Adverse Events of Light-Assisted Hair Removal: An Updated Review.

BACKGROUND: With light-assisted hair removal becoming widely used, reports of adverse effects are increasing. OBJECTIVE: To review all the reported optical incidents and cutaneous complications of laser or intense pulse light-assisted hair removal. METHODS: A PubMed database systematic search was performed to identify studies reporting such adverse events before July 2022 using the Mesh terms "adverse effects" AND "hair removal" AND ("laser" OR "intense pulse light"). RESULTS: Altogether, 358 references were identified. After excluding duplicates, unrelated articles, guidelines, and conference abstracts, then adding references from studies bibliography, 104 publications were included. Ocular incidents consisted of anterior uveitis, iritis and iris atrophy, pupillary distortion, posterior synechiae, anterior chamber pigment, and cataracts in the anterior subcapsular region. Cutaneous complications consisted of pain, burns, folliculitis, leukotrichia, paradoxical hypertrichosis, pigmentary changes, changes in nevi, pili bigemini, herpes infection, hyperhidrosis, bromhidrosis, Fox-Fordyce disease, and frostbite from the cooling system. They were mostly correlated to skin type and body area as well as to light device and set parameters. Intense pulse light devices were found to be less painful than alexandrite laser, yet more painful than diode laser; Nd:YAG laser had the highest pain score. CONCLUSION: Optical incidents can be systematically avoided. Cutaneous complications are usually related to professional errors and patient characteristics. Better knowledge of laser physics and adequate training of laser operators are key recommendations to avoid undesirable side effects. Safety recommendations help prevent most of the reported complications.

Searching predictive factors of efficacy and safety in a fractional CO2 laser.

A few studies discussed short outcomes in fractional CO2 laser. This study aimed to seek factors of medium-term efficacy and safety in patients treated for facial rejuvenation or acne scars. This single-center, prospective, single-arm, evaluator-blinded cohort study included patients of 18 years and older undergoing a fractional CO2 laser for facial skin rejuvenation or atrophic acne scars. One session of ultrapulsed fractional 10 600 nm CO2 laser was performed with the Deep FX TM mode in acne scars and the Active FX TM mode in facial rejuvenation and acne scars. Follow-up was carried out for 6 months. In the end, a patient self-satisfaction assessment was obtained. A blinded physician graded improvement based on pretreatment and 6-month photography. The study included 75 patients, of whom 88% were women. Forty-five had facial rejuvenation, and 30 had atrophic acne scars treatment. Half of the patients were satisfied. The physician-blinded evaluation indicated "good to very good" improvement in 46.7% of facial rejuvenation patients, and 30% of acne scars patients. Hyperpigmentation and folliculitis were recorded in 15 and 3 patients, respectively. This study did not find statistically significant factors to predict outcomes in a fractional CO2 laser. We could however note better results in acne scar patients of thicker skin, and facial rejuvenation patients of younger age and thinner skin. We counted more hyperpigmentation events in phototypes III and IV, and it was reversible in all cases.

Light and Laser Treatments for Keratosis Pilaris: A Systematic Review.

BACKGROUND: Keratosis pilaris (KP) is a common hereditary keratinization disorder. Keratosis pilaris rubra and KP atrophicans faciei are less frequent variants of the disease. Topical treatments often yield ineffective and temporary results. OBJECTIVE: The objective of this article is to review and assess all the studies that used light and laser devices to treat KP and its variants. MATERIAL AND METHODS: On January 15, 2017, an online search of the MEDLINE, Embase, and Cochrane databases was performed using the following combination of keywords: "keratosis pilaris" and "treatment." RESULTS: Seventeen studies related to light and laser treatments were retained for analysis. The total number of treated patients was 175. Of which, 22 patients had KP atrophicans faciei, 17 patients had KP rubra, and 136 patients had KP. CONCLUSION: Light and laser devices have been emerging as promising therapeutic options for a disfiguring disease that still lacks, until today, an effective long-term treatment.

Triggers, clinical manifestations, and management of pediatric erythema multiforme: A systematic review.

BACKGROUND: Erythema multiforme (EM) is an acute inflammatory mucocutaneous condition. EM is rarely described in children and infants. OBJECTIVE: To investigate the triggers, clinical manifestations, and treatment of pediatric EM. METHODS: Systematic literature review of pediatric EM. RESULTS: After full-text article review, we included 113 articles, representing 580 patients. The mean age was 5.6 years, ranging 0.1-17 years. Infectious agents were the main triggers: herpes simplex virus (HSV) in 104 patients (17.9%) and Mycoplasma pneumoniae in 91 patients (15.7%). In total, 140 cases (24.1%) were drug-related and 89 cases (15.3%) had other triggers, such as vaccines (19 patients, 3.2%). In total, 229 patients had EM major (39.5%). Treatment was supportive care only (180 patients, 31.1%), systemic corticosteroids (115 patients, 19.8%), antivirals (85 patients, 14.6%), and antibiotics (66 patients, 11.3%), mostly macrolides (45 patients, 7.7%). Long-term sequelae were rare (1.3%). Pediatric EM was reported in 19 infants (3.2%). The main trigger was vaccination (9 patients). Infantile EM was EM major in 2 cases and EM minor in 17. Infants were less prone to develop EM major than older children (P < .01). Pediatric EM was recurrent in 83 cases (14.3%), which was triggered by HSV in 36 patients (61%). Recurrence affected older children. LIMITATIONS: Potential confusion between Steven Johnson syndrome and EM major in addition to publication bias. CONCLUSION: Pediatric EM is a rare disease, mainly triggered by infections. This condition can affect all mucosal surfaces, most commonly the oral mucosae. The diagnosis is clinical, and management relies on supportive care. Vaccines are a particular trigger in infants. Recurrent cases are most commonly linked to HSV. Dermatologists and pediatricians should be aware of this potentially recurrent and severe condition.

Spectrum of Autoimmune Bullous Diseases in the Middle East: A 15-Year Review.

Characteristics of autoimmune bullous diseases (AIBDs) show wide geographic variation. The aim of this study was to determine retrospectively the characteristics of patients with AIBD admitted to Hôtel-Dieu de France Hospital in Beirut, Lebanon, between 1999 and 2014 and to compare them with those from other areas in the Middle East, the Far East, Asia, North Africa, Europe, and North America. For the patients with AIBDs and who were hospitalized at a major tertiary referral center between 1999 and 2004, we studied demographics, diagnosis, length of stay, department/floor, comorbidities, clinical features, in-hospital evolution, diagnostic tests, and treatment. Bullous pemphigoides was the most frequent bullous disease in Lebanon. This and other findings contrast with those of studies conducted in regional countries. This is the first report of AIBD from the Middle Eastern region.

Fractional CO2 laser treatment for a skin graft.

Skin grafts are widely used in reconstructive and plastic surgery, leaving an inevitable scar appearance on the body, affecting the quality of life of the patients. Fractional ablative lasers have become a leading procedure for the treatment of acne and burn scars. We report a case of a skin graft showing excellent improvement in overall appearance after three sessions of fractional CO2 laser. The undamaged tissue left between the microthermal treatment zones is responsible of collagen formation and reepithelialization. Remodeling and collagen formation are observed even 6 months after a fractional CO2 laser session.

A case of generalized bromhidrosis following whole-body depilatory laser.

BACKGROUND: Laser treatment is a widespread method for hair removal. Despite its very common use, side effects remain relatively rare and transient. OBJECTIVE: Axillary hyperhidrosis and bromhidrosis have already been reported in the literature after depilatory lasers. We report here a novel side effect of total body bromhidrosis following hair removal laser. RESULTS: A 27-year-old man, phototype 3 underwent four sessions of total body depilatory laser, combining pulsed alexandrite and pulsed diode lasers. A few days afterwards, a generalized foul odor was noted and was resistant to regular deodorants and Aluminum chloride based antiperspirants. Possible mechanisms include the activation of dormant bacteria in the skin flora, sweat gland dysfunction, altered skin flora, sweat gland hormone receptor disturbances, and genetic factors. CONCLUSION: Total body bromhidrosis and hyperhidrosis are potential complications of total body laser hair removal.

Reversibility of hyperhidrosis post axillary depilatory laser.

Hyperhidrosis and bromhidrosis were lately reported as novel side effects of laser-assisted removal of axillary hair. The goal of our study was to evaluate the reversibility of these two side effects. An observational, single-center cohort study included over a 30-month screening period 30 patients with newly reported hyperhidrosis and/or bromhidrosis related to axillary depilatory laser. After 26 weeks of follow-up, each patient was assessed for spontaneous reversibility. A 12-week duration treatment with topical aluminum chloride was evaluated in patients with persisting hyperhidrosis. Hyperhidrosis was assessed using the Hyperhidrosis Disease Severity Scale (HDSS). Spontaneous reversibility was observed in 20% of patients. In total, 23 out of 30 patients recovered normal axillary transpiration either spontaneously or after treatment. Mean HDSS score was significantly lower in the treated group. It appears that axillary hyperhidrosis and bromhidrosis, secondary to laser depilation, reverse either spontaneously or after using topical antiperspirant.

Iron Supplementation May Improve the Patient's Level of Satisfaction in Not-Low-Ferritin Telogen Effluvium: A Real-Life Observational Study.

Background: Telogen effluvium (TE) is the most common cause of alopecia in women. Treatment should address the etiological factors and may include adjuvant therapies. In practice, physicians may employ modified approaches and utilize various combinations of topical and oral molecules. Aims: In this real-life observational study, the aim was to evaluate the response of TE to iron supplementation. Materials and Methods: The population consisted of all patients who sought consultation for TE at our dermatology department between March 2021 and February 2022. Eligible participants were women, aged between 18 and 65, having a clinical diagnosis of TE, and intended for treatment with iron supplementation. Exclusion criteria comprised current pregnancy, chronic or active inflammatory disease, newly discovered dysthyroidism, concurrent use of hair supplements, topical minoxidil, or any other medications. The response was assessed based on the patient's level of satisfaction, a significant indicator, given the substantial psychological impact of TE on women's daily lives. Results: The analysis included 200 women. The average age was 32.9 ± 11.4 years. A recent history of COVID-19 or treated dysthyroidism was present in 18.5% and 8% of patients, respectively, but did not impact their response. Significantly, patients with baseline ferritin ≥50 ng/ml were mostly "very satisfied", those with baseline ferritin <50 ng/ml were mostly "not satisfied", and those with unknown levels were mostly "partially satisfied" with iron supplementation. A high dose of elemental iron and a prolonged duration of treatment significantly improved the patients' level of satisfaction. Conclusion: Iron supplementation can improve the patient's level of satisfaction in TE even if serum ferritin is not low.

Efficacy and safety of the enzymatic mixture - Lipase, collagenase and hyaluronidase - In the treatment of moderate to severe submental fat: A prospective cohort study.

Purpose: To study the effect of the enzymatic mixture: Lipase, Collagenase and Hyaluronidase in the treatment of submental fat. Methods: A monocentric prospective cohort study including 10 female patients, aged between 18 and 65 years old, who received treatment for submental fat with a mixture of Lipase, Collagenase, and Hyaluronidase. The treatment protocol consisted of one treatment session every 21 days for a total of 3 sessions. In each session, 4 ml of the enzymatic mixture (1 ml of Collagenase GH PB20, 1 ml of Hyaluronidase PB 3000 and 2 ml of Lipase PB 500) + 2 ml of Lidocaine 2% were injected in the submental fat (SMF). Efficacy was assessed four weeks after the last session. Co-Primary Outcome was defined as the improvement of ≥ 1-point in Clinician-Reported and Patient-Reported Sub-mental Fat Rating Scales (CR-SMFRS and PR-SMFRS). Secondary Outcomes included score reductions in Patient-Reported Sub-mental Fat Impact Scale (PR-SMFIS), ≥10% reduction in submental fat pad thickness by ultrasound, and Subject Self-Rating Scale (SSRS) responses of 4, 5, or 6. Results: The Co-Primary outcome was achieved in 9 out of 10 patients. A considerable reduction of 22.8% in the PR-SMFIS was observed. Furthermore, 9 out of 10 patients expressed overall satisfaction with the treatment. Submental fat reduction of more than 10% was observed in 9 out of 10 patients in neutral position and in all patients in flexed position. Adverse effects were only limited to local reactions. Conclusion: The enzymatic mixture of Lipase, Collagenase and Hyaluronidase is an effective and safe minimally-invasive method for the reduction of SMF that can be used alone or in conjunction with other treatment modalities.

Raynaud's phenomenon and vitamin D.

To our knowledge, there have not been studies to evaluate the effect of vitamin D supplementation on Raynaud's phenomenon (RP). To test in a randomized, placebo-controlled, double blind, and prospective way whether 8 weeks of 600,000 IU monthly supplementation of oral vitamin D3 would contribute to improvements in RP, 53 patients describing RP were recruited during winter 2010-2011. 42 patients were deficient in vitamin D dosage and randomly assigned into either the vitamin D group or placebo group. Every 4 weeks (for a total of 3 doses), patients received their treatment and answered on a visual analogue scale (VAS) basis about their RP. In the vitamin D group, baseline average blood vitamin D level was 20.9 ng/mL. VAS 0, VAS 1, and VAS 2 were 58.33, 48.09, and 36.2, respectively. At the end of the study, the average blood vitamin D level was 32.9 ng/mL. In the placebo group, baseline average blood vitamin D level was 21.8 ng/mL. VAS 0, VAS 1, and VAS 2 were 58.33, 51.19, and 64.28, respectively. At the end of the study, the average blood vitamin D level was 23.2 ng/mL. Following our observations, we concluded to an objective augmentation of vitamin D blood level and RP self-judgment improvement after 8 weeks of monthly supplementation of vitamin D3. One can ask whether vitamin D has as a vasodilator effect in patients with RP who are deficient in vitamin D. Other studies and researches are needed to answer these questions.

Depilatory laser: a potential causative factor for inguinal hyperhidrosis: report of three cases.

Hyperhidrosis has recently been described as a novel adverse effect of laser-assisted hair removal in the axillary area. Inguinal Hyperhidrosis (IH) is a localized and, typically, a primary form of hyperhidrosis affecting the groin area in individuals before age 25. IH has been reported in the literature after traumas and as a dysfunction of the central sympathetic nervous system. To the best of our knowledge, IH has never been reported as secondary to laser-assisted hair removal. Herein, we report three cases of IH following depilatory laser of the inguinal zone. Three female patients with no relevant medical history presented with the complaint of excessive sweating in the inguinal area after undergoing full bikini depilatory laser sessions. Although never described before, depilatory laser seems to trigger the occurrence of hyperhidrosis in the inguinal zone.

Fox-Fordyce-like disease following laser hair removal appearing on all treated areas.

Fox-Fordyce disease is an uncommon inflammatory disease of the apocrine sweat glands. Two recent reports indicated laser hair removal as a novel cause of axillary Fox-Fordyce disease. We report the first case of Fox-Fordyce disease developing in women after completing treatment with a depilatory hair laser appearing in the axillae, umbilicus, and pubis. We describe a case of Fox-Fordyce disease that developed in a 27-year-old woman 3 months after she had completed two LightSheer Diode laser treatments of her axilla, periumbilical region, and bikini area. Clinical and histopathological changes are as well detailed. Laser therapy induces damage to follicular infundibulum, resulting in altered maturation of keratinocytes which led to keratin plugging causing the common pathologic features in Fox-Fordyce disease. Differences in the physiologic features of the anatomic sites, in the susceptibility to laser-induced injury among these areas, or additional factors may contribute to Fox-Fordyce disease.

Prevalence of adverse events varies with the different oral isotretinoin brands in acne treatment: a retrospective observational study.

Oral isotretinoin remains the most effective treatment for acne. The aim of this retrospective single-center cohort study was to estimate the prevalence of adverse events with the different oral isotretinoin brands used in acne treatment. The population consisted of all patients who consulted for acne between January 2015 and January 2020. The inclusion criterion was the initiation of treatment with oral isotretinoin. The exclusion criteria were the use of two or more brands during the same course of treatment and previous treatment with oral isotretinoin. Statistical analysis was carried out using Chi-square and Mann-Whitney tests. We analyzed 468 patients of whom 68.6% were female. The median age was 21 years. The median weight was 65 kg. The treatment was Roaccutane®, Curacné®, Acnotren®, Isosupra®, Contracné®, or Acnogen® in 44.2%, 28%, 14.5%, 10.5%, 1.7% and 0.4% of cases, respectively. Xerosis was the most frequently reported side effect regardless of the brand. The highest frequencies of hypercholesterolemia (25.6%) and eczema (13%) were noted with Roaccutane®; hypertriglyceridemia (16.8%), epistaxis (9.9%) and fatigue (3.1%) with Curacné®; excessive sweating (4.1%) and headache (4.1%) with Isosupra®; and abnormal liver function tests (11%) with Acnotren®. We found a significant correlation mainly between abnormal ASAT and Acnotren® (p = 0.009), hypercholesterolemia and Roaccutane® [OR = 1.652 (95% CI 1.056-2.585)], hypertriglyceridemia and higher body weight (p = 0.004). Factors related to the drug brand and to characteristics of acne patients could explain the variability in the prevalence of some adverse events.

Combination Topical Tranexamic Acid and Vitamin C for the Treatment of Refractory Melasma.

Background: Melasma is a widespread condition that affects people of many ethnicities and is prevalent in the Middle East. To date, the therapeutic arsenal is still not effective, especially in countries with high ultraviolet light index. New treatment options are needed. Objective: The aim of this pilot study was to assess the efficacy of topical tranexamic acid (TA) 2% combined with vitamin C 2% in the treatment of resistant melasma in the Mediterranean region. Methods: This prospective interventional pilot study included 10 women, aged 18 to 55 years, with resistant melasma. Intervention consisted in application of a topical formulation containing 2% TA and 2% vitamin C, every night for eight weeks. The primary outcome was the Melasma Area and Severity Index (MASI) score measured at baseline and at Weeks 4 and 8. Melasma Quality of Life Scale (MelasQoL) and Physician Global Assessment (PGA) were used at baseline and at Weeks 4 and 8 of treatment, and they were set as the secondary outcomes. Results: The mean MASI score varied from 12.76±3.91 at baseline to 7.00±4.85 at Week 4 (p<0.01) then to 3.39 ± 1 at Week 8 (p=0.03). The mean MelasQoL decreased from 35.2 ± 16.03 at baseline to 28.8 ± 12.96 at Week 4 (p<0.01) then to 24.9±13.96 at Week 8 (p=0.14). The PGA increased between Weeks 4 and 8 passing from 2.2±0.79 to 2.4±1.07. No major side effects were reported. Conclusion: Our pilot study demonstrated the possibility of a topical combination of TA 2% and vitamin C 2 %, which may be a useful therapeutic strategy in the treatment of resistant melasma in the Middle east, a region of the world with high UV index. This combination treatment is a safer alternative to dangerous bleaching treatments that are still being used.

Clinical and pathological features associated with high-risk, multiple, and recurrent basal cell carcinomas: a retrospective cohort analysis from the Levantine coast of the Mediterranean Sea.

Basal cell carcinoma (BCC) data coming from the Levantine coast of the Mediterranean Sea are limited. The study aimed to primarily analyze the demographic, clinical, pathological, and prognostic characteristics of BCC in this region of the world and secondarily identify features associated with high-risk, recurrent, or multiple BCCs. Patients with at least one diagnosis of BCC registered in the pathology department between January 2015 and December 2019 were included in this analytical retrospective single-center cohort study. Patients with basal cell nevus syndrome were excluded. Patients' characteristics and pathological features were collected through file check for a first analysis. Risk factors and evolution were sought through a phone call interview for the second analysis. The first analysis included 506 BCCs corresponding to 365 patients with a mean age of 65 ± 15 years, twenty-two (6%) were less than 40 years old, 180 (49.3%) were women, and 85 (23.3%) had two or more BCCs. The second analysis included 279 BCCs corresponding to 205 patients. Periorificial and infiltrative BCCs were more frequent in men. Periorificial tumors were more frequently nodular or infiltrative and were associated with recurrence. Tumors with perineural involvement were histologically never nodular nor superficial. Recurrence was more frequent in BCCs having periorificial location, a size larger than 2 cm, or an infiltrative subtype. Multiple BCCs were more frequent in patients with light skin type or familial history of skin cancer. High-risk BCCs were more common in patients with low sun exposure.

Big toenail onychomycosis features associated with response to 1064 nm Nd: YAG laser treatment.

BACKGROUND: A few studies discussed the factors correlated to response in laser treatment of onychomycosis. OBJECTIVE: This study aimed to seek big toenail onychomycosis features that correlate with response to 1064 nm Nd: YAG laser treatment. METHODS: This single-center, retrospective study included patients who had only one big toenail onychomycosis, with a confirmed mycological diagnosis and/or a high clinical suspicion. Patients had three sessions 1 month apart. The following characteristics were collected from the patients' files: age, sex, smoking and arterial hypertension statuses, results of baseline mycological culture, Onychomycosis Severity Index (OSI) score at baseline and at the end of the 6-month follow-up, as well as the reported side effects. RESULTS: We included 105 patients, 86 women and 19 men, with a mean age of 43 years. Demographics have shown that 73.6% of patients were smokers, 17.9% had arterial hypertension, 61.9% had a culture positive for Trichophyton species, and 9.4% had a culture positive for Candida species. According to the OSI score, onychomycosis was mild in 18.9%, moderate in 39.6%, and severe in 41.5% of patients. At 6 months, clinical cure was achieved in 57.1% of patients. CONCLUSION: The OSI decrease after 3 sessions of Nd: YAG laser was significantly more important in women and in patients with positive mycology culture, smaller affected area of the nail, no subungual hyperkeratosis, and no nail matrix involvement. Age, smoking, hypertension, and side effects were not shown to significantly correlate with the decrease of the OSI score.

Pediatric lichen planus: a systematic review of 985 published cases.

BACKGROUND: Lichen planus (LP) is a chronic inflammatory disorder usually occurring in middle-aged adults. Data are scarce in the pediatric population. OBJECTIVE: To describe the patients' characteristics, clinical presentation, and management of pediatric LP. METHODS: A systematic literature review of pediatric LP was performed in the Medline and Cochrane databases up to February 1, 2020. Demographic and clinical data were extracted for analysis, in addition to laboratory and histology findings, treatments used, and response to treatment. LP pemphigoides (LPP) was further pooled for a subcategory analysis. RESULTS: One hundred and sixty-four articles were included representing 985 patients. The most common country of origin was India. The most common clinical signs were flat-topped papules (51%); the linear variant was present in 9%. Oral involvement was present in 22%. The most commonly used treatment was topical corticosteroids followed by systemic corticosteroids. The mean duration of treatment was 124.4 days. LPP patients had a short disease duration before diagnosis (4.1 months, P < 0.001) and failed previous treatment more frequently (P < 0.001). Systemic corticosteroids were more often prescribed in this subgroup (75%, P < 0.001) with more recurrence after treatment (31%, P = 0.048). LIMITATIONS: Lack of randomized controlled studies, in addition to publication bias. CONCLUSION: In children, LP had a wide polymorphous clinical presentation, and the reported cases were mostly from India. The linear variant was more common and the oral mucosa was less affected in children. LPP, a rare subtype in children, was treated with systemic corticosteroids and recurred more frequently.