Pulsed dye laser and adjuvant topical therapies for the treatment of port-wine stains: A systematic review.

OBJECTIVES: The current gold standard treatment for port-wine stains (PWS) is pulsed dye laser (PDL). However, multiple treatment sessions may be necessary and complete resolution is often not achieved. Neoangiogenesis can occur soon after treatment and is thought to be a major factor contributing to treatment failure. Adjuvant antiangiogenic topical therapies may therefore improve the efficacy of pulsed dye laser treatment of port-wine stains. MATERIAL AND METHODS: Following PRISMA guidelines, we searched PubMed, Embase, Web of Science, and clinicaltrials.gov using "port-wine stain," "nevus flammeus," "capillary malformation," "sturge weber," and "pulsed dye laser" as keywords and medical subject heading (MeSH) terms. Articles were included if they (1) were a randomized controlled trial (RCT); (2) studied patients with PWS; and (3) investigated topical adjuvant therapies with PDL. Bias was assessed using the Critical Appraisal Skills Programme (CASP) Randomized Controlled Trial Standard Checklist. RESULTS: 1835 studies were identified, with six studies meeting inclusion criteria. The total number of patients studied was 103 (range: 9-23), with 8-36 week follow-up. The average age ranged from 11 to 33.5 years old. Three studies examined adjuvant topical sirolimus (n = 52), two examined timolol (n = 29), and one studied imiquimod (n = 22). Two of three RCTs reported no improvement through colorimetric analysis with topical sirolimus; however, one of these studies did show a significant improvement through Investigator Global Assessment (IGA) score. The last sirolimus study showed significant improvement through digital photographic image scoring (DPIA). Studies examining topical timolol reported no change in PWS appearance compared to placebo. The addition of 5% adjuvant imiquimod cream did lead to significant improvement. A variety of outcome measures were used. Imiquimod and sirolimus led to mild cutaneous adverse events, while timolol caused no side effects. None of the adverse events led to treatment discontinuation. Study quality was moderate in three, high in two, and low in one. CONCLUSION: The efficacy of adjuvant topical therapy was unclear. Limitations included variation in concentration and duration of adjuvant therapies, differences in follow-up time, and inconsistent outcome measure reporting. Given their potential clinical promise, larger prospective studies examining topical adjuvant therapies should be considered.

Intraoral laser hair removal: A scoping review.

PURPOSE: Intraoral hair growth is a debilitating side effect of flap or graft-based oropharyngeal reconstruction. There is no standardized treatment, but groups have successfully eradicated unwanted hair growth with intraoral laser hair removal. This scoping review assesses the utility of laser therapy in managing this condition. METHODS: This scoping review followed PRISMA-ScR guidelines. Ovid Medline, Embase (Ovid) and Scopus were queried using index terms and keywords. Resulting articles were reviewed for inclusion by two independent reviewers against inclusion criteria and relevant data were extracted. RESULTS: The literature search yielded 297 articles, 22 of which met inclusion criteria. In total, 77 patients were treated: 38 patients with an Alexandrite laser, 19 with an Nd:YAG laser, 18 with a diode laser, and two with a CO2 laser. Complete response defined as 80% or more reduction in hair count was achieved in 70 patients (90%) and six patients (8%) achieved a partial response (10%-79% reduction in hair count). One patient (1%) with gray hair saw less than a 10% reduction in hair count. On average, 3.84 treatment sessions were needed, spaced 5.4 weeks apart. Treatments were well tolerated without major side effects. CONCLUSIONS: This is the first scoping review assessing the utility of intraoral laser hair therapy and suggests it may be a safe and effective treatment. However, surgeons should advise preoperative hair removal when clinically feasible to mitigate this side effect as much as possible.

Changes in melanocytic nevi treated with laser hair removal: A systematic review.

BACKGROUND: Incidental treatment of melanocytic nevi during laser hair removal (LHR) has been noted to cause clinical and dermoscopic changes that may appear similar to findings seen in atypical or neoplastic melanocytic lesions. The rate and characteristics of these changes has not been well-studied. OBJECTIVES: The objective of this review article is to assess the literature for reported changes in melanocytic nevi following LHR to guide clinical practice. METHODS: PubMed was searched December 5, 2022 for articles evaluating changes in melanocytic nevi after LHR treatment using the following search terms: "nevi laser hair removal," "nevi diode," "nevi long pulse alexandrite," "nevi long pulse neodymium doped yttrium aluminum garnet," and "melanoma laser hair removal." All English language patient-based reports discussing incidental treatment of melanocytic nevi while undergoing LHR with a laser were eligible for inclusion, while reports of changes following hair removal with non-laser devices such as intense pulsed light were excluded. Studies evaluating non-melanocytic nevi such as Becker's nevus or nevus of Ota were excluded as were those evaluating the intentional ablation or removal of melanocytic lesions. RESULTS: Ten relevant studies were included, consisting of seven case reports or series and three observational trials, two of which were prospective and one retrospective. Among the seven case reports or series there were a total of 11 patients, six of which had multiple affected nevi. Clinical and dermoscopic changes to nevi following LHR appear to be common in clinical practice, though not well studied. Clinical and dermoscopic changes have been noted to present as early as 15 days after treatment and persist to the maximum time of follow up at 3 years. Commonly reported changes include regression, decreased size, laser induced asymmetry, bleaching, darkening, and altered pattern on dermoscopy. Histologic changes include mild atypia, thermal damage, scar formation, and regression. Although some of the clinical and dermoscopic alterations may be concerning for malignancy, to our knowledge, there are no documented cases of malignant transformation of nevi following treatment with LHR. LIMITATIONS: This study is limited by the low number of relevant reports and their generally small sample size, many of which is limited to single cases. Additionally, comparison of available data was limited by variable reporting of treatment regimens and outcomes. CONCLUSIONS: Changes to nevi treated during LHR are not uncommon. Modifications to nevi may occur and look similar to changes seen in dysplastic or neoplastic melanocytic lesions. Notably, despite the widespread use of LHR since the first device was Food and Drug Administration approved in 1995, a time span of nearly three decades, there have been no reported cases of melanoma or severe dysplastic changes within treated nevi. However, dermatologists should be aware that morphologic and dermoscopic alterations can occur after LHR to prevent unnecessary surgical procedures. Although melanoma has not been reported to occur in nevi treated with LHR nor with any other laser exposures, further long-term data is needed to fully elucidate this concern. Optimally, nevi should be examined by a dermatologist before LHR to determine a baseline clinical and dermoscopic morphology. If there is concern for potential atypia, laser should be avoided over such nevi to avoid confusion at future follow up visits.

Noninvasive Hands-free Bipolar Radiofrequency Facial Remodeling Device for the Improvement of Skin Appearance.

BACKGROUND: Aging is a multifactorial response to genetic preprogramming nuances, sun exposure, and ultraviolet radiation. Recently, there has been a paradigm shift toward minimally invasive rejuvenation. OBJECTIVE: This prospective multicenter study aims to evaluate the efficacy and safety of a novel hands-free bipolar bulk radiofrequency (RF) device in terms of improvement in skin appearance. PATIENTS AND METHODS: This multicenter prospective study enrolled subjects aged 35 to 75 years with visible signs of aging. The primary objective was to evaluate skin appearance pretreatment and at 1, 3, and 6 months after the final treatment. Each patient received 3 total treatments to the chin and cheeks using the hands-free RF device spaced 2 weeks apart. RESULTS: In total, data from 87 patients were assessed from 6 treatment sites. The average age was 54 years (range 35-75 years). Most patients were female (97%), and Fitzpatrick skin types I to V were represented. Overall, patients found the procedures to be relatively pain-free, and both patients and investigators felt they noted some improvement in their skin appearance. Histological sections demonstrated an increase in collagen or elastic fibers within the papillary dermis. CONCLUSION: This study supports the use of this novel noninvasive hands-free bipolar facial remodeling device for the improvement of skin appearance.

Actinic Keratosis Color and Its Associations: A Retrospective Photographic, Dermoscopic, and Histologic Evaluation.

BACKGROUND AND OBJECTIVE: Actinic keratoses (AKs) have been described with varying color and morphology; however, no reports have demonstrated associations between color, vasculature, and inflammation. In this retrospective study, we analyze the clinical, dermoscopic, and histopathologic features of AKs to elucidate this relationship. METHODS: A retrospective search for patients diagnosed with AK between January 2018 and October 2019 was performed. Clinical and dermoscopic photographs and pathology slides for all included subjects were reviewed. RESULTS: Forty-nine images and histopathology slides were analyzed. Dermoscopy of white AKs demonstrated scale and absence of erythema with corresponding absence of inflammation on histopathology. Dermoscopy of brown AKs revealed pseudonetwork, absent scale, and a variable vessel pattern with pigment incontinence and absence of inflammation on histopathology. Red AKs had a distinct polymorphous vessel pattern and presence of erythema on dermoscopy. On histopathology, about half of samples showed increased vascularity and variable inflammation. Pink AK dermoscopy revealed a presence of erythema with corresponding presence of inflammation on histopathology. CONCLUSION: This report adds to our understanding of AKs and confirms that, in general, the pinker or redder the AK, the more prominent the inflammatory infiltrate and vasculature, respectively. Dermatologists should continue to use their diagnostic skills to successfully diagnose and triage AKs.

Fractional CO2 laser for the treatment of sclerodermatous cGVHD.

Sclerodermatous graft versus host disease (sclGVHD) is a debilitating complication of hematopoietic stem cell transplant and is characterized by skin thickening and fibrosis that can result in severe contractures. While immunosuppressive therapy remains a mainstay of treatment, the disease course often progresses and, in severe cases, renders patients immobile and wheelchair-bound. Lasers that can target sclerotic lesions to improve tissue pliability and restore range of motion are a promising potential treatment for sclGVHD. Fractional CO2 lasers promote selective collagen remodeling by creating microcolumns of thermal injury that stimulate a wound healing response. Here, we present 2 patients with sclGVHD who underwent treatment with fractional ablative CO2 laser. In this pilot case series demonstrating the novel use of CO2 laser for severe, refractory sclGVHD, two patients were treated with fractional ablative CO2 laser to a focal area of sclerosis. One patient also received clobetasol ointment under occlusion in between treatments. Both patients reported marked subjective improvement in pain and mobility. Objective measurements were recorded for patient 2 who gained roughly 10 degrees of extension and 2 degrees of flexion, as well as a 10% reduction in skin thickness in the treated area. CO2 laser therapy with or without clobetasol ointment under occlusion is a promising treatment modality for sclGVHD.

Long pulsed dye laser with a back-to-back double-pulse technique and compression for the treatment of epidermal pigmented lesions.

BACKGROUND: In the recent past, long pulsed dye lasers (LPDL) have been investigated for the treatment of epidermal pigmented lesions (EPLs). Using a pigmented lesion compression headpiece, blood is pushed laterally out of the laser field focusing laser energy on melanin. Recent studies have demonstrated excellent responses using a single-pulse at the following settings: 9-12 J/cm2 , 1.5 milliseconds, 7-10 mm spot size with compression. However, the majority of these studies report patients requiring up to four treatments for lesion resolution. Herein, we describe our experiences utilizing a back-to-back double-pulse technique to decrease the total number of treatments needed for EPL clearance. METHODS: Thirty-six patients (27 females, 9 males; skin types I-IV) with benign facial EPLs were included. Each lesion received two back-to-back pulses (fluence of 9-12 J/cm2 , 1.5 milliseconds duration, and 7 mm spot size). If needed, a second treatment was delivered 4-8 weeks later. Pre- and post-photos after the first treatment were evaluated by two independent board-certified dermatologists. RESULTS: Lesion clearance after the first treatment was graded on a Likert scale as: 1 = poor (<25% clearance); 2 = fair (25-50%); 3 = good (51-75%); and 4 = excellent (>75%). Of the 36 participants, 23 had excellent clearing, 10 with good, 2 with fair and 1 with poor clearance. There was only one case of post-inflammatory hyperpigmentation that subsequently resolved, and no cases or scarring or hypopigmentation. CONCLUSION: LPDL with compression continues to be a safe and effective modality for treatment of EPLs. Double-pulsing decreases the total number of treatments needed for lesion resolution, while maintaining safety and potentially decreasing cost. Lasers Surg. Med. 51:136-140, 2019. © 2018 Wiley Periodicals, Inc.

Vulvar Majocchi granuloma and kerion formation in an immunocompetent female.

We report a rare case of vulvar Majocchi granuloma and kerion formation secondary to Trichophyton in an immunocompetent woman. The patient responded well to oral terbinafine and a short course of oral corticosteroids with a slow taper. Resolution of deep dermatophytosis requires prompt pathogen identification and treatment to avoid scarring and hair loss. Herein, we aim to increase clinical awareness and early recognition of this atypical presentation of a Majocchi granuloma with kerion formation.

Micropapular Cutaneous Sarcoidosis Reviewed.

BACKGROUND: Micropapular cutaneous sarcoidosis (MPCS) is a rare variant of sarcoidosis. Herein we review the literature and include a recent case of MPCS discussing pathogenesis, diagnosis, treatment, and prognosis. METHOD: A review was conducted using the terms "micropapular sarcoidosis" and "micropapular sarcoid." A recent case of a 50-year-old male patient with biopsy-identified MPCS was also included in the review. RESULTS: In total, 12 cases with an aggregate of 18 patients were included in the review. Presentation among all patients was consistent, with scattered, occasionally pruritic, faintly erythematous shiny white papules. Skin biopsy demonstrated noncaseating granulomas. Systemic prednisone, oxytetracycline, and hydroxychloroquine, as well as topical betamethasone, were used for therapy. CONCLUSION: In our review there does not seem to be a clear link as to the definite cause of the MPCS. While the relationships to tuberculosis and autoimmunity seem to be often emphasized, there was no clear association with either etiology.

Cutaneous Hypersensitivity-Like Reactions Associated With Breast Implants: A Review.

BACKGROUND: Breast implantation is an increasingly common procedure for both cosmesis and reconstruction. Risk of cutaneous reactions to breast implants is low and typically described in postsurgical settings. Adverse skin hypersensitivity-like reactions to implants have also been reported but are not well described. OBJECTIVE: To review the scientific literature on cutaneous hypersensitivity-like reactions to breast implants. METHODS: A systematic literature review was conducted using PubMed. Articles pertaining to breast implants and cutaneous hypersensitivity-like reactions in humans were included. RESULTS: In total, 10 studies on hypersensitivity-like reactions from breast implants were included in the review. Potential allergenic compounds in breast implants include silicone, polyurethane texturing, and acellular dermal matrix. Perivascular lymphocytic infiltrate was a common finding on histopathology. Patch testing and preoperative silicone cube implantation were used to determine sensitivity. Attempted treatments included topical and oral corticosteroids, montelukast and antibiotics. Most cases required implant removal for resolution of symptoms. CONCLUSION: Cutaneous hypersensitivity-like reactions to breast implants seem to be rare complications, sometimes necessitating implant removal. Future studies are needed to establish their incidence and etiology, and the diagnostic role of patch testing and preoperative screening.

Ewing-Like Sarcoma: A Case of a Primary Cutaneous Primitive Neuroectodermal Tumor With Atypical Immunohistochemistry and Lack of Fusion Oncogene Detection.

We present a 25-year-old male patient with a primary cutaneous primitive neuroectodermal tumor (cPNET) with unusual immunohistochemistry and lack of fusion oncogene generation. The lesion expressed CD99 and WT-1, and the histological features were consistent with cPNET. Differential diagnoses such as rhabdomyosarcoma, desmoplastic small round blue cell tumor, hematolymphoid neoplasm, neuroblastoma, and CIC-DUX round cell sarcoma were ruled out based on immunohistochemistry, genetic studies, and histology. Previous cPNET cases have been published detailing abnormal immunochemistry and genetic expression. However, to our knowledge, fusion oncogene negativity in cPNET tumors has only been reported in one other published case series. These reports, including this study, reinforce the fact that a high index of suspicion should be used when diagnosing these tumors, regardless of immunohistochemical and genetic variability. This case highlights that the typical genetic and immunohistochemical features of cPNET may be more variable than previously thought. Future studies are needed to better understand these variations of cPNET.