AND METHODS: A prospective, double-blinded, randomized controlled trial was performed in 15 healthy participants. Four separate square areas on the abdomen were randomly injected intradermally with different dilutions of BoNT-A (1:2.5, 1:5, 1:7.5) and normal saline (control). Two weeks after injection, hyperpigmented spots were induced by UVB irradiation at the experimental sites. The lightness index and hyperpigmentation scores from blinded physician and participants were evaluated. RESULTS: Fifteen participants completed the study. One week after UVB irradiation, all BoNT-A-treated sites had a significantly lower degree of hyperpigmentation than the control site in lightness index and hyperpigmentation scores from blinded physician and participants (p < .05). However, no statistically significant difference was observed between different concentrations of BoNT-A. No side effects were observed throughout the study period. CONCLUSION: Intradermal BoNT-A injection provided a protective effect from UVB-induced hyperpigmentation. It may be used for other hyperpigmentation disorders that are aggravated by UVB.

Mycobacterium haemophilum skin and soft tissue infection in a kidney transplant recipient: A case report and summary of the literature.

Non-tuberculous mycobacteria are ubiquitous pathogens causing infections in immunocompromised patients. Here, we describe a kidney transplant recipient who developed skin and soft tissue infection by Mycobacterium haemophilum, complicated by tenosynovitis and fluid collection, following an injury sustained to her right foot. Her immunosuppressant dose was reduced, and she underwent prolonged antimicrobial therapy followed by surgical debridement with a favorable outcome. Non-tuberculous mycobacteria should be considered as a potential etiology of subacute skin and soft tissue infections.

Comparison of the effectiveness of fractional 1550-nm erbium fiber laser and 0.05% tretinoin cream in the treatment of acanthosis nigricans: a prospective, randomized, controlled trial.

Acanthosis nigricans is a common dermatological problem. There are currently limited clinical trials to determine the efficacy and safety of laser treatments. To compare the efficacy of fractional 1550-nm erbium fiber laser versus 0.05% tretinoin cream for the treatment of acanthosis nigricans at neck, a randomized, controlled, assessor-blinded study was conducted in 18 subjects with acanthosis nigricans at the neck. All patients were treated with both fractional 1550-nm erbium fiber laser and 0.05% tretinoin cream on each side of the neck. The laser side was treated with three treatment sessions, with a 4-week interval of 1550-nm fractional erbium laser. Another side was treated with 0.05% tretinoin cream daily at bedtime for 12 weeks. We evaluated at baseline, with a 4-week interval until 4 weeks after the last treatment. The efficacy was assessed by skin color ratio, melanin index, average roughness, photographic evaluation, patients' satisfaction, and the adverse effects. At the study endpoint, week 12, the mean Visiometer-average roughness showed greater reduction in laser-treated side (24.65%) than tretinoin side (22.94%) (p = 0.004). Laser-treated side also showed greater percentage of skin color ratio reduction, melanin index reduction, and better mean of photographic-based evaluation percentage change from the baseline than tretinoin side with no significant different (p = 0.331, p = 0.116, p = 0.327, respectively). The study showed one post-inflammatory hyperpigmentation in tretinoin side. Regarding to the average roughness, fractional 1550-nm erbium fiber laser was superior to 0.05% tretinoin cream for treatment of neck-acanthosis nigricans with less side effect. Fractional 1550-nm erbium fiber laser could be considered as an alternative treatment for acanthosis nigricans.

Low-fluence Q-switched Nd:YAG 1064-nm laser versus Q-switched Nd:YAG 532-nm laser in the treatment of hyperpigmented lips: a prospective, randomized, controlled, evaluator-blinded trial.

Lip hyperpigmentation is an esthetic problem. Clinical data from controlled comparative studies is insufficient to support the efficacy of laser treatments for hyperpigmented lips. This study is aimed to compare the efficacy of low-fluence Q-switched Nd:YAG 1064-nm laser (LFQS 1064-nm) versus Q-switched Nd:YAG 532-nm laser (QS 532-nm) for the treatment of hyperpigmented lips. A randomized, controlled, evaluator-blinded study was conducted in thirty subjects. They were randomized into 2 groups. The first group was treated with five treatment sessions with a 2-week interval of LFQS 1064-nm laser while the second group was treated with a single session of QS 532-nm laser. The evaluation was conducted at baseline, 2 weeks of each post treatment, and 4 weeks after the last treatment session. The efficacy was assessed by melanin index, Methuen colored plate, photographic evaluation, pain score, patient's satisfaction, and patient's Dermatology Life Quality Index. The adverse effects were also recorded. All patients attained throughout the study protocol. The most frequent fluence applied was 2.4 J/cm2 (2.2-2.5 J/cm2) and 2.0 J/cm2 (1.7-2.4 J/cm2) in the LFQS 1064-nm group and QS 532-nm group, respectively. The results of the QS 532-nm group showed greater percentage of melanin index reduction and better average mean of photographic evaluation percentage changes from the baseline than the LFQS 1064-nm group (p < 0.001 and p < 0.001, respectively). The adverse effects were less likely to occur in the LFQS 1064-nm group. Few cases of scale, hypopigmentation, bleb formation, postinflammatory hyperpigmentation, and labial edema occurred only in the QS 532-nm group.

The study of histological changes of the arterial vascular structure after hyaluronidase exposure.

BACKGROUND: Hyaluronic acid (HA) filler injection is commonly used for soft tissue augmentation. Uncommon but serious complication from filler injection is vascular occlusion. Hyaluronidase enzyme can be used to dissolve HA filler. Evidence demonstrates that hyaluronidase can penetrate through vessel wall after incubation. However, studies regarding effects of hyaluronidase on vessel wall after intraluminal injection are limited. The objective of this study is to evaluate histological changes of postmortem arteries after intravascular injection of hyaluronidase enzyme. METHODS: This was an ex vivo experiment including arterial specimens from four cadavers which recently deceased within 24 hours. All vessels were examined at baseline and then were divided into two groups. The first was the control group treated with normal saline and the second hyaluronidase-treated group was intra-luminally injected with hyaluronidase enzyme (1500 IU/mL). Gross and histological examination was performed at baseline, 30-minutes and 4 hours after. RESULTS: Gross examination of vessels revealed no significant difference at baseline, 30 minutes and 4 hours after injection in both groups. Histological examinations at baseline and 30 minutes after injection revealed viable endothelial cells in both experimental and NSS-control group. At 4 hours after hyaluronidase injection, two of the four arterial specimens had degeneration of endothelial cell, and one artery showed separation of tunica intima from tunica media. CONCLUSION: There were endothelial injuries in the arterial specimens after intravascular concentrated hyaluronidase injection.

Non-invasive high-intensity focused ultrasound for UV-induced hyperpigmentation in Fitzpatrick skin types III and IV: a prospective, randomized, controlled, evaluator-blinded trial.

Skin hyperpigmentation is a frequently encountered problem, particularly in darker skin types. Unfortunately, standard treatments for this condition have shown disappointing results. High-intensity focused ultrasound (HIFU) is commonly indicated for skin laxity, but recently was used to treat UV-induced hyperpigmentation in animal models. This study is aimed to evaluate the efficacy and safety of high-intensity focused ultrasound for UVB-induced hyperpigmentation in human subjects. A randomized, evaluator-blinded pilot study was conducted on 20 subjects. Each subject was induced three hyperpigmentary spots by local broadband UVB. After 2 weeks, each spot was randomly allocated to control, low-energy, and high-energy HIFU. Subjects were instructed to follow up weekly for a duration of 1 month. Lightness index measurements, mean improvement scores, subjects' satisfaction, pain scores, and side effects were evaluated. All 20 subjects completed the study. Fourteen subjects had Fitzpatrick (FPT) skin type III and six subjects had FPT skin type IV. Twelve subjects showed greater improvement at control sites while eight subjects showed greater improvement at HIFU-treated sites. In FPT skin type III, HIFU appeared to be inferior to control in both lightness index and mean improvement scores, but in FPT skin type IV, HIFU had greater lightness index improvement and higher improvement scores than control. Side effects were more frequent in high-energy-treated areas. Focused ultrasound may be offered in some patients with hyperpigmentary conditions. More research is needed to determine proper energy settings for optimal outcome.