Color Atlas of Cosmetic Dermatology (2nd Ed.) - McGraw-Hill Medical (PDFDrive)

Color Atlas of
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ZEINA TANNOUS I MATHEW M. AVRAM
SANDY TSAO I 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
Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School
Affiliate Faculty, Wellman Center for Photomedicine
Sandy Tsao, M D
Director of Procedural Dermatology
Harvard Medical School
Marc R . Avram, M D
Clinical Professor of Dermatology
Weill Cornell Medical School
Private Practice-905 Fifth Avenue
New York, New York
B Medical
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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
CONTENTS
Preface ix SECTION THREE: DISORDERS OF ECCRINE GLANDS
Chapter 16: Hyperhidrosis.... .... ... .. 86 . . . .
SECTION ONE: PHO TOAGING
Chapter 1: Analysis of the Aging Face and

SECTION FOUR: DISORDERS OF HAIR FOLLICLES
Non-Facial Regions . . . . . . . . . . . . . . . 2
Chapter 17: Hirsutism . . . . . . . . . . . . . . . . . . . . 92
Chapter 2: Topical Treatment Options. . . . . . . . . . 7

Chapter 18: Pseudofolliculitis .... . . . . . . . . . . 99
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 21: Low Level Light Therapy (LLLT)

and Hair Loss. . .. ..
. . . . . . . . . . 133
Chapter 6: Nonablative Laser Resurfacing . . . . . 39
Chapter 7: Ablative Laser Resurfacing . . . . . . . . 43

SECTION FIVE: DISORDERS OF PIGMENTATION
Chapter 22: Cafe Au Lait Macule ... ...... 136 . .

Chapter 8: Nonablative Fractional Laser
Resurfacing .............. .... 52 .
Chapter 23: Ephelides . . . . . . . . . . . . . . . . . . . 139
Chapter 9: Ablative Fractional Laser

Resurfacing . . . . . . . . . . . . . . . . . . . 57 Chapter 24: Lentigines . . . . . . . . . . . . . . . . .. 144
Chapter 10: Tissue Tightening . . . . . . . . . . . . . . 62 Chapter 25: Melasma . .. .... . . . . . . . . . 149

. . .
Chapter 11: Dermatochalasis........ . . ..... 64 Chapter 26: Nevus of Ota . . . . . . . . . . . . . . . . 154
Chapter 12: Poikiloderma of Civatte . . . . . . . . . . 67 Chapter 27: Postinflammatory

hyperpigmentation ............ 158
SECTION TWO: DISORDERS OF SEBACEOUS Chapter 28: Vitiligo.... .... . . . . . . . . .. .. 163

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

. . . .
SECTION SIX: VASCULAR ALTERATIONS
Chapter 14: Rosacea . . . . . . . . . . . . . . . . . . . . . 76 Chapter 29: Angiokeratoma . . . . . . . . . . . . . . . 168
Chapter 15: Sebaceous Hyperplasia ......... 81 . Chapter 30: Cherry and Spider Angiomas .... . 170
vi i
Chapter 31: Granuloma Faciale . . . . . . . .. . . . 174
SECTION EIGHT: CUTANEOUS CARCINOMAS
Chapter 51: Actinic Keratosis . . . . . . . . . . . . .248

Chapter 32: Infantile Hemangioma . . . . . . . . 177
.
Chapter 52: Basal Cell Carcinoma . . . . . . . . . . 252

Chapter 33: Keratosis Pilaris Atrophicans . . . .181
.
Chapter 53: Squamous Cell Carcinoma . . . . . . . 256

Chapter 34: Port-wine Stains . . . . . . . . . . . . . . 183
Chapter 35: Pyogenic Granuloma . . . . . . . . . . . 188

SECTION NINE: INFLAMMATORY DISORDERS
Chapter 36: Facial Telangiectasias . . . . . . . . . . 192 Chapter 54: Lichen Planus . . . . . . . . . . . . . . . 262
Chapter 37: Lower Extremity Telangiectasias, Chapter 55: Morphea . . . . . . . . . . . . . . . . . . . 265

Reticular and Varicose Veins . . . . . 198
Chapter 56: Psoriasis . . . . . . . . . . . . . . . . . . . 267
Chapter 38: Venous Lakes . . . . . . . . . . . . . . . .203
Chapter 39: Warts . . . . . . . . . . . . . . . . . . . . 206

. . SECTION TEN: ADIPOSE TISSUE ALTERATIONS
Chapter 57: Gynecomastia . . . . . . . . . . . . . . . . 272
SECTION SEVEN: BENIGN GROWTHS

Chapter 58: Cellulite . . . .. ..
. . . . . . .. .
. . . . 276
Chapter 40: Angiofibroma . . . .. .
. . . . . . . . . .212
Chapter 59: HIV Lipodystrophy/Facial
Lipoatrophy . . . . . . . . . . . . . . . . . 280
Chapter 41: Becker's Nevus . . . . . . . . . . . . .. 216 .
Chapter 60: Striae Distensae . . . . . . . . . . . . . . 285

Chapter 42: Epidermal Inclusion Cyst . . . . . . . 219
Chapter 43: Epidermal Nevus . . . . . . . . . . . . . 222

SECTION ELEVEN: WOUND HEALING ALTERATIONS
Chapter 44: Lipoma . . . . . . . . . . . . . . . . . . . . 226 Chapter 61: Hypertrophic Scars, Keloids,

and Acne Scars . . . . . . . . . . . . . . 290
Chapter 45: Milium . . . . . . . . . . . . . . . . . . . . . 229
SECTION TWELVE EXOGENOUS

Chapter 46: Neurofibroma . . . . . . . . . . . . . . . . 231
CUTANEOUS ALTERATIONS
Chapter 47: Seborrheic Keratosis . . . . . . . . . . . 234 Chapter 62: Ear Piercing . . . . . . . . . . . . . . . . . 298
Chapter 48: Syringoma . . . . . . . . . . . . . . . . .238

.
Chapter 63: Tattoo Removal. . . . . . . . . . . . . . . 300
Chapter 49: Dermatosis Papulosa Nigra . . . . . . 241 Chapter 64: Torn Earlobe . . . . . . . . . . . . . . . . . 308
Chapter 50: Xanthelasma . . . . . . . . . . . . . . . .243 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
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
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.
ONE
Photoaging
2 I 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
A
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
B
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 I 3
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) B

• 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
- 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
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 • Fitzpatrick's Classification of Skin Types
S k i n type Color Reactio n to s u n
I Very wh ite or frec kled Always b u r n s

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
v 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
B
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 I 5
• 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- A
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

ced u res. I n : Nouri K, Leai-Nouri S, eds.Techniques in
Dermatologic Surgery. Lond o n : Mosby; 2003, pp. 333-344.
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.
M ontagna W, Carlisle K, Kirchner S . Epidermal and
Dermal Histological Markers of Photodamaged Human
Facial Skin. Shelto n , CT: R i c h a rdson-Vicks; 1 988.
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
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
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 Figure 2 . 1 Patient with an acute sunburn. There is marked swelling and
gen free rad icals, thought to contr i bute to ca rc i n o redness present. The upper back scar is the site of a previous superficial
genesis. It c auses i m m u nosu ppress ion through the 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
Figure 2 . 2 Patient with marked photodamage due to chronic sun exposure.
Tro la m i ne sa l i cylate
The patient was an avid golfer and reported only occasional sunscreen use
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
CH20H
rad iati o n . C a n a l so a bsorb U V l ight and release it as
heat.
�
Retinol
TAB L E 2 . 2 • Physical Su nscreen: Active I ngredients COOH
Tita n i u m d ioxide
Tretinoin
Zinc oxide
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 . 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 � - - -
COOH
u n protected ski n . The American Academy of Dermatology

c u rrently recom mends the d a i ly use of sunscreen with Etretinate
H3CO .l.Ql. -
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 Acitretin
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
Third Generation (Poly-Aromatics)
red ucti o n .
- 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
.£) IAlf)( COOH
these prod u cts.

- Antioxida nts may work synergistica l l y to provide thei r Adapalene �
greatest benefit. 0
- 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 .
Tazarotene
- 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 Figure 2 . 3 Chemical structures of retinoic acids. The addition of aromatic
d e rmatitis risk. rings has made third-generation retinoids more stable for more targeted
therapy with less potential side effects. (Reproduced, with permission,
- Coenzyme Q l O-natu ra l l y occ u rring n utrient a d d ed
from Baumann L. Cosmetic Dermatology: Principles and Practice, 2nd ed.
to m a n y over-the-cou nter prod ucts . C u rrently t h ere
New York: McGraw-Hill; 2009)
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 .

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

TAB L E 2 . 3 • Ski n Lighte n i n g Agents
col lagen-degra d i ng matrix meta l l o protei nases, includ
• Tyrosi nase i n h i bitors
ing col lagenase, gelatinase, and stromelys i n , which
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 M u l berry extract
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 e l a n ocyte tra nsfer i n h i bition
Avita . C u rre ntly R e n ova is F D A a p proved fo r p h o 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 0 . 0 5 % f l u o c i n o l o n e aceto n i d e fo r M eq u i nol
hyperpigme ntation . M on o benzone
- Reti nol-this prod uct m u st be converted to reti na lde • Skin turnover acce l e ration
hyde a n d then to a l l -tra ns-retinoic acid with i n the ker 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.
• 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 I Color Atlas of Cosmetic Dermatology
Ca n be cytotoxi c to mela n ocytes prod u c i n g i rre

Table 2.4 • Use of the ''teaspoon rule" for su nscreen application can be
vers i b l e cel l d a m age with monobenzyl ether of
benefi c i a l i n educating patients on the proper of amount of sunscreen
hyd roq u i none.
that shou l d be appl ied with each appl ication.
Concern rega rd ing carci n ogen i c potentia l-cu rrently
Use of m ore tha n h a lf a teaspoon each on:
heavily regulated a n d/or ba n ned i n E u rope, As i a ,
• Head a n d neck region
a n d severa l African cou ntries.
• R ight a rm
Ava i l a ble i n over-the-cou nter prod u cts up to 2% • Left a r m
and by presc r i ption i n 3 % to 4% concentrations.
Use o f m ore than a teaspoon e a c h o n :
Ca n be c o m p o u n d ed u p to 1 0 % concentration .
• Anterior torso
C u rrently ava i l a ble in 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 Saund ers, 2005 . )
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 linneva. I ts 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 i n h i bit kerati nocyte melanosome

phagocytosis, th us red ucing 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.
Sect i o n 1 : Ph otoa g i n g I 1 1
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 non-
melanoma 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 .
• 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 I 13
• 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 .
CHAPT E R 3 Soft Tissue Aug m e ntatio 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

Den mark)
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
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 No No 4-6 mo

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

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 No 4-6 m o
O baji M e d i ca l , C h icago, I L h u m a n cadaveric tissue
(continued)
TAB L E 3 . 1 • Commonly Used F i l l ing Agents (Continued)
Name Com position FDA approva l Skin testing req u i red Longevity
Fasc i a n ( Fascia B iomaterials, B everly H u m a n cadaveric preserved No 3-4 mo

H i l ls, CAl pa rticu late fascia lata
Fat, su bcuta neous Auto logous N/A No 9-1 2 m o
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 Yes No 4-6 mo

! 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 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
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 Yes No 4-6 mo

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
Mateo, CAl
Restylane, Restylane-L, Perlane, Non-a n i ma l-sta bil ized hya l u ro n i c Yes No 6- 9 mo

Perlane L™ (Q-Med AB, Swed e n ; a c i d ( N AS H A l derived fro m
M e d i c i s , Phoenix, AZl bacterial fe rmentation .
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, S i l i cone No No Perma nent

I n c , Fo rt Wort h , TXl
Softform ( McGhan Med ica l , Santa G ore-Tex N/A No Perma nent

Barbara , CAl
Scul ptra ™ ( B iotech I n d ustry, SA, Lyop h i l ized poly- L-Iactic acid Yes No 1-2 y r
Luxe m bo u rg; Derm i k , Berwy n , PAl
Zyd erm ® , Zyplast® (AIIerga n , I rvi n e , CAl Bovin e col lagen Yes Yes 3-4 mo

• 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
• 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 Figure 3.1 Massager utilized during filler placement to minimize treat
ment discomfort
- Expense
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
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 Fat
a n d/or i nfraorbita l n e rve blocks t o avoid m u cosa l i nj u ry
Figure 3 . 3 Recommended filler injection depths. (A dapted from Keyvan
d ue to i n a b i l ity to d etect tem pe rature a cc u rate ly.
N, Susana L-K, eds. Techniques in Dermatologic Surgery. United
• Loca l ized tumescent a n esth esia is util ized fo r fat 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 x 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 x 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 A
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 ug-
mentation
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, B
more su bsta ntia l defects a n d rhytides ( Fig. 3 . 4 ) Figure 3.4 (A) Prominent nasolabial folds prior to augmentation with
Autologous fat tra n sfe r; Gore-Tex; Hylaform P l us ; hyaluronic acid. ( B ) Softening of folds after 3 c hyaluronic placed into
J uved erm U ltra P l u s ; Perla ne; Rad iesse; S c u l ptra treatment sites
• 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 A
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

B
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
• 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

Figure 3 . 6 Injection techniques A . Linear threading technique B. Serial
the treatment res ponse is va riable and can last less
puncture technique. (Adapted from Keyvan N, Susana L-K, eds.
t h a n or greater tha n the ave rage expected t i m e . Re peat
Techniques in Dermatologic Surgery. United Kingdom: Mosby; 2003.)
treatment w i l l be req u i red over t i m e .
• 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
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 ) : 276-
281 .
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

Figure 3.8 L inear threading method of injection
tissue defects on the face usi ng a utologous fat tra nsplan
tation . Facial Plast Surg. 1997 ; 1 3 ( 2 ) : 1 9-24.
Figure 3.9 Filler beading due to too superficial placement

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 = 4 U Dysport Average 1-4 mL in
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 1 U Botox = 2 . 5-4 U

AZ), Dys port ( I psen L i m ited , Berks h i re , powde r
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 Reported 1 U B otox = 1 U N ot wel l esta bl ished
F ra n kfu rt, Germa ny)-type A Xeo m i n
N e u ro n ox ( M edy-Tox, I n c , Seo u l , 1 00 U vial Reported 1 U B otox = 1 U N ot wel l esta b l is hed

South Korea )-type A N e u ronox
P rosigne ( La nzhou I nstitute of B i ologica l 50 U vial a n d 100 U vial N ot wel l esta b l ished N ot we l l esta blished
P rod ucts, La nzhou, C h i n a )-type A
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 .
DI LUTION
Procerus
BTX-A i s stored i n lyo p h i l ized vials. It ca n b e reconsti m usc l e
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
i njected vol u me m ust be sufficiently sma l l to provide m usc l e -+++--=-==:..___;-
a c c u rate toxin d e l ivery without a n excessive vo l u me Levator lab i i

effect or del ivery of tox i n to s u rro u n d i ng m u scles other s u perioris
alaeq ue nasi
tha n the targeted m uscles. The vo l u me m ust be suffi �-+--- Zygomaticus
m uscle
c i ently l a rge to permit a cc u rate i njection i nto the targeted major m u sc l e
m uscles.
CONTRA I N D I CAT I O N S
Levator
I\ superioris muscle
• A b so l u te
• U nderlying n e u rom usc u l a r cond ition s u ch as myasthe-

n 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 Figure 4.1 Anatomical illustration of the upper and midfacial muscula
ture
• U n rea l istic patient expectations
• 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
X X X X
• 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
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
red uction
A
• Patient placed u p right
• Treatment a reas wi ped with a l cohol

• 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) B
Insertion: Originates at fro nta l bone ga lea a poneurotica Figure 4.3 (A) Forehead lines prior to B TX-A treatment. (B) Forehead
and i nserts i nto fibers of the procerus, corrugator, a n d lines 1 month following B TX-A treatment
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.
• 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 X X
su perioris a n d orbicula ris m uscles may lead to d i plopia .
X 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
� ) l
M u sc l es ( F i gs . 4.4 and 4. 5) .·
A
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
X X
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 ;
B
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 Figure 4.4 Approximate injection sites for the glabellar frown lines.
cerus; 4 to 6 U in the i nfe rior and s u perior bel l i es of the (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
A
( 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
B
Figure 4 . 5 (A) Glabellar complex before BTX-A injection and (B) 3 weeks
following B TX-A injection
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 N ��
• Overtreatment o f this a rea ; i m proper eye c l os u re, brow ..
X
� ··.
ptosis, or l i d ptosis may ensue
• An i njection a i med too low at the lower periorbita l wrin ) t X

kles. Wea ken i n g of the levator labii su perioris m uscles
X , •'
with a n u p per l i p d roop and a bnorma l s m i l e may be X

.:···
observed
Figure 4.6 Approximate injection sites for periorbital lines

• U p p e r N a sa l R oot ( F i g . 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
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
A
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
Avoid: B
• Complete re laxation of this a rea ; u p per l i p ptosis c reat Figure 4.7 (A) Periorbital lines prior to treatment with B TX-A. (B)
i n g a sad a p pea ra nce may occ u r Periorbital lines 6 weeks following B TX-A treatment
• 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
) l
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) X 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 A u r i c u l ar i s su perior m u sc le
• Deep i nj ecti ons; i n c reased risk of side effects

A u r i c u l a r i s anterior m usc le
• Too h igh of an i nj ecti on for the DAO; i n a b i l ity to raise
the corner of the mouth may d evelop
su perioris
• N ec k- P l atys m a M u sc l e Co m p l ex muscle
-"71--'T-=-''-----T--
- +- 0 r b i c u l a r i s o r i s m usc l e
( F ig. 4 . 1 4) :.dr!'J-f- Depressor angu l i oris m usc l e
Depressor l a b i i i nferioris m uscle
Insertion: Origi nates on the fascia of the u p per pectora l i s
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
Figure 4.9 Anatomical illustration of the m usculature of the lower face
Lines noted: Neck wri n k l i ng; centra l ba nds
and neck
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
Figure 4. 1 0 Approximate injection sites for nasolabial folds
• Physical a ctivity s h o u l d be l i m ited for 4 h o u rs after
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 Figure 4. 1 1 Approximate injection sites for the perioral muscles
• 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
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

• 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 59-
166.
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
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

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
TAB L E 5 . 1 • C l inical I n d ications and Peel Types
I n d i cation Peel type Peel d e pth/treatment e n d po i n t
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
with s u perfi c i a l a pp l ication
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 ;
i nconsistent res ponse
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
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
Peel type Color end poi nt Appl ication H ea l i n g time Safe for
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
e n d point mon itored for 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 I a n d I I ; caution
loca l i zed a p p l ications for s u n b u rn - l i ke pee l i n g with I l l and I V
l ighter wh ite a reas may observed
be considered
Phenol G ray wh ite S i ngle even a p p l icatio n ; can 1 0-14 d ; su perfi c i a l I and I I
be conservatively rea p p l ied b u r n a p pea ra n ce
• 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
• 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.
Figure 5 . 1 Thirty-one-year-old female with melasma. Wood's lamp accen

I D EAL CAN D I DATE tuated her facial pigmen tation
• 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

• 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. A
- The face has m o re sebaceous glands tha n the n o n Figure 5.2 (A) Epidermal melasma unresponsive to topical bleaching
fac i a l a reas i nc l u d i n g the neck. creams.
- 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

resu lt i n d eeper s k i n peel i n g
• A m o u nt o f agent a p pl ied-deeper s k i n penetration with

each peel layer a p p l ied
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.
B
- The n u m be r of a p p l icators used and the p ressu re
Figure 5.2 (continued) (8) Mild improvement noted following two 50%
a p plied to the treatment site with agent a ppl ication
glycolic acid peels
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 .
• 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 A
• 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 .

• 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 .
• 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. 8
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
fo l l ow- u p of phenol face peels . Plast Reconstr Surg.
35% TCA peels
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 ) : 285-
307 .
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 .
Figure 5.4 Fine white color immediately following a 20% salicylic acid
peel
Figure 5 . 5 Pale white color immediately following a Jessner peel
Figure 5.6 Solid white color immediately following a Jessner/35% TCA

peel
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
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
I t is a lso effective i n t h e treatment o f a c n e scars. pletely cleared without sequelae 3 days later
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.
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
A
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
• 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 B
• 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)

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. A
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
bruising pulsed dye laser treatments. There is mild erythema after treat
Adverse side effects: fa r less co m mo n than a blative pro ments. Many patients note an improvement in the texture and tone of
ced u res, but do occ u r with h igher fl u e n ces as we l l as skin after a series of treatments
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 ) .
• 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 .
CHAPT E R 7 A b l ative Lase r R es u rfaci ng
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
A
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
Figure 7 . 1 (A) A 58-year-old woman with extensive actinic damage.
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 . Long-term col lagen
re model i ng is l i m ited ( Fig. 7 . 2 ) .
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 .
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
B
u s e o f a n esthetic medications; existi ng d rug a l le rgies;
Figure 7.1 ( continuedJ (B) A marked reduction in rhytides and dyspig
tobacco use; a ctive acne vu lga r i s .
mentation is noted 2 months after full-face carbon dioxide resurfacing
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,
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

A
• P reexisti ng ectropion
Figure 7.2 (A) A 45-year-old woman with facial photoaging and mild acne
• Poor patient c o m p l ia nce scarring.
• 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)
• 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 x 10 to 14 d ays or azith romyc i n 500 mg
PO x 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
• 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.
- 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 A

avo i d i nadve rtent cornea l d a mage . Figure 7.3 (A) A female patient who was most bothered by her perioral
• Operative field rhytides, but was also noted to have moderate dermatoheliosis with
- All reflective su rfaces and windows m ust be covered n umerous lentigines and actinic damage of the remainder of her face.
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 .
- 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 per-
form 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 B
( Fig. 7 . 2 ) .
Figure 7 . 3 ( continuec!J (8) Same patient immediately after perioral
- T h e patient's postope rative considerations a lso affect carbon dioxide laser resurfacing and a Jessner/35% trichloroacetic acid
the choice of laser. The C02 laser wi l l have a n peel to the remainder of her face.
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.
• 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 c
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
Figure 7.3 ( continued) (C) Same patient 6 months following her treat
the use of an occ l usive d ressi ng. I t can genera l ly be
ment. A marked reduction in both her rhytides and dyspigmentation is
controlled with ice pac ks , cold c o m p resses, a n d a ceta
appreciated.
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

hea l i ng o f t h e treated sites ( Figs. 7 . 4 a n d 7 . 5 ) .
• Prophylactic a ntibiotics a n d a ntivira l med ications a re
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.
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
Figure 7.4 Under aggressive wound care. A substantial amount o f crust
benefits w i l l not be a p p reciated for 6 to 12 months
ing is observed. Proper wound care was demonstrated in-office and with
posto peratively.
repeat written instructions reviewed
• 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 .
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. J 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.
Figure 7 . 5 Postinf/ammatory hyperpigmentation 6 weeks after perioral
Arch Dermatol. 2004; 140( 1 1 ) : 1 333- 1336.
carbon dioxide resurfacing. This pigmentation resolved with the use of
R u iz-Esparza J, Ba rba G o m ez J M , Gomez de Ia To rre OL.
4 % hydroquinone twice daily for 2 months
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 .
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

I I I
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
m a l coagu lative da mage, refe rred to as m i c rothermal
Epidermis I I I
treatment zones ( M TZs) ( Fig. 8. 1 ) . N A F R c h a racteristi I l l
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
i n g fast epidermal repa i r d u e to m ic rosco pic size of the 'fiN

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 S u bc uta neous fat --

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 Figure 8 . 1 Schematic of microscopic treatment zones (MTZJ created by
( M EN D ) ( Fig. 8 . 2 ) . M E N D formation is thought to re p re fractional resurfacing laser (note the characteristic sparing of the sur
sent the p rocess of e l i m i nation of the therma l ly d a m aged 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) .
• 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 Figure 8.2 H & E histology of microthermal treatment zone (MTZ) 1 day
ced u res, the pati ent's res ponse, and the associated after fractional resurfacing treatment (note the microscopic epidermal
side effects. necrotic debris (MEND) overlying a column of homogenized dermis)
• 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 A B
s h o u l d be awa re that the treatment wi l l i m prove fine
Figure 8.3 Periorbital rhytides (A) following one fractional resurfacing
to-moderate wri n kles, pigmentati o n , a n d s u perficial
treatment and (B) following four fractional resurfacing treatments. An
sca rs but d oes not e l i m i nate moderate-to-deep
appreciable softening is noted (Courtesy of R. Fitzpatrick, MDJ
rhytides. A modest benefit may be noted for d eeper
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
Figure 8.4 Mild sunburn-like erythema immediately following Fraxel laser
• Anti bacterial therapy: prophylactic a nti biotics a re gen treatment with 6 to 8 mJ, 250 M TZ!cm2 , eight passes. This erythema
era l l y n o t req u i red may persist for 3 to 7 days
• 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. Figure 8 . 5 Postinflammatory hyperpigmentation following fractional
• Topical a n esthesia (oil or crea m base) a ppl ied at least 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 .

Figure 8.6 Milia on the chin 1 day after NAFR
• 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 .
• 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
Figure 8.7 A patient with rosacea who developed pinpoint hemorrhage
i n sta nces of ma rked swe l l i ng, o ra l p red n isone ca n be
1 day after Fraxel Restore treatment. Pinpoint hemorrhage can occur with
p resc ri bed for 3 to 7 days.
higher energies and usually resolves in few days with no sequelae
• 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.
• 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 Ti p M a x energy/MTZ Density

wavelength ( n m ) d i a meter ( m m ) or m ic ro bea m ( mJ ) d e l ivered ( c m 2 )
Sa lta Medical F raxel R estore 1 , 550 Sca n n i ng 7 70 1 2-4,000 ( 5-48% )

( Fraxel SR 1 , 500) 15
Pa l o m a r Lux 1 , 540 1 , 540 Sta m ping 10 1 00 1 00
15 15 320
Cynosure Affi rm 1 ,440 N d : YAG 1 , 440 Sta m ping 10 8 J/cm 2/pu lse 1 , 000
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 .
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. Figure 9 . 1 Immediate endpoint of pixilated damage pattern with an
By contrast, nona blative lasers, with m u ltiple treatment erbium fractional ablative device
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

mented lesions, a n d vasc u l a r dysc h ro m i a as we l l
• Sign ificant red uction i n posto perative d ownti m e com

pa red to tra d itio n a l a b lative devices
• 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 . Figure 9.2 Patient immediately after C0 ablative fractional resurfacing
2
The patient s h o u l d a lso be i nformed t h a t the ben efits of treatment. Note erythema, edema, and pinpoint hemorrhage
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

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,
Figure 9.3 Patient at 72-hour follow-up. Note that hemorrhage is no
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
longer present, but edema and erythema persist
cation for 2 to 3 days
• Fo l l ow- u p at 48 to 72 h o u rs
( Fig. 9.3)
• 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
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
Figure 9.4 Test spot treatments with a C0 ablative fractional resurfacing
da rker ski n phototypes ( Fig. 9.4). Hypertrophic sca rring of 2
device in a young male with Fitzpatrick skin type 5. The test spots are
the neck is a sign ifica nt a nd potentially permanent com
not arranged in order of aggressiveness. The darker areas of PIH coincide
p l ication of fractionated C0 2 laser res u rfacing ( Fig. 9 . 5 ) .
with increased treatment density. Increasing pulse energies do little to
Caution is req u i red for these proced u res .
worsen PIH
The fol l owing p ractices a l l sign ificantly i nc rease the
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 Figure 9 . 5 Hypertrophic scar after treatment with a C0 fractional abla
2
strongly a dvised that fractional a blative res u rfa c i ng tive device
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 .

Figure 9.6 Localized minute pustules, edema, and erythema representing
- Req u i res 1 wee k away fro m w o r k a n d soc i a l activities.
a localized pseudomonas infection in the setting of post-C0 fractional
2
- Series nona blative treatments may be more tolera ble ablative resurfacing for a burn scar. It cleared fully without sequelae after
a n d practical for m a n y patients. oval antibiotic treatment.
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.
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
A
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 a 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.

• 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
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 B
• Oc u l a r da mage Figure 10. 1 (continued) (B) Six months after treatment appearance of the
jowl and neck is improved slightly. (Reproduced, with permission, from
Hirsch R, Sadick N, Cohen JL. Aesthetic Rejuvenation: A Regional
CLI N I CAL PEARLS
Approach. New York: McGraw-Hill, 2009: 97. )
• 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 .
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 A
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 B
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
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 . and forehead wrinkles. (B) Improvement of the blepharloptosis, sunken
Coexisting b row ptosis may f u rther c o m p rom ise the eyes, and forehead wrinkles 9 months following upper lid blepharop/asty
peri phera l visio n . and leavator aponeurotica advancement. (Reproduced, with permission,
Tests for lower l i d laxity h e l p determ ine i f a l id-tighte n i ng from Harue Suzuki, MD, Kyoto, Japan.)
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.
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 ectro-

pion 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 rfac-

ing.
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 .
• 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

tion : A ra n d o m ized p rospective c l i n ic a l stu dy.
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): 284-
288 .
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 J 67
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 . Figure 1 2 . 1 Poikiloderma of Civatte. Reticulated pigmentation, ery
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 thema, and atrophy can be seen with characteristic sparing of the sub
( Figs. 1 2 . 1 a n d 1 2 . 2 ) . mental area. The erythematous component is more prominent in this
patient. (Courtesy of Richard A. Johnson, MO. )
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 ; B l oo m 's syn d ro m e ; Ataxia
tela ngiectasi a .
COU RS E
C h ro n i c p rogressive cou rse with conti n u ed s u n expos u re .

• 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 A
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.
• A conservative a p proac h m u st be fo l l owed with a ny
B
treatment used for POC, given the sign ifica nt risk of
Figure 1 2 . 3 (A) Poikiloderma of Civatte pretreatmen t. (B) Poikiloderma of
u n even remova l of the pigmentation a n d e rythema
Civatte following three VersaPulse 532-nm laser treatments. Marked
res u lting i n a "footprint" - l i ke a p pearance ( Fig. 1 2 . 4 ) .
reduction in erythematous component is observed.
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.
Figure 1 2 .4 "Footprinting" o f the anterior neck after a single intense
Gero n e m u s R . Po i k i loderma o f Civatte . Arch Dermatol. pulsed light (!PL) source treatment for Poikiloderma of Civatte. This sub
1 990; 1 26(4) : 547-548. sequently resolved with continued IPL treatments
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 4-
3 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 .
TWO
D isord e rs of S e baceo u s G l and s
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
Figure 13.1 An 1 8-year-old male with cystic acne being treated with
d isord e rs, stress, mec h a n ical factors (fricti o n , p ress u re,
1 , 450-nm diode laser
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 .

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.
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
Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s I 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 A
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
B
• Ant i biotics: tetracyc l i ne , d oxycyc l i ne, m i nocyc l i n e a re Figure 13.2 (A) Facial inflammatory acne vulgaris unresponsive to multi
m ost commonly used . Alternatives i n c l ude e ry ple topical and oral treatment regimens. (B) Marked improvement of acne
t h romyc i n , azith romyc i n , a n d a m oxic i l l i n . 6 months following five 1 , 450-nm diode laser treatments (Smoothbeam,
• Hormones: o ra l contraceptives or spi ronolacto ne for Candela Corp. , Wayland, MA), 6-mm spot, 1 4 J/cm 2 , DCD 30 ms
women with persistent acn e on lowe r face, c h i n , a n d
neck.
• 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 hyperpig- A
mentation 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 B
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
- Lower fl u e n c ies of 8 J/c m 2 with two fu l l-face passes of photodynamic therapy with topical 5-aminolevulinic acid and pulsed
versus a si ngle ful l-fa ce pass at h igher fluenc ies dye laser, 7-mm spot, 6 J!cm 2 , 6-ms pulse duration (Courtesy of Mark
( 1 0- 1 4 J/cm 2 ) have been used to red uce pa i n . Nestor, MD, PhD)
Sect i o n 2 : D i so rd e rs o f Sebaceous G l a n d s I 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 A B

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 A

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 B
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 . resurfacing. (B) Four months after Er: YA G laser resurfacing utilizing a
Yeu ng C K , S h e k SY, Yu CS, Ko no T, C h a n H H . Treatment 5-mm spot at 1 J with four passes results in significant improvement
of i nfla m matory fac i a l ac n e with 1 ,450- n m d iode laser in (Reproduced, with permission, from Dover J, Arndt K, Geronemus R,
type I V to V Asia n skin using an o pti m a l c o m b i nation of et a!. Illustrated Cutaneous & Aesthetic Laser Surgery. McGraw-Hi//,
laser pa ra meters . Dermatol Surg. 2009;35(4): 593-600. Inc.; 2000)
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 )
A
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.

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 .
B
Acne vu lga ris, seborrheic d e rmatitis, periora l dermatitis,
steroi d rosacea, system ic l u pus erythematosus, a n d Figure 14. 1 A&B Severe rhinophyma prior to electrosurgery (Courtesy of
B l u pu s m i l ia ris d isse m i natus fac ie i . Suzanne Olbricht, MD)
Sect i o n 2: D i so rd e rs of Sebaceous G l a n d s J 77
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
c
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. o '-- - """""'
• 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. E
D i rect i nj ection of a n esthesia req u i res m u lt i p l e i nfi ltra
Figure 14. 1 ( continued) C, D,&E Debulking and recontouring of the
tions a n d is less effective and fa r more pa i nfu l .
rhinophymatous nose in a relatively bloodless field utilizing large wire
• Electrosu rgery: electrosection (cutti ng) is very effective
loop electrosurgery Impressive flattening of the rhinophymatous nose
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 after electrosurgery. The wound is left to heal by secondary intention
nose with the added adva n tage of a relatively b l ood less (Courtesy of Suzanne Olbricht, MDJ
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 ) .
• 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 A

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 rel-
atively 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.
8
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 , c

Wayla n d , M A ) with stuttered pu lse d u rations ( i e , -
Figure 14.2 (A, B, C) Prominent facial erythema prior to treatment with
0.45, 1 . 5, 3, 6, 10, 20, 30, 40 ms) can provide a
/PL .
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.
Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s J 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
D
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

E
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 F
iectasia with va r i a b l e- p u lse h igh-fl uence pu lsed-dye Figure 14.2 (continued) (0, E, F) Reduction of the facial erythema after
laser: Com pa rison of efficacy with fl uences i m med iately two treatments with /PL, Starlux L ux G handpiece
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 .
Bernste i n EF, Kligm a n A. R osacea treatment using the

new-gen eratio n , h igh-energy, 595 nm, long pu lse
d u ration p u l sed-dye laser. 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
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
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 Figure 1 5 . 1 Large sebaceous hyperplasia on the forehead
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.

Any h i story of the lesion bleed i ng.
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
A
• " 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 cool-

i 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 . B
• Erbi u m : YAG or C0 2 laser a b lation c a n a lso i m p rove
Figure 1 5 . 2 (A) Patient with sebaceous hyperplasia on the right temple
sebaceo u s hyperplasia .
and forehead. (8) Improvement 1 month after treatment with 1 , 4 50-nm
• Laser-assisted photodyna m i c thera py with topica l 20% diode laser (Smoothbeam, Candela Corp., Wayland, MA) utilizing a 6-mm
5-a m i no l evu l i n ic acid and PDL i rrad iation (595 n m ) , spot with a f/uence of 1 4 J/cm 2 and a pulse duration of 35 ms
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.
- 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 elec-
trod es iccation can prod uce pigmenta ry c h a n ges a n d A
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 triglycerides and c h oleste ro l , d iffuse
skeleta l hyperostosis, l iver fu nction 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,

B
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
month after treatment with 1 450 nm diode laser 1 4 . 5 J/cm 2 , 35 ms
B I B L I OG RAPHY cooling, single pulse per lesion
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 .
TH RE E
D isord e rs of Ecc rine G l and s
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

the prominent dark blue-black discoloration at sites of hyperhidrosis
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
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 ) .
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 .
Sect i o n 3 : D i so rd e rs of Ecc ri n e G l a n d s J 87
KEY CO N S U LTAT I V E QU EST I O N S HYPERHIDROSIS Antipersp i rant

Botox
• Med ication h i story
Antipersp i ra nt M e d i cation
• Past treatments a n d response • F i rst l i n e t reatment S u rgery
• A l u m i n u m c h l or i d e (20%-25%)
• Assess fo r syste m i c a bnormal ity
a p p l ied in the eve n i ng 2-4 t i m es per week
• Recent s u rgery • Effective for many patie nts
• Dryness and i rritat i o n are m a i n s i d e effects
MANAG E M ENT
Botox
o Botu l i n u m tox i n type A ( 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
most com m o n l y used .
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
• Average dose, 50- 1 00 u n i ts per axi l l a
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 o 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 . 1 6 . 2 ) . Botu l i n u m o Expensive if not covered by i n surance
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
M e d i cati ons
t h e ra py. • Antich o l i nergics; h igh
Com pensatory hyperh id rosis sec o n d a ry to sym pathec 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.
.
. . . .. . . . . . . . . .. S u rgery
TOP I CAL M E D I CATI O N S • 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
• A l u m i n u m c h loride hexahyd rate . effect ive for pa l mar or fac i a l hyper h i d rosis
• H ig h l y effect ive proced u re w h e n performed by a
- Appl ication of 1 0 % to 30% a l u m i n u m c h loride hexa
s k i l l ed spec i a l i st
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
Figure 16.2 Hyperhidrosis treatment diagram
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.
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:
Sympathet i c n erve Acety l c h o l i n e sweat
• Endoscopic or c l assic sym path ecto my is usua l ly 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
--•IIII X
pensatory hyperh i d rosis, gustatory sweating, pneu Sym pathet i c n e rve Acety l c h o l i n e
moth orax, a n d Horner's syn d ro m 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. Figure 16.3 Mechanism of action of Botox in hyperhidrosis. Blocking
• Li posuction for axi l l a ry hyperh id rosis i n volves su bder 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 .
t
• 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
especia l ly with i n c reasi n g d osages . Patie nts should use injection should be approximately 1 to 2 em apart
Sect i o n 3: D i so rd e rs of Ecc ri n e G l a n d s J 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 .

Benefits ge nera l ly a re n oted between 3 a n d 9 months.
• Side effects may i n c l u d e loca l m uscle wea kness for pal

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 linum toxin A injection
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 prod uctio n . Dermatol Surg. 201 0;36(4) :
496-498.
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 J 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
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 .

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.
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 J 93
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 .

• Menstru a l h istory-reg u l a r or i rreg u l a r
• 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
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 .

Figure 1 7 . 6 Extensive dyschromia secondary to inappropriate fluence and
• N ot practical fo r la rge a reas o f the body. 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 J 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 A .._______________________....,
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 B

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 a 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
t h e risk o f dysc h ro m i a i s ma rked l y i n c rease d . treated with the long-pulsed 1 , 064-nm Nd: YA G laser
• 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 Safest s k i n type Wavelength ( n m l P u lse d u rati o n Energy (J/cm 2 l Comments
R u by I-I I I 694 1-20 ms 1 0-40 J/c m 2 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; S k i n types I-I I I 3 ms and 1 0-20 ms
skin types I l l and I V 20-25 J/cm 2 ; s k i n pu lse d u ration demonstrate
1 0-20 ms type I V 1 5-20 J/cm 2 eq u a l efficacy
Diode 1-V 810 3- 100 ms 30-40 J/cm 2 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; Skin types I-I I I 30-50 Safest d evice for
ski n types IV-VI 25-100 ms J/c m 2 ; skin types 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
I ntense p u lsed I-I V 550- 1 200 1 . 5-3 . 5 ms 25-50 J/cm 2 M ost va riable resu lts
I ight-noncoherent
l ight
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 be da m aged
Laser goggle optrcal densrty (00) shou ld be
Damage can oc c u r equ a l to or greater t h a n 7 (c h ec k gogg l es)
f r o m d i r e c t exposure or
re f lec t ed beams, I . e . 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 E n h a n c e Safety
All lasers c a n pote n t i a l l y R emove . ebonrze. or cover any relfectrve
cause fire hazards su rfaces i n l a se r room , i.e. m irrors, metal l ic
garbage cans
Most common ly seen
w i t h C02 lasers Avoi d alcohol or ensure that it i s f u l ly
vapori zed prior to st a rt of treatment
Damage can oc c u r
f r o m d i rec t exposure or Drape treatment srte wrth wet gauze or towe l s
ref lected beams
Remove a l l f lamm a b l e items, i . e . dry gauze,
t owe l s, d rapes
Coat exposed harr w i t h water-based j e l l y
Decrease F i02 t o 40% when treat r ng near

e ndotrac heal t u bes
H a z a r d : p l ume, sp l att e r, infection

B
I n tact v i r rons and viral Use mask
D N A such as H PV may
be present rn the p l u m e Smoke evac uator
of COz l asers
nssue part i c les can

splatter a n d aerosol ize
with Q·switched lasers
Hazard: el ectrocution
Even with power off, O n l y q u a l i f ied laser tec h n r c rans should
ca n ca use shock/ open l ase rs
e l ec t rocu t i o n
Check for water s p i l ls, hose ruptures or
condensations
H a z a r d : general
A n t i c i pate da ngers 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
• 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 .
(:)-�""
LASER A N D
• If u n certa i n as to treatment pa ra m eters, perfo rm test EYE INJ U R I E S
sites with va ria ble fluencies a n d p u lse d u rations.
--
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
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

Wave- Signs or symptoms
risk of d ysc h ro m i a . l ength ( n ml Lasers Eye injury of injury
• Use l a rger s pot s izes for d eeper penetration a n d m o re
Cornea : lens : Retina
ra pid treatm e nt of l a rger a reas .
• Safety goggles for patient a n d med ical tea m .

<300 yes
• 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 30().. 4 00 Exc 1 mer yes : yes : yes
(308 n m )
regi o n .
400-600 Argon : yes Flash of the
(488 nm) em1 tted wavelength
• Postt reat m e n t I n st r u ct i o n s to Pat i e n t fol l owed by
KTP : yes aften mage of a
( 532 m n ) complementary color
• 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

Pu lsed dye : yes
t h e office. If there a re a n y c uta neous cha nges i n the
laser ( 585-
s k i n the day afte r the p roced u re o r beyo n d , the patient 600 nml
m ust be to ld to conta ct the treati ng physic i a n .
600- as N d : VAG : yes Damage from a a-switc hed
O n c e red ness fades, patient may conti n ue t o wea r
1 000 ( 532 n m ) N d : VAG l a se r m a y n o t
•
be
m a ke u p . detected as reh na
as R u by : yes lacks pam f i bers
• Avoi d s u n for 4 8 h o u rs; no ta n n i ng.
(694 n m )
• Hair remova l is not entirely i m med iate . Some hair wi l l a-switc hed lasers have
fa l l o u t 1 t o 3 d ays after treatment. A lexa ndrite : yes h ighest pote n t i a l to
(755 nm) c a u se b l i n d ness
• Do not worry if some hair persists after treatment.
D1ode : yes May produce a popping
• Ca l l the office if d iscoloration develops i n the treated sites.
(810 nm) sou nd, then v1sual
• Ca l l the office with q u esti ons or concerns. d i sorientation
1 000- as Nd: VAG : yes

1 400 ( 1 064 n m )
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) N d : VAG : yes
( 1 320 n m )
• There is no effective mecha n is m for laser remova l of
l ight or blond ha i r. D1ode : yes
( 1 4 50 n m )
• 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 1 4DO- Er: VAG yes B u r n mg pam at the site of
effects a re typica l ly te m po ra ry but can be permanent. If 1 0000 (2940 n m ) exposure on the cornea o r
sclera
there is a n y d o u bt rega rd i ng laser pa ra m eters, pe rfo rm
CO:! yes
a test site . ( 1 0,600 n m )
• S k i n types IV to VI req u i re longer p u lse d u rations a n d
l ower fl uenc ies. 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)
e n i ng. Patie nts s h o u l d be i nformed of this poss i b i l ity.
• A lways kee p contact coo l i ng aga i nst the s k i n to avo i d
b u r n i ng.
• 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 .
Sect i o n 4 : D i so rd e rs o f H a i r Fo l l i c l es J 99
• 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 .
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 .
1 00 I Color Atlas of Cosmetic Dermatology
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 .
A
Acne vu lga ris, fol l i c u l itis.

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 .
B
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 liculitis barbae prior to treatment. (B) Same patient 3 months later after
the pa p u les, pustu les, sca rring, a n d posti nfla m matory several treatments with long-pulsed 1, 064-nm Nd: YAG laser. (Courtesy of
hyperpigmentation associated with this d isord e r. There E. Victor Ross, MD)
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
Sect i o n 4 : D i so rd e rs o f H a i r Fol l i c les I 101
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 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 . 18. 1

and 1 8.2)
• 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 .

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
• 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.
A
• 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. B
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
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 for darker skin phototypes before treating pseudofolliculitis. (B) Two
treatment. J Am Acad Dermatol. 2006; 54( 1 ) :64-67. weeks after test spot treatment, some hair removal is achieved with no
R oss EV, Cooke L M , Ti m ko AL, Overstreet KA, G ra h a m pigmentary changes
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 I 1 03
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 I IV

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 II IVa
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 II a v
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 .
Ilia Va
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 III VI
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 .
III vertex VII

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.
Figure 19. 1 Norwood classification of the natural progression of male
pattern hair loss
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.
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
Fi nasteride M i n oxi d i l
M ec h a n is m of action 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 E m p hasize m a i ntena nce over regrowth of
fo r at least 6-8 months to see ben efit h a i r and com p l i a nce 6-8 months to
see benefit
S i d e effects 2% of men expe rience sex u a l d ysfu ncti o n . Revers i b l e with i n D ryness and pru ritus of the sca l p . R a re
days i f d iscont i n ued 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

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 Figure 19.2 Unnatural "pluggy" hairline using 1 0 to 25 hair grafts.
pla nted h a i r wi l l grow for d ecades. 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 I 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,
have been tried and for h ow long?
• Expectations?
• 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
Norwood V
• N et perce ived dens ity fro m a h a i r tra ns p l a nt = the
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
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 . 19.5
and 1 9 . 1 0)
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
Figure 19.6 Patient in prone position
• Fol l i c u l a r u n it extractio n : <5% of patients ( Fig. 1 9 . 1 1 )
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 -G reater tra nsection of
with exte ns ive sca rri ng h a i r fo l l ic l es with
i n posterior sca l p from potenti a l decreased
Figure 1 9 . 7 Donor strip should not be more than 1 em wide. Strips
m u ltiple p revious s u rge ries yield
>1 em have an increased risk of creating a hypertrophic scar
TAB L E 1 9 . 3 • 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 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 Figure 19.8 Closing donor region with staples
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 .
• 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
• 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 pig-

mented term i n a l h a i r Figure 19.9 A 2-cm-wide donor scar from 1 . 5-cm-wide ellipse
• S P 8 8 t o 90 ga uge n eed le
• 0 . 5- to 1 . 0-m m cag need l e
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
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
Figure 1 9. 1 1 Skin hooks to aid in removal of donor ellipse
pla nted zo n e .
- 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 Figure 1 9 . 1 2 Donor ellipse with natural follicular bundles
• 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
• 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

Figure 1 9 . 1 3 Magnification helps visualize 1 to 4 hair bundles and mini
• Dye h a i r 2 weeks after su rgery
mize transection when separating with surgical prep blades
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
Exc ision of grafts Patient req u esti ng "I wo u l d rather j u st be ba l d " Status 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
seven does not work on b l a n d h a i r
Com bi nation Red u ce " pl uggy" grafts A s a bove
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 Figure 1 9 . 14 1 to 4 hair grafts
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 .
Sect i o n 4: D i so rd e rs of H a i r Fol l i c les I 111
Figure 19. 1 5 1 to 4 hair grafts in chilled saline
Figure 1 9 . 1 6 Natural irregular frontal hairline

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

Figure 1 9 . 1 9 Preoperative Norwood Ill

Figure 19.20 A fter 2, 400 1 to 4 hair grafts
Figure 1 9 . 2 1 Preoperative Norwood Ill to I V

Figure 19.22 A fter 900 1 to 4 hair grafts
Figure 1 9.23 Preoperative Norwood I V to V

Figure 19.24 A fter 2, 030 1 to 4 hair grafts
Figure 19.25 Preoperative Norwood I V to V

Figure 19.26 A fter 1 , 000 1 to 4 hair grafts
Figure 19.27 Straight "pluggy" frontal hairline

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

Figure 1 9 . 3 1 Preoperative Norwood IV to V
Figure 19.32 A fter an additional 700 hair grafts (second surgery)

Figure 1 9.33 Straight "pluggy" hairline
Figure 1 9 .34 A fter 500 1 to 3 hair grafts

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

I l l ustration 19.3 1 to 3 hair follicular groupings within donor strip
A 8
I l l ustration 19.4 Versus 1 0 to 20 hair "pluggy" graft. Natural 1 to 3 fol

licular groupings
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
I l l ustration 1 9 . 7 Corrective hair transplant adding 1 to 3 hair grafts

between and in front of "p/uggy" grafts
I l l ustration 19.8 Adding 1 to 3 hair grafts between large "pluggy" grafts

to improve cosmetic appearance
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.

• 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

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 I 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-

ease, polycystic or oth er en docrine i m ba l a nce
• Med ication -related hair loss
• 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
• 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 . Figure 20.3 Preoperative temporal scar-chief complaint: "I cannot wear
my hair back"
• Thyroid function tests, i ron stud ies, a nti n uclear a nti
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
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

• Donor density Figure 20.6 A fter 600 1 to 3 hair grafts
• Ca l i be r of h a i r l oss
• Exte nt of h a i r l oss
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,
Figure 20.7 Preoperative L udwig I to II.
a n esthes i a , and p re- and postsu rge ry cou rse .
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 Sta ble h a i r l i nes. Major cosmetic adva n tage
cosmetic a p pea ra nce ( > 1 0 yea rs) 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 existi ng h a i r a n d decrease risk o f postsu rgery
Med ication a lways rema i n s elective te logen effl uvi u m
N eed to d esign h a i r tra nsplant ass u m i ng ongoi ng Density = n u m be r of h a i r fol l i c l es tra nspla nted
hair loss and reced i n g h a i r l i nes ongoi ng h a i r loss
Expectations Key to su ccess Key to su ccess
• 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 ropri-
ate 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

power.
• Apply topical a nti biotic or Aq u a p h o r to donor region
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.
• If te logen effl uvi u m occ u rs, h a i r density wi l l decrease

Fema le
I I I l l
but w i l l ra rely be cosmeti c a l l y n oticea b l e .
• 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
l l l 1 1 1 e r te x
for the majority of patie nts .
• 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 . "
I l l ustration 20. 1 Female versus male pattern hair loss

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 .
• 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 7-
818.
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.
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)
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 0-
1 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
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
Sex: none A
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 B
lesions conta i n more melanocytes than l ighter ones.

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 .
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.
c
Figure 22. 1 (A) Cafe au lait macule on left cheek of a 1 7-year-old female
B i o psy i s not i n d i cated . Ad d itional laboratory work u p may prior to treatment. (B) Erythema and lightening of cafe au Ia it macule
be a p p ro p riate i n the eve nt of suspicion of a n u n derlying after one treatment with 694-nm Q-switched ruby laser. (C) Significant
system i c d i sorder. 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 I 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 .

• 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
A
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
B
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 epidermal white n i ng after treatm e nt. Figure 22.2 (A) Cafe au fait macule adjoining right lateral commissure of
Without epidermal white n i ng, the treatment is lips. (B) Near clearance after three treatments with a 755-nm Q-switched
u n I i kely to be effective . a/exandrite laser
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 A

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 B
EXPECTAT I O N S/CO M P L I CAT I O N S/ Figure 22.3 (A) Treatment of cafe au fait macule on the chin of a young
MANAG E M E N T 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
• U nfortunately, despite their s u pe rfi c i a l nat u re, CALMs
clinical endpoint of tissue whitening and erythema
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 .

Secti o n 5 : D i so rd e rs o f Pigmenta t i o n I 1 39
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 Ephe l id es
Ephelides , 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 .
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 .
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.

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 .
The d ifferentia l d iagnosis i n c l u d es other benign lesions A
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 .
B
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 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 c

e m p l oyed .
Figure 23. 1 (A) A 38-year-old male from Southern California with exten
- 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
sive ephelides. (B) Same patient with posttreatment whitening immedi
ove r 3 months is ge nera l l y necessa ry to a c h i eve sig ately after frequency-doubled a-switched Nd: YA G (532 nmJ laser
n ificant, if n ot c o m p l ete, i m provement. therapy. (C) Significant improvement 2 weeks after single treatment with
- Side effects i n c l u d e i rritatio n , pru ritus, pee l i ng, a n d frequency-doubled a-switched Nd: YA G (532 nmJ laser utilizing a f/uence
d ryness o f the treated a reas. 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 I 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.
A
• 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
B
greate r penetration of the TCA pee l .
Figure 23.2 (A) A 40-year-old Japanese female with ephelides and lentig
- M u ltiple peels a re gen e ra l l y needed . Contra i n d i cated
ines prior to 694-nm Q-switched ruby laser treatment. (8) Immediate
in pregna n t a n d lactat i ng women .
tissue whitening and erythema after treatment
• 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 i-

ate 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 . Eighty percent of patients showed better than
50% 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- A
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 nolo-

gies, 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.
B
- 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 I 1 43
- 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
com m o n .
• 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
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.
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 A
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.

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
B
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
can be l a rger tha n lentigo s i m plex. laser at a fluence of 1 . 0 J/cm2 and a 2-mm spot size
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 .

• 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 A
• 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

Figure 24.2 Two examples of chrysiasis, a rare but well-described compli
• B leac h i ng c rea ms suc h a s 4% hyd roq u i none can cation of a-switched laser therapy in patients with a history of ingesting
l ighten lesions over a period of severa l months. A topical gold salts. In both of these patients, the characteristic dark-blue pigmen
com b i nation of hyd roq u i none, stero i d , a n d ret i n o i d , ie, tation was produced after a-switched laser treatments of lentigines on
Tri l u ma (4% hyd roq u i none, 0.05% treti noi n , 0 . 0 1 % the (A) dorsal hand and (B) forehead, respectively
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 i-

ate 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 .
- 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 .
• 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 patients with
F itzpatrick skin type I I , I l l , and I V. 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.
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 ,
Figure 25. 1 Female with extensive melasma recalcitrant to m ultiple
I nd i a n , East As i a n fe males a re most freq uently affected
topical regimens for several years
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 .
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 .
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.

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 .

• 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 . A
N evertheless, many patie nts u n dersta nd a bly a re d is
Figure 25.2 (A) A female patient with therapy-resistant melasma.
tressed by its a ppea ra nce a n d desire treatment. The goa l
(Courtesy of Howard Conn)
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 .
Secti o n 5 : D i so rd e rs of Pigmenta t i o n I 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. B
• 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 d a i ly s u n sc reen and a c o m b i nation treatment sessions with Fraxel laser. (Courtesy of Howard Conn)
TAB L E 2 5 . 1 • Treatment o f Pigmented Lesions o n the Face
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
Melasma 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 Yes ; weeks to months Va ria b l e i m prove ment No No No
hyperpigmentation to see c l i n ica l
i m provement
Lentigo M i n i m a l/mod erate M i n i m a l/moderate Yes; one to two Yes; M i l d/moderate
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 No No
treatments res u lt
in i m provement
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

relative to treatments for rhytid es and acne sca rs .
• Treatment is genera l ly performed at h igher densities.
B
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 Figure 25.3 (A) Young female with melasma. (B) Characteristic darkening
p red i cta b l e in sk i n type I l l , but is often a c h i eved . of melasma 1 -day post intense pulsed light treatment
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 .
• 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 . • 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,
• Some treatme nts worse n its a p pea ra n c e .
in any com b i nation
• Strict s u n avo i d a n ce is c r u cia l w i t h a su nscreen with • Wood 's Light to determ i n e e p i dermal vs.
UVNUVB protection a nd/o r a physical block such as d e r m a l d i stri b u t i o n of pigment
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

C l i n ical
treatment regi men . approach to D ifferential Diagnosis
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 . • Pregnancy
To pica l treti n o i n ( reti noic a c i d ) i m proves melasm a . A • Oral contracepti ves
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: • I ncreased p igme ntat i o n w i t h s u n expos ure
4 1 5-42 1 .
Figure 25.4 Clinical approach to diagnosing melasma
G r i mes P E . M a nagement of hyperpigme ntation i n d a rker
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.
Top i c a l Mechanical Lasers
To ro k HM, J ones T, Rich P, S m ith S, Tschen E. • H yd roq u i n o n e • M i crodermabras i o n • Fract i o n a l
Hyd roq u i none 4 % , treti n o i n 0 . 0 5 % , fl uocinolone ace • Ret i n o i d s photothermolysis
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
• Koj i c a c i d • Q-switched
ment for melasma . Cutis. 2005 ; 7 5( 1 } ; 57-62 .
• Aze l a i c a c i d lasers
Vera l lo- Rowe l l V M , Ve ra lo V, G ra u pe K, Lo pez-V i l lafuerte • Licorice extracts
L, G a rcia Lopez M . Double- b l i n d com parison of azeleic I
+ +
acid and hyd roq u i none i n the treatment of melasma .
A com b i n at i o n of a topical s u c h as
Acta Derm Venereal. 1 989 ; 143: 58-6 1 .
hyd roq u i n o n e , w i t h month ly pee l s a n d/or
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
• 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

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 .
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 a 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.
A

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.
B
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 Figure 26. 1 (A) Nevus of Ota prior to treatment with Q-switched ruby
d rug eru ption, a n d other m ed ication-related eru ptions laser. (8) Significant clearance after serial treatments with Q-switched
should be considered i n the proper c l i n ical setting. ruby laser

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 .

• O nset o f eru ption
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.

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
Topica l Mechanical Lasers
width at 3-to-4- month treatment i nterva ls.
• Camouflage • M i croderma b rasi o n • Q-switched l asers
- I n a study of 46 c h i l d ren a n d 107 a d u lts with nevus may be h e l pfu l s h o u l d not b e performed are the t reat ment of
for some patients • H igh risk of dysc h rom i a choice
of Ota , treatments were more s uccessfu l i n c h i l d ren
a n d/or scarr i ng • 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 • 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
age gro u p and 5.9 fo r the older age gro u p .
• Q-switched l aser treatment of lesions that arise in i nfancy may
- Ad d itional ly, com p l i cations we re lowe r i n t h e c h i l d ren 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
t h a n ad u lts, that is, 4.8% as com pa red to 22.4% .
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
- One retros pective study exa m i ned 101 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
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 .


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

cussed with the patient prior to thera py.
• Add itiona l ly, a test site can be treated before perform

i n g fu l l treatment of a n y les i o n .
• Q-switc hed l a s e r treatment can be associated w i t h tra 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 .
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
fractional resurfacing for a scar. The PIH resolved on its own within
Sex: none
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 .
Basa l cel l layer pigme ntatio n and dermal mela n o p hages
a re see n .

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 .
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 .
A _____
Figure 27.2 (A) Pseudo-ochronosis seen after years of hydroquinone
None. treatment.
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.

• 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 8
Figure 27.2 (B) ( Continued) Significan t improvement after treatment with

W h i l e there is no medical i n d ication to treat P I H , m a n y
a-switched laser
patients a re as bothered by P I H as t h ey a re by t h e
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
Thera peutic R eti n oid/ Peels/ Fractio n a l

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
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 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
B
Chem ica l peels a re an effective treatment option for the
Figure 27.3 (A) Hyperpigmentation on left side of face before treatment.
red uction of P I H .
(8) Improvement after a series of salicylic acid peels and topical applica
• Over-the-cou nter a-hyd roxy a c i d peels a re a benefi c i a l
tion of 4 % hydroquinone (Courtesy of Pearl E. Grimes, MDJ
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.
• 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 .

A
• 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 B
reco m m e n d ed .
Figure 27.4 (A) Hyperpigmentation after a series of Q-switched laser tat
F racti o n a l phototh ermolysis ( F P ) ca n , however, provide
too treatments. (B) Improvement of PIH after two nonablative fractional
i m prove ment of P I H ( Fig. 27 .4) . T h i s is espec i a l l y true for
resurfacing treatments utilizing superficial depth and lower treatment
patients with l ighter s k i n p h ototypes. I n d a rker s k i n types,
densities
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.

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 .
• 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 .
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 .
There a re no melanocytes i n basa l cel l layer.

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 Figure 28. 1 Vitiligo on the trunk and neck of a young patient
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.

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
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.

• 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 Figure 28.2 White forelock in the same patient
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
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 rrowba 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
A
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

B
c u ltured epidermal grafting after treatment with C0 2 laser
have been shown to be successful in treating viti l igo . Figure 28.3 (A) Depigmented patch of skin on right mandible.
(B) Significan t improvement after m ultiple 1 -mm punch grafts (Courtesy
- Resu lts were best i n loca l ized cases of viti l igo.
of Pearl E. Grimes, MD)
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 .
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 308-
nm 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. 2004; 140( 1 0 ) :
1 203- 1 208.
S IX
Vasc u l a r A l te rat i o n s
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.
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 .

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 . A
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 B
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 I 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
Figure 29.2 Angiokeratoma on the left thigh resistant to m ultiple treat
col l i mated hand piece, with an energy of 300 to 500 mJ
ments with pulsed dye laser
with nonoverlapping pu lses . The va rious sca n ned C0 2
lasers such as the Sharplan FeatherTouch a re
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 proce-
d 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 A
system (595 a n d 1 , 064 n m ) has been rece ntly
reported ( 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.
• 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
B I B L I OG RAPHY
Figure 29.3 (A) Biopsy-proven angiokeratoma on the thigh of a young
Gorse SJ , J a mes W , M u rison M S . S u ccessful treatment of child. (B) Some resolution after one treatment with pulsed dye laser at a
a ngioke ratoma with potass i u m tita nyl phosphate laser. Br wavelength of 595 nm with a 1 0-mm spot, pulse duration of 1 . 5 ms, a
J Dermatol. 2004; 1 50 ( 3 ) : 620-622. fluence of 7. 5 J/cm2 , and DCD 30120
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
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 I 171

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. B
- 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
s pot size s h o u l d be selected that matc h es d ia meter
angioma after a single pulsed dye laser treatment to central vessel and
of the a ngioma . With spider a ngiomas, the ce ntra l
surrounding skin
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
A
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 B
expected w h i c h may be less cosmetically pleasing
Figure 30.2 (A) Cherry angiomas on the trunk in a middle-aged female.
t h a n the a ngioma .
(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.
A
Figure 30.3 (A) Cherry angioma, chest.
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
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.
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
PATH OG E N ES I S Figure 3 1 . 1 Granuloma faciale on the scalp
U n k nown , but may b e mediated b y i m m u ne c o m p lex

d e position .

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 .
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.
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.
• Corticosteroids: topica l , i ntra lesio n a l
• Tac ro l i m u s o i ntment (0. 1 % )
• Da psone
• Anti m a l a ri a l s
• Colc h ic i n e
A
• 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
B
• Laser thera py: d ifferent lasers have been used in the
Figure 3 1 .2 (A) Multiple lesions of granuloma faciale on the face. (8) No
treatment of GF with p ro m i s in g resu lts, either as an
significant improvement detected after one treatment with cryotherapy on
a b lative thera py with ca rbon d i oxid e laser o r as a selec
a 4-month follow-up visit
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.
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 .
A
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 I 1 77
CHAPT E R 3 2 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 a 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

A
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 .
B
Figure 32. 1 (A) Left upper eyelid hemangioma in its early growth phase,
D I F F E R E N T I AL D I AG N OS ES a lesion that may threaten the child 's vision. (B) Marked lightening and
Congen ita l hema ngiomas ca n be confused with a vasc u
flattening of the hemangioma after m ultiple pulsed dye laser treatments
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
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.
• 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 A
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 ngiec-
tasi 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. B
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
• Onset o f lesion ments
• 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,
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 , A
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 B
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 old girl. {B) Complete resolution of the hemangioma after four treatments
P D L. PDL ma rked ly dec reases the associated with 595-nm pulsed dye laser at low fluences
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 the s u rface o f i nvol uted
hemangiomas.
- 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.
• 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 A
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 B
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 , Ta·leb A. Propranolol for severe
hema ngiomas of i n fa n cy. N Eng! J Med. 2008;358: 2649-
265 1 . c
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
M a rt i n FJ . S uccessfu l treatment o f i nfa nti le h a e m a n
painful and hemorrhaging, treated twice with pulsed dye laser 6 Jlcm 2 ,
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
7-mm spot size, 590 nm. (B) At 2 months ' follow-up, significant healing
Ophthalmol. 2010;38(6): 5 54-559 . of the ulceration after a single treatment with pulsed dye laser. (C) Four
More l l i J G , Ta n OT, Yoh n J J , Weston WL. Treatment of months after initial pulsed dye laser treatment and 2 months after
u l cerated hema ngiomas i nfa n cy. Arch Pediatr Ado/esc second pulsed dye laser treatment, there is complete healing of the
Med. 1 994; 148( 1 0) : 1 1 04- 1 1 0 5 . ulceration
CHAPT E R 33 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
PATH OG E N ES I S Figure 33. 1 Keratosis pilaris: fine, sandpaper-like follicular papules on

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.

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 .
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 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 .
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 prove-
ment. R i s k of fac i a l atro ph y l i m its their use. A
• 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 B

Q-switc hed ru by l a s e r may be a n effective treatment
Figure 33.2 (A) Keratosis pilaris atrophicans. Patient is emotionally both
i n patients with KFS D .
ered by persistent erythema. (8) Marked lightening of erythema 2 years
following three pulsed dye laser treatments
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):469-
475.
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.
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 .
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 .
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- A
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
B
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 .

• 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

c
• B l eed i ng
Figure 34. 1 (A) PWS on the right inner thigh of an infant girl.
• 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
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 A
cool i n g (CSC). Fou r to twe lve laser sessions with 4-to-8-
week 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 i-
tia 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 treat-
ment 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 B
p rotect the epidermis a n d i n c reas i n g the wavelength u p
Figure 34.2 (A) Extensive port-wine stain on the right face and forehead
to 600 n m to ta rget deeper vesse ls. A pi lot study demon
of an infant male. (8) Significant resolution after multiple treatments
strated that PWS that a re treated with to pica l imiquimod
with pulsed dye laser
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 ong-
p 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
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 .
• 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- A
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
B
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. Figure 34.3 (A) Extensive port-wine stain on the right neck of a young
2009 ; 3 5 ( 5 ) : 8 1 3-8 1 5 . female. (B) Marked resolution of the port-wine stain after multiple treat-
ments with pulsed dye laser
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
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 top-
ical 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 ) : 563-
568 .
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-
�. A
Figure 34.4 (A) Port-wine stain on the lower mucosal and cutaneous lip.
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 B
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. three treatments with a combination of pulsed dye laser to the cutaneous lip
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 , and vermilion and long-pulsed 1 , 064-nm Nd: YAG laser to the inner
Ke n n edy WR , Z e l i c kson B D. Confocal m i c roscopy stu d y 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
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.

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 ) .
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.
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
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 .
Figure 35.3 Pyogenic granuloma overlying a dermal nevus
• S u rgical treatment: a l l treatments may res u lt in sca r for
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
• 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, Figure 35.4 Pyogenic granuloma mimicking a squamous cell carcinoma
P i e ra rd G E . Treatment o f pyogen ic gra n u lomas with t h e on the left lower mucosa/ lip of a patient with multiple nonmelanoma
N d-YAG laser. J Dermatolog Treat. 2006; 1 7(4) : 247-249 . skin cancers
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
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)
CHAPT E R 3 6 Facial Te l a ngiectasias
Fac i a l 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
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 , A
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

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 i lated , t h i n-wa lled vessels i n the u p per d e r m i s .
B
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

c
for fac i a l telangiectasias ( Figs. 36 . 1-36 . 5) .
Figure 36. 1 (A) Middle-aged male with multiple facial telangiectasias.
The trad itional P D L with a short pu lse d u ration of
(B) Purpura observed immediately after pulsed dye laser treatment.
0.45 or 1 . 5 ms provides the most effective treatment
(C) Significan t reduction in telangiectasias after a single-pulsed dye
for fac i al tela ngiectasias. However, posttreatment
laser treatment
p u r p u ra occ u rs which genera l ly lasts 7 to 14 days
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 , A
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 x 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 B
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 595-
and 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. c
• Flashla m p ( i ntense pu lsed l ight [ I P Ll l treatment 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.
- I P L provi des a n other effective, p u r p u ra-free method
(B) Immediately posttreatment. (C) Ten days after pulsed dye laser
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
treatment
with 20-ms pu lse d u ration a re effective with the Starlux
Lux G handpiece ( Palomar Medical Tech nologies,
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
• 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
A
• 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) : 233-
239 .
J 0rgensen G F, Hedel u nd L, Haedersda l M . Lo ng-pu lsed B
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 ngiec-

tasia 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 ) : 702-
708 .
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 63-
1 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 treat-
ment of te la ngiectases. Dermatol Surg. 2007 ;33( 1 2 ) :
c
1 466- 1469 .
Figure 36.3 (A) Female with centrofacial telangiectasias and erythema
Sa rradet D M , H ussa i n M , Gold berg DJ . M i l l isecond
prior to pulsed dye laser therapy (B) Pulsed dye laser treatment at a
1 064- n m neodym i u m :YAG laser treatment of fa c i a l
wavelength of 595 nm, 1 O-ms pulse duration, 7 J/cm 2 , 7-mm spot size.
te la ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58.
(C) Appropriate clinical endpoint of erythema and slight edema at sites of
treatment. No purpura was produced
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
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 .
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
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.
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 .
A
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.

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 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: B
• Asym ptomatic va ricosity greater tha n 4 mm i n d i a meter Figure 37. 1 (A) Sclerotherapy of spider veins. The needle is bent at a
• Sym ptomatic vei n s 45-degree angle and the vessel is canalized. (B) Immediate vessel
blanching seen after injecting the sclerosant agent
• 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
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
A
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 B
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
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 . A
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 sclerother-
a py a n d u p to 2 to 3 wee ks after the proced u re , espe-
c 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) B

• 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.
tec h n i q u e used , the size of the treated vessels, the type Note the development of slight telangiectatic matting superior to the
of sclerosi n g agent, a n d the solution conce ntratio n . treated area
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 Sclerosa nt types Mecha n ism
Hyperosmotic agents 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%

solution
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
TAB L E 3 7 . 3 • Com p l ications of Sclerotherapy
Sclerosa nt Al lerge n i city C ra m pi n g Pa i n Hyperpigmentati on Te la ngiectatic matting S k i n necrosis
Hyperto n i c sa l i ne + + + + +
Sod i u m tetrad ecyl s u l fate + An a p hylaxis + + + +
( 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 ) , 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 ) .
A
Figure 37.4 (A) Marked erythema immediately after pulsed dye laser
• Laser a n d I n te n se P u l sed L i g ht treatment to lower extremity spider veins.
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
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. B
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

CHAPT E R 38 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.
A
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 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 B
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
sions with the pulsed dye laser
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.
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.
A
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 .
B
Wa l l TL, G rassi A M , Avra m M M . Cleara n ce of m u lti p l e
Figure 38.2 (A) Venous lake on the upper lip. (B) Five-month follow-up
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 .
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)
(_ � _)
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
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
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 A
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 .

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.
B
Figure 39. 1 (A) Verruca vulgaris on the left thumb immediately
Hypertro p h i c acti n i c keratosis, seborrheic keratosis,
posttreatment with pulsed dye laser, 590-nm wavelength, 7-mm spot
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
size, 1 0 J!cm2 , with pulse stacking. (B) Five-month follow-up with com
a c ra l a mela notic melanoma . Pla nta r warts can a lso be
plete resolution of the wart after single pulsed dye laser treatment
m ista ken for corns o r call uses .
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.
Sect i o n 6 : Va sc u l a r A l te rat i o n s I 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
A
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.
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 B
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
d u ring treatment.
after three POL treatments.
• 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
Efficacy Va r i a b l e Effective
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
• 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

c
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 Figure 39.2 (Continued) (C) Recurrence of the wart after six POL
tive, but should be performed with caution . 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;
A
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 B
between passes u nt i l tissue sepa ration occu rs a n d nor
Figure 39.3 (A) Plantar verruca with characteristic thrombosed capillaries.
m a l tissue is observed .
(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 I 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.
• 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 Figure 39.4 Mechanism of action of pulsed dye laser treatment of
- I m p rovement is va riable with a n y treatment modal ity verruca. (A) The verruca is characterized by a rich vascular supply.
(B) The pulsed dye laser selectively targets the vascular component of the
- Warts ca n rec u r after a n y treatment
verruca. (C) The laser light is selectively absorbed by the blood leading
to coagulation of the vessels (0) and resolution of the wart
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 .
S EVE N
B enign G rowths
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
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.
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
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 I 21 3

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 .

• Onset a n d location o f lesions A
• 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 treat- 8
ment 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
c
been see n . Adverse reactions i n c l u d i n g tem pora ry
a n d/or perma nent dyspigmentation espec i a l l y 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
fo rmatio n . Lesional rec u rrence is expected ove r time on the leg of the same patient
- 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
• 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
A
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 ) : 1 849-
185 1 . B
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 I 215
Figure 40.3 (Continued) (C) Partial recurrence of angiofibromas noted

13 months after C02 laser treatment
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
Figure 4 1 . 1 Becker's nevus. A slightly raised ligh t-tan plaque with
PATHOG E N E S I S sharply defined and highly irregular border and hypertrichosis on the
chest of a 35-year-old male (Wolff K, Johnson RA, Suurmond D.
U nclear etio logy. Post u l ated t o have a loca l ized i n c rease Fitzpatrick's Color A tlas & Synopsis of Clinical Dermatology, 5th ed. New
in a n d rogen receptors a n d heightened sensitivity to 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 .

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 .
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 Figure 4 1 .2 Becker's nevus. Large brown plaque that becomes noticeable
associated hypoplasia of the i psi late ra l arm, b reast, a re at puberty with increased pigment followed by hair growth (Wolff K,
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 Johnson RA, Suurmond D. Fitzpatrick's Color A tlas & Synopsis of Clinical
tu m o r thorac i c scoliosis. Dermatology, 5th ed. New York: McGraw-Hill; 2005)
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.
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 Figure 4 1 . 3 Incomplete improvement of Becker's nevus on upper buttock

after three treatments with Q-switched ruby laser. Associated pigmentary
T here is n o med ical i nd ication t o treat Becke r's nevus. changes noted
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: Q-switc hed r u by (694 nm), Q-switc hed

N d : YAG (532 nm or 1 , 064 n m ) , and 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
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 . • P igmentati o n
- It is i m porta nt to note that there is a h igh risk of tex • 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
in i m prov i n g pigmentation a n d h a i r loss .
Lasers Lasers
• Q-switched R u by, N d : VAG a n d • Long p u l sed N d : VAG ( 1 064)
A l exand rite l asers most effective i s t h e least l i kely h a i r
P I T FALLS TO AVO I D/CO M PL I CAT I O N S/ • Var i a b l e i m provement re mova l l aser to cause post
MANAG E M E N T/O UTCO M E • R i sk u n even pigment red uction i nflam matory changes.
creat i n g poor cosmet ic res u l t Long-p u l sed ru by, a l exa nd rite
EXPECTAT I O N S • A b l ative lasers have h igher risk a n d d iode l asers are more
of side effects l i ke l y to cause hypo p igmentati o n
• Treatment o f t h e pigme nta ry com ponent o f t h e nevus is
i n a Becker's nevus
often i neffective and rec u rrences a re common S u rgical
•S e r i a l exc i sion should only be
• Laser h a i r remova l ca n i m prove overlyi ng hypertrichosis
pursued in lesions of I i m i ted s i ze
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

• Perman e n t hair red uction i s a n effective safe opt i o n for
fre q u e ntly, therefore a conservative laser a p p roach is
i m prov i ng a Becker's nevu s. A long p u l sed N d : VAG l aser shou l d
vita l to m i n i m ize a ny assoc iated pigme nta ry c h a nge be used .
• Laser red uct i o n of t h e p i gmented component is less effecti ve
• Patie nts with d a rk s k i n p h ototypes (types I V a nd V)
a n d may prod uce worse cosmetic appeara nce
s h o u l d be treated ca utiously and at lowe r fl ue nces, as
• Any i m provement with l asers a n d pigment red uction may be
t h e i r t h reshold res ponse occ u rs at lower en ergies . A 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 ) : 1488-
1 490.
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 ; c l i n ic a l and
h istopathologica l fi n d i ngs . B r J Dermatol. 2005; 1 52
( 2 ) :308-3 1 3 .
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 .
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 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 B
giant cells.
Figure 42 . 1 (A) Elliptical excision around epidermal inclusion cyst
punctum. (8) Cyst sac being "delivered" from excision site.
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 .
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.

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
A B
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.

• 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?

D
• 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
- 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
A
• 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
B
Figure 42.3 (A) Epidermal inclusion cyst prior to punch biopsy

(B) Epidermal inclusion cyst immediately following removal. An intact
MANAG E M ENT/O UTCO M E cyst sac decreases the risk of cyst recurrence.
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 .
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 Epid e r m a I Nevus
Epidermal nevus (EN) is a 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 .
Figure 43 . 1 Young man with epidermal nevus limited to his neck nape
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 .
Sect i o n 7: B e n ign G rowt h s I 223

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 .
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
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 ,
CO U RS E
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
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
appropri ate d i agnostic tests shou l d be performed to r u l e out E N
u les i n itia l l y wh i c h th icken ove r time. Eighty percent of
syn d rome
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
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

I I
• Age o f onset Lasers Mechanical
• P u l sed carbon d ioxide • Derma brasi o n- a b lat i ve l asers
• C N S a bnorma l ities laser, treatment of choice provide better contro l
• Skeleta l d efects with moderate to exce l l e n t
i m provement depen d i ng on S u rgical excision
• Pru ritus depth of lesion • L i m ited
• Les i o n s may part i a l l y rec u r • Var i a b l e scar fo l lowi ng exc i s i o n
over t i me
• R i sk of dysc h ro m i a or sca rring
MANAG E M ENT 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 needs to
c o n s i d e r whether treatment wi l l p rod uce a su perior
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
A
CRYOT H E RAPY/E LECTROCAUTERYI
Figure 43.4 (A) Young patient with epidermal nevus syndrome. Note the
D E R MAB RAS I ON
extensive nature of these lesions even after several surgical procedures
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
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 .
• 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

in sca r formation a n d/or d yspigmentation
• There is a lways the risk that treatment wi l l prod uce an

i nferior res u l t to n o n i nterve ntion
• Adve rse side effects as d escri bed a bove m ust be

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 29-
132.
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

B
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 . Figure 43.4 (Continued) (B) and after greater than 30 subsequent surgical
procedures including flaps and skin grafts (Courtesy of Richard Bennett,
M o reno Arias GA, Ferra n d o J . I ntense pu lsed l ight for
Muba Taher, and Mathew A vram)
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 al.
Assessment o f c ryosu rgery for t h e treatm e nt o f verrucous
A b l a t ive
epidermal naevi . Acta Derm Venereal. 2009 ; 89 ( 3 ) : C02 lase r
292-294.
Pa rk J H , Hwang ES, Kim S N , et a l . Er:YAG laser treat Derm a l

ment of verrucous epidermal n evi . Dermatol Surg. 2004; compon e n t
re m a i n s
30(3 ) : 3 78-38 1 .
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
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

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 Figure 44 . 1 A middle-aged female with two lipomas on her arms
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 .

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 .
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 .

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 .

A
• 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 Figure 44.2 (A) Lipoma on posterior neck prior to surgical excision.
(8) Excision of lipoma.
• 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 .
- 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 .
c
P I T FALLS T O AVO I D/CO M P L I CATI O N S/
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.
D
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 Figure 44.2 ( Continued) (C) Subcutaneous suture for closure. (D) Gross
path specimen of lipoma
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 .
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

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 Figure 45 . 1 Small milia on face of a 3 7-year-old female
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 .
T h e i r c l i n ic a l a ppea ra nce i s c h a racteristi c .

None.
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.

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
A
• 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 B
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 I 23 1
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.
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 .
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
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
• Soft, s k i n -col ored , red/brown papu l e/nod u l e
cated o f a c l i nica l ly atypical N F. M u ltiple N Fs merit refe rra l
• S o l i tary lesion more common t h a n m u l t i p l e
to n e u rologic, ophth a l mologic, genetics, a n d orthoped ic
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 Sol i tary l e s i o n ( most com m o n ) I f m u lt i p l e les i o n s , r u l e out
relatives is i n d icated as wel l . Skin exa m i nation should • S u rgical shave or exc i s i o n , assoc i ated n e u rof i bromatosi s
treatment of choice • S u rgical shave or exc i s i o n ,
assess for axi l l a ry freckl i ng, cafe a u Ia it macu les, plexiform
• No rol e for lasers treatment of choice
N Fs, j uven i le xa nthogra n u lomas, a n d Lisch nod u les. • Lasers: seco n d - l i n e therapy
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 .

• N u m ber o f lesions
• 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 uti-

l 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
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 B
lesions
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
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.
• 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

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 .
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.

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.
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 .

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 Figure 47. 1 Multiple seborrheic keratoses on back of elderly male
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.

• 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
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
Figure 47.2 Posttreatment whitening of seborrheic keratoses after
- C0 2 a n d erbi u m : YAG lasers can a blate S Ks
treatment with a 755-nm Q-switched alexandrite laser with a fluence of
- Repigmentation of S Ks occ u rs i nfreq ue ntly after
10 J!cm2 and a 3-mm spot size. The procedure was performed after
treatment fractional resurfacing, which explains the blue dye remnants apparent
- Expensive com pa red to tra d itional thera p ies on his face

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
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
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 .

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- A
tive syri ngomas.
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,
B
LABORATORY EXA M I NAT I O N Figure 48.2 (A) Infraorbital syringomas in a young female. (8) Follow-up
B i o psy may b e i n d icated i f basa l ce l l carc i noma i s sus picture at 1 week after ablative fractional C0 2 laser resurfacing showing
pected . N o other la borato ries a re i n d icate d . improvement of the syringomas. This improvement is attributed mostly to
the postprocedure edema. No significant improvement was noted at a
later follow up
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 .

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 Figure 48.3 Multiple syringomas on the chest of a female
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 .
- 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. • 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
• 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
Topical Mechanical Lasers
cacy a n d sid e-effect profi l e .
• N o effective • Local a nesthes i a • A b l a t ive-Pu l sed C02 the
topical therapy w i t h l ight el ectro most effective moda l ity.
desi ccati o n Post-l aser erythema for 1 -2
P I T FALLS TO AVO I D/CO M P L I CATI O N S/ weeks . Apply emo l l i e n t over
treated area for opt i m a l
MANAG E M E N T/O UTCO M E hea l i n g.
EXPECTAT I O N S
• Although there a re m u ltiple treatment modal ities, they
H igh rec u rrence rate
a re often resista nt to thera py. Recu rrence is c o m m o n
L-------+• w i t h any mod a l ity i n
( Figs. 48 .3 a n d 48.4 ) . 1 2-36 months
• 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 . Figure 48.4 Diagram of syringoma treatment
• 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 .
• 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 ) : 1 370-
1374.
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.
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.
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.

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 .
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.

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.

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.
- 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.

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 .
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 .

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.
Syri ngomas, sebaceo us neoplasms, m i l i a , necrobiotic
xa nthogra n u l o m a .
Col lections of foa m cells i n the superfi c i a l d e r m i s .
COU RS E
A
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 .
B
• Loca l i zed Ti ss u e Dest r u ct i o n
Figure 50. 1 Xanthelasma on the left upper medial eyelid in a middle
C02 o r erb i u m laser va porization, tric h l o roacetic a c i d ,
aged woman. (B) The resulting defect is sutured using ethilon sutures.
el ectrosu rgery, o r c ryothera py.
This procedure produced a very good cosmetic result
• 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.
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
E I GH T
C utaneo u s Ca rcino mas
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 .
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) A
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.

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
B
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 .
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.
c
• Eczematous d e rmatitis
• Extra m a m m a ry Paget's Figure 5 1 . 1 (A) Numerous facial actinic keratosis pre-Aidara treatment.
(B) Expected erythema and crusting during A ldara treatment. (C) Facial
• Sq u a m o u s cell ca rc i n o m a
actinic keratosis post-Aidara treatment applied twice weekly for 4 weeks
• Basa l cell carc i noma (Courtesy of Richard Johnson, MDJ
Secti o n 8 : C u ta n eo u s Ca rc i n o m a s I 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 .

• 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 A

• 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 . B
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
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 in red u c i n g lesion cou nt.
Postoperative 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
• 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 I 25 1
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) : 1 875-
1 880 .
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 ) : 203-
2 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 .
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 Figure 52. 1 Large BCC on the face. Note the characteristic rolled bor
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 ders, overlying telangiectasias, and the central ulceration
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 a 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 .

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.
Dermal m e l a n ocytic nevi , sebaceous hyperplasia, sq ua
mous cel l c a rc i noma (SCC).
Secti o n 8: C u ta n eo u s Ca rc i n o m a s I 253
LABO RATORY DATA
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.

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
A
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 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
sion on biopsy ( Figs . 52 . 2-52.4) . M o hs m i c rogra ph i c surgery is the ideal treatment for this type of skin cancer providing the
su rgery has the h ighest c u re rate o f a n y treatm ent of highest cure rate among all other treatment modalities
BCC
• El ectrodessication a n d c u rettage
• Cryothera py
• 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 a 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 por-
phyri n , protoporphyri n IX. The m ethyl d e rivative of 5- A
ALA, 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
- 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
8
with the patient prior to treatment.
Figure 52.3 (A) Surgical defect after Mohs micrographic surgery of BCC
- Nonsurgica l thera pies may provide better cosmesis but
on the right forehead. (B) Repair of the defect with an A to T advance
sign ificantly h igher rates of recu rrence. Fu rthermore,
ment flap. Notice that the horizontal incision line is hidden within the
nonsurgical i nterventions d o not provide the opportu
eyebrow hairs for a better cosmetic outcome
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.
Secti o n 8: C u ta n eo u s Ca rc i n o m a s I 255
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 .
A
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
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 , ionizing ra d iati o n , a rse n i c expos u re ,
ge netic d isord e rs (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 .

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 .
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
LABO RATORY DATA
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
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

mended
• Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice A

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.
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)
B
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
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. A
Figure 53.5 {A) Surgical defect after Mohs micrographic surgery of an

sec on the left cheek.
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
NINE
I nf l a m matory Disord e rs
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

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 .
Figure 54. 1 Actinic LP on the forehead, temples, and lateral cheek,

mimicking melasma
LABORATORY DATA
G iven the association with h e patitis B a n d C , h e patitis
serologies can be i nvestigated .
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.
Secti o n 9 : I nfla m m atory D i so rd e rs I 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
• 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
Figure 54.2 Generalized lichen planus in a patient with skin type 1 V-V
• Corticoste roids 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
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 I 265
CHAPT E R 5 5 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 ) .
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 A
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 .

B
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 Figure 5 5 . 1 (A) Early morphea on the left leg presenting as an erythema
plaq ues with a l ight violaceous bord e r a n d a s h i n y s u r tous plaque. (B) Same patient with late stage morphea on the right leg
face. Posti nfla m matory hyperpigmentation is p reva lent presenting as linear depressed yellowish to white hard plaques with ery
( Fig. 55. 1 ) . Linear morphea presents with a l i nea r e rythe thematous margins
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.
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.

• 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.
A
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
B
• 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 for l i nea r m o r phea and fa c i a l h e m iatro p h y. taneous atrophy. (8) Elevation of the atrophic plaque of morphea after a
S u bc i s i o n is performed u n d e r loca l i nfi ltrative a n esthe single autologous fat transfer. The associated telangiectasias were subse
sia to the affected s ite with 1% l i d oca i n e with quently treated with the pulsed dye laser with substantial improvement
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 I 267
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) : 793-
797.
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 Figure 56. 1 Classic psoriatic plaques on the knees
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
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.

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.
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.
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 I 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

T
- Cyc lospori ne
- B i o logics suc h as a l efa cept, eta ne rcept, efa l uz i m a b , Figure 56.3 Improvement in treated psoriatic plaque 3 months after
a n d i nfl ixi m a b pulsed dye laser treatment (585 nm, 1 0-mm spot size, 5 J/cm 2 , no cool
• Laser a n d Light Treatme nts ing, 0. 45-ms pulse duration), as compared to the control site
- Psora len with U ltraviolet A ( P UVAJ (Reproduced, with permission, from Brian Zelickson, MD)
- U l travio l et B ( U V B ) , 3 1 1 - n m na rrowba nd-UVB ( N B-

UVBJ
- 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
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) :420-
424 .
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 ) :429-
436
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
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 .
A
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 B
I n cases of hormonal i m ba l a n ces, the fu n d a m enta l Figure 57. 1 Characteristic appearance of gynecomastia in a middle-aged
defect is a decrease in a n d rogen levels with a concomi male
ta nt i n c rease i n estroge n levels.

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.
B reast ca ncer, pse ud ogynecom asti a , b reast hypertrophy.

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
Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s I 273
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.

• 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 .
• 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 .

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.
• 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 , Ha RY, Ken kel JM, Ad a m s WP J r.
Classificatio n and ma nagement of 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 .
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
Figure 58. 1 Classic appearance of cellulite
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 .

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.
None.

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.

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
Figure 58.2 VelaSmooth laser treatment of thigh of young female
• 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;
however, typica l l y it d oes n ot i m p rove ce l l u l ite
• I n some cases, it accentuates the a p pea ra nce of cel

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
• 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 sep-
tae 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)

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 ,
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 ) : 204-
209 .
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
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 i n c l u d i ng hyperglyc e m i a , A
hyperl i pi d e m i a , and hypertriglycerid e m i a . Treatments
va ry accord i n g to the c l i n ical fi n d i ngs.
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 8
presents i n freq ue ntly in H IV patients na'lve to H I V ther
Figure 59. 1 (A) "Buffalo h ump " in dorsocervical back of HIV-infected
a py. Typical ly, pati ents a re on com b i nation thera pies.
male. (8) Substantial reduction in size of buffalo h ump after liposuction
procedure
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 .
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.

Fat a cc u m u lation a n d fat loss a re d isplayed .
• Fat acc u m u lation
Sect i o n 10: Ad i pose Tissue Alterati o n s I 28 1
- 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
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.

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 .

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
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
- N ot FDA c l ea red
• A h ighly pu rified 1 , 000-cSt s i l icon o i l has been exa m

i n ed i n 77 patients
• 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/

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.
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 .
CHAPT E R 60 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 .
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, A

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 . B
The i nfi ltrate fades i n older lesions.
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
PHYS I CAL L ES I ON S 1 4 J!cni2 , using a 6-mm spot size with a pulse duration of 30 ms.
M u ltiple sym metric l i nea r ba nd-l i ke plaq ues o f atro p h i c Treatment was performed at intervals of 2 to 3 months
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.
Linear foca l elastosis.

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 .
A
• 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
B
p l etely successfu l . In fact, m ost treatme nts provide mod
est or no benefit. Thus, prior to treatment, patie nts' Figure 60.2 (A) White striae, axilla. Prominent atrophy, textural changes,
expectations n eed to be tem pered . C o m b i nation treat and depigmentation are observed. (B) White striae, axilla, following three
ment i nvolving laser and topical regimens s u c h as fractional resurfacing laser treatments. Mild improvement of the atrophy
treti n o i n is often a hel pfu l method of treatment. More and textural changes are noted. Mild post-inflammatory hyperpigmenta
recently, nona blative a nd a b lative fractional treatm ents tion is observed, which resolved 3 weeks after the last laser treatment
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 10-
mm 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
Sect i o n 10: Ad i pose Ti s s u e Alterati o n s I 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 A

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 colori-
metric 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 B
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
• 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
be used i n assoc iation with laser thera py given its fa irly

benign sid e-effect profi l e .

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) : 955-
960.
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 ) : 368-
370.
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
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 :

Figure 6 1 . 1 Dermal injection of hypertrophic scar that resulted from a
Hypertro p h i c sca rs prese nt as thick, firm l i nea r plaq ues
shave biopsy
at the site of tra u m a . I n itial ly, they may be erythematous
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.
Dermatofi broma , sca r sarco i d , d ermatofi b rosa rcoma pro
tu bera ns, gra n u lo m a .

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
Ke loid Hypertro p h i c sca r
Defi n ition 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 Often sponta neous regression months after the i nj u ry
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 , 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 I 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
with o r fol l owed by oth e r thera pies. Treatments can produce eventual clinical improvement after a series of treatments
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
Dose I nterva l of time Hypertro p h i c sca r Keloids Com ments
l ntra les ional 1 5-40 mg!m l Every 2-6 weeks For m ost scars, Va ria ble su ccess; m ost Effective, safe,
tri a m c i nolone (site dependent) moderate to d ra matic successful with i nexpensive; ca re
aceto n i d e i m prove ment early i ntervention to avoid atrophy
( Fig. 6 1 . 1 )
I ntra lesional 50 mg/m l 1 -3 ti mes wee kly Ca n be effective; Va riable success No clea r adva ntage
5-fl u o ro u rac i l for t h e fi rst secon d - l i n e thera py ove r tria m c i nolone
1-2 wee ks; aceto n i d e
then every
2-5 weeks
S i l icone sheeti ng 1 2 h o u rs per Va ria b l e i m provement Va riable i m p rovement Safe
day for
1 2 weeks
l m i q u i mod I n d u ces t u m o r N ightly N ot stud ied Study showed no N o lo ng-term
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
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 low-density treatments. Typical ly, sca r A
re m od e l i ng 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 B
age of nea rly two treatme nts, 77% i m provement was
Figure 6 1 .3 (A) Pre- and (B) postappearance of a traumatic scar after a
noted . After th ree treatm e nts, 7 of the 1 5 patients had
series of fractional resurfacing treatments. There is some m ild residual
complete reso l ut i o n .
PIH that faded within 1 to 2 weeks
• Another stu d y u s i n g the 585- n m P D L treated one h a lf
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 4-6; but may req u i re fa r A
treatments 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 I 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
keloids/hypertro p h i c sca rring.
• Consider begi n n i ng therapy at the t i m e of su rgery o r at

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 rgi-
cal o r a blative thera py, it is i m porta nt to e l icit a ny recent B
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
c
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 Figure 6 1 .4 (Continued) (8) Improvement in acne scar erythema after a
de pressed a p pearance reflects a n u n d erlyi ng fi b rosis of series of pulsed dye laser treatments. (C) Further improvement with acne
the d e r m i s a n d su bcuta neous fat. scars with subsequent nonablative fractional resurfacing
• 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 .
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 S i d e effects i n c l u d e tem po ra ry erythema,
treatments; d eeper d e pth of i m provement afte r five to six edema, crusti ng, a n d mild pa i n
treatment is more effective, treatm ents
u nclear if h igher or lower density A blative: moderate i m provement
of treatment is m ore effective 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 40---{)0 % i m provement; m ore M o re d ownti m e a n d side effects t h a n
laser effective than nona blative 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 , Good , tem pora ry i m provement Req u i res test site for a l l e rgy
Zyd erm I I , Zyplast 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 I 295
TAB L E 6 1 .4 • 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 i cyl ic acid peels ( Fig. 6 1 .4) sa l icyl ic acid pee ls safe in s k i n types I V-V I ;
TCA peels; derma b rasion derma brasion s h o u l d n ot be performed
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
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 Good i m provement Ti me cons u m i ng. M u ltiple treatme nts. Better
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
A
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 .
B
C h u a S H , Ang P, Khoo LS , Goh C L . N o n a b lative 1450 n m
Figure 6 1 . 5 (A) Ice pick scars prior to punch excisions. (8) Improvement
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
of ice pick scars 1 week after suture removal. Further improvement was
type IV Asian ski n . Dermatol Surg. 2004 ; ( 1 0) : 1 287- 1 29 1 .
achieved with nonab/ative fractional resurfacing
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 .
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 Figure 6 1 .6 Patient after numerous punch excisions. Sutures are
removed 5 to 7 days after the procedure
Wa i bel J, Beer K. Fractional laser resu rfa c i n g fo r thermal
burns. J Drugs Dermatol. 2008; 7 ( 1 ) : 59-6 1 .
TAB L E 6 1 . 5 • I ce-Pick/Boxcar Scar
Adva ntage D isdva ntage
P u n c h h a rvesting and suture or Low cost, potentia l d ra m atic i m p rovement; U n p red i cta b l e , risk of m a k i ng cosmetic
punch ha rvest a n d i m p l a nt full best fo r na rrow, deep sca rs s u c h as a p pea ra nce worse; time consu m i ng
thickness graft 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; Postlaser erythema weeks to months; risk
best for s h a l l ow boxcar sca rs 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
F i l l e rs, ie, R estylane, collage n , No perma nent i m p rovement
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 Low risk of serious side effects I m prove ment 1 0-30 %
ie, 1 ,450- n m d iode No d ownti m e
1 2- 1 3 J/c m 2 (one pass) Treats a ny a ctive a cn e
l ower fl uenc ies (two passes)
m u ltiple monthly treatme nts
TWE LVE
Exogeno u s C utaneo u s A l te rat i ons
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.

• 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

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 Figure 62. 1 Ear-piercing gun being used on earlobe of a young female
• 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
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 I 299

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.
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 A
• 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 ther-
a 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

B
• H istory of a l le rgic or gra n u l omatous reactio n to tattoo
pigment 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
TABLE 63 . 1 • 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 ) Least pa i nfu l o f Q-switc hed lasers
Ye l l ow G reen Freq ue ncy-d ou bled Q-switc hed N d :YAG N ot very effective
( 532 n m )
G reen Red/nea r i nfra red Q-switc hed ru by ( 694 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 Q-switched N d : YAG ( 1 ,064 n m ) safe i n
skin types on ly a l l s k i n types. Less p i g m e n t loss
Q-switc hed N d : YAG ( 1 , 064 n m ) : a l l
s k in 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 I 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
A
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- B
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 c
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
• 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
laser a l lowi ng for up to a 10% overlap (Ta ble 63 .2)
A
• 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
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
treatment with dermabrasion. (B) Improvement after six treatments with
• S u n avoida nce, s u n sc reens 1 , 064-nm Q-switched Nd: YA G laser. While improvement is not complete,
• Telfa d ress i n g and hyd rated petrolatu m o i ntment with 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)
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 Figure 63.4 Traumatic tattoo on knee of a female that has persisted
o r tita n i u m oxi d e pigment with i n the tattoo 30 years after childhood bicycle fall. a-switched 1 , 064-nm Nd: YA G
cleared the tattoo i n three treatments
- A test site can be performed 4 to 8 weeks prior to
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

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 Figure 63.5 Tissue whitening after treatment with the 532-nm frequency
l ighte n i ng may be the best feasible c l i n ical resu l t doubled a-switched Nd: YAG and 694-nm a-switched ruby laser. Tissue
whitening is the appropriate endpoint when treating tattoos with a
• Tattoo treatment can prod uce hyper- a n d hypopigmen
switched lasers. Pinpoint bleeding resulted from injection of lidocaine
tation i n a ny patient, espec i a l l y those with da rker skin
with epinephrine prior to treatment
types
• 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
Figure 63.8 Scarring after treatment with a Q-switched ruby laser

(Courtesy of Teresa Soriano, MD)
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
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
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?
A
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 B
- 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
• 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
A

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
b
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

B
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
8 c
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.
1, 450-nm diode laser, 82, 82f, 83f pathogenesis, 72

5-a m inolevu l i n i c acid (5-ALA), 75, 254 physical exa m i nation, 72
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 Acra l amela notic melanoma, 206
1 450- n m diode laser, 4 1 , 74 Acti n i c c h e i l itis, 248
Actinic keratosis (AK), 248
consu ltative q uestions, 249
A cou rse, 249
Ablative fractional laser resu rfaci ng, 39, 57 dermatopathology, 248
adva ntages of, 57 d ifferential d iagnosis, 248
ind ications, 58 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 treatment, 249-250
postoperative care, 57f, 58f, 59 Acti n i c keratoses
preoperative eva l uation, 58 vs. wa rts, 206
prophylaxis/a nesth esia, 58-59 Acyclovir, 32, 46, 54
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 Adenoma sebaceu m , 2 1 2
for Becker's nevus, 2 1 8 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 preoperative eva l uation, 3
ca rbon d i oxide laser, 43, 43f, 44f 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 su bcuta neous fat atrophy, 5
proced ure, 48-49, 49f 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 Alcon La bs, 1 5t
ACE i n h i bito rs . See Angiotensi n-converting enzyme (ACE) i n h i bitors Al lerga n , 1 4t, 1 5t, 2 1 1
Aceta m i nophen, 58 Allergic reactions
Acetone, 48 to sclerothera py, 20 1
Acne scars, 290, 293 Al loderm , 14t
physica l lesions, 293-295 Aloe vera , 10
treatment, 295 Aloesi n , 9t, 10
Acne vu lga ris, 72, 76, 1 00 a-hyd roxy acid, 32
vs. angiofi broma, 2 1 2 lotions, 182
cou rse, 73 for posti nfl a m matory hyperpigmentation, 1 60
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 A m b u latory phle bectomy, 202
dermatopathology, 73 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 58-59
topical treatment, 73 for a blative laser resu rfaci ng, 46-47
31 1
31 2 I I ndex
for a ngiofi broma, 2 1 3 B

for l i poma treatment, 227 B l u pu s m i l iaris d isse m i natus faciei, 76
for neurofi broma, 236 B - H C G . See � - H u m a n chorionic gonadotropin
for nonablative fractional laser resu rfaci ng, 54 B a n naya n-Zonana synd rome, 226
for nonablative laser resu rfa c i ng, 40
Basa l cell carci noma ( BCC), 81, 252-254
m i d - i nfrared lasers, 40f, 4 1
epidermal nevus a n d , 222, 223
for soft tissue augmentation, 1 6f, 1 7
consu ltative q uestions, 253
for wa rt remova l , 207t, 208
cou rse, 253
Angiofi broma, 2 1 2-2 1 5 de rmatopathology, 252
consu ltative q uestions, 2 1 3
d ifferential d iagnoses, 252
cou rse, 2 1 3 , 2 1 3f
epidemiology, 252
de rmatopathology, 2 1 2
la boratory data, 253
d ifferenti a l d iagnosis, 2 1 2
ma nagement, 253-254, 253f, 254f, 255f
epidemiology, 2 1 2
pathogenesis, 252
laboratory data , 2 1 3
physical exa m i nation, 252, 252f
ma nagement, 2 1 3-2 14, 2 1 4f, 2 1 5f
pitfa l l s , 254
pathogenesis, 2 1 2
B ea rberry, 1 0
physical exa m i nation, 2 1 2 , 2 1 2f
B ecker's nevus, 2 1 6--2 1 8
pitfa l l s , 2 1 4
consu ltative q uestions, 2 1 7
Angiokeratoma, 1 68
cou rse, 2 1 7
vs. angiomas, 1 7 1
d ifferential d iagnosis, 2 1 6
cou rse ma nagement, 1 68-1 69, 1 69f
epidemiology, 2 1 6
de rmatopathology, 1 68
la boratory exa m i nation, 2 1 6
differentia l d i agnoses, 1 68
ma nagement, 2 1 7-2 18, 2 1 7f
epidemiology, 1 68
pathogenesis, 2 1 6
physical exa m i nation, 1 68
pathology, 2 1 6
pitfa l l s to avo i d , 1 69
physical exa m i nation, 2 1 6, 2 1 6f
Angio l i poma, 226
pitfa l l s , 2 1 8
Angiomas, cherry and spider, 170
B e l otero Basic, 1 4t
cou rse, 1 7 1
B e l otero Soft, 14t
differentia l d i agnoses, 1 7 1
Benign growths
epidemiology, 1 70
a ngiofi broma, 2 1 2-2 1 5
ma nagement, 1 7 1 - 1 7 2
Becker's nevus, 2 1 6--2 1 8
pathogenesis, 1 70
epidermal i nclusion cyst, 2 1 9-22 1
pathology, 1 7 1
epidermal nevus, 222-225
physical exa m i nation, 1 7 1
Benzoyl peroxide, 73
pitfa l l s to avo i d , 1 7 2
Angiotensi n-converti ng enzyme (ACE)
�- H u ma n chorionic gonadotropin ( B- H C G )
Betaca ine Enha nced Gel, 1 7
i n h i bitors, 89
B etaca ine P l u s , 1 7
Anth ra l i n , 224
B io-Aica m i d , 14t
Anti bacterial agents, 73
B i oform M e d i ca l , 1 5t
Anti bacteria l thera py, 46, 53
B iomatrix I nc . , 1 5t
Anti biotics, 73
B i o psies
Antima la ria ls, 1 75
epidermal i nclusion cysts, 220
Antioxida nts, 8
Anti pers p i ra nt, 89 epidermal nevus a n d , 223
Antivira l med ications, 49 l i poma, 227
Antivira l thera py, 46, 54 neurofi broma, 232
Apraclo n i d i n e hydrochloride, 28 seborrheic keratosis, 235
Aq ua m i d , 1 4t B i otech I n d u stry, 1 5t
Aquaphor H ea l ing O i ntment, 49 B laschke, l i nes of, 222
Arbuti n , 9t, 1 0 B leac h i n g crea ms, 46
Artefi l l , 1 4t B l e p h a rochalasis, 64
Arterial spider, 1 70- 1 73 B loom's synd rome, 67, 136
Ascorbic acid , 9t, 1 1 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 Botox Cosmetic, 2 1!
AstraZeneca , 1 7 Botu l i n u m toxin
Ataxiatela ngiectasia, 67 com pl ications, 27
Ativa n , 58 contra i n d ications
Atro p h i c scars, 294-295 a bsol ute, 22
Atrophoderma verm iculatu m (AV), 1 8 1 relative, 22
Avila , 9 d i l ution, 22
Avobenzone, 7t mecha nism of action, 21
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 forehea d , 22f, 23-24, 23f
I n d ex I 313
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 course, 276
periorbital regio n , 24-25, 25f epidemiology, 276
u pper nasal root, 25, 26f 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 treatments, 277-278, 277f
prepa rations, 2 lt Centrofacial te la ngiectasias, 194f
proced u re, 23 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 ideal ca n d i d ate, 3 1
a n esthesi a , 88 less ideal ca n d idate, 3 1
antipers p i ra nt, 89 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 wou n d depth, 32
treatment, 88-89, 88f, 89f 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
Clostridium botulinum, 2 1
C02 l a s e r a b lation, 82
c C02 resu rfacing. See Carbon d ioxide (C02 ) laser
Cafe au lait macu les (CALMs), 136 Coenzyme Q10, 8
vs. B ecker's nevus, 2 1 6 Colchicine, 1 7 5
consu ltative q uestions, 137 Col lagen, i n a ngiofi broma, 2 1 2
cou rse, 137 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 Complete tea rs, 308
laser treatment, 1 37-138 Compression stocki ngs, 200
ma nagement, 137 Congen ital ad renal hyperplasia, 92
vs. neurofi bromas, 232 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 Cooltouch I n c . , 4 1
pitfa l ls, 138 Corrective h a i r transplant su rgery, 1 10, 1 1 0t
topical treatment, 138 Corrugator s u perc i l i i , 24, 24f
Calci potriol, 224 Corticosteroids, 1 64, 1 75
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 for m i l ia , 229
Canderm Pharma, I n c . , 1 4t Cosmod ermrM , 14t
Ca n i n us, 26, 27f, 28f Cosmoplas(TM , 14t
Cantharone, 207 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 Cryothera py
Carbon d ioxide laser resu rfacing for de rmatosis pa pu losa n igra , 242
for a ngiofi broma, 213, 2 1 4-2 1 5f for ephelides, 142
for a ngiomas, 1 72 for epidermal nevus, 224
for basa l cell ca rcinoma, 254 for lentigines, 146
for epidermal nevus, 224 for sebaceous hyperplasia, 83
for neu rofi broma, 232 for seborrheic keratosis, 236
for seborrheic keratosis, 236 for sq uamous cell carcinoma, 258
for sq uamous cell carcinoma, 258 for venous lakes, 204
for venous la kes, 208 for wart remova l , 209
for wa rts, 207t, 208 for seborrheic keratosis, 236, 237, 237f
314 I I ndex
C u rettage Dyschromia
for epidermal nevus, 224 from wart remova l , 207t, 208, 209
for wa rt remova l , 209 Dysport, 2 lt
Cushi ng's d isease, 92, 285
Cutting tool , 44
Cymetra Life Cell Corp., 14t E
Cynosure, 56, 56t Ea r piercing, 298
Cyproterone acetate, 1 28 consu ltative q uestions, 298
Cysts 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 pitfa l l s , 299, 299f
m i l i a , 229-230 treatment, 298
pilar cysts, 220 Ectopic ad renocorticotropic hormone prod uction, 92
Electroca utery, 239
for epidermal nevus, 224
Electrodesiccation, 83
D for a ngiofi bromas, 2 1 3
DAO. See Depressor angu l i oris for seborrheic keratoses, 236
Dapsone, 1 75 Electrolysis, 94, 2 1 7
Deep-depth strength peels, 30t, 33 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 vs. fol l i c u l a r unit extraction ( F U E) , 107, 107t
Derc u m 's d i sease, 226 E l l m a n S u rgitro n , 78
Derma brasion , 1 75 Em bol ization, 180
for epidermal nevus, 224 Endermologie
for a ngiofi broma, 2 1 4 for cel l u l ite, 277-278
Derm a l melasma, 149 Endocrine stud ies, of acne v ulgaris, 72-73
Dermatochalasis, 64 Endocrinology, consu ltation with, 93
consu ltative q uestions, 65 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 d ifferential d iagnosis, 1 40
pathogenesis, 64 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 pathogenesis, 139
Dermatosis pa pu losa n i gra ( D P N s ) , pathology, 140
24 1 , 24lf physical lesions, 140
consu ltative q uestions, 242 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 pitfa l l s to avoid/com plications/ma nagement, 143
ma nagement, 242 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 d ifferential d iagnosis, 220
Destructive modal ities, 83 epidemiology, 2 1 9
of sebaceous hyperplasia la boratory data, 220
Diazepa m , 17 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 physical exa m i nation, 2 1 9, 2 19f
for venous la kes, 204 pitfa l l s , 22 1
Dioxybenzone, 7t 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 I 31 5
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 physical exa m i nation, 1 26, 1 28-129
la boratory data, 223 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 preoperative i n structions, 1 3 0
vs. seborrheic keratosis, 223, 235 Fern d a l e La bs, 1 7
treatment, 224-225 Fi brous pa pu les, 2 1 2
Epidermis F i l iform wa rts, 206
a n d epidermal i n c l usion cysts, 2 1 9 F i l lers
i n l i poma, 226 permanent, 282-283
Epidermoid cyst, 2 1 9 tem porary, 282
E pi l u m i nescence microscopy ( E L M ) , 203 Finasteride, 104, 104t, 1 28, 1 33
Epinephrine, 59 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 Foam sclerothera py, 199-200
and seborrheic keratos is, 236 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!
Eryth romyc i n , 73 vs. e l l i ptica l strip ha rvesting, 1 07t
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 m i l i a , 229-230
Eye i nj u ries 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 Fronta l i s m u scles, 24, 24f
Facial age-related conto u r changes, 2t 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 G
epidemiology, 192 Gelatinase, 9
ma nagement, 192-194 Genita l wa rts, 206-209
physica l exa m i nation, 192 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 G l oga u Photoaging Classification, 2f, 3 -4 , 3f, 4f, 51
prior to p u l sed dye laser treatment, 1 931 G lycolic acid , 9t, 30!
Fa n n i ng, 18 G lycolic acid pee l , 32, 331, 74, 1 60
Fascia B iomateria ls, 1 5t and e p h i l ides, 1 4 1
Fascia n, 1 5t and melasma, 1 5 1 , 1 5 1 t
Fat accu m u lation G lycopyrro n i u m bromide, 8 7
treatment of, 283 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 G rafts, s k i n , 2251
c h i ef com pla i nt, 1 3 1 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 l ight treatment, 1 75
female hair transplantation, 1 3 1 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 m u ltiple lesions of, 1 75f
female surgica l pla n n i ng, 129 pathogenesis, 1 74
postoperative i n structions, 130 physical exa m i nation, 1 74
postoperative period , 130- 1 3 1 pitfa l l s to avoid, 1 7 5
preoperative i n structions, 1 30 syste m i c treatment, 1 75
vs. male pattern h a i r loss, 1 29, 1 29t, 1 3 1 1 topical treatment, 1 7 5
31 6 I 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 botox, 89
consu ltative q u estions, 273 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 de rmatopathology, 86
pathogenesis, 272 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
H physica l fi ndi ngs, 86
H a i r loss. See Female pattern h a i r loss; M a l e pattern h a i r loss pitfa l l s , 89-90
H a i r remova l , 2 1 7 su rgery, 88
H a i r tra nspla ntation, 1 04-1 05 topical med ications, 87
H a i r l i n e design , 1 08 Hyperh i d rosis
H a rn a rto rna , 2 16, 222 sites of, 90f
treatment d iagra m , 87f
Hemangioma, segmenta l , 1 80f
Hemangioma, u l cerated , 1 79f Hyperpigrnentation
Herna ngiornas, 1 7 7 a n d cryotherapy, 209
H i bernoma, 226 and post-sclerothera py, 200
H i biclens, 48 Hype rsensitive rea ctions, of soft tissue augmentation , 18
H i rsutism, 92 Hypertonic sa l i n e , 199, 200t, 201t
Hypertrichosis, 2 1 6, 2 1 7
consu ltative q u estions, 93
cou rse, 93 Hypertrophic sca rs, 290
differentia l d iagnosis, 92-93 c l i n ical experience, 293
epidern iology, 92 d ifferential d iagnosis, 290
laboratory tests, 93 vs. keloids, 290!
la boratory exa m i nation, 290
ma nagement, 93
laser, 29lf, 292, 292f
electrolysis, 94
endocrinology, consultation with , 93 ma nagement, 291
j ust prior to treatment, 96 physica l exa m i nation, 290
laser h a i r remova l tech n i q ue, 95, 96-98 pu I sed dye laser, 292t
non laser thera p ies, 93-94 stud ies, 292
Hypopigmentation, 67, 187f
patient consu ltation, 95-96
and cryothera py, 209 , 236
posttreatment i n structions to patient, 98
physical exa m i nation, 92 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 lcod i n , 58
differentia l d iagnosis, 281 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 I nfa nti le hemangioma ( I H ) , 1 7 7 , 1 7 7f, 1 78f
physical lesions, 280-281 a n c i l l a ry tests, 1 78
pitfa l ls, 283-284 com pl ications, 1 78
prec i pitating factors, 280 course, 1 78
prevention, 28 1 de rmatopathology, 1 7 7
treatments, 282-283 d ifferential d iagnoses, 1 7 7
Homosalate, 7t epidem i ology, 1 7 7
Hormones, 73 la boratory tests, 1 77
H u ma n pa pil lomavirus ( H PV), 206-209 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, pitfa l l s t o avo i d , 180
Hyd roxy acid, 73 I ntense pu lsed l ight lasers
Hyd roxycou marins, 9t for pseudofo l l i c u l itis, 1 0 1
Hylaform ® , 1 5t for Becker's nevus, 2 1 8
Hyperhid rosis, 86 for cherry and spider a ngiomas, 1 72
I n d ex I 31 7
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 Laser safety, 97f
l ntra lesional 5-fl uoro u racil (5-FU ) , 29 1 , 29 lt nona b lative laser resu rfaci ng, 41
l ntra lesional steroid i njection, 74 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 nonfacial ski n, 60-6 1
lsolage n , 1 5t postoperative care, 57f, 58f, 59
Isopropyl a lcohol , 48 Laser thera py
lsotreti n o i n , 40, 58, 74, 77 for d ermatochalasis, 65
for gra n u loma faciale, 1 75
for Poiki loderma of Civatte, 68, 68f
J 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
cou rse, 1 45
Keflex, 1 7 , 46
cryothera py, 146
Keloids
d ifferential d iagnosis, 145
epidemiology, 144
vs. hypertrophic scars, 29ot
la boratory exa m i nation, 145
vs. keloids, 290t
laser and l ight sou rce treatment, 146-147
laboratory exa m i nation, 290
ma nagement, 1 45
laser, 29lf, 292, 292f
pathogenesis, 1 44
ma nagement, 29 1
pathology, 144
physica l exa m i nation, 290
physical lesions, 144
pulsed dye laser, 292t
pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations,
stud ies, 292
147-148
Keratinocytes, 1 40, 222
vs. seborrheic keratosis, 235
Keratolytic agents, 73
topical med ications, 1 45-146
Keratoses
Lentigo sim plex, 144
seborrheic, 223
LEOPA R D synd rome, 1 44
Keratosis fol liculari s s p i n u losa deca lva ns ( KFSD), 1 8 1
Lichen planus ( L P ) , 262-264
Keratosis p i l a r i s atroph ica ns ( KPA), 1 8 1 , 1 8lf, 1 82f
course, 263, 264f
cou rse, 1 8 1
de rmatopathology, 262
dermatopathology, 1 8 1
d ifferential d iagnosis, 1 8 1
epidemiology, 262
epidemiology, 1 8 1
la boratory data , 262
ma nagement, 1 8 2
ma nagement, 263
pathogenesis, 1 8 1
pathogenesis, 262
physica l exa m i nation, 1 8 1
physical exa m i nation, 262, 262f, 263f
pitfa l l s t o avoid , 182
Lichen striatus, 223
Keratosis pila ris atroph ica ns faciei ( KPA F ) , 181
Licorice extract, 9t, 10
Keratoses
Lidoca i ne, 47, 59, 107
actinic, 206
for wart removal , 208
seborrheic, 206, 234-237
Life Cell Corp. , 1 4t
Kindler synd rome, 67
Light treatment, of acne vu lgaris, 72f, 73f, 74-75, 75f
Koenen's tumor, 2 1 2
Koj ic acid , 9t, 1 0 , 1 4 1 Light cryothera py, 82
Linear foca l elastosis.
KTP laser. See Potass i u m -tita nyl-phosphate laser
Linear th readi ng, 1 8
Linoleic acid, 9t
Li pectomy, 283
L Lipoma, 22&-228
L- M -X-4 a n d 5, 1 7 consu ltative q uestions, 227
Lactic acid, 182 cou rse, 227
Lactic acid, 9t d ifferentia l d iagnosis, 226
LAM B synd rome, 1 44 epidemiology, 226
La nzhou I nstitute of B iologica l Prod ucts, 2 1t la boratory data , 227
Laser h a i r remova l pathology, 226
31 8 I I ndex
physical exa m i nation, 226, 226f, 227f, 228f Melanin

pitfa l l s , 228 i n post-sclerothera py hyperpigmentation , 200
treatment, 227-228, 227f, 228f in seborrheic keratosis, 236
Li posa rcom a , 226 M ela nocyte cytotoxic agents, 9t
Li posucti o n , 88 Melanocyte tra nsfer i n h i bition, 9t
for cel l u l ite, 277 Melanoma
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 M elasma, 1 4 9 , 1 49f
Lob u l a r ca p i l l a ry hemangioma, 188-- 1 9 1 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
mecha nism of action , 133 de rmatopathology, 149
pea rls of wisd o m , 1 33 d ifferential d iagnosis, 1 50
use of, 1 33 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 pathogenesis, 1 49
LP. See Lichen planus physical lesions, 149
Lux 1 , 540 n m laser, 56, 56t pitfa l l s , 1 52-153
Q-switched laser, 1 52
topical treatment, 1 5 1 , 1 5 lt
M M EN D . See M icroscopic epidermal necrotic debris
Macu les, 2 1 6, 223 M enta l i s m uscle, 26, 27f, 28f
Madelu ng's d i sease, 226 Mentor Corporation, 1 5t
Male pattern hair loss, 1 03 . See also Female M eq u i n o l , 9t
pattern hair l oss M e rz Pharma, 1 4t, 2 lt
consult, 105 M esothera py
d ifferential d iagnosis, 1 03 for cel l u l ite, 278
epidemiology, 1 03 M ethanthel i u m bromide, 87
vs. fem a l e pattern h a i r loss, 129, 1 29t, 1 3 1 1 M ethyl a m i nolevu l i nic acid ( MAL), 254
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
medica l thera py, 1 04, 1 04t M exoryl SX, 7t
natural progression, 1 03 M exoryl XL, 7t
pathogenesis, 103 M icroderma brasion, 74, 229, 287
physical exa m i nation, 1 03 , 1 03f, 1 05f M icrosco pic epidermal necrotic debris ( M E N D ) , 52
s u rgica l proced u re M icroth ermal treatment zones ( MTZs ) , 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 M i l i a , 229-230
fol l i c u l a r unit extraction ( F U E) , 107, 107t 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 physica l exa m i nation, 229, 229f, 2301
postsu rgica l period after sutu res/sta ples pitfa l l s , 230
removed , 1 09-1 1 0 treatment, 230, 2301
preoperative i n structions, 1 06 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 M ixed dermal melasma, 149
McCune-A l bright syndrome, 136 M ixed su perficial a n d deep hema ngioma ( M H ) , 177
M c G h a n Medica l , 1 5t 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 de rmatopathology, 266
M ed i u m -d e pth pee l , 30t, 3 3 , 34f, 35f d ifferential d iagnosis, 265
M edy-Tox, Inc, 2 l t epidemiology, 265
I n d ex I 31 9
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 preoperative pre paratio n , 54
pitfa l l , 267 proced ura l tips, 54-55
M TZs. See M icrothermal treatment zones 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 adve rse side effects, 4, 4 1 f l
nasola bial fol d , 25-26, 27f postoperative care, 4 1 -42
neck, 26-27 , 28f 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 m i d - i nfra red lasers, 40f, 4 1
Myobloc, 2 l t 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
N Non laser thera py, 93
N A F R . See Nona blative fractional laser res u rfacing depi lati o n , 94
Nasal sebaceous hyperp lasia . See R h i nophyma topical eflorn ith i n e , 94
Norwood classification, 103f
Nasolabial fol d , 25-26, 27f
N d :YAG laser, 99, 1 93
for seborrheic keratosis, 236
N eck, 26-27 , 28f 0
N e u rofi bromas ( N F) , 23 1-234 Octocrylene, 7t
consu ltative q uestions, 232 Octyl methoxycinna mate, 7t
cou rse, 232 Octyl sa l i cylate, 7t
d ifferential d iagnosis, 23 1 Ocular rosacea , 76
epidemiology, 2 3 1 Oral medications
la boratory data, 232 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 Orbicularis ocu l i tone, 64
physica l exa m i nation, 23 1 , 23lf Orbicularis oris, 26, 27f, 28f
pitfa l ls, 223-224 Oxybenzone, 7t
treatment, 232-233, 232f
N e u rofi bromatosis, 136
N e u ronox, 2 l t p
N e v u s a ra neus, 1 70- 1 73 rf>3 tumor suppressor gene, 252
N evus, Becker's, 2 1 6-2 1 8 PABA. See Pa ra-a m i n o benzoic acid
N evus, epiderma l , 222-225, 235 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
consu ltative q uestions, 1 55 Paper m u l berry, 1 0
cou rse, 155 Papu les
d ifferential d iagnosis, 1 54 in angiofi bromas, 2 1 2
epidemiology, 1 54 i n epidermal nevus, 223
la boratory exa m i nation, 155 i n warts, 206
ma nagement, 1 55 Papu lopustular rosacea, 76
pathogenesis, 1 54 Pa ra-a m i n o benzoic acid ( PABA), 7t
pathology, 1 54 Partial tears, 308
physical lesions, 1 54 Patient consu ltation, 95
pitfa l ls, 1 57 prior to treatment, 95-96
topical treatment, 155 P D L. See Pu lsed d ye laser
treatment, 1 55- 1 56 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 Peel types, 33
Nonablative fractional laser resu rfacing ( N A F R ) 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 Penici l l i u m , 1 0
dermatopathology, 52, 52f 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 Periorbita l region, 24-25, 25f, 26, 27f, 28f
mecha nism of action, 52, 52f Periorbita I rhyti d es, 55f
320 I 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 expectations, 1 6 1
P H A G E synd rome, 1 78 s u n p rotection, 1 59
Phenol, 30! 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 Pregna ncy
P hymatous rosacea . See Sebaceous hyperplasia and telangiectasias, 1 98, 201
P hysical screen , 8, 8t 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 Primary and rogen-prod ucing neoplasms, 92
hypertension Procerus, 24, 24f
Pilar cysts, 220, 226 Propanth e l i ne, 87
P i mecro l i m u s, 1 64 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 prophylaxis in, 273
in a ngiofi broma, 2 1 2 Proteus syn d rome, 226
i n Becker's nevus, 2 1 6 Pseudofollicul itis, 99
i n seborrheic keratosis, 235 course, 100
P latysma m uscle co m p l ex, 26--27, 28f 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 la boratory exa m i nation, 100
Poiki loderma of Civatte ( POC), 67 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 treatment
epidemiology, 67 laser hair remova l , lOOt, 1 0 1 , 1 0 1 1
ma nagement, 68 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 Pseudofo l l i c u l itis, a n d etrology, 1 0 1 1
pretreatment, 68f Pseudogynecomasti a , 272
treatment, 68, 68f Pseudo-och ronosis, 34, 1 59f
Polidoca n o l , 199, 200, 200! 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 course, 268
Port-wine sta i n s ( PWS), 1 83 , 1 84f, 1 85f, 1 86f d ifferential d iagnosis, 268
ancil lary tests, 1 83 epidemiology, 267
course, 183 la boratory data, 268
dermatopathology, 183 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 pitfa l l s , 270
physical exa m i nation, 1 83 Psuedogynecomastia, 274
pitfa l l s to avo i d , 183 P u l sed carbon d i oxide laser, 250
Post hair tra nsplant side effects, 109 Pu lsed dye laser ( P OL)
Post i nfla m matory erythema for acne vulga ris, 75
a n d cu rettage, 237f for a ngiofi broma, 2 1 3
Post i nfla mmatory hyperpigmentation ( P I H ) , 1 58, 1 58f for a ngiokeratomas, 1 69
chemical peels, 1 6(}- 1 6 1 for cherry and spider a ngiomas, 1 7 1
consu ltative q uestions, 1 59 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 for m orphea , 266
lasers, 1 6 1 for Poiki loderma of Civatte, 68
treatment, 2 18, 233 for port-wine sta ins, 185
ma nagement, 1 59 for psorias, 269
I n d ex I 32 1
for pyogenic gra n u lo m a , 189 Rete ridges

for rosacea , 78 in epidermal nevus, 222
for sebacious hyperplasia, 82 Reticular veins, 198-202
for striae d i ste nsae, 287 Reticulated hyperpigmentation , 67
for telangiectasias, 201 Reti n-A, 1 82
for venous la kes, 203, 205f Reti naldehyde, 8, 9
for warts, 206f, 208, 208f, 209f Reti noic acid, 8-9, 9t, 10, 1 2
for warts, 208 chemical structu res of, Sf
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 Reti n o l , 8
PUVA. See Psora len a n d u ltraviolet A Retinyl esters, 8
Pyogenic gra n u loma ( PG ) , 1 88, 188f, 1 89f 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
d ifferential d iagnoses, 1 88 cou rse, 77
epidemiology, 188 de rmatopathology, 77
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 systemic thera py, 77
s u rgica l treatment, 189 topical thera py, 77
vs. venous la kes, 203 pathogenesis, 76
physical exa m i nation, 76
Roth m u nd-Thomson synd rome, 67
Q R u by spot, 1 70-1 73 . See also Cherry a ngiomas
Q-M ed AB, 1 5t R ussell-Silver synd rome, 1 36
Q-switched lasers, 1 52
alexa nd rite
for Becker's nevus, 2 1 7, 2 1 8f s
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 Sa l i n e
for epidermal nevus, 225 a n d warts, 2 0 7 , 208
for nevus of Ota , 1 55, 1 56 and tela ngiectasias, 201
for seborrheic keratosis, 236 Scarring
a rgon from a n giofi broma treatment, 2 1 4
and gra n u loma faciale, 1 75 from surgica l i ncision, 224, 228
N d :YAG from wart remova l , 207t, 208, 209
for Becker's nevus, 2 1 7, 2 1 8f SCC . See Squamous cell carcinoma
for cafe au Ia it macules, 1 3 7 , 138 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 Se baceo us hyperplasia, 76, 77, 8 1 , 8lf
r u by consu ltative q uestions, 81
for Becker's nevus, 2 1 7, 2 1 8f 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 la boratory exa m i nation, 81
for seborrheic keratosis, 236 ma nagement, 82
for tattoo remova l , 300!, 302t pathogenesis, 81
pathology, 8 1
physical lesions, 8 1
R pitfa l l s , 83
Rad iation dermatitis, 67 treatments, 82
Rad iation thera py, 2 54 destructive modal ities, 82
Radiesse TM , 1 5t 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 d ifferential d iagnosis, 235
R estylane, 1 5t epidemiology, 234
R estyla ne-L, 1 5t vs. epidermal nevus, 223, 235
322 I 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 vs. epidermal nevus, 223
treatment, 236 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 vs. seborrheic keratosis, 235
Sharplan FeatherTouch, 1 69 vs. wa rts, 206, 207
Shave biopsies a n d excisions 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 Strawberry, 1 77- 1 80
for seborrheic keratosis, 236 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 cou rse, 286
S i l i kone- 1 000, 1 5t 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 pathogenesis, 285
a n d Becker's nevus, 2 1 8 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 treatment, 286-287
Sod i u m tetradecyl su lfate, 199, 200t, 20lt Stromelysi n , 9
Soft tissue a ugmentation Stu rge-Weber syndrome (SWS) , 184
adve rse reactions 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 Su bcuta neous fat atro phy, 5
a n esthesia, 1 6f, 1 7 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 and sclerothera py, 200
i njection tech n i q ue, 18, 1 8f, 19f and venous lakes, 203
level of i njection, 1 7- 18, 1 7f, 18f Sun protective factor ( S P F ) , 8
mecha n ism of action , 14 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 in hyperhidrosis, 88
Softform, 1 5t S u rgica l excision, 1 75
Solar le ntigo vs. ephel i d , 145t S u rgica l proced u re, for hair tra nsplantation
Solar le ntigos, 144 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 fol l i c u l a r u n it extraction ( F U E) , 107, 107t
Soybea n/m i l k extracts, 9t 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 postsu rgica l period after sutu res/sta ples
Squamous cell carcinoma (SCC), 256-258 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 I 323
reci pient region, a nesthesia i n , 1 08 proced ure, 62

reci pient site creation, 1 08, 1 12f checkl ist, 62-63
S u rgica l thera py side effects, 63
of acne vu lgaris, 74 Topica l 5-fl uorou raci l , 254
for a ngiofi broma, 2 1 3 Topica l eflorn ith ine, 94
for Becker's nevus, 2 1 7 Topica l i m iq u i m od , 254
for Dermatochalasis, 64f, 65 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
for neu rofi broma, 232-233, 232f Topica l thera py
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
Syri ngoma, 238, 238f of pseudofo l l i c u l itis, 1 0 1
consu ltative q uestions, 239 o f Rosacea , 77
cou rse, 239 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 i nd ications, 1 1
pathology, 238 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 pretreatment eva l uation, 1 1
System i c l u pus erythematosus, 76 treatment pearls, 12-13
System i c thera py Topica l treti n o i n , 46, 146
of acne vu lgaris, 73-74 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 treatments, 308-309, 308f, 309f, 3 1 0f
Tacro l i m us, 1 64 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 TriActive Laserd ermology, 278
consu ltative q uestions, 300-301 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 Trola m i n e sa l i cylate, 7t
tattoo treatment, 302, 302t, 303f, 304f 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 Tyrosinase, 9
lower extremity, 198-202 Tyrosi nase i n h i b itors, 9t
epidemiology, 198
laboratory data, 198
ma nagement, 199-202, 1 98f, 1 99f, 200f u
pathophysiology, 198 U l cerated hemangioma, 1 79f
physical exa m i nati o n , 198 U ltra , 1 5t
Telangiectatic matting rM , 201 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
Thyroid-sti m u lating hormone (TS H ) , 1 63 U ltraviolet A ( U VA), 67
Tissue tighte n i ng, 62 U ltraviolet B ( U V B ) , 67
ca n d idate selection, 62 U p per a n d m idfacial m uscu latu re, a natom ical i l l u stration
c l i n ical pea rls, 63 of, 22f
mecha n ism of action, 62 U p per face, 2-3
324 I 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
UVA. See U ltraviolet A exci mer laser, 1 65
UVB exposu re, 9 ma nagement, 1 64
U V B . See U ltraviolet B oral thera py, 1 65
pathoge nesis, 1 63
photothera py, 165
v physical lesions, 1 63
Valacyclovir, 46 pitfa l l s to avoid/co m p l ications/managem ent!
Valacyclovir, 54 outcome expectations, 1 66
Valtrex, 1 7 , 32 preventi o n , 1 64
Va n iqa . See Topica l eflorn ith i n e s u rgica l treatments, 1 65
Va porizi ng tool , 44 topical treatment, 1 64
Variable-pu lse P D L, 78
Varicose veins, 198-202
Vascular a lterations w
lower extremity telangiectasias, 198-202 Warts, 206-209
reticular and va ricose veins, 198-202 cou rse, 207
venous lakes, 203-205 de rmatopathology, 206
warts, 206-209 differentia l d iagnosis, 206
Vascular a lterations epidemiology, 206
venous lakes, 203-205 pathogenesis, 206
warts, 206-209 physica l exa m i nation, 206
Vasc u l a r ectasia, 77 pitfa l l s , 209
Vascular lasers, 39 treatment, 207-209, 206f, 207f, 205f, 209f
Vascular rosa cea , 76 Watson's syndrome, 136
Vascular spid er, 1 70- 1 73 Westerhof's syndrome, 136
Vaseli ne, 34 Wickha m 's striae, 262
Vei ns, reticular a n d varicose, 198-202 Wood's l a m p eva l uation, 3 1 , 3 1 1, 1 63
VelaSmooth system , 278 Wydase. See Hya l u ron idase
Venous lakes, 203-205
cou rse, 203
de rmato pathology, 203
X
d ifferenti a l d iagnosis, 203
Xa nthelasma pa l pebraru m . See Xa nthelasrnas
epidemiology, 203
Xa nthelasmas, 243
e p i l u m i n escence m i c roscopy ( EL M ) , 203
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
Venous o bstruction, 198
ma nagement, 244
Venous va lvular incom petence, 198
pathoge nesis, 243
Verruca , 223, 235
physica l exa m i nation, 244
Vincristine, 1 79
pitfa l l s , 244
Vita m i n C, 8
Xeom i n , 2 1 !
Vita m i n E, 8
Vitiligo, 1 63
consu ltative q uestions, 1 64
cou rse, 1 63-1 64 z
dermato pat hology, 1 63 Z-plasty repa i r, 308
d ifferential d iagnosis, 1 63 Zyd erm ® , 1 5t
epidemiology, 1 63 Zyplast® , 1 5t

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Color Atlas of

ZEINA TANNOUS I MATHEW M. AVRAM

SANDY TSAO I MARC R. AVRAM

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

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

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

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 .

Preface ix SECTION THREE: DISORDERS OF ECCRINE GLANDS

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

SECTION ONE: PHO TOAGING

Chapter 1: Analysis of the Aging Face and

Chapter 2: Topical Treatment Options. . . . . . . . . . 7

Chapter 3: Soft Tissue Augmentation . . . . . . ... 14

Chapter 4: Botulinum Toxin . . . . . . . . . . . . . . . . 21

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

Chapter 21: Low Level Light Therapy (LLLT)

Chapter 7: Ablative Laser Resurfacing . . . . . . . . 43

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

Chapter 23: Ephelides . . . . . . . . . . . . . . . . . . . 139

Chapter 9: Ablative Fractional Laser

Chapter 10: Tissue Tightening . . . . . . . . . . . . . . 62 Chapter 25: Melasma . .. .... . . . . . . . . . 149

Chapter 11: Dermatochalasis........ . . ..... 64 Chapter 26: Nevus of Ota . . . . . . . . . . . . . . . . 154

Chapter 12: Poikiloderma of Civatte . . . . . . . . . . 67 Chapter 27: Postinflammatory

SECTION TWO: DISORDERS OF SEBACEOUS Chapter 28: Vitiligo.... .... . . . . . . . . .. .. 163

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

SECTION SIX: VASCULAR ALTERATIONS

Chapter 14: Rosacea . . . . . . . . . . . . . . . . . . . . . 76 Chapter 29: Angiokeratoma . . . . . . . . . . . . . . . 168

Chapter 51: Actinic Keratosis . . . . . . . . . . . . .248

Chapter 52: Basal Cell Carcinoma . . . . . . . . . . 252

Chapter 53: Squamous Cell Carcinoma . . . . . . . 256

Chapter 35: Pyogenic Granuloma . . . . . . . . . . . 188

Chapter 37: Lower Extremity Telangiectasias, Chapter 55: Morphea . . . . . . . . . . . . . . . . . . . 265

Chapter 39: Warts . . . . . . . . . . . . . . . . . . . . 206

Chapter 57: Gynecomastia . . . . . . . . . . . . . . . . 272

SECTION SEVEN: BENIGN GROWTHS

Chapter 60: Striae Distensae . . . . . . . . . . . . . . 285

Chapter 43: Epidermal Nevus . . . . . . . . . . . . . 222

Chapter 44: Lipoma . . . . . . . . . . . . . . . . . . . . 226 Chapter 61: Hypertrophic Scars, Keloids,

Chapter 45: Milium . . . . . . . . . . . . . . . . . . . . . 229

SECTION TWELVE EXOGENOUS

Chapter 48: Syringoma . . . . . . . . . . . . . . . . .238

Chapter 50: Xanthelasma . . . . . . . . . . . . . . . .243 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

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

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

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

TAB L E 1 . 1 • Fac ial Age-Related Contour Cha nges

TAB L E 1 . 2 • Age-Re lated Textura l Changes

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

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

P R EOPERAT IVE EVALUAT I O N

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

The G loga u P h otoagi ng Classification has been d evised

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

- M i ld pigme nta ry cha nge

• Patient age : twenties o r t h i rties

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

- 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

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

- O bvious dysc h ro m i a , tela ngiectasia

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

Davis R E. Facelift and a n c i l l a ry facial cosmetic surgery pro

- UVB a bsorption by DNA res u l ts i n a p53 tumor s u p

- UVA l ight penetrates d eeply i n to the dermis, prod uc

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

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

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

Aloes i n-d e rived from a l oe vera . I t a cts as a com

• Patie nts with rea l istic expectations that topica l medica

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

Dreher F, M a i bach H. Protective effects of topica l antioxi