[Telemedicine in pediatric dermatology:focus on current practices]. / Télémédecine en dermatologie pédiatrique†: mise au point sur les pratiques actuelles.

Pediatric teledermatology (PTD) allows offering long distance health care advice in pediatric dermatology trough telecommunication technologies. Due to the lack of pediatric dermatologists, the frequency of dermatological questions in general pediatrics, the visual nature of the specialty, and the rare occurrence of vital emergencies in dermatology, PTD appears to be a good option for giving long distance advice in a certain number of skin conditions. In this article, we will discuss benefits and limitations of PTD. We will also talk about diagnostic and therapeutic concordance between PTD and traditional consultations, as well as the most frequent advices asked.

La télédermatologie pédiatrique (TDP) correspond à l'utilisation des technologies de télécommunication pour offrir à distance des conseils de prise en charge spécialisés de l'atteinte cutanée chez l'enfant. La TDP semble adaptée pour un grand nombre de pathologies cutanées, étant donné le caractère visuel de la spécialité, l'occurrence rare d'urgence vitale en dermatologie, le faible nombre de spécialistes en dermatologie pédiatrique et la fréquence des motifs dermatologiques en consultation de pédiatrie. Nous discuterons, dans cet article, des avantages et limites de la TDP. Nous aborderons également les concordances diagnostique et thérapeutique entre la TDP et la consultation traditionnelle, ainsi que les demandes d'avis les plus fréquentes.

[Reflectance confocal microscopy : what future for dermatology ?] / Microscopie confocale in vivo : quel avenir en dermatologie ?

Reflectance confocal microscopy is a non invasive imaging technique which provides in vivo and real time images of different skin tissues with a resolution close to histology, however with a depth limited to superficial dermis.The first lesions that were morphologically analyzed are melanocytic lesions. Reflectance confocal microscopy has been used for about ten years in dermatology. Its progressive improvement over the years has allowed it to be an efficient tool for diagnosing cutaneous tumors. It has been developed for inflammatory dermatosis, cutaneous infections, angiomas, cosmetology. Furthermore, it is also used to delimit the edges of lesions or the area to biopsy. This cutaneous imaging technique represents a major innovation and has its place in dermatological practice.

La microscopie confocale (MC) par réflectance est une technique d'imagerie non invasive qui permet d'obtenir in vivo et en temps réel des images de différents tissus de la peau avec une résolution proche de l'histologie, avec toutefois une profondeur limitée au derme superficiel.Les premières lésions qui ont été analysées morphologiquement sont les lésions mélanocytaires. Utilisée depuis une dizaine d'années en dermatologie, la MC est arrivée à maturité pour le diagnostic des tumeurs cutanées. Elle se développe pour les dermatoses inflammatoires, les infections cutanées, les angiomes, la cosmétologie mais aussi lors d'excision pour préciser les limites d'une lésion ou la zone d'intérêt à biopsier. Cette technique d'imagerie cutanée représente une innovation majeure et a une place logique en pratique dermatologique.

A pilot study using reflectance confocal microscopy (RCM) in the assessment of a novel formulation for the treatment of melasma.

INTRODUCTION: Melasma is a common pigmentary disorder caused by abnormal melanin deposits within the skin. Hydroquinone (HQ) is presently the most popular depigmenting agent, however the treatment of melasma remains unsatisfactory, resulting in a need to evaluate new depigmenting agents. OBJECTIVE: The objective of this study was to assess, using standard methods and a novel technique, in vivo Reflectance Confocal Microscopy (RCM), the efficacy and safety of a new non-HQ bleaching agent Dermamelan® (Mesoestetic, Barcelona, Spain) in the treatment of melasma. METHODS: Ten women with melasma were enrolled in an open-label trial lasting four months. Patients were of Fitzpatrick skin types II-IV. A non-HQ depigmenting agent (Dermamelan) was applied once-daily for three months. Melasma Area and Severity Indices (MASI) were measured. Standard and UV-light photographs were taken and in vivo RCM, which detects pigmentary changes at a cellular level, was done. Evaluations were performed before treatment, on the first, second and third month of treatment and one month after treatment. Upon cessation of the trial, patients completed a questionnaire regarding efficacy and tolerance. RESULTS: At baseline, RCM detected hyperpigmented keratinocytes in all patients, dendritic cells in 2/10 patients, and melanophages in 2/10 patients. Based on the MASI score, Dermamelan treatment improved melasma by 50 percent. This was confirmed by standard and UV-light photography. Maximum therapeutic effect was usually reached by one month of treatment and was maintained at one month following its completion. Interestingly Dermamelan treatment also induced a statistically significant decrease of pigmented epidermal keratinocytes as detected by RCM. Patients with melanophages on RCM at baseline had a poorer outcome, but not those with dendritic cells. Mild irritation was the only adverse event observed during treatment. The majority of patients were satisfied with the result. CONCLUSION: This study suggests that Dermamelan produces significant rapid improvement of melasma at a clinical and cellular level and demonstrates the potential of RCM to monitor and possibly predict efficacy of a new depigmenting agent in the treatment of melasma.

Efficacy of nonablative laser treatment for rhytids: a controlled study with objective evaluation via clinical, profilometric, and computer assessments.

BACKGROUND: A 980-nm diode laser was evaluated in rhytids treatment to ascertain its short- and long-term efficacy, as well as its potential value as an adjunct to aesthetic surgery. SUBJECTS AND METHODS: Twenty subjects, 10 in each of 2 geographically distant sites, were treated with a 980-nm diode laser (macropulse of 1.9 seconds, two 200-ms micropulses, 25 J/cm(2) each). Group A subjects received 5 treatments, 15 days apart, with assessments at 1 and 6 months after the last treatment. Group B subjects received 2 treatment sessions, 30 days apart, with assessments at 1 and 6 months after the second treatment. The patient subjective satisfaction index (SI) was calculated, in addition to objective photographic, computer-based, profilometric, and histologic assessments. RESULTS: Results were rated more highly by objective evaluation than by subjective patient evaluation. Improvement peaked around 1 month after the final treatment, and by the 6-month assessment, the skin condition had started to deteriorate. Among all evaluation methods, only the histology values showed some improvement at the 6-month compared with the 1-month assessment point. Group A patients responded better than Group B patients, and side effects were minimal. CONCLUSIONS: A course of 5 treatments with the 980-nm diode laser gave positive short-term results in skin enhancement following nonablative rhytids treatment, which might have significance for the plastic surgeon when considering epidermal improvement after any surgical procedure. Introducing a "top-up" treatment, perhaps at the 3- or 4-month posttreatment point, supplemented with other adjunctive epidermal care regimens, might well increase overall efficacy and reverse the downward trend seen in all of the data except for histology. This strategy might well help the epidermis to better reflect the excellent histologic changes and is worthy of further study.

Results of fractional ablative facial skin resurfacing with the erbium:yttrium-aluminium-garnet laser 1 week and 2 months after one single treatment in 30 patients.

The erbium:yttrium-aluminium-garnet (Er:YAG) laser has recently been used in the fractional resurfacing of photo-aged skin. Our study evaluated the results after one single session of fractional resurfacing with Er:YAG. Thirty women participated in the study, with an average age of 46 years, skin types from II to IV, and wrinkle grades I to III. The 2,940 nm Er:YAG system used (Pixel, Alma Laser, Israel) had variable pulse durations (1 ms to 2 ms) and energy densities (800 mJ/cm(2) to 1,400 mJ/cm(2)) which, together with the number of passes (four to eight), were selected as a function of wrinkle severity. All patients received only one treatment. Postoperative side effects were evaluated. The number of wrinkles was documented with clinical photography and was scored. Histological assessment was carried out on two patients before and 2 months after treatment. All patients completed the study. Of the patients, 93% reported good or very good improvement of the degree of their wrinkles, with a satisfaction index of 83%. Pain was not a problem during treatment, and there were no side effects except for in one phototype IV patient, who had hyperpigmentation. Histology 2 months after the single treatment demonstrated younger morphology of both the epidermis and dermis, with improvement of the pretreatment typical elastotic appearance. At the parameters used in our study, only one treatment session of Er:YAG laser could achieve effective skin rejuvenation, with effects recognized in both the dermis and, more importantly, the epidermis. This regimen offers an interesting alternative to the conventional approach of multi-session fractional resurfacing.

In vitro evaluation of the effect of electrotreatment on skin permeability.

BACKGROUND: Stratum corneum composition and structure limit cutaneous bioavailability of pharmaceutical and cosmetical agents. Electrically assisted transport can increase the rate and extent of delivery; moreover, it also enables the administration of polar and charged molecules into the skin. AIMS: The objective of this study was to investigate the effect of electrotreatment on skin permeability by measuring the cumulative delivery of caffeine and sodium ascorbyl phosphate. Furthermore, confocal microscopy was used to visualize the effect of electrotreatment on the penetration of calcein. METHODS: Porcine ear skin was used for the in vitro permeation studies, which involved application of either the caffeine or sodium ascorbyl phosphate (NAP) containing gels using the roll-on supplied with the electrotreatment device. RESULTS: Electrotreatment increased the amount of caffeine and NAP in the skin. Enhancement factors (EF) for NAP of 7.2 and 14.9 were observed following 20 min of electrotreatment and either immediate sampling or a further 60 min of passive diffusion compared with passive diffusion for either 20 or 80 min. The effect on caffeine permeation was less significant (EF = 2.1 for 20 min electrotreatment compared with passive diffusion for 20 min). The confocal microscopy images showed that electrotreatment significantly increased calcein permeation; fluorescence was observed deep into the viable epidermis-reaching depths of up to 60 to 80 microns. CONCLUSIONS: We have shown that electrotreatment increases skin permeability and the cumulative delivery of cosmeticals into the skin.

Combined effects of silymarin and methylsulfonylmethane in the management of rosacea: clinical and instrumental evaluation.

OBJECTIVE: This study aims to evaluate a topical treatment based on silymarin/methylsulfonilmethane (S-MSM) to improve erythematous-telangiectactic rosacea. METHODS: Forty-six patients affected by stage I-III rosacea entered this double-blind, placebo-controlled study. Subjects were treated for 1 month. Clinical and instrumental evaluations were done at baseline, after 10 and 20 days, and at the end of the study. Itching, stinging, erythema, and papules were investigated clinically as well as hydration and erythema instrumentally with capacitance and color measurements. RESULTS: A statistically significant improvement was observed in many clinical and instrumental parameters investigated (P < 0.001). In particular, improvement of skin redness, papules, itching, hydration, and skin color occurred. CONCLUSIONS: The combination of silymarin and S-MSM can be useful in managing symptoms and condition of rosacea skin, especially in the rosacea subtype 1 erythemato-telangiectatic phase. The action can be considered multicentric and multiphase because of the direct modulating action on cytokines and angiokines normally involved and up-regulated in the case of such skin condition.

A double-blind controlled study of a nonhydroquinone bleaching cream in the treatment of melasma.

BACKGROUND: Melasma is an acquired hypermelanosis predominantly affecting the face of women. It is often recalcitrant to treatment with hypopigmenting agents. OBJECTIVE: To assess the efficacy of a nonhydroquinone cream (Amelan M) vs. another (Mela-D) as treatment for melasma. METHODS: Twenty-two French women with bilateral epidermal and/or mixed melasma were enrolled in a split-faced prospective trial lasting 4 months during summer season weeks. Twelve patients applied once-daily Amelan M to one side of the face with sun-protective factor 60 UVA sunscreen each morning and Mela-D once-daily to the other side of the face. Pigmentation was measured objectively using a mexameter and the melasma area and severity index (MASI) were measured subjectively. RESULTS: The mean decrease of pigmentation was statistically significant on the MASI with both cream and only with Amelan M with the mexameter. Some adverse side effects were observed. CONCLUSIONS: Amelan M is really more effective than Mela D cream on melasma. Even though some side effects were observed patients preferred the Amelan M-treated side.

New operative technique for treatment of xanthelasma palpebrarum: laser-inverted resurfacing: preliminary report.

Xanthelasma palpebrarum lesions are benign but present cosmetic problems to the patient. Their surgical removal has also presented problems to the surgeon. A new laser operative technique for xanthelasma palpebrarum is introduced to avoid the risk for scarring and pigmentary changes after vaporization of eyelid tissue to remove benign lesions, for example, xanthelasma. The authors propose pulsed erbium yttrium aluminum garnet (Er:YAG) vaporization of the lipomatous tissue off the inner surface of the eyelid after incision and eversion of the incised tissue to expose the xanthelasma. The Er:YAG is the laser of choice because of its high absorption in water and thus its self-limiting depth of penetration coupled with extremely precise tissue ablation. Two illustrative case reports are presented, with no recurrence seen in a maximum of 1 year of follow-up. This technique offers the following advantages: no excision of tumor tissue is required (bearing in mind the high rate of recurrence of this lesion) and this wavelength allows good control of tissue removal and accurate recognition of the end point.

Treatment of vascular abnormalities with a long-pulse diode at 980 nm.

BACKGROUND: Lasers have been used to treat a variety of vascular abnormalities for over 20 years. For minor vascular targets, a small and friendly diode laser with cooling handpiece appears to be a challenger to other systems. OBJECTIVE: The purpose of this study was to compile treatment data and to examine the effectiveness of a longer pulse duration diode laser in the treatment of vascular pathologies such as facial telangiectasia, venous lakes, spider nevi, blue telangiectasia, leg veins and dermatological treatments. SUBJECTS AND METHODS: Thirty patients were treated with the diode laser with a pulse of 150 ms, energy densities of 300-500 J/cm(2) and wavelength at 980 nm. Patients were treated with a surface cooling device. Clinical evaluations were categorized into improvements of 0-25%, 25-50%, 50-75% and greater than 75%. RESULTS: 60% of the patients have up to 50% improvement. The maximum clearance was obtained with only one treatment. However even the cooling system is performed +5 degrees C, pain was relatively high for a majority of patients. CONCLUSIONS: The long-pulse diode laser at 980 nm is effective for treating a wide variety of small vascular abnormalities, for deep and thick vascular lesions and leg veins. The surface cooling device is useful for epidermal protection and pain-free treatment.

Botulinum toxin A: a 9-month clinical and 3D in vivo profilometric crow's feet wrinkle formation study.

OBJECTIVE: The objective of this study was to determine the duration of the effects of a defined dose of BTX-A on crow's feet formation wrinkles. MATERIALS AND METHODS: Twenty-five patients each received one injection of 12 units of BTX-A in the orbicularis oculi muscle on both sides of the face. The results were evaluated at 3, 6 and 9 months. Standardized photographs were taken of the wrinkle formations at rest at each step of the 9-month period following the treatment, and the wrinkles were then rated on photographs by blinded observers. Three-dimensional (3D) in vivo profilometry was also used to quantify the degree of improvement. RESULTS: Both the self-assessments by the patients themselves and the objective assessments of the 3D profilometry study provided similar results, but the independent observer assessment results were slightly more optimistic. There was a statistically significant difference observed between baseline and the evaluations at both 3 and 6 months. CONCLUSION: BTX-A is a safe and effective method for treating crow's feet wrinkles. In both the observer assessment and the 3D skin profilometric assessment, a clear improvement was shown at 6 months.

Determination of optimal parameters for laser for nonablative remodeling with a 1.54 microm Er:glass laser: a dose-response study.

BACKGROUND: Nonablative subsurface heating is a challenge for medical laser companies. Among the different lasers proposed today, the erbium-glass (Er:glass) laser combined with contact cooling could be an alternative for nonablative remodeling. OBJECTIVE: To investigate the risk of side effects according to the quality of cooling and number of pulses. METHODS: A clinical evaluation was performed on 10 patients using an Er:glass laser (1.54 microm) with contact sapphire cooling handpiece (+5 degrees C). Periorbital and perioral areas were treated with a number of pulses increasing gradually from three to eight for a total energy of 24-64 J/cm2. The presence or absence of swelling, crust, blister, and erythema were graded at 7 days. At 3 months postoperatively, hypopigmentation, hyperpigmentation, textural changes, and scars were evaluated clinically. RESULTS: Periorbital and perioral areas respond differently to the number of pulses defining a "safe" clinical threshold. The periorbital site is very sensitive to dermal heating and efficacy of contact cooling; the anatomic features of this body location may explain these differences. CONCLUSION: Selective dermal heating can be achieved with an Er:glass laser coupled with a contact cooling handpiece. The quality of the contact cooling and the number of pulses appear to be important parameters for safety and reproducible clinical results.

Comparison and sequential study of long pulsed Nd:YAG 1,064 nm laser and sclerotherapy in leg telangiectasias treatment.

BACKGROUND AND OBJECTIVES: Millisecond pulsed 1,064 nm Nd:YAG lasers have been developed for the treatment of leg telangiectasias. To date there have been very few side by side comparison studies of laser versus the gold standard sclerotherapy in treating small leg veins. This study aims to compare a long pulsed Nd:YAG laser with contact cooling to sclerotherapy for treating small diameter leg telangiectasias by evaluating objective and subjective clinical effects. STUDY DESIGN/PATIENTS AND METHODS: Fourteen patients were selected with leg telangiectasias ranging from 0.5 to 2 mm at four comparable sites. One site was treated with long pulsed Nd:YAG alone, the second received sclerotherapy alone, the third laser then sclerotherapy, and the last one sclerotherapy then laser. The patients were followed up at 3 months after the last treatment. Photographs were taken pre-operatively and at 3 months after the last session. They were used for objective and comparative analysis. Statistical analysis was performed using Friedman's test controlling for subject. RESULTS: Improvement was tabulated from the photographic assessment on an improvement scale from 0 (no change) to 4 (greater than 75% clearing). There were clinical improvements in the laser group than sclerotherapy without statistical significance. Side effects were minimal and included hyperpigmentation. CONCLUSIONS: This pilot study demonstrates that the Smartepil LS long pulse Nd:YAG 1,064 nm laser can yield results similar to sclerotherapy in the treatment of small leg telangiectasias. Combination of both methods could increase response to treatment.

Non-ablative skin remodeling: an 8-month clinical and 3D in vivo profilometric study with an 810 nm diode laser.

BACKGROUND: Non-ablative remodeling has recently been proposed as a new anti-aging treatment with no downtime. OBJECTIVE: This study aimed to evaluate objectively, with a three-dimensional (3D) in vivo profilometric study, the efficacy and safety of non-ablative skin remodeling with an 810 nm diode laser on periorbital wrinkles with an 8-month follow-up. METHODS: Ten female patients (mean age: 55 years) were treated three times at 1-month intervals and then evaluated 5 months after the last treatment. Patients were evaluated using clinical data, standardized photographs and 3D in vivo profilometry in order to quantify the degree of improvement. This objective method evaluates the general degree of roughness (anisotropy) and the depth of the wrinkles. RESULTS: An observer independent from the study showed slight improvement in the quality of the skin and visual aspect of the wrinkles at 3 months. Eight months later this was confirmed to a lesser degree by clinical and 3D profilometry. No immediate or late adverse effects were noted at any stage of the procedure. CONCLUSION: This study demonstrated that irradiation with a 810 nm laser emitting in a pulsed mode and connected to a cooling system reduced anisotropy of the skin and improved the clinical aspects of the wrinkles. Results appear quickly at 3 months and are stable at 8 months.