You are on page 1of 337

Color Atlas of

osme
-.,

erma o o
ZEINA TANNOUS
SANDY TSAO

MATHEW M. AVRAM

MARC R. AVRAM

___

Color Atlas of

Cosmetic
Dermatology

This page intentionally left blank

Color Atlas of

Cosmetic
Dermatology
Second Edition

Ze ina Tannous, M D
Chief, Mohs/Dermatologi c Surgery, Boston VA Medical Center
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Affiliate Faculty, Wellman Center for Photomedicine
Faculty Director for Dermatopathology, Department of Dermatology, Harvard Medical School
Assistant Professor in Dermatology, Harvard Medical School
Boston, Massachusetts

Mathew M . Avram, M D, JD
Director
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School
Affiliate Faculty, Wellman Center for Photomedicine
Boston, Massachusetts

Sandy Tsao, M D
Director of Procedural Dermatology
Harvard Medical School
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Boston, Massachusetts

Marc R . Avram, M D
Clinical Professor of Dermatology
Weill Cornell Medical School
Private Practice-905 Fifth Avenue
New York, New York

B Medical
New York
Mexico City

Milan

Chicago

San Francisco

New Delhi

San J uan

Lisbon
Seoul

London

Madrid

Singapore

Sydney

Toronto

The McGrowH/11 Companies

Copyright

2011

by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of

1976,

no part of this

publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the
publisher.
ISBN:

978-0-07-163975-0

MinD : 0-07-163975-6
The material in this eBook also appears in the print version of this title: ISBN:

MinD : 0-07-163503-3.

978-0-07-163503-5,

All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occunence of a trademarked name, we use names in an
editorial faslllon only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they
have been printed with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a
representative please e-mail us at bulksales@mcgraw-lllll.com.
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors
and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the
standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher
nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or
complete, and they clisclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are
encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet
included in the package of each drug they plan to adntinister to be certain that the information contained in this work is accurate and that changes have not been made
in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently
used drugs.
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. ("McGrawHill") and its licensors reserve all rights in and to the work. Use of this work is subject
to these terms. Except as permitted under the Copyright Act of

1976

and the right to store and retrieve one copy of the work, you may not decompile, disassemble,

reverse engineer, reproduce, moclify, create derivative works based upon, transntit, distribute, clisseminate, sell, publish or sublicense the work or any part of it without
McGraw-Hill's prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prolllbited. Your right to use
the work may be terminated if you fail to comply with these terms.
THE WORK IS PROVIDED "AS IS." McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY,
ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN
BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED,
INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and
its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or enor free.
Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages
resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/
or its licensors be liable for any indirect, incidental, special, punitive, consequential or s.irnilar damages that result from the use of or inability to use the work, even if
any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause
arises in contract, tort or otherwise.

D E D I CATI O N

I wou ld l i ke t o ded icate this book t o the memory of m y beloved father,


who a l ways gave me h is u lti mate love a n d s u p port.

Zeina Tannous, MD

I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morre l l a n d


M a ria Avra m . You have provided me u ncond itional love a n d end less
s u p po rt s i n ce the day I was born . I love yo u .

Mathew M. Avram, MD, JD

To my h us ba n d , Hensi n . You a re my stre ngth a n d i n s p i ration. You r l ove, wisd o m a n d


encou ragement h e l p m e rea l ize a nyth i n g is poss i b l e . You a re a wo n d e rfu l h us ba n d ,
father a n d best fri e n d . I wi l l love y o u a lways . To my sons, Se basti a n a n d H u nter. You r
u nconditional love, enthusiasm a n d sense o f adventure h e l p me remem ber what is truly
i m porta nt. Yo u brighten my days a n d fi l l my l ife with h a p p i n ess and love .

Sandy Tsao, MD

T h i s book is ded icated to my wife R o b i n a n d my two sons Robert a n d J a c o b .


I tha n k t h e m f o r the love a n d s u p port t h a t they give me every day.

Marc R. Avram, MD

This page intentionally left blank

CONTENTS
ix

Preface

SECTION THREE: DISORDERS OF ECCRINE GLANDS

Chapter 16: Hyperhidrosis.... .... ... .. 86


.

SECTION ONE: PHO TOAGING

Chapter 1: Analysis of the Aging Face and


Non-Facial Regions
.
.

SECTION FOUR: DISORDERS OF HAIR FOLLICLES

Chapter 17: Hirsutism


Chapter 2: Topical Treatment Options.

92

99

7
Chapter 18: Pseudofolliculitis ....

Chapter 3: Soft Tissue Augmentation

... 14
Chapter 19: Male Pattern Hair Loss .... .... 103
.

Chapter 4: Botulinum Toxin

21
Chapter 20: Female Pattern Hair Loss

126

Chapter 5: Chemical Peels .. ...... .. ... 29


.

Chapter 6: Nonablative Laser Resurfacing

Chapter 7: Ablative Laser Resurfacing

39

43

Chapter 21: Low Level Light Therapy (LLLT)


and Hair Loss. .
..
..
.

. 133

SECTION FIVE: DISORDERS OF PIGMENTATION

Chapter 22: Cafe Au Lait Macule ... ...... 136


.

Chapter 8: Nonablative Fractional Laser


Resurfacing .............. .... 52

Chapter 23: Ephelides


Chapter 9: Ablative Fractional Laser
Resurfacing
.

Chapter 10: Tissue Tightening

57

Chapter 24: Lentigines

62

Chapter 25: Melasma . .. ...

Chapter 11: Dermatochalasis........

Chapter 26: Nevus of Ota

Chapter 12: Poikiloderma of Civatte

..... 64

. .

67

. .
.

139

.. 144

. . . 149
.

154

Chapter 27: Postinflammatory


hyperpigmentation ............ 158

Chapter 28: Vitiligo.... ....

SECTION TWO: DISORDERS OF SEBACEOUS

. .
.

.. .. 163
.

GLANDS

Chapter 13: Acne Vulgaris ...... .. ... .. 72


.

SECTION SIX: VASCULAR ALTERATIONS

Chapter 14: Rosacea

76

Chapter 29: Angiokeratoma

Chapter 15: Sebaceous Hyperplasia ......... 81

Chapter 30: Cherry and Spider Angiomas ....

vi i

168

170

Chapter 31: Granuloma Faciale

. .
.

Chapter 32: Infantile Hemangioma

..

. .
.

Chapter 33: Keratosis Pilaris Atrophicans

Chapter 34: Port-wine Stains

Chapter 35: Pyogenic Granuloma

. 177

183

188

192

Chapter 39: Warts

. .

Chapter 41: Becker's Nevus

.203

. . 206

Chapter 42: Epidermal Inclusion Cyst

Chapter 43: Epidermal Nevus

.248

252

. .

256

Chapter 54: Lichen Planus

Chapter 55: Morphea

Chapter 56: Psoriasis

262

265

267

272

. .. .

276

Chapter 59: HIV Lipodystrophy/Facial


Lipoatrophy

Chapter 60: Striae Distensae

SECTION TEN: ADIPOSE TISSUE ALTERATIONS

SECTION NINE: INFLAMMATORY DISORDERS

Chapter 58: Cellulite

198

. .. .

Chapter 53: Squamous Cell Carcinoma

SECTION SEVEN: BENIGN GROWTHS


.

Chapter 52: Basal Cell Carcinoma

Chapter 57: Gynecomastia

Chapter 40: Angiofibroma

Chapter 38: Venous Lakes

Chapter 51: Actinic Keratosis

. .181

Chapter 37: Lower Extremity Telangiectasias,


Reticular and Varicose Veins

SECTION EIGHT: CUTANEOUS CARCINOMAS

Chapter 36: Facial Telangiectasias

174

. .. ..
.

.212

.. 216

219

222

280

285

SECTION ELEVEN: WOUND HEALING ALTERATIONS

Chapter 44: Lipoma

Chapter 61: Hypertrophic Scars, Keloids,


and Acne Scars

226

290

298

Chapter 63: Tattoo Removal.

300

Chapter 64: Torn Earlobe

308

Index

311

Chapter 45: Milium

Chapter 47: Seborrheic Keratosis

Chapter 48: Syringoma

Chapter 49: Dermatosis Papulosa Nigra

Chapter 50: Xanthelasma

Chapter 46: Neurofibroma

. .
.

229

231

234

SECTION TWELVE EXOGENOUS


CUTANEOUS ALTERATIONS

Chapter 62: Ear Piercing

. .238
.

241

.243
viii

PREFACE
There has been a revol ution in the treatment of med ical a n d cos

go these proced u res. The decision as to when not to treat a patient

m etic d isord ers of the s ki n . I n la rge part, this is d u e to the ava i l

is perha ps the m ost i m porta nt i n this fie l d .

a b i l ity o f procedu res a n d tec h nologies t h a t prod uce clear, cosmet

With t h i s i n m i n d , Color Atlas o f Cosmetic Dermatology, Second

ic benefit with few side effects a n d l ittle downti m e . With the advent

Edition seeks to provide a succ i n ct yet broad overview of cosmetic

of lasers and l ight sou rces over the past 20 yea rs, cosmetic

thera py. There a re a plethora i l l ustrations and gra phs to e l u c i date

i m prove ment is a m atter of q u ic k , relatively pa i n less proced u res.

consu ltati o n , management, treatment and side effects of n u m e r

N on-laser treatments such as soft tissue fi l l ers, botu l i n u m tox i n

ous cos metic proced u res. Its pra ctica l format is gea red to the busy

i njections, sclerothera py, h a i r tra ns p l a n tation a n d others have a lso

practitioner or tra i nee who seeks a q u ic k , comprehensive refer

d ra matica l ly expa nded the scope of this field . These procedu res

ence fo r a pproa c h i n g the cosmetic patient. It a lso e m p h asizes

coincide with the busy l ifestyle of many patients who seek a n

pitfa l l s of treatment in ord e r to ed ucate the reader as to potenti a l

i m prove ment i n a p pea ra nce that does n ot interfere with t h e i r pro

p r o b l e m s w i t h certa i n treatments. It serves as a n i nva l ua ble

fessiona l , soc i a l or perso n a l obl igati o n s .

resource to both the experienced a n d novice.

These proced u res, however, a re n ot without potentia l side


effects o r co m p l icati o n s . Physicians who perform these treatments

Zeina Ta n nous, M D

in the a bsence of tra i n i ng or ed u cation a re certa i n to encou nter

M athew M . Avra m , M D , J D

poor resu lts , c o m p l ications and i rate patie nts . Beca use patients

Sandy Tsao, M D

a re p u rs u i ng el ective treatments fo r cosmetic benefit, a ny worsen

M a rc R . Avra m , M D

i ng o f a p pea ra n c e wi l l u n d e rsta n d a bly a nger patients who u n d e r-

ix

This page intentionally left blank

ACKNOWLEDG M E NTS

We wou l d l i ke to tha n k two people who provided sign ificant h e l p i n the


prod uction of this textbook, D r. R ox Anderson a n d Dr. G a ry Lask. In add iti o n , we wo u l d
l i ke t o tha n k t h e office staff at the M assa c h u setts Genera l H os pita l Dermato l ogy
Laser & Cosmetic Center a n d the office staff of Dr. M a rc Avra m for their h a rd work a n d
d ed ication i n o bta i n i ng high-q u a l ity photogra ph s .

F i n a l ly, w e wou l d l i ke t o tha n k the professiona l staff at M c G raw- H i l l for


t h e i r great h e l p and d evotion in p rod u c i n g this book. Tha n k you for push i n g us to
strive for the best possi ble Atlas.

This page intentionally left blank

ONE
Photoaging

Color Atlas of Cosmeti c Dermatology

CHAPT E R 1

A n a lysis of the Agi ng Face a nd No n-Facial R eg i o ns

The face is the foc a l point of h u m a n bea uty. Although


va rious factors i nfluence fac i a l bea uty, the aging process
is the m ost common as pect prom pt i n g non-s u rgica l
a n d/or s u rgica l i n tervention. Agi ng is a dyna m i c a n d con
tinual process . D iffe rent c u lt u ra l , eth n i c , a n d ge nder
norms (Ta ble 1 . 1 ) of bea uty exist; however, there a re cer
ta i n featu res w h i c h globa l ly tra nscend these d ifferences
to d ete r m i n e what is perceptua l l y pleas i n g . H ered ity a n d
environ mental fa ctors ( e g , s u n expos u re , w i n d , tra u ma )
a re t h e m a i n determ i n a nts o f aging. I n a d d ition , ciga rette
smoking a n d estrogen loss ca n accelerate the aging
process. As one ages, c h a nges c a n be o bse rved i n a l l
fac i a l a n d non-fa c i a l a nato m i c a l com pa rtments, i n c l u d
i n g t h e ski n , s u bcuta neous fat, m uscle, a n d b o n y struc
tu re . Use of a systematic a p proach i n the a n a lysis of
fac i a l a n d n o n -fac i a l aging wi l l a l low for the selection of
a p propriate, safe, a n d effective thera p ies.

TAB L E 1 . 1

Fac ial Age-Related Contour Cha nges

M a l a r c rescent
Cheek d e p ression
Nasola b i a l fold formation
P rej owl s u l c u s
P latys m a ! ba nds

J owl formation

ANATO M I C CO N S I D ERAT I O N S
S uccessfu l

rej uve nation o f the face a nd

non-fa c i a l

regio n s req u i res a thorough u n d e rsta n d i n g o f age-related


conto u r cha nges ( u nderlying soft tissue aging) a n d tex
tu ra l cha nges (skin aging) (Ta bles 1 . 1 a n d 1 . 2 ) .

TAB L E 1 . 2

Age-Re lated Textura l Changes

S u perficia l a n d deep rhytides


Pigmenta ry d istu r b a n ces
Te la ngiectasia fo rmatio n
Loss o f s k i n elastic ity
Acti n ic ke ratoses

A youthfu l face can be d ivided i nto th ree facial zones:


u p per, m id d le, and lower zones, as wel l as the u pper neck.
The u p per face incl udes the forehead , tem ple, a n d peri
orbita l region . Agi ng resu lts i n flatte n i ng of the brow a rc h ,
eyelid s k i n red u nda ncy, pseudo fat hern iation , a n d forma
tion of dyna m i c rhytid es at the latera l canthus. Horizonta l
forehead s k i n creases develop secondary t o sustai ned con
traction of the fronta l is m uscle i n a su bconsc ious atte m pt to
elevate the sagging brows. A ri m sulcus d eformity d evelops
between the cheek and the eyelid with u p per cheek

Figure 1.1 A&B G/ogau type 1 photoaging. Minimal signs of aging present

Secti o n 1: Ph otoa g i n g

th i n n i ng. This sulcus is exacerbated by a preexisti ng tea r


trough deform ity. Orbicula ris oc u l i m uscle ptosis can create
a malar fu l l ness, referred to as a malar crescent.
The m i d face i n c l u d es the cheekbones that form a
s mooth conti nuous convexity fro m the eyeli d to the l i p .
T h e m e l o l a b i a l fol d re prese nts a flat, smooth j u n ction
between the lowe r cheek a n d the u p per lip. The aging
face res u lts i n a downward m igration of the malar soft tis
sue, accentuati ng skeleto n i zation of the orbital

ri m .

Centra l cheek fat ptos is c reates a fu l l n ess latera l to the


melola b i a l fol d , refe rred to as nasola b i a l fo lds.
The lower face possesses a wel l-defi ned mand i b u l a r bor
der and a well-defi ned cervicomental a ngle. With aging,
platysma! m uscle ptosis a nd cheek fat ptosis a long the
mandi ble prod uce "jowls" overlyi ng the jawl ine. Soft tissue
atrophy a nterior to the jowls creates a " prejowl sulcus"
which accentuates the skeleton ized a ppea ra nce. P latysma!
ptosis of the u pper neck blu nts the cervico-mental a ngle,
creati ng platysma! ba nds or a "turkey neck" d eformity.
Facial textu ra l cha nges i n c l u d e su perfi c i a l a nd deep
rhytides, pigme nta ry d istu rba nces, telangiectasia forma
tion, loss of s k i n elasticity, a n d acti n i c keratoses .

P R EOPERAT IVE EVALUAT I O N


A n individual ized treatment plan designed to m i n i m ize sur
gica l risk is essenti al . The goa l is a youthfu l and natura l post
operative result. A strategy should be formu lated for eac h of
the three facial zones as well as each ind ividual non-facial
regio n , as each a natomic region req ui res a specific man
agement which influences the rema i n i ng a natomic regions.
A systematic eva l uation s h o u l d i n c l u d e the d egree of
textura l c h a n ges, rhyti d format i o n , pigmenta ry c h a nges,
loss of su bcuta neous fat, cha nges in fac ia l m usculature,
c a rti lagi n o u s a n d bony structu res, a nd elastic ity l oss.

G l oga u P h otoag i n g C l ass i f i c at i o n

Wri n k l e Sca l e
The G loga u P h otoagi ng Classification has been d evised
w h i c h b road ly d efi nes the cha nges that may be seen at
d ifferent ages with c u m u lative sun exposure.

Type 1 -"no wri nkl es" (Fig. 1 . 1 )

Ea rly photoaging
- M i ld pigme nta ry cha nge
- N o ke ratoses
- M i n i m a l wri n kles

Patient age : twenties o r t h i rties

M i n i ma l or n o m a keu p use

Type 2-"wrinkles i n motion" (Fig. 1 .2)

Ea rly to moderate photoaging

Figure 1.2 A&B Glogau type 2 photoaging. Fine lines barely visible.

- Ea rly se n i l e lentigines visi ble

Minimal pigmentary changes noted

Color Atlas of Cosmeti c Dermatology

- Keratoses pa l pa ble but not visi b l e


- Para l lel s m i l e l i nes begi n n i ng t o a ppea r

Patient age : late t h i rties or forties

U s u a l l y wea rs some fou n dation

Type 3-"wrinkles at rest" (Fig. 1 .3)

Adva nced photoaging


- O bvious dysc h ro m i a , tela ngiectasia
- Visi ble keratoses
- Wrin kles eve n when n ot movi ng

Patient age: fifties o r older

Always wea rs heavy fo u ndation

Type 4-"on l y wrinkles" (Fig. 1 .4)

Severe photoaging
- Yel l ow-gray [A3l color of skin
- Prior s k i n m a l igna nc ies
- Wrin kled throughout, n o normal s k i n

Patient age : sixties or seventies

Ca n n ot wea r m a k e u p-" ca kes and cracks"

P i g m e nta ry C h a n ges
A vita l as pect of the patient eva l uation is the dete r m i n a

tion o f the patie nt's s k i n res ponse t o eryth ema-prod ucing


d oses of u ltraviolet l ight. Fitz patrick's classifi cation of
skin types prov i d e s a stro ng i n d i ca t i o n of t h e pote nt i a l
f o r post- i nfla m mato ry h y p e r p i g m e n ta t i o n a n d hypopig
m e n ta t i o n and pote n t i a l fo r d ysc h ro m i a u po n e p i d e r
m a l a n d/or pa p i l l a ry d e r m a l i n j u ry ( Ta b l e 1 . 3 ) .

TAB LE 1 . 3
S k i n type

Fitzpatrick's Classification of Skin Types

Color

Reactio n to s u n
Always b u r n s

Very wh ite or frec kled

II

Wh ite

U s u a l ly b u rns

Ill

Wh ite to ol ive

Someti mes b u rns

IV

B rown

R a rely bu rns

Dark brown

Very ra rely b u rns

VI

B la c k

N ever b u rns

A patient's treatment res ponse c a n be d ete rm i n ed


by assess i ng both t h e d egree of p h otod a mage p resent
and the p i g m e nta ry skin type. A proced u ra l risk
benefit ratio wi l l d iffer, d e pe n d i ng on the patient's i n d i
vid u a l fi n d i n gs ( F igs . 1 . 5 a n d 1 . 6 ) . I n ge n e ra l , patie nts
with Fitzpatrick s k i n types I -I I I can tolerate more e p i d e r
m a l a n d d e r m a l i n j u ry with m i n i ma l risk of res i d u a l
d ysc h ro m i a . Patie nts w i t h Fitz patrick s k i n types I V-V
have a h igh risk of res i d u a l d ysc h ro m i a with i n c reased

s k i n i nj u ry that may p rec l u d e the use of m a n y treatm e n t

Figure 1.3 A&B G/ogau type 3 photoaging. Dyspigmentation and wrinkles

m od a l ities.

are evident

Secti o n 1 : Ph otoa g i n g

S u b c u ta n e o u s Fat At ro p h y
Agi ng resu lts i n a sign ifica nt d egree of loss or red istri bu
tion of su bcuta neous fat, espec i a l ly of the forehea d , tem
pora l fossae , periora l a rea , c h i n , a n d pre m a l a r a reas.
This leads to a skeleton ized a p pea ra nce. R estorati o n of
vol u m e loss resu lts i n the res h a p i n g of the face for a
fu l ler, ro u nder a p peara nc e .

Fac i a l M u sc u l at u re C h a n ges
Agi ng a l so res u lts i n m uscu l a r atrophy, contri buti ng to
vol u m e loss. As wel l , dyna mic rhyti d es, which a re m uscu
lar i n origi n , often create a n a ngry, t i re d , or aged a p pea r
ance. Selective c h e m ical denervation provides ma rked
relaxation of these l i nes.

C h a n ges i n Ca rt i l age , B o n y

S t r u c t u res, a n d U n d e r l y i n g
S u p po rt i ve S t r u c t u res
Agi ng resu lts i n sagging and loss of res i l iency. Red ra pi ng,
repositio n i ng, and j u d icious rem ova l of skin and soft tis
sue assist i n the restoration of a youthfu l a p pea ra n c e .
Once a syste m i c a p p roach has b e e n fol l owed , the fou r
Rs of fac i a l rej uvenation-relax, refi l l , red ra pe, a n d res u r-

face-can be a ppl ied solely or in combi nation to h e l p


restore a m ore youthfu l a p pea ra nce.

B I B L I OG RAPHY
C h u ng J H , E u n H C . Angiogenesis i n s k i n a g i n g a n d pho
toaging. J Dermatol. 2007 ;34(9) : 593-600 .
Davis R E. Facelift and a n c i l l a ry facial cosmetic surgery pro

Techniques in
Dermatologic Surgery. Lond o n : Mosby; 2003, pp. 333-344.

ced u res. I n : Nouri K, Leai-Nouri S, eds.

Fitzpatrick T. The va l i d ity a n d practica l ity of sun-reactive


ski n types I through V I . Arch Dermatol. 1 998 ; 1 24:869-87 1 .
G l oga u R . Aesthetic a n d a nato m i c a na lys is of the aging
ski n . Semin Cutan Med Surg 1 996; 1 5( 3 ) : 1 34- 138.

Epidermal and
Dermal Histological Markers of Photodamaged Human
Facial Skin. Shelto n , CT: R i c h a rdson-Vicks; 1 988.
M ontagna W, Carlisle K, Kirchner S .

Paes EC, Teepen H J , Koop WA, et a l . Periora l wrin kles:


H i stologic d iffere nces between men and wom e n . Aesthet

Surg J. 2009 ; 29(6) :467-472.


S haw RB J r, Katzel E B , Koltz P F, et al. Agi ng of the
m a n d i ble a n d its aesthetic i m pl ications. Plast Reconst

Surg 2010; 12 5 (9 1 ) :332-342 .


B

Figure 1.4 A&B Glogau type 4 photoaging. Extensive wrinkles and


prominent dyspigmentation

Color Atlas of Cosmeti c Dermatology

Figure 1.5 Female patient who avoided sun exposure throughout her life.

Her skin reflects only minimal signs of photoaging

Figure 1.6 Female patient with a history of extensive sun exposure in her
life. Her skin reflects extensive photodamage with dyspigmentation and
extensive wrinkle formation

Secti o n 1 : Ph otoa g i n g

CHAPT E R 2

Topica l Treat m e nt Optio ns

M ECHAN I S M OF ACT I O N

S u n sc reen
- The u ltraviolet ( U V) wave lengths of l ight associated
with c uta neous da m age a re UVB ( 290-320 n m ) a n d
UVA (320-400 n m ) l ight.
- UVB a bsorption by DNA res u l ts i n a p53 tumor s u p
pressor ge ne m utation res u lting i n pyri m i d i ne d i mer
fo rmatio n , w h i c h is m utage n i c a n d l i n ked to cuta
neous carc i n ogenesis.
- Acute UVB expos u re resu lts i n a s u n b u r n ( Fig. 2 . 1 ) .
- Re peat ac ute UVB exposu res over t i m e have been
assoc iated with the formation of basa l cell carc i noma
a n d melanoma .
- Chronic UVB exposure has been l i n ked to the develop
ment of acti nic keratoses and squamous cell carcinoma.
- UVA is u naffected by wi n d ow glass, a ltitude, time of
d ay, or season and can prod uce a ta n and dyspig
mentation without preced i n g eryt h e m a .
- UVA l ight penetrates d eeply i n to the dermis, prod uc
i n g m a ny of the c l i n ical fi n d i ngs associated with
photo d a mage ( Fig. 2 . 2 ) .
- UVA a bsorptio n b y D N A res u lts i n fo rmation o f oxy
gen free rad icals, thought to contr i bute to ca rc i n o
genesis. It c auses i m m u nosu ppress ion through the

Figure 2 . 1 Patient with an acute sunburn. There is marked swelling and


redness present. The upper back scar is the site of a previous superficial
spreading melanoma (Courtesy of Richard Johnson, MD)

d e pletion of La ngerhans' cells and red uced a ntigen


prese nti ng cell activity.
- UVA expos u re has been l i n ked to the d eve l o pment of
melanoma in a n i ma l models.
Chem ica l s u n sc reen (Ta ble 2 . 1 )-a bsorbs l ight i n the
UV wave length of l ight ( UVB 290-320 nm) and UVA

TAB L E 2 . 1

Chemical Sunscreen: Active Ingred ients

Avobenzone
C i n oxate
Dioxybenzone
H omosa late
M ethyl a nt h ra n i late
M exoryl SX
M exoryl XL
Octocrylene
Octyl m ethoxyc i n n a mate
Octyl sa l i cylate
Oxybenzone
Pad i mate 0
Pa ra-a m i nobenzoic acid ( PABA)
Phenyl benzi m idazole su lfo n i c acid
S u l isobenzone
Tro la m i ne sa l i cylate

Figure 2 . 2 Patient with marked photodamage due to chronic sun exposure.

The patient was an avid golfer and reported only occasional sunscreen use

Color Atlas of Cosmeti c Dermatology

320-400 n m ) , tra n sfo r m i n g this l ight i nto h a r m less long

First Generation (Nonaromatics)

wave rad iation and re-e m itti ng as heat en ergy.


Physica l screen ( Ta b le 2 . 2 )-scatters or reflects UV
heat.

TAB L E 2 . 2

Retinol

Physical Su nscreen: Active I ngredients

Tita n i u m d ioxide
Zinc oxide

COOH

Tretinoin

S u n protective factor-opt i ma l ly a s u nscreen wo u l d p ro


vide protection aga i n st the fu l l spectr u m of UV rad iation .

CH20H

rad iati o n . C a n a l so a bsorb U V l ight and release it as

Isotretinoin

OOH

The s u n p rotective factor ( S P F ) is the only i nternationa l ly


sta ndard ized measure of a sunsc reen's a bi l ity to filter UV

Second Generation (Mono-Aromatics)

rad iatio n . It is the ratio of the UV e nergy needed to prod uce


a m i n i ma l erythema d ose ( M ED ) on su nscreen-protected
skin to the UV energy req u i red to prod uce an M ED on
c u rrently recom mends the d a i ly use of sunscreen with

.l.Ql.
-

u n protected ski n . The American Academy of Dermatology


Etretinate

COOH

H3CO

S P F 30 o r greater.

Antioxida nts-theoretica l ly work to red uce a n d neutra l


i z e free rad icals t h a t d a mage DNA, cytoskeleta l struc
tu res, and cel l u l a r proteins. They a lso possess a nti-i
nflammatory effects a n d m a n y play a role in pigment
red ucti o n .

Acitretin

Third Generation (Poly-Aromatics)

- I n ord e r to be b i o l ogica l ly effective, th ese prod ucts


m ust be a ble to penetrate i nto the s k i n a n d rema i n
biologica l l y active l o n g enough t o exert t h e desired
benefits . A majority of the c u rrently ava i la b l e a ntioxi

Arotinoid

d a nt prod ucts a re very u n sta ble, with oxidation m a k


i n g them c hem ically i n a ctive. M o l e c u l a r formation
and packagi ng a re key factors i n the sta b i l izatio n of
these prod u cts.
- Antioxida nts may work synergistica l l y to provide thei r

Adapalene

greatest benefit.

.) IAlf)(

COOH

- Vita m i n C-the only a ntioxi d a nt to date to have


prove n benefit for wri nkle i m p rovement due to its
a b i l ity to i n c rease col lagen formation rather than its
a ntioxidative effects .
- Vita m i n E-d emo nstrated to i n h i b it UV-i nd uced ery
thema a n d edema in a n i ma l s . It has h igh contact
d e rmatitis risk.

rings has made third-generation retinoids more stable for more targeted
therapy with less potential side effects. (Reproduced, with permission,
from Baumann L. Cosmetic Dermatology: Principles and Practice, 2nd ed.
New York: McGraw-Hill; 2009)

- Coenzyme Q l O-natu ra l l y occ u rring n utrient a d d ed


to m a n y over-the-cou nter prod ucts . C u rrently t h ere
a re no stud ies ava i la ble to docu m ent its long-te rm
benefits on skin aging.
- l d ebeno n e-synthetic a na l og of Coenzyme Q l O .

Tazarotene

Figure 2 . 3 Chemical structures of retinoic acids. The addition of aromatic

Reti noic ac i d-reti noids a re natu ra l ly occ u rr i n g d e riva


tives of I)-ca rotene and la beled as vita m i n A and its
derivatives . I n cl uded a re reti n o l , reti n a l d ehyd e , reti nyl
este rs, and retinoic acid ( Fig. 2.3). Its benefits a re both
preve ntative a n d repa rative .

Secti o n 1 : Ph otoa g i n g

- UVB exposu re res u lts in the u p-regu lation of severa l


col lagen-degra d i ng matrix meta l l o protei nases, includ
ing col lagenase, gelatinase, and stromelys i n , which

TAB L E 2 . 3

Ski n Lighte n i n g Agents

Hyd roq u i none

cause collagen degradation. Reti noids act to i n h i bit the

Aloes in

i n d uction of th ese meta l lo p rote i n ases.

Arbuti n

- UVB exposu re a lso dec reases collagen prod ucti o n .

Ascorbic acid

Reti noids work t o i n h i bit t h i s loss o f pro-co l lagen syn

Flavonoids

thesis.

Gentisic a c i d

- Tret i n o i n-a fi rst-ge neration reti n o i d which was the

H y d roxyco u m a r i n s

fi rst ava i l a b l e to pica l reti n o i d . I t is a nonsel ective

Koj ic acid

ret i n o i d , a ctiva t i n g a l l reti n o i c a c i d pathways . I t is

Licorice extract

n ot p h oto-sta b l e . I t is ava i l a b le i n a ge neric fo r m , as


we l l as i n bra nd for m u lations s u c h as R e n ova a n d

M u l berry extract

Avita . C u rre ntly R e n ova is F D A a p proved fo r p h o

M e l a n ocyte tra nsfer i n h i bition


Lec ith i n s

toa g i n g . Treti n o i n is a lso ava i l a b l e in com b i nation a s

N ia c i n a m i d e

treti n o i n 0 . 02 5 % w i t h c l i n d a myc i n f o r patie nts seek

Soybea n/m i l k extracts

ing benefits fo r both acne and p h otoa g i n g and as

M e l a n ocyte cytotoxic agents

treti n o i n 0 . 2 5 % i n com b i nation with 4% hyd ro

Azela i c acid

q u i none a n d

M eq u i nol

0 . 0 5 % f l u o c i n o l o n e aceto n i d e fo r

hyperpigme ntation .

M on o benzone

- Reti nol-this prod uct m u st be converted to reti na lde


hyde a n d then to a l l -tra ns-retinoic acid with i n the ker

Skin turnover acce l e ration


G lyco l i c a c i d

atinocyte in order to become a ctive, t h u s d isplayi ng

La ctic a c i d

less activity than treti noi n . I t is thought to be a p p roxi

Linoleic acid

mately 20% less potent than retinoic acid . It is not as

Reti noic a c i d

freq uently assoc iated with i rritation or e rythema . It is


pri m a ri ly fo u n d i n over-the-cou nter prod u cts at va ri
o u s concentratio ns.
- Ad a pa l e n e-a t h i rd -ge neration reti noid wi t h selective
affi nity for specific ret i n o i c a c i d rece ptors, w h i c h
a l lows for m ore targeted benefit a n d red uction of
potentia l si d e effects . It is m ore c h e m i c a l l y sta ble
t h a n tret i n o i n a nd d oes not brea k d own i n the pres
ence of l ight. C u rrently ava i la b l e as D ifferin in a 0. 1 %
a n d a 0 . 3 % concentrati o n .

I t i s c u rrently FDA

a p proved for to pica l acne thera py.


- Taza rotene-a t h i rd-ge neration retinoid with sel ective
affi n ity for s pecific retinoic rece ptors for more tar
geted benefit. Has been associated with sign ificantly
h igher i rritati o n than othe r retinoids. I t is ava i l a ble in
0 . 1 % and 0.05% gels and in 0 . 1 % and 0.05%
c rea m s . It is c u rrently FDA a p proved for topica l acne
thera py a n d plaque psoriasis.

Tyrosi nase i n h i bitors

Skin l ighte n i ng agents-these prod ucts act to i n h i bit


one o r more ste ps in the mela n i n biosynthesis pathway.
The m a i n target is tyrosi nase, wh i c h is the rate- l i m iting
step i n mela n i n prod uction (Ta ble 2 . 3 ) .
- Hyd roq u i none-phenolic c o m p o u n d fo u n d natu ra l ly
in m a ny pla nts , coffee, tea , bea r, a n d w i n e .
I n h i bits conversion o f tyrosi nase t o m e la n i n .
Decreases tyrosi nase activity b y 90% .
May i n h i b it D N A synthesis.
M ay i n h i b it RNA synthesis.

10

Color Atlas of Cosmetic Dermatology

Ca n be cytotoxi c to mela n ocytes prod u c i n g i rre


vers i b l e cel l d a m age with monobenzyl ether of
hyd roq u i none.
Concern rega rd ing carci n ogen i c potentia l-cu rrently
heavily regulated a n d/or ba n ned i n E u rope, As i a ,
a n d severa l African cou ntries.
Ava i l a ble i n over-the-cou nter prod u cts up to 2%
and by presc r i ption i n 3 % to 4% concentrations.
Ca n be c o m p o u n d ed u p to 1 0 % concentration .
C u rrently ava i l a ble

in

Table 2.4 Use of the ''teaspoon rule" for su nscreen application can be
benefi c i a l i n educating patients on the proper of amount of sunscreen
that shou l d be appl ied with each appl ication.
Use of m ore tha n h a lf a teaspoon each on:

Head a n d neck region

R ight a rm

Left a r m

Use o f m ore than a teaspoon e a c h o n :

Anterior torso

c o m b i nation with to pica l

Posterior torso

reti noid acid a n d to pical stero i d a n d with other s k i n

R ight leg

l ighte n i ng agents.

Left leg

- Reti noic a c i d

( Data from D raelos ZD. P roced u res i n Cosmetic Dermatology Cosmeceuticals.

Acce lerate e p i d e r m a l turnover res u l t i n g i n i n c re


ased keratin ocyte s h ed d i n g lea d i ng to pigment loss
May i n h i bit tyrosi nase i n d uction
May res u l t in keratinocyte pigment d ispersion
May i nterfere with kerati n ocyte pigment tra nsfer
- Natu ra l cosmeceuticals
Koj ic a c i d-d e rived from va rious fu nga l species
suc h as Aspergillus and Penicillium. Primari ly used
as a food preservative and to promote the redd e n
i n g o f u n r i pe strawberries . Genera l ly u s e d i n 1 % t o
4 % conce ntration . N oted t o have h igh sensitizi ng
potentia l .
Licorice extract-derived from the root of G/ycyrrhiza
g/abra

I ts

linneva.

main

active

i ngred ient

is

gla brid i n . It i n h i bits tyros i nase activity with associ


ated cytotoxicity. It has been shown to be 1 6 x
m ore efficacious t h a n hyd roq u i none.
Azelaic a c i d-d e rived from Pityros poru m ova l e . I ts
mec h a n is m of action i n not fu l l y u nd e rstood . I t
works best on active melanocytes.
Aloes i n-d e rived from a l oe vera . I t a cts as a com
petitive i n h i bitor o n DOPA oxidation and noncom
petitive

i n h i bitor

on

tyros i n e .

When

used

in

c o m b i nation with a rbuti n , it has been demon


strated to i n h i bit UV- i n d uced melanogenesis.
Arbut i n -derived from the bea rbe rry. I t a cts to
i n h i bit mela noso m a l tyrosi nase activity. Ava i l a ble as
a mono treatment o r i n 1% conce ntration with other
d e pigme nti ng agents.
Paper m u l berry-derived from the roots of an orna
mental tree, Broussonetia papyrifera.
Soy-acts

to

phagocytosis,

i n h i bit
th us

kerati nocyte
red ucing

melanosome

m e la n i n

tra nsfer.

Cos meceutica l effect noted on ly with fresh soy m i l k .


N ia c i n a m i d e-acts t o i n h i bit m e l a n ocyte tra n sfer.
Also exh i bits anti- i nfla m matory a n d a nti-oxidant
properties.

Saund ers, 2005 . )

Sect i o n 1 : Ph otoa g i n g

Ascorbic a c id-acts at va rious oxidative steps


in mela n i n synth esis by i nteracting with copper ions
at the tyros i nase a ctive site a nd red u c i n g d o pa
q u i none.
G lyco l i c acid-has a n epidermal d iscohesive effect,
res u lti n g

in

i n c reased

epidermal

turnover

fo r

i n c reased shed d i ng of pigme nted kerati n ocytes.


S h o u l d be used i n lower concentrations to avoid
s k i n i rritation .

I N D I CAT I O N S

Red uce t h e occu rrence o f acti n i c keratoses a n d nonmelanoma s k i n cancer

Red uce the formation of s k i n aging

R hytides

Ephelides

Lentigin es

Melasma

Postinfla m matory hyperpigme ntation

P R ET R EAT M E NT EVALUAT I O N

Eva l uation of pre-existing a l lergies t o a n y active i ngred ient

Past prod u ct use a nd res ponse

I D EAL CAN D I DATE

A l l patients benefit from the d a i ly a ppl ication of a topi


cal s u nsc ree n , SPF 30 or greater

Patie nts with rea l istic expectations that topica l medica


tions may provide preve ntative benefits a n d a re less
l i kely to red uce moderate to d eep rhytides

LESS THAN I D EAL CAN D I DATE

U n real istic patient expectations


Patients with ma rked ly d ry or sensitive ski n-topical
treatments may exa cerbate cond ition

CONTRA I N D I CAT I O N S

P re-existing a l lergy t o active i ngred ient


Use of topical treti n o i n , sa l i cyl i c acid, and s k i n l ighten
i n g agents i n pregnant a n d lactati ng women

APPLI CAT I O N TECH N I QU ES

A su nscreen shou ld be a p p l ied a m i n i m u m of 30 m i n


utes prior t o s u n expos u re .

1 1

12

Color Atlas of Cosmetic Dermatology

A p p roxi m ate ly 35 m l is the average a m o u nt of s u n


screen t h a t s h o u l d be a ppl ied t o t h e average-sized
a d u lt with each a p p l icati o n . T h i s tra nslates to a tea
spoon ( a p proxi mately 6 mU of s u n screen to each leg,
back, a n d chest a n d h a l f a teaspoon ( a pproxi mately
3 m l) a p pl ied to the a rms, face, a nd neck for fu l l cover
age (Ta ble 2 . 4 ) .

Topical retinoic acid prod u cts s h o u l d b e a pp l ied spa r


i ngly to treatment a reas 30 m i n utes after was h i n g to
m i n i m ize pote ntia l for i rritation .

B l eac h i ng c rea ms s h o u l d

be a p p l ied to hyperpig

mented treatment a reas on ly, with efforts made to avoid


u n i nvolved ski n .

COM P L I CAT I ON$

Conta ct a l lergic dermatitis

Conta ct i rritant dermatitis

Ac ne fla re

S k i n pee l i ng

Xerosis

Erythema

P h otoa l lergic rea ction

Ph ototoxic reacti on

Theoreti c a l red uction i n vita m i n D a bsorption with s u n screen use

Hyperpigmentation with blea c h i ng crea m use

Exogenous ochro n osis with bleac h i ng crea m

Hypopigm entation with blea c h i ng c rea m

Potentia l carc i n oge n i c risk of hyd roq u i no n e use

POSTTREAT M E N T CAR E

Strict photo protection s h o u l d b e fol l owed d a i ly, i n c l u d


i n g s u n avo i d a n ce as m u c h as possi ble, t h e u s e o f a
d a i l y s u nscreen S P F 30 or greater, use of a wide
bri m med hat, a n d s u n protective c l oth i n g

PEARLS FOR T R EATM ENT S U CCESS

M i n i m ize the n u m ber o f prod ucts a ppl ied d a i ly t o avo i d


the potentia l fo r i rritation .

Check the expi ration d ates of a l l prod u cts a p pl ied . Th i s


is pa rti c u l a r k e y fo r s u n sc reens, as the active i ngred i
ents may not provi d e benefit beyo nd the recommended
d ate of use.

Topical retinoic a c i d prod u cts shou l d be d isconti n u ed


2 weeks prior to fac i a l proced u res such as wax in g or
tweezi n g i n order to avo i d s k i n d esq ua mati o n .

Sect i o n 1 : Ph otoa g i n g

B leac h i n g agents s h o u l d be d i sconti n ued if red ness or


i rritation d evelops, as they may worse n existing pig
mentatio n .

I t is usefu l t o d isconti n ue t h e use o f a hyd roq u i none


c rea m every 3 to 4 months to dec rease the risk of
exogenous och ronosis a n d to preve nt s i de effects .

B I B L I OG RAPHY
B ruce S . Cosmeceuticals for t h e atten uation o f extrinsic
a n d i ntrinsic dermal aging. J Drugs Dermatol, 2008;
7(2 S u p p l ) : s 1 7-s22 .
Colven R M , P i n n e l l S R . To pica l vita m i n C in aging. Clin
Dermatol. 1 996; 1 4 : 227-234.
Dreher F, M a i bach H. Protective effects of topica l antioxi
da nts i n h u mans. Curr Probl Dermatol. 2000;29: 1 57- 1 64.
Fisher GJ , Ta lwa r H S , Lin J, et al. M o l ec u l a r mechanisms
of photoaging i n human s k i n i n vivo a n d their prevention
by a l l -tra ns reti noic acid . Photochem Photobiol. 1 999;69 :
1 54- 1 5 7 .
Gensler H L, Aickin M , Peng Y M , e t a l . I m porta nce o f the
fo rm of to pica l vita m i n E for prevention of ph otoca rcino
genesis. Nutr Cancer. 1 996;26 : 1 83- 1 9 1 .
G u eva ra I L, Panda AG . Melasma treated with hyd ro
q u i none, treti noin a n d a fluori nated steroid . lnt J Dermatol.
200 1 ;30: 2 1 2 -2 1 5 .
Ka ng S , Voorhees J J . P h otoaging thera py with topica l
treti n o i n :

An

eviden ce-based

a n a lysis.

J Am Acad

Dermatol. 1 998;39 : S 55-S6 1 .


Kligman A M . The growi ng i m porta nce of topica l reti noids
i n c l i n ic a l dermato l ogy: A retros pective a nd prospective
a n a lysis. JAmAcad Dermatol. 1998;39:S2-S 7 .
L i n HW,

N aylor M ,

H o n igma n n H , e t a l . America n

Aca demy of Dermato l ogy Consensus Confe rence on UVA


protection of s u nscree ns, s u m m a ry a n d reco m menda
tions. JAmAcad Dermatol. 2000;44: 505-508 .
Naylor M , Boyd A, S m ith D, et a l . H igh s u n protection
factor su nscreens i n the s u p pression of acti n i c neoplas i a .
Arch Dermato/. 1995; 1 3 1 : 1 70- 1 7 5 .
Ogden S , Sa m u e l M , G riffiths S E . A review o f taza rote ne
i n the treatment of ph otoda maged s k i n . Clin lntervAging.
2008;3( 1 ) : 7 1 - 7 6 .
P i ca rd M , Ca rrera M . N ew a n d experi menta l treatments
of c h loasma a n d oth er hypermela noses. Dermatol Clin.
2007 ; 25 : 3 53-362 .
Schneider J . The teaspoon rule of a p plying s u n sc ree n .
Arch Dermatol. 2002; 138:838-839.
Solano F, B riga nti S , Picard o M, et al. Hypopigmenti ng
agents : An u pd ated review on biologica l , c h e m i c a l a n d
c l i n ical as pects . Pigment Cell Res. 2006; 1 9 : 550-57 1 .

13

14

Color Atlas of Cosmetic Dermatology

CHAPT E R 3

Soft Tissue Aug m e ntatio n

M ECHAN I S M OF ACT I O N
Use of a synthetic or biologica l prod uct or s u rgical restruc
turing for the replacement of vol u m e loss and en h a nce
ment of derma l , su bcuta n eous, and m usc u l a r d eficiencies
that resu lt from tra u m a , s u rgical defects, l i poatrophic con
d itions, photoaging, or c h ronological aging.

I D EAL F I LLER (Table 3.1)

B iocom pati b l e

N o n i m m u noge n i c

Noncarc i noge n i c , nonte ratogen i c

N o n resorba b l e

N o n m igratory

I nexpensive

Eas i l y o bta i n ed a n d stored

Easy to a d m i n ister

P rovid es re prod u c i ble cosmetica l ly benefi c i a l res u lts

FDA a p p roved if not a utologous

Demonstrates m u lt i p u rpose use

N o side effects

Easy to re m ove in the event of a poor cosmetic outcome

TAB L E 3 . 1

Com monly Used F i l l ing Agents

Name

Com position

FDA approval

Skin testing req u i red

Longevity

Adatos i l 5000 ( Dow-Cor n i ng, M i d l a n d , M l )

S i l icone

No

No

Permanent

Al loderm ( Life C e l l Cor p . , B ra n c h b u rg, N J ;

Ace l l u l a r processed h u ma n

Yes

No

1-2 yr

O baj i M e d i ca l , C h i cago, I L)

cadaveric dermal a l l ograft

Aq u a m i d (Contu ra I nternatio na l , Soe bora ,

Po ly-a c ryl a m i d e gel

No

No

Permanent

Artefi l l (Canderm P h a r m a , I n c . , Quebec,

Bovi n e col lagen with poly( methyl

No

Yes

Perma nent

Ca n a d a ; Medical I nternational BV, B red a ,

methacrylate) beads

No

No

4-6 mo

Den mark)

The N etherla nds)


B elotero Soft; B e l otero Basic ( M e rz

Non-a n i m a l hya l u ro n i c a c i d d e rived

P h a rma , Fra n kfu rt, Germa ny)

from bacteria l fe rmentation

B i o-Aica m i d ( B ri n d is, Italy)

Poly-a c ryla m i d e

No

Yes

Perma nent

Ca pti que ( l named Corp, Sa nta

Non-a n i ma l-sta b i l ized hya l u ronic

Yes

No

4-6 m o

Monica, CA)

acid ( NASHA) d e rived from plant

Cosmoderm , Cosmoplast (AIIerga n ,

Recom b i na nt h u m a n col lagen

Yes

No

4-6 m o

No

4-6 m o

I rvine, CA)
Cymetra Life Cell Corp. , B ra n c h b u rg, N J ;

Ace l l u l a r processed lyo p h i l ized

O baji M e d i ca l , C h icago, I L

h u m a n cadaveric tissue
(continued)

Sect i o n 1 : Ph otoa g i n g

TAB L E 3 . 1

15

Commonly Used F i l l ing Agents (Continued)

Name

Com position

Fasc i a n ( Fascia B iomaterials, B everly

H u m a n cadaveric preserved

H i l ls, CAl

pa rticu late fascia lata

Fat, su bcuta neous

Auto logous

Hylaform ( B iomatrix I n c . , R i d gefi e l d , N J ;

H ya l u ro n i c acid derived from

! na med Corp . , Santa M o n i c a , CAl

dom estic fowl coxcom bs

l solagen ( l so l agen I n c . , H o u sto n , TXl

FDA approva l

Skin testing req u i red

Longevity

No

3-4 mo

N/A

No

9-1 2 m o

Yes

No

4-6 mo

Autologous f ibro blasts

Yes

No

1-2 y r

J uved erm U ltra , U ltra XC, U ltra Pl us,

N on-a n i m a l-sta b i l ized hya l u ro n i c

Yes

No

6-9 mo

U ltra P l u s XC (AIIerga n , I n c . , I rvi n e , CAl

acid ( N AS HAl d erived from

Yes

No

4-6 mo

bacteria l fe rmentation . XC
formu lations with 0.3% lidoca ine
P reve l l e Silk ( M entor Corporat i o n , Sa nta

N o n -a n i ma l -derived hya l u ro n i c

B a r ba ra , CAl

a ci d w i t h 0. 3% l i d oc a i n e

Rad iesse ( B ioform Med ica l , San

Synthetic calci u m hyd roxyla patite

Yes

No

9- 1 2 m o

Non-a n i ma l-sta bil ized hya l u ro n i c

Yes

No

6- 9 mo

S i l i cone

No

No

Perma nent

G ore-Tex

N/A

No

Perma nent

Lyop h i l ized poly- L-Iactic acid

Yes

No

1-2 y r

Bovin e col lagen

Yes

Yes

3-4 mo

Mateo, CAl
Restylane, Restylane-L, Perlane,
Perlane L (Q-Med AB, Swed e n ;

a c i d ( N AS H A l derived fro m
bacterial fe rmentation .

M e d i c i s , Phoenix, AZl

L form u l ations with 0 . 3 % l i d ocaine


S i l i kone- 1 000, Adatos i l-5000 (Alcon La bs,
I n c , Fo rt Wort h , TXl
Softform ( McGhan Med ica l , Santa
Barbara , CAl
Scul ptra ( B iotech I n d ustry, SA,
Luxe m bo u rg; Derm i k , Berwy n , PAl
Zyd erm , Zyplast (AIIerga n , I rvi n e , CAl

P R EOPERAT IVE EVALUAT I O N

I d entify the a ppropriate patient and treatment region


- Sign ificant past medical h istory, i n c l u d i ng h istory of
b l eed i ng or c l otti n g d isord e rs; keloid formation ; exist
ing d rug a l l ergies; i m m u nocom p ro m i sed state
- Cu rrent med ication use; past or c u rrent isotreti noin use
- Past s u rgica l

i nterventions,

yea r,

and

treatment

res ponse
- C l i n ic a l eva l u ation to d eterm i n e if the d esi red treat
ment a reas a re a me n a b l e to correction; outl i ne base
l i n e structu ra l i rregula rities
- Discuss l i ne softe n i ng versus vol u m e re placement for
fi l le r selection
- Discuss med ications to avo i d 1 0 days p reoperatively
when med ica l l y safe , i n c l u d i n g aspiri n , nonsteroid a l
med icati ons, vita m i n E s u p plements, S t . J o h n 's Wort,
a n d other herbal m e d i cations that have an a nticoagu
lative effect

16

Color Atlas of Cosmetic Dermatology

Disc uss the risks a n d benefits of the treatment


- Al lergic reacti o n , loca l ized versus system i c
- P roced u ra l a n d posto perative d iscomfort
- Postoperative edema
- Posto perative bru ising
- Sca r formation
- I nfection
- Reactivation of herpes s i m plex virus
- I n complete a ugme ntation
- I rreg u l a r co nto u r/textu re

I d e ntify contra i n d ications to treatment


- Active i nfection at the treatment site
- Nond iste nsi ble, rigi d , or icepick sca rs
- Extensive jowl formation, prom i nent folds, a n d furrows
- U n d e rlying connective tissue d isord e r
- I m m u nologic d isease
- Prior a l le rgic reaction to fi l le r/re lated fi l l e r/positive
s k i n test
- Use of isotretinoin with i n the preced ing 6 to 12 m onths
- Pregna n cy
- U n real istic expectations

O utl i n e the pred icted outcome and l i m itations to the


treatment
- D u ration of co rrection
- Posto perative recovery period
- Tissue sou rce
- Expense

Figure 3.1 Massager utilized during filler placement to minimize treat

ment discomfort

S K I N TESTI N G (WH E N APP L I CAB LE)

I n itial test d ose-two s k i n tests recom me n d ed


- I nj ected in tu berc u l i n m a n n e r i nto vol a r forea rm
- Fou r-week o bservation period for fi rst test
- Re peat s k i n test placed in o pposite forea rm
- Two-week o bservation period fo r second test

Retest d ose-si ngle test recommended


- For new patients who have received treatment by
a n other physic i a n or patients who have not received
treatment for more than 1 yea r
- Two-week o bservation period recom mended

Positive fi l l e r reaction
- Swe l l i ng, i n d u rati o n , ten derness , o r erythema that
pe rsists o r occ u rs 6 h o u rs or longer after test i m p l a n
tation
- A pos itive s k i n test is a n a bsol ute contra i n d ication to
fi l l e r use

Figure 3 . 2 Clinical findings after EMLA application to skin. Expected

blanching lasts approximately 2 to 3 hours after application

Sect i o n 1 : Ph otoa g i n g

17

AN ESTH ES I A

I njection of soft tissue fil lers may b e pa i nfu l , espec ia l ly


with treatment of the l i ps . M ost patients req u i re some
form of a n esthesia to m i n i m ize treatment d iscomfort.

Epidermis

"Ta l kesthesia , " h a n d - h o l d i ng, v i b ratory massager nea r


the treatment s ite a re usefu l for patient d istraction
( Fig. 3 . 1 ) .

Topica l a n esthesia ca n b e uti l ized fo r s m a l l treatment


a reas .

Commonly

used

agents

include

Betaca i n e

E n h a n ced G e l ( C a n d e r m , Quebec, Canada ) , Betaca i n e


P l us

( Ca n d e r m ,

Quebec,

Canada ) ,

L- M -X-4

and

5 ( Ferndale La bs, Fernd a l e , M l ) , E M LA (AstraZeneca,


Boston , MA), and ice ( Fig. 3 . 2 ) .

Lidoca i n e i ntegrated d i rectly i nto t h e fi l l e r m a y e l i m i


nate the need fo r a lternate forms of a n esthesia .

Regiona l n e rve blocks a re eas i l y a d m i n istered prior to


treatment. The patient s h o u l d avoid extremely hot or
cold beverages a n d foods for 2 to 3 h o u rs after menta l
a n d/or i nfraorbita l n e rve blocks t o avoid m u cosa l i nj u ry
d ue to i n a b i l ity to d etect tem pe rature a cc u rate ly.

Loca l ized tumescent a n esth esia

is util ized fo r fat

Fat

Figure 3 . 3 Recommended filler injection depths. (A dapted from Keyvan

N, Susana L-K, eds. Techniques in Dermatologic Surgery. United


Kingdom: Mosby; 2003.)

extraction with a utologous fat tra n sfer.

I nfi ltrative a n esthesia is to be avo i ded to o bviate tissue


d i sto rtion of the treatment site .

PROCEDU RAL M E D I CAT I O N S

Va ltrex 500 mg B I D

5 t o 7 days i n itiated 1 day prior

to the proced u re for patients with a h i story of h erpes


s i m plex virus in or nea r the treatment site

Keflex 500 mg B I D

7 days i n itiated 1 day prior to the

proced u re for patients u n d e rgoi n g a uto l ogo us fat trans


fe r o r Gore-Tex i m pla ntation

D iazepa m 5 to 1 0 mg can be offe red to a nxious


patients 30 m i n utes prior to the proced u re

LEVEL OF I NJ ECT I O N (Fig. 3.3)

S u perfi c i a l dermis: fi ne l i nes; verm i l ion bord e r l i p a ugmentation

Zyd erm I,

I I ; Cosmoderm I, I I ; Restylane Fine L i n e ;

Hylaform F i n e L i n e

M i d t o deep d e r m i s : s u perficial t o moderate rhyti des,


sca rs, and d efects; lip a ugm entation

Ca ptiq ue;

Cosmoderm

II,

Cosmoplast;

Hylafo r m ;

J uved erm U ltra ; P reve l l e S i l k ; Restylane; Zyder m I I ,


Zyplast

Deep dermis, s u bc uta neous fat, and m uscle: dee per,


more su bsta ntia l defects a n d rhytides ( Fig. 3 . 4 )

Autologous

fat

tra n sfe r;

Gore-Tex;

Hylaform

J uved erm U ltra P l u s ; Perla ne; Rad iesse; S c u l ptra

Figure 3.4 (A) Prominent nasolabial folds prior to augmentation with


P l us ;

hyaluronic acid. ( B ) Softening of folds after 3 c hyaluronic placed into


treatment sites

18

Color Atlas of Cosmetic Dermatology

Com bi nation

derm a l ,

s u bcuta neous,

and

m uscle:

defects with both a su perfi c i a l a n d a d ee p com ponent


uti l ize both a su perfi c i a l and deep fixer for opti m a l a u g
m entation ( Fig. 3 . 5 )

I NJ ECT I O N TECH N I QU E (Fig. 3.6)

Seria l pu nctu re : c l osely spaced p u n ctu res created


a long l i nes, folds ( Fig. 3 . 7 ) .

Li nea r t h rea d i ng: withd rawa l o f fi l l e r a long t h e length


of the fac i a l d efect as a conti n uous th read of material
( Fig. 3 . 8 ) .

Fa n n i ng: s i m i l a r t o l i near threa d i ng. N eed le d i rection is


conti n ua l ly cha nged without with d rawing the need le
tip.

U sefu l for ora l com m issu res, u p per nasola bia l

folds.

C ross-hatc h i ng: similar to l i near t h rea d i ng. M aterial is


i nj ected at right a ngles to the fi rst i nj ecti ons. U sed for
s h a p i n g fac i a l conto u rs .

DEG R E E O F COR R ECT I O N

Dependent o n the fi l l e r used . I n ge nera l , ove rcorrection


is not reco m m ended . The m ost com mon tec h n i q u e
error is u n d e r-correctio n .

M u lti p l e treatment sessions a re genera l ly req u i red for


vol u m e re placement agents, i n c l u d i ng s i l icone a n d
poly-L-Iactic a c i d .

D U RAT I O N OF COR R ECT I O N


Dependent on t h e material i m pl a nted , i m p la ntation tec h

n i q ue, a n d a m o u nt i m pl a nted , the type o f d efect a n d

Figure 3 . 5 (A) Facial lipoatrophy with "sunken cheek appearance " prior

mec h a n ical stresses at the i m p l a ntation sites.

to Cymetra treatment. ( B ) Improvement of cheek volume after Cymetra


treatment, 2. 0 cc total volume

ADV E R S E R EACT I O N S
H y pe rse n s i t i ve

Prolonged e rythema a n d edema at i njection sites


Cyst/a bscess formation-long-lasti ng; can persist for
m ore than 2 to 3 yea rs

G ra n u loma formation

Ana phylaxis

N o n - H y p e rse n s i t i ve

B i ofi l m

B r u ising

I nfection-i n c l udes reactivation of h erpes s i m plex virus


a n d bacteri a l i nfection

Sect i o n 1 : Ph otoa g i n g

19

Necrosis-d ue to vasc u l a r com pro m i se at the treat


ment site

N od u l e formation/bea d i ng
Pa rtial vision loss-d ue to vasc u l a r comprom ise at the
treatment site

U lceration

Tec h n i q u e C o m p l i cat i o n s

I rreg u l a r texture-d ue to u neven placement

Bea d i ng-d ue to too superficia l p lacement ( Fig. 3 . 9 )

I m p la nt rejectio n -d u e t o too s u perficia l placement

Necrosis-d u e to vasc u l a r i njection o r vasc u l a r com


pression

PEARLS FOR T R EAT M ENT S UCCESS

With fi l l e rs, the affected treatment sites should be fu l ly


a ugme nted to ensu re an eve n , c o m p l ete a ugmentati o n .
U n der-correction w i l l l e a d t o a n i nadeq uate a ugmenta
tion a n d patient d issatisfaction . With m ost tem pora ry
fi l lers, this is o bta i ned at the fi rst treatment. Permanent
fi l lers req u i re repeat treatments fo r correctio n comple
tio n .

With tem pora ry fi l lers, patie nts m u st u n d e rsta n d that


the treatment res ponse is va riable and can last less
t h a n or greater tha n the ave rage expected t i m e . Re peat
treatment w i l l be req u i red over t i m e .

Figure 3 . 6 Injection techniques A . Linear threading technique B. Serial


puncture technique. (Adapted from Keyvan N, Susana L-K, eds.
Techniques in Dermatologic Surgery. United Kingdom: Mosby; 2003.)

Patient expectations m u st be tem pered t o m i n i m ize


u n rea l istic expectations a bout fi l l e r benefits . Patie nts
m ust be awa re that the treatment e n d point is a soften
i n g of the affected a reas .

Posto perative bea d i ng is ge nera l ly responsive t o local


ized massage over 5 to 7 days. Persiste nt bead i n g can
be corrected by i njecting 2 mg/m l of tria mci nolone
a ceto n i d e i nto the bead o r by 1 1 -blade i n cisional
extraction of the fi l ler materi a l .

A thorough preoperative eva l uation is necessa ry to


e n s u re that there a re no contra i nd i cations to fi l l e r use,
espec i a l ly when using perm a nent fi l lers.

Conservative a ugm entation of the gla bel l a r region is


c ritica l to avoid vasc u l a r necrosis.

B I B L I OG RAPHY
B e e r K, S o l i c h N . H ya l u ron ics for soft tissue a ugmenta
tion : Practical considerations and tec h n ical recom m e n
d a t i o n s . J Drugs Dermatol. 2009;8( 1 2 ) : 1 086- 1 09 1 .
C l a rk D P, H a n ke CW, Swa nson N . Derma l i m p l a nts:
Safety of prod ucts i nj ected for soft tissue a ugmentation . J

Am Acad Dermatol. 1 989;2 1 :992-998.

Figure 3 . 7 Serial puncture method of injection

20

Color Atlas of Cosmetic Dermatology

Cohen J L. U n dersta n d i ng, avoid i ng a n d ma naging d er


m a l fi l l e r c o m p l icati o n . Dermatol Surg. 2008; (34 S u ppl
1 ) : S92-S93 .
Colem a n S R . Fac i a l reconto u ring with l i posc u l pture. Clin

Plast Surg. 1 997;24( 2 ) :347-367 .


G l a i c h AS, Cohen J L, G o l d berg LH . I njection nec ros is of
the gla bel l a : P rotocol for prevention a n d treatment after
use of d e r m a l fi l lers. Dermatol Surg. 2006 ;32 ( 2 ) : 276281 .
J ones D H . Sem i perman ent a nd perma nent i njecta ble
fi l lers. Dermatol C!in. 2009;27(4) :433-444.
Mata rasso S L . I njecta ble collagens: Lost but not forgot
ten-a review of prod u cts, i n d ications a n d i njection tec h
n i q ues.

Plast Reconstruct Surg. 2007; 1 20(6 S u p pl ) :

1 7S-26S .
S c h u l l e r- Petrovic S. I m p rovi ng the aesthetic aspect of soft
tissue defects on the face usi ng a utologous fat tra nsplan

Figure 3.8 L inear threading method of injection

tation . Facial Plast Surg. 1997 ; 1 3 ( 2 ) : 1 9-24.

Figure 3.9 Filler beading due to too superficial placement

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 4

B otulinum Toxi n

PHARMACOLOGY
Botu l i n u m tox i n is a prote i n prod uced by the bacteri u m
Clostridium botulinum. Seven serotypes exist, designated
as A, B, C 1 , D, E, F, a n d G. Eac h one of them is a pro
tease with a l ight c h a i n l i n ked to a h eavy c h a i n by a d is u l
fide bond .
Ea c h is a ntigen ica l ly d isti n ct. H owever, botu l i n u m tox i n
A ( BTX-A) , B ( BTX-B ) , a n d F a re the on ly serotypes c u r
rently ava i la b l e for c l i n ical use (Ta b le 4 . 1 ) .

TAB L E 4 . 1

Bot u l inum Toxin Preparations

Type

U n its toxi n/bottle

Dos i n g eq u iva le nts

D i l ution

Botox Cosmetic (AIIerga n I n c . , I rvine,

1 00 U lyo p h i l ized powder

1 U Botox

Average 1-4 mL in

4 U Dysport

CA)-type A

prese rvative-free or
prese rved sa l i n e

R e l ax i n ( M edicis Esthetics, Scottsdale,

500 U i n lyo p h i l ized

AZ), Dys port ( I psen L i m ited , Berks h i re ,

powde r

1 U Botox

2 . 5-4 U

U K)-type A
R e l oxi n/Dys port

Average 1-2 . 5 m L i n
prese rvative-free o r
prese rved sa l i n e

Myobloc (Soltice N e u rosciences, San

2 , 500, 5,000, a n d

N ot we l l esta bl ished for

M a y b e used as is or d i l ute

F ra n c i sco, CA)-type B

10,000 U/m L a q ueous

cosmetic use

with sa l i n e

solution
Xeo m i n ( M erz P h a rmaceutica ls,

1 00 U via l

F ra n kfu rt, Germa ny)-type A


N e u ro n ox ( M edy-Tox, I n c , Seo u l ,

1 00 U vial

South Korea )-type A


P rosigne ( La nzhou I nstitute of B i ologica l

Reported 1 U B otox

1 U

N ot wel l esta bl ished

1 U

N ot wel l esta b l is hed

Xeo m i n
Reported 1 U B otox
N e u ronox
50 U vial a n d 100 U vial

P rod ucts, La nzhou, C h i n a )-type A

M ECHAN I S M OF ACT I O N
I n h i bition of acetyl c h o l i n e release at the n e u rom uscu l a r
j u n ction res u lting i n m usc u la r f l a c c i d pa ra lysis. Receptor
site b i n d i n g is med iated by the h eavy c h a i n portion of the
toxi n , is spec ific for the toxin serotype, and is i rrevers i b l e .
O n c e bou n d , the recepto r-neu rotoxi n comp lex is i n ter
n a l ized i nto the nerve term i n a l a n d the tox i n l ight c h a i n
acts as a protease t o c l eave specific syn a ptic prote i n
peptide bonds req u i red for acetylc h o l i n e formati o n . The
ta rget of BTX-A is the syna ptasome-associated prote i n of
25 k Da , S N A P-25. BTX- B a n d B TX-E cleave the vesicle
associated mem b ra n e prote i n , syna ptob rev i n .

N ot wel l esta b l ished

N ot we l l esta blished

21

22

Color Atlas of Cosmetic Dermatology

DI LUTION
Procerus
m usc l e

BTX-A i s stored i n lyo p h i l ized vials. It ca n b e reconsti


tuted in prese rved sa l i n e or preservative-free sa l i n e .
D i l utions va ry accord i n g t o physicia n preference a n d
expe rience with BTX . A d i l ution ra nges from 1 m l
( 1 0 U/0 . 1 cc) t o 4 m L ( 2 . 5 U/0 . 1 c c ) . Dysport d i l uted to
2 . 5 ml wi l l atta i n a conce ntration of 20 U/0 . 1 cc. The

N asal i s
m usc l e -+++--=-==:..___;-

i njected vol u me m ust be sufficiently sma l l to provide


a c c u rate toxin d e l ivery without a n excessive vo l u me
effect or del ivery of tox i n to s u rro u n d i ng m u scles other
tha n the targeted m uscles. The vo l u me m ust be suffi
c i ently l a rge to permit a cc u rate i njection i nto the targeted

Levator lab i i
s u perioris
alaeq ue nasi
m uscle

-+--- Zygomaticus
major m u sc l e

m uscles.

CONTRA I N D I CAT I O N S
I\

A b so l u te

Levator
superioris muscle

U nderlying n e u rom usc u l a r cond ition s u ch as myasthen ia gravis or a myotro p h i c late ra l sclerosis

P regnan cy/breast-feed i n g-pregna ncy category C

Active i nfection in treatment a rea

U n rea l istic patient expectations

Figure 4.1 Anatomical illustration of the upper and midfacial muscula

ture

R e l at i ve

Ca l c i u m c h a n n e l bloc kers use-may pote ntiate effect

A m i n oglycosi d e a nti b i otic use-may potentiate effect

Patie nts who a re d e pend ent on fac i a l expression for


t h e i r l i ve l i hood (eg, actors)

P ro m i n e nt eye l i d ptosis, heavy b row or ectropion

P R EOPERATIVE EVALUAT I O N

Patient expectations m u st b e d efi ned a n d matched


with the expected treatment outcomes

Patient med ical h i story

Past treatment h i sto ry a n d outcome

C l i n ical eva l uation

Determ i n e location and extent of i nvolvement of the


treatment site

Doc u ment asy m m etries n oted ; presence of ptosis/l i d

laxity/brow prom i nence

Lowe r Eye l i d " S n a p B a c k " Test to

Assess Lower L i d Lax i ty

The m i d d l e of the lower l i d is grasped between the i n d ex


fi nger a n d the th u m b a n d p u l led forwa rd a n d u pwa rd .

Figure 4.2 Approximate injection sites for the forehead to obtain a more

The l i d is then released a n d a l l owed to "sna p " back

horizontal brow. This pattern is most frequently used to create a more


masculine brow

Sect i o n 1 : Ph otoa g i n g

aga i nst the globe. A q u ic k return to its norma l state i n d i


cates m i n i m a l laxity. Botu l i n u m toxin t o t h i s region c a n
provide benefit. A slow return o f s k i n t o its nat u ra l posi
tion i n d icates sign ifica nt laxity. Botu l i n u m toxin s h o u l d
not be u s e d i n these patients, as it may accentuate t h e
l i nes present.

P ROCEDU R E

Patient consent o bta i ned


P reope rative pictures ta ken at rest and with targeted
m usc le grou ps contra cted

P retreatment with topica l a n esthetic or ice for pa i n

Patient placed u p right

Treatment a reas wi ped with a l cohol

red uction

I njections a d m i n istered . Use of 1 ml syri nges with a 30


to 32 ga uge need l e is freq uently u t il ized . Use of i nsu l i n
syringes with a n i n tegrated 30-ga uge syri nge a n d a
h u b less system may hel p to red uce toxin vol u m e loss

M U SCLE G RO U PS
A thorough knowledge of the fac i a l m uscu latu re a n d
fac i a l a natomy is req u i red for the proper u s e a n d place
ment of botu l i n u m toxin ( Fig. 4. 1 ) .

Fore h ea d - F ro n ta l i s M u sc l e

( F i gs .

4.2

and

4.3)

Insertion: Originates at fro nta l bone ga lea a poneurotica


and i nserts i nto fibers of the procerus, corrugator, a n d
orbic u l a ris oc u l i
Function: O pposes depressor m uscles o f t h e g la be l l a r
com plex a n d brows t o elevate the brow a n d fo rehead
Lines noted: H o rizonta l l i nes ac ross the fo rehead
Injection technique: 2 to 3 u n its ( U ) added at 1 . 5-cm
i nterva ls ac ross the m idforehea d , a m i n i m u m of 2 e m
a bove t h e u pper brow
Dose injected: Average 12 to 20 U
Avoid:

Excess treatment of this m uscle; u n o pposed d e p ressor


fu nction wi l l res u l t in loss of u pper fac i a l express i o n , a
"ti red " a p pea ra nce, a n d risk of b row ptos is.

Treatment of this m uscle if the fronta l i s is s u p porting a


ptotic u pper eye l i d or if the patient has low-set brows
a n d/or excess u pper eye l i d s k i n .

I nject 1 e m a bove the eye b rows t o red uce t h e r i s k of


b row ptos i s . Patient m ust be awa re that res i d u a l l i nes
wi l l be present after the treatment if low fore head wrin
kles a re present.

Figure 4.3 (A) Forehead lines prior to B TX-A treatment. (B) Forehead
lines 1 month following B TX-A treatment

23

24

Color Atlas of Cosmetic Dermatology

I njection too c l ose to the med i a l orbita l ri m ; toxin d iffu

sion t h rough the orbital sept u m to the levator pa l pebrae


su perioris a n d orbicula ris m uscles may lead to d i plopia .

X
X

G l a b e l l a r Co m p l ex-T h e C o r r u gator

S u p e rc i l i i , the Proce r u s , M ed i a l

O r b i c u l a r i s O c u l i , a n d F r o n ta l i s
M u sc l es ( F i gs .

4.4

and

4. 5)

Insertion: Originates a t the nasa l process of the fronta l


bone a n d extends latera l l y a n d u pward to i nsert i nto the
m id d le t h i rd of the eye b row

Function: O p poses el evator m uscles of the fronta l i s for

b row a d d uction a n d brow/s k i n d ownward a n d med i a l


m ove ment
Lines noted: Frown l i nes; "a ngry" or "worried " a p pea r
a n ce
Injection technique: Fema les have a rc hed eye brows ;
ma les have flatter or horizonta l eyebrows ; tec h n i q ue ta i
lored to match the b row sha pe; 3 to 1 0 U i nto the pro
cerus; 4 to 6 U in the i nfe rior and s u perior bel l i es of the

Figure 4.4 Approximate injection sites for the glabellar frown lines.
(A) Female brow. (B) Male brow

corrugators; 2 to 3 U i nto the medial orbic u l a ris oc u l i


Dose injected: 1 5 t o 4 0 U ( d e pendent on m uscle mass)
Avoid:

U nd e rtreatment of t h i s region
Too low of a n i njection resu lting i n tox i n d iffusion i nto
the orbital se ptu m a n d orbit with resu lta nt l i d ptos is.
Pal pation of the su perior bony orbita l ri m with i nj ection
1 e m or more a bove this l a n d mark h e l ps to m i n i m ize
t h i s risk

Con c u rrent treatment of the forehead if a heavy brow is


noted

Pe r i o r b i t a l R eg i o n-O rb i c u l a r i s Oc u I i

( F igs.

4.6

and

4. 7)

Insertion: Enc i rcles the periorbita l region a n d i nserts i nto


the m e d i a l a n d latera l canthal te ndons as wel l as i nto the
fibers of the fronta l , proce rus, a n d corrugator su perc i l i i
m usc les
Function: Forcefu l closure of the eyes a n d d e p ression of
the brows a n d eye l i d s
Lines noted: Late ra l c a n t h a l l i nes; " c rows feet"
Injection technique: 3 to 5 U a re i njected i nto th ree
poi nts in a vertica l l i n e 1 em from the latera l canth us; if a
strong sna p test is n oted , 2 to 4 U c a n be placed 3 e m
below the m i d p u p i l lary l i ne
Dose injected: 22 to 38 U

Figure 4 . 5 (A) Glabellar complex before BTX-A injection and (B) 3 weeks

following B TX-A injection

Sect i o n 1 : Ph otoa g i n g

Avoid:

I njecti on of the i nfraorbita l region if a d e layed s n a p test

is n ote d ; ectropion of the i njected l i d may d eve l o p

Overtreatment o f this a rea ; i m proper eye c l os u re, brow

..

An i njection a i med too low at the lower periorbita l wrin


kles. Wea ken i n g of the levator labii su perioris m uscles

with a n u p per l i p d roop and a bnorma l s m i l e may be

U p p e r N a sa l R oot ( F i g .

, '

.:

observed

ptosis, or l i d ptosis may ensue

X
X

Figure 4.6 Approximate injection sites for periorbital lines

4 . 8)

Insertion: Encircles the periorbita l regio n a n d i nserts i nto


the m e d i a l a n d latera l ca ntha l te ndons as wel l as i nto the
fibers of the fronta l , proce rus, and corrugator su perc i l i i
m usc les

Function: Nasa l wri n k l i ng


Lines noted: U p per nose fa n n ing rhytides; " b u n n y l i nes"
I njection tec h n iq u e : 2 to 4 U is i nj ected i nto each latera l
nasa l wa l l i nto the be l l y of the u p per nasa l i s as it traverses
the d o rs u m of the n ose

Dose injected: 4 to 8 U
Avoid: I njection i nto the u p per nasofa c i a l groove may
resu lt i n lip ptosis
Use of botu l i n u m toxin i n the lowe r face is m i n i ma l ly
benefi c i a l . Other treatment modal ities a re l i kely to be
m ore benefic i a l with fewer potentia l side effects. A stro ng
u ndersta n d i n g of the lower fa ce and neck a natomy is c rit
ical for i njection placement ( Fig. 4 . 9 ) .

N a so l a b i a l Fo l d ( F i gs .

4. 1 0

and

4. 1 1)

It is key to weigh the l i m ited benefit of BTX-A in t h i s


region com pa red w i t h the i n c reased risk o f compl ica

tions. F i l l i ng agents may provide greater benefit with


fewer side effects.

Insertion: Result of s k i n laxity, gravitatio n a l ptosis, a n d


su bc uta neous fat loss overlying t h e c uta neous atta ch
ment i n the zygomaticus m a jor a n d m i nor, levator la bi i
su perioris, a n d

levator l a b i i s u perioris a laeq ue n a s i

m usc les

Function: Associated with mouth a n d l i p movement


Lines noted: Pro m i nent c rease, med i a l c heek; " g u m m y
show"

Injection technique: 1 to 2 U i njected i nto the u p per


aspect of the nasola b i a l fold 2 to 3 m m latera l to its i n ser
tion with the n ose

Dose injected: 2 to 4 U
Avoid:

Complete re laxation of this a rea ; u p per l i p ptosis c reat


i n g a sad a p pea ra nce may occ u r

Figure 4.7 (A) Periorbital lines prior to treatment with B TX-A. (B)
Periorbital lines 6 weeks following B TX-A treatment

25

26

Color Atlas of Cosmetic Dermatology

U n even pa ra lysis; a n asy m m etric s m i l e or d ispro por


tionate l i p may be seen

Per i o ra l R eg i o n-O r b i c u l a r i s O r i s

w i t h C o n t r i b u t i n g F i bers f r o m
t h e B u c c i n ator, C a n i n u s , a n d

Tr i a n g u l a r i s M u sc l es ; D e p ressor
A n g u l i O r i s ; M e n ta l i s M u sc l e
( F igs.

4. 1 2

and

4. 1 3)

l
X

Figure 4.8 Approximate injection sites for upper nasal root rhytides

Insertion: O r b i c u l a ris oris origi nates fro m the maxi l l a ry


a lveol a r bord e r ru n n i ng c i rc u mferentia l l y a ro u n d the
mouth to the overlyi ng cuta n eous attach me nts; d epres
sor a ngu l i oris ( DAOl a rises from the m a n d i b u la r o b l i q u e
l i n e , i nserting i nto the a ngle o f t h e mouth . I t is conti n uous
with the pl atysm a m uscle; menta l is m uscle origi nates
from the m a n d i b u l a r i n c i sive fossa and d escends to a
c uta neous i nsertion

Function: Op position a n d protrusion of the l i ps; mouth


a ngle d e p ression; lower lip protrusion a n d chin d i m p l i ng

Lines noted: Deep a n d s u p e rfic i a l rhyt id es, u p per a n d


lower l i p ; pro m i nent a n g u l a r folds, " s a d a p pea ra n c e " ;
c h i n wri n kl i n g

Injection technique: 0 . 5 t o 1 . 0 U i njected 2 t o 3 m m


a bove t h e verm i l i on bord er i n fou r a reas each for the
u pper and lowe r lip; 1 to 2 U i njected at the i ntersection
of a line d rawn from the naso l a b i a l fol d and a n a rea 1 e m
a bove the jawl i n e a ngle; 5 t o 1 0 U i nto the i nfe rior m id
chin

Dose injected: 4 t o 8 U for t h e u p per a n d lower l i ps ; 2 to


4 U for the DAO; 5 to 10 U for the menta l i s m usc le

Avoid:

Overtreatment of this a rea ; s peech d iffi c u lties, a n


asym metric s m i le, i n a b i l ity t o c l ose t h e m o u t h , d rooling
a n d a ltered fac i a l expressions may ensue

Deep i nj ecti ons; i n c reased risk of side effects

Too h igh of an i nj ecti on for the DAO; i n a b i l ity to raise

A u r i c u l ar i s su perior m u sc le
A u r i c u l a r i s anterior m usc le

the corner of the mouth may d evelop

N ec k- P l atys m a M u sc l e Co m p l ex

( F ig.

4 . 1 4)

Insertion: Origi nates on the fascia of the u p per pectora l i s

su perioris
muscle

-"71--'T-=-''-----T-+- 0 r b i c u l a r i s o r i s m usc l e
:.dr!'J-f- Depressor angu l i oris m usc l e
Depressor l a b i i i nferioris m uscle

major a n d de ltoid m uscles a n d proceeds u pwa rd a n d


med ia l ly a long t h e s i d es o f t h e neck. Fi bers a re i n serted
i nto the m a n d i ble, su bc uta neous tissue of the lower face,
periora l m uscle, and s k i n

Function: Fac i a l a n i mati o n ; lower jaw depressio n ; lowe r


l i p d e p ression

Lines noted: Neck wri n k l i ng; centra l ba nds

Figure 4.9 Anatomical illustration of the m usculature of the lower face


and neck

Sect i o n 1 : Ph otoa g i n g

Injection technique: 2 to 5 U i njected from the s u perior to


i nferior portion of each platys m a ! ba nd at 1 to 1 . 5 e m
i nterva ls w i t h the patient's teeth c l e n c hed to contract t h e
m usc le d u ri n g i njection
Dose injected: 20 to 1 00 U
Avoid: Too deep an i njection; neck wea kness, l a ryngea l
m usc le wea kness, or dysphagia may d evelop

POSTOPERAT I V E CO N S I D E RAT I O N S

I c e or cold compresses may b e a p plied to red uce pos


s i b l e bruising a n d edema

Active co ntraction of the treated m uscles for 20 to 30


seco nds every 30 m i n utes for 4 h o u rs afte r treatment
may exped ite tox i n u pta ke

Physical a ctivity s h o u l d be l i m ited for 4 h o u rs after

Figure 4. 1 0 Approximate injection sites for nasolabial folds

treatment to avoid the th eoretica l poss i b i l ity of u nto


wa rd toxin d iffusion

CO M P L I CAT I O N S

Tra nsi ent pa i n

Eye l i d ptosis

Eye brow ptosis

Bruising

Headache

I nc o m p l ete or asy m m etric chemical denervation

D i plo pia

D ry eyes

Ectro pion

Asym metrical s m i l e

Droo l i ng

Decreased p uc ke r

Dysphagia

P u n ctate keratitis

Mask- l i ke expression less face

Anti body resista nce

F l u - l i ke sym ptoms

Figure 4. 1 1 Approximate injection sites for the perioral muscles

T R EAT M E N T B E N E F I TS
R ecovery from B TX-A paralysis gen e ra l ly begins at 3 to
4 months after i njection . Patients who routinely receive
BTX-A may note the recovery time to exte nd to 4 to
6 months over ti m e . Side effects i n c l u d i ng eye l i d a n d
eye b row ptos is a n d b r u i s i n g ge nera l ly resolve with i n 2 to
3 weeks of onset. Treatment benefits may be lengthened
with concom ita nt conservative use of a fi l l e r fo r soft tissue

Figure 4. 1 2 Approximate injection sites for the depressor anguli oris

a ugme ntati o n .

muscle

27

28

Color Atlas of Cosmetic Dermatology

PEARLS FOR T R EATM ENT S U CCESS

Patie nts w i t h known neutra l iz i ng a nti bod ies aga i nst


Botox-A may res pond to Myo b l oc given the la ck of sig
n ificant c ross reactivity between the two tox i n s .

O n l y F DA-a pproved botu l i n u m prod ucts s h o u l d be uti


l i zed . U n l icensed botu l i n u m toxin may res u lt i n seve re,
l ife-th reate n i ng bot u l i s m .

I n the eve nt of an eye l i d ptos is, use of (a.-ad re nergic


agon ist eyed rops suc h as a p raclon i d i n e hyd roc h l oride
0.5% eyed rops ( l e p i d i n e , Alco n , Fort Wort h , TXl may
be used to provide tem pora ry lid elevation .

Patie nts s h o u l d be i nformed that the maxi m u m benefit


of Botox ca n ta ke up to 4 weeks to d eve l o p .

D e e p fu rrows w i l l o n l y pa rtia l l y respond to botu l i n u m

Figure 4 . 1 3 Approximate injection site for the mentalis muscle

treatment. C o m b i nation thera py with a filler su bsta nce


may provide the best c l i n ical end poi nt.

I t s h o u l d be em phasized to patients that a s i ngle botu


l i n u m treatment wi l l not be c o m p l etely effective i n e l i m
i nating a l l treated l i nes a n d wri n kles. A s we l l , it s h o u l d
be expla i ned t h a t s o m e res i d u a l m usc u l a r movement is
the desired treatment end point.

B I B L I OG RAPHY
Alam M , Dove r J S , Arndt KA . Pa i n associated with i njec
tion of botu l i n u m A exotoxin reconstituted using isoto n i c
sod i u m c h l o r i d e w i t h a n d without preservative: A dou ble
blind,

ra n d o m i zed

control led

tria l . Arch

Dermatol.

2002; 1 38 : 5 1 0- 5 1 4 .
Alste r T, L u pton , J . Botu l i n u m tox i n type B f o r dyna m i c
glabel l a r rhyti d es refractory t o botu l i n u m tox i n type A .
Dermatol Surg 2003 ; 29 ( 5 ) : 5 1 6- 5 1 8 .
B l itze r A, B i n der WJ , Aviv J E, e t a l . The ma nagement of
hyperfu nctional fac i a l l i nes with botu l i n u m tox i n . A col
la borative study of 210 i njection sites in 1 62 patients .
Arch Otolaryngol Head Neck Surg. 1 997 ; 1 23 : 389-392 .
B ra n d t F S , Boeker A . Botu l i n u m tox i n for t h e treatment of
neck l i nes a n d neck ba nds. Dermatol C l i n . 2004 ; 2 2 : 1 59166.
Carruthers A, Bogie M , Carruthers JD, et al. A ra ndom
ized , eva l u ator- b l i nded two-center stu dy of the safety and
effect of vo l u me on the d iffusion a n d efficacy of botu
l i n u m toxi n type A in the treatment of latera l orbita l
rhytides. Dermatol Surg. 2007;33: 567-57 1 .
Carruthers A , Kiene K, Carruthers J . Botu l i n u m A exo
tox i n use in c l i n ical d ermato l ogy. J Am Acad Dermatol.
1 996;34: 788-797 .
Carruthers J , Carruthers A . Botu l i n u m tox i n A i n t h e m i d
a n d lowe r face a n d nec k . Dermatol Clin. 2004;22 : 1 5 1 1 58 .

Figure 4.1 4 Approximate injection sites for the platysma muscle complex

Sect i o n 1 : Ph otoa g i n g

Carruthers J , Mata rraso S ;

Botox Consensus G ro u p .

Consensus recom mendation on t h e u s e o f botu l i n u m


tox i n type A i n fac i a l aesthetics. Plastic Reconstruct Surg.
2004; 1 1 4 : 1 S-22S.
Chertow DS, Ta n ET, Masla n ka S E , et al. Botu l ism i n
4 a d u lts fol lowi ng cosmetic i njections with a n u n l icensed ,
h ighly

conce ntrated

botu l i n u m

prepa rati o n .

JAMA.

2006 ; 296:2476-2479.
H s u TS, Dover J S , Arndt KA. Effect of vol u m e a n d con
centration on the d iffusion of botu l i n u m exotoxi n . Arch
Dermatol. 2004; 140: 135 1 - 1 354 .
Lelouarn C. Botu l i n u m tox i n A a n d fac i a l l i nes: The va ri
able concentratio n . Aesth Plast Surg. 200 1 ;2 5: 73-84.
Z i m bler MS, Holds J B , Ko l oska MS, et a l . Effect of botu
l i n u m tox i n p retreatment on laser res u rfa c i ng res u lts: A
p rospective, ra nd o m ized , b l i nded tria l . Arch Facial Plast
Surg. 200 1 ;3 : 1 6 5- 1 69 .

CHAPT E R 5

Che mical Peels

M ECHAN I S M O F ACT I O N
T h e a ppl ication o f a wou n d i ng agent t o i n d uce epidermal
a n d/or dermal slough i n g .

I N D I CAT I O N S

Epiderm a l d efects-e p h e l i des, melasma


Epiderm a l a n d dermal defects-melasma, lentigi nes,
post- i nfla m matory

hyperpigme ntati o n ,

acti n i c

ker

atoses, s u perfi c i a l rhytides, acne vu lga ris

Dermal d efects-deep rhytid es, acne sca rring, sca rs

P R EOPERAT IVE EVALUAT I O N


Peel i n g agents a re selected based o n t h e patient's
l i festyle, defect d e pth , s k i n cha racteristics, a n d defect
location (Ta bles 5 . 1 -5 .3 ) .

Past med ical h i story


- Past rad iation h i story-decreased a d nexa l structu res
l i kely
- H i story of ora l herpes s i m p lex virus-rea ctivation
may occ u r
- Pregna ncy-peels contra i n d i cated with t h e exception
of glyco l i c a c i d
- H i story o f k e l o i d formation-moderate a n d d eep
d e pth peels should be avoided

29

30

Color Atlas of Cosmetic Dermatology

TAB L E 5 . 1

C l inical I n d ications and Peel Types

I n d i cation

Peel d e pth/treatment e n d po i n t

Peel type

A c n e vu lga ris

S u perficia l when active

Localized epidermal peel i n g req u i red ; lesion a l i m p rovement

Ephelides; lentigines

S u perfic i a l or m ed i u m

Tota l epidermal pee l i ng req u i red for com plete remova l ; l ighte n i ng

Post-i nflam matory i nfla m mation

S u perfi c i a l or med i u m

Tota l epidermal pee l i ng req u i red ; l ighte n i n g with either strength

Melasma

S u perficia l or m ed i u m

Tota l epidermal pee l i ng req u i red ; l ighte n i ng with either strengt h ;

S u perficial rhytides

S u perficia l

Loca l i zed e p i d e r m a l pee l i ng req u i red ; softe n i ng

with s u perfi c i a l a pp l ication

i nconsistent res ponse


Moderate rhytid es

M ed i u m or deep

Tota l epiderma l a n d pa p i l l a ry d e r m a l peel ing req u i red ; softe n i ng

Deep rhytides

Deep

Tota l epidermal to reti c u l a r d e rma l peel req u i red ; softe n i ng

Acti n ic ke ratoses

M ed i u m

Tota l epidermal to pa p i l l a ry dermal pee l i n g req u i red ; lesio n a l cleara n ce

Depressed sca rs

M ed i u m o r deep

Les i o n a l ed ges targeted ; tota l epidermal a n d pa rtia l d e r m a l


pee l i ng req u i red; l esional flatte n i ng; va riable res ponse

TAB L E 5 . 2

Woun d i ng Depth of Superfi c i a l , Medium-Depth, and Deep-Depth Strength Peels

S u perfic i a l peel

M ed i u m -d e pth peel

Deep peel

a- Hyd roxy a c i d

G lyco l i c acid a n d TCA

Ba ker's Gordon phenol , u n occ l u d ed

M od ified U n na 's resorc i n o l paste

J essner's and TCA

Ba ker's Gordon phenol , occ l uded

J essner's

Solid carbon d ioxide a n d TCA

Sal icyl ic acid

50% TCA

Solid carbon d ioxide s l u s h

Pyruvic a c i d

Treti n o i n

8 8 % F u l l -strength p h e n o l

1 0%-25% TCA; 35% va ria b l e

TAB L E 5 . 3

Pee l i ng Agent Characteristics


Safe for

Peel type

Color end poi nt

G lyco l i c a c i d

Confl uent erythema

1-2 coats

1-2 h

A l l s k i n types

J essner

Pale wh ite

Coats a re a pp l ied singly a n d

4-5 d ; m i l d epidermal

A l l s k i n types

Appl ication

e n d point mon itored for

H ea l i n g time

d esq u a mation noted

3-4 m i n prior to repeat


a p pl ication
TCA (30% or greater)

Sol i d wh ite

Si ngle even a p pl icati o n ;

1 0-14 d ; severe

loca l i zed a p p l ications for

s u n b u rn - l i ke pee l i n g

l ighter wh ite a reas may

observed

I a n d I I ; caution
with I l l and I V

be considered
Phenol

G ray wh ite

S i ngle even a p p l icatio n ; can


be conservatively rea p p l ied

Past s u rgica l h i story


- Prior cosmetic proced u res-prior face l ift, blep h a ro
plasty, carbon d ioxi d e resu rfa c i ng, o r derma b rasion
may affect peel o utcome . I nc reased ectropion risk
prese nt.

Medication use
- Previous isotreti n o i n use and yea r
- To pica l med ications such as tret i n o i n a n d a-hyd roxy
acids may potentiate peel penetration
- Couma d i n use

1 0-14 d ; su perfi c i a l
b u r n a p pea ra n ce

I and I I

Sect i o n 1 : Ph otoa g i n g

31

Fitz patric k s k i n ph ototype


- Skin p hototypes I-I I I patients respond to a l l peel types.
- S k i n ph ototypes IV a n d V patients a lso respond to a l l
peel types, b u t the risk o f post-treatment dyspigmen
tation is greater.
- A test site may be wa rra nted for d a rker s k i n types to
eva l uate peel outco me .

Degree o f acti n i c d a mage a n d p h otoaging


- A wh ite l i ne of d e m a rcation between peeled a n d
u n peeled s k i n m a y b e pro m i nent i n t h e p resence of
moderate to severe dermatohel iosis.

Wood's lamp eva l uation


- H e l pfu l i n ascerta i n i ng pigmentation type p rese nt
- Epiderm a l

origi n :

lesional

color

e n h a ncement

( Fig. 5. 1 )
- Dermal o r c o m b i nation epidermal a n d derma l : n o
lesional color e n ha ncement to l ight
- Exa m i nation d oes not acc u rately pred ict c l i n ical peel
res ponse
- Epidermal pigment may res pond better to pee l i ng
agents com pared with d e r m a l or c o m b i nation p ig
ment d e position

Medical cleara n ce
- A rece nt electroca rd iogra m is necessa ry to serve as a
base l i n e for phenol peels in the event of ca rd i otoxicity.
- Liver fu nction a n d ren a l function tests s h o u l d be eva l
uated t o e n s u re adequate he patorenal fu n ction fo r
phenol pee ls.

I D EAL CAN D I DATE

S k i n p h ototype I or I I

Acti n i c d a maged s k i n

Static rhytides associated w i t h s u n expos u re

LESS I D EAL CAN D I DATE

Dyn a m i c rhyti d es-a c h i eved benefits a re tem pora ry i n


natu re

Exte nsive gravitati o n a l folds a n d fu rrows- l i kely to


req u i re s u rgica l i nterve ntion in conj u n ction with c h e m i
cal peels

Deep rhytides

Boxc a r a c n e o r mod erate d e pth atro p h i c sca rring

CONTRAI N D I CAT I O N S

U n rea l i stic patient expectations

Patient u n a b l e to perform necessa ry postoperative ca re

Figure 5 . 1 Thirty-one-year-old female with melasma. Wood's lamp accen

tuated her facial pigmen tation

32

Color Atlas of Cosmetic Dermatology

Patients with ice p i c k sca rs or d ee p atro p h i c sca rs

Patients with d i lated , la rge pore size

H i story of o ra l isotret i n o i n use with i n 1 yea r prior to p ro


ced u re

H i story of keloid formation


Patient with u n d e rlying ca rd iac a rrhyth m ias (for deep
peels)

Coumad i n use (for deep pee ls)

Skin p hototypes I l l-V I (fo r deep pee ls)

M E D I CAT I O N S

P reo perative a ntivi ra l medications a re reco m m e n d ed .


Va ltrex 500 mg B I D or Acyc lovir 400 mg T I D i n itiated
o n the day of p roced u re and conti n ued for 5 to 1 4 days
is a d m i n istered depend i n g on peel d e pt h .

Topical retinoic a c i d a n d a-hyd roxy a c i d prod ucts a re


d isconti n ued 48 h o u rs prior to a glycol i c acid peel a n d
1 wee k prior t o a deeper peel a n d n ot rei n itiated for
1 week post treatment.

WOU N D DEPTH
Determ i ned b y m u lt i p l e factors.

Anato m i c consid e rations


Fac i a l skin d iffers from non-fa c i a l s k i n i n the relative
n u m be r of p i l osebaceous u n its per cosmetic u n it a n d
t h i c kness. P ro m i nent a d nexa l structu res a re req u i red
to promote re-e pith e l i a l ization post treatment.
- The nose a n d forehead have more sebaceo us g l a n d s
t h a n d o the c h eeks or tem ples.
- The face has m o re sebaceous glands tha n the n o n
fac i a l a reas i nc l u d i n g the neck.
- M o re a cti n i c a l l y d a maged s k i n is t h i n n e r with fewer
p i l osebaceous u n its prese nt.
Body location and prese nce of acti n i c a l l y d a m aged

ski n sign ificantly affects the selection of the wo u n d i n g


agent. The pee l i ng agent m a y be m o re d estru ctive i n
a reas with fewer a d nexa l structu res a n d th i n ne r ski n ;
therefore a less aggressive pee l i ng agent s h o u l d b e uti-

1 ized in these a reas.

Prepeel s k i n d efatt i ng-use of acetone to d efat the


treatment a rea res u lts i n a deeper penetrati ng peel

Wo u n d i ng agent strength-a n i n c reased stre ngth wi l l

A m o u nt o f agent a p pl ied-deeper s k i n penetration with

resu lt i n d eeper s k i n peel i n g


each peel layer a p p l ied

Figure 5.2 (A) Epidermal melasma unresponsive to topical bleaching

creams.

Sect i o n 1 : Ph otoa g i n g

P E E L TYP ES

S u perfi c i a l peels-pa rtia l o r complete epidermal i nj u ry;


may exten d i nto the pa p i l l a ry dermis ( Fig. 5.2A a n d B)

M ed i u m-d e pth peels-i nj u ry exten d s i nto the pa p i l l a ry


to u p pe r reti c u l a r dermis ( Fig. 5.3A a n d B )

Deep

peels-i nj u ry exte nds

i nto the

m id - reti c u l a r

dermis

PROCED U R E

P reoperative written consent o bta i ned .

P reoperative p i ctu res ta ke n .

Patie nt's m a ke u p rem oved a nd face c l ea nsed with a n


a n tise ptic wash (eg, c h lorhexid i n e ) .

Scru b t h e treatment a rea with a cetone on cotton ga uze


for 2 to 3 m i n utes.

The pee l i ng agent s h o u l d be pou red i nto a glass c u p .

T h e pee l i ng agent is a p p l ied t o t h e treatment site .


- A pai ntbrush or cotton ba l l may be used to a p ply gly
colic a c i d .
- A sa ble b r u s h is rec o m m e nded f o r J essner peel for
i n c reased penetration .
- Cotton-ti p ped a p p l icators or cotton ga uze may be
used to a p ply tri c h l o roacetic a c i d

(TCA)

peel i n g

agents .
- One or two s m a l l cotto n-ti p ped a p p l icators a re used
fo r phenol a p p l icati o n .
- A rou n d toot h p i c k or wood en porti on o f a broken
cotton -ti p ped

a p p l icator

may

be

used

to

treat

i n d ivid u a l rhytides a n d icepick a cn e sca rs.


- The n u m be r of a p p l icators used and the p ressu re
a p plied to the treatment site with agent a ppl ication
will affect solution del ivery a n d d e pth of penetration
( Figs. 5.4 a n d 5 . 5 ) .

A fa n is req u i red t o h e l p red uce t h e associated patient


d iscomfort.

P retreatment with J essner o r glyc o l i c acid prior to a


TCA peel a l l ows for d ee per peel penetrati o n .

Feathering i nto t h e h a i r l i n e a n d at the jawl i n e con cea ls


the poss i b l e line of d e m a rcati o n . Feathering s h o u l d
a lso be performed when the periora l a rea is treated
a lone to p reve nt l i nes of d e m a rcation ( Fig. 5 . 6 ) .

The periorbita l tissue s h o u l d b e treated fi rst with TCA


peels, fol l owed by the n ose, c h eeks, peri o ra l a rea , a n d
forehead for best patient tolera n c e . The u pper a n d
lower eye l i d s m a y b e treated . Extension 2 t o 3 m m o nto
the periora l verm i l l ion is benefi c i a l for rhytid es red uc
tio n .

A sa l i n e syri nge s h o u l d b e ava i l a b l e i n t h e case o f i na d


verte nt i ntrod uction o f the pee l i ng agent i nto the eye .

Figure 5.2 (continued) (8) Mild improvement noted following two 50%
glycolic acid peels

33

34

Color Atlas of Cosmetic Dermatology

The a pp l icator should be wrung out a n d sem i-d ried to


p reve nt d ri p p i ng. The glass conta i ner s h o u l d be h e l d
away from the patient to avoid d i rect s pi l l i ng o n t o t h e
patient.

J essner

pee l ,

TCA,

and

phenol

peels

a re

self

neutra l izi ng. G lycol i c a c i d pee ls m ust be neutra l ized


with water o r bica rbonate solution .

Cool was h c l oth is a p p l ied to the treated a reas.

Vase l i n e is a p plied to the treatment site fo r J essner,


TCA, a n d phenol peels. G lyco l i c a ci d peels req u i re a
I ight moistu rizer.

Deep peels have i n h erent card ia c , rena l , a n d h e patic


toxicities. F u l l -face a p p l ication req u i res i ntravenous f lu
ids, sedation , cardiac mon itoring, p u lse oxi meter, a n d
blood pressu re mon itoring.

COM P L I CAT I ON$

G reater d e pth of peel provided than expected ( Fig. 5 . 7 )

I nfection-vira l , bacteria l , funga l

Tem po ra ry o r perma nent hyperpigme ntation o r d e pig


mentation

Prolonged e rythema
Sca rring-atro p h i c , hypertro p h i c , keloida l ; ectro p i o n ,
d e layed hea l i n g

Conta ct dermatitis

Text u ra l c h a n ges

Acne

M i l ia

Figure 5.3 (A) Pseudo-ochronosis. The pigmentary changes persisted

Cardiac a rrhyth m ias (deep phenol pee l )

despite discontinuation of the inciting medication.

La ryngea l edema ( d e e p p h e n o l pee l )

POSTOP E RAT I V E CAR E

A l ight moistu rizer i s a p p l ied twice d a i l y for glyco l i c a c i d


peels.

Vase l i n e is ke pt o n rou n d the clock with twice d a i ly


c l ea n s i ng soa p a n d water, J essner, TCA, a n d phenol
peels.

Strict photoprotection is stressed fo r a m i n i m u m of


1 month after a glycol i c acid peel and 2 to 3 months for
the re m a i nd e r of peels.

Patie nts a re i n structed to a l low nat u ra l slough i n g of the


treated ski n . The skin m ust n ot be m a n u a l ly removed .

PEARLS FOR T R EATM ENT S U CCESS

Ca refu l patient selection a n d p e e l selection is n eces


sa ry for treatment s uccess. I t is best to u nd e rtreat with
a less potent peel i n g agent in non-fa c i a l a reas to m i n i
m ize the risk of sca r formati o n .

Sect i o n 1 : Ph otoa g i n g

35

Patie nts m u st be awa re of the expected recovery time


with each chemical peel a n d the n ecessa ry posto pera
tive wou n d care they wi l l n eed to perform to exped ite
hea l i ng . Although one deep peel may provide the great
est benefit, l ifestyle or work constrai nts make seria l
su perfi c i a l or med i u m -d e pth peels a bette r long-te rm
goa l .

T h e m a rgi n o f safety is m u c h n a r rower a n d t h e risk of


c o m p l ications

much

greate r

with

i n c reased

peel

strengths .

Patients w i t h s k i n ph ototypes I l l a n d I V h a v e a greater


risk of d eve l o p i n g pregna n cy- i n d uced hypertension
after a chemical peel . Consideration of a test site is wa r
ra nted for m ed i u m-depth pee l s .

C h e m i c a l pee ls w i l l n o t a lter pore s i z e a n d may i n fact


i n c rease thei r size.

B I B L I OG RAPHY
Ba ker TJ , Gordon H L, M osienko P, e t a l . Long-term h i sto
logica l study of s k i n after c h e m i c a l fac i a l pee l i ng. Plast

Reconstr Surg 1 9 74;53: 522-52 5 .


B rody HJ . M ed i u m-depth c h e m i c a l pee l i ng o f the s k i n : A
va riation of su perfi c i a l che mosu rgery.

Adv Dermatol.

1 988; 3 : 205-220.
G r i mes PE. Melasma : Etio l ogic and therapeutic consid e r
ations. Arch Dermatol. 1 997; 1 3 1 : 1453-1457.
G ross D . Ca rd iac a rrhyth m i a d u ri n g phenol face pee l i ng.

Plast Reconstr Surg 1 984; 73: 590-594.

Kligman A M , B a ker TJ , Gordon H L. Long-term h isto logic

Figure 5.3 (continued) (B) Marked pigment lightening after three Jessner
35% TCA peels

fo l l ow- u p of phenol face peels . Plast Reconstr Surg.


1 985 ; 7 5 : 652-659 .
La n d a u M . Com bination of c h e m i c a l pee l i ngs with botu
l i n u m toxi n i njections and

dermal fi l l ers . J Cosmet

Dermatol. 2006; 5(2 ) : 1 2 1 - 1 26.


M a c Kee G M , Ka rp FL. The treatment of post-a c n e sca rs
with p h e no l . Br J Dermatol. 1 9 52 ; 64( 1 2 ) :456-459 .
Mata rasso SL, G loga u R G . C h e m i c a l face peels. Dermatol

C!in. 1 99 1 ;9 : 1 3 1 - 1 50.
M o n h eit

G.

The J essner's-tric h l o roacetic

acid

pee l .

Dermatol Clin. 1995 ; 1 3 ( 2 ) : 2 77-283 .


M u ra d H , S h a m b a n AT, Premo PS. The use of glycol i c
acid as a pee l i ng agent. Dermatol Clin. 1995; 1 3 ( 2 ) : 285307 .
Que SK, Bergstrom KG . Hyperpigmentati o n : O l d p roblem,
new thera pies. J Drugs Derma tal. 2009;8(9 ) : 879-882 .
R u l l a n P, Ka ra m A M . Chemical peels for d a rker skin types.

Facial Plast Surg Clin North Am. 2010; 1 8( 1 ) : 1 1 1- 1 3 1 .


Szzc h owicz E H , Wright W K . Delayed hea l i ng after fu l l
face c h e m i c a l pee ls. Facial Plast Surg. 1 989;6( 1 ) :6- 1 3 .

36

Color Atlas of Cosmetic Dermatology

Figure 5.4 Fine white color immediately following a 20% salicylic acid

peel

Sect i o n 1 : Ph otoa g i n g

Figure 5 . 5 Pale white color immediately following a Jessner peel

Figure 5.6 Solid white color immediately following a Jessner/35% TCA

peel

37

38

Color Atlas of Cosmetic Dermatology

Figure 5.7 Patient with line of demarcation between the Jessner/35%

TCA peel treated perioral area and untreated skin. Patient appears
hypopigmented in the treatment site. A subsequent medium-depth peel
to the remainder of the face resulted in a more even facial appearance

Figure 5.8 Localized frosting following application of a 50% glycolic acid


peel. The localized peel resulted in some mild desquamation for 3 days

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 6

No n a blative Lase r R esu rfaci n g

I N TRODUCT I O N
There a re m u lti ple laser a n d l ight sou rce treatments for
p h otoaging. These treatme nts ra nge in effi cacy a n d side
effects . Typical ly, there is a trad e-off between c l i n ica l
i m prove ment a n d a concom ita nt i n c rease i n s i de effects
a n d d ownt i m e fro m work a n d soc i a l activities . Oth e r
cha pte rs have foc used o n s u c h treatments as n o n a b l a
tive fra ctional resu rfaci ng, a blative fractional res u rfa c i ng,
and tra d itional res u rfa c i ng. This c h a pter exa m i nes non
a b lative laser resu rfa c i n g a n d , i n partic u la r, the use of
m id-i nfra red lasers . Other d evices such as i ntense pu lsed
l ight, n o n a b lative fractional res u rfa c i ng lasers, and vas
c u l a r lasers a lso ach ieve n o n a b l ative benefits, a n d a re
add ressed i n d eta i l i n oth er cha pters .
P h otoaging encom passes a l l the cha nges prod uced by
expos u re to u ltraviolet ( UV) rad iation, i n c l ud i ng tela ngiec
tasias, rhyti d es, poor skin text u re, and tone as we l l as
ski n laxity (see Dermatohel iosis c h a pter) . N o n a b l ative
rej uve nation treats s u n -da maged s k i n by heati ng d e r m a l

Figure 6.1 Vesicles appeared 1 day after treatment with a 1 4 50-nm

col lagen w i t h the a i m o f sti m u lating n ew collagen growt h .

diode laser with a Fitzpatrick skin type 1 patient. These vesicles com
pletely cleared without sequelae 3 days later

I t is a lso effective i n t h e treatment o f a c n e scars.


Epiderma l cool i n g is p rovid ed to e n s u re that thermal
heati ng is ta rgeti n g the dermis, a n d n ot the e p i d e r m i s .
The best adva n tage o f nona b lative treatme nts is t h a t they
req u i re l ittle, if a n y, d ownti me from work a n d soc i a l activ
ities. This is i n contrast to a blative and fra ctional a b lative
treatm ents . In s k i l led h a n d s , side effects a re typ i ca l ly
m i l d a n d tem pora ry ( Fig. 6. 1 ) .
Ofte n , they p rod uce s u btle o r m i l d ben efits , eve n after
m u ltiple treatments. U nfort u nately, the p red icta b i l ity of
i m prove ment is u ncerta i n . Some patients d o not experi
ence a ny d iscern i b l e ben efit even after m u ltiple treat
ments. In the past few yea rs, nona blative fractional lasers
have p rod uced e n h a nced results from other forms of
n o n a b l ative res u rfa c i ng, with m u ltiple treatments. Th ese
lasers have a lso p roven to be safe in s k i l led h a n d s . With
the advent of nona b lative fractional lasers, trad itio n a l
n o n a b l ative laser res u rfa c i n g has decl i n ed i n popula rity.
In add ition to i ntense p u l sed l ight sou rces a n d vasc u l a r
lasers, there a re m a n y n o n a b lative devices t h a t util ize vis
i b le, nea r- i nfra red , and m id - i nfra red wavelengths with
e p i d e r m a l skin coo l i n g . These wavele ngths target the
water that is a b u nda nt in dermal tiss u e. The skin cool i ng
p rotects aga i n st epidermal da mage. T hese lasers p ro
d uce d ee pe r dermal penetrati o n , greate r a bsorption , a n d
d e r m a l therma l i nj u ry t h a n vasc u l a r lasers. F u rther, there
is sign ifica ntly decreased risk of pigme nta ry c h a nges i n
d a rker s k i n phototypes a t these wavelength s . W h i l e the
best ca n d id ates for treatment a re those with m i ld to mod
e rate static rhytides, the d egree of i m provement after
treatment is d iffic u lt to q ua ntify.

39

40

Color Atlas of Cosmetic Dermatology

N o n a b lative lasers

Su btle i m provement of rhyti d es, pa rti c u l a rly when com


pa red to a blative d evices
- Best for patients with m i l d to moderate p h otod a m
age, s k i n laxity, a n d s k i n coa rseness

Req u i res m u ltiple treatments to p rovide m i l d i m p rove


ment of s k i n text u re, tone, a n d rhytides

Little to no posto perative d ownti me compared to tra d i


t i o n a l a blative d evices

Patient can return to work o r soc i a l activities the sa me


day as the proced u re

Ca n treat cosmetic u n its effective ly without l i nes of


dema rcation

I N D I CAT I O N S

I n d ications
- M i l d rhyt id es
- P h otoda mage, i n c l u d i n g s k i n texture a n d tone
- Acne sca rs, i n c l u d i n g boxca r, atro p h i c , ro l l i n g sca rs
- S u btle benefit
- M i ld i m provement in s k i n laxity
- N ot effective for dyna m ic or deeper rhyti des

P R EOPERATIVE EVALUAT I O N

S k i n type (can treat d a rker s k i n types with m id-i nfra red


lasers, but req u i res caution with s k i n coo l i ng)

Sun exposu re

H istory of ke loids

Figure 6 . 2 (A) Patient with EMLA under occlusion prior to treatment of

l sotret i n o i n use i n past 6 months

acne scars. (B) Treatment with 1 4 50-nm diode laser with DCD cooling

Patie nts with u n rea l istic expectations


A consu ltation is req u i red before this treatment to

assess the patient as wel l as a p p ro p riately prepare the


patient for the proced u re . The patient s h o u l d be fully
educated as to the risks a n d benefits of the proced u re . I t
is i m perative t h a t expectations a re s e t rea l i stica l ly i n
te rms o f t h e m i l d d egree of i m provement that w i l l often
be seen for rhytides . The patient s h o u l d a lso be i nfo rmed
that the ben efits of rhytid treatment accrue 3 to 6 months
after treatment.

PROPHYLAX I S/AN ESTH ES I A


M a y i nc l u d e a n y o f t h e fol l owi ng:

Antiviral prophylaxis

Topical a n esthetic
- 23% Lidoca i n e!? % tetraca i n e
- 7 % Lidoca i n e/7 % tetra ca i n e
- Eutectic m ixtu re o f loca l a n esthetic ( E M LA)

Sect i o n 1 : Ph otoa g i n g

41

Beca use some of m id-i nfra red laser treatme nts c a n be


pa i n fu l , some form of a n esthesia is ofte n req u i red . It wi l l
va ry accord i ng t o t h e aggressiveness o f treatment, the
pa rti c u l a r suscepti b i l ities of the patient, a nd the physi
c i a n 's comfort with va rious a n esthetic reg i m e n s .

M i d - i n fra red Lasers


The 1320- n m N d :YAG laser ( Coolto u c h I n c . , Rosevi l le ,
CAl featu res a t h e r m a l feed back system t h a t measu res
e p i d e r m a l tem peratu re to more precisely ta rget dermal
collage n . Thus, the laser s u rgeon can control h eati ng
with more p recision . I t is theorized that n ew col lagen
sti m u lation is caused by i nfla m matory cyto k i n es after

d e r m a l heati ng.
The 1450-n m d iode laser ( S m ooth bea m , Candela
Corp . , Wayl a n d , MAl a lso targets dermal water, while
p rotecti ng the e p i d e r m i s with a c ryoge n s p ray d evice
( Fig. 6 . 2 ) . There is n o tem peratu re feed back device. With
either device, aggressive coo l i ng can p rod uce tem pora ry
pigmenta ry c h a nges.

LAS E R SAFETY

Eye protection : m eta l eye goggles


- All perso n n e l p resent at the time of treatment m ust
wea r safety glasses/goggles to avoid

i nadverte nt

cornea l d a mage.

Figure 6.3 Pretreatment and immediate posttreatment photos of non

ADV E R S E S I DE EFFECTS
Adverse side effects: fa r less co m mo n than a blative pro
ced u res, but do occ u r with h igher fl u e n ces as we l l as
i nadvertent pu lse sta c k i n g ( ie, fi r i ng twice in ra p i d s u c
cession over the sa me a real

Sca rring

B u l lae ( Fig. 6 . 2 )

Posti nfla m matory

hyperpigme ntation

( us u a l l y

from

ove rly aggressive s k i n cool i ng)

Posto perat i ve C a re ( F i g .

6. 1)

Little postp roced u re pa i n .

A n y e rythema i s m i l d a n d resolves sh ortly after treat


ment.

There is no req u i rement for a fol l ow- u p visit afte r treat


ment.

N o posto perative c a re is req u i re d .


Patient s h o u l d b e i nstru cted t o ca l l if erythema persists
or if vesic les or b u l lae d evel o p ( Fig. 6 . 1 ) .

bruising pulsed dye laser treatments. There is mild erythema after treat
ments. Many patients note an improvement in the texture and tone of
skin after a series of treatments

42

Color Atlas of Cosmetic Dermatology

Postoperative erythema resolves q u ic kly. Strict s u n


avoidance is recom mended .
The fol l owing practices a l l sign ifica ntly i n c rease the

risk of sca r:

Aggressive treatments i n c rease risk of sca r

Poor tec h n iq u e, ie, excess ive overla p ( p u lse stacking)


In sum, nona b lative laser resu rfa c i n g proced u res offer

the adva ntage of q u ic k , safe treatments that p rod uce


m i l d i m provement of photoda maged ski n . U s u a l ly, they
can be performed on the sa m e day as work a n d soc i a l
o b l igation s. N o n etheless, the treatment has i t s d raw
backs s u c h as

Resu lts a re usua l ly modest.

D u ration of benefit, if a n y, is n ot known .

Best resu l ts often req u i re more m u ltiple treatments.


Beca use the i m provement i s often s u btle and u n p re

d icta b le, eve n after m u lt i p l e treatme nts, other proce


d u res s u c h as nona blative fract i o n a l resu rfa c i ng have
i n c reasingly s u p pla nted the a p pea l of trad iti o n a l nona bla
tive p roced u res.

B I B L I OG RAPHY
Ta nzi EL, W i l l i a m s C M , Alster TS. Treatment o f fac i a l
rhytides with a nona b lative 1450- n m d iode laser: A con
trol led c l i n ic a l a n d

h istologic study.

Dermatol Surg.

2003 ; 2 9 ( 2 ) : 1 24- 1 28 .
Ta nzi E L , Alster TS. C o m pa rison o f a 1450- n m d iode
laser and a 1320- n m N d :YAG laser i n the treatment of
atro p h i c fa c i a l scars: A prospective c l i n ical and h isto logic
stu d y. Dermatol Surg. 2004;30(2 Pt 1 ) : 1 52- 1 57 .

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 7

A b l ative Lase r R es u rfaci ng

M ECHAN I S M OF ACT I O N
U t i l i z i n g t h e p r i n c i ples of selective photothermolysis,
a b lative rem ova l of s k i n i n a precisely control led fas h i o n
w i t h resu lta nt m i n i ma l s u rro u n d i n g t h e r m a l d a m age is
ach ieved . The d e pth of tissue penetration is dependent
on sel ective a bsorptio n of water. I m med iate tissue effects
a re d e pendent on the s pot s ize a n d power uti l ized as we l l
as t h e s peed o f treatment a d m i n istration . T h e ti me of
laser-tissue i nteraction is the critical factor for res i d u a l
thermal da mage. Epidermal o b l iteration a n d (or pa rtia l
a b lation o r coagu lation o f t h e u pper d e r m i s is t h e en d
point. Re-epith e l i a l ization resu lts fro m the m igration of
cells that a rise from su rro u n d i ng fol l i c u l a r ad nexae .
N o r m a l com pact col lagen a n d elastic fibers re place the
a m orphous elastotic dermal com pone nts, a n d norma l ,
we l l-orga n ized epith e l i a l cells replace t h e d i sorga n ized
p hotoda maged epidermis. Col lagen re mode l i n g is n oted
both i ntraoperatively via therm a l s h r i n kage and contrac
tion and postoperatively with i n the re mod e l i ng phase of
wo u n d hea l i ng.

C a r b o n D i ox i d e Laser

( C 0 2 R es u rfac i n g)
Conti n uo u s

wave

( 10,600 n m ) ,

s u per- p u lsed ,

and

sca n ned C0 2 lasers a re util ized for res u rfa c i ng. A rela
tively b l ood less su rgery with red uced swe l l i ng is a c h ieved
via the p h otocoagu lative effect on blood vesse ls and lym
phatics. The risk of sca rring, u n p red icta b l e level of th er
mal d a mage, a n d d e layed hea l i ng of the conti n uous wave
laser l i m it its c l i n ical use. The sca n n ed a n d p u lsed C0 2
lasers d e l iver high pea k fl u en ces in less tha n 0.001 sec
onds to a c h i eve tissue va porizatio n of 20 to 30 1-1m per
pass . Approxi mately 40 to 120 1-1m of res i d u a l thermal
d a mage is n oted per pass ( Fig. 7 . 1 ) .

E r b i u m : Ytt r i u m - A i u m i n u m G a r n et

Laser ( E r : YA G )
A laser o f wave length 2 ,490 n m i s uti l ized for more
s u perfic i a l

resu rfa c i ng.

It

is

16x

m ore

selectively

a bsorbed by water. It a c h i eves tissue va porization of 1 to


5 1-1m per pass. It res u l ts in a na rrower zon e of res i d u a l
t h e r m a l da mage ( 5-30 1-J m ) . A s a z o n e o f therm a l d a m
a g e o f 50 1-1 m o r greate r is req u i red f o r ph otocoagulati o n ,
Er:YAG treatment resu l ts i n a s l ightly b l oody s u rgica l fie l d .
The t h e r m a l d a mage is a lso i n s ufficient t o prod uce
i m med iate

c o l l agen

contra cti o n .

re model i ng is l i m ited ( Fig. 7 . 2 ) .

Long-term

col lagen

Figure 7 . 1 (A) A 58-year-old woman with extensive actinic damage.

43

44

Color Atlas of Cosmetic Dermatology

I N D I CAT I O N S
Ablative lasers have been util ized as a c utti ng too l a n d
va poriz i n g tool t o treat epidermal a n d su perfi c i a l d e r m a l
lesions.

Cutting too l :

keloids, acne kelo i d a l i s n uchae, cyst

remova l , basa l carc i n o m a , b u r n , a n d u l ce r d e b ri d e


ment; h a i r tra nspla ntat i o n ; b l e p h a ro p lasty; other i n c i
sional s u rgeries where control led hemostasis is desi red
or where e p i n e p h r i n e is contra i nd icated or a pacer pre
c l udes use of e l ectrosu rgery.

Va porizi ng tool : treatment of n u merous cond itions


i n c l u d i ng static and dyna m ic rhyt id es, boxca r, c rateri
form and hypertro p h i c acne sca rs, pox scars, wa rts,
lentigines, adenoma sebace u m , a ngi okeratomas, pyo
gen i c

gra n u l o m a ,

lym pha ngioma

c i rc u mscri ptu m ,

Bowe n 's d i sease, eryt h roplasia o f Queyrat, o ra l florid


pa p i l l om atosis, acti n i c c h e i l itis, acti n i c keratoses , epi
d e r m a l n evi , syri ngomas, gra n u loma faciale, n e u rofi
b romas, xa nthelasma , and tattoos.

N ot i n d icated for the treatment of icepick acne sca rs .

P R EOPERATIVE EVALUAT I O N
Sign ifi cant past med ical h istory i nc l udes a h istory o f her
pes l a b ia l is; u n derlyi ng a uto i m m u ne d i sease or i m m u n e
d eficiency; u nd e rlyi ng koe bnerizing/i nfectious cond itions
i n c l u d i ng psoriasis, verrucae, and m o l l u sc u m ; h i story of
keloid or hypertro p h i c sca r format i o n ; u n derlying card ia c
o r p u l m o n a ry cond itions t h a t may be exacerbated by t h e
u s e o f a n esthetic medications; existi ng d rug a l le rgies;
tobacco use; a ctive acne vu lga r i s .
Sign ifica nt past s u rgica l h i story i n c l udes prior s u rgica l
treatments to the treatment sites, s u rgica l dates, a n d
patient response.
The patient m ust be awa re of the lengthy recovery
period that w i l l req u i re extens ive h a n d s-on patient care
for o pti m a l treatment resu lts . Re-epit h e l i a l ization req u i res
7 to 10 days with associated pa i n , ed e m a , a n d e rythe m a .
Posto perative erythema resolves over a n ave rage period
of 3 to 5 months. Strict sun avoida nce m u st be fol l owed
for a m i n i m u m of 1 yea r posto peratively to avoid pigmen
ta ry cha nges a n d p h otose nsitivity. Rea l istic expectations
a re the m ost i m porta nt d ete r m i n a nts of treatment suc
cess . The patient m ust be aware that the treatment wi l l
i m prove b u t d oes n ot e l i m i nate a l l or even m ost rhytides
or sca rs a n d that dyna m i c rhytides a re l i kely to rec u r
with i n a few months postoperative ly.
P roced u ra l

risks to em phasize i n c l u d e tem pora ry

a n d/or perma nent hyperpigme ntation a n d d e pigme nta


t i o n , i nfection (vi ra l , bacteria l , yeast ) , a n d sca r (atro p h i c ,
hypertro p h i c , keloi d a l ) fo rmati o n ; a c n e fla re; eczema
last i n g 1 to 2 months. Pred icta ble side effects i n c l u d e
proced u ra l a n d posto perative d iscomfort; edema , oozi ng,

Figure 7.1 ( continuedJ (B) A marked reduction in rhytides and dyspig

mentation is noted 2 months after full-face carbon dioxide resurfacing

Sect i o n 1 : Ph otoa g i n g

45

a n d crusti ng lasting 1 to 2 weeks; e ryth em a , s k i n tight


ness, a n d pruritus lasti ng u p to 3 to 4 months.

I D EAL LAS E R CAN D I DATE

Fa i r s k i n type ( Fitzpatrick phototypes I-l l )

Laser-a menable lesions

M i n i ma l assoc iated dyspigme ntation of neck a n d c h est

Abl e to tole rate exte n d ed period of conva lesce nce post


operatively

Able to fo l low and exec ute necessa ry posto perative s k i n


ca re regi men

Rea l istic treatment expectations

LESS THAN I D EAL LAS E R CAN D I DATE

Da rker s k i n type ( Fitzpatrick ph ototypes I l l , IV, a n d Vl;


treat with cauti o n , d ue to sign ifica nt risk of tem po ra ry
a n d/or permanent pigmenta ry a lterations

Moderate associated d ys p igme ntation of neck and


c h est

U na b l e to fol low a n d execute necessa ry postoperative


s k i n care regi m e n

P r i o r fac i a l s u rgica l proced u res performed


P ro m i nent fac i a l pore pattern-laser treatment may
exacerbate the i r a ppea ra nce

ABSOLUTE CONTRA I N D I CATI O N S

Use of o ra l treti n o i n with i n 1 yea r o f su rgery

S k i n p h ototypes V a n d V I

Active cuta neous i n fection

P reexisti ng ectropion

Poor patient c o m p l ia nce

U n re a l istic patient expectations

R E LAT IVE CO NTRA I N D I CAT I O N S

Exte nsive u nderlying dyspigmentation of face a n d


su rrou n d i n g neck a n d c h est-risk o f d e m a rcatio n l i ne/
d ifference in s k i n color of treated vers us u ntreated s k i n

S k i n p h ototypes I l l a n d I V

U n d erlying connective tissue

U n d erlying koebnerizing cond ition

U n d erlying i m m u nologic d i sease

P revious lower lid a n d/or blepha roplasty (for i nfraorbita l


resu rfa c i ng)

Figure 7.2 (A) A 45-year-old woman with facial photoaging and mild acne
scarring.

46

Color Atlas of Cosmetic Dermatology

Previous ablative resurfacing, derma brasion, cryosu rgery;


face l i ft or phenol peel

H i story of fac i a l rad iation treatment

M E D I CAT I O N S

Anti bacterial thera py: t o avoid i m petigi n i zation a n d


bacterial i nfection o f t h e treatment sites, prop hylactic
a nti biotics a re i n itiated 1 day p reo peratively.
- Dic loxa c i l l i n 500 mg PO B I D or Keflex 500 mg PO
B I D for 1 0 to 14 days is presc ri bed .
- I n pen i c i l l i n-a l lergic i n d ivi d ua ls, Ci profloxa c i n 500 mg
PO B I D
PO

10 to 14 d ays or azith romyc i n 500 mg

1 day fo l l owed by 250 mg d a i ly for 5 days is

reco m m e n d ed .

Antiviral thera py: laser resu rfa c i n g may trigger a herpes


s i m p l ex outbrea k that can spread to the treatment sites
with an i n c reased risk of sca r fo rmation .
- Prop hylactic a ntiviral medications a re i n itiated 1 day
p reoperatively.
- Va lacyc lov i r 500 mg PO B I D for 14 days or acyc l ovi r
400 mg PO T I D for 14 d ays is reco m m ended .

Topical treti n o i n
- Use o f treti n o i n prior t o C02 l a s e r res u rfa c i n g h a s
b e e n shown c l i n ica l ly a n d v i a b i o c h e m i c a l a na lysis to
not provide e n h a n ced collage n formati o n , acceler
ated re-e pithe l i a l izati o n , or q u icker resol ution of post
operative erythema.
- Use of this med ication is o ptiona l .
- Use o f this medication postoperatively s h o u l d be
postponed u n t i l a l l associated e rythema and i nfla m
mation have resolved .

B l eac h i ng c rea ms: no p u b l ished , control led trials have

Figure 7 . 2 ( continued) (B) Improvement of photoaging 3 weeks after full

demonstrated the ben efits of preo perative bleac h i ng

face erbium treatment

c rea ms to red uce the risk of postinfl a m matory hyper


pigme ntati o n . To possi bly red uce this risk, patients with
skin p h ototypes I l l and I V a re presc ri bed a blea c h i ng
c rea m to be a ppl ied twice d a i ly for 6 to 7 weeks prior to
treatment. As we l l , strict s u n avo i d a n ce is m a n d atory.

AN ESTH ES I A

Cold-a i r cool i n g ( Z i m mer) may b e a d eq uate for loca l


ized or si ngle-pass C0 2 treatment or Er:YAG treatment.

Topical a n esthesia may be adeq uate for loca l ized or


si ngle-pass C0 2 treatment o r Er:YAG treatment.

Regio n a l n e rve b l oc ks with su pple menta l i nfi ltrative


a n esth esia a re ge nera l ly a d m i n istered for m u lti ple- pass
C0 2 treatment.

Sect i o n 1 : Ph otoa g i n g

- Site-dependent b l ocks i n c l u d e s u p raorbita l , s u p ra


troc h lea r, i nfraorbita l , and menta l blocks.
- Lid oca i ne (1 % ) with 1 : 1 00,000 o r 1 :200, 000 epi
n e p h r i n e , a tota l of 0 . 5 to 1 . 0 ml is a d m i n istered per
site .
- S u p plementa l i nfi ltrative a n esthesia consisting o f a n
eq u a l m ixtu re o f 1 % l idoca i n e , 0 . 5 % b u pivaca i n e ,
a n d 1 : 1 0 sod i u m bica rbonate is ge nera l ly req u i red ,
espec ia l ly for the jawl i n e , u pper eyel ids, a nd te m ples.
- Hya l u ro n i dase (Wyd ase) 7 5 U for tissue d iffusion
may be a d d ed to the i nfi ltrative a nesthes i a .
- Treatment is delayed 1 0 t o 1 5 m i n utes to a l low for
c o m plete a n esthetic effect.

Conscious i ntravenous sed ation a n d gen e ra l a n esthesia


have been e m p l oyed by tra i ned physicians i n ce rtified
fac i l ities i n patients u n a b l e to tolerate the i njections or
for la rger proced u res.

SAFETY M EAS U R ES

Eye protection
- One o r two d ro ps of 0 . 05% to pica l pro pa raca i n e
(Aica i n e ) or 0.05% topica l tetra ca i n e ( Pontoca i n e )
a re placed i nto e a c h eye o f the patient, fol l owed by
the a ppl ication of to pica l e ryth romyc i n oi ntment o r
o p htha l m i c l u bricant ( e g , Lacri-Lu be) a n d non reflec
tive m eta l l ic ocu l a r shields (eg,

Byron

Medica l ,

Tucso n , AZ; Ocu lo-Piasti k , M o ntrea l , Canad a ) .


- A l l perso n n e l m ust wea r clea r p lastic safety glasses to
avo i d i nadve rtent cornea l d a mage .

Operative field
- All reflective su rfaces and windows m ust be covered
to avoid inadve rtent treatment of a reflective s u rface.
- The treatment room door m u st be la beled properly to
wa rn others not to enter d u ri n g laser treatm ent.
- A l l fla m ma ble materials and a nesthetic gases m ust
be kept away fro m the operative field .
- Wet d ra pes a n d sponges a re pla ced a ro u n d the s u r
gica l s ite to preve nt accide nta l i rrad iation of s u r
ro u n d i ng s k i n a n d to m i n i m ize potentia l fi re risk.
- A nonfla m m a b l e oi ntment (eg, S u rgi l u be; KY J e l ly)
m ust be placed ove r the exposed h a i r l i n e and eye
brows to avoid h a i r si nge i n g . S u rgi l u be s h o u l d not be
used over the eyelas hes to avoid the risk of cornea l
keratitis.
- All s u rgica l tools uti l ized m ust possess a non reflective
or ro ughened black coati ng to preve nt laser bea m
d eflection .
- A laser smoke evac uator that fi lters pa rticles as s m a l l
as 0. 1 2 m i n d ia meter a n d laser-gra d e s u rgica l
masks m ust be used to red uce potenti a l s p read of
i nfectious pa rtic l es in the laser p l u m e .

Figure 7.3 (A) A female patient who was most bothered by her perioral
rhytides, but was also noted to have moderate dermatoheliosis with
n umerous lentigines and actinic damage of the remainder of her face.

47

48

Color Atlas of Cosmetic Dermatology

- Use of H i biclens, isopropyl a lc o h o l , a n d acetone is


proh i bited due to their fla m ma bl e nature. All m a keu p
a n d h a i rs pray a re to be removed , as they a re poten
tia l ly fla m m a b l e .
- The l a s e r s h o u l d be ke pt i n the sta n d by m o d e at a l l
ti mes other than a ctive treatment t o avo i d accid ental
fi ri ng.
- Oxygen s h o u l d be avoid e d , but if need ed, s h o u l d be
c l osely mon itored a n d o n ly used in conj u nction with a
c l osed gas system that i n c l udes either en dotracheal
i n t u bation of l a ryngea l mask a i rway.

PROCEDU R E

A thorough review of the risks a n d benefits i s perform ed .

Patient written consent is o bta i n ed .

R e p rese ntative preoperative pictu res a re o bta i ned .

P retreatment preparation is performed.

The choice of laser and laser pa ra meters va ries,


d e pend i ng on the c l i n ica l situation .
- The C0 2 laser is prefe ra ble for d ee per l i nes a n d
sca rring p rocesses a n d for fa i r-sk i n ned patients
( Fig. 7 . 1 ) .
- The Er:YAG laser is beneficia l for s u perfic i a l l i nes a n d
dyspigme ntation a n d for da rker s k i n ned patients
( Fig. 7 . 2 ) .
- T h e patient's postope rative considerations a lso affect
the choice of laser. The C02 laser wi l l have a n
expected longer recovery c o m pa red with t h e Er:YAG
laser.

I n ge nera l , treatment of a cosmetic u n it or fu l l face is


best to m i n i m ize the risk of text u ra l mismatch between
nontreated a n d treated a reas. I n an isolated treatment,
one m ust treat the entire lesion or line to their end
rather than rema i n with i n a cosmetic u n it .

The ve rm i l ion border can be treated conservatively t o


m i n i m ize l i pstic k " bleed i n g . "

Treatment s h o u l d extend beyond the a nato m i c a l u n it


being treated with a feathering tec h n i q u e (decreased
fluence) e m p l oyed to blend i nto the untreated ski n .

For d e p ressed scars, a d d iti o n a l passes with a s m a l l e r


s pot s i z e o n t h e d efect edge a l l ow for more sign ifica nt
flatte n i ng of the sca r.

Sca r contraction wi l l occ u r with hea l i ng. To avo i d


atro p h i c sca r formati o n , a d m i n iste r treatment to the
l evel of nea r normal adjacent s k i n on ly.

Ab lative resu rfa c i n g of dyna m i c rhytides provides o n l y


tem pora ry benefit. Consideration o f c o m b i nation ther
a py with botu l i n u m toxi n or a fi l l e r su bsta nce s h o u l d be
enterta i ned to a c h i eve maxi m u m benefit.

Figure 7 . 3 ( continuec!J (8) Same patient immediately after perioral

carbon dioxide laser resurfacing and a Jessner/35% trichloroacetic acid


peel to the remainder of her face.

Sect i o n 1 : Ph otoa g i n g

M i n i m a l mechanical tra u ma tec h n i q u e : fewer C0 2


passes performed with reta i n ment of the last pass
esc h a r to exped ite hea l i ng a n d m i n i m ize sca r risk a n d
pigme nta ry cha nges. T h i s tec h n i q u e is o pti m a l for
you nger patients with more s u perfic i a l lesions a n d fo r
d a rker s k i n types.

With any treatment m od a l ity, the presence of l a rger col


lagen b u n d les hera l d entry i nto the deep retic u l a r d e r
m is a n d wa rn of the poss i b i l ity of scar formation .
Treatment s h o u l d be d i sconti n ued i m med iately.

Res u rfa c i n g of nonfa c i a l rhyti d es is associated with a


h igh risk for textura l a n d pigmenta ry cha nges d u e to
the red uction in a d nexa l stru ctu res a n d poor vasc u l a rity
in compa rison to the face. The C0 2 laser s h o u l d n ot be
util ized for the treatment of nonfa c i a l rhyti d e s . The
Er:YAG laser should be util ized with extre me caution .

Combi nation thera pies of ca rbon d i oxide res u rfa c i n g


a n d c h e m i c a l pee ls, botu l i n u m tox i n , or soft tissue a ug
mentation may p rovide the greatest benefit ( F ig. 7 . 3 ) .

POSTOPERAT I V E CAR E

An open wou n d tech n i q u e or c l osed tec h n i q u e may be


fo l l owed .

Posto perative d iscomfort is cha racterized by moderate


b u r n i ng with i n the fi rst 24 h o u rs . T h i s is m i n i m ized with
the use of an occ l usive d ressi ng. I t can genera l ly be
controlled with ice pac ks , cold c o m p resses, a n d a ceta
m i no p h e n , as we l l as freq uent wo u n d ca re.

Posto perative edema d evelops 24 to 48 h o u rs postop


eratively and c a n be contro l l ed with ice packs and head
e l evati o n . O ra l steroids a re e m ployed when ma rked
swe l l i ng d eve lops i ntraoperatively or i m med iately post
operative ly.

Re-epith e l i a l izati on occ u rs with i n 3 to 10 days a nd is


d e pendent on the laser util ized , the n u m ber of laser
passes exec uted , and the s u rgica l ca n d i d ate. You nger
patients, patients who u nd e rgo Er:YAG treatment, a n d
fewer passes show faste r h ea l i ng. Delayed h ea l i ng is
observed i n older patie nts, sm okers, and i nc reased
laser passes.

Topica l a nt i b i otics and Aq u a p h o r H ea l i ng O i ntment


should be avoided d ue to the risk of a l lergic co ntact
d e rmatitis.

C l ose fol l ow- u p is m a n d a tory to ensure p ro per care a n d

Prophylactic a ntibiotics a n d a ntivira l med ications a re

hea l i ng o f t h e treated sites ( Figs. 7 . 4 a n d 7 . 5 ) .


conti n ued for 10 to 14 days posto pe rative ly to avoid
infecti o n .

Strict s u n avo i d a n ce is m a i nta i ned fo r 1 yea r postopera


tively to avoid photose nsitivity and to m i n i m ize the risk
of posti nfla m matory hyperpigmentation.

Figure 7.3 ( continued) (C) Same patient 6 months following her treat

ment. A marked reduction in both her rhytides and dyspigmentation is


appreciated.

49

50

Color Atlas of Cosmetic Dermatology

P EARLS FOR T R EATM ENT S U CCESS

P reoperative wou nd c a re i n structions a r e critica l for


treatment su ccess. The patient a n d sign ificant others
m ust be pre pa red fo r the exten sive ca re that w i l l be
req u i red fo r exped ient a n d

safe

hea l i ng.

Patients

s h o u l d be shown postoperative pictures to prepare


them for how they wi l l a p pea r. Posto perative s u p p l i es,
i n c l u d i n g wo u n d ca re s u p p l ies and d esi red ca m ouflage
fou ndation, s h o u l d be o bta i ned prior to the treatment
date. Patie nts with you nger c h i l d re n m ust prepare
them for the sign ificant c h a nges that wi l l be noted d u r
i ng the hea l i ng period . Any posto perative assista nce the
patient may req u i re should be a rra nged prior to treat
ment if possi b l e .

Patients req u i re freq uent postoperative eva l uation for


the fi rst 14 d ays to e n s u re proper wo u n d ca re is being
e m ployed , pred icted hea l i ng is noted , and no side
effects s u c h as sca r formation or i nfection occ u r.
Patients s h o u l d be eva l u ated on posto perative day 2 ,
posto perative d a y 5 t o 7 , a n d postoperative day 1 0 to
1 4 a n d a nyti m e the patient exp resses a concern of
need for eva I uation .

Patie nts' expectations m ust be ta i l o red to the expected


be nefits . Patients s h o u l d be i nfo rmed that the greatest
benefits w i l l not be a p p reciated for 6 to 12 months
posto peratively.

Strict ph otoprotection a n d s u n protection a re c ritical i n


red u c i n g t h e occ u rrence o f posti nfla m m atory hyperpig
m entation and s u n b u r n and should be fo l l owed for a
m i n i m u m of 1 yea r after treatment.

Treated skin is sensitive to a majority of fac i a l prod u cts,


perfu mes, a n d to pica l medications for an average of 1 2
weeks posttreatment. B l a n d p rod u cts, i n c l u d i ng a s u n
block, a re recom mended d u ri n g this hea l i ng t i m e .

Persistent a reas o f erythema s h o u l d ra ise concern


rega rd i ng sca r formation or i nfection . A c u lture is rec
o m m ended to rule out bacterial or yeast i nfectio n . Use
of a pote nt topical corticosteroid a n d/o r pu lsed dye
laser is crucial with close fol low- u p to ensure resol ution .

B I B L I OG RAPHY
Alster

TS. C uta neous resu rfa c i n g with C0 2 a n d


erbi u m : VAG lasers : P reoperative, i ntraoperative a n d post

operative

consid erations.

Plast

Reconstr

Surg.

1 999; 1 03 : 6 1 9-634.
Anderson R R , Parrish JA. Selective photothermolysis:
P recise m i c rosu rgery by selective a bsorption of p u l sed
rad iatio n . Science. 1 983 ;220: 524-527 .
Carruthers J , Carruthers A , Zelichowska A. T h e power of
c o m b i ned thera pies: Botox a n d a blative laser res u rfac
ing. Am J Cosmet Surg. 2000; 1 7 : 129- 1 3 1 .

Figure 7.4 Under aggressive wound care. A substantial amount o f crust

ing is observed. Proper wound care was demonstrated in-office and with
repeat written instructions reviewed

Sect i o n 1 : Ph otoa g i n g

David I, R u i z- Es pa rza J . Fast hea l i n g after laser s k i n


resu rfa c i ng . The m i n i ma l mecha n ical tra u ma tec h n i q u e .

Dermatol Surg. 1997;23:359-36 1 .


Dover J S , H ruza GJ , Arndt KA . Lasers i n s k i n resu rfa c i n g .

Semin Cutan Med Surg. 1 996; 1 5: 1 7 7 - 1 88 .


D u ke D, G reve l i n k J M . Ca re before a n d a ft e r l a s e r s k i n
resu rfa c i ng .

A s u rvey a n d

review o f the

l iterature.

Dermatol Surg. 1 998;24:201 -206.


Fitz patrick RS, G o l d m a n M P, Sat u r N M , Tope WD. P u lsed
ca rbon d i oxide laser resu rfa c i ng of p h otoaged fac i a l s ki n .

Arch Dermatol. 1996 ; 1 32 : 395-402.


Fitzpatrick R E, To pe W D , Gold m a n M P, et al. P u lsed
ca rbon d ioxid e laser, tric h l o roacetic a c i d , Backer-Gordon
phenol and derma b rasi o n : A com pa rative c l i n ical a n d
h istologic study o f cutaneous res u rfa c i n g i n a porc i n e
model . Arch Dermatol. 1 996; 132:469-47 1 .
N a n n i CA, Alster TS. Com pl ications of ca rbon d ioxi d e
l a s e r res u rfa c i n g : An eva l uation o f 5 0 0 patients. Dermatol

Surg. 1 998;24: 3 1 5-320.


Orringer JS, Ka ng S, J o h nson TM, et al. Treti n o i n treat
ment before carbon-dioxide laser res u rfacing: A c l i n ica l
and

biochemical

a n a lysis.

Am

Acad

Dermatol.

Decem ber 2004; 5 1 ( 6 ) : 940-946.


R a u l i n C , G rema H. S i ngle-pass carbon d ioxid e laser s k i n
resurfa c i ng com bined w i t h cold-a i r cool i ng: Efficacy a n d
patient satisfaction o f a pros pective side-by-side study.

Arch Dermatol. 2004; 140( 1 1 ) : 1 333- 1336.


R u iz-Esparza J, Ba rba G o m ez J M , Gomez de Ia To rre OL.
Wou n d ca re after laser skin res u rfa c i ng. A combi nation of
open a n d c l osed methods using a new polyethylene
mask. Dermatol Surg. 1 998;24: 79-8 1 .

Figure 7 . 5 Postinf/ammatory hyperpigmentation 6 weeks after perioral


carbon dioxide resurfacing. This pigmentation resolved with the use of
4 % hydroquinone twice daily for 2 months

51

52

Color Atlas of Cosmetic Dermatology

CHAPT E R 8

N o n a b l at i ve F ract i o nal Lase r R esurfaci ng

M ECHAN I S M OF ACT I O N

Fract i o n a l p h otothermolysis

Nona blative fractio n a l res u rfa c i ng ( N A F R ) is a n ovel con


cept of skin rej uvenation that ca n ta rget both e p i d ermal

Laser

---

I I I
I I I

a n d d e r m a l cond iti ons. NAFR p rod uces a u n iq ue thermal

I I I

d a mage patte rn consisti ng of m u ltiple col u m n s of th er

I I I

I I I
I I I

m a l coagu lative da mage, refe rred to as m i c rothermal


treatment zones ( M TZs) ( Fig. 8. 1 ) . N A F R c h a racteristi

I I I
I l l

Epidermis

c a l l y spares the tissue su rrou n d i n g each MTZ, thus a l l ow

I I I

'fiN

i n g fast epidermal repa i r d u e to m ic rosco pic size of the


wou nd s a n d short m igratory d ista nce fo r the via b l e ker
atinocytes p resent at the MTZ epidermal m a rgins. On ly a
fractio n of the s k i n of the s u rface a rea is treated .

D E R M ATOPAT H O LOGY
M TZ revea ls homogen ized col u m ns of dermal matrix a n d
t h e formation o f m i c roscopic e p i d e r m a l nec rotic d e bris
( M EN D ) ( Fig. 8 . 2 ) . M E N D formation is thought to re p re
sent the p rocess of e l i m i nation of the therma l ly d a m aged

S u bc uta neous fat

--

Figure 8 . 1 Schematic of microscopic treatment zones (MTZJ created by

fractional resurfacing laser (note the characteristic sparing of the sur


rounding tissue between the treatment zones)

epidermis conta i n i ng pigment by the ra p i d l y m igrati ng


via ble kerat i n ocytes at the MTZ ma rgi ns. M E N D may a lso
conta i n d e r m a l structu res s u ch as the elastic fi bers .
Vesse ls i n t h e M T Z regions can be therm a l ly d estroyed i n
a nonselective m a n ner. H igher energies res u l t i n deeper
and wider MTZs. H igher energies resu l t i n deeper a n d
wider M TZs. N A F R can b e hel pfu l i n t h e treatment o f epi
d e r m a l pigmentation suc h as melasma a n d lentigi nes
d ue to the process of M EN D formatio n . N A F R can a lso
be h e l pfu l in i m p rovi ng rhytides and sca rring due to the
p rocess of col lagen remod el i ng and n ew col lagen forma
tion, i nd uced by the dermal thermal da mage.

I N D I CAT I O N S
N A F R c a n b e a n effective treatment o f fine-to- moderate
rhytides; acne scars, s u rgica l , tra u matic, a n d burn sca rs;
melasm a ; dysc h ro m i a ; and d e rmatohel iosis ( Fig. 8 . 3) .

P R EOPERATIVE EVALUAT I O N

Sign ificant past medical history i n c l udes h i story o f h e r


pes l a b i a l is, keloid or hypertro p h i c scar formatio n , ora l
treti n o i n i ntake (d ate last cou rse com pleted ) , to pical
retinoid use, tobacco use, a n d k n own d rug a l lergies
i n c l u d i n g l i doca ine a l lergy.

Sign ificant past s u rgica l h i story i n c l udes prior s u rgical


treatments to the treatment sites, the dates of the p ro
ced u res, the pati ent's res ponse, and the associated
side effects.

Figure 8.2 H & E histology of microthermal treatment zone (MTZ) 1 day


after fractional resurfacing treatment (note the microscopic epidermal
necrotic debris (MEND) overlying a column of homogenized dermis)

Sect i o n 1 : Ph otoa g i n g

53

The patient s h o u l d be awa re of the fol lowi ng:


- Proced u ra l d iscomfort.
- S u n burn-l i ke sensation for severa l h o u rs after the
proced u re.
- S u n b urn- l i ke postoperative erythema that may per
sist for 3 to 7 days ( Fig. 8.4 l .
- Posto perative edema, ge nera l ly m i l d , that usually
resolves with i n 2 to 3 days.
- Posto perative bronzing that is ge nera l ly noted o n the
t h i rd posto perative day and often persists for 3 to
4 days .
- Posto perative su perfi c i a l pee l i ng t h a t is often m i l d
a n d is noted t o sta rt o n the th i rd postoperative day
a n d to persist for 3 to 4 days .
- Rea l istic expectations f o r the proced ure: the patient
s h o u l d be awa re that the treatment wi l l i m prove fine
to-moderate wri n kles, pigmentati o n , a n d s u perficial
sca rs

but d oes

not e l i m i nate

moderate-to-deep

rhytides. A modest benefit may be noted for d eeper

Figure 8.3 Periorbital rhytides (A) following one fractional resurfacing

treatment and (B) following four fractional resurfacing treatments. An


appreciable softening is noted (Courtesy of R. Fitzpatrick, MDJ

wri n k l es.
- Proced u ra l risks: a lthough these adverse eve nts a re
u ncommon a n d a re m u c h less freq uent than those
assoc iated with a blative resu rfa c i ng, they sti l l exist.
They i n c l u d e te m pora ry posti nfla m mato ry hyperpig
mentation

( Fig.

8.5),

b l i ste ri ng,

c rusti ng,

m i l ia

( Fig. 8 . 6 ) , acn eiform e r u ption , p i n po i nt hemorrhage


( Fig. 8 . 7 ) , herpes s i m plex reactivati o n , a n d ra rely
hypertro p h i c sca rri ng. This is in a d d ition to the p re
d icta b l e side effects that i nc l u d e proced u ra l d iscom
fo rt, posto perative e rythema, bronzing, and edema .
There is usua l l y no assoc iated oozing or c rusti ng
u n l ess very h igh energies a n d/or h igh densities a re
util ized .

The i d ea l ca n d i d ate is a fa i r-s k i n patient ( Fitzpatrick


p hototypes 1-1 1 1 ) . H owever, NAFR can be safe and
effective i n d a rker s k i n types ( F itz patrick p h ototypes I V
a n d V ) . I t is a lso safe t o u s e o n nonfa c i a l a reas i n c l u d
i n g the n e c k , tru n k , a n d extrem ities, provided that
decreased fluences and d e nsities a re uti l i zed .

CO NTRAI N D I CAT I O N S

Ora l treti n o i n use with i n 6 months t o 1 yea r o f su rgery

Active c uta neous i nfection

U n real istic patient expectations

P regnant or lactating wom a n

M ED I CAT I O N S

Anti bacterial therapy: prophylactic a nti biotics a re gen


era l l y n o t req u i red

Figure 8.4 Mild sunburn-like erythema immediately following Fraxel laser

treatment with 6 to 8 mJ, 250 M TZ!cm2 , eight passes. This erythema


may persist for 3 to 7 days

54

Color Atlas of Cosmetic Dermatology

Antiviral thera py
- Fracti o n a l resu rfac i ng may trigger reactivation of her
pes s i m plex that ca n s p read to the treatment sites .
- Prophylactic

a ntivi ra l

m ed i cations

a re

i n itiated

1 d a y prior to the proced u re . Va la cyc lovir 500 mg


PO B I D o r acyc l ovi r 400 mg PO T I D fo r 7 d a ys is
u s u a l l y recom m e n d ed . An a l ternative is va l acyc l ov i r
2 PO B I D f o r 1 d a y t o be sta rted t h e m o rn i ng o f t h e
proced u re .

Treti noi n : i t is advised t o d isconti n u e treti n o i n c rea m at


severa l days before N A F R to preve nt s k i n i rritation at
the treatment sites.

AN ESTH ES I A

Cold-a i r cool i ng (Zi m mer) i s very effective i n decreasi n g


the proced u ra l d iscomfort.

Topical a n esthesia (oil or crea m base) a ppl ied at least

Figure 8 . 5 Postinflammatory hyperpigmentation following fractional


resurfacing treatment to the upper lip

1 hour before the proced u re is genera l ly adeq uate, espe


cially in combi nation with cold-a i r cool ing ( Z i m mer) .

Regio n a l n e rve blocks ca n be effective to red uce the


d iscomfort for patients with low pa i n t h resholds, espe
c i a l l y when uti l i z i n g higher fl u ences a n d d e nsities .
I nfraorbita l a n d menta l b l oc ks can be h e l pful when
treati ng periora l wrin kles, but a re usually not necessa ry.

P R EOPERATIVE P R E PARAT I O N

Ex p l a i n t h e risks a n d benefits o f the proced u re .

O bta i n t h e patient's writte n consent.

Wash the a rea to be treated with soa p and water.

O bta i n preo perative pictu res .

A p p l y a t h i c k layer of topical a n esthetic i n an o i l or


c rea m base to the treatment site .

Wa it at l east 6 0 m i n utes t o a c h i eve o pti m a l a nesthetic


effect.

Wi pe off the to pical a n esthetic with a d a m p c l oth .

PROCEDU RAL T I PS

The laser pa ra meters a re c h osen accord i n g to the c l i n i


cal ta rget.
- For e p i derma l cond itions s u ch as p h otod a mage,
lentigi nes, melasma, and dysc h ro m i a : lowe r f lu ences
and h igher densities a re u s u a l l y uti l ized .
- For deeper processes such a s rhytid es or a cn e sca r
ring: h igher fl uences a re uti l ized .

Lower percent coverage of s k i n su rface a rea ; that is,


lower d e nsities a re i n d icated i n d a rker s k i n types to
avoid postinfl a m matory hyperpigme ntation .

Figure 8.6 Milia on the chin 1 day after NAFR

Sect i o n 1 : Ph otoa g i n g

55

Caution s h o u l d be exerted when treating s m a l l e r a reas


s u c h as u p per l i p , nose, and tem ple in ord e r to avoid
b u l k heating that can res u l t in bl istering and sca rri ng.
- Al l ow adequate time between passes for the heat to
d issi pate and the s k i n to cool d own before the next
pass .
- When treati ng the u pper l i p, a l ternate the treatment
between the right side and the left side, and sta rt
each pass from the sa m e point.

Th ree to six treatment sessions ( d e pe n d i ng o n the i n d i


cation for treatment) a re a d m i n istered 3 to 4 weeks
a pa rt . Longer period between treatments is a dvised i n
d a rker-s k i n patients t o avo i d o r decrease t h e i nc i dence
of posti nfla m m atory hyperpigmentation ( P I H ) .

POSTOPERAT I V E CAR E

Posto perative d i scomfo rt is genera l ly m i l d a n d tra n


sient. The patient wi l l experience a s u n b u rn sensatio n
for seve ra l h o u rs .

Patie nts may a p p ly m a ke u p i m med iately after the treat


ment.

Patie nts a re encou raged to use m i ld moisturize rs fo r


severa l days after the p roced u re .

Posto perative e d e m a is u s u a l l y m i n i ma l but can be


controlled with ice packs a n d head elevatio n . I n ra re
i n sta nces of ma rked swe l l i ng, o ra l p red n isone ca n be
p resc ri bed for 3 to 7 days.

Sun avo i d a nce is m a i nta i ned for at least 4 to 6 weeks


after the proced u re to m i n i m ize the risk of posti nfla m
matory hyperpigmentation . S u n sc reens with a m i n i
m u m S P F of 30 a re reco m mended .

Typical ly, patie nts can retu rn to work on the fi rst post
operative day.

PEA R LS FOR TREAT M ENT S UCCESS

Patient selectio n is the key. Treating rhyti d es o r sca rs


that a re too deep w i l l p rove d isa ppointing to the patient
a n d physic ia n . The patient m u st be awa re of the need
for m u ltiple treatments to o bta i n the d esi red c l i n ical
benefit.

NAFR ca n res u lt i n serious side effects such as sca r


ri ng when used at very h igh fl uenc ies by i n experien ced
physicia ns o r health ca re workers. Caution s h o u l d be
ta ken to stay with i n the recom m e nded pa ra meters a n d
a p ply a p propriate

ove r l a p p i n g tec h n i q u e t o avoid

potentia l com p l i cations.

Patients m ust be awa re that benefits may be s h o rt last


i n g a n d may req u i re m a i nte na nce treatments for con
t i n ued c l i n i c a l benefit.

Figure 8.7 A patient with rosacea who developed pinpoint hemorrhage

1 day after Fraxel Restore treatment. Pinpoint hemorrhage can occur with
higher energies and usually resolves in few days with no sequelae

56

Color Atlas of Cosmetic Dermatology

Effective N A F R treatment i n patients with ski n ph oto


types I l l to V c a n be a c h ieved . An i n c reased i n c i d e n ce
of posti nfla m matory hyperpigmentation

is genera l ly

noted . Patients m u st be aware of the poss i b i l ity of P I H


with each treatment. Decreasing t h e density o f treat
ment red uces the risk of PI H .

DEV I CES
The m ost c o m m o n l y used N A F R d evices t h a t a re ava i l
a b le i n t h e ma rket a re Fraxel R estore (Solta Medica l , I n c . ,
Haywa rd , C A ) , L u x 1 , 540 n m laser ( Pa l o m a r Medical
Tech n ologies, B u rl i ngto n , M A ) , a n d Affi rm 1 ,440 nm
N d : YAG laser ( Cynos u re, Westford , MAl (Ta ble 8. 1 ) .
Fraxel R estore util izes the sca n n i ng tec h n o l ogy whereas
Lux 1 , 540 nm and Affi rm 1 ,440 nm lasers uti l ize the
sta m p i n g tec h nology and d o not usually req u i re to pical
a n esthesia or d isposa ble tips.

TAB L E 8. 1

Nonab lative Fractiona l Lasers

Com pany

Laser d evice

Laser

M od e

wavelength ( n m )

Sa lta Medical

F raxel R estore

1 , 550

Sca n n i ng

Cynosure

Lux 1 , 540
Affi rm 1 ,440 N d : YAG

1 , 540
1 , 440

B I B L I OG RAPHY
La u bach HJ , Ta n nous Z , Anderson R R , M a nste i n D . S k i n
res ponses t o fra ctional photothermolysis. Lasers Surg

Med. 2006;38(2 ) : 142- 149 .


M a nste i n D , H e rro n G S , S i n k R K , Ta n n e r H , And erson
R R . F ractiona l ph otothermolysis: A new concept fo r c uta
neous remod e l i ng u s i n g m i c rosco pic patterns of thermal
i nj u ry. Lasers Surg Med. 2004;34( 5) :426-438.
N a r u rka r VA . N o n a b lative fracti o n a l laser resu rfa c i ng.

Dermatol Clin. 2009 ;27(4) :473-478, vi.


Ta n n o u s Z . Fractio n a l res u rfa c i ng. Clin Dermatol. 2007;
2 5 ( 5 ) : 480-486 .

M a x energy/MTZ

d i a meter ( m m )

or m ic ro bea m ( mJ )

d e l ivered ( c m 2 )

70

1 2-4,000 ( 5-48% )

Density

15

( Fraxel SR 1 , 500)

Pa l o m a r

Ti p

Sta m ping
Sta m ping

10

1 00

1 00

15

15

320

10

8 J/cm 2/pu lse

1 , 000

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 9

A b l ative Fract i o nal Lase r R esu rfaci ng

I N TRODUCT I O N
Treatme nts for photoaging ra nge fro m nona blative laser
resu rfa c i ng to a blative laser res u rfa c i n g . Both of these
tec h n i q ues a re d escri bed in d eta i l in previous cha pters.
Put s i m ply, the m ost effective lasers, carbon d ioxi d e
a n d e r b i u m a blative res u rfa c i ng lasers , provid e the m ost
d ra matic benefit for photoaging a n d other s k i n co n d i
t i o n s , but a lso ca rry t h e h ighest r i s k f o r adverse effects.
They rema i n the gol d sta n d a rd treatment for photod a m
aged ski n . Dramatic res u l ts, however, ca n be seen with
one treatment. Side effects i n c l u d e prolonged erythema
(fo r months ) , perma nent hypopigmentat i o n , te m pora ry
hyperpigmentat i o n ,

i nfect i o n ,

and

sca r.

Ad d itional ly,

d ownt i m e from work a n d soc i a l a ctivities is sign ifica nt.


For this reaso n , the po p u l a rity of a blative lasers has
decreased d ra matica l ly over the past seve ra l yea rs
a mong patients a n d physicians.
By contrast, nona blative lasers, with m u ltiple treatment
sessions,

p rovide a safe method for provid i ng m i ld

i m prove ment of m i l d -to- moderate p h otoda mage with l it


tle risk of si d e effects. U nfortu nate ly, the p red icta b i l ity of
i m prove ment is u ncerta i n . Some patients do n ot experi
ence a n y d iscern i b l e benefit even after m u ltiple treat
ments. In the past 5 years, nona blative fractional lasers
have prod uced e n h a nced results from other forms of
n o n a b l ative res u rfaci ng with m u lt i p l e treatm e nts . These
lasers have a lso p roven to be safe in s k i l led h a n d s . Sti l l ,
thei r efficacy is l i m ited , espec ia l ly w h e n c o m p a red to
a b lative laser resu rfaci ng.
M ore rece ntly, fractional a blative lasers, both carbon
d ioxid e and erb i u m va riants, have been d evelo ped to pro
vide e n h a nced res u l ts with relatively good safety. The
concept is to provi d e the more aggressive tec h nology of
a b lati o n , but to confi ne potential d ownt i m e a n d s i de
effects b y e m p l oying a fra ctional pattern of tissue d a m
age, w h i c h encou rages more ra pid h ea l i ng t i m e s with
fewer side effects. O n ly a fraction of the skin is a blated at
each treatment, as o p posed to trad iti o n a l a b lative res u r
fac i ng proced u res . F u rther, the d e pth of a blation is
d ee pe r tha n with tra d iti o n a l a blative resu rfa c i n g proce
d u res.
Adva ntages of fractional a blative lasers a re as fo l l ows :

Better i m provement of deeper rhyti des t h a n nona bla


tive d evices

Sign ificant benefit with one treatment

Ca n provid e some i m p rovement for s k i n laxity, pig

Sign ificant red uction i n posto perative d ownti m e com

mented lesions, a n d vasc u l a r dysc h ro m i a as we l l


pa red to tra d itio n a l a b lative devices

Figure 9 . 1 Immediate endpoint of pixilated damage pattern with an


erbium fractional ablative device

57

58

Color Atlas of Cosmetic Dermatology

Ca n treat cosmetic u n its effective ly without l i nes of


d e m a rcation often seen with trad itional a blative proce
d u res, that is, perioral/periorbita l a reas

I N D I CAT I O N S

R hytides, espec i a l ly moderate-to-severe periora l a n d


periorbita l rhytid es

P h otoda m age, i nc l u d i ng s k i n text u re a n d tone

Acne sca rs, i n c l u d i ng boxca r, atro p h i c , ro l l i n g sca rs

S u rgical a n d b u r n sca rs

M i l d i m provement in s k i n laxity

N ot effective for dyna m i c rhytid es

P R EOPERATI V E EVALUAT I O N

S k i n type ( I-I I I a re best ca n d i d ates )

S u n exposu re

H istory of ke loids

System ic i nfections

Prior plastic s u rgery, espec i a l ly neck l ifting p roced u res


a n d face lifts

l sotret i n o i n use i n past 6 months

Patients with u n rea l istic expectations


A consu ltati on is req u i red before this treatment to

assess the patient as wel l as a p p ro p riately prepa re the


patient for the proced u re . The patient s h o u l d be fu l ly
educated as to the risks a n d benefits of this proced u re.
The patient m u st be awa re of the recove ry period of 4 to
7 days (on average ) . The patient should be shown post
operative pictu res to prepa re them fo r h ow they w i l l
a p pea r. Any posto perative assista nce the patient m a y
req u i re s h o u l d be a rra nged prior t o treatment if poss i b l e .
The patient s h o u l d a lso be i nformed t h a t the ben efits of
the treatment accrue 3 to 6 months after treatment. A
patient who is u n a ble to fol l ow a n d execute necessa ry
postoperative s k i n ca re regi men s h o u l d n ot be treated .

PROPHYLAX I SIAN ESTH ES lA


May include any of the fol lowi ng:

Antiviral and a nti biotic prophylaxis

Topical a n esthetic
- 23% Lidoca i n e/7 % tetra ca i ne

Oral pa i n med ication a n d a nxiolytic


- Vicod i n/a ceta m i n o p hen/ativa n/not h i n g

N e rve blocks/1 M Torad o l

Genera l a n esth esia

Figure 9.2 Patient immediately after C0 ablative fractional resurfacing

2
treatment. Note erythema, edema, and pinpoint hemorrhage

Sect i o n 1 : Ph otoa g i n g

Beca use this proced u re is pa i nfu l , some form of


a n esthesia is req u i red .

It wi l l va ry accord i ng to the

aggressiven ess of treatment, the pa rt i c u l a r suscepti b i l i


ties o f t h e patient, a n d the p hysi c ia n 's co mfort with
va rious a n esthetic reg i me n s . R egio n a l nerve blocks with
s u p plementa l i nfi ltrative a n esthesia a re ge n e ra l l y h e l pfu l .
S ite-d ependent b l ocks i nc l u d e su praorbita l , i nfraorb ita l ,
a n d menta l b l ocks. Lid oca i ne ( 1 % ) with 1 : 1 00, 000 o r
1 : 200,000 e p i n e p h r i n e , at a tota l o f 0 . 5 to 1 .0 m l c a n b e
i njected at eac h site .

LAS E R SAF ETY

Eye protect i o n : m eta l eye s h ields


- One o r two d ro ps of 0 . 05% to pica l p ropa raca i ne
(Aica i n e ) or 0.05% topica l tetra ca i n e ( Po ntoca i n e )
a re placed i nto e a c h eye o f the patient, fol l owed by
the a p pl ication of to pical e ryth romyc i n oi ntment o r
ophth a l m i c l u bricant ( e g , Lacri-Lu be) a n d non reflec
tive meta l oc u l a r s h ields.
- A l l perso n n e l present at the treatment m ust wea r
safety glasses/goggles to avo i d i nadverte nt cornea l
d a mage .
Due to the pa i n , bleed i ng, a n d pa i n med ications assoc i

ated with this treatment, it is i m perative that the patient be


acco m pa n ied by a friend , spouse or relative who can d rive
or accompany the patient home after the proced u re .

Posto p e rat i ve C a re ( F i g .

9. 1)

I nterestingly, l ittle postp roced u re pa i n ( Fig. 9 . 2 )

Best expla nati o n : heat release th rough a blated c h a n n e l s

I m perative t o give ora l a n d written wou n d care i nstruc


tions to patient

Ga uze soa ks and e m o l l ie nts i m med iately posto perative


Room tem peratu re sterile water soa ks for 20 m i n utes,
every 3 to 4 h o u rs fol l owed by Aq u a p horNase l i n e a pp l i
cation for 2 to 3 days

Fo l l ow- u p at

( Fig.

9.3)

48

to

72

h o u rs

Re-epith e l i a l izati on i s usually com plete .

Eryt h e m a , edema, a n d resi d u a l p i n po i n t h e morrhagic


crusting a re expected .

M i l i a a re com m o n a n d often clear with i n a few days .

Assess fo r vesicles, b u l la e , p ustu les.

E m o l l i ents twice d a i ly for 3 to 7 days.

I nstructions to ca l l if a n y concerns or cha nges i n wou n d


hea l i ng .
Postoperative e rythema

resolves over a

period of

wee ks. Strict s u n avo i d a n ce m u st be fol l owed fo r a

Figure 9.3 Patient at 72-hour follow-up. Note that hemorrhage is no

longer present, but edema and erythema persist

59

60

Color Atlas of Cosmetic Dermatology

m i n i m u m of 3 mo nths postoperatively to avoid pigmen


ta ry c h a nges and p h otosensitivity.

Adve rse S i d e Effects

Delayed onset hypopigmentation

Sca rring

Posti nfla m m atory hyperpigme ntation

Persistent erythema

I nfection
The side effects for fractional a blative resu rfa c i ng a re

the same as those for trad itiona l a blative res u rfaci ng


proced u res, a l beit fa r less freq uent or severe i n s k i l l ed
hands.

As

with

nonablative

fractional

resu rfaci ng,

post-i nfla m matory hyperpigmentation ( P I H ) is more l i kely


to occ u r with h igher treatment densities, pa rtic u l a rly in
da rker ski n phototypes ( Fig. 9.4). Hypertrophic sca rring of
the neck is a sign ifica nt a nd potentially permanent com
p l ication of fractionated C0 2 laser res u rfacing ( Fig. 9 . 5 ) .
Caution is req u i red for these proced u res .
The fol l owing p ractices a l l sign ificantly i nc rease the

Figure 9.4 Test spot treatments with a C0 ablative fractional resurfacing

2
device in a young male with Fitzpatrick skin type 5. The test spots are
not arranged in order of aggressiveness. The darker areas of PIH coincide
with increased treatment density. Increasing pulse energies do little to
worsen PIH

risk of sca r:

Aggressive treatments i n c rease risk of sca r

Poor tec h n iq u e , that is, excessive overl a p

Postoperative wo u n d i nfection

H i story of face lift o r neck l ifti n g proced u res

Treatment of nonfa c i a l ski n , espec i a l l y the neck

I n fect i o n ( F i g .

9.6)

The key to treating i nfection i s to recogn ize i t at its i n cep


tion . I nfections a re d iagnosed c l i n i c a l ly. C u ltures can
confi rm a d iagnosis. E m p i ric a nti biotics a n d c l ose c l i n ical
fo l l ow- u p a re the keys to treatment. Persistent a reas of
e rythema s h o u l d raise concern rega rd i ng sca r formation
o r i nfection . A c u lture is rec o m m e n d ed to r u l e out bacte
rial o r yeast i nfection . Do not perform these proced u res if
you can n ot recogn ize a n d treat bacteria l , v i ra l , fu nga l
i nfections.

N o n fa c i a l S k i n
Nonfa c i a l s k i n i s more v u l nera b l e to thermal energy d u e
t o u n derprivileged wo u n d h ea l i ng c a pa b i l ities. Th ere a re
fewer p i l osebaceous u n its on the neck a n d more l i m ited
c uta neous vasc u latu re to s u p port wou nd h ea l i ng. T h i s is
espec ia l ly true where there is a h i story of prior plastic
su rgery. Face/neck l ifti ng proced u res place neck s k i n
onto the face; t h u s , y o u may be treating " neck" s k i n o n
the fa ce. If there is a h i story o f p r i o r plastic s u rgery, it i s
best to treat at lowe r setti ngs .
Beca use of the risks of serious side effects, it is
strongly a dvised

that fractional

a blative

res u rfa c i ng

Figure 9 . 5 Hypertrophic scar after treatment with a C0 fractional abla


2
tive device

Sect i o n 1 : Ph otoa g i n g

61

s h o u l d only be performed by a n a p p ro p riately tra i ned


phys i c i a n experien ced i n postoperative wou n d ca re fol
lowi ng resu rfa c i n g p roced u res.
In s u m , a b lative fractio n a l res u rfa c i n g p roced u res offer
the adva ntage of good res u lts with one treatment as wel l
as offering sign ifica nt i m p rovement where nonablative
fra ctional a n d n onfractional d evices do not, such as mod
e rate a n d severe rhytides. At the sa me time, it offers the
flex i b i l ity of treati ng s m a l l e r a reas than tra d itional resu r
faci ng p roced u res beca use it d oes not typica lly leave
l i nes of d e m a rcati o n . Ad d itional ly, there is sign ifica ntly
red uced c l i n ic a l and soc i a l d ownt i m e com pared to fu l l
s u rface a b lative proced u res. N o n etheless, t h e treatment
has its d rawba c ks s uc h as

lighte n i n g is usual l y modest.

D u ration of benefits i s not known .

Best resu l ts often req u i re more than one treatment.


- Espec i a l l y acne sca rs .
- Req u i res 1 wee k away fro m w o r k a n d soc i a l activities.
- Series nona blative treatments may be more tolera ble
a n d practical for m a n y patients.

Figure 9.6 Localized minute pustules, edema, and erythema representing


a localized pseudomonas infection in the setting of post-C0 fractional
2
ablative resurfacing for a burn scar. It cleared fully without sequelae after
oval antibiotic treatment.

62

Color Atlas of Cosmetic Dermatology

CHAPT E R 1 0

Tissue Tighte ning

There have been a va riety o f n o n i nvasive d evices that


p u r port to l ift a n d tighten " l oose" necks, jawl i nes, a n d
eyes . These d evices work b y del iveri ng monopolar, bi po
l a r, or i nfra red energy to the d ee p dermis a n d su bc uta
neous tissue, resu lting in tighte n i ng a n d l ifti ng of s k i n a n d
c reation o f new collage n . T h e c h ief o bstacle for th ese
d evices has been i nconsistent c l i n ica l resu lts . Some
patients have had d ra m atic res u l ts i n com pa rison to tra
d itional i nvasive s u rgery a nd oth e rs have seen l ittle or no
i m provement. Patients who u n d e rsta n d the risks before
the proced u re a re ha ppy with excellent resu lts a n d not
d isappoi nted by lack of i m p rovement.

M ECHAN I S M OF ACT I O N
There a re d iffe rent rad i ofreq uency ( R F) tec h n o l ogy a n d
i nfrared d evices that del iver vol u m etric h eat t o t h e deep
dermis and s u bcuta neous tissue wh i c h tightens existi ng
col lagen and h e l ps c reate new collage n .

CAN D I DATE S E LECT I O N


A s with a l l proce d u res, ca n d i d ate selection i s vita l t o the
success of the proced u re . These devices wi l l n ot treat epi
dermal cha nges of aging such as lentigo, tela ngiectasia,
or ro ugh ski n . Ca n d idates should have deep cuta neous
signs of aging such as "saggi ng" skin in the neck, jaw, or
around the eyes. Some physicians have re ported good
success in treating a reas off the face i n c l ud i ng u pper
arms, a bdomen , and b reasts . All patients m u st be awa re
that the a m o u nt of c l i n ic a l i m prove ment is h ighly va riable
not pred icta b l e before the proced u re. Patients that d o not
u n d e rsta nd this should not u n d e rgo the proced u re .

Figure 10.1 (A) Prior to treatment skin laxity is observed in the jowl

region.

THE PROCEDU R E
When fi rst i ntrod uced t h e c h ief c o m p l a i n t with

RF

d evices was i ntolera b l e pa i n . The proced u re was done


with a single pass at h igh energy settings. Over the yea rs
the trend has been towa rd more passes with lower fluen
cies. T h i s has greatly red u ced the pa i n associated with
the proced u re. M u ltiple passes, lowe r fl uenc ies, and d if
fe rent s pot sizes have resu lted i n greater i m med iate tis
sue tighte n i n g o bserved

in

patie nts

and

h igher

percentage of patients with i m provement after 6 months.

P re p roced u re C h ec k l i st

Remove a l l m a ke u p .

Remove a l l jewel ry.

Sect i o n 1 : Ph otoa g i n g

No pacema ker or d efi bri l lator.

A l l patients with fac i a l i m pla nts s h o u l d have the mater

63

ial of the i m p l a n t i d e ntified before the proced u re . If it is


u n kn own , d o not treat d i rectly over the i m p la nt.

A p p l y thick layer of topica l a n esthetic 30 m i n utes


before p roced u re .

Determ i n e a p p ro priate s pot size a n d fl uence.


Kee p the h a n d piece even with the s k i n t h roughout the
p roced ure.

After the proced u re patie nts c a n res u m e reg u l a r a ctivi


ties i m med iately.

Patie nts s h o u l d com m u n icate with their phys i c i a n i n


case o f a n y q u estions or concerns.

I m provement occ u rs fo r u p to 6 months after the p ro


ced u re .

S I DE EFFECTS
The a m o u nt of serious side effects has been red uced
ove r the yea rs as treatment protocols have been refi ned .
With l ower fluences the risk of side effects has been s u b
sta ntia l ly red uced .

Pote n t i a l S i d e Effects

Atro phoderma which may be tem pora ry or perm a nent

B u rn

Erosion/ulcer

Sca r

Dysc h ro m i a

N e rve da mage

Oc u l a r da mage

Figure 10. 1 (continued) (B) Six months after treatment appearance of the

CLI N I CAL PEARLS

A l l patients s h o u l d be wa rned before a n y proced u re


that the a m o u nt of c l i n ic a l i m provement va ries from
person to person . I m prove ment can ra nge from d ra
matic to N O i m provement at a l l . Any patient who d oes
not u nd e rsta n d

the

potenti a l for n o i m prove ment

should not have the proced u re performed .

W h i le treating each patient conti n u ously, observe the


skin and ask the patient to inform the physici a n if there is
a partic u l a r s pot with i n c reased pa i n or u n usual sym p
toms. If a patient complains of u n usual pa i n or sym p
toms, sto p the p roced u re a n d reeva l uate the setti ngs.

M a ke s u re a u n iform a m o u n t of energy is d e l ivered with


each pu lse. This is done by usi ng the a p propriate spot
size a n d a pplyi ng u n iform gentle but firm p ress u re to
the ski n .

D o not perform t h e p roced u re o n a patient with a ctive


s u n burn or ta n .

jowl and neck is improved slightly. (Reproduced, with permission, from


Hirsch R, Sadick N, Cohen JL. Aesthetic Rejuvenation: A Regional
Approach. New York: McGraw-Hill, 2009: 97. )

64

Color Atlas of Cosmetic Dermatology

CHAPT E R 1 1

D e r m atochalasis

Dermatoc ha lasis is a cond ition cha racterized by u p per


a n d/or lowe r eye l i d s k i n , m uscle red u n d a ncy a nd laxity,
a n d fat pad hern iation . It is m a i n ly attri buta b l e to c h rono
logica l aging a n d c h ro n i c s u n expos u re .

EPI D E M I O LOGY
Incidence: ve ry c o m m o n
Age: m ost freq uently o bserved i n i n d iv i d u a l s older tha n
50 yea rs

Sex: no pred i l ectio n


Race: most common i n fa i r-s k i n ned i n d ivi d u a ls (skin

phototypes I a n d I I ) ; l ess common in da rker-s k i n ned i nd i vid u a l s (ski n p hototypes IV-V I )

Precipitating factors: c h ronologica l aging; c h ro n i c s u n


expos u re ; thyroid d isease

PATHOG E N ES I S
U p per a n d/o r lower eye l i d s k in a n d m uscle hypertro phy
and prola pse; fat pad d escen s ion .

PHYS I CAL EXAM I NAT I O N


Ea rly fi n d i ngs i n c l u d e a d o u b l e l i d c rease with o n l y mod

est hood i ng. Severe fi n d i ngs i n c l u d e pro m i nent eye l i d

Figure 11.1 (A) A 59-year-old female concerned about her sunken eyes
and forehead wrinkles. (B) Improvement of the blepharloptosis, sunken
eyes, and forehead wrinkles 9 months following upper lid blepharop/asty
and leavator aponeurotica advancement. (Reproduced, with permission,
from Harue Suzuki, MD, Kyoto, Japan.)

h ood i n g w i t h u pper a n d latera l v i s u a l f i e l d obstruction .


Coexisting b row ptosis may f u rther c o m p rom ise the
peri phera l visio n .
Tests for lower l i d laxity h e l p determ ine i f a l id-tighte n i ng
proced u re is needed .
Lower l i d horizonta l laxity is measu red by the d istrac
tion test that req u i res p u l l i ng the lowe r lid a nteriorly away
from the globe. A greater than 7-mm lid excu rsion i n d i
cates laxity.
Orbic u l a ris oc u l i tone is measu red by the s n a p test that
is performed by p u l l i ng the lowe r lid i nfe riorly. If the l i d
d oes not sponta neously retu rn t o the n o r m a l position
prior to the next b l i n k , the test is positive i nd icati ng l ower
lid laxity.

D I F F E R E N T I A L D I AG N OS I S
B l e p h a rochalasis ( recu rrent i d i o path ic eye l i d i nfla m ma
tion with resu lta nt re laxation of the u p per lid ski n ) ; u p pe r
eye l i d hood i n g seco ndary t o eye b row ptos is.

Sect i o n 1 : Ph otoa g i n g

D E R M ATOPAT H O LOGY
Epidermal aca nthosis with flatte n i ng of the derma l
e p i derma l j u ncti o n ; dermal col lagen brea kd own with
fo rmation of a m orphous masses and i n c rease i n gly
cosa m i noglyca ns.

CO U RS E

C h ro n i c p rogressive cou rse ; visual eye fields may be


affected .

KEY CO N S U LTAT I V E QU EST I O N S

A n y assoc iated sym ptoms i n c l u d i n g visual o bstruction,


d ry eyes, excessive tea ring

U nderlying medical cond itions, espec i a l l y eye d i sease


a n d thyroid cond itions

Prior treatment and response

MANAG E M ENT

P reventi o n : strict s u n avoida nce

Control u n derlying thyro i d d isease

TREATM ENT

Topica l thera py: d a i ly su nscreen a pp l ication with UVB/


UVA coverage

S u rgical thera py
- Coro n a l browlift-u pper face rej uvenation
- Trichophytic browlift-u pper face rej uvenation
- Blepha roplasty-u p per and lower eye l i d rej uve nation
( Fig. 1 1 . 1 )

Laser thera py
- Placement of protective eye s h i e l d s prior to laser
treatment if pa ra m o u nt.
- Conservative treatment is necessa ry to avoid ectropion formation a n d/or sca r formatio n .
- Carbon d i oxide laser resu rfa c i ng.
- Erbi u m : YAG laser.
- Fractionated a b lative carbon d ioxide laser resu rfacing.

P I T FALLS TO AVO I D

A conservative a pproa c h to s u rgica l rem ova l of this s k in


is vita l to prevent a " sta rtled " a ppea ra nce o r ectropion .

65

66

Color Atlas of Cosmetic Dermatology

Retention of a l l or portions of a ny hern iated fat pads


h e l ps m i n i m ize the skeleto n ized a p pea ra nce ofte n
noted to d eve l o p with age a n d loss of fa c i a l vol u m e .

D i rect visual ization o f t h e i nferior o b l i q u e m uscle is vita l


t o avoid m uscle i nj u ry.

Treatment with l u brica nts a n d ta p i n g l i d s may h e l p pre


vent keratoconj u n ctivitis.

B I B L I OG RAPHY
A n c o n a D , Katz B E . A p ros pective study o f the i m prove
ment in periorbita l wrin kles a n d eye brow elevation with a
n ovel fractiona l C0 2 laser-th e fractional eye l ift. J Drugs
Dermatol. 20 10;90 ) : 1 6-2 1 .
Ca rte r S , Seiff S, Chao P. Lower eye l i d C02 laser rej uvena
A
ra n d o m ized
p rospective
c l i n ic a l
stu dy.

tion :

Ophthalmology. 200 1 ; 1 08:437-44 1 .


Cod ner MA, Wo lfl i J N , Anza rut A . P r i m a ry transc uta
neous lower b l e p h a roplasty with routi ne latera l canthal
s u p po rt: A com prehensive 1 0-yea r review. Plast Reconst
Surg. 2008; 1 2 1 : 1 24 1 - 1 250 .
J u nzeker C M , We iss ET, Geron e m us R G . Fractionated
C0 2 laser res u rfa c i ng: Our experience with m o re t h a n
2000 treatments. Aesthet Surg J. 2009 ; 29(4) : 3 1 7-32 2 .
K o r n B S , Ki kkawa DO, Cohen S R . Tra nscuta n eous lower
eye l i d

b l e p h a roplasty

with

orbitomala r

suspensio n :

Retros pective review o f 2 1 2 consecutive cases. Plast


Reconstr Surg. 20 1 0 ; 12 5 ( 1 ) : 3 1 5-323 .
Lee D, Law V. S u bbrow blepha roplasty for u p per eye l i d
rej uve nation i n Asia n s . Aesthet Surg J . 2009 ;29(4): 284288 .
Le m ke B N , Stasior OG . T h e a n atomy o f eye l i d ptosis.
Arch Ophthalmol. 1 932 ; 1 00:981 -986 .
Levine

MR.

Manual

of

Oculoplastic

Surgrery.

P h i la d e l p h i a : B utterworth H ei n em a n n ; 2003 .
Shorr N , Enzer Y. Considerations i n aesthetic eye l i d
su rgery. J Dermatol Surg Oneal. 1992 ; 1 : 1 08 1 - 1 09 5 .

Sect i o n 1 : Ph otoa g i n g

CHAPT E R 1 2

Poi kilod e r m a of Civatte

Poi k i l oderma of Civatte ( POC) is a cond ition that is attri b


uta ble to chronic sun expos u re of the neck and the c h est.
The seve rity of fi n d i ngs is d e pend ent on the d u ration a n d
i ntensity

of

sun

expos u re,

constitutive

skin

color

( Fitzpatrick s k i n type ) , and the capac ity to ta n .

EPI D E M I O LOGY
Incidence: common
Age: most freq uently o bserved i n persons older than
40 yea rs

Sex: sl ight fem a l e pred o m i na nce


Race: m ost common in fa i r-s k i n ned i n d ivid u a l s ( s k i n
p hototypes I a n d I l l ; rarely seen i n da rker-s k i n ned i n d i
vid u a l s (ski n p hototypes I V-V I )

Precipitating factors: c h ro n i c s u n expos u re i n c l u d i n g


i ntentio n a l s u n exposu re s i n ce youth a n d occ u pationa l
expos u re; tra u m a ; c h ronologica l aging

PATHOG E N ES I S
U ltraviolet B ( U V B ) i s the m ost d a maging U V rad iati o n ,
with h igh d ose u ltraviolet A ( U VA) contri buting t o t h e
n oted cha nges . I n a d d it i o n , vis i b l e a n d i nfra red ra d iations
have been shown to a ugment the action of UVB .

PHYS I CAL EXA M I NAT I O N


Te langiectases, m i l d atrophy, ret i c u l ated hyperpigmenta
tion , a n d hypopigm entation affect i n g the late ra l a n d pos
teri or as pect of the neck, a nterior c h est, a n d jawl i n e .
S u b menta l neck is s pa re d . Perifo l l i c u l a r s p a r i n g noted
( Figs. 1 2 . 1 a n d 1 2 . 2 ) .

D E R M ATOPATHOLOGY
Epiderma l a ca nthosis with flatte n i ng of the d e r m a l
e p i d e r m a l j u ncti o n . Foca l i n c rease i n e pi d e r m a l basa l
c e l l m e l a n ocytes; i rreg u l a r basa l c e l l hyperpigme ntati o n .
Dermal c o l lagen brea kdown with fo rmation o f a m o r
p h o u s m asses a n d i nc rease i n glycosa m i n oglyca ns.
Te l a ngiectasia noted .

D I F F E R E N T I AL D I AG N OS I S
R oth m u n d-Thomson syn d ro m e ; ra d iation dermatitis;
Ki n d l e r

syn d ro m e ;

tela ngiectasi a .

B l oo m 's

syn d ro m e ;

Ataxia

Figure 1 2 . 1 Poikiloderma of Civatte. Reticulated pigmentation, ery

thema, and atrophy can be seen with characteristic sparing of the sub
mental area. The erythematous component is more prominent in this
patient. (Courtesy of Richard A. Johnson, MO. )

67

68

Color Atlas of Cosmetic Dermatology

COU RS E
C h ro n i c p rogressive cou rse with conti n u ed s u n expos u re .

KEY CO N S U LTAT I V E QU EST I O N S

Past a n d c u rrent s u n expos u re h i story

Occu pation

H o b b i es/sporting activities

U nd e rlying medical cond itions

H/o rad iation thera py

Past treatments a n d response

MANAG E M E N T
P revention : strict s u n avo i d a n ce .

Figure 1 2 . 2 Poikiloderma o f Civatte-the pigmented component is more


prominent in this patient.

TREAT M ENT

Topical

thera py:

d a i ly

su nscreen

a p p l ication

with

UVB/UVA cove rage .

Laser thera py: great caution m ust be fo l l owed with a ny


laser treatment a d m i n istered to m i n i m ize the risk of
sca r formati o n , dyspigmentati o n , "finger- p r i nting" o r
treatment s k i p a reas, a n d text u ra l cha nges. The neck i s
pa rtic u l a rly p r o n e t o sca rring given fewer pi losebaceous
u n its. A test site is recom mended . M u lt i p l e sess ions a re
genera l ly req u i red .
Laser fl ue nces should be lowered by a pproxi mately

25% to 30% of fac i a l pa ra m eters to avoid adve rse


effects .
- Pu lsed dye laser-low flue nces util ized (eg, Vbea m
595 n m , 0.45- 1 . 0 ms, J/cm 2 , 7- 1 0-m m spot,
DCD 30/20). I m p rovement in te langiectasia a n d atro

phy see n . L i m ited benefit for dyspigmentatio n .


- I ntense

p u lsed

l ight

(eg,

Sta rLux,

20-30

ms,

28-34 J/d m 2 , 1 0 % pass overla p )-i m provement of

a l l com pon ents may be poss i b l e .


- Versa P u lse 532-n m laser-l ow fl ue nces necessary
( Fig. 1 2 . 3 ) .
- Fractionated n o nab l ative a n d a blative laser-a l l com
ponents may be targeted . Can be safely util ized in
affected body a reas, though conservative laser pa ra
meters a re req u i red to avoid potenti a l sca rring.

P I T FALLS TO AVO I D

A conservative a p proac h m u st be fo l l owed with a ny


treatment used for POC, given the sign ifica nt risk of
u n even remova l of the pigmentation a n d e rythema
res u lting i n a "footprint" - l i ke a p pearance ( Fig. 1 2 . 4 ) .

Figure 1 2 . 3 (A) Poikiloderma of Civatte pretreatmen t. (B) Poikiloderma of

Civatte following three VersaPulse 532-nm laser treatments. Marked


reduction in erythematous component is observed.

Sect i o n 1 : Ph otoa g i n g

69

T h i s m ottled a p pea ra nce can occ u r norma l ly d u ri ng the


cou rse of treatment. The patient m ust be awa re of t h i s
poss i b i l ity. Cont i n ued treatment t o the resid ua l lesions
genera l ly res u l ts i n a resol ution of t h i s side effect.

Patients m u st be awa re of the d ifficu lty in i m provin g


t h i s condition. M u lt i p l e treatments a re expected for end
point of l ighte n i ng. Textural c h a nges a re l i kely to per
sist.

POC with a p r i m a ry e rythemato us com ponent typica l ly


res ponds better than POC with a primarily hyperpig
mented com ponent.

B I B L I OG RAPHY
B a tta K, H i n d s o n C , Cotte r i l l J A , Fo u l d s I S . Trea t m e n t
of poi k i l od e r m a o f C i va tte with t h e potass i u m tita nyl
p h o s p hate ( KT P ) laser. Br J Dermatol. 1 999 ; 1 40( 6 ) :
1 19 1 - 1 192.
Gero n e m u s R . Po i k i loderma o f Civatte . Arch Dermatol.
1 990; 1 26(4) : 547-548.
Kato u l is AC, Stavria neas N G , Panayiotides J G , et a l .
Poi k i loderma of Civatte : A h i stopathologica l a n d u ltra
struct u ra l study. Dermatology. 2007 ; 2 14(2) : 1 7 7 - 1 82 .
La nge l a n d J . Treatment o f poiki loderma o f Civatte with
the p u lsed d ye laser: A series of seven cases. J Cutan

Laser Ther. 1 999; 1 (2 ) : 1 2 7 .


R uscia n i A, Motta A, F i n o P, Men i c h i n i G . Treatment of
poi k i l oderma of C ivatte u s i n g i ntense p u lsed l ight sou rce:
7 yea rs of experience. Dermatol Surg. 2008;34( 3 ) : 3 1 43 19 .
Ti erney EP, H a n ke CW. Treatment o f poi k i loderma of
Civatte

with

a b lative

fractional

laser

res u rfa c i ng :

P ros pective study a n d review o f the l i teratu re . J Drugs

Dermatol. 2009;8(6) : 527-534.


Ti erney EP, Kou ba DJ , H a n ke CW. R eview of fractional
photothermolysis: Treatment i n d ications a n d effi cacy.

Dermatol Surg. 2009 ;35( 1 0 ) : 1 445- 146 1 .

Figure 1 2 .4 "Footprinting" o f the anterior neck after a single intense


pulsed light (!PL) source treatment for Poikiloderma of Civatte. This sub
sequently resolved with continued IPL treatments

This page intentionally left blank

TWO
D isord e rs of S e baceo u s G l and s

72

Color Atlas of Cosmetic Dermatology

CHAPT E R 1 3

Ac n e Vulga ris

Acne vu lga ris is a c h ro n i c i nfla m m atory d isease of the


pi losebaceous u n it. Ac ne lesions favor the face, neck,
u pper ba ck, c hest, a n d u pper arms. M u lti ple c l i n ical va ri
a nts exist and they i nc l u d e comedonal acne, pa p u l opus
tular acne, nod u l ocystic a c n e , a cn e conglobata , a n d
a c n e fu l m i na n s .

EPI O E M I O LOGY
Incidence and age: pred o m i n a ntly a d isord e r of adoles
cence; affects 85% of i n d ivid u a l s between

12 a n d

2 4 yea rs o f age; m a y affect a l l age grou ps

Race: lowe r i nc i d e n ce in Africa n-America ns a n d Asi a n s


Sex: more severe forms i n m a l es
Precipitating factors: ge netic p red isposition, endocri ne
d isord e rs, stress, mec h a n ical factors (fricti o n , p ress u re,
occ l usion ) , contact with a cnege n i c materials ( o i l s , c h lori
nated hyd roca rbons, cosmetics) , a n d d rugs (steroids,
l ith i u m , a n d rogens, hyda ntoi n )

PATHOG E N E S I S
Many patients with nod u locystic acne have a fi rst-degree
relative with a history of severe acne. The primary patho
physiology i nvolves a ltered fol l i c u l a r keratin ization resu lting
i n o bstruction of sebaceous fol l ic les, increased seb u m pro
d uction, hyperprol iferation of Propion i bacteri u m acnes,
and i n c reased prod uction of chemotactic factors which
resu lt i n i nfla m matio n .

PHYS I CAL EXAM I NAT I O N


Comedones ( c l osed a n d open ) , erythematous pa p u les,
p ustu les, nod u les, and cysts. May resolve with res i d u a l
hyperpigmentation or sca rri ng.

D I F F E R E N T I A L D I AG N OS I S
Ac n e

rosa cea ,

ste roid

acne,

acne

mecha n i c a ,

P ityros poru m fol l i c u l itis, a n d bacteria l fol l i c u l it i s .

LABORATORY DATA
E n d oc r i n e St u d i es
No routi n e stu d i es a re needed . If h i story a n d physical
exa m i nation ra ise concerns then consider ordering
screen for free a n d tota l testosterone, d e hyd roe p ia n d ros
terone,

and

fo l l ic l e

sti m u lating

hormone/l ute n i z i n g

Figure 13.1 An 1 8-year-old male with cystic acne being treated with

1 , 450-nm diode laser

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

73

hormone ( FS H/LH ) ratios to exc l u d e polycystic ova ry syn


d rome or other hormonal a bnorma l ities espec i a l l y in
wo men with mode rate-to-severe a c n e , h i rsutism , i rregu
l a r menses, a n d weight ga i n . D i et may play a role i n fla res
of a c n e . H igh glyce m i c d i ets may exacerbate a c n e .
F u rther stu d ies a re need ed .

D e r m at o p at h o l ogy
Pathology of early lesion (comedone) revea ls o bstruction
of the fol l i c u l a r i nfu n d i b u l u m by corn ified cells lead i ng to
d i latation . Later lesions revea l fol l i c u l a r r u pt u re with lym
p hocytes, neutro p h i l s , and macrophages . Sca rring may
be see n .

COU RSE
T h i s d isease dem onstrates a c h ro n i c cou rse a n d rem its
s ponta n eously in the early-to-mid-th i rd decade in the
majority of patients. However, a c n e may persist m u c h
longer i n some patients .

MANAG E M ENT
Ea rly treatment o f a c n e is essential for t h e preve ntion of

d ysc h ro m i a or assoc iated sca rring (see sca r treatment


cha pter 6 1 ) . M a ny acne patients benefit from c o m b i n a
tion thera pies. A thorough h i story a n d physical exa m i na
tion a re para m o u nt to a d m i n istering a maxi m a l ly effective
p la n . T h i s s h o u l d i n c l u d e c u rrent cosmetics a n d s u n
screens, s k i n type, l ifestyle, occ u pati o n , medications,
past treatments a n d res ponse, d i et, menstrua l and ora l
contraceptive h i story.

To p i c a l Treat m e n t
To pical treatment may b e req u i red for the d u ration o f t h i s
c o n d ition . To pical for m u l ations s h o u l d be a p pl ied t o the
lesions as wel l as to the adjacent a c n e-prone c l i n ica l l y
normal ski n .

Reti noids: treti noi n , a d a pa l e n e , taza roten e

Anti bacterial agents: benzoyl peroxide, c l i n d a m yc i n ,


e ryt h romyc i n

Kerato lytic agents: sa l icyl i c a ci d , hyd roxy a c i d , aze l a i c


a c i d , sod i u m su lfaceta m i d e , a n d s u lfu r

Syste m i c Treat m e n t

Ant i biotics: tetracyc l i ne , d oxycyc l i ne, m i nocyc l i n e a re


m ost

commonly

used .

Alternatives

i n c l ude

e ry

t h romyc i n , azith romyc i n , a n d a m oxic i l l i n .

Hormones: o ra l contraceptives or spi ronolacto ne for


women with persistent acn e on lowe r face, c h i n , a n d
neck.

Figure 13.2 (A) Facial inflammatory acne vulgaris unresponsive to multi


ple topical and oral treatment regimens. (B) Marked improvement of acne
6 months following five 1 , 450-nm diode laser treatments (Smoothbeam,
Candela Corp. , Wayland, MA), 6-mm spot, 1 4 J/cm 2 , DCD 30 ms

74

Color Atlas of Cosmetic Dermatology

l sotreti n oi n : fo r severe n od u l ocystic acne that has fa i l ed


other to pical a n d syste m i c thera pies.

S u rg i c a l Treat m e n t

Comedone extraction : expression of kerati nous con


tents of open comedones by a pplying the comedone
extractor to the comedones and a pplying p ress u re .
A n i c k m a y b e m a d e t o t h e overlyi ng s k i n with a
# 1 1 - blade or 1 8-ga uge need le to ease in the extracti o n .
The

Scham berg,

Unna,

and

Saalfi e l d

comedone

expressors a re m ost com m o n l y uti l i zed . Comedone


extraction is contra i n d icated for i nfla m ed comedones
or pustu les d ue to i n c reased sca r risk.

l ntra l esional steroid i njection : tri a m c i nolone aceto n i d e


( 2-3 mg/m U is i njected i nto i nfla m ed cystic lesions
using a 30-ga uge need l e . Maxi m u m d ose i njected
s h o u l d not exceed 0 . 1 mL per lesion to avo i d atro phy.
Patients s h o u l d be wa rned that atrophy from an i nflam
m atory cystic lesion can occ u r with o r without an
i ntra lesiona l steroid i nj ectio n .

Chemical pee l s : seri a l sa l i cyl ic a c i d peels, glyco l i c a c i d


peels ( 20-70% ) , a n d tri c h loroacetic a c i d ( T C A ) peels
( 1 0-20) have been util ized to red uce the n u m ber of
comed ones a n d i m prove posti nfl a m m atory hyperpigmentation a n d persistent erythema . Peels may be per-

formed every 2 to 4 weeks, with i n c reasing strengths


and time a p p l ied as tol erated . M i ld i rritation may be
o bserve d . Adj u nctive thera py is genera l ly necessa ry.

M i c roderma b ras ion : this is prima rily effective for come


donal acne. It is usua l ly performed every 2 to 3 weeks.
M u lti ple treatments a re needed with va ria ble i m prove
ment.

L i g h t Trea t m e n t

Lasers: lasers a n d l ight sou rces a re not the fi rst-l i n e


thera py f o r a c n e b u t ca n b e a n effective a lternative o r
adj uva nt t o m e d i c a l thera py when req u i red .
- 1450- n m d i ode laser ( S m ooth bea m laser, Candela
Corp . , Wayla n d , M A ) : treatment fl u en cies from 8 to
14 J/c m 2 , 6-m m s pot size, a n d dyna m i c cool i n g
device setting o f 30-35 ms can res u lt i n m i ld t o d ra
matic i m provement of i nflam matory tru n k a n d fa c i a l
acne w i t h a sign ificant red uction i n l e s i o n count after
an ave rage of t h ree, sepa rated by 4-to-6-week i nter
va ls ( F igs. 1 3 . 1 a n d 1 3 . 2 ) . I t is i m porta nt to d e l iver
nonoverla p p i n g pu lses to red uce the risk of side
effects. To pical l i doca i ne c rea m a p p l ied prior to treat
ment is needed to m i n i m ize the treatment-assoc iated
pa i n . It is vita l to a p ply the c rea m over a l i m ited body

s u rface to l i m it a ny risk of l idoca i n e toxic ity.

Figure 13.3 (A) Severe acne before treatment. (B) A fter three treatments
of photodynamic therapy with topical 5-aminolevulinic acid and pulsed
dye laser, 7-mm spot, 6 J!cm 2 , 6-ms pulse duration (Courtesy of Mark
Nestor, MD, PhD)

- Lower fl u e n c ies of 8 J/c m 2 with two fu l l-face passes


versus a si ngle ful l-fa ce pass at h igher fluenc ies
( 1 0- 1 4 J/cm 2 ) have been used to red uce pa i n .

Sect i o n 2 : D i so rd e rs o f Sebaceous G l a n d s

75

- P u lsed dye laser ( P D U : stu d i es exa m i n i ng the effi


cacy of P D L for i nfla m mato ry acne have prod uced
conflicti ng data . P u lsed dye laser alone or i n c o m b i
n a t i o n w i t h long p u lsed 1 , 064- n m YAG l a s e r h a s
b e e n effective i n red u c i n g i nfla m matory a c n e . P D L
can i m p rove postacne erythe m a . F l u ences o f 5 . 5 t o
7 J/c m 2 , 7-m m spot s i z e w i t h pu lse d u rations o f 3 t o
6 ms a re most c o m m o n l y em ployed . Severa l treat
ments a re n eeded to ach ieve the greatest benefit.

P h ototh era py:

m u lt i p l e

l ight

sou rces

have

been

reported to sign ifica ntly i m prove acne with m i n i ma l side

Figure 1 3 .4 (A) Facial inflammatory acne prior to photodynamic therapy.

effects. These sou rces i n c l u d e h igh-i ntensity narrow

(8) Marked reduction of the inflammatory acne after three sessions of

ba nd b l u e l ight, h igh-i ntens ity meta l h a l i d e la m p, h igh

photodynamic therapy (Courtesy of Mark Nestor, MD, PhD)

energy b road-s pect r u m b l u e l ight, as wel l as m ixed


b l u e a n d red l ight.

P h otodyna m ic thera py ( P DT ) : PDT uti lizing the topica l


a d m i n istration of 5-a m i nolevu l i n i c acid (ALA, Levulan
Kerastick, D U SA Pha rmaceutica ls, I nc . , W i l m i ngto n ,
M A ) activated b y l ight exposure is a n other potentia l l y
effective modal ity t o treat acne ( Figs . 1 3 . 3 a n d 1 3 .4) .
Short contact A LA- PDT ( 1 5-60- m i n ute d rug i n c u bati o n )
w a s c a p a b l e o f i m p roving acne sign ifica ntly i n a va riety
of c l i nical stu d i es . Diffe rent l ight sou rces have been
uti l ized i ncl u d i ng b l u e l ight (405-420 n m ) , red l ight
(635 n m ) , long- p u lsed 595- n m pu lsed dye lasers, a n d
i ntense pu lsed l ight (430- 1 200 n m ) ( Fig. 1 3 . 5 ) .

B I B L I OG RAPHY
Bowe WP, J osh i SS, S h a l ita A R . D i et a n d a c n e . J Am

Acad Dermatol. 20 1 0 ; 63( 1 ) : 1 24- 14 1 .

Fried m a n P M , J i h M H , Ki mya i-Asa d i A , Gold berg LH .


Treatment of i nflam matory fac i a l acne vu lga ris with the
1 450- n m d iode lase r : A pilot stu d y.

Dermatol Surg.

2004;30(2 pt 1 ) : 147- 1 5 1 .
H a m i lton F L , C a r J , Lyons C , C a r M , Layton A , Majeed A .
Laser a n d oth e r l ight thera pies for the treatment of a cn e
vu lga ris: Systematic revi ew. Br J Dermatol. 2009 ; 1 60(6):
1 273- 1 285.
Leheta TM. Role of the 585- n m p u lsed dye laser i n the
treatm ent of a c n e in c o m pa rison with other topica l thera
peutic modal ities. J Cosmet Laser Ther. 2009; 1 1 ( 2 ) :
1 1 8- 1 24 .
P o l l o c k B , Tu rner D , Stringer M R , e t a l . Topical a m i n ole
vu l i n i c acid-photodyna m i c thera py for the treatment of

acne vulga ris: A study of c l i n ical efficacy a n d mec h a n ism

Figure 1 3 . 5 (A) Mild acne scarring and dyschromia prior to Er: YAG laser

of acti o n . Br J Dermato/. 2004; 1 5 1 (3 ) : 6 1 6-62 2 .


Yeu ng C K , S h e k SY, Yu CS, Ko no T, C h a n H H . Treatment
of i nfla m matory fac i a l ac n e with 1 ,450- n m d iode laser in
type I V to V Asia n skin using an o pti m a l c o m b i nation of
laser pa ra meters . Dermatol Surg. 2009;35(4): 593-600.

resurfacing. (B) Four months after Er: YA G laser resurfacing utilizing a


5-mm spot at 1 J with four passes results in significant improvement
(Reproduced, with permission, from Dover J, Arndt K, Geronemus R,
et a!. Illustrated Cutaneous & Aesthetic Laser Surgery. McGraw-Hi//,
Inc.; 2000)

76

Color Atlas of Cosmetic Dermatology

CHAPT E R 1 4

R osacea

A c n e rosacea is a c h ro n i c vasc u l a r a n d a c neiform d isor


der of the p i l osebaceo us u n it that affects p red o m i n a ntly
the centra l face i n c l u d i ng the centra l c h eeks, n ose, a n d
c h i n . The eyes a n d the eye l i d s can occasiona l ly be
i nvolved . Typical ly, there is an i n c reased reactivity of cap
i l la ries to h eat, lead i n g to fl u s h i n g and u ltimately tela ng
iectasia .

S u btypes of

rosacea

include

(1)

vasc u l a r

rosacea (erythematotela ngiectatic), ( 2 ) pa p u l o pust u l a r


rosacea , (3) sebaceous hyperplasia ( phymatous rosacea )
i n c l u d i n g r h i nophyma ( nasa l sebaceous hyperplas i a ) ,
a n d ( 4 ) oc u l a r rosacea . G ra n u lomatous rosacea is a vari
a nt of rosacea .

EPI O E M I O LOGY
Incidence: common
Age: 30 to 50 yea rs; pea k i nc i d e n ce between 40 and
50 yea rs

Sex: fe male pred i lect i o n ; m a l e pred o m i n a nce for r h i n o


phyma

Race: m ost common in fa i r-s k i n ned i n d ivid uals (skin


phototypes I and I I ) ; rarely seen i n da rker-ski n ned i nd i
vid u a l s (ski n p hototypes IV-V I )

Precipitating factors: excessive s u n exposu re, caffe i n e ,

s picy food s , h ot foods a n d beverages, heat, a lcohol, seb


orrhea ,

topical

corticosteroid

use,

and

u n derlyi ng

Pa rkinso n 's d isease

PATHOG E N E S I S
M u ltiple facto rs a re i nvolved i n the pathogenesis of
rosacea i n c l u d i n g vasc u l a r hypera ctivity, Demodex fol
l i c u lorum m ites, H e l icobacter pyl ori, a n d hypersensitivity
to Pro p i o n i bacteri u m acnes.

PHYS I CAL EXAM I NAT I O N


Va riable c l i n ic a l featu res ca n b e p resent d e pen d i ng o n
the severity a n d t h e s u btype o f rosacea . Ea rly featu res
i n c l u d e tra nsient a n d nontra nsient f l u s h i ng, e rythema
to us pa p u les, a n d p ustu les. N o comedones a re n oted .
Late featu res i n c l u d e tela ngiectasias, sebaceous hyper
plasia, nasa l t h i c k e n i n g and e n l a rge ment ( r h i nophym a ) ,
a n d lym phedema . Oc u l a r i nvolvement is freq ue ntly see n .

D I F F E R E N T I A L D I AG N OS I S
Acne vu lga ris, seborrheic d e rmatitis, periora l dermatitis,
steroi d

rosacea, system ic l u pus erythematosus, a n d

B l u pu s m i l ia ris d isse m i natus fac ie i .

Figure 14. 1 A&B Severe rhinophyma prior to electrosurgery (Courtesy of

Suzanne Olbricht, MD)

Sect i o n 2: D i so rd e rs of Sebaceous G l a n d s

D E R M ATOPAT H O LOGY
Vasc u l a r ectasia as wel l as perifo l l i c u l a r and perivasc u l a r
lym phoh istiocytic i nfi ltrates a re t h e most c o m m o n fi n d
i ngs. Demod ex fol l ic u l o r u m is usua l ly d etected i n the fol l i
c l es . N oncaseating epithelioid gra n u lomas a re seen i n
t h e gra n u lo matous va riant. Sebaceous hype rplasia a n d
fi b rosis a re seen i n rhi nophym a .

CO U RS E
C h ro n i c with freq uent rec u rre nces. May sponta n eously
resolve afte r several yea rs .

MANAG E M ENT
P reventi o n , red u ctio n , or e l i m i nation o f exacerba nts ; s u n

avoida nce.

To p i c a l T h e ra py
M etro n idazole (0. 7 5%- 1 % ) once or twice d a i ly, 1 0 %
sod i u m s u lfaceta m i d e w i t h 5 % sulfur o n ce d a i ly, a n d
aze l a i c a c i d o n c e d a i ly, a l o n e or i n c o m b i nati o n , a re h e l p
ful i n s u p p ressi n g the pa pu l o pustu l a r com ponent of
rosacea .

Syste m i c T h e ra py

Tetracyc l i ne, 1 ,000 to 1 , 500 mg d a i ly in d ivided d oses,


u nt i l clear; then ta per to a m a i nte n a n ce d ose of 250 to
500 mg d a i ly.

M i nocyc l i n e a n d d oxycyc l i n e , 50 to 1 00 mg twice d a i ly,


with a ta peri ng to once d a i l y use.

Oral

isotret i n o i n

is

'-- - """""'

reserved for severe cases not

res pond i ng to o ra l a nti biotics and req u i res c l ose fol low
u p . A low-dose regi men may be effective .

S u rg i c a l T h e ra py

Rh i nophyma
M u ltiple s u rgica l mod a l ities have been used to correct
the hypertro p h i c c h a nges of r h i nophyma . It is i m porta nt
to exa m i n e a ph otogra ph of the patient prior to the onset
of the r h i n o phymatous c h a nge in order to h e l p g u i d e the
s u rgeon i n the re mod e l i ng of the nose . A regional nerve
block with a d d itiona l loca l a n esthesia is suffic i ent in the
majority of cases fo r perioperative pa i n m a n agement.
D i rect i nj ection of a n esthesia req u i res m u lt i p l e i nfi ltra
tions a n d is less effective and fa r more pa i nfu l .

Electrosu rgery: electrosection (cutti ng) is very effective


in d e b u l k i ng a n d reconto u r i n g the r h i n o p hymatous
nose with the added adva n tage of a relatively b l ood less
fie l d . It is s i m i l a r in efficacy to C0 2 laser treatment a n d
less expensive ( Fig. 14. 1 ) .

Figure 14. 1 ( continued) C, D,&E Debulking and recontouring of the


rhinophymatous nose in a relatively bloodless field utilizing large wire
loop electrosurgery Impressive flattening of the rhinophymatous nose
after electrosurgery. The wound is left to heal by secondary intention
(Courtesy of Suzanne Olbricht, MDJ

77

78

Color Atlas of Cosmetic Dermatology

The hypertro p h ied tissue is re moved with care to pre


serve the p i l osebaceous u n its .

Overcorrection wi l l prod uce sca rring a n d contractu res .


Wou n d contractu re with hea l i ng may p u l l the nasa l t i p
u pwa rd .

Perma n e nt d e pigmentation may res u l t from overvigo r


ous treatment.
- The El l m a n S u rgitron can be used with a la rge wi re
loop in

blended waveform "fu l l y rectifi ed" mode

which provides c utti ng with hem ostasis, at a powe r


control between 4 a n d 5 .
- A vac u u m evac uator s h o u l d be u t i l ized for e l i m i nat
ing p l u mes of smoke.
- Any rem a i n i ng b l eed i ng poi nts ca n be coagu lated at

t h e end of the proced u re by switc h i ng to t h e coagu l a tion " pa rtia l ly rectified " m o d e .
- The wo u n d is a l l owed to heal b y seco n d a ry i nte ntio n .
- The patients a re i n structed to kee p t h e wo u n d moist
by m u lt i p l e a p pl ications of petro l e u m j e l l y d a i l y u nt i l
re-epith e l i a l ization is com plete a p p roximately 2 weeks
postop .

Exc ision b y t h e fa r- i nfra red lasers ( i e , C0 2 o r Er:YA G )


fol l owed b y va porization is a lso ve ry effective w i t h a relatively blood less s u rgica l fie l d . A sca n n ed C0 2 laser is
t h e o pti m a l d evice given the need to d e b u l k la rge, t h i c k
a reas o f ski n . The pu lsed C0 2 laser can a lso b e used i n
t h e conti n u o u s wave mode t o rem ove t h e b u l k o f the
r h i n o phyma a n d i n t h e p u lsed mode to scu l pt and
resu rface t h e rem a i n d e r of the nose.

Te langi ectasias
Laser a n d flash la m p treatments based on selective l ight
a bsorption by he mogl o b i n a re usua l ly very effective for
re movi ng tela ngiectasias a n d pa rtia l ly effective in i n h i bit
ing f l u s h i n g . Patie nts m ust be awa re that over time they
a re l i kely to deve l o p more tela ngiectasias a n d back
grou n d erythema .

Laser treatment: m u lt i p l e effective o ptions a re ava i l


a ble.
- P u lsed d y e lasers ( P O L) a re the treatment o f c h o i c e
for fac i a l telangiectasias.
The tra d itiona l P O L with a short pu lse d u ration of
0.45 or 1 . 5 ms provides the m ost effective treat
ment for fac i a l te la ngiectasias. H owever, posttreat
ment p u r p u ra occ u rs w h i c h ge nera l ly lasts 1 0 to
14 days.

A va ria ble-pu lse POL ( 59 5 n m , Candela V-bea m ,


Wayla n d , M A ) with stuttered pu lse d u rations ( i e ,
0.45, 1 . 5, 3, 6, 10, 20, 30, 40 ms) can provide a
red uced p u r p u ra t reatm ent of fac i a l tela ngiec
tasias, b u t is somewhat less effective and usua l ly
req u i res m u lti ple treatments.

Figure 14.2 (A, B, C) Prominent facial erythema prior to treatment with

/PL .

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

79

0 C o m m o n ly, s u b p u rp u ric fl uences of less t h a n


1 0 J/cm 2 at pu lse d u ration of 1 0 ms wit h a 7 - m m
spot s i z e a re util ized .

0 Better efficacy of the va riable-pu lse P D L i n treat


ing fac i a l telangiectasias can be a c h ieved by uti
l iz i n g p u r p u ri c fl uences or with a p u lse sta c k i n g
o f s u b p u r p u ric pu lses (sta c ked 2-4 s u b p u rpuric
p u l ses at a 1 . 5- H z repetition rate, 7.5 J/c m 2 ,
1 0-ms pu lse d u rati o n , 1 0- m m spot size, D C D of
30/20).

0 Facial edema, eryth em a , a n d d isco mfort c a n


occ u r after exte nsive treatment w i t h the p u r p u ra
free va ria ble-pu lse P D L. H owever, these u nde
si red effects a re ge nera l l y better tolerated when
compared to a p u r p u ra- i n d u c i ng laser treatment.

- I ntense pu lsed l ight ( I PL) can be h ighly effective in


treating backgro u n d erythema while P O Ls work bet
te r for i n d ivid u a l telangiectasia . I P L fl uenc ies of 30 to
40 J/c m 2 with a 20 msec p u lse d u ration a re usua l ly
effective ( Sta r l u x Lux G h a n d piece, Pa lomar Med ical
Tec h n o logies, B u r l i ngton , M A J . The treatment end
point is i m med iate vessel clearance or selective ves
sel d a rke n i ng. M u lt i p l e treatments may be req u i red
fo r the greatest treatment benefit.
- The va riable pu lse width 1 , 064- n m N d : YAG laser
has proven to be effective i n the treatm ent of fac i a l
te la ngiectasias. S h o rter p u lse widths with h igher f lu
en ces m ight be n ecessa ry for effective treatment of
s m a l l e r vessels but have a n increased risk of b l i ster
and sca r formatio n .
- Freq uency-d o u bled 532 n m N d : YAG laser, a lso
cal led potass i u m-tita nyl-phosphate ( KT P ) laser, pro

vides effective a bsorptio n of hemogl o b i n with a pu lse


d u ration of 1 to 50 m s m a k i ng it idea l ly su ited to treat
su perfi c i a l vessels without p u r p u ra formati o n . Tra c i n g
o f i n d iv i d u a l vessels is a usefu l tec h n iq ue for patients
with a cou nta b l e n u m be r of d iscrete , visi ble vesse ls.

Flashla m p

( p u lsed

l ight)

treatment:

IPL

provides

a n othe r effective, p u r p u ra-free method for red ucing


fa c i a l tel a ngiectasias a n d erythema ( Figs . 1 4 . 2 and
14.3 ) .

B I B L I OG RAPHY
Afe rzon M , M i l l ma n B . Exc ision o f r h i n o phyma with h igh
freq u ency electrosu rgery. Dermatol Surg. 2002 ; 28(8 ) :
735-738.
Alam M, Dover JS, Arndt KA. Treatment of fac i a l telang

iectasia

Figure 14.2 (continued) (0, E, F) Reduction of the facial erythema after

with

va r i a b l e- p u lse

h igh-fl uence

pu lsed-dye

laser: Com pa rison of efficacy with fl uences i m med iately


a bove and below the p u r p u ra t h reshold . Dermatol Surg.
2003 ; 29 ( 7 ) : 68 1 -684 . D iscussion 685 .

two treatments with /PL, Starlux L ux G handpiece

80

Color Atlas of Cosmetic Dermatology

Bernste i n EF, Kligm a n A. R osacea treatment using the


new-gen eratio n ,
d u ration

h igh-energy,

p u l sed-dye laser.

595

nm,

long

pu lse

Lasers Surg Med. 2008;

40(4): 233-239 .
Del Rosso J Q . Anti-i nfla m matory d ose d oxycyc l i n e in the
treatment of rosacea . J Drugs Dermatol. 2009 ; 8( 7 ) :
664-668 .
J a s i m Z F, Woo WK, H a n d ley J M . Long-p u lsed (6-ms) d ye
laser

treatment

of

rosacea-associated

te la ngiectasia

using s u b p u rp u ric c l i n ica l t h reshold . Dermatol Surg.


2004;30( 1 ) : 37-40 .
Mark KA, S pa racio R M , Voigt A, M a re n u s K, Sa rnoff D S .
O bjective a n d

q u a ntitative i m prove ment o f rosacea

assoc iated erythema after i ntense p u l sed l ight treatment.

Dermatol

Surg.

2003 ; 29(6) : 600-604;

1 63- 1 6 7 .

Discussion 1 6 7 .
N e u h a u s I M , Za ne LT, Tope W D . Comparative efficacy of
n o n p u r p u rage n i c p u l sed dye laser a n d i ntense p u lsed
l ight fo r erythematotela ngiectatic rosacea . Dermatol Surg.
2009 ;35(6):920-928.
Sa rradet DM,

H ussa i n M , Gold berg DJ .

M i l l isecond

1 064- n m neodym i u m : YAG laser treatment of fa c i a l


tela ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58.
T h i boutot D M , Fleisc h e r AB, Del Rosso JQ, R i c h P.
Re lated Articles 7: A m u lticenter study of topical aze l a i c

a c i d 1 5% gel i n c o m b i nation with ora l d oxycyc l i n e as i n i t i a l th era py a n d azela ic a c i d 1 5 % g e l as m a i nte nance


monothera py. J Drugs Dermatol. 2009;8( 7 ) : 639-648.

Figure 14.3 (A) Prominent facial telangiectasias prior to treatment with

/PL . (B) Posttreatmen t erythema immediately after IPL treatment

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

CHAPT E R 1 5

Se baceous H ype rp l a s i a

Sebaceous hyperplasia a p pea rs a s 1 -to-3-m m ye l l ow


u m bi l icated pa pu les with overlying te la ngiectasias on the
face of m id d le-aged i n d iv i du a ls ( Fig. 1 5 . 1 ) . They re p re
sent a benign prol iferation of sebaceous glands. The
lesions a re someti mes m i sta ken for basa l cell carc i n o m a .

E P I D E M I O LOGY
Incidence: very common
Age: m ost c o m m o n l y middle age a n d elderly but can
a p pea r i n you ng i n d ivid u a l s as wel l
Race: more common in Caucasians
Sex: eq ual
Precipitating factors: orga n tra nspla ntation is a ra re p re
c i pita nt

PATH OG E N ES I S
U n known .

PATHOLOGY
I nc reased n u m bers of l a rge, matu re sebaceous l o b u les
a re c l u stered a ro u n d a centra l d u ct in the u p per d e r m i s .
The lobu les l i e closer tha n normal t o the e p i d e r m i s .

PHYS I CAL LES I ON S


There a re si ngle or m u lti p l e 1 -to-3-m m ye l low u m b i l i
cated pa p u les with overlying telangiectasias t h a t a p pea r
on the face. The forehea d , c h eeks, a n d nose a re the
m ost common locatio ns. I t can rarely present on the
a reo l a .

D I FFERENTIAL D I AG N OS I S
M ost c o m m o n l y m ista ken for basa l cel l carci n o m a .

LABO RATORY EXA M I NAT I O N


N o n e i s i n d icated . B i o psy i f consideri ng basa l cell carci
noma.

CO U RS E
Ben ign , but d o not regress o r resolve without thera py.

KEY CO N S U LTAT I V E QU EST I O N S


Any h i story of the lesion bleed i ng.

Figure 1 5 . 1 Large sebaceous hyperplasia on the forehead

81

82

Color Atlas of Cosmetic Dermatology

MANAG E M ENT
There i s no me d i c al i n d ication t o treat sebaceo us hyper
plasia . Sti l l , some i n d ivid u a l s a re sign ifica ntly bothe red by
its a p pea ra nce a n d req uest re mova l , pa rticula rly in the
c i rc u msta nce of m u ltiple lesions. Treatme nts i n c l u d e
o ra l , destructive, laser, a n d photodyna m ic thera p ies.
Eac h has its side effects and risk of rec u rrence.

TREAT M ENTS
A l l patie nts s h o u l d be i nformed before a ny treatment
modal ity that i m prove ment is va ria b l e and i n the futu re
new lesions may a rise req u i ri n g fol low- u p treatme nts.

Dest r u ct i ve M o d a l i t i es

" Light" c ryothera py a n d electrosu rgery a re q u ic k , i n ex

pens ive means of treating sebaceo us hyperplasia .

Laser T h era py

The

1 ,450- n m

d iode

laser has

been stu d i ed

in

1 0 patients for the treatment of sebaceous hyperplasia


( Figs. 1 5 .2 and 1 5 . 3 ) .
- Ea c h patient was treated 1 t o 5 times.
- F l u e n ces of 1 6 to 17 J/c m 2 were em ployed , with cooli n g d u rations of 40 to 50 ms.
- After two to th ree treatm ents with the d iode laser,
84% of lesions d ec reased in size greate r t h a n 50%,
a n d 70% decreased greate r tha n 75%. Patient a n d
phys i c i a n satisfaction was h igh .
- Side effects i n c l uded one case of a n atro p h i c sca r
a n d one case of hyperpigme ntati o n .

Pu lsed d y e laser ( P D U ( 585 n m ) h a s been shown to


i m prove sebaceous hyperplasia .
- Su ccessful treatment has been shown with t h ree
sta c ked 5-mm p u lses at fl u e n ces of 7 a n d 7 . 5 J/cm 2 .
- M ost lesions respond after one treatment with flatten
i ng, s h r i n k i ng, o r resol ution .
- Seve n percent of lesions rec u rred com p l ete ly.
- One study s h owed cleara n ce i n two patients treated
with the P D L at 585 n m , 6 . 5 to 8 J/cm2 , a n d a p u lse
width of 300 to 450 seconds. Two to t h ree treatments
were performed .

Erbi u m : YAG or C0 2 laser a b lation c a n a lso i m p rove


sebaceo u s hyperplasia .

Laser-assisted photodyna m i c thera py with topica l 20%


5-a m i no l evu l i n ic acid and PDL i rrad iation (595 n m ) ,
b l u e l ight or i ntense p u lse l ight; 1 t o 4 treatme nts a re
needed with va ria b l e i m provement a n d futu re recu r
rence a c h i eved m ore effective i m provem e nt of seba
ceous hyperplasia than P D L a l one.

Figure 1 5 . 2 (A) Patient with sebaceous hyperplasia on the right temple

and forehead. (8) Improvement 1 month after treatment with 1 , 4 50-nm


diode laser (Smoothbeam, Candela Corp., Wayland, MA) utilizing a 6-mm
spot with a f/uence of 1 4 J/cm 2 and a pulse duration of 35 ms

Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s

- Treatme nts were performed at 1 -to-6-week i nterva l s .


- B o t h thera pies showed greater i m provement t h a n no
thera py at a l l . There were no long-term res u lts.
- Side effects were l i m ited to m i l d tem po ra ry red ness,
edema, and crusting.

P I T FALLS TO AVO I D/O UTCO M E


EXPECTAT I O N S/CO M P L I CAT I O N S/
MANAG E M ENT

Patie nts should b e i nfo rmed that com p l ete resol ution i s
d iffic u lt a n d n ot a l ways permanent.

Destructive modal ities su ch as c ryothera py a n d electrod es iccation can prod uce pigmenta ry c h a n ges a n d
eve n sca rring if done too aggressively. Recu rrences a re

co m m o n .

Loca l exc ision leaves a sca r.

Ora l thera py with isotret i n o i n is clearly an a lte rnative


treatment a n d is n ot as efficacious as other mod a l ities
and ca rries with it the risk of sign ifica nt side effects
s u c h as teratogen icity, d ry s k i n a nd m ucous mem
b ra n es,

h igh

skeleta l

hyperostosis,

triglycerides and
l iver

c h oleste ro l ,

fu nction

d iffuse

a bnormal ities,

red uced n ight vision, pse u d otu m o r cere b r i , l e u ko pe n i a ,


possi ble d e p ress i o n , a n d s u i c i d a l i d eati o n . To pical
treti n o i n can p rod uce s k i n i rritation .

Laser thera py m ust be used with caution, especially i n


dark s k i n phototypes, given t h e risk o f hyperpigmentatio n .

There ca n be sca rri ng, red ness, e d e m a , a n d c rusti ng,


as shown i n Figure 1 5 . 3 . Recu rrence is n ot u ncom m o n .

Figure 1 5.3 (A) Sebaceous hyperplasia-before. (8) Improvement one

B I B L I OG RAPHY
Aghassi D, Gonza l ez E, And erson R R , R ajad hya ksha M ,
Go nza lez S . E l u c i d ati ng t h e p u lsed -dye laser treatment of
sebaceous hyperplasia in vivo with rea l-ti me confoca l
sca n n i ng laser m ic roscopy. J Am Acad Dermatol. 2000;
43 ( 1 pt 1 ) :49-53 .
Alste r TS, Ta nzi EL. P hotodyna m i c thera py with topical
a m i nolevu l i n ic acid and pu lsed dye laser i rra d iation for
sebaceous hyperplas i a . J Drugs Dermatol. 2003 ; 2 ( 5 ) :
50 1 - 504.
Kim SK, Do J E, Ka ng H Y, Lee ES, Kim YC. Combi nation of
topica l 5-a m i nolevu l i n ic a c i d - photodyna m i c thera py with
carbon d ioxi d e laser for sebaceous hyperplasia. J Am

Acad Dermatol. 2007 ; 56(3 ) : 523-524.


R i c hey D F. A m i n o l evu l i n ic acid photodyna m i c thera py for
sebaceous gla nd hyperplasia . Dermatol Clin. 2007 ;25( 1 ) :
59-65. Review.
Schonermark M P, Sc h m id t C , Ra u l i n C. Treatment of
sebaceous gland hyperplasia with the p u lsed dye laser.

Lasers Surg Med. 1997 ; 2 1 (4) :3 13-3 1 6 .

month after treatment with 1 450 nm diode laser 1 4 . 5 J/cm 2 , 35 ms


cooling, single pulse per lesion

83

This page intentionally left blank

TH RE E
D isord e rs of Ecc rine G l and s

86

Color Atlas of Cosmetic Dermatology

CHAPT E R 1 6

H ype rhid ros is

Hyperh i d rosis is t h e secretion o f excessive a m o u nts of


sweat from the ecc ri ne sweat glands at rest a n d at normal
room tem peratu re . It pro d u ces both physica l a n d soc i a l
d iscomfort. The m ost com m o n l y affected a reas a re the
axi l lae, pa l m s , a n d pla nta r feet. I t can present i n a b i lat
eral o r sym m etric fas h i o n . The m ost c o m m o n cause of
hyper h i d rosis is i d i o path i c .

EPI DEM I O LOGY


Incidence: no good e p i d e m i ologic stu d i es of p reva lence.
Age: pa l mo p l a nta r: b i rt h ; axi l l a ry: p u be rty.
Race: no rac i a l pred i l ection .
Sex: eq ua l .
Precipitating factors: i d i o path ic, emotiona l , centra l nervous
system injury/d isease, d rug, s u rgica l i nj u ry a re the most
common ca uses. In most cases, there is a fa m i ly h i story.

Figure 1 6 . 1 An example of the starch-iodine test in the left axilla. Note

PATHOG E N E S I S
Ecc rine glands a re primarily i n nervated b y sym pathetic
fibers that a re c h o l i n ergic rather t h a n ad renergic in
n e u ra l response.

PHYS I CAL F I N D I N G S

Pa l m o pla nta r: excessive sweat a n d sweat d roplets p ro


d uc i n g a moist a p pea ra n ce a n d c l a m m y feel

Axi l l a ry: sta i n i ng of s h i rts i n the u nd e ra r m a rea

D I F F E R E N T I A L D I AG N OS I S
C l i n ical a p pea ra nce d oes n ot s u ggest other d isord ers .

LABORATORY EXAM I NAT I O N


Sta rch-iod i n e or n i n hyd rin test a re usefu l i n d efi n i ng
a reas of sweati ng ( Fig. 1 6 . 1 ) .

D E R M ATOPAT H O LOGY
N o c h a racteristic fi n d i ngs . B i o psy plays no ro le i n m a n
agement.

COU RS E
Does n ot remit sponta neously; may i m p rove sl ightly with
age .

the prominent dark blue-black discoloration at sites of hyperhidrosis

Sect i o n 3 : D i so rd e rs of Ecc ri n e G l a n d s

KEY CO N S U LTAT I V E QU EST I O N S

Med ication h i story

Past treatments a n d response

Assess fo r syste m i c a bnormal ity

Recent s u rgery

HYPERHIDROSIS

Antipersp i rant
Botox
M e d i cation

Antipersp i ra nt

F i rst l i n e t reatment

A l u m i n u m c h l or i d e (20%-25%)

S u rgery

a p p l ied in the eve n i ng 2-4 t i m es per week

MANAG E M ENT

Effective for many patie nts

Dryness and i rritat i o n are m a i n s i d e effects

Botox

T h e goa l o f the treat m e n t is t o s u bsta ntia l l y d e c rease


sweat p rod u c t i o n to i m p rove p h ys i ca l a n d soc i a l d i s

Botu l i n u m tox i n type A ( Botox)

most com m o n l y used .

co mfort, n ot c o m p l ete e l i m i nati o n . T h e re a re m u lt i p l e

Average dose, 50- 1 00 u n i ts per axi l l a

Safe, h i g h l y effect ive 3-9 months

treat m e nts fo r h y pe r h i d ros i s ( F i g .

Expensive if not covered by i n surance

1 6 . 2 ) . Botu l i n u m

tox i n A i s a very effective treat m e n t p rov i d i ng tem po


ra ry red uction in sweati n g . To p i c a l a n d ora l m e d i c a
t i o n s a re o n l y m o d estly effective . S u rg i c a l t h e ra py,
i n c l u d i ng l i pos u c ti o n , is m o re effective tha n to p i ca l
t h e ra py.

M e d i cati ons

Com pensatory hyperh id rosis sec o n d a ry to sym pathec

Antich o l i nergics; h igh

i n c i d e nce of side effects

tomy l i m its its use at present except as a fi n a l therapeutic


modal ity.

.
. . . .. . . . . . . . . ..

TOP I CAL M E D I CATI O N S

A l u m i n u m c h loride hexahyd rate .

hyd rate solution in etha nol with o r without occ l usion


to u nshaven sk i n for 6 to 8 h o u rs n ightly for 3 to
4 days ca n be benefi c i a l but is com pl icated by loca l
i rritati o n . R etreatment once or twice wee kly for m a i n
tenance is reco m m e n d e d . Treated s k i n s h o u l d b e
washed t h e fol lowi ng m o r n i n g .
- I n the axillae, it is a p pl ied at n ight to u nshaven s k i n
a n d washed off i n t h e morn i n g .
- Freq u ency o f a p pl ication d i m i n ishes w i t h i m p rove
ment.
Ta p water iontophoresis can be effective.
- The proced u re req u i res conti n u a l a p p l i cation for 1 5
t o 2 0 m i n utes 2 t o 3 ti m es per wee k .
- B l istering a n d b u r n i ng have been reported as s i d e
effects.
- Contra i nd ications i n c l u d e p regnancy, ca rd iac pace
m a kers, and m etal i m pl a nts.

ORAL M E D I CATI O N S
Oral a ntichol i n e rgics i n c l u d i ng born a p r i n e , glycopyrro
nium

brom i d e ,

propa nth e l i ne,

and

metha ntha l i ne

b rom ide a re of l i m ited efficacy. They prod uce d ose


related a ntichol i n ergic side effects.

Consider if a l l other t h e ra py fa i l s

E n d osco p i c thora c i c sympath ecto my; m ost

effect ive for pa l mar or fac i a l hyper h i d rosis

- Appl ication of 1 0 % to 30% a l u m i n u m c h loride hexa

S u rgery

H ig h l y effect ive proced u re w h e n performed by a

s k i l l ed spec i a l i st

Figure 16.2 Hyperhidrosis treatment diagram

87

88

Color Atlas of Cosmetic Dermatology

S U RG E RY

N o r m a l i n n ervat i o n
Eccr i n e

S u rgica l proced u res i nc l u d e the fol lowi ng:

Endoscopic

or

c l assic

sym path ecto my

Sympathet i c n erve

is

Acety l c h o l i n e

usua l ly

sweat
gland

reserved as a fi n a l therapeutic option for pa l m a r hyper


h i d rosis. S u rgery p rovides long-lasting control . Genera l
a n esth esia is req u i red . S i d e effects i n c l u d e bleed i ng,

I n nervat i o n b l oc ked by Botox

sca r formatio n , i n fectio n , reaction to a n esthes i a , com


pensatory hyperh i d rosis, gustatory sweating,

pneu

moth orax, a n d Horner's syn d ro m e .

Li posuction for axi l l a ry hyperh id rosis i n volves su bder

Acety l c h o l i n e

--+ X

Selective g l a n d rem ova l is reserved f o r axi l l a ry hyper


h i d rosis.

--IIII X
Sym pathet i c n e rve

Figure 16.3 Mechanism of action of Botox in hyperhidrosis. Blocking


acetylcholine release from cholinergic presynaptic vesicles

m a l l i posucti on . The l i posuction ca n n u la is held with


the bevel side up at the s u bdermal level for sucti o n i ng
of this regi o n .

BOTU L I N U M TOX I N A
Botu l i n u m tox i n A provides tem pora ry effective treatment
fo r this cond ition . I t is a bacterial tox i n that dec reases
sweating by i rrevers i bly blocking a cetyl c h o l i n e release
from c h o l i n e rgic p resyna ptic vesicles ( F ig. 1 6 . 3 ) .

A n e st h es i a

Topical a n esthetic c rea m a nd/or ice ge nera l ly ca n p ro


vide sufficient a n esthetic effect.

Sti l l , nerve blocks s h o u l d be considered prior to pla nta r


a n d pa l m a r treatme nts to m i n i m ize the associated pa i n .
- P l a nta r: s u ra l a n d posterior ti b i a l nerves
- Pa l m a r : u l n a r a n d med i a n nerves

Treat m e n t

A sta rc h - i od i n e test perfo rmed prior t o treatment can


h e l p d e l i n eate the a reas to be injected . Iodine is placed
on the affected a rea , fol l owed by the a pp l ication of
cornsta rch p rod u c i n g a pro m i nent d a rk bl u e- bla ck d is
colorat i o n . The sta rch-iod i ne paste s h o u l d be washed
off prior to Botox i njections.

Effective Botox d i l utions va ry. A Botox A ( 1 00 U/via l )


d i l ution o f 2 . 0 U/0 . 1 c c i s effective .

I njecti ons a re performed at 1 to 2 em i nterva ls i ntra d e r


m a l l y t h roughout the affected a rea ( Figs. 1 6.4, 1 6 . 5
a n d 1 6 . 6 ) . Two u n its s h o u l d b e i njected p e r site .

A tota l d ose ra nging from 50 t o 1 00 U/axi l l a , pa l m , o r


s o l e can be i njected , for a tota l d ose o f 1 00 t o 200 U for
both treatment sites. A decreased d ose can be used for
l oca l i zed hype r h i d rosi s.

Tem po ra ry h a n d a n d fi nger m uscle wea kness may be a

Figure 1 6.4 Appropriate injection sites of botulinum toxin A for

c o m p l ication of pa l m a r botu l i n u m tox i n A i njections,

treatment of (A) palmar hyperhidrosis and (B) axillary hyperhidrosis. Each


injection should be approximately 1 to 2 em apart

especia l ly with i n c reasi n g d osages . Patie nts should use

Sect i o n 3: D i so rd e rs of Ecc ri n e G l a n d s

89

caution when ho l d i ng c u ps a n d other o bj ects s u p


ported by the thenar m uscle w h i l e the wea kness is p re
sent. T h i s wea kness ge nera l ly d issi pates with i n 3 to
4 weeks .

Decreased sweati n g is o bserved with i n 1 to 2 weeks .

Side effects may i n c l u d e loca l m uscle wea kness for pal

Benefits ge nera l ly a re n oted between 3 a n d 9 months.


m a r i njections, bru isi ng, a nti body resista nce, a n d ra rely
an a n a phylactic reactio n .

T h e efficacy o f botu l i n u m tox i n i njections is not affected


by laser h a i r rem ova l in the sa me a rea of treatment.

M ed i c at i o n s

Antichol i ne rgics; h igh i n c i d ence of s i de effects

P I T FALLS TO AVO I D

Figure 16.5 Injection sites marked on right axilla of a male prior to botu

Tem porary h a n d a n d fi nge r m usc l e wea kness may be a


c o m p l ication of pa l m a r i njections of botu l i n u m tox i n A,
espec i a l ly with i n c reasing d osages .

Botox i nj ecti ons are contra i n d i cated i n patients with


u n d erlyi ng n e u ro m u sc u l a r cond itions as wel l as in
p regna nt and lactating patie nts.

Decreased d oses s h o u l d be consid ered fo r patients on


a ngiotensin-converting enzyme (ACE) i n h i bitors, wh i c h
ca n potentiate Botox effects.

It is i m porta nt to cou nsel that the benefits of Botox a re


te m po ra ry a n d req u i re repeat treatments.

None of the thera pies is u n iversa l ly efficacious. The


patient m u st be awa re that the treatm ent end point is a
red uction i n sweating a n d n ot c o m p l ete e l i m i nation .

Treatment side effects may be considera ble d e pend i n g


on the treatment c h ose n , a n d m ust b e revi ewed a t
d e pth with t h e patient prior t o a n y treatment i n itiati o n .

B I B L I OG RAPHY
Ca m panati A, Laga lla G , P e n n a L, Gesu ita R , Offi d a n i A .
Loc a l n e u ra l block at t h e wrist for treatment o f pa l m a r
hyperh id rosis with botu l i n u m toxi n : Tec h n ical i m prove
ments . J Am Acad Dermatol. 2004 ; 5 1 (3) :345-348.
G laser

DA.

Treatment

of

axi l l a ry

hyperh i d rosis

by

c h e modenervation of sweat gla nds using botu l i n u m tox i n


type A . J Drugs Dermatol. 2004;3 ( 6 ) : 627-63 1 .
G o h C L . A l u m i n u m c h l oride hexa hyd rate versus pa l m a r
hyper h i d rosis. lnt J Dermatol. 1 990;29:368-370.
G regoriou S , R igo pou los D, M a kris M , et al. Effects of bot
u l i n u m toxi n-a thera py for pa l m a r hyperhid ros is in p l a n
ta r

sweat

496-498.

prod uctio n .

Dermatol Surg.

201 0;36(4) :

linum toxin A injection

90

Color Atlas of Cosmetic Dermatology

H a m m H . The place of botu l i n u m tox i n type A in the


treatment

of

foca l

hyperh i d rosis.

Br

Dermatol.

2004; 1 5 1 (6) : 1 1 1 5- 1 1 2 2 .
Heckma n n

M,

Ceba l l os- Ba u m a n

AO,

Plewig

G.

Bot u l i n u m tox i n A f o r axi l l a ry hyperh i d rosis (excessive


sweat i n g ) . N Eng/ J Med. 200 1 ;344:488-493.
H erbst F, Plas EG, Fuggo R, F ritsch A . Endoscop i c tho
racic sym pathectomy for pri m a ry hyperh i d rosis of the
u pper l i m bs : A critical a na lysis and long-term res u lts in
480 operations. Ann Surg. 1 994;220: 86-90.
Lowe N, Ca m pa nati A, Bodokh I, et a l . The use of topical
glycopyrrolate i n the treatment of hyperh id rosis. Clin Exp
Dermatol. 1998;23: 204-205.
Pa u l A, Kra nz G, Sc h i n d l A, Kra n z G S , Auff E, Syc ha T.
Diode laser h a i r rem ova l d oes not i nterfere with botu
l i n u m tox i n A treatment aga i n st axi l l a ry hyperh i d rosis.
Lasers Surg Med. 2010;42(3 ) : 2 1 1 -2 1 4.
R e i n a uer S , N uesser A, Schauf G , H olzle E . I o ntophoresis
with a lternati ng c u rrent and d i rect c u rrent offset (A/C ion
to phoresis): A n ew a p p roac h fo r treatment of hype r h i d ro
sis. Br J Dermatol. 1993 ; 1 29 : 1 66- 1 69 .

Figure 1 6 . 6 The sites of hyperhidrosis

FOUR
D isord e rs of H air Fo l l ic l es

92

Color Atlas of Cosmetic Dermatology

CHAPT E R 1 7

Hirsutis m

H i rsutism rep rese nts a male pattern overgrowth of term i


n a l a n d vel l us h a i rs i n women . Fa r fro m be i n g solely a
cosmetic concern , h i rsutism can be a n i m porta nt m a n i
festation of an u nderlying endocrine d isord e r a rising from
i n c reased a n d roge n i c activity. Ofte n , it res u l ts from a n
ove rprod uction of a d re n a l a n d ova ri a n hormones a n d
m a y acco m pa ny oth e r s i g n s o f v i r i l izatio n . I ts a ppea ra nce
prod u ces soc i a l a nxiety,

d i stress,

and

ostracism

in

affected patients. I t a l so merits a n a p pro p riate med ical


work u p . By contrast, hypertrichosis feat u res fi ne h a i rs in
a n d roge n-sens itive as wel l as a n d rogen-i nsensitive a reas.
Normal ra c i a l and eth n i c va riations may cause confusion
with these d isord ers .

EPI O E M I O LOGY
Incidence: com m o n .
Age: u s u a l l y postpu berta l b u t age o f o nset ca n va ry i n t h e
setti ng o f med icati o n , t u m o r, or endocrine a b normal ity.

Race: rac i a l a n d c u ltura l factors affect the perception of


what constitutes a bnormal h a i r growt h . S k i n type affects
treatment options as wel l .

Sex: fe m a l e .
Precipitating factors: h i rsutism is ca used b y a h ost of
endocrine

a bnorma l ities.

Ad rena l

ca uses

include

C u s h i ng's d isease, ecto pic ad renocorticotropic hormone


(ACT H J prod ucti o n , p r i m a ry a n d rogen-prod u c i n g neo

Figure 1 7 . 1 Spot size, 8 mm versus 1 5 mm. Larger spot sizes penetrate

plasms, and congen ita l a d re n a l hyperplasia . Ova r i a n

deeper and allow quicker treatments

causes can be related to polycystic ova ri a n synd rome


a n d p r i m a ry t u m o rs a m o ng oth e r causes. F i n a l ly, med
ications

suc h

as

o ra l

contrace ptive

pills,

a n a bo l i c

steroids, a n d a n d roge ns may ca use h i rsutis m .

PHYS I CAL EXAM I NAT I O N


There i s a n overgrowth o f h a i r i n a n d rogen-sensitive h a i r
fo l l icles. C o m m o n sites i n c l u d e t h e bea rd a rea o f the
face, c h i n , prea u ri c u l a r face, l i nea a l ba , pe r i a reola r a rea ,
a n d c hest. Depend i ng on the severity of the cond ition ,
other signs of v i r i l ization such as i nc reased m uscle mass,
deep vo ice, male pattern h a i r loss, and c l itora l e n l a rge
ment may be prese nt.

D I F F E R E N T I A L D I AG N OS I S
W h i l e both h i rsutism a nd hypertric h osis featu re h a i r over
growt h , these conditions ca n be d iffe re ntiated by the
location and q u a l ity of the hair growth . H i rsutism is c h a r
a cterized

by term i n a l

h a i r overgrowth

i n a n d rogen

d e pendent a reas, wh i l e hypertrichosis featu res fi ne h a i rs

Figure 1 7 . 2 Hair trimmed prior to treatment

Sect i o n 4 : D i so rd e rs o f H a i r Fo l l i c l es

in a n d roge n-sensitive as wel l as a n d rogen-i nsensitive


a reas. Normal rac i a l a n d eth n i c va riations may cause
confusion with these d isorders.

LABO RATORY TESTS


The la boratory workup should be gu ided by the patient's
c l i n ical fi n d i ngs as wel l as by a deta i l ed patient h istory.
Testing ca n hel p esta blish if there is an a d renal or ova ria n
sou rce of the h a i r growth . Ova ria n , a d re n a l , a n d pitu ita ry
tu mors should be ruled out in cases of ra pid onset by a n
endocri n ologist a n d/or a gynecologist. Tota l testosterone
levels, dehyd roepiand rosterone su lfate levels, u r i n a ry free
cortisol levels, d exa methasone s u ppression test, prolacti n
levels,

ACTH

sti m u lation,

l ute i n izing

hormone/foll icle

sti m u lating hormone ( LH/FS H ) ratio, 1 7- hyd roxy proges


terone levels, a n d pelvic u ltrasou n d may a l l present i m por
ta nt com ponents of a thorough endocri nologic work u p .

CO U RS E
Cou rse i s dependent o n t h e etiology o f t h e h i rsutism .

KEY CO N S U LTAT I V E QU EST I O N S

Menstru a l h istory-reg u l a r or i rreg u l a r

Med ication h i story

O nset a n d p rogression of sym pto ms

Fa m i ly h i story of i nfla m m atory cystic acne and h a i r loss

H istory of endocrine a bnorma l ities

Figure 17.3 Laser light firing

MANAG E M ENT
T h e pri m a ry goa l o f t h e treatment is t o d eterm i n e the
u nderlying cause of h i rsutism a nd treat. After d eterm i n
i n g t h e ca use a n d e n s u r i n g a pp ropriate med ical thera py,
the goa l ca n tra n s ition to reversi n g the a bn o r m a l h a i r
growth . There a re m u lti ple mea ns b y w h i c h tem po ra ry
a n d perma nent h a i r rem ova l can be ach ieved .

C o n s u l t at i o n w i t h E n d oc r i n o l ogy
I n cases of h i rsutism, the fi rst priority is to u n cove r the
sou rce of the a be rra nt hair growth . N u merous la boratory
i n vestigatio n s, as d eta i led a bove,

may be req u i red .

Consu ltation a nd referra l to a n en docri n ologist is stro ngly


recom men d ed as pa rt of such a worku p .

N o n l a ser T h e ra p i es
There a re severa l tem pora ry means to con cea l h a i r ove r
growth . They i n c l u d e m a ke u p , b l ea c h es, a n d hyd roge n
perox i d e . S havi ng a lso c a n te m pora ri l y h id e h a i r growt h .

Figure 1 7.4 Characteristic posttreatment perifollicular erythema

93

94

Color Atlas of Cosmetic Dermatology

H a i r remova l can be ach ieved with d e p i lati o n , e p i l a


t i o n , l a s e r thera py, e l ectrolysis, a n d to pical eflorn ith i n e .

Depi lation
Depi lation is the process of removing pa rt of the h a i r
shaft. Its effects a re tem pora ry. There a re c h e m i c a l a n d
mec h a n ical methods o f d e p i lati o n . C h e m i c a l depi latories,
such as th ioglycolate sa lts and su lfides of a l ka l i m eta ls,
d issolve hair shafts. They can prod uce loca l ized i rritati on
at the site of treatment. Mecha n i c a l depi lation c a n be
q u ite crude i n c l u d i ng shaving of h a i r as we l l as r u b b i n g
h a i r w i t h a p u m ice stone.

E p i lation
Epi lation is the process of removing the enti re hair shaft.
I t provides more longevity tha n d e p i lation but is not per
manent. It i n c l udes waxi ng, p l u c k i ng, t h rea d i ng, a n d
e l ectrical d evices t h a t re move t h e h a i r shaft. Eac h of
th ese o ptions is relatively i n expensive but can prod uce
pa i n and irritation as side effects . P l u c k i n g can res u lt in
loca l ized i nfection , i ngrown h a i rs, and even sca rring.
Eac h of these treatm ents can be used i n com bi nation
with topical eflorn ith i n e on the face of wo m e n .

Top i c a l eflorn i th i ne (Va n i qa)


To pical eflorn ith i n e twice d a i ly has been a p proved by the
U . S . Food a n d Drug Ad m i n istration ( F DA) for tem pora ry
h a i r remova l on the face of wome n . It s h o u l d o n l y be
used on the face a n d not on other pa rts of the body. It
decreases the rate of hair growth by i n h i biti ng ornith i n e
d eca r boxylase . I t s h o u l d be used i n conj u nction with
other h a i r remova l methods, such as shaving, waxing, or
p l u c k i ng.

Patie nts

should

use the

med ications for

Figure 1 7 . 5 Bizarre growth of back hair on a male due to poor technique

8 weeks to j u dge its efficacy. If there is n o i m provement


after 8 weeks, the med ication should be d isconti n ued . If
the

med i cation

works,

it

should

be

conti n ued .

Disconti n uation of treatment resu l ts in a res u m ption of


h a i r growt h . S i d e effects i n c l u d e loca l irritation . It s h o u l d
n ot be used d u ri n g pregnancy.

E l ectro l ys i s

Remova l can be permanent.


El ectrolys i s uses d i rect e l ectrica l c u rrent to d estroy the
dermal pa p i l l a of t h e h a i r fo l l ic l e . A fi ne need le placed
d i rectly i nto the h a i r fo l l i c l e d e l ivers the e l ectri c a l
c u rrent to the fo l l i c l e's b a s e w i t h o u t p rod u c i ng sca r
r i n g . T h e site of treatment is shaved severa l d ays prior
to thera py and to pica l a n esthetic c rea m ca n be used
1 hour prior to the p roced u re to red uce pa i n . Side
effects i n c l u d e sca r, hy po-/hyperpigmentat i o n , and
i nfecti o n . I t i s m ost a p p ro p r i ate fo r s m a l l a reas of
treatment.

Need for m u lt i p l e treatm ents for l i m ited treatment zon e .

G reater r i s k o f side effects, pa i nfu l .

N ot practical fo r la rge a reas o f the body.

Figure 1 7 . 6 Extensive dyschromia secondary to inappropriate fluence and


pulse duration

Sect i o n 4 : D i so rd e rs of H a i r Fo l l i c l es

95

Laser h a i r re m ova l
Lasers a re the treatment of choice for permanent red uc
tion of u nwa nted , pigmented term i n a l hair fol l icles. Laser
h a i r remova l is q u ic k , relatively n o n pa i nfu l , espec i a l l y
compared to e l ectrolysis. Fu rthermore, it ca n cover a fa r
m ore exte nsive a rea of affected s k i n with less pa i n in less
( i e , i m proper spaci ng and overla p) time. An average of
five to seven treatments a re needed for greater tha n 50%
red ucti o n .

Mechan ism of a cti on


Lasers a re based on the selective p h otothermo lysis. The
l ight is a bsorbed

by the

pigment i n

hair fol l i c les.

Therefore, if h a i r fol l i c l es have no pigment ( ie , blond or


gray h a i r ) , lasers d o n ot work. Lasers work best o n t h i c ke r
h a i r fol l ic l es .

.._______________________....,

Pat i e n t Co n s u l tat i o n

H a i r color.

S k i n type-a l l s k i n types ca n benefit from laser h a i r


remova l .

Past med ical h i story.

Med ications.

Past treatments .

E m p hasize the n e e d for five t o seven treatments on a n


average t o re move t h e majority o f u nwa nted h a i r.

I m provement is va r i a b l e .
Low risk o f no i m p rove ment or i n c reased h a i r (es pe

c i a l ly in fe ma les of Med iterra nea n he ritage ) .

Figure 1 7 . 7 (A) Appearance of skin prior to laser hair removal. (B) Hair on

R isk o f hyper- or hypopigme ntation that m a y last

lateral cheeks

months; rarely perma nent.

Sca rring is ra re.


Like l i hood of at l east some pa i n ; the a m o u nt of pa i n
assoc iated with t h e proced u re is a refl ection o f t h e cal
i be r a n d d e nsity of hair i n the treated regio n .

Ideal ca n d idate h a s d a r k cou rse h a i r a n d l ight s k i n


phototype.

Average ca n d i d ate-fi ne/l ight brown h a i r


Poor ca n d i date-blond/gray h a i r s h o u l d n ot b e treated
with

8 1 0-n m

d iode

laser

with

c u r rent

lasers .

Ad d itional ly, pati ents with u n rea l i stic expectations or


med ic a l contra i n d i cations should not be treated .

Pat i e n t Co n s u ltat i o n P r i o r to

Treat m e n t

S u n avoidance is crucia l . If a patient is ta n ned , t h e pro


ced u re s h o u l d be postponed u nt i l the ta n com pletely

Figure 17.8 Appropriate clinical endpoint of perifollicular erythema in

fa des. If the proced u re is performed on ta n ned ski n ,

this 24-year-old female with type VI skin and polycystic ovarian syndrome
treated with the long-pulsed 1 , 064-nm Nd: YA G laser

t h e risk o f dysc h ro m i a i s ma rked l y i n c rease d .

96

Color Atlas of Cosmetic Dermatology

Shave h a i r prior to a rrivi ng i n the offi ce. Alte rnatively,


the h a i r can be tri m m ed in the office with a moustache
tri m mer. T h i s w i l l foc us the majority of energy to the
pigme nted hair fol l i c l es i n the ski n .

A topica l a n esthetic crea m ca n b e a p p l ied 1 h o u r prior


to thera py to decrease the pa i n d u ri n g the proced u re . I t
is i m porta nt t o advise the pati ent t o a p ply to pical a nes
thetic over a l i m ited s u rface of the s k i n to avoid a ny risk
of l i doca i ne toxicity.

H a i r waxing s h o u l d not be performed 2 to 3 weeks


before treatment.

If there is a h i story of recu rrent herpes s i m plex vi rus,


prophylaxis should

be

provided

before

laser

hair

remova l on face.

P regnancy: there a re no clear stud ies dem onstrating


safety or risk. I t is i m porta nt to edu cate pregn a n t
patients desi ri ng h a i r re mova l as t o this uncerta i nty.
M ost physicians wi l l not treat patients w h i l e pregna nt. If
treatment is p u rs ued , it is recommended to treat only
l i m ited a reas d u ri n g t h i rd tri meste r after m e d i ca l clear
a nce from an o bstetric ia n .

J u st P r i o r to Treat m e n t

Written consent

Ph otogra phy

Tri m h a i r

Laser H a i r R e m ova l Tec h n i q u e

( F igs.

1 7 . 1 - 1 7 . 8)

(Ta b l e

17. 1)

Key concepts for o pti m a l resu lts a re as fo l l ows :

For s k i n types I to I l l , use relatively h igh energy with a


shorter pu lse d u ration for o pti m a l resu lts.

TAB L E 1 7 . 1

Laser Hair Remova l Technique

Laser type
R u by

Safest s k i n type
I-I I I

Wavelength ( n m l
694

P u lse d u rati o n

Energy (J/cm 2 l

1-20 ms

1 0-40 J/c m 2

Comments
Fi rst laser used for
h a i r rem ova l ; slower to use

Al exa nd rite

I-I I I

755

Skin types I-I I I 3 ms;


skin types I l l and I V

Diode

1-V

810

S k i n types I-I I I
20-25 J/cm 2 ; s k i n

1 0-20 ms

type I V 1 5-20 J/cm 2

3- 100 ms

30-40 J/cm 2

3 ms and 1 0-20 ms
pu lse d u ration demonstrate
eq u a l efficacy
Longer p u lse d u ration for
treatment of s k i n types IV
and V

N d : YAG

I-V I

1 064

S k i n types I-I I I 1 0-20 ms;


ski n types IV-VI 25-100 ms

I ntense p u lsed
I ight-noncoherent
l ight

I-I V

550- 1 200

1 . 5-3 . 5 ms

Skin types I-I I I 30-50


J/c m 2 ; skin types

Safest d evice for


rem ovi ng h a i r i n s k i n

I l l-V I 25-35 J/c m 2

types I V-V I

25-50 J/cm 2

M ost va riable resu lts

LAS E R SAFETY
Hazard: o c u l a r
Da ngers

E n h a n c e Safety

Cornea , ret i n a , or lens

Base l i ne eye exam

can oc c u r
f r o m d i r e c t exposure
re f lec t ed beams, I . e .

equ a l to or greater t h a n

can be da m aged

Laser goggle optrcal

Damage

densrty (00) shou ld be


7 (c h ec k gogg l es)

or

I nspect goggles for vrsible damage or

pat ien t jewel ry, watches

degradation of t h e f i l ler med ia

Q-sw itc hed lasers are

Always c heck that appropriate gogg l es for

most hazardous, can

wavelength are used

cause b l i n d ness

Remove, e bon ize or cove r any ref lect iVe

r cornea
Lens

surfaces in laser room , i .e . m i r rors,


meta l l ic garbage cans
Remove pat ient jewe l ry, watches

H a z a r d : fire
Dangers
All lasers c a n pote n t i a l l y

cause fire hazards

su rfaces i n l a se r room , i.e. m irrors, metal l ic

Most common ly seen


w i t h C02

E n h a n c e Safety
R emove . ebonrze. or cover any relfectrve

lasers

garbage cans
Avoi d alcohol or ensure that it i s f u l ly
vapori zed prior to st a rt of

Damage can oc c u r
f r o m d i rec t exposure or
ref lected beams

treatment

Drape treatment srte wrth wet


Remove a l l f lamm a b l e

t owe l s,

d rapes

gauze or

items, i . e .

dry

towe l s

gauze,

Coat exposed harr w i t h water-based j e l l y


Decrease F i02 t o

40%

e ndotrac heal t u bes

H a z a r d : p l ume,

sp l att e r, infection

Dangers

E n h a n c e Safety

I n tact v i r rons and viral

Use mask

D N A such as

when treat r ng near

H PV

may

be present rn the p l u m e
of COz l asers

Smoke

evac uator

nssue part i c les can


splatter a n d aerosol ize
with Qswitched lasers

Hazard: el ectrocution
Dangers

E n h a n c e Safety

Even

O n l y q u a l i f ied laser tec h n r c rans should

with power off,

ca n ca use shock/

e l ec t rocu t i o n

open l ase rs

Check for water s p i l ls, hose ruptures or


condensations

H a z a r d : general
Dangers
A n t i c i pate da ngers

E n h a n c e Safety
Always r m mcd iatcly put laser on standby

mode when not treat rng pa t ren t


E n s u re proper srgn rs on the door of laser room
Ed ucate staff members as to laser safety

Figure 17.9 Laser safety. It is important to emphasize that lasers present special safety concerns for physicians, staff, and patients.
Among the risks are ocular injury, fire, electrocution, and dissemination of infectious disease. No lasers should be operated in the
absence of a detailed knowledge of laser safety issues between the physician and the staff. Educating staff members is an essential
component of safe laser practices. Periodic laser safety training is required by many hospitals and remains good practice for private
physician offices as well. (A) Patient and all personnel are wearing protective eyewear. Note gauze is moist to reduce the risk of fire.
(8) Smoke evacuator. (C) Safety sign placed outside appropriate laser room to ensure proper warning of laser use

98

Color Atlas of Cosmetic Dermatology

S k i n types IV to VI m u st use l onger pu lse a n d lo nger


wavele ngth such as a 1 064- n m YAG .

If u n certa i n as to treatment pa ra m eters, perfo rm test

LASER A N D
EYE INJ U R I E S

sites with va ria ble fluencies a n d p u lse d u rations.

gen , contact coo l i ng, or ge l .

Opti m a l cool i n g setti ngs m ust b e util ized to lower the


risk of d ysc h ro m i a .

Wavel ength ( n ml Lasers

Use l a rger s pot s izes for d eeper penetration a n d m o re


Safety goggles for patient a n d med ical tea m .

Use the la rgest spot size possi ble for ta rget region .

Overla p laser p u lses 1 0 % over the enti re treatment


regi o n .

Postt reat m e n t I n st r u ct i o n s to Pat i e n t

Ex pect red ness fo r u p t o severa l h o u rs afte r treatment.

If red ness o r pa i n persists for m o re than 1 2 h o u rs, ca l l


t h e office. If there a re a n y c uta neous cha nges i n the
s k i n the day afte r the p roced u re o r beyo n d , the patient
m ust be to ld to conta ct the treati ng physic i a n .

O n c e red ness fades, patient may conti n ue t o wea r


m a ke u p .

Avoi d s u n for 4 8 h o u rs; no ta n n i ng.


Hair remova l is not entirely i m med iate . Some hair wi l l
fa l l o u t 1 t o 3 d ays after treatment.

Do not worry if some hair persists after treatment.

Ca l l the office if d iscoloration develops i n the treated sites.

Ca l l the office with q u esti ons or concerns.

P I T FALLS TO AVO I D/CO M PL I CATI O N S/


MANAG E M E N T ( F igs . 1 7 . 5-17 . 6)

There is no effective mecha n is m for laser remova l of


l ight or blond ha i r.

Excess ive fluenc ies or i ncorrect pu lse d u ration may


prod uce epidermal d a mage and dysc h ro m i a . These
effects a re typica l ly te m po ra ry but can be permanent. If
there is a n y d o u bt rega rd i ng laser pa ra m eters, pe rfo rm
a test site .

30().. 4 00 Exc 1 mer


(308 n m )

yes

: yes

400-600 Argon
(488 nm)

: yes

KTP

( 532 m n )

yes

Flash of the

em1 tted wavelength

fol l owed by

aften mage of a

complementary color

: yes

Pu lsed dye

laser

: yes

( 585-

600 nml

600- as N d : VAG
1 000 ( 532 n m )

: yes

as R u by

: yes

A lexa ndrite

: yes

D1ode

(694 n m )

(755 nm)
(810 nm)

yes

detected as reh na
lacks pam f i bers

a-switc hed lasers have


h ighest pote n t i a l to

c a u se b l i n d ness

May produce a popping

sou nd, then v1sual

: yes

N d : VAG

: yes

D1ode

( 1 320 n m )
( 1 4 50 n m )
yes

yes
CO:!
( 1 0,600 n m )

yes

B u r n mg pam at the site of

exposure on the cornea o r


sclera

Figure 1 7 . 1 0 Lasers and eye injuries

Coincident tattoos and lentigi nes may expe rience l ight

(http:!lwww. eyesafety. 4ursafety. com/laser-eye-safety. h tm l)

A lways kee p contact coo l i ng aga i nst the s k i n to avo i d


Overla p ( 10 % ) i n the treated zo n e . Do not leave "ga ps"
that can c reate biza rre h a i r growth patte rns as h a i r
regrows .

be

d i sorientation

1 000- as Nd: VAG


1 400 ( 1 064 n m )

1 4DO- Er: VAG


1 0000 (2940 n m )

Damage from a a-switc hed

N d : VAG l a se r m a y n o t

S k i n types IV to VI req u i re longer p u lse d u rations a n d

b u r n i ng.

yes

<300

l ower fl uenc ies.


e n i ng. Patie nts s h o u l d be i nformed of this poss i b i l ity.

Signs or symptoms
of injury

Eye injury

Cornea : lens : Retina

ra pid treatm e nt of l a rger a reas .

(:)-""
1 - Lens
--

A l l m a c h i nes util ize coo l i ng of epidermal s k i n via c ryo

Sect i o n 4 : D i so rd e rs o f H a i r Fo l l i c l es

For N d : YAG lasers, patie nts may expe rience pa i n eve n


after to pical a nesthes i a .

B I B L I OG RAPHY
Azziz R . The eva l uation a n d ma nagement o f h i rsutis m .
Obstet Gynecol. 2003 ; 1 0 1 ( 5 p t 1 ) :995- 1 007 .
Battle EF, H o b bs LM . Laser-assisted h a i r rem ova l for
d a rker s k i n types . Dermatol Ther. 2004; 1 7 ( 2 ) : 1 77 - 1 83 .
Bouzari N , Ta bata ba i H , A b basi Z , Fi rooz A, Dowlati Y.
Laser h a i r re m ova l : Com parison of long-pu lsed N d : YAG ,
long-pu lsed a l exa n d rite, a n d long-pu lsed d iode lasers .
Dermatol Surg. 2004;30(4 pt 1 ) :498-502 .
Gold berg

DJ .

Laser

hair

remova l .

Dermatol

Clin.

2002 ; 20(3) : 56 1 -567 .


Ta nzi EL, Alste r TS. Lo ng-pu lsed 1 064- n m N d : YAG laser
assisted h a i r remova l in a l l s k i n types. Dermatol Surg.
2004;30( 1 ) : 1 3- 1 7 .

CHAPT E R 1 8

Pseud ofoll icu I itis

Pseu d ofo l l i c u l itis is a com m o n , c h ro n i c i nfla m m atory d is


order that prese nts with i nfla m mato ry pa pu les a n d pus
tu les in the bea rd d istri bution of m a l es, pa rticularly those
with d a rker s k i n phototypes a n d tightly coiled h a i r.
N o n etheless, pse u d ofol l i c u l itis ca n present in a n y s k i n
t h a t is reg u l a rly sh aved a n d i n a l l s k i n p h ototypes . I n
fe ma les it is m ost commonly seen i n the axi l l a ry a n d
p u b i c a reas. It tends t o prese nt i n a more m i ld form i n
l ighter s k i n ph ototypes .

E P I D E M I O LOGY
Incidence: ove r 50% of African American ma les
Age: begi ns with shaving or p l u c k i n g
Race: more common i n bea rd d istri bution o f ma les with
d a rker skin phototypes
Sex: male > fe ma les
Precipitating factors: shaving in any region of the body

PATH OG E N ES I S
T h i s d isord e r i s i n d u ced by shavi ng. Shaving sha rpens
c u rled h a i r. Sha rpened , tightly c u rled h a i rs pierce i nto the
ski n adjacent to the hair fo l l ic l e and i nvad e i nto the der
mis prod u c i ng a n i nfla m matory reactio n . I t c a n a lso fol
low hair p l u c k i ng, espec i a l ly i n fe m a l es with h i rsuti s m .

99

1 00

Color Atlas of Cosmetic Dermatology

D E R M ATOPAT H O LOGY
H a i r pe netration resu lts i n e p i d e r m a l i nvagi nation with
associated m i c roa bscess , m i xed i nfla m m atory i nfi ltrate,
and foreign body giant reaction at the tip of the i nvad i n g
h a i r. Dermal fi brosis m a y b e o bserved .

PHYS I CAL LES I O N S


M ost c o m m o n ly, i t presents with fol l i c u l a r pa p u les, pus
tu les, and posti nfla m matory hyperpigme ntation in the
bea rd a rea and a nterolatera l neck of ma les and u n d er
a rms a n d biki n i a reas of fe males. Pa p u les can d eve lop
i nto cysts. Sca r formation may be o bserved . The u p per
c uta neous lip is typica l ly spared .

D I F F E R E N T I A L D I AG N OS I S
Acne vu lga ris, fol l i c u l itis.

LABORATORY EXAM I NAT I O N


None.

COU RS E
Begi n s with shaving o r p l u c k i n g a n d conti n ues u nt i l
cessation o r mod ification i n the h a i r rem ova l tec h n i q ue .

MANAG E M ENT

Figure 18. 1 (A) A young male with type VI skin phototype and pseudofol

T h e goa l o f t h e treatment is t o prevent t h e formation of


the pa p u les, pustu les, sca rring, a n d posti nfla m matory
hyperpigmentation associated with this d isord e r. There
a re m u ltiple treatment options ava i la ble to acco m p l ish
this goa l . Cessation of shaving or p l u c k i ng is the m ost
successful treatment but it is i m p ractica l a n d u ndesira b le
fo r many patients . Laser thera py is h ighly effective with
h igh patient satisfactio n .

TREAT M ENT
S h a v i n g Cessat i o n
The most s i m ple, i nexpensive, a n d effective treatment for
pseu d ofo l l i c u l itis is the cessation of shaving.

Many

patients w i l l fi nd this o p t i o n u nd es i ra b l e o r i m practica l .

M o d i f i c at i o n of S h a v i n g Tec h n i q u e
A proper shaving tec h n i q u e may preve nt o r sign ificantly
decrease the risk of pse u d ofo l l i c u l itis. Among these prac
tices a re l ifti ng, n ot p l u c k i n g i ngrown h a i rs, thoroughly

liculitis barbae prior to treatment. (B) Same patient 3 months later after
several treatments with long-pulsed 1, 064-nm Nd: YAG laser. (Courtesy of
E. Victor Ross, MD)

Sect i o n 4 : D i so rd e rs o f H a i r Fol l i c les

wetti ng the a rea prior to a pplying shaving c rea m , using a


sharp razor, shaving i n the d i rection of the h a i r growth,
a n d avo i d i ng shaving i n more t h a n one d i rection i n the
sa m e a rea . The B u m p Fighter Razor p revents the shaved
h a i r from being cut too short . Additional ly, c utting the h a i r
twice d a i l y with h a i r c l i p pers p revents h a i rs from piercing
i nto the skin.

To p i c a l Treat m e n t
To pical a nti biotics a re effective i n treati ng the i nfla m ma
tion and occasional i m petigi n ization assoc iated with this
conditi o n . To pical treti noi n , benzoyl peroxide, and gly
colic acids can be h e l pfu l a dj u n cts.

Laser H a i r R e m ova l ( F i g s .

and

1 8.2)

18. 1

Laser h a i r remova l i s a safe, h ighly effective treatment


modal ity for short and long-te rm i m provement.

S k i n types I to I l l
- The long-pu lsed a lexa n d rite laser ( 755 n m ) , d iode
laser (810 n m ) , i ntense pu lse l ight ( 590-1 00 n m ) ,

Figure 18.2 Pseudofolliculitis-laser therapy: pigmented versus

a n d long- p u lsed N d : YAG ( 1 064 n m ) laser have the

unpigmented hair follicle

a p pro p riate wavele ngths to selectively ta rget the


c h ro m o p h ore mela n i n fou n d in the hair b u l b .
- M u ltiple treatme nts (average o f 5- 1 0 ) every 4 t o 8
weeks ach ieve a n average of 50% to 75% perma nent
red uction of fol l i c u l a r pa p u l es/pust u l es .

S k i n types I V to V I
- The long-pu lsed 1 , 064-n m N d : YAG l a s e r is the treat
ment of choice in s k i n p h ototypes IV to V I . It is safe
a n d effective . Long pu lse d u rations a re necessa ry
fo r epidermal p rotection . P u lse d u rations of 30 to
1 00 ms a re genera lly recom m ended . O pti m a l flue nces

ra nge from 20 to 40 J/cm 2 . Treatment is performed

with nonoverla p p i ng p u lses uti l i z i n g coo l i ng to the


epidermis via c ryoge n , contact coo l i ng, or gel .
- N ewer ge neration d iode lasers with longer p u lse
d u rations up to 400 ms can a lso be util ized with ca u
tion i n d a rker s k i n types.
- Typical ly, 5 to 1 0 treatments spaced every 4 to 8 weeks
a re needed for 50% to 75% perma nent red uctio n .

P I T FALLS TO AVO I D/O UTCO M E


EXPECTAT I O N S/CO M P L I CAT I O N S/
MANAG E M ENT

Ta n ned patients s h o u l d not b e treated with laser h a i r


remova l . O n ce the ta n/i nfl a m mation su bsides, h a i r
remova l can beg i n .

Do not p l u c k or wax h a i r prior t o o r d u ri ng t h e cou rse of


laser h a i r remova l .

Figure 18.3 Etiology of pseudofolliculitis

101

1 02

Color Atlas of Cosmetic Dermatology

Patients with u n pigme nted h a i r ( b l o n d , gray, red ) wi l l


not benefit from laser h a i r rem ova l a n d s h o u l d n ot be
treated .

There is the risk of tra nsient a n d long-te rm hyperpig


m entation and hypopigmentatio n . Tra nsient erythema,
sca b b i ng, and risk of sca r formation also exist.

A majority of patients wi l l see 75% i m p rovement. A


sma l l m i n ority w i l l see l ittle or no i m provement .

Futu re m a i ntena nce treatments may be needed .


A s m a l l m i nority of patients w i l l experience a paradoxi
cal i n c rease i n hair growth, pa rt i c u l a rly fe ma les of
Med iterra nean descent.

Treatment may n ot benefit p reexisting hyperpigme nta


tion and wi l l n ot i m p rove sca rs.

I t is i m porta nt to i nform patients that side effects a re


often delayed in s k i n p hototypes IV to VI a n d may not
be o bserved for 1 to 2 weeks after treatment. Test s pot
is a dvised fo r these patients ( Figs . 1 8 . 3 a n d 1 8 . 4 ) .

B I B L I OG RAPHY
Battle EF J r, H o b bs LM . Laser-assisted h a i r remova l for
d a rker s k i n types. Dermatol Ther. 2004; 1 7 (2 ) : 1 77 - 1 83 .
B ridgema n-Shah S . T h e med ical a n d s u rgica l thera py of
pseu d ofo l l i c u l itis barbae. Dermatol Ther. 2004; 1 7 ( 2 ) :
1 58- 163.
Haedersd a l M , Wulf HC. Evi d e nce- based review of ha i r
remova l u s i n g lasers a n d l ight sou rces. J Eur Acad

Dermatol Venereal. 2006;20( 1 ) :9-20.

Kontoes P, Vlachos S , Konsta nti nos M, Anastasia L, M yrta

Figure 18.4 (A) Test spot treatment under chin and on cheek is advised
for darker skin phototypes before treating pseudofolliculitis. (B) Two
weeks after test spot treatment, some hair removal is achieved with no
pigmentary changes

S. H a i r i n d uction after laser-assi sted h a i r re m ova l a n d its


treatment. J Am Acad Dermatol. 2006; 54( 1 ) :64-67.
R oss EV, Cooke L M , Ti m ko AL, Overstreet KA, G ra h a m
B S , Barnette DJ . Treatment o f pse udofo l l i c u l itis ba rbae i n
s k i n types IV, V, a n d V I with a long-pu lsed neodym i u m :
Yttr i u m a l u m i n u m ga rnet laser. J Am Acad Dermatol.
2002 ;47 ( 2 ) : 888-893.

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

CHAPT E R 1 9

M a l e Patte r n H ai r Loss

M a l e pattern h a i r loss c lassica l ly presents with bite m pora l

IV

II

IVa

II a

Ilia

Va

III

VI

III vertex

VII

h a i r loss that progresses t o t h e loss o f h a i r o n t h e vertex,


fro nta l , a n d te m pora l sca l p . Parieta l a n d occi p ita l h a i rs
a re usually u naffected . It is a no nsca rring forrn of a l o pe
cia that occ u rs in gen etica l l y suscepti ble males. The
gra d u a l involuntary loss of hair d oes cha nge the natura l
fra m e h a i r provides a ro u n d o u r face. T h e gra d u a l loss of
h a i r resulting in an i nvol u nta ry cha nge in a ppea ra nce
c reates varyi ng d egree of emotional a nd psyc hologica l
stress. M a ny men seek treatment fo r m a l e patte rn h a i r
loss because o f u n ha ppi ness with its cosmetic a p pea r
a n ce a n d association with aging.

E P I D E M I O LOGY
Incidence: 30% of ma les older than 30 yea rs; more t h a n
h a l f of m a l es o l d e r than 50 yea rs .

Age: begi ns after p u be rty.


Precipitating factors: polygenetic i n herited pred is positio n .
N o d iagnostic tests exist t o d eterm i ne t h e etio l ogy a n d
natura l progression .

PATH OG E N ES I S
The prec ise pathophysiology rema i n s u n k n own . This
process is bel ieved to res u lt from both a polygenetic
i n h erited suscepti b i l ity as we l l as a nd roge n i c sti m u lati o n .
T h e m ost i m porta nt a n d rogen i n t h i s process is d i hy
d rotestoste ron e .
There is a d i m i n ution i n the size o f affected term i n a l
fo l l i c les that regress t o become vei l u s fo l l icles that even
tua l l y d isa p pea r. There is a n i n c rease i n telogen h a i rs and
a decrease i n a nagen h a i rs .

PHYS I CAL EXAM I NAT I O N AN D


NATU RAL PROG R ES S I O N
Typica l ly, fronta l a n d tem pora l h a i r loss/th i n n i ng is pre
sent first. T h i s beg i ns in pu berty a n d progresses ove r
d ecades. The rate a n d extent of h a i r loss va ries from i n d i
vid u a l t o i n d ivid u a l . S o m e progress t o co m plete ba l d n ess
in early 20s a n d others grad u a l l y t h i n over decades.

D I F F E R E N T I AL D I AG N OS I S
I n ma les, the pattern of h a i r loss i s c h a racteristic s u ggest
i n g no other d iagnoses.

Figure 19. 1 Norwood classification of the natural progression of male


pattern hair loss

1 03

1 04

Color Atlas of Cosmetic Dermatology

TAB L E 1 9 . 1

M i noxi d i l and Finasteride-The Only Two FDA-Approved Medications for Male Pattern Hair Loss

M ec h a n is m of action

Fi nasteride

M i n oxi d i l

5-a red uctase type II i n h i bitor blocking the conversion of

U n known

testostero ne to d i hyd rotestosterone


Key to success

E m p hasize m a i ntena nce ove r regrowth of h a i r and c o m p l i a n ce


fo r at least 6-8 months to see ben efit

E m p hasize m a i ntena nce over regrowth of


h a i r and com p l i a nce 6-8 months to
see benefit

2% of men expe rience sex u a l d ysfu ncti o n . Revers i b l e with i n

S i d e effects

days i f d iscont i n ued

D ryness and pru ritus of the sca l p . R a re


a l lergic reacti on

N o a l lergic reactions, bl ood m o n itori ng o r d rug i nteractions.


P re m e n o pa use of fe ma les should never h a n d le or take
medicati o n . Women may have some benefit
C l i n ical onset of action

6-8 months

6-8 months

Dose

1 mg q d with o r without food

Two to fou r d rops one to two t i m es d a i ly


to fronta l a n d vertex of sca l p

Ca n d i d ate selection
N o rwood I I- IV

H ighly effective

H igh l y effective

N o rwood IV-V I I

Somewhat effective

Somewhat effective

LABORATORY EXAM I NAT I O N


I n ma les, no laboratory work u p i s typica l l y req u i red .

M E D I CAL TH ERAPY
K ey C o n s u l tat i ve Q u est i o n s

Age of onset

Rate of h a i r loss

Past med ical h istory

Med ications used to date a n d success of thera py

Patient expectation of a ny med ical or s u rgical thera py

F DA-A p p roved M ed i c a l T h e ra py

(Ta b l e

19. 1)

M i noxid i l a n d fi nasteride a re the on ly two medications for


male pattern h a i r loss a p p roved by the U . S . Food & Drug
Ad m i n istration ( F DA).

HAI R TRA N S P LA N TAT I O N


Def i n i t i o n
All patients s h o u l d expect consistently natu ra l a p pea ri ng
tra nspla nted h a i r. Based on the theory of donor d o m i
na nce, h a i r fol l ic l es m a i nta i n t h e i r genetic d esti ny wher
ever they grow on o u r sca l p . H a i r tra nspla nted from the
posterior sca l p will grow fo r as long as it was ge netica l ly
progra m med to grow. For the vast majority of m e n , tra n s
pla nted h a i r wi l l grow for d ecades.

Figure 19.2 Unnatural "pluggy" hairline using 1 0 to 25 hair grafts.

Should never happen in twenty-first century

Sect i o n 4 : D i so rd e rs of H a i r Fol l i c les

1 05

H a i r nat u ra l ly grows in 1 to 4 h a i r fol l i c u l a r b u n d les.


Contem pora ry hair tra nspla ntation uti l izes a la rge n u m
b e r o f 1 t o 4 h a i r fol l i c u l a r gro u p i ngs . The res u lt is consis
tently nat u ra l a p pea r i n g tra nspla nted h a i r fo r men a n d
wo m e n .

THE CON S U LT
K ey Q u est i o n s

H ow long h ave you n oticed h a i r loss?

Rate of h a i r loss?

W h i c h m e d i cations, wheth er p rescri ption or a lternative,

Expectations?

have been tried and for h ow long?

P h ys i c a l Exa m i n at i o n

N o rwood stage ( F ig. 1 9 . 1 )

Donor density

Ca l i ber of h a i r fol l i c les


- I d ea l c a n d i d ate : h igh donor density, t h i c k ca l i be r h a i r
fo l l icle, rea l i stic expectation ( Figs . 1 9 . 3 a n d 1 9 .4)
- Poor ca n d idate: poor donor den sity, below average
h a i r ca l i ber, u n rea l istic ex pectations

Key P o i nts to E m p h a s i ze B efore H a i r

Tra n s p l a ntat i o n

Figure 19.3 Realistic expectations using 1 to 4 hair grafts. Before

N et perce ived dens ity fro m a h a i r tra ns p l a nt

the

Norwood V

n u m be r of hair fol l icles tra nspla nted-{)ngo i ng hair loss.

F i n e hair fol l icles will c reate th i n natu ra l coverage , a n d


t h i c k ca l i ber fol l icles wi l l c reate more perceived density.

O ngoi ng h a i r l oss w i l l affect the cosmetic a p pea ra nce of


a tra nspla nt.

Visible donor sca r o r sca rs if h a i r is shaved o r c l osely


c rop ped i n poste rior sca l p .

L i m ited d o n o r s u pply!
Key to success: phys i c i a n and pati ent have s i m i l a r

expectations o f what t h e proced u re w i l l a n d wi l l not


ach ieve over the short ( 1-3 yea rs) and

long term

( 1 0-20 yea rs ) .

M ed i c at i o n a n d Tra n s p l a n tat i o n
Med ication to m a i nta i n existi ng h a i r wi l l maxim ize the
density from a tra ns p l a nt but med ications should a l ways
rema i n elective . H a i r l i ne design a n d d istri bution of rec i pi
ent sites should a lways ass u m e ongoin g hair loss.

Figure 19.4 Realistic expectations using 1 to 4 hair grafts. A fter 1 , 1 00

1 to 4 hair grafts

1 06

Color Atlas of Cosmetic Dermatology

S U RG I CAL PROCED U R E
P reo p e rat i ve I n st r u ct i o n s

N o s pecific b l ood tests

Medical clearance if a p p ropriate

Ph otogra phs

I nformed written consent sent to the patient for review


at least 1 week before the p roced u re

Day of P roced u re

Written consent with postoperative i nstructions reviewed

I ntrod uce h a i r tra ns p l a nt tea m

Review p roced u re a n d goa ls with patient

Figure 19.5 Trim donor region with moustache trimmer, and tape hair up
so donor suture will not be visible in the postoperative period

D o n o r R eg i o n -O n l y L i m i t i n g Factor

i n H a i r Tra n s p l a ntat i o n ( F i g s .
and

1 9 . 1 0)

19.5

An esth esia in donor region

1 % Lidoca i n e w i t h 1 : 200, 000 e p i n e p h r i n e

30 t o 6 0 cc sa l i n e
Sa l i ne i n d o n o r region p rovides

a nesthesia

hemostasis

less tra nsection of hair fol l i c les

less l i kely to tra nsect the occi pita l a rteries

Donor harvesting tec h ni ques (Ta b l es 1 9. 2


a n d 1 9.3)

El l i ptica l str i p h a rvesting: >95% of patients

Fol l i c u l a r u n it extractio n : <5% of patients ( Fig. 1 9 . 1 1 )

Figure 19.6 Patient in prone position

E l l i ptical stri p harvesting

Use ski n hooks to retract when re movi ng d o n o r e l l i pse


to m i n i m ize tra nsactio n of h a i r fol l ic les ( Fig. 1 9 . 1 2 )

TAB LE 1 9 . 2 Advantages and Disadva ntages of


Fol l icular Unit Extraction (FUE)
Adva ntage

Disadva n tage

-No l i nea r donor scar

-More t i m e consu m i ng

-Ofte n m i n i ma l ly visi ble

-More F U E sess ions to

sca rri ng i n tri m med

eq u a l d e nsity from

donor region ; adva n tage

e l l i pse

for patients with short


h a i rstyle
-Can be used for patients
with exte ns ive sca rri ng

-G reater tra nsection of


h a i r fo l l ic l es with

i n posterior sca l p from

potenti a l decreased

m u ltiple p revious s u rge ries

yield

Figure 1 9 . 7 Donor strip should not be more than 1 em wide. Strips

>1 em have an increased risk of creating a hypertrophic scar

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

TAB L E 1 9 . 3

Fol l i c u l a r u n it extraction

M i n i m a l tra nsection of donor h a i r

Yes

No

N u m ber o f 1-4 grafts safely ha rvested p e r proced u re

1 , 500-2, 000

200-500

Ti me to ha rvest donor h a i r

1 5-20 m i n

1-2 h

Visi b l e d o n o r sca r with h a i r length > 1 e m

No

No

Visi b l e d o n o r sca r with h a i r length <0 . 5 e m

Yes

Likely not

Overa l l percentage o f cases used

>95%

<5%

U nd e rm i n i ng donor region ra rely n ecessa ry

Dou ble layer of sutu res ra rely necessa ry

Sutures or sta p l es to close in si ngle layer

Sutu res or sta p l es out in 7 to 1 0 d ays

Keys to success in donor harvesting of e l l i pse

Donor str i p width <1 em

After l idoca i ne , add sa l i n e to donor region to provide


hemostasis, a nesthesia , a n d red uce tra nsection of h a i r
fo l l i c les

S k i n h oo ks to retra ct tissue w h i l e re moving e l l i pse

Do not rush!

Fo l l i c u l a r u n i t ext ract i o n
Defi n ition: re m ova l of fo l l ic u l a r gro u p i ngs from the poste
rior sca l p u s i ng 1 - m m p u nches.
Exce l lent treatment o ption for patients' ve ry short
donor h a i r that do want a visi ble donor sca r a n d for
patients with severely depleted donor regions from m u lti
p l e previous hair transpla nts .

G ra ft c reat i o n
A l l grafts should m i m ic the natu ra l 1 to 4 fol l i c u l a r b u n
d les t h a t natura l ly occ u r o n the sca l p .

Keys t o success i n creating 1 to 4 h a i r grafts


Good ergo n o m i cs a n d i n stru ments. Prep blades a n d
# 1 0 blades a re often used t o sepa rate fol l ic u l a r gro u p
i ngs from the donor e l l i pse. Magn ificatio n can a i d the
process i n sepa rating fol l ic u l a r gro u p i ngs from the
donor e l l i pse.

Do not a l low grafts to d ry. They m ust a l ways be i n


c h i l led sa l i n e .

1 07

Donor Harvesting Tec hniques: E l l i ptical Strip Harvesting Versus Fol l i c u l a r Unit Extraction
E l l i pse

We l l -tra i ned staff o f th ree t o fou r s u rgical assista nts .

Staff tra i n i ng

Enth usiasm/i nterest in proced u re

Patie nce; 6 to 1 2 months for an assista nt to learn to


c reate 200 to 300 grafts per h o u r

Figure 19.8 Closing donor region with staples

1 08

Color Atlas of Cosmetic Dermatology

A n est h es i a i n R ec i p i e n t R eg i o n

Field block a n d loca l i nfi ltration with 1 % l idoca i n e with


1 : 200,000 e p i n e p h r i n e and

0.25%

M a rca i n e with

1 : 200,000 e p i n e p h r i n e .

S u p raorbita l a n d s u p ratroc h l ea r b l o c k is o ptio n a l .

Su perfi c i a l i nfi ltration i n d e r m i s , n o t su bc uta neous tis


sue, will c reate good hemostasis.

H a i r l i n e Des i g n
Defi n ition: a h a i r l i n e is a n i rregu l a r, i l l-defi ned tra nsition
zone from skin to i n c reas i n g dens ity of term i n a l pig
mented hair fol l icles.

Always consider the fronta l , te m pora l , and poste rior


h a i r l i nes.

The fronta l and poste rior h a i r l i nes should be i rregu l a r


a n d i n t h e sa me pla i n . T h i s m e a n s genera l ly avoid i ng
tra nspla nting

the

ve rtex,

partic u l a rly

in

you nge r

patients . The reason is the ever-expa n d i ng ba l d i ng s pot


in the ve rtex.
- When design i n g a fronta l tem poral h a i r l i ne, a l ways
assume p rogression of h a i r loss to N orwood stage V.
- Fronta l h a i r l i n e at least 9 em a bove gla be l l a .
- Be conservative .

R ec i p i e nt S i te C reat i o n ( F i g .

1 9 . 1 8)

Com m o n l y used need les to create rec i p ient sites a re

# 1 9 or #20 ga uge need le


- Magn ification to red uce tra nsaction of existing pigmented term i n a l h a i r

S P 8 8 t o 90 ga uge n eed le

0 . 5- to 1 . 0-m m cag need l e

Figure 19.9 A 2-cm-wide donor scar from 1 . 5-cm-wide ellipse

K e y p o i nts

D istri b ute rec i pient sites ra n d o m ly a n d c l osely together


a n d i n a d istri bution that will a p pea r nat u ra l if all hair is
lost i n the fro nta l two-t h i rds of the sca l p

Avo i d tra u ma t o existi ng h a i r fol l i c l es


- Magn ification in rec i pient sites
- Fol low the natura l 1 5- to 30-degree a ngle of h a i r fol l i c l es i n t h e fronta l two-th i rds o f t h e sca l p

Excellent he mostasis using 1 : 1 00,000 e p i n e p h r i n e


1 0 to 30 sites/cm 2 d e pend i ng on the a mo u nt o f existi ng
hair and a rea ( c m 2 ) to d i stri b ute grafts

G ra ft P l a c e m e n t ( F i g .

1 9 . 1 9)

Two or th ree s u rgical assista nts place the grafts i nto


reci pient sites u s i n g m i c rovasc u l a r forceps.

Figure 1 9 . 1 0 Follicular unit extraction using 1 -mm sites

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

1 09

Keys to success

H a n d l e grafts i n perifo l l i c u l a r tissue-never crush h a i r


fo l l i c les

Kee p a l l grafts in c h i l led sa l i n e-neve r a l low a graft to


desiccate

Staff tra i n i ng

Excellent h e mostasis using 1 : 1 00,000 e p i n e p h r i n e

Patience

Posto p e rat i ve P e r i od

Overnight d ress i ng t o protect grafts .


Ora l steroids 40 mg qd for 3 to 4 days to red uce fronta l
edema .

Tylenol #3, one ta b l et q 4 to 6 h o u rs for 1 day P R N .


There s h o u l d b e n o d iscomfort morn i n g afte r su rgery.

S h ower in morn i n g afte r s u rgery. Avoid tra u ma to tra ns


pla nted zo n e .

Figure 1 9. 1 1 Skin hooks to aid in removal of donor ellipse

- Perifo l l i c u l a r hemorrhagic c rusti ng rem a i ns 5 t o 8 days


- The vast majority of patients retu rn to work 2 to
3 days after the proced u re

N o r m a l a ctivities i m med iately. No heavy exe rcise for


5 to 7 days.

Topica l a nti biotic to donor wou n d for 7 to 1 0 days.

Sutu res or sta p l es rem oved 7 to 1 0 days after su rgery.

Co m m o n Post H a i r Tra n s p l a n t S i d e

Effects

Fronta l edema lasting 3 to 4 days posto peratively

Pru ritus in donor a n d/or rec i pient zone

Tra nsitory fol l i c u l itis

Te logen effl uvi u m i n patients with d iffuse t h i n n i ng

Figure 1 9 . 1 2 Donor ellipse with natural follicular bundles

R a re S i d e Effects

Hypertro p h i c sca rring i n donor region i n e l l i pses less


t h a n 1 em

Persistent n u m bness or d i sco mfort in donor or rec i p i ent zone

Cystic nod u les

Poor q u a l ity growth of tra ns p la nted h a i r

I nfection

Posts u rg i c a l Pe r i od after

S u t u res/Sta p l es R e m oved

Resume fu l l s ports 1 wee k after s u rgery

Dye h a i r 2 weeks after su rgery

Figure 1 9 . 1 3 Magnification helps visualize 1 to 4 hair bundles and mini

mize transection when separating with surgical prep blades

1 10

Color Atlas of Cosmetic Dermatology

TAB L E 1 9 . 4

Treatment Options for Corrective H a i r Transplant Surgery

Treatment o ption

Adva ntage

Disadva n tage

Ad d i ng 1-3 h a i r grafts

Dra matica l ly soften h a i r l i n e and a d d further density to

Donor region may be depleted

between existi ng la rge

existing " pl ugs"

1 0-25 h a i r " pl ugs"


Pati ent not psyc hologica l ly a b l e to go
t h rough a nother h a i r tra ns p l a nt p roced u re
Patient req u esti ng "I wo u l d rather j u st be ba l d " Status

Exc ision of grafts

Potentia l visible e rythem atous sca r

quo a nte

for wee ks to months


Permanent sca r a n d/or d ysc h ro m i a

Laser h a i r remova l

N o n i nvasive

40-80% i m prove ment afte r-five to

Com bi nation

Red u ce " pl uggy" grafts

A s a bove

seven does not work on b l a n d h a i r


Majority of patients util ize a c o m b i nation of the a bove
for o pti m a l res u lts

I n itial fo l lowu p 8 to 1 2 months after su rgery

Fu l l cosmetic res u lt 9 to 15 months afte r s u rgery

Correct i ve H a i r Tra n s p l a n t S u rgery

(Ta b l e

1 9 .4)

For the majority o f m e n , corrective h a i r tra nsplant su rgery


is cosmetic a l l y a n d emotiona l ly m a n d atory, not elective .

Consult
Key q uestio n : what is yo u r c h ief concern a n d goa l for
poss i b l e corrective su rgery?

B I B L I OG RAPHY
Avra m M R . Polarized l ight-em itting d iode magn ification
fo r o pti m a l rec i pient site c reation d u ri n g hair transpla nt.
Dermatol Surg. 2005 ;3 1 (9 pt 1 ) : 1 1 24- 1 1 2 7 . Discussion
1 127.
Epste i n J S . The treatment o f fe male pattern h a i r loss a n d
other a p p l ications o f s u rgica l h a i r restoration i n women .
Facial Plast Surg Clin NorthAm. 2004; 1 2 ( 2 ) :24 1 -247 .
H a rris J A . Fol l ic u l a r u n it tra nsplantation : Dissecting a n d
p l a nting tec h n i q ues. Facial Plast Surg C!in North Am.
2004; 1 2 ( 2 ) : 225-23 2 .
Leavitt M, Pe rez- Meza D, Rao NA, et a l . Effects of finas
te ride

(1

mg)

on

h a i r tra nspla nt.

Dermatol Surg.

2005 ;3 1 ( 10) : 1 268- 1 276. Disc ussion 1276.


Li m m e r B L. E l l i ptical donor ste reosco pica l ly assisted
m icrografti n g as an a p p roach to further refi nement in ha i r
tra nspla ntation . J Dermatol Surg Oneal. 1994;20( 1 2 ) :
789-793 .

Figure 1 9 . 14 1 to 4 hair grafts

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

Figure 19. 1 5 1 to 4 hair grafts in chilled saline

Figure 1 9 . 1 6 Natural irregular frontal hairline

111

1 12

Color Atlas of Cosmetic Dermatology

Figure 1 9 . 1 7 Magnification with polarized ligh t to create recipient sites

Figure 1 9 . 1 8 Placing 1 to 4 hair grafts with microvascular forceps

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

Figure 1 9 . 1 9 Preoperative Norwood Ill

1 13

1 14

Color Atlas of Cosmetic Dermatology

Figure 19.20 A fter 2, 400 1 to 4 hair grafts

Figure 1 9 . 2 1 Preoperative Norwood Ill to I V

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

Figure 19.22 A fter 900 1 to 4 hair grafts

Figure 1 9.23 Preoperative Norwood I V to V

1 15

1 16

Color Atlas of Cosmetic Dermatology

Figure 19.24 A fter 2, 030 1 to 4 hair grafts

Figure 19.25 Preoperative Norwood I V to V

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

Figure 19.26 A fter 1 , 000 1 to 4 hair grafts

Figure 19.27 Straight "pluggy" frontal hairline

1 17

1 18

Color Atlas of Cosmetic Dermatology

Figure 19.28 A fter 650 1 to 3 hair grafts. Note improvement. Not com
pletely natural hairline

Figure 19.29 Straight "pluggy" hairline. Depressed scars

Figure 19.30 A fter 1 , 000 1 to 3 grafts

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

Figure 1 9 . 3 1 Preoperative Norwood IV to V

Figure 19.32 A fter an additional 700 hair grafts (second surgery)

1 19

1 20

Color Atlas of Cosmetic Dermatology

Figure 1 9.33 Straight "pluggy" hairline

Figure 1 9 .34 A fter 500 1 to 3 hair grafts

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

I l l ustration 19. 1 Obsolete 4-mm "pluggy" grafts

S i te of
donor st r i p

E l l i p t i c a l d o n o r str i p
from poste rior sca l p

I l l ustration 19.2 Elliptical donor strip from posterior scalp

121

1 22

Color Atlas of Cosmetic Dermatology

I l l ustration 19.3 1 to 3 hair follicular groupings within donor strip

I l l ustration 19.4 Versus 1 0 to 20 hair "pluggy" graft. Natural 1 to 3 fol

licular groupings

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

1 23

I l l ustration 1 9 . 5 Straight artificial "pluggy" hairline using 1 0 to 20 hair

grafts

I l l ustration 1 9 . 6 Recipient sites created at 1 5- to 45-degree angles not

90 degrees

1 24

Color Atlas of Cosmetic Dermatology

I l l ustration 1 9 . 7 Corrective hair transplant adding 1 to 3 hair grafts

between and in front of "p/uggy" grafts

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

1 25

I l l ustration 19.8 Adding 1 to 3 hair grafts between large "pluggy" grafts

to improve cosmetic appearance

1 26

Color Atlas of Cosmetic Dermatology

CHAPT E R 2 0

Fe m ale Patte rn H air Loss

Female patte rn h a i r loss p resents with a d iffuse th i n n i ng


of the m i d -sca l p with a cha racte ristic m a i ntenance of the
fronta l h a i r l i n e . I t may a lso p resent with the typical bitem
pora l h a i r recession seen i n male pattern h a i r loss.
Pa rieta l

and

occi pita l

h a i rs a re

usua l l y u naffected .

Female patte rn h a i r loss is pa rtic u larly p ro b l e m atic for


women for whom h a i r loss p rod u ces greater soc i a l a n d
self-esteem d ifficu lties t h a n for men with m a l e pattern
h a i r loss ( Figs. 20. 1 and 20. 2 ) .

EPI O E M I O LOGY
Incidence: nea rly 30% of fe ma les older than 30 yea rs .
Age: begins in second a n d in t h i rd decade.
Race: none reported i n fe ma les.
Precipitating factors: polygenetic i n h erited pred isposition
is p rese nt. It is n ot o n e pa rent's fa u lt!

Figure 20. 1 Preoperative L udwig Ill

PATHOG E N ES I S
There i s a d i m i n ution i n the size of affected term i n a l fol l i
c l es that regress t o beco me vei l us fo l l ic les that eventua l ly
d isa p pea r. There is an i n c rease in telogen h a i rs a n d a
decrease in a nagen h a i rs . Hormones play a rol e but the
exact path o physio l ogy is u n certa i n .

COU RS E
Begi ns i n twenties a n d p rogresses over decades. T h e rate
a n d extent of h a i r loss va ries.

KEY CO N S U LTAT I V E QU EST I O N S

D u ration o f h a i r loss

Menstrual h istory

Medication h i story

N utrition, d i eti ng, weight loss

H a i r ca re-blea c h i ng, b ra i d i ng

Fa m i ly h i story of h a i r loss

H istory of major u n expected e motional or p hysi cal


stress

Medical h istory, that is, thyroid d isease, i ro n d eficiency

PHYS I CAL EXAM I NAT I O N


N onsca rring a l o pecia-no erythem a , sca le, atro phy i n
s k i n with fe male pattern h a i r loss

Figure 20.2 After 900 1 to 4 hair grafts

Sect i o n 4 : D i so rd e rs of H a i r Fol l i c les

1 27

D I FFERENTIAL D I AG N OS I S OF FEMALE
PATTE R N HAI R LOSS

Te logen effl uvi u m

Poor h a i r sty l i ng-c h e m icals, excessive dying

I ron d efi ciency, thyro i d d i sease, c h ro n i c med ica l d is-

Med ication -related hair loss

ease, polycystic or oth er en docrine i m ba l a nce

Poor n utriti o n , weight loss

Tri c h oti lloma n ia

D iffuse a l o pecia a reata-ra re

KEY QU EST I O N S TO D I ST I N G U I S H
D I F F E R E N T I AL D I AG N OS I S

H ow long has you r h a i r loss persisted?

Changes in d iet or weight loss over past 6 to 12 months?

Any n ew presc ri pti o n , over-the-cou nter (OTCJ medica


tions, or s u pplements?

Any major su rgery or u n us u a l e m otional stress?

Any cha nge in h a i r ca re? Ch em icals to h a i r?

KEY PO I NTS

Patients may have a com bi nation of eti ologies .


If there is a ny q u estion i ng afte r h i story a n d physical
exa m i nati o n , sca l p bio psy is i n d icated .

Thyroid function tests, i ron stud ies, a nti n uclear a nti

Figure 20.3 Preoperative temporal scar-chief complaint: "I cannot wear


my hair back"

body ( A N A l , ra pid plasma reagin ( R P R J .

Referra l t o gynecologist a n d/or en docri nologist if a p p ro


priate on h i sto ry a n d/or exa m i nation .

M E D I CAL TH ERAPY
To pica l m i noxi d i l (2% and 5 % solution) a re the o n ly med
ications fo r fem a l e patte rn ha i r loss a pp roved by the U . S .
Food a n d D r u g Ad m i n istration ( F DA ) (Ta ble 20. 1 ) . The
mec h a n ism of action is u n known . It is safe fo r long-term
a p pl icati o n .

TAB L E 20. 1

M inoxi d i l

Mecha n is m o f action

U n known

Onset of action

6-8 months

Side effects

Dryness, pru ritus, "greasy h a i r "

Use with p regna ncy

No

or b reast-feed i ng
5% versus 2 %

5% sl ightly m o re effective b u t
m ore "greasy" sl ight
i n c reased risk of h i rsutism

Figure 20.4 A fter 650 1 to 3 hair grafts

1 28

Color Atlas of Cosmetic Dermatology

M i noxi d i l 5% foa m is only a p proved for men but often


is used by wom e n . The reason is d ue to m i noxi d i l in s m a l l
pe rcentage o f wom e n , i n d u c i n g u nwa nted pigmented
term i n a l

h a i rs .

The

med icatio n - i n d u ced

h i rsutism

is

revers i b l e if the med ication is d iscont i n u ed .


M a n y women who d o get m i n oxi d i l - i n d uced h i rsutism
a lso get excellent growth of hair on their sca l p a nd opt to
conti n u e the m e d i cation and use lasers to re move the
u nwa nted hair on the face.
The foa m creates much less i rritation o n the sca l p
m a k i n g i t m uc h easier t o b e com p l i a nt tha n t h e sol utio n .

KEYS TO S U CCESS

Com pliance: m ust u s e for 6 t o 8 m o n t h s t o prod uce t h e


d esi red effect.

Em phasize mai ntenance over regrowth of h a i r. M i noxi d i l

Figure 20.5 Preoperative Ludwig I to II

stops h a i r loss i n t h e majority o f patients a n d grows bac k


pigmented term i n a l h a i r i n a m i nority of patients.

N O N - FDA APPROVED M E D I CAT I O N S

Fi nasteride, a type I I 5-a red uctase i n h i b itor, i s con


tra i nd i cated i n women of c h i l d bea ring age. Stu d i es
demonstrate

some

efficacy

in

postmenopausa l

fe males.

Oral a n d roge n receptor a ntago n i sts s u ch as s p i ronolac


tone and cyproterone a cetate a re other a lternatives with
l i m ited p roof of efficacy i n both p re m e n o pa usa l a n d
postmenopausal fema les. They a re contra i n d i cated i n
p regna nt patients, given t h e risk o f p rod u c i n g sexual
d efects i n a male fetus. T h ey shou l d , therefore , be d is
conti n u ed months prior to a pl a n ned p regnancy.

S U RG I CAL
C o n s u l tat i o n
C h i ef com pla i nt: "see t h rough" fronta l h a i r l i n e , " l i m ited
sty l i n g o ptions, " "fea r of windy days . "

K e y Q u est i o n s

H ow long has h a i r loss persisted on?

Medical work u p to d ate

Med ication used to treat h a i r loss a n d for how long

Patie nt's c h ief cosmetic concern

Patie nt's goa l fo r hair tra nspla ntation

PHYS I CAL EXAM I NAT I O N

Donor density

Figure 20.6 A fter 600 1 to 3 hair grafts

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

Ca l i be r of h a i r l oss

Exte nt of h a i r l oss

1 29

KEY PO I NTS

Em phasize u n pred icta ble donor density. The tra ns


p l a nted h a i r w i l l grow for as long as it was gen etica l ly
p rogra m m ed to grow.

I nc reased risk of posts u rgica l te logen effl uvi u m .


Ongoing h a i r loss wi l l affect perce ived den sity o f h a i r
tra nspla nt.

S U RG I CAL APPROACH :
FEMALE VERS U S MALE HAI R
TRA N S P LANTAT I O N (Table 2 0 . 2)
H a i r tra nspla ntation for men a n d wom e n util ize the same
donor ha rvesting tec h n i q u es, graft c reation , i n stru ments,
a n esthes i a , and p re- and postsu rge ry cou rse .

Figure 20.7 Preoperative L udwig I to II.

FE MALE S U RG I CAL PLAN N I NG


Tra nsplant fronta l one-t h i rd of sca l p on ly! Th i s wi l l
add ress c h i ef com p l a i n t a n d red uce the risk o f telogen
effl uvi u m .

C h i ef com p l a i nt: "see t h rough " fronta l h a i r l i n e

Sta ble fronta l , tempora l , a n d posterior h a i r l i nes

D iffuse th i n n i n g-no ba l d spots

R isk of telogen effl uvi u m


- U n pred icta ble long-te rm growth o f h a i r from the
donor region

TAB L E 20.2

Surgica l Approach : Female Versus M a l e Hair Transplantation


Male

Female

Donor density

M ore pred i cta b l e

Less p redicta b l e long term

H a i rl i ne design

U nsta ble a n d reced i n g fronta l tem pora l a n d poste rior


h a i r- l i n e
N eed t o design h a i r tra ns p l a nt f o r lo ng-term natu ra l
cosmetic a p pea ra nce ( > 1 0 yea rs)

Sta ble h a i r l i nes. Major cosmetic adva n tage


ove r men for s u rgica l pla n n i ng

Ca l i be r of ha i r

Va r i a b l e between i n d ivi d u a l s

Va r i a b l e between i n d ivid ua l s

M ed ication use with h a i r

If existi ng h a i r rem a i ns, med ication w i l l add dens ity

A l l women s h o u l d u s e m i n oxi d i l t o h e l p m a i nta i n

tra nspla ntation

by l i m iti ng fu rther h a i r loss


Med ication a lways rema i n s elective
N eed to d esign h a i r tra nsplant ass u m i ng ongoi ng
hair loss and reced i n g h a i r l i nes

Expectations

Key to su ccess

existi ng h a i r a n d decrease risk o f postsu rgery


te logen effl uvi u m
Density = n u m be r of h a i r fol l i c l es tra nspla nted
ongoi ng h a i r loss
Key to su ccess

1 30

Color Atlas of Cosmetic Dermatology

P reo p e rat i ve I n st r u ct i o n s

- H u m a n c h o ri o n i c gonadotro p i n ( B- H C G ) i n a p p ropriate patient

Consent

Ph otos

Medical cleara n ce if a p p ro p riate

Ok to dye h a i r u p u nt i l day before p roced u re

P roced u re

I ntrod uce staff

Review s u rgica l plan

Review posts u rgica l care, a n esthes i a ,

i n stru m e nts,

donor ha rvesti ng, graft c reati o n , grafts placement a re


the sa me as for m e n

Posto p e rat i ve I n st r u ct i o n s

Figure 20.8 A fter 750 1 to 3 hair grafts.

Overnight d ressi ng to p rotect grafts a s they hea l .


Resume regula r a ctivities. Light exercise 2 t o 3 days
after

su rgery.

Full

exercise

when

sta ples/sutu res

removed 7 to 10 days posto peratively.

If any d iscomfo rt o r pa i n , ta ke Tylenol #3 with food q 4


to 6 h o u rs . Fifty percent of patients ta ke no pa i n med
ication and the other 50% take one or two ta blets . If a
patient has a ny d iscomfort or pa i n after the day of
su rgery, they s h o u l d co ntact thei r p hysicia n .

P red n isone 4 0 mg qd for 3 t o 4 d ays t o p revent fronta l


edema . If a patient can not or w i l l not ta ke p red n isone,
ice forehead for 1 0 m i n utes every 30 m i n utes over the
d ressin g for the fi rst afternoon/even i n g of su rgery to
red uce

but

n ot

e l i m i nate

edema .

Edema

begins

24 h o u rs after su rgery, pea ks 72 h o u rs postsu rgery,


a n d d i sa p pea rs 5 to 6 days postsu rgery. R a re perior
bita l ecchymoses.

The m o r n i n g after s u rgery the d ressing is rem oved . A l l


patients a re encou raged to shower to h e l p red uce post
s u rge ry h e morrhagic crusti ng. Patients s h o u l d NOT
pick or ru b scabs; t h i s may perma n ently d a m age trans
pla nted h a i r.

After shower, blow d ry with wa rm not h ot a i r on low

Apply topical a nti biotic or Aq u a p h o r to donor region

power.
twice daily for 7 days.

Resume m i noxi d i l 48 to 72 h o u rs post s u rgery.

Posto p e rat i ve Pe r i od

Conti n u e m i noxi d i l one to two t i m es d a i ly.

Telogen effl uvi u m may beg i n 2 to 3 weeks after su rgery


a n d conti n u e for 2 to 3 months.

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

If te logen effl uvi u m occ u rs, h a i r density wi l l decrease


but w i l l ra rely be cosmeti c a l l y n oticea b l e .

I I

Fema le

I l l

Ca n d y e h a i r 2 weeks a ft e r su rgery.
I n itial fol l ow u p 9 to 12 months after s u rgery a n d then
every 3 months u ntil 1 5 mo nths when fi n a l density from
the proced u re w i l l a p pea r.

KEYS TO S UCCESS W I T H FEMALE


H A I R TRA N S P LA N TAT I O N
Male

Em phasize ongo i n g h a i r loss wi l l affect long-term den


sity of h a i r tra ns p l a nt. The net perceived density of the

I I

hair tra ns p l a n t = n u m ber of hair fol l icles tra nspla nted


ongoi ng h a i r loss .

Patie nts with t h i c k ca l i be r h a i r w i l l a p pea r to have more


h a i r than a patient with a n eq u a l n u m ber of fine h a i r fol
l icles. The sa me effect w i l l occ u r with a h a i r tra ns p l a nt.

Discuss the risk of posts u rgica l telogen effl uvi u m .


M i noxid i l wi l l hel p red uce not e l i m i nate t h e risk o f te lo
ge n effl uvi u m and h e l p slow or sto p ongo i n g h a i r loss
for the majority of patie nts .

l l l

1 1 1

e r te x

U n p red icta b l e futu re loss of d o n o r h a i r. Tra nspla nted


h a i r w i l l grow for as long as it was geneti cally p ro
gra m med .

L i m i t the majority of tra nspla nted grafts to frontal one


t h i rd of sca l p for maxi m u m cosmetic i m pact.

We l l -tra i ned staff.

HAI R TRA N S P LA N TAT I O N TO COR R ECT


ALT E R E D T E M PORAL HAI R L I N E FROM
L I FT I N G PROCEDU R E
After fe m a l e patte rn h a i r l oss, tra nsplanting to correct
sca rs left from l ifting p roced u res s u ch as facel ifts a n d
b rowl ifts a re the m ost common reaso ns for h a i r tra ns
p l a ntation in wom e n .

I I

CH I E F CO M P LAI NT ( Figs . 20.3 AN D


2 0 . 4)
" I can not wea r my h a i r u p or bac k . "

CON S U LT ( Figs. 2 0 . 5-2 0 . 8)


K ey Po i n ts

After h a i r loss fol l owi ng a l i ft, wa it at least 12 months


before considering su rgery.

The loss may be a te logen effl uvi u m a n d the h a i r may


grow back o n its own .

I l l ustration 20. 1 Female versus male pattern hair loss

131

1 32

Color Atlas of Cosmetic Dermatology

H a i r growth in sca r tissue is u n pred i cta b l e . The majority


of patie nts have excellent growth but a s ma l l m i nority
do not.

Em phasize greate r risk of fronta l and potenti a l ly perior


bita l ede m a . It is not med ica l ly concern i ng, but may
i m pact

postoperative cosmetic a ppea ra nce of the

patient.

P roced u re
P reo perative, i ntrao perative, a n d posto perative med ica
tion , tec h n iq ue, and wo u n d ca re a re the sa me fo r male
and fe m a l e hair tra nspla ntati o n . When creat in g rec i pient
sites, fo l l ow the natu ra l d i rection of hair growth i n the
te m po ra l regio n .

K eys to S u cc ess

Wa it at least 12 months after loss before considering


su rgery.

Fol l ow the nat u ra l a ngle of h a i r in the tem po ra l regio n ,


t h a t is, 1 5-degree a ngle pointing d own towa rd the
neck.

With a ppro priate patient sel ecti o n , there is h igh patient


satisfaction .

B I B L I OG RAPHY
Avra m M R . Accu rately com m u n icating t h e extent o f a
h a i r tra nsplant proced u re . A proposa l of a fol l ic u l a r- based
c lassification scheme. Dermatol Surg. 1997;23(9 ) :8 1 7818.
Avra m M R . Pola rized l ight-em itting d iode magn ifi cation
fo r o pti m a l rec i pient site c reation d u ri n g hair tra n splant.
Dermatol Surg. 2005 ; 3 1 ( 9 pt 1 ) : 1 1 24- 1 1 2 7 . Discussion
1 127.
Avra m M R , C o l e J P, G a n d e l m a n M , e t a l . The potentia l
ro le of m i noxid i l i n the h a i r tra nspla ntation setti ng.
Dermatol Surg. 2002 ;28( 1 0 ) : 894-900. Discussion 900 .
Epste i n J S . The treatment of fe male pattern h a i r l oss a n d
other a p pl ications o f s u rgica l h a i r restoration i n wome n .
Facial Plast Surg Clin NorthAm. 2004; 1 2 ( 2 ) : 24 1 -247 .
H a rris J A . Fol l ic u l a r u n it tra nsplantation : Dissecti ng a n d
p l a nting tec h n i q ues. Facial Plast Surg Clin North Am.
2004; 1 2 ( 2 ) : 225-23 2 .
Leavitt M , Perez- M eza D , Rao NA, Ba rusco M , Ka ufm a n
K D , Z i e r i n g C . Effects o f finasteride ( l m g ) on h a i r
tra nsplant.

Dermatol

Surg.

2005;3 1 ( 1 0 ) : 1 268- 1 276.

Discussion 1 276.
Limmer B L. E l l i ptica l d o n o r ste reosco pica l ly assisted
m ic rografti n g as an a p p roach to f u rther refi nement in h a i r
tra nspla ntation . J Dermatol Surg Oneal. 1 994;20( 1 2 ) :
789-793.

Sect i o n 4: D i so rd e rs of H a i r Fol l i c les

CHAPT E R 2 1

Low Leve l Light The rapy ( L L LT) a nd H air Loss

Low level l ight laser thera py ( LLLT) has been used to treat
a va riety of medical d isorders from u l ce rs to m uscu
loskeleta l d isord ers . In 200 7 , a low leve l l ight d evice was
a p proved by the U . S . Food a n d Drug Ad m i n istration
( FDA) to treat male patte rn hair loss ( Fig. 2 1 . 1 ; H a i rmax,
Boca Rato n , Flori d a ) . The laser co m b is a h a n d h e l d
d evice t h a t was a p p roved as a device w h i c h has a d i ffe r
ent sta n d a rd for FDA a pprova l than a medication . The
d evice is sold over the cou nter without phys i c i a n p re
scri ption o r physi c i a n mon itoring. There a re various other
m a n u factu rers of l ight thera py devices that a re sold to
physicia ns' offi ces that a re not h a n d h e l d , s u ch as the
S u n etics

d evice

( Figs.

2 1 .2

and

2 1 .3 ;

S u netics

I nternationa l , Las Vegas NV) .

Figure 2 1 . 1 Hand held LLLT device (hairmax lasecomb Boca Raton,

Florida)

M ECHAN I S M OF ACT I O N-U N KNOWN

Ca n d idate selection-a l l s k i n types . A l l h a i r colors .


M ost effective at ea rlier stages o f h a i r loss .

F DA

a p proved for male pattern h a i r loss. M a n y physicians


believe it may have a ro le i n treati ng fe m a l e pattern h a i r
loss.

APPROPR IATE U S E

T h e m a n ufa ct u re r reco m m e n d s slowly c o m b i n g the


device t h roughout the affected a reas of hair more t h a n
1 0 m i n utes three ti m es wee kly ( Fig. 2 1 .4 ) .

There a re n o p u b l ished stu d i es c o m pa r i n g d ifferent fre


q uency a n d time of use of the d evice.

PEARLS OF W I SDOM

A l l patients with h a i r loss s h o u l d be eva l uated b y a der


matologist to esta blish a d iagnosis before considering
a ny medical thera py.

M i noxi d i l for m e n a n d wo men a n d finasteride for m e n


rema i n the medical treatment o f c h o i c e for m a l e a n d
fe male pattern h a i r loss.

LLLT a p pea rs to be safe but long-term i n d ependent


stu d ies confi rm i n g efficacy over placebo have not been
done.

Corporate-fu nded stu d ies have demonstrated some


efficacy i n the treatment of male patte rn hair loss.

LLLT s h o u l d be considered after clear medical fa i l u re


with m i noxi d i l a n d/or fi nasteride.

Figure 2 1 .2 Office based LLLT device (Sunnetics, las Vegas, Nevada)

1 33

1 34

Color Atlas of Cosmetic Dermatology

B I B L I OG RAPHY
Avra m M R , Leon a rd RT J r, Epste i n E S , Wi l l ia m s J L,
B a u m a n AJ . The c u rrent ro le of laser/l ight sou rces in the
treatment of male and fem a l e pattern hair loss . J Cosmet
Laser Ther. 2007;9( 1 ) : 27-28. Review.
Avra m M R , R ogers N E. H a i r tra ns p l a ntation fo r m e n . J
Cosmet Laser Ther. 2008; 1 0(3 ) : 1 54- 1 60. R eview.
Avra m M R , R ogers N E . The use of low-level l ight fo r h a i r
growth : P a rt I . J Cosmet Laser Ther. 2009 ; 1 1 ( 2 ) : 1 1 01 1 7.
H odson D S . C u rrent a n d futu re trends i n home laser
d evices. Semin Cutan Med Surg. 2008;27(4): 292-300.
Leavitt M, C h a rles G, H eyma n E, M ichaels D. H a i rMax
LaserCo m b laser p h otothera py d evice i n the treatment of
male a n d rogenetic a l o pec i a : A ra n d o m ized , dou ble
b l i n d , s h a m d evi ce-control led , m u lticentre tria l . Clin Drug

Figure 2 1 .3 Patient undergoing LLLT treatment for male pattern hair loss

lnvestig. 2009;29( 5 ) : 283-292.

in a physician office

Figure 2 1 .4 Patient performing home LLLT treatment

F I VE
D isord e rs of Pigm entation

1 36

Color Atlas of Cosmetic Dermatology

CHAPT E R 2 2

Cafe Au Lait M acu l e

Cafe a u lait ma c u les (CALMs) a re benign we l l -demar


cated , l ight b rown ma c u les that typica l ly present in ea rly
c h i ld h ood . The pigmentatio n is typica l ly u n ifo r m . Lesions
may be m u lt i p l e or isolate d . They grow i n p roportion to
the growth of the c h i l d . They a re p resent i n as m a ny as
20% of the po pu lation a n d , ra rely, can be associated with
a h ost of ge nodermatoses.

EPI O E M I O LOGY
Incidence: 10% to 20% of the popu lation
Age: b i rth and early c h i l d hood
Race: more common in Africa n Americans than Caucasians
A

Sex: none
Precipitating factors: m ost commonly these a re ben ign ,
isolated fi n d i ngs in healthy c h i l d re n . M u lt i p l e CALMs can
be associated with genodermatoses s u c h as n e u ro
fi b romatosis,

tu berous

sclerosis,

B loom

synd rom e,

McCu ne-A l b right synd ro m e, R usse l l-Si lver synd rom e,


Watson synd rome, a n d Westerhof syn d rome

PATHOG E N E S I S
U n known .

PATH OLOGY
I n c reased mela n i n in basa l keratinocytes . C l i n ically da rker

lesions conta i n more melanocytes than l ighter ones.

PHYS I CAL LES I O N S


Lesions a re wel l d e m a rcated , u n iformly pigmented mac
u l es that va ry i n color fro m h u es of tan to l ight b rown to
b rown . They ca n present a nywhere on the body but
spare m u cous m e m b ra nes. The i r size can ra nge from a
few m i l l i m eters to over 20 e m .

D I F F E R E N T I A L D I AG N OS I S
Posti nfla m m atory hyperpigmentation,

Bec ker's nevus,

melasma, lentigi nes, e p h e l i d es, berloq u e d e rmatitis, a n d


congen ita l nevus.

LABORATORY EXAM I NAT I O N


B i o psy i s not i n d i cated . Ad d itional laboratory work u p may
be a p p ro p riate i n the eve nt of suspicion of a n u n derlying
system i c d i sorder.

Figure 22. 1 (A) Cafe au lait macule on left cheek of a 1 7-year-old female
prior to treatment. (B) Erythema and lightening of cafe au Ia it macule
after one treatment with 694-nm Q-switched ruby laser. (C) Significant
clearing after four treatments with Q-switched ruby laser

Secti o n 5: D i so rd e rs of Pigmenta t i o n

1 37

CO U RS E
T h ey grow i n proporti o n t o t h e growth o f t h e c h i l d . O n c e
a c h i l d has fu l ly grow n , C A L M s d o n ot c h a nge i n size
o r c o l o r. T h e re is n o i n c reased risk of m a l ig n a n t tra ns
fo rmat i o n .

KEY CO N S U LTAT I V E QU EST I O N S

li m e o f onset

Fa i l u re to m eet m i l estones

Ph otosensitivity

I ntel lectual i m pa i rment

H i story of m u lt i p l e fractu res

Centra l nervous system d isord e rs or t u mo rs

Poor growth

Sco l iosis

O p hth a l m ologic i m pa i rment

MANAG E M ENT
CALMs d o not req u i re treatment u n less t h e i r a p pea ra nce
is d isfiguring or d istressi n g to the patient or parents.
M u ltiple lesions may suggest an u n d e rlying syste m i c d is
order. If there is a ny i n d ication of u n derlying system i c
a b normal ities i n t h e setti ng o f m u ltiple CALMs, referra l to
a p propriate pediatric spec i a l i sts is i n d icated . Laser ther
a py is often e m ployed as a treatment. CALMs te n d to be
m ore d iffic u lt to treat tha n other benign pigmented
lesions s u c h as e p h e l ides a nd lentigi nes. They req u i re
m u ltiple treatments a n d com plete reso l ution can be chal
lenging. Recu rrence is com m o n . Cryothera py a n d s u rgi
cal exc ision a re a l ternatives to laser thera py but carry the
risk of pigme nta ry a lterations, poor cosmesis, pa i n , a n d

sca rring.

LAS E R T R EAT M E N T ( Figs. 2 2.1-2 2 . 3)


Prior to treatment, a test s ite s h o u l d be performed to
assess for

efficacy

and

hyperpigme ntation .

CALMs

res pond va riably to m u ltiple modal ities of laser thera py.

Q-switc hed

lasers i n c l u d i n g the freq ue ncy-dou bled

Q-switc hed

N d : YAG

( 532

nm),

Q-switc hed

ru by

( 694 n m ) , a n d the Q-switc hed a l exa n d rite (755 n m ) a re


e m p loyed for selective pigment rem ova l .
It i s i m po rtant t o n ote that treatment with Q
switc hed lasers is not cookbook. Energy setti ngs va ry
fro m laser to laser. They a lso va ry before a n d after
m a i nte nance. T h u s , treatm ent s h o u l d be based on

a c h iev i n g

Figure 22.2 (A) Cafe au fait macule adjoining right lateral commissure of

Without

epidermal
epidermal

white n i ng
white n i ng,

u n I i kely to be effective .

after
the

treatm e nt.

treatment

is

lips. (B) Near clearance after three treatments with a 755-nm Q-switched
a/exandrite laser

1 38

Color Atlas of Cosmetic Dermatology

H owever, it is i m porta nt to note that overly aggressive


treatments prod uce pigme nta ry cha nges s u ch as hypo
a n d hyperpigmentatio n .
- I n o n e study,

Q-switched

r u by a n d

fre q u e n cy

d o u b led Q-switc hed N d : YAG treatments , each at


6 J/cm 2 , prod uced va ria b l e responses i n c l u d i ng
Sign ificant l ighte n i ng, which was m ost freq uently
o bse rved
C l ea ra nce with rec u rrence
Da rke n i n g
- Q-switched lasers have a decreased r i s k o f text u ra l
cha nge versus other laser thera p ies, but sti l l ca rry the
risk of hyperpigmentation .
- Resu lts a re va r i a b l e with a pprox im ately 50%

of

lesions showing a res ponse.


- W h i l e fu l l

resol ution

ca n

be o bta i ned

with the

Q-switc hed lasers, th ere a re freq uent rec u rrences .


Frustratingly, rec u rrences may occ u r 6 months to
1 yea r after treatment. Someti mes l ighte n i ng, rather
t h a n fu l l resolution, is the best o bta i n a ble result. A l l of
these lasers prod uce equ iva lent resu lts i n the treat
ment of CALMs.

TOP I CAL T R EATM ENT


CALMs a re not res ponsive t o topical blea c h i ng c rea ms.

P I T FALLS TO AVO I D/O UTCO M E


EXPECTAT I O N S/CO M P L I CAT I O N S/
MANAG E M E N T

U nfortunately, despite their s u pe rfi c i a l nat u re, CALMs


can be d iffic u lt to treat completely.

The key c l i n ica l fi n d i ng is epidermal white n i ng after


Q-switc hed laser treatment.

Lighte n i ng, rather than fu l l clearance, is often the best


res u lt, even after m u lti ple treatments.

There is a h igh risk of rec u rrence of CALMs u p to 1 yea r


after treatment.

Stud ies i n d icate a risk for hyper- a n d hypopigmentation


associated with the Q-switc hed lasers, espec i a l ly in
d a rker s k i n p h ototypes.

Treating a bove the therapeutic t h res h o l d may result i n


prolonged hea l i ng a n d i n c reased risk o f pigme nta ry
cha nges.

Patie nts with d a rker s k i n types s h o u l d be treated cau


tiously a n d conservatively, given the lower therapeutic
t h reshold .

Laser treatment of ta n ned patients s h o u l d be avoided .

B
Figure 22.3 (A) Treatment of cafe au fait macule on the chin of a young

man with a 532-nm frequency-doubled Q-switched Nd: YA G laser.


(B) Completion of treatment of cafe au fait macule with the appropriate

clinical endpoint of tissue whitening and erythema

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

B I B L I OG RAPHY
Al ora M B , Arndt K A . Treatment o f a cafe-a u-lait macule
with the erbi u m : YAG

laser.

J Am Acad Dermatol.

200 1 ;45(4 ) : 566-568 .


G ross m a n M C , Anderson R R , Fa rinel l i W, Flotte TJ ,
G reve l i n k J M . Treatment of cafe au lait m a c u l es with
lasers: A c l i n i co patho l ogic correlatio n . Arch Dermato/.
1995; 1 3 1 : 1 4 1 6 - 1 420.
K i m JS, K i m MJ , C h o SB. Treatment of segmenta l cafe au
l a it macu les using 1 064- n m Q-switched N d : YAG laser
with l ow p u lse energy. C/in Exp Dermatol. 2009;34( 7 ) :
222-223 .
Levy J L, Mordon S, Pizzi-Anse l m e M . Treatment of i n d i
vid u a l cafe a u l a i t macu les with t h e Q-switched N d : YAG :
A c l i n i copathologic correlation . Cutan Laser Ther. 1 999;
1 (4) : 2 1 7-223 .

CHAPTE R 23
Ephelides ,

Ephe l id es

more c o m m o n l y known

as frec kles, a re

benign, s ma l l , wel l -d e m a rcated , b rown macu les fo u n d


on t h e s u n -exposed s k i n o f blon d , l ight brow n , a n d red
h a i red i n d ivid u a l s . They present in early c h i l d hood a n d
decrease i n older age . They can b e d isti ngu ished fro m
lentigi nes in that they da rken in t i m es of h igh s u n expo
s u re a n d fad e d u ri ng periods of l i m ited sun expos u re .

E P I D E M I O LOGY
Incidence: very com m o n , pa rticula rly i n fa i r-s k i n ned
patients

Age: early c h i l d h ood


Race: more common in Caucasians, but a lso seen i n
As ians

Sex: eq ual
Precipitating factors: i n d ivi d u a ls with l ight hair a n d com
p lexion s u c h as blonds a n d red heads

PATHOG EN ES I S
The

b rown

pigm entation

assoc iated

with

ephel i d es

resu lts from i n c reased p rod uction of m e la n i n in s u n


exposed a reas o f the s ki n .

1 39

1 40

Color Atlas of Cosmetic Dermatology

PATHOLOGY
Kerati nocytes d i s play an i n c rease in mela n i n especia l ly i n
the basa l layer, but there i s n o su bsta ntial i n c rease i n the
n u m be r of m e l a n ocytes i n e p h e l ides.

PHYS I CAL LES I O N S


Ephelides a re wel l-dema rcated l ight brown to dark b rown
macu les of severa l m i l l i m eters d i a m eter that p resent i n
s u n-exposed a reas o f t h e ski n .

D I F F E R E N T I A L D I AG N OS I S
The d ifferentia l d iagnosis i n c l u d es other benign lesions

s u c h as lentigines a n d j u nctio n a l nevi .

LABORATORY EXA M I NAT I O N


None.

COU RS E
T hey p resent i n ea rly c h i l d hood . They d a rken i n periods
of h igh sun exposu re and l ighten d u ri ng periods of l i m
ited s u n exposu re .

KEY CON S U LTAT I V E QU EST I O N S

S u n expos u re .

MANAG E M ENT
There is no medical i n d ication t o treat e p h e l i d es . The
cosmetic a p pea ra n ce, however, may d i s please some
i n d ivi d u a ls.

Sun

avoidance

and

s u n sc reens

protect

aga i nst d a rken i n g of ephel ides. B leac h i n g c rea ms, s u ch


as hyd roq u i none, a nd topica l reti noids can prod uce l ight
e n i ng. C ryothera py a n d laser treatment a re a l so effective .
Recu rrence is freq uent, pa rti c u l a rly with s u n expos u re .

T R EAT M E NTS
To p i c a l Treat m e n t
To pical blea c h i ng c rea ms m a y p rovi d e some l ighte n i ng .
M u ltiple for m u lations a re ava i la b le d iffe ring i n t h e i r p rod
uct co ntents a n d stre ngths.

H yd roq u i n one (2-4 % ) c rea ms have tra d iti o n a l l y been


e m p l oyed .
- Twice d a i ly a p p l ication of the c rea m to the e p h e l i d es
ove r 3 months is ge nera l l y necessa ry to a c h i eve sig
n ificant, if n ot c o m p l ete, i m provement.
- Side effects i n c l u d e i rritatio n , pru ritus, pee l i ng, a n d
d ryness o f the treated a reas.

Figure 23. 1 (A) A 38-year-old male from Southern California with exten
sive ephelides. (B) Same patient with posttreatment whitening immedi
ately after frequency-doubled a-switched Nd: YA G (532 nmJ laser
therapy. (C) Significant improvement 2 weeks after single treatment with
frequency-doubled a-switched Nd: YA G (532 nmJ laser utilizing a f/uence
of 1 . 5 J/cm2 and a 2. 0 mm spot size

Secti o n 5: D i so rd e rs of Pigmenta t i o n

141

- If eryth ema a n d i rritation occ u r, exercise caution to


avo i d hyperpigme ntatio n , espec i a l l y in d a rker s k i n
phototypes .
- Patients m ust d isconti n u e the treatment if a ny l ight
e n i ng of non lesion a l s k i n is o bserved .
- B leac h i ng c rea ms a re contra i n d i cated in pregnant
a n d lactat i n g women .
- Prolonged treatment may prod uce s k i n d iscoloratio n
known as pseu d o-oc h ronosis.

Reti noids
- Retinoids have been added i n prod ucts such as Solage
(2%

meq u i nol and

O.Q l % treti n o i n ) a n d Tri l u m a

(0.0 1 % fluocinolone acetonide, 4% hyd roq u i none, a n d


0.05% tretinoi n ) t o provide a n exfol iative benefit.
- Appl ication of Tri l u ma m ust be l i m ited in d u ration
d ue to the poss i b i l ity of side effects with repeated
corticoste roid usage su ch as s k i n atrophy a n d a c n e .

Aze l a i c ac i d (20%) c rea m is u n pred i cta bly effective for


e p h e l i d es a n d le ntigi nes.

Koj ic a c i d 0-2 . 5% ) c rea m .

C h e m i c a l Pee l s
Chem ica l peels can b e h e l pful i n red u c i n g the a p pea r
a nce of ephel ides . Su perfi c i a l d e pth peels, med i u m
d e pth peels, a n d deeper pee ls a re a l l effective . A ca refu l
eva l uation of s k i n type, however, is esse ntia l prior to treat
ment. As the d e pth of the peel i n c reases, the c h a nce for
i m prove ment, a long with adverse s i de effects, i nc reases .

Over-the-co u nter a-hyd roxy acid peels a re a benefi c i a l


a dj u n ct to physician-strength c h e m i ca l pee ls. The c o n
t i n u a l exfol iation ach ieved from cons iste nt u s e o f t h e
peels wi l l res u lt i n m i ld l ighte n i ng.

G lyco l i c a c i d pee ls (35-70%) a re ad m i n istered every 2

to 3 weeks uti l iz i n g i n creasing strengths as to lerated .


Lighte n i ng of e p h e l i d es may be o bserved after fou r to
six pee ls. Strict photo protection is stressed . S a l icyl ic
a c i d peels ( 20-30% ) a re a lso effective . They can be
used safely in a l l s k i n types .

J essner pee ls ( resorc i n o l , lactic acid , a n d sa l icyl ic a c i d )


a re a d m i n istered every 6 t o 8 weeks.
- Strict photo protection fo r 2 to 3 months is advised .
- M u ltiple treatments a re reco m m e n d ed .
- Contra i n d icated i n pregnant a n d lactating women .

Com bi nation J essner/10% tri c h loroacetic (TCA) peels


may a lso be em ployed in a s i m i l a r fas h i o n as the
J essner pee l .
- The J essner pee l results i n exfol iation a l l owing fo r
greate r penetration of the TCA pee l .
- M u ltiple peels a re gen e ra l l y needed . Contra i n d i cated
in pregna n t a n d lactat i ng women .

Figure 23.2 (A) A 40-year-old Japanese female with ephelides and lentig

ines prior to 694-nm Q-switched ruby laser treatment. (8) Immediate


tissue whitening and erythema after treatment

1 42

Color Atlas of Cosmetic Dermatology

Caution to avoid pigmenta ry cha nges, es pec i a l l y i n


d a rker s k i n types.

A test site can be considered .

C ryot h e ra py
C ryoth era py can prod uce l ighte n i ng of frec k l i ng.

Has a risk of hypo- or hyperpigmentation at a n d around


treated sites, especially i n da rker s k in phototypes and
ta n ned pati ents .

Recu rrence is com m o n .

Laser T h era py ( F i gs .

23 . 1

and

23 . 2 )

Laser a n d l ight sou rce thera py can be effective i n treating


ephel i d es .

I ntense p u l sed l ight, freq uency-d ou bled Q-switc hed


N d :YAG ( 532 n m ) , Q-switc hed a l exa n d rite (755 n m ) ,
Q-switc hed

r u by

(694

nm),

Q-switc hed

N d :YAG

( 1 064 n m ) , p u l sed dye ( 59 5 n m ) , fractional res u rfac


i ng, and KT P lasers ( 532 nm) a re all effective .

With Q-switched lasers:


- Perform a test s pot on d a rker skin types.
- Treatment end point for Q-switc hed lasers is i m med iate tissue whiten i ng. For the Q-switc hed N d : YAG
( 1 064 n m ) , sma l l p i n po i nt bleed i n g may be see n .
- A 7-to- 10-day hea l i n g t i m e c a n b e expected for crust
i n g to resolve with Q-switc hed lasers .

One

study

used

the

frequency-doubled

N d: YAG

(532 n m ) to treat ephel ides in 20 patients with type IV


ski n .
50%

Eighty percent of patients showed better than


i m provement.

Recu rrence

was

com mon .

Hypopigmentation, textura l changes, and hyperpigmenta


tion a l l resolved with i n 2 to 6 months after final treatment.

In a n other study, 197 Asians were treated with the

Q-switched a l exa nd rite (755 nm) at 7.0 J/cm 2 , with a


pu lse width of 100 ns at 8-week i nterva ls. C l i n ical fol-

lowu p after an average of 1 . 5 treatment sessions showed


a 76% decrease in the n u m ber of ephel ides. No sca rri ng,
textura l cha nges, or pigmentary cha nges were noted .

The Q-switc hed ru by ( 694 n m ) a n d a l exa nd rite lasers


(755 n m ) a re a l so effective.
- If the c l i n ical end point of im med iate whitening is
achieved , the ephel ides should clea r with one treatment.

Q-switc hed lasers a re m ost effective for d a rker lesions.


Fractiona l res u rfa c i n g ( F raxel Laser; Reliant tec h nologies, San Diego, CA) is a lso effective ( Fig. 23 . 3 ) .
- Treatment is ge nera l ly performed at su perficial d e pths
compared to treatme nts of rhytides and acne sca rs.
- H igh treatment dens ities a re m ost effective .
- M i ld -to-moderate e ryth e m a , rese m b l i ng a s u n b u r n

Figure 23.3 (A) Young male with ephelides on his left cheek at baseline.

reaction , is observed . Postproced u re swe l l i ng is a lso

(B) Improvement of ephelides after several nonablative fractional resur

com m o n .

facing treatments.

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

- The erythema reso lves in 3 to 5 d ays a n d can be cov


ered with m a ke u p wit h i n a day of the treatment.
- Long-te rm d ata a re c u rrently lacking.

I ntense p u lse l ight is a lso effective.


- The c l i n ic a l end po i n t is da rken i n g of the lentigi nes.

Caution should be e m ployed when treating pati ents


with d a rker s k i n types to avo i d hyperpigme ntation that
may persist for months.

Recu rrence of frec k l i n g after treatment, however, is

S u n sc reen a n d s u n avo i d a n ce a re m a n d ato ry adj u n cts

com m o n .
to laser thera py.

P I T FALLS TO AVO I D/CO M P L I CATI O N S/


MANAG E M ENT

Laser treatment o f ephel i d es is freq uently su ccessful


but often tra nsient.

Patients should be i nformed that rec u rrence is h ighly


l i kely, espec i a l l y with s u n expos u re .

D a i l y strict photo protection with a s u n sc reen with


UVAIUVB p rotection a nd/o r a physica l block such as
tita n i u m d ioxi d e or z i n c oxi d e a re stressed as wel l as
sun avoidance.

I f blea c h i ng c reams prod uce erythema, ca ution is


advised as e rythema c a n prod uce i rritation and hyper
pigme ntation .

Patie nts s h o u l d be cou nseled rega rd i ng the poss i b i l ity


of posti nfla m m atory pigme ntatio n c h a nges after treat
ment. Laser remova l of ephel i d es may a lso prod uce a n
u nattractive, s potty hypopigmentation , espec i a l ly i n
d a rken s k i n phototypes .

B I B L I OG RAPHY
J a ng KA , C h u ng E C , Choi J H , S u n g KJ , M o o n K C , Koh
J K . S u ccessful remova l of freckles in Asia n skin with a Q
switc hed a lexa nd rite laser. Dermatol Surg. 2000; 26(3 ) :
23 1 -234.
M is h i m a Y, Ohyama Y, S h i bata T, et a l . I n h i bitory action of
koj ic acid on melanogenesis and its therapeutic effect for
va rious h u m a n hyperpigme ntation d isorders . Skin Res.
1 994;36( 2 ) : 134- 1 50 .
N a kagawa M , Kawa i K . Contact a l lergy t o koj i c a c i d i n
ski n ca re prod ucts . Contact Dermatitis. 1995;3 1 ( 1 ) : 9 - 1 3 .
Ngujen Q H , B u i T P. Azelaic a ci d : Pha rmacoki netic a n d
pha rmacodyn a m ic properties a n d its thera peutic role i n
hyperpigmenta ry d i sorders a n d acne. lnt J Dermatol.
1995;34( 2 ) : 75-84 .
R a s h i d T , H ussa i n I , H a i d e r M , H a roon TS. Laser thera py
of freckles a n d le ntigi nes with q uasi-conti n uous, fre
q uency-dou bled , N d : YAG (532 n m ) laser in Fitzpatrick
ski n type IV: A 24-month fol l ow-u p . J Cosmet Laser Ther.
2002 ;4(3-4 ) :8 1 -85.

1 43

1 44

Color Atlas of Cosmetic Dermatology

CHAPT E R 24

Le ntigi n es

T h e re a re two major types of lentigines: lentigo s i m plex


and solar lentigos. They a re ben ign lesions. Although
both a re c l i n ica l ly i d e ntica l , they a p pear i n enti rely
d ifferent c l i n i c a l setti ngs. Lentigo s i m p l ex typi c a l l y fi rst
p resent

in

c h i l d hood

as

m u lti p l e wel l - d e m a rcated ,

b rown or b l a c k m a c u les that ca n a p pear on a n y pa rt of


the s k i n or m ucous m e m branes. T h ey a re c l i n i c a l l y
i n d isti n g u i s h a b l e fro m j u nctio n a l n evi . T h e re is n o a sso
ciation with s u n exposu re in t h i s type of lentigo . I n
co ntrast, sola r lentigos, m o re c o m m o n l y k n own a s " l iver
s pots , " a re we l l - d efi ned , b rown m a c u les that a p pea r o n
s u n -exposed s k i n o f a d u lts . T hey i n c rease i n n u m be r
w i t h a g e . T h ey m ost often a p pea r o n the d o rsa l h a n d s ,
s h o u l d e rs, a n d fa ce o f l ightly pigmented a n d red - ha i red
patients.

EPI OEM I O LOGY


Incidence: very com m o n , pa rt i c u l a rly i n fa i r-s k i n ned
pati ents

Age: bimodal d istri bution in c h i l d hood a n d i n s u n


d a m aged s k i n o f a d u lts

Race: m o re common in Caucasians


Sex: eq u a l
Precipitating factors: s u n expos u re is c l osely related to
sol a r lentigines. M u lti p l e lentig i n es a re associated with a
few ge nodermatoses

i n c l u d i ng

LEO PA R D synd ro m e ,

LAM B syn d rome, a n d Peutz-J eghers syn d rome

PATHOG E N E S I S
U n known .

PATHOLOGY
There is a u n iform elongation of the rete rid ges of the e p i
d e r m i s a long w i t h i n c reased mela n i n i n melanocytes a n d
basa l keratin ocytes. I n a d d it i o n , there a re a n i nc reased
n u m be r

of

mela nocytes

in

the

basa l

cell

layer.

M e l a n o p hages a re p resent in the pa p i l l a ry dermis.

PHYS I CAL LES I O N S


Wel l -d efi ned b rown ma c u les. Le ntigo s i m p l ex m a c u l es
te nd to be evenly d i stri b uted a nd s m a l l , meas u r i n g o n ly a

few m i l l i mete rs . Solar lentigos have a p red i lection for the

Figure 24. 1 (A) Lentigo on left cheek of a female. (B) Significant

s u n-exposed a reas of the d o rsa l hands a n d face. They

improvement after one treatment with a 532-nm Q-switched Nd: YA G


laser at a fluence of 1 . 0 J/cm2 and a 2-mm spot size

can be l a rger tha n lentigo s i m plex.

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

1 45

D I FFERENTIAL D I AG N OS I S
Seborrheic keratosis, j u nctional nevi , ephel ides, lentigo
m a l igna , melanoma may a l l m i m i c lentigines.

TAB L E 24. 1

Solar Lentigo Versus Ephelid


Sola r lentigo

Ephel i d

P resents i n c h i l d h ood

No

Yes

Permanent

Yes

No

Dec reases with age

No

Yes

H igh rec u rre nce after treatment

Yes

Yes

I nc rease in m e la n i n

Yes

Yes

I nc rease in m e l a n ocytes

Yes

No

LABO RATORY EXAM I NAT I O N


B i o psy i s i n d icated i f there i s suspicion o f a le ntigo
m a l igna o r melanoma . Medical worku p is a ppropriate if
there is suspicion for a genode rmatosis.

CO U RS E
There i s a b i m od a l d istri bution for le ntigi nes. They a p pea r
in c h i l d hood a n d i n s u n -exposed a d u lts .

KEY CO N S U LTAT I V E QU EST I O N S

H a s there been a n y cha nge i n the color o r size o f the


lesion?

Does the lesion bleed?

Sun exposu re

S u n sc reen use

MANAG E M ENT
There is no med ica l i n d ication t o treat lentigi nes. T h e cos
metic a p pea ra nce, however, d ispleases m a ny d ue to the
perception that lentigines a re associated with aging.
Cryothera py a n d laser treatment a re the m a i n stays of treat
ment. Laser thera py is more effective than one-ti me a ppli
cation of cryothera py. C ryothera py, however, is a n effective
a n d less expensive o ption for the pati ent. Chemical peels,
topical tret i n o i n , l oca l derma brasio n , and topica l blea c h i ng
agents represent other treatment options.

TOP I CAL M E D I CATI O N S

B leac h i ng c rea ms suc h a s 4% hyd roq u i none can


l ighten lesions over a period of severa l months. A topical
com b i nation of hyd roq u i none, stero i d , a n d ret i n o i d , ie,
Tri l u ma (4% hyd roq u i none, 0.05% treti noi n , 0 . 0 1 %

Figure 24.2 Two examples of chrysiasis, a rare but well-described compli

cation of a-switched laser therapy in patients with a history of ingesting


gold salts. In both of these patients, the characteristic dark-blue pigmen
tation was produced after a-switched laser treatments of lentigines on
the (A) dorsal hand and (B) forehead, respectively

1 46

Color Atlas of Cosmetic Dermatology

fluocinolone a cetonide) can be used as we l l . However,


blea c h i ng c rea ms a re often not completely effective.

Topical tret i n o i n ca n prod uce lighte n i ng, but not usua l l y


c l e a r a n c e o f l e s i o n s . It may a lso, i n c o m b i nation with
sun avoidance and s u n sc reen use, p revent the d evel
o p ment of lentigi nes.

Retreatment is often necessa ry.


If a n y of these to pical med ications prod uce sign ifica nt
i nfla m mation o r i rritat i o n , it is i m porta nt to d isconti n u e
t h e i r use t o avoid posti nfla m matory hyperpigmentatio n .
I n a d d it i o n , pseud o-oc h ro n osis m a y occ u r with contin
uous, l ong-term use of topica l hyd roq u i n o n e .

B l eac h i ng c rea m s a re relatively contra i n d icated

in

p regna nt a n d lactati ng women .

CRYOTH E RAPY

This is a cheap, swift, and effective mea ns for treating


lentigines.

A p p l ication of c ryothera py c a n be accom p l i shed with a


sma l l cotton -ti p a p p l i cator or with a cryoth e ra py gu n .

I t i s ofte n l ess effective th a n one-t i m e treatment with a


Q-switc hed laser.
There is a sign ifica nt risk of hypo pigmentation with

c ryothera py if it is a pp l ied excess ively, or on a ta n ned


patient.

C H EM I CAL P E E LS
S u perficial d e pth peels, med i u m d e pth peels, a n d deeper
peels a re all effective for lentigines. A carefu l eva l uation of
skin type, however, is essential to avoid pigmenta ry com pli
cations. As the d e pth of the peel i n c reases, the chance of
i m provement, a l ong with adverse side effects, i n c reases.

LAS ER AND LIGHT SOU RCE TREATMENT


M u ltiple d ifferent thera pies a re effective for treating lentig
i nes. In genera l , da rker lentigines fare best with Q-switched
lasers. Where there a re n u merous, fa inter lentigines,
i ntense pulsed l ight sou rces a n d , to a lesser extent, nonab
lative fractional resurfacing lasers a re very effective.

I ntense p u l sed l ight, freq uency-d o u bled Q-switc hed


N d :YAG laser (532 n m ) ( Fig. 24. 1 ) , Q-switched a l exa n
d rite laser (755 nm) ( F ig. 24. 2 ) , Q-switc hed r u by laser
(694 n m ) , Q-switc hed N d :YAG laser ( 1 064 n m ) , p u l sed
dye laser with pigmented lesion w i n d ow ( 595 n m ) , a n d
fractional resu rfa c i ng lasers a re a l l effective .

With Q-switched lasers:


- Perform a test s pot on d a rker skin types.
- Treatment end point for Q-switc hed lasers is i m med iate tissue white n i ng. For the Q-switc hed N d : YAG
( 1 064 n m ) , sma l l p i n po i nt bleed i n g may be see n .

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

- A 7-to- 1 0-day hea l i ng t i m e can be expected for c rust


i n g to resolve after Q-switc hed laser treatm ent.
- Legs res pond m o re s l owly than the face and h a n d s .
- C a u t i o n s h o u l d be t a k e n wh i l e treating lowe r legs as
they often hyperpigment.

Hyperpigme ntation may

persist for months.

The freq uency-d o u b led Q-switc hed N d : YAG (532 n m )


laser h a s been shown t o i m p rove le ntigi nes safely a n d
effective ly.
- In one study, 37 patients were treated once with a
fluence of 2 to 5 J/c m 2, a 2 . 0-m m s pot size, a n d a
1 0-ns p u lse width .
- H i gher fl ue n ces provided best resu lts with 60% of
patients showi ng 75% or better clea ra nces.
- M i n or, tra nsient hypopigmentati o n , hyperpigmenta
tion , and e rythema were noted in a few patients.
- Has been shown to prod uce bette r cleari ng t h a n
35% T C A peel .
- Has been shown to treat lentigi n es more effectively
t h a n cryothera py.

The Q-switched ruby (694 n m ) laser is a lso very effective.


- In one treatment, su bsta ntia l cleari ng occu rred at
fl uences of 4 . 5 a n d/or 7 . 5 J/c m 2 a n d a pu lse width of
40 ns.
- I f the c l i n ic a l end poi nt of i m m ed iate white n i n g is
a c h ieved , the lentigo should clear with one treatment.

Fractio nal res u rfa c i n g can also be effective .


- Treatment

is

ge nera l ly

performed

at

s u perfi c i a l

d e pths a n d lower e ne rgies c o m p a red to treatm ents of


rhytides a n d acne sca rs.
- H igh treatment d ensities a re m ost effective . Typical ly,
req u i res m u ltiple treatments .
- M i ld -to-mod erate erythema , rese m b l i ng a s u n bu r n
react i o n , is o bserved . Postproced u re swe l l i ng is a l so
co m m o n .
- T h e e rythema resolves i n 3 t o 5 days a n d ca n be
covered with m a keu p with i n a day of the treatment.
- Long-te rm d ata a re c u rrently lacking.

I ntense p u l se l ight is a lso effective.


- Seve nty-fo u r percent c l ea ra nce of lentigi nes in 18
patients with one treatment.
- The c l i n ic a l end point is da rken i ng of the lentigi nes.

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M ENTIOUTCO M E
EXPECTAT I O N S

Q-switc hed laser a n d l ight source treatment for le ntig


i n es is freq uently successfu l . N o n a b lative fractio n a l
res u rfa c i n g is the least effective o f t h i s grou p .

1 47

1 48

Color Atlas of Cosmetic Dermatology

Patients should be cou nseled rega rd i n g the possi b i l ity


of posti nfla m matory pigmentation c h a nges after treat
ment, espec i a l l y on the lowe r legs.

Recu rrence after treatment is not u ncom mon .


B i o psy a ny lesion that demonstrates a n y c l i n ica l atypia
prior to treating with laser o r c ryothera py. Laser thera py
of a m a l ignant lesion s u ch as a lentigo m a l igna o r
m e l a n o m a may mask its c l i n i c a l a p pea ra nce a n d thus
cause a delay i n d iagnosis.
Avoi d using Q-switc hed lasers i n patie nts with a n y

p r i o r h i story o f g o l d i nta ke . C h rys iasis, p resenting as


b l ue-gray c i rc u l a r m a c u les on the skin, can occ u r after
Q-switched laser treatment of so l a r l e ntigi nes i n th ese
patie nts ( Fig. 24. 2 ) .

B I B L I OG RAPHY
Bjerring P, C h ristia nsen K. I ntense p u lsed l i ght sou rce for
treatment of s m a l l mela nocytic nevi a n d sol a r lentigines.

J Cutan Laser Ther. 2000; 2 : 1 7 7 - 1 8 1 .


G a l eckas KJ , R oss EV, U e b e l h oer N S . A p u lsed dye laser
with a 1 0- m m bea m d i a m eter and a pigmented lesion
wi n d ow for p u r p u ra-free photorej uvenat i o n .

Dermatol

Surg. 2008;34(3 ) :308-3 1 3 .


Geist D E , P h i l l i ps TJ . Development o f c h rysiasis afte r Q
switc hed ru by laser treatment of sol a r lentigines. Am
Acad Dermatol. 2006; 5 5 ( S u p p l 2 l : S 59-S60.
K i l mer SL. Laser e rad ication of pigme nted lesions a n d
tattoos . Dermatol Clin. 2002 ; 20( 1 ) :37-53.
K i l m e r SL, Whee l a n d RG, Gold berg DJ , Anderson R R .
Treatment of e p i derma l pigmented lesions with the fre
q uency-dou bled Q-switched N d : YAG laser. A control led ,
si ngle- i m pact,

d ose-res ponse,

m u lticenter tria l . Arch

Dermatol. 1 994; 1 30( 1 2 ) : 1 5 1 5- 1 5 1 9 .


L i YT, Ya ng KC . Compa rison o f t h e freq uency-dou b l ed Q
switc hed N d : YAG laser a n d 35% trichloroacetic acid for
the

treatment

of

face

lentigines.

Dermatol

Surg.

1 999 ; 25(3) : 202-204 .


Sadighha A, Saatee S, M u haghegh -Za hed G . Efficacy
and adverse effects of Q-switc hed r u by laser on sol a r
lentigi nes: A p rospective study o f 9 1
F itzpatrick skin type I I ,

I l l , and

I V.

patients with

Dermatol Surg.

2008;34( 1 1 ) : 1 465- 1468.


Ste rn RS, Dove r JS, Lev i n JA, Arndt KA. Laser therapy
vers us c ryothera py of lentigines: A com pa rative tri a l . J
AmAcad Dermatol. 1 994;30(6 ) : 985-987.
Taylor CR, Anderson RR. Treatment of ben ign pigme nted
epidermal

lesions

by Q-switc hed

ru by

laser.

tnt J

Dermatol. 1 993;32 ( 1 2) : 908-9 1 2 .


Todd M M , R a l l is T M , G e rwels J W, Hata T R . A com parison
of 3 lasers and l i q u id n itrogen in the treatment of solar
lentigi nes: A ra nd o m ized , control led , c o m pa rative tria l .
Arch Dermatol. 2000; 136( 7 ) : 84 1 -846.

Secti o n 5: D i so rd e rs of Pigmenta t i o n

CHAPT E R 2 5

M e lasma

M e l a s m a i s a n a cq u i red b rown m a c u l a r hyperpigm e n


tati o n u s u a l ly o f t h e fa c e . It is fa r m o re c o m m o n i n
fe m a l es t h a n i n m a les. I t u s u a l ly p resents b i latera l ly
a n d sym m etrica l l y on the fa c e , but exte nsor forea rms
may a lso be i nvolved . T h e re a re b e l i eved to be th ree
h i stologic va ria nts of m e l a s m a : e p i d er m a l , d e r m a l , a n d
m ixed d e r m a l a n d

epidermal .

Epiderma l

melasma

res ponds best to th e ra py. A l l fo rms have a h igh rate o f


rec u rre n c e , m a k i n g t h i s a frustrat i n g c o n d ition to treat.
S u n expos u re , pregn a n cy, a n d o ra l contraceptive pi l ls
a re a l l associ ated with its presentati o n a n d rec u rrence
( Fig. 25. 1 ) .

EPI D E M I O LOGY
Incidence: common
Age: you ng fem a l es
Race: Centra l a n d South America n , M i d d le Easter n ,
I nd i a n , East As i a n fe males a re most freq uently affected

Sex: fe ma les > m a les ( 9 : 1 )


Precipitating factors: pregna ncy, ora l contraceptive p i l ls ,
s u n expos u re, hormone rep lacement thera py

PATHOG E N ES I S
U n k nown .

D E R M ATOPAT H O LOGY
In epidermal melasma, there is i n c reased mela n i n d e po
sition in the epiderm is, pa rti c u l a rly in the basa l a n d
su pra basa l layers . I n d e r m a l melasma, there a re perivas
c u l a r m e l a n i n-conta i n i ng macrophages i n the su perfi c i a l
a n d m iddermis. M ixed-type m e l a s m a exh i b its featu res of
each of the a bove fi nd i ngs.

PHYS I CAL L ES I ON S
Patients p rese nt with wel l -d e m a rcated l ight b rown to
d a r k b rown sym m etric m a c u l a r hyperpigmentati o n . I n
a p p roxi mately two-th i rd s of pat i e n ts i t a p pea rs o n
the centra l fa ce i n c l u d i n g t h e fo rehead , n o s e , u p per
c uta neous l i p, and c h i n . I t presents less freq u e n t l y o n
the m a l a r a reas a n d jawl i n e . M o re ra rely, it a p pea rs o n
t h e d o rsa l forea r m s . Derm a l m e l a s m a h a s m ore of a
b l u e-gray h u e . M i xed-type m e l a s m a has a brown-gray
c o l o rat i o n .

Figure 25. 1 Female with extensive melasma recalcitrant to m ultiple

topical regimens for several years

1 49

1 50

Color Atlas of Cosmetic Dermatology

D I F F E R E N T I A L D I AG N OS I S
Postinfl a m matory hyperpigmentation, exogenous och rono
sis, d rug- i n d u ced/photo-hyperpigmentati o n , nevus of Ota ,
erythema dysc h ro m i c u m persta ns.

LABORATORY EXAM I NAT I O N


Wood 's la m p exa m i nation accentuates the i n c reased ep i
d e r m a l pigmentation i n me l a s m a but d oes not h ig h l ight
its dermal com ponent.

COU RS E
T h e p i g m e ntat i o n p rese nts over a period of weeks. I t
occ u rs m ost co m m o n ly i n s u m m e rti m e , with

h igh

estroge n states , d u ri ng preg n a n cy, and p r i o r to men


struat i o n . I t may fa d e c o m p letely months after d e l ivery
or afte r d i sconti n u ation of o ra l co ntrace ptive p i l l s . It
may rea p pea r in s u bseq u e n t preg n a n c ies a nd/o r s u n
expos u re .

KEY CON S U LTAT I V E QU EST I O N S

Med ication h i story

P regna n cy

S u n exposu re

Ti m e of onset

P revious treatments

MANAG E M E N T
There

is

no

med ica l

i n d ication t o treat

melasma .

N evertheless, many patie nts u n dersta nd a bly a re d is


tressed by its a ppea ra nce a n d desire treatment. The goa l
of the treatment is to l ighte n or rem ove the pigmentati o n .
Treating melasma can b e q u ite frustrati ng. P r i o r t o i n itiat
ing thera py, it is esse nti a l for the physicia n to expla i n
melasma a n d its treatment i n d eta i l t o the patient. W h i l e
there a re many treatments for m e l a s m a , it s h o u l d b e
stressed t h a t many a re often only p a rti a l ly effective.
Recu rrences a re very c o mmo n .
I t is a lso i m porta nt t o d eterm i n e which fo rm of
melasma is being treated, that is, epidermal versus
m ixed -type versus d e r m a l melasma ( Fig. 2 5 . 2 ) . There
a re

m u lt i p l e

topica l

and

laser

thera pies

ava i l a b l e

( Fig. 2 5 . 3 ) . Treatment is frustrating a n d ofte n i n effective .


There is a h igh rate of rec u rrence. Derm a l a n d m ixed
type melasma a re least responsive to thera py. I n a l l
melasma patients, strict s u n avo i d a n ce is cr u cia l with a
s u n sc reen with UVNUVB protection a n d/or a physical
block suc h as tita n i u m d ioxide o r z i n c oxide d u ri n g and
after any treatment regi m e n .

Figure 25.2 (A) A female patient with therapy-resistant melasma.

(Courtesy of Howard Conn)

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

151

TOP I CAL TREAT M ENT (Table 2 5 . 1)


There a re a h ost of to pica l treatme nts for melasma .

N u merous for m u lations conta i n i ng blea c h i n g agents


s u c h as 4% hyd roq u i none a re effective treatments to
l ighten or resolve pigme ntation. They a re most effective
if used ove r a period of weeks to a few months. If the
skin becomes sign ificantly i rritated from treatm e nt, d is
conti n u e its use to avoid posti nfla m mato ry hyperpig
mentation . Prolonged usage of hyd roq u i none can res u lt
in a c h a racteristic s k i n d i scoloration k nown as pse udo
ochronosis.

Reti noids s u c h as topical 0 . 1 % treti n o i n a ppl ied once


d a i ly fo r 40 weeks has been shown to be effective, but
less effective tha n hyd roq u i none.

Com b i nation thera py of 0.05% treti noi n , 4% hyd ro


q u i none, a n d 0.0 1 % fluocinolone acetonide, that is,
Tri l u ma , prod uces favorable c l i n ica l resu lts for melasma
and postinflam matory hyperpigmentation with decreased
irritatio n . Treatment d u ration is l i m ited by side effects
of prolonged topical steroid use i nc l u d i ng skin atrophy
and acne.

Aze l a i c acid has also been shown to prod uce i m p rove


ment.

CH EM I CAL P E E LS
Chem ica l peels a re often effective for melasma .

I n one study, there was no d ifference i n resu lts when


comparing J ess ner's solution versus 70% glycol i c a c i d
peels after perfo r m i n g th ree peels 1 m o n t h a pa rt on

each side of the face.

G lyco l i c a c i d peels performed every 3 weeks i n co m b i

Figure 25.2 (B) ( Continued) Marked resolution in the melasma after four

nation with

treatment sessions with Fraxel laser. (Courtesy of Howard Conn)

TAB L E 2 5 . 1

d a i ly s u n sc reen

and

c o m b i nation

Treatment o f Pigmented Lesions o n the Face

Melasma

Ret i n o i d/hyd roq u i none

G lyco l i c a c i d peels

Q-switc hed laser

A blative res u rfa c i ng

Fractional resu rfa c i ng

Va r i a b l e i m provement

M u ltiple l ight pee ls in

No

Yes; but ca refu l

Yes in s k i n

conj u n ction with

patient selection

types 1-1 1 1 ;

su nscreen a n d

a n d l o n g postlaser

caution s k i n

topica l ret i n oid/

recovery

type IV

hyd roq u i none


Posti nfl a m matory
hyperpigmentation

Yes ; weeks to months

Va ria b l e i m prove ment

No

No

No

M i n i m a l/moderate

Yes; one to two

Yes;

M i l d/moderate

to see c l i n ica l
i m provement

Lentigo

M i n i m a l/mod erate
i m provement afte r

c h a nge with th ree

treatments a re

post-i nfla m matory

months of use

to fo u r peels

h igh ly s uccessfu l

erythema c h ief
o bstacle

N evus of Ota

None

Non e

Yes; m u lti ple


treatments res u lt
in i m provement

No

No

1 52

Color Atlas of Cosmetic Dermatology

glyco l i c a c id/hyd roq u i no n e c rea m has been shown to


be effective .

Seria l su perfic i a l c h e m i c a l peels s u ch as sa l icyl ic a c i d


a n d glyco l i c acid pee ls a re the safest peels i n d a rker
skin phototypes.
Caution is req u i red for d a rker skin phototypes to avo i d

hyperpigmentati o n .

LAS ERS
Q-Sw i t c h e d Lasers
a-switched laser treatment for melasma is not recom
mended given its h igh i ncid ence of posti nflam matory
hyperpigmentation . Add itiona l ly, it is not d ra matica l ly effec
tive except in some cases of su perficial melasm a .

A
A b l at i ve Laser
I n cases refractory t o topica l crea ms and chem ica l peels,
erbium :YAG laser prod uced sign ificant, tem porary i m prove
ment in 10 patients in one study but was com p l i cated by
su bseq uent posti nfla m mato ry hyperpigme ntation in a l l
1 0 patie nts.

N o n -A b l a t i ve Fract i o n a l R e s u rfac i n g
N o n -A blative Fracti o n a l res u rfacing can be su ccessful for
some cases of melasma , espec i a l ly epidermal types
( Fig. 2 5 . 2 ) .

Long-term data a re lacking.

Treatment is ge nera l ly performed at su perfic i a l d e pth

Treatment is genera l ly performed at h igher densities.

relative to treatments for rhytid es and acne sca rs .

I t is m ost successfu l i n patients with l ighter skin p h o


totypes, suc h as s k i n types I a n d I I . I m provement is less
p red i cta b l e in sk i n type I l l , but is often a c h i eved .
S k i n ph ototypes IV a n d V often do not respond favor
a b ly to fra ctional resu rfa c i ng. Postinflam mato ry hyper
pigme ntation is a high risk.

P re- a n d posttreatment use of hyd roq u i none a n d l onger


i nterva ls between treatments may red uce postinflam
matory hyperpigme ntation i n d a rker s k i n phototypes.

P I T FALLS TO AVO I D/
COM P L I CAT I O N S/MANAG E M ENTI
O U TCO M E EXPECTAT I O N S

A l l forms o f melasma a re d iffic u lt a n d frustrating to


treat. Recu rrence is co m m o n .

Derm a l melasma is pa rticula rly d iffic u lt.

Patie nts should be a p prised of the reca lc itra nt nature of


t h i s condition in some cases .

Figure 25.3 (A) Young female with melasma. (B) Characteristic darkening
of melasma 1 -day post intense pulsed light treatment

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

Postpa rtu m state a n d d isconti n ua n ce of oral contra

Phys i c a l Exam

ce ptive p i l ls a re freq uently s uccessfu l thera pies .

Some treatme nts worse n its a p pea ra n c e .

Strict s u n avo i d a n ce is c r u cia l w i t h a su nscreen with

S u n exposed a rea-face more often t h a n arms

D i st r i b ut i on-cheeks, l ower face , med i a l face,

in any com b i nation


Wood 's Light to determ i n e e p i dermal vs.

d e r m a l d i stri b u t i o n of pigment

UVNUVB protection a nd/o r a physical block such as


tita n i u m d ioxide o r z i n c oxi d e d u ri n g a n d after a ny
treatment regi men .

C l i n ical

D ifferential Diagnosis

approach to
diagnosing

Post- i nf l a m matory hyperpigme ntat i o n

melasma

M e d i cation i n d uced hyperpigme ntat ion

B I B L I OG RAPHY
Risk Factors

F i n ke l U , D itre C M , H a m i lton TA, E l l is C N , Voorhees J J .


To pica l treti n o i n ( reti noic a c i d ) i m proves melasm a . A
veh i c l e-contro l l ed , c l i n i c a l tria l . Br J Dermatol. 1 993 ; 129:
4 1 5-42 1 .
G r i mes P E . M a nagement of hyperpigme ntation i n d a rker

Pregnancy

Oral contracepti ves

I ncreased p igme ntat i o n w i t h s u n expos ure

Figure 25.4 Clinical approach to diagnosing melasma

rac i a l eth n i c grou ps. Semin Cutan Med Surg. 2009 ;


28( 2 ) : 77-85.
Lawre nce N, Cox S E , B rody HJ . Treatment of melasma
with J essner's sol ution versus glycol i c acid : A com pa rison
of c l i n ic a l efficacy and eva l uation of the pred ictive a bi l ity
of Wood 's l ight exa m i nati o n . J Am Acad Dermatol.
1997;36: 589-593 .
Lee H S , Won C H , Lee D H , et a l . Treatment of melasma i n
As i a n s k i n using a fractional 1 , 550 n m laser: An open
c l i n ical study. Dermatol Surg. 2009;35( 1 0 ) : 1499 - 1 504 .
M a n a loto R M , Alser T M . Erb i u m :YAG laser resu rfa c i n g

MELASMA

f o r refractory melas m a . Dermatol Surg. 1999 ; 25 : 1 2 1 -

Vig i l a nt sunscreen is cruc ial

123.

S P F30 before , d u r i ng a n d after any therapy

R o k h s a r C K , Fitzpatrick R E. The treatment o f melasma

I m provem e n t i s var i a b l e a n d rec u rrence i s common

with fractional p h otothermo lysis: A p i lot study. Dermatol

Surg. 2005;3 1 ( 1 2 ) : 1 645- 1 650.


To ro k

HM,

J ones T,

Rich

P, S m ith

S,

Tschen

E.

Top i c a l

Mechanical

Lasers

H yd roq u i n o n e

Ret i n o i d s

to n i de 0 . 0 1 % : A safe a n d efficacious 1 2-month treat

S u perf i c i a l pee l s

A b l at i ve resorfa c i n g

ment for melasma . Cutis. 2005 ; 7 5( 1 } ; 57-62 .

Koj i c a c i d

Q-switched

Aze l a i c a c i d

lasers

Licorice extracts

Hyd roq u i none 4 % , treti n o i n 0 . 0 5 % , fl uocinolone ace

Vera l lo- Rowe l l V M , Ve ra lo V, G ra u pe K, Lo pez-V i l lafuerte


L, G a rcia Lopez M . Double- b l i n d com parison of azeleic
acid and hyd roq u i none i n the treatment of melasma .

M i crodermabras i o n

Fract i o n a l

photothermolysis

Acta Derm Venereal. 1 989 ; 143: 58-6 1 .

A com b i n at i o n of a topical s u c h as

Victor FC, G e l ber J , Rao B . Melasma : A revi ew. J Cutan

m i crodermabrasion for 6 months is a n

Med Surg. 2004; 8(2) :97- 1 02 .

effect ive a n d safe com b i n at i o n t h erapy

hyd roq u i n o n e , w i t h month ly pee l s a n d/or

Laser/l ight sou rces s h o u l d be u sed o n l y after c o m b i nation of topicals

a n d pee l s m i crodermabrasion fa i l

R i sk of post- i n f l a m matory hyperpigme ntat i o n from a n y l aser

( m ay persist for months)

Fract i o n a l photothermolysis has fewer s i d e effects a n d l ess down

time t h a n a b l at i ve lasers

A b l at i ve resorfa c i n g o n l y for t h e m ost refractory cases in patie nts

who can tolerate months of post i nf l a m m atory c h a n ges

Q-switched l asers a re ofte n not effect ive a n d often worsen m e l asma

Figure 25.5 Melasma treatment protocol

1 53

1 54

Color Atlas of Cosmetic Dermatology

CHAPT E R 2 6

Nevus of Ota

N evus of Ota , a lso known as nevus fuscoceru leus oph


tha l momaxi l l a ris, represents a ben ign pa rtia l ly confl uent
mac u l a r

b rown- b l u e

pigme ntation

of the ski n

and

m ucous mem bra nes i n t h e d istri bution o f the fi rst a n d


second b ra n c hes o f t h e trige m i n a l nerve. It may b e u n i
late ra l o r bi latera l . The i psi latera l scl era is freq ue ntly
i nvolved .

E P I D E M I O LOGY
Incidence: 0.4% to 0.8% of J a pa nese dermatology patients
Age: b i modal d istri bution at birth a n d p u berty
Race: m ore common in Asia ns a n d b l a c ks than wh ites
Sex: m ore fema les t h a n ma les seek treatment for this
cond ition ; u n known if there is a sex p red i lection

Precipitating factors: spora d i c , not a n i n h e rited d isord er

PATHOG E N E S I S
Hyperpigme ntation

a rises

as

res u l t

of

dermal

melan ocytes t h a t have n o t m igrated to the epid erm i s .

PATHOLOGY
H eavily pigme nted , e l ongated , d e n d ritic melan ocytes a re
located a mong the reti c u l a r dermal collage n . Most typi
c a l l y, these mela nocytes a re fo u n d i n the u p per one-t h i rd
of the reticu l a r dermis but a re a lso seen in the pa p i l l a ry
d e r m i s i n s o m e lesions.

PHYS I CAL LES I O N S


I t presents a s confl uent o r pa rtia l ly co nfl uent b rown- b l u e
patches i n the d istri bution o f the fi rst a n d second
b ra n c h es of the trige m i n a l n e rve . G ray, black, and p u r p l e
coloration may be p resent i n s o m e lesions as wel l . I t can
be u n i latera l o r bi latera l . The magnitude of i nvolvement
can va ry fro m loca l perioc u l a r i nvolvement to much of the
side of the face. A p p roxi mately two-th i rd s of patie nts fea
t u re i psi latera l sclera l i nvolvement.

D I FFERENTIAL D I AG N OS I S
Melasma, cafe a u I ai t m a c u l e , H o ri's macule b l u e nevus,
bru ising, och ronosis, a rgyria ,

p h otod ermatoses, fixed

d rug eru ption, a n d other m ed ication-related eru ptions


should be considered i n the proper c l i n ical setting.

B
Figure 26. 1 (A) Nevus of Ota prior to treatment with Q-switched ruby
laser. (8) Significant clearance after serial treatments with Q-switched
ruby laser

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

1 55

LABO RATORY EXA M I NAT I O N


B i o psy m a y b e i n d icated i f t h e d iagnosis i s i n q u estio n o r
t o exc l u d e the ra re case o f melanoma a rising i n this
lesion .

CO U RS E
There i s a b i modal d istri bution fo r n evus o f Ota , b i rth a n d
p u be rty. It rema i n s relatively s i m i l a r i n a p pearance after
i n itia l presentatio n .

KEY CO N S U LTAT I V E QU EST I O N S

O nset o f eru ption

Med ication h i story

MANAG E M ENT
There is no medical i n d ication t o treat nevus o f Ota .
Cosmetic a p pea ra n ce, however, is d istressi n g to patients.
W h i l e c ryothera py and topica l b l ea c h i n g treatments have
been util ized , the treatment of c h oice is Q-switc hed laser
treatment.

TOP I CAL T R EATM ENT


M a k e u p can camouflage o r assist i n ca mo uflag i n g nevus
of Ota . To pica l med ications a re less effective than laser.

Figure 26.2 Nevus of Ota. Periorbital blue-gray pigmentation with scleral

involvement (Kay K, Jen R, Richard J, et at eds. Color Atlas & Synopsis of


Pediatric Dermatology. McGraw-Hill, Inc. ; 2002)

T R EAT M E N T

N u merous stu d ies have s hown that nevus o f Ota i s


a m e n a b l e t o su ccessfu l reso l ution with Q-switc hed
laser

thera pies

i n c l u d i ng

the

Q-switched

ru by

( 694 n m ) , the a l exa n d rite (755 n m ) , a n d the N d :YAG


( 1 , 064 n m ) lasers ( Figs . 2 6 . 2 a n d 26 . 3 ) .

Test s pot ca n be performed prior t o treatment.


The Q-switc hed r u by laser has been shown to be effec

NEVUS OF OTA

tive at prod u c i n g 7 5 % or greater c l ea ra nce at fl uences


of 5 to 7 J/c m 2 , 4-m m s pot size, a n d a 30-ns pu lse
width at 3-to-4- month treatment i nterva ls.
- I n a study of 46 c h i l d ren a n d 107 a d u lts with nevus
of Ota , treatments were more s uccessfu l i n c h i l d ren

Topica l

Mechanical

Lasers

Camouflage
may be h e l pfu l
for some patients

M i croderma b rasi o n
s h o u l d not b e performed
H igh risk of dysc h rom i a
a n d/or scarr i ng

Q-switched l asers
are the t reat ment of
choice
A b l a t i ve-no

t h a n i n a d u lts.

- The mean n u m be r of treatment sess ions to a c h ieve


sign ifica nt cleari ng or better was 3 . 5 for the younger

age gro u p and 5.9 fo r the older age gro u p .


- Ad d itional ly, com p l i cations we re lowe r i n t h e c h i l d ren
t h a n ad u lts, that is, 4.8% as com pa red to 22.4% .
- One

retros pective study exa m i ned

101

M u l t i p l e t reatments with Q-switched l asers are needed


I m p rovement moderate to dramatic after m u lt i p l e treatments
Q-switched l aser treatment of lesions that arise in i nfancy may
respond better to l aser t h erapy than l ater in l ife
If a Q-switched VAG l aser is u sed a com b i n a t i o n of 532 n m/ 1 064 n m
m a y res u l t i n better c l i n i cal i m provement t h a n 1 064 n m a l o n e

pati ents

1 yea r after treatment with Q-switc hed r u by laser a n d

Figure 26.3 Treatment of nevus of Ota algorithm

1 56

Color Atlas of Cosmetic Dermatology

fo u n d that 1 6 .8% d is played hypopigme ntation a n d


5 . 9 % showed hyperpigmentatio n . One patient w h o
had com plete resol ution d eve loped rec u rrence.

The Q-switched a lexa nd rite laser is a lso effective for the


treatment of nevus of Ota . Dermal white n i n g is the
key c l i n ica l end point when treati ng nevus of Ota with
Q-switc hed lasers .
- One gro u p reported the su ccessful treatm e nt o f
nevus

of

Ota

with

fractional

p h otothermo lysis.

N o n etheless, Q-switc hed laser is the treatment of


choice.

To p i c a l

Ca mouflage may be hel pf u l fo r some patients .

M ec h a n i c a l

M i c roderma b rasion s h o u l d not be performed .

H igh risk of dysc h ro m i a a n d/o r sca rring.

Lasers

Q-switched lasers a re the treatment of choice.

Ablative-no.

M u lt i p l e treatme nts with Q-switc hed lasers a re need e d .

I m provement moderate t o d ra matic after m u ltiple treat


ments.

Q-switched laser treatment of lesions that a rise i n


i nfa ncy may respond better t o laser thera py t h a n later
in l ife .

If a Q-switc hed YAG laser is use d , a c o m b i nation of


532 n m/ 1 , 064 nm may res u l t in better c l i n ical i m prove
ment tha n 1 , 064 nm a l o n e .
- One study treated 1 3 patients at fl uen ces ra ngi ng
between 6 a n d 8 J/c m 2 at 8-week i n terva ls. T h e
mea n

n u m ber o f treatments w a s a pproxi mately

seve n . Seve n patients ach ieved 75% or bette r l ight


e n i ng, th ree patie nts a c h ieved between 5 1 % a n d
7 5 % i m prove ment, one a c h ieved between 2 5 % a n d
5 0 % i m p rovement, a n d a noth e r a c h i eved less tha n
25% i m provement.
- Two patie nts experienced tra nsient hyperpigme nta
t i o n ; one ex perienced tra nsient hypopigme ntatio n .

T h e Q-switc hed N d : YAG ( 1 ,064 n m ) laser h a s a lso


prove n to be effective.
- Sl ightly less effective than other Q-switc hed lasers.
- I t is safer for use in dark skin types .
- Less risk of hypopigme ntatio n .

Secti o n 5: D i so rd e rs of Pigmenta t i o n

P I T FALLS TO AVO I D/O UTCO M E


EXPECTAT I O N S/CO M P L I CAT I O N S/
MANAG E M ENT

Laser treatment for nevus o f Ota is freq uently successfu l .

G iven t h e h igh proportio n o f patients with d a r k s k i n


phototypes, there is the r i s k o f hypo- a n d hyperpigmen
tatio n .

The r i s k o f suc h a n a dverse reaction s h o u l d be d is

Add itiona l ly, a test site can be treated before perform

Q-switc hed l a s e r treatment can be associated w i t h tra n

cussed with the patient prior to thera py.


i n g fu l l treatment of a n y les i o n .
sient hyperpigme ntation .

Recu rrence after treatment is i n freq uent.

B I B L I OG RAPHY
C h a n H H , Le u n g R S , Ying SY, e t a l . A retrospective a n a ly
sis of compl ications in the treatment of n evus of Ota with
the Q-switc hed a l exa n d rite and

Q-switched

N d : YAG

lasers . Dermato/ Surg. 2000;26( 1 1 ): 1 000- 1 006.


Chan H H , Ying SY, Ho WS, Kono T, King WW. An i n vivo
trial c o m pa ri ng the c l i n ic a l efficacy and c o m p l icati ons of
Q-switc hed 755 nm a lexa nd rite a n d Q-switched 1 064 n m
N d :YAG lasers i n t h e treatm e nt o f nevus o f Ota . Dermatol
Surg. 2000;26( 1 0 ) : 9 1 9-92 2 .
Ko no T , C h a n H H , Ercocen A R , e t a l . Use o f Q-switc hed
r u by laser in the treatment of nevus of Ota i n d i ffe rent age
gro u ps . Lasers Surg Med. 2003;32(5) :39 1 -395.
Ko no T, N oza ki M, Chan H H , M i ka s h i m a Y. A retrospec
tive study looking at the long-term com pl ications of
Q-switc hed r u by laser in the treatment of nevus of Ota .
Lasers Surg Med. 200 1 ;29(2) : 1 56 - 1 5 9 .
Ko u ba DJ , F i n c h e r EF, M oy R L. N e v u s o f Ota successfu l ly
treated by fractio n a l p h otothermo lysis u s i ng a fra ction
ated

1440- n m N d :YAG laser. Arch Dermatol. 2008;

144( 2 ) : 1 56- 1 58 .
R a d m a n esh M . Naevus o f Ota treatment w i t h c ryother
a py. J Dermatol Treat. 200 1 ; 1 2 (4) : 205-209 .

1 57

1 58

Color Atlas of Cosmetic Dermatology

CHAPT E R 2 7

Posti nfl a m mato ry hype rpig m e ntatio n

Posti nfla m matory hyperpigmentation ( P I H ) is a c o m m o n


seq uela o f i nfla m matory dermatoses or i nj u ry t o the ski n .
It

occ u rs

most

commonly

in

d a rker

skin

types .

Depend i n g on the etiology of the hyperpigmentation , p ig


ment may be de posited in the dermis o r epidermis with
i m porta nt i m p l ications for treati ng the pigment c h a nges .
It is a c o m m o n seq uela of laser treatment, pa rti c u l a rly i n
d a rker s k i n p hototypes ( Fig. 27 . 1 ) .

EPI D E M I O LOGY
Incidence: com m o n , espec i a l ly in d a rker skin types
Age: a l l ages
Race: m ore common in d a rker s k i n types

Figure 27. 1 PI H seen after a series of treatments with nonablative

Sex: none

fractional resurfacing for a scar. The PIH resolved on its own within
3 weeks

Precipitating factors: a ny i nfla m m atory d isorder o r i nj u ry


to the ski n can p rod uce hyperpigmentatio n . It may a lso
res u lt from laser thera py, derma b rasi o n , c ryothera py, or
c h e m i ca l peels. I t p rese nts more exu bera ntly a n d with a
greate r d u ration i n d a rker s k i n ph ototypes

PATHOG E N ES I S
U n known .

D E R M ATOPAT H O LOGY
Basa l cel l layer pigme ntatio n and dermal mela n o p hages
a re see n .

PHYS I CAL LES I O N S


I n epidermal P I H , patients d isplay i n d isti nct ta n t o d a rk
b rown m a c u l es at s ites of previous s k in i nfla m mation . I n
d e r m a l P I H , there i s m o re of a brown-gray h u e .

D I F F E R E N T I A L D I AG N OS I S
M astocytosis, m a c u l a r a myloidosis, m i noc i n hyperpig
mentatio n , exogenous oc h ronosis, melasma, and ery
thema dysc h ro m i c u m persta n s .

LABORATORY EXAM I NAT I O N


None.

_____

Figure 27.2 (A) Pseudo-ochronosis seen after years of hydroquinone

treatment.

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n

1 59

CO U RS E
P I H d oes not worse n i n the a bsence o f further i ns u lt o r
i nfla m mation a t the affected site . P I H usually resolves
ove r a period of a few months. In the case of dermal
hyperpigmentati o n , th ere may n ot be i m provement.

KEY CO N S U LTAT I V E QU EST I O N S

S u n expos u re, s u nscreen use

lime of onset

Recent rashes, i nj u ry, or treatment of s k i n

Med ication use

MANAG E M ENT
W h i l e there is no medical i n d ication to treat P I H , m a n y
patients a re as bothered by P I H as t h ey a re by t h e

Figure 27.2 (B) ( Continued) Significan t improvement after treatment with

a-switched laser

p rocesses that prod uced it i n itial ly. F u rthermore, P I H c a n


end u re fa r longer tha n the origi n a l e r u ptio n . There a re
m u ltiple treatments i n c l u d i ng to pica l , laser, a n d c h e m ical
peels ( Ta ble 2 7 . 1 ) . I t is essentia l to fi rst dete r m i n e the
cause of the hyperpigmentation . C u l prits ra nge from
hemosiderin to pigment to vasc u l a r. Without d eterm i n i ng
the etio l ogy correctly, treatment w i l l , at best, provide no
i m provement, o r worsen the P I H . Freq ue ntly, the safest
a n d most effective treatment is ti m e . Atte m pted treat
ment of P I H , espec ia l ly in da rker s k in ph ototypes, c a n
often worsen a n d prolong hyperpigmentatio n . N o r m a l ly,
e p i d e r m a l P I H w i l l resolve on its own ove r a period of
months.
Thera peutic o ptions i n c l u d e topical reti noids, bleach
i n g crea ms, chemical pee ls ( i nc l u d i ng glycol i c a c i d peels,

TAB L E 27. 1

Post- i nflammatory Hyperpigmentation treatment


Fractio n a l

Thera peutic

R eti n oid/

Peels/

o ptions

hyd roq u i none

m i c roderm a b rasion

Q-switc hed laser

Ablative lasers

resu rfa c i ng

Post-i nfla m m atory

N eeds to be used

20-70% glycol i c acid

No

No

No

hyperpigmentation

for weeks to

peels, jessner peels,

months for

c o m b i nation j essner

i m prove ment

TCNpee ls and Sa l ic i lyc


acid peels a n d/or
m ic roderma brasion
may h e l p i m prove
m ore q u ickly

Fa ce/u pper body

R i s k of pa rad oxic a l l y

i m proves more

m a k i ng posti nfla m matory

q u ickly t h a n lower

c h a nges worse if too

ha If of the body

m u c h i nf la m mation
is c reated

1 60

Color Atlas of Cosmetic Dermatology

J essner peels, c o m b i nation J essnerfTCA pee ls, a n d sa l i


cyl i c a c i d pee l s ), a n d fractional laser treatment. There is
a risk of paradoxica l ly m a k i n g post- i nfla m matory c h a nges

worse if too m uc h i nfla m mation is created .

S U N P ROTECT I O N
S u n b l oc ks a n d s u n sc reens used d a i ly a re c r u c i a l t o pre
vent worse n i ng, as is sun avoid a n c e . Without their use,
other thera pies w i l l n ot be effective . If a patient d oes n ot
avoid s u n expos u re , P I H wi l l worsen . S u n avo i d a n ce
i n c l udes avoid i ng pea k s u n h o u rs , wea r i n g a hat out
d oors to protect the face from s u n exposu re a n d a n
awa re ness t h a t UVA rays pen etrates through w i n d ows
w h i l e d riving, w h i l e at work a n d wh i l e at home.

TOP I CAL T R EATM ENTS


T here a re a h ost of topical treatments fo r P I H that pro
d uce m i l d i m provement and may exped ite reso l ution .

Hyd roq u i none form u lations, pa rticu larly with su nscreens


- Hyd roq u i none ( 2 %-4% ) c rea ms a re effective, fi rst
l i n e treatment.
- Prolonged usage of hyd roq u i none can res u lt i n a

c h a ra cteristic s k i n d iscol oration known as pse udo


och ronosis ( Fig. 2 7 . 2 ) .
- B lea c h i ng c rea ms a re contra i n d i cated i n pregnant
a n d lactat i n g wo m e n .

Reti noids
- Solage ( 2 % meq u i nol a n d 0 . 0 1 % treti n o i n ) and
Tri l u ma ( 0 .0 1 % fluoc i nolone aceto n i d e , 4% hyd ro
q u i none, a n d 0.05% treti n o i n ) provide an exfol iative
benefit.
- Tri l u m a s h o u l d n ot be used i n defi n itely d ue to its cor
ticosteroid content and risk for atrophy.

Aze l a i c ac i d ( 20% ) c rea m a p pl ied twice d a i ly provides


slow l ighte n i ng of pigmentati o n .

Koj ic a c i d ( 1 %-2 . 5 % ) c rea m .


- The exact conce ntratio n of koj i c a c i d needed for
effective res u lts is u n known .

If any of these to picals prod uces sign ifi ca nt i nfla m ma


tion or i rritati o n , it is i m porta nt t o d isconti n u e its use to
avoid worse n i ng of P I H .

C H EM I CAL P E E LS
Chem ica l peels a re an effective treatment option for the
red uction of P I H .

Over-the-cou nter a-hyd roxy a c i d peels a re a benefi c i a l


adj u nct to phys i c i a n -strength c h e m i c a l

pee ls. The

conti n u a l exfoliation ach ieved from cons iste nt use of


the peels may res u l t i n m i l d l ighte n i ng.

Figure 27.3 (A) Hyperpigmentation on left side of face before treatment.


(8) Improvement after a series of salicylic acid peels and topical applica

tion of 4 % hydroquinone (Courtesy of Pearl E. Grimes, MDJ

Secti o n 5: D i so rd e rs of Pigmenta t i o n

1 61

G lyco l i c a c i d pee ls (20%-70% ) a re a d m i n istered every


2 to 3 weeks utilizing i n c reasing strengths as tole rated .
- The treatment end poi nt is m i ld confl uent e rythe m a .
- Treated a reas m ust b e f u l l y ne utra l ized with sod i u m
b i ca rbonate or wate r a t t h e com pletion o f t h e pee l .
- Lighte n i ng o f su perfi c i a l P I H m a y b e o bserved after
fo u r to six peels.
- Strict photoprotection for 1 m o nth is essential and
m u st be stressed .

J essner peels ( resorc i n o l , lactic acid , a n d sa l icyl ic a c i d )


a re a d m i n i stered every 6 t o 8 weeks.
- Treatment end point is a l ight white n i ng of the ski n .
- Strict photo protection for 2 t o 3 months i s advised .
- M u ltiple treatments a re reco m m e nded .
- Contra i n d icated i n p regnant a n d lactating women .

Com bi nation J essner/10% tri c h loroacetic (TCA) peels

may a lso be em ployed in a s i m i l a r fas h i o n as the


J essne r pee l . The J ess ner peel res u l ts i n exfo l iation
a l lowi ng for greater penetration of the TCA pee l .
- M u ltiple peels a re ge nera l ly needed .
- Contra i nd icated in p regnant a n d lactating wom e n .
- Deeper pee ls a re ra re ly e m ployed given t h e r i s k of
P I H exacerbation with h ea l i ng.

Caution m u st be used i n treating s k i n phototypes I l l to


VI, pa rti c u l a rly with med i u m-depth pee l s . Sa l i cyl ic a c i d
peels a re safest for d a r k s k i n phototypes ( Fig. 2 7 . 3 ) .

LAS ERS
Trad itiona l ly, laser treatment for P I H d oes n ot p rod uce
re l i a b l e i m provement and is n ot fi rst- l i n e thera py. In fa ct,
laser thera py may exacerbate P I H . In genera l , it is n ot
reco m m e n d ed .
F racti o n a l phototh ermolysis ( F P ) ca n , however, provide
i m prove ment of P I H ( Fig. 27 .4) . T h i s is espec i a l l y true for
patients with l ighter s k i n p h ototypes. I n d a rker s k i n types,
P I H often worsen s . I t s h o u l d not be recom m e nd ed as a
fi rst- l i n e thera py. Rather, blea c h i ng c reams a n d c h e m i c a l
p e e l s provide more consistent, reprod u c i ble resu lts.
Typical ly, F P treatments s h o u l d be d i rected toward
s u perfic i a l s k i n d e pth a n d avoid higher treatment densi
ties.

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M E NTIOUTCO M E
EXPECTAT I O N S

I t is i m porta nt t o reassu re patie nts that P I H w i l l resolve


on its own with t i m e , except if it is a dermal process .

Laser treatment is u n re l i a b l e a n d may prod uce worsen


i n g . It is u s u a l l y not reco m m e n d ed .

Figure 27.4 (A) Hyperpigmentation after a series of Q-switched laser tat

too treatments. (B) Improvement of PIH after two nonablative fractional


resurfacing treatments utilizing superficial depth and lower treatment
densities

1 62

Color Atlas of Cosmetic Dermatology

It is i m porta nt to d isconti n u e a n y to pical m ed i cations


that prod uce i nfla m mation or i rritation to avoid wo rsen
i ng P I H .

C h e m i c a l peels a re l i kely to only l i ghten a n d not f u l l y


e l i m i nate the P I H . C a u t i o n s h o u l d be ta ken i n d a r ker
s k i n phototypes.

I t is bette r and safe r to uti l ize seri a l s u perfi c i a l peels


rather tha n a si ngle deeper peel to m i n i m ize the risk of
PI H .

P I H may not i m prove d espite seria l c h e m i c a l peel use.


P I H res u lt i n g from hemosiderin (ie, leg vei n treatme nts)
w i l l not res pond to lasers, pee ls, a nd bleac h i ng c rea ms.
In fact, treatment w i l l l i kely worsen the P I H .

B I B L I OG RAPHY
K i l mer S L . Laser erad ication o f pigme nted lesions a n d
tattoos . Dermatol. Clin. 2002;20( 1 ) :37-53.
M is h i m a Y, Ohyama Y, S h i bata T, et a l . I n h i b itory action of
koj ic acid on m e l a n ogenesis and its therapeutic effect for
va rious h u m a n hyperpigme ntation d isorders. Skin Res.
1 994;36( 2 ) : 1 34- 1 50 .
N a kagawa M , Kawa i K . Conta ct a l le rgy t o koj i c a c i d i n
s k i n c a re prod ucts . Contact Dermatitis. 1995;3 1 ( 1 ) :9- 1 3 .
Ngujen Q H , B u i T P. Azel a ic a c i d : Pha rmacoki netic a n d
pha rmacodyn a m i c properties a n d its therapeutic role i n
hyperpigmenta ry d isorders a n d a c n e . lnt J Dermatol.
1995;34( 2 ) : 75-84 .

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

CHAPT E R 28

Vitiligo

Viti l igo is an acq u i red i d i o path ic cond ition that prod u ces
sym metric d e pigm ented patc hes of the ski n . It is pa rtic u
larly d istress i n g a n d c l i n i ca l ly a p pa rent i n patients with
d a rker skin p h ototypes.

EPI D E M I O LOGY
Incidence: a p p roxi mately 2% of the world popu lation
Age: can present at a ny age but most commonly presents
in the second to fou rt h decade

Race: eq u a l
Sex: eq ual
Precipitating factors: i n h erita nce, tra u m a , i l l ness, emo
tional states

PATHOG EN ES I S
U n k nown .

D E R M ATOPATHOLOGY
There a re no melanocytes i n basa l cel l layer.

PHYS I CAL LES I ON S


Patients

d isplay

wel l-demarcated ,

sym metric,

depig

mented , chal k-wh ite macules. Common locations include


el bows, knees, sacra l a rea , pen is, periora l a reas, a n d neck.
H a i r may also lose pigmentation ( Figs . 28. 1 and 28.2 ) .

D I F F E R E N T I AL D I AG N OS I S
Chem ical leukoderma, postinfl a m matory hypopigme nta
tion, nevus depigmentosus, nevus a nemicus, pityriasis
a l ba , l u pus erythe matos us, leprosy, and genodermatoses.

LABO RATORY EXA M I NAT I O N


Wood 's l a m p exa m i nation i s h e l pfu l i n m a k i n g the d iag
nosis. In cases of u ncerta i nty, b i o psy s h o u l d be per
fo rmed of both lesiona l a n d n o n lesional s k i n in order to
d eter m i n e if there is an a bsence of melan ocytes in the
affected s ki n . Check thyro i d-st i m u lating hormone (TS H )
fo r hypothyro i d i s m .

CO U RS E
Viti l igo c a n p u rsue a va ria ble cou rse . After a n i n itial ra pid
p resentati o n , it te nds to sta bi l ize. Typical ly, it is a c h ro n i c

Figure 28. 1 Vitiligo on the trunk and neck of a young patient

1 63

1 64

Color Atlas of Cosmetic Dermatology

d isease with periods of pa rt i a l re pigmentation but not res


ol ution . It may i m p rove in the s u m merti m e . I n some
cases, depigmentation beco mes extensive.

KEY CO N S U LTAT I V E QU EST I O N S

Age o f patient

Time of onset

Fa m i ly h i story

Occu pation

Chemical exposu res

MANAG E M ENT
There a re m u ltiple treatment modal ities for viti ligo.
U n fo rtu nately, treatment is frustrating a n d often i n effec
tive .

Patie nts u nd e rsta n d a bly a re d istressed

by the

a p pearance of viti l igo and desi re treatment. In exte ns ive


cases, it p rod u ces a stri ki ng a ppea ra nce, pa rti c u l a rly for
patients with darker s k i n ph ototypes .

P R EV E N T I O N
S u nscreens a n d s u n avoida nce protect viti l iginous s k in
from b u rn i ng a n d a re a n i m porta nt com ponent of ther
a py. F u rther, ta n n i ng u naffected s k i n wi l l accentuate the
contrast between normal a n d viti l iginous ski n , worse n i ng
the cosmetic a ppea ra nce of the d i sease .

TOP I CAL T R EAT M E N T


There a re a host o f topical treatments for viti l i go . T h ey
include

Corticosteroids
- To pica l
- l ntra lesi o n a l

Ca l c i n e u r i n i n h i bitors: tac ro l i m us, pi mecrol i m us


Monobenzylether of hyd roq u i none
- Prod u ces permanent d e pigmentation
- Twice d a i l y ove r 1-yea r period
- Permanent d e p igmentation is prod uced in less t h a n
50% o f patie nts
- Poor or no depigmentation in nearly h a lf of patients
- Caution prior to p u rs u i n g this permanent treatment
- Side effects i n c l u d e contact d ermatitis, e ryt h e m a ,
a n d pru ritus
- He ightened risk of s u n burn after this perma nent
treatment

Cam ouflaging m a ke u p and self-ta n n i ng agents to h i d e


depigmented m a c u l es

Figure 28.2 White forelock in the same patient

Secti o n 5 : D i so rd e rs of Pigmenta t i o n

1 65

PH OTOTH E RAPY
P h otothera py is a m a i nstay of viti l igo treatment.

Psora len and u ltravio l et A ( P UVA) with topical o r o ra l


5-methoxypsora len or 8-methoxypsora len

N a rrow- ba n d UVB

ORAL T H E RAPY
Oral thera pies i n c l u d e

Ora l 5- or 8-methoxypsora len i n c o m b i nation w i t h gra d


u a l , l i m ited s u n exposu re

P u lse thera py with corticosteroi d s

S U RG I CAL TREATM ENTS


Autologous s k i n grafti n g can be a h e l pf u l treatment for
viti l igo reca lc itra nt to other thera p ies. I t is not a fi rst- or
seco n d - l i n e treatment. S p l it-t h i c k n ess grafts, epidermal
bl iste r grafts, c u ltu red melanocyte grafts, si ngle hair
grafts, a nd noncu ltu red epidermal suspension grafts
have a l l been exa m i n ed . Pa i n after graft p roced u res is
com m o n , pa rti c u l a rly at the ha rvest site ( Fig. 28. 3 ) .

A majority o f patients e m p loying t h e epidermal suction


graft tec h n i q u e sh owed i m prove ment.

S p l it-thi c k ness grafting and derma brasion have a lso


a c h i eved re pigmentation with i n an ave rage of 6 months
i n one stu dy of 22 patients .

Si ngle h a i r grafts a re m ost effective i n loca l ized or seg


mental viti l igo . Success in genera l i zed viti l igo is poor.

Both c u ltured p u re melanocyte suspension as wel l as


c u ltured epidermal grafting after treatment with C0 2 laser
have been shown to be successful in treating viti l igo .
- Resu lts were best i n loca l ized cases of viti l igo.

LAS ER T H E RAPY
Exc i m e r Laser
An exci mer laser em its UVB ra nge l ight a t 308 n m , close to
the wavelength of na rrow-ba nd UVB thera py that has been
used to successfu lly treat viti l igo. Begi n n i ng with a starting

d ose of 1 00 mJ/cm 2 , with i n c reasing d oses i n sta ndard


photothera py increments , there was good i m provement i n
reca lc itra nt viti l igo after 30 weeks o f treatments.

Acra l lesions were m ost refractory to treatment.

Few adverse effects.

Best res u l ts a re p rod uced on the face > neck, extre m i


ties, tru n k , a n d gen ita l i a > hands, feet.

M ore

expensive

tha n

m a ny

trad itiona l

thera pies.

Co m bi nation treatment with tacro l i m u s 0 . 1 % is more


effective than treatment with exc i m e r laser a l o n e .

B
Figure 28.3 (A) Depigmented patch of skin on right mandible.
(B) Significan t improvement after m ultiple 1 -mm punch grafts (Courtesy

of Pearl E. Grimes, MD)

1 66

Color Atlas of Cosmetic Dermatology

P I T FALLS TO AVO I D/CO M PL I CAT I O N S/


MANAG E M E N T/O UTCO M E
EXPECTAT I O N S

Viti l igo is a d i ffi c u lt d isease to treat.

There a re m u ltiple fi rst- a n d secon d - l i n e therapies that


should be e m p loyed before seeking s u rgica l o r laser
treatments.

I t is es pec i a l ly d iffi c u lt to p rod uce long-term sign ifica nt


cosmetic i m provement i n extensive cases.

Freq ue ntly, re pigmentation may be confi ned to perifol


l i c u l a r a reas c reating a "spotty" a ppea ra n c e .

Patients n eed to be e d u cated t h a t a n y thera py m a y not


succeed .

The exc i m e r laser is not widely ava i la b l e , ma king its use


pa rtic u la rly d iffi c u lt.

B I B L I OG RAPHY
Chen Y F, Ya ng PY, H u D N , Kuo FS, H u ng CS, H u ng C M .
Treatment o f viti l igo by tra nspla ntation o f c u l t u red p u re
melanocyte suspensi o n : Ana lysis of 1 20 cases . J Am
Acad Dermato/. 2004; 5 1 ( 1 ) : 68-74.
H a d i S M , Spencer J M , Lebwo h l M . The use of the 308nm exc i m e r laser fo r the treatment of viti l igo . Dermatol
Surg. 2004;30 ( 7 ) :983-986 .
Koga M . Epidermal grafting u s i ng the tops of s uction b l is
te rs

in

the

treatment

of

viti l igo.

Arch

Dermatol.

1 988; 1 24( 1 1 ) : 1 656- 1 658.


Na GY, Seo SK, Choi SK. Single hair grafting for the treat
ment of viti l igo . JAmAcad Dermatol. 1 998;38(4): 580-584.
Ozd e m i r M, Ceti n ka l e 0, Wolf R, et a l . Com parison of two
s u rgica l a p proa c hes for treati ng viti l igo: A pre l i m i n a ry
study. lnt J Dermatol. 2002 ;4 1 ( 3 ) : 135-138.
Passeron T, Ostova ri

N,

Zakaria W, et al.

To pical

tacrol i m us a n d the 308 n m exc i m e r laser: A synergistic


c o m b i nation for the treatment of viti l igo. Arch Dermatol.
2004; 140(9 ) : 1 065- 1 069 .
Ta neja A, Tre h a n M , Taylor C R . 308- n m exc i m e r laser for
the

treatment of

loca l ized

viti l igo .

tnt J Dermatol.

2003 ;42(8) : 658-662 .


To riya ma K, Ka mei Y, Kazeto T, et a l . Combi nation of
s h o rt- p u l sed C02 laser resu rfa c i n g a n d c u l t u red epid er
mal sheet a utografting in the treatm e nt of vitil igo: A
prel i m i n a ry report. Ann Plast Surg. 2004 ; 53 ( 2 ) : 1 78- 1 80 .
va n G e e l N , Ongenae K, De M i l M , Haeghen YV, Vervaet
C, N aeyaert J M. Dou ble-b l i n d placebo-controlled stu dy of
a utologous tra nsplanted epidermal c e l l suspensions for
re pigmenting viti ligo. Arch Dermatol.
1 203- 1 208.

2004; 140( 1 0 ) :

S IX
Vasc u l a r A l te rat i o n s

1 68

Color Atlas of Cosmetic Dermatology

CHAPT E R 29

Angio ke rato m a

Angioke ratomas a re te la ngiectasias with keratotic ele


ments . They present i n d i ffe rent c l i n ical scena rios i n c l u d
i n g ( a ) solitary or m u lt i p l e a ngioke ratomas occ urring
p red o m i n a ntly on lower extre m ities; ( b) a ngiokeratoma of
Fordyce affecti n g the sc rotu m a n d the vu lva ; ( c ) a ngiok
e ratom a of M i be l l i , a n a utoso m a l d o m i n a nt d isorder
affecti n g d o rs u m of h a n d s a n d feet, e l bows, a n d knees;
(d) a ngiokerato ma corporis d iffus u m associated with
Fa bry's d isease, an X- l i n ked recessive d isord e r c h a rac
terized by a.-ga lactosidase-A d eficie ncy and affecting
the lowe r a bd o m e n , buttoc ks, a n d ge n ita l ia ; a n d ( e )
a ngioke ratoma c i rc u mscri ptu m usua l ly grou ped on one
extre m ity.

E P I D E M I O LOGY
Age: solita ry o r m u ltiple a ngiokeratomas u s u a l l y affect
you n g a d u lts , a ngiokeratomas of Fordyce affect m i d d le
aged and elderly i n d ivid u a l s . Angioke ratoma of M i be l l i
a n d a ngioke rato ma c i rc u msc r i ptu m a re u s u a l l y d iag
n osed in c h i l d h ood .

Sex: a ngiokeratoma of M i be l l i a nd a ngioke ratoma c i r


c u mscri pt u m exh i bit fem a l e pred o m i na nce. Otherwise,
there is no sex pred is position .

PHYS I CAL EXAM I NAT I O N


R ed t o violaceous, we l l - c i rc u m sc r i bed hyperke ratotic
pa p u les a n d p l a q ue s .

D I F F E R E N T I A L D I AG N OS ES
Sol ita ry lesions ca n be m ista ken for mela noma , a cq u i red
hemangioma, lym p ha ngio m a , seborrheic ke ratos is, a n d
wa rts .

LABORATORY DATA
D e r m atopat h o l ogy
M a rked d i lated , t h i n -wa l l ed blood vesse ls in the pa p i l l a ry
d e r m i s , associated with an overlying acanthotic hyperker
atotic epidermis.

COU RS E MANAG E M ENT

M a nagement o f a ngiokeratomas rema i ns a c h a l lenge.

Figure 29. 1 (A) Angiokeratomas on the abdomen of a young patient.

M a n y m od a l ities have been reported i n the l iterature with

(B) Angiokeratoma imaged through an epiluminescence microscope

va riable s uccess . Treatment m od a l ities i n c l u d e

(DermLite)

Sect i o n 6 : Va sc u l a r A l te rat i o n s

1 69

Lasers : a ngiokeratomas have occasionally been treated


successfu lly with lasers.
- The p u lsed dye laser ( P OL) is an effective d evice for
the i m provement of the vasc u l a r component of
a ngiokeratomas,

but

freq uently

some

keratosis

rema i n s . The target c h romophore is hemogl o b i n .


P O L has proven successful a t 595 n m , 5-to-7- m m

spot, 9 t o 1 1 J/c m 2 , O C O 30/20. Cove ring the a ngiok


e rato m a with a glass s l i d e , that is, d iascopy, is h e l p

fu l . The end point is lesional p u r p u ra . H ea l i ng occ u rs


in more than 10 to 14 days. M u lt i p l e treatments may
be req u i red ( Fig. 29 . 3 ) .
- Res u rfacing lasers s u c h as C0 2 and Er:YAG lasers ca n
be uti l ized for lesiona l va porizatio n . Patients genera l ly
req u i re local i nfi ltration with 1 % l id oca i n e with or with
out epinephrine prior to treatment. The U ltra Pu lse C0 2
( Lu men is, Sa nta Clara, CAl is employed using a 3-m m
col l i mated hand piece, with an energy of 300 to 500 mJ
with nonoverlapping pu lses . The va rious sca n ned C0 2
lasers such as the Sharplan FeatherTouch a re

Figure 29.2 Angiokeratoma on the left thigh resistant to m ultiple treat

ments with pulsed dye laser

em ployed using the 1 25-m m hand piece, 3-m m sca n


size at 14 to 40 W. The treatment end point is a blation
to

achieve

lesional

flattening

and

opalescence.

Treatment sites should be clea nsed with sa l i ne soa ked


ga uze

between

laser

passes.

Postoperative

care

req u i res twice d a i ly wash i ng with soa p and water a n d


a ppl ication o f a n a nti biotic oi ntment. Hea l ing occ u rs i n
more t h a n 2 t o 6 weeks. A s with a l l a blative proced u res, sca rring may be observed .
- Other lasers that have been used i n the past with
va riable success i n c l u d e potass i u m -tita nyl-phosphate
laser, a rgon laser, a n d copper va por lase r. Long
pu lsed N d : YAG ( 1 , 064 n m ) laser has been shown to
be effective in i m prov i n g a ngioke ratomas d u e to its
selectivity a nd its deeper penetration i nto the ski n .
Successfu l treatment with a d ua l -wave length laser

system (595 a n d
reported

1 , 064 n m ) has been rece ntly


( Cynergy with M u lti plex , Cynosu re,

Westford , MA, U S A ) .

O t h e r s u rgical treatments i n c l u d e excision , electro


ca utery, electrofu lgu ratio n , or c ryosu rgery.

P I T FALLS TO AVO I D

Patients s h o u l d be advised that the P O L treatment wi l l


cause o bvious b r u i s i n g for u p t o 14 days.

Keratotic

featu res

may

persist

after

treatment.

I m provement is often el usive.

B I B L I OG RAPHY
Gorse SJ , J a mes W , M u rison M S . S u ccessful treatment of
a ngioke ratoma with potass i u m tita nyl phosphate laser. Br
J Dermatol. 2004; 1 50 ( 3 ) : 620-622.

Figure 29.3 (A) Biopsy-proven angiokeratoma on the thigh of a young

child. (B) Some resolution after one treatment with pulsed dye laser at a
wavelength of 595 nm with a 1 0-mm spot, pulse duration of 1 . 5 ms, a
fluence of 7. 5 J/cm2 , and DCD 30120

1 70

Color Atlas of Cosmetic Dermatology

La pi ns J , Emtesta m L, M a rcusson J A . Angiokeratomas i n


Fa bry's d isease a n d Fordyce's d i sease : Successful treat
ment with copper va pour laser. Acta Derm Venereal.
1 993; 73 ( 2 ) : 1 33- 1 3 5 .
Occella C , B l e i d l D , R a m p i n i P, Schiazza L, R a m p i n i E.
Argon laser treatment of c uta neous m u lt i p l e a ngioker
atomas. Dermatol Surg. 1995;2 1 ( 2 ) : 1 70- 1 7 2 .
Ozd e m i r M , Baysa l I , Engi n B , Ozd e m i r S . Treatment of
a ngiokeratoma of Fordyce with long- p u lse neodym i u m
d o ped ytt r i u m a l u m i n i u m garnet laser. Dermatol Surg.
2009;35( 1 ) : 92-97 .
Pfi rrma n n G , R a u l i n C , Ka rsa i S . Angioke rato ma o f the
lower extre m ities: Successfu l treatment with a d ua l
wavele ngth laser system ( 595 a n d 1 064 n m ) . Eur Acad
Dermatol Venereal. 2009;23( 2 ) : 1 86- 187.
Sommer S , M e rc h a nt WJ , Shee h a n - Da re R . Severe p re
d o m i n a ntly acra l va riant of angiokeratoma of M i be l l i :
Response t o long-pu lse N d : YAG ( 1 064 n m ) laser treat
ment. JAmAcad Dermatol. 200 1 ;45 ( 5 ) : 764-766 .

CHAPT E R 3 0

Che r ry a nd Spid e r Angio mas

Cherry a ngiomas, a lso known a s r u by spots, se n i l e


hema ngiomas,

a cq u i red

ca p i l lary

hemangioma,

and

Ca m p bell d e Morga n spots a re very c o m m o n benign vas


c u l a r lesions that pred o m i n a ntly affect the tru n k . Spider
a ngiomas, a lso known as nevus a ra n eus, spider telangiec
tasia, a rteri a l spid er, and vasc u l a r spid er, re present loca l
ized

telangiectasias

rad iating

from

centra l

feed ing

a rterioles. They a re common vasc u l a r lesions that pre


d o m i n a ntly affect the face, u pper tru n k , a rms, and hands.

EPI OEM I O LOGY


Incidence: very common
Age: cherry a ngiomas-m i d d l e-aged a n d elderly peo ple;
s p i d e r a ngiomas-a l l ages
Sex: more common in fema les
Precipitating factors: cherry a ngiomas can e r u pt d u ri n g
p regnancy or w i t h h e patic d i sease. S pider a ngiomas a re
strongly associated with pregna n cy, i nta ke of ora l contra
ceptive p i l ls, a n d h e patoce l l u l a r d isease

PATHOG EN ES I S
U n known for both . Assoc iation with pregna n cy, o ra l con
traceptive use, a n d l iver d isease suggest a hormona l ly
med iated a ngioge n i c mecha n is m .

Sect i o n 6: Va sc u l a r A l te rat i o n s

171

PHYS I CAL EXAM I NAT I O N


Cherry a ngioma prese nts as a 1 -to-3-m m bright red to
violaceous,

s mooth ,

d o m e-sha ped

pa p u l e .

Spider

a ngioma d is plays a network o f d i l ated ca p i l l a ries rad iati ng


from a ce ntra l vessel . B oth may bleed when tra u matized .

PATHOLOGY
Che rry a ngiomas show loss of rete ridges as we l l as con
gested and ectatic ca p i l l a ries a n d postca p i l l a ry ven u les in
the pa p i l la ry dermis. S p i d e r a ngiomas revea l a centra l
asce n d i ng a rte riole that b ra nc hes a n d co m m u n icates
with m u lt i p l e d i lated c a p i l l a ries.

D I F F E R E N T I AL D I AG N OS ES
Cherry a ngiomas ca n be m ista ken for angiokerato m a ,
glomeruloid

hema ngioma ,

pyoge n i c

gra n u l o m a ,

and

n od u l a r mela noma . S p i d e r a ngiomas can be m i sta ken for


genera l i zed essentia l te langi ectasias a n d h ered ita ry h em
orrhagic tela ngiectasia .

CO U RS E
Che rry a nd spider a ngiomas a ri s i n g d u ri n g pregnancy
may regress postpa rt u m . S p i d e r a ngiomas a rising i n
c h i l d hood m a y a lso resolve sponta neous ly. Otherwise,
both lesions ten d to persist.

MANAG E M ENT
Although

med ica l l y

i nsign ifica nt,

c h e rry a n d

spider

a ngiomas a re freq u e ntly treated for cosmetic p u r poses .


M u ltiple

effective

s u rgica l

treatment

o ptions

exist.

Depend i ng on the proced u re selected , the cost to the


patient

may

va ry

sign ificantly.

Che rry

and

spider

a ngiomas that present d u ri ng pregnancy s h o u l d n ot be


treated u ntil seve ra l months after d e l ivery as they may
resolve on their own .

El ectrosu rgery
- El ectrod essication with coagulation ( monopolar set
ti ng, 1-2 W fol l owed by gentle c u rettage with end
point of lesional flatte n i ng a n d h em ostas is) has been
the trad itiona l treatment m od a l ity for th ese lesions.
- I t is effective and easi l y a ccess i b l e .
- The potential f o r sca r formation m ust b e considered .

Laser su rgery : d ifferent lasers have been used su ccess


fu l ly in treatment of c h e rry a n d spider angiomas.

- P u l sed dye laser ( P OL) is the treatm e nt of c h oice. A

Figure 30. 1 (A) Spider angioma, right nose. (B) Full resolution of spider
angioma after a single pulsed dye laser treatment to central vessel and
surrounding skin

s pot size s h o u l d be selected that matc h es d ia meter


of the a ngioma . With spider a ngiomas, the ce ntra l

1 72

Color Atlas of Cosmetic Dermatology

feed i n g vessel as we l l as the s u r ro u n d i n g vessels


s h o u l d be treated . It is best to com press the lesion
with a m i c roscope s l i d e to b l a n c h all but the centra l
fee d i n g vesse l . A p u r p u r i c laser pu lse s h o u l d be
d e l ivered . The m i c roscope s l i d e shou ld be rem oved
to a l low for coo l i n g of the a rea . S u bseq uently, a p u r
p u r i c laser p u lse ca n be e m p l oyed to target the
te la ngiectasias rad iating from the feed i n g vesse l . The
p u r p u ric treatment end point re presents coagu lation
of the targeted vessels ( Figs . 30. 1 and 3 0 . 2 ) .
- The potass i u m -tita nyl-phosphate ( KT P ) 532-n m laser
prod u ces a favora b l e res ponse. S pot size s h o u l d
match the lesion d i a m eter. The vessels shou l d b e
traced out c o m p l etely for m ost effective treatment.
Treatment end point is lesional cleara nce or su perfi
c i a l white n i ng. E rythema ca n be expected posttreat
ment, last i n g 24 to 48 h o u rs .

- Ca rbon d ioxid e laser ( U itra P u lse 3-m m co l l i m ated


h a n d piece,

300-400

mJ/pu lse,

nonoverlapping

p u l ses; Sharplan FeatherTou ch 1 25- m m h a n d piece,


14-40 W, 3-mm sca n size, nonoverla p p i n g p u lses)
has been e m p l oyed as secon d-l i n e thera py with
su ccess . Treatment e n d po i n t is lesional flatte n i n g .
Potentia l sca r formation m ust be consid ered .

Light thera py
- I ntense p u l sed l ight ( I P L) has a lso been e m p l oyed
with some su ccess. As coagu lation is needed fo r
lesional reso l ut i o n , h igher fluences may be req u i red
for treatm ent efficacy.

S u rgical exc ision


- Excision should be reserved for lesions that a re resis
ta nt to other treatments. A posto perative sca r is
expected w h i c h may be less cosmetically pleasing
t h a n the a ngioma .

P I T FALLS TO AVO I D

Figure 30.2 (A) Cherry angiomas on the trunk in a middle-aged female.


(B) The appropriate endpoint is purpura obtained after pulsed dye laser

treatment (wavelength of 595 nm, 7-mm spot. 1 . 5-ms pulse duration,


f/uence of 1 2 J/cm 2 , DCD 30120)

Patie nts need to be cou nseled as to the l i ke l i h ood of


o bvious p u r p u ra fo l l owi n g treatment with P D L that may
persist for 1 0 to 14 d ays , espec i a l l y off the face. Lesions
a re less l i kely to be com pletely treated at s u b p u r p u ric
fluences.

S i m ple electrocautery may be j u st as effective as P D L


at a red uced cost t o t h e patient.

Com press i n g the lesion with a glass slide d u ri n g PDL o r


K T P treatment is h e l pful t o m i n i mize its s i z e a n d a l low
i ng for greate r laser penetrati o n . This red u ces the tota l
energy needed for coagu lation a n d i n c reases the treat
ment success rate .

M u lt i p l e treatme nts may be req u i red , in pa rti c u l a r for


la rge spider a ngiomas.

Figure 30.3 (A) Cherry angioma, chest.

Sect i o n 6 : Va sc u l a r A l te rat i o n s

1 73

B I B L I OG RAPHY
Dawn G , G u pta G . Com pa rison o f potass i u m tita nyl p h os
p hate vasc u l a r laser a n d hyfrecato r in the treatment of
vasc u l a r

spiders

and

che rry

a ngiomas.

Clin

Exp

Dermatol. 2003 ; 28(6) : 58 1 -583 .


Fod or L, R a m o n Y, Fodo r A, Ca r m i N , Peled I J , U l l ma n n
Y. A side- by-side pros pective study o f i ntense p u l sed l ight
and N d : YAG laser treatment fo r vasc u l a r lesions. Ann

Plast Surg. 2006; 56(2 } : 1 64- 1 70 .

Figure 30.3 (ContinuedJ (B) Pulsed dye laser treatment to cherry angioma

utilizing diascopy (C) Purpura immediately post pulsed dye laser treat
ment. (D) Complete resolution of cherry angioma after one pulsed dye
laser treatment

1 74

Color Atlas of Cosmetic Dermatology

CHAPT E R 3 1

G ra nu l o m a Facia l e

G ra n u loma fac i a l e ( G F ) was fi rst d escri bed by Wigley i n


1 945 w h o la beled t h e d i sease "eos i n o p h i l ic gra n u l o ma . "
P i n kus re n a m ed this d isorder gra n u loma fac i a l e i n 1952.
G F is a n i d i o pathic c h ro n i c c uta neous d isorder that usu
a l ly i nvolves the face, pa rt i c u l a rly the nose . It ca n prese nt
with a si ngle lesion or m u ltiple lesions.

E P I D E M I O LOGY
Incidence: u n c o m m o n
Age: 30 t o 50 yea rs
Race: pri m a ri ly seen in Caucasians
Sex: ma les > fem a l es

Figure 3 1 . 1 Granuloma faciale on the scalp

PATH OG E N ES I S
U n k nown , but may b e mediated b y i m m u ne c o m p lex
d e position .

PHYS I CAL EXAM I NAT I O N


Si ngle i n d u rated facial brown ish-red pa pule o r plaque.
Some lesions may have telangiectasia . M u ltiple lesions may
be present. Extrafacial sites rarely observed . Lesions may
vary in size from m i l l i meters to centimeters ( Fig. 3 1 . 1 ) .

D I FFERENTIAL D I AG N OS ES
Cutaneous l u pus erythematos us, sa rco idosis, lym p h o m a ,
pseudolym phoma , c uta neous T-ce l l

lym p h o m a , fixed

d ru g e r u pti o n , rosacea .

D E R M ATOPATHOLOGY
Dense, polymorphous i nflam matory cell i nfi ltrate i n the
u pper two-t h i rds of the dermis. The i nfi ltrate is com posed
of n u merous eosinoph i ls, neutrophi ls, lym phocytes, a n d
h istiocytes . A pro m i nent grenz zone is c h a racteristica lly
present. Leu kocytoclastic vasc u l itis is freq uently observed .

CO U RS E
The lesions of G F a re usua l ly c h ro n i c a n d o n l y occasion
a l ly resolve s ponta neously.

Sect i o n 6 : Va sc u l a r A l te rat i o n s

1 75

MANAG E M ENT
Difficu lt t o treat with a ny modal ity. A n y s uccessfu l treat
ment often leaves sca rring.

To p i c a l Treat m e n t

Corticosteroids: topica l , i ntra lesio n a l

Tac ro l i m u s o i ntment (0. 1 % )

Syste m i c Treat m e n t

Da psone

Anti m a l a ri a l s

Colc h ic i n e

Cl ofaz i m i n e

G o l d i nj ecti ons

S U RG I CAL TREAT M E N T

C ryos u rgery:

m u ltiple

reports

i n d icati ng su ccessful

c l ea ra n c e . Resu lts a re u n pred icta ble ( Fig. 3 1 . 2 ) .

S u rgical excision .

Derm a b rasion .

El ectrosu rgery.

L i g h t Treat m e n t

Topica l psora len a n d u l traviolet A ( P UVA) rad iation


thera py

Laser thera py: d ifferent lasers have been used in the


treatment of GF with p ro m i s in g resu lts, either as an
a b lative thera py with ca rbon d i oxid e laser o r as a selec
tive thera py ta rget i n g the prom i n ent vasc u latu re in G F
lesions using the Q-switc hed a rgon laser, p u lsed dye,
d i ode laser, and potass i u m tita nyl phosphate ( KT P )
532-nm l a s e r ( F ig. 3 1 .3 ) .

P I T FALLS T O AVO I D

G F is often reca lc itra nt to thera py. Patie nts s h o u l d be


cou nseled that successfu l treatment is often el usive.

B I B L I OG RAPHY
A m m i rati CT, H ruza GJ . Treatment o f gra n u l o m a fac i a l e
w i t h the 585- n m p u l sed d y e laser.

Arch Dermatol.

1 999; 135(8) :903-905.


Apfel berg DB, Dru ker D , Maser M R , Las h H, S pence B
J r, Denea u D. G ra n u l o m a fac i a l e . Treatment with the
a rgon laser. Arch Dermatol. 1 983 ; 1 1 9 ( 7 ) : 573-576.

Figure 3 1 .2 (A) Multiple lesions of granuloma faciale on the face. (8) No


significant improvement detected after one treatment with cryotherapy on
a 4-month follow-up visit

1 76

Color Atlas of Cosmetic Dermatology

Chatrath V, R o h rer TE. G ra n u loma fac i a l e successfu l l y


treated w i t h long-pu lsed t u n a b l e d y e laser. Dermatol

Surg. 2002 ;28( 6 ) : 527-529 .


Elston O M . Treatment of gra n u loma fac i a l e with the
p u l sed dye laser. Cutis. 2000;65(2 ) : 9 7-98.
Khaled A , J ones M, Zerma n i R, et a l . G ra n u loma fac i a l e .

Pathologica. 2007 ;99( 5 ) : 306-308.


M a i l l a rd H, G rogna rd C , Toled a n o C, J a n V, Mac het L,
Va i l la nt L. G ra n u l o m a fac i a l e : Efficacy of c ryosu rgery i n
2 cases. Ann Dermatol Venereal. 2000; 1 2 7 0 ) : 77-79 .
To mson N , Ste rl i ng J C , Sa lva ry I . G ra n u loma fac i a l e
treated successfu l l y w i t h topica l tac ro l i m us . Clin Exp

Dermatol. 2009;34(3) :424-42 5 .


Wheela nd R G , Ash l ey J R , S m ith O A , E l l i s O L, Wheela n d
O N . Ca rbon d ioxid e l a s e r treatment o f gra n u loma fac i a l e .

J Dermatol Surg Oneal. 1 984; 1 0 ( 9 ) : 730-733 .

Figure 3 1 .3 (A) Indurated brownish-red plaque on the left cheek of a


middle-aged female with granuloma facia/e. (B) Two-year follow-up show
ing resolution of granuloma faciale after m ultiple pulsed dye laser treat
ments

Sect i o n 6: Va sc u l a r A l te rat i o n s

CHAPT E R 3 2

1 77

I nfa ntile H e m a ngio m a

I nfa nti le hema ngioma ( I H l , a lso known as strawberry,


ca p i l l a ry,

or

cavernous

hema ngiom a ,

is

benign

e n d oth e l i a l prol iferation that re presents the most com


mon tumor i n i nfa ncy. I t ca n be c lassified i nto su perfic i a l
hema ngioma ( S H , 55% o f cases ) , deep hema ngioma
( D H , 30% of cases ) , and m ixed su perfi c i a l and deep
hema ngioma ( M H , 1 5% of cases ) . They occ u r m ost com
m o n ly o n head a n d neck a reas .

EPI D E M I O LOGY
Incidence: 1% to 3 % a re p resent at b i rt h , 10% to 1 2 %
a re p resent b y 1 yea r o f age

Age: majority (80 % ) become a p pa rent between 2 a n d


5 weeks o f age; 2 0 % a re n oted at b i rt h .

Sex: fe ma les a re affected two t o fou r ti mes more t h a n


m a l es

Precipitating factors: prematu re i nfa nts a re more com


monly affected

PHYS I CAL EXA M I NAT I O N


The a p pearance depends o n t h e d e pth o f the heman
gioma a n d the phase of evol utio n . S H p resents as bright
red -colored p l a q u e . D H presents as a soft dermal o r s u b
c uta neous nod u l e with a b l u ish- p u r p l e col or. M H shows
featu res of both SH a n d D H . M u lt i p l e truncal heman
giomas

may

be

o bserved .

I nvol uting

hema ngiomas

demonstrate a flatter su rfa ce with a grayis h - p u r p l e h u e


t h a t begi ns ce ntra l l y a n d expa n d s outwa rd . The h e m a n
giomas

m ight

become

u lcerated

and

he morrhag i c .

Resi d u a l fatty tissue, atrop hy, tela ngiecta s i a , s c a r forma


tion , and hypertrophy may be observed .

D I F F E R E N T I AL D I AG N OS ES
Congen ita l hema ngiomas ca n be confused with a vasc u
lar

ma lformation

such

as

port-wi n e sta i n

at

b i rt h .

H ema ngiomas a re ge nera l ly present after b i rth versus


vasc u l a r ma lformations, which a re genera l l y present at
b i rth .

LABO RATORY TESTS


D e r m at o p at h o l ogy
Prol iferations of p l u m p e n d oth e l i a l cel ls that may exte n d
fro m the su perfi c i a l d e r m i s t o the deep su bcuta neous
tiss u e , d e pen d i ng o n the hem a ngioma s u btype.

Figure 32. 1 (A) Left upper eyelid hemangioma in its early growth phase,
a lesion that may threaten the child 's vision. (B) Marked lightening and
flattening of the hemangioma after m ultiple pulsed dye laser treatments

1 78

Color Atlas of Cosmetic Dermatology

A n c i l l a ry Tests

A n a bd o m i n a l u ltraso u n d s h o u l d be o bta i ned if m o re


t h a n fo u r tru ncal hema ngiomas a re noted prior to
4 months of age .

An electroca rd iogra m ( ECG) a n d a ca rd iac EC H O should


be considered for a n y concern of h igh ca rd iac output.

COU RS E
H ema ngiomas c h a racteristica l l y exh i bit th ree phases of
evol ution : ( a ) prol iferative phase, ( b ) i nvol uting phase,
and (c) i nvo l uted phase. The prol iferati ng phase is c h a r
a cterized by a ra p i d growth p hase that starts at 1 to
2 m o nths of age a n d lasts u nt i l 6 to 9 months of age. This
growth phase is fol l owed by the i nvol uting phase that
usua l l y starts i n the second yea r of l i fe a n d persists for

severa l yea rs. M ore than 90% of u ntreated hema ngiomas


i nvol ute, that is, atta i n maxi m a l regression by 9 yea rs of
age. U p to 30% of hema ngiomas leave posti nvol ution
cha nges i n c l u d ing hypopigme ntati o n , sca rring, tela ngiectasi a , and fi b rofatty tiss u e .

COM P L I CAT I O N S
B leed i n g a n d u lceratio n with seco n d a ry i nfection a n d
sca rring, espec ia l ly i n hema ngiomas i nvolvi ng t h e d i a pe r
a rea , a re c o m m o n l y see n . Oth er serious com pl ications
i n c l u d e orbital o bstruction and a m b lyo pia with periorbita l
hema ngiomas, u pper a i rway o bstruction with h e m a n
g i o m a s i n the bea rd d istri bution , s p i n a l a bnorma l ities
with l u m bosacra l hema ngiomas, posterior fossa ma lfor
mation in la rge fac i a l hema ngioma ( P H A C E syn d rome) ,
a n d h igh output c a rd ia c fa i l u re with m u lt i p l e c uta neous
hema ngiomas assoc iated with viscera l i nvolvement.

Figure 32.2 (A) Hemangioma on the left fifth toe pad, a location that

in terfered with the child's ability to ambulate. (B) Significant clearing and
near resolution of the hemangioma after multiple pulsed dye laser treat
ments

KEY CO N S U LTAT I V E QU EST I O N S

Onset o f lesion

N u m ber of lesions noted

U l ceration n oted

B l eed i ng noted

Prior treatm ents a n d res ponse

MANAG E M E N T
T h e treatment o f I H s is controve rsia l . G iven t h e natu ra l
cou rse o f I H with sponta neous reso l ution, m a n y physi
cians c h oose to ca refu l ly o bserve the a rea with no
i ntervention, espec i a l l y i n nonfacia l , sma l l , a n d u ncom
p l icated

hema ngiomas.

Ea rly i ntervention

is recom

m e n d ed for ( a ) all I H s that i nterfere with the function of


vita l

orga ns

(eg,

periorbita l

hema ngiomas,

a i rway

o bstruction with hema ngiomas i n the bea rd d istr i b ution,

Sect i o n 6 : Va sc u l a r A l te rat i o n s

1 79

h igh-output cardiac fa i l u re ) ; ( b ) la rge facia l hema ngiomas


that usua l ly i nvo l ute with permanent d i sfiguri ng; (c) u l cer
ated hema ngiomas; and (d) hema ngiomas in the d ia per
a rea that a re very l i kely to u lcerate causing severe pa i n .

Medica l treatment
- Steroids i n c l u d i ng topica l steroid a pp l i cation ( c lass 1
corticoste roid a p pl ied twice d a i ly with mon itoring
every 2 wee ks) , i ntra lesiona l steroids (tria m c i nolone
a ceto n i d e 1 0 mg!m L a d m i n istered monthly), and oral
steroids ( 1 . 5-2 mg/kg/d of pred n isone) a re the m a i n
stay o f treatment. Patie nts m ust be mon itored c l osely,
espec ia l ly with oral steroid use given the risk of sys
temic com p l ications i nc l u d i ng growth reta rdation a n d
g l u cose a lterations. Loca l ized side effects i n c l u d e
atrophy a n d yeast infect i o n .
- Other treatment options i nc l u d e to pica l i m i q u i mod
( a p p l ied d a i ly ) , i nterferon-a (3 m i l l ion u n its/m 2/d ,

S C ) , a nd v i n c ristine (0.05 mg/kg/d if less than 10 kg,


IV ), espec ia l ly in steroid-resista nt I H . As i nterferon-a
is associated with spastic d i plegi a , patients m u st be
mon itored c l osely.

P ro p ra nolol at a d ose of 2 mg/kg/d has been recently


reported to be ve ry effective i n treating severe I H s , even
in steroid-resista nt I H s . T h i s treatment is proposed to
re place ora l or i ntravenous steroids that a re associated
with sign ifica nt side effects. H owever, patients on p ro
pra n olol s h o u l d be c l osely m o n itored for bradyca rd i a ,
hypotension , a n d hypoglycemia espec ia l ly a t the o nset
of the treatment.

Laser treatment
- P u lsed dye laser ( P D U treatment i n d u ces sign ifi
ca ntly faster regression of the I H . Fl u e nces lower
than those of PWS a re effective and a re assoc iated
with lowe r risk of laser- i n d u ced sca rri ng ( Figs . 3 2 . 1 ,
3 2 . 2 a n d 3 2 . 3 ) . P D L has been used exte nsively i n

the treatment of I H i n th ree c l i n ical scena rios:

Figure 32.3 {A) Segmental hemangioma in volving the hand of a 1 -year

1. U l cerated hema ngiomas res pond effectively to


P D L. PDL ma rked ly dec reases the associated
pa i n a n d i n d uces ra pid hea l i ng of the u l ceration
(75% with i n 2 weeks) ( Fig. 32.4) . Res i d u a l sca r
fo rmation from the u l ce ration is expected .
2. S H s c a n respond wel l to P D L if sta rted either
before

or

early

in

the

prol ife rative

phase.

M u ltiple treatments, every 4 to 6 weeks, a re


req u i red in the prol iferative phase. T h e o n ly
exception is a ra pid ly prol ife rating fa c i a l hema n
gioma . P D L treatment may i n d uce u lceratio n of
these va ria nts so treatm ent s h o u l d be avoided .
I H with deeper components ( M H , D H J res pond
less effectively to PDL beca use of the l i m itation
of penetration of PDL to 1 . 2 mm i n the ski n .
3 . P D L ca n h e l p treat the res i d u a l erythema a n d
tela ngiectasias o n
hemangiomas.

the

s u rface o f i nvol uted

old girl. {B) Complete resolution of the hemangioma after four treatments
with 595-nm pulsed dye laser at low fluences

1 80

Color Atlas of Cosmetic Dermatology

- Long-pu lsed N d : YAG lasers a re usefu l for photocoagu


lation of D H s but have a h igher incidence of sca rring.

Other

interventions

include

s u rgical

debulking

and

em bol ization . The risks and benefits of each s u rgica l


a pproach should be considered ca refu l ly before i nterven
tion since the sca r from spontaneous regression is usua l ly
better than the surgica l scar. Em bol ization is uti l ized in
hema ngiomas associated with h igh-output ca rd iac fa i l u re.

P I T FALLS TO AVO I D

Use of excessive P O L fluences without s k i n coo l i ng ca n


cause sca r.

Pa rents a re u nd ersta n d a bly a nxious a bout their c h i l d 's


hema ngioma . A f u l l d iscussion of the natu ra l c o u rse of

hema ngiomas is m a ndatory prior to sta rt i n g thera py.


The option of foregoi n g treatm ent a n d c l i n ica l l y m o n i
toring a patient s h o u l d b e reviewed ca refu l ly p r i o r to
sta rt i n g treatment.

Pa rents s h o u l d a lso have a rea l i stic idea of the l i m ita


tions of thera py. La rge hema ngiomas res pond less suc
cessfu l ly

to

o ra l ,

s u rgica l ,

and

laser

thera py.

C o m p l icated hema ngiomas that may i n te rfere with the


c h i l d 's health s h o u l d be referred to an a p p ropriate
ped iatric spec i a l i st. P a re nts m ust be awa re that treat
ment wi l l provide an i m provement but may n ot res u lt i n
fu l l resol ution o f t h e h e m a ngioma .

Parents n eed to be ed ucated on proper wou n d care,


espec i a l ly for u lcerated hema ngiomas, i n order to
i m prove the c h i l d 's q u a l ity of l ife .

F i b rofatty c h a n ges a re ofte n a seq uela of resolved


hema ngiomas.

Such

c h a nges

can

be

i m p roved

sign ificantly with n o n a b l ative a n d a blative fract i o n a l


resu rfa c i ng.

B I B L I OG RAPHY
Batta K, G oodyea r H M , M oss C, Wi l l i a m s H C , H i l ler L,
Waters R. R a n d o m ised control led study of early p u lsed
dye laser treatment of u ncompl icated c h i l d hood haeman
giomas: Resu lts of a 1 -yea r a na lysis.

Lancet 2002 ;

360(9332 ) : 5 2 1 -527 .
Lea ute-La breze C, Du mas de Ia Roq ue E, H u biche T,
Bora levi F, Tha m bo J - B , Taleb A. Propranolol for severe
hema ngiomas of i n fa n cy. N Eng! J Med. 2008;358: 2649265 1 .

L i YC, McCa h a n E , R owe N A , M a rt i n PA, Wilcsek G A ,

Figure 32.4 (A) Ulcerated hemangioma, isolated nodular type, extremely


painful and hemorrhaging, treated twice with pulsed dye laser 6 Jlcm 2 ,
7-mm spot size, 590 nm. (B) At 2 months ' follow-up, significant healing
of the ulceration after a single treatment with pulsed dye laser. (C) Four
months after initial pulsed dye laser treatment and 2 months after
second pulsed dye laser treatment, there is complete healing of the
ulceration

M a rt i n FJ . S uccessfu l treatment o f i nfa nti le h a e m a n


g i o m a s o f the o r b i t w i t h pro p ra n olol . Clin Experiment

Ophthalmol. 2010;38(6): 5 54-559 .


More l l i J G , Ta n OT, Yoh n J J , Weston WL. Treatment of
u l cerated hema ngiomas i nfa n cy. Arch Pediatr Ado/esc

Med. 1 994; 148( 1 0) : 1 1 04- 1 1 0 5 .

Sect i o n 6: Va sc u l a r A l te rat i o n s

CHAPT E R 33

1 81

Ke ratosis Pi l a ris At rophica ns

Ke ratosis p i l a ris atro p h ica ns ( K PA) is a gro u p o f i n he rited


d i so rd e rs with th ree su btypes i n c l u d i ng (a) keratosis
p i l a ris atro p h i ca n s fac i e i ( KPAF ) , (b) atrophoderma ver
m ic u latu m (AV ) , a n d (c) ke ratosis fo l l i c u l a ris s p i n u losa
d ecalva n s ( KFS D ) . KPA F a n d AV present m a i n ly on the
face with K FS D often a p pea r i n g o n the eye b row a n d AV
m ost com m o n l y seen on the c heeks, sparing the eye
brows a n d sca l p . KFSD can affect the face, sca l p , a n d
tru n k . I n herita nce pattern can b e a utosom a l d o m i na nt
( KPAF, AV) , recessive (AV ) , or X-l i n ked ( KFS D ) .

EPI D E M I O LOGY
Incidence: very ra re; KPAF is the m ost c o m m o n su btype
Age: KPAF a n d KFSD in i nfa ncy; AV in c h i l d h ood
Sex: ma les a re more seve rely affected in KFSD

Figure 33. 1 Keratosis pilaris: fine, sandpaper-like follicular papules on

PATH OG E N ES I S

the arm of a young man

Abnormal fol l i c u l a r keratin ization of the u pper sectio n of


the h a i r fol l icle that may later res u lt in atro p h i c fo l l i c u l a r
sca rring.

PHYS I CAL EXAM I NAT I O N


Fol l i c u l a r

pl u gging

with

erythema

in

early

stages

( Figu re 33. 1 ) . Atro p h i c fol l i c u l a r sca r fo rmation with


assoc iated a lopecia in later stages .

D I FFERENTIAL D I AG N OS I S
Ke ratos is p i l a ris, keratosis pila ris ru b ra , seborrheic der
matitis ( KPA F ) , atopic d e rmatitis ( KFS D ) , other etiologies
of sca rring a l o pecia ( KFS D ) , acne sca rri ng (AV), Rom bo
syn d rome (AV ) , a n d K I D syn d rome ( K FS D ) .

D E R M ATOPAT H O LOGY
D i lated fo l l ic l es with fo l l i c u l a r hyperkeratosis and i nfla m
m a t i o n i n e a r l y stages . Fol l i c u l a r fi brosis a n d atrophy i n
later stages .

CO U RS E
The cou rse i s c h ro n i c with n o sponta n eous reso l ution .
With t i m e , the e ryt h e m ato u s fo l l i c u l a r hyperkeratotic
pa p u les i nvol u te i nto d e p ressed atro p h i c fo l l i c u l a r sca rs
with a l opec i a .

1 82

Color Atlas of Cosmetic Dermatology

MANAG E M ENT
There is n o com pletely effective treatment for KPA.
M u ltiple treatment options have been tried with only va ri
a b le s uccess . Patients should be cou nseled that thera py
may not be effective.

Topical thera py may, at best, prod uce modest benefit.


- Lactic acid a n d a-hyd roxy acid lotions ( 1 0 %- 1 2 % )
a p plied twice d a i ly may i m p rove the text u ra l ro ugh
ness. H owever, they may p rod uce i rritatio n .
- R eti n o i d s (taza rote n e , reti n-A) a p p l ied n i ghtly may
i m p rove text u r a l ro ugh ness. T h ey may prod uce i rri
tati o n .
- Corticosteroids a p p l ied s pa ri ngly m a y show i m provement. R i s k of fac i a l atro ph y l i m its their use.

System i c thera py
- Other o ptions that have p rovided va ria ble su ccess
i n c l u d e o ra l reti noids a n d d a pso n e .
- They a re m ost h e l pfu l fo r the i nfla m m atory stage of
KPA, but provide m i n i m a l i m prove ment in the fol l ic u
l a r hyperkeratos is.
- They req u i re ca refu l mon itoring for potentia l side
effects.

Laser thera py
- P u lsed dye laser ( 59 5 n m , 7-m m spot, 7-1 0 J/cm 2 ,
D C D 40/20, p u lse d u ration of 1 . 5-3 ms) c a n be
effective in the treatment of the assoc iated e rythema
of KPAF but will not sign ifica ntly i m prove the text u ra l
rough n ess o f KPA ( Fig. 33 . 2A , B ) .
- Laser-assisted h a i r remova l with long- p u lsed n o n
Q-switc hed ru by l a s e r may be a n effective treatment
i n patients with KFS D .

P I T FALLS T O AVO I D
Pati ent expectations a re ge nera l ly very h i g h . They m ust
be cou nseled as to the c h ro n i c natu re of the cond ition
and m i n i m a l res ponse to ava i la ble thera pies.

B I B L I OG RAPHY
Baden H P, Byers H R . C l i n i c a l fi n d i ngs, c uta neous pathol
ogy, and response to therapy i n 21 patients with keratosis
p i l a ris atro p h ica n s . Arch Dermatol. 1 994; 130(4):469475.
C h u i CT, B e rger TG , P rice VH, Za c h a ry CB. R eca lcitra nt
sca rring fol l ic u l a r d isord e rs treated by laser-assisted h a i r
re mova l : A prel i m i na ry report. Dermatol Surg. 1 999 ;
25( 1 ) : 34-3 7 .
C l a rk S M , M i l l s C M , La n iga n SW. Treatment o f keratosis
p i l a ris atro p h i c a n s with the p u lsed tunable dye laser. J

Cutan Laser Ther. 2000 ; 2 (3 ) : 1 5 1 - 1 56.

Figure 33.2 (A) Keratosis pilaris atrophicans. Patient is emotionally both


ered by persistent erythema. (8) Marked lightening of erythema 2 years
following three pulsed dye laser treatments

Sect i o n 6: Va sc u l a r A l te rat i o n s

Ka u n e K M , Haas E, E m m e rt S, Schon M P, Z utt M .


Successfu l treatment of severe keratos is p i l a ris ru bra with
a 595- n m pu lsed dye laser. Dermatol Surg. 2009 ; 3 5 :
1 592- 1 595.
M a rq ue l i ng AL, G i l l ia m AE, P rend ivi l l e J, et al. Keratosis
p i l a ris ru b ra : A c o m m o n but u n d errecogn ized conditi o n .
Arch Dermatol. 2006; 142( 1 2 ) : 1 6 1 1 - 1 6 1 6 .
R i c h a rd

G,

H a rth W . Keratosis fol l ic u l a ris s p i n u losa

d ecalva n s . T he ra py with isotret i n o i n and etreti nate in the


i nfla m matory stage. Hautarzt. 1 993;44(8) : 529-534.

CHAPT E R 34

Po rt-wi n e Stains

Port-wine sta i n s ( PWS) a re low-flow ca p i l lary m a lforma


tions. They represent the m ost common type of vasc u l a r
ma lformations. Any a rea o f t h e body can b e affected .
H owever, the head a n d neck a reas a re m ost co m mo n ly
affected .

EPI D E M I O LOGY
Incidence: 3 per 1 , 000 newborns
Age: prese nt at b i rt h i n the majo rity of patients ; rarely
a p pea r i n adolesce nce o r a d u lthood
Sex: no sex pred i l ection
Race: less common i n Asi a n s a n d African Americans
Associated syndromes: PWS can be a m a n ifestation of
severa l synd romes i n c l u d i n g Stu rge-We ber syn d rome,
K l i ppel-Tre n a u nay synd ro m e , P rote us syn d rome, and
pha komatos is pigmentovasc u la ris

P H YS I CAL EXA M I NAT I O N


PWS prese nts a t b i rth a s l ight p i n k , we l l-dema rcated
m a c u l a r lesions a n d patc hes usua l l y in a segmenta l d is
tri butio n . They ca n tra n sform with age i nto hypertro p h i c
d a r k r e d a n d/or p u r p u ric pla q u es w i t h nod u l a rity. PWS
i nvolves the face m ost c o m m o n l y a l ong the trigem i n a l
n e rve d istri bution : ophtha l m i c b ra n c h V 1 ( u pper eye l i d
a n d forehea d ) , maxi l l a ry b ra n c h V2 ( u pper l i p , cheek,
lower eye l id ) , a n d m a n d i b u l a r b ra n c h V3 .

D I FFERENTIAL D I AG N OS I S
PWS exh i bits c h a racteristic c l i n i cal featu res a n d i s sel
d o m m isd iagnosed . I t can be confused with the mac u l a r
stage o f h e m a ngioma at b i rth .

1 83

1 84

Color Atlas of Cosmetic Dermatology

D E R M ATOPAT H O LOGY
M u ltiple d i lated t h i n -wa l led vesse ls in the pa p i l l a ry a n d
reti c u l a r d e r m i s .

A N C I LLARY TESTS

The pa rents s h o u l d be cou nseled rega rd i n g the possi


b i l ity of Stu rge-We ber synd rome (SWS) i n lesions
l ocated i n a fac i a l Vl o r V2 dermatom a l d istri bution .
SWS is cha racterized by the prese nce of fac i a l PWS
with i psi latera l o c u l a r a n d lepto m e n i ngea l a n o m a l ies.
Ten to fifteen percent of pati ents with PWS i n the V l
d istr i b ution wi l l have SWS . Patients w i t h b i latera l PWS
h ave even a h igher risk of SWS . An ophthal mologic
exa m i nation to ru l e out gla ucoma a nd cata ract forma
tion with conti n ued fo l lowu p is necessa ry for these
patients . A head c o m p uted tomogra phy ( CT) or mag-

netic reson a n ce i maging ( M R I ) s h o u l d be o bta i ned to


r u l e out b ra i n i nvolvement that could affect menta l
development a n d res u l t i n sei z u res.

PWS overlyi ng the s p i n e ca n be associated with s p i n a l


a n o m a l y s u c h as s p i n a l dysra p h i s m o r tethered s p i n a l
cord . N e u ro l ogic eva l uation a n d a p p ro priate i maging
stu d ies a re recom m e n d ed .

Large extremity PWS should ra ise the consideration of


Kl i ppel-Trenau nay syn d rome, cha racterized by capillary
venous ma lformations or ca pil lary-lym phatic-venous mal
formations with hypertrophy of the affected extrem ity. Leg
girth and length should be measu red and followed over
time.

COU RS E
PWS grows proporti o n a l l y with the patient a n d gra d ua l ly
t h i c kens a n d d a rkens i n color from p i n k to d a r k red to

deep p u rple. Eleven percent may d eve l o p n od u l a rity a n d


2 4 % may d eve l o p pyoge n i c gra n u lomas. PWS may b e
associated with hypertro phy o f u n derlying soft tissue a n d
bone,

pa rtic u l a rly

in

Stu rge-We ber

syn d rome

and

K l i ppel-Tre n a u nay syn d ro m e .

KEY CO N S U LTAT I V E QU EST I O N S

On set o f lesion

Assoc iated c l i nical fi n d i ngs

Is the c h i l d m eeti ng d eve l o pmenta l m i lestones?

Has the c h i l d had an eye exa m i nation?

Has the c h i l d had a head M R I or CT?

Past treatments a n d response

B l eed i ng

B l ebs

(B) Significant lightening of the PWS after a single POL treatment.

G rowth of PWS

(C) Complete resolution of the PWS after POL treatments

Figure 34. 1 (A) PWS on the right inner thigh of an infant girl.

Sect i o n 6: Va sc u l a r A l te rat i o n s

1 85

MANAG E M ENT
PWS d e m o nstrates progressive vasc u l a r d i latation a n d
hypertrophy with age, t h u s m a k i ng treatment d u ri ng
ea rly i nfa ncy esse ntial for a bette r res ponse. Treatment
ca n be sta rted as ea rly as 2 weeks of age . Treatment p ro
vides a red uction in the n u m be r of vessels a n d d oes n ot
c o m p l ete ly rem ove the enti re lesio n . T h e refore , the PWS
may exh i bit some d a rke n i n g a n d t h i c ke n i ng over t i m e
despite

i n terventio n .

G e n e ra l

a n esthesia

m ight

be

needed for treati ng la rge PWS i n c h i ld re n .

Laser treatm e n t ( F igs . 34. 1-34. 5 ) .


P u lsed dye laser ( P O L) rema i n s the gol d sta n d a rd for

the treatment of PWS . Effective P O L pa ra meters i n c l u d e


wavele ngths o f 5 8 5 t o 600 n m , flue nces o f 6 t o 1 5 J/c m 2 ,
p u l se d u rations of 0.45 or 1 . 5 ms with cryogen spray

cool i n g (CSC). Fou r to twe lve laser sessions with 4-to-8week i nterva ls a re u s u a l l y req u i red in order to ach ieve
sign ificant b la n c h i n g of the PWS . Lower fl uen ces a re i n itia l ly uti l i zed for PWS off the face a n d in d a rker s k i n
types . The use o f e s c concom ita ntly d u ri n g P O L treatment sign ificantly dec reases the pa i n associated with the
proced u re a n d the i n c i d ence of bl istering. esc protects
the epidermis a n d a l l ows for d e l ivery of h igher flu ences,
resulting in more effective b l a n c h i ng of the PWS . P O L
treatm ent is fo l l owed b y tem pora ry p u r p u ra that usua l ly
resolves in 7 to 14 days. Complete l ighte n i ng of PWS with
POL treatment is a c h i eved i n l ess than 20% of PWS .
Resista nce to

P O L treatment

is

more freq ue ntly

encou nte red in deeper and hypertro p h i c PWS . H e l pful


m a n e u ve rs to potentiate the efficacy of P O L i n c l u d e
i n c reasi n g t h e fl u e n ces with adeq uate c ryogen cool i n g to
p rotect the epidermis a n d i n c reas i n g the wavelength u p
to 600 n m to ta rget deeper vesse ls. A pi lot study demon
strated that PWS that a re treated with to pica l imiquimod
once d a i ly for 1 month after P O L exposu re m a n ifest
su perior b l a n c h i ng res ponse over time as compared to
P O L a l o n e . Another re port i n vestigated the c o m b i ned use
of POL and a topica l a n giogenesis i n h i bitor, rapamycin,
using the in vivo rodent wi n d ow c ha m ber mode l . There
was no reformation a n d reperfusion of blood vessels after
treatment with P O L fol l owed by topical ra pamyc i n for
14 d ays, i n contrast to P O L a l o n e . With extreme ca ution
to avo i d sca rring and dyspigmentatio n , it is poss i b l e to
treat P O L-resista nt PWS and deeper or hypertro p h i c
a d u lt P W S su ccessfu l ly w i t h longer wavele ngth lasers that
a l low d eeper penetration i nto the skin such as l ongp u l sed a l exa n d rite (755 n m ) laser, long-pu lsed N d :YAG
( 1 , 064 n m ) laser, and d u a l 595- n m P O L a n d 1 ,064- n m
N d :YAG laser cou pled w i t h adeq uate coo l i ng. U s e o f t h e
N d :YAG laser can be treac h e rous as there is a narrow
thera peutic ra nge. R isk of sca r ca n be sign ificant.

Light treatment: i ntense pu lsed l ight ( I P L ) may be effec


tive in treatment of PWS , i n c l u d i n g P O L- resista nt PWS .
A green-ye l l ow waveband a n d lowest ava i l a ble p u lse

B
Figure 34.2 (A) Extensive port-wine stain on the right face and forehead

of an infant male. (8) Significant resolution after multiple treatments


with pulsed dye laser

1 86

Color Atlas of Cosmetic Dermatology

d u ration s h o u l d be used , with s k i n coo l i ng. A recent


ra ndom ized c l i n ical tria l com pa r i ng P O L a n d I P L side
by side revea led a better efficacy a n d h igher patient
preference after POL treatment. P h otodyna m ic thera py
may a lso prove to be an a lternative efficacious treat
ment for PWS .

Other treatment modal ities for PWS that can be effec


tive i n c l u d e tattooing a n d cosmetic m a keu p .

P I T FALLS TO AVO I D

Patients s h o u l d be cou nseled that PWS d isplay a va ri


a b le response to treatment. M o re extens ive and th icker
lesions respond less wel l when com pa red to su perfi c i a l
lesions. Fac i a l PWS responds best. P W S treatment effi-

cacy decreases as one d escends from face to feet, with


the lower extre m ities d isplaying the least treatment
benefit.

M u lt i p l e treatment sessions may be req u i red . B r u i s i n g


is a necessa ry side effect t o o bta i n efficacious thera py.

Laser treatment may prod uce "footpri nti ng" or o n ly pa r


tial i m p rovement.

Treatme nts should be ceased when the patient is satis


fied with l ighte n i ng, o r when n o fu rther benefit has
been noted , that is, afte r two su bseq uent treatments.

B I B L I OG RAPHY
Alste r TS, Ta nzi EL. C o m b i ned 595- n m a n d 1 , 064- n m
laser i rrad iation o f rec a l c itra nt a n d hypertro p h i c port
wine sta i n s in

c h i l d ren a n d a d u lts.

Dermatol Surg.

2009 ; 3 5 ( 5 ) : 8 1 3-8 1 5 .
C h a n g CJ , Hsiao Y C , M i h m M C J r, N elson J S . P i lot stu d y

Figure 34.3 (A) Extensive port-wine stain on the right neck of a young

female. (B) Marked resolution of the port-wine stain after multiple treatments with pulsed dye laser

exa m i n i ng the com b i ned u s e o f p u lsed d y e l a s e r a n d topical l m i q u i mod versus laser a l o n e for treatment of port
wine sta i n b i rt h m a rks. Lasers Surg Med. 2008;40(9 ) :
605-6 1 0 .
C h a pas A M , Eickhorst K, G e ron e m u s R G . Efficacy of
early treatment of fac i a l port w i n e sta i n s in newborns: A
review of 49 cases. Lasers Surg Med. 2007;39 ( 7 ) : 563568 .
C h i u C H , C h a n H H , H o WS , Ye u ng C K , N e lson J S .
P ros pective stu d y o f p u l sed d ye laser i n conj u nction with
c ryogen s p ray coo l i n g fo r treatment of port wine sta i ns i n
C h i n ese patients. Dermatol Surg. 2003;29(9):909-9 1 5 .
Discussion 9 1 5 .
Fa u rsc h o u A , Togsverd- B o K , Zachariae C , Haedersdal
M. P u lsed dye laser vs . i ntense p u lsed l ight for po rt-wine
sta i ns : A ra nd o m ized side-by-side tria l with b l i n ded
res ponse eva l uati o n . Br J Dermatol. 2009 ; 1 60(2) :359-

Figure 34.4 (A) Port-wine stain on the lower mucosal and cutaneous lip.

Sect i o n 6: Va sc u l a r A l te rat i o n s

1 87

Ho WS, Ying SY, C h a n PC, C h a n H H . Treatment of port


wine sta i n s with i ntense pu lsed l ight: A prospective study.

Dermatol Surg. 2004;30(6):887-890.


H u i keshoven M, Koste r P H , d e B orgie CA, Beek J F, va n
Gernert M J , va n d e r H o rst C M . Reda rken i n g of port-wine
sta i n s 1 0 years after p u l sed-dye-laser treatment. N Eng! J

Med 2007;356( 1 2 ) : 1 235- 1 240.


Li L, Kon o T, G roff WF, C h a n H H , Kitazawa Y, N oza ki M .
Com parison study of a long-pu lse p u lsed dye laser a n d a
long-pu lse p u lsed a lexa nd rite laser in the treatment of
port w i n e sta i ns . J Cosmet Laser Ther. 2008; 1 0( 1 ) :

12-15.
P h u ng T L , O ble D A , J ia W , B enja m i n L E , M i h m M C J r,
N elson J S . Can the wo u n d hea l i ng res ponse of h u ma n
s k i n b e mod u l ated afte r laser treatment a n d t h e effects of
exposu re exte nded? I m pl ications on the c o m b i ned use of
the p u l sed dye laser a n d a topical a ngioge nesis i n h i bitor

fo r treatment of port wine sta i n b i rth ma rks . Lasers Surg

Figure 34.4 (Continued) (B) Significant lightening of port-wine stain after

Med. 2008;40( 1 ) : 1-5.


Se l i m M M , Ke l l y K M , N e lson J S, We nd elsc hafe r-Cra b b G ,
Ke n n edy WR , Z e l i c kson B D. Confocal m i c roscopy stu d y

three treatments with a combination of pulsed dye laser to the cutaneous lip
and vermilion and long-pulsed 1 , 064-nm Nd: YAG laser to the inner
mucosa/ lip and vermillion

o f nerves a n d blood vessels i n u ntreated a n d treated


portwine sta i ns : Pre l i m i n a ry o bservati ons. Dermatol Surg.

2004;30:892-897.
Ya ng M , Ya roslavsky A , Fari n e l l i , e t a l .

Long-pu lsed

neodym i u m : Yttri u m -a l u m i n u m -ga rnet laser treatment


for port-wi ne sta i n s . J Am Acad Dermatol. 2005 ; 52(3):

480-490.

Figure 34.5 Hypopigmentation, which can be permanen t, after aggres


sive treatment of a PWS in an A frican-American patient

1 88

Color Atlas of Cosmetic Dermatology

CHAPT E R 3 5

Pyoge nic G ra n ulo m a

Pyoge n i c gra n u l o m a ( PG ) c a n be rega rded a s a benign


vasc u l a r tu m o r o r a s a reactive vasc u l a r process a risi ng
at sites of prev i o u s tra u m a or i rritat i o n . PG is a lso k n own
as l o b u l a r ca p i l l a ry h e m a n g i o m a , gra n u l o m a tela ng
iectatic u m , a n d gra n u lo m a gravi d a r u m when p rese nting
o n t h e gi ngiva of preg n a n t wo m e n . I t commonly occ u rs
i n a reas of tra u ma i n c l u d i n g the face a n d finge rs .

EPI D E M I O LOGY
Incidence: c o m m o n
Age: most common i n c h i l d ren a n d yo u ng a d u lts
Precipitating factors: m i nor tra u ma , pregna n cy, laser treat
ment of port-wi ne sta ins, isotretinoin

Figure 35. 1 Classic hemorrhagic pyogenic granuloma

PATHOG E N E S I S
Reactive neovasc u l a rization suggested b y c o m m o n asso
c iation with preexisting tra u m a o r i rritation a n d l i m ited
growth ca pac ity.

PHYS I CAL EXAM I NAT I O N


Red t o violaceous, d o me-sha ped , friable

pa p u l e or

nod u le , 0.5 to 1 . 5 e m i n size, with s m ooth surfa ce that


freq uently ulcerates ( Figs. 35. 1 , 3 5 . 2 and 3 5 . 3 ) .

D I F F E R E N T I A L D I AG N OS ES
N od u l a r a me l a n otic m e l a n o m a , glomus tumor, h e m a n
gioma , sq u a m o us c e l l carci noma ( S C C ) ( F ig. 3 5 . 4 ) ,
nod u la r basa l cel l carc i n o m a , wa rt, bac i l l a ry a ngiomato
sis, Ka posi 's sa rco m a , and m etastatic cancer.

D E R M ATOPAT H O LOGY
Wel l -circ u mscri bed exo phytic l o b u l a r pro l i feration of ca p
i l l a ries with flattened a n d someti mes e roded overlyi n g
epidermis w i t h pe r i p hera l epidermal "colla rettes . "

COU RS E
P G u s u a l l y grows ra p i d ly over the cou rse of weeks o r
months a n d then sta b i l izes. It b l eeds freq u e ntly with
m i nor tra u ma and ca n persist i n d efin itely if n ot treated .

Figure 35.2 Pyogenic granuloma on the palm of a pregnant woman,


bleeding frequently

Sect i o n 6: Va sc u l a r A l te rat i o n s

1 89

MANAG E M ENT

Laser treatment
- Pu lsed dye laser (585--600 n m , 0.45- 1 . 5 ms, 7-10 m m ,
6-- 1 5 J/cm 2, O C O 20-40/20 with or without d iascopy) is
a safe and effective device for the treatment of small
lesions and for ped iatric patients. Seria l treatments are
usua l ly req uired . Treatment is wel l tolerated without
anesthesia. A recent report suggested shave excision
followed by immed iate pu lse dye laser ( P OLl for larger
lesions. POL has been also reported to be effective i n
gi ngival PG. Nd:YAG laser c a n also be effective.
- Carbon d ioxi d e is effective . Lesional flatte n i ng is the
c l i n ica l end point. l ntra l esional l i doca i n e 1% is neces
sa ry prior to treatment. Postoperative ca re req u i res
twice d a i ly cleansing with soa p a n d water a n d a p p l i
cation o f a nt i b i otic oi ntment over a 2 t o 6 wee ks heal
i n g t i m e . Sca r formation is l i kely. A low rec u rrence
rate is noted .

S u rgical treatment: a l l treatments may res u lt in sca r for

Figure 35.3 Pyogenic granuloma overlying a dermal nevus

mati o n .
- Shave exc ision fol l owed b y electrod essication o f t h e
base is t h e proced u re most c o m m o n l y e m p loyed .
Recu rrence is common ( Figs . 3 5 . 5 a n d 3 5 . 6 )
- El l i ptica l exc ision c a n be pe rformed w i t h l o w rec u r
rence but wi l l leave a sca r
- Ligation of the base
- C ryos u rgery

Alternative treatment options i n c l ud e


- l m iq u i m od 5 % c rea m h a s been recently reported to
be effective in ped iatric patients a n d in patients with
recu rrent PG
- l ntralesional i njection of a bsol ute etha nol
- Scleroth erapy with monoetha nola m i n e oleate
- To pica l a l itreti n o i n (9- cis-ret i n oic c i d ) ge l , a d rug that
is used for the treatment of Ka pos i 's sa rcoma

P I T FALLS TO AVO I D

Patients s h o u l d be awa re that rec u rre nce is common


after treatment.

Patie nts s h o u l d be i nformed that all treatments may


result i n sca rring.

Amela notic melanoma as wel l as SCC and other skin can


cers can m i mic PG . A biopsy should be performed for
any suspicious lesions in the a ppropriate c l i nical setti ng.

B I B L I OG RAPHY
B o u rguignon

R,

Paq uet

P,

P i e ra rd - F ra n c h i mont

C,

P i e ra rd G E . Treatment o f pyogen ic gra n u lomas with t h e


N d-YAG laser. J Dermatolog Treat. 2006; 1 7(4) : 247-249 .

Figure 35.4 Pyogenic granuloma mimicking a squamous cell carcinoma

on the left lower mucosa/ lip of a patient with multiple nonmelanoma


skin cancers

1 90

Color Atlas of Cosmetic Dermatology

Fa l l a h H , Fisc h e r G , Zaga re l l a S. Pyoge n i c gra n u loma i n


c h i ld re n : Treatment with to pical i m i q u i m od . A ustralas J

Dermatol. 2007;48(4) : 2 1 7-220


Kha n d p u r S , Sharma VK. S u ccessfu l treatment of m u lti
p l e gi ngiva l pyoge n i c gra n u lomas with p u lsed-dye laser.

Indian J Dermatol Venereal Lepra/. 2008; 74( 3 ) : 275-27 7 .


M a loney D M , S c h m idt J D , D u v i c M . A l itreti n o i n g e l to
treat pyoge n i c gra n u loma . J Am Acad Dermatol. 2002 ;
47( 6 ) : 969-970.
Mats u m oto K, N a ka n is h i H, Seike T, Koiz u m i Y, M i h a ra K,
Ku bo Y. Treatment of pyogen i c gra n u loma with a scleros
ing agent. Dermatol Surg. 200 1 ;27(6) : 52 1 -523 .
R a u l i n C, G reve B , H a m mes S. The combi ned conti n u
ouswave( pu I sed carbon d ioxide laser for treatment o f pyo
gen i c gra n u lo m a . Arch Dermatol. 2002 ; 138( 1 ) :33-3 7 .
S u d A R , Ta n ST.

Pyoge n i c gra n u loma c o m p l icating

p u lsed -dye laser thera py for c h e rry a ngioma . J Plast

Reconstr Aesthet Surg. 2010;63(8) : 1 364- 1368.

Figure 35.5 (A) Shaving a hemorrhagic and painful pyogenic granuloma


on the plantar foot with # 1 5 blade. The specimen was sent for histological
confirmation. (B) Electrodessication of the residual pyogenic granuloma

Sect i o n 6: Va sc u l a r A l te rat i o n s

1 91

Figure 3 5 . 6 (A) Biopsy-proven pyogenic granuloma on the right chin of a


young female. (8) Shave excision of pyogenic granuloma with Derma
Blade (Personna Medical, Verona, VA)

1 92

Color Atlas of Cosmetic Dermatology

CHAPT E R 3 6
Fac i a l

Facial Te l a ngiectasias

tela ngiectasias a re d i lated

vesse ls a p pea ring

su perfi c i a l l y i n the dermis m ostly on the a l a e nas i .


Te la ngiectasias a re a lso c o m m o n i n sca rs a n d va rious
s k i n lesions .

EPI O E M I O LOGY
Incidence: very common
Age: most common i n a d u lts and elderly peop le
Sex, race: n o se x o r ra ce pred isposition
Prec i p itati ng facto rs: c h ro n i c a cti n i c d a mage, rosacea,
and topical steroid use a re the m ost common preci pitat
ing factors. Other less c o m m o n etiologies i n c l u d e hered i ta ry hemorrhagic telengiectasia , Cockayne synd ro m e ,
ataxia telengiectasia ,

B l oo m 's syn d ro m e ,

Roth m u nd

Thomson synd rome, sclerod erma, C R EST syn d rome,


l u pus, a n d ra d iation dermatitis

PHYS I CAL EXAM I NAT I O N


Te la ngiectasias consist o f fi n e , tiny, e rythe matous l i n ea r
vessels, typica l ly 0 . 2 t o 2 m m i n d ia m eter, c o u rs i n g
a l ong the s u rface o f the ski n , w h i c h b l a n c h ea s ily u po n
press u re .

D E R M ATOPAT H O LOGY
D i lated , t h i n-wa lled vessels i n the u p per d e r m i s .

COU RS E
Fac i a l telangiectasias a re usua l ly c h ro n i c i n natu re with
no sponta neous resol ution .

MANAG E M E N T
Fac i a l tela ngiectasias a re freq uently treated for cosmetic
p u r poses . M u ltiple effective treatment opti ons exist.

Laser treatment: m u lt i p l e effective options a re ava i l


a b l e . Patients m u st b e awa re that ove r t i m e they a re
l i kely to d eve l o p more te la ngiectas ias.
- Pu lsed dye lasers ( P D U a re the treatment of choice
for fac i a l telangiectasias ( Figs. 36 . 1-36 . 5) .
The trad itional P D L with a short pu lse d u ration of
0.45 or 1 . 5 ms provides the most effective treatment
for fac i al tela ngiectasias. However, posttreatment
p u r p u ra occ u rs which genera l ly lasts 7 to 14 days

Figure 36. 1 (A) Middle-aged male with multiple facial telangiectasias.


(B) Purpura observed immediately after pulsed dye laser treatment.
(C) Significan t reduction in telangiectasias after a single-pulsed dye

laser treatment

Sect i o n 6 : Va sc u l a r A l te rat i o n s

1 93

N ewer generation 595- n m P D L ( i e , V- bea m or


V- bea m Perfecta lasers, Ca ndela Corp . , Wayl a n d ,
M A l with va ria b l e pu lse d u rations ( 0 .45, 1 . 5, 3, 6,
10, 20, 30, 40 msl can provide a red u ced p u r p u ra
treatment of fac i a l tela ngi ectasias when longer
p u l se d u rations a re util ized , but is somewhat less
effective and u s u a l l y req u i res m u lt i p l e treatme nts

0 C o m m o n ly, s u b p u r p u ric fluences of less t h a n 1 0


J/c m 2 at pu lse d u ration o f 1 0 m s , with a 7-mm
spot size a re util ized .

0 Better efficacy of the va riable-pu lse P D L i n treat


ing fac i a l tela ngi ectasias can be a c h ieved by uti
l iz i n g p u r p u ric fl ue n ces o r by pu lse sta c k i n g with
s u b p u rpuric pu lses (stac ked 2-4 s u b p u p u ric
p u lses at a 1 . 5- H z repetition rate, 7 . 5 J/cm 2 ,
1 0-ms p u lse d u rati o n , 1 0- m m spot size, D C D of

30/20l or by perfo r m i n g m u ltiple passes d u ri n g


the sa m e session .

0 La rger t h icker l i near vessels can be treated with


the newest ge neration 595- n m long- P O L (V- bea m
Perfecta , Candela Corp . , Wayla n d , MAl using a
3

10 mm e l l i ptical spot size, 40- ms pu lse d u ra

tio n , 1 5 to 1 7 J/cm 2 , a n d DCD 30 to 40/20. The


end point is tra nsient b l u ish d a rke n i ng of the
vessel fol l owed by vessel b l a n c h i n g ( Figs . 36.4
and 36. 5 l . T h is treatment may res u lt in m i ld
p u r p u ra in a ro u n d 23% of patients .
Fac i a l edema , eryt h e m a , a n d d iscomfort c a n occ u r
after exte nsive treatment with the p u r p u ra-free va ri
a ble-pu lse PDL. H owever, these u nd es i red effects
a re ge nera l ly better tolerated when c o m pa red to a

p u r p u ra-i n d u c i ng laser treatment


- The va riable pu lse width 1 ,064-n m N d : YAG laser has
prove n to be effective i n the treatment of fac i a l
telangiectasias. S h o rter pu lse w i d t h s w i t h h igher fl u
en ces m ight be n ecessa ry for effective treatment of
s m a l l e r vessels but have an i n c reased risk of bl ister
and scar formati o n . The seq uential d e l ivery of 595and 1 , 064- n m wavelength has been re ported to be
more effective than a single wavelength treatment.
- Freq u e ncy-d o u bled

532- n m

N d :YAG

laser

a lso

cal led potass i u m-tita nyl-p hosphate ( KT P l laser pro


vides effective a bsorptio n of hemogl o b i n with a pu lse
d u ration of 1 to 50 m s m a k i ng it idea l ly su ited to treat
su perfi c i a l vesse ls without p u r p u ra formati o n . Tra c i n g
o f i n d ivid u a l vessels is a usefu l tec h n i q u e for patients
with a counta b le n u m be r of d iscrete , visi ble vesse ls.

Flashla m p ( i ntense pu lsed l ight [ I P Ll l treatment


- I P L provi des a n other effective, p u r p u ra-free method
fo r red ucing fac i a l tel a ngiectasias and

e rythema
( Fig. 36.6l . For exa m ple, fluences of 30 to 40 J/c m 2

with 20-ms pu lse d u ration a re effective with the Starlux


Lux G handpiece ( Palomar Medical Tech nologies,

Figure 36.2 (A) Telangiectasias prior to pulsed dye laser treatment. The
setting was 1 0-mm spot, 595 nm, 8 J!cm2 , 6-ms pulse duration.
(B) Immediately posttreatment. (C) Ten days after pulsed dye laser
treatment

1 94

Color Atlas of Cosmetic Dermatology

B u rl i ngton, M A l . The treatment end poi nt is i m med iate


vessel cleara nce or selective vessel d a rken i ng. M u ltiple
treatments may be req u i red for the greatest treatment
benefit.

Other

treatment

options

include

electrosu rgery,

c ryothera py, a n d i nfi ltration of scleros i n g agents. These


a re less selective, often less effective, a n d more l i kely to
resu lt in sca rring than laser or I P L treatment

P I T FALLS TO AVO I D

Treatment typica l l y is wel l tolerated


O bvious posttreatment p u r p u ra for 7 to 1 4 days with
p u r p u r i c setti ngs is expected

P u r p u ra ca n be avoided by uti l iz i n g non pu rpu ric set

ti ngs at the expense of dec reased efficacy

Fac ia l edema, erythema , a nd d isco mfort can occ u r after


extens ive treatment with the p u r p u ra-free va riable-pu lse
POL

Tela ngiectasias w i l l rec u r over yea rs

Caution in da rker s k i n types

B I B L I OG RAPHY
Bernste i n EF, Kligm a n A . R osacea treatment u s i n g the
new-generation , h igh-energy, 595 nm, long p u lse-d u ra
tion p u lsed -dye laser. Lasers Surg Med. 2008;40(4) : 233239 .
J 0rgensen G F, Hedel u nd L, Haedersda l M . Lo ng-pu lsed

dye laser versus i ntense pu lsed l ight for ph otodamaged


ski n : A ra n d o m ized spl it-face trial with b l i n d ed res ponse
eva l uation . Lasers Surg Med. 2008;40 ( 5 ) : 293-299.
Ka rsa i S , R oos S, R a u l i n C . Treatment of fac i a l te la ngiectasia using a d ua l -wavelength laser system ( 59 5 a n d
1 , 064 n m ) : A ra n d o m ized control led tri a l w i t h b l i nded
res ponse eva l uati o n . Dermatol Surg. 2008;34( 5 ) : 702708 .
R o h re r TE, C hatrath V, Iyenga r V . Does p u lse stacking
i m prove the res u lts of treatment with va ria ble-pu lse
p u l sed -dye lase rs? Dermatol Surg. 2004;30(2, pt 1 ) : 1 631 6 7 . Disc ussion 1 6 7 . 6 .
R oss EV, U e bel hoer N S , Doman kevitz Y . U s e o f a novel
p u lse d ye laser for ra pid s i ngle- pass p u r p u ra -free treatment of te la ngiectases. Dermatol Surg. 2007 ;33( 1 2 ) :
1 466- 1469 .
Sa rradet D M ,
1 064- n m

H ussa i n

M , Gold berg DJ .

neodym i u m :YAG

M i l l isecond

laser treatment of fa c i a l

te la ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58.

c
Figure 36.3 (A) Female with centrofacial telangiectasias and erythema
prior to pulsed dye laser therapy (B) Pulsed dye laser treatment at a
wavelength of 595 nm, 1 O-ms pulse duration, 7 J/cm 2 , 7-mm spot size.
(C) Appropriate clinical endpoint of erythema and slight edema at sites of

treatment. No purpura was produced

Sect i o n 6: Va sc u l a r A l te rat i o n s

1 95

c
Figure 36.4 Telangiectasias prior to long pulse-duration pulsed dye laser

treatment. The settings were 40-ms pulse duration, 7-mm spot, 595 nm,
1 2J!cm2 . (B) Note the transient vasoconstriction with almost complete
disappearance of the telangiectasias immediately posttreatment.
(C) Slight decrease in diameter of the telangiectasias 1 month after one
treatment

1 96

Color Atlas of Cosmetic Dermatology

B
Figure 36.5 (A) Large caliber nasal telangiectasias on the nose prior to

long-pulse duration pulsed dye laser treatment. (B) Decrease in the diam
eter of the telangiectasias after six treatments with PDL using long pulse
duration of 40 ms, 7-mm spot size, and f/uences up to 1 1 . 5 J/cm 2 .

Sect i o n 6: Va sc u l a r A l te rat i o n s

1 97

c
Figure 36.5 ( Continued) {C) Marked resolution of the telangiectasias after

an additional four POL treatments utilizing short pulse duration of 1 . 5


ms, 7-mm spot size, and 1 2Jicm 2

Figure 36.6 Intense pulsed treatment with Starlux (Palomar Inc. ,

Burlington, MAJ of facial telangiectasias. The handpiece is in full contact


with the skin

1 98

Color Atlas of Cosmetic Dermatology

CHAPT E R 3 7

Lowe r Extre mity Tela ngiectasias , R eticula r a nd


Va ricose Veins

Lower extrem ity telangiectasias, ret i c u l a r a n d va ricose


ve i n s d eve l o p as a res u lt of ve nous system i m pa i rment.

E P I D E M I O LOGY
Incidence: very common and the i n c idence i n c reases
with age . R eti c u l a r vei n s can occ u r in up to 10% of c h i l
d ren 1 0 t o 1 2 yea rs old . The i n c id e nce o f va ricose vei ns
in the seventh d ecade is 72% i n wo men a n d 43 % in men

Age: m ore common i n a d u lts a n d e l d erly


Sex: more common i n wom e n
Precipitating factors: fa m i l ia l pred i s position, p reg n a n cy,
static gravitational p ressu res, dyna m i c m uscu l a r forces,
hormonal i nfl ue n ces

PATHOPHYS I OLOGY
Venous

pathology d evelops when

venous

ret u r n

is

i m pa i red for a n y reason .


I t can d evelop from venous o bstruction (thro m botic o r

nonthro m botic ) o r from ve nous va lvu l a r i n com petence.

PHYS I CAL EXAM I NAT I O N


Lower extrem ity te la ngiectasias a re red t o violaceous i n
color a n d u p t o 2 m m i n d i a m eter. R eti c u l a r ve i n s a re
b l u e to b l u e-green in color a n d u p to 4 m m in d i a meter.
Va ricose vei ns a re b l u e to b l u e-gree n in color with a
d ia meter greater than 3 to 4 m m .

LABORATORY DATA
D e r m at o p at h o l ogy
D i lated vasc u l a r c h a n nels in the d e r m i s .

Vasc u l a r St u d i es
Doppler u ltraso u n d a n d/or d u plex sca n n i ng a re i n d i cated
in the fol l owing c l i n ical scenarios:

Asym ptomatic va ricosity greater tha n 4 mm i n d i a meter

Sym ptomatic vei n s

Reti c u l a r, perforati ng, a n d/or va ricose ve i n s

S i g n s o f ve nous i nsufficiency o r stasis c h a nges

Prior h istory of deep vei n throm bosis or t h rom boph leb itis

Prior h i story of sclerothera py with rec u rrences or bad


outcome

Figure 37. 1 (A) Sclerotherapy of spider veins. The needle is bent at a


45-degree angle and the vessel is canalized. (B) Immediate vessel
blanching seen after injecting the sclerosant agent

Sect i o n 6 : Va sc u l a r A l te rat i o n s

1 99

MANAG E M ENT
S c l e rot h e ra py ( F i gs .

37 1 37 3)
.

Sclerotherapy i s the treatment of c h oice fo r lowe r leg


tela ngiectasias a n d reti c u l a r ve i n s . It s h o u l d be repeated
at 6 to 8 week i nterva l s . Patients may req u i re two to six
scleroth e ra py sess ions to ach i eve the greatest treatment
benefit.

S c l erosi n g agents
An ideal sclerosing agent ca uses complete local endothe
l i a l d estruction of the vesse l wa l l with seco n d a ry fibrosis
and

l u men

obl iteratio n ,

with

no

system i c

toxicity.

Sclerosing agents a re classified i nto th ree gro u ps depend


i ng on their mecha nism of action of i n d ucing endoth e l i a l
i nj u ry. These i n c l u d e hyperosmotic agents, d etergents,

and chem ical i rrita nts (Ta bles 37 . 1 and 3 7 . 2 ) . The most
commonly used sclerosa nt agents in the U n ited States a re
hype rto n i c sa l i n e ( HS) a n d sod i u m tetradecyl su lfate
(STS ) . Both HS a n d STS a re FDA a p p roved a n d have low
est i n c idence of a l lergen i city. Sod i u m morrhuate a nd poli
d oca nol a re a lso FDA a p p roved .

S c l erothera py tec h n i q u e for te langiectasias a n d


reticular v e i ns

Fi l l the sclerosa nt agent i nto 3 c m 3 d isposa ble syri nges


with d isposa ble 30-ga uge h a lf i n c h need les.

Swa b the site to be treated with a lcohol to better visual


ize the vesse l s .

Treat l a rger vessels fi rst.

Bend the need le at a 30-d egree a ngle to 45-d egree


a ngle.

Figure 37.2 (A) Spider veins, prior to treatment with sclerotherapy.

Stretc h the s k i n overlying the vessels being treated .

(B) Marked resolution of the spider veins after sclerotherapy treatment

I nsert the need le slowly in the vessel wa l l . Yo u may use


the a i r bo l u s tec h n i q u e by i njecti ng less than 0.5 c m 3 of
a i r in the vessel o r the p u nctu re-fi l l tec h n i q u e relyi ng on
the feel associated with vessel wa l l perforation w h i l e
i nj ecti ng. The em pty vei n tec h n i q u e , performed b y e l e
vati ng the leg a n d gently knead i n g the vei n prior to
i nj ecti o n , a l lows for thro m b u s red uction a n d need fo r
s m a l l e r sclerosa nt vo l u mes. When treat i n g reti c u l a r a n d
va ricose vei n s , aspirate a sma l l a m o u nt o f blood t o con
firm i ntravasc u l a r locati o n .

I nject the sclerosa nt very slowly t o ensu re sufficient


co ntact of the sclerosa nt with the vessel endoth e l i a l wa l l
a n d t o preve nt d i stention a n d r u pture. I nject less t h a n
0 . 5 c m 3 per i njection at 3-cm i nterva ls.

Apply small circular band a i d s , ta ped cotton ba l ls o r


ro l l s at the i njection sites f o r com pression .

Foa m sclerotherapy
A treatment mod ification can be made for la rge r vesse ls
by vigorously foa m i ng a n a i r-sc l e rosa nt solution j ust prior
to i njection to i n d uce a solution that d isplaces b l ood a n d
re m a i n s for a n extended t i m e i n t h e ta rget vessel without

200

Color Atlas of Cosmetic Dermatology

being fl ushed . Theoretical ly, lowe r sclerosa nt conce ntra


tions can be used with a lower i n c i d e nce of pigmentation
and matti ng (Ta b les 37.2 and 3 7 . 3 ) . The foa m i ng d eter
gent of either sotradechol or po l i d oca nol is prepa red by
m ixing the d etergent with a i r ( usua l ly 1 :4 ml ratio of
d eterge nt to a i r) i n a back a n d forth motion using a th ree
way sto p lock u n t i l a foa med e m u lsion is c reated . The
foa m sclerosa nt is i nj ected i n a m a n ner s i m i l a r to that
with other scl erothera py tec h n i q u es .

Postop erative care

Com pression i n c reases the efficacy of sclerothera py


a n d decreases the i nc i d ence of hyperpigme ntatio n .

Elastic com p ression stoc k i ngs ( 1 5-60 mm Hg) a re


h ighly recommended i m med iately fol lowi ng sclerothera py a n d u p to 2 to 3 wee ks after the proced u re , espec i a l l y posttreatment of la rger ca l i be r vesse ls. Fas h i o n
hose ( 1 5- 1 8 m m Hg) a n d Class I h ose (20-30 m m H g )
a re the m ost commonly u s e d grad uated com pression
h ose used postsc leroth erapy of te la ngiectasias and
reti c u l a r vei n s .

Encou rage wa l k i n g to avoid thromboe m bo l i c d iseases .

Avo i d s u n exposu re to m i n i m ize posttreatment hyper


pigme ntation .

C o m p l i cati ons (Ta b l e 37 .3)

Postsc lerothera py hyperpigme ntatio n ( PS H ) : The i nci

Figure 37.3 (A) Lower leg telangiectasias at baseline. (B) Marked resolu

dence of PSH can be u p to 30% d e pe n d i ng on the

tion of the telangiectasias 1 month after one sclerotherapy treatment.


Note the development of slight telangiectatic matting superior to the
treated area

tec h n i q u e used , the size of the treated vessels, the type


of sclerosi n g agent, a n d the solution conce ntratio n .
Postsc lerothera py c o m p ress ion decreases t h e i nc i
dence o f PS H . P S H is caused b y perivasc u l a r d e posi
tion of hemosiderin rather than mela n i n and fol l ows the

TABLE 3 7 . 1

Sclerosi ng Agents

Sclerosa nt c lass
Hyperosmotic agents

Sclerosa nt types

Mecha n ism

Hyperto n i c sa l i ne ( 1 0-30 % )

Dehyd ration

Hyperto n i c sa l i ne ( 1 0 % ) d extrose ( 2 5 % ) (Sclerodex)


Detergents

Sod i u m tetrad ecyl s u l fate (Sotradechol, Thromboinject)

S u rface tension c h a nge

Polid oca nol (Aethoxysc lero l , Aetoxisc l e ro l , Sclerove i n )


Sod i u m morrh uate (Scleromate)
Etha n o l a m i n e oleate
C h e m i c a l i rrita nts

Polyiod ide iod i d e (Va rigloba n , Va rigl o b i n , Sclerod i n e )

Corrosives

G lyceri n ( 7 2 % ) w i t h 8% c h rom i u m potass i u m a l u m ( C h ro m ex)

TAB L E 37.2

Recommended Sclerosa nt Concentration

Sclerosa nt/rec o m m e nded


concentratio n

Te la ngiectasias

Reti c u l a r vei n s

Va ricose ve i n s

Dose l i m itatio n

Hyperto n i c sa l i ne

1 1 . 7-23.4%

23.4%

N ot commonly used

6-1 0 m L o f 18-30%

Sod i u m tetrad ecyl su lfate

0 . 1 -0 . 5 %

0.3-0 . 5 % , 0 . 1 -0 . 2 5 % foa m

0 . 5-3 % , 0 . 5- 1 % foa m

1 0 ml of 3 % sol ution

solution

Sect i o n 6: Va sc u l a r A l te rat i o n s

TAB L E 3 7 . 3

Com p l ications of Sclerotherapy

Sclerosa nt

Al lerge n i city

Hyperto n i c sa l i ne

C ra m pi n g

Pa i n

Hyperpigmentati on

Te la ngiectatic matting

S k i n necrosis

+ An a p hylaxis

Sod i u m tetrad ecyl s u l fate

( ra re, < 0.01 % )

cou rse of the treated site. The pigme ntation usua l ly


resolves in 6 to 12 months. It can i m prove with the use
of i ntense pu lsed l ight ( I P U .

Tel a n giectatic matting (TM ) : T h e i nc i d e n ce o f T M can


be up to 16%. It consists of a network of b l u s h - l i ke, fine
( <0 . 2 mml tela ngiectatic vessels s u rrou n d i n g a p revi
ously treated a rea , occ u rring with i n days to months
after sclerothera py. They u s u a l l y reso lve with i n 3 to
12 months. P red ispos i n g factors i n c l u d e pregna ncy,
o besity, hormona l thera py, a n d fa m i ly h istory of tela ng
iectasias. TM can i m p rove with p u lsed dye laser or I P L .
Ways t o avo i d thi s com p l ication i nc l ude
- Lower i njection pressu re
- Lower sclerosa nt vol u m e ( u p to 1 . 0 m L per i njection
site)
- Lower sclerosa nt concentration
- Li m iti ng blanching ( u p to 1-2 e m )

S k i n nec rosis a n d u l ce ration : Necrosis ca n occ u r sec


o n d a ry to extravasatio n of the scleros i n g agent i nto the
tiss u e , rega rd less of the tec h n i q u e used o r the scle
rosa nt type . To m i n i m ize extravasation, the s u rgeo n
s h o u l d sto p the i njection when encou nte r i ng
- Eve n sl ight resista nce to i njection
- Bleb formation
- I n c reased pa i n reported by the patient
If extravasation is recogn ized i m med iately, the s u rgeon

can i nject normal sa l i n e at the site o r a p ply 2 % n itroglyc


e r i n paste .

Other com pl ications i n c l u d e pa i n a n d c ra m pi ng (com


m on ) ,

20 1

a l l ergic

reactions

( ra re ) ,

su perfi c i a l

t h rom

boph l e b itis (up to 1 %), a n d t h ro m boe m bo l i c reactions


(very ra re ) .

Laser a n d I n te n se P u l sed L i g ht

T h e ra p i es ( F i gs .

37.4

and

3 7 . 5)

Lasers a n d I P L sou rces can occasionally be successful i n


t h e treatment o f lowe r extrem ity tela ngi ectasias a n d retic
u l a r vei ns, espec i a l l y when coupled with lo nger p u lse
d u ration a n d coo l i n g d evices. They a re considered sec
ond-line treatment after sclerothe ra py. Wavelengths in the
ra nge of 500 to 1 , 1 00 nm a re most effective , with shorter
wavelengths [eg, pu lsed dye laser ( P O l l , potassi u m tita nyl
phosphate ( KTP)l being used for red su perficia l blood

Figure 37.4 (A) Marked erythema immediately after pulsed dye laser

treatment to lower extremity spider veins.

202

Color Atlas of Cosmetic Dermatology

vesse ls a n d longer wavelengths (eg, 755- n m Alexa n d rite


laser with around 60 ms pu lse d u ration , 1 064 N d : YAG
laser) for b l u ish deeper blood vessels. I n d ications for
laser/ I P L treatments i n c l u d e the fo l l owing:

Need le phobic patients

Vessels res ista nt to sclerothera py

Vesse ls located below the a n kle

TM

Propens ity f o r P S H or T M

A m b u l atory P h l e b ecto m y,

E n d ovasc u l a r Tec h n i q u e s , S u rg i c a l
L i gat i o n/Str i p p i n g
M u ltiple treatment options exist for va ricose vei n s i n c l u d
ing a m b u latory p h l e bectomy, endovasc u l a r laser a blatio n ,
endovasc u l a r rad iofreq uency obl iteratio n , as wel l as s u rgi
ca l l i gation and stri pping proced u res. A m b u latory ph le
becto my can be used for l a rge va ricosities. Endovenous
occ l usion ca n be ach ieved with rad iofreq uency ( R Fl or
laser sou rces . Either a laser fiber o r a n RF catheter is
i nserted i nto the sa phenous vei n at or j ust below the knee.
Laser systems i n c l u d e 8 1 0- n m d iode, 940- n m d iode,
980- n m d iode, and 1 ,320- n m N d :YAG lasers . These
d evices spa re the

need for genera l a n esthesia a n d

extended recovery t i m e associated with vei n stri p p i ng a n d


l igation . There is l ittle d owntime, with patie nts res u m i ng
normal activities on the same day of the proced u re .

B I B L I OG RAPHY
B a r rett

JM,

Allen

B,

Oc kelford

A,

Gold m a n

M P.

M ic rofoam u ltraso u n d-gu i ded scle rotherapy of va ricose

Figure 37.4 (Continued) (B) Mild reduction in spider veins after a single

vei n s in 1 00 legs. Dermatol Surg. 2004;30( 1 ) : 6- 1 2 .

pulsed dye laser treatment

Coleridge S m ith P. Sclerothera py a n d foa m scleroth e ra py


fo r va ricose ve i ns . Phlebology. 2009 ; 24( 6 ) : 260-269 .
Ka h l e B, Leng K. Efficacy of sclerotherapy i n va ricose
vei ns-prospective, b l i nded , placebo-controlled stu dy.

Dermatol Surg 2004;30( 5 ) : 723-728.


Kern P, Ra melet AA, WOtsc hert R, H ayoz D . Com pression
after sclerotherapy for tela ngiectasias a n d reticu l a r leg
vei n s : A ra nd o m ized control led stu dy. J Vase S u rg .
2007;45(6) : 1 2 1 2 - 1 2 1 6 .
Morrison N , Neuhardt DL. Foa m sclerothera py: Cardiac
and cerebra l mon itori ng. Phlebology. 2009;24(6) :252-259 .
R oss EV, Meehan KJ , G i l be rt S , Doman kevitz Y. O pti m a l
p u l se d u rations f o r the treatment o f l e g te la ngiectasias
with a n a lexa nd rite laser. Lasers Surg Med. 2009 ;4 1 (2 ) :
1 04- 109.

Figure 37.5 Postinflammatory changes after laser leg vein treatment

Sect i o n 6: Va sc u l a r A l te rat i o n s

CHAPT E R 38

203

Ve n o us La kes

Venous la kes a re benign vasc u l a r lesions that resu lt from


d i lated ven u les. They commonly affect the l i ps , face, a n d
ears.

EPI D E M I O LOGY
Incidence: common
Age: m ost c o m m o n l y o bserved i n the e l d erly
Precipitating factors: may be related to sun exposu re

P H YS I CAL EXAM I NAT I O N


Venous Jake presents as dark b l u e t o violaceous, e l e
vated , soft, a nd easily compress i b l e papule or nodule.

D I FFERENTIAL D I AG N OS ES

Pyoge n i c gra n u lo m a , m e l a n o m a , labial melanotic mac

ule, atypical nevus, hema ngioma .

D E R M ATOPATHOLOGY
D i lated t h i n-wa l led ve n u l es in the s u pe rfi c i a l d e r m i s .
T h rom bosis may be o bserved .

EPI LU M I N ESCENCE M I CROSCO PY


Epi l u m i nescence m ic roscopy ( ELM ) revea ls erythema
tous glo b u l es with n o pigmenta ry network. It is hel pful in
d ifferentiati ng this vasc u l a r lesion from a m e l a n ocytic
lesion .

Figure 38. 1 (A) Venous like on the lower lip of an elderly man.
(B) Marked resolution of the venous Jake after m ultiple treatment ses

CO U RS E
They u s u a l l y persist for yea rs a nd c a n bleed afte r tra u m a .

MANAG E M ENT
Venous la kes a re freq u e ntly treated for cosmetic p u r
poses. M u ltiple treatment options exist.

Light treatment
- Lasers ( Figs . 38. 1-38.3 )
P u lsed d y e laser ( 585--5 95 n m , 0.45-- 1 . 5 m s , 5-1 0

m m s pot, 7- 1 0 J/cm 2 , D C D 30-40/20, with a n d

without d iascopy). Pulsed dye laser provides incon


sistent benefit for venous Jakes.

sions with the pulsed dye laser

204

Color Atlas of Cosmetic Dermatology

Diode laser (800--8 1 0 n m , 30 ms, 30-50 J/c m 2 )


can a lso be a very effective treatment. It is h e l pfu l
to a l low 3 seconds of compression of the lesion with
the c h i l l tip prior to the laser p u lse. A physical
" k i c kback" is often felt by the laser s u rgeon at the
t i m e of the pu lsatio n . The c l i n ical e n d point is
i m med iate p u r p u ra .
Long- p u lsed N d : YAG laser a n d i ntense p u lsed l ight
( I P U have a lso been re ported to be effective .

Sc lerotherapy: I n one study, i ntra lesiona l i njections with


1% pol i d oca nol have been shown to be effective i n
clearing two ve nous la kes after two sessions o f scle
rothera py. A scar was noted to occ u r i n one patient.

Electrosu rgery, s u rgical excisio n , c ryothera py a re other


a lternate treatment o ptio n s . H owever, these modal ities
can res u lt i n a sca r.

P I T FALLS

Often req u i res seve ra l treatments with laser.

A l l thera peutic modal ities may prod uce a scar.

B I B L I OG RAPHY
B e k h o r PS.

Long- p u lsed

N d : YAG laser treatment of

venous l a kes: R e port of a series of 34 cases. Dermatol

Surg. 2006;32(9 ) : 1 1 5 1 - 1 1 54 .
Jay H , Borek C . Treatment o f a ve nous- l a ke a ngioma with
i ntense p u lsed light. Lancet. 1 998; 3 5 1 (9096) : 1 1 2 .
K u o HW, Ya ng C H . Ve nous l a ke o f t h e l i p treated with a
scleros i n g agent: Report of two cases. Dermatol Surg.
2003 ; 29(4) :425-428 .
Wa l l TL, G rassi A M , Avra m M M . Cleara n ce of m u lti p l e
ve nous la kes w i t h a n 800-n m d iode laser: A novel
a p proa c h . Dermatol Surg. 2007;33( 1 ) : 1 00- 1 03 .

Figure 38.2 (A) Venous lake on the upper lip. (B) Five-month follow-up

demonstrating complete resolution of the venous lake after a single treat


ment with an 800-nm diode lase, 30-ms pulse duration, at energy set
tings of 45 J!cm2 (one pulse), and 50 J!cm2 (one pulse)

Sect i o n 6: Va sc u l a r A l te rat i o n s

205

(_ _)

C ross sect ion of l i p

Com press ion a p p l i e d

Figure 38.3 Clinical efficacy of pulsed dye laser for a venous lake with

compression of the vessels during treatment versus no compression

Diode

'

(800 nm)

Pu I sed d ye laser
( 59 5 n m )

Laser penetrat i o n : p u l sed dye vs d iode

Figure 38.4 Pulsed dye laser does not penetrate deep enough.

Compression is needed. Diode laser penetrates deeper and therefore is


more effective than PDL

206

Color Atlas of Cosmetic Dermatology

CHAPT E R 39

Wa rts

V i ra l wa rts a re caused by h u ma n pa p i l lo maviruses ( H PV) .


Va rious types of H PV- i n d u ced wa rts exist i n c l u d i ng com
mon wa rts (70% of all wa rts ) , pa l m o p l a nta r wa rts, plane
wa rts, a n d ge n ita l wa rts .

EPI D E M I O LOGY
Incidence: c o m m o n
Age: c h i l d ren a n d a d u lts
Precipitating factors: s k i n tra u m a , i m m u nosu p p ression
( H IV a n d tra nsplant patients ) , genetic pred is position
( e p i dermodysplasia ve rruc iform is)

PATHOG E N E S I S
H PVs a re nonenvelo ped d o u ble-stra nded D N A vi ruses

that prod uce i nfection a n d i n d uction of hyperprol ife ratio n


w h e n the v i r u s enters prol ife rating basa l epithe l i a l c e l l s .
Avo ida nce o f h ost i m m u n e s u rve i l l a nce occ u rs . Exact
mec h a n isms of i nfectio n , latency, a n d reactivation of
H PV a re u n known .

PHYS I CAL EXAM I NAT I O N


Warts present as s i ngle o r m u lt i p l e hyperkeratotic, exo
p hytic , skin-colored pa p u les, nod u l es or plaq ues. They
can have finger- l i ke proj ections (fi l iform wa rts) or ca n be
flat-top ped ( p l a n e wa rts ) . B l a c k p u n ctate d ots re present
ing t h rom bosed ca p i l l a ries a re observed freq ue ntly. They
m ost commonly present on fi ngers, d o rsal h a n d s , pla nta r
su rfaces, a n d press u re a reas.

D I F F E R E N T I A L D I AG N OS ES
Hypertro p h i c

acti n i c

keratosis,

seborrheic

keratosis,

sq u a m o u s cell c a rc i n o m a , verrucous ca rc i n o m a , a n d
a c ra l a mela notic melanoma . Pla nta r warts can a lso be
m ista ken for corns o r call uses .

D E R M ATOPAT H O LOGY
The e p i d e r m i s featu res hyperkeratosis, aca nthosis, pa p i l
lomatosis, with tiers o f pa ra ke ratos is, va l l eys o f hyper
gra n u losis and koi locytosis. The d e r m i s featu res d i lated
ca p i l l a ry loops and hemorrhage.

Figure 39. 1 (A) Verruca vulgaris on the left thumb immediately

posttreatment with pulsed dye laser, 590-nm wavelength, 7-mm spot


size, 1 0 J!cm2 , with pulse stacking. (B) Five-month follow-up with com
plete resolution of the wart after single pulsed dye laser treatment

Sect i o n 6 : Va sc u l a r A l te rat i o n s

207

CO U RS E
They ge nera l ly resolve sponta neously i n i m m u nocom pe
tent patients, but this may ta ke yea rs . They tend to per
sist a n d resist treatment in i m m u nosu p pressed patients.
Auto i n ocu lation by scratc h i ng may occ u r.

MANAG E M ENT
There is n o c u rrent s pecific a ntivi ra l thera py fo r H PV.
There a re m u ltiple treatment options that either i n d uce
loca l physical destruction of the warts or sti m u late the
i m m u ne

response

aga i nst

H PV

i nfection

or

both .

S q u a m o u s cell carc i noma ca n a rise from some lesions,


that is, condylomata a nd epidermodysplasia ve rruci
fo rmis and req u i re conti n uous mon itori ng. H i stologica l
eva l uation s h o u l d be considered for wa rts that a re u n re

spons ive to m u lt i p l e treatment modal ities to r u l e out


m a l i gna n cy.

To p i c a l Treat m e n t
Patients should b e ed ucated a s t o the vira l , i nfectious, a n d
recu rrent natu re o f H PV despite therapeutic i ntervention .
Patients m ust also be i nformed of the need for repetitive
treatments for a l l treatment modal ities employed . M u ltiple
effective topica l treatments exist. There is n o current treat
ment of choice.

Loca l ized tissue destructi o n : sa l icyl ic a c i d , 5% ca n


t h a rone, tric h loracetic a c i d , a n d 0 . 5 % pod o phyl lotox i n
a re e m p l oyed d a i ly. Loca l ized wa rt occ l usion w i t h d u ct

ta pe has d e m onstrated efficacy in a study. S u r ro u n d i ng

Figure 39.2 (A) Verruca vulgaris on the left middle finger resistant to

normal tissue may d e m onstrate te m po ra ry m aceration

multiple treatments with cryotherapy. (B) Marked resolution of the wart


after three POL treatments.

d u ring treatment.

Vi ra l cell d ivision a lterati o n : i ntra l es i o n a l bleomyc i n (0.4


mg/m U

in

normal

prese rved sa l i n e ;

5-fl uoro u ra c i l

crea m .

I m m u ne mod ulation : to pical i m i q u i m od has demon


strated effica cy.

S u rg i c a l Treat m e n t

Lasers (Ta b l e 39. 1 )


TAB L E 39 . 1

Laser Treatment of Wa rts


PDL

C02
Effective

Efficacy

Va r i a b l e

Average n u m be r of sessions

2-1 2

1-3

Anesthesia needed

Occasionally

Yes

Sca rring risk

Low

H igh

Dysc h ro m i a risk

Low

Moderate

I nfection risk

Low

Low

Pa i n

Moderate t o h igh

M i n i m a l to h igh

208

Color Atlas of Cosmetic Dermatology

P u lsed d ye laser ( P D U ( Figs . 39 . 1-39.4)


- PDL is the m ost commonly e m p l oyed laser for wa rts .
It may i n d uce a therapeutic res ponse by vasc u l a r
a bsorption o f laser l ight prod u c i n g therma l nec rosis
of wa rt tissue as wel l as by i nd uction of a host
i m m u ne res ponse. C l i n ical i m provement is va ria b l e .
P D L is ge nera l ly uti l ized after fa i l u re o f fi rst- l i n e
thera pies.
- PDL protocol
P rotective laser masks, gloves , and gowns as wel l
as u s e o f a smoke eva c uator a re reco m mended to
avoid tra nsm ission of the wa rt virus.
The hyperkeratotic portion of the wart should be
pa red prior to treatment. B leed i ng is to be avoided, as
this w i l l m i n i m ize laser l ight a bsorption by the wa rt.
H igh fluences (585-595 n m , 0.45- 1 . 5 ms pu lse

d u rati o n , 8- 1 5 J/cm 2 ) a re typica l ly req u i red for


effective treatment. M u ltiple p u lses a re m ost effec
tive,

but

should

be

performed

with

caution .

Figure 39.2 (Continued) (C) Recurrence of the wart after six POL

treatments

Diascopy with p u lses s h o u l d be considered . Treat


1 to 2 m m of s u r ro u n d i ng healthy ski n .
Treat u n t i l lesiona l p u r p u ra i s a pparent.
Re petitive treatments spaced 3 weeks a pa rt a re
genera l l y o pti ma l . Longer i nterva ls between treat
ment sessions may fac i l itate wa rt regrowth a n d
shorter i nterva ls m a y preve nt com plete hea l i ng.

Carbon d i oxide laser (C0 2 )


- C0 2 laser treatment is gen e ra l ly reserved for reca lci
tra nt, widesprea d , pai nfu l , o r hyperke ratotic warts
- Adva ntages : h igh success rate u s u a l l y after one or
two sess ions, no bleed i n g
- Disadva ntages: u n known haza rd o f H PV i n laser
p l u me, risks of dysc h ro m i a , rec u rrence and i nfec
tio n ; pro l onged hea l i ng t i m e of weeks to months;
resid u a l sca rring that can be pa i nfu l ; risk of perma

nent nail dystrophy with peri u n g u a l treatment


- C0 2 protocol

P rotective laser masks, gloves, and gowns as we l l as


use of a sm oke evac uator a re reco m mended to avoid
tra n s m ission of the wa rt virus.

Ad m i n ister i ntra lesi o n a l i nfi ltrative a n esthesia or a d igi


ta l block ( 1 % l id oca i n e with or without 1 : 1 00,000 epi
nephrine).

Va porize the wart a n d a 2- t o 5-m m marg i n u nt i l t h e s u r


face is cha rred ( U itra pu lse CW defocused , 1 5-20 W;
Sharplan su perpu lsed mode, 1-2 mm spot, 5-1 5 W).

Remove the c h a r by r u b b i ng a sa l i ne-soa ked ga uze


pad . Al low the a rea to d ry.

Reva porize the wa rt as a bove with c h a r remova l


between passes u nt i l tissue sepa ration occu rs a n d nor
m a l tissue is observed .

Figure 39.3 (A) Plantar verruca with characteristic thrombosed capillaries.


(8) Paring of wart with # 1 5 blade prior to pulsed dye therapy

Sect i o n 6 : Va sc u l a r A l te rat i o n s

209

N o n laser surgi cal moda l ities

C ryothera py with l i q u i d n itrogen is the most com m o n l y


e m p l oyed

s u rgica l

treatment

modal ity

em ployed .

Treatment benefit is d e pendent on ice crysta l - i n d uced


cell death as wel l as the i n d u cti on of a host i m m u n e
res ponse.
- Treatment may be d e l ivered via a c ryos u rgica l u n it
( B ry m i l l C ryoge n i c Syste ms, E l l i ngto n , CTJ or via a
cotton -t i p ped a p p l i cator, d i psti ck , or forceps.
- A s i ngle o r d o u ble 5 to 15 seco nds freeze-thaw cycle
may be d e l ivered d e pe n d i ng o n the treatment s ite
a n d lesion thickness. T h i c ker lesions a n d pla nta r
lesions req u i re more aggressive treatment. M u ltiple
treatment sess ions a re genera l ly req u i red .
- Treatment

may

i n d uce te m pora ry or

pe rmanent

hyperpigmentatio n a n d hypopigmentati o n , bl istering


and sca r formatio n .

El ectrodessication a n d c u rettage a n d s u rgica l excision


have a lso been e m ployed with va ria ble res ponse.

P I T FALLS TO AVO I D

Be very awa re of the d e pth of d estruction with C02


laser. As you go below the pa p i l l a ry dermis, the risk of
sca rri ng a n d d ysc h ro m i a i n c reases.

Patie nts m u st be awa re that sca r formation is l i kely a n d


m a y b e pa i nfu l . Pa i nful sca rring is m ost c o m m o n on
pressu re-bea ring a reas.

Recu rrences most freq uently occ u r at the wou n d edge .


Treating a m a rg i n of normal s k i n m i n i m izes t h i s risk.
- C ryothera py c a n prod uce pigment cha nges a n d sca r
- I m p rovement is va riable with a n y treatment modal ity
- Warts ca n rec u r after a n y treatment

B I B L I OG RAPHY
Pa rk H S , Choi W S . P u lsed dye laser treatm ent for v i ra l
wa rts : A stu dy o f 1 2 0 patients. J Dermatol. 2008;35(8) :
49 1 -498 .
Schell haas U , Gerber W , H a m mes S, Oc kenfels H M .
P u lsed dye laser treatment i s effective i n the treatment of
reca lc itra nt v i ra l wa rts . Dermatol Surg. 2008;34( 1 ) :67-72.
Sero u r F, Somekh E. S uccessfu l treatment of reca lcitrant
wa rts i n ped iatric patie nts with carbon d ioxid e laser. Eur J

Pediatr Surg. 2003; 1 3(4) : 2 1 9-223 .


Seth u ra m a n G , R i c ha rds KA, H i remaga lore R N , Wagner
A. Effective ness of p u lsed d ye laser i n the treatment of
reca lc itra nt wa rts i n c h i l d re n .

Dermatol Surg. 2 0 1 0 ;

36( 1 ) : 58-65.
S h u m er SM, O' Keefe EJ . B leomyc i n i n the treatment of
reca lc itra nt wa rts . J Am Acad Dermatol. 1 983 ;9 :9 1 .

Figure 39.4 Mechanism of action of pulsed dye laser treatment of

verruca. (A) The verruca is characterized by a rich vascular supply.


(B) The pulsed dye laser selectively targets the vascular component of the

verruca. (C) The laser light is selectively absorbed by the blood leading
to coagulation of the vessels (0) and resolution of the wart

This page intentionally left blank

S EVE N
B enign G rowths

21 2

Color Atlas of Cosmetic Dermatology

CHAPT E R 40

Angiofi b ro m a

Angiofi broma is a d escri ptive te rm for a gro u p of lesions


with d iffe rent c l i n ical prese ntations but with the sa me
h istopathology. These lesions i n c l ud e fibrous pa p u l e ,
fac i a l a ngiofi broma ,

pea rly pen i l e

pa p u l e ,

adenoma

sebace u m , peri u ngual fibro m a , a n d Koe n e n 's tu mo r.


T h i s c h a pter w i l l foc us on fac i a l a ngiofi broma . Genera l ly,
an a ngiofi broma presents as a 1 to 5 mm s k i n -colored to
e rythematous d o me-sha ped pa p u le on the face. When it
presents as m u ltiple fac i a l lesions, it can be associated
with tu berous sc lerosis o r m u lt i p l e endocrine neoplasia
type 1 ( M E N 1 ) .

EPI D E M I O LOGY
Incidence: c o m m o n
Age: majority i n e a r l y t o m i d c h i ld hood
Figure 40. 1 Patient with n umerous facial angiofibromas. He is noted to

Race: none

have associated tuberous sclerosis

Sex: eq ual
Precipitating factors: tu berous sclerosis, MEN 1

PATHOG E N E S I S
U n known .

PHYS I CAL EXAM I NAT I O N (Fig. 40 . 1)


F i r m s k i n -colored to eryth ematous pa p u l es ( 1-5 m m ) o n
the nose, c h i n , a n d c h eeks, wh i c h may b e a rra n ged
b i latera l ly. I n d iv i d u a l s with tu berous sc lerosis can a lso
have peri u ngua l fi bromas, fi brous plaq ues, a n d ash -leaf
macu les.

D I F F E R E N T I A L D I AG N OS I S
I ntradermal

mela nocytic

nev i ,

a p pend agea l

t u mo rs,

basa l cell carc i n o m a , a c n e vu lga ris

D E R M ATOPAT H O LOGY
A sym metric, we l l-c i rc u mscri bed pa p u l e with a normal to
sl ightly atro p h i c epidermis. The pa p i l l a ry and reti c u l a r
d e r m i s feat u res a prol iferation o f va ry i n g d egrees o f nor
mal b l ood vesse ls with i n a f ibrotic stro m a . The col lagen
fibers a re a r ra nged perpend i c u l a rly to the epidermis a n d
concentrica l ly a r o u n d t h e vessels a n d

h a i r fol l ic l es .

Ste l late-sha ped m u lti n u c l eated fibroblasts may be seen .

Sect i o n 7 : B e n ign G rowt h s

21 3

LABO RATORY EXA M I NAT I O N


I n the sett i n g o f m u lti ple fac i a l a n d/or peri u ngual a ngiofi
b romas, tu berous scl erosis and M EN 1 m ust be i nvesti
gate d . This is best performed by refe rra l to ped iatric
spec i a l ists .

CO U RS E
M u ltiple fac i a l a ngiofi bromas typica l ly p resent i n c h i l d
hood a n d m a y be associated with tu berous sclerosis
( Fig. 40 . 2 ) . Isolated lesions rema i n u ncha nged . F u rther
a ngiofi bromas may d evelop i n a d u lthood .

KEY CO N S U LTAT I V E QU EST I O N S


A

Onset a n d location o f lesions

Fa m i ly h i sto ry of s i m i l a r lesions

Fa m i l y h i sto ry of cancer

Associated centra l nervous system d i sorders

MANAG E M ENT
There is no med ical i n d ication t o treat a ngiofi bromas.
Thei r cos metic a p pea ra nce, however, may be stri k i n g
a n d u n d e rsta nda bly concern i n g t o s o m e i n d ivid u a l s .

Treat m e n t
M u ltiple treatment modal ities a re ava i la bl e . Recu rre n ce
rate is high with the majority of the treatment option s .
Treatment o pti ons may be c o m b i ned for the best treatment outco m e .

S u rgical
- Shave excision-outl i n e lesion prior to a p plyi ng loca l
a n esthesia as the lesion may b l a n c h after the a nes
thesia is i nj ected
- P u n c h or e l l i ptical excision-l i m ited to isolated few
lesions. R es i d u a l sca r expected
- Electrod essication and c u rettage-may l eave resid u a l
scar

Laser su rgery-best fo r m u lti ple lesions


- P u lsed d ye laser-red u ces the erythematous com po
nent of the lesion on ly. Possi ble lesio n a l flatte n i ng
with use of 5-a m i no l evu l i n ic acid b l u e l ight photody
n a m i c thera py fo l l owed by p u lsed dye laser treatment
- Carbon d ioxide laser ( F ig. 40.3)--conti n uo u s wave
mode most effective . Long-term i m provement has
been see n . Adverse reactions i n c l u d i n g tem pora ry

in

Figure 40.2 (A) Fibrous plaques on the forehead in an adult patient with

F itzpatrick s k i n ph ototypes I l l a n d IV, as we l l as scar

tuberous sclerosis. (B) Fibrous plaques on the scalp. (C) Ash leaf macule
on the leg of the same patient

a n d/or

perma nent dyspigmentation

espec i a l l y

fo rmatio n . Lesional rec u rrence is expected ove r time

214

Color Atlas of Cosmetic Dermatology

- KT P laser-sta c ked p u lses without cool i n g has been


uti l ized with some su ccess . Req u i res two to five
sessions fo r lesional flatte n i ng . Dyspigme ntation a n d
sca r formation a re poss i b l e . Les i o n a l rec u rrence i s
expected

Derma b rasion-s i m i l a r outcome to conti n uo u s wave


ca rbon d ioxi d e laser treatment

P I T FALLS TO AVO I D

Though there a re many treatment modal ities for the


i m provement of a ngiofi bromas, the e n d point is genera l ly
lesion a l flatte n i ng a n d not c lea ra nce. Setting rea l isti c
expectations p r i o r t o treatment is key

Patients m u st be awa re of the l i ke l i hood of lesional rec u r


rence over time. With u n derlyi ng tu berous sclerosis, new
lesions a re l i kely to occ u r

Ab lative thera pies carry a r i s k o f sca rring a n d d yspig


mentatio n . U se of conservative pa ra m eters a re pa ra
mount to avoid potential s i de effects

B I B L I OG RAPHY

Bittencou rt R C , H u i lgol SC, Seed PT, Ca lonje E, M a rkey


AC, Ba rlow RJ . Treatment of a ngiofi b romas with a sca n
n i ng carbon d i oxide laser: a c l i n ico path ologic study with
long-te rm fol l ow- u p . J Am Acad Dermatol. 200 1 ;45 ( 5 ) :
73 1 -735.
Boixeda P, Sanc hez- M i ra l les E, Aza na J M , Arrazola J M ,
Moreno R , Ledo A . C0 2 , a rgo n , a n d pu lsed dye laser
treatment of a ngiofi bromas. J Dermatol Surg Oneal.
1 994;20( 1 2 ) :808-8 1 2 .
Papadavid E, Ma rkey A, B e l l a n ey G , Wa l ke r N P. Carbon
d i oxide and p u lsed dye laser treatment of a ngiofi bromas
i n 29 patients with tu berous sclerosis. Br J Dermatol.
2002; 147(2) :337 -342 .
Tope W D , Kageya m a N . " H ot" KTP-Iaser treatment of
fa c i a l a ngiomata . Lases Surg Med. 200 1 ;29( 1 ) : 78-8 1 .
Wei n berger, C H , End rizzi B . Hook KP, Lee P K . Treatment of
a ngiofi bromas of tu berous sclerosis with 5-a m i nolevu l i n i c
a c i d b l u e l ight photodyn a m ic thera py fol l owed by i m me
d iate pu lsed dye laser. Dermatol Surg. 2009;35( 1 1 ) : 1 849185 1 .

Figure 40.3 (A) Multiple angiofibromas on a 1 6-year-old male with tuber

ous sclerosis. (B) Improvement 2 months after single treatmen t with C02
laser.

Sect i o n 7 : B e n ign G rowt h s

Figure 40.3 (Continued) (C) Partial recurrence of angiofibromas noted

13 months after C02 laser treatment

215

21 6

Color Atlas of Cosmetic Dermatology

CHAPT E R 4 1

B ecke r's Nevus

Bec ker's nevus i s a sharply dem a rcated ta n to brown


patch or sl ightly ra ised ve rrucous p l a q u e that most com
m o n l y a p pea rs o n the s h o u l d e r, c h est, o r u p per bac k . It
typica l l y prese nts u n i latera l ly and is freq u e ntly associated
with overlying hypertrichosis. It is a benign h a m a rtom a .

EPI D E M I O LOGY
Incidence: 0 . 5 % of ma les
Age: teens to t h i rties, ra rely conge n ita l , fa m i l ia l cases
reported

Race: a l l races
Sex: ma les > fem a l es ( 6 : 1 )
Precipitating factors: n o ne

PATHOG E N E S I S
U nclear etio logy. Post u l ated t o have a loca l ized i n c rease
in a n d rogen receptors a n d heightened sensitivity to

Figure 4 1 . 1 Becker's nevus. A slightly raised ligh t-tan plaque with


sharply defined and highly irregular border and hypertrichosis on the
chest of a 35-year-old male (Wolff K, Johnson RA, Suurmond D.
Fitzpatrick's Color A tlas & Synopsis of Clinical Dermatology, 5th ed. New
York: McGraw-Hill; 2005)

a n d roge ns.

PATHOLOGY
There is pa p i l lomatosis, hyperke ratosis, aca nthosis, a n d
basa l layer hyperpigmentati o n . Th ere is a n i nc rease i n
t h e m e l a n i n content o f kerati n ocytes with l ittle or n o
cha nge i n t h e n u m be r o f m e l a n ocytes. A s mooth m uscle
h a m a rto ma is frequently present in the d e r m i s .

PHYS I CAL LES I O N S


They occ u r m ost often on t h e u p per tru n k as a we l l
dema rcated u n i latera l ta n t o d a r k b rown patc h with a
block- l i ke configuration ra nging fro m a few to > 1 5 e m .
Hypertrichosis usua l ly d eve l o ps afte r t h e hyperpigme nta
tion ( Figs. 4 1 . 1 and 4 1 . 2 ) . Ac neiform lesions strictly l i m
ited to a reas of hyperpigmentati on have been reported .

D I F F E R E N T I A L D I AG N OS I S
Congen ita l nevus, cafe a u lait m a c u l e , e p i d e r m a l nevus,
p l exiform neu rofi broma

LABORATORY EXA M I NAT I O N


Physical exa m i nation should b e performed t o r u l e out
associated hypoplasia of the i psi late ra l arm, b reast, a re
o l a , or i psi latera l arm shorte n i n g as wel l as pectus c a r i n a
tu m o r thorac i c scoliosis.

Figure 4 1 .2 Becker's nevus. Large brown plaque that becomes noticeable


at puberty with increased pigment followed by hair growth (Wolff K,
Johnson RA, Suurmond D. Fitzpatrick's Color A tlas & Synopsis of Clinical
Dermatology, 5th ed. New York: McGraw-Hill; 2005)

Sect i o n 7 : B e n ign G rowt h s

217

CO U RS E
It m ost c o m m o n l y p resents a t p u berty a s a u n i late ra l ta n
patc h . Over t i m e , it may develop i nto a plaque a n d d is
play a d a rker b rown h u e . H a i r growth , which becomes
d a rker

and

coarser

over

time,

fol l ows

pigme nta ry

cha nges. They tend to e n l a rge slowly fo r a few yea rs, then
rema i n sta b l e over t i m e . The color may fad e with time;
h owever, the hair growth usua l ly persists.

KEY CO N S U LTAT I V E QU EST I O N S


Onset o f lesion?
I s the lesion sta ble?
I s the pigme nt, the h a i r growt h , or both cosmetica l ly trou
b l i ng?

MANAG E M ENT
T here is n o med ical i nd ication t o treat Becke r's nevus.
The cosmetic a p pea ra nce, however, may d isplease some
i n d ivi d u a ls-most often fem a l es who note its hypertri
chosis. Treatment options a re m u ltiple, but n ot a l ways
effective

i n c l u d i ng camo uflage

m a ke u p ,

electrolysis,

waxi ng, laser thera py, a n d s u rgica l excision . S u rgica l


exc ision is i m practica l for la rger lesions. Laser thera p i es
can be ta i l o red for h a i r rem ova l or pigment resol ution
( Fig. 4 1 . 3 ) .

Laser Treat m e n t

A test site i s reco m m e n d ed before i n itiati ng a n y laser


thera py to assess for efficacy and side effects .

Pigment:

nm),

Q-switc hed

N d : YAG (532 nm or 1 , 064 n m ) , and

Q-switc hed

r u by

(694

Q-switc hed

a lexa n d rite (755 nm) lasers have been reported effec


tive in treating the pigmenta ry com ponent of a Bec ker's
nevus ( Fig. 4 1 .4) .
- I n genera l , res ponse is poor. M u lt i p l e treatments a re
usua l l y req u i red for l ighte n i ng.
- There is a h igh rate of re pigmentation . T h i s is l i kely
d ue to deep hair fo l l ic l e mela nocytes .

Fractionated laser treatm ent: the 1 , 550- n m wave length


fractionated laser has been shown to safely and effec
tively red uce the pigmenta ry com ponent. M u ltiple treat
ments s paced 4 weeks a p a rt were e m p l oyed .

Hair

remova l :

long- p u lsed

a lexa nd rite

a nd

d iode

(800 n m ) lasers can prod uce hair red uction but a re


less effective with long-term pigment l ighte n i ng.

Ablative thera py: Erb i u m : YAG laser (2,940 nm) has


been demonstrated to be more effective than long
pu lsed N d : YAG laser ( 1 ,064 n m ) in s i de by side com
parison treatment of Bec ker's

nevus.

B oth

lasers

Figure 4 1 . 3 Incomplete improvement of Becker's nevus on upper buttock


after three treatments with Q-switched ruby laser. Associated pigmentary
changes noted

21 8

Color Atlas of Cosmetic Dermatology

prod uce e rythema which clears with i n 1 5 days. The

BECKER'S NEVUS

l ong-term c l i n ica l a n d h i stological clearance has been

Therapy di rected toward

noted .

- It is i m porta nt to note that there is a h igh risk of tex

P igmentati o n
Excessive h a i r with i n the lesion

t u re cha nge a n d/or scar formation associated with


a b lative thera py.

I ntense pu lsed l ight has dem o nstrated m ixed success

Pigment reduction

H a i r reduction

Lasers

Lasers

Q-switched R u by, N d : VAG a n d


A l exand rite l asers most effective
Var i a b l e i m provement
R i sk u n even pigment red uction
creat i n g poor cosmet ic res u l t
A b l ative lasers have h igher risk
of side effects

Long p u l sed N d : VAG ( 1 064)


i s t h e least l i kely h a i r
re mova l l aser to cause post
i nflam matory changes.
Long-p u l sed ru by, a l exa nd rite
a n d d iode l asers are more
l i ke l y to cause hypo p igmentati o n
i n a Becker's nevus

in i m prov i n g pigmentation a n d h a i r loss .

P I T FALLS TO AVO I D/CO M PL I CAT I O N S/


MANAG E M E N T/O UTCO M E
EXPECTAT I O N S

Treatment o f t h e pigme nta ry com ponent o f t h e nevus is


often i neffective and rec u rrences a re common

S u rgical

Laser h a i r remova l ca n i m prove overlyi ng hypertrichosis


and is genera l ly perm a n ent i n natu re

Postinfl a m m atory hypo- a n d hyperpigme ntation occ u r


fre q u e ntly, therefore a conservative laser a p p roach is
vita l to m i n i m ize a ny assoc iated pigme nta ry c h a nge

Patie nts with d a rk s k i n p h ototypes (types I V a nd V)


s h o u l d be treated ca utiously and at lowe r fl ue nces, as
t h e i r t h reshold res ponse occ u rs at lower en ergies . A

S e r i a l exc i sion should only be


pursued in lesions of I i m i ted s i ze

Perman e n t hair red uction i s a n effective safe opt i o n for


i m prov i ng a Becker's nevu s. A long p u l sed N d : VAG l aser shou l d
be used .
Laser red uct i o n of t h e p i gmented component is less effecti ve
a n d may prod uce worse cosmetic appeara nce
Any i m provement with l asers a n d pigment red uction may be
tem porary with future recu rrence

conservative laser a p proach is best to avoid posti nfl a m


matory hyperpigme ntation a n d/or hypopigmentation

Figure 4 1 .4 Becker's nevus treatment diagram

Laser treatment should be l i m ited to nonta n ned i n d ivid


u a l s to avo i d tem pora ry or perm a n e n t dyspigme ntation

S u rgical exc ision is d e pendent o n the size and locatio n


o f a l e s i o n a n d is ge nera l ly l i m ited to ve ry sma l l lesions

B I B L I OG RAPHY
Choi J E, Kim J W, S e a S H , S o n SW, A h n H H , Kye Y C .
Treatment o f Becke r's N evi with a Long- p u lse A l exa n d rite
laser. Dermatol Surg 2009;35( 7 ) : 1 105- 1 1 08 .
G l a i c h AS, G o l d berg L H , Da i T, K u n ish ige J H , Fried m a n
P M . Fractio n a l Res u rfa c i n g : A n ew thera peutic modal ity
fo r Bec ker's nevus. Arch Dermatol. 2007 ; 143 ( 1 2 ) : 14881 490.
Kopera

D,

H o h e n l eutner

U,

La ndthaler

M.

Qu a l ity

switc hed ru by laser treatment of sola r lentigi nes a n d


Bec ker's nevus : A h istopathologic a l a n d i m m u n oh isto
c h e m i c a l study. Dermatology. 1997 ; 1 94(4) :338-343 .
N a n n i CA, Alster TS. Treatment of a Becker's nevus u s i ng
a

694- n m

long- p u lsed

ru by

laser.

Dermatol Surg.

1 998;24(9 ) : 1 032- 1 034.


Tre l les

MA,

Allones

I,

M o ren o-Arias

GA,

Ve lez

M.

Becker's nevus: A c o m pa rative study between erbi u m :


YAG

and

Q-switc hed

neodym i u m : YA G ;

h istopathologica l fi n d i ngs .
( 2 ) :308-3 1 3 .

c l i n ic a l

and

B r J Dermatol. 2005; 1 52

Sect i o n 7 : B e n ign G rowt h s

CHAPT E R 42

Epid e rm a l I nclusio n Cyst

The epidermal i n c l usion cyst ( EI C ) , a lso known as seba


ceous cyst and epidermoid cyst, is the m ost common
cyst of the ski n . I t ra nges i n size from a few m i l l i m ete rs to
a few centi meters a n d origi nates fro m the fol l ic u l a r
i nfund i b u l u m . Its contents a re a c h eesy, malodorous m ix
t u re of d egraded l i p i d a n d kerati n . It ofte n ru ptu res, with
associated pa i n and i nfla m matio n .

E P I D E M I O LOGY
Incidence: very common
Age: a d u lts
Race: none
Sex: eq u a l
Precipitating factors: deve l o p sponta neously o r as a res u lt
of tra u m a

PATHOG E N ES I S
Arise from epidermal cells i n the d e r m i s . T h ese cells may
be i m pla nted as a res u lt of tra u ma o r a rise fro m fo l l i c u l a r
i nfund i b u l a r c e l l s . These c e l l s m a y prol iferate as a res u lt
of p i l osebaceous occ l usio n . M u lt i p l e lesions have assoc i
ated with G a rd ner synd rome a n d basa l cell nevus syn
d ro m e .

PATHOLOGY
With i n the dermis o r s u bcuta neous fat, there is a wel l
dema rcated cyst conta i n i ng la m i n ated kerati n debris.
The cyst wa l l is l i ned by stratified sq u a m ous epithel i u m
featu ri ng a gra n u la r c e l l laye r. I n ru ptu red cysts, there i s a
fo reign body gra n u lo matous reaction with m u lt i n u c l eated
giant cells.

PHYS I CAL L ES I ON S
An E I C i s a d o m e-s ha ped , s m ooth , fi r m , we l l -c i rc u m
scri bed m o b i l e nod u l e freq u e ntly protru d i ng a bove the
s k i n s u rfa ce with a ce ntra l pore ( Fig. 42 . 1 ) . T h ey ra nge
in size from a few m i l l i m eters to a few centi m eters . They
ty pica l l y present on h a i r- b ea r i ng s ki n , s u c h as the u p per
tru n k , neck, e a r l o bes, and face. After ru ptu re, th ese
cysts deve l o p a stro ng i nfla m matory reaction as a resu lt
of the s p i l lage of cyst co ntents i nto the d e r m i s . I n t h i s
sett i n g , the cysts become red , i nfla m ed, te n der, a n d
e n l a rged . Periles i o n a l fi b rosis may d evelop with c h ro n i c
i nfla mma ti o n .

Figure 42 . 1 (A) Elliptical excision around epidermal inclusion cyst


punctum. (8) Cyst sac being "delivered" from excision site.

219

220

Color Atlas of Cosmetic Dermatology

D I F F E R E N T I A L D I AG N OS I S
P i l a rs cyst, dermoid cyst, bra n c h i a l c l eft cyst, nod u l a r
f i b r o m a , a n d d e r m a l tu mors m a y c a u s e confusion with
E I Cs . Of these lesions, only E I Cs feature centra l pores.

LABORATORY EXAM I NAT I O N


I n t h e event o f u n ce rta i nty o f d iagnosis, a bio psy c a n be
performed to r u l e out neoplas m .

COU RS E
E I Cs may i n c rease i n size over ti m e , especia l ly with phys
ical

m a n i p u latio n .

These

lesions freq ue ntly become

i nfla med , resu lti ng i n d iscomfort. Fra n k puru lence may


a rise, req u i ri n g i n c ision and d ra i nage.

KEY CON S U LTAT I V E QU EST I O N S

I s t h e lesion recu r rently i nfla med a nd pa i nful?

I s the l esion sym ptom atic?

I s the l esion i n c reasing in size?

Has the lesion been i nflamed before?

Has the lesion been d ra i n ed or exc ised in the past?

Wo u l d the patient prefe r a s u rgica l sca r rather than


kee p i n g the cyst?

Figure 42.2 (A) Removal of cyst with punch biopsy, (B) dissection of cyst

from surrounding skin, (C,O) extrusion of cyst sac

MANAG E M E N T
There is no medical i n d ication t o treat E I Cs i f they a re not
sym ptomatic . The cosmetic a p pea ra nce, however, may
d isplease some i n d ivid u a l s . I n these i nsta nces, s u rgica l
exc ision is the treatment of choice. R u ptu red E I Cs can
prod uce rec u rrent d iscomfort a n d repeated i nfections fo r
some patients. For these lesions, s u rgica l remova l is ben
eficia l . Cyst recu rrence is highest for cysts that have been
i nflamed with the d evelopment of associated fi brosis.

TREAT M ENT

Patient e d u cation is pa ra mount t o avo i d cyst e n l a rge


ment. Disconti n uation of cyst m a n i p u lation red uces the
risk of cyst e n l a rge ment and cyst r u pt u re

S u rgical excision is the treatment of choice for cyst


re mova l

For n o n i nflamed E I Cs
- The cyst m a rgins s h o u l d be pa l pated a n d d e l i n eated
prior to a n esthesia
- The s u rgica l i ncision l i ne s h o u l d tra nsect the epid er
mal pore as poss i b l e

Sect i o n 7 : B e n ign G rowt h s

22 1

- Typica l ly, a s m a l l e l l i ptical-sha ped excision or a sma l l


p u n c h bio psy is performed ove r t h e cyst a ro u n d the
ce ntra l pore ( F igs . 42. 1 and 42 . 2 )
- The cyst s a c is t h e n identified a n d ca refu l l y d i ssected
to kee p the sac i ntact
- Sac remova l may req u i re latera l com p ress ion to
extru d e the cyst. A portion of the cyst co ntents may
be removed to assist i n sac re mova l
- It is i m porta n t to note that short of fu l l remova l of the
entire sac wa l l , there is a l i ke l i hood of rec u rrence.
Consider i r rigation of the wo u nd with sa l i ne if cystic
contents a re noted i n the wou n d
- T h e patient m ust b e awa re o f t h e potentia l dead
space that may resu l t fro m cyst remova l . H ea l i n g in
these i nsta nces may res u lt i n a n i n d e ntatio n of the
affected s k i n

F o r i nflamed E I Cs

- I n the eve nt of an i nfla m ed , i nfected , or newly r u p


tu red cyst, s u rgica l remova l s h o u l d be postponed
u nt i l the i nfection a nd i nflam mation have resolved
- I nflamed E I Cs a re more d iffic u lt to exc ise as they
become more fi rmly a d herent to the s u rrou n d i n g d e r
ma I structu res
- D ra i nage of contents is i m porta nt prior to treating
la rge r i nflamed cysts
- l ntralesional corticoste roids, wa rm com p resses , a n d
a nti biotics ( i n t h e eve nt o f i nfection) c a n a i d i n
decreasi n g i nfl a m mation
- When the i nfla m mation has su bsi d e d , s u rgica l exc i
sion c a n proceed
- Consider a cou rse of postexc isiona l o ra l a nt i b i otics
when cysts a re i nflamed or have d ra i nage

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M ENT/O UTCO M E
EXPECTAT I O N S

I t i s i m porta nt to d iscuss with t h e patient that w h i l e s u r


gica l exc ision of a n E I C is a routi ne s u rgical p roced u re,
the sca r left from the s u rgery may be m o re cosmetica l ly
d istu r b i n g tha n the E I C itse lf.

Patie nts m ust be awa re that cyst rec u rrence may occ u r.

C h ro n i ca l ly i nflamed E I Cs s h o u l d be exc ised to avoid


further i nfl a m mation/i nfectio n .

B I B L I OG RAPHY
M e h ra bi D , Leon h a rdt J M , B rodell RT. R e mova l o f kerati
nous and p i l a r cysts with the p u n c h i ncision tec h n i q u e :
Ana lysis o f s u rgical outcomes. Dermatol Surg. 2002 ; 28:
673-677 .

Figure 42.3 (A) Epidermal inclusion cyst prior to punch biopsy


(B) Epidermal inclusion cyst immediately following removal. An intact

cyst sac decreases the risk of cyst recurrence.

222

Color Atlas of Cosmetic Dermatology

Rao K, Teh ra n i H . Exc ision of epidermoid cysts with a


minimal

l i nea r

incision.

Dermatol Online J.

2006;

1 2( 1 ) : 2 1 .
S m oot EC . R e mova l of la rge i n c l usion cysts with m i n i ma l
i n c ision sca rs. Plast Reconstr Surg. 2007; 1 1 9 (4) : 1395.
Wad e C L , H a l ey JC, H ood AF. The util ity of s u b m itti ng
epidermoid

cysts

fo r

h i stologic

exa m i nation .

lnt J

Dermatol. 2000;39 : 3 1 4-3 1 5 .

CHAPT E R 43
Epidermal

nevus

(EN)

is a

Epid e r m a I Nevus
ben ign

h a m a rtomato u s

growth . I t presents as a gro u p o f verrucous, c l osely


grou ped , skin-colored to b rown pa p u l es often in a l i near
a rra ngement fol l owing the Lines of B lasc h ke ( F ig. 43 . 1 ) .
It d eve lops p r i m a r i l y i n c h i l d h ood . There a re severa l va ri
ations of EN i nc l u d i n g loca l ized nevus u n i us lateris, sys
tematized

EN,

EN

synd rome,

and

i nfla m m atory

verrucous epidermal nevus ( I LV E N ) ( F ig. 43 . 2 ) .

EPI O E M I O LOGY
Incidence: 0 . 1 % of b i rths
Age: majority in the fi rst yea r of l ife; few d evelop in
p u berty

Race: none
Sex: fe male pred o m i n a nce i n I LV E N
Precipitating factors: u s u a l l y spora d i c ; fa m i l ia l cases
reported

PATHOG E N E S I S
E N i s c reated b y overprod u ction of kerat i nocytes from
p l u ri potent e m b ryon i c epidermal basa l kerat i n ocytes.
Genetic mosa i cism is thought to be respons i b l e for most
epidermal nevi .

PATHOLOGY
Pa p i l lomatosis, aca nthosis, epidermal hyperplasia , a n d
hyperkeratosis a long with elongated rete ridges a re p re
sent. In some lesions, epidermolytic hyperkeratosis a n d
va ria ble pa ra keratosis m a y b e prese nt. If t h i s fi n d i n g i s
m a d e i n t h e setting o f m u ltiple epidermal nev i , ge n etic
cou nsel i n g s h o u l d be offered i n o rd e r to ed ucate patients
as to the risk of e p i d e rm olytic hype rkeratosis in offspring.
Neoplasms s u c h as keratoacanthoma , basa l cell carci
n o m a , and sq u a m o u s cell ca rc i noma may rarely d evelop
i n assoc iation w i th epidermal nevi .

Figure 43 . 1 Young man with epidermal nevus limited to his neck nape

Sect i o n 7: B e n ign G rowt h s

223

PHYS I CAL LES I ON S


Com m o n ly p resent a s a si ngle l i n ear les i o n , a lthough
u n i latera l o r b i latera l l i ne a r plaq ues may be prese nt.
M ost cons ist of m u lt i p l e , we l l - d efi ned , c l osely gro u ped
l i n ea r, yel l ow, p i n k , or b rown verrucous pa p u les on a n y
b o d y s i t e . E N often fol l ows the L i n es o f B lasc h ko on t h e
tru n k a n d travels longitu d i na l l y on the extre m ities. Size
ca n va ry from a few m i l l i meters to m u ltiple centi m eters .
May t h i c ken a n d become m o re ve rrucous over t i m e ,
espec i a l l y i n flex u ra l regions. Erythema is a c o m m o n fea
t u re of I LVEN .

D I FFERENTIAL D I AG N OS I S
N evus sebaceo us, seborrheic ke ratos is, ve rruca vu l
ga ris, l ich e n striatus, m e l a n ocytic nevus, l i c h e n p l a n u s ,
psoriasis.

Figure 43.2 An extensive epidermal nevus on the left face and left ear

LABO RATORY EXA M I NAT I O N


A biopsy m a y b e i n d icated t o d isti nguish fro m nevus
sebaceo u s o r l i c h e n striatus. Ra rely, basa l cel l and sq u a
mous c e l l ca rc i n o m a may a rise i n E N .

E P I DERMAL NEVUS

U n known et i o l ogy; rare


R a rely, pat ients have an assoc i ated syn d rome with C N S ,
oc u l a r, m uscu l oskeletal cha nges
Deta i l ed rev i ew of systems and eva l uation by ped i atrics w i t h
appropri ate d i agnostic tests shou l d be performed to r u l e out E N
syn d rome

CO U RS E
A n E N ge nera l ly presents a t b i rt h o r c h i l d h ood a s mac
u les i n itia l l y wh i c h th icken ove r time. Eighty percent of
E N s a p pea r with i n the fi rst yea r of l ife . At p u berty, they

te n d to e n l a rge, d a rke n , a n d becom e more verruco u s .


I LVEN may be pru ritic i n nature.

Treatment of an epidermal nevus


Cosmeti c i m provement i s var i a b l e
w i t h a l l treatments

KEY CO N S U LTAT I V E QU EST I O N S

Age o f onset

C N S a bnorma l ities

Skeleta l d efects

Pru ritus

Fa m i ly h i story

P u l sed carbon d ioxide


laser, treatment of choice
with moderate to exce l l e n t
i m provement depen d i ng on
depth of lesion
Les i o n s may part i a l l y rec u r
over t i me
R i sk of dysc h ro m i a or sca rring

MANAG E M ENT

Mechanical

Derma brasi o n- a b lat i ve l asers


provide better contro l

S u rgical excision

L i m ited
Var i a b l e scar fo l lowi ng exc i s i o n

Figure 43.3 Epidermal nevus treatment diagram

I n pati e n ts with m u lti p l e E N s , a thorough exa m i nation


fo r syste m i c a b n o rm a l ities is i n d icated . Th ere is n o
med i c a l i n d ication t o treat E N . The cosmetic a p pea r
a nce, h oweve r, may be both erso m e to the affected i n d i
vid u a l or pa re nts of c h i l d re n with d isfigu r i n g growt h s .
T h e re a re m u lt i p l e treatment m od a l ities for E N i n c l u d i n g
su rgery, d e r m a b ras i o n , to pica l t h era py, a n d laser ther
a py ( F ig. 43 . 3 ) . Patients s h o u l d be c o u nseled that treat
m e n t res u lts a re va r i a b l e . The phys i c i a n

I
Lasers

needs to

c o n s i d e r whether treatment wi l l p rod uce a su perior

224

Color Atlas of Cosmetic Dermatology

o utco m e to n o n i nterve n ti o n . T h e m ost aggressive fo rms


of thera py, laser a b lation and s u rgica l exc i s i o n , ca rry a
h igh risk of sca r fo rmation a n d/or dyspigm entati o n
( Fig. 43 .4) .

TOP I CAL T R EATM E NTS


The fo l lowi ng topica l thera pies provide l i m ited su ccess
for lesional i m provement a n d

may best util ized for

sym ptomatic re l i ef of pru ritus: h igh-potency corticos


teroids, treti n o i n , a n t h ra l i n , 5-fl u o ro u ra c i l , podophyl l i n ,
calci potrio l , a n d 5 % 5-fl uoro u ra c i l .

S U RG E RY

F u l l-th ickness s u rgical excision of EN is c u rative

Postoperative sca r is expected

Cosmesis is va riable

Poss i b i l ity of hypertro p h i c or kel o i d a l sca rring

S u rgical outcome is best for smaller lesions

Excision may be d iffi c u l t for yo u n g c h i l d re n to tolerate

Shave biopsy a n d c u rettage may be too su perfi c i a l ,


rec u rrences l i kely

CRYOT H E RAPY/E LECTROCAUTERYI


D E R MAB RAS I ON
C ryoth era py, e l ectrocautery, a n d dermabrasion have l i m
ited efficacy, a h igh rate o f rec u rrence, a nd h igh r i s k o f a
perma nent pigmenta ry a lteration a n d sca rring.

LAS E R T R EAT M E N T
Laser thera py ca n b e effective i n treat i n g E N . A test site is
reco m m e n d ed prior to treatment

C0 2 laser ( Fig. 43 . 5 )
- Laser a blation c a n p rovide good control o f the d e pth
of treatment
- Treatment d e pth is l i m ited to the pa p i l l a ry dermis i n
order to avoid sca r fo rmation

Erbi u m : YAG laser


Fractio nated a blative laser
- M ost effective for more su perfi c i a l lesions
- Treatment d e pth is l i m ited to the pa p i l l a ry dermis

With a blative laser treatment, there is a na rrow m a rgi n


between successful treatment a nd h a rmfu l side effects
s u c h as sca rri ng a n d perma nent d yspigmentation

Recu rrences a re common after laser treatment

Q-switched lasers

Figure 43.4 (A) Young patient with epidermal nevus syndrome. Note the

extensive nature of these lesions even after several surgical procedures

Sect i o n 7: B e n ign G rowt h s

225

The Q-switc hed a lexa nd rite ( 7 5 5 n m l a n d fre q u e n cy


d o u bled Q-switc hed N d : YAG 532- n m lasers may be
effective for i m p rovement of th i n E N s .

P I T FALLS TO AVO I D

I t is i m po rta nt to i nform patients that treatment may


o n ly be pa rti a l ly successful and may rec u r

Laser treatment o f t h e epidermis a l o n e w i l l res u l t i n


i n c o m plete remova l

Laser treatment beyon d the pa p i l l a ry d e r m i s may res u lt

There is a lways the risk that treatment wi l l prod uce an

Adve rse side effects as d escri bed a bove m ust be

in sca r formation a n d/or d yspigmentation


i nferior res u l t to n o n i nterve ntion
expl a i ned i n d eta i l to patients for rea l istic expectations
rega rd i ng treatment outcom e

B I B L I OG RAPHY
Boyce S , Alster TS. C02 laser treatment o f e p i derma l
nevi : Long-te rm su ccess. Dermatol Surg. 2002 ; 28( 7 ) :
6 1 1 -6 1 4 .
K i m J J , C h a n g MW, Schwayd er T . To pica l tret i n o i n a n d
5-fl uoro u rac i l i n t h e treatment o f l i n ea r verrucous epid er
mal nevus. J Am Acad Dermatol. 2000 ;43 ( 1 pt 1 ) : 1 29132.
Lee BJ , M a n c i n i AJ , R e n u cc i J , Pa l l e r AS, B a u e r B S . F u l l
t h i c kness s u rgica l excision fo r t h e treatment o f i nfla m ma
tory l i near verrucous epidermal nevus. Ann Plast Surg.
200 1 ;47 ( 3 ) : 285-29 2 .
M itsu h a s h i Y , Katagi ri Y , Ko n d o S . Treatment o f i nfla m
matory l i n e a r ve rrucous e p i d e r m a l naevus w i t h to pical
vita m i n 03. Br J Dermatol. 1997 ; 1 3 6( 1 ) : 1 34- 1 3 5 .
M o reno Arias GA, Ferra n d o J . I ntense pu lsed l ight for
mela nocytic lesions. Dermatol Surg. 200 1 ; 27(4) :397-400.
Pa nagioto po u l os

A,

C hasa p i

V,

N i kolaou

V,

et

naevi .

Acta Derm

Venereal.

Figure 43.4 (Continued) (B) and after greater than 30 subsequent surgical
procedures including flaps and skin grafts (Courtesy of Richard Bennett,
Muba Taher, and Mathew A vram)

al.

Assessment o f c ryosu rgery for t h e treatm e nt o f verrucous


epidermal

2009 ; 89 ( 3 ) :

A b l a t ive
C02 lase r

292-294.
Pa rk J H , Hwang ES, Kim S N , et a l . Er:YAG laser treat
ment of verrucous epidermal n evi . Dermatol Surg. 2004;
30(3 ) : 3 78-38 1 .

Derm a l
compon e n t
re m a i n s

Toyozawa S , Ya m a m oto Y, Ka m i n a ka C , Kishi oka A , Yo nei


N . , F u r u kawa F. S u ccessfu l treatment with tric h loroacetic
acid pee l i ng for i nfla m m atory l i nea r verrucous epidermal
nevus. J Dermatol. 2010;37(4):384-386.
Zvu l u nov A , G r u nwa l d M H , H a lvy S . To pical calci potriol
fo r treatment of i nfla m m atory l i nea r verrucous epidermal
nevus. Arch Dermatol. 1 997 ; 1 33 ( 5 ) : 567-568.

Figure 43 . 5 Effect of ablative C02 laser on removing an epidermal nevus.

With the dermal component remaining, there is a risk of recurrence

226

Color Atlas of Cosmetic Dermatology

CHAPT E R 44

Lipo m a

Li poma i s a benign t u m o r of matu re fat . I t presents a s a


soft s u bcuta n eous flesh-colored t u m o r that freely moves
aga i n st overlying s ki n . M ost often , it presents as a sol i
ta ry l e s i o n on the tru n k , n e c k , a n d prox i m a l extre m ities
( Fig. 44 . 1 ) . I nfreq u e n tly, i n d iv i d u a l s may present with
m u lt i p l e l i po m a s , ra rely as a pa rt of an i n h e rited syn
d ro m e .

EPI DEM I O LOGY


Incidence: very common
Age: can present at a n y age but m ost com m o n ly i n the
fo u rth decade

Race: none
Sex: eq u a l
Precipitating factors: m ost freq uently, there is n o p rec i p i
tati ng factor. M u lt i p l e l i pomas c a n be associated with
syn d romes such as Derc u m 's d i sease, fa m i l i a l m u ltiple
l i pomatosis, M a d e l u ng's d i sease, G a r d n e r's syn d rome,
B a n naya n-Zo nana a n d P roteus syn d rome

PATHOG E N E S I S
U n known .

PATHOLOGY
Wel l -c i rc u mscri bed , l o b u lated t u m o r of u n iform , mat u re
a d i pocytes in the s u bcuta neous fat, often with a th i n s u r
ro u n d ing fi brous ca ps u l e a n d eccentric n uc l e i .

PHYS I CAL LES I O N S


A l i poma p resents as a soft, freely m o b i l e flesh-colored
ova l or rou n d su bcuta n eous nod u le with a norma l overly
ing epidermis. I ts size can va ry greatly from m i l l i m eters to
many centi meters . It is nontender u n l ess prese nting as
pa rt of Derc u m 's d isease, as an a ngiol i poma o r if i m p i ng
i n g on a nerve .

D I F F E R E N T I A L D I AG N OS I S
Epidermal i n c l usion cyst, p i l a r cyst, h i bernoma, angi
o l i po m a , a n d other fatty t u m o rs i n c l u d i ng l i posa rcoma
m ust be considered . If the lesion is greater than 1 0 e m or
fixed , m a l igna ncy should be considered .

Figure 44 . 1 A middle-aged female with two lipomas on her arms

Sect i o n 7 : B e n ign G rowt h s

LABO RATORY EXA M I NAT I O N


I n normal c i rc u msta nces, no wo rku p i s i n d icated . I n the
eve nt of ra p i d or extensive growt h , however, biopsy may
be i n d icated if m a l igna n cy is suspected . Caution is i n d i
cated i n the eve nt of exc i s i n g a l i poma located i n the m i d
l i n e sac rococcygea l

regio n .

I t may re present s p i n a l

d ysra p h ism . I n t h i s c i rc u msta nce, consider rad iologica l


a n d neu ros u rgica l eva l uati o n . Do n ot perform a b i opsy.

CO U RS E
They te n d t o grow s l owly t o a certa i n size a n d d o not i n vo
l ute without i nterventi o n .

KEY CO N S U LTAT I V E QU EST I O N S

N u m ber a n d location o f l i pomas

Fa m i ly h i sto ry of s i m i l a r lesions

H i story of keloids/hypertro p h i c sca rring

Associated pa i n

Recent lesiona l growth

MANAG E M ENT
There is no medical i n d ication t o treat l i pomas u n l ess
they p rod uce

pa i n or constriction of movement or

demonstrate accelerated growth . M a ny patients, h ow


ever, req uest treatm ent for cosmesis. S u rgica l rem ova l ,
via exc ision or l i pos uction , is t h e m a i nstay of thera py. I f
t h e lesion is located i n t h e m i d l i ne sac rococcygea l reg i o n ,
c o n s i d e r s p i n a l dysra ph i s m .

TREATM ENT

S u rgical excision : best for s m a l l l i pomas ( F igs . 44. 2 a n d


44 . 3 )
- Depe n d i ng on t h e size o f t h e l i po m a , a s ma l l e l l i ptical
excision is performed over the tu mor. Once the
l i poma is encou ntered , it is d i ssected from its s u r
ro u n d i ng tissue.
- Afte r remova l , a laye red closure with su bcuta neous
sutu res is ge n e ra l ly req u i red to repa i r the cavity pro
d uced by the proced u re .
- Recu rrence is c o m m o n d u e t o t h e d ifficu lty o f d isti n
g u i s h i ng t u m o r fro m n o r m a l su bcuta n eous fat .
- S u rgica l exc ision is preferred f o r s m a l le r l i pomas a n d
is less expe nsive than l i posuction .

Li posuctio n : best for la rge l i pomas


- A sma l l i ncision is c reated with i n the center of the
l i poma after regional a n esth esia and l i pos u ction of
the l i poma is performed .

Figure 44.2 (A) Lipoma on posterior neck prior to surgical excision.


(8) Excision of lipoma.

227

228

Color Atlas of Cosmetic Dermatology

- The entire t u m o r is not necessa rily removed . Rather,


porti ons of the l i poma a re removed u n t i l the affected
a rea l ies flush with the s u rrou n d i ng ski n .
- Postproced u re f i b rosis c a n ensu re a persistent flat
te n ed conto u r of the rema i n i ng l i poma tiss u e .
- The advantage o f l i pos u ction over excision is t h a t i t
prod uces a s m a l ler sca r.
- It is more expe nsive tha n sta n d a rd excisio n .
Low conce ntration d eoxych olate i njections have been
s h own to be effective for the treatment of l i pomas in a
l i m ited study. These i njections o bviate the need fo r
su rgery, a n d thus sca rring. N o netheless, further study is
reco m m e n d ed before this a l te rn ative treatment can be
reco m m e n d ed .

P I T FALLS T O AVO I D/CO M P L I CATI O N S/


MANAG E M E N T/O UTCO M E
EXPECTAT I O N S

T h e phys i c i a n s h o u l d i nfor m t h e patient that a l l s u rgica l


i nterventions prod uce some d egree of sca rri ng.

Sca rring may bother patients more t h a n the l i poma


itse lf.

Ad d itiona l ly, re m ova l of la rge l i pomas freq uently resu lts


in a posto perative s k i n d e p ressio n .

Recu rrence is com m o n , espec i a l ly with l i posucti o n .

B I B L I OG RAPHY
H a rri ngton A C , Ad m ot J , Chesser R S . I nfi ltrati n g l i pomas
of the u pper extrem ities. J Dermatol Surg Oneal. 1 990;
1 6 : 834-836.
R ot u n d a AR, Ablon G, Ko lod ney MS. Lipomas treated
with s u bcuta neous deoxyc holate i njections. Dermatol

Surg. 53 ( 6 ) : 73-78.
Salasche SJ , McCollough M L, Ange l o n i VL, G ra bski WJ .
Fronta l is-assoc iated l i poma of the forehead . J Am Acad

Dermatol. 1 989 ;20:462-468 .


Sanc h ez M R , Golom b FA , M oy J A , Potozk i n J R . G ia n t
l i po m a : c a s e report a n d review o f the l iteratu re . J Am

Acad Dermatol. 1 993;28: 266-268 .


Tru h a n A P, G a rd e n J M , et a l . Fac i a l a n d sca l p l i pomas:
case reports a n d study of preva lence. J Dermatol Surg
Oneal. 1 985; 1 1 : 9 1 .

Figure 44.2 ( Continued) (C) Subcutaneous suture for closure. (D) Gross

path specimen of lipoma

Sect i o n 7 : B e n ign G rowt h s

CHAPT E R 45

M iliu m

M i l ia a re benign su perficial wh ite-ye l low kerati naceo u s


cysts t h a t typ ica l l y prese nt on the eye l i d s , forehea d , a n d
face but may present a nywhere ( Fig. 45. 1 ) . They occ u r a t
a l l ages a n d a re very co m m o n .

EPI DEM I O LOGY


Incidence: very common
Age: a ny age; m ost common i n newborns a n d a d u lts
Race: none
Sex: eq u a l
Precipitating factors: These a re most freq uently spora d i c
lesions but they can be assoc iated with s u bepidermal
b l istering d i seases s u c h as porphyria cuta n ea ta rda , ep i
derm olysis b u l losa acq u isita , va ricella zoster vi rus, b u l
lous pem ph igo i d , a n d b u l lous l i c h e n pla n u s . T h e y a re
a lso associated with s k i n tra u ma s u c h as a brasions,
b u rns, dermatologic s u rgery, a blative a n d n o n a b l ative
fractional res u rfa c i ng, C02 res u rfa c i ng, a n d ra d iation
thera py. They may a lso occ u r fol lowi n g treatm ent with
topical 5-fl uoro u rac i l , topical corti costeroids, and m i c ro
derma brasion

PATHOG EN ES I S
M i l ia a re believed to b e retention cysts d erived from vel
Ius h a i r fo l l ic l es . M i l i a seco n d a ry to tra u ma or b u l lous d is
eases a rise from ecto pic h a i r fol l icles.

PATHOLOGY
They re present s m a l l epidermoid cysts and feature c h a r
acteristic stratified sq u a m o us epithe l i u m with l a m i nated
kerat i n debris. A gra n u l a r layer is p resent in the cyst wa l l .

P H YS I CAL LES I ON S
M i l i a present as 1 t o 4 m m s u perfi c i a l wh ite-yel low cysts
that m ost c o m m o n l y a p pea r on the eye l i d s , cheeks, a n d
fo reh ea d .

D I F F E R E N T I A L D I AG N OS I S
T h e i r c l i n ic a l a ppea ra nce i s c h a racteristi c .

LABO RATORY EXA M I NAT I O N


None.

Figure 45 . 1 Small milia on face of a 3 7-year-old female

229

230

Color Atlas of Cosmetic Dermatology

COU RS E
They c a n present a t a n y age a n d d o n ot resolve without
i n tervention.

KEY CO N S U LTAT I V E QU EST I O N S


I s there a n y h i story o f bl istering or tra u ma?

MANAG E M ENT
There is no med ica l i n d ication t o treat m i l ia . T h e cosmetic
a p pea ra n ce, however, may d isplease some i n d ivid u a l s .

TREAT M ENT

I ncision a n d exp ress i o n : treatment o f choice ( Fig. 4 5 . 2 )

- Local a n esthesia m a y b e req u i red .


- I n cision with a # 1 1 blade a n d remova l of kerati n a ceous d e b ris w i t h press u re from comedone extractor,
m i c rovasc u l a r force ps, or cotton swa b ti ps.
- The proced u re is fast, s i m ple, and effective .

Topical medications
- To pica l treti n o i n c a n be effective for m u ltiple m i l i a .

Other treatments
- Electrica l fulgurati o n .
- Ab lative o r fractional a b lative lasers c a n b e effective
but a re fa r more expensive with a h igher rate of side
effects a n d recovery time.

EXPECTAT I O N S

Treatment o f m i l ia is stra ightforwa rd . I ncision a n d exp res


sion is fast, s i m ple, a n d successfu l . It rem a i n s the treat
ment of choice.

In

cases of m u lt i p l e m i l i a , topica l

treti n o i n is a good choice, partic u larly if the lesions a re


s m a l l ( F ig. 45. 1 ) . Laser plays no practical ro le in the
treatment of m i l i a .

B I B L I OG RAPHY
M a rra D E , Pourra bba n i S, F i n c h e r EF, M oy R L. Fractional
photothe rmolysis for the treatment of a d u lt colloid m i l
i u m . Arch Dermatol. 2007 ; 143 ( 5) : 572-574.
D movsek-O i u p B, Ved l i n B. Use of Er:YAG laser fo r
benign s k i n d i sorders. Lasers Surg Med. 1997;2 1 ( 1 ) :
13-19.

Figure 45.2 (A) Lancet piercing a milium on the left lower anterior neck
of a patient. (B) Comedone extractor extruding keratinaceous debris from
milium. (C) Postprocedure resolution of milium after comedone extraction

Sect i o n 7: B e n ign G rowt h s

CHAPT E R 46

Neu rofi b ro m a

N e u rofi bromas ( N Fs) a re ben ig n , soft, p i n k , neu romes


enchymal tu mors

that

can

be

sol ita ry o r

m u ltiple

( Fig. 46. 1 ) . Sol ita ry tumors a re n ot associated with sys


te m i c fi n d i ngs. M u lt i p l e N Fs a re assoc iated with neu rofi
b romatosis types I and I I , both neu roc uta neous d isord e rs
with i m porta nt system i c m a n ifestations i n c l u d i ng m a l ig
na ncies. P l exiform N Fs a re seen in patients with n e u rofi
bromatosis type I .

EPI DEM I O LOGY


Incidence: common
Age: you ng a d u lts
Race: none
Sex: eq u a l
Precipitating factors: m u ltiple N Fs a re s e e n i n assoc iation
with n e u rofi b romatosis I and I I . There a re n o p rec i p itati ng
factors for sol ita ry N Fs

Figure 46. 1 Multiple nonracial neurofibromas

PATH OG E N ES I S
The pathogenesis of sol ita ry lesions i s u n known . M u ltiple
germ l i n e a nd somatic m utations have been i d entified for
patients with n e u rofi b romatosis types I a n d I I .

PATHOLOGY
NF is c h a ra cteri zed by a wel l -c i r c u mscri bed , u nenca ps u
lated dermal a n d s u bc utic u l a r collection o f s m a l l nerve
fibers a n d loosely a rra nged s p i n d l e cells possessi ng wavy
n uclei in an eos i n o p h i l i c matrix. M ast cells a re c o m m o n l y
see n . M itoses a re a bsent.

PHYS I CAL L ES I ON S
N Fs p rese n t as s k i n c o l o red t o p i n k t o b rown soft o r
ru b b e ry, pa p u les o r nod u les ( Fi g . 46 . 2 ) . T h e a b i l ity to
e a s i l y i nvag i n ate the l e s i o n with press u re , k n ow n as
" b utto n h o l i n g , "

is a c h a racteristic p h ys i c a l fi n d i n g.

T h ey ra nge i n size fro m a few m i l l i m eters to a few c e n


t i m eters. P l exifo r m N Fs a re c h a racterized by la rge ,
bag- l i ke m a sses that may have associ ated hyperpig
m e ntati o n .

D I F F E R E N T I A L D I AG N OS I S
Derma l nevi ; congen ita l nevi ; dermatofi bromas; neu ro
mas; a n d fi bromas

Figure 46.2 Multiple neurofibromas on the left face

23 1

232

Color Atlas of Cosmetic Dermatology

LABORATORY EXAM I NAT I O N

N E U ROFIBROMA

C l i n i c a l exa m

A sol ita ry N F d oes not merit a work u p . Biopsy may b e i n d i


cated o f a c l i nica l ly atypical N F. M u ltiple N Fs merit refe rra l
to n e u rologic, ophth a l mologic, genetics, a n d orthoped ic

Soft, s k i n -col ored , red/brown papu l e/nod u l e


S o l i tary lesion more common t h a n m u l t i p l e

special ists to assess for neu rofi bromatosis I or I I . Complete


skin a n d eye exa m i nation of the patient a n d i m med iate
relatives is i n d icated as wel l . Skin exa m i nation should
assess for axi l l a ry freckl i ng, cafe a u Ia it macu les, plexiform
N Fs, j uven i le xa nthogra n u lomas, a n d Lisch nod u les.

Sol i tary l e s i o n ( most com m o n )


S u rgical shave or exc i s i o n ,
treatment of choice
No rol e for lasers

Figure 46.3 Neurofibroma diagram

COU RS E
They tend t o grow i n d o lently a n d pa i n lessly. Plexiform N F
req u i re conti n u ous mon itoring for potentia l m a l ignant
cha nge .

KEY CO N S U LTAT I V E QU EST I O N S

N u m ber o f lesions

Fa m i ly h i story

Centra l nervous system ( C N S J a bnorma l ities

Sco l i osis

Eye a bnorma l ities

Bone defects

Loss of hea r i n g

MANAG E M ENT
There is no med ical i n d ication t o treat N Fs u n less they
prod uce pa i n or a re cosmeti cally d isfigu ring or a re
cha nging in growt h . M a ny patients , however, req u est
treatment for i m provem e nt of cosmetic a p pea ra nce.

T R EAT M ENT (Fig. 4 6 . 3)

S u rgical exc ision


- W h i l e there a re many methods for removing N Fs,
s u rgica l excision is the m ost common and efficient
means of rem ova l . Recu rrence is l i kely if the NF is
not completely excised
- El l i ptica l exc ision is an effective, i n expens ive treat
ment and is pa rti c u la rly a ppropriate for management
of a few n u m ber of lesions. As with a ny s u rgery, an
expected sca r will resu l t ( Fig. 46 .4)

Laser a b lation
- N ot fi rst- l i ne thera py
- Carbon d ioxid e (C02 ) laser res u rfa c i n g can be util ized for fac i a l lesions. C0 2 laser treatment of no nfa
c i a l l e s i o n s is ge nera l ly n o t reco m men ded given r i s k
o f hypertro p h i c sca r/ke loid formation

I f m u lt i p l e les i o n s , r u l e out
assoc i ated n e u rof i bromatosi s
S u rgical shave or exc i s i o n ,
treatment of choice
Lasers: seco n d - l i n e therapy

Sect i o n 7: B e n ign G rowt h s

233

A cutting tec h n i q u e ca n be uti l i zed to exc ise


tu mors. C0 2 treatment in a foc used conti n u o u s
wave bea m , 1 5 to 30 W is performed a long the
m a rked m a rgi n . R e i n cise a l o n g the m a rg i n u ntil the
d esi red d e pth is o bta i ned . Tissue u n d e rm i n i ng a n d
hemorrhage control ca n b e o bta i ned uti l i z i n g the
sa m e laser pa ra m eters with the h a n d piece held
away from the wou n d to defoc us the bea m . Wo u n d
c l osu re is performed i n a sta n d a rd fas h i o n
A va porization tec h n iq ue may be uti l i zed t o flatten
and remove t u m ors. C0 2 treatment with a d efo
c u sed bea m a n d 3 to 6 W is performed to the level
of adjacent normal ski n . I t may be necessa ry to
m a n u a l ly extract la rge resi d u a l dermal tumor once
visual ized .

Char

should

be d e brided

between

passes with a wet ga uze a n d d ried f u l l y prior to con


t i n u i ng treatment
Seve ra l treatment sessions may be req u i red for
pati ents with n u merous N Fs
Posti nfl a m matory

hyperpigmentati o n ,

atro p h i c

sca rring, hypertro p h i c sca rring, a n d i ncom plete


remova l have been reported as side effects. A test
site s h o u l d be considered , in partic u l a r in patients
with Fitzpatrick s k i n phototypes I l l-V I
- Erbi u m : ytt ri u m a l u m i n u m ga r n et laser res u rfa c i n g
can be util ized fo r fac i a l lesions
S u rfa ce va porization to flatte n t u m o rs . This treat
ment modal ity is less effective t h a n the C0 2 laser i n
l es i o n a l re m ova l . H owever, t h i s laser m a y b e m o re
a p pro priate for patie nts with d a rker Fitz patrick s k i n
p hototypes t o m i n i m ize posti nfla m m atory pigmen
ta ry cha nges
I nterstiti a l ph otocoagu lation ca n be performed for
the treatment of b u l kier lesions, i n c l u d i ng nonfacial
lesions

P I T FALLS TO AVO I D/CO M P L I CATI O N S/


MANAG E M ENTIOUTCO M E
EXPECTAT I O N S

T h e physicia n shou l d i nform t h e pati ent that a n y s u rgi


cal o r laser i n tervention p rod uces some d egree of scar
ring.

Remova l

of N Fs via

laser a blation

may prod uce

posti nfla m matory hyperpigmentation a n d/or sca rri ng.


Recu rrence is com mon .

C0 2 laser i n cisiona l treatm ent ca n lead to decreased


te nsile wou n d strength d u ri ng the wou n d hea l i ng phase
when com pa red to sta n d a rd s u rgica l exc ision due to
laser therma l d a m age at the wou nd m a rg i n . S utu res
s h o u l d be left in for an a d d itiona l wee k to assist i n
wou nd hea l i ng.

Figure 46.4 (A) Solitary neurofibroma preop. (8) Solitary neurofibroma

following simple excision. This is the treatment of choice for solitary neu
rofibromas. It is also a good option for removal of limited neurofibromas

234

Color Atlas of Cosmetic Dermatology

C0 2 laser va porization treatment s h o u l d be l i m ited to


fac i a l N Fs, given an i nc reased risk of sca r formation
with use o n nonfa c i a l sites .

B I B L I OG RAPHY
Cole

R P,

Widd owson

D,

M oore

JC.

Outcome

of

erbi u m : yttri u m a l u m i n u m ga rnet laser resu rfa c i n g treat


ments . Lasers Med Sci. 2008;23(4) :427-433.
Elwa k i l T F, Samy N A , E l basiouny M S . N on-exc ision treat
ment of m u lt i p l e c uta neous neu rofi bromas by laser pho
tocoagu lation . Lasers Med Sci. 2008;23 ( 3 ) : 30 1 -3 1 6 .
M oren o J C , Mathoret C , La ntieri L, Sel ler J , Revuz, J ,
Wol kenste i n P. Carbon d ioxi d e laser for remova l o f m u lti
p l e c uta neous n e u rofi bromas. Br J Dermato/. 200 1 ;
144 ( 5 ) : 1 096- 1 098.
N evi l l e H L, Sey m o u r-Dem psey K, Slopis J, et al. The role
of s u rgery in c h i l d ren with neu rofi b ro matosis. J Pediatr

Surg. 200 1 ;36( 1 ) : 2 5-29 .

CHAPT E R 47

Se b o r rhe ic Ke ratosis

Seborrheic ke ratosis ( S K) a re the m ost common be n ign


c uta neous t u m ors, and i n a d u lts S K a re wa rty, ke ratotic
skin growth that fi rst present after the fou rth d eca d e . The
mea s u re from a few m i l l i meters to centi mete rs The color
ra nges fro m p i n k to ta n to dark b row n . Lesions can be
sol ita ry or m u lt i p l e ( Fig. 47. 1 ) .

Over time,

patients

d eve l o p a nywhere from a few to h u n d reds of S Ks . M a n y


patients req u est rem ova l o f S Ks, pa rticula rly w h e n m u lti
p l e or la rge , beca use of their u nsightly a p peara nce.

EPI D E M I O LOGY
Incidence: very common
Age: usua l l y i n fou rth decade a n d become more n u mer
ous in m i d d l e age a n d beyon d

Race: m ore common i n Ca ucasi a n s


Sex: eq u a l
Precipitating factors: fa m i ly h i story w i t h l i kely a utoso m a l
d o m i n a nt i n he rita nce

PATHOG E N ES I S
U n known .

Sect i o n 7 : B e n ign G rowt h s

PATHOLOGY
C lassica l ly, S Ks a re wel l -c i rc u mscri bed epidermal growths
that rise a bove the s u rface of the s u r ro u n d i ng ski n . A l l
featu re hyperke ratos is, pa p i l l o matosis, a n d acanthosis.
The epidermis conta i ns basa loid cells that show sq ua
mous d ifferentiati o n . Sq u a m ous edd ies may be prese nt.

PHYS I CAL LES I ON S


There a re m a n y c l i n ica l va ria nts o f S Ks . They range i n
size from a few m i l l i m eters t o a few centi m eters a n d m ost
c o m m o n l y occ u r on the fa ce, neck, a nd tru n k . They typi
ca l ly fi rst present as we l l-demarcated ta n o r l ight b rown
macu les. With time, they rise to becom e p l a q u es a n d
d eve l o p a wa rty a n d stu c k-on a p pea ra n c e . H o r n cysts
become a p pa rent with i n the lesions. They ca n occ u r a ny
where on h a i r-bea ring sk i n a n d a re not seen on the pa l m s
a n d soles.

D I F F E R E N T I A L D I AG N OS I S
Lentigi nes, verruca , a c rochordons, condyloma a c u m i na
tum, a c rokeratosis verruciformis, dermatosis pa pu losa
n igra , Bowe n 's d isease, nevus, epidermal nevus, lentigo
m a l igna, m e l a n oma , a n d sq u a m ous c e l l carc i n o m a . The
c l i n i c a l a p pea ra nce and prese nce of horn cysts in S Ks
ma kes the d iagnosis stra ightforwa rd .

LABO RATORY EXAM I NAT I O N


N o n e ; s k i n b i o psy i f sus pect m a l igna ncy.

CO U RS E
They present i n t h e fou rth decade a n d persist for yea rs .
Over time, they becom e la rger, more pigmented a n d fea
t u re a

m o re verrucous a p pea ra nce.

They typ ica l ly

become more n u m erous with age. I nfreque ntly, they can


regress sponta neous ly.

KEY CO N S U LTAT I V E QU EST I O N S

Fa m i ly h istory o f s k i n ca ncer

H istory of bleed i ng

li m e of onset

Was there a ra p i d o nset of n u merous S Ks?

MANAG E M ENT
There is n o medical i n d ication t o treat S Ks, u n l ess they
a re i rritated . Sti l l , the cosmetic a p peara n ce bothers many
patients. There a re m u ltiple modal ities for treating S Ks

Figure 47. 1 Multiple seborrheic keratoses on back of elderly male

235

236

Color Atlas of Cosmetic Dermatology

i n c l ud i ng c ryothera py, el ectrodesiccati o n , c u rettage, a


switc hed a n d a blative laser thera py. M ost often , the tra d i
t i o n a l methods o f treati ng S Ks a re m ost a p propriate . If
there is a ra pid onset of widespread lesions, perform a
review of systems a n d consider a fu l l physical exa m i na
tion to rule out a n y u n d e rlyi ng medical cond ition or carci
noma (Sign of Leser Tre let ) .

TRA D I T I ONAL T R EATM ENTS


E m p has ize r i s k o f i ncom plete remova l a n d recu rrence
with a ny treatment modal ity.

C ryothera py
- Light c ryothera py is a q u ic k , i n expensive , a n d effec
tive method of treating S Ks . R i s k hypo- or hyperpig
mentation and low risk of sca rring
- If the lesion d oes n ot resolve, retreatment is neces
sa ry in 3 to 4 weeks

C u rrettage and light cautery


- El ectrod esiccation of S Ks is a n other q u ic k a n d effec
tive method of treatment. Sl ight d iscomfort assoc i
ated with loca l a nesthesia
- C u retti n g the lesion after electrodesiccation can
e n s u re remova l
- Light, q u ic k e l ectrod esiccation of the base may a lso
e n ha nce effi cacy a n d preve nt rec u rre nce
- Postproced u re wo u n d care is needed with e m o l l ient
for 7 to 1 0 days

Shave excision
- Shave excision ca n effectively remove S Ks

LAS ER T R EAT M E NTS


Laser is not a fi rst- l i n e treatment for S Ks . Rather, it s h o u l d
be considered a n a lternative treatment a n d only u s e d i n
the correct c l i n ical setting.

M e la n i n ta rget i n g lasers fo r t h i n S Ks
- Q-switched ru by (694 n m ) a n d Q-switc hed a l exa n
d rite (755 n m ) , a n d the long-pu lsed 5 3 2 n m lasers
ca n effectively treat t h i n S Ks ( Fig. 47 . 2 )
- Somet i m es

i n effective,

espec i a l l y

as

t h i c kness

i n c reases; repeat treatments may be req u i red


- R isk of hypopigmentation
- Expensive compared to tra d itional thera p ies, but may
be more tolera ble to a patient with m u lti ple lesions

Ab lative lasers
- C0 2 a n d erbi u m : YAG lasers can a blate S Ks
- Repigmentation of S Ks occ u rs i nfreq ue ntly after
treatment
- Expensive com pa red to tra d itional thera p ies

Figure 47.2 Posttreatment whitening of seborrheic keratoses after

treatment with a 755-nm Q-switched alexandrite laser with a fluence of


10 J!cm2 and a 3-mm spot size. The procedure was performed after
fractional resurfacing, which explains the blue dye remnants apparent
on his face

Sect i o n 7: B e n ign G rowt h s

237

P I T FALLS TO AVO I D/CO M P L I CATI O N S/


MANAG E M ENT/O UTCO M E
EXPECTAT I O N S

S Ks c a n b e treated with a n u m ber o f d ifferent a n d


effective modal ities.

The phys i c i a n s h o u l d ed ucate the pati ent that a ny ther


a py has poss i b l e adverse effects such as pigmenta ry
cha nges, sca rring, a n d rec u rre nce.

Tra d iti o n a l thera pies s u c h as l ight c ryothera py or c u ret


tage a re s i m p l e , q u ick, a n d effective ( Fig. 47 . 3 ) .

Laser thera py is a n a lternative treatment at a h igher


expense.

B I B L I OG RAPHY
B rodsky J . M a nagement o f benign s k i n lesions com
mon ly affecti n g the face: acti n i c keratos is, seborrheic
keratosis, a n d rosacea . Curr Opin Otolaryngo/ Head Neck
Surg. 2009 ; (4) : 3 1 5-320.
C u l bertson G R . 532-nm d i ode laser treatment of sebor
rheic

ke ratoses with

color e n h a ncement [ p u b l ished

o n l i n e a head of print J a n u a ry 29, 2008] . Dermatol Surg.


2008;34(4 ) : 525-528; d iscussion 528 .
K i l m e r SL. Laser erad ication of pigme nted lesions a n d
tattoos. Dermatol Clin. 2002 ; 200 ) :37-53.
M e h ra bi D, B rod e l l RT. Use of the a lexa nd rite laser for
treatm ent

of

seborrheic

keratoses .

Dermatol

Surg.

2002 ; 28 ( 5 ) : 43 7-439.

Figure 47.3 (A) Curettage of seborrheic keratosis. (B) Immediately after

curettage of seborrheic keratosis. (C) Postinflammatory erythema 1 month


after curettage of seborrheic keratosis

238

Color Atlas of Cosmetic Dermatology

CHAPT E R 48

Sy ringo m a

Syri ngomas a re c o m m o n benign a d nexa l neoplasms of


eccri ne d uct d e rivation that present most freq uently
i n fem a l es on the face, espec i a l ly a ro u n d the eyes
( Fig. 48. 1 ) . They may also be seen on the c h est, u m bi l i
c u s , a x i l l a e , a n d vulva .

EPI D E M I O LOGY
Incidence: c o m m o n
Age: usua l ly prese nt at puberty
Race: none
Sex: fe m a l e > m a l e
Precipitating factors: m o re common i n Dow n 's synd rome

PATHOG E N ES I S

Figure 48. 1 Infraorbital syringomas being treated with low setting elec

trocautery on a young female. The treatment was not effective.

U n known .

PATHOLOGY
T hese

benign

sym metric, wel l - c i rc u mscri bed d e r m a l

tu mors a re com posed o f m u lt i p l e s m a l l d ucts w i t h two


layers of c u bo i d a l epithel i u m , often with a "ta i l " givi ng a
"ta d pole, " or comma-l i ke a p peara nce i n the u p per d er
m is . These d u cts a re someti mes d i lated a n d a re l i ned by
an eosi n o p h i l i c cuticle. There is a s u r ro u n d i n g dense
fi b rous eos i n o p h i l i c stro m a .

PHYS I CAL LES I O N S


Ski n-co l o red t o yel l ow, 1 - t o 3-m m firm pa pu les. They a re
seen most freq u ently a ro u n d the eyes, espec i a l ly the
lower eyel i d . Typical ly, they a re m u ltiple and sym m etric .
They c a n a lso be seen on t h e chest, u m bi l icus, axi l la e ,
a n d genita l i a ( Fig. 48 . 2 ) . Acra l lesions a re seen in e r u p-

tive syri ngomas.

D I F F E R E N T I A L D I AG N OS I S
M i l i a , sebaceous hyperplasia, basa l cell carci n o m a , tri
c h oepith e l i o m a , fi brous pa p u le,

LABORATORY EXA M I NAT I O N


B i o psy may b e i n d icated i f basa l ce l l carc i noma i s sus
pected . N o other la borato ries a re i n d icate d .

Figure 48.2 (A) Infraorbital syringomas in a young female. (8) Follow-up

picture at 1 week after ablative fractional C0 2 laser resurfacing showing


improvement of the syringomas. This improvement is attributed mostly to
the postprocedure edema. No significant improvement was noted at a
later follow up

Sect i o n 7 : B e n ign G rowt h s

CO U RS E
They present a t p u berty a n d d o n ot resolve without i n ter
ventio n .

KEY CO N S U LTAT I V E QU EST I O N S


Ti me o f onset

MANAG E M ENT
There is no me d i c a l i nd ication t o treat syringomas. M a n y
patients,

however,

req uest

treatment

for

cosmetic

a p pea ra nce. Syri ngomas a re thera peutica l l y c h a l lenging.


Although there a re m u ltiple treatment modal ities ava i l
a b l e , n o n e is co m p letely su ccessful i n c o m p l ete or
permanent remova l of syri ngomas. Ofte n , the s i de effects
of treatment w i l l bother patients more than the syr i n go
mas the mselves. Ideal ly, the treatment of syri ngomas
s h o u l d prod uce destruction of the tumor with m i n i m a l
sca rring a n d n o rec u rrence. There a re no effective topical
med ications.

TREATM ENT

S u rgical excision : best rese rved for sol ita ry lesions.


- Sca r will be prod uced

El ectroca utery : can be successfu l


- Loca l i zed a n esthes ia with 1 % l idoca i n e with or with
out e p i n e p h r i n e may be em ployed .
- Low-energy setti ng electroca ute ry performed at 1 to
2 W with the el ectrode placed in the center of the
syri ngo m a .
- C l i n ic a l end point is lesiona l flatte n i ng.
- Light setti ngs a re a dvised

to avoid

pigmenta ry

cha nges or sca rring.


- Gentle c u rretage is reco m m en ded to e n s u re that
effective

remova l

of

the

syri ngoma

has

been

obta i n ed .

Carbon d i oxide (C02 ) laser i s a n effective means of


i m proving these lesions. The goa l is to flatten rather
t h a n re m ove the lesio n s.
- Li m ited to patients w i th s k in p hototypes I-I I I .
- I n d iv i d u a l lesions o r m u ltiple syri ngomas with the
sa m e cosmeti c u n it may be treated .
- C0 2 treatment in a d efocused mode, 3 to 6 W, 3- m m
spot, 0 . 1 to 0 . 2 seconds may be e m p loyed .
- M u ltiple passes a re performed with remova l of resid
u a l char between passes with sa l i n e-soa ked ga uze
pads. Lesions a re treated to the l evel of adjacent nor
m a l s ki n .

Figure 48.3 Multiple syringomas on the chest of a female

239

240

Color Atlas of Cosmetic Dermatology

- Les i o n a l rec u rrence is com m o n . Posti nfla m matory

SYRINGOMA

hyperpigmentation a n d sca rring may occ u r.

cacy a n d sid e-effect profi l e .

( Figs. 48 .3 a n d 48.4 ) .
Caution s h o u l d b e exercised w i t h e a c h o f t h e a bove
l isted modal ities .

Patie nts m ust a lso be i nformed that the side effects of


treatment may be more cosmetica l l y u ndesira b l e tha n
the syri ngomas themselves. These side effects i n c l u d e
sca rring,

hyperpigmentation ,

rec u rrence,

and

ery

thema .

When treati ng syri ngomas, ca re s h o u l d be ta ken to not


ove rtreat the l esions. I t is n ot n ecessa ry to complete ly
e l i m i nate the lesions, as some d e r m a l fi b rosis is
expected with hea l i ng, with res i d u a l lesions beco m i ng
l ess a p pa rent over t i m e .

Mechanical

Lasers

N o effective
topical therapy

Local a nesthes i a
w i t h l ight el ectro
desi ccati o n

A b l a t ive-Pu l sed C02 the


most effective moda l ity.
Post-l aser erythema for 1 -2
weeks . Apply emo l l i e n t over
treated area for opt i m a l
hea l i n g.

Although there a re m u ltiple treatment modal ities, they


a re often resista nt to thera py. Recu rrence is c o m m o n

Topical

P I T FALLS TO AVO I D/CO M P L I CATI O N S/


MANAG E M E N T/O UTCO M E
EXPECTAT I O N S

Other treatme nts: i n c l u d e c ryos u rgery a n d derma bra


sio n . There is l ittle d ata with w h i c h to j u dge thei r effi

D i ff i c u l t to treat with a n y moda l i ty


C l i n i cal i m provement is var i a b l e

G reat ca re s h o u l d be given t o the treatment o f patients


with s k i n p h ototypes IV a n d h igher to avo i d tem porary
and perma nent pigmenta ry cha nges .

B I B L I OG RAPHY
Akita H , Ta kasu E, Was h i m i Y , Sugaya N , N a kazawa Y,
Mats u naga K. Syri ngoma of the fa ce treated with frac
tional photothermolys i s . J Cosmet Laser Ther. 2009 ;
1 1 (4) : 2 1 6-2 1 9 .
Frazier CC, Ca macho AP, Coc kere l l CJ . The treatm ent of
eru ptive syri n gomas in an Africa n America n patient with
a combi nation of trich lo roacetic acid and C02 laser
d estruction . Dermatol Surg. 200 1 ; 2 7 ( 5 ) :489-49 2 .
Ka ng W H , Km N S , K i m Y B , S h i m WC. A n ew treatment
fo r syri ngo m a . Com bi nation of carbon d ioxide laser a n d
trichloroacetic a c i d . Dermatol Surg. 1998; 24( 1 2 ) : 1 3701374.
Ka ra m P, B ened etto AV. Syri ngomas: new a p proa c h to an
o l d tec h n i q u e . lnt J Dermatol. 1 996;35( 3 ) : 2 1 9-220.
Saj ben FP, R oss EV. The use of the 1 .0 mm h a n d piece i n
h igh e n e rgy, pu lsed C02 laser d estructi o n o f fa c i a l
a d nexa l t u m ors. Dermatol Surg. 1 999;25( 1 ) : 4 1 -44.
Wa ng J l , Roenigk H H J r. Treatment of m u lti ple fac i a l
syri ngomas with the ca rbon d i oxide (C02 ) laser. Dermatol
Surg. 1 999;25( 2 ) : 136-139.

L-------+

Figure 48.4 Diagram of syringoma treatment

H igh rec u rrence rate


w i t h any mod a l ity i n
1 2-36 months

Sect i o n 7 : B e n ign G rowt h s

CHAPT E R 49

D e r m a tosis Papu l osa Nig ra

Dermatosis pa pu losa n igra ( D P Ns l a re very common


ben ign brown warty pa p u les that a p pea r i n African
Americans a n d othe r patients with d a rk ski n phototypes,
D P N s usually affect the cheeks, neck, a n d u p per c hest
( Fig. 49 . 1 ) . D P N s a re a type of seborrheic keratosis. M a ny
patients req uest re m ova l of D P N s, pa rtic u larly when m u l
tiple or l a rge, d ue to their u nsightly a p pea ra nce.

E P I D E M I O LOGY
Incidence: very common in Africa n Americans and Asians
Age: second decade to m i d d le age
Race: more common in Africa n America ns a n d Asi a n s
Sex: fe males > m a l es ( 2 : l l
Precipitating factors: strongly associated with fa m i ly history
Figure 49 . 1 Dermatosis papulos nigra on the forehead of an A frican
American female

PATH OG E N ES I S
U n known .

PATHOLOGY
D P N s featu re hyperkeratosis, pa p i l lo matosis, and acan
thosis as seen i n seborrheic keratoses . N o sq ua mous
edd ies a re present.

PHYS I CAL LES I ON S


They present i n a sym m etric fas h i o n as s m a l l brown
s mooth sess i l e pa pu les o n the face, neck, a n d u p per
tru n k of African America ns and Asia n s . They range from
1 to 5 mm in d ia meter and a re often ped u n c u lated .

D I FFERENTIAL D I AG N OS I S
Seborrheic

ke ratosis,

lentigo,

ve rruca ,

acrochord o n ,

m e l a n ocytic nevus, a n giofi bro m a , a n d ad nexa l tumors


a re a l l in the d iffe rential d iagnosis.

LABO RATORY EXAM I NAT I O N


None.

CO U RS E
They present d u ri ng teenage yea rs . Over t i m e , they
become la rger and m ore n u m erou s , pea king i n m id d l e
age. They d o n ot regress sponta neously.

24 1

242

Color Atlas of Cosmetic Dermatology

KEY CON S U LTAT I V E QU EST I O N S


Fa m i ly h i story o f D P N s .

MANAG E M E N T
There is no med ical i n d i cation t o treat D P N s , u n less they
a re i rritated . Sti l l , the cosmetic a p peara n ce bothers m a n y
patients pa rti c u l a rly when n u mero u s . Th ere a re m u lti p l e
modal ities f o r treating D P N s i n c l u d i ng c ryothera py, elec
trodessicatio n , gra d l e scissor remova l , c u rettage, a n d
a b lative laser thera py. P r i m a ry consideration befo re treat
ment s h o u l d be the effective remova l of the D P N s without
prod u c i n g pigmenta ry cha nge .

TREAT M ENTS

Shave or gra d l e scissor excision c a n effectively re move


DPNs
- Local i nfi ltration with loca l a n esthesia fol l owed b y gra
dle scissor rem ova l is safe, fast and has the lowest
risk of posti nfla m m atory dysc h ro m i a

C ryothera py
- Light c ryothera py is a q u ic k , i nexpensive, s l i ghtly
pa i nfu l , and effective method of treating D P N s
- Cautio n : cryothera py can p rod uce hypopigmentation
by d estroyi ng m e l a n ocytes. Hyperpigme ntation ca n
a lso occu r

Light electrodesiccation a n d c u rettage


- Light electrod esiccation of D P N s is a n other q u ic k
a n d effective m ethod o f treatment. There is a r i s k of
posti nfla m matory dysc h ro m ia
- With l ight electrodesiccati o n , the lesion w i l l turn wh ite

O n ly l ight e l ectrod esiccation s h o u l d be e m p l oyed to


decrease the risk of pigme nta ry cha nges

LAS E R T R EAT M E NTS

M e la n i n ta rgeting lasers fo r t h i n D P N s
- Q-switched ru by (694 n m ) a n d Q-switc hed a l exa n
d rite ( 7 5 5 n m ) c a n someti mes effectively treat t h i n
ner D P N s .
- S pot size s h o u l d b e l ess tha n the size o f the lesion .
- R e peat treatme nts may be req u i red .
- R isk of hypopigmentation a n d hyperpigme ntation
should be exp l a i ned ca refu l l y to patient.
- Expensive com pa red to tra d it i o n a l thera p ies.

Ab lative lasers
- C0 2 , fractional a blative a n d erbi u m :YAG lase rs can
a b late these epidermal lesions.

Sect i o n 7 : B e n ign G rowt h s

- Expensive compared to tra d itional thera p ies.


- R isk of hypopigmentation and

hyperpigmentation

should be exp l a i n ed ca refu l ly to the patient.

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M ENTIOUTCO M E
EXPECTAT I O N S

A n y thera py h a s poss i b l e adverse effects s u ch a s pig


menta ry c h a n ges, sca rring, a n d rec u rre nce. G ra d l e
scissor remova l has the lowest r i s k o f dysc h ro m i a .

D P N s ca n be treated with a n u m ber o f d iffe rent a n d


effective moda l ities.

Tra d iti o n a l thera p i es such as scissor excision, c u rettage,


or l ight c ryothera py a re s i m ple, q u ick, a n d effective.

Laser thera py is more expensive a nd ca rries a h igher


potential for hyper- o r hypopigmentation . Test spot may
be a p p ropriate.

B I B L I OG RAPHY
K i l m e r S L . Laser eradication o f pigme nted lesions a n d
tattoos. Dermatol Clin. 2002 ;20( 1 ) :37-53.
Sc hweiger ES , Kwa s n i a k L, Ai res OJ . Treatment of d e r
matosis pa p u l osa n igra with a 1 064 nm N d : YAG laser:
Report of two cases. J Cosmet Laser Ther. 2008; 1 0(2 ) :
1 20- 1 2 2 .

CHAPTE R 50

Xa n t h elas m a

Xanthelasmas, a lso referred to as xa nthelasma pa l pe


b ra r u m , a re pla n e xa nthomas, occ u rring on the eye l i d s .

E P I D E M I O LOGY
Incidence: relatively com mon
Age: m id d le-aged a d u lts
Precipitating factors: hyperl i p i d e m i a prese nt in 50% of
patients with xa nthelasmas, fa m i ly h i story of hyperl i ped
i m a , and xa nthelsma . Yo u nger a d u lts who p resent with
xa nthelasma a re more l i kely to have l i pid a bnormal ities

PATHOG E N ES I S
Abnorma l ities of a po l i poprote i n E phen otypes o r oth e r
l i poprote i n s .

243

244

Color Atlas of Cosmetic Dermatology

PHYS I CAL EXAM I NAT I O N


Xanthelasmas commonly present a s m u ltiple soft sym met
rical ova l yel l owish pa pu les a n d pla q u es on the eyelids.

D I F F E R E N T I A L D I AG N OS ES
Syri ngomas, sebaceo us neoplasms, m i l i a , necrobiotic
xa nthogra n u l o m a .

D E R M ATOPAT H O LOGY
Col lections of foa m cells i n the superfi c i a l d e r m i s .

COU RS E

T hey a re ge n e ra l l y perma nent with tendency t o i n c rease


in n u m be r a n d coa lesce with t i m e .

MANAG E M ENT
Xa nthelasmas often

rec u r after treatment with a ny

modal ity.

S u rg i c a l Exc i s i o n
S u rgica l excision i s the treatment of choice fo r xa nthelas
mas. The lesion is l ifted and then exc ised using a blade
o r a G ra d l e scissor. The d efect is either left to heal by
second i ntentio n o r sutu red using silk o r eth i l o n sutu res
( Fig. 50. 1 ) . This proced u re u s u a l l y res u lts in a ve ry cos
metica l l y acce pta ble outco m e .

Loca l i zed Ti ss u e Dest r u ct i o n


C02 o r erb i u m laser va porization, tric h l o roacetic a c i d ,
el ectrosu rgery, o r c ryothera py.

P I T FALLS TO AVO I D

Although

50%

of patients with xa nthelasmas a re

normoli p e mi c , it is c r u c i a l to screen new patients with


xa nthelasmas fo r the p resence of hyperl i p i d e m i a . This
is pa rti c u l a rly i m porta nt i n you nger patie nts who pre
sent with xa nthelasma s i n c e they a re more l i kely to
have assoc iated l i p i d a bnorma l ities.

Patie nts m ust be made awa re that complete remova l of


the xa nthelasmas d oes not preve nt futu re d evelopment
of new lesions.

Extre me caution should be exerted when operati ng o n


the eye l i d s i n o r d e r t o avoid eye i nj u ry.

Figure 50. 1 Xanthelasma on the left upper medial eyelid in a middle


aged woman. (B) The resulting defect is sutured using ethilon sutures.
This procedure produced a very good cosmetic result

Sect i o n 7: B e n ign G rowt h s

B I B L I OG RAPHY
Eedy DJ . Treatment o f xa nthelasma b y excision with sec
o n d a ry i nte ntion h ea l i ng. Clin Exp Dermatol. 1 996;2 1 :
273-27 5 .
G h osh YK, Pra d h a n E, A h l uwa l ia H S . Exc ision o f xa nthe
lasm ata-c la m p , shave, and suture. lnt J Dermatol.
2009 ;48 ( 2 ) : 1 8 1 - 18 3 .
Hawk J L. C ryothera py ma y be effective f or eyel i d xa nthe
las m a . Clin Exp Dermatol. 2000;25:35 1 .
M a n n i no G ,

Pa pa le A , D e Bella

F, et a l .

Use of

erbi u m : YAG laser in the treatment of pa l pe b ra l xa nthelas


mas. Ophthalmic Surg Lasers. 200 1 ;32: 129-133.
N a has T R , M a rq u es J C , N i coletti A, Cunha M, N is h iwa ki
Da ntas M C , Filho JV. Treatment of eye l i d xa nthelasma
with 70% tri c h l o roacetic a c i d . Ophtha/ P/ast Reconstr
Surg. 2009;25(4): 280-283 .
U l l m a n n Y, H a r-Shai Y, Peled IJ . The use of C0 2 laser fo r
the treatment of xa nthelasma pa l pe b ra r u m . Ann Plast
Surg. 1 993;3 1 : 504-507

245

This page intentionally left blank

E I GH T
C utaneo u s Ca rcino mas

248

Color Atlas of Cosmetic Dermatology

CHAPT E R 5 1

Acti nic Ke ratosis

Acti n ic keratos is (AK) present as si ngle or m u ltiple d is


c rete, sca ly lesions, fou n d m ost freq uently in ha bitua l ly
s u n-exposed sk i n of ad u lts .

E P I D E M I O LOGY
Age: m ost c o m m o n l y noted i n m id d le age, occasionally
occ u rs i n patients u n d e r 30 yea rs

Sex: more common in m a les


Incidence: very c o m m o n ; i n Austra l i a 1 : 1 ,000 persons

Race: s k i n phototypes I-I I I , rarely seen i n s k i n phototypes


I V-V I
Occupation: outdoor workers (eg, fa rmer, ra ncher, sa i lor)
and outdoor sports (golf, te n n is, sa i l i ng)

PATHOG E N E S I S
Prolonged a n d re peated s u n expos u re i n suscepti ble per
sons resu lts in c u m u lative kerati n ocyte d a mage. The
p r i n c i p l e sun d a m age is secondary to u ltravoi l et B ( UV B )
( 290-320 n m l l ight.

PHYS I CAL EXAM I NAT I O N


AKs present as s i ngle o r m u ltiple ski n-colored , e rythema
to us, o r b rown sca ly patc hes. There is a pred i lection for
s u n-exposed a reas i n c l u d i ng the fa ce, ears, neck, fore
a rms, and dorsa l h a n d s . A Ks may become t h i c kened,
fo rm i n g a cuta neous horn . M o re easily pa l pated t h a n
see n . They a re genera l ly asym ptomatic but may be ten

d e r o r pru riti c . Act i n i c c h e i l itis d eve lops o n the verm i l i o n


bord e r as d iffuse sca l i ng o r d ryn ess . Associated tela ng
iectasia, so l a r elastosis, and lentigi nes a re freq uently
o bse rved .

D E R M ATOPAT H O LOGY
Epidermal pro l iferation with m i l d -to- moderate bas i l a r ker
atinocyte pleomorph i s m , pa ra ke ratosi s , and dyskeratotic
keratinocytes. Cytologica l ly, atypical kerati n ocytes a re
usua l l y confi ned to the epidermal basa l laye r.

D I F F E R E N T I A L D I AG N OS I S

Eczematous d e rmatitis

Extra m a m m a ry Paget's

Sq u a m o u s cell ca rc i n o m a

Basa l cell carc i noma

Figure 5 1 . 1 (A) Numerous facial actinic keratosis pre-Aidara treatment.


(B) Expected erythema and crusting during A ldara treatment. (C) Facial

actinic keratosis post-Aidara treatment applied twice weekly for 4 weeks


(Courtesy of Richard Johnson, MDJ

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

249

CO U RS E
A Ks ca n self-resolve, b u t genera l l y a re persistent i n
natu re . T h e progress ion t o s k i n cancer with i n preexist i n g
A Ks is u n known but is estimated at less t h a n 1 % o f i n d i
vid u a l lesion s . B i o psy wa rra nted for pigme nted A Ks
( s u perfi c i a l

pigme nted a cti n i c

ke ratosis)

or

nod u la r

ke ratosi s .

KEY CO N S U LTAT I V E QU EST I O N S

D u ration o f lesion(s)

Lesiona l rate of growth

Prior treatment for lesions a nd response

Perso n a l and fa m i ly h i story of prior s k i n ca n ce rs

H i story of prior rad iation treatment to the a rea

Cu rrent med ica l h i story

Med ication use

Evidence of i m m u n os u ppression

P red ispos i n g synd romes

MANAG E M ENT
Assess ment o f t h e n u m be r, size, location, freq uency of
deve l opment, a n d any u nderlying i m m u nosu ppressed
state s h o u l d be o bta i n ed . A b i o psy should be o bta i ned of
any

lesion

that

is

suspicious

for

skin

c a n cers .

Consideration m a y t h e n b e given t o treatment o f i n d ivid


ual or m u lt i p l e lesions, prophylactic thera py, and deter
m i nation of the n eed for c l i n ical fol low- u p .

Figure 5 1 .2 (A) Actinic cheilitis, lower lip. Patient complained of fre

quent peeling that was poorly responsive to cryosurgery and efudex.

T R EATM ENT

(8) Reduction in actinic damage following carbon dioxide resurfacing.

Patient reported complete resolution of peeling

P reve ntion
- A p p l ication of da i ly s u n s creen with U VN U V B pro
tectio n
- To pica l treti n o i n a pp l ied n ightly

Topica l
- Once d a i ly ( Ca ra c ) or twice d a i ly ( Efudex) a p pl ication
of 5-fl u o ro u ra c i l fo r 3 to 4 weeks
- Twice weekly o r every th i rd

day a p p l ication

of

i m i q u i nod (Aida ra 3M St. Pa u l , M N ) for 4 weeks


( Fig. 52 . 1 )
- D i c l ofenac (Sola raze) 3% sod i u m topica l gel twice
d a i ly for 2 to 3 m o nths
- l ngenol mebutate a p p l ied on 2 su bseq uent days or
twice 1 week a pa rt

Gentle c ryosu rgery with a si ngle freeze-thaw cyc l e .


B l ister formation poss i b l e . R e peat treatment may b e
req u i red . R isk o f tempora ry hyperpigmentation a n d

250

Color Atlas of Cosmetic Dermatology

permanent depigme ntation m ust be a d d ressed with the


patient. T hi s modal ity is best for isolated n u m ber of
lesions

System ic
- Long-te rm low-dose oral retinoid has been used , t h i s
treatment req u i res c l ose fol low- u p to avo i d pote ntial
side effects. Benefi c i a l o n l y while on m ed i cation
- O ra l vita m i n A has been used , req u i res close fol l ow
up to avoid potentia l side effects. Benefi c i a l o n l y
w h i l e on med ication

S u rgica l
- Photodyna mic thera py with topical a m i nolevu linic acid
( Levu len , Dusa Pharmaceutica ls, I nc . , Wilmi ngton, MAl
has been successfu lly uti l ized . The pu lsed dye laser
595 nm, blue l ight 415 n m , nea r-infrared 830 n m ,
i ntense pu lsed light sou rce, a n d l ight-em itting d iode
have been e m ployed for del ivery of treatment. M ulti ple
treatments a re usually req u i red . Topica l levu lan appl ied
1

hour

prior

to

l ight treatment

may

be

used .

Photosensitivity posttreatment promi nent


- C h e m i c a l pee ls-seria l med i u m-depth peels i n c l u d
i n g J essner/10% t o 35% tri c h loroacetic a ci d peels
a re

h ig hl y

beneficia l

Postoperative

in

red u c i n g

lesion

cou nt.

pee l i ng may last u p to 2 weeks

d e pe nd i ng on the strength util ized


- Fractionated a b l ative carbon d i oxi d e laser-seria l
treatments may be req u i red to reac h treatment e n d
point o f lesio n a l red uction
- P u lsed ca rbon d ioxide laser-h ighly effective i n m a n
agement o f acti n i c c h e i l itis ( Fig. 5 2 . 2 ) . The ve rm i l io n
bord e r is outl i n ed p r i o r t o the ad m i n istration o f m e n
ta l block a n d/or loca l ized i nfi ltrative a n esthesia with
1% l i d oca i n e with 1 : 100,000 e p i n e p h ri n e . Passes
a re performed u nt i l remova l of epidermis is o bse rved .
Area wi ped with sa l i ne soa ked spo nges between the
passes . Posto perative care req u i res soa king the treat
ment site with water a n d a clean wash c l oth to rem ove
a n y crusti n g a n d a p pl icati o n of vase l i n e th ree to fou r
ti mes a day. R i s k of sca r formation a n d i nfection m ust
be consid ered

P I T FALLS TO AVO I D

With acti n i c c h e i l itis, it is esse ntia l to avo i d vaporiza


ti on of the verm i l io n

bord e r to p reve n t sca rring.

D e l i n eati n g the bord e r prior to a d m i n istration of a n es


thesia is h e l pfu l .

Patients m u st b e awa re that a ny treatment a d m i n istered


d oes not e l i m i nate the d evelopment of fut u re pre m a l ig
nant a nd m a l igna nt growths. Strict photoprotection a n d
s u n avoida nce is m a n d atory.

Patients uti lizing to pica l treatments m ust be made awa re


of the expected erythema, crusti ng, a n d d iscomfort that

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

w i l l persist d u ri ng the d u ration of treatment a nd for 1 to


2 weeks posttreatment. A m i ld topica l corticosteroid may
be prescri bed posttreatment completion to assist i n the
resol ution of these fi ndi ngs.

B I B L I OG RAPHY
A l be rts D , Ra nger- M oore J , Einspa h r J , e t a l . Safety a n d
efficacy o f d ose-i ntens ive o ra l vita m i n A i n s u bjects with
su n-da maged ski n . Clin Cancer Res. 2004; 10(6) : 1 8751 880 .
Ericson

MB,

Sand berg

C,

Stenq u ist

B,

et

al.

P h otodyna m i c thera py o f acti n i c keratosis a t va ry i n g flu


ence rates : Assessment of photo b l ea c h i ng, pa i n a n d pri
m a ry c l i n i cal outcome. Br J Dermatol. 2004; 1 5 1 (6 ) :
1 204- 1 2 1 2 .
H a d ley G , Derry S , M oore R A . l m iq u i m od for acti n c ker
atosis: Syste m i c review a nd

meta-a na lysis. J Invest

Dermatol. 2006; 1 26(6) : 1 2 5 1 - 1 255


J a rvis B , Figgitt D P. To pical 3 % d i c l ofenac i n 2 . 5 %
hya l u ro n i c ac i d ge l : A review o f its u s e i n patients with
acti n i c ke ratosis. Am J Clin Dermatol. 2003 ;4( 3 ) : 2032 13 .
J orizzo J , Weiss J , F u rst K, Va n d e Pol C . Effect o f a
1 -wee k treatment with 0 . 5 % to pical fl uoro u ra c i l o n
occu rrence o f acti n i c keratosis afate r c ryos u rgery: A ra n
d o m ized , veh i c le-contro l l ed c l i n ical tria l . Arch Dermatol.
2004; 140( 7 ) : 8 1 3-8 1 6 .
Rolf-Ma rkus S , M atheson R , Davis S , e t a l . To pica l methyl
a m i nolevu l i nate photodyna m i c thera py using red ! l ight
emitting d iode l ight for m u lt i p l e a cti n i c ke ratosis: A ra n
d o m ized study. J Dermatol Surg. 2009 ;35(4): 586-59 2 .
S i l le r G , G e ba ue r K, Wel b u rn P , Katsa mas J , Ogbo u rn e
S M . P EP005 ( i ngenol me b utate) ge l , a n ovel agent fo r
the treatment of acti n i c keratosis: Resu lts of a ra ndom
ized , d o u ble- bl i n d , ve h icle-control led , m u l tice ntre phase
l l a study. Australas J Dermatol. 2009 ; 50( 1 ) : 1 6-22.
Thai KE, Ferg i n P, F ree m a n M, et a l . A pros pective stu dy
of the use of c ryosu rgery fo r the treatment of acti n i c ker
atosis. lnt J Dermatol. 2004;43 ( 9 ) : 687-69 2 .

25 1

252

Color Atlas of Cosmetic Dermatology

CHAPT E R 5 2

B asal Cell Ca rci n o m a

Basa l cel l carc i noma ( BCC) i s a slow-growing m a l ignant


skin tumor that presents i n d isti nct h isto l ogica l s u btypes
i n c l u d i ng nod u l a r, su perfi c i a l , m i c ronod u la r, i nfi ltrati ng,
and morpheafo r m . N od u la r BCC is the most common
type occ u rring pred o m i n a ntly on the head a n d neck
regions.

EPI OEM I O LOGY


Incidence: the m ost com mon skin cancer i n Ca ucasia ns
with a p proxi mately 800,000 cases/year d i agnosed i n the
U n ited States

Age: most common in patients over 40 yea rs


Race: m ost c o m m o n in Caucasians
Sex: h igher i n c idence i n ma les
Precipitating factors: c h ro n i c u lt raviolet ra d iation a n d
fa i r s k i n a re t h e m ost s i g n ificant p red isposing fa ctors .
Oth e r fa ctors i n c l u d e i o n i z i n g ra d i ati o n , a rs e n i c expo
s u re , i m m u n os u p p ress i o n , P U VA , and ge netic p red is
positi o n .

PATHOG E N E S I S
T h e m ost c o m m o n a ltered gene i n B C C i s t h e PTCH
tumor

s u ppressor

ge ne

with

res u lta n t

a ltered

H edgehog signa l i ng pathway lea d i ng to u n reg u lated cel l


prolife ration a n d a l te red c e l l d ifferentiatio n . M u tations i n
t h e p53 t u m o r s u p p ressor gene a re a lso freq uently
o bserved lea d i ng to cel l u l a r i m m o rta l ity a n d resista nce
to a po ptos i s .

PHYS I CAL EXAM I NAT I O N


P i n k , e rythematous, pea rly tra nsl ucent pa p u l e , nod u l e ,
o r pla q u e with a ro l led bord e r a n d overlying tela ngiec
tasias ( Fig. 52 . 1 ) . S u perfi c i a l B CC p resents as a p i n k or
e rythematous thin sca ly plaq u e . The center may become
u l cerated and covered by a c rust, that is, " rodent u lcer. "
Morpheaform B C C exh i bits a scar- l i ke a p pea ra nce with
i l l-defi ned borders. They m ost commonly present in pho
tod istri buted a reas.

D I F F E R E N T I A L D I AG N OS ES
Dermal m e l a n ocytic nevi , sebaceous hyperplasia, sq ua
mous cel l c a rc i noma (SCC).

Figure 52. 1 Large BCC on the face. Note the characteristic rolled bor
ders, overlying telangiectasias, and the central ulceration

Secti o n 8: C u ta n eo u s Ca rc i n o m a s

253

LABO RATORY DATA


D e r m at o p at h o l ogy
Lo b u les, nests, or cords of neoplastic basa loid cells with
peri phera l pa l isa d i ng, c lefti ng, and m u ci n o u s stroma .

CO U RS E
Loca l ly i nvasive a n d slow growi ng over m o nths a n d even
yea rs. M etastasis is an exceed i ngly ra re occ u rre nce.

KEY CO N S U LTAT I V E QU EST I O N S


Excessive s u n expos u re a n d other pred ispos i n g factors,
prior h istory of BCC or SCC, perso n a l a n d fa m i ly h i story of
s k i n cancer, i m m u nos u p pressio n .

MANAG E M ENT

There a re m u lti ple methods for treating B C C . Treatment


selectio n should be based u po n the age, hea lth, a n d
prefe rences o f t h e patient after a fu l l d iscussion o f treat
ment options, risks, a n d benefits. G iven the loca l ly
d estructive nature of B C C, h istologica l confi rmation of
com plete remova l is o pti m a l . S u rgica l excision a n d h i sto
logical eva l uation rem a i n the treatment of choice in most
cases. Tu m o rs fixed to u nd e rlying bone, espec i a l ly the
sca l p , merit rad io l ogica l work u p prior to s u rgica l excision
o r M o h s m i c rogra ph i c su rgery. Topical thera pies req u i re
c l ose fo l l ow- u p for a n y evidence of treatment fa i l u re or
recu rrence. Patient ed ucation rega rd i n g the benefits of
sun avoida nce, s u n sc reen use, and reg u l a r self-exa m i na
tions a re i m porta nt preventive measures.

F i rst- l i n e T h e ra p i es

Exc isional s u rgery: ge n e ra l ly with 4-m m m a rgins is the


treatment of choice for nonsu perficia l BCC that d o n ot
meet the criteria of Mohs m i c rogra p h i c s u rgery

Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice


for h igh-risk a nato m i c a l locations (ie, " mask" a rea of
the face), locations where tissue conservati o n is c r u c i a l
for fu n ctional o r cosmetic reasons, rec u rrent tu mors, i l l
d efi ned c l i n ical m a rgi ns, h i stologica l l y aggressive s u b

types , t u m o rs in i m m u nosu ppressed patients, t u m o rs

Figure 52.2 (A) BCC on the nose with very ill-defined clinical margins.

la rge r than 2 e m , i rrad iated ski n , a n d peri n e u ra l i nva

(B) Large defect after Mohs micrographic surgery. Mohs micrographic


surgery is the ideal treatment for this type of skin cancer providing the
highest cure rate among all other treatment modalities

sion on biopsy ( Figs . 52 . 2-52.4) . M o hs m i c rogra ph i c


su rgery has the h ighest c u re rate o f a n y treatm ent of
BCC

El ectrodessication a n d c u rettage

Cryothera py

254

Color Atlas of Cosmetic Dermatology

Rad iation thera py is a nother treatment option espe


c i a l ly when su rgery i s not feasible or contra i n d icated . It
can a lso be used as a n adj uva nt thera py when per
i n e u ra l i nvasion is i d e ntified

A l te r n ate T h e ra p i es

Topical i m i q u i mod , a p p l ied five t i m es a week for a tota l


d u ration of 6 wee ks . It is FDA a pproved for treatment of
su perfi c i a l B C C .

Recu rrence

rates a re sign ifica ntly

h igher than s u rgica l excision .

Topical 5-fl uoro u ra c i l is primarily reserved for treatment


of su perfi c i a l B C C . H owever, rec u rrence rates a re h i g h .

P h otodyn a m i c

thera py

prod u ces

p h otoc h e m i c a l

reaction t h a t req u i res the prese nce o f a p h otosensitiz


i ng agent, tissue oxyge n , a n d l ight with ph otoactivating
wavelength . The m ost common to pical photosens itizer
is 5-a m i nolevu l i n i c acid (5-ALA ) . 5-ALA is a precu rsor
of the i ntri nsic i ntrace l l u l a r hemebiosynthetic pathway,
w h i c h resu l ts in the prod uction of a photoactive porphyri n , protoporphyri n IX. The m ethyl d e rivative of 5ALA, methyl a m i nolevu l i n ic acid ( M AL) is a lso very

c o m m o n l y used a n d demonstrates a bette r sel ectivity


for m a l igna nt cells. The l ight sou rces a re usua l ly in the
visi ble l ight ra nge and they i n c l u d e laser (coherent)
l ight sou rces (eg, pu lsed dye lasers) or noncoherent
l ight sou rces ( red, blue l ight) . Red l ight provides the
dee pest penetration of these l ight based treatment
modal ities. PDT ca n provide 76% to 97% clearance
rates for su perficia l BCC. I t is pa rticula rly useful i n
patients who a re poor s u rgica l ca n d i d ates or those who
h ave m u ltiple BCCs that req u i re m u ltiple s u rge ries.
C l ose c l i n ical fol l ow- u p after treatment is req u i red for
a n y evidence of rec u rrence or i ncom plete remova l

l ntra lesi o n a l i n te rfe ron is ra re ly performed

Carbon d ioxi d e laser-may be effective for s u perfi cia l


B C C a n d patients w i th m u lt i p l e s h a l l ow tumors s u c h as
i n basa l cell nevus synd rome

P I T FALLS TO AVO I D
- I nfecti o n , bleed ing, pa i n , nerve da mage, poor cosme
sis fo l lowi ng surgical repa i r, hypertro p h i c or atrophic
sca rring, a n d rec u rrence a re all com mon pitfa l ls of
BCC s u rgica l thera py a n d should be fu l ly d iscussed
with the patient prior to treatment.
- Nonsurgica l thera pies may provide better cosmesis but
sign ificantly h igher rates of recu rrence. Fu rthermore,
nonsurgical i nterventions d o not provide the opportu
n ity for h istological confi rmation of complete remova l .
They a re best for patients w h o have n u merous BCCs
and i n those who a re poor surgica l candidates.

Figure 52.3 (A) Surgical defect after Mohs micrographic surgery of BCC
on the right forehead. (B) Repair of the defect with an A to T advance
ment flap. Notice that the horizontal incision line is hidden within the
eyebrow hairs for a better cosmetic outcome

Secti o n 8: C u ta n eo u s Ca rc i n o m a s

B I B L I OG RAPHY
Atti l i S K, Lesa r A, M c N e i l l A , e t a l . An o p e n pilot study of
a m bu latory photodyn a m i c thera py u s i ng a wea ra ble low
i rrad ia nce orga n i c l ight-e m itti ng d iode l ight sou rce in the
treatment of n o n m e l a noma s k i n cancer. Br J Dermatol.

2009 .
M u ller

FM,

Dawe

RS,

M oseley

H,

Fleming

CJ .

R a n d om ized com pa rison of mohs m ic rogra p h i c s u rgery


a n d s u rgica l excision fo r s m a l l nod u la r basa l c e l l carci
n o m a : Tissue-sparing o utco m e. Dermatol Surg. 2009 .
R owe D E , Carro l l RJ , Day CL J r. Long term rec u rrence
rates in previously u ntreated ( pr i m a ry) basa l ce l l carci
n o m a : I m pl ications for patient fol l ow- u p . J Dermatol Surg

Oneal. 1989; 1 5 : 3 1 5-328 .

Ti erney E, Ba rker A, Ahdout J , H a n ke CW, M oy R L,


Ko u ba DJ . P h otodyna m i c thera py for the treatment of
c uta neous neoplasia , i nfla m matory d isord e rs , a n d p h o
toaging. Dermatol Surg. 2009;35(5): 725-746.
Wolf DJ , Zite l l i JA. S u rgica l m a rg i n s for basa l cel l carci
noma. Arch dermatol. 1987 ; 1 23 : 340-344 .

Figure 52.4 (A) Nodular basal cell carcinoma on the left preauricular

area. (B) Clearance of basal cell carcinoma after Mohs surgery.


(C) Primary closure of the Mohs defect with dog-ear repair

255

256

Color Atlas of Cosmetic Dermatology

CHAPT E R 53

Sq u a m ous Cell Ca rci n o m a

S q u a m ous cell c a rc i noma (SCC) m ost c o m m o n l y origi


nates from kerati nocytes i n su n-da maged skin either d e
novo or from a preexisting a cti n i c keratosis o r sec i n situ
(a lso known as Bowe n 's d isease ) , predom i na ntly affect
ing the h ea d , neck, a n d a r m s . I t can a l so a rise in non
su n-exposed s k i n most commonly from c h ro n i c leg
u l ce rs a n d b u rn sca rs .

EPI DEM I O LOGY


Incidence: it is the seco n d most common skin cancer in
Caucasians and the most common skin cancer i n d a rkly
pigmented s ki n . A p proxi mately 1 50,000 cases/year a re
d iagnosed in the U n ited States

Age: most common in patients over 55 yea rs


Race: m a i n ly affects Caucasians
Sex: h igher i n c idence i n ma les
Precipitating factors: c h ro n i c u ltravio l et rad iation and fa i r

Figure 53 . 1 Invasive squamous cell carcinoma on the right neck

s k i n a re the most significant pred ispos i n g factors . Other


factors i n c l u d e i m m u nos u p press i o n , h u ma n pa p i l loma
virus

i n fection ,

ge netic

ionizing

d isord e rs

ra d iati o n , a rse n i c expos u re ,

(epidermodysplasia

verruc iform is,

a l b i n i s m , xerod erma pigmentos u m , epid ermolysis bul


losa ) , P U VA expos u re, smoki ng, a n d c h ro n i c i nfla m m a
t i o n ( u lcers, b u rn scars, d iscoid l u pus)

PATHOG E N E S I S
The most common a ltered gene i n SCC i s the p53 tu mor
s u p p resso r gene, res u lting i n keratinocyte i m m orta l iza
tion and u n reg u l ated c e l l prol ife ratio n .

PHYS I CAL EXAM I NAT I O N


Hyperkeratotic ski n-col ored t o erythematous

pa p u l e ,

p l a q u e , or nod u le ( Figs . 53 . 1 a n d 53 . 2 ) . I t can b e u l ce r


ated , fria ble, or exo p hyti c . It m ost commonly presents
with i n su n-da maged ski n .

D I F F E R E N T I A L D I AG N OS ES
Keratoacanthoma ( F ig. 53 . 3 ) , hypertro p h i c acti n ic ker
atosis, basa l cell carc i n o m a ( B C C ) , i nfla med seborrh eic
keratosis.

Figure 53.2 Recurrent squamous cell carcinoma on the chest of an

elderly woman

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

257

LABO RATORY DATA


D e r m at o p at h o l ogy
Prol iferation of atypical kerati nocytes with va ria b l e d iffer
entiation of the epidermis a n d va riably sized n ests a n d
islands i nvad i ng t h e d e r m i s . Foci o f kerat i n izatio n a re
n oted i n we l l-diffe rentiated va ria nts . Peri n e u ra l i nvolve
ment may be o bse rved .

CO U RS E
SCC tends t o b e more aggressive t h a n B CC, with a
reported

2%

to

3%

i nc i d e n ce

of

metastasis.

M ucocuta neous SCC has a h igher rate of m etastasis, as


h igh as 1 1 % . M ore aggress ive forms of SCC a re o bserved
in i m m u n os u p p ressed patients o r sec that a rises with i n
previously i rrad i ated sites, sca rs, b u rns, a n d a reas of
i nfla m mati o n . There is a h igher m etastatic potential for

sec a rising on the ea r a n d the l i p.

Figure 53.3 Giant keratoacanthoma on the chest. Many authors regard

keratoacanthomas as variants of well-differentiated squamous cell


carcinoma

KEY CO N S U LTAT I V E QU EST I O N S


Eva l uate fo r past h i story o f bl istering s u n b u rns a n d
c h ro n i c s u n expos u re . Determine i f other pred ispos in g
factors a re present s u c h as perso n a l a n d fa m i ly h istory of
ski n cancer a n d i m m u n os u p pression , especia l ly orga n
tra nspla ntatio n .

MANAG E M ENT
P reventative measu res, s u c h as s u n avoi da nce a n d d a i l y
s u n sc reen u s e , a re c ritica l for lo ng-term preventio n .
Treatment selection s h o u l d be based u pon the age,
hea lth , and preferences of the patient after a fu l l d iscus
sion of treatment options, risks, and benefits . G iven the
m etastatic potentia l of sec, h i stologica l confi rmation of
complete remova l is a l ways advised . S u rgica l excision
and

h i stological eva l uation

rema i n the treatment of

choice i n m ost cases . Tu m o rs fixed to u nderlying bone,


espec ia l ly the sca l p, merit ra d iological work u p prior to
s u rgica l excision o r Mohs m i c rogra p h i c su rgery. Prior to
treatment, lym p h node pa l pation is a p propriate for la rge

sec, sec in i m m u n osu p pressed patients, a n d h igh-risk


SCCs. To pica l thera pies req u i re c l ose fol l ow- u p fo r any
evidence of treatment fa i l u re o r rec u rrence.

F i rst- L i n e T h e ra p i es

Exc isional s u rgery: 4-m m m a rgins a re ge nera l ly recom

Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice

for high-risk a nato m i c a l locations (ie, " mask" a rea of

Figure 53.4 (A) Defect on the ear after Mohs excision of a squamous cell

the face ), locations where tissue conservation is c r u c i a l

carcinoma.

mended

258

Color Atlas of Cosmetic Dermatology

for fu nctional or cosmetic reasons, rec u r rent t u m o rs, i l l


defined c l i n i cal m a rgins, h i stologica lly aggressive s u b
types, t u m o rs in i m m u n osu ppressed patients, t u mo rs
la rge r than 2 e m , i rrad iated ski n , a n d per i n e u ra l i nva
sion on biopsy ( Figs. 53.4 a n d 53 . 5 ) . C u re rates of SCC
depend o n size, h isto l ogica l gra d e, peri n e u ra l i nvasion,
a n d i m m u nos u p pressi o n . La rge r lesions, less d iffe renti
ated va ria nts with per i n e u ra l i nvolvement, and lesions
i n i m m u noco m p ro m ised patie nts demonstrate lowe r
c u re rates

Electrodessication a n d c u rettage ( usua l ly not recom


mended d u e to lack of h i stologic confi rmation of
remova l )

C ryothera py ( u s ua l ly not reco m m e nded d u e t o l a c k of


h isto l ogica l confi rmation of remova l )

Rad i othera py ( a p p ropriate for poor s u rgical ca n d i d ates)

Figure 5 3 . 4 ( Continued) {8) The Mohs defect is repaired with a

A l te r n ate T h e ra p i es

full-thickness skin graft

Topical 5-fl uorouraci is l i m ited to SCC in situ

Topical i m i q u i m od is l i m ited to SCC i n situ

l ntra lesional i n terfe ron

P h otodyn a m i c thera py ( P DT) u s i n g topica l o r syste m i c


photosensitize rs with lasers or noncoh erent red l ight
a re m ost effective for SCC in situ . Clearance rates ra nge
from 72% to 94% . PDT can act as an a lternative treat
ment for la rge lesions, espec i a l l y for those patients who
a re poor s u rgica l c a n d i d ates. It can serve as a n a lterna
tive treatment i n patients with m u ltiple SCCs. For these
patients, P DT and c l ose c l i n ical fol l ow- u p may o bviate
the need for m u lti p l e s u rgeries. P DT is a lso effective for
decreasing the n u m ber of acti n i c keratosis, t h us acting
as a preventative of future sec development

Carbon d ioxide laser is h ighly effective fo r a cti n i c chei l i


t i s . It can a l so b e used t o treat S C C i n situ

P I T FALLS TO AVO I D
I nfection , bleed i ng, ne rve d a mage, pa i n , hypertro p h i c
sca rring, p o o r cosmesis fol lowi n g s u rgica l repa i r, a n d
recu rrence a re a l l c o m m o n pitfa l ls o f S C C treatm ent a n d
s h o u l d b e fu l l y d iscussed with the patient p r i o r t o treat
ment. Nonsu rgica l thera pies may provide better cosme
sis

but

sign ifica ntly

h igher

rates

of

rec u rre nce.

F u rthermore, nonsu rgica l i nterve ntions d o not provide


the o p portu n ity for h i sto logica l confi rmation of complete
remova l . T h i s is pa rti c u l a rly cr u cia l given the potential of
metastatic s p read with SCC. T h u s , sta n d a rd or Mohs
m ic rogra p h i c s u rgica l exc ision with h istologica l confi rma
tion of clear m a rg i n s is a l ways the treatment of choice for

sec.

Figure 53.5 {A) Surgical defect after Mohs micrographic surgery of an


sec on the left cheek.

Secti o n 8 : C u ta n eo u s Ca rc i n o m a s

259

B I B L I OG RAPHY
Covadonga M a rtinez-G onza lez M , d e l Pozo J , Paradela S ,
Fernandez-J orge B , Fern a n dez-Torres R , Fonseca E .
Bowe n 's d i sease treated b y ca rbon d i oxide laser. A series
of 44 patients. J Dermatolog Treat. 2008; 1 9 ( 5 ) : 293-299 .
M orton CA, McKenna KE, R hodes LE. B ritish Assoc iation
of

Dermatologists

Thera py

G u i d e l i nes

and

Aud it

S u bcomm ittee and the B ritish P hotod ermatology G rou p .


G u i d e l i nes for to pical p h otodyna m i c thera py : Update. Br

J Dermatol. 2008; 1 59 ( 6) : 1 245- 1 246.


P reston DS, Ste rn RS. N o n melanoma cancers of the ski n .

N Eng/ J Med. 1 992;327 : 1 649- 1 662.


R owe D E , Carro l l RJ , Day C L J r. P rognostic factors for
loca l rec u rre nce, m etastasis, a n d s u rviva l rates in sq ua
mous cel l carc i n o m a of the skin, ear, a n d l i p. I m p l ications
fo r treatment m od a l ity selecti o n . J Am Acad Dermatol.
1992;26:976-990.

Figure 5 3 . 5 (Continued) (B) The Mohs defect is repaired with a transposi

tion flap. (C) A fter suture removal 1 week later

This page intentionally left blank

NINE
I nf l a m matory Disord e rs

262

Color Atlas of Cosmetic Dermatology

CHAPT E R 54

Liche n Pla nus

Lichen p l a n u s ( LP ) is a c o m m o n i nfla m m atory d isease


i nvo lvi ng the s k i n a n d m u cous m e m b ra nes. M a n y c l i n ical
va ria nts exist that include atro p h i c , u lcerative, b u l lous,
a n n u la r, l i nea r, i nverse , hypertro p h i c , l i c h e n pla n o p i l a ris,
acti n i c LP and LP pigme ntos u s .

EPI D E M I O LOGY
Incidence: About 0 . 5 %
Age: 30 t o 6 0 yea rs
Race: A l l races a re affected eq u a l ly i n m ost va riants
Sex: H igher i n c i d e n ce in fe ma les
Precipitating Factors: M ost c o m m o n l y i d iopath ic medica
tions may i nd uce a LP- I i ke e r u ption

PATHOG E N E S I S
Primari ly, a T- hel per cell-med iated reaction

PHYS I CAL EXAM I NAT I O N


Most common ly, primary lesions consist of m u ltiple viola
ceous,

polygo n a l ,

flat-topped ,

grou ped

pa pu les,

and

plaq ues that a re usually pru ritic. T h e i r su rface is s h iny o r


tra nspa rent a n d m a y exh i b it small gray-white punctae o r
reticular fine wh ite li nes known as Wickha m 's striae . T h e
lesions favor t h e oropharynx, flexural wrists, dorsa l hands,
med i a l th ighs, s h i ns, tru n k , a n d gen ita l i a . Posti nfla m matory
hyperpigmentation is com mo n . Acti nic LP a n d LP pigmen
tosus can present with melasma - l i ke hyperpigmented
patc hes on the forehead and the face ( Figs. 54. 1-54.3) .

D I F F E R E NT I A L D I AG N OS I S
Psoriasis, l ic h e n s i m plex, l ic h en oid graft-versus-host d is
ease, c h ro n ic c uta neous l u pus e rythe matos us, l i chenoid
d rug e r u ptio n , melasm a .

LABORATORY DATA
G iven the association with h e patitis B a n d C , h e patitis
serologies can be i nvestigated .

D e r m at o p at h o l ogy
Pathology reveals l i chenoid i nterface dermatitis, hyperk
e ratosis, hypergra n u losis, saw-tooth aca nthosis, associ
ated with colloid o r civatte bodies.

Figure 54. 1 Actinic LP on the forehead, temples, and lateral cheek,


mimicking melasma

Secti o n 9 : I nfla m m atory D i so rd e rs

263

CO U RS E
S ponta neous re m ission of cuta n eous L P occ u rs with i n
1 yea r o f onset i n t h e majority o f patients. O ra l LP persists
for many yea rs . Sq u a m o u s ce l l carc i noma may a rise from
these

lesions,

pred o m i n a ntly from

the

oral

va riant

( Fig. 54.4).

MANAG E M ENT
To p i c a l Treat m e n t

Corticosteroids, topica l , i ntra lesi o n a l

l m m u n omod u lators, s u c h as tac rol i m us

Cyc losporine retention mouthwash for o ra l LP

Syste m i c Treat m e n t

Corticoste roids

Figure 54.2 Generalized lichen planus in a patient with skin type 1 V-V

in volving the trunk and buttocks with postinflammatory hyperpigmentation

Reti n o i d s : isotret i n o i n a n d acitreti n . Acitret i n is the


only syste m i c treatment that has been eva l uated i n a
d o u b l e - b l i n d , p l a cebo-contro l led study

G riseofu lvi n , metro n i d azole, a ntima l a ri a l s , m ethotrex


ate, cyc l ospori ne, a n d mycophenolate m ofet i l

L i g h t Treat m e n t

N a rrow B a n d UVB

P U VA

308- n m UVB exc i mer laser for o ra l LP

C0 2 laser for o ra l L P : va ria b l e resu lts with i n c reased


risks of side effects

Extracorporea l photophoresis

B I B L I OG RAPHY
Da m m a k A , Masmoud i A , Bou daya S , Bouassida S ,
M a rrekc h i S , Tu rki H . C h i l d h ood acti n i c l i c h e n pla n u s
( 6 cases) [ p u b l ished o n l i ne a head o f p r i n t J a n u a ry 18,
2008] . Arch Pediatr. 2008; 1 5( 2 ) : 1 1 1 - 1 14.
La u rberg G , Geiger J M , Hjorth N , et al. Treatment of
l i c h e n p l a n us with a c itreti n . A d o u ble-bl i n d , place bo
contro l l ed study in 65 patients. J Am Acad Dermatol
1 99 1 ; 24(3):434-437 .
Tre h a n M , Taylor C R . Low-dose exc i mer 308- n m laser for
the treatment of o ra l l i c h e n pla n us . Arch Dermatol
2004; 140(4) :41 5-420.
va n der Hem PS, Egges M, va n der Wa l J E, Rooden b u rg
J L. C0 2 laser eva poration of oral l i c h e n p l a n u s . tnt J Oral
Maxillofac Surg. 2008; 3 7 ( 7 ) : 630-633.

Figure 54.3 Hypertrophic lichen planus on the legs of 4 years duration

resistant to topical and intralesional steroid therapy. The patient


improved markedly after 1 month treatment with acetretin

264

Color Atlas of Cosmetic Dermatology

Figure 54.4 (A) Ora/ lichen planus at baseline. (B) Two month follow-up
after 1 8 treatments with excimer laser administered weekly (Courtesy of
Charles Taylor, MDJ

Secti o n 9 : I nfla m m atory D i so rd e rs

CHAPT E R 5 5

265

M o rphea

M orphea is l oca l ized scleroderma confi ned t o the ski n . It


m ost commonly affects the tru n k but a lso occ u rs on the
face and extre m ities. The fo u r c l i n ical va ria nts i n c l u de
p l a q u e-type morphea, gen e ra l ized morphea, l i near mor
phea (en cou p de sabre), a n d pa nsclerotic morphea of
c h i l d re n ( morphea profu n d a ) .

E P I D E M I O LOGY
Incidence: ra re
Age: m ost com m o n l y occ u rs i n the seco n d to fifth
d eca d e . Li nea r scleroderma a nd morphea profu nda a re
more c o m m o n i n c h i l d ren

Race: sl ightly more common in Caucasians


Sex: fe ma les more than ma les (2-3 : 1 )
Precipitating factors: Borrelia c a n trigger morphea i n
some cases, pred o m i n a ntly i n E u ro pe

PATHOG EN ES I S
Overprod uction of col lagen (types I , I I , I l l ) a n d gly
cosa m i noglyca ns by s k i n fi broblasts a nd vasc u l a r d a m
age. Proba ble T-cell med iated phenomeno n .

PHYS I CAL EXAM I NAT I O N


I l l-d efi ned p i n k t o violaceous, i nd u rated 2 - t o 1 5-cm
plaq ues that tra n sform to sm ooth sclerotic ivory-colored
plaq ues with a l ight violaceous bord e r a n d a s h i n y s u r
face. Posti nfla m matory hyperpigmentation is p reva lent
( Fig. 55. 1 ) . Linear morphea presents with a l i nea r e rythe
matous i nfla m matory streak that may progress to form a
sca r- l i ke ba n d i nvolvi ng u n d e rlying fasc i a , m usc le, a n d
te ndons.

D I F F E R E N T I A L D I AG N OS ES
Acrod ermatitis c h ron ica atro p h icans, eos i n o p h i l i c fasc i
itis, l i c h e n sclerosus et atro p h i c u s , sclered e m a , sc l e
ro myxed e m a , a n d n e p h roge n i c system i c fi b rosis.

LABO RATO RY DATA


S e ro l ogy
Check for Borre l i a a n t i bodies.

Figure 5 5 . 1 (A) Early morphea on the left leg presenting as an erythema

tous plaque. (B) Same patient with late stage morphea on the right leg
presenting as linear depressed yellowish to white hard plaques with ery
thematous margins

266

Color Atlas of Cosmetic Dermatology

D e r m atopat h o l ogy
H omogen ization a n d thickening of derma l col lagen b u n
d l es, tra p ped a n d atro p h i c eccrine glands, perivasc u l a r
mononuclear i nfi ltrate o f lym p h ocytes a n d plasma cells
with normal o r atro p h i c overlying epidermis. U n d erlying
su bcuta neous fat may a lso be i nvolved with sclerosis in
adva n ced cases.

COU RS E
Cou rse i s va ria b l e . M a ny patients re m it s ponta n eously
but others have a p rogress ive cou rse.

MANAG E M ENT
Treatment for t h i s cond ition ca n b e frustrating d ue t o fre
q uent treatment fa i l u re . Patients s h o u l d be cou nseled
that thera py may not be effective .

Topical treatment
- Corticosteroids
- Calci potriene

System i c treatment
- Corticosteroids, D-penicillami ne, vitamin 03, methotrexate

Light treatment
- U ltraviolet A l photothera py
- P u lsed dye laser ( 585 n m , 5 J/cm 2 twice monthly),
reported to be effective i n s i ngle case report

S u bc i s io n : s u bcision with a N okor 18G need le may

help to elevate the b o u n d -down ski n . It is m ost effec

Figure 5 5 . 2 (A) Morphea with significant epidermal, dermal, and subcu

tive

taneous atrophy. (8) Elevation of the atrophic plaque of morphea after a


single autologous fat transfer. The associated telangiectasias were subse
quently treated with the pulsed dye laser with substantial improvement

for

l i nea r

m o r phea

and

fa c i a l

h e m iatro p h y.

S u bc i s i o n is performed u n d e r loca l i nfi ltrative a n esthe


sia

to the affected

s ite with

1%

l i d oca i n e with

1 : 1 00,000 e p i n e p h ri n e . The Nokor need le is i ntro


d uced at a 45-degree a ngle i nto the skin uti l i z i n g a
swee p i n g

motion

to

release

a ny tethered

a reas.

M u lt i p l e entra nce sites should be performed fo r opti


m a l benefit. F i r m press u re is a p pl ied to the treatment
sites fo r h e m ostasis

Soft tissue a ugmentatio n : va rious fi l lers have been


e m ployed with va riable s uccess to a ugment the scle
rotic sites . They a re m ost com monly uti l i zed for l i near
morphea a n d fac i a l h e m i atrophy. Te m pora ry fi l l e rs c u r
rently rec o m m e n d ed given the u n p red i cta ble c o u rse of
morphea . Autologous fat tra n sfer can provi d e sign ifi
cant a ugme ntation of the affected sites ( Fig. 5 5 . 2 ) .
R e peat i njections genera l ly req u i red . En bloc a u tolo
gous dermal fat graft re ported to be effective i n one
case re port.

Secti o n 9: I nfla m m atory D i so rd e rs

P I T FALL TO AVO I D
Patients must be awa re of the u n pred icta ble natu re of mor
phea, therefore the u n pred icta ble nature of the treatment.

B I B L I OG RAPHY
Eisen D , Alster TS. U s e o f 5 8 5 n m p u lsed dye laser fo r
the treatment of morphea . Dermatol Surg. 2002 ; 28( 7 ) :
6 1 5-6 1 6 .
La piere J C , Aasi S , Cook B , M onta lvo A . S u ccessful cor
rection of d e p ressed sca rs of the forehead seco n da ry to
tra u ma a n d morphea e n cou p de sa b re by en b l oc a utol
ogous d e r m a l fat graft. Dermatol Surg. 2000 ; 26(8) : 793797.
N i stico

S P,

Saraceno

R,

Sc h i pa n i

C,

Costa nzo

A,

C h i menti S . Differe nt a p pl ications o f m on oc h romatic


exc i mer l ight i n skin d iseases. Photomed Laser Surg.
2009 ; 27(4) : 647-654 .

CHAPTER 56

Pso riasis

Psoriasis is a c o m m o n c h ron i c i nfla m m atory d isease of


the s ki n . They a re sym metric in d istri bution a n d favor
e l bows, knees, sca l p , retroa u r i c u l a r ski n , and i nte rtrigi
nous a reas. Many c l i n ical va riants exist and i n c l u d e
p l a q u e psoriasis, pustu l a r psoriasis, guttate psoriasis,
i nve rse psoriasis, and eryth rod ermic psoriasis, with the
plaque va riant bei ng the m ost common type ( Figs . 56. 1
and

56 . 2 ) .

N a i ls a n d

m ucous mem bra n es can

be

affected . Psoriasis is associated with psoriatic a rth ritis i n


a t least 5 % o f patients .

EPI DEM I O LOGY


Incidence: About 1 . 5 % to 2 % of the wor l d 's population
Age: can occ u r at a n y age. Two pea ks of onset, the sec
ond

and sixth decades. Onset is ea rlier in wo m e n .

U ncom m o n ly affects c h i l d ren

Race: lower i n c idence i n African Ame rica n s , Native


America ns, a n d Asians

Sex: eq ual
Precipitating factors: bacterial i nfections, especia l ly strepto
cocca l i nfection (guttate psoriasis), tra u m a ( Koebner p he
nomenon ) , stress, ge netic pred isposition, a nd med ication
use ( m ost com monly l it h i u m , beta blockers, antimalarials) .
Rapid corticosteroid ta pers may ind uce pustu lar psoriasis

Figure 56. 1 Classic psoriatic plaques on the knees

267

268

Color Atlas of Cosmetic Dermatology

PATHOG E N E S I S
Polyge n i c d i sease with a 4 1 % risk for a c h i l d to d evelop
psoriasis if both the pa rents a re affected . The p r i m a ry
pathophysiology i nvolves hyperprol iferation a n d a b nor
m a l d ifferentiation of epidermal kerati nocytes as well as
a b normal cel l u la r i m m u n e res ponse.

PHYS I CAL EXAM I NAT I O N


P l a q u e va riant with we l l-demarcated , p i n k t o erythema
to us pa pu les a n d plaq ues with overlyi ng s ilvery-wh ite
sca l e . P i n po i n t bleed i n g o bserved with sca le re mova l
(Ausp itz sign ) . G uttate va riant with tea r d rop-sha ped
lesions. Erythe mato u s genera l ized pustu les a re seen with
p ustu l a r pso riasis.

D I F F E R E N T I A L D I AG N OS ES

Figure 56.2 Psoriatic plaques koebnerizing vitiligo patches

Ti nea corporis, seborrheic d e rmatitis, eczematous d er


matitis, mycosis fu ngoides, pa ra pso riasis, l i c h e n s i m plex
c h ro n i c us ,

p ityriasis

ru bra

pila ris,

Reiter's

d isease,

Bowe n 's d isease.

LABORATORY DATA
S e ro l ogy
Antistrepto lys i n O(ASO) titer for guttate psoriasis.

D e r m at o p at h o l ogy
Regu l a r psoriasiform epidermal hyperplasia with a bsent
gra n u la r cell layer and th i n n i ng a bove the dermal pa p i l
l a e . Othe r c h a racteristic featu res i n c l u d e col lections of
ne utro p h i l s in epidermis as wel l as tortuous blood vessels
i n the pa p i l l a ry d e r m i s .

COU RS E
T h i s d isease d e mo nstrates a c h ro n i c cou rse with m u ltiple
exacerbations a n d re m issions, w h i c h ca n be season a l or
related to stress.

MANAG E M ENT
There a re m u lt i p l e thera peutic options for treatm e nt of
psoriasis. C hoos i n g an a p pro p riate thera py d e pen ds o n
the a g e , h e a l t h , a n d prefe ren ces o f the patient. It a lso
d e pends on the exte nt of the psoriasis. The costs of ther
a py va ry d ra m atically as we l l . Alternative thera pies a re
m ost a pprop riate in refractory cases. Assessing the side
effect profi le of treatments is a n other cruc i a l com ponent

Secti o n 9: I nfla m m atory D i so rd e rs

269

of thera py. Com bi nation thera p i es a re gen e ra l ly m ost


effective to decrease inflam mation a n d red uce sca le p ro
d ucti o n .

Topica l Treatment
- Corticosteroids, to pical a n d i ntra l es i o n a l
- Calci potriene
- Taza rotene
- Coa l ta r
- Anthra l i n
- Sa l icyl ic acid

System i c Treatment
- M ethorexate
- Reti noids, p red o m i n a n etly a c itret i n
- Cyc lospori ne
- B i o logics suc h as a l efa cept, eta ne rcept, efa l uz i m a b ,
a n d i nfl ixi m a b

Laser a n d Light Treatme nts


- Psora len with U ltraviolet A ( P UVAJ
- U l travio l et B ( U V B ) , 3 1 1 - n m na rrowba nd-UVB ( N BUVBJ
- 308- n m UVB exc i m e r laser
An a lternative fo r treatment of m i ld-to- moderate
psoriasis, where m o re conventi o n a l t h era pies have
fa i led . It is espec i a l l y h e l pfu l for loca l i zed refractory
p l a q u e psoriasis
Stu d i es have demonstrated that this local ized UVB
treatm ent provides much lowe r c u m u lative d oses of
UVB to i n d uce cleara n ce of psoriatic plaq u es com
pa red to N B-UVB thera py
The exc i mer laser m ight a lso prod uce longer re m is
sion periods, with m i n i m ization of UVB expos u re to
healthy su rrou n d i ng s k i n
Exc i m e r l a s e r has proved t o be effective a n d safe i n
treating refractory sca l p psoriasis
D rawbacks of exc i m e r laser in psoriasis treatment
i n c l u d e l i m ited ava i l a b i l ity, treatment expense and
exte ns ive treatment time n eeded per session

Ph otodyna m i c thera py has been shown to i m prove pso


riasis

in

m u lt i p l e stud ies.

The

major side effects

i n c l uded pa i n a n d b u r n i n g sensation associated with


PDT

Pu lsed dye laser (0.45- 1 . 5 m s , 7-mm s pot, 7-9 J/c m 2 ,


D C D 30-40/20) has been e m p l oyed to ta rget the vas
c u la rity assoc iated with psoriatic lesions with noted
benefit. I n a recent study, P D L p roved to be effective i n
t h e treatment o f n a i l psoriasis ( Fig. 56.3)

In a recent study, N d : YAG laser ( 1 ,064 nm) fa i led to


i m prove loca l ized p l a q u e type psoriasis

T
Figure 56.3 Improvement in treated psoriatic plaque 3 months after
pulsed dye laser treatment (585 nm, 1 0-mm spot size, 5 J/cm 2 , no cool
ing, 0. 45-ms pulse duration), as compared to the control site
(Reproduced, with permission, from Brian Zelickson, MD)

270

Color Atlas of Cosmetic Dermatology

P I T FALLS

Patients s h o u l d be cou nseled t h a t psoriasis is a c h ro n i c


cond ition with fla res a n d re m issions. Laser th era py,
such as the exc i m e r laser, is an a l ternative treatment
that should o n ly be considered afte r a pati ent has fa i led
m u ltiple other treatment reg im en s .

Patients s h o u l d be awa re t h a t any treatment a d m i n is


tered , it may res u l t in s p read of the psoriasis ( Koebner
phenomenon ) . They should a lso be awa re that s u rgica l
treatments performed for a ny reason may a lso res u lt i n
si m i l a r s p rea d .

B I B L I OG RAPHY
Ferna n dez-G u a r i n o

M,

H a rto A ,

Sanc hez- Ronco

M,

Ga rcfa - M o ra les I , J a e n P. P u lsed dye laser vs . p h otody


n a m i c therapy in the treatm e nt of refractory n a i l pso ria
sis: A comparative p i lot study. J Eur Acad Dermatal
Venereal. 2009 ; 23(8) : 89 1 -895 .
Gattu S , R a s h i d R M , Wu JJ . 308- n m exci mer laser i n
psoriasis vu lga ris, sca l p psoriasis, a n d pa l m o p l a nta r pso
riasis. J EurAcad Dermatal Venereal. 2009; 23( 1 ) :36-4 1 .
N o borio

R,

Ku rokawa

M,

Kobaya s h i

K,

Morita

A.

Eva l uation o f t h e c l i nica l a n d i m m u n o h istologica l efficacy


of the 585- n m p u lsed dye laser in the treatment of psori
asis. J Eur Acad Dermatal Venereal. 2009 ;23(4) :420424 .
S m its T, Klei n pe n n i ng M M , va n Erp P E , va n de Ke rkhof
P C , Ge rritsen

MJ .

A placebo-controlled

ra n dom ized

study on the c l i n ic a l effectiveness, i m m u noh istoc h em ica l


cha nges a n d p rotoporphyri n I X accu m u lation i n fraction
ated 5-a m i nolaevu l i n i c a c i d - p hotodyn a m i c th era py in
patients with psoriasis. Br J Dermatal. 2006; 1 55 ( 2 ) :429436
Taylor C R , Racette AL. A 308- n m exc i m e r laser for the
treatment

of

sca l p

psoriasis.

Lasers

Surg

Med.

2004;34(2) : 1 36- 140.


Va n Li ngen RG, d e J ong EM, va n Erp P E , va n M eeteren
WS, va n De Kerkhof PC, Seyger M M . N d : YAG laser
( 1 , 064 n m ) fa i l s to i m prove loca l ized p l a q u e type psoria
sis: A c l i n ic a l and i m m u n oh i stoc h e m i c a l pi lot study
[ p u b l ished o n l i n e a h ead of p r i nt Octo ber 2 7 , 2008] . Eur
J Derma tal. 2008; 18(6) :67 1 -676.

TE N
Ad i pose Ti ss u e A l te ratio n s

272

Color Atlas of Cosmetic Dermatology

CHAPT E R 5 7

G y n eco m astia

Gynecomastia is the i nc reased p resence of benign gla n


d u l a r tissue, i n the form of a firm mass, a r o u n d the n i pple
i n m a l es ( Fig. 5 7 . 1 ) . I t is accom pa n i ed by i n c reased fat
d e position . I n contrast, i nc reased fat de position a lone, i n
the a bsence of gla n d u l a r prol ife ratio n , i s known as
pseudogyn ecomasti a . It ca n be b i l atera l or u n i latera l . I t is
common at b i rt h , p u berty, m id d l e age, a n d i n elderly
a d u lts. M a ny cases a re i d i o path i c . M u ltiple prec i pitat i n g
factors exist i n c l u d i n g hormonal a bn or m a lities, m ed ica
tion , c i rrhosis, hypogo n a d i s m , test i c u l a r t u m o rs, hyper
thyro i d i s m , a n d c h ro n i c re n a l i n s uffi c i e n cy.

For t h i s

reason , i n the a p p ropriate c l i n ical setting, the a ppea r


a n ce of gynecomastia d e m a n d s a med ical work u p .

E P I D E M I O LOGY
Incidence: most common i n newborns but a lso c o m m o n
i n p u berty a n d o l d e r ma les

Age: b i rth (0-3 weeks ) , p u be rty ( 1 0- 1 7 yea rs) , m i dd le


aged and elderly age gro u ps ( 50-80 yea rs)

Race: none
Sex: ma les
Precipitating factors: hormonal i m ba l a nces, hormonal
thera py for prostate ca ncer, d rugs s u c h as, finasteride,
c i rrhosis, hypogonad i s m , testic u l a r tu mors, hyperthy
roid i s m , c h ro n i c re n a l i n s ufficiency. About one-q u a rter of
cases a re id iopath ic

PATHOG E N E S I S
I n cases of hormonal

B
i m ba l a n ces, the fu n d a m enta l

defect is a decrease in a n d rogen levels with a concomi


ta nt i n c rease i n estroge n levels.

PHYS I CAL LES I O N S


A fi rm su bcuta neous n o d u l e extends con centrica l ly from
the n i p pl e . It may be u n i latera l or bi latera l . I n pse u d ogy
necomastia, the exa m i ned a rea is less firm as there is no
excess gla n d u l a r tissue.

D I F F E R E N T I A L D I AG N OS I S
B reast ca ncer, pse ud ogynecom asti a , b reast hypertrophy.

LABORATORY EXAM I NAT I O N


Seru m h C G , L H , testosteron e , estra d i o l leve ls s h o u l d be
i n vestigated in the setti n g of pa i n , tenderness, o r recent

Figure 57. 1 Characteristic appearance of gynecomastia in a middle-aged

male

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

onset or c l i n ica l suspicion of endocrine a b normal ities.


F u rther worku p i s i n d icated i n the eve nt of u n i latera l
b reast e n l a rgement.

CO U RS E
T h i s depends on t h e etio l ogy. N ewborn gynecomastia
persists for a few weeks. In tee nagers, it may last a few
yea rs .

D i sconti n u a nce of med ication w i l l a m e l io rate

sym ptom s in d rug- i n d u ced cases. In cases of hormonal


i m ba la n ce, k i d n ey d isease, a n d hyperthyroid ism , correc
tion of the u n d e rlying i l l ness w i l l prod uce i m provement.

KEY CO N S U LTAT I V E QU EST I O N S

Medication h i story

Hormonal c h a nges

R e n a l or thyroid d i sease

Hormonal thera py for prostate cancer

Assoc iated sym pto ms

U n i latera l or b i latera l

MANAG E M ENT
M ost gynecomastia is tem pora ry a n d wi l l resolve without
thera py. If it is related to p u be rty, c l i n i ca l o bservation and
fo l l ow- u p wi l l l i kely be all that is needed . Disconti n uation
of a n offe n d i ng med i cation is typi c a l l y a l l that is req u i red
to treat d rug- i n d uced gynecomastia . U n i latera l gyneco
m astia req u i res a m a m mogra m with a p propriate fo l low
u p as needed . Med ica l a n d s u rgica l opti ons a re ava i la ble
for patients who have persistent gynecomastia i nto late
p u be rty p rod ucing e m otional d istress, pa i n , or tend er
ness . Ben ign psued ogynecomastia is the m ost c o m m o n
cause o f m a l e b reast e n l a rgement.

T R EATM ENT
O ra l M e d i cat i o n s
Medical thera py for gynecomastia i s beyond the scope of
this textbook. It is best performed by a physician who is
tra i ned in internal med icine or endocri nology. Med ications
include androgens, a ntiestrogens, and aromatase i n h i bitors .

P ro p h y l ax i s i n P rostate C a n c e r
B reast rad iation c a n b e performed prophylactica l ly i n
pati ents u n d e rgoing a ntiand rogen thera py or orch iec
tomy for prostate c a ncer. Concom ita nt ta m oxifen a d m i n
istration with f i nasteride/fl uta m i d e thera py ca n a lso be
prophylactic for gynecomastia .

273

274

Color Atlas of Cosmetic Dermatology

S u rge ry
I n the event of medical treatment fa i l u re , s u rgica l thera py
is the next o pti o n . It is reserved for pati ents with refra c
tory gyn eco mastia that has fa i led medical thera py. The
treatments depend on the exte nt of gyn ecomastia . A few
options a re descri bed bel ow.

S u rgical excision i n c l u d i ng sta n d a rd el l i ptical excision


as we l l as s u bcuta neous mastectomy.

Conventiona l a n d u ltraso u n d -assisted l i posucti o n , that


is, l oca l ized rem ova l of gla n d u l a r tissue a n d/o r excess
fat . T h i s is part i c u l a rly successfu l in early stage a n d
l i m ited gyn ecomastia .
- Li posuction is performed th rough s m a l l incisions i n
t h e axilla a n d ste rn u m t o m i n i m ize sca rring
- Li posuction is less effective i n longsta n d i ng a n d s u b
sta ntial gynecomastia
- In prostate cancer patie nts, ea r l i e r i nte rvention is
more efficacious
- Resid u a l pe ri areola r fat may be n oted postl i pos uction
that can be i m p roved with local ized d issection of fat
via a s m a l l peria reo l a r i n cision
- Postproced u re s k i n laxity may be n oted

Com bi nation of s u rgica l excision a n d t u m escent l i po


sucti o n . T h i s i nvolves l i posuctio n , open excision , a n d
s k i n red uction for laxity. Li posuction h a s a lso been
c o m b i ned with su bcuta neous mastectomy.

S u rgical excision with plastic s u rgica l repa i r, p a rticu


la rly i n the event of b reast tissue sagging. Excessive fat,
gla n d u l a r tiss u e , and loose skin a re exc ised via e l l i ptica l
excision ,

i n c l u d i ng

the

ni pple

and

a reola.

The

n i p ple/a reola co m pl ex is then p laced i n the a p p ro priate


a nato m i c position as a fu l l t h i c k n ess s k i n graft after the
excess gla n d u l a r tissue is re m oved .

Psuedogynecomastia c a n be treated with l i posuction .


M a l e b reast fat tends to be re latively fi b rous, a n d t h us
more d ifficult to treat. F u rther, ca re m ust be ta ken to
avoid i nj u ry to the pectora lis m uscle. I n true gynecos
m asti a , excess gla n d u l a r tissue ren ders the p roced u re
eve n more c h a l lenging.

W h i l e tra d itiona l l i posuction a n d t u m escent l i posuction


have d o m i nated l i posuction treatment of gynecomastia
and pse u d ogynecomast i a , laser-assisted l i posuction is
a recent a d d ition to this fie l d . Th ere is no evidence to
show that laser-assisted l i posuction is su perior to either
of these forms of I i posucti o n .

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M E N T/O UTCO M E
EXPECTAT I O N S

I t is i m porta nt t o recogn ize that gyn ecomastia h a s m u l


t i p l e etio l ogies before atte m pting t o treat it.

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

I n most cases, watc hfu l wa iti ng is the best thera py.


I n cases of a n u nd e rlying syste m i c ca use, referral to the
a p propriate spec i a l ist is m a n dated .

I n cases of d rug- i n d uced gyn ecomasti a , d isconti n ua


tion of the med ication is the best ma nagement.

In cases of refractory to medical manage ment, there a re


severa l s u rgica l options. C o m p l i cations from these pro
ced u res i n c l ude a poor cosmetic res u lt, posto perative
sca rring, i ncom plete re mova l , postproced u re s k in laxity,
perma nent n u m bness i n the a rea , a n d he matoma for
mation .

B I B L I OG RAPHY
As i a n G , Tu n ca l i D , Te rziogl u A, B i ng u l F . Peria reolar
tra nsa reol a r-perithe l i a l i n cision for the s u rgica l treatment
of gyn eco mastia . Ann Plast Surg. 2005; 54( 2 ) : 1 30-134.
B e m bo SA, Ca rlson H E. Gynecomasti a : I ts features, and
when a n d h ow to treat it. Cleve Clin J Med. 2004; 7 1 (6 ) :
51 1-517.
G a b ra

HO,

M o ra bito

A,

Bianchi

A,

B owen

J.

Gynaecomastia i n t h e adolescent: A surgica lly releva nt


cond ition . Eur J Pediatr Surg. 2004; 1 4( 1 ) :3-6.
Gaspero n i C , Sa lgare l l o M, Gaspero n i P. Tec h n ic a l refi ne
ments in the s u rgica l treatment of gyn ecomasti a . Ann
Plast Surg. 2000;44(4) :455-458
lwuagwu OC, Calvey TA, l lsley D, D rew PJ . U ltraso u n d
g u ided m i n i m a l ly i nvasive breast s u rgery ( U M I BS ) : A
s u perior tec h n i q u e for gynecom asti a . Ann P/ast Surg.
2004 ; 52( 2 ) : 1 3 1 - 1 3 3 .
R o h rich

RJ ,

Classificatio n

Ha

RY,

and

Ken kel

JM,

ma nagement

Ad a m s
of

WP

J r.

gynecomasti a :

Defi n i ng the ro le o f u ltraso u n d -assisted l i posucti o n . Plast


Reconstr Surg 2003 ; 1 1 1 ( 2 ) : 909-923.
G raf R, Auersva ld A, Da masio R C , R i ppel R, d e Ara ujo
LR, B iga re l l i LH, F ra n c k CL. U ltraso u n d-assisted l i posuc
tion : An a na lysis of 348 cases. Aesthetic Plast Surg.
2003 ; 2 7 ( 2 ) : 146- 1 53 .
Z e l i c kson B D , Dresse l T D . Discussion o f laser-assisted
l i pos u ction . Lasers Surg Med. 2009;4 1 ( 1 0 ) : 709-9 1 3 .

275

276

Color Atlas of Cosmetic Dermatology

CHAPT E R 58

Cellulite

Cel l u l ite d escri bes an orange peel type d i m pl i ng of s k i n i n


t h e u p per poste rior th ighs a n d buttoc ks ( Fig. 58. 1 ) .
Although there i s n o assoc iated morbid ity o r morta l ity, i t is
a mong the m ost common cosmetic com p l a i nts a mong
fe male patients . I t is present i n nearly all post p u berta l
fe males, rega rd less of weight. It is best thought of as a
fe male

seco n d a ry sexua l

cha racteristic .

I m po rta ntly,

treatments for fat remova l a n d cel l u l ite s h o u l d be consid


e red d isti nct. Effective treatments fo r fat remova l typica l ly
have no benefit for cel l u l ite .

EPI D E M I O LOGY
Incidence: 85% to 98% of postpu be rta l fe ma les, fa r less
c o m m o n in ma les

Age: begins in fem a l es after p u be rty


Race: m ore common in Caucasians
Sex: fa r more c o m m o n i n fem a les, ra re i n m a l es
Precipitating factors: fe m a l e ge nder, a n d roge n deficiency
in m a les ( ra re)

PATHOG E N E S I S
U n known .

PHYS I CAL LES I O N S


There is a n ora nge peel o r cottage c h eese type d i m p l i n g
o f t h e u p per a n d outer th ighs a n d buttoc ks. Other com
mon locations i n c l u d e the breasts, lowe r a bd o m e n ,
u pper a rms, a n d n a pe o f neck.

D I F F E R E N T I A L D I AG N OS I S
None.

LABORATORY EXAM I NAT I O N


None i n d icated a s the c l i n ic a l a p pea ra nce is class i c .

COU RS E
Begi ns i n p u berty i n fe males a n d persists t h roughout l ife .
I n m a l es with a n d rogen d eficienc ies, the c l i n i c a l a p pea r
a n ce worsens as the a n d rogen d eficie ncy becom es m o re
severe . It may p resent de novo in m a l es u n d e rgoing hor
m o n a l thera py for prostate cancer.

Figure 58. 1 Classic appearance of cellulite

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

KEY CO N S U LTAT I V E QU EST I O N S


I n m a l es, i n q u i re a s t o a n y poss i b i l ity o f endocrine a b n or
m a l ities. T hi s is a very rare assoc iation of cel l u l ite i n
males.

MANAG E M ENT
There is no med ica l i n d ication t o treat cel l u l ite. Sti l l , many
patients req uest thera py. C u rrently, there a re n u merous
p u r ported thera pies, none of which have proven to be
very effective . I nteresti ngly, despite the lack of sci entific
evi dence of i m provement, many patients report su bjective
i m provement a n d satisfaction with thera py.

T R EATM ENTS
D i et

We ight has o n l y a m i nor association with ce l l u l ite

I t is c o m m o n in t h i n fe m a l es a n d ra re in o bese m a l es

There is no d ata to s h ow that d i et a n d exe rcise a re


effective treatme nts

To p i c a l Treat m e nts

A m i nophyl l i ne, reti noids, lactic a c i d , xa nth i n es, a n d


many others have a l l b e e n used w i t h l ittle evi d e nce o f
efficacy

Some c rea m s may prod uce more harm t h a n benefit


In fact, one study i n d icated 25% of cel l u l ite c rea ms
exa m i ned conta i ned known contact a l l erge ns

I n t e rve n t i o n a I Treat m e nts

Liposucti o n

There a re a few pu bl ished re ports o f i m prove ment;

I n some cases, it accentuates the a p pea ra nce of cel

however, typica l l y it d oes n ot i m p rove ce l l u l ite


l u l ite

Prior to perfo r m i n g a l i posuction proced u re, it is usefu l


to i n form patients that their cel l u l ite wi l l not reso lve .
T h i s wi l l protect aga i n st postproced u re d is a p poi ntment

Endermologie

Endermologie is a n FDA cleared device to i m prove the


a p peara nce of cel l u l ite

S k i n is kneaded by a h a n d held m a c h i n e
I t is rol led over affected a reas o f the body t h a t a re cov
ered by a nylon s u it

It p u r ports to i m prove blood a n d lym phatic flow as wel l


as s k i n a rc h itect u re

Figure 58.2 VelaSmooth laser treatment of thigh of young female

277

278

Color Atlas of Cosmetic Dermatology

Twice wee kly treatm e nts of 10 to 45 m i n utes each a re


reco m m e n d ed

There is a l ittle evi d e nce to s u p po rt its efficacy

Subcision

Req u i res l o c a l a n esthesia


U s i n g a sca l pel or special 1 6-ga uge need le, the fat septae a re cut i n the deep s u bcuta n eous fat

Side effects i n c l u d e pa i n , bruisi ng, sca r, a n d puckering

Little d ata to su pport tem pora ry effi cacy

M esotherapy
P h os p h ati d y l c h o l i n e i njecti o n s : n ot a reco m m e n ded
t h e ra py.

I njecti on of c o m b i nations of i ngredie nts d i rectly i nto


su bc uta neous fat

P h osp hatidylchol i ne a n d d eoxycho late prepa rati ons a re


most c o m m o n ly used
- Deoxyc holate is the a ctive i ngred ient

N o p u b l ished d ata to show efficacy

Laser

Ve laSmooth system (Syneron

I nc.,

R i c h m on d

Hill,

O nta rio, C a n a d a ) com b i n es near-i nfra red l ight a t a


wavele ngth of 700 to 2 , 000 n m , conti n u o u s-wave rad io
freq u ency, a n d mecha n ic a l suction ( Fig. 58 . 2 )
- Twice wee kly treatments fo r a tota l o f eight t o t e n ses
sions have been recommended
- Th ere a re no long-term d ata to su pport its efficacy i n
patients

The TriActive Laserdermology (Cynosure, I nc, Chel msford,


Massachusetts) combi nes six near-infrared d iode lasers at
a wavelength of 810 nm, loca l ized cooling, and mechani
ca l massage
- Th ree wee kly treatments fo r 2 weeks a n d then
b iweekly treatme nts for 5 weeks a re suggested
- Th ere a re no long-term d ata to s u p po rt its effi cacy i n
patients

Other FDA clea red devices include a u n i polar rad i ofre


quency device (Alma Accent, Alma, I n c . , B uffa l o G rove,
I l l . ) a n d a d ua l wavelength laser system (SmoothSha pes,
Eleme Med ica l , I nc . , Merri mack, N ew H a m ps h i re)

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M E N T/O UTCO M E
EXPECTAT I O N S
Patients s h o u l d b e i nformed that there a re no truly effec
tive treatments fo r cel l u l ite. It is a lso i m porta nt to d isti n
guish treatments for body conto u r i n g and fat re m ova l
from those of cel l u l ite. M ost of the positive resu lts relati ng
to ce l l u l ite treatment a re a n ecd ota l or reported i n sma l l ,

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

u nscientific stud ies . M a n y of the thera p i es a re expensive,


espec ia l ly given the i r lack of efficacy. Some may even
prod uce more harm than benefit. There may be a more
p ro m ising futu re for laser a n d l ight sou rce treatments.

B I B L I OG RAPHY
Avra m M M . Cel l u l ite; A review o f i t s physiology a n d treat
ment. J Cosmet Laser Ther. 2005 ; 7 : 1 -5 .
Gold berg DJ , Faze l i A , Berl i n AL. C l i n ica l , la boratory, a n d
MRI

a n a lysis o f cel l u l ite treatment with a

u n i po l a r

rad i ofreq uency device. Dermatol Surg. 2008;34( 2 ) : 204209 .


K i n ney B M . Cel l u l ite treatment: A myth or rea l ity: a
p rospective ra ndom ized , controlled tria l of two thera pies,
endermologie a nd a m i nophyl l i n e c rea m . Plast Reconstr

Surg. 1999 ; 1 04: 1 1 1 5- 1 1 1 7 .


Lis-Ba l c h i n M . Pa ra l lel-placebo-control led c l i n ica l study
of a m ixtu re of herbs sold as a remedy for cel l u l ite.

Phytother Res. 1999 ; 1 3 : 627-629 .


P i era rd-Fra n c h i mont C , P i era rd G E, H e n ry F, Vroome V,
Ca uwen bergh G . A ra ndom ized , place bo-control led tria l
of topical reti n a l in the treatment of cel l u l ite . Am J Clin

Derma to/. 2000; 1 :369-37 4 .


Rao J , Gold M H , G o l d m a n M P. A two-center, dou ble
b l i nded , ra n d o m ized tria l testi ng the to lera b i l ity a n d effi
cacy of a novel thera peutic agent for cel l u l ite red ucti o n .

J Cosmet Dermatol. 2005;4(2) :93- 1 02


R ossi A R , Vergna n i n i A L . Cel l u l ite: A review. J Eur Acad

Dermatol Venereal. 2000; 14:25 1 -262 .


va n V l i et M , O rtiz A, Avra m M M , Ya m a u c h i PS. An
assessm e nt of traditional a n d n ovel thera p ies fo r cel l u l ite.

J Cosmet Laser Ther. 2005; 7 ( 1 ) : 7- 1 0 .


Wa n ne r M , Avra m M M . An evi d ence-based assessment
of treatments fo r cel l u l ite . J Drugs Dermatol. 2008 ; 7 (4) :
341 -345

279

280

Color Atlas of Cosmetic Dermatology

CHAPT E R 59

H IV Lipod ystrophy/Facia l Lipoatrophy

H IV l i podystrophy d escri bes a conste l lation of cha nges i n


su bcuta neous a n d viscera l fat d istri bution i n patients on
a nti retrovira l

thera py.

In

d isti nction

to

" l i poatrophy"

(wh ich descri bes local fat loss ) , l i podystro phy refers to
both the acc u m u lation of fat as wel l as the loss of fat in
other a reas. I n H I V l i postro phy, the fi n d i ngs i n c l u d e s u b
cuta n eous fat loss in the m a l a r a n d b u cca l fat pads, ie,
fa cial l i poatrophy, as wel l as o n the extre m ities. It a l so fea
tu res fat a cc u m u lation on the d o rsocervica l fat pad ,
( Fig 59 . 1 ) ie, buffa l o h u m p, b reasts, a n d i ntra-a bdom i n a l
cavity. Its c h a racteristic a p pearance is sign ificant, i n t h a t i t
red uces patient com plia nce with a nti retrov i ra l thera py
a n d d e prives patients of H I V status privacy, pa rti c u l a rly i n
com m u n ities where H IV rates a re h ig h . T h i s d isord er is
a lso associated with a host of meta bol ic d isord e rs with
long-term i m pa ct on health
hyperl i pi d e m i a ,

and

i n c l u d i ng hyperglyc e m i a ,

hypertriglycerid e m i a .

Treatments

va ry accord i n g to the c l i n ical fi n d i ngs.

E P I D E M I O LOGY
Incidence: 25% to 83 % of patients treated with a nti retro
virals depend i ng on c riteria used

Age: A l l ages , but older age is p red i ctive of severity


Race: N o n e
Sex: Eq u a l , severe fi n d i ngs m ore freq uent i n fem a les

P R EC I P I TAT I NG FACTORS
Anti retrov i ra l thera pies a re the prec i p itating factor. It a lso
presents i n freq ue ntly in H IV patients na'lve to H I V ther
a py. Typical ly, pati ents a re on com b i nation thera pies.

PATHOG E N ES I S
Path oge nesis rem a i ns u n known . I t i s a m u ltifactorial d is
order that va ries a ccord i ng to the med ications ta ke n .

D E R M ATOPAT H O LOGY
Com p l ete or nea r complete loss of fat. J uxta position of
the dermis a n d fascia may be see n . Ad i pocytes a re
ma rked ly red uced in n u m be r a n d size.

PHYS I CAL LES I O N S


Fat a cc u m u lation a n d fat loss a re d isplayed .

Fat acc u m u lation

Figure 59. 1 (A) "Buffalo h ump " in dorsocervical back of HIV-infected

male. (8) Substantial reduction in size of buffalo h ump after liposuction


procedure

Sect i o n 10: Ad i pose Tissue Alterati o n s

- Dorsocervica l fat pa d , ie, buffa l o h u m p


- B reasts
- I ntra-a bdo m i n a l cavity, ie, Crix bel ly

Fat loss
- M a l a r a n d bucca l fat pads
- Extrem ities and buttocks

D I F F E R E N T I A L D I AG N OS I S
Other l i podystrop h i es fac i a l l i poatrophy from aging, H IV
wasting synd rome, C u s h i ng's d i sease, m a l n utrition states,
a n o rexia nervosa , meta bolic X synd ro m e , cachexia sec
o n d a ry to cancer, m a l a bsorptio n synd romes, thyrotoxico
sis, and m u lt i p l e sym metric l i pomatosis.

LABO RATORY EXAM I NAT I O N


B i o psy i s not usefu l . T h e c l i n ical fi n d i ngs a re sufficient to
make a d iagnosis. La boratory work u p s h o u l d i n c l u d e
assessm e nt o f blood g l u cose, l i pids, a n d triglycerides. If
C u s h i ng's is c l i n ica l ly suspected , la boratory exa m i nation
should be performed .

CO U RS E
H I V l i podystro phy d oes n ot sponta neously regress i n the
a bsence of treatment or medication cha nge .

KEY CO N S U LTAT I V E QU EST I O N S


M ed ication use
Com p l i a nce
H I V status
D u ration of l i podystoprhy
Associated hyperglycem i a , hyperl i p i d e m i a , a n d hyper
triglycerid e m i a

P R EV E N T I O N
Once a patient h a s been treated fo r t h e H IV virus, there i s
no prevention o f H IV l i podystro phy.

MANAG E M ENT
Cosmetic i m provement ca n b e essentia l t o promoting a
patient's ad herence to their H IV med ication regimen. There
a re several means by which the cosmetic a ppea ra nce of
H IV l i pcdystrophy ca n be i m proved . These include medica
tion cha nges, filler su bsta nces, and l i posu ctio n . Diet and
exercise can be helpfu l both for cosmesis a n d meta bolic

28 1

282

Color Atlas of Cosmetic Dermatology

dera ngements. Treating the meta bolic derangements is


best referred to physicians skilled in treating hyperl i pi
demia, hypertriglyceridemia, and i nsu l i n resista nce.

T R EAT M E NTS
There a re severa l treatme nts that can

i m p rove the

cosmetic a p pea ra n ce of these d isord ers . They ca n be


d ivided i nto two sections: treatment of l i poatrophy a n d
treatment o f fat accu m u lati o n . Ad d itional ly, cha nges i n
med ications c a n b e p u rsued . T h i s i s best entrusted t o a
p hysic i a n who spec i a l i zes in the care of patients with H I V.

O ra l M e d i cat i o n s
A l l c h a n ges to a n a nti retrov i ra l reg i m e n a re best h a n d led
by physic i ans who spec i a l ize i n H I V treatment. These
cha nges can i m prove the a p pea ra nce of H I V l i podystro
p hy. Med ication cha nges i n c l u d e

D isconti n ua n ce o f a nti retrovira l thera py


- O bvious risks of d i sconti n u i ng med ications for a l ife
t h reate n i n g i l l ness

Cha nge H IV medications


- Other H IV med ications prod uce the sa me cond ition
- Some a ntiretrov i ra ls have a

lower i n c id e nce of

l i podysto phy

Treat m e n t of Fac i a l L i poatro p h y

Tempora ry fi l l ers

Poly-L-Iactic a c i d , Scu l ptra , is FDA cleared for the treat


ment of H IV fac i a l l i poatro phy
- Synthetic, biodegra d a b l e polymer
The materi a l used i n Vicry l sutures
- Seve ra l treatme nts a re req u i red , d e pend i ng on sever
ity of l i poatrophy
Benefits a re n ot seen u nt i l weeks after each treat
ment
- 18 to 24 month d u ration of fi l l e r material
- N o n eed for a l lergy testing

Ca l c i u m hyd roxyla patite, Rad iesee , is FDA cleared for


the treatment of H IV fac i a l l i poatro phy
- I m med iate correction
- D u ration up to 1 8 months
- N o need for a l lergy testing

Perma nent fi l l ers

S i l icone

A h ighly pu rified 1 , 000-cSt s i l icon o i l has been exa m

- N ot FDA c l ea red
i n ed i n 77 patients

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

The data showed that the n u m be r of treatments a n d


a m o u n t o f s i l icone req u i red for fu l l treatment was corre
lated to the i n itia l seve rity of fa c i a l l i poatrophy

The i n vestigato rs n oted no adverse events but cau


tioned that long-term effi cacy a n d safety a re yet to be
determ i ned

Treat m e n t of Fat Acc u m u l a t i o n

L i p osucti o n/l i pectomy

Loca l ized l i posuction/li pectomy uses tu mescent loca l


ized a n esthesia rather t h a n ge nera l a n esthesia

U ltraso u n d assisted l i posuction has a lso been em ployed


It is effective in rem ovi ng excess fat in the d o rsocervical
regi o n , that is, buffa lo h u m p

P I T FALLS T O AVO I D/CO M PL I CAT I O N S/


MANAG E M ENTIOUTCO M E
EXPECTAT I O N S
It is i m porta nt t o m a ke certa i n that t h e m u ltiple med ica l
issues

a re

being

mon itored

a p p ropriately

in

th ese

patients. It is a lso i m porta nt to e m p hasize the l i m ited


a b i l ity of th ese treatments in the fa ce of exte nsive H I V
l i podystro phy. General ly, however, patients a re ve ry eager
to see i m p rovement and gratefu l for the h e l p they
receive.
F i l lers can be very effective for i m proving fac i a l l i poat
rophy. Tem pora ry fi l l e rs, s u c h as Scul ptra or R a d i esse,
have the adva ntage of FDA clearance and stu d i es docu
menting the i r efficacy.

F u rt h er, thei r

non permanent

nature a l lows for tem pora ry side effects i n the eve nt of


poor resu lts or gra n u l oma fo rmatio n . U nfortu nately, tem
pora ry fi l l e rs req u i re perpetua l treatment sessions a n d
expense .
Permanent fi l l ers such as s i l icone a re attractive i n
these patients because t h e i r d isord e r is perm a nent. Data
a re pro m i s i ng, but fu rthe r lo ng-term stud ies a re n eeded
to assess lo ng-term efficacy and safety concerns. After a
series of i njections, fu rther treatment a n d expense is n ot
req u i red . U nfo rtunately, poor tec h n i q u e a n d gra n u loma
formation a re haza rds . W h i l e gra n u lomas a re i nfreq uent
side effects, they prod uce o bvious cosmetic d isfigu re
ment. Th e re is the potenti a l of gra n u loma formation m a ny
years afte r i n itial treatment as wel l . These gra n u lomas do
n ot resolve with the relative ra pid ity of n o n perm a nent
fi l l e r s u bsta nces.

F u rthermore,

s i l icone

is

n ot

F DA

cleared for the treatment of H IV l i podystro phy.


Li posuction can be very effective in patients with buf
fa lo h u m ps . Local ized l i posu ction/l i pectomy uses t um es
cent loca l ized a n esthesia rather t h a n ge nera l a n esthes i a ,
w h i c h dec reases the possi b i l ity o f s e r i o u s adverse eve nts.
Sti l l , l i posuction can be expensive and

res u lts va ry

accord i ng to the experience of the p ractitioner.

283

284

Color Atlas of Cosmetic Dermatology

Fac i a l plastic s u rgica l proced u res ca n be effective, but


req u i re major i nvasive s u rgery with its atte n d a n t risks of
morbid ity. There is also i n c reased d own t i m e , pa i n , a n d
t h e r i s k o f ge neral a n esthes i a .

B I B L I OG RAPHY
B o i x V . Polylactic acid i m p l a nts . A n e w s m i l e f o r l i poat
ro p h i c faces? AIDS. 2003 ; 1 7 ( 1 7 ) : 2533-253 5 .
Carruthers A , Ca rruthers J . Eva l uation o f i nj ecta ble c a l
c i u m hyd roxyla patite f o r the treatment o f fac i a l l i poatro
phy associated with h u m a n i m m u n od efi ciency virus.
Dermatol Surg 2008;34( 1 1 ) : 1486- 1 499 .
Carruthers A, Liebeskind M , Carruthers J , Fo rster B B .
Rad iogra p h i c a n d com puted tomogra p h i c stud ies of cal
cium hyd roxyla patite for treatment of H IV-associated
fac i a l l i poatro phy a n d correction of naso l a b i a l fol d s .
Dermatol Surg 2008;34( S u p p l 1 l : S 78-S84
Con nolly N , M a n d e rs E, R id d ler S. Sh ort com m u n icati o n :
S uctio n -assisted l i pectomy for l i podystro phy. AIDS Res
Hum Retroviruses. 2004;20(8 ) : 8 13-8 1 5 .
H a d iga n C , Yawetz S , Thomas A , Havers F, Sax P E ,
G r i nspoon S . Meta bo l i c effects o f rosigl itazo ne i n H IV
l i podystro phy; A ra ndom ized , control led tria l . Ann Intern
Med. 2004; 786-794.
J ones D H , Carruthers A , O rentrei ch D, et a l . H ig h ly p u r i
f i e d 1 000 est s i l icon o i l f o r treatment o f h u ma n i m m u n
odeficiency virus-assoc iated fac i a l l i poatro phy: A n open
p i l ot tria l . Dermatol Surg 2004;30( 1 0) : 1 279-1 286 .
Koutkia P, Canava n B, B reu J , Torria n i M , Kissko J ,
G r i nspoon S . G rowth hormone-releasing h o r m o n r i n H I V
i n fected m e n with l i podystro phy: A ra n d om ized con
trol led tria l . JAMA. 2004;292 ( 2 ) : 2 1 0-2 1 8 .
Levy R M , Red bord KP, H a n ke CW. Treatment o f H IV
l i poatro phy a n d l i poatro phy of aging with poly-L-Iactic
a c i d : a prospective 3-yea r fol l ow- u p study. J Am Acad
Dermatol. 2008;59( 6 ) : 923-933.
P i lero PJ , H u bbard M , King J, Fa ragon J J . Use of u ltra
sonogra phy-assisted

l i posuction for the treatment of

h u m a n i m m u n odefi c i ency vi rus-assoc iated e n l a rgement


of the d o rsocervica l fat pad . Clin Infect Dis. 2003 ; 3 7 :
1374- 1 3 7 7 .
Vl egga a r D ,

Bauer U.

Fac i a l e n h a ncement a n d the

E u ropean experience with Scu l ptra ( poly-L-Iactic a cid ) .


J Drugs Dermatol. 2004;3 ( 5 ) : 542-547 .

Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s

CHAPT E R 60

285

Str i a e Diste nsa e

Striae d istensae, m ore com m o n l y known as " stretch


marks, " a re atro p h i c l i nea r ba nds of skin that a p pear
after certa i n p rec i p itati ng factors such as pregna ncy,
steroid use, a n d d ra matic cha nges i n weight or m uscle
mass ( F ig. 60. 1 ) . At prese ntatio n , they feature a pu rple or
p i n k color (striae ru bra) that fad es to a pa ler wh ite (striae
a l ba ) over time. They a re most common in a d u lt women .

E P I D E M I O LOGY
Incidence: common
Age: pu berty, pregna ncy
Race: more common in Ca ucasians
Sex: fe males > ma les (associated with pu berty a n d preg
na ncy)

Precipitating factors: to pical

and

o ra l

ste roid

use,

C u s h i ng's synd rome, p regna ncy, b reast-feed i ng, pu berty,


genetic col lagen d efects,

and

d ra matic c h a nges

in

weight, height, or m uscle mass

PATHOG E N ES I S
There a re cha nges i n the extrace l l u l a r dermal matrix
i n c l u d i ng fi b ri l l i n , elasti n , a nd collage n , resulting from
p rolonged stretc h i ng of the s ki n .

PATHOLOGY
There a re sca r- l i ke featu res . Typica l ly, there is an atro p h i c
epidermis w i t h na rrow col lagen b u n d l es a rra nged pa ra l lel
to the ski n s u rface. The rete ridges a re effaced . I n early
striae, there is a s u perficia l , deep, a nd i nterstitia l lym p h o
cytic perivasc u l a r i nfi ltrate a n d occasional eos i n o p h i l s .
The i nfi ltrate fades i n older lesions.

PHYS I CAL L ES I ON S
M u ltiple sym metric l i nea r ba nd-l i ke plaq ues o f atro p h i c
ski n t h a t present most commonly i n the outer thighs,
b reasts, a n d buttocks of wo men a long the l i nes of cleav
age. They p resent with a p i n k/purple h ue (striae ru bra )
a n d become pa ler with fi ne wri n kl i n g over time (striae
a l ba ) . Striae a re la rgest a n d m ost a b u nd a nt i n pati ents
with C u s h i ng's d isease. I n preg n a ncy, striae a re m ost
a b u n d a nt on the a bd o m e n . In weight l ifters, they a re
m ost p ro m i nent on the s h o u l d ers. To pical corticoste roid
use most c o m m o n l y produces striae on the face, ge n i
ta l i a , flex u ra l a reas, a n d body folds.

Figure 60. 1 (A) Striae alba at baseline. (B) Striae alba at 1 1 months

follow-up after four treatments with a 1 450-nm diode laser


(Smoothbeam, Candela Corp., Wayland, MAJ at energy settings of 1 3 to
1 4 J!cni2 , using a 6-mm spot size with a pulse duration of 30 ms.
Treatment was performed at intervals of 2 to 3 months

286

Color Atlas of Cosmetic Dermatology

D I F F E R E NT I A L D I AG N OS I S
Linear foca l elastosis.

LABORATORY EXAM I NAT I O N


T h e c h a ra cteristic c l i n i c a l a p pea ra n c e of striae n egates
a ny n eed fo r s k i n b i o psy. Ad d itional la boratory work u p to
rule out C u s h i ng's d i sease is i n d icated in the a p p rop riate
c l i n ica l setting.

COU RS E
Striae beg i n a s p i n k o r pu rple atro p h i c lesions that
becom e pa ler and less o bvious ove r t i m e .

KEY CO N S U LTAT I V E QU EST I O N S

D u ration

S k i n phototype

P regna n cy

Assess for sym ptoms of Cush i ng's d isease

Use of corticostero i d s

H istory o f weight cha nge

H istory of weight l ifti n g

MANAG E M E N T
There is no medical i n d ication t o treat stria e . Sti l l , ma ny
i n d ivi d u a ls a re sign ifica ntly bothered by the i r a p pea ra nce
and req u est treatment. There a re n u m e rous options to
treat stria e . U nfort u n ately, none of the treatments is com
p l etely successfu l . In fact, m ost treatme nts provide mod
est or no benefit. Thus, prior to treatment, patie nts'
expectations n eed to be tem pered . C o m b i nation treat
ment i nvolving laser and

topical regimens s u c h as

treti n o i n is often a hel pfu l method of treatment. More


recently, nona blative a nd a b lative fractional treatm ents
have emerged . Fort u nately, the a p pea ra nce, parti c u la rly
the color of striae, i m proves with t i m e . Patients with s k i n
phototypes 1-1 1 1 respond better t h a n those w i t h types
I V-VI to laser thera py. Test sites prior to thera py a re rec
om mended . There is some data to show that treatments
i m prove striae over n o n i nterventio n . The fi rst priority is to
esta bl ish whether stria r u b ra or stria a l ba a re be i n g
treated , as the i r treatments d iffe r sign ifica ntly.

TREAT M ENT (Fig. 6 0 . 2)

Stria ru bra : the pu lsed dye laser (585 n m ) with a 7- or 10mm spot size and 2 to 4 J/cm 2 fluence has been shown
to i m prove the erythema of striae, but is associated with

Figure 60.2 (A) White striae, axilla. Prominent atrophy, textural changes,
and depigmentation are observed. (B) White striae, axilla, following three
fractional resurfacing laser treatments. Mild improvement of the atrophy
and textural changes are noted. Mild post-inflammatory hyperpigmenta
tion is observed, which resolved 3 weeks after the last laser treatment

Sect i o n 10: Ad i pose Ti s s u e Alterati o n s

287

the risk of hyperpigmentation in da rker skin phototypes.


A c l i n ica l end point of deep erythema o r l ight purpura is
o pti m a l . In o u r experience, lower fluences a re more suc
cessful than h igher fluences ( Fig. 60. 3 ) .
- P u lsed d y e l a s e r treatments d o l ittle, if a nyth i ng, to
i m prove the textu re a n d atro phy of striae.
- I m p rovement ca n be seen even i n cases of poor i n i
ti al res ponse 6 months afte r treatment.
- Stu d ies recom mend aga i n st treating s k in phototypes
V-V I .
- Some d ata casts d o u bt on the effectiveness of pu lsed
dye laser.

Stria a l ba : nona blative fractional resurfa c i ng has been


s h own to provide some benefit for striae a l ba e . Stud i es
show a ra nge of efficacy with these treatments.
There is l ittle data to suggest whether deep d e pth , h igh

coverage treatme nts a re more effective t h a n lower d e pt h ,


lower coverage treatme nts.

I n o u r experience, m ost

patients see a modest benefit from treatment. A m i no rity


sees more sign ificant resu lts .

S hort- p u l sed erbi u m :YAG a n d C0 2 lasers can be mod


estly effective but a re no lo nger commonly used due to
s u c h side effects as prolonged , d iffic u lt h ea l i ng and
pigme nta ry a lte rat i o n . They a re n ot reco m mended .

The exc i m e r laser (308 n m ) has been exa m i ned for


treatment of striae a l ba

and

sca rs in

31

a d u lts .

Treatme nts bega n at t h e M i n i ma l Erythema Dose


( M ED l m i n us 50 mJ/cm 2 to affected a reas a n d were
performed biweekly for 1 0 weeks. An i m prove m ent i n
coloratio n , b y visual i n s pection ( 60-70% ) a n d colorimetric a na lysis ( 1 00% ) , was n oted and correlated
strongly with the n u m ber of treatme nts performed . The
pigment correctio n , h owever, retu rned c l ose to base l i n e
after a 6-month fol l ow- u p . N o bl iste r i ng or pigmenta ry

d istu r ba nces were noted .

Figure 60.3 (A) Numerous striae rubra and alba on the abdomen of a
young woman . (8) Immediate endpoint of purpura following low energy,
short pulse duration treatment with a pulsed dye laser

TOP I CAL T R EATM ENT

Ea rly striae
- Tre n i n o i n (0. 1 %) crea m can i m prove the a ppea ra nce
of striae, partic u l a rly early stria e , wh i l e decreasi ng
t h e i r length a n d width .

Matu re striae
- Treti n o i n (0.05 % ) and 20% glyco l i c acid ca n i m prove
striae.
- G lyco l i c a c i d (20 % ) a n d 10% L-ascorbic acid can
i m prove striae.

M I CRODERMABRAS I O N
M icrod erma brasion ca n

prod uce sma l l

i m provement

after six to ten treatments . M ic roderma brasion ca n also

288

Color Atlas of Cosmetic Dermatology

be used i n assoc iation with laser thera py given its fa irly


benign sid e-effect profi l e .

P I T FALLS TO AVO I D/O UTCO M E


EXPECTAT I O N S/CO M P L I CAT I O N S/
MANAG E M ENT

Patients s h o u l d b e i nformed that com p l ete resol ution i s


not rea l isti c . Rather, m i l d-to-moderate benefit is most
rea l istic . Thus, h ighly motivated patients with rea l istic
expectations a re the best ca n d i dates for treatment.

Laser thera py m ust be used with caution i n dark s k i n


phototypes given the r i s k o f hyperpigme ntati o n .

Topical treti n o i n can prod uce s k i n i rritati o n .

B I B L I OG RAPHY
Alexiades-Arme n a kas M R , Bernste i n U , Fried m a n P M ,
Gero n e m u s R G . The safety a nd efficacy o f t h e 308- n m
exc i mer laser for pigment correctio n o f hypopigme nted
sca rs a n d striae a l ba . Arch Dermatol. 2004; 1 40(8) : 955960.
Ash K, Lord J, Z u kows ki M, M c Da n iel D H . Comparison of
to pical thera py fo r striae a l ba (20% glycol i c a c id/0.05%
treti n o i n versus 20% glyc o l i c acid/10% L-ascorbic a cid ) .
Dermatol Surg 1 998;24( 8 ) : 849-856.
Bak H, Kim BJ , Lee WJ , et a l . Treatment of striae d i sten
s a e w i t h fractional

phototherm olysis.

Dermatol Surg.

2009 ; 3 5 ( 5 ) : 826-83 2 .
Gold berg OJ , Sa rradet D , H ussa i n M . 308- n m Exc i m e r
laser treatment o f mature hypo pigmented striae. Dermatol
Surg. 2003 ;29(6): 596-598. Discussion 598-599.
J i menez G P,

Flores

F,

Berman

B,

G u nja-S m ith

Z.

Treatment of striae ru bra and striae a l ba with the 585-n m


p u l sed-dye laser. Dermatol Surg. 2003 ;29(4) :362-365 .
M c D a n iel D H , Ash K, Z u kowski M . Treatment of stretc h
ma rks with the 585- n m flash la m p- p u m ped pu lsed dye
laser. Dermatol Surg 1 996;22(4) :332-33 7 .
Nehal

K S , Lichte nste i n

DA,

Ka m i no

H,

Levi n e VJ ,

As h i n off R . Treatment of matu re striae with the p u lsed


dye laser. J Cutan Laser Ther. 1 999; 1 ( 1 ) : 4 1 -44.
N o u ri K, R o magosa R, C h a rtier T, Bowes L, Spencer J M .
Com parison of the 585 n m pu lse dye laser a n d the short
p u l sed C02 laser i n the treatment of striae d istensae in
s k i n types IV a n d VI. Dermatol Surg. 1 999 ; 2 5 ( 5 ) : 368370.
Stotla n d M, Cha pas AM, B rightm a n L, et al. The safety
a n d effi cacy of fra ctional p h otothermolysis for the correc
tion of striae d i stensae. J Drugs Dermatol. 2008; 7 ( 9 ) :
857-86 1 .

E L EVE N
Wo und H ea l ing A l te rations

290

Color Atlas of Cosmetic Dermatology

CHAPT E R 6 1

H ype rtrop hic Sca rs , Ke l oids , a nd Ac n e Sca rs

I NTRODUCT I O N
Hypertro p h i c sca rs a n d keloids a re both c h a ra cte rized by
excess fibrous tissue at a site of i nj u ry in the s ki n .
Hypertro p h i c sca rs a re confi ned t o t h e origi n a l wou n d
site, whereas keloids, b y contrast, exten d beyond the
origi n a l wou n d site (Ta b l e 6 1 . 1 ) . Both a re common a n d
freq u e ntly d istu r b patients greatly, both as a n u n s ightly
sca r as wel l as a rem i nd e r of p revious tra u ma o r s u rgery.
Acne sca rs res u l t from the loss of u n d erlying col lage n
a n d elastic tissue from d e r m a l i nflam mation assoc iated
with a c n e , pa rti c u larly cystic acne. Ac ne sca rs a re a lso
very c o m m o n a n d a sou rce of d istress to the patient, both
fo r thei r obvious a p pea ra nce o n the face as wel l as a
re m i nder of p revious a c n e .

HYPERTROPH I C SCARS AND KELO I DS :


PHYS I CAL EXAM I NAT I O N
Hypertro p h i c sca rs prese nt as thick, firm l i nea r plaq ues
at the site of tra u m a . I n itial ly, they may be erythematous

Figure 6 1 . 1 Dermal injection of hypertrophic scar that resulted from a

shave biopsy

but often become s k i n -colored with time. Ke loids a re


fi r m , fibrous p l a q u es that exte nd outside the s ite of i nj u ry
with claw- l i ke projectio ns.

D I F F E R E NT I A L D I AG N OS I S
Dermatofi broma , sca r sarco i d , d ermatofi b rosa rcoma pro
tu bera ns, gra n u lo m a .

LABORATORY EXAM I NAT I O N


N o n e . If, however, a keloid i s u n res ponsive t o m u lti p l e
thera pies, s k i n b i o psy t o rule out d e rmatofi b rosa rcoma
protu bera ns is i n d icated .

TABLE 6 1 . 1

Hypertrophic Scars Versus Keloids

Defi n ition

Ke loid

Hypertro p h i c sca r

Excess fibrous tissue formation i n a wo u n d that

Excess fi brous tissue formation in a wo u n d that

exte nds beyon d the orig i n a l wou n d site

re m a i n s with i n the origi n a l wo u n d site

Cou rse

Does n ot sponta neously regress


May a rise weeks or months afte r i nj u ry

U s u a l l y a rise with i n weeks of i nj u ry

Prec i p itati ng factors

Fa m i ly h i story, s u rgery, tra u m a , b u r n , a c n e , earlobe

Fa m i l y history, su rgery, tra u m a , b u r n , acne; may

pierc i ng; most common in skin types I V-V I ,

Often sponta neous regression months after the i nj u ry

a rise in a n y patient at all ages

but may a rise in a l l s k i n types a n d a l l ages


I n cidence

Co m mo n ; M a les = fe ma les

Com m o n ; M a les = fe ma les

Ste rn u m : most c o m m o n location

Ste rn u m : most common location

Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s

29 1

MANAG E M ENT
There a re

m u ltiple thera pies that a re effective for

decreasing the u nsightly a p peara n ce of ke loids a n d


hypertro p h i c sca rs . N o n e is complete ly satisfactory a n d
n o n e ca n be designated as a treatment o f choice.
Patients s h o u l d be ed ucated as to the refractory natu re of
keloids a n d hypertro p h i c sca rs a n d that m u ltiple treat
ments ove r months a re typ ica l l y req u i red for effi cacy.
Ke loids tend to be more resista nt to thera py than hyper
tro p h i c scars.
These treatment opti ons i n c l u d e i ntra l es i o n a l tri a m c i
n o l o n e aceto n i d e , i ntra lesiona l 5-fl uoro u ra c i l ( 5- F U ) ,
s i l icone s h eeti ng, i m i q u i m od , rad iati o n , e l l i ptical exc i
sion, fractio n a l res u rfa c i ng, a n d p u lsed dye laser ( P D U
( 59 5 n m ) . These treatme nts provide d iffe rent ben efits.
Some red uce eryth e m a , others flatten lesions, a n d some
perform both the functions. M ost ofte n , i ntra l esio n a l

Figure 6 1 .2 Mild purpura after pulsed dye laser treatment of keloidal

stero ids a re a good i n itia l th era py t h a t ca n b e com bi ned

acne on back of a teenager. lntralesional kenalog was also used to


produce eventual clinical improvement after a series of treatments

with o r fol l owed by oth e r thera pies. Treatments can


be b roa d ly d ivided i nto laser and non laser thera p i es
(Ta b l e 6 1 . 2 ) .

TAB L E 6 1 . 2

Non laser Treatment Options

l ntra les ional 1


tri a m c i nolone

Dose

I nterva l of time

Hypertro p h i c sca r

Keloids

Com ments

5-40 mg!m l

Every 2-6 weeks

For m ost scars,

Va ria ble su ccess; m ost

Effective, safe,

(site dependent)

aceto n i d e

moderate to d ra matic

successful with

i nexpensive; ca re

i m prove ment

early i ntervention

to avoid atrophy

( Fig. 6 1 . 1 )
I ntra lesional

50 mg/m l

5-fl u o ro u rac i l

1 -3 ti mes wee kly


for t h e fi rst

Ca n be effective;

Va riable success

No clea r adva ntage


ove r tria m c i nolone

secon d - l i n e thera py

1-2 wee ks;

aceto n i d e

then every
2-5 weeks
1 2 h o u rs per

S i l icone sheeti ng

Va ria b l e i m provement

Va riable i m p rovement

Safe

N ot stud ied

Study showed no

N o lo ng-term

day for
1 2 weeks
l m i q u i mod

I n d u ces t u m o r

N ightly

necrosis facto r

a p pl ication for

recu rrences u p to

stud ies for

a l pha a n d

6- 8 weeks

6 months; risk

rec u rre nce rates

i n terfero n a l pha

sta rti n g the

hyper pigmentation

and ga m m a

d a y o f su rgery

i n sca r. F u rther
study needed to
confi rm these results

Excision s u rgical

M ostly u n s u ccessfu l ,

Very high rec u rre nce

I m med iate

n ot recom mended

rate without adj u n ct

gratification but

without adj uva nt

thera py. All patie nts

i nc reased risk of

thera py

m ust be awa re

rec u rrence

rec u rrent keloid may


be worse than original

292

Color Atlas of Cosmetic Dermatology

LAS E R
P D L ( 595 n m lhas e me rged as a n i m porta nt adjuvant for
treatment of ke loids a n d hype rtro p h i c sca rs ( Fig. 6 1 . 2 ) .
G ive n its selective ta rgeting o f su perfi c i a l b l ood vessels,
PDL can d ra matica l l y i m prove the erythema assoc iated
with

hypertro p h i c

sca rs

and

keloids

(Ta ble

6 1 .3).

I nteresti ngly, lowe r fluence treatments at short pu lse


d u rations te n d to be more successfu l than higher fl uence
treatments. It has a lso been shown h e l p to flatten lesions
as wel l .
Ab lative a n d n o n a blative fractio n a l res u rfa c i n g res u r
fac i ng has been shown to provide moderate i m provement
for acne, s u rgica l , hypertro p h i c , a n d b u r n sca rs . It is sti l l
u n k n own wh eth er h igh-d e nsity treatments a re m o re
effective than
re m od e l i ng

low-density treatments. Typical ly, sca r

with

nona blative

fra ctional

res u rfa c i n g

req u i res six t o eight treatments t o a c h i eve a bout 50%


benefit ( Fig. 6 1 .3) . S ig n ificant i m prove ment is seen with
one to two treatments with a b lative fractio n a l resu rfa c i n g .
C0 2 l a s e r treatment o f these lesions, w h i l e reported
successful in some of the l iteratu re, is not reco m me n d ed
d ue to a h igh rate of rec u rre nce. l ntra l esional corticos
teroids a re a h e l pf u l adjuva n t to laser thera py to h e l p flat
ten lesions and red uce pru ritus.

STU D I ES

One study exa m i ned the effect of a flash la m p p u m ped


P D L at 585 nm o r a flash l a m p P D L at 5 1 0 nm o n
1 5 patients with red hypertro p h i c scars. After a n aver
age of nea rly two treatme nts, 77% i m provement was
noted . After th ree treatm e nts, 7 of the 1 5 patients had
complete reso l ut i o n .

Another stu d y u s i n g the 585- n m P D L treated one h a lf

Figure 6 1 .3 (A) Pre- and (B) postappearance of a traumatic scar after a


series of fractional resurfacing treatments. There is some m ild residual
PIH that faded within 1 to 2 weeks

of m e d i a n ste rnotomy hypertro p h i c sca rs/ke loids i n 1 6


patients a n d l eft t h e other s i de u ntreated . Patients
received two treatm ents every 6 to 8 weeks a n d we re
exa m i ned after 6 months. B l i nded o bserve rs a nd pho
togra phy revea led "significant i m p rovement" in red
ness, sca r height, skin s u rface texture , and pru ritis i n
laser-treated sca r a reas after 6 m onths .

TAB LE 6 1 .3 Pu lsed Dye Laser for Hypertrophic


Scars/Keloids
Mecha n is m of action

U n k n own

Expectation

I m proves erythema ,
t h i c kness, a n d p l ia b i l ity
by u p to 30-90%

PDL setti ngs

3-7 J/cm 2 , 7 or 1 0-m m


spot, 0.45- or 1 . 5-ms
p u lse d u ration

Average n u m ber of
treatments

4-6; but may req u i re fa r


m ore

Figure 6 1 .4 (A) Erythematous deep acne scars.

Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s

293

C L I N I CAL EXPER I E NCE

Avo id elective su rgery i n patie nts with a h istory of

Consider begi n n i ng therapy at the t i m e of su rgery o r at

keloids/hypertro p h i c sca rring.


suture remova l .

Keloids a re more d iffi c u lt t o treat a n d more u n pre


d i cta b l e in the i r res ponse tha n hypertro p h i c sca rs.

Hypertro p h i c sca rs often i m prove with no treatment i n


6 months.
P O L a n d fractional res u rfa c i ng lasers a re effective in

i m proving hypertro p h i c sca rs,


F ra ctio n a l res u rfa c i ng can i m prove the text u re a n d
a p pearance o f s u rgica l a nd b u r n sca rs

AC N E SCARS
Acne sca rring is a co m mon seq uela of severe i nfla m ma
tory o r cystic a c n e . It can present i n a m i ld o r cosmeti
ca l ly d i sfigu ri ng fo rm . The best prevention of acne
sca rring is aggressive treatment of a c n e vu lga ris at the
time

of

presentati o n ,

i n c l u d i ng,

when

a p propriate,

isotretinoi n . Acne sca rs have severa l va rieties i n c l u d i ng


atro p h i c , ice-pick, ro l l i ng, a n d boxca r sca rs. Treatme nts
va ry accord i ng to the type of sca r being treated . I n fact, a
c o m b i nation of treatments is ofte n m erited , that is, P O L
fo r sca r erythema a n d s u bseq u e nt n o n a b l ative fractional
resu rfa c i ng for a c n e sca rs ( Fig. 6 1 .4) They a lso va ry in
terms of d u ration of efficacy a n d expe nse. Prior to s u rgical o r a blative thera py, it is i m porta nt to e l icit a ny recent

h istory of Acc uta ne use with i n the previous 6 months as


we l l as a h istory of hypertro p h i c or keloida l sca rring to
avo id poor wou n d hea l i ng a n d sca rring after thera py.

P h ys i c a l Les i o n s

Atro phic sca rs a re d e p ressed from the s k i n s u rface a n d


result from loca l loss o f tissue from i nfla m mati o n ,
i ntra lesi o n a l stero ids, s k i n s u rgery, weight loss, or ra pid
growth (Ta ble 6 1 . 4 ) .

Ice-pick sca rs a re na rrow, d e e p , vertica l , cyl i n d rica l


de pressions at the site of the i n fu n d i bu l u m . G iven t h e i r
d e pth , they a re more resista nt t o l a s e r thera py. P u n c h
excisions, fol l owed b y nona b lative fractional resu rfac
i ng, can be h e l pfu l ( Fig. 6 1 . 5 ) .

R ol l i ng sca rs a re s h a l low de pressions that a re best


a p preciated with a c h a nge in surface l ighti ng. They c a n
va ry i n s i z e a n d often coa l esce w i t h n e i g h b o r i n g rol l i n g
sca rs . They a re w i d e r tha n

ice-pick sca rs. T h e i r

de pressed a p pearance reflects a n u n d erlyi ng fi b rosis of


the d e r m i s a n d su bcuta neous fat.

Boxc a r sca rs a re wider than ice-pick sca rs but less


deep. They have a wel l-defi ned c i rc u l a r o r ova l s h a pe .

Figure 6 1 .4 (Continued) (8) Improvement in acne scar erythema after a


series of pulsed dye laser treatments. (C) Further improvement with acne
scars with subsequent nonablative fractional resurfacing

294

Color Atlas of Cosmetic Dermatology

TAB L E 6 1 .4

Treatment Options for Atroph ic Scars

Thera py

Type of thera py

Cou rse

C o m m ents

To pical

Tret i n o i n 0 . 0 5-1 % n ightly

Sl ight i m provement after

S l ight i m provement as monothera py. M ost

6-- 1 2 months

effective as an a dj u nct with other modal ities.


If i n it i a l i rritation , a p ply every other n ight u nti l
better tolerated

Laser

1 ,450-n m d iode: 1 2- 13 J/c m 2 ,

1 0-30% i m p rovement

M i l d i m provement

6-m m s pot size 30-40-ms


c ryogen coo l i ng spray, th ree to
fou r treatments over 4-6 months;
treats active acne as we l l
Safe in a l l s k i n types
R isk of transito ry hyperpigmentatio n ; postlaser
erythema weeks to months; may cause acne
fla re
Fractional resu rfa c i ng: five t o six

N o n a b l ative : moderate

treatments; d eeper d e pth of

i m provement afte r five to six

treatment is more effective,

treatm ents

u nclear if h igher or lower density


of treatment is m ore effective

S i d e effects i n c l u d e tem po ra ry erythema,


edema, crusti ng, a n d mild pa i n

A blative: moderate i m provement


after two treatme nts
Some m a y d evelop bronzing a n d m i ld fla k i n g
at 5-7 days
H igher i n c idence of hyperpigmentation i n
d a rker s k i n p hototypes
Low risk for lo ng-term adve rse side effects;
except that scarri ng may occ u r with a blative
fractional d evices

U ltra p u lsed pu lse carbon d ioxide


laser

40---{)0 % i m provement; m ore


effective than nona blative

M o re d ownti m e a n d side effects t h a n


nona blative laser

laser
Postlaser erythema lasting weeks to months;
risk of hyperpigmentatio n , i n fect i o n , sca r, a n d
permanent hypopigmentation
Best for s h a l l ow, wide sca rs such as boxcar sca rs
Antivi ra ls for patients with history of H SV
F i l l e rs

R estylane ( h ya l u ro n i c a c i d )

D ra matic i m provement

Te m po ra ry

6--8 months
Low-risk a l lergy, gra n uloma; do not overcorrect
sca rs
F i l l e rs

Auto logous fat

D ra matic i m provement a n d

Longer d u ration

longer d u ration t h a n other


fi l lers
N o risk of a l lergy, gra n u loma
M ore d iffic u lt to master effective tec h n i q u e
F i l l e rs

Bovine collage n : Zyd erm I ,


Zyd erm I I , Zyplast

Good , tem pora ry i m provement

Req u i res test site for a l l e rgy

fo r 2-3 months
H igher risk of a l lergy ( ie , 1-3 % )
Tec h n i q ue: overcorrect sca rs
Easier proced u re for i nexpe rienced practitioners
t h a n other fi l le rs
Adverse effects: s h o rter d u ration

F i l l e rs

H u ma n col lagen

Good , tem pora ry i m provement


fo r 2-3 months

Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s

TAB L E 6 1 .4

295

Treatment Options for Atrophic Scars ( Continued)

Thera py

Type of thera py

Cou rse

C o m m e nts

Mecha n ical/

M icoderma b rasi o n , glyco l i c a n d

M i ld i m p rovement

M ic rod e r m a b rasion/glyc o l i c a c i d peels a re safe;

chem ical

sa l icyl ic acid pee ls safe in s k i n types I V-V I ;

sa l i cyl ic acid peels ( Fig. 6 1 .4)

derma brasion s h o u l d n ot be performed

TCA peels; derma b rasion

except i n extremely expe rienced h a n d s


S u rgica l

S u bcision ( i ncision i nto dermis with

M i l d i m p rovement

Safe

Good i m provement

Ti me cons u m i ng. M u ltiple treatme nts. Better

mec h a n ical tra u ma i n d u c i n g


fi b rosis)
S u rgica l

P u n c h exc ision Fig. 6 1 . 6 ) , p u n c h


grafting, p u n c h a utografti ng,

for ice- p i c k sca rs

punch elevation

K ey P o i nts i n Treat i n g Ac n e S c a rs

Em phasize i m provement rather tha n complete reso l u


tion as a n o bta i n a bl e res u lt .

D iscuss a l l treatment o ptio n s . A l l o ptions have adva n


tages a n d d isadva ntages .

M a n y patients w i l l benefit from a com bination of ther


a py.

O bta i n com plete medical h i sto ry a n d med ication use,


that is, Accuta ne with i n 6 months of a ny s u rgica l/a bla
tive treatment.

M a ke s u re a c n e is being o r has been treated to p revent


futu re sca rs .

B I B L I OG RAPHY
Alste r T S , W i l l ia m s C M . Treatment o f kel o i d sternotomy

sca rs with 585 nm flash la m p-pu m ped p u l sed -dye laser.

Lancet. 1 995;345(8959) : 1 1 98- 1 200 .


Avra m M M , Tope W D , Yu T, Szacowicz E, Nelson J S .
Hypertro p h i c sca rring o f the neck fo l l owi n g a blative fra c
tional carbon d ioxide laser res u rfa c i n g . Lasers Surg Med.
2009 ; 4 1 ( 3 ) : 185-188.
Berma n B , Ka ufm a n J. P i lot study of the effect of posto p
e rative i m i q u i mod 5% c ream on the rec u rre nce rate of
exc ised keloids. J Am Acad Dermatol. 2002;47(su ppl
4 ) : S209-S2 1 1 .
Berma n B, Via l l A. l m iq u i mod 5% c rea m fo r keloid m a n
agement. Dermatol Surg. 2003 ;29( 1 0) : 1 050- 1 05 1 .
C h u a S H , Ang P, Khoo LS , Goh C L . N o n a b lative 1450 n m
d iode laser i n treatment o f fac i a l atro p h i c a c n e sca rs i n
type IV Asian ski n . Dermatol Surg. 2004 ; ( 1 0) : 1 287- 1 29 1 .
Fitzpatrick R E. Treatment of i nfla med hypertro p h i c sca rs
using i ntra lesi o n a l 5 - F U . Dermatol Surg. 1 999 ; 2 5 ( 3 ) :
224-23 2 .

Figure 6 1 . 5 (A) Ice pick scars prior to punch excisions. (8) Improvement

of ice pick scars 1 week after suture removal. Further improvement was
achieved with nonab/ative fractional resurfacing

296

Color Atlas of Cosmetic Dermatology

G l a i c h AS,

R a h m a n Z, Gold berg L H , Fried m a n P M .

Fracti o n a l resurfa c i ng for the treatment of hypopig


mented sca rs: A p i lot stu dy. Dermatol Surg. 2007;33 ( 3 ) :
289-294 .
Haedersd a l

M,

M o rea u

KE,

Beyer D M ,

Nyma n n P,

Alsbjorn B . Fractional nona blative 1 540 n m laser resu r


fac i ng or thermal b u r n scars: A ra ndom ized control led
tri a l . Lasers Surg Med. 2009 ;4 1 ( 3 ) : 1 89 - 1 9 5 .
Jacob C l , Dover J S , Ka m i n e r M S . Ac ne sca rring: A c lassi
fication system and review of treatment o ptio n s . J Am

Acad Dermato/. 200 1 ;45( 1 ) : 1 09- 1 1 8 .


N iwa A B , M e l l o AP, Toreza n L A , Oso rio N . Fractional p h o
tothermolysis for the treatment o f hypertro p h i c sca rs:
C l i n ical experience of eight cases. Dermatol Surg. 2009 ;
35( 5 ) : 773- 7 7 7 .
N o u ri K, J i menez G P, Ha rriso n - B a l estra C , Elga rt GW.
585 nm p u l sed d ye laser in treatment of s u rgical sca rs
sta rti ng on suture remova l day. Dermatol Surg. 2003 ;
29( 1 ) : 65-73
Wa i bel J, Beer K. Fractional laser resu rfa c i n g fo r thermal

Figure 6 1 .6 Patient after numerous punch excisions. Sutures are


removed 5 to 7 days after the procedure

burns. J Drugs Dermatol. 2008; 7 ( 1 ) : 59-6 1 .

TAB L E 6 1 . 5

I ce-Pick/Boxcar Scar
Adva ntage

P u n c h h a rvesting and suture or


punch ha rvest a n d i m p l a nt full
thickness graft

Low cost, potentia l d ra m atic i m p rovement;


best fo r na rrow, deep sca rs s u c h as

D isdva ntage
U n p red i cta b l e , risk of m a k i ng cosmetic
a p pea ra nce worse; time consu m i ng

ice-pick sca rs or deep boxcar sca rs; p u n c h


exc ision ca n b e fo l l owed b y a blative or
nona b lative fractional resurfa c i ng treatments

Ablative C0 2/Erbi u m : YAG

Potentia l 40-60% long-term i m provement;


best for s h a l l ow boxcar sca rs

Postlaser erythema weeks to months; risk


of hyperpigmentati o n , i n fectio n , sca r, and
permanent hypopigmentation

Q u i c k , sign ificant i m p rovement


Antivi ra ls for patients with history of H SV
No perma nent i m p rovement

F i l l e rs, ie, R estylane, collage n ,


etc . (see Ta ble 6 1 .4)
Low risk

N eed to repeat at least twice a n n ua l ly

Lasts 4-8 m o nths


N o n a b lative laser
ie, 1 ,450- n m d iode
1 2- 1 3 J/c m 2 (one pass)
l ower fl uenc ies (two passes)
m u ltiple monthly treatme nts

Low risk of serious side effects


No d ownti m e
Treats a ny a ctive a cn e

I m prove ment 1 0-30 %

TWE LVE
Exogeno u s C utaneo u s A l te rat i ons

298

Color Atlas of Cosmetic Dermatology

CHAPT E R 62

Ea r P i e rei ng

Ea r pierc i ng i s performed t o fac i l itate a n i n d ivid u a l 's


desire to wea r earri ngs. By having the proced u re per
formed in a medical fac i l ity by a physic i a n , the patient is
reassu red that the proced u re is being performed i n a
safe , control led environment.

KEY CO N S U LTAT I V E QU EST I O N S

Contact a l le rge ns t o meta ls

H istorY of ke loids or hypertro p h i c sca rri ng

Desi red site of pierc i ng

PHYS I CAL EXAM I NAT I O N


Assess the thickness of ea rlobes.

MANAG E M ENT
There a re two common methods for ea r pierc i n g . It c a n
b e performed with a need le b y h a n d or with t h e h e l p of
an a utomatic ea r-pierc i n g g u n ( Fig. 62 . 1 ) . Before per
fo rm i n g either proced u re , it is i m porta nt to m a ke certa i n
that the correct location for pierc i ng h a s been selected .
Sym metrY with the contra late ra l ear is esse ntia l for a good
cosmetic a ppea ra n c e . The patient s h o u l d review the sites
using a m i rror prior to treatment.

TREAT M E N T

Steril ize a l l i n stru me nts

Ste r i l ize a n d a nesthetize both ea r lobu les

Identify the exact sites to be pierced with a marking pen


on the a nterior and posterior portions of the ear lobule.
Confirm proper placement with patient before proceed ing

U s i n g slow press u re, adva n ce a 1 4- to 18-ga uge need le


t h rough the poste rior lobule i nto the a nterior l o b u l e

If a n a utomatic ea r-pierc i n g g u n is used , the g u n is


advanced from the a nterior l o b u l e towa rd the poste rior
lobule

Use a steril ized ea rring w i t h a sta i n l ess steel post

A n ickel-free post of the ea rring is adva n ced with the


needle a n d the tip is p u l led back t h rough the ea r

The clasp is put on the posterior post


Leave the ea rring in place for a pproxi mately 14 days
u ntil re-epithe l i a l ization of the tra c k

C l e a n t h e site with hyd rogen peroxide a n d topical


a nti biotic oi ntment twice d a i ly

Figure 62. 1 Ear-piercing gun being used on earlobe of a young female

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

P I T FALLS TO AVO I D/CO M P L I CATI O N S/


MANAG E M ENT/O UTCO M E
EXPECTAT I O N S

T h i n ea rlo bes m a y spl it, espec ia l ly with heavier earri ngs


P lace earri ngs o n the sa m e level horizonta l ly to assu re
sym metry

A good clean steri l e tec h n iq u e c a n avoid postproced u re


i nfections

I t is i m porta nt to el icit a n y h i story of hypertro p h i c scars


or ke loids i n these patients ( Fig. 62 . 2 ) . Ea r pierc i ng
s h o u l d not be performed on th ese patients

Any h i story of n i c kel or other m eta l a l lergens s h o u l d be


e l i c ited prior to a ny proced u re as wel l

Ed u cate patients as t o wou n d care a n d t h e need to


co ntact you in the event of i nfection

In the event of co ntact dermatitis or a l le rgy, topical


steroids a re the m a i nstay of treatment

Figure 62.2 Keloid on posterior earlobe secondary to ear piercing

(Courtesy of Tomi Panda/fino, MD)

B I B L I OG RAPHY
Atk i n D H , Lask G P. E a r pierc i n g a n d s u rgica l repa i r o f the
earlobe .

In:

Lask G P, M oy R L, ed s .

Principles and

Techniques of Cutaneous Surgery. N ew York: M c G raw


H i l l , I n c ; 1 996.

299

300

Color Atlas of Cosmetic Dermatology

CHAPT E R 63

Tattoo R e m ova l

Tens of m i l l ions of Am erica ns have tattoos . Over t i m e ,


many d e c i d e t h a t they wa nt the tattoo t o be re moved .
Qual ity-switched

( Q-switc hed ) lasers a re effective i n

re movi ng most tattoo pigme nts safe ly ( Figs . 63 . 1-63 . 3 ) .


T h e a p propriate laser wave length is determ i ned b y the
tattoo i n k's a bsorption s pectru m . It is bel i eved that laser
p u l ses in the n a n osecond range target tattoo pigments
a n d brea k them i nto s m a l l e r pa rticles, there by fac i l itati ng
remova l

of

the

pigment

tra nse piderma l l y

or

via

macro phages and loca l scave nger cells. In order to treat


m u lticol ored tattoos, seve ra l Q-switched

laser wave

lengths m ust be e m p l oyed .

KEY CO N S U LTAT I V E QU EST I O N S

Was the tattoo placed b y a n a mate u r or a profess ional


tattoo a rtist?

Was the tattoo placed for the p u rpose of rad iation thera py?

Is the tattoo the res u l t of tra u m a or i nj u ry?

What colors a re conta i ned with i n the tattoo? (Ta ble 63 . 1 )

P revious treatments

Use of isotret i n o i n with i n 6 months

H istory of keloids/hypertro p h i c sca rs

D u ration of tattoo

S k i n p hototype

H istory of H SV at site of treatment

H istory of a l le rgic or gra n u l omatous reactio n to tattoo


pigment

TABLE 63 . 1

B
Figure 63 . 1 (A) Tattoo on left earlobe prior to therapy. (8) Resolution after
six treatments with 1 , 064-nm Q-switched Nd: YA G laser

Laser Therapy by Tattoo Color

Tattoo pigment

Light s pectrum

M ost effective lasers

Comment

Red

G reen

Freq uency-d ou bled Q-switc hed N d :YAG

May cause pigment a lteration i n da rker s k i n

( 532 n m )
Ye l l ow

G reen

Freq ue ncy-d ou bled Q-switc hed N d :YAG

G reen

Red/nea r i nfra red

Q-switc hed ru by ( 694 n m )

Least pa i nfu l o f Q-switc hed lasers


N ot very effective

( 532 n m )
May ca use hypopigme ntation in da rker s k i n

Q-switc hed a l exa nd rite ( 7 5 5 n m )


Light b l ue

Red/nea r i nfra red

Q-switc hed ru by (694 n m )

May ca use hypopigme ntation i n da rker s k i n

Q-switc hed a l exa nd rite ( 7 5 5 n m )


Dark blue

Red/nea r i nfra red

a-switc hed ru by (694 n m ) : l ight s k i n


types o n l y

B la c k

Q-switc hed a l exa nd rite (755 n m ) : l ight


skin types on ly
Q-switc hed N d : YAG ( 1 , 064 n m ) : a l l
s k in types

Q-switched N d : YAG ( 1 ,064 n m ) safe i n


a l l s k i n types. Less p i g m e n t loss

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

30 1

Is the tattoo placed over or covering a nother tattoo?

H i story of go ld i n gestion

Does the tattoo conta i n rust-col ored o r wh ite pigment?

MANAG E M ENT
It is i m porta nt t o a s k t h e patient w h o placed t h e tattoo .
P rofessional tattoo pigments a re denser a n d placed
d ee per in the dermis than most a mate u r tattoos. This
re nders these tattoos m o re refractory to treatment, partic
u l a rly those that a re m u lticolored and conta i n meta l l ic
pigments . It is i m porta nt to i nform the patient prior to
treatment that c o m p l ete resol ution is not a l ways fea s i b l e .
It is a lso i m porta nt to cou nsel t h a t m u ltiple treatments
ove r 1 to 2 yea rs may be req u i red for maxi m a l i m prove
ment. There is no fixed a n swer as to the n u m be r of treat
ments for tattoo rem ova l .

P R ET R EAT M E NT ASS ESS M E NT

Patients w i t h da rker s k i n types a re m o re l i kely t o suffer


pigme nta ry cha nges

Professional tattoos req u i re more treatm ents than a ma


te u r tattoos

O l d e r tattoos res pond m o re favora bly than new tattoos


B la c k a n d d a r k b l u e tattoos res pond more effectively
t h a n yel l ow tattoos

Assess for s u nta n . If patient is ta n ned , delay treatment


u nt i l ta n resolves

M u lticolored tattoos a re more d ifficult to su ccessfu lly


clear than si ngle-color tattoos. D u ri ng treatment, some
patients may be frustrated at the n o n u n iform i m p rove-

ment of these tattoos

Assess for sca rring with i n the tattoo . If p resent, s how


the patient a n d doc u ment prior to treating

N U M B E R OF T R EAT M E NTS

Professional tattoos req u i re a bout 6 to 20 treatments


prior to rem ova l ; not i nfreq ue ntly, more than 20 treat
ments a re needed for max i m a l i m p rovement

Amate u r tattoos conta i n less dense pigment particles


a n d usua l ly req u i re a bout fou r to six treatments

Rad iation tattoos a n d tra u matic tattoos a re more su per


ficia l and less de nse than professiona l tattoos, req u i ri n g
o n l y a few treatments for resol ution ( Fig. 63 .4)

In genera l , rad iation tattoos can be removed i n one to


th ree treatme nts. Someti mes, they req u i re a d d itional

treatments

Figure 63.2 (A) Tattoo on arm with underlying port-wine stain. (B) Note

Lower fluences a n d la rger s pot sizes can be as effective

the selective removal of the tattoo, while the port-wine stain persists.

as s m a l ler spot s izes a n d i n c reased f l u ences

(C) Tattoo clearance

302

Color Atlas of Cosmetic Dermatology

Test spot may be a p pro priate i n d a rker s k i n phototypes


if concern i n g

Test spots a re c l ea rly i n d icated f o r cosmetic tattoos ,


rust-colored tattoos, a n d wh ite tattoos

TATTOO TREATM E NT

Ph otogra ph of tattoo prior to treatment

Topical a n esthesia o r 1% l i d oca i n e, i n the form of l oca l


i njection or nerve block, w i l l m a ke the treatment more
comforta ble for the patient

Treat the affected a reas with the a p propriate a-switc hed

The c l i n ica l e n d po i n t is i m med iate tissue wh iten i ng. For

laser a l lowi ng for up to a 10% overlap (Ta ble 63 .2)

the 1 ,064-n m a-switc hed N d :YAG , i n a d d ition to tissue


white n i ng there may be a sma l l a m o u nt of p i n point
bleed i n g at the site of treatment ( Figs. 63 . 5 a n d 63 .6)

Tissue "splatter" (ie, epid erma l/dermal d isruption a n d


bleed i ng) m a y prod uce sca rring. If this occ u rs, decrease
the fluence

If the tattoo is m u lticolored , treat the red pigment fi rst.


E rythema a n d i nfl a m mation from other treated sites
may o bsc u re vis u a l ization of red tattoo pigment

Apply to pical hyd rated petrolatu m a n d a nonad herent


d ressing after completing the treatment

Counsel s u nscreen a n d sun avoi da nce to the treatment


a rea

B
Figure 63.3 (A) Left shoulder tattoo with inferior scar resulting from prior

POSTTREAT M E N T CAR E

S u n avoida nce, s u n sc reens

Telfa d ress i n g and hyd rated petrolatu m o i ntment with

treatment with dermabrasion. (B) Improvement after six treatments with


1 , 064-nm Q-switched Nd: YA G laser. While improvement is not complete,
the cosmetic result is far superior to that of dermabrasion

paper ta pe

If tattoo is located in belt-l i n e a rea o r a bove a n kles, cau


tion patients from wea ring tight belts o r boots that may
prod uce friction aga i nst the treated a rea

Retu rn for treatment in 6 to 8 weeks

TAB L E 63.2

Laser Therapy by Qual ity-Switched Lasers

Laser

I n itial setti ngs

Effective aga i n st th ese tattoo i n ks

Freq uency d o u b l ed a-switc hed N d : YAG (532 n m )

1 . 5-5 .0 J , 4 . 0-8 . 0 mm spot size

Red , orange, ye l l ow

a-switc hed r u by (694 n m )

3 . 0-8 . 0 J, 6.5 mm s pot size

G ree n , b l u e , black

a-switc hed a lexa nd rite ( 7 5 5 n m )

5 . 0-6 . 5 J, 2 . 0-4. 0 mm spot size

G reen , blue, b l a c k

a-switc hed N d : YAG ( 1 , 064 n m )

3 . 0- 1 2 . 0 J, 2 .0-8. 0 mm s pot size

B l ue , b l a c k (safest i n d a rk s k i n types)

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

303

ADV E R S E EFFECTS/PR ECAUT I O N S

Pigmenta ry a lterati o n
B l iste r i ng ( es pec i a l ly, Q-switc hed a l exa n d rite a n d r u by)
( Fig. 63 . 7 )

Sca rring ( Fig. 63.8)


In a patient with a n a l lergic reaction to tattoo ink i n the
past ( Fig. 63 . 9 ) , th ere is the poss i b i l ity of a rec u rre nce
seco nd ary to the re lease of tattoo ink fol lowi ng laser
thera py. A l l e rgic p reca utions s h o u l d be ta ke n . Syste m i c
a l lergic reactions c a n occ u r with Q-switc hed lasers
( u n l ike d estructive modal ities-derma brasion, etc . )

R u st-co lored a n d wh ite tattoos s h o u l d b e treated ca re


fu l l y as wel l as red a n d flesh-colored cosmetic tattoos,
for exa m ple, l i p l i ner. Someti mes wh ite i n k is m ixed with
other pigme nts ( Fig. 63 . 1 0)
- The tattoo may d a rken as a result of oxidation of i ron
o r tita n i u m oxi d e pigment with i n the tattoo
- A test site can be performed 4 to 8 weeks prior to

Figure 63.4 Traumatic tattoo on knee of a female that has persisted


30 years after childhood bicycle fall. a-switched 1 , 064-nm Nd: YA G
cleared the tattoo i n three treatments

treatment for possible d a rke n i ng


- This d a rken i n g ca n someti mes be treated with lasers
or may req u i re excision
- They respond slowly to laser thera py

Perform a test s pot prior to treating patie nts with h i story


of gold salt i n gestio n . C h rys iasis, m a n i fested as da rk
b l u e pigmentation , can res u lt fro m treatment with Q
switc hed lasers

Ra rely, patients w i l l experience a tra nsient i m m u n e


res ponse fol l owi ng a

laser tattoo treatment. S u c h

responses i n c l u d e fl u - l i ke sym ptoms a n d e n l a rged


lym ph nodes

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M ENT/O UTCO M E
EXPECTAT I O N S

Response t o tattoo treatment is dependent u pon the


d e pth of pigment, the color of pigment, and the size of
pigment pa rticles. I t c a n va ry d ra matica l l y fro m one to
tattoo to a nother

Effective treatment for a professional tattoo may req u i re


u p to a 20 or more treatment sessions over a period of 1
to 2 yea rs . F u rt h e rmore, complete remova l is often not
fea s i b l e

A su ccessful treatment often leaves s o m e res i d u a l tat


too pigment. T hi s can be i m proved with n o n a b l ative
fractiona l res u rfa c i n g

Physicians s h o u l d c o u n s e l patients t h a t sign ifica nt


l ighte n i ng may be the best feasible c l i n ical resu l t

Tattoo treatment can prod uce hyper- a n d hypopigmen


tation i n a ny patient, espec i a l l y those with da rker skin
types

Figure 63.5 Tissue whitening after treatment with the 532-nm frequency

doubled a-switched Nd: YAG and 694-nm a-switched ruby laser. Tissue
whitening is the appropriate endpoint when treating tattoos with a
switched lasers. Pinpoint bleeding resulted from injection of lidocaine
with epinephrine prior to treatment

304

Color Atlas of Cosmetic Dermatology

Treatment of tattoos in a reas of h a i r growth ( i e , eye

b rows ) may prod uce tem porary h a i r remova l


The freq uency-dou bled Q-switc hed N d : YAG , Q-switc hed

ru by, and Q-switched a l exa nd rite lasers a re more l i kely to


ca use d u ra ble pigmenta ry cha nges than the Q-switc hed
N d : YAG ( 1 ,064 n m )
M ost freq uently,

pigment

a l teration

is

te m pora ry.

Hyperpigme ntation typ i ca l ly resolves more q u i c kly


Lower fl uences and a d d itio n a l time between treatments

s h o u l d be e m ployed i n da rker s k i n p h ototypes

B I B L I OG RAPHY
Alster T . Q-switched a l exa n d rite laser ( 7 5 5 n m ) treatment
of

professiona l

a nd

a mate u r

tattoos .

J Am Acad

Dermatol. 1 995;33 : 69-73.


Ferguson J E, August PJ . Eva l uation of the Nd/YAG laser

Figure 63.6 Purpura immediately after treatment of an eyebrow tattoo

fo r treatment of a m ateu r and profess iona l tattoos. Br J

with a Q-switched Nd: YAG laser

Dermatol. 1996; 135(4) : 586-59 1 .


F itzpatri ck R E, G o l d m a n M P. Tattoo re m ova l using the
a l exa n d rite laser. Arch Dermatol. 1994 ; 1 30 : 1 508- 1 5 14.
G reve l i n k J M ,

M u las

MW,

Hata

TR,

Goldman

M P,

F itzpatrick R E, G reve l i n k J M . Laser treatment of tattoos i n


d a rkly pigme nted patients : Efficacy a n d side effects .

J Am Acad Dermatol. 1 996;34: 653-656.


l z i kson

L,

Avra m

MM,

Anderson

RR.

Tra nsient

i m m u noreactivity after laser tattoo remova l : Re port of two


cases. Lasers Surg Med. 2008;40(4) :23 1 -232.
K i l mer S L, Anderson R R . C l i n ical use of the Q-switc hed
r u by and the Q-switc hed N d : YAG ( 1 064 nm and 532 n m )
lasers fo r treatment o f tattoos . J Dermatol Surg Oneal.
1 993; 1 9 (4) : 330-338.
Levine VJ , Gero n e m u s RG. Tattoo remova l with the Q
switc hed r u by laser and the Q-switc hed N d : YAG laser: A
comparative study. Cutis. 1 995; 55:29 1 -296.

Figure 63.7 Blistering after tattoo treatment. This reaction is common


and usually resolves completely within a week with routine topical skin
care

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

Figure 63.8 Scarring after treatment with a Q-switched ruby laser

(Courtesy of Teresa Soriano, MD)

305

306

Color Atlas of Cosmetic Dermatology

B
Figure 63.9 (A) Allergic hypersensitivity reaction to tattoo (see elevated

portions of tattoo). (B) To avoid systemic allergic reaction with traditional


Q-switched laser treatment of the entire tattoo, focal treatment with an
ablative fractional erbium laser was performed. Note focal improvement
after several treatments

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

307

B
Figure 63. 1 0 (A) Tattoo prior to test spot treatment. (B) Test spot treat

ment of tattoo with a 694-nm Q-switched ruby laser produces discol


oration. Tattoo ink combined blue and white inks

308

Color Atlas of Cosmetic Dermatology

CHAPT E R 64

To r n Ea rl o be

Torn earlobe a n d e n l a rged p ierced earlobe canals a re a


c o m m o n conseq u e n ce of wea ring heavy earri ngs for a
pro l onged pe riod of t i m e ( F ig. 64 . 1 ) as we l l as other fac
tors such as tra u ma , heavy earri ngs, i nfecti o n , low place
ment of pierc i ng, pressu re necrosis, etc . It occ u rs most
easi ly in t h i n ear l o b u les. D roo p i n g or easily torn ea rlobes
may also be secondary to a congen ita l d efect o r tra u m a .

K E Y CO N S U LTAT I V E QU EST I O N S

P rec i pitating event of earlobe tea r

H istory of ke loids or hypertro p h i c sca rri ng

Does patient desire to wea r ea rri ngs aga i n after the


repa i r?

MANAG E M ENT

There a re n u merous s u rgica l methods t o repa i r com


p l etely a n d pa rti a l ly torn earlo bes. D iffe rent tec h n i q ues
a re su ited for d iffe re nt tea rs. Partial tea rs a re m o re easily
treated a n d c a n be corrected via sid e-to-s ide closure as
we l l as punch exc ision and repa i r.

T R EAT M E NTS ( Figs . 64 . 1-64 . 3)


Com plete tea rs a re m ore d iffic u lt to treat tha n pa rtial
tea rs . There a re n u merous d iffe rent tec h n i q ues that ca n
be successfu l . M ost c o m m o n ly, the Z-plasty repa i r o r
i nterloc k i n g L s repa i r prod uce the best res u lt .

Sterile pre paration a n d tec h n i q u e

Loca l a n esthesia s h o u l d be i njected i nto t h e repa i r site

The epidermis of the opposing edges of the tea r wo u n d

s h o u l d b e exc ised

- Sca l pel

Figure 64. 1 (A) Female with large tear defect of earlobe at the site of

- Scissors

heavy earring. (B) Torn earlobe reconstructed by primary repair

I nterru pted 6-0 epidermal sutures a pproxi mate a n d


eve rt t h e wou n d edges o f t h e a nte rior a n d posterior
lobe
- Be certa i n to a p prox i mate the wou n d ed ges of the
i nferior r i m of the ea r ca refu l ly to avoid d istortion o r
m isa l ignment
- The wo u n d edges s h o u l d be u n d e r m i n i ma l tension

N o su bcuta n eous sutu res a re used

Z-plasty re pa i r ( Fig. 64 . 2 ) or i nterloc k i n g Ls repa i r on


the rim wi l l prod uce tissue a p p roxi mation wh i l e pre
venting the d i m pl i ng of the i nferior rim of the earlobe

Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

309

Patients should be cou nseled to refra i n from wea ring


earrings for 3 months fol l owi n g the repa i r

P I T FALLS TO AVO I D/CO M P L I CAT I O N S/


MANAG E M ENTIOUTCO M E
EXPECTAT I O N S

M eti c u lous attention t o a p p roximating t h e wou n d edges


a n d the i nfe rior r i m of the ea r a re esse ntia l for a satis
fa ctory resu lt. N otc h i ng of the i nfe rior rim of the earlobe

ca n occ u r easi ly, sign ifica ntly compromising a esthetic


a p pea ra nce

Caution i n a patient with a h i story of keloids or hyper


tro p h i c sca rs

Patient s h o u l d n ot wea r earrings for 2 to 3 m o nths after


s u rgery

Wou n d strength is less than the origi nal strength of the


lobe. Avoid wea ring heavy earri ngs to prevent rec u rrence

B I B L I OG RAPHY
Ti pton J B . A s i m ple tec h n iq u e for red uction o f the ea r
lobe. Plast Reconstr Surg. 1 980;66: 630-63 2 .

Figure 64.2 Repair of complete earlobe tear utilizing a Z-plasty to pre

vent dimpling of the inferior aspect of earlobe

31 0

Color Atlas of Cosmetic Dermatology

Figure 64.3 One stage preauricular flap to repair earlobe deformities

INDEX
N ote : I n this i ndex, the letters "f" and "t" denote figu res and ta bles, respectively.

pathogenesis, 72

1, 450-nm diode laser, 82, 82f, 83f

physical exa m i nation, 72

5-a m inolevu l i n i c acid (5-ALA), 75, 254


5-fl uorouraci l , 207, 224, 229

Acq u i red ca p i l l a ry hema ngioma, 1 70-1 73

1320-nm N d : YAG laser, 4 1


1 450- n m diode laser, 4 1 , 74

Acra l amela notic melanoma, 206


Acti n i c c h e i l itis, 248
Actinic keratosis (AK), 248
consu ltative q uestions, 249

cou rse, 249

Ablative fractional laser resu rfaci ng, 39, 57

dermatopathology, 248

adva ntages of, 57


ind ications, 58

d ifferential d iagnosis, 248


epidemiology, 248

laser safety, 59

ma nagement, 249

adverse side effects, 60, 601

pathoge nesis, 248

fol low- u p , 59-60, 59f

physical exa m i nation, 248

i nfectio n , 60, 6 1 1

pitfa l l s , 250-2 5 1

nonfacial skin, 60-6 1


postoperative care, 57f, 58f, 59

treatment, 249-250
Acti n i c keratoses
vs. wa rts, 206

preoperative eva l uation, 58

Acyclovir, 32, 46, 54

prophylaxis/a nesth esia, 58-59


Ablative laser res u rfacing, 1 5 11, 1 52

Ada palene, 9, 73

a bsol ute contra i nd ications, 45

Adatosil 5000, 14t, 1 5t

a n esthesi a , 46-47
for Becker's nevus, 2 1 8

Adenoma sebaceu m , 2 1 2
Affirm 1 , 440 n m N d : YAG laser, 56, 56t

for epidermal nevus, 224

Age-related textural cha nges, 2t

ideal laser candidate, 45

Agi ng, 2

i n d ications, 44

Aging face and non-facial regions, a na lysis of

less than ideal laser cand idate, 45

a natomic consid erations, 2-3 , 2t

mecha n ism of action, 43


ca rbon d i oxide laser, 43, 43f, 44f

preoperative eva l uation, 3


ca rti lage, bony structures, and s u p portive structures,

Er:YAG, 43, 45f

cha nges in, 5

medications, 46

facial m uscu lature cha nges, 5

for m i l ia , 230

G l oga u Photoaging Classification, 2f, 3-4, 3f, 4f, 5f

postoperative care, 49, 501, 5 1 1

pigmenta ry cha nges, 4, 6f

preoperative eva l uation, 44-45


proced ure, 48-49, 49f

su bcuta neous fat atrophy, 5


AK. See Acti nic keratosis

relative contra ind ications, 45-46

A LA . See 5-a m i n olevu l i n i c acid

safety mea s u res, 47-48

Alca i ne. See Topica l proparaca ine

for seborrheic keratosis, 236

Alcon, 28

treatment pearls, 50
ACE i n h i bito rs . See Angiotensi n-converting enzyme (ACE) i n h i bitors

Alcon La bs, 1 5t
Al lerga n , 1 4t, 1 5t, 2 1 1

Aceta m i nophen, 58

Allergic reactions

Acetone, 48

to sclerothera py, 20 1
Al loderm , 14t

Acne scars, 290, 293

Aloe vera , 10

physica l lesions, 293-295


treatment, 295
Acne vu lga ris, 72, 76, 1 00

Aloesi n , 9t, 10
a-hyd roxy acid, 32
lotions, 182

vs. angiofi broma, 2 1 2

for posti nfl a m matory hyperpigmentation, 1 60

cou rse, 73
d ifferential d iagnosis, 72

peels, 1 4 1

epidemiology, 72

A l u m i n u m c h l oride hexa hydrate, 8 7

la boratory data
dermatopathology, 73

A m b u latory phle bectomy, 202


American Academy of Dermatology, 8

endocrine stud ies, 72-73

Amoxici l l i n , 73

ma nagement, 73

Amyotro phic latera l sclerosis, 22

l ight treatment, 72f, 73f, 74-75, 75f

Anesthesia , 88

s u rgica l treatment, 74

for a blative fractional laser resu rfaci ng,

systemic treatment, 73-74


topical treatment, 73

58-59
for a blative laser resu rfaci ng, 46-47

31 1

31 2

I ndex

for a ngiofi broma, 2 1 3


for l i poma treatment, 227
for neurofi broma, 236
for nonablative fractional laser resu rfaci ng, 54
for nonablative laser resu rfa c i ng, 40
m i d - i nfrared lasers, 40f, 4 1
for soft tissue augmentation, 1 6f, 1 7
for wa rt remova l , 207t, 208
Angiofi broma, 2 1 2-2 1 5
consu ltative q uestions, 2 1 3
cou rse, 2 1 3 , 2 1 3f
de rmatopathology, 2 1 2
d ifferenti a l d iagnosis, 2 1 2
epidemiology, 2 1 2
laboratory data , 2 1 3
ma nagement, 2 1 3-2 14, 2 1 4f, 2 1 5f
pathogenesis, 2 1 2
physical exa m i nation, 2 1 2 , 2 1 2f
pitfa l l s , 2 1 4
Angiokeratoma, 1 68
vs. angiomas, 1 7 1

cou rse ma nagement, 1 68-1 69, 1 69f


de rmatopathology, 1 68
differentia l d i agnoses, 1 68
epidemiology, 1 68
physical exa m i nation, 1 68
pitfa l l s to avo i d , 1 69
Angio l i poma, 226
Angiomas, cherry and spider, 170
cou rse, 1 7 1
differentia l d i agnoses, 1 7 1
epidemiology, 1 70
ma nagement, 1 7 1 - 1 7 2
pathogenesis, 1 70
pathology, 1 7 1
physical exa m i nation, 1 7 1
pitfa l l s to avo i d , 1 7 2
Angiotensi n-converti ng enzyme (ACE)
i n h i bitors, 89
Anth ra l i n , 224
Anti bacterial agents, 73
Anti bacteria l thera py, 46, 53
Anti biotics, 73
Antima la ria ls, 1 75
Antioxida nts, 8
Anti pers p i ra nt, 89
Antivira l med ications, 49
Antivira l thera py, 46, 54
Apraclo n i d i n e hydrochloride, 28
Aq ua m i d , 1 4t
Aquaphor H ea l ing O i ntment, 49
Arbuti n , 9t, 1 0
Artefi l l , 1 4t
Arterial spider, 1 70- 1 73
Ascorbic acid , 9t, 1 1

B
B l u pu s m i l iaris d isse m i natus faciei, 76

B - H C G . See - H u m a n chorionic gonadotropin


B a n naya n-Zonana synd rome, 226
Basa l cell carci noma ( BCC), 81, 252-254
epidermal nevus a n d , 222, 223
consu ltative q uestions, 253
cou rse, 253
de rmatopathology, 252
d ifferential d iagnoses, 252
epidemiology, 252
la boratory data, 253
ma nagement, 253-254, 253f, 254f, 255f
pathogenesis, 252
physical exa m i nation, 252, 252f
pitfa l l s , 254
B ea rberry, 1 0
B ecker's nevus, 2 1 6--2 1 8
consu ltative q uestions, 2 1 7
cou rse, 2 1 7
d ifferential d iagnosis, 2 1 6
epidemiology, 2 1 6
la boratory exa m i nation, 2 1 6
ma nagement, 2 1 7-2 18, 2 1 7f
pathogenesis, 2 1 6
pathology, 2 1 6
physical exa m i nation, 2 1 6, 2 1 6f
pitfa l l s , 2 1 8
B e l otero Basic, 1 4t
B e l otero Soft, 14t
Benign growths
a ngiofi broma, 2 1 2-2 1 5
Becker's nevus, 2 1 6--2 1 8
epidermal i nclusion cyst, 2 1 9-22 1
epidermal nevus, 222-225
Benzoyl peroxide, 73

- H u ma n

chorionic gonadotropin ( B- H C G )

Betaca ine Enha nced Gel, 1 7


B etaca ine P l u s , 1 7
B io-Aica m i d , 14t
B i oform M e d i ca l , 1 5t
B iomatrix I nc . , 1 5t
B i o psies
epidermal i nclusion cysts, 220
epidermal nevus a n d , 223
l i poma, 227
neurofi broma, 232
seborrheic keratosis, 235
B i otech I n d u stry, 1 5t
B laschke, l i nes of, 222
B leac h i n g crea ms, 46
B l e p h a rochalasis, 64
B loom's synd rome, 67, 136
Bornaprine, 87

Ash leaf macule, 2 1 2, 2 1 3f

Botox, 89 . See also Botu l i n u m toxin A

Aspergillus, 1 0
AstraZeneca , 1 7

Botu l i n u m toxin

Botox Cosmetic, 2 1!

Ataxiatela ngiectasia, 67

com pl ications, 27

Ativa n , 58

contra i n d ications

Atro p h i c scars, 294-295


Atrophoderma verm iculatu m (AV), 1 8 1

a bsol ute, 22
relative, 22

Avila , 9
Avobenzone, 7t

d i l ution, 22

Azelaic a c i d , 9t, 10, 73, 77, 1 4 1 , 1 5 1 , 1 60

m uscle gro u ps, 22f, 23

Azit h romyc i n , 46, 73

mecha nism of action, 21


forehea d , 22f, 23-24, 23f

I n d ex

gla bellar com plex, 24, 24f

Cavernous hemangioma, 1 77-1 80

nasolabial fol d , 25--2 6, 27f

Cel l u l ite, 276-279, 276f

neck, 26-27, 28f

consu ltative q uestions, 277

periora l region, 26, 27f, 28f


periorbital regio n , 24-25, 25f

course, 276

u pper nasal root, 25, 26f

epidemiology, 276
la boratory exa m i nation, 276

pharmacology, 2 1 , 2 1 !

ma nagement, 277

postoperative considerations, 27

physical lesions, 276

preoperative eva l uatio n , 22

pitfa l l s , 278--279

lower eyelid snap back test, 22-23


prepa rations, 2 lt

treatments, 277-278, 277f

proced u re, 23

Centrofacial te la ngiectasias, 194f


Chem ical peels, 30, 74, 1 4 1

treatment benefits, 27

compl ications, 3 4 , 38f

treatment pearls, 28

contra i n d ications, 3 1-32

B otu l i n u m toxin A ( BTX-Al , 2 1 , 22, 87, 88, 88f


a n esthesi a , 88
antipers p i ra nt, 89

ideal ca n d i d ate, 3 1
less ideal ca n d idate, 3 1
med ications, 32

Botox, 89

peel types, 33

hyperh i d rosis, mechanism of action i n , 88f

postoperative care, 34

i njection sites of, 88f, 89f

proced ure, 33-34, 36f, 37f

med ications, 89

treatment pearls, 34-35

su rgery, 89
treatment, 88-89, 88f, 89f

wou n d depth, 32
Chem ical su nscreen, 7-8, 7t

Botu l i n u m toxin B ( BTX- B l , 2 1

Cherry a ngiomas, 1 70-- 1 73 , 1 72f

B otu l i n u m toxin E ( BTX-E), 2 1

Cinoxate, 7t

B r i n d is, 14t

C i p rofloxa c i n , 46

Broussonetia papyrifera, 1 0

C l i ndamyc i n , 73

B ucci nator, 2 6 , 27f, 28f

Clofazimine, 1 7 5

C02 l a s e r a b lation, 82
C02 resu rfacing. See Carbon d ioxide (C02 ) laser
Coenzyme Q10, 8

Clostridium botulinum, 2 1

Cafe au lait macu les (CALMs), 136


vs. B ecker's nevus, 2 1 6
consu ltative q uestions, 137

Colchicine, 1 7 5

cou rse, 137

Col lagen, i n a ngiofi broma, 2 1 2


Col lagenase, 9

d ifferential d iagnosis, 136

Comedone extractio n , 74

epidemiology, 136

Common wa rts, 206-209

la boratory exa m i nation, 136


laser treatment, 1 37-138

Compression stocki ngs, 200

ma nagement, 137

Complete tea rs, 308

vs. neurofi bromas, 232

Congen ital ad renal hyperplasia, 92


Congen ita l hema ngiomas, 1 7 7

pathogenesis, 136

Congen ita l nevus, 2 1 6

pathology, 136

Contu ra I nternationa l , 1 4t

physica l lesions, 136


pitfa l ls, 138

Cooltouch I n c . , 4 1

topical treatment, 138

Corrugator s u perc i l i i , 24, 24f


Corticosteroids, 1 64, 1 75

Calci potriol, 224

Corrective h a i r transplant su rgery, 1 10, 1 1 0t

Campbell de Morga n spots, 1 70--1 73

for epidermal nevi , 224

Candela Corp . , 4 1

for epidermal i ncl usion cysts, 22 1

Canderm, 1 7
Canderm Pharma, I n c . , 1 4t
Ca n i n us, 26, 27f, 28f

for m i l ia , 229
Cosmod ermrM , 14t

Cantharone, 207

Cosmoplas(TM , 14t
Cross-hatch ing, 18

Ca p i l l a ry, 1 77

Cryogen spray coo l i n g (CSC ) , 185

Ca ptiq uerM , 1 4t

Cryosu rgery, 175

Carbon d ioxide (C02 ) laser, 43, 43f, 48, 49, 57, 1 7 2 , 239
Carbon d ioxide laser resu rfacing

Cryothera py

for a ngiofi broma, 213, 2 1 4-2 1 5f


for a ngiomas, 1 72

for de rmatosis pa pu losa n igra , 242


for ephelides, 142
for epidermal nevus, 224

for basa l cell ca rcinoma, 254

for lentigines, 146

for epidermal nevus, 224


for neu rofi broma, 232

for sebaceous hyperplasia, 83

for seborrheic keratosis, 236

for sq uamous cell carcinoma, 258

for sq uamous cell carcinoma, 258


for venous la kes, 208

for venous lakes, 204


for wart remova l , 209

for wa rts, 207t, 208

for seborrheic keratosis, 236, 237, 237f

for seborrheic keratosis, 236

313

314

I ndex

C u rettage

Dyschromia

for epidermal nevus, 224


for wa rt remova l , 209

from wart remova l , 207t, 208, 209


Dysport, 2 lt

Cushi ng's d isease, 92, 285


Cutting tool , 44
Cymetra Life Cell Corp., 14t

Cynosure, 56, 56t

Ea r piercing, 298

Cyproterone acetate, 1 28
Cysts

consu ltative q uestions, 298


ma nagement, 298, 298f

epidermal incl usion cysts, 2 1 9-2 2 1

physical exa m i nation, 298

h o r n , 235
m i l i a , 229-230

pitfa l l s , 299, 299f

pilar cysts, 220

treatment, 298
Ectopic ad renocorticotropic hormone prod uction, 92
Electroca utery, 239
for epidermal nevus, 224
Electrodesiccation, 83

for a ngiofi bromas, 2 1 3

DAO. See Depressor angu l i oris

for seborrheic keratoses, 236

Dapsone, 1 75
Deep-depth strength peels, 30t, 33

Electrolysis, 94, 2 1 7
Electrosection, 7 7

Deep hema ngioma ( D H ) , 1 7 7

Electrosu rgery, 76f, 7 7 , 77f, 8 2 , 1 7 5

Deep vei n throm bosis, 198

for venous lakes, 204

Demodex fol l ic u l o ru m , 77

El l i ptical excision, 2 1 3 , 2 1 9f, 227, 2 132

Depilation, 94

El l i ptical strip h a rvesti ng, 1 06

Depressor angu l i oris ( DAO), 26, 27f, 28f


Derc u m 's d i sease, 226

vs. fol l i c u l a r unit extraction ( F U E) , 107, 107t


E l l m a n S u rgitro n , 78

Derma brasion , 1 75

Em bol ization, 180

for epidermal nevus, 224


for a ngiofi broma, 2 1 4

Endermologie
for cel l u l ite, 277-278

Derm a l melasma, 149

Endocrine stud ies, of acne v ulgaris, 72-73

Dermatochalasis, 64
consu ltative q uestions, 65

Endocrinology, consu ltation with, 93


End osco pic/classic sym pathectomy, 88

cou rse, 65

Eosi noph i l ic gra n u loma, 1 74

de rmatopathology, 65

Ephelides, 139

differentia l d iagnosis, 64

consu ltative q uestions, 1 40

epidemiology, 64

course, 140

ma nagement, 65
pathogenesis, 64

d ifferential d iagnosis, 1 40
epidemiology, 1 39

physical exa m i nation, 64

la boratory exa m i nation, 140

pitfa l ls, 65-66

ma nagement, 140

treatment, 65
Dermatosis pa pu losa n i gra ( D P N s ) ,

pathogenesis, 139
pathology, 140

24 1 , 24lf
consu ltative q uestions, 242

physical lesions, 140


vs. solar lentigo, 1 45t

cou rse, 24 1

treatments

differentia l d iagnosis, 241

chemical peels, 14 1-142

epidemiology, 241

cryothera py, 1 42

laboratory exa m i nation, 241

laser thera py, 1 42- 143

laser treatments, 242-243


ma nagement, 242

pitfa l l s to avoid/com plications/ma nagement, 143


topical treatment, 1 40- 1 4 1

pathogenesis, 241

E p i d e r m a l acanthosis, 6 5 , 6 7

pathology, 24 1

E p i d e r m a l inclusion cysts ( EI C ) , 2 1 9-22 1

physical lesions, 241

consu ltative q uestions, 220

pitfa l ls, 243

cou rse, 220

Derm ik, 1 5t
Destructive modal ities, 83
of sebaceous hyperplasia
Diazepa m , 17

d ifferential d iagnosis, 220


epidemiology, 2 1 9
la boratory data, 220
ma nagement, 220

Dicloxa c i l l i n , 46

pathogenesis, 2 1 9

Diode laser treatments

pathology, 2 1 9

for Becker's nevus, 2 1 8


for venous la kes, 204
Dioxybenzone, 7t

physical exa m i nation, 2 1 9, 2 19f


pitfa l l s , 22 1
treatment, 220-22 1 , 2 1 9f, 220f

Dow-Corn ing, 1 4t

Epidermal melasma, 32f, 1 49

Doxycyc l i ne, 73, 77

Epidermal nevus ( E N ) , 222

D P N s . See Dermatosis pa pu losa n igra

vs. Becker's nevus, 2 1 6

I n d ex

consu ltative q uestions, 223

medical thera py, 1 27-1 28

course, 223

non-FDA a p p roved medications, 1 28

d ifferentia l d iagnosis, 223

pathogenesis, 1 26

epidemiology, 222
la boratory data, 223

physical exa m i nation, 1 26, 1 28-129


su rgery, 128

pathogenesis, 222

Female s u rgica l pla n n i ng, 129

pathology, 222

postoperative i n structions, 130

physica l exa m i nation, 223

postoperative period , 130- 1 3 1

pitfa l ls, 225


vs. seborrheic keratosis, 223, 235

treatment, 224-225
Epidermis
a n d epidermal i n c l usion cysts, 2 1 9

preoperative i n structions, 1 3 0
Fern d a l e La bs, 1 7
Fi brous pa pu les, 2 1 2
F i l iform wa rts, 206
F i l lers
permanent, 282-283

i n l i poma, 226
Epidermoid cyst, 2 1 9
E pi l u m i nescence microscopy ( E L M ) , 203
Epinephrine, 59

tem porary, 282


Finasteride, 104, 104t, 1 28, 1 33
Fitzpatrick skin phototype, 3 1

Er:YAG . See Erbi u m : Yttr i u m-Al u m i n u m Ga rnet Laser

Fitzpatrick's classificatio n , of skin types, 4t

Erbi u m ablative resu rfacing lasers, 57

Flash l a m p , 78f, 79, 79f, 801

Erbi u m : Yttriu m-Ai u m i n u m Garnet ( Er:YAG) laser

treatment, 193

and a blative laser resu rfacing, 43, 451, 48, 49

Flavonoids, 9t

a n d epidermal nevus, 224


and seborrheic keratos is, 236

Foam sclerothera py, 199-200


Follicular i nfu n d i b u l u m , 2 1 9

Erythematotela ngiectatic rosacea . See Vasc u l a r rosacea

Follicular u n it extraction ( FU El , 1 06t, 1 0 7 , 1 08!


vs. e l l i ptica l strip ha rvesting, 1 07t

Eryth romyc i n , 73
Eutectic m i xture of loca l a n esthetic (EM LA), 17, 40

Fo l l i c u l itis, 1 00

Exci mer laser, 1 65, 287

Forehea d , 22f, 23-24, 24f

Excision su rgica l , 253, 257, 29 1 , 29 11


Eye i nj u ries

m i l i a , 229-230
Fractional photothermolysis ( F P )

and lasers, 981

Fractional res u rfaci ng, 1 5 11, 152, 1 53f


Fraxel Restore, 56, 56!
Freckles. See Ephel ides
Fronta l i s m u scle, 221, 23-24, 23f

F
Facial age-related conto u r changes, 2t

Fronta l i s m u scles, 24, 24f


F U E . See Follicular u n it extraction

Facia l m uscu lature changes, 5


Facial telangiectasias, 192, 192f
cou rse, 192
dermatopathology, 192

epidemiology, 192

Gelatinase, 9

ma nagement, 192-194
physica l exa m i nation, 192

Genita l wa rts, 206-209


Gentisic acid , 9t

pitfa l l s to avo i d , 194

G l a be l l a r com p l ex, 24, 24f

prior to long p u l se-d u ration pu lsed dye laser

G la brid i n , 1 0

treatment, 1 951
prior to p u l sed dye laser treatment, 1 931
Fa n n i ng, 18
Fascia B iomateria ls, 1 5t
Fascia n, 1 5t
Fat accu m u lation
treatment of, 283

G l oga u Photoaging Classification, 2f, 3 -4 , 3f, 4f, 51


G lycolic acid , 9t, 30!
G lycolic acid pee l , 32, 331, 74, 1 60
and e p h i l ides, 1 4 1
and melasma, 1 5 1 , 1 5 1 t
G lycopyrro n i u m bromide, 8 7
G/ycyrrhiza g/abra linneva, 1 0

F DA-a pproved med ications, for male pattern h a i r loss, 104, 1 04t

G o l d i njections, 1 7 5

Female pattern h a i r loss, 126, 1 26f. See also M a l e pattern hair loss
c h i ef com pla i nt, 1 3 1

G rafts, s k i n , 2251
G ra n u loma faciale, 1 74, 1 741, 1 76f

consult, 1 3 1-132

cou rse, 1 74

consu ltative q u estions, 1 26

de rmatopathology, 17 4

course, 126

d ifferential d iagnoses, 1 74

d ifferentia l d iagnosis, 1 2 7

epidemiology, 1 74

epidemiology, 1 26
female hair transplantation, 1 3 1

l ight treatment, 1 75
ma nagement, 175

t o correct a ltered tem pora l h a i r l i ne, from l ifting proced u re, 1 3 1


female surgica l pla n n i ng, 129
postoperative i n structions, 130
postoperative period , 130- 1 3 1
preoperative i n structions, 1 30
vs. male pattern h a i r loss, 1 29, 1 29t, 1 3 1 1

m u ltiple lesions of, 1 75f


pathogenesis, 1 74
physical exa m i nation, 1 74
pitfa l l s to avoid, 1 7 5
syste m i c treatment, 1 75
topical treatment, 1 7 5

31 5

31 6

I ndex

G ra n u loma gravida r u m , 1 88- 1 9 1

botu l i n u m toxin A, 88, 88f

G ra n u loma tela ngiectaticu m , 188- 1 9 1

anesthesi a , 88

G ra n u lomatous rosacea , 7 6

antipers p i ra nt, 89

Gynecomastia, 2 72-275, 272f


consu ltative q u estions, 273

botox, 89
medications, 89

cou rse, 273

su rgery, 89

differentia l d iagnosis, 272

treatment, 88-89, 88f, 89f

epidemiology, 272

consu ltative q uestions, 87

laboratory exa m i nation, 272-273

cou rse, 86

ma nagement, 273
pathogenesis, 272

de rmatopathology, 86
d ifferential d iagnosis, 86

physical lesions, 272

epidemiology, 86

pitfa l ls/com p l ications/outcome expectations, 274-275

la boratory exa m i nation, 86, 86f

treatment, 273-274

ma nagement, 87, 87f


ora l med ications, 87
pathogenesis, 86
physica l fi ndi ngs, 86

H
H a i r loss. See Female pattern h a i r loss; M a l e pattern h a i r loss
H a i r remova l , 2 1 7
H a i r tra nspla ntation, 1 04-1 05
H a i r l i n e design , 1 08
H a rn a rto rna , 2 16, 222
Hemangioma, segmenta l , 1 80f
Hemangioma, u l cerated , 1 79f
Herna ngiornas, 1 7 7
H i bernoma, 226
H i biclens, 48
H i rsutism, 92
consu ltative q u estions, 93
cou rse, 93
differentia l d iagnosis, 92-93
epidern iology, 92
laboratory tests, 93
ma nagement, 93
electrolysis, 94
endocrinology, consultation with , 93
j ust prior to treatment, 96
laser h a i r remova l tech n i q ue, 95, 96-98
non laser thera p ies, 93-94
patient consu ltation, 95-96
posttreatment i n structions to patient, 98
physical exa m i nation, 92

pitfa l l s , 89-90
su rgery, 88
topical med ications, 87
Hyperh i d rosis
sites of, 90f
treatment d iagra m , 87f
Hyperpigrnentation
a n d cryotherapy, 209
and post-sclerothera py, 200
Hype rsensitive rea ctions, of soft tissue augmentation , 18
Hypertonic sa l i n e , 199, 200t, 201t
Hypertrichosis, 2 1 6, 2 1 7
Hypertrophic sca rs, 290
c l i n ical experience, 293
d ifferential d iagnosis, 290
vs. keloids, 290!
la boratory exa m i nation, 290

laser, 29lf, 292, 292f


ma nagement, 291
physica l exa m i nation, 290
pu I sed dye laser, 292t
stud ies, 292
Hypopigmentation, 67, 187f
and cryothera py, 209 , 236
and laser treatments, 2 1 8

pitfa l l s , 94f, 98-99


H IV l i podystrophy/facial l i poatrophy, 280-284
consu ltative q u estions, 281
cou rse, 28 1

Ice-Pick/Boxcar Sca r

dermatopathol ogy, 280


differentia l d iagnosis, 281

lcod i n , 58
l d e benone, 8

epidemiology, 280

l m i q u imod , 1 79 , 207, 29 1 , 29 1 T

laboratory exa m i nation, 281

l named Corp, 14t

ma nagement, 281-282

l named Corp. , 1 5t

pathogenesis, 280
physical lesions, 280-281

I nfa nti le hemangioma ( I H ) , 1 7 7 , 1 7 7f, 1 78f

pitfa l ls, 283-284

a n c i l l a ry tests, 1 78
com pl ications, 1 78

prec i pitating factors, 280

course, 1 78

prevention, 28 1

de rmatopathology, 1 7 7

treatments, 282-283
Homosalate, 7t
Hormones, 73

d ifferential d iagnoses, 1 7 7
epidem i ology, 1 7 7

H u ma n pa pil lomavirus ( H PV), 206-209

la boratory tests, 1 77
ma nagement, 1 78-180

Hya l u ronidase, 47

physical exa m i nation, 1 7 7

Hyd roq u i none, 9 , 9t, 13, 140, 146, 15 1!, 160,


Hyd roxy acid, 73
Hyd roxycou marins, 9t
Hylaform , 1 5t
Hyperhid rosis, 86

pitfa l l s t o avo i d , 180


I ntense pu lsed l ight lasers
for pseudofo l l i c u l itis, 1 0 1
for Becker's nevus, 2 1 8
for cherry and spider a ngiomas, 1 72

I n d ex

for port-wine sta i ns, 185

and h i rsutism , 95

for postsclerothera py hyperpigmentatio n , 201-202, 20lf, 202f

and pseudofolliculitis, 1 001, 1 0 1 , 1 0 l f

for venous lakes, 204

tech niq ue, 9&-98

I nterferon-a, 179

Laser l ight firing, 93f

I nterlocking Ls repa ir, 308


l ntra lesional 5-fl uoro u racil (5-FU ) , 29 1 , 29 lt

Laser safety, 97f

l ntra lesional steroid i njection, 74

nona b lative laser resu rfaci ng, 41


for a blative fractional laser resurfaci ng, 59

l ntra lesional tria mcinolone acetonides, 29 1 , 29 lt

adve rse side effects, 60, 601

l o p i d i n e , 28

fol low- u p , 59-60, 59f

I PL. See I ntense pulsed l ight

i nfection, 60, 6 1 f

I psen L i mited, 2 1 t
lsolage n , 1 5t

nonfacial ski n, 60-6 1

Isopropyl a lcohol , 48
lsotreti n o i n , 40, 58, 74, 77

postoperative care, 57f, 58f, 59


Laser thera py
for d ermatochalasis, 65
for gra n u loma faciale, 1 75
for Poiki loderma of Civatte, 68, 68f

for sebaceous hyperplasia, 82--83, 82f, 83f

J essner, 30t, 35f

Laser-assisted photodynamic thera py, 82

J essner peels, 14 1 , 160

Lasers, 74

J uvedermrM , 1 5t

Lecithins, 9t
Lentigines, 144
chem ical peels, 146
consu ltative q uestions, 1 45-146

K
Keflex, 1 7 , 46
Keloids
d ifferential d iagnosis, 290
vs. hypertrophic scars, 29ot
vs. keloids, 290t

laboratory exa m i nation, 290


laser, 29lf, 292, 292f
ma nagement, 29 1
physica l exa m i nation, 290
pulsed dye laser, 292t
stud ies, 292
Keratinocytes, 1 40, 222
Keratolytic agents, 73
Keratoses
seborrheic, 223
Keratosis fol liculari s s p i n u losa deca lva ns ( KFSD), 1 8 1
Keratosis p i l a r i s atroph ica ns ( KPA), 1 8 1 , 1 8lf, 1 82f
cou rse, 1 8 1
dermatopathology, 1 8 1
d ifferential d iagnosis, 1 8 1
epidemiology, 1 8 1
ma nagement, 1 8 2
pathogenesis, 1 8 1
physica l exa m i nation, 1 8 1
pitfa l l s t o avoid , 182
Keratosis pila ris atroph ica ns faciei ( KPA F ) , 181
Keratoses
actinic, 206
seborrheic, 206, 234-237
Kindler synd rome, 67
Koenen's tumor, 2 1 2
Koj ic acid , 9t, 1 0 , 1 4 1
KTP laser. See Potass i u m -tita nyl-phosphate laser

cou rse, 1 45
cryothera py, 146
d ifferential d iagnosis, 145
epidemiology, 144
la boratory exa m i nation, 145
laser and l ight sou rce treatment, 146-147
ma nagement, 1 45
pathogenesis, 1 44
pathology, 144
physical lesions, 144
pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations,
147-148
vs. seborrheic keratosis, 235

topical med ications, 1 45-146


Lentigo sim plex, 144
LEOPA R D synd rome, 1 44
Lichen planus ( L P ) , 262-264
course, 263, 264f
de rmatopathology, 262
d ifferential d iagnosis, 262
epidemiology, 262
la boratory data , 262
ma nagement, 263
pathogenesis, 262
physical exa m i nation, 262, 262f, 263f
Lichen striatus, 223
Licorice extract, 9t, 10
Lidoca i ne, 47, 59, 107
for wart removal , 208
Life Cell Corp. , 1 4t
Light treatment, of acne vu lgaris, 72f, 73f, 74-75, 75f
Light cryothera py, 82
Linear foca l elastosis.
Linear th readi ng, 1 8
Linoleic acid, 9t

L
L- M -X-4 a n d 5, 1 7

Li pectomy, 283
Lipoma, 22&-228
consu ltative q uestions, 227

Lactic acid, 182

cou rse, 227

Lactic acid, 9t

d ifferentia l d iagnosis, 226


epidemiology, 226

LAM B synd rome, 1 44


La nzhou I nstitute of B iologica l Prod ucts, 2 1t
Laser h a i r remova l

la boratory data , 227


pathology, 226

31 7

31 8

I ndex

physical exa m i nation, 226, 226f, 227f, 228f


pitfa l l s , 228
treatment, 227-228, 227f, 228f

Melanin
i n post-sclerothera py hyperpigmentation , 200
in seborrheic keratosis, 236

Li posa rcom a , 226

M ela nocyte cytotoxic agents, 9t

Li posucti o n , 88
for cel l u l ite, 277

Melanoma

Melanocyte tra nsfer i n h i bition, 9t

for gynecomasti a , 274

vs. seborrheic keratosis, 235

for HIV l i podystrophy/facial l i poatrophy, 283

venous la kes a n d , 203

for l i poma, 227

warts a n d , 206

Liver s pots. See Solar lentigos

M elanophages, 1 44

LLLT. See Low level l ight laser therapy


Lob u l a r ca p i l l a ry hemangioma, 188-- 1 9 1

M elasma, 1 4 9 , 1 49f
a blative laser, 152

Long- p u lsed alexa nd rite laser, 1 0 1

chemical peels, 1 5 1- 152

Long- p ulsed N d : YAG laser, 1 0 1

consu ltative q uestions, 1 50

Low level l ight laser thera py ( LLLT), 1 33, 1 33f, 1 34f

cou rse, 1 50
de rmatopathology, 149

mecha nism of action , 133


pea rls of wisd o m , 1 33
use of, 1 33

d ifferential d iagnosis, 1 50
epidemiology, 149

Lower extremity telangiectasias, 198--202

fractional resu rfaci ng, 1 52 , 1 53f

Lower eye l i d snap back test, 22-23

la boratory exa m i nation, 1 50

Lower face, 3

ma nagement, 1 50, 1 50f, 1 5 11, 1 52f

Lower lid horizonta l laxity, 64


LP. See Lichen planus

pathogenesis, 1 49

Lux 1 , 540 n m laser, 56, 56t

pitfa l l s , 1 52-153

physical lesions, 149


Q-switched laser, 1 52
topical treatment, 1 5 1 , 1 5 lt

M EN D . See M icroscopic epidermal necrotic debris

Macu les, 2 1 6, 223


Madelu ng's d i sease, 226

M enta l i s m uscle, 26, 27f, 28f

Male pattern hair loss, 1 03 . See also Female

M eq u i n o l , 9t

pattern hair l oss


consult, 105
d ifferential d iagnosis, 1 03

Mentor Corporation, 1 5t
M e rz Pharma, 1 4t, 2 lt
M esothera py
for cel l u l ite, 278

epidemiology, 1 03
vs. fem a l e pattern h a i r loss, 129, 1 29t, 1 3 1 1

M ethanthel i u m bromide, 87

h a i r transpla ntation, 1 04- 1 05

M ethyl a nthra n i late, 7t

laboratory exa m i nation, 104

M etron idazole, 77
M exoryl SX, 7t

medica l thera py, 1 04, 1 04t

M ethyl a m i nolevu l i nic acid ( MAL), 254

natural progression, 1 03

M exoryl XL, 7t

pathogenesis, 103
physical exa m i nation, 1 03 , 1 03f, 1 05f

M icroderma brasion, 74, 229, 287

s u rgica l proced u re

M icroth ermal treatment zones ( MTZs ) , 52

M icrosco pic epidermal necrotic debris ( M E N D ) , 52

corrective h a i r transplant su rgery, 1 10, 1 10t

M idface, 3

day of proced u re, 1 06

M id-i nfrared lasers, 401, 4 1

donor h a rvesti ng tec h n i q ues, 1 06, 1 06f, 106t, 107t

M i ld atrophy, 67

donor regi o n , a n esthesia i n , 1 06


fol l i c u l a r unit extraction ( F U E) , 107, 107t

M i l i a , 229-230
consu ltative q uestions, 230

graft creation, 107

cou rse, 230

graft placement, 108--1 09, 1 13f

epidemiology, 229

h a i r l i n e design , 1 08

pathogenesis, 229

post h a i r tra n splant side effects, 109

pathology, 229

postoperative period , 109


postsu rgica l period after sutu res/sta ples

physica l exa m i nation, 229, 229f, 2301

removed , 1 09-1 1 0

treatment, 230, 2301

preoperative i n structions, 1 06

pitfa l l s , 230
M i n i m a l erythema d ose ( M ED ) , 8

ra re side effects, 1 09

M i nocyc l i ne, 73, 77

reci pient region, anesthesia i n , 1 08

M i noxid i l , 104, 1 04t, 1 2 7-1 28, 1 2 7t, 1 3 1 , 133

reci pient site creation, 1 08, 1 12f


McCune-A l bright syndrome, 136
M c G h a n Medica l , 1 5t

M ixed dermal melasma, 149


M ixed su perficial a n d deep hema ngioma ( M H ) , 177
Mohs microgra p h i c surgery, 254, 257-258

M ED. See M i n i m a l erythema d ose

M onobenzone, 9t

Medial orbicularis ocu l i , 24, 24f

Morphea, 265--267

M ed icis, 1 5t

cou rse, 266

Medicis Esthetics, 2 l t
M ed i u m -d e pth pee l , 30t, 3 3 , 34f, 35f

de rmatopathology, 266

M edy-Tox, Inc, 2 l t

epidemiology, 265

d ifferential d iagnosis, 265

I n d ex

la boratory data, 265-266

med ications, 53-54

ma nagement, 266, 266f

postoperative care, 55

pathogenesis, 265

preoperative eva l uation, 52-53, 53f, 54f

physica l exa m i nation, 265, 265f


pitfa l l , 267

preoperative pre paratio n , 54

M TZs. See M icrothermal treatment zones

proced ura l tips, 54-55


treatment pearls, 55-56

M u l berry extract, 9t

Nonablative fractional lasers, 57

M uscle grou ps, 23

Nonablative fractional resu rfacing, 39, 60

forehea d , 23-24

Nonablative laser resurfaci ng, 39, 39f

glabellar com p l ex, 24, 24f


nasola bial fol d , 25-26, 27f

adve rse side effects, 4, 4 1 f l

neck, 26-27 , 28f

postoperative care, 4 1 -42


i n d ications, 40

periora l region, 26, 27f, 28f

laser safety, 4 1

periorbita l regio n , 24-25, 25f

preoperative eva l uation, 40

u pper nasal root, 25, 26f

prophylaxis/a nesthesia , 40

M yasthenia gravis, 22
Myobloc, 2 l t

m i d - i nfra red lasers, 40f, 4 1


N onfacial s k i n , 60--6 1
N o n - F DA approved med ications, for fe male pattern h a i r loss, 128
Non-hypersensitive reactions, of soft tissue augmentation, 18-19

Non laser thera py, 93

N A F R . See Nona blative fractional laser res u rfacing


Nasal sebaceous hyperp lasia . See R h i nophyma
Nasolabial fol d , 25-26, 27f
N d :YAG laser, 99, 1 93
for seborrheic keratosis, 236

depi lati o n , 94
topical eflorn ith i n e , 94
Norwood classification, 103f

N eck, 26-27 , 28f

N e u rofi bromas ( N F) , 23 1-234

Octocrylene, 7t

consu ltative q uestions, 232


cou rse, 232
d ifferential d iagnosis, 23 1
epidemiology, 2 3 1
la boratory data, 232

Octyl methoxycinna mate, 7t


Octyl sa l i cylate, 7t
Ocular rosacea , 76
Oral medications
i n hyperh i d rosis, 87

ma nagement, 232

Oral thera py, 1 65

pathogenesis, 231

Orbicularis ocu l i , 24-25, 25f

pathology, 23 1
physica l exa m i nation, 23 1 , 23lf
pitfa l ls, 223-224

Orbicularis ocu l i tone, 64


Orbicularis oris, 26, 27f, 28f
Oxybenzone, 7t

treatment, 232-233, 232f


N e u rofi bromatosis, 136
N e u ronox, 2 l t
N e v u s a ra neus, 1 70- 1 73
N evus, Becker's, 2 1 6-2 1 8
N evus, epiderma l , 222-225, 235

p
rf>3 tumor suppressor gene,

252

PABA. See Pa ra-a m i n o benzoic acid


Padi mate 0, 7t

Nevus fuscoceruleus ophtha l momaxilla ris, 1 54

Palmoplanta r warts , 206-209

Nevus of Ota , 1 54

Palomar Medical Tec h nologies, 56, 56t, 79


Paper m u l berry, 1 0

consu ltative q uestions, 1 55


cou rse, 155
d ifferential d iagnosis, 1 54
epidemiology, 1 54
la boratory exa m i nation, 155
ma nagement, 1 55
pathogenesis, 1 54
pathology, 1 54
physical lesions, 1 54
pitfa l ls, 1 57
topical treatment, 155
treatment, 1 55- 1 56

Papu les
in angiofi bromas, 2 1 2
i n epidermal nevus, 223
i n warts, 206
Papu lopustular rosacea, 76
Pa ra-a m i n o benzoic acid ( PABA), 7t
Partial tears, 308
Patient consu ltation, 95
prior to treatment, 95-96
P D L. See Pu lsed d ye laser
P DT. See Photodyna mic thera py

Nevus sebaceous, 223

Pearly pen ile pa p u l es, 2 1 2

N ia c i n a m i d e , 9t, 10
Nonablative fractional laser resu rfacing ( N A F R )

Peel types, 33
and c l i n ica l i n d ications, 30t

a n esthesia, 54

Pee l i ng agent characteristics, 30t

contra i n d i cations, 53
dermatopathology, 52, 52f

Penici l l i u m , 1 0
Perifo l l i c u l a r erythema, cha racteristic posttreatment, 93f

devices, 56, 56t

Periora l dermatitis, 76

i n d ications, 52
mecha nism of action, 52, 52f

Periorbita l region, 24-25, 25f, 26, 27f, 28f


Periorbita I rhyti d es, 55f

31 9

320

I ndex

Peri u ngua l fibromas, 2 1 2

pathogenesis, 1 58

Perlane, 1 5t

physica l lesions, 1 58

Perla ne LrM , 1 5t

pitfa l l s to avoid/co m p l ications/ma nagem ent/outcome

Peutz-Jeghers syndrome, 144


P H A G E synd rome, 1 78
Phenol, 30!

expectations, 1 6 1
s u n p rotection, 1 59
topical treatment, 1 60

Phenyl benz i m i d azole su lfonic acid , 7t

Postsclerotherapy hyperpigmentation ( P S H ) , 200

Photodyn a m i c thera py ( P DT ) , 75

Potass i u m -tita nyl-phosphate laser, 79, 193

Photodyn a m i c thera py, 254, 258, 269

Pred nisone, 130, 1 79

Photothera py, 75, 1 65


P hymatous rosacea . See Sebaceous hyperplasia

Pregna ncy

P hysical screen , 8, 8t

and telangiectasias, 1 98, 201


Pregna ncy-ind uced hypertension ( P I H ) , 60

Pigmentary cha nges, i n face, 4, 6f

Prevelle s i l k , 1 5t

P I H. See Posti nflam matory hyperpigmentati o n ; Pregna ncy-ind uced


hypertension

Primary and rogen-prod ucing neoplasms, 92


Procerus, 24, 24f

Pilar cysts, 220, 226


P i mecro l i m u s, 1 64

Propanth e l i ne, 87
Prophylactic anti biotics, 49 , 53

P ityros poru m ova l e , 1 0

Propranolol, 1 79

P l a n e warts, 206--209

Prosigne , 2 1 !

Pla ntar wa rts, 206

Prostate cancer

Plaques
in a ngiofi broma, 2 1 2
i n Becker's nevus, 2 1 6
i n seborrheic keratosis, 235
P latysma m uscle co m p l ex, 26--27, 28f

prophylaxis in, 273


Proteus syn d rome, 226
Pseudofollicul itis, 99
course, 100
de rmatopathology, 100

POC. See Poiki loderma of Civatte

d ifferentia l d iagnosis, 1 00

Podophyl l i n , 224

epidemiology, 99

Podophyllotox i n , 207
Poiki loderma of Civatte ( POC), 67

la boratory exa m i nation, 100


ma nagement, 1 00

consu ltative q uestions, 68

pathogenesis, 99

course, 68

physical lesions, 100

de rmato pathology, 67

pitfa l l s , 1 0 1-102, 1 0 11, 1 02f

differentia l d iagnosis, 67
epidemiology, 67

treatment

ma nagement, 68

laser hair remova l , lOOt, 1 0 1 , 1 0 1 1


shaving cessation, 100

pathogenesis, 67

shaving tech n i q ue , mod ification of, 10(}- 1 0 1

physical exa m i nation, 67, 67f, 68f

topical treatment, 1 0 1

pitfa l ls, 68-69, 69f


pretreatment, 68f
treatment, 68, 68f

Pseudofo l l i c u l itis, a n d etrology, 1 0 1 1


Pseudogynecomasti a , 272

Polidoca n o l , 199, 200, 200!

Pseudo-och ronosis, 34, 1 59f


Psora len a n d ultraviolet A ( P UVA ) , 1 65, 1 75

Poly-L-Iactic acid, 1 8

Psoriasis, 267-270, 267f, 268f

Pontoca i n e . See Topica l tetraca ine


Port-wine sta i n s ( PWS), 1 83 , 1 84f, 1 85f, 1 86f
ancil lary tests, 1 83
course, 183

course, 268
d ifferential d iagnosis, 268
epidemiology, 267

dermatopathology, 183

la boratory data, 268


ma nagement, 268-269, 269f

differentia l d iagnosis, 1 83

pathogenesis, 268

epidemiology, 183

physica l exa m i nation, 268

ma nagement, 1 83
physical exa m i nation, 1 83
pitfa l l s to avo i d , 183
Post hair tra nsplant side effects, 109
Post i nfla m matory erythema
a n d cu rettage, 237f
Post i nfla mmatory hyperpigmentation ( P I H ) , 1 58, 1 58f
chemical peels, 1 6(}- 1 6 1
consu ltative q uestions, 1 59

pitfa l l s , 270
Psuedogynecomastia, 274
P u l sed carbon d i oxide laser, 250
Pu lsed dye laser ( P OL)
for acne vulga ris, 75
for a ngiofi broma, 2 1 3
for a ngiokeratomas, 1 69
for cherry and spider a ngiomas, 1 7 1
for facial telangiectasia, 203, 203f, 205f

course, 1 59

for facial tela ngiectasias, 192

dermato pathology, 1 58

for hypertrophic scars/ke loids, 292t

differentia l d iagnosis, 1 58

for i nfa ntile hema ngiomas, 1 79

epidemiology, 1 58

for keratosis pila ris atrophicans, 182

laboratory exa m i nation, 1 58


lasers, 1 6 1

for m orphea , 266


for Poiki loderma of Civatte, 68

treatment, 2 18, 233


ma nagement, 1 59

for port-wine sta ins, 185


for psorias, 269

I n d ex

for pyogenic gra n u lo m a , 189

Rete ridges
in epidermal nevus, 222

for rosacea , 78
for sebacious hyperplasia, 82
for striae d i ste nsae, 287
for telangiectasias, 201

Reticular veins, 198-202


Reticulated hyperpigmentation , 67

for venous la kes, 203, 205f

Reti n-A, 1 82
Reti naldehyde, 8, 9

for warts, 206f, 208, 208f, 209f

Reti noic acid, 8-9, 9t, 10, 1 2


chemical structu res of, Sf

for warts, 208


P u n c h excision, 2 1 3

Reti noids, 73, 1 4 1 , 1 5 1 , 1 5 1!, 1 60, 182

Pu rpura, 204, 208


PUVA. See Psora len a n d u ltraviolet A

Reti n o l , 8

Pyogenic gra n u loma ( PG ) , 1 88, 188f, 1 89f

Retinyl esters, 8
R F technology. See Radiofreq uency ( R F) tech nology

biopsy-proven , 1 9 l f

R h i nophyma, 76, 76f, 77-78

cou rse, 188

R hytides, 58

dermatopathology, 1 88

R osacea , 76
cou rse, 77
de rmatopathology, 77

d ifferential d iagnoses, 1 88
epidemiology, 188
laser treatment, 1 89

d ifferential d iagnosis, 76

ma nagement, 1 89

epidemiology, 76

pathogenesis, 1 88

ma nagement, 77

physica l exa m i nation, 1 88

surgica l thera py, 77-79

pitfa l l s to avo i d , 189


s u rgica l treatment, 189

systemic thera py, 77


topical thera py, 77
pathogenesis, 76

vs. venous la kes, 203

physical exa m i nation, 76


Roth m u nd-Thomson synd rome, 67

R u by spot, 1 70-1 73 . See also Cherry a ngiomas

Q-M ed AB, 1 5t
Q-switched lasers, 1 52

R ussell-Silver synd rome, 1 36

alexa nd rite
for Becker's nevus, 2 1 7, 2 1 8f

for cafe au Ia it macules, 1 3 7 , 138

Sa l icyl ic acid , 73, 207

for dermatosis pa pu losa n igra , 242


for epidermal nevus, 225

Sa l i n e

for nevus of Ota , 1 55, 1 56


for seborrheic keratosis, 236
a rgon
and gra n u loma faciale, 1 75
N d :YAG
for Becker's nevus, 2 1 7, 2 1 8f

a n d warts, 2 0 7 , 208
and tela ngiectasias, 201
Scarring
from a n giofi broma treatment, 2 1 4
from surgica l i ncision, 224, 228
from wart remova l , 207t, 208, 209

for cafe au Ia it macules, 1 3 7 , 138

SCC . See Squamous cell carcinoma


Sclerothera py, 199-20 1 , 1 98f, 1 99f, 200f, 200t, 201t, 204

a n d e p h i l ides, 142

Scoliosis, 232

a n d lentigines, 1 46

Sc u l ptra TM , 1 5t

for nevus of Ota , 155

Se baceo us cyst, 2 19

for tattoo remova l , 300!, 302


r u by
for Becker's nevus, 2 1 7, 2 1 8f

Se baceo us hyperplasia, 76, 77, 8 1 , 8lf


consu ltative q uestions, 81
cou rse, 8 1

for dermatosis pa p u l osa n igra , 242

d ifferential d iagnosis, 8 1

for e p h i l ides, 1 42

epidemiology, 8 1

for lentigines, 1 46, 1 47

for seborrheic keratosis, 236f

for nevus of Ota , 155


for seborrheic keratosis, 236
for tattoo remova l , 300!, 302t

la boratory exa m i nation, 81


ma nagement, 82
pathogenesis, 81
pathology, 8 1

R
Rad iation dermatitis, 67
Rad iation thera py, 2 54
Radiesse TM , 1 5t

physical lesions, 8 1
pitfa l l s , 83
treatments, 82
destructive modal ities, 82
laser thera py, 82-83, 82f, 83f

Radiofreq uency ( R F) tech nology, 62

Seborrheic dermatitis, 76

Rad iothera py, 258

Seborrheic keratosis, 234--2 37. See also Dermatosis pa pulosa n igra

R e-epithe l i a l ization, 49

consu ltative q uestions, 235

Relaxi n , 2 1 !

cou rse, 235

Renova , 9
R estylane, 1 5t

d ifferential d iagnosis, 235


epidemiology, 234

R estyla ne-L, 1 5t

vs. epidermal nevus, 223, 235

32 1

322

I ndex

ma nagement, 235-236

de rmatopathology, 257

pathology, 235

d ifferential d iagnosis, 256, 257f

physical exa m i nation, 235

epidemiology, 256

pitfa l l s , 237
treatment, 236

vs. epidermal nevus, 223


la boratory data , 257

vs. wa rts, 206

ma nagement, 257-258, 258f, 259f

Segmenta l hemangioma, 1801

pathogenesis, 256

Senile hema ngiomas, 1 70-1 73

physical exa m i nation, 256, 256f

Seria l p u n ctu re, 18

pitfa l l s , 258

Seria l sa l icylic acid peels, 74


Sharplan FeatherTouch, 1 69

vs. seborrheic keratosis, 235

Shave biopsies a n d excisions

vs. wa rts, 206, 207

Sta rch-iod ine test, 88

for a ngiofi bromas, 2 1 3

Sta rlux Lux G hand piece, 79

for epidermal nevus, 224

Steroid rosacea , 76

for l i poma, 227, 227f

Stockings, elastic com pression, 200

for n e u rofi bromas, 236


for seborrheic keratosis, 236

Strawberry, 1 77- 1 80
Stretch marks. See Striae d i stensae

Shaving cessation, 100

Stria a l ba , 287

Shaving tech n i q u e , mod ification of, 1 00-1 0 1

Stria ru bra , 286-287, 287f

Short-pu lsed erbi u m , 287

Striae d i stensae, 285, 285f

S i l icone, 18

consu ltative q uestions, 286

S i l icone sheeti ng, 29 1 , 29 lt


S i l i kone- 1 000, 1 5t

cou rse, 286


d ifferential d iagnosis, 286

Skin grafts, 225f

epidemiology, 285

Skin l ightening agents, 9-1 1

la boratory exa m i nation, 286

Skin testi ng, 1 6

ma nagement, 286

Skin turnover acceleration, 9t

m icroderma brasion , 287

Skin types
a n d Becker's nevus, 2 1 8

pathogenesis, 285
pathology, 285

Smooth bea m , 4 1

physica l lesions, 285

SNAP-25, 2 1

pitfa l l s , 288

Sod i u m morrh uate, 199

topical treatment, 287

Sod i u m sulfaceta mide, 73, 77


Sod i u m tetradecyl su lfate, 199, 200t, 20lt
Soft tissue a ugmentation
adve rse reactions

treatment, 286-287
Stromelysi n , 9
Stu rge-Weber syndrome (SWS) , 184
S u bcision, 278

hypersensitive, 18

Su bcuta neous fat, i n l i poma, 226

non-hypersensitive, 1 8- 1 9

Su bcuta neous fat, 1 5t

tec h n i q u e compl ications, 1 9


a n esthesia, 1 6f, 1 7

Su bcuta neous fat atro phy, 5


Su lfu r, 73

degree o f correction, 1 8

S u l isobenzone, 7t

d u ration o f correction, 18

S u n expos ure

ideal fil ler, 14, 14t- 1 5t


i njection tech n i q ue, 18, 1 8f, 19f
level of i njection, 1 7- 18, 1 7f, 18f
mecha n ism of action , 14

and sclerothera py, 200


and venous lakes, 203
Sun protective factor ( S P F ) , 8
Su nscreen , 7-8, 7f, 7t

preoperative eva l uation, 1 5- 1 6

Su perficial hemangioma ( S H ) , 1 77 , 1 79

proced ura l medications, 1 7

Su perficial pee l , 30t, 32f, 33, 33f

skin testi ng, 1 6

Su rgery

treatment pearls, 19
Softform, 1 5t
Solar le ntigo vs. ephel i d , 145t
Solar le ntigos, 144

in hyperhidrosis, 88
S u rgica l excision, 1 75
S u rgica l proced u re, for hair tra nsplantation
corrective hair tra nsplant su rgery, 1 10, 1 10t

Solta Medica l , I n c . , 56, 56t

day of proced u re, 1 06

Soltice Neu rosciences, 2 lt

donor h a rvesti ng tec h n i q ues, 1 06, 1 06f, 106t, 107t

Sotradechol, 200

donor region, a nesthesia i n , 1 06

Soy, 1 0
Soybea n/m i l k extracts, 9t

fol l i c u l a r u n it extraction ( F U E) , 107, 107t


graft creation, 107

S P F. See S u n protective factor

graft placement, 108-1 09, 1 1 3f

Spider a ngiomas, 1 70-173, 1 7 11

hairline design , 1 08

Spider tela ngiectasia, 1 70-1 73

post h a i r tra n s plant side effects, 109

S p i n a l dysra p h i s m , 227

postoperative period , 109

Spi ronolactone, 73, 1 28


Squamous cell carcinoma (SCC), 256-258

postsu rgica l period after sutu res/sta ples


removed , 1 09-1 1 0

consu ltative q uestions, 257

preoperative i n structions, 1 06

cou rse, 257

rare side effects, 1 09

I n d ex

checkl ist, 62-63


side effects, 63

S u rgica l thera py
of acne vu lgaris, 74

for Dermatochalasis, 64f, 65

Topica l 5-fl uorou raci l , 254


Topica l eflorn ith ine, 94
Topica l i m iq u i m od , 254
Topica l med ications, in hyperh i d rosis, 87

for epidermal i ncl usion cysts, 220

Topica l proparaca ine, 47, 59

for epidermal nevus , 224

Topica l retinoic acid , 32

for l i poma, 227, 227f, 228f

Topica l tetraca ine, 47, 59


Topica l thera py

for neu rofi broma, 232-233, 232f


of Rosacea , 76f, 77-79 , 79f, 80f

of acne vu lgaris, 73

for venous lakes, 204

for dermatochalasis, 65

for wa rt remova l , 207-209

for Poiki loderma of Civatte, 68


of pseudofo l l i c u l itis, 1 0 1

Syri ngoma, 238, 238f


consu ltative q uestions, 239
cou rse, 239

o f Rosacea , 77
Topica l treatment options

d ifferential d iagnosis, 238

a p p l ication tec h n i q ues, 1 1- 1 2

epidemiology, 238

com pl ications, 1 2

laboratory exa m i nation, 238

contra i n d icatio ns, 1 1

ma nagement, 239

ideal ca ndidate, 1 1

pathogenesis, 238
pathology, 238

i nd ications, 1 1
less than ideal ca ndidate, 1 1

physica l lesions, 238, 238f

mecha nism of action , 7-1 1

pitfa l ls, 239f, 240, 240f

posttreatment care, 1 2

treatment, 239-240
System i c l u pus erythematosus, 76
System i c thera py
of acne vu lgaris, 73-74

323

proced ure, 62

reci pient region, a nesthesia i n , 1 08


reci pient site creation, 1 08, 1 12f

for a ngiofi broma, 2 1 3


for Becker's nevus, 2 1 7

pretreatment eva l uation, 1 1


treatment pearls, 12-13
Topica l treti n o i n , 46, 146
Torn earlobe, 308

of Rosacea , 77

key consu ltative q uestions, 308


ma nagement, 308
pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations, 309

T
Tacro l i m us, 1 64

treatments, 308-309, 308f, 309f, 3 1 0f


Trad ition a l P D L, 78

Tacro l i m u s oi ntment, 1 75

Trad ition a l resu rfaci ng, 39

Ta l kesthesia, 1 7

Tretinoi n , 9, 46, 54, 73

Ta p water iontophoresis, 87

and epidermal nevus, 224

Tattoo remova l , 300, 300f

and m i l i u m , 230

adverse effects/preca utions, 303, 304f, 305f, 306, 307f


consu ltative q uestions, 300-301

TriActive Laserd ermology, 278


Tria mci nolone aceton ide, 1 79

laser thera py, 300t

Triangula ris m uscles, 26, 27f, 28f

ma nagement, 301

Trich l o racetic acid (TCA) peels, 301, 74

pitfa l ls, 303-304

for wart removal , 207

posttreatment care, 302

Tri l u ma , 1 46

pretreatment assessment, 30 1
tattoo treatment, 302, 302t, 303f, 304f

Trola m i n e sa l i cylate, 7t
TS H . See Thyroid-sti m u lating hormone

treatment, 30 1-302, 303f

Tu berous sclerosis, 136

Tazarotene, 9, 73, 1 82

Tu berous sclerosis, 213, 2 1 3f

TCA peels. See Trichloroacetic acid peels

Tu rnors, 220

Telangiectases, 67

Tylenol, 109

Tela ngiectasias, 78-79, 78f, 79f, 80f


lower extremity, 198-202

Tyrosinase, 9
Tyrosi nase i n h i b itors, 9t

epidemiology, 198
laboratory data, 198
ma nagement, 199-202, 1 98f, 1 99f, 200f
pathophysiology, 198
physical exa m i nati o n , 198
Telangiectatic matting rM , 201

u
U l cerated hemangioma, 1 79f
U ltra , 1 5t
U ltra P l u s , 1 5t

Telogen effl uvi u m , 1 29, 130-13 1

U ltra P l u s XC, 1 5t

Tetracycl i ne, 73, 77

U ltra XC, 1 5t

T h ro m boph lebitis, 198

U ltrasou n d , 198
U ltraviolet A ( U VA), 67

Thyroid-sti m u lating hormone (TS H ) , 1 63


Tissue tighte n i ng, 62
ca n d idate selection, 62
c l i n ical pea rls, 63
mecha n ism of action, 62

U ltraviolet B ( U V B ) , 67
U p per a n d m idfacial m uscu latu re, a natom ical i l l u stration
of, 22f
U p per face, 2-3

324

I ndex

U p per nasal root, 25, 26f

la boratory exa m i nation, 1 63

U .S . Food a n d Drug Ad m i n istration, 94

laser thera py
exci mer laser, 1 65

UVA. See U ltraviolet A


UVB exposu re, 9

ma nagement, 1 64

U V B . See U ltraviolet B

oral thera py, 1 65


pathoge nesis, 1 63

physical lesions, 1 63

photothera py, 165


pitfa l l s to avoid/co m p l ications/managem ent!

Valacyclovir, 46

outcome expectations, 1 66

Valacyclovir, 54

preventi o n , 1 64
s u rgica l treatments, 1 65

Valtrex, 1 7 , 32
Va n iqa . See Topica l eflorn ith i n e

topical treatment, 1 64

Va porizi ng tool , 44
Variable-pu lse P D L, 78
Varicose veins, 198-202
Vascular a lterations
lower extremity telangiectasias, 198-202
reticular and va ricose veins, 198-202

w
Warts, 206-209
cou rse, 207

venous lakes, 203-205

de rmatopathology, 206

warts, 206-209

differentia l d iagnosis, 206


epidemiology, 206

Vascular a lterations

pathogenesis, 206

venous lakes, 203-205

physica l exa m i nation, 206

warts, 206-209
Vasc u l a r ectasia, 77

pitfa l l s , 209
treatment, 207-209, 206f, 207f, 205f, 209f

Vascular lasers, 39
Vascular rosa cea , 76
Vascular spid er, 1 70- 1 73

Watson's syndrome, 136


Westerhof's syndrome, 136

Vaseli ne, 34

Wickha m 's striae, 262

Vei ns, reticular a n d varicose, 198-202


VelaSmooth system , 278

Wood's l a m p eva l uation, 3 1 , 3 1 1, 1 63


Wydase. See Hya l u ron idase

Venous lakes, 203-205


cou rse, 203
de rmato pathology, 203
d ifferenti a l d iagnosis, 203
epidemiology, 203
e p i l u m i n escence m i c roscopy ( EL M ) , 203

X
Xa nthelasma pa l pebraru m . See Xa nthelasrnas
Xa nthelasmas, 243
cou rse, 244

ma nagement, 203-204, 203f, 204f, 205f

de rmatopathology, 244

physical exa m i nation, 203

differentia l d iagnosis, 244

pitfa l ls, 204

epidemiology, 243
ma nagement, 244

Venous o bstruction, 198


Venous va lvular incom petence, 198
Verruca , 223, 235

pathoge nesis, 243


physica l exa m i nation, 244

Vincristine, 1 79
Vita m i n C, 8
Vita m i n E, 8

pitfa l l s , 244
Xeom i n , 2 1 !

Vitiligo, 1 63
consu ltative q uestions, 1 64
cou rse, 1 63-1 64
dermato pat hology, 1 63

d ifferential d iagnosis, 1 63

Z-plasty repa i r, 308


Zyd erm , 1 5t

epidemiology, 1 63

Zyplast , 1 5t