atlas de dermatologie cosmetica.pdf

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Color Atlas of

CosmeticDeraologySon ton

Zeina Tannous, MDChef Mohs/Dermatologc Surgery, Boston VA Medcal Center

Massachsetts Genera Hospta Dermatoogy Lase & Cosmetic CeterAffate Facuty Welan Center for Photomedce

Facuty Direcor or Deraopathology Depatet of Deatoogy, Harard Medca SchooAssstant Proesso n Deatoogy, Harard Medca Schoo

Bosto Massachsetts

Mathew M Avram, MD, DDecor

Massachsetts General Hospta Dermatoogy Lase & Cosmetic Ceteracty Diecor for Poceda Dermaology Traning Depatment o Deraology Haad Medical Schoo

Affate Facuty Welan Center for Photomedce

Bosto Massachsetts

Sandy Tsao, MDDrecor of Procedura Deatology

Haad Medca SchoolMassachsetts General Hospta Dermatoogy Lase & Cosmetic Ceter

Boston Massachsetts

Marc R Avram, MDClncal Professor of Dermatology

Well Cornell Medcal SchoolPrate Practce- Fift Aene

New York, New York

B Medical

New York Chicago San Francsco Lisbon London Madrid

Mexico City ilan ew Deh San Juan Seo Singapore Sydney Toronto



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rises in conrct, ort o oheise



DEDCATON

I woul ke o e icae ts book o e eory o y belove ate

wo always gave e his uliate ove an suppot

Zeina Tannous M

I woul ke o eicae ts book to y woeu parents, Moe an

Maa Ava ou ave provie e u ncot io nal l ove a en esssuppor since te ay I was bo I love you

Mathew M vram M J

To y husba , ensi n ou ae y strengt an nsp raio our ove wiso aencourageent elp e eal ize anytn g s possib le ou are a woneu h usban

ae an bes e I wi l l ove you aways To y sons Sebastian a H uter ouncon it o a love, eusas an sense o aveue ep e emebe wa s uly

potan ou bigten my ays an i l y e wih ap pi ess an ove

Sandy Tsao M

Tis book is eicate o y we R obi n an y wo sons Robet an acob

I t a k te o te love an s up pot a t ey gve e evey ay

Marc vram M






COTTS

Preface x

T HOOGINGChapte 1: Analysis of the Agig Face ad

Non-Fcial Regios . 2

Chapte 2: Topic reatmen Options. 7

Chapte 3: So Tissue Agmentatio . .. 4

Chapte 4: Botuium Toxi . . 2

Chapte 5: Chemic Pees . .. . . 29

Chapte 6: Nonabative Laser Resurfacig . 39

Chapte 7: Abltive aser Resurfacng . 43

Chapte 8: Nonabative Fractiona serResurfacig ....... .. 52

Chapte 9: Abltive Fractonal aseResuacig . . 57

Chapte 10: Tissue geng . 62

Chapte 11: Dematochaasis.... ... 64

Chapte 12: Poikilodema of Civae . 67

T TW DISORDERS O SEEOUSGLNDS

Chapte 13: Ace Vgaris ... . .. . 72

Chapte 14: Rosacea . 76

Chapte 15: Sebaceous Hypepasa..... 8

T T DSORDERS O ERINE GLNDS

Chapte 16 Hypehidrosis. ... . . 86

T DSORDERS O HIR OLLILES

Chapte 17: istism . 92

Chapte 18: Pseudofolicults .. . 99

Chapte 19: Mae Pattern Hair oss .. .. 03

Chapte 20: Female Patern Hir oss 26

Chapte 21: Low eve Light Tepy (L)and ar Loss . . 33

T DISORDES O IGMENION

Chapte 22: Caf Au ait Mcule .. ... 36

Chapte 23: Eedes . 39

Chapte 24: Lentigines . . . . . . 44

Chapte 25: Measma . .. 49

Chapte 26: Nevus of Oa . 54

Chapte 27: Postinmmtoryhyperpigmetation ..... .. 58

Chapte 28: Vitilgo... . . . . . 63

T X SUL LRIONS

Chapte 29: Angokeratoma 68

Chapte 30: Chery ad Spder Angomas ... 170

v



Chapter 31: Granuloma Faciale . . .. 74

Chapter 32: Infantle emangioma . . . 77

Chapter 33: Keraosis Plars Atropicas . .8

Chapter 34: Po-wine Stains . 83

Chapter 35: Pyogenc Granoma 88

Chapter 36: Faca Telangectasas 92

Chapter 37: Lower Extremty Telangectasias,Reticuar and Varicose Vens 98

Chapter 38: Venos akes . .203

Chapter 39: Was . . . . . 206

T ENGN GROHS

Chapter 40: Angofbroma . .. . . .22

Chapter 41: Becker's Nevus . . .. 26

Chapter 42: Epderma Incusion Cyst 29

Chapter 43: Epderma Nevus 222

Chapter 44: Lipoma 226

Chapter 45: Mum . . . 229

Capter 46: Neurofibroma

.

23

Chapter 47: Seborreic Keratoss . . 234

Chapter 48: Syrngoma . . . . .238

Chapter 49: Dermatoss Papulosa Nigra . 24

Chapter 50: Xanthelasma . . . .243

vii

T UNEOUS RNOMS

Chapter 51: Actnc Keratoss . .248

Chapter 52: Basa Ce Carcnoma 5

Chapte 53: Sqamous Ce Carcinoma . . 256

INLMMOR DSORDERS

Chapter 54: chen lanus . 262

Chapte 55: Morphea 265

Chapte 56: Psoriass 67

T DIOSE ISSUE LERIONS

Chapte 57: Gynecomastia 272

Chapter 58: Ceute . .. .. . .. . 276

Chapte 59: HIV Lipodystrophy/FacaLipoatrophy 280

Chapte 60: Strae Distensae 285

T OUND HELING LERONS

Chapte 61: Hyperophc Scars, Keods,and Acne Scars 290

T TW EOGENOUSUNEOUS ERIONS

Chapte 62: Ear Percng 298

Chapte 63: Tattoo Remova. . 300

Chapter 64: Torn Earlobe . . 308

ndex 3



PRFAC

Thee has bee a revoutio he treatmet of meical a cos

meic soes o he ski I large part this is ue to the availab ity of poceures a echnologes tha t pouce clear cosme

ic beef with ew si e eects an l ttle owtim e Wh the avetof lasers a ligh sources over the pas 20 years, cosmetc

impoveme is a matte o qick elat vey pailess proceres.

Noaser treatmets sch as soft isse f ers, botul ium toxiijectos, scl erotheapy, h ai transpa ntaio a oters have also

ramatcally expae he scope of is fiel hese poceuescoice wit the busy lifesye o may paiets who seek a

im poveme ap pearace tha oes ot erfere wth e r pro

fessioa, social o persoa obligatios

These proceres howeve, are ot without poteta sie

effects or compcatios Pysicias wo perform ese treatmets

i te absece of tag or eucatio are cea to ecoterpoo resus, complcatios a rate patets Because patiets

are prsug elecive teatmets for cosmetc benefit, ay worse

ig o appearace wi erstaaby age patiets who uer

ix

go these poceres. The ecsio as to whe not to reat a patiet

s pehaps he most mpoat tis ie With h s i m Color Atlas o f Cosmetic Dermatolo Second

Edition seeks to prov e a succ ct yet broa overview of cosmeic

therapy ere are a plethoa il usratios a graps to elcae

consutao, maagemet, treatmet a sie efects of nmer

ous cosmetic poce es. ts praccal oma is geare o the busypractiioer or raiee who seeks a quick comprehesive reer

ece for approachg te cosmetc patet t a so emphasizespialls of teatmet i orer o eucate the reae as to poteial

prob ems wt ceai treatmets t serves as a i va uabl e

resorce to both te experiece a ovice

Ze ia Taous M

Mathew M Avram MD, JSay Tsao M D

Mac R Avram, M






ACKNOWEDGMENTS

We wol i ke o tak wo eople wo prove sgifcant e l n e

prodction o tis textbook Dr Rox Aderso a Dr Gary ask a i io we wol

i ke to ta k te office staff at te Massacses Geera Hosta Dermatoogy

Laser Cosmetic Cete a e oce sa of Dr Mac Avra for ther har work addedicato obtag hgqaity otograps

Fi al ly we wol i ke to tak te rofessiona l sta at McGraw l l forteir great elp a devoto i rocig his book Tak yo or psig s to

strve or te best possi ble Atlas










tnnig Tis slcs s exacebated by a reexstng tea

tog defomty O bicl aris oc li m sce tosis can ceatea m ala r fl ness, efered to as a mal a cescent

Te midface ices te ceekboes tat form asmoot contnos convexty om te eyel to te l

Te meoabial od epesets a fa smoot jcto

between te owe ceek ad te ppe l p Te agngace ests n a ownwa migraion of e maar soft tis

se accetating skeeonzatio of te orbital imCetral ceek fat toss creates a fness ateral to te

melo abi a fod refered o as asolab ial fods

Te lowe face ossesses a weldefied madba bode an a weldefned cevicometal angle Wt aging

latysma! msce osis an ceek fat ptosis alog temanibe prodce jows" oveyig te awline So tsse

atopy anteior to te jows creates a rejow scs"

wi c acceates te skeletonized aearance Platysmatosis of te pe neck blnts te ceicomental agle

ceatig platysma bas o a tkey neck" defomity

Facial extral cages icle serficia an deeytes, gmentary dstbances, telangiectasia foma

ton oss of skin eastcity and actiic keratoses

PREOPERATVE EVALUATON

An inividalzed treatmen pan desiged to mnimize s

gica isk is essentia Te goal is a yotfl and naa postoeatve reslt A stae so d be fom lated for eac of

te tee facia zoes as wel as eac ndivdal nonfacia

egio as eac aaomic regio eqies a specific management wic infl eces te reman ig aatomic egios

A systematic evalao sod inclde te degree otexa cages, yd fomation pigmeay canges

loss o sbctaneos at, ca nges in acia m scate

cart i agos a nd bony srctes an eastic ty oss

Goga Phooag ig C lass i ca oW k l e S c a e

Te Gloga Potoagng Cassficao as been devsed

wc broady efnes te canges tat may be see at

differen ages wit c m ave s expose

ype 1-"no wnkes (Fg. 1 . 1 )

Early potoagng

Mild gmetary cage

No keatoses

Mn ma wr k es

Patiet age: wenties or t iies

Mi i ma o no make se

ype 2-"wrnkes n moton (Fg. 1 .2)

Early o moderate potoaging

Ear y sen e lent ig nes v sb le

Secion 1: Photoaging 3

igue A&B logau pe photoaging Fine lines barely visible

Minimal pigmenta changes noted



4 Coor Atas of Cosmetc Deratolo

Keratoses alabl e bt ot visib e

Para l le l smi l e l i es begi g to apear

Patet age: late thties or otes

Us al y wears soe fo datio

Type 3-"wn kle s at est (Fg 1 3)

Advaced hotoagig

Obvos dyschro a telagiectasa

Visible eatoses

Wri les eve we ot movg

Patiet age: ies or older

Aways weas heavy fo atio

Type "onl y wnes (Fg 1 4)

Sevee photoagg

ellowgray A3 col o o s

P o s mal igacies Wri led togo o oal s i

Patet age: sxtes o seveies

Ca ot wea ma ep caes a cacks"

• Pgmetay Cages

A vtal asect o te atiet eva atio is te eterma

tio o f the aiets ski respose to eythemapodc g

doses o lavoet l g Ftzpatcks class icaio of

ski tyes ov des a stog i cat o of e otet a

for ost lamatory yer igmetat io ad hypopig

metat io a oet a l o yscomia o e de

ma l ad/o pa l la y ema l i jy (Tab e 1 .3)

TABE ipaticks Classifcaton of Skn ypes

Ski tye Colo Reactio to s

I Vey wh ite o frecled Always b sI I Wte sa ly brs

I l Wte to olive Sometimes bsI V Bow Rare y bs

Da bow Vey aely brs

V B lack Neve bs

A atiets teatet esose ca be deemedby assessig both te degree o hotodamage peset

ad te igmeay s tye A roceda isk

beefit ratio wil l d e eedg o te atets ii

v ida d gs (F gs 5 a 6) . I geea l , at iets

wth Fitzatr ic ski tyes I I I ca oleate moe ederma l ad derma l j w th m ima l r isk o res da l

dyschromia Pat iets wit F itzatr ick s i tyes IVV

ave a ig isk of residal dyschromia wit ceases ij ry tat may ec de the se o may treatmet

modal ies .

gue A&B /ogau pe photoaging yspigmentation and wrinkles

are evident



Su bcaeos a Aophy

Agng reslts in a sgicat degee o oss or redistrb

t on o s bctaneos a especa l y o te oreead em

poral ossae perioral area cin and emaa aeas

Ts leads to a skeetonized aearance Restoration o

volme oss ests n te resapng o te ace or a

e onde appeaace

F a c i a l M s c a r e C h a g e s

Agng aso rests n msclar atroy contibng o

vom e loss As well dyamc yt es wc ae m sc

la n or igi n oten ceae an a g t ed or aged appearance Seectve cemca denevaton ovides maked

relaxation o tese lines.

Cha ges i Ca l age , Boy

Scues a Uer y gSuppo ive Sruces

Agng rests in saggig and loss o esil iency R ed apgrepostonng and dicios remova o skin and sot ts

se assist n te resorato o a yol appeaaceOce a systemc a proac as been ol owed te or

Secion 1 : Photoaging 5

Rs o aca re venaionrelax re l l ed rape and esr- acecan be applied soley or in combination to erestore a moe yot aearance

BBLOGRAPHY

Cng J En HC Angogenes is in sk n ag ng ad po

toaging J ermal 2007;3(9):593600

Davis RE Faceli ad anc l a acal cosmetic srge procedres Noi K eaoi S eds eiqe iermalgi Srge ondon Mosby 2003, p 33334

Fitzatick T Te validity and pactica o snreactive

ski n types I trog VI Ar ermal. 1998;12869871

Gloga R Aesteic ad anatomic analysis o te agng

s k in . Semi a Me Sr 199615(3) 134-138.

Montagna W Car s le K Kircne S piermal aermal ilgial Marer f Pamage ma

Faial Si. Selton C: RicardsonVcks 1988

Paes EC Teeen HJ Koop WA et al Peioral wrnkles:

Histologic deences between men and women AeeSrgJ. 2009;29(6):6772

Saw R B J r Kael EB Kolz PF et a Agng o te

mandib le and ts aestet ic iml ica ons Pla ReSr 201025(9) 332342

igue A&B logau pe 4 photoaging tensive wrinkle andpminent dyspigmentation




gure Female patient who avoided sun exposure throughout her lifeHer skin reects only minimal signs of photoaging

gure Female patient with a histo of extensive sun exposure in herlife Her skin reects extensive photodamage with dyspigmentation and

extensive wrinkle formation




CHAPTER 2 Topca reatment Optons

MECHANSM OF ACON

Suscree

The ulavioe (UV) aveleghs o lig associaed

cuaeous damage ae UVB (290320 m) a dUVA (32000 m ) igh.

UVB absorpio by DNA esuts a p53 uor sup

presso gene muaio resu ig pyrdne de

orma ion , ich is muageic ad ked to cua

eous carciogeess.

Acue UVB exposue resus n a suburn (Fg. 2).

Repea acue UVB exposues ove me ave been

assocaed i e omaion o basal ce cacnoa

and meaoa

Croic UVB exposure as bee ked o e deveope o aci c eraoses and squamo us cel caci om a.

UVA s uaeced by ndo gass, a itude, ie oday, or seaso ad ca poduce a a and dyspig

eaion out pecedi g eyem a

UVA lg peeraes deeply o he deis, poduc

ig many o e cl ical dings assocaed

phoo damage (Fig. 22)

UVA absopo by DNA resuls oration o oxy

ge ee radicas tought o conrbue o caco

geess. I causes mmunosuppresso ough hedepeo o angerans ce s ad reduced aige

presening cel acivty.

UVA exposure as bee lnked o he deveopmen omelaoa an ima modes .

Ceical suscee (Tabe 2 )absobs l gt n e

UV avelegth o g (UVB 29320 n) ad UVA

TABLE Chemcal Susceen Active IgedientsAvobezone

Cnoxae

Dioxybezone

omosaae

eyl anhran laeexoyl SX

exoyl XOcocyee

Ocy eoxycaate

Ocyl saicylaeOxybenzoe

Padate Paraam iobezoc ac id ( PABA)

Peyl bezimdazoe su lon ic ac d

Sul isobezoe

Troam ne sa icyate

Figue Patient with an acute sunbu There is marked swelling andredness present The upper back scar is the si te of a previous superficialspreading melanoma Courtesy of ichard Johnson M

Figue Patient with marked photodamage due to chronic sun exposureThe patient was an avid golfer and reported only occasional sunscreen use




32000 m) rasormg is l ig ino armless og

ave rad ao and re-emg as ea ene rgy.

Pysica screen (abe 2.2)scaers or relecs UV

rada ion . Ca a so absorb V l ig and re ease as

ea .

TABE . Physica Sunscreen Active IngredientsTiaiu m d ioxide

Zinc oxide

Sun proecve acorpmaly a suscreen oud provide proecion aga s e ul l specrum o V radaon .

e su proecve acor (S PF) s e oly ernaioa ly

sandardzed measure o a suscreens abily o ier UVradiao . I s e rao o e UV energy eeded o produce

a mimal erema dose (MED) o sunscreeproeced

sk o e UV eergy required o produce an MED o

un proeced sk . e America Academ y o Dermaoogy

currey recommeds e daiy use o suscreen

SP F 30 or greaer

Aioxidanseorecaly ork o reduce ad neura

ze ree radcals a damage DNA cyoskeeal srucures and celular proens. Tey also possess ai

nlammaory eecs and may pay a role i pigme

reduc ion .

n order o be bioogicaly eecive ese producs

mus be able o peerae ino e skin and remain

bologca ly acive og eoug o exe e desiredbeneis. A majoriy o e currenly availabe aoxi

dan p roducs are very usable i oxiaon makng em cemca l ly inac ive . Moecu lar orma ion

and packagng are key acors e sabizaon o

ese producs

Anioxdans may ork synergscaly o provde er

greaes benei.

Viamin Ce only anioxda o dae o aveproven beei or rikle mproveme due o s

ab l iy o icrease collage ormaio raer a isanioxdaive eecs.

Vamin demonsraed o iib V-nduced ey

ema ad edema i animals. as g coac

dermai s r isk.

Coezyme Qaural ly occurr g nur ien added

o many overe-couer producs. Currely ere

are o sudes available o documen s log-erm

beneis on sk agi ng.

debeon esyneic anal og o Coenzyme Q .

Re o ic ac dreoids are naural ly occurrg deriva

ves o -caroee ad labeed as vam A and is

derivaves ncluded are reinol realdeyde rey

esers ad renoc acid (Fg. 23) Is bees are bo

prevenave and reparave.

First Generation (onaromtics)

Retinol

CH20H

Tretinoin COOH

Iortinoin �OOH

Second GeneratonMonoAromtics)

Etretiate

Acitretin

OO

H

H

3

CO

-

Third Genertion oly-Aromtic)

Aroinoid

Adpalene

OOH

0

Tzrotene

Figure Chemical structures of retinoic acids The addition of aromatic

rings has made thirdgeneration retinoids more stable for more targetedtherapy with less potential side eects eproduced with permission,from Baumann L Cosmetic ermatolo Principles and Practice nd ed

New York McGrawHill 00



UVB exposure resuls e upeglaio o sevea

colagedegadg ax ealopoenases, cldig colagese, geainase ad soeys ic

case colage degadao Reods ac o i n bi eind ucion o ese ea opoeiases

UVB exposure aso decreses collage poducion

Renods ok o i bit is l oss o pocolage syess

Treona isgeeaion enod ic as e

is avai abe opicl eioid I is a oselecvere o d , ac iva ig a e io c ac d paays is

no potosab le s ava ab le a gene ic o as

el l as n band oua ios suc as Reova adAva Cenly Reov s DA appoved or po

oagig Te io is a lso ava a b le i cob na io as

e no n 0. 025% c nd ayc or pa es seek

ig beeis or bo acne ad pooagig ad as

e no in 0.25% cobna io 4% ydo

qu oe ad 0.05% uoc ino lone aceo ide oypepigenao

Renotis podc ust be coveted o etade

yde and e o al seioic cid ii e ke

aocye ode o becoe acve us dspayingless aciviy a etio I is toug o be appox

aely 20% less poe a eioc acid s no as

eqey associaed i rriaion o erytea is

pi ai ly ond overecoe poducs a vai

os coceaions

Adapaenea idgeneaion eoid t seecive

aity o specic eoic acid ecepos, c

alos o oe ageed beei and educto opotea sde eecs I s oe ceically sabe

a eoi and does o beak don in e pes

ence o l ig C urely avaiab e as Dieri n a 0. %

and a 0.3% cocenta on I is cue ly DA

appoved or opica ace teapy

Tazaroeea ti dgeneaion einod seecive

aiy o speciic reinoc ecepos or oe a

geted beei Has bee associaed sgiicay

ge ir i o an oer reinods I s v lable n

0. % ad 005% ges ad in 0. % d 005%ceas s cu ely DA ap poved o opcal acne

eapy ad plaque psoiass

Skin l igening agestese poducs ac o ibi

one or mo e seps i e ela ni n bosytess paay

Te ai age is yrosase ic is e ae ingsep ean n poduc on (able 23 )

ydroqu ionepeo ic copoud ound aura y

i many plas, coee ea bear ad e

In b s covers on o yos ase o mea i

Deceases yrosi ase acviy by 90% .

ay i b i DA syes s

ay ibi RA syess

TABE Skn Lghteni ng Agents Tyrosinase ibtos

ydroquoneAoes

Arbun

Ascobic ac d

avoodsGe is c ac idyd roxycou arin s

Koji c acid

Licorice exac l bey exac

ea ocye ase i n ib io

Lecs

Nac iaide

Soybea/i exacs e aocye cyooxic agens

Azela c ac id

equ o loobenzone

Skn uove acceeao

Gyco c ac i d

Lacc acidL io le c ac id

Reno c ac d




1 0 Color Atlas of Cosmetic Deratoo

Can be cooxc o elanocyes poducing e

vesible ce damage i onobenzyl eer oydoqunoe

Cocern egarding cacnogenc poeiaurrenly

eaviy regulaed and/o baned i Eope Asaand sevea Aca cou nr ies

Availabe over-e-couer producs up o 2%and by pescpion n 3% o % coceaonsCan be copou nded u p o 0% cocenaion .

Cureny avai able n cobnao opica

reinod a cid a nd opcal seoid a nd i oe sk n

l igeni g agens

Reino ic ac i d

Acceleae epidera unover esu ing n increased keanocye seddg eading o pigen oss

ay nibi yrosnase ndcion

ay esu in keranocye pigme d sperson

ay neere i keanocye pgme n a se

Naural coseceucals

Kojc acdderived o vaious unga species

suc as Aspergillus and Penicilium Pra ly usedas a ood pesevaive and o pooe he edden

ing o unpe saberies Geneal y used n % o% concenaon. Noed o ave g sensi zing

poen ia

Licori ce exraceved ro e roo o Gcyrriza

g/abra linneva Is ain acve igredie is

gabidin I iibs yosnase acviy assocaed cooxiciy. as been so o be 6

oe eicacious a n ydoquinone

Azeac acdderived ro Pyospou ovale Isecansm o acion n o ul ly udersood I

orks bes o acive ea nocyes.

Aoesndeived ro aoe vea. I acs as a copei ive nibior on OPA oxidaio and nonco

pei ive nhibior o yosine We used n

cobnaion i arbun, as been demon

saed to inb UV-duced eanogeesis

Arbunerived om e bearbery I acs oin i bi ea nosoal yosiase acviy Avai la be as

a ono eae or n % concenao i oedepge ning agens.

Pape u bey-eived o e roos o a ona

enal ee Broussonetia papyrifera

Soyacs o nb keanocye elanosoepagocyosis us reducig ela ranser

Cosmeceuica l eec noed ol y res soy lk

Niaciadeacs o inbi eanocye ranser

Aso exbs ani naaory ad an-oxda

propees

Table Use of the ''teaspoon ule" for sunscreen a ppi caton can bebenefic a n educatng patients on the proper of amount of sunscreethat shoud be appied with each appl cation.

Use o ore an a a easpoo each on:

ead ad neck egion

Rig a

e ar

Use o ore an a easpoon eac o :

Aerio orso Poseor oso

Rig eg

e leg

(D fro Daos ZD. ocds i Costic Dtoo Cosctics.

Sds 2005.)



Ascobc acidacts at vaos oxdatve steps

n ean in synthesis by ieractg wh coppe i onsat the yosnase active sie and educ ig d opa

q noe .

Glycoi c acidhas a ep dea d scohesive eect,esult ing in ncrease epideal tnover or

nceased shedng o pgented keatnocytesShoud be se in lowe cocentaons o avod

skn i at io

NDCAONS

Reduce e occence o actic keatoses and non

eanoa skn cancer

Redce te oaon o sk n agng

Rhytides

Ephe des

Lentigines easma

Postinlaatoy ypepigentaion

PREREAMEN EVALUAON

Eva uaon o peexistng al lergies to a y actve ingedent

Past poduct use and esponse

DEAL CANDDAE

Al patients benet ro e daiy appcao o a topi

cal s usceen, SPF 30 o geate

Patents wth reastic expectatons that topca edica

tions may povie peveatve benets an ae ess

ikey to edce oerate o deep hytides

LESS HAN DEAL CANDDAE

U ealist ic paient expectatons

Patents wth arkedy dry o sensitive skintopcal

teatents ay exacerbate condito

CONRANDCAONS

Preexisng a legy to actve ngredent

Use o topica l etino i sa cy ic ac i and skn ghte

ing agets n p egnant and lactang woen

APPLCAON ECHN QU ES

A sunsceen shold be appl ed a n u o 30 in

utes prio to sun expose

Secon 1 : Photoaging 1 1




Approxiaey 35 s e aveage ao o s

scee a soud be applied o e average-sizedadl eac appicaio Tis aslaes o a ea

spoo (approxiaey 6 o suscee o eac leg,

back ad ces ad a a easpoo (appoximaely

3 m ) ap p ed o e as ace a d eck o u l cover

age (abe 2) opical reioc acd producs sould be appled spa

gly o eae aeas 30 iues ae asig o

i i mize poeial o ir a io.

Beachg ceams should be app ied o ypepg

eed eae aeas oy eos ade o avod

vo ved ski

COM PLCA ON$

Coac al egic derai is

Coac iia derais

Ace la e

Ski peel g

Xeoss

yea

Phooaegic eaco

Phoooxic eaco

eoeca edcio viai D absopio i su

scee use

Hypepigeao ih beac g crea se

xogeous o cooss i bleac ig cea

Hypopigeaio beac g crea

Poeial cacogec r isk o ydoqu o e se

POSREAMEN CARE

Sic poopoecio sho ld be o oed dai y ic ld

g su avodace as uch as poss ib le , e use o a

daly sscee SPF 30 o geaer use o a debred a ad s proecve clog

PEARLS FOR REAM EN SU CCESS

i ze e u be o podcs app ied da i y o avode poeial or iiaio

Check he expaio daes o al poducs appl ied hs

s paicular key o suscees, as e acive iged

es ay o povde beei beyod e ecoeded

dae o use

opical eoic acd poducs soud be dscoied

2 eeks pro o acal pocedues suc as axig o

eezi g i ode o avod ski d esquaaio



Beachig ages should be discoiued i edess o

iriaio deveops as hey ay ose exsig pgea io.

s useu o dscoue he use o a hydoquoe

cream every 3 o mohs o decrease he risk oexogeous o cooss a d o peve s de eecs

BBLOGRAPHY

Bruce S Coseceucals o he aeuao o exr sc

ad s ic dea agig. J Drugs Dermatol, 2008;

7(2 Supp) s17s22.

Cove R, Piel SR. opca l v iami C agg Clin

Dermaol 1996; :22723

Dreher F, aibach Poecve eecs o opical aoxdas i huas. Curr Pbl Dermatol 200029: 1 576.

Fiser G, Talar S, Li e a olecula mecasms

o phooagg i hua s i i v ivo ad he preve oby al l as rei oic acid . Phoochem Phoobiol. 999;69:

1557.

Gesler L, Aick Peg e a I porace o heor o opica viai E o peveio o phoocarcio

geesis. Nutr Cance 996;26:183191

Guevara L, Pada AG. elasa reaed ih ydoqu oe reio i an d a uoraed seod lnt J Dermatol

2001 ;30:212215

Kag S Vooees Pooagg erapy i opical

reoi: An evidecebased aalyss. J Am Acad

Dermatol 1998;39:S55S61

Ki ga A The grog i porace o opica reiod s

in cliica deaoogy: A reospecve ad prospecve

aalys is JAmAcad Dermatol. 998;39:S2S7

L W aylor , oiga , e a . Aer ica

Academy o erao ogy Cosesus C oerece o U VA

proeco o suscees, suay ad recommenda os . JAm Acad Dermatol 2000:505508.

Naylo , Boyd A, Smih D, e a . Hig su proecioacor suscrees i e s uppessio o acc eopas a

Arch Dermato/ 1 995 3 : 70 75 .

Ogde S, Sauel , Grihs SE. A evie o azaoee

in e eae o phoodaaged s i Clin lntervAging2008;3( ) :776 .

Picad , Carera e ad experea eaeso cloasa ad oe ypemeaoses. Dermatol Clin

2007;25:353362

Scheide The easpoo u le o appy ig sunscee.

Arch Dermatol. 2002; 38:838839.

Soao F Briga S, Pcardo , e a . Hypopigeig

ages: A updaed revie o boogcal, ceca adciical aspecs. Pigment Cell Res 2006;19:550571

Secon 1 : Photoaging 1 3




CHAPTER 3 Soft Tssue Augmentaton

M ECHANS M OF ACTON

Use o a syneic or bo ogcal produc or srgca resrc

ring or e repacee o voue loss and enance

e o dera subcaeous and uscla r deciences

ha resu ro rau a s rgca deecs poaroph ic co

d ons pooaging or croological agng.

DEAL FLLER (Table 31)

Bocopa b e

Non iuoge ic

Noncarcnogenic noneraogec

Nonresorbabe

Nongraory

nexpensive

as y obained and sored

asy o adiiser

Provdes reproduc ble coseically beecal res s

FDA approved o auoogos

Deosraes u ipu rpose se

No sde eecs

asy o reove n he even o a poor cosec oucoe

TABE . Commoy Used Fi l ig Agets

Name

Adaos i 5000 (DoCorn ng d l and l )

A oder (L e Cel Corp. Brancbu rg N ;Obaji edca C cago L)

Aqad (Conura Inernaional SoeboraDenar)

Are i l (Cander Phara nc Quebec

Canada edca nera iona V B redae Neerands)

Beoero So Beoero Basic (erzPara Franur Gerany)

BioAcad (Br ind is I a ly)

Capique (l naed Corp Sana

oca CA)

Cosoder™ Cosoplas™ (A ergan

I rv ie CA)

Cyera Lie Cell Corp. Brancburg NObaj i edica Ch icago IL

Co posiion FDA app rova Ski esig requ red

S icone No No

Acel lar processed u an es Nocadaveric dera al logra

Polyacrylaid e ge No No

Bovne collagen i poy( ey No es

ehacrylae) beads

Noaal ya ron ic ac d der ved No Noro baceria erenaon

Poy-acrya de No es

Non-an alsab l zed yaluroc es No

acid(NASA) derved ro pan

Recobian u an co lage es No

Acelu ar processed lyop izedhu a n cadaverc ssue

No

Longeviy

Perae

2 yr

Perae

Perane

6 o

Perane

6 o

6 o

6 o

(coninued)



TABLE Commoy Used Fiig Agets ontinued

Name

Fasca (Fascia Biomaeia s, evey

Hi l s CA

Fa, subcuaneous

Hyaom® (Bioma ix nc . , Ridgeie ld , N ;! naed Cop Sana oica , CA

lso age ( l so agen c . , Hoson, TX

uvedem™ Ua, Ura XC Ulra Pls,

Ula P us XC (A Iegan, I nc . , ine, CA

Preve le Si k ( eo Copoaio, Sana

Barbara, CA

Radiesse (B ioom edica , San

aeo CA

Resyae Resyae, Peane

Per ae ™ (Qed AB, Sede;edc is Phoex, AZ

Sil ikone000 Adaos l5000 (Acon absI nc, For Woh, TX

Soorm (cGa edica Sana

Babaa, CA

Sculpa™ (Boec ndsy, SA,

Luxeboug Dek Beyn, PA

Zyderm®, Zyplas (AI egan, ine, CA


Composi ion

H um a cadavei c pesevedpaicuae ascia aa

Aoogos

Hyal oc acid deri ved odom esic ol coxcom bs

Auoogous ibrobass

o-a ma sabi ized yauron ic

acd (NASHA deived ombacea ere naion. XC

omulaions ih 03% id ocane

onan i malder ived ya uoic

ac d ih 03% idocane

Syheic cac iu m hydroxyapae

oamasabil ized hyaluonic

acid (ASHA deived rom

bacea ermeao

ormua ons h 03% idocae

S l icoe

Goeex

yoph il zed poyLacic acd

Bovie co agen

deiy he appropae paen and eame egion

Sgiica pas medca soy, icudig isoy obeed ng o co ig d sordes; kelod omaio; exs

ing dug al egies; immunocomprosed sae

Cure medicaio use pas o curen isoeinoin se

Pas surgical inevenions, year, ad eamen

response

Cin cal evaluaion o deemie i e desed eame areas are aenab e o coecion ou ie base

l i e sucua iregular i es

Dscuss lie soeing vesus volue epaceme o

i ler seecion

Discuss medicaos o avod 10 days preopeavely

en medica ly sae, inc d ng aspr in , nonsero ida l

edicaos, vamn suppees, S os Wo

and oer erba ed icaons a ave a a nicoagulai ve eec

Secon 1 : Photoaging 5

FDA appova Sk esg equ ed Longevy

No 3 m o

N/A No 9 2 mo

es No 6 m o

es No 2 yr

es No 69 mo

es No 6 m o

es No 92 mo

es No 9 mo

No No Pemane

N/A No Peanen

es No 2 yr

es es 3 o




Dscuss te rss ad beeits o te treamet

A ergc reactio , localzed versus sysemc

Procedura ad posoperatve discomo

Posoperatve edema

Posoperave bruisg

Scar ormato ecio

Reacvaio o erpes sm plex vrus

compl ete augmetao

rregula r coou /texu re

deiy cora d icaos o reamet

Active ieco at t e treame ste

Nodisesibe r gd, or icepic scars

Extesve jol ormaio promi e olds a d urros

d eryig coecive t ssue disorder

m mu ologic d isease Pro alergc reacio o ller/reaed l er/postive

s es

se o sore oi ii te precedg 6 o 2 m os

Pregacy

reast ic expectaios

Out e the predicted oucome ad l imiatos to ereame

Duraio o correcio

Posopeatve recovey perod

ssue source

Expese

SK N TESTNG (WHEN APPLCABLE)

iial es doseto si ess recommeded

eced i ubercul i ma er o vola orearm

Fouree o bseratio per od or s test

Repea s es placed i oppose orearm

Toee observao period or secod test

Retest d osesig e test recomme ded

Fo e pates o ave received reame byaoer pysca or paies ho have o received

reame or more ha yea

Toee observaio period recommeded

Post ive i l er reacio

Sel ig, duraio ederess or eryema apersss or occurs 6 hours o loger aer test impa

tao

A postive si tes s a absolute coraidicao o

l l er use

Fgure Massager utilie uring filler placement to minimie treat

ment iscomfort

Fgure Clinical finings afer EMLA application to skin Expecteblanching lasts apprximately to hours afer application



ANESHESA

eco o so ssue l ers may be paiu, especa ly

w reame o e ips. os paies require someorm o aesesia o mimize reame dscomor

"Takesesia, adodig, vibraoy assager ear

e reame sie are useu o pae disracio( F i g 3 . ) .

opca aesesa ca be ui l zed or smal reae

areas. Commoy used ages icude Beacaie

Eaced Ge (Caderm, Quebec, Caada), Beaca e

Pus (Caderm, Quebec Caada), X ad5 (Ferdae Labs, Ferda e , ) , ELA (AsraZeeca

Boso A), ad ice (F ig 32)

Ldocaie iegraed drecly io e i ler may e imi

ae e eed or aeae ors o a esesa .

Regioal erve bocks are eas ly admsered prior o

reame. e pae sould avoid exremey o or

cold beverages ad oods or 2 o 3 ours aer mealad/or raorba erve blocks o avoid m ucosa iu ry

due o iab iy o deec eperaure accuraely

Localzed umesce aesesia is ui zed or a

exracio w auoogous a raser

ilraive aesesia is o be avoded o obviae issued so o o e eame sie.

PROCEDURAL MED CAON S

Varex 500 mg BID x 5 o 7 days i aed 1 day prior

o e procedure or paies wi a sory o erpes

sm plex vrus or ear e reae sie

Keex 500 mg BID x 7 days iaed 1 day prior o e

procedure or paies udergog auoogous a ras

er or Goreex impaao

Dazepa 5 o 0 mg ca be oered o axious

paies 30 mues prior o e pocedure

LEVEL OF NJECON (Fig 33)

Superic ia ders e l es; verm io boder l p aug

eaio

Zyderm , I ; Cosmoderm , ; Resy lae F e ie;Hy aorm F e ie

id o deep dermis supericia o moderae rydes,

scars, ad deecs; ip augmeao

Capque; Cosmoderm I Cosmoplas; yaorm;

uvederm ra ; Prevel le S lk ; Resy ae; Zyderm I I ,

Zyplas

Deep dermis, subcuaeous a, ad musce: deeper,

more subsaa deecs ad rydes ( Fig. 3 )

Auologous a raser; GoeTex; ylaor Pus;uvederm ra Plus; Perae; Radesse; Scupra


Figure ecommene filler injection epths Aapte from KeyvanN, usana LK, es Tech niques in ermatologic urge Unite

Kingom Mosby; 00

A

BFigure (A) Prominent nasolabial fols prior to augmentation withhyaluronic aci (B) ofening of fols aer c hyalunic place intotreatment sites




Comba io demal subcuaeous ad muscle :

deecs ih boh a supeicia l ad a deep compoeui ize bo a supeic a ad deep ixe o opma aug

mea io (F g 3 5)

NJECON ECHN QU E (Fig 36) Seal pucue: cosely spaced pucues ceaed

alog es o ds (F ig 37 )

Liea headig: daal o l e alog he egh

o e aca deec as a coi uous h read o maea(F g 3 8) .

Fai g: s m lar o ea headi g N eede d rec io is

couay caged hou ihdraig he eedle

p Useu o oa commissues uppe asoabia Aolds

Crosshacg: simia o l iea readg aeial s

jeced a ig ages o e rs ijecos Used o

sapg ac ia coous

DEGREE OF CORRECON

Depede o he l le used I geeal overcoecio

s o ecommeded The mos commo ecique

ero is udecoecio

u ipe eame sessios ae geealy equred o

volume epaceme ages c lud g s i l coe ad

poy-Lacic acid

DURAON OF CORRECON

Depede o e mae ia l m paed m paa io ech

que ad amou mpaed he ype o deec admeca cal sresses a e i mp aaio ses

ADVERSE REACONS

• Hypesens ve

Prooged eryema a d edema a ecio ses

Cysabscess omaologasig ca persis o

moe ha 2 o 3 yeas

Grau oma oma o

Aapyaxs

• Nonypesens i t ve

Bo m

Bru s g

ecoic lud es eacivao o epes sm plex vrus

ad bacea eco

BFigue (A) Facial lipoatrophy with "sunken cheek appearance priorto Cymetra treatment (B) Impvement of cheek volume afer Cymetratreatment, 0 cc total volume



Necrossde o vasclar coprose a e ea

e se

Nod e oaon/bead g

Paa vs o osse o vascar coprose a e

reaen s e

Ulcerao

• e c h q e C o m p i c a i o s

rregl ar exede o u even placeen

Beadgue o oo sper c a p acee ( F g 3 9)

I p lan rejeconue o oo supeca placee

Necrossde o vascar eco or vasclar co

presso

PEARLS FOR TREATM ENT S UCCESS

W lers e aeced eaen ses sod be y

age ed o esre a eve cop lee ageaoUdercorreco w l lead o a nadequae agena

o and pae dssasacon W os epoay

lers s s oba ed a e s reae Per aelers reqe repea reaes or corecon cople

o

W eporay l lers paens s dersad a

e reamen respose s varable and ca as less

a or greae an e average expeced e Repea

reaen w be req red over e

Paen expecaos s be epered o nze

nreasc expecaos abo ller benes Paess be aware a e reaen edpo s a soe

g o e aeced a reas

Posopeave beadng s geneally resposve o local

zed assage over 5 o 7 days Perssen beadg can

be correced by njecg 2 g/ o r acoloeaceon de no e bead or by -b lade nc s oa l

exraco o e l ler aera

A ooug preoperave evaaon s necessary oensure a ere are o cora dcaos o l er se

especa y wen sg perae ers.

Coservave ageao o e gabe a rego scr ca o avod vasc a r necoss

BBLOGRAPHY

Beer K Solc N yalurocs or so sse agea

o: Paccal consderaos and eccal recoeda ons J Drgs Dermao. 20098(2) 086-09

Clak DP ake CW Swanso N. Dera plas:

Saey o p oducs jeced or so ssue a ge ao J

Am Aa Dermao 9892 :992998


Figure Injection techniques A Linear threaing technique B eriapuncture technique Aapte from Keyvan N, usana L-K, esTech niques in ermatoogic urge Unite Kingom Mosby; 00

Figure eria puncture metho of injection



20 Color Atlas of Cosmetic Deratoo

Cohe J desandg avoid ig and anagig der

a l le copl ca io Dermal Srg 2008;(3 Spp) :S92S93.

Coean S R Fac ia l recoour g ih i poscupure lPlas Sr 19972(2)37367

Glac AS, Coe L, Godberg H necio ecross o

he gabea: Proocol or preveio and reate aeruse o deral ers Dermal Srg 2006;32(2) :27628

oes DH Seiperaet ad perane iecabe

i lers . Dermal 200927()33

aarasso SL ecable collages: os b o ogo

ea eve o producs, dicaios ad eco echques Plas Recsrc Srg 200720(6 Supp ) :

7S26S

Sc u le rPeovic S I povig he aesheic aspec o soisse deecs o he ace us ng auoogous a ran sp an

aio. acal Plas Srg. 19973(2) 192

Fgure Lnear threang metho of njecton

Fgure Fller beang ue to too superfcal placement



CHAPTER 4 Botunum Toxn

PHARMACOLOGY

Bou um oxn is poen poduced by the bceum

Clostrdum botulnum Seve seoypes exs, desigteds A, B, C , D, , F, d G c oe o em is pro

ese ih gt c i ed to evy c i by dis ul

de bondc s gecl ly ds inc Hoeve, botu um oxi

A (BTXA) B ( BTXB) , nd e te oly seoypes curret ly v i l b e o c i c l use (Tble 4. 1) .

TABE Botul um Toxi Preparatios

Type

Boox Cosmetic (AI Iegn c. , vieCA )ype A

Rex (edicis setics, Scosde,

AZ) Dyspor ( pse Lmited, Bekshie

U )ype A

Reox/Dyspor

yoboc (So ice eurosceces, S

rncisco CA)ype B

Xeomi ( ez Prmceu c ls ,

rut, Germny)ype A

euoox (edyox, Ic, Seou,Sout ore)ype A

Prosge (nzou Isitue o BiologcProducts, nzou, Ci)ype A

M ECHAN SM OF ACON

is oxi/bole

100 yopil zed pode

500 yop l ized

poder

Avege 12.5 m i

preservtiveee opreserved sle

2,500, 5000, d

0,000 /m queous

soluo

100 U v i

1 00 v il

50 U vl d 100 v

I b i io o cey lchol ine e lese t the eu romuscu

ju c ion resu lt g i muscu cc id p lys is Receptose bi dn g s med ited by e evy ch poion o he

ox, is specic or e ox seotype, d is evesbe.

Oce boud e ecepore u ooxi complex s intezed into te ee eml d e oxi g ch

cs s poese o ceve specic syptc poe

peptide bods equired or ceylchoie omio Therge o BTXA s the sypsomessocited poe o

25 kD SAP25. BXB d BX ceve e vesicessocied m emb ne prote synpobevi

Dosg equ ivlets

1 Boox Dyspo

1 Botox 2.5

No e estblsed o

cosmeic use

Repoted 1 Boox 1

Xeomi

Repoed 1 Boox 1 Neuoox

o e l esb sed


D lu io

Avege 1 mL inpreserviveee opreserved sl e

My be used s s or d i l ue

ih s l e

o e l estb ised

o e l esb is ed

o ell esblis hed




DLU TON

BTX-A is soed in yophi zed vials can be recos

ued i preserved saline o presevaiveree salne.D lu ios vay accodg o physician peerece and

experence h BTX. A d u on ranges om m

(0 U/0 cc) o m L (25 /0 1 cc) . Dyspo di l ued o2.5 l aain a concenraio o 20 /0. cc. The

injeced voume mus be suiciey sal o provideaccurae oxin delvery hou an excessive voume

eec o delivey o oxn o suoudng musces ohe

han e argeed uscles. he voue mus be suicey age o permi accurae njecon no he ageed

usces .

CONTRANDCATONS

• Absolue

Udeyng neuouscula codi ion such as yashenia gravis o ayoroph c aera sclerosis

Pregnancy/breas-eedigpegnancy caegory C

Acve i necio in eaen area

U ea is ic paien expecaions

• Rea ive

Calciu chane blockes usemay poenae eec

Anogycosde anibioic usemay poeniae eec

Paens ho ae dependen o acia expresson o

her i ve hood (eg, acos)

Proen eyeid poss, heavy bro o ecopion


Paen expecaons us be deined and ached

ih h e expeced eamen oucom es

Paen edca l hsoy

Pas eaen hi sory and ou come

C in ca l eva ua on

Deemie locaon and exen o nvovemen o he

reaen si e

Documen asymeies noed presence o posis/ld

axy/bo poence

• owe Eyel i "Sap Back es oAssess Lowe Laxy

The ddle o he oe id is grasped beeen he index

inger ad he hub ad pu ed oad and upad

The l id s hen eeased and al oed o snap" back

rocrsscl

s l sscl -=

:.

vo ispior is

siscl

I

vo\ sp o s scl

Zyg maticus

jo sc

Fgure Anatomical illustration of the upper an mifacial musculature

X

�

Fgure Approximate injection sites for the forehea to obtain a more

horiontal brow This patte is most frequen tly use to create a moremasculine bw



agais he globe. A q uic k eu o s omal sae di

caes mi ma l la xiy. Boul u m oxi o i s ego caprovide beei . A slow eu o ski o is aura posi

o dicaes sg ca axy Bou ium ox shoud

o be used ese paies as i may acceuae he

l es pese

PROCEDURE

Pae cose obaied

Preoperave picues ake a es ad wi ageed

musce groups coraced

Prereame w opcal aesheic o ice or pai

reducio

Pae paced u prig

eame areas wiped wih a coo

jecos adm i iseed. Use o 1 m syiges wih a 30

o 32 gauge eede s requey ui zed. Use o su syriges w a iegraed 30gauge syrge ad a

ubess sysem may ep o educe ox volume loss

MU SCLE GROUPS

A hooug kowledge o he aca muscuaure ad

aca aaomy s equred o e poper use ad paceme o bou i um oxi ( F g . )

oehearoa i s M sc e( g s 4 . 2 a 4 . 3

Inseion: Origaes a oal boe gaea apoeuoca

ad ses o ibes o e poceus corrugao ad

orb cu la rs ocu

Function: Opposes depesso m uscles o e gabel a

compex a d brows o eevae e bow a d orehead

Lines noted Horizoal ies acoss he oeead

Injection technique: 2 o 3 uis (U) added a 15cmievas across e mdorehead a miimum o 2 m

above e up per bow

Dose injected: Average 12 o 20 U

Avoid:

xcess reame o s muscle uopposed depresso

ucio wl l esul i oss o upper acia expressio a" red" a ppearace a d r sk o brow poss.

eame o s musce e oals is su ppoig apoc upper eyeid o e pae as owse bows

ad/o excess upper eyelid s k

Ijec 1 m above he eyebrows o reduce e isk o

brow posis Paie mus be awae ha esdua ies

wl l be p rese ae he reame i ow orehead wr

kes are pese


A

BFigure . () Forehea lnes pror to BTXA treatment (B) Forehea

lnes 1 month followng BTX-A treatment




jeco oo close o e med a obia r im ; oxi d iu

sio roug e obial sepum o e levao pa pebaesuper ior is ad ob icu a s uscles ay lead o d p opia

• G abe l a Comp exhe Corgaor

S u p e rc l , he P ro ce r s , M e a lO rb i c l a i s O c , a o na l i sM s c l e s ( g s 4 . 4 a 4 . 5

Inseion O gi aes a e asa pocess o e oa

boe ad exeds laeay ad upad o iset io em id de d o e eyebo

Function Opposes elevaor muscles o e roas o

bro adducio ad bo/ski doad ad edalovee

Lines noted ro ies; agy" o oied" appea

ace

Injection techniqu Femaes ave aced eyebos;maes ave ae o ozoa eyebos; ecque aloed o ac e bo sape; 3 o 0 U o e pro

ceus; o 6 U e ierio ad supeio bees o e

cougaos; 2 o 3 o e media obicu as ocul i

Dose injected 15 o 0 U (depede o usce mass)

Avoid

U deeame o i s egio

Too o o a ijeco esu ig i oxi diusio io

e orbial sepu ad obi resua id poss

Pa paio o e supeor boy obial im i ijeco m o moe above is adak eps o mize

is r isk

Coc ure reame o e oeead a eavy bo soed

• Per ob a l Reg oOrb i c a s Oc I ( F g s . 4 . 6 a 4 . 7

Insetion Ec rces e peoba ego a d ses o

e media a d laera ca a edos as e as o e

ibes o e oal, pocerus ad corugao supec l i musces

Function oceu closure o e eyes ad depresso oe bos ad eyelid s

Lines noted aeral caal es; cos ee"

Injection technique 3 o 5 are eced io ee

pois i a veica le 1 m rom e aeral caus; i asog sap es is oed 2 o U ca be placed 3 m

belo e mi d pupi l ay ie

Dose injected 22 o 38 U

X X

XX

X

�

.

X X

Fgure Appximate injection sites for the glabellar frwn lines() Female brow (B) Male brow

Fgure () Glabellar complex before BTX-A injection an (B) weeksfollowing BTX-A injection



A

njeco o he iaoba ego i a delayed snp es

is noed; ecopo o he injeced d may deveop

Oveeame o is aea mpope eye cosue, bo

poss o lid posis may esue

An ecio ai med oo o a e loe peiobial

kes Weakeing o he evao abi supeiois musces

h a uppe l ip doop nd boma sm e may beobseved

• ppe Nasa l Roo (F ig 4.8

se cicles he peiobil egio and ises i no

he m edil and aea ca hal endos as e l s io ebes o he oal, poceus ad cougo supec l

musces

t sa k ing

es te Up pe ose a g hdes; bu y l es"Ijecio ecque: 2 o U s ijeced no ech ae

sa l l no he bel y o he u ppe asa i s as i aveseshe dosu m o he ose

Dse jete o 8 U

A Ijecon o e uppe asoacial goove may

esu i l ip poss

Use o bou um oxin he loe ce is mnimaly

beneca Ohe eame moda es ae l kely o be

moe benecal h ee poeia side eecs A sog

und esand g o he l oe ace d eck aomy s c iica o eco pcemen (Fig 9)

• N a s o l a b i a l o l ( F g s 4 1 0 a 4 .

I s key o eig e imied benei o BTXA hs

egion comped h he nceased isk o compicos Fll g ages may povide geae bee h

ee sde eecs

se Resul o ski lax gvaio poss and

subcueous a loss oveying e cuaneous atch

men e zygomacus mao nd mio evao ab isupe o is ad evao ab i supe o is a laeque as

musces

t Assocaed i mou ad p moveme

es te Pomien cease, media l cheek gummy

sho"

jet teqe o 2 U neced o he uppe

aspec o he nasoa bia od 2 o 3 m m l aea o is ise

o ih he nose

Dse jete 2 o U

A

Complee eaxon o hs ea; uppe lp poss ce

ig sd appeaace my occu


N

�

� ·

t

, '

·

Figure Apprxmate njetn stes fr perrbtal lnes

A

BFigure 7 () Perrbtal lnes prr t treatmen t wth BTXA (B)

Perrbtal lnes 6 weeks fllwng BTXA treatment




Ueve paralyss a asymmeric smle or dspopor

oae l i p may be see

• P e o a l R e g i o O b i c u a s O sw i h C o i b u i g b e s o m

h e B u c c n a o , C a n i u s , a agu a is Musc les ; DepessoA ng u l i O s ; M e a s M u sc e( F g s . 4 . 1 2 a 4 . 3

sei Orbicuar s ois orgiaes from e max lay

a veoar border ruig c rcmere ia ly arod emou o e overy g cuaeous aacmes depres

sor agu i oris ( DAO ar ses om e mad b lar ob l q ue

l ie iser ig o e age o e mo I s co iuosw e playsma muscle; mealis muscle origiaes

from e madbular cisve fossa ad desceds o acaeos serio

i Oppos o ad proruso o e ps mou

age depresso lowe l p prorusio ad c dimpg

ies e Deep ad superficia rhydes, ppe ad

lowe l ip ; promie agula o ds sad appearace" ;

ch i w l g

jei eie 0 5 o 0 U eced 2 o 3 mm

above e vemi o border i or aeas each for e

upper ad lower p 1 o 2 ijeced a e ersecioo a l ie d raw from e asolaba l od ad a aea 1 m

above e awlie age 5 o 0 io e ferior midc h i

Dse ijee o 8 U or e u pper ad ower ps; 2 o U or e DAO; 5 o 0 or e meals musce

Ai

Overreame of is area; speec dfcules, a

asymmer ic smi e ia b i l y o c ose e mou d roo l ig

ad alered acia expressios may esue

Dee p eco s; i creased rsk o sde efecs

oo ig o a iecio or e DAO abliy o raisee corer o e mou may develop

• NeckPlaysma Musc e Comp lex( F g . 4 . 14

sei Oigaes o e fascia o e upper pecoalismaor ad deod musces ad proceeds upward ad

media ly al og e sdes o e e c Fi bers are seedio e ma di ble, subcuaeous issue of e ower face,

peroral musce, ad si

i Facial aimaio; lowe jaw depesso; ower

i p depresso

ies e ec wri l g; cera l bads

·

)

l

Figure 8 Approximae injection sites for upper nasal root es

sporss

r ar s sp or s

r ar s atr or us

-

= +

0 rb cu la is or is us:fDepesso

a o s s

psso abi i rors s

Figure 9 Ana tomical illustration of the musculature of the lower facean neck



Injction tchniqu 2 o 5 njeced rom e supe io o

ineior poio o eac paysma! bad a o .5 minevas i e paies ee cleced o conac e

musce d ur g ec o

Dos injctd 20 o 00

Avoid Too deep a injeco neck eakness larygeal

musc e eakess or dysphagia may develop

POSTOPRATVE CONS DRATO NS

c e o cold c ompresses may be app i ed o reduce pos

s ib le bru is i g ad edema

Acive conacio o he reaed muscles or 20 o 30

seconds evey 30 miues or ours aer reamemay expedie oxi upake

Physca aciviy sould be imed or ours aer

reamen o avoid he eoeical possbi iy o uo

ard oxi d iusion

COMPLCATONS

asie pai

Eyeid poss

Eyebro poss

Bru is ing

Headache

ncomp ee or asymmeric chemica deervaio

Dpopia

Dry eyes

Ecropio

Asymmer ical smi e

Drooling

Deceased pucker

Dysphagia

Puncae keraiis

asklike expressionless ace

Anbody resisace

Flul ike sympoms

TREATMEN T BEN EFTS

Recovery rom BXA paralysis geerally begis a 3 o

4 mohs aer iecio. Paiens ho ouiely eceive

BTXA may noe e recovery ime o exend o o6 mos over ime. Side eecs icudig eyeld ad

eyebro poss ad bruising geneay resolve ihi 2 o3 eeks o ose Teame bees may be egeed

ih c ocom a coservave use o a i le or so issu e

augmenaio


Figure Approximate injection sites for nasolabial folds

Figure Approximate injection sites for the perioral muscles

Figure 2 Approximate injection sites for the depressor anguli orismuscle




PEARLS FOR TREATM ENT SU CCESS

Paties ith o eual izig atibodies agaist

BooxA may respod o yoboc give he ack o sigi ca coss eacivy betee he o oxi s

Oy FDAappoved botu ium poducts should be ui

zed Ulcesed boul num oxin may esul i severe, eeaei g botulis m

he eve o an eyeid poss, use o (adrenegic

agos eyedops such as apraclondie hydochoide0.5% eyedops (lpdie, Alcon, For Woth, may

be used o povide empoay id elevaio

Paties shoud be nomed ha he maxmum beeto Boox ca tae up o ees to deveo p

Deep uros il oly pa a l y espod to boulium

reatme Combiaion therapy th a i e subsacemay pov ide the bes c l i ica edpoi

shoul d be emphas zed o paiets ha a sgle bou

u m reame i l no be compeely eecive i e im na ig a l reaed l nes ad r kles As e l , i t shou d

be expa ed tha some es idua l muscular moveme ishe des ied eatme ed poi

BBLOGRAPHY

Alam , Dover S Adt Pai associated ith i ec

tio o boulum A exooxi ecosiuted usig isotocsodiu m ch lori de h ad thout pesevave: A dou ble

b id , adomized coto ed t a Arch Dermatol

2002; 38:505

Alse T, upo Bou i u m toxi ype B o dyam ic

gabear hyes eracoy o bou um toxi ype A

Dermatol Sur 200329(5) 5658

Blizer A Binde WJ, Aviv e a The managemet o

hypeucioa aca l ies ith bou um oxin A collaboaive study o 20 injecto stes n 162 paes

Arch Otolangol Head Neck Surg 199723:389392.

Bad FS , Boe A Botu l i um oxi o the eatme oec ies ad ec bads Demao C 200;22: 1 59

66

Cauhers A Boge Caruers D e a A andom

ized, eval uaobl i nded ocente sudy o he saey adeect o voume o he duso ad ecacy o botul ium toxi ype A in he eatme o ateal obia

rhyes Dermatol Surg 200733:56757

Caruhers A Kiee K Caruhes Bou ium A exooxi use i cl iical demaoogy J Am Acad Dermatol

996;3:788797

Caruhers Carruhes A Botu l i num oxi A i th e mdand loer ace and ec Dermatol Clin 200225

58

Figure Approximate injection site for the mentalis muscle

Figure Approximate injection sites for the platysma muscle complex



Crruhers Mrrso S; Botox Consensus Grou

Consensus recoed o on he use o bou l nuoxn ye A n c eshecs Plastic Reconstruct Surg

2004; 14 1 S-22S

Cheow S Tn E Mslnk SE e Bou is i4 d s ol l owng coseic necions wih n u n censed

hghly concened bolu preprion JAMA2006;29624762479

Hs TS ove S Arnd KA Eec o volue d co

cenron on he dusion o boul n exotoxn Arch

Dermatol. 20044035354

Leoun C Bou l in oxn A nd c i nes he vr

be cocentron Aesth Plast Surg. 200257384

Zibler MS ods B Koosk MS e Eec o bou

l nu oxn reemen on ser resucing ess A

rosecive rndozed b nded r Arch Facial Plast

Surg. 200 36569

CHAPTER 5 Chemca ees

MECHANSM OF ACON

Th e ppl ic ion o woudi ng gen o i nduce epiderlnd/o der s loghng

NDCAONS

Eder deecsehel des es

Eder nd derl deecsels ent g nes

pos-inlory hypergmenton cinic ker

oses s uperci l ryes cne vugrs

erl deecsdee rhyes cne scrig scrs

PREOPERAVE EVALUAON

Peeling gens e seeced bsed on he pes

lesyle deec deph skin chrcteistics nd deeclocion (Tbles 5 15 3 )

Ps edcl hsoy

Ps rdo hsoryecresed dex structresl ike y

Hsory o or hees splex vrusrecvon

y occur

Pregnncyees conr di ced wh he exceion

o gycoic c d

Hsory o keoid oronodere nd deedeh peels should be voided





TABE C iical Ind ications and Pee Types

Ind c ion Peel type Peel deh/ree ed pon

Acne vu lgr sEphe des e ig ies

Su erici l when civeSuper ic i l or ediu

Loc zed eder eelng requred eso roveenTol eider peeling requ red or coee remov ; l gheing

wih superc l ic ion

Pos-l ory i nlonMels

Super ic i or ediuSuperic i l or ediu

ol ep ider l peei g equ ired; l ighei ng wh either srenghTol ei der peel ing requ red; l igheni g wih eihe srengh;

ncossten resonseLoclzed eider peeling requred; soenngSupeci rhytes

Mod ere hy es

ee rhyes

Acn c ke roses

epressed scrs

Supeic i l

Mediu o deeee

o ederl nd ppil ry der pee g required; soeningo eder l o recul r der peel requi red; soeni ng

Me d iu

Med iu or deep

o ederl o ppil del peeg requred; esion clerce

Leson edges rgeed; otl epider d ri derl

peeling requied esiol leing; vrible response

TABE 2 Wound ing Depth of Supeicia l, Medu mDepth ad DeepDepth Strength Peels

Superci peel Medi umdeph peel ee pee

ydroxy cdModi ied nns resorcino se

esser's

Gyco c c id d CAesser's nd TCA

Bker's Gordon pheno, uoccludedBker's Gordon pheno, occuded

Sl cy l c c d

Sol d crbon d ioxde s lush

renon 0%25 % TCA 35% vbe

TABE 3 Peeling Agent Characterstics

Peel ype

Glyco c c id

essner

CA (30 % or geter)

Phenol

Ps surgc hsory

Color end pon

Conue erhe

Ple wh te

Sol d whie

Gry wh ie

Sol d crbon d ioxide nd TCA50% TCA

Pyruvc cid

88% Full-sength phenol

Ap cion

2 cos

Cos re pp lied s gy nd

endpoin oniored or

34 n prior o repe

l ic ionSinge even pp ic on ;

oclzed icos or

gher whie res ybe consideed

Snge eve l icion ; cnbe conservvely reped

Pror cosec proceduresprior ce blephropsy, crbon doxide resurcing or derbrson

y ec eel oucoe Icresed ecropion r isk

presen

Medcon use

Prevous soreion use nd yer

Topic edicions such s reino nd -hydroxycids y oenie ee enerion

Coudn use

Hel ing ie

2 h

45 d i ld epde

desquto noed

104 d ; sevee

sunburn- ike pee ig

observed

104 d; suer c i

burn ernce

Se or

A sk i ypes

A sk in yes

I nd I ; cu ion

wh I nd IV

I n d I I



Fizrck skn hooye

Skn ooyes I I I ens resond o l eel yes

Skin hooyes IV nd V iens lso resond o

ee yes, b u e r isk o osree dysigen

io is greer

A es se y be wrr ned or drker sk yes oeve eel oucoe

egree o cn c d ge nd ooging

A we le o dercion beween eeled ndun eeed skin y be roinen e resece o

odere o severe deroheloss

Woods l evluon

He l i n scer ni g igenion ye resen

Eider or g in es o co or ennceen

(F ig 5 )

er l o r cob i o e ider l nd der l no

lesionl color enhncee o g

xnion does no ccurely redc cl iic eelresonse

Eiderl igen y resond beer o eeling

ges cored wi der or cobinion gen deos ion

Medic clernce

A recen elecrocrdogr s necessry o serve s bsel ne or henol eels n he even o crdi ooxcy

Lver n con nd re un cion ess shol d be ev

ued o ensure deqe heoren uncon or

heno eels

DEAL CANDDAE

Skin ooye I or I

Aci i c dged skn

Sc rhdes ssocied wi sun exosure

LESS DEAL CANDDAE

ync rhyeschieved benes re eorry in

nure

Exensive grvionl ods nd rrowsikey o

reqi re surgcl nervenon n conjuncio wh ce i

cl ees

ee rhyes

Boxcr cne o r odere de roc scrr ig

CONRA ND CA ONS

Un reis ic ien execions

Pien uble o eor ecessry osoerve cre


Figure Thirty-one-year-ol female with melasma Woo 's lamp accentuate her facial pigmentation




Ptients with iceck scrs or deep troic scrs

Ptients with dited rge ore sze

History o or isotretnoin use within yer pror to pro

cedure

History o keoid ortion

Ptient wit underlyng crdic rrhhis (or deeeels)

Coud n use (or dee peels)

Skin hototypes I l V (or deep ees)

MEDCATONS

Preoertve ntvir edictios re recoended

Vltrex 500 g B or Acyclovir 400 g n t ited

on te dy o rocedure nd contiued or 5 to 4 dys

s dinstered depending o ee deth

opicl retinoic cd d -ydroxy cid rodcts re

discontiued 48 hours rior to glyco ic cid eel nd week pror to deeper eel nd not reinit ted or

week ost tretent

WOUN D DEPH

eter ed by ut ip e ctors

Antoc considertions

Fcl sk ders ro noncil skn i the relt ive

nuber o i losebceos units er cosetic unit dthickness Proinet dex strctures re required

to proote reeiteztion ost tretent The nose nd oreed hve ore sebceos gnds

thn do te ceeks or teles

The ce hs ore sebceos glnds thn the onc i res inc l d ig the neck

More ctin i c ly d ged skin is t n ner with ewer

p osebceous u its present

Body loctio nd presence o ctiicl y dged

skin signi icntly ects te seection o the wonding

get he pee ing gent y be ore destructive n

res with ewer dnexl strctures nd thinner skin;

thereore ess ggressve peeling gent shoud be ut

ized in these res

Preeel ski dettngse o cetone to det the

tretent re reslts i deeer enetrtng pee

Wondig gent strengt ncresed strength wi l

resu t i deeper ski n peel ing

Aou t o gent li edeeer skn enetrtion with

ec eel yer lied

AFigue 2 () Epiermal melasma unresponsive to topical bleaching

creams



PEE L YPES

Suerici eelsr or coee eiderl nury;

y exend ino he i ry ders (Fig 52A nd B)

Mediudeh eelsinury exends ino he lry

o uer eicu r ders (F ig 53A nd B)

ee eelsinuy exends no he d-reicurderis

PROCEDURE

Preoerve wrten consen obned

Preoerve icures ken

Pens keu reoved nd ce censed wh nnisec wsh (eg chorhexidine)

Scrb he reen re wih ceone on coon guze

or 2 o 3 nues

he eelng gen shou d be oured no gss cu h e eel ng gen s ied o he reen sie

A inbush o coon b y be used o ly glyco l ic c d

A sble br sh s recoended o essne ee or

incresed enerion

Coton-ed icos or coon guze y be

used o ly ichoocec cid (CA) eeling

gens

One or two sl coon-ed icors re used

or heno icion

A round oohick o wooden orion o brokencoton-ied ico y be sed o re

ind iv idu l hy des nd ce ck cne scrs

he nuber o icors used nd he ressure ied o he reen sie wih gen licon

wl ec souon delvery nd deh o eneron

(F igs 5 4 nd 5 .5 ) .

A n s req ired o he educe he ssoced en

dscoo

Prereen wih essner or glycoic cd ror o

CA eel ows or deeer eel enerion

Feher ng ino he h i r in e nd he w ine concels

he ossible ine o dercion Fehering shoudso be eored when he erio re s reed

one o reven l nes o dercion ( Fig 5 .6)

he eriorb issue shold be eed is wih TCAees, olowed by he nose cheeks eior re nd

orehed o bes en olernce he uer ndowe eyeld s y be reed Exension 2 o 3 ono

he eiol vei on s benecil or rhyes reduc

ion

A s ne syr inge should b e v i l b e n h e cse o nd

veren noducon o he eeling gen ino he eye


Figue 2 (continue 8 Mil improvement note following two 50%glycolic aci peels




he icor shoud be wrng ou nd sei-dred o

reven driig The gss conine shold be hedwy o e en o void drec si l ing oo he

en

essner ee CA d heno eels re se

nelzig Gyco c cid ees s be neurl zed

wih we or bicrboe souion Cool wshco s ied o he reed res

Vselne is ied o he reen sie or esser

TCA nd henol ees Gycolc cd ees equre

g osr ize

ee eels hve inheren crdic ren d heic

oxc ies F ce cion req es nrveos ds sedion crdc oioring ulse oxieer nd

blood resse o ior ng

COM PLCA ON$

Greer deh o eel rovided hn execed ( Fig 5 7)

neconvr bcer ugl

eorry o ernen hyerigenon or deg

enon

Proonged eryhe

Scrngrohic hyerrohc keoid ecoon

de yed hel ng

Conc deriis

exrl ch ges

Acne

Mi l Crd ic rryhs (dee heno eel)

Lryngel ede (dee he o ee )

POSTOPERATVE CARE

A l gh osizer s l ied wce d l y or gycoic c d

eels

Vselne is ke on ound e cock wih wice d y

clensig so nd wer esser CA nd heno

eels

Sic hooroecion is sressed or ini o onh er gycolc cid eel d 2 o 3 onhs or

he re nder o eels

Pens re nsruced o l low nurl s lough g o he

reed ski n Te skin s no be n ly reoved

PEARLS FOR REAM ENT SU CCESS

Ceul en seleco nd eel seleco is neces

sry or een su ccess I s bes o un dere wh ess oen eelng gen i noncil res o ii

ize e r sk o sc or on

AFgure 3 () Pseuoochnosis The pigmenta changes persisteespite iscontinuation of the inc iting meication



Pens s be wre o the exected recovery e

wh ech cheic eel nd he necessy osoerive wound ce hey wil need o eror o exede

heng. Alhough one dee ee y ovide he gre

es beet iesye or work consrins ke serl

suercl or ediu-deh ees beer ong-er

go h e rgn o sey is ch nrrower d he r sk o

cocions ch greer wh ncresed eel

seghs

Piens wh skn hooyes I l l nd IV hve greer

r isk o deveoing regnncyindced hyereso

e che cl ee Cos derio n o test site is w

rned or eddeth ees

Cheic l ee s wi l no lter oe s ze nd y in c

inc rese heir sze

BBLOGRAPHYBke Godon H L M osenko P e Longer hi so

logcl sudy o skin e cheic cil eeng. PlasRecsr Sr 197453522-525

Brody H Med deh chec eel ng o he skin : A

vro o suerc cheosurgery. A Dermal1988;3205-220

Gries PE. Mes Eiologc nd theretc cosider

ios. Arc Dermal 19973 453-1457

Gross . Cdc rhyhi duing henol ce ee ing.

Plas Recsr Sr 1984 73 590594

Klign AM Bke Gordo H. onger hisoogcollowu o henol ce eels. Plas Recsr Srg1985;75652659

Lndu M . Co b ion o cheic l ee ngs wth bol n oxi iec ons nd derl i l ers . J smeDermal 20065(2) 226

Mc Kee GM Kr L T he ree o os-cne scrswih heo Br J Dermal 195264(12) 456-459

Mrsso S G logu RG Che cl ce eels. Dermal

i 1 99 9 3 50

Monhei G he essner'sr ichloroceic cid eel.

Dermal li 19953(2) 277-283

Murd H Shbn AT Preo PS The se o gyco ccd s eeling gen. Dermal li 995; 13(2) 285-

307

Que SK Bergsro KG Hyergeion Od robe

new heres. Drgs Derma l 20098(9)879882

R ll P Kr A M. Cheicl ees or drke skn yes

acial Plas Srg li Nr Am 2 0 1 0 ; 1 8 ( ) 1 1 3 1

Szzchowicz EH Wigh WK. eyed he ing er ul l

ce chec ee s . acial Plas Srg 19896(1 ) 6-13


Figure 3 (continue (B) Marke pigment lightening aer three Jessner5% TCA peels




Fgue Fine white color immeiately following a 0% salicylic aci

peel




Figue Pale white color immeiately following a Jessner peel

Figue oli white color immeiately following a Jessner5 % TCApeel




Figue 7 Patient with line of emarcation between the Jessner5 %TCA peel treate perioral area an untreate skin Patient appears

hypopigmente in the treatment site A subsequent meiumepth peelto the remainer of the face resulte in a more even facial appearance

Figue 8 Localie fsting following application of a 50% glycolic aci

peel The localie peel resulte in some mil esquamation for ays




CHAPTER 6 Nonabatve Lase Resufacng

NTRODUCTON

Thee re l le lser nd l ight sorce eens or

hooging These reens rnge n eiccy nd side

eecs. Tycly here is rde-o beween clinic

i oveen nd concon i ncrese n sd e eecs

nd downe ro work nd socl civi es Oher

chers hve ocsed on sc eens s nonb

ve rcon resrcng blive rcionl resrcingnd rdi ionl resrcng. Tis cher exines non

b ve lser resurcng nd n cl e se o

i di nrred lsers. Oher devices sch s i nense lsedlgh nonbve rcionl rescing sers nd vs

cr lses so chieve nonbtve benes nd re

ddessed n deil i n oer chers.

Phoogng encosses l he chnges odced byexosre o rviole (V) rd on incding elngiec

sis hytes oor skn exre nd one s wel s

skin xiy (see eohelioss cher) Nonbive

revenon es sn dged ski n by heing der l

co l gen wih he i o s i ng new col lgen grohI is lso eecve n he reen o cne scs

der coolng s rovided o ensure h her

heing s rgeing e deis nd no he eideris.The bes dvnge o nonb ve reens s h hey

reqi e l i le ny downe ro work nd soci cvies Ths s in conrs o blive nd rcon blive

retens. n ski led hnds side eecs re yiclly

i d nd eorry (F g 6 ) Oen ey rodce sbe or i d benes even er

t ile reens. nornely e redicb iy o

ioveen is ncerin Soe iens do no exeri

ence ny discenibe bene even er l le re

ens. In he s ew yers nonblive rconl lsershve rodced enhnced resls ro oer ors o

nonb live rescng wih l le reens Theselsers ve lso roven o be se in skled hnds W

the dven o nonbve rcionl sers rdi on

nonb live lser rescing hs declin ed n o r yn dd i on o nense lsed l igh sorces nd vsc r

lsers ere re n y nonb lve devices h l ize vsible ner-inrred nd idinrred wveenghs wh

eder skn coo ing These wvelenghs get he

wer h s b ndn in derl isse The skn coo ngroecs gins eide dge hese sers ro

d ce deeer derl enerion greer bsoron nd

der l hel inu ry th n vsculr lsers Fher here

is signicnly decresed risk o igenry chnges n

drker skn hooyes hese wveenghs. Whie hebes cndides or reen e those wih ild o od

ere sc rhyes e degree o iroveen erreten s diic o qny

Figue Vesicles appeare 1 ay afer treatment with a 1450nmioe laser with a Fipatrick skin type 1 patient These esicles com

pletely cleare without sequelae ays later




No bve sers

Su ble proveen o rhy es rcul r ly when copred o b ltve devices

Bes or pens wih ld o odere phood

ge skin xiy, nd ski n corseess Requres u iple reents o rovide d prove

en o ski n exure, one, nd rhyes Le o no osoperive dowie copred o rdi

o a bve devces

Pten c reur o work or soci civ ies the se

dy s he proced re

Cn re coseic uis eecivey whou lines odercio

NDCAONS

nd c ios

Mld rhydes

Phoodge i c udi ng skin exure d one

Acne scrs in cu din g boxcr ropi c ro l g scrs

Su be bee

Mld proveen in skn lxy

No eectve or dync or deeper rhyides

PREOPERAVE EVALUAON

Sk in ye (cn tre drker sk in ypes wih id rred

sers bu req res cton wih ski coo ng)

Sun exposure Hsory o keoids

sotreno in use in st 6 ohs

Ptens wih unresc expecions

A consulon is requred beore s reen ossess the pie s we l s rorey prepre he

ptien or he procedure The ten should be yeduced s o he r isks nd bees o he p rocedu re I

is ierve h expectos re se reis ic y n

ers o h e i ld degree o i roveen ht w l l oenbe see or rhes The en shoul d so be i ored

h he ben eis o rhyid reen ccrue 3 o 6 onhs

er ree

PROPHYLAXS/ANESHESA

M y n c ld e n y o he o l owing

Antvir proyxs

opicl nesheic

23% idocne% ercne

7% docine/7% ercne

utecc ixure o oc neshec (E MA)

A

BFigure 2 () Patient with EMLA uner occlusion prior to treatment ofacne scars (B) Treatment with 1450nm ioe laser with C cooling



Becse soe o d-inrred lser reens cn be

nul soe or o neshesi s oen requi red . w lvry ccodng o he ggressveness o reen he

riculr ssceibi i es o he ien, nd e hys

c ns coo wih vros neshec regens .

Mi iae Lases

The 320-n NdAG ser (Coooc Inc Rosevi e CA eures erl eedbck syse h esres

eder eerre o oe recsely rge derco gen. Ths he lse sgeon cn conro heng

wih oe recson I s heorized h new colgen

siion is cused by inlory cyoknes er


derl he ing. AThe 450-n d iode ser (Soohbe Cndel

Cor. Wynd MA so rges derl wer while

roecng he ederis wh cryogen sy device

( Fg 6. 2) The re s no e ere eedbck device. Wheher device ggressive coong cn odce eory

igen chnges.

LASER SAFETY

Eye oecon el eye gogges

A esonnel resen e e o reen s

wer sey glsses/gogges o void indverenconel dge.

ADVERS E S DE EFFECTS

Adverse side eecs r ess coon n blive ocedres bu do occur wh higher lences s wel s

indveren lse scking (ie, ir ng wice n id sc

cesson over he se e

Scrr ng

B e ( g . 6 2)

Posinlory hyergenion (sl y roovery ggressve skn cooing)

Posopeaive Cae (Fig 6 . 1

L e osrocede i n

Any erye s d nd resolves shoy er re

en

hee s no reqireen or ollow- vs er re

en .

No osoerive cre s reqired.

Pen shod be i nsrced o cl i erhe ersiss

or i ves ic les or b le develo (F ig . 6 )

B

Fgure 3 Pretreatment an immeiate posttreatmen t photos of nonbruising pulse ye laser treatments There is mil erythema aer treatments Many patients note an impvement in the texture an tone ofskin after a series of treatments




Posoerve eryhe resoves qicky Sric sn

voidnce s recoended

The o owing prcices l l s ign icny ncrese he

risk o scr

Aggressve reens i ncrese risk o scr

Poor ech iq e ie excessive overl ( se scking)

In s onb lve ser resrci g rocedres oer

he dvnge o qick se reens h roduce

ild iproveen o hoodged skin slly hey

cn be erored on he se dy s work nd socl

oblgions Noeheless, he reen hs s drwbcks sch s

Resuls re s y odes

ro o benei, i ny s no known

Bes resus oen reqire ore ile reens

Becse he iroveen s oen sbe nd nre

dcbe even er ile reens oher roce

dres sch s nonblve rcon resrcng hvein cresigy s lned he el o rd on no bl

ive rocedres

BBLOGRAPHY

nzi EL, Wl s CM Aser S reen o ci

ryides wi nonbive 450 diode ser A con

ro ed cl n ic nd hsologc sdy Dermal Srg.2003;29(2 ) 124-128

nzi E Alser TS Corison o 1450-n dode

lser d 320n dAG lser he ree orohic c l scrs A rosecve cl in icl d hsoogc

sdy Dermal Sr 200430(2 P ) 15257




CHAPTER 7 Ablatve ase Resacng

MECHANSM OF ACON

Uti zing the rinciples of selective hoothemosis

aba ve remova of skn n a recisel coo led fasho

with resu lant mi ima srrondig herma damage is

achieved Te deth of t issue eneraion is deenden

on se ective a bsotion of waer I mm ed ae ss ue eecsare deenden on he spot sze ad owe uized as wel

as e seed o reatme admnistrao The me oflasertissue neaction is the ci ical factor fo resdua

therma damage E iderma ob ierat io and(o art ia l

ab a on or coaguat ion o the uper dermis s the edpon Reeithe ia ization resus from te mgraion of

cel s that ar ise from srrounding fo l cu ar adnexae

Norma comact co lagen and elastic ibes repace the

amorhos easotic derma comonens and normalweoganized epithelia l cels repace the dsorganized

hotodamaged eiderms Collagen remodelg s noted

both ntraoperative via themal shr inkage and conrac

ton and ostoeratve wiin the remodeig phase of

wond hea ig

Cabon D ox e Lase(C02 Resuac ing)

Contin uos wave ( 0600 nm) sue-ulsed and

scanned C asers are ti zed or esfacig A rela

t ve b oodess surger wih educed swel l i ng is ac hievedvia the hoocoagu ative efec on blood vessels and lm

phatics The r isk o scarr ing unpredictable evel of themal da mage and d eaed hea ing of he coniuous wave

laser imt its c iica se he scanned and ulsed Clasers de iver igh peak uences in less an 00 0 seconds to achieve tssue vaoizaion of 20 o 30 m er

pass Approximatel 40 o 20 m of residual thermadamage is noted pe ass (F ig 7 )

E b u m : Y i u m A u m n u m G a e tLase (E :YAG)

A aser of wavelegth 2490 n m i s uti l zed or moresuerficia resufacng I is 6 moe selectvel

absorbed b waer t acheves tissue vaporizaion of to

5 m per ass It resuts n a naowe zone of esidualtherma damage (30 m ) A s a zone of thema dam

age o 50 m or greaer is equi red or photocoaguation

Er:YAG teament resuts in a s i ghtl bood surgica ied

The therma damage s a so isc ient to produce

immediate colagen coracto ongerm colagenremode ing is imited (F ig 72)

AFgue 7 () A 5-year-ol woman with extensive actinic amage



Color Atlas of Cosmetic Deratoo

NDCAONS

Abative lasers have been uti ized as a cutting too ad

vaporz ing tool t o treat e dermal and supef ic ia l dermallesons.

Cung too kelods, ace keloidal s nuchae, cst

remova , basa l cac ioma bur and u cer debr dement hair taslatato beharopast othe nci

siona s urgeries where coto ed hemostasis s desired

or whee ei ephr ne is containd cated or a pace precl udes use of eectosuger

Vaporzng tool treatment of numerous condit ionsncluding static and dnamic rhtdes boxcar cratei

form ad hertrophc acne scars pox scars, warts,

entigines, adenoma sebaceum agokeratomas, o

genic granu oma, lmhangioma c rcumsc iptum,

Bowen's disease ethroasia of Queat, ora f o dpapi omatosis, actn ic chei t is , actn ic keratoses, ep

dermal nevi, sringomas ganuoma faciae, neurofi

bromas, xanthelasma, and tattoos.

Not idcated for the treatment of cepick ace scas

PREOPERAVE EVALUAON

Sgn ifcat ast med ca h sto nc udes a hi sto of her

pes lab ia l is unde ing auto mmue d isease o immune

deficenc underlig koebnerizng/infectious condit ions

including psoriasis, verucae, and mouscum histo of

keloid o hpertrohic scar fomation underig cadiac

or pu lmo nar condit ions that ma be exacebated b the

use of anesthetc medications exst ing drug al lergestobacco use a ctive ace vulgaris

Significat past surgica h sto icudes pro surgicatreatments to the treatment sites, surgica dates, and

patent esponse

The patient must be aware of the ength recoverperod that wi equire extesive hands-on patent cae

for otima treatment resuts. Re-epithe a izato equi res7 to 0 das with associated pai , edema, and e rthema

Postoperative erthema resolves ove a average period

of 3 to 5 months Strict su avodance must be foowed

for a mnmum of 1 ear postoeative to avod pigme

tar changes and photosensitvit Reaistic exectatons

are the most impotant determinants of treatment success. The patient must be aware that the treatment wi l

im ove but does not e im inate a l or eve most rhtides

or scars and that damc htides are l ke to recur

within a few months postoeratvel.Procedural r isks to emphasze icude temoar

and/o permanet hperpgmentato and degmentation, infecto (viral, bacterial , east) and scar (atrophc

hertrophic, kelodal) formation acne flare eczema

lastng 1 to 2 moths. Pedictable sde effects incudeprocedu ra a nd ostoperatve discomfot edem a, oozing,

BFgure (continue (B) A marke reuction in rhyties an yspigmentation is note months after fullface carbon ioxie resurfacing



and crusing lasig o 2 weeks; ehema ski igh

ness, and prurius lasing u p o 3 o 4 monhs.

DEAL LASER CANDDATE

Fair sk n ye (Fparick phooyes I l l )

Laserame nabe lesions

Mi i ma associaed dysigmenaion o eck and ches

Abl e o olerae exended eiod o convalesce nce pos

oeraivey

Abe o o low and execue ecessary posoperave ski

cae regimen

Realisic eamen expecaions

LESS THAN DEAL LASER CANDDATE

Darker skn type (Fizpar ick phooyes I l IV and V;

rea wih cauion due o signi ican r sk o emporaryand/or permaen igmenary aeraions

Moderae associaed dysgmenaion o neck and

ches

Uabe o oow ad execue ecessay posoperaive

skin care regme

Pri o acial surgica procedures peomed

Promien acia pore paernaser reame may

exacerbae hei r a ppearance

ABSOLUTE CONTRA ND CATO NS Use o ora rein oin whi 1 year o surgey

Ski n hooypes V ad V

Acive cuaeous ineco

Preexsing ecropion

Poor pa ien coml ance

U reais ic aien expecaions

RELATVE CONRANDCATONS

Exensive undery ng dysigmenaion o ace andsurounding eck ad ches-risk o demarca ion i e/deece in skn color o reaed versus ureaed skin

Skin hooypes I l ad IV

U deryin g conecve issue

Uder y ing koeber z ing condi ion

Uder ly ing mm unoogic d isease

Previous ower lid and/or bepharolasty (o inraorbial

resuacng)


AFigure 72 () A 45yearol woman with facial photoaging an mil acne

scarring




Pevious ab lative resuac g demab rasion crosurge

ace l ft or heno eel

Histor o faca radiation treatment

MEDCAONS

Antbacteal thea: to avoid imetign zation and

bacterial inection of e treatment sites rohacticantbiotcs are iitiaed 1 da reoerativel

Dicloxaci l i 500 mg PO BID o eex 500 mg PO

B I D for 1 0 to 14 das s escri bed.

n en ic i l in-a ergic id v dua ls , Cio oxac 500 mg

P O B I D x 0 to 1 das or azihomcin 500 mg

PO x da followed b 250 mg dal or 5 das isrecommended

Antvira thea: laser esurfacig ma trigger a heres

simex outbeak tha ca sead to the treatment sites

with a creased isk of sca ormation Prohlactic antivial medicatos are iit iated da

reoeative

Valaccov 500 mg PO BD fo 4 das or acclovir

400 mg PO TID for 1 das is recommended

oical tretioi n

Use of tret o in r ior to C aser esuacing has

bee show c ica l ad v ia b iochemica ana ls is onot ovde ehanced collagen fomao accee

ated re-eiheazatio o qucker resolution o ost

oeaive ehema

Use of th is med icat o s oiona

Use o this medication ostoerativel sould be

osoned unt l a l l associated erthema and iflam

mation have resolved.

Beachig creams no ubished controed tr a ls have

demostrated he benefis of eoeratve bleachigcreams o educe he isk of ostiammator her

igmentation. To ossib reduce this i sk aiets wih

skin hototes l and IV are escibed a bleaching

cream to be alied twice dai fo 6 to 7 weeks rio to

treatment. As we l s ic sun avoida nce s mand ato

ANESHESA

Colda ir coo ig (Z immer) ma be adequate for loca l

zed o sing eass C treatment o Er:YAG treatmet

oical aeshesia ma be adequate fo ocaized o

sig e-ass C treatment o Er:YAG treatmet.

Regiona erve bocks wi sulemea ifi trative

anesthesa are geneall ad mi istered fo mut i leass

C treatment.

BFgure 72 (continue (B) Impvement of photoaging weeks aer fullface erbium treatment



Ste-dependet b locks c ude supraorb ita supra

trochlear ifaorbtal ad mental bocks.

L docaie ( %) wih 00,000 or 1 200000 epi

nephe, a tota of 05 to 0 m is admnsteed per

ste.

Suppemental infi ltrative anesthesia cosistig o a

equal mixtue of 1% idocae, 05% bupivaca eand :0 sodium b carboate is genera l requ ired,especa for the jaw e, upper ee ds, a nd tem ples.

Haluroidase (Wdase) 75 U or t issue dffusio

ma be add ed to the i nfi ra ve aesthesia.

Treatment is delaed 0 o 15 mnutes to a low for

com pete an esthetc effect

Coscious taveous sedato a nd geera anesthesiahave been empoed b traed phscas n cefied

aci t ies patiets uabe to toerae he nectios oror arge procedures.

SAFETY MEASURES

Ee p otecton

Oe or two drops of 005% topca proparacaie(Acaie) o 0.05% opcal tetacaie (Potocane)

are p aced to ea ch ee of he patiet fo owed b

the applcatio o opica erthromci oitment orophtha lmic u br cant (eg, acr i-Lube) ad nonefec

tive metal ic ocular sheds (eg Bro MedicalTucson AZ Ocu o-Past ik , Montrea l Caada) .

A person el m ust wear cear p astic safet glasses to

avod nadvertet conea damage. Operative field

A relectve surfaces ad wdows must be covered

to avod a dvertent treatmet of a efectve surface.

The reatmet room door mu st be abeed poper to

war others ot to eter d ui g lase treatme.

A f lammable materals and anesthetic gases mustbe kept awa rom the operative field

Wet drapes ad spoges are pla ced around the su

gica sie to prevent accidental rradaton of suroundg skn and to minmze poteta f re r isk.

A oflammable o ntmet (eg Surg lube; Y Je l l)mus be placed over te exposed haire ad eebrows to avod ha ir singeing Su rg ube should not be

used over the eelashes to avoid the rsk of cornealkeaits

A surgical tools utlized must possess a onrelective

or roughened back coatg to prevent aser beamdeflectio

A laser smoke evacuator that lters particles as small

as 0 2 m i d ameter and aser-grade surgicamasks must be used to reduce potentia spread of

ifectous partices n the lase pume.


AFigure 7 3 () A female patient who was most bothere by her perioralrhyties but was also note to have moerate ermatoheliosis with

numerous lentigines an actinic amage of the remainer of her face




Use of Hbcens isoprop alcoo and acetoe is

prohbied due to heir ammabe naure. A makeuand hairsa are o be removed, as te are poen

t ia l ammabe

The ase shoud be ket n the stadb mode a a lt imes oher ta acive treament to avod acci dental

ir ng Oxgen should be avoided, bu if needed soud be

closel moitored and on used n conjuncion wth a

closed gas ssem ta incudes eier endoraceal

nubaion o larngeal mask arwa.

PROCEDURE

A thoroug eview of e risks and benefis is per

ormed

Patien wrtten cosen s obained

Reresentative preoperatve ictures are obtaned. Pretreamen preparation is perormed

he choce of aser and lase arameers varies

deeding on e c l n ica s ituation .

The C aser s preferabe or deeer lnes and

scarring rocesses and fo fasknned patiets

(F g . 7 )

The Er:YAG aser is beneficia or supeficia l ies anddspigmentaion and or darker skinned patiens

(F g . 7 2 )

Th e atient's postoperative co sderati ons al so afectthe choice o aser. Te C

aser wil have an

expected longer recover compared wih e ErYAG

aser.

n genera reatme o a cosmec uit or ful l ace is

bes to miimize e risk of textural mismatc beween

nontreaed and reated aeas. In an isolated teament,one mus trea te eire esion or ine to eir end

rathe han rema n withi n a cosmetic un t .

he vermi ion border can be treated conseativel o

min imize i ps ick b leed ing "

reament sould exed beod te aatomica unibeng reaed wh a featheing echnique (deceased

uence) em poed o blend i nto he ureated ski n For depressed scars, addit ional passes wi a sma ler

so size on te deect edge aow or moe significant

attenin g of he scar.

Scar conracion wi occur wih healing. o avoid

atrohic scar ormaion, admister reame o the

evel of ear nor mal adjacent skin ol.

Ablaive resufacin g of dnamc rtes provides onl

temorar benefi Consdeaion o combinaion ther

a with boul in um oxin or a i l l e subsance shou d beentertained to achieve maxm um benefit.

Figure 73 continue 8 ame patient immeiately afer perioralcarbon ioxie laser resurfacing an a Jessner5% trichloroacetic aci

peel to the remainer of her face



Mima mechaca l tauma techque fewe Cpasses peformed wth etainment of the ast passeschar to expedte hea ng and mnmze scar r isk and

pgmentar changes. is techique s opimal fo

ouge patents with moe suefcial lesions ad for

darke sk in es.

Wit a teatment modat, te esence o ager collagen bundles head ent into the dee eticular der

ms ad wan of he possib l it of scar fomato

Treatment shoul d be di scontnued im mediate

Resufacig of nonacia htes s associaed with a

hgh isk fo textua and pigmeta changes due to

the eduction n adnexa stuctues ad poo vascularit

in compa rson to the face Te C aser shoud not be

utlized for the teatment of nofacial rhtes The

ErYAG laser should be ut ized with extreme cauon

Combinato theraies of cabo doxde esuacing

and chemica l eels botu in um toxin , or so t ssue aug

metation ma rovde the greatest benef (Fig 73)

POSTOPE RAT VE CARE

An ope wound techiq ue o closed tech q ue ma be

olowed

Postoeative discomort s characteized b modeate

bun i ng with i the f irst 24 hous T h is s mi n i mized wit

the use o an occlusve dessig. It can geea be

contoled with ce packs cod comesses and aceta

m nope n, as we as frequet woun d cae

Postoeative edema develops 24 to hous postopeativel and ca be controled with ice acks and head

eevaton Ora steoids ae emloed when markedsweling develops intaoperative or mmedatel post

oeatve.

Re-epite a zato occurs witin 3 o 10 das ad s

deedent on the lase utlized the numbe of laser

passes executed and the s urgica ca did ate Younge

patients patiets who undego EAG teatment and

ewer asses show faster ealg eaed heaig is

observed n older aents smokers and icreased

aser passes

opca atibiotics ad Aquaho Healg Ointmentshould be avoided due to the isk of aegc contact

dermatit s

Cose olowup is m andator o esue oe cae ad

hea ng of the teated s tes (F gs 7 4 and 75 )

Prophactic atibiotics and aivia medicatos ae

continued fo 10 to 14 das postoerative to avoid

infecton

Stic sun avodace s maianed for 1 ea postopea

tive to avod hotosenst iv it ad to m in m ize the r iskof postiam mato hperpigmentatio


cFigure 73 (continue (C) ame patient 6 months following her treat

ment A marke reuction in both her rhyties an yspigmentation isappreciate




PEARLS FOR TREATM ENT SU CCESS

Preoeratve wound care instructons ae ciical o

treatment success. Te atient and sigicant othesmus be preaed or e extensive care tat will be

requed or exedient and sae eaing. Paients

shoud be shown posopeative pictues to preae

them for how he wi apea. Postoeaive supples

ncluding wound care sulies and desired camouageoundation should be obtaied ior to te teament

date Patients with ounger ch lden must repare

them fo te signiica changes that w l be noted d ung the eaig eiod A ostoeave assisance te

atent ma requie shoud be arranged prio to treatment ossbe

Patients equire equent postoperative evauation fo

the ist 14 das to ensure oer wound care is beingemoed edicted heaing s oted and no side

eects such as sca ormation o ifection occur.

Paties shoud be evaluated on ostoeative da 2,posoeative da 5 o 7 , an d postoeratve da 0 to

4 and antime e atient exresses a concer oneed o eva uati on

Patients exectatos must be tailored to the expected

benefits. Paients should be iformed tha e greaest

benefits wi ot be apeciaed fo 6 o 12 months

osoerative.

Stic hotoprotecion and su n otectio ae cr t ical n

reduci g te occurrence of ostifla mmaor eig

mentaion and suburn and shoud be fo lowed or aminimum of ea ate treatment.

eaed skin s sesiive o a majort of facal poducts

eumes, a d toica m edicatios or an average o 2weeks postteatment Bland roducts ncludng a sun

block, are ecommeded du ing is hea i ng ime.

Pesiste aeas of ethema soud raise concernregadig sca ormation o infecton A culture is rec

ommeded to rule out bacteria or east iection. Useof a otent oca corticosteoid and/or pused de

aser s cucal wit cose olow-u to esue resolution .

BBLOGRAPHY

Aster TS Cutaneous resurfacing wth C ande r b u mAG lasers: Preoeratve, intaoperative and ost

opeative consdeatons. Past Recostr Srg.999; 03:6 19-634

Anderson RR, Parr is JA Selectve hoothemolsis

Precise microsurger b seective absopion of used

rad a ion . Sciece 1983220:524527

Carruthers Carruthes A Zel ichowska A h e ower o

combined theapies Botox and ablat ve aser esufac

ing Am J Cosmet Srg 2000 7 293 1

Figure 7 Uner aressive woun care A substantia amount of crusting is observe Proper woun care was emonstrate in-oce an withrepeat written instructions reviewe



David , Ruiz-Esaza J. Fast heang ate aser skn

resuac ng The m i i mal mechanca tauma echnique .

Dermaol Srg 99723:35936

Dove S uza G Andt K asers n ski n esuracin g.

Semi a Me Srg 19965:7788

Duke D Grevel nk M Care beoe and aer laser ski

resuacng A survey and review o the ieratue.Dermaol Srg 99824:20206

Fitzatr ck RS Go dma n M P Satur M oe WD. P used

cabo di oxde laser esurfaci ng o otoaged aca s kn .

Ar Dermaol. 199632:395402

Fitzatr ck RE Toe WD Goldma MP et al Pulsed

cabo dioxide laser t cl oroacetc ac d BackerGordonhenol and dermabras ion : A comaa ve c in ica l and

hisoogc study of cutaeous esuracig in a ocine

mode. Ar Dermaol 99632:46947

Nan CA Aste S. Comlicaions of carbon dioxde

lase r resuacing An evauaton o 500 atients. DermaolSrg. 19982435320

Oinger S ang S Johnson M et a Tetinoi teat

ment befoe carbondioxide aser esuacing: A cl in ica

and b iocemca l ana ys is . J Am Aa Dermaol.December 20045 (6) :940946

Rau l in C G rema . Sigeass carbon d oxide laser skiesuacing combied with coldair cooling: Eicacy and

atent satisaction of a rosectve sidebyside study.

Ar Dermaol. 200440( ) 333336

Ru iz-Esarza Barba Gomez M Gomez de a Torre O.

Wound cae aer laser skin esuaci ng. A com bi natio o

oen and closed methods usng a new olyeyenemask. Dermaol Srg 99824:798


Figure 7 Postinammato hyperpigmentation 6 weeks after perioral

arbon ioxie resurfaing This pigmentation resolve with the use of4 % hyroquinone twie aily for mon ths




CHAPTER 8 onabatve Fractona aser Resurfacng

MECHANSM OF ACTON

Noablaive ractiona resuacing (NAR) is a nove co

ce o ski reuvenaion hat can arget boh edemal

and derma cod i ios NAFR roduces a u que hermal

damage aern consstig of mut ie colums o ther

mal coagulative damage, reerred to as micotermal

treatment zoes (MTZs) (g 8) NAFR characterist i

call sares the t issue surroun d g eac MZ thus al l ow

ing ast edemal reair due to microscoic sze o the

wounds and short migrato disance or the viabe ker

atioces resent a he MZ edermal margis O l a

fraction of he sk in of the s urface area is treated

DERMAOPATHOLOGYMTZ eveals homogenzed colu mns o derma matr x andthe omaion o microscoic edermal necroic debrs

(MEND) ( ig 82) MEND format o s hought to ree

se e rocess o elimnation o the hermall damaged

eidermis contaiig igmet b e raid migating

vable keranoctes at the MTZ ma rgins ME D ma aso

contan derma sucures such as the elastc bers

Vessels in t he MT Z regos can be thermal destroed i

a nonseective manner igher energies result i deeeand wder MTZs Hgher eerges resut i deee ad

wider MZs NAF R can be he u l in e reatmet o e

dermal igmetatio suc as melasma ad enignesdue to the rocess of MEND omaion AFR can also

be helful in imrovng rhtdes and scarng due to therocess of co agen remode i ng ad new colage orma

t ion , nduced b the derma herma damage

NDCATONS

NA R ca n be a n effectve treatment of eomoderate

rtides acne scars, surgca, taumatic and bur scars

melasma dscroma and dermatoel ios s (F g 83)


Sgni ican ast medcal hso ic udes hstor o er

es aba s keod or heroic scar omaion, oa

retioin iake (date as course cometed), tocalretoid use, tobacco use, and known drug a lerges

nc l ud in g doca ie a eg

Sgni icant ast surgica hisor cudes rior surgcal

treatments to he treament stes he dates of te ro

cedures, the atie's resonse, and he associatedside eects

Laser

-

E p dr m i s

Subcutaous fat

Fract oa phootrmoyss

I I II I I II II II I I I I I

Fgure 8 chematic of microscopic treatment ones MTZ create by

fractional resurfacing laser note the characteristic sparing of the surrouning tissue between the treatment ones

Figure 82 H & E histolo of microthermal treatme nt one MTZ 1 ayafter fractional resurfacing treatment note the microscopic epiermalnecrotic ebris MEN overlying a column of homogenie ermis



he atient shoud be aware o the folowing

Procedu a d iscomfot

Sunbun- l ke sensaton fo seveal hours ate theprocedure

Sunbun l ke ostoperative ertema that ma e

sst for 3 to 7 das (Fg 84

Postoeative edema geneal mld that usua

resoves witi n 2 to 3 das

Postoeative bronzng that is geneall noted on thethrd postoerative da ad often erssts fo 3 to

4 das

Postoeative suefcial peeing that s oten mdand s noted to stat on the thrd postoeratve da

an d to ersst o 3 to 4 das

Rea ist ic expectatons for the ocedu e: te atent

shoul d be aware that the treatment wil im ove fine

tomoderate wikes pigmetato and supecal

scars but does not elimate moderate-to-deertides A modest benet ma be oted or deepew ink es

Procedua risks athough these advese events are

uncommon and are much ess frequet tha thoseassocated wth ablatve resuacing the stil exst

The ncude temoa ostnfammator heig

mentat ion (F g 85) b l ster ng crust g m a(Fig. 8.6), acnefom erutio inoit hemorhage

(Fig. 87) hees simlex reactvation and aehetophc scaring. Ts s in addt ion to the re

dctabe side eects that nclude procedura discom

o ostoeative erthema bonzing and edema.hee is usual no associated oozig o crustig

unless ve hg eneges and/or hgh densit ies ae

ut l ized

he idea candidate is a fair-skin atet (Fitzatick

hototes Howeve AFR can be sae andefectve daker sk tes (Fitzatick hototes IV

and V) It s a so sae to use on nofaca aeas nclud

ing the neck tuk and extemit es rovded thatdeceased fuences ad de nsit ies are ut l ized

CONTRA ND CAT ONS Ora tretinon use within 6 months to ea of surge

Actve cutaeous infecto

U realist ic ati ent exectations

Pregnant o actating woma

MEDCAONS

Antbactea theap: oplactic antibiotics ae gen

ea l ot equi red


A BFigure 8 3 Perirbital rhytides () fllwing ne fractinal resurfacing

treatment and (B) fllwing fur fractinal resurfacing treatments Anappreciable sftening is nted Curtesy f Fitzpatrick, M

Figure 8 Mild sunbu like ethema immediately fllwing Fraxel lasertreatment with 6 t mJ, 50 MTcm, eight passes This ethemamay persist fr t days




Antivira theap

ractional esuacng ma tigge reactvaton o hepes s m plex tat can sp read to he teatment sites.

Poplact c ant v a medcat ions are n i iated

da pior to he procedure Vaaccovir 500 mgPO BID or acc ov ir 400 mg PO TID o 7 das s

usua l recommended An a ternat ve s va acclov 2 PO B D for 1 da to be started he mon i ng o theprocedue

etino n: it s advised to dsconinue tretnoi n cream at

seveal das before NAFR to prevent skn rritation atthe eatment sites

ANESHESA

Cold-a r cool ng (Z mm er) s ver eective in decreasng

the pocedu ral d scomo.

opca anestesia (oi or ceam base) apied a east hou before he procedue s general adequate, ese

cia n combi naton wih colda coolng (Zm mer)

Regiona nerve blocks can be efecve to reduce the

discomfo o patents wi low ai n thresods ese

c ia l l when ut i z ing h ighe uences and densit es .

Inraobial and mental bocks can be helpul wen

treating perioal wrin kes but ae usual l not necessar.

PREOPERAVE PREPARAO N

Expa n th e r isks and benefts of the procedure .

Obtain the patient's witten consent

Wash the area to be teated wh soa and waer

Obtain preoperative pctures.

A a hick lae of topcal aneshetic in an oi l orcream base o the treament site

Wat at east 60 m in utes o acheve opm al anesthec

eect

Wipe off the topica anesthetc with a damp cloth

PROCEDU RAL PS

e laser arametes are chosen accordn g to the c l n ca taget.

Fo eiderma condt ions such as hotodamage,

entigines, melasma, and dschromia lower fuencesand hghe denst ies are usua l uti l zed

o deeer processes such as htes or acne scar

r ing: highe u ences ae uti ized

Lowe pecent coverage o skin surace area tha is,

owe densit es are ndicaed n darke skn tpes to

avoid posnam mato hperpigmentaton

Figure 8 Pstnflammat hyperpgmentatn fllwng fractnal

resurfacng treatment t the upper lp

Figure 8 Mla n the chn 1 day after NAF



Caution s hou d be exeted wen teaing small er areas

suc as ue l nose ad teme order to avodb lk heang at can result in b serng and scaring

Aow adequate ime between asses for the heat to

dssae and the ski to cool down before the nextass

When reatng he uer a tenae the reatmebetween he rigt sde and e e side and staeac ass rom the same ont

hee to six treatmet sessons (deed ing on the ndi

cation or reatmet) ae administeed 3 to weeksaa Longer eriod beween reaments is advised in

darker-ski atents o avoid or decease the i cdeceof ostiam maor herigmentatio (P I H ) .

POSOPE RA VE CARE

Postoeaive discomfo is geerall mld and ta

sent The atent wi exerece a snburn sesationor severa hous

Patents ma a l makeu mmed ate afte the treat

ment

Patents are encoaged to use mld mostuzers or

sevea d as after the rocedure

Postoea ive edema is usua l min ima but ca becontoled with ice acks and head elevaton In rare

insances of marked swel ig oral redisoe can berescrbed for 3 to 7 das

Sun avodance s maintaned for a east to 6 weeks

afte the ocedure to minimize e risk o ostflammator hergmeato Suscreens wth a min

mu m S PF of 30 are ecommended

cal, atients can reun o wok on the irst ostoeave da

PEARLS FOR REAMEN SUCCESS

Patent seection is the ke Treatng rtes or scars

that are too dee w l rove disaoi nting o he aienand hsician The atient ms be awae of e need

or mul ie teaments to obtain the desred c ical

benefit

NAFR can resu in serious side effecs such as scar

r ing when used a ver high fl ences b nexeriencedhsicans or heath care workes Caton sould be

take to sta witin he recommended aametes ad

al ao ae over ang ecique to avoid

otea comlcaions

Patients m ust be aware that benefs ma be sh ort as

ing and ma equire maitenance teaments fo con

in ued c l in ica l beneft


Figure 8 7 A patien t with rsacea wh develped pinpint hemrrhage1 day after Fraxel estre treatment Pinpint hemrrhage can ccur with

higher energies and usually reslves in few days with n sequelae




Eecve NAFR reamen in paes wi skn phoo

pes l l o V ca be achieved. An icreased incidenceof posinflammaor perpgmenaton is geneall

noed Patiens mus be aware o he possbi of P

wih each reamen. ecreasing he densi of tea

men reduces e isk o PI .

DEVCES

he mos common used NAR devces ha are ava ab le in he make are Faxe Resore (Soa Medica I c. ,

Haward, CA) ux 1 540 nm aser (Pa lomar Medica l

ecologies Burl ingon, MA), and Airm 1440 nmNd:YAG aser (Cnosue Wesford, MA (Tabe 81)

raxe Resore utlizes he scannng ecolog whereasLux 1540 nm and Affirm 1,440 nm asers uilze he

samping ecnoog and do no usua requie opcal

anesthesia or dsposabl e ips.

TABE 8 Noabate Fractoal asers

Compa Lase devce Laser

waveengh (nm)

lta al Fraxel Resoe 1 550

(Fraxel SR 1500)

a ma Lux 1,540 1540

Cue Airm 1440 Nd:YAG 1440

BBLOGRAPHY

Laubach , Tannous Z Andeson RR Ma nse i Sk in

responses o faciona phoohemolsis asers Sre 200638(2) 142-149

Manse , Herron GS, Sink R, anner , Anderson

R R . Fraciona phoohermosis A new cocep for cua

neous emodeli g usn g m croscopc paerns o hermal

inju asers Sr e 200434(5)426438

Narurkar VA Nonablaive ractonal aser esurfacg

Dermal li. 200927(4)473-478 v .

annous Z Fracoa esurfacing. li Dermal 2007

25(5):480486

Mode Tip

d ameer (mm)

Scanng 7

1 5

Stampg 10

1 5

Stampg 10

Max eerg/MTZ

or mcrobeam (mJ)

70

100

1 5

8 J/cm/pulse

ensi

devered (cm )

124000 (548%)

100

320

1000




CHAPTER 9 Ablatve Factiona ase Resuacng

NTRODUCTON

Treatments or photoagng range from nonablative aser

resuracng to ablative aser resuacng. Bo o these

technq es are descrbed in deta l in previous capters

Pt simpl te most eectve lasers carbon doxide

and erbim abative resuacng asers provde the mostdramatc bene for potoagng and other skin condi

t o ns but a so carr te h igest r i sk or adverse eects.The remain the god standard treatment for potodam

aged skin ramatic resuts however can be seen wt

one reatment Sde eects nclude rolonged erthema(for months) permanent hopgmentaton temporar

herpgmentaton inecion and scar. Addt ional downtime rom work and soca activit es s sgni ican

For this reason te popularit o ablative asers hasdecreased dramatcall over te past severa ears

among paients and hscans

B contrast nona batve asers with mu t ipl e treatmentsessions rovide a sae method or providing mld

improvemen o mildto-moderate poodamage wh tte risk o sde eects. Unfotnael e redictabi it o

improvemen is uncertain Some paients do not exeri

ence an discernibe beneit even ater mlt ple reatments. n te past 5 ears n ona blative ractio nal lasers

have produced enhanced resuls rom oer forms o

nonablative resuacng with mult le treaments hese

lasers ave aso proven to be safe n skied hands. Stil

ther ecac is l mted especal when compared oab a ve laser resuraci ng

More recent fractona abatve asers both carbondi oxide and erb u m variants have been develoed to pro

vde enanced resuts wth relative good saet. he

concept is to provde the more aggressve technolog oaba on but to conine potenta downtime and sde

eects b empong a ractional pattern o tissue dam

age whic encorages more rapd ealing t mes with

fewer sde eects. O n a racton of the skn is ab laed at

eac treatment as opposed o raditona abative resurfacng procedres Futher the deth of abaton s

deeer tan w tradit iona ablative resurfacng procedures

Advantages of raciona l a blative las ers are as fol ows

Better improvement o deeer rtdes tan nonaba

tive devces

Sign i cant beneit with one treatment

Can provde some imrovemen for skin axit pigmented lesions and vascula r dschroma as well

Signi cant reducton n posoperative downtime com

pared to tradtiona abative devces

Figure 9 Immediate endpint f pixilated damage patte with anerbium fractinal ablative device




Can reat cosmec unis effective wthou lines of

demarcao oen seen wth tradtiona ablative ocedu res tha is eroral/eriorbital areas

NDCATONS

Rhtes eseca modeaeosevee perioa and

eriorba rhtes

Photodamage, i c ud ing skin exure and toe

Acne scars in cl udi ng boxca arohic rol l ng scars

Sugica and burn scas

Mild mprovemen in skn axt

Not effecve or dna m c r hides


Sk i n tpe ( II I I are best canddaes)

Su n exosure

Hstor o keoids

Ssemic necions

Prio lastc surger especal neck l g rocedures

an d face l fts

sotreno in use in ast 6 mohs

Patiens with uneastc expectaions

A consultaton s requed before ts treament o

assess te ate as wel as aroiate prepae the

patent for the procedure The atient should be u educated as o e isks and benefis of is procedure

he patie must be aware of the recover erod of 4 o

7 das (on average) he atent should be shown post

oeaive ictures to eare em for ow he wl

aear An posoeratve assistance e aient ma

requi e sou d be aranged pro to treatment i possib e

he paten shoud also be iformed that he benefits of

the treament accrue 3 o 6 months ae treatmen Apaten who is unabe o foow and execue necessar

posoeave skin care regmen should not be reated

PRO PHY LAX SIAN EST H ES lA

Ma nclude an of he fol owi ng

Antvira and anibiotic rohaxis

opical anestheic

23% idocane/7% tetacane

Ora pa n med icat o and anxo t c

Vcodin/acetaminohen/atvan/nothing

Nerve blocks/M Toradol

General a esthesia

Figure 92 Patient immediately after C ablative fractinal resurfacingtreatment Nte erythema, edema, and pinpint hemrrhage



Because this rocedure is painfu some form o

anesthesa is requed. t wi l vary accordng to theaggressveness of treatment, he pacular suscetb i

t es of the atent, and e hysican s comfor wivarous aesthec regimens Regional neve bocks wth

sulemental nf ltrat ve anesthesa ae general y elpful

Site-deendent b ocks i c ude suraorb ta infraob ia l ,and mena b ocks . docaine (%) wh 1 00000 or

1 :200000 einehr ne, at a tota o 0.5 to 1 0 m ca be

injected at each sie

LASER SAFETY

Eye oecton: metal eye shelds

Oe or two drops of 0.05% toca roaracaine(Acaie) or 0.05% opcal tetacaine (Pontocane)

are aced no eac h eye of the aient, foll owed by

the applcation o toica erythromyci oinment or

ohtha lmic u br cant (eg, acr i-Lube) and nonefective meta ocular shieds

A ersonnel prese at e treatment must wearsafety gasses/gogges to avoid nadvertent corneal

damage

Due to the ai , b eeding, an d pai n med cations assoc

ated with thi s teatmet, t is m erave that the atient be

accoman ed by a frend, spouse or reative who can d riveo accompany the patet home aer the procedu re

• Posoperave Cae (Fg 9 . 1

nterestngly, l itt le ostrocedure pan (Fi g 9 2) Best exanaion: heat release through abated cannes

meratve to give oa a nd wrien wound care i nstructions to atent

Gauze soaks and emoents mmedatey ostoeratve

Room temerature steie water soaks for 20 minutes

every 3 to 4 hou s fol owed by Aqua ho rasel ne a pi

cation for 2 o 3 days

• ol owp a 48 o 72 hous( i g . 9 .3

Re-eie a zat o s usua l ly comlete

Eytema, edema and res dua io nt emorrhagc

crusting are exected.

M il a a re commo n ad oen cl ear whi n a few days

Assess for vesicles, bu a e, ustues.

Emoles twce daly for 3 o 7 days.

nstructos to ca f any concens or changes i woud

hea ng

Postoperatve erytema resolves over a erod of

weeks Strct sun avoidance mus be olowed or a


Figure 93 Patient at -hour followup Note that hemorrhage is nolonger present, but edema and ethema persist




minimum of 3 months postoperativel to avoid pigmen

tar cha nges and photosensitivit

• Adverse Sie Eects

Delaed onset hpopigmentation

Scar ing

Postinflam mator hpepgmentation

Pesistet ehema

nfecton

he side effects for fractiona abative resuacing are

the same as those for tradtional ablatve resuracingprocedures abeit far less frequet or severe in ski led

hands As with onabative actiona resurfacing

postnflammator hperigmentation (PI) is more kelto occur wt higher treatment desit ies paicular in

darker skin phototpes (Fig 94) perophic scarrng o

the neck is a sg ficant and potential l permaent compication o fractonated C laser resuracing (Fg 95)

Caution s requred for these procedues

he fo owing practices al l s ignficant ncease the

risk of scar:

Aggessive treatments i ncrease isk of scar

Poor tech iqu e that i s excessive ovela

Postoperative wound nfection

Hi stor o face or eck i ing procedues

Treatment o nofacial ski especial the neck

• I n f e c i o ( F g . 9 6 The ke to teating i ection s to recogize i t at ts ncep

tion Infections are diagnosed cl n ical l Cultues can

confirm a d iagnosis Em p ic at ib iot ics and c lose c l i ica

followup are the kes to teatment Persstent areas of

erthema sho uld aise concen egardi ng scar formationor necton A cultue is recommended to rue out bacte

rial or east inecton Do not perform these procedures ifou cannot recognize ad treat bacterial , v ra funga

infectons

• N o a c a l S k i

Nofacia l sk in i s moe vu neab e to thermal eneg due

to underiv leged wound heaing caabil it ies here are

fewer plosebaceous units on te neck and more mited

cutaneous vasculature to suport woud hea ing hi s isespeca true where thee is a histo of pior lastic

suger Face/neck iftig pocedures place neck skinonto the face tus ou ma be treating neck sk on

the face I there is a histor of pior plastc surge it is

best to treat at lower sengsBecause of the isks of seious side eects it is

stog advsed that ractional abatve resurfacing

Fgure 9 Test spot treatments with a C abative fractiona resurfacingdevice in a young mae with tzpatrick skin type 5 The test spots are

not arranged in order of aressiveness The darker areas of PIH coincidewith increased treatment densi Increasing puse energies do itte to

worsen PIH

Fgure 9 Hypertphic scar aer treatment with a C

fractiona aba

tive device



shoud o be erformed b a arorate traned

hscian exerenced n ostoperative woud care folowng resurfacn g rocedures

n sum , ablative ractiona resu rfacing rocedu res oferthe advaage of good esuts wth oe treatment as we

as offerng signficant mrovemen where nonabatve

ractona an d n onractiona devces do ot such as moderae and severe rhdes At he same ime it offers the

exib it o treating smaer aeas than tradit ional resuacg rocedures because it does ot tpcal eave

nes of demarcation Addit oa there is sgnifcant

reduced c n ica and socia downtme compaed to ul surface a baive rocedu res onetheess the teatment

has ts drawbacks such as

ghtenig is usua modest.

Durato of benefits s not known

Bes resu ts ofte requ re mo re tha oe treament.

Especa acne scars

Requ res 1 week awa rom work and socia actvit ies.

Seres onabatve reatments ma be more toerabe

and ractca or man patents.


Figure 9 Localized miu te pustules, edema ad erythema represetiga localized pseudomoas ifectio i the settig of post-C fractioalablative resurfacig for a bu scar It cleared fully without sequelae aeroval atibiotic treatmet




CHAPTER 10 Tssue Tghtenng

hee have been a va e o f on invasive devices ha

prpor o l i ad ighen loose" necks jawines and

ees. These devices work b delivering monoola bi ola o ifrared energ o he deep dems and sbca

neous isse es i g in ighenig and l i ing of skin a d

creaion of new colagen. The chief obsace or hese

devices has bee nconsise clnica ress. Somepaens have had dramaic resus in comparison o a

dioal nvasive srge ad ohers have seen lile or o

imoveme Paes who ndersand he isks befoe

he procedue ae happ wih excellen esuls and o

d sapoied b lack o im proveme

MECHANSM OF ACTON

hee ae differen radiofeqenc (RF) echoog and

infraed devces ha del iver volu meric h ea o h e deep

derms and sbcuaeous issue which ighens exisingcollage and hel ps creae new collagen

CANDDATE SELECTON

As wih a procedres can didae selecio s vial o he

success of he rocedre . These devces wi n o rea epi

dema chages of agg such as lenigo eangiecasa

o rogh skn Candidaes shold have deep cuaneos

signs of aging such as saggng" ski in he neck aw oaound he ees. Some hscas have reored goodsuccess i reaing aeas o he ace incldig ppe

ams abdomen and breass. Al paies ms be awae

ha he amo n of c i ica i provemen s highl variabl eno predicab e before he poced e Paiens ha do no

ndersand his should no ndergo he procedre

THE PROCEDURE

When f irs noduced he ch ief compla i wi RF

devices was nolerabe ain. The pocedure was doe

wih a sigle pass a hig eerg seigs. Over he eashe rend has been oward moe passes wi lower flue

ces Ths has greal redced he pai assocaed wihhe ocedue Ml ipe passes lower uencies and dif

feren so sizes have esued in greae immediae s

sue ighening obseved in paiens ad a igher

perceage o paes wih im ovemen aer 6 mon hs.

• Peproceue Check is

Remove a l makep

Rem ove al l jewelr.

AFgure (A) Prior to treatment skin axity is observed in the jowregion



No acemake or defbriator.

A l atents wt facal m ants soud ave te mateia l o the i m ant identifed before the ocedu e. f t s

un known do ot teat di ectly ove he i m an

Ay tick ayer o toical anestetic 30 mnutes

befoe rocedure

Deteme a roriate sot size ad fluence

Kee e h and ece eve wt te skn t hrougout the

rocedure

Afte the ocedure atients ca esume egua activi

t ies i mmed ately

Patents should communicate with ter hyscian n

case of ay qu estions o co ncerns.

movemet occus for u to 6 monts ater e o

cedue

SDE EFFECS

The amount of serous sde eecs has been educedover the years as treatment otocols ave been refned.

With ower f uences the i sk o sde eects has bee su bstatal y educed

Pote ia l S de Eecs

Atrohoderma whch may be emoay o emaent

Burn

Eosion/uce

Scar

Dyschroma

Nerve damage

Ocua damage

CL N CAL PEARLS

Al atents should be waed befoe ay rocedure

that the amount o cl n ca imovement vaes rom

erson to erson Imrovemet ca range rom da

matic to NO imrovement at a l Any atent wo does

not uderstand the otenta for no imovement

sould not ave the ocedue efomed

Wie teatig each atent cotinuously obseve te

ski a d ask the atient to in form the hysca n f tere sa at icul ar sot with ncreased a n o u nusual sym

toms f a atient comlains of unusua an o sym

toms sto te rocedure and reevaluate te settings

Ma ke sue a uni form am ount of enegy is deivered with

eac ulse. This is done by using e aoriate sosize and alying unfom gente but firm ressure to

the skin

Do not efom the rocedure on a atient wth actve

sunbun o tan


BFigure (continue () ix months afer treatment appearance of thejowl and neck is impved slightl eproduced with permission, fromHirsch adick N, Cohen JL Aesthetic ejuvenation A egionalApproach New York McGrawHill, 00




CHAPTER 11 Dematochaass

Dermatocaasis is a condi ion characterized b pe

and/or lower eeid skn, muscle redndac and laxi

an d fat ad heniat on t s ma in attibua be to ch ronologica l aging and chron c su n exposure .

EPDEMOLOGY

dee ver commo n

Ae most frequent obseved n ndividals oder an

50 eas

Sex no predi ection

Rae mos common in fa irskinned nd iv dua ls (skin Aphotopes I ad I ) ess common in dakerskinned ndi-

vidu as (sk n p ootpes VV I )

repa ars crooogica l aging chron ic sun

exposure throd d isease

PAHOGENESS

Uer and/or lower eeld skin and msce hpertrohand proase fat ad descensio .

PHYSCA EXAMNAON

Ear ind ngs inc ude a do be l id crease wih on mod

es hooding. Severe findngs nclde rominen eeldhooding wi per ad atera l v sa l e ld obsrct ion .

Coexsting brow tosis ma furer comromise he

per era v s ion

Tests for ower id axit ep deemin e i a l dtghening

procedure is eeded

owe lid horizona axi is measred b he disrac

tion es that req ires ing he lower l id anteror l awafrom e globe A greaer tha 7mm id excusion ind

cates laxit

Orbic ar is ocul tone is meas red b e snap tes that

is erformed b ul ing the lower l id nferior If the l id

does ot spontaeous retun to the normal osit ionprio o the nex bl in k te tes is osit ive id icaing l ower

lid axit.

D FFERENA DAGNOSS

Bleharochalas is (recrren id iopath ic ee id n lammation wth reslan reaxato o the uer id skin); uper

eed hooding seconda to eebrow oss

BFigure () A 5yearold female conceed about her sunken eyesand forehead wrinkles (B) Impvement of the blepharloptoss sunkeneyes and forehead wrinkles months followin upper lid blepharop/astyand leavator aponeurotca advancement eproduced wth permssonfm Harue uzuk M Kyoto Japan



DERMATOPATHOLOGY

Epdema acanthosis wth fattening o the derma

ederma uction derma colagen breakdown wthormation of amophous masses and ncrease in gl

cosamioglcans.

COURSE

Chronic rogressive course; visua ee elds ma beaected.

KEY CONS ULTATVE QU ESTON S

An assocated smptoms incuding visual obsruction

d r ees excessive ear ing

Uderng medical condit ons especial l ee disease

and hod condit os

Prio treatmet and response

MANAGEMENT

Prevento s ict sun avoda nce

Control un derg throd d sease

TREATMENT

opca thera dail sunscreen appicaton wth UVB/UVA coverage

Su gica thea

Coronal bowftupper face euvenato

Trchophtc bowltuper ace ejuveato

Bepharopastup er ad lower eeld reuvenation

( F i g 1 1 1 )

Laser thera p

Pacement of otectve ee sheds pro to aser

treatment if paamou nt

Conservave teatment s necessa to avoid ectropon omaion and/o sca omaton

Carbon d oxde aser esurfaci ng ErbumYAG laser.

ractonated abative carbon doxide aser esuac

ing

P TFALLS TO AVO D

A conservatve approach to surgical remova of this skin

is vta to peve a saed" appearance or ectropio





Retenion of al or oions of an herniaed fat ads

hes miimize the skeeonzed aeaance oennoed to develo with age and loss of facal volme.

Drec v sua zaton of the infeor ob l q e muscle s v ta

to avod musce in r.

reamen wh ubica nts and tai g l d s ma hel e

ve keraoconctivtis.

BBLOGRAPHY

Anc ona D az BE . A rosectve sd of he m rovement n eriorbia wrinkes ad eebow elevaion wih a

novel fracional C lasere fracional eelif J Drugs

Dermatol 20109 ) 1 6-21

Carter S Se S Co P ower eeld C laser ejvena

ton: A andomzed rosecive cl in ca sud.

Ophthalmolo 2001108:437-441.

Codne MA Wolf Anzar A Prima transctaneous lower beharoast wh roine aeral canthalsuor A comeensive 10-ear eview Plast Reconst

Surg 2008121 :12411250

unzeker CM Wess E Geoems RG Fracionaed

C aser resufacing: Our exeriece wi more an

2000 reatmens. Aesthet Surg J 200929(4)317322.

orn BS kkawa DO Cohen SR. anscaeos loweeed blearolas wh orbiomaar ssenson:

Retrosecive review of 212 consectve cases Plast

Reconstr Sur 2010125(1 ) 315-323

Lee D aw V. Subbrow beharolast fo e eed

rejvenation n Asians. Aesthet Surg J . 2009;29(4):284288.

Lemke BN Sasor OG he anatom of ee id osis.

Arch Ophthalmol 1932100:981986.

Lev ne MR Manual of Oculoplastic Surgre

Ph ade h ia : Beoh eneman 2003.

Shor N, Enzer Y Consideraions in aesthetc eeidsuger J Dermatol Surg Onl 19921 10811095.



Secon 1 : Photoaging J 6

CHAPTER 12 okodema of Cvatte

Pok i odema of Cvae ( POC) i s a cond ion ha s at ib

uabe o chonc sun exosue o the eck and he chest.

The sevei of fin d ngs is deenden on he d uaion andinensi of sun exosue cosuive skin coo

( Fiaick skin e) and e caaci o an.

EPDEMOLOGY

iee common

ge mos feque obseved in esons olde an

40 ea s

Se s gh female edomi nance

Rae mos common in fa i-skinned ind iv idua ls (skin

hotoes I and I ; ael seen in dake-skinned idvdua s (sk n ooes VV )

reiiig aor chon ic sun exosue nc ud ng

inenona su exosue since outh and occuaionaexosue auma; chonoogica agng

PAHOGENESS

Ulavio e B (V B) i s he mos damagng V ad a ion

wih high dose ulavoe A (VA) conbug to he

noed changes. n add i on vis ib e an d inaed ada os

have been shown o augmen he acio o UVB .

PHYSCAL EXAMNATON

Telangiecases md aoh eicuaed hegmena

on and hoigmenaon affecng he aea ad os

eo asec of he neck aeio ches and jawine

Submena l neck s saed Pe ifo l icu la sa ng noed

(F gs . 12 1 and 2 2)

DERMAOPAHOLOGY

Eidema acanhoss wi aenng o he dema

eidema junc io Focal ncease e idemal basacel meanoces; iegua basal cel eigmenaon

Dema collagen beakdown wih fomaion of amo

hous masses and ncease in gcosaminogcansTelangiecasa noed.

DFFERENA DAGNOSS

RothmudTomson sndome; ad ia io dema is ;

Knd e sndome; B oom's sdome; Aaxa

eangecasa.

Fgue 2 oikiloderma of Civatte etiulated pigmentation, ethema, and atrophy an be een ith harateriti paring of the ubmental area The erythematou omponent i more prminent in thipatient Courtey of ihard A Johnon, M




COURSE

Ch ronic rogressve course with contin ued sun exosure.

KEY CONSULATVE QUESONS

Past and curre su exosure histor Occuato

Hobb es/soing activities

Uder ng medca l condit ions

H/o radat o therap

Past treatments ad resonse

MANAGEMEN

Preveo : str ict sun avoda nce

REAMENT

oical thera: dail sunscree alcaion with

UVB/UVA coverage

Laser thera great caution must be foowed with an

aser treatment admiistered to mimze the r isk o

scar formato dsgmentation figer-rint ig" ortreatment skp areas ad textural ch anges The nec k is

aicu la r rone to scarr ig given fewer i osebaceous

un ts. A test ste s recomme nded . Mu l il e sessions are

geera required.

Laser fuences shoud be lowered b aproximatel25% to 30% of facia arameters to avoid adverse

eects.

Pulsed de aser-ow fluences utilzed (eg, Vbeam

595 m 04.0 ms J/cm 7 10-mm sot

DCD 30/20) Im roveme in telangiectasa a d atroh seen. im ted benet for dsigmentation .

ntese used igh (eg StarLux 230 ms

234 J/dm 10% ass overa)mrovement oal comonets ma be possible.

Versa Pu lse 532n m laserlow fuences ecessar

(F g . 12 .3) .

Fractionated noab lative ad a blative lasera l comonets ma be targeted Can be safe utilzed inaected bod areas hough conservative aser ara

meters are requi red to avoid oteta scar r ng.

P FALLS TO AVO D

A consevatve aproach mus be foowed wth an

treatment used or POC gven the sigificat risk o

uneven removal of the igmentation and erthema

resut ing in a footr int" l ike aearance (F g . 12.4)

Figure 2 2 Poikiloderma of Civattethe pigmented component is more

pminent in this patient

A

BFigure 2 3 () Poikiloderma of Civatte pretreatmen t (B) Poikiloderma ofCivatte following three VersaPulse 5nm laser treatments Markedreduction in ethematous component is observed



This motted appearace can occur nomal drng the

corse of treatment he patient mst be aware of thispossibi l it Contined treatmet to the residal esions

genera ests i a resoltion o ths side efect

Patients ms be awae o he dicult n improving

ths co ndt io . M lt l e treaments are execed for ed

poin of gtenng Textual changes are ke to pesist

POC with a pri mar erthematos com poent tpical

responds bee tha POC with a prmari hepig

mented compone

BBLOGRAPHY

Batta i ndson C Cotter i A Fo ds S Treatmen

of po ik oderma o Civatte wih he oass um ita phosphate (P) laser . r J Drml. 1 9991 40(6 ) :

1 1 9 1 - 1 1 9 2

Geronems R Poiki odema of Civatte Ar Drml.1990; 26(4) 547-548

atoulis AC Stavrianeas G Panaoides G et a

Poki oderma of Cvatte: A histopathoogca and lrastcural std Drml. 2007214(2) : 17782

Langelad Teatmet of poiki loderma of Cvae with

the lsed de aser A series o seve cases J sr r. 1 9991 (2 ) : 1 2 7

Rusciani A Motta A Fo P Menichni G Treatment of

pok i oderma of Civae sn g intense plsed igh sorce7 eas o experece Drml Srg 200834(3):34-

3 9 Terne EP anke CW Treatmet of poikloderma of

Civate with abatve fractioa laser resrfacing

Prospective std ad eview of the iteatre J DrgsDrml. 20098(6):527534

Terne EP ouba DJ ake CW Revew o ractiona

photohermolsis Treatme ndications and efcac.Drml Srg 200935(10) : 1445-46


Figure 2 "Footprinting o f th ntrior nk fr singl intnspulsd light PL sour trtmnt for Poikilodrm of Civtt his subsquntly rsolvd with ontinud IPL trtmnts






TW

Disordes of Sebaceous G lands




CHAPER 13 Acn e Vuga rs

Acne vulgas is a chronic nammator disease of the

p losebaceous ni Acne esos favo the face neck

uppe back chest and pe ams M lt e c n ica l var ants exist and the inclde comedonal acne papopus

ta acne oduocstic acne acne congobata and

acne fu lmnans .

EP E M OLOGY

a ag predominant a dsode o adolescence affects 85% of ndivduas between 12 and

24 eas of age ma aec al age groups

Ra lower ncidence in Ar can-Amercas and Asians

S moe severe forms n maes

rg ars genetc redisposit o endocrine

dsordes sress mechaca factos ( ic ion resseoccus ion) conact wth acnegenc mate a ls (o i s ch o

nated hdrocarbons cosmetcs) and drugs (steods

l i th um adrogens hdanto n)

PAHOGENESS

Ma patens wth nodulocstic ace have a fistdegree

relative wih a hsto of sevee acne. The rma pahophsiolog voves aeed folcar keratzaion resutng

i o bstucto o sebaceous o lc es iceased seb m p ro

dction heroliferation of Poponibacterum acesand increased poduction of cemotacc factos whch

resut n iammato.

PHYSCAL EAMNAON

Comedones (cosed and open) ehemaous paulespstues nodules and csts Ma esove with esidual

herpigmeation o scaig.

D FFERENTAL DAGNOSS

Acne osacea steoid ace acne mecaica

Ptrospom o l l cu t is and baceia fo l l ic u t s .

LABORAORY DAA

• E n d o c n e S t d i e s

No rotne studies are needed If hstor and phscal

examnaion aise concens hen cosider odeig

sceen fo free and total testosteone de hdoea d rosterone and fo ic e st imulat ig homoe/ luteiz ing

Fgure An 1 -year-old male wth yst ane beng treated wth1450-nm dode laser



hormone (S/LH) ratios to exclude polcstic ova sn

drome or other hormonal abnormalit ies esecal inwomen with moderatetosevere acne h rsutism rregu

la menses and weight gai iet may pa a role i n laresof acne. High gcemic diets ma exacerbate acne

uther stud ies are eeded

• Demaopahoogy

Patholog of ear lesion (comedone) reveals obstruction

of the fo c u a i nfundib u u m b con ied ce l s ead ng to

dilatatio ater esos reveal fol icua upture wth m

phoctes neutrophils, and macrohages Scarr ig ma

be see

COURSE

Ths dsease demostrates a chronic course and remts

sotaneousl in the earltomidthid decade i themaorit of atients owever, acne ma pesist much

longer i some patets.

MANAGEMEN

Ear treatmet of acne is essentia or the prevento of

dschromia or assocated scarr ing (see scar treatment

chater 6) Man ace patients beet from combinaton theraies. A thorough histor ad hsica examna

t on a re aam ount to ad mi nistering a maxi mal l eectiveplan h is should inc ude current cosmet ics and sun

screens skn te festle occupatio medications

past teatments ad esponse det mestrua and oal

contracetive h stor

• Topica Teae

Toical treatmet ma be requi red or the du ration of th scondit ion Topica ormuations shoud be aplied to the

lesons as wel as to the adjacent acneone cl n ica lnorma l sk in

Retnoids tretnoin adapaene tazarotene

Antbactera agents benzol peroxide cl indamcin,

erthromcin

Keratoltic agents sa icl c acd hdrox acd azelaic

ac id sod um su lfacetamide an d su fur

• Sysem c Teamet

Antbiot cs: tetraccline doxccline minoccline ae

most commonl used Alternatives ncude er

thromc n az ith romc in and amoxic l l n

Hormones: oral cotracetives or srooactone or

women with persstent acne on lower face chin andneck

Secton 2 : Disorders of Sebaceos Glands 73

A

BFigure 32 () Facial iammato ace ulgaris uresposie to multiple topical ad oral treatmet regimes (B) Marked improemet of ace

6 moths folloig fie 1 450m diode laser treatmets moothbeamadela orp , Waylad, MA, 6mm spot, 1 4 Jm 0 ms




sotretnoin or severe nodu ocsic ac e hat has fai led

other tocal and sstem c heraies

• Sug ca Teamet

Comedone exractio exresson of keratious con

tents of oen comedones b alng the comedoneexractor to the comedoes and aplig ressureA n ick ma be made to the over l ng skn with a

#11blade or 18gauge needle to ease n the extraction

The Schamberg na and Saalf ie d comedoneexressors are most common ui zed Comedone

exracto s contraidicated for inflamed comedonesor pustues due to increased scar rsk

ntralesional steroid injecon: tr iamcnooe acetoide

(23 mg/m is ineced no iflamed cstc lesionsusg a 30gauge neede Maxmum dose injected

shoud ot exceed 01 m er eso to avod atroh

Paties shoul d be warned tha atroh from an nammator cstic esion can occur wth or wthout an

ntraesona steroid injection

Chemca l ee s ser a l sa l c ic ac id ees g lcol ic ac id

eels (270%) and tr chloroacetc acid (TCA) ees

(1020) have been uti l zed o reduce he number ocomedones and improve postilammator erg Amentaon and ersisen erthema Pees ma be er

ormed ever 2 o 4 weeks wh ncreasig srengthsand tme apled as toeraed Mild irr ta ion ma be

observed Adunctive thera is geeral necessar

Microdermabraso: this s rimarl efective or come

donal ace t is usual eormed ever 2 to 3 weeks

Mulile treames are needed with varabe imrove

me

• Lgh Teame

Lasers lasers and light sources are no te firs-line

thera for acne but ca n be a n efective a ternaive oraduvant to med ca hera wen requi red

1450-nm diode aser (Smoothbeam laser Candea

Cor , Waland MA) treatme fluencies rom 8 to14 J/cm 6mm sot s ze and dnamic coo ing

device seting of 335 ms can resut m il d o dra

matc improvement of nfammator trunk and facalacne wi a sgnficant reducion in eson coun after

an average of three searaed b 4-to-6week nterva s (F igs 131 and 132) I t s imortat o de ver

nonoverlappng ulses to reduce the r isk of side

efects Toical l doca ne cream ap l ed ror to reatmet s needed to mimze the treatment-assocated

a n I is vita o al the cream over a im ted bodsurface to limt an rsk of idocae toxc

Lower luencies of 8 /cm with two ful-face asses

versus a single ful l-face ass at hgher fuecies(1 014 /cm) have been used to reduce a

BFigure () evere acne before treatment (B) Aer three treatmentsof photodynamic therapy with topical 5aminolevulinic acid and pulseddye laser mm spot 6 !m 6ms pulse duration Courtesy of MarkNesto M h



Plsed dye laser (PD stdes examiing the e

cacy of PDL or inlammatory acne ave odcedconf ict ig data. Plsed dye laser aone or i combi

nat ion with long sed 1 ,064-nm YAG lase asbee effective n reducng nflammatoy acne PDL

can mrove ostace eyhema Flences of 55 to

7 /cm

, 7-mm spot s ze wth lse du rat ons of 3 o6 ms are most commoly emoyed. Severa treat

mets are n eeded to ach eve the greatest benefi.

Phototheray: mut e l ight sorces have been

reoted to sigicantly im prove acne wh m n ma side

eects These soces icde igh-intesy narowband b e l ght , h ig- intens ty mea ha ide la m h gh

enegy broadspecrm be l igt, as well as mixed

b e and red l ight

Photodynamc eay (PD): PDT ti l z ng the topica

administatio of 5amnolev in ic acid (AA evlan

Kerast ick DUSA Parmaceut ica s , Inc Wi mingon,

MA) activated by lght exosure is aother otetiayeective modality to teat acne (Fgs. 13.3 and 134).Sho contac AAPD ( 160min te drg ncu baon)

was capabe of i mrovng ace sgficaty n a variety

of cinica stdes Dierent gh soces have beent l zed icdng blue l ght (405420 nm), ed l ght

(635 nm), long-ulsed 595-m ulsed dye asers and

intense sed ight (4301200 nm) (Fg. 13.5).

BBLOGRAPHY

Secton 2 : Disorders of Sebaceos Gla nds 75

A BFgue 3 () Facial inammato acne prior to photodynamic therapy Marked redction of the inammato acne er three eion ofphotodynmic therapy Cortesy of Mrk Neto M, Ph

Bowe WP, osh SS, Sha ta AR. Det and acne. J Am AAc Derml 2 01 0 6 3(1 ) 1 2 4 1 41 .r edman PM, M, K imya Asad A , Go ldberg .

Treatment of iflammatory faca ace vulgaris wth the

1450nm diode laser A ot sdy. Derml Srg.200430(2 pt 1) :147151

Ham to F , Car J , Lyons C, Ca M, ayo A, Maeed A.

Laser an d other ght thera es for e treatment of acnevgaris: Systematic revew r J Derml. 2009160(6)

12731285.

Leheta M. Role of e 585nm p sed dye aser thetreatment of acne n c omarison wit othe toical tera

etic moda t es J me er er. 2 0091 1 (2 )

118-124

Po lock B, urner D, Str inger MR, et a l opca l amio e

v n c acdpotodynamic theapy for the reatme oface vlgaris: A stdy of c cal efficacy and mec an ism

of act io r J Derm/ 2004151(3) 616622.

Yeng CK, Shek SY, Y CS, Kono T, Chan H. reamentof inflammatoy facal acne wth 1450-nm dode ase n

tye V o V Asa skin sig an otimal combinato of

laser arametes. Derml Sr 200935(4)593-600.

BFgue 3 () Mild acne scarring and dyschromia prior to Er YG laerresrfacing (B) For months aer Er YG laser rerfacing tiliing a5mm spot at 1 J with for passes reslts in significant impvement

eprodced with permission, from over J, dt K Geronems ,et a Illstrated Ctaneos & Aesthetic aser rge McGrawi//Inc; 000




CHAPTER 14 Rosacea

Acne rosacea s a chronic vascular ad aceiorm disor

der of the l osebaceous u nit that aects redomin ant

the cetra face cudig he centa cheeks nose andchin e ees and the eelids can occasona be

involved Tical thee is an icreased reactvit of cai l ar es o eat leading to lushing and ut imate eang

iecasia Subtes of rosacea include (1) vascuarrosacea (erthematotelangiectac) (2) auloustula

rosacea (3) sebaceous herasia (maous rosacea)

inc ud ing rh noha (nasa sebaceous her as ia)

and ( 4) ocula r rosacea G rau omatous rosacea is a var

ant of rosacea

EP E M OLOGY

iee comon

Ae 30 to 50 ears eak ncdece between 40 and

50 ears

Sex femae red lecton male redomnance or hino

hma

Re: most common n far-sked indviduas (skn

hototes I and I ) rarel seen n darker-skn ned id

vdu as (sk n ototes VV I )

reiii rs excessive su exosue caenesic oods ot foods and beveages heat acoho seb

orrhea tocal coicosteoid use ad uderling

Parki nsons dsease

PAHOGENESS

Mutie actors are nvoved n the ahogeesis of

rosacea incuding vascuar heractivit emodex foll icuorum mites Helcobacter or i and hersest iv t

to Poonibacteium aces

PHYSCAL EXMNAON

Variable c n cal features can be reset deending on

the sevet an d th e subte o osacea Eal featuesincude ransent and ontransent flusing ertema

tous aules ad ustules No coedoes ae noed

Late features cude telagiectasas sebaceous er

as ia nasa th ckenig and en argeet (rh inohma)

and medema Ocula invovemen is equent seen

D FFERENAL DAGNOSS

Acne vulgaris seborrheic dermati s erioa demait s

sterod rosacea sstemc uus erthematosus ad

B uus mi l a is d issem natus fac e i

A

BFigure 14.1 A&B evere rhinophyma prior to electrosurery Courtesy ofuzanne Olbriht M



DERMATOPATHOLOGY

Vascul ar ectasia as wel as perfo l i cu ar and perivascula r

lmphohistioctic infi trates are he most common fidings Demodex o ic uor um is usua l detected in the fol

c es Nocaseat ig epthe o id gau omas ae seen n

the granulomatous vaiat Sebaceos hperpasa and bross ae seen i rh nophma

COURSE

Ch ronic with fequent ecurrences Ma spontaneouslresolve afer seveal eas

MANAGEMEN

Preveion reducion o e imination of exacebas; suavodance

Topica Therapy

Metonidazole (0. 75%1 %) once o twce da 10%

sodium su lfacetamide with 5% su lfur oce da i , and

azela ic ac d once da i a lone o n combinat ion , a re he lp

l in suppress ing the papopustu lar componen of

rosacea

Sysemc Terapy

eracci ne 1 000 to 1 500 mg dai in d ivided doses

untl clea hen tape to a manteance dose of 250 to

500 mg da M ioccli e ad d oxccline , 50 to 00 mg twice da

Secton 2: Disorders of Sebaceos Glands J

c

with a tapeing to oce dai use '- "

Ora sotretnoin is reserved for sevee cases ot

respond ng o oral anti biotics and equ ires close fol lowup A lowdose regme ma be eective

Su g ic a Therapy

RhinophymaMut iple surgica modai ies have been used to coect

the hpertrophic changes of rhnophma t s impotant

to examne a photograph of the patiet pior to the onsetof the rh nophmaous chage n oder to help g ide thesugeon in he emodelng of the nose A egional neve

bock wth addit ional local anesthesa is suffic et in he

maorit of cases for periopeative pai managemeDirect nectio of anesthesia equires mul ipe ifi tra

tos ad s ess efective and far more painful

Electrosurger elecosecton (cuing) s ve efecive

in debuking and econtouring he hiophmatous

nose with the added advantage of a eativel bloodessfield t is sm la in ecac to C aser reatmen and

ess expensive ( g 14 1)

Figure (continue C, D,&E ebulking and recontouring of therhinophymatous nose in a relatively bloodless field utiliing large wire

loop electrosurger Impressive attening of the rhinophymatous noseafter electrosurge The wound is left to heal by seconda intentionourtesy of uanne Olbricht, M




he herrohed issue s removed wi cae o pre

serve he iosebaceous uns.

Overcorrecion wil l oduce scarr ng a d conacures.

Wound conracure wh hea l ng ma u e nasa

uward

Pemaen depgmeao ma resu from overvgor

ous reamen.

The E lman Surgiron can be used wih a large wireoo n blended waveform ul l recif ed" mode

wch rovdes cuing wh hemosass, a a ower

conro beween 4 and 5.

A vacuum evacuaor shoud be ui zed or e imina

ng l umes o smoke.

An remaning beedng ons can be coaguaed a Ahe end o he procedue b swiching o he coagua-

ion aia l recf ied" mode

The woun d s a owed o hea b secondar inenion.

The aes are n sruced o kee h e woun d m osb mu i e apl ica ios of ero eum e l da i un lre-ephei a l i zaion s com lee aroxmae 2 weeks

oso.

Excsion b e far-i nrared lasers (e , C or Er :YAG)olowed b vaoizaion s also ver eecve w h a r e-

aive bloodess surgical ield A scaned C aser s

he opima device gven he need o debul k arge hck

areas of skin . The u lsed C aser can also be used in

he con iuous wave mode o remove he bu k of her nohma and n he pu lsed mode o scu l and

resurface he reman der o he nose.

TeangectasasLaser and asham reames based on selecve ig

absoron b emogobin are usua ver eecive for

removing elangiecasas a d aria l l eecve n in h b

ing ush ing Paens m us be awae ha ove me he

are l kel o develo more eangecasias and back

ground erema

Lase eamen: mul e eecive oions are avail

ab e

Pulsed de asers (P) ae he reamen o coceor facia el angiecasias.

he radional P wih a shor u lse duraio of045 or 1 5 ms rovides he mos eecive ea

men or faca elangecasias. However, osrea

men purura occurs whic generall ass 10 o14 das

A var ab le-u se P (595 nm, Candela V-beam

Waad MA ) wh suered u se du ra ios ( ie

045 15 3 6 10, 20 30 40 ms) can ovde a

reduced urura reamen of acia elagiec

asias bu s somewha less efecive and usua

requires mul le reamens

cFgure ( B, C) Pminent facia ethema prior to treatment with

/PL



Commol, subpurpurc luences of less tan

0 J/cm at pu lse durat o of 10 ms with a 7- mmsot size a re uti l zed

Better eicac of the varia blepu se PD L n treat

ing faca teangiectasias can be acheved b uti izing purpuric fluences o with a puse stackng

of subpururic uses (stacked 2 subpurpurcpulses at a 5Hz repett ion rate 75 J/cm ,

0ms puse duratio 0mm spot size CD of

30/20).

aca edema, ethema and discomfo can

occur after extensive treatment wt h the purp ura

ree variabepulse PD. owever these undesred effects are general better tolerated wen

compared to a pu ru rai du cng laser treatment

Intense pused l ght ( PL) can be igh eective in

treatig background erthema while P s wok bet

ter for id ividu al teangectasia I PL uencies of 30 to

40 J/cm with a 20 msec pulse duraton are usualleffectve (Staux ux G adpiece, Paoma MedcalTecoogies Bur ington, MA The treatment end

point s i mmed iate vessel cle arace or seectve ves

se darkenng. Mult e treatments ma be requredor the greatest treatment beneft.

The variabe puse wdth 064-nm d YAG aser

has roven to be eective i the treatmet of facateagectasias Shorter ulse widts with higher fu

ences migt be necessar for eective treatment ofsmaler vessels but have an ias risk of blister

and scar fomaton.

requecdoubed 532 nm d YAG aser asocalled potassiumttaphoshate (TP) lase pro

vdes effective absorption of hemoglobin with a puse

duratio of to 50 ms makng it ideal suited to treatsu eric a l vessels wtout pur pura formation acing

of i dvid ual vesses is a useful tech iq ue for atientswth a cou ntable n um ber of discrete vs ibl e vessels

lashamp (pulsed l ght) treatment P provdes

anoter eectve pururaree metod for reducigac ia l te angectas ias and ehema (F igs . 142 and

4 . 3 ) .

BBLOGRAPHY

Aferzo M M i l ma B. Exc is ion o r inophma wit h ighrequenc electrosurger. Dma Sg. 200228(8)

735-738

Aam M Dover JS, Arndt Treatment of facal telag

iectasia wth variabeulse higfluence pusedde

laser Comariso o efficac wit fluences mmedateabove and below the purpura threshod. Dma Sg.2003;29(7)681-684 Discusson 685.

Secton 2 : Disorders of Sebaceos Glands J

Figure 2 (contnue (0, E, F) eduction of the facia ethema afte

two teatments with PL taux Lux G handpiece




Besten EF igman A. Rosacea teament usig the

new-geeation h gh-energ 595 nm long useduato ulsedde ase. asrs Srg M. 2008;

40(4):233-239.

De Rosso Q Ani nammato dose doxcci e in thetreatment o osacea. J Drgs Drmal. 2009;8(7)

664668asm ZF Woo W andle M. Long-ulsed (6-ms) delaser treatmet o osacea-associaed teagiectasa

us ig subuu ic c l n ica theshold Drmal Srg.2004;30( 1) :37-40.

Mak K Saaco RM Voigt A Maeus Sano DS.

Objective and quanttaive imoveme o osacea

assocated ethema ae ntese ulsed ght treament.

Drmal Sr 2003;29(6):600-604 163-167.

Discusson 167.

Neu haus I M Za ne T Toe WD Comaatve eicac o

nonuuagenic ulsed de laser and intense ulsed

li ght or erthematotelang iectaic rosacea Drmal Srg2009;35(6)920928.

Sarradet DM Hussa n M Goldberg D Mi l isecond064-nm eodmium: YAG ase eatmen o acial

telagiectases. Drmal Srg. 200329 ( 1): 5658

hbouot DM Fescher AB Del Rosso Q Rich P.

Reated Aticles 7: A mult icener stud of tocal azelaic Aacid 15% ge i combnato wih ora doxcclne as ii-t ia l thea and azea c ac d 5% gel as matenance

monohea. J Drgs Drmal. 20098(7):639-648.

BFigure 3 () Prminent facial elangiectasias prir reatment with/PL (B) Psttreatmen erhema immeiately afer IPL treament



Secton 2 : Disorders of Sebaceos Glands J 8

CHAPTER 15 Sebaceous Hyperpasa

Sebaceus erlasia aears as 1-t-3-mm ellw

um bil cated a ules with verig tea gectasias n he

ace mdde-aged ind v idua ls (F ig . 5.1) he reresen a bengn rieatin sebaceus glands The

less are smeimes misaken r basa cell carcin ma

EPDEMOLOGY

Icidece ve cmm

Age ms cmml mdd le age ad e der but can

aear i ung id v id ua ls as wel

Race mre cmmn in Caucasians

Sex equa

Precipitatig factors rga translatatn is a rare re

c ant

PAHOGENESS

Unknwn

PAHOLOGY

Increased numbers large maure sebaceus bues

are clustered arud a cetra duc n he uer dermisThe lbu es e c ser than nrmal t the e idermis

PHYSCAL LESONS

Thee are s inge r mut e -t-3-mm e w umb l i

cated aules with verlng elagiecasas tha t aear

n he ace he ehead, cheeks and nse are he

ms cmmn lcains It can rare resent n the

arela

D FFERENAL DAGNOSS

Ms cmm nl m saken r basa ce l carcin ma

LABORATORY EXAMNATON

Ne i s nd icated. B is i cns derig basa l ce l carc inma

COURSE

Ben ign but d regress r reslve wthu thera

KEY CONSULTATVE QUESTONS

An hsr he lesin bleedig

Figue Lage sebaceous hypeplasia on the foehead




MANAGEMEN

hee s no medic a ind icaon o teat sebaceous hper

pasia Si some idividas are signficant bothered bits apearance and eques emova paicuar n the

ccumstace of m iple lesions eatments icde

ora destcive lase and hotodnamic heaesEach has is side effecs and isk of ecuence

REAMENS

Al patients shold be inomed before an teatmentmoda it that impovement is vaabe and n the fte

new lesions ma a ise requi ig ol owp teatments

• Destct ve Modal t es

igh" crohera and el ectrosger ae qu ick nexpensve means of reang sebaceous hperp asia

• aser eapy

he 1 450-nm d iode ase has bee stud ied n

10 aients fo he eatme of sebaceous hperasi a

( gs 15 2 and 15 3)

Eac atient was eated 1 to 5 times

ue ces o 16 o 17 /cm were emoed wi cool-

ng d ratios of 40 to 50 ms

Ate wo to thee eatmes with he diode lase

84% of lesions deceased i size geater an 50%

and 70% decreased greaer than 75% Patient and

phscian satisacion was igh

Sde effects icuded one case of a aophc scar

and one case o hperpgmentation

Pulsed de ase (P (585 nm) has bee show to

m ove sebaceous easia

Successu reament as been shown with ee

stacked 5mm pu ses a e nces o 7 and 7 5 J/cm

Most esions respond ate one treatment wit flaenng s i k ng or esout on

Seven percent o esio ns ecued com p ee

Oe std showed cleaance in two paties teatedwith te P L at 585 nm 6 5 to 8 J/cm ad a ulse

width of 300 to 450 seconds wo to ree reatmenswere eformed

EbumYAG o C laser abaion ca aso mrove

sebaceos eplasia

Laseasssed hoodnamic era wi toica 20%

5amno levl i ic ac id and PDL ir rad a ion (595 m)

blue l gh o nese pulse l ght 1 to 4 treaments are

needed wih vaiabe improvement and fuue ec

ence acieved moe effective mpovemen of seba

ceous eplasia than PL aone

A

B

Fgure 2 () Patient with sebaeous hyperplasia on the right templeand forehead 8 Improvement 1 month aer treatment with 1,450nmdiode laser moothbeam, Candela Corp , ayland, MA utilizing a 6-mmspot with a uene of 14 Jm and a pulse duration of 5 ms



Treatments were erormed at 1-to-6-week i nterval s

Both theraies showed greater im rovement than nothera at al l . There wee no l ongterm resuts

Sde efects wee imited to mild temorar edess

edema ad custng

PTFALLS O AVOD/OUTCOMEEXPECTATONS/COMPLCATONS/MANAGEMENT

Patients shoud be i normed that com ete resoution s

dicut and not alwas ermaent.

Destructive modaites such as cothea and elec

Secton 2 : Disorders of Sebaceos Glands J 83

trodesccation can roduce igmentar chages and Aeven sca rri ng i done too aggessivel. Recu rences arecommon

Local excson eaves a scar

Ora tera with isotretinoin s cear an aternativetreatment and s not as eicacious as other moda t ies

and carries with it the risk o signiicat side eectssuch as teratogenict d skn and mucous mem

branes high tr gcerdes and choesterol diuse

skeetal heostoss iver unction abnomalt ies

reduced ight vis o seudotumor cerebri leukoenia

oss ib e deress ion and su ic da deat o Toica tretnoin can oduce skin ir itat ion.

se thea must be used with caution esecal in

dark sk in hototes given th e risk o herigmentation

here can be scarr ing redness edema and crusting

as shown i Figue 153. Recurrence is not uncommon

BBLOGRAPHY

Aghassi D Gonzalez E Anderson RR Raadhaksha M

Gonzalez S. Eluc idating the u sed-de lase treatmet o

sebaceous herlasia i vivo with ea-tme conocascanning aser mcrosco. J Am Aa Drmaol. 2000

43(1 t 1) :49-53.

Alster TS anzi E Photodnamic thera with toicalaminolevulin ic acid ad ulsed de aser irradiation or

sebaceous herlasia. J Drs Drmaol 20032(5)

501-504Kim SK Do J E Kang HY ee ES Kim YC. Combinatio o

tocal 5aminoevulin c acidhotodnamic thera with

cabon doxide lase or sebaceous herasia J AmAa Drmaol 200756(3)523524.

Ri che DF Ami noevu i ic acid hotodam c thera orsebaceous gand herlasia. Drmaol li. 200725(1 ) :

59-65. Revew.

Schoermark MP Schmdt C Rauln C eatment osebaceous glad heasa with the used de ase.

asrs Sr . 199721 (4) 313-316 .

BFigure 3 () ebaceous hyperplasiabefore 8 Improvement one

month ar treatment with 1 450 nm diode lasr 14 5 Jm 5 mscoolin sinl pulse per lesion






Disordes of Eccrine Glands




CHAPER 16 yperhdross

Herhdoss is e seceion o excessve amounts of

swea om the eccr ne sweat gland s a est an d a nor mal

room emeraure. oduces both hsca and socialdscomor he most common afected aeas are te

axi ae, alms and anar ee It can resen n a b lat

eral or smmetric fasion. Te most common cause of

her idros is is id i oath ic .

EPDEMOLOGY

d: no good eidem ologc studies o revalence.

A amolanar bih ax l lar ubert.

R: no racal ed ecion.

Sx equa .

r r d io atc, emoiona central nervoussstem inur/disease dug, surgcal injur are he mos

common causes. n most cases, there is a amil histo.

PAHOGENESS

Eccine glands are rimai l innevated b smathec

fibes tha are coinergc rathe an adrenegic in

neual resonse.

PHYSCAL F ND NGS

Palmolanar excessive sweat and sweat dolets roducin g a most aearance and c am m fee

Axi ar staning o shis in e underarm area

D FFERENAL DAGNOSS

Cl in ical a earance d oes not suggest othe dsoders.

LABORAORY EMNAON

Starch-odne or nnhdrn test are useful n defining

areas o sweat ng (F ig 16 1) .

DERMAOPAHOLOGY

No characterst c ndings. Bios las no role n management.

COURSE

Does not rem sonaneous ma m rove sl gtl with

age

Figure 16.1 An xml of th strhodn tst n th lft xll Not

th romnnt drk blublk dsolorton t sts of hyrhdss




Medication histo

Past teatments and response

Assess for sstemi c a bnor ma i

Recent s urger

MANAGEMENT

The goa of the treament is to substan ia decrease

swea roduct on to mrove phsica and socia l d is

comfort not complee e im nat ion There are mu t p e

t eatments or herh d ros s (F ig 16 2) Bou num

toxn A s a ver effectve treament roviding emorar educt on in sweat ing Topca and ora l medica

tions are onl modestl effectve Surgical therainc ud ng posuct ion , s more effect ive than opica

therapComensator hehdross seconda to smahectom l m ts ts use at present except as a fina l theapeut ic

modalit

TOPCAL MEDCATONS

A um n um ch or de hexahdrate

Applicaton of 10% to 30% alumnum choride hexa

hdate souion n ethano with or without occusionto unshaven skin fo 6 o 8 hous nght for 3 to

4 das can be benefcal but s comcated b ocal

irritation Retreatment once o twice weekl fo maintenance is recommended Treated skn should be

washed the ol l owng mornin g

In he ax lae t s appl ed at n ght to unshaven sknand washed off in the moni ng

Frequenc of a cat ion d mn shes wth mprove

ment

ap water ion tohoress ca n be eective

The rocedue requires continua applcation for 15

to 20 mi nues 2 to 3 mes er week

B istering and burning ave been reoed as side

effects

Containdcaions nclude regnanc cardiac pace

makers, and metal imants

ORAL M ED CATONS

Oral anticholnergics ncludng bonaprine glcoprron ium bromide, propanthel ne and metantha l ine

bromde are of limited effcac The produce dose

relaed anicholnegic side effects

Section Disorders of Eccr ne G and s J 87

HYPERHROSIS

Atiperspant Firs tratmnt A u m u m c o i d (0%5%

Atiperspat

Boto

app d in vg t m s p wk

Effctv for may patits

Dyss and itat o a ma si d cts

Botoo Bot n m ox typ A ( Botox)

most commony sd Avag dos 5000 us p ax a

o Saf h g y ffctiv 3-9 mo hso Expnsv f not covd by suanc

ecatis

At ico ingcs; ighcdc o sd fcs

Sur

ecati

Suge

Consid i a o tapy a s

Edoscop c oacic sympacomy mostfcv o pama or faca hypid osis

H ighy ctv pocdu whn pomd by ask i d spca is

Fgue 2 Hyperhidrosis treatent diagra




SURGERY

Srgica ocedues icde the folowng

Endoscoc or classc smathecom is usua l

reserved as a fina teraeutc otion fo amar herhidrosis Srge rovides onglasng contro. Geeral

aneshesa is eqred. Side eects nclude bleedg,scar fomaion, infecion, eacto to anesesa, com

ensato herhidoss, gustaor sweaing, ne

mothorax, and oners sdrome.

Selecve gad remova s reserved fo ax a her

h idros is

Losucto for axi a herhdross volves subder

mal iosuct on . he l iosct o cau a s he d wh

the beve side u a the sbdemal eve for sctonigof hs rego .

BOTUL NU M TOX N ABotnum oxn A rovides emoar eectve treatmet

for hs condit on is a bacterial oxn tha decreasessweang b evesibl blockig acetcho ine eease

from cho nergic esnaic vesicles (Fg 16.3)

• Anesthes a

oica anesthetc cream and/or ce generall can ro

vide s cent an eshec eect.

Sil , neve blocks shold be considered or o la ntaand alm ar reatments o mi ni mize e associated ain .

Pa ntar sural an d osteior t ib ia erves

Palmar a r and median erves

• Teatmen

A starchiodne est erformed rior o treament ca

he deli eate the areas to be jected. Iodne is lacedon the aected aea, folowed b te acation of

constarch roducng a ominent dak beblack ds

coorato he stach-iodne aste shod be washedo rior to Botox ectios

Eecve Boox diuons var A Botox A (100 /vial)

d i lut ion of 2.0 U/0. 1 cc s eec ve .

nectos are erformed a 1 to 2 m ntervals intrader

mall throughot the aected area (Figs 164, 16.5

and 16. 6). wo n ts so l d be ieced e sie.

A otal dose anging from 50 to 100 U/axi a alm, or

sol e can be nected for a tota d ose of 100 to 200 forboth reatme ses A decreased dose can be sed for

oca zed herhidross.

em orar ha d an d fnge m sce weakness ma be a

coml ica ion of a mar bo inm toxin A n ec ios,

esecial l wh ic reasing dosages. Paients sod use

Nora ina o

Sympati nv Atyl o

Irvaon bokd by Boox

XSypai nv Atylo i

X

E inswagand

Fgure 3 Mechanism of action of Botox in hyperhidsis Blockingacetylcholine release fm cholinergic presynaptic vesicles

t

Figure Apppriate injection sites of botlinm toxin A fortreatment of () palmar hyperhidrosis and (B) axillary hyperhidrosis Eachinection sho ld be appximately 1 to m apart



caution wen odig cus ad other obects su

oed b e tear m uscle w e the weakness is rese Ths weakess genea dssiaes within 3 to

4 weeks

Deceased sweating is obseed within to 2 weeks.

Benefits geneal are noted betwee 3 and 9 monts.

Side effecs ma incude ocal muscle weakness or almar njectios brusig antibod resistace and rare

an analacic reaction

Th e eicac of bou i nu m toxin nectios s ot aeced

b aser a r emova i the same area of reatmen

M e c a o s

Antco i nergics; igh inci dece of sde effects

PTFALLS TO AVOD Tem orar h ad and nger musc e weakness ma be a

comcaion o alma injecions of botu ium toxn Aeseca wth i ncreasng dosages

Botox inectos ae contraindicated in atients wt

under ing neuomuscular condi ions as wel as inregnat ad lactating atients

Deceased doses should be consdeed or aets onangiotensin-covertig ezme (ACE) inhibiors whc

can oteiate Botox eects

t is imora to counsel that te beefits of Boox aretemorar and requre reeat reatmes.

None o te teraes s uivesall effcacious. Te

atient must be awae that e treatment endoi is a

reduction in sweatng and not comlete e iminato

reament side effects ma be considerabe deending

on the treament cosen ad must be evewed atdet wih te atient ior to an treatment in t iat on

BBLOGRAPHY

Camaat i A aga a G Pe na L Gesuita R Of dai A.

Loca neura bock at te wrist or reatme of amar

heridrosis wit botu ium toxin Technical imrovements. J Am A ad Derma. 20045(3)345-348.

Glaser DA. Teatment of ax lar herhdross bchemoden ervation of sweat gands usng botul i um toxin

te A. J Drg Derma 20043(6) 627-63.

Goh C Aumium ch or ide hexahdrate versus a marheridrosis. J Derma. 99029:368-370.

Gregoriou S Rigooulos D Makrs M et al Effects of bo

ul ium toxina tera o almar hehidrosis in pantar sweat roducton Derma Sr 20036(4)

496-498.

Section Disorders of Eccr ne G and s J 89

Figure Injection sites marked on right axia of a mae prior to botuinum toxin A injection




Hamm H The lace o botl inm oxi te A in he

treament o foca hehidosis Br J Dermatol

2004; 15 6 5- 22

Heckma M, Ceba losBaman AO, Pewig G

Bot nm toxn A or axi ar herhdross (excessvesweang) N Eng/ J Med 2001344488-493

Herbst F Plas EG Fggo R Fr tsch A Endoscoc horacc smathecom or imar herhidross of thee mbs: A ci ical anasis and ong-tem esls n

480 oeratons Ann Sur 99422086-90

Lowe Camanat A, Bodokh I et a he use of ocalgcorroate i the eament o herhid rosis Clin p

Dermatol 99823204205

Pa A Kranz G Schind A Kranz GS A E Scha T

Dode ase hair emoval does ot nefere with bo

inm toxin A treament agans axi a hehdrosisLasers Surg Med 200423 21 1-2 14

Rena uer S, esse A Scha G oz e E Iontohores s

wh a tenaing c rrent and d ect current ose (A/C ontohoresis): A n ew aroach or treatment o herhi dro

s s Br J Dermatol 9931 29 166-169

Figure 166 The sites of hyperhidrosis



FOURDisorde s of H ai Fo ic es




CHAPER 17 rsutsm

Hirsutism represents a mae paen overgroh o temi

nal and ve us has in women Far rom beng solel a

cosmetic concern hirsutism can be a important manfesato of an u nder n g endocrne dsorder ar s i ng rom

increased andogenic activit Oten it esults from anoverproduction of adrea and ovarian hormones and

ma accompan other s igns o v ir i izat o. I ts appearaceproduces socia anxiet distress ad ostacism in

afected patients I aso merts an appropriate medcal

worku. B corast hperrichosis eaues fine ars n

and ogensest ive as we as and rogeninsensit ive areas

Normal racia and ehnic varat ions ma cause conusionwith these disorders

EP E M O LOGYee: common .

Age usu al ostubeta b ut age o onset can var n the

setting o medicatio n tu mor or endocr ine ab noma it

Rae: racial and culua actors aect te perception ofwat constitutes abnormal hair grow Skin tpe aects

treatment opions as well .

Sex: emae .

reg ars: hirsuism s caused b a host ofendocr ine abnorma i ies Adrea causes inc lude

Cushig's dsease ectopic adrenococoropic hormone

(ACTH production pr mar androgeproducig eopasms and cogenita adrenal hperpasa Ovarian

causes can be relaed to pocstic ovarian sndome

and prima tumors among other causes Fina l med

ications such as oral coracetive i s anabo csterods and a ndogens ma cause hi rsutism

PHYSCAL EM NATON

hee s an overgrowth of ha in an drogensensit ive ha irfo l l ic les . Common s tes ic lude te beard aea o the

face chn eauricular ace l nea aba periareolar aea

and chest Depeding o he severit of the conditonother signs o vir i l izatio such as increased musce mass

dee voice mae paern hair loss and c itoral earge

ment ma be present

D FFERENTAL DAGNOSS

Wh le both h irsutism ad pertr ichosis eature ha ir over

groh tese coditos can be diferentiated b thelocation and q ua it o the hair growth Hi rsuism is car

acterized b termnal hair overgrowth in androgendepede nt areas wh ile hpertr ichosis featues ie hai rs

Fgure 7 pot se, mm versus 1 5 mm Larger spot ses penetratedeeper and aow qucker treatments

Fgure 7 2 Har trmmed pror to treatment



in androgen-sensiive as well as androgen-insensiive

areas. Norma raca and ehnc varia ions ma caseconfusion wih hese dsorders

LABORATORY T ESTS

The aborao worku shold be gided b the atent'sclnica fndings as wel as b a detaied aent histo.Testing can el establi sh f there s an a drena o ovarian

souce of the hair groh Ovaian adrenal, and ititatumos should be red o n cases o rad onse b an

endocrnoogst and/or a gnecologist. Total testosterone

leves dehdroeiandrosterone slfate leves rinar reecortiso evels dexamehasone suression test rolacn

leves ACT simuation einzing ormoneoll ic lesmating homone (H/FS) ratio 17hdrox roges

terone eves, and evc urasound ma al resent mor

tant comonents of a thorogh endocrinoogic wok

COURSE

Course is deenden on th e et io og of th e h irsism


Menstrua hisorregar or i regar

Medication histo

Onse and rogession o smoms

Fami hstor of inflammator csic acne and hai oss

istor o endocr ne abno rma i ies

MANAGEMEN

The imar goa of the treament is to deermine he

ndeng case o hirstism and trea Aer determin

ing the case a nd en sr i ng aror ate medica therathe goal can tanst ion to reversng the abnorma air

groh. Tere are mt i le mea ns b whi ch temorarand ermanen hai r removal can be ach eved.

C o s l a o w E o c n o o gy

In cases of hstsm e first riorit is to ncover thesource o the aberant hai growth. Nmeros laboaor

investigations as dea led above ma be reqred.

Consultation and referal to an endocrinologs is srongrecommended as art of such a work.

No ase herap es

Thee ae several emorar means to concea ar overgrowth. Te ncde makeu beaches, and hdrogen

eroxide. Shavng also can emoari hde ha groh

Secion 4 Disorders of Hair Fol ic es J 93

Fgue 7 3 aser light firing

Fgue 7 Characteristic posttreatment perifolliclar ethema




ar emoval can be achieved with deiat on, epi a

t ion as er thera eectrolss, a d toical efornith ne.

Dep at onDeilat ion is the process of emovng pa of the hai

shaf. ts effects ae temoar. There ae chemca andmechanca l methods of de at io. Ch emic a de lator es ,

such as thogcoate salts ad sufides o akal metasdssove hair shafts. The can roduce ocazed tat ionat the site o treatment. Mechanical dep at on ca be

qte cude inc d ing shavng of ha r as we as ubbghai with a pum ice stone

p a onEp at on s the pocess of removig the entire hair shaftIt provides more ongevit than depiaton but is not er

manet I t ic udes waxing, p luckng, threadng, and

eectr cal devices that remove the har shaf Each ofthese otions s reat ve inexensve but can oduce

pain ad irr itat o as side effects. Puckng can reslt in

localized infection ngown has, ad even scarrng.Each of these treatments can be used n combation

with toical efornth ine o the ace of women

Topca efonthne anqa)oca efornth ine wice dail has been aproved b the

US Food and Drug Admnstraton (FDA) for tempoa

hai remova o the face of women. It should onl be

used on the ace and not on othe ats of the bod. Itdeceases the rate o hai growh b nhibit ng orthine

decarboxase. It shoud be sed n conjnction with

other hai remova methods such as shavng waxig, o

puckng Patients should use the medicatos fo

8 weeks to udge its eicac. I there is no imrovementafte 8 weeks, the medication shod be dscontinued. If

the medcation woks, t should be continued.

Dscontnuaton of teatment results a esumption ofhai groh. Sde effects ncde loca irr tat o t should

not be used dring pregnac.

• E eco lys s

Remova ca be ermanent

Eectross uses d rect eect ca c rent to destro thedemal a i l l a of the ha i r o l l ic l e . A f ne needle placed

direct into the ha r fo l l c e de ives the e lectr ica lcrrent to the fo c le 's base without roducing scarr ng . he ste of treatment s shaved severa d as pior

to therap and toca aesthetc cream can be sed

1 hou o to the rocedure to redce pa n Side

efects ncde scar ho/hpegmentation and

nfect ion . t s most appror iate or sma areas of

treatment

Need for mu lt e treatments fo i mited teatment zone.

Greate r sk of side eects, anfu l.

Not actc a for a ge areas of the bod

Fgure 7 Bizarre growth of back hair on a male due to poor technique

Fgure 7 tensive dyschromia seconda to inappropriate uence andpulse duration



Lase a i emova

Lasers are the treatment of choice fo permanent reduc

ton of uwanted, pigmented termna ha fol ic es aserha removal s qu ick, re lat ive nonpaifu , especa

compared to eectrolsis uhemore, t can cove a far

moe extensive area of afected ski n with less pa n n less(e, imprope spacng and ovelap) t ime An average of

ve to seven treatmets are eeded or geate than 50%reduct ion

Mechan sm of actonLasers are based on the selectve phototermoss he

lght s absobed b te pgment in ha fol l c les

Theefore, f hair fol ic es ave no pgment ( e, blond or

Secion 4 Disorders of Hair Fol ic es J 95

gra air), asers do not wok asers work best o tcker Aha o l ic es

.

at ent Consu tat ion

Ha r co o r

Skin tpall skn tpes can beneft fom aser hair

remova

Past medical hstor

Medications

Past teatmen ts

Emphasize the need for fve to seven teatments on an

average to rem ove t e majoit o unwanted ha ir

mpovement is vaable

Low risk of no mprovemet or increased hair (espe

ca l n emaes of Mediterranean hertage)

Rsk o hpe- o hpopgmentat on that ma ast

months rarel pemanent

Scarrng s are

Lkeiood of at east some pain te amout of pan

assocated wth the procedure is a reflection of t e caliber and densit of hair i th e treated region

dea l cand idate has dak course ha ir and ight ski

phototpe

Average candidatefine/lght brown hair

Poo candi dateblond/gra h ai r shou d not be teated

wth a 80-nm dode aser wth curent lasersAddt ioa patents with unealst c expectations or

medic a contra in dcations should not be treated

a ent Cons lta on io oTeatment

Su n avoidance s crucia If a patiet is taned , the procedure shoud be postponed unti l te tan completel

fades If the pocedue is pefomed on taned skn,

th e isk of dschromia s marked ncreased

BFgue 7 7 () Appearance of skin prior to laser hair remoal (B) Hair onlateral cheeks

Fgue 7 8 Appropriate clinical endpoint of perifollicular ethema in

this 4-year-old female with type VI skin and polycystic oarian syndrometreated with the long-pulsed 1 064-nm NdYAG laser




Shave ai por to ar v ing in the oice Alerativey

the ha ir can be im med the ofice wth a mou stacetrimme hs w l l focus e majoity o eegy to the

pigmented a i fo l ic es the skin .

A toica a esthetc ceam ca n be apl ed 1 h ou r por

to eapy to decrease te ai d uri ng the procedu e. It

s i mpotant to advse te pate to ap ply topical a esthetic ove a m ited suface of the ski n to avoid a ny isk

of lidocane toxici.

Hai waxng shoud ot be efomed 2 to 3 weeks

beoe teament.

f thee s a hstoy of ecurent hees smplex vrus

prohyaxis sould be provided befoe ase haemova o face

Pregacy there ae no cea studes demonstrating

safety o sk t is mpota to educate pegnatpatents desir ing hai emoval as to his uncetainty

Mos hysca s wil not eat pates wh le prega f

treatment s usued is ecommeded to tea only mied aeas du rng thid meser ater medca c ear

ance fom a obsetrician.

• Js Pr io o Treame

Witten conse

Photogahy

m ha

• aser Ha i r Remova Tech qe

( F g s 1 7 . - 7 8 (Table 1 7 Key coc es fo otima l esu ls are as fo lows

o skn types I to I l l use eatvey gh eergy wth a

shoter u se du ratio o otima l esuls.

TABE 7 • Laser Hai Removal Techque

Lase tye Safest ski n type Waveleg (n m Pulse d uation Enegy (/cm Comments

Ruby I I

Aexandrite I I I

Dode V

NdYAG IV

Intese pulsed I IV

I gtnoc oheen

igh

694

755

8 1 0

1064

5501200

120 ms

Sk tyes I I 3 ms

skn types I and IV1020 ms

3100 ms

1040 /cm

Ski types I I I

2025 /cm

sk tye V 1 20 J/cm

300 /cm

is lase used fo

ha removal s lower to use

3 ms ad 1020 ms

use d urao emostateequa eicacy

Loge u lse du rato otreatment of sk n tyes Vand V

Sk tyes I I 1020 ms Skn tyes I I 350 Saest devce foskin tyes IVVI 21 ms /cm sk tyes emovng a i in sk

1 . 53 . 5 ms

I l lVI 2535 /cm tyes IVV

2550 /cm Mos variable esuls



LASR SAFTY

Hazard: ocula

DangesCoea, tina o lean amag

Dmg cu rfrom d t o f l ct d bas .paie n t jewery, ches

Q-h la armo hazadu caa b

�

corea

ens

Hazard: fire

DangersA ar a poially f

Mos como y sih C02

aa a ufom d i c xpou rfl bam

Enhance SafeyBale eye exam

Le ol p ty 0 hd bq u l t ga tha h ck s)

I spc ols fo s il dama degradain f e filer d ia

a k at apppat fowvlngh u

Rmov boiz cov r ny cVa i a m, i e. irm a l l i aa ca

Rmov pa jwl wahs

han ce Safeyem e o v ay in le m . miro tlliaba a

A h r a t i uy

vapo p to trt f ttmtape ame wh we z o toe l

Remve l l f lmb l tm i. d zw l,

a xps ha w waba jlly

cas F02 o % wh at aaha tb

Hazard l lar Dangrs ha ne SafeyIa a val U makDNA uh P mb h pum Sk vaaof CO

ue ptce apa a d ah Q·hd la

Hazar DangesEvn w w ffan aue h/ t

Hazar:

DaesApa a

hane Safeyy al l c a ope la

Ch fo te pll oe p i

nhn e SfetyAlw mmtly pt on tndbme h ea pat e t

u pp la

u a ms a las ety

Fgure 7 9 Laser safet It is important to emphasize that lasers present special safety conces for physicians s ta and patientsAmong the risks are ocular inju fire electrocution and dissemination of infectious disease No lasers should be operated in theabsence of a detailed knowledge of laser safety issues between the physician and the staf Educating staff members is an essentialcomponen t of safe laser practices Periodic laser safety training is required by many hospitals and remains good practice for privatephysician offices as well () Patient and all personnel are wearing protective eye wear Note gauze is moist to reduce the risk of fire

8 moke evacuato (C) afety sign placed outside appropriate laser room to ensure proper warning of laser use




Skin tpes V o V mus use longer pulse and longer

waveength such as a 1064-m YAG

f ucera as to treatment parameers perform tes

sies with varia be fluencies ad p ulse du raions

A l machies u ize coo ig of epidermal ski v ia croge coact cooling or ge

Optmal coog sett gs must be ut ized to lower he

rsk of dschromi a

Use larger spo szes for deeper penerao ad more

rapid treatmet of arger areas

Safet gogges for patient and medca team

Use the argest spo size possib le for target regio

Overlap laser pulses 10% over the etire treatment

region

• Poseamen src ios o Pa en

Expect red ess for u p t o several ho urs afer treamen t

f red ness or pai perssts for more tha 12 h ours cal the oice I there are an cutaneous changes i the

ski n he da afer the p rocedure or beod the paiet

mus be old to cotact the treaing psici a

Once redess fades patiet ma conue to wear

makeup

Avod s u or 48 hou rs o ta ig

Hair removal is o entrel mmedate Some har w l l

al ou 1 to 3 d as aer treatmet

Do ot worr if some h air persss aer reatme

Cal the oice f dscooration develops i the reaed sites

Cal the oce wi qu estos or concerns

PTFALLS TO AVOD/COMPLCATONS/MANAGEM ENT (Figs 1 75-176

There is o effecive mechansm or aser removal of

g or blod hair

Excessive fluecies or icorrec pulse durato maproduce epidermal damage ad dschroma These

effects are tpicall temporar but ca be permanet f

there s a doub regardg laser parameters performa est sie

Skin tpes IV o VI require loger pulse duratos adower fue cies

Coic de tattoos ad letges ma experece l ght

en ng Patets shoud be formed of ths possibi l t

Awas keep contact cooing agast the skn to avod

burng

Overlap ( 10% ) i the treated zone Do not leave gaps"that can create biza rre hai r growth paterns as ha ir

regrows

(� "

Y JLens

Wae- Sign or ymtomlenh nm Laer Ee njr of n

Cornea len Retna

<0 ys

0 0 Exc1mr ys : ys : ys0 nm)

000 Agon es Fash of te nm) emt wavlnh

: solowed by

KTP atmag o a m n ) complmntay color

Pusd y s

la 0 nm

N VAG es Damage om a -switchd0 nm) NdVAG ar may not

dettd as rena Ruby e lacks pa ibrs nm)

swiched lases haveAlexandrte yes hghes ential to nm) cau bindne

Do : y Ma uce a poping nm) sound, hn sualdsoientation

0 N VAG e00 0 m )

Nd VAG

0 m

D1od : s

0 m

E AG yes Burg pa at the ite of00 0 nm exsu on the cornea o

scea

CO

ys000 nm

Fgure 7 Lasers and eye inurieshttp eyesafet4ursafety cmlasereyesafety htm



For dYAG lasers patients ma experence pain even

afte opical anesesia.

BBLOGRAPHY

Azziz R. Te evauat ion and maagement of h rsu ism.

Obstet Gynecol. 2003101 (5 pt 1 ) 995-1007.

Battle EF, Hobbs M. aserassised hair remova fordarker sk in pes. Dermatol Ther 2004 17 (2) 177183

Bouzari Tabataba H, Abbasi Z, Fiooz A Dowai Y.

aser air removal Comparison of ongpulsed d:YAG

longpused aexandrie, and longpulsed diode asers.

Dermatol Surg 200430(4 pt 1)498502

Godberg DJ. ase ar remova Dermatol Clin.

2002;20(3) 561-567.

Tanzi E Aster TS ongpused 1 064m d YAG laser

asssted har removal in al l skn pes. Dermatol Surg

2004;30(1 ) 1317 .

CHAPTER 18 Pseudofo cu ts

Pseudofol icu it is s a common, chronc inflammaor dis

order at presens wi infammator papules ad pustules n he beard distr bution of maes, paicula those

with darker skin photopes ad gl coied ar

oetheless, pseudofo l cu it is ca preset n a skinthat s reguar shaved and in al l ski phototpes. n

females it is most commonl seen in the axi lar adpubic areas teds to pesent n a more mld form i

l gher sk n photopes.

EPDEMOLOGY

Incidence over 50% of African American males

Age begis wi savig or puckng

Race more common in beard dis ibuion of males wth

darke skin phototpes

Sex male > females

Precipiting factors shavng in an region of the bod

PATHOGENESS

Ths d isoder s induced b savig. Shav ng shapes

cu red a r Sharpened igh cu rled a rs pierce io theskin adjacen o the hair fo ic le and nvade ino he der

mis producing an nfammaor reacion. I can also fol

low ar puckig, especal n femaes wi hsutsm.

Secion 4 Disorders of Hair Fol ic es J



Color Atlas of Cosmetic Dermatology

DERMAOPATHOLOGY

Hair enetration esuls in edema invagiation with

associated microabscess, mxed inlammato nfiltrate

and foreign bod ga reacion at the i o the ivading

hai . emal fi brosis ma be observed

PHYSCAL LESON S

Mos common, it esents wth fo l icua aples us

tes and ostinflammato hpergmentato in the

bead aea and anteolateal neck o maes and undearms ad bikin i areas o emales. Paues can develop

into csts. Sca ormation ma be obseed. The ue

ctaneous ip i s tical sared

D FFERENAL DAGNOS S

Acne vu lgar s fo i cu l t is

LABORAORY EXAMNAON

Noe .

COURSE

Begns with shaving or lucking and cont iues nt i

cessaion or modficatio in he ar emoval echnique.

MANAGEMENT

h e goal o t e treatmet i s to pevent th e omaion o

the paules usules scar ing and ostilammaor

herpigmeation associated wth this dsorder There

are mt ipe treatment optos available to accomish

this goal. Cessation o shavng o luckng s e most

successu teatment but t is m racica and nd esirable

for man patiens. aser era is hghl eective withhgh patient satsaction.

TREAMEN

• Shav i g Cessa io

he mos sim le iexpensive a nd eective eatme fopseudofol cul it is is the cessaton o shaving. Man

pat ents wi l f ind h is ot on ndesiab le or i mpactca l

• M o f a o o f S h a v g e i q e

A oper shaving techn iq ue ma event or sgifcatl

decease the r sk o sedoo i cul i is A mong these prac

tices are ift ing no uckng igrow hairs, thorough

BFgure 8 () A youg male with type VI ski phototype ad pseudofolliculitis barbae prior to treatmet (B) ame patiet moths later aerseveral treatmets with logpulsed 1, 064m Nd YAG laser Courtesy ofE Victor oss M



wetting the area ror to ain g shavig cream usig a

sha razor, shavig in te drection of the har growth,and avoid ig shaving more than one d irect ion i the

same area The Bu m Fighter Razor revents the shavedha from being cut too shot Addt ional l, cuig te a ir

twice dai l wit ha cl ers revents hai rs fom ercig

into the sk

Topica Treaet

Toical ati biotics ae effectve n treating the i flam ma

to and occasona metgiizato associated with thiscodt io Toical tretoin, benzol eroxide, ad g

colic acids can be helful adjucts

Laser Ha r Remova (F gs . 1 8 . a d 8 . 2

Laser hai r removal s a sae, h igh effective teatmentmodat for short ad og-term mrovement

Skin tes to I l

The long-u sed a exadr ite lase (755 m), d odelaser (810 m), itese u se ght (590100 m)

and ong-used NdYAG (1064 m) aser have theaorate waveengts to seective target the

chromohore mela n found i the ha ir bu l b

Mut ile treatments (average of 10) ever 4 to 8weeks achieve a aveage of 50% to 75% ema ent

reduction of fol l cular aules/ustules

Ski n tes V to VI

The long-u lsed 1 ,064-m d YAG aser s te treatmet of choice n sk hototes IV to V It s safe

and effectve Log ulse durations are ecessaror edermal rotectio Pulse duratos o 30 to

100 ms ae generall recommended Otma uences

range from 20 to 40 /cm Treatment s erfomed

wth nooverlang uses uti l zing cooig to the

eide rms va crogen, contact cool g, or ge

ewer generation diode asers wth loger ulse

du ratios u to 400 ms ca also be uti zed wth cau

tio in d arke sk tes

Tc a l, 5 to 10 treatmets saced ever 4 to 8 weeks

ae eeded fo 50% to 75% ermanent reducto n

P TFALLS O AVO D/OUTCOM EEXPECTATONS/COMPLCATONS/MANAGEMENT

Taed atets soud ot be treated wth aser hair

remova Once the ta/nfammatio subsdes har

remova ca begin

Do ot u ck or wax h a ir r or to or dur ig te course of

aser ha ir emoval

Secon 4 Disorders of Har Fol c es 0

igure 8 2 Pseudofolliculitislaser therapy pigmented versusunpigmented hair follicle

Fgue 8 3 Etiolo of pseudofolliculitis



102 Color Atlas of Cosmetic Dermatology

Patients with unigmented hair (blond gray red) wi

not beefit from aser hair removal and shoud not betreated

here is te risk of transient and ongterm yeig

mentation ad hyoigmetatio Transient erythemascabbi ng an d r sk of scar formation also exist

A maority o atients wi see 75% mprovement. Asmal m no ity w l l see l itt e or no im ovemet.

Futue maintenance treatments may be eeded

A smal m iority of patiets w l l exerience a paradox

ca ncrease in hair growh part cuar ly emales o

Mediterranea descent.

reatment may not benet reexistig yeigmenta

ton and will not imrove scars

t is imortant to inorm atiets tat side eects are

often delayed in ski hototypes IV to V ad may ot

be observed for 1 to 2 weeks after treatment. Test spot

s advsed for these patiets (Figs 183 an d 184 ).

BBLOGRAPHY

Battle EF Jr Hobbs M aserassisted hair removal fo

darker sk in tyes. Demal Te 200417(2) 177183

Br idgema-Shah S . Th e medca l and surgica theay of

pseudofol cul it is barbae Demal e 2004; 17(2 ) :158163

Haedersdal M Wulf HC Evidencebased review of hair

remova usng asers and l ght sources. J AadDemal Veeel 200620(1) 920

Kontoes P Vlacos S, Konstantnos M Anastasia L, Myrt

S. Ha ir nd ucto aer laserasssted a r remova a nd ts

treatment. J Am Aad Demal. 200654(1) 6467

Ross EV, Cooke M imko AL Oversteet KA, Graham

BS Banete J Teatment of seudofo i cul t is barbae nskin tyes V V ad VI with a og-pused neodymum

Yttr um alumnum garnet aser. J Am Aad Demal2002;47(2):888-893

A

BFigure 8 () Test sot teatment unde chin and on chee is advisedfo dae sin hototyes befoe teating seudofolliculitis (B) Twowees ae test sot teatment, some hai emoval is achieved with noigmenta changes




CHAPTER 19 Mae aern ar oss

Mal e paen h air oss classcall p eses wth bempora

ha l oss that progesses o the loss of ha r on t he vetex,

rontal and empoal scalp Paieta and occpita asare usua uafeced It is a onscarrng or of alope

ca ha occurs i geneical susceptbe males. The

gradua ioa oss of har does chage he naural

frame ha r p rovdes around o u face T he gradual loss ofha resu ng n an ivoutar chage n appeaance

creaes varng degree of emotona and pschologicastess Man me seek eamen for mae paern hair

loss because of unhappness wth its cosmetic appear

ance and association with agg

EPDEMOLOGY

iee 30% o maes oder than 30 ears more than

ha of ma es ode than 50 ears

Age begs ate pubert

eipiaig faos pogenetic erited pedisposit on

No diagnosic tests exis to deermne the eoog and

natual progession

PAHOGENESS

The pecise pahophsolog remans uknown Ths

process s beleved to resut fom bo a pogenec

inheied suscepibi l as wel as androgenc simuaion.The mos mporant androge n this process is dih

drotestoserone.Thee s a dinuion in the sze o aeced ermnal

fol l c es tha egress to become ve us fo l ic les tha even

tua l disappear Thee is a inc rease n teloge h ai rs anda decrease in anage hars

PHYSCAL EM NAON ANDNAURAL PROGRESSON

Tpcall, onal ad tempoal hair oss/hnning s pre

sen fist. This begins in pube and progesses overdecades The ate and exte of hair oss vaes from ndi

v dua o nd iv dua Some progress to complee ba dness

in earl 20s ad others gradu all th n over decades.

DFFERENAL DAGNOSS

I n males the paen o hair oss s chaacterst c sugges

ing no ohe dagnoses.

Fgue 9 Nowood cassification of the natua pogession of maepatte hai loss



1 04 Color Atlas of Cosmetic Dermatology

TABE 9 • Minoxidi and inasteridhe Only Two DA-Approved Medications for Male Pattern air oss

Mecha nsm o action

Ke to su ccess

S de eects

Cl in ical on set of action

Dose

Can dd ate seectio

Noood I IV

Norwood IVV I I

nasterde

5 reductase te n hi bior bock g the coversio oftestosterone to dhdrotesosteroe

Em hasze mai neance over regrowh of hai r and com l ance

or at least moths to see benefi

2% o men experece sexua dsunction Reversb e wth n

das i dscotn ued

o al l ergic reacios, b ood mo itor ng or drug iteractiosPre menoa use of fema es shoud ever hande or take

medcaio Wome ma have some benef

moths

1 mg qd wh or wthout ood

H ghl effective

Somewha effecive

ABORATORY EXAMNATON

I n ma les o l aborator worku i s tpica requi red

M ED CAL THERAPY

• Key Consu tat ve Qes os

Age of onset

Rate of hair oss Past medcal hstor

Medcatons used to date ad success of era

Patent exectato of an medical or surgica therap

• DA-Appoved Medca eapy(a e 9 .

M inoxid l a d inasteride are the ol two medications for

mae patter hair loss aproved b e US Food DrugAdmi n istrat io (FDA)

HA R TRANSP LANTATO N

• D e n t o

Minox id l

Uknown

Emhasze maintenace over regrowth of

ha r and coml iance mohs osee beef

Drness and pruritus of the scalp Rarea ergic reaction

moths

wo to fou r drops o ne to wo tm es da

to froal a nd veex o sca p

H gh effectve

Somewhat effectve

Al pates sou d exec conssel atura ap earigtranspanted har Based o the heor of door domi

nance, ha r o l ic es ma ta he ir geetc dest wer

ever the grow o our scal ar trasplated from theposterior sca wil l grow or as ong as i was genetcal l

progra m med to grow For the vas majorit of me transpa ed hai r wi grow or decades

Figure 92 Unnatural "pluy hairline using 10 to 5 hair grashould never happen in twentyfirst century



a ir naura l gows in 1 to 4 hair o icu lar bu nd les

Contemporar hai ransplantation uti l izes a large umber o 1 to 4 ha ir fo l l cu ar groupings The resu lt s cons is

tentl atural apearng transpanted hair for men and

women

THE CONSULT

Key Ques ios

How og have ou noticed hai loss?

Rate of hai r oss?

Whic h m edicaions wethe presciption or alernative

have been tied a d for how long?

Expectations?

y s c a E x a m a o

Norwood stage (Fig 191)

Dono densit

Cal i ber o ha ir fo l ic les

Idea l cadi date: h g donor dens it ick ca l i ber ha r

o l ic le rea l s ic exectat ion ( F igs 9.3 a nd 194)

Poo candidate poo dono densi, beow average

hai r ca iber u neals ic exectations

Key o ts o mphas ize Beoe Ha i Tas laat ion

Net peceived densit rom a a transat = the

nu mber of har fol l ic les tanspl aed{gong hai r loss

Fine hair fol c es wi create thn natual coveage and

th ck cal iber o l ic les w l ceate more peceived densit

Ongoig hai r oss wil aec e cosmetc appeaance oa ranslant

Visble donor sca or scas i har is shaved or cose

croped in posero scalp

Limted donor su pp

Ke to success hscian and patient have simiar

expectaions o what te rocedue wil l and wi notachieve over the so (13 ears) and ong term

( 1020 ears).

M e d c a o a d Ta n s p a at o

Medicat io to maia n exist ing ha ir w l maximize the

denst from a transpla nt bu med ications should alwas

remai eective Hair ine design and distr bution o ecii

ent stes should alwas assume ongoing hair oss


Fgue 9 3 ealitic expectation uing 1 to 4 hair graf Before

Noood V

Fgue 9 ealitic expectation uing 1 to 4 hair graf er 1 1 001 to 4 hair gra




SURGCAL PROCEDURE

• Peopera ive src os

No seci c b ood tests

Medca l cearance aroriate

Photograhs

nformed wren consent sent to the aient for review

at least 1 week befoe the rocedure

• Day o Procedre

Wrtten consent with ostoerative isructons reviewed

ntroduce h ar rasla nt team

Review rocedure and goals with atient

• D o o r eg i o O y L m i t i g ac o r

H a Ta s p a a i o ( F g s 1 9 . 5a d 1 9 . 1 0

Anesthesa n dono egon

% docaine wth 1 200000 einehr i e

30 o 60 cc sa ine

Sa i ne i n door region rov ides

anesthesa

hemostass

less transecton of hair fol l c es

less ikey to transect the occi ital arteies

Dono havestng technques (ab es 1 9.2and 193)

E l it ica str ha rvesting: >95 % of atents

Fol cu lar uit extrac ion <5% of atents ( F ig 19. 1 )

Ell ptca stp harvestng

Use sk hooks to retract when removing donor e l l se

to mn mize transact on of ha i ol l ic es (F ig 19 12)

TABE 9 2 • Advantages an d Dsadvantages ofFocular Unt Extracton (FUE)

Advaage

No near donor scar

Oen mn mal y v is ib e

scarr ng n t im med

donor region; advantageor atens with sho

hastyeCan be used for aties

with extensive scarring

n osterior sca frommu lt il e revious sugeres

Disadvantage

More t me consumng

More FU E sessons to

equa l d esity from

e ise

Greate transectio of

ha ir fo ic es with

otentia decreasedye ld

Fgure 9 Trim donor region with moustache trimmer, and tape hair upso donor suture will not be visible in the postoperative period

Fgure 9 Patient in prone position

Fgure 9 7 onor strip shou ld not be more than 1 m wide trips>1 m have an increased risk of creating a hypertrphic scar




TABLE 93 • Door Harvestig Techq ues E l iptic al Sti p Harvestig Vesus Fol ic u ar t Extracto

Mi n im a ansect io of dono ha i

N um ber of 1 gras sae harvested pe r poced e

Tme to havest dono ha

Vs ib e dono scar wth h a egt >1 mVis ib e dono scar wth h a egt <05 m

Oveal l percentage o cases used

U derm in ing donor egon rare necessa

Do be l ae of st res ael necessar

Sutes o sapes to cose in sige lae

Sutes o sapes ot i 7 to 10 das

Keys to success door haestg of elpse

Dono st width <1 m

Ae l idocaine add saline to dono region to povdehemostasis a nesthesia a nd redce tasecion o ha r

o l ic les

Ski n h ooks to retract t sse whil e removing el l se

Do ot sh

• F o c u a i t e x t a c t o n

Den t ion remova of fo l i cu a goupi ngs fom the poste

r ior sca l p us ng 1m m p nches

Excelet teament oto fo patients ver shotdono hair at do want a vis be dono sca and fo

patents wth seveel depeted donor regios from mulpe previous hair tansplants

• Gat ceat on

All grafts shoud mimc the naua 1 to 4 fo iclar bu

d les that naua l l occ on the sca p .

Keys to success i c eatig to ha gafts

Good egonomics and nsuments Pep bades and

#10 blades are often sed to seaate fo i cul ar goup

ings from te dono e ipse Magnfication ca aid theprocess n separatig fo icla grouigs from the

dono e l i pse

Do not allow gafs to d The must alwas be n

ch i l ed sa ine

Well -tai ned staff of hree to four su gical assistas

Sta tanng

Enthusiasm/nterest n pocedue

Patience 6 to 12 months or an assista o earn to

creae 200 to 300 gas per hour

E l ipse Fo icar un extracton

Yes o

1 , 5002000 200500

1520 min 12

o oYes Likel no

>95% <5%

Fgue 9 8 losig door regio ith stples




• A n e s t h e s a n R e c p i e n R e g i o n

Fie d b lock an d oca if i t at ion wth 1% idoca ie wth

1 200000 eiehr ine and 0.25% Marca ine with1 200000 eiehr ine .

Suaorb ita l and suatoch ear b o ck is ot iona

Suef ic a inf i l t rat ion i d emi s no t subcutaneous t ssue wll ceate good hemostasis

• a i n e e s i g n

Den t ion a ha ir l ne is an ir regu ar i l def ned rans it ionzoe from skin to inceasing denst of termnal ig

mented hai fol ic es

Awas cosde the fota temoral and osterior

ha l ines

he fonta and ostero hai l ines shoud be iregular

and n the same la i . Th is means genera l avo d ng

translantig the vertex aicua n ougeratents. he reason is te ever-exandng bading sotn e veex.

When designing a fonta temoal hai l ne a was

assume rogression of hai loss o owood stage V

Fronta hai r l ne at east 9 m above glabe la

Be co nservative

• Rec p ient S te Ceat o ( ig 9 . 8

Commol used needes to ceae eciet sites are

#19 or #20 gauge eedle Magicato to reduce tansaction of existig ig-

mented temia l ha i

SP 88 to 90 gauge need le

0.5- to 1 .0-mm cag eed e

Key ponts

Dstr ibute reciie nt sites rand oml a d c osel ogetherand i a d istribut io that w l l aea atura l if a l l ha ir is

ost i the fronta two-thds of the sca

Avod trau ma to existng h ai r fol l c les

Magifcato n recii ent sites

Follow the natural 15 to 30degee angle of hair fol l

c les i n th e frontal twothirds of the scal

Excel lent emostas is us ig 1 : 100000 eineh ie

10 to 30 s tes/cm deed ing on the am oun of existing

ha and area (cm ) to dsribute grafts

• Grat lacement ( g . 1 9 . 9

wo o three surgica assistas lace the gras ntoreciient sites using mi crovascular forces

Figure 9 9 A cwide door scar fro 1 5cwide ellipse

Fgure 9 Follicular uit extractio usig 1 - sites



Keys to success

Hande gafts in perol l cuar t issueneve cus hairo l ic les

Keep all grafts n ch led sanenever alow a grat to

desccate

Staff tran ing

Excel ent hemostas is us ig 1 100000 epner e

Patence

osoperave e o

Ovenight d ress ng to p rotect gras

Ora sterods 40 mg qd for 3 to 4 days to educe ontaledema.

yleno #3 oe tabet q 4 to 6 hours fo 1 day PR

Thee shoul d b e no d iscomort morin g after surge

Sh ower n m on ng after surgey. Avod tra um a to trans

panted zone

Peiol cu ar emorrhagi c crusting rema ns 5 to 8 days

The vast maorty o patents eturn to work 2 to

3 days ater the procedure

Norma actvties immediatey o heavy exercse for

5 to 7 days.

opca a tibiotic to dono wound for 7 to 1 0 days

Sutu es o stapes em oved 7 to 0 days aer sugery.

Co o os H a ras a S i e

Eecs Fontal ed ema astin g 3 to 4 days postoperatvely

Pruri tus n dono r and/or reci pient zone

asitory o ic u t s

eloge eluv um n patets wit dffuse th n ni g

Rae Se Eecs

Hyetropic scarr ng donor region in el ipses less

than 1 m

Pesistet numbess or discomo in door or recipi

ent zone

Cystic nodules

Poo qua ity growth of transpa nted hai r

necto

ossurgca Pe io aeSuues/Saples Reove

Resume fu spos 1 week ate surge

Dye ha i 2 weeks ater surgery


Fgue 9 kin hooks to aid in removal of donor ellipse

Fgue 9 2 onor ellipse with natural follicular bundles

Figue 93 Magnification helps visualize 1 to 4 hair bundles and minimize transection when separating with surgical prep blades



1 1 0 Color Atlas of Cosmetic Dermatology

TABE 9 • Teatment Options fo Corective H ai Trans plan t Surge

reatment o on Advaage

Adding 13 ha i graftsbetwee existig large

1025 hai ugs"

Excso o gafts

Laser ai r emoval

Combat o

Damatcall sote h air i e and ad d fuer dest to

exstg ugs"

Pate requestig " woud rathe ust be ba d" Stausquo ante

Novasve

Reduce ugg" grafts

Maort of ates ulize a combatio of he above

or otimal esults

n i ia l fo lowu 8 o 2 monts aer s urger

Ful cosmec resul 9 o 5 moths after s urge

• Correc ve H a Tansp la n S gery

(a e 9 . 4

For the majort of me n corecive ha ir translan t surgeris cosmeticall ad emotonal man daor o elective

ConsutKe queso: wa is our ce conce ad goal for

ossibl e correctve suger?

BBLOGRAPHY

Avram MR Poar zed ghtemitt ig dode magifcatio

for otima recet ste ceaio during har trasat

Dermatol Surg 2005319 1 1 1 2 4 1 1 2 7 iscusson

1 1 27

Este S h e teament of female atter a r oss and

other alicatios of surgica ar estoaton i women

Facial Plast Surg Clin North Am 2004 12 2 241 -247

Harr is JA. Fo icu l ar u t translatat o: ssect g ad

a ng techniques Facial Plast Surg C!n Noh Am

2004; 12 2 225232

Dsadvatage

Donor rego ma be deeted

Patet not schologcal abe to gothroug an oer har tas la rocedure

Poteta v is b e e ematous scaror weeks to months

Permae scar and/o dschromi a

4080% moveme aterfve to

seve does ot work o band a

As above

Leavitt M PerezMeza D Rao NA et al Eecs of finas

terde 1 mg) o ha aslat Dermatol Surg

2005;3110 1268-276 Discussio 1276

Figure 9 1 to 4 a ir gra

Lmmer B El it ical doo sereoscocall assistedmi cograg as a a roach to uhe ref ement a r

translantaon J Dermatol Surg Onl 1994;2012

789793




Fgue 9 1 to 4 hai gas in chilled saline

Fgue 9 Natual iegula fontal hailine




Figure 9 7 Magnification with polaized light to ceate ecipient sites

Fgure 9 8 Placing 1 to 4 hai gas with micovascula foceps




Figue 99 Preoperatve Norwood Ill




Fgure 9 2 Aer ,400 1 to 4 hair grafs

Fgure 9 2 Preoperative Norwood Ill to IV




Fgue 9 2 2 After 00 1 to 4 hair grafts

Fgue 9 23 Preoperative Norwood IV to V




Figure 9 2 Aer ,00 1 to 4 hair gras

Figure 9 2 Preoperative Norwood IV to V




Figue 9 2 Afer 1 , 000 1 o 4 hair grafs

Figue 9 2 7 raigh "pluy fronal hairline






Figue 9 3 Preoperative Norwood IV to V

igure 9 3 2 Aer an additional 00 hair gras second surge




Figure 9 33 traight "plu hairline

Figure 9 3 Ater 500 1 to hair gras




Illustration . Obsolete 4-mm "pluy gras

S fd

E d o o

I l lustration . lliptical door strip fm posterior scalp




Ilustation . to hair follicular groupings ithin donor strip

Ilustation . Versus to hair pluy graf Natural to follicular groupings




Il lustration . traight artificial "plug hairl ine using 1 to hairgras

I l lustration ecipient sites created at 1 5 to 45degree angles not degrees




A

8

I lustatio Corrective hair transplant adding 1 to hair grasbetween and in front of "p/uy gras




Illustration Adding 1 to hair gras between large "plug grasto improve cosmetic appearance




CHAPTER 20 Femae atten a oss

emae aern hair loss resents with a duse thnnng

of the mi dsca wth a characteris ic ma ntenace of he

frontal har n e It ma also resent wih the tca biemoral hair recesson seen n male atten har loss

Paretal and occiial hars are usua unafectedemae aern hair oss is ar icuar robematc for

women for whom har oss roduces greater soca andself-esteem diicuies than for men wth male attern

ha i r oss ( igs 201 and 20.2) .

EP E M OLOGY

ee: nea 30% of femaes older tha 30 ears

ge begis n secod ad in thrd decade

Rae: none reored n femaes

reg ar olgenetc i nheited redisosion

is resen I is o one ae's fau

PAHOGENESS

hee is a d m nuton in the sze of affeced tem a fol l

c es that regess o become vel us fo icles tha eventua

dsaear Thee is an ncease i teogen hairs ad adecease anage ars Hormones la a roe bu the

exact athosioog is unceain

COURSE

Begns in entes a nd rogresses over decades T he rae

and extent of har oss vares

KEY CONSULAVE QUESONS

Durat on of ha i oss

Mestrual hstor

Medcaton histor

N utrt on d eing weight oss

Hai r carebleach ng bra d ing

aml histor of hair loss

Hstor of majo unexected emotioal or hsica

stress

Medca l histor hat is throid d isease ron defcenc

PHYSCAL EXAMNAON

Noscarr ig aoecano erhema scale, atroh n

sk in with femae attern a ir loss

Figure 2 reoperatve Lu dwg l l

Fgure 2 2 Ater 0 0 1 t o 4 har grafs



D FFERENAL DAGNOSS OF FEMALEPAERN HAR LOSS

eloge eluvi um

Poo hai s ngchem icas excessive dig

ro defcienc hrod disease chroic medcal dis-

ease polcsc o ohe endocie im balace Medicaionreaed hair loss

Poor nr io n weigh loss

choi l omania

Dffuse aloecia areaaare

KEY QUESONS O DSNG US HDFFERENAL DAGNOSS

How o g has ou h ai oss persised?

Changes n die o weigh oss over pas 6 o 12 mohs?

An new prescriio ove-he-couner (OC medica

ions o sup peme s?

An major srge o nusua emoional sess?

An change n hai r care? Chemica s o ha r?

KEY PONTS

Paiens ma have a combnaion of eologes

f here is an quesionng afer hisor and phsicalexamnaion scalp bios is ndicaed

hrod ncion ess iron sudies ainclear anibod (AA apid pasma eagi (R PR

Refera o gecologis and/o endocinoogs apro

priae on hsor and/o exam naion

MEDCAL HERAPY

Toical minoxidi l (2% and 5% soluion) ae he ol medcaions for emale aern hai r oss aoved b he U S

Food and Drg Admin sa ion (FDA) (Table 201) The

mechan ism of acion is u known s sae for log-erm

al ica ion

TLE 2 • Mnoxd

Mechanism of ac ionOnse of acion

Sid e eecsUse wih reganc

or beasfeed ng

5% versus 2%

Unknown6 monhs

Dness prurius greas har o

5% slighl more eecive bmoe geas slgh

nc eased isk o hisusm


Figure 2 3 Preoperative temporal scarchief complaint "I cannot wear

my hair back

Figure 2 After 65 0 1 to hair grafts




Minoxidil 5% foam s oly aoved for men but ofte

is used by women. The reason s d ue to minoxid l in sma lerceage of women inducng unwanted igmeted

termia ars he medcaton-induced irsutsm is

reversib e if the medcatio is discotnu ed

Many women who do get mi noxid i l- nd uced h i sut ism

a so get exce ent gowth of har o their scal and ot tocontinue e medcation and use ases to remove the

unwanted hai on e face.The foam ceaes much ess irr iat o on the scal

making i t much eas ier to be coml i ant han h e so lut ion .

KEYS TO SUCCESS

Com iance: must use fo 6 o 8 monh s o roduce the

desired eec

Emhasize mainteace over regrowth of air Mioxid

stos ha r oss i e ma oity of atients and grows back

igmeed teminal ha i n a m nority o atients.

NONFDA APPROVED MEDCATONS

Fnasterde a tye I 5 reductase inhbitor is contrandicated i women of ch ldbearng age. Sudes

demostrate some effcacy n osmenoausa

emales

Ora androgen eceto antagonss such as sronoac

tone ad cyoterone acetate are other a tenatves with mied roof of effcacy n both remenoausa and

osmenoausa femaes. They are contrandicated in

regnat atets given he isk of roducng sexuadefects n a mae etus They shoud theefore be dis

cotnued months or to a an ned regnancy

SURGCAL

• C o s a o

Chef comla nt : see hough fronta ha ir l ine l mited

sty ng oions fear of wdy days.

• Key Qest ion s How og has a r oss ersisted on?

Medca l worku to date

Medcaton used to reat ar loss ad fo how long

Patient's c hief cosmetc concern

Patient's goal or hair taslatato

PHYSCAL EAMNATON

Dono densty

Fgure 2 Preoperative Ludwig I to II

Fgure 2 After 600 1 t o hair grafs



Ca iber o har oss

Exent o hai r oss

KEY PONTS

Emhasize unedictabe donor densit The ransaned hai wi grow for as long as it was genecal

rogammed o gow

Increased rsk o ostsurgical teloge effluvium.

Ongoig hair oss wi afect eceived densit of hai

transant.

SU RG CAL APPROACH :FEMALE VERSUS MALE HA RTRANSPLANTAON (Table 202)


Ha r transa ntation fo men and women uti l ze the samedono ha rvesing techn qu es, gat creatio instumes,

an esthesa and re- and ostsuger couse.igure 27 Preoperative Ludwig I to II

FEMALE SURGCAL PLANNNG

Transant rontal onehrd o sca ol hs wil l

addess che comai nt ad reduce the isk of teoge

ef luv um

Chief coma see though" frona ha l ne

Sable fotal temora ad osteror ha l nes

Difuse th i nn ingno bad sots

Rs k of telogen euvu m

Uredctabe long-erm growth of har from the

donor regon

TABLE 22 • Surgical Approach: emale Versus Ma e Hair Tansplantaton

Donor densiHar l ne des ign

Ca i ber of ha rMedicatio use with har

transantaion

Exectations

Ma le

Moe red cab eU nstabe a d recedin g ronta tem ora and osterior

ha ir l ineNeed o desgn ha r trans ant or longtem natural

cosmetic aeaance (> 10 ears)

Var iab e between n d iv dua s

If exist ig hair emans medication w l add dest

b mi i ng urher hair ossMedcatio awas rema ins eectve

Need to desgn ha ir trans ant assu mi ng ogoing

hair loss and recedg har nesKe to su ccess

Femae

Less redicabe ong term

Stabl e ha r l nes Mao cosmetic advantage

over me fo sugical anng

Variabe between ndviduasA l women shou d use mi nox id l to he m a na i

exstig hai r a d decrease r isk of ostsugerteogen euvi um

Densit = n um ber of ha ir fo l c es tanslaed

ongoing ha i lossKe to success




• Peopera ive src os

�-uman cho ion c gonadoro n (B-CG) in aro i-

ate atent

Consent

Photos

Medcal ceaance aroriate

Ok o de a r u u nti l da beore ocedu e

Procedure

ntroduce staff

Revew surgcal la n

Revew ossurgca care anesthesa nstumets

donor harvesting graft creato grafts acemen are

the same as or me

• Posopera ive src os

Ovenght d ress ng to rotec grafs as e hea

Resume regular acivies Lght exercise 2 to 3 das

aer surge Ful exercise when stales/sutuesremoved 7 to 0 das ostoerative.

f an dscomfort or an ake Tenol #3 wth ood q 4

to 6 hours Fif ercent o aties take no ain med

caion ad e other 50% take oe o two tablets I a

atent as an discomfo or an after te da ofsuger te should contact their hsicia n

Prednsone 4 0 mg q d for 3 o 4 das to eve frontal

edema I a aient cannot or w l not take redn isoe

ce oehead for 0 minues ever 30 mnutes ove edressing fo the first aftenoon/evening of suger o

reduce bu no e mate edema Edema begns

24 ours after suger eaks 72 hours ostsurger

and disaeas 5 to 6 das ostsurger Rare eorbital ecchmoses

The morn ng afte surge the dessng s removed A l

atents are encou raged to showe o he educe ostsuger emorhagc crustig Paients should OT

ick o ru b scabs; ths ma erma nen damage translaned ha r

Afte showe bow dr with wam not ot air on ow

ower A ocal antbiot c o Aquahor to door egion

twice da l for 7 das

Resume mi noxidi 48 o 72 ho us ost surge.

• Posoperat ive Per od

Continu e m noxd i o ne to two tmes da l

Teogen effuv um ma beg n 2 to 3 weeks afte surgerand continu e for 2 o 3 months

Figure 2 8 Aer 50 1 to hair gras








CHAPTER 2 ow evel ght Therapy (T) and Har oss

Low leve ig aser herap (LT) has been sed o tea

a vaie of medcal disordes fom cers o msc

loskelea disordes In 2007 a low eve g device wasapoved b he .S. Food ad rg Adminsraion

(FDA) o rea mae aern ha i loss (F ig . 2 . ; a i rmaxBoca Raon, F or ida) . The lase comb s a handhed

device ha was aproved as a devce whch has a differ

ent sandad fo FA approval ha a medicaon The

device is sold over the cone witho psica e

scp on or phscan mooring hee ae varios oter

manfacres of ligh era devices ha ae sold o

phsicians offces a ae o handhed such as heSne ics device (F gs 2 2 and 2 .3; Sne cs

I nenaiona Las Vegas NV).

MECHAN S M OF ACONUN KNOWN

Canddae seectional skin pes. All ha colos.

Mos effective a eaer sages of hai oss. FA

apoved for male aen hair loss. Ma phscasbeieve i ma ave a roe i eaing femae paen hai

oss

APPROPRAE USE

he manfacuer ecommends s low combig he

device throgo e affeced aeas of a more han

0 m n es hee imes week (F ig . 21 4)

hee ae no pb shed sdes com aig d ifeen e

qenc and me o se of he devce

PEARLS OF W SDOM

A l paies wh ha i loss shold be evalaed b a der

maologs o esablsh a diagnoss before consderng

an m edica heap.

Mioxid l or men and women ad fiasterde for men

remai the medica l reamen of choice fo mae ad

emale paen a oss.

LT appears o be safe b longem independen

sdes confimi ng effcac over pacebo ave not bee

done

Cooaended sudies have demonsaed some

efcac i he reatme of mae aen hai loss.

LLT sold be consdered ae cear medcal fa re

wh mioxid l and/o naseride

Figue 2 Had hed LL LT device hairmax asecomb Boca ato,orida

Figure 2 2 Oice based LL LT device uetics, as Vegas, Nevada




BBLOGRAPHY

Avram MR, eoard RT r, Epstei ES W l iams ,

Bau ma A T e cu rret role o laser/ g sources i thetreatmet of male ad emae paer hair loss J Cosmet

Laser Ther 20079 1 2728 Review

Avram MR , Rogers N E H a r trasatatio or me JCosmet Laser Ther 2008 1 03 1 54-1 60 Review

Avram MR, Rogers NE he use of lowleve light for hair

growth Part J Cosmet Laser Ther 2009; 1 1 2 1 10-

1 1 7

Hodso S Curret ad future treds i ome laser

devces Semin Cutan Med Surg 2008274292300

Leavitt M Carles G eyma E, Mchaes HarMax

LaserComb aser pototherapy device the treatmet o

mae adrogeetc alopeca A radomzed doubleb d sam devcecotro l led , mu lt cetre tr a Clin Drug

lnvesti 2009295283-292

Fgure 2 3 Patient undergoing LLLT treatment for male patte hair lossin a physician office

Fgure 2 Patient performing home LLL T treatment



FIVEDisordes of Pgmentation




CHAPER 22 Caf Au at Macue

Caf au a macules (CAMs) are beign we demar

cated ight brown macues that tcall resent in earl

chidhood. Te igmentation s tical unform. Lesionsma be mu ile or isolated. he grow i roportion o

the growth o the ch d . Te are resent n as an as20% o e popu aion a nd rarel can be assocated wih

a host of genodermatoses

EP E M O LOGY

idee: 10% to 20% of the oulatio

Age brth and ear childhood

Rae ore comon n African Aercas than Caucasians

Sex none

Preipiaig ar: ost coonl hese are begn

iso ated ind gs i heah ch ldren . Mu t i e CAMs canbe associated with genodermatoses such as neuro

fibromatosis tuberous sceross Bloo sdroe

McCuneAlbrgh sdrome RussellS lver sdroe

Waso sndroe and Westerof sndrome

PATHOGENESS

Unkown.

PATHOLOGY

A

I ncreased melan n n basal keratoces. Cl n cal darker Blesons contan more elaoctes tha lger ones.

PHYSCAL LESONS

Lesos are wel dearcaed uniform pgmeted mac

ues that var n color fro hues of an o lg brown o

brown The ca prese anwere on the bod butsare mucous embranes. Ther s ze can range ro a

ew mil meters to over 20 m.

D FFERENTAL DAGNOSS

Posinlammato hergmeato Becker's nevus

measma entigies eedes beroque deratit s and

congenta evus

LABORATORY EMNATON

Bio s is o in dcated. Add it ional laborator workup abe aroriate n the event of suspcion of an u nderi ng

sstemic dsorder

cFigure 22 () Caf au lai macule o le cheek of a 1 earold femaleprior o reame (B) Ehema ad ligheig of caf au a i macule

aer oe reame wih 64m Qswiched rub laer (C) igificaclearig aer four reames wih Qswiched rub laser



COURSE

Te grow n roort ion to the growt of t e c h i d O n ce

a c d has u gown, CAMs do not change n s izeor co or There is no increased r isk o mal igant tras

omat ion


me of onset

Fai ure to meet mi estones

Photosensitivit

nte lectua l im aiment

Hi sto o ult i e ractues

Cental nevous sstem d isoders or tumo rs

Poo gowth

Scoiosis Ohthamologc imaiment

MANAGEMEN

CAMs d o not equ ire treatment un less th ei a eaace

is dsguig o distessing to the atient or aentsMu t il e lesions ma suggest an und erling sstem c dis

orde f tee is an indicaton o underling sstemic

ab nomal t ies in th e setting o mu t ile CA Ms referal toaoiate ediatr ic secia ists is indicated ase the

a s oten emloed as a treatment CAMs tend to be

moe diicut to teat than other benign igmentedlesons sc as eeides and entigines Te equre

mu t il e teatments and com lete reso ut o can be callenging Recuence is common Cotea ad surgi

ca excision ae atenatives to ase thera but ca the

risk of gmenta alteratios, oor cosmesis ain ad

scaring

L SER TREATM EN ( Fgs 221-22 3)

Prior to treatment a test site shoud be erfomed toassess or ecac and eigmentato CAMs

resond variab l to mu t ile modal it ies o laser thea

Q-swtced lasers inclding te feqenc-doubled

Q-switched NdYAG (532 m) Q-swtced ub

(694 nm) , and te Q-switched aexand te (755 nm ) ae

emloed fo selective igment emova

It is imoant to note tat treatment wit Q

switced lases s not cookbook Energ sengs var

from lase to ase Te also var beore and aer

maitenance hus treatment should be based onachievig eidermal whitenng ater teatment

Wtout eiderma witenng the teatment is

u n I i ke to be effective

Secion 5 Disorders of Pigenaton 37

A

BFigue 222 (A) Caf au ait macule adjoining right lateral commissure oflips (B) Near clearance aer three treatments with a 55nm Qswitcheda/exandrite laser




Howeve, it s impotant to note hat ovel aggessive

treatments produce igmenta changes such as hpoand herigmenation

n one sud Q-switched rub and fequenc

doubled Qswitched d:YAG treatments, each at6 J/cm oduced vara be responses ncl ud ng

Sgnican ightenng which was most fequentlobserved

Cearance with ecurrence

Darken g

Q-switched asers have a dec reased r s k o textu ralchange versus oher laser heraies, but sti l carr he

risk o hperpgmetato

Resuls ae variabe wth approximate 50% of Aesions showing a esose

Whie u resolution ca be obtained wh he

Qswitched asers thee are frequent ecurrences

Frustaing recurreces ma occur 6 months o1 ear after treatment Sometimes ightening aher

than u l resoluti on s the best obaina be result Al ofthese asers oduce equivaent resus in the teat

ment of CALMs

TOPCAL TREATM ENT

CALMs ae not resosive to opcal beachi ng creams

P TFALLS TO AVO D/OUTCOM EEXPECTATONS/COMPLCATONS/MANAGEMENT

Uotunatel, despie their superfcia l nature, CALMs

can be d icult to treat completel

he ke cl in ica f inding is ederma whitenng after

Qswtched laser treatmen

Lghteni g, rather than ul l c eaace s oten the best

resut even after mutple treatments

here s a h gh ri sk of recurece of CALMs u to 1 ear

after reatme

Studies in dicate a isk or he- and hopigmeationassociated wth the Q-switched ases especa in

darker s kn phototpes

eatng a bove the theaeutic threshod ma resul i n

prologed hea ing and increased r sk o igmenta

changes

Patents wth da rker skn tpes should be reated cautous a nd conservatvel gve n the low er heraeuic

threshod

Lase treatmet of tanned atents shoud be avoded

Figue 223 (A) Tretment of cf u it mcule on the chin of youngmn with 5nm frequencydoubled Qwitched Nd YAG ler(B) Completion of tretment of cf u it mcule with the ppropriteclinicl endpoint of tiue whitening nd ethem



BBLOGRAPHY

Aoa MB Ardt KA. Teatment o a cafeaua t macue

with the erbum:YAG laser. J Am Aad Drmal.2001;45(4):566568.

Grossman MC, Aderso RR Farnell W Flotte TJ

Grevelink JM. Treatment of ca au la it macues withlasers A c iicoathoogic correlation Ar Drma/1995; 131 14161420.

Kim JS Km MJ C o SB. reatment of segmental ca aulait macules using 1064nm Qswtced d:YAG aser

with ow ulse eneg. /i Drmal 200934(7) :222223.

Lev J ordon S PizAnseme M. reatment o id

vdua cafe au a it macules with te Qswitced dYAG:A c in coatoogic correat ion. a asr r. 1999

1(4) 217223.

CHAPTER 23 Ephedes

Eheldes moe common known as freckes, are

benign, sma , welldemarcated brown macules oundon the suexosed skn of bond, l gt bown and ed

haed ndivduas Te resent earl ch dhood anddecease n olde age. e can be dst ingushed rom

lentignes in that te daken in tmes of igh sun exo

sue and ade durng eiods of l i mited sun exosure.

EPDEMOLOGY

id ver common acu ar l in fa irskinned

atents

Ag ea chil dood

Ra more common n Caucasians but also see in

AsansSx equa

Priiig ars nd v dua s wt gt ha ir and com

exion suc as b londs an d redheads

PAHOGENESS

The brown igmetation associated wt eedes

results rom inceased roducton of meain i suexosed areas of te ski n.





PAHOLOGY

Keratnoces disla an nc rease in mela n n esecial l in

the basal lae but ere s n o substanta increase in tenumber of melanoces in eheides

PHYSCAL LESON SEhedes are welldemarcated light bown to dark brown

macules of several m l l imeters dameter that resent nsun-exosed areas of the skin .

D FFERENAL DAGNOS S

he dierenta diagnosis includes other benign lesons Asuc as ent ig ines and u nciona l nev .

ABORAORY EXAMNATON

None

COURSE

he resent n eal ch ldood. The darken in erods

of hgh sun exosure and l gten durng eriods of mited sun exosure

KEY CONSULTAVE QUESONS

Sun exosure

MANAGEMEN

hee is no medcal nd icaton to reat ehel des The

cosmetc aearance however ma disease some

indviduals Sun avodance and sunscreens otect

aganst darken ng of ehel des B leacing ceams suchas hdroqunone and toica renoids can roduce l ight

ening. Crotera and laser treatment ae aso effectve.

Recu rrence is fequent art icua r wth sun exosure.

TREAMENS

• Topi ca l Teamentoca bleachng creams ma rovde some ightening

Mu t i e fomuat ons are ava i lab e d ier ing n te ir roduct contens an d strengths

Hdroqu none ( 2%) c reams have trad t iona l l been

emoed

Twce dail aication of he cream o the eheldes

over 3 months is general necessar to achieve sg

nfcant if no comete imrovement.

Side effecs incude rr itat ion uritus eelng and

d rness of the reated a reas

B

cFigure 23 () A yearold male fm outhe Califoia with exten

sive ephelides (B) ame patient with posttreatment whitening immediately afer frequencydoubled switched Nd YAG 5 nm laser

therapy C) ignificant improvement weeks aer single treatment with

frequency-doubled -switched Nd YAG 5 nm laser utilizing a uenceof 1 5 Jcm and a 0 mm spot size



If erthema and irritaton occur exercise caution to

avod hyperpgmentation especial ly darke sknphototypes

Patents m ust dscontnue the teatmet f any l ght

eni ng of nonlesonal skn s observed

Beacing creams are contraindicated in pegant

and lactatng women

Prooged treatment may produce sk di scoloation

known as pseudoochonosis

Ret no ids

Retods have been added n products such as Solage(2% mequnol ad % tretnoin) and Tri luma

(001 % fluocnoone acetonde 4% ydroqunoe an d

005 % tretnoi n) to provide an exfoiative benefit

Appicato of ri luma must be mited in duraton

due to the possibilty of side eects with repeated

cocosteroid usage such as ski atrophy and acne

Azeac acd (20% ) cream s u npred ctab y eective forephel des ad ent gines

Koc acid 2 5% ) cream

C e i c a l e e l s

Chemica pees can be he lpfu l n reducig the appear

ance o ephel des Superf c a depth pees medum

depth pees an d deeper pees are a l eective A ca reful

evalu aton of skn type owever s essenta l p rior to treatment As the depth of the pee increases the cance fo

impovemet along with advese sde efects ncreases

Ove-thecounter -ydoxy acid pees are a beneficaladju ct to physicanstrength chem ica pees he con

tinual exfo iat on achieved from cosistent use of thepees w l resu lt n m ld ighten ng

Gycoi c acd pees (370%) a re ad m nsteed every 2

to 3 weeks utilzing increasng strengths as toleatedLightenng o epheldes may be observed ae fou to

six pees Strict photopotecton is stressed Saicycac id peels (2030 % ) are also efectve hey can be

used saey n al l sk in types

Jessner peels (resoc ino l act ic ac d and sa l cy ic ac d)

are ad mi isteed eve 6 to 8 weeks

Strict ph oto protecton for 2 to 3 months s advsed

Mu t iple treatmets are recommen ded

Conta id cated i n pregant and lactatng women

Combinato Jessne/0% tr choroacetc (TCA) pees

may aso be empoyed i a sm ar fashon as the

Jesser pee

The Jesser pee esults in exolat o a lowing for

greater peetrato of the TCA pee

Mut iple peels are geera ly eeded Cotraindicated

in pegnant and actatng women


A

BFgue 23 2 () A 40-year-old Japanese female wih ephelides and lenig

ines prior o 64-nm Q-swiched ruby laser reamen 8 Immediaeissue whiening and eryhema aer reamen




Caution to avod pigmear chages eseca n

darker sk in tpes

A est sie can be consi dered

• Cyoheapy

Crotherap ca produce l ightei ng o reck ig Has a r sk o hpo- or hperpgmetation at and ar ond

treated stes especial i darker skin phototes andtaned patents

Recurrece is common

• aser heapy (F gs 2 3 . 1 a d 2 3 . 2

Laser and ight sorce therap can be eective i treatigehe des

ntese lsed l ght requencdoubled Qswiched

Nd:YAG (532 nm) Qswitched aexandrite (755 nm)

Qswtched rub (694 nm) Qswitched Nd:YAG(1064 nm) pused de (595 nm) ractona resac

ng and TP asers (532 m) are all efective

Wih Qswitched lasers:

Perorm a est so o d arker skn es

Treatment ed pont or Qswtched asers is mmed ate t ssue whteng For the Qswitched Nd:YAG

(1 064 nm) sma l p n pont b leedig ma be seen

A 7-to- 10-da hea ng t m e ca be exected or crustn g to resolve wth Qswtched lasers

O e std used h e requecdoub ed d: YAG

(532 nm) to treat eheldes i 20 patients with tpe V

sk Eight percent o atents showed better than

50% improvemet Recurrece was commo

Hopigmentaton teura changes ad herigmenta

tion a resoved with 2 to 6 moths aer i a treatmet

a other stud 197 Asian s were treated with the

Qswiched aexadrte (755 nm) a 70 J/cm wth a

pulse width o 100 ns a 8week itervals Clncal o Aow p aer an average o 1 5 treatment sessios showeda 76% decrease in the n um ber o ehel des No scarring

textural chages or pgmetar changes were oted

he Qswched rb (694 nm) ad aexandrite lasers

(755 m ) are aso eective

I the cinca edoit o mmediate whitening is

achieved the ephelides shoud clear wh one treatmet

Qswitched asers are m ost efecive or da rker le so s

Fracional resuacg (Fraxel aser Relat techoo-

gies San Diego CA) s aso eective (ig 233 )

Treatmet s genera l perormed at supec ial dephs

com pared to treatments o rhdes ad ace sca rs

gh treatment den sites a re most efective

Mld-o-moderae erthema resemblg a sunburn

reaction s observed Postprocedure swelng s also

common

BFigure 23 3 () Young male with ephelides on his left cheek at baseline(B) Improement of ephelides afer seeral nonablatie fractional resurfacing treatments



The erhema resoves i 3 to 5 das and c an be cov

ered wi makeu wiin a da of he treamen.

Log-erm daa are cu rren lackig .

I ntese pu se l ight is aso eecive

The c i ica l endpoint is darkeng of he lent g ies

Caution shoud be emoed when treatig atienswih da rker skn tpes o avod hperigmentation hat

ma erss for months.

Recurrence of recklng afte treatment owever is

common .

Suscree and su avodace are mandaor adjunctsto lase r thera.

PFALLS O AVOD/COMPLCAONS/MANAGEMEN

Laser reatme of ehelides is reque successul

but often ansien.

Paients sould be infomed ha recurrece is highl

i ke especial l wh sun exosue.

Dail stric hotooecio wih a sunscreen whUVVB rotecon and/or a phsical bock such as

itanium dioxide o inc oxde ae sessed as we assun avodace.

If bleachig creams oduce ehema cauion is

advised as erhema ca produce irr iat io and her

pgmentation.

Paients should be couseled regardng e ossibi iof postinlammator gmentaion changes aer reat

ment ase remova of ehelides ma also roduce aunattractive so hoigmenaon esecal in

darke s k n phototpes.

BBLOGRAPHY

Jag Chung EC Choi J Sung KJ Moon KC KoJ K. Successful removal of freckes n Asian skin wih a Q

swced alexadrie laser. Dermatol Surg 200026(3) :

231234

M ish ma Y Ohama Y Sh baa T et a . In h bior acion of

koic acd o melanogenesis and its theraeutic eec forvarious huma hperpigmentation disoders Skn Res

1994;36(2) : 1341 50

Nakagawa M Kawai K Contac a lerg o ko c acid n

skn care roducs Contact Dermatts 1 995 ;31 (1 ) : 9 1 3

Ngujen Q Bu i TP Aela ic ac d Phamacokiet ic adphamacodamic propeies ad is heraeuic role n

herpigmear disoders and ace. lnt J Dermatol

1995;34(2) :7584

Rashid T ussa in I Ha ider M H aroon TS aser therap

of freckles and lentignes with quasiconiuous frequenc-doubled NdYAG (532 m) lase i Fiatr ick

skin tpe IV A 24-month fo owu J Cosmet Laser Ther

2002;4(34):8185





CHAPTER 24 entgnes

ere are two major tyes o lentgines entgo simex

and solar lenigos. Tey are bengn lesions. Alough

both are c l in ca l ly dent ca l , they aea n ent re lydieent cl in ca settings Lentigo smlex yica y irst

resent in ch i dood as mult e wel ldemarcated,

brown or black macules that can aear on any at o

the skin or mucous membranes They are c l in ica yind ist ngusabl e rom unc iona l nev There is no asso

cation with sun exosure n his ye o lengo Incontrast, so la lent igos, more common y known as l iver

sots," are we ldeined brown macules that aear on

sunexosed skin o adu lts hey increase in n um ber

wth age They most oen aear on te dorsa hands

shou ders and ace o l ight ly igmented and reda i redatients

EP EM O LOGY

ee very common acu a ly in a ir-skinned

atents

Ae bmoda d sr ibut ion n ch i dood and in sun

damaged skin o adu ls

Re more common n Caucasians

Sex equal

re os sun exosure s closey related to

solar enigines Mult i e entgines are associated wth aew genodermatoses ncluding EOPARD syndrome,

LAMB syndome, and PeuzJeghers synd rome

PATHOGENESS

Unknown

PATHOLOGY

hee s a u norm el ongation o the ree ridges o te ei dermis a long with nc reased mean in in melanocytes and

basal keratinoctes n addt ion, thee ae an ncreasednumber o melanoctes in te basa cel layer

Mea nohages are resent n the ai l l ary dermi s

PHYSCAL LESON S

Welldeined brown macules Lentigo smex maculestend to be evenly distr ibuted and sm all measu ing only a

ew mi imeters Solar lent gos have a redi lection or the

sun-exosed areas o the dorsal hands and ace Tey

can be larger than lentgo sim lex

A

BFigure 2 () Lento on le cheek of a female (B) nficantmprovement aer one tretment wth a 5-nm Q-switched Nd YAGlaser at a fluence of 1 0 Jm and a mm spot sie






uocioone acetoide) ca be used as wel . However

bleac i ng creams a re often ot com letel eective.

oical tein on can roduce ighteni ng but not usua

c learance of es os I t ma a lso i combinat ion wit

sun avoidance and sunscreen use evet te devel

omet of lentignes.

Retreament is often necessar.

f an of these toca medicaons roduce signficantnfammation or r itat ion i is imortant to discontnue

the r use to avoid ostnfa mmato herigmetatio

I n a ddit ion seudoocronosis ma occu wit cont iuous ogtem use of ocal droqu io ne.

Beachig creams are reat ivel corandicated n

regnat a d actating wome

CRYOHERAPY

is is a chea swi and effective means for reating

entigines.

A ication o crotera can be accoml ised wt a

smal cottoi a cator or with a crotera gun .

t is oen ess effecive than oetime treatmet with a

Q-switched laser.

Tere is a signficant isk o hoigmentation with

crohera f it s aled excessve or on a taed

atent.

CH EM CAL PEELS

Su eicial deh eels mediu m det eels and deeereels are al eectve for etgies. A caeu evaluaton of

sk te owever is essentia to avod gm entar com li

cations. A s the de h of he eel n creases te ca ce oimrovemet along wh adverse side eects creases

LASER A ND LGH SOURCE REAMEN

Multie dieen teraies are eective for treating entig

ines In genera darker lentigines fare best wth Qswitched

lasers Were tere are numerous fainte lentignesintense u sed l ight sources and to a esser extent oab

lative fraction a resuacg lasers are ve eective ntese ulsed l gt frequencdoubed Qswiched

Nd :YAG lase (532 nm ) ( F ig . 24. ) Qswitced a exan

drte laser (755 nm) (Fig 242) Qswtced rub laser

(694 m) Qswtced Nd:YAG laser (064 nm) ulsedde laser wt gmeted lesio widow (595 nm) and

ractiona resurfacing lases ae al effective.

Wi Qswitced lases:

Peom a test so on da rker skn es.

Treatment end ont fo Qswitched asers is im med

ate t ssue wteng For the Qswitced Nd:YAG

( 1064 nm) sma l n oint b leedig ma be seen



A 7-to- 0-da heal ing t me can be exected fo crust

in g to resolve ae Q-switched aser treatment

Legs resond more sowl tha the face ad hands

Caution should be take wh le treatig ower legs asthe often heigment Herigmentation ma

ersist for months

he frequecdoubled Qswitched dYAG (532 nm)

aser has been shown to imrove lentigines safel andeectve

In one stud 37 atents were treated once with afluence o 2 to 5 J/cm a 20mm sot size ad a

0ns ulse width

Highe fuences ovded best results with 60% of

atients showig 75% or better ceaaces

Minor transient hoigmentation hergmenta

tion and erthema wee noted i a few atients

Has been shown to oduce beer clearng than

35% TCA eel

Has bee shown to teat letigines more eective

tha n cotera

he Qswitched ru b (694 nm ) l aser s a so ver eective

In one treatment substantial clearing occurred atflueces of 45 a d/or 75 J/cm and a ulse width of

40 ns

I the c l i ica l endont of mmediate whiten g s

ach ieved the etigo should c lear wth oe treatmet

actiona resurfacig can also be eective

reatment is general erformed at suerfciade ths and owe energes coma red to treatmets o

rhtes and acne scars

H igh teatment den sites a re most effective Tic al

requies mu t ie teatments

Mild-to-modeate erthema resembig a sunbun

reaction is obseved Postrocedue sweing is aso

common

he erthema esoves in 3 to 5 das ad ca be

covered with makeu withn a da of the treatment

Longterm d ata are crrent lacki g

ntese u se l ight is aso eective Sevent-four ercet cearance o letiges in 18

atients with oe treatment

The c i ica l edoint is darkeng of the lent g ies

PFALLS O AVOD/COMPLCAONS/

MANAGEMENOUCOMEEXPECAONS

Qswtched laser and lght source treatmet fo lentig

ines s frequentl successu onablative fractionalresufac ng s the least efectve of th s grou





Patients shoud be counseled regarding te ossib l it

of postiammator gmentation changes ae teatment especial on the ower egs.

Recurence ater teatment s not unco mmon .

Bo s an leso that demostrates an cl n ical ata

ro to treatig with laser or cotheap. Lase thera

of a ma ignant esio such as a etigo maligna ormelanoma ma mask its c in ca aearance and thus

cause a dela in diagnosis.

Avoid usig Q-switched asers in patients with an

pri or histo of go d intake. Ch rsiasis resetig asb uegra c ircu lar macues o te ski can occur aer

Q-switched aser treatment of soar letigines in thesepat ients (F ig 24.2) .

BBLOGRAPHY

Bjerr ing P Crist iansen K. I ntense u sed l gt souce or

treatment of sma meanoctic nevi ad solar entigines.J Cuan Lase The 20002 77-8 .

Ga eckas KJ Ross EV U ebelh oer N S . A used de lase

with a 10mm beam dameter and a igmented esionwindow fo pururafree photoejuvenato. Demaol

Sug 200834(3)308-33.

Gest DE Ph l l i ps TJ. Deveopment o chsiasis aer Q

swtced rub aser teatment of solar lentigines Am

Acad Demaol 200655(Sup 2 S 59-S60.

K me SL. Laser eradcaton o gmented lesions and

tattoos. Demaol Clin 200220() 37-53.

Ki m er SL Wheeand RG Gold berg D Anderson RR .reatment of epdema igmented lesos with te re

quencdoubled Qswtched d:YAG lase. A contoed

sigle-imact dose-esponse mult icenter t ia . Ach

Demaol 1 994 30(1 2 ) 5 5 5 9 .

L Y Yang KC. Compa rson o th e eque ncdoub ed Qswtced d:YAG aser and 35% tr ichoroacetc acid fo

the treatmet of face lentgines Demaol Sug

999;25(3):202204.

Sadighha A Saatee S Muaghegh-Zahed G Eficac

and adverse eects of Q-switched rub lase on solar

lentignes: A rospective stud of 9 atients with

tzpatr ck skn te I I l l and IV Demaol Sug2008;34(1 ) : 14651468

Stern RS Dover S evin JA Arndt K aser theapversus crotera o lentgies A comarative tal. JAmAcad Demaol 199430(6)985-987

alor CR Andeson RR Treatment o beng pigmented

eiderma esions b Qswtced rub aser n J

Demaol 199332(2) 908-92.

odd M M Ra is TM Gerwels W ata TR . A compaison

of 3 lasers and iquid itroge in the teatment o sola

lentignes: A andomized cotrol led comaative t ia l .

Ach Demaol 200036(7)84846.



CHAPTER 25 Measma

Melasma s an acqu i red brown macu a r hpep gmen

tat on usua l of te face. t is far mo re common i n

femaes than i males . I t usua pesents b i latera and smmetr ica l l on the face but extensor foearms

ma aso be ivolved. There ae be eved to be threeh sto log c var iats of me asma ep derma l dema and

mixed derma l and ep iderma l . Ep iderma me asmaresponds best to theap All forms have a hgh ate of

recurence makng th is a frustra ing cond t io to teat .Sun exposure peganc and ora contracept ive p l s

are al l assocated with its presentaton ad ecurence

( F g . 2 5 . 1 ) .

EPDEMOLOGY

i common

g oug femaes

Ra Centra l and South Amer ican Mdd le Easten

Inda East Asan females ae most fequentl affected

S fema es > ma es (9 : 1 )

Priiaig ars pregnac ora contraceptve pi l ls

sun exposue homone eplacement therap

PAHOGENESS

Unknown.

DERMAOPAHOLOGY

In epderma measma tere is increased melanin depo

s ion in the epiderms part icular l in the basa andsupabasal aes n der mal melasma tere ae per vas

cu ar me aincoa n ng macophages the superfc ia

and mi ddermi s M ixed-tpe meas ma exhb ts feaues ofeach of the above fid ngs.

PHYSCAL LESONS

Patents present wih we-demarcated l ight brown todak b rown smme ic m acu la hperp gmetat ion . n

app roxmate two-th ids of pat ients i t appeas on

the centra face inc lud ing he foreead nose upper

cutaneous p and ch in . t presents less fequent on

te malar aeas ad jawl ine . More rare i t appeas onte dorsa l forearms. Dermal measma has moe of a

b lue-ga hue. Mixed-tpe melasma has a brown-gra

cooat ion .


Fgue 2 Fmal ith tnsiv mlasma rcalcitrant t multipltpical rgimns fr svral yars




D FFERENAL DAGNOSS

Posifa mmaor erpigmenaio, exogenous ochrono

sis, drug-duced/oo-erigmeaion, nevus of Oaerema dschromicum ersans

LABORAORY EMNAON

Wood's lam p exam iatio accenuaes e i creased ep i

dermal pgmenation n measma bu does o igh g

its dermal comoen

COURSE

he igmenaon reses over a perod of weeks

occurs mos common i summer me, wit igesrogen saes du ri ng regnanc, ad pri or to me

strua ion t ma fade co mplee mons aer de l iver

or afer d iscont inuat ion of ora l conracept ive i l ls ma reaear in subsequen regancies and/or sun

exosure

KEY CONSULAVE QUESONS

Medication istor

Pregnanc

Su n exosure

m e of ose

Previous reamens

MANAGEMEN

ere is no medica i nd caton o reat measma

Neverteless, man aiens undersandabl are disressed b is apearace ad desire reamen Te goal

of te reame is o igen or remove he pgmenationreaig melasma can be qu te frustraing P rio r o in t ia

ing erap, s essental for e scian o exan

measma and is treament i detai to the paien Wieere are ma treaments for measma, i shoud be

sressed ha man are ofen onl arial effecve

Recu rrences are ver commo nI is also imoa o deermine whic form of

measma s being reated ta s eidermal versus

mixed-e versus derma melasma (Fg 252). Tere

are mul e opca and laser thera ies ava i lab e( Fig 25 3) . Treamen is frusratig an d oen neffecve

ere is a gh rate of recurrece Derma ad mxedte meas ma are leas responsi ve o era I n a l

measma atiens, sr ic sun avoidance is crucia w a

sunscreen wi VV roecion ad/or a scalb ock such as ian iu m d oxide or z inc oxde dur ig and

aer an reamen regmen

AFigure 2 2 () A female patient ith therapyresistant melasmaCourtesy of Hoard Conn



OPCAL REAMEN (abe 251)

Thee are a host o topica teatments fo melas ma

Numerous formulations contaiing bleachg agets

suc as 4% hdroquione are eective treatments to

lighten o resove pigmentatio he are most effective

if used over a perod of weeks to a few months f theskin becomes signficantl irr itated from treatment d is

continue its use to avoid postinflammator hperpg

metation Proonged usage o hdoqu non e can result

in a chaacterstc skn dscoloratio kow as seudo

ochoosis

Ret no ids such as topca 0.1% tret ino n apl ed oce

dail for 40 weeks has been shown to be eectve but

ess effective tha hdroqui noe

Combation thera of 0.05% tretinon 4% hdro

quinone, ad 0.01% fuocinoloe acetode that is

Triuma produces favorabe clnical results for melasma

and postif ammato hperpgmentation wt d ecreasedirrtation Treatmet duration s limited b side eectsof prolonged topical steoid use ncudig skin atroph

and acne

Azeac acid has also been show to produce m prove

met

CH EM CAL PEELS

Chemical peels are often efective fo melasma

n one stud there was no diference resuts whe

comparng Jessner's sout on versus 70% glcoc acidpees ate performing three peels 1 mot apart oneac si de of the face


B Gcoc acd peels performed ever 3 weeks comb

nat ion wit da i sunscreen and a combinat on

Fgure 22 (B) (Continue Marked resolution in the melasma ater fourtreatm ent sessions with Fraxel laser Courtesy of Howard Conn

TABLE 2 • Teatent of Pgented Lesions on the ace

Retnoid/hdoquinone Gcoi c acd peels Qswtced laser Abative resuacng Fractona resuracg

Melasma Variabe imovement Mut ip le ght pee s i o Yes; but carefu Yes i skn

cojunction with patent seecto tes ;suscree and and ong postaser caut ion ski

tocal retinod/ recover tpe Vhdoquinone

Postinammato Yes; weeks to mont hs Vaiabe impovemet o No No

herpgmentatio to see c l in ica lmrovemet

Letigo Min ima/moderate Mima/modeate Yes; one to two Yes; M d/modeate

mrovemet after change with tree teatments are ostinflammator

month s of use to fou peels hgh s uccessful ertema che

obstacle

Nevus o f Ota Noe None Yes; mult e No No

treatments resultn improvement




gco c ac d/hdroqu none cream has bee show to

be effective.

Seral suercia l chemica pees such as salclc acid

ad gcoic acid ees are the safest pees n daker

skn ototpesCauto is requred or darker skn phototes to avoid

herpigmetatio

LASERS

• QSwitce ases

swtced aser treatmet fo measma s ot recom

mended give its high incidence o ostinfammato

herigmentation Additona l it s ot dramatca l eectve except in some cases of superical measma.

• Aat ive Lase

I cases refractor to topca ceams ad chemical eelserbum:YAG ase produced signcat temoar improve

met i 0 atets i oe stud but was com l icated bsubsequet ostinfammator hperigmentation n a l

0 atets.

• NoA a ve ract ioa l esurfac g

NoAbatve ractional resurfacig can be successful or

some cases of measma esecal epdemal tpes

(F ig . 25.2) .

Log-term data are lacking.

reatment is genea eormed at suerficia l deth

relatve to treatmets or rhtes ad acne sca rs.

reatment s geera erformed at hgher d enst es

It is most successful n atients with ighter skin ho

totpes such as skin tpes a d I I mp rovement s essredctabe in sk tpe l l but s oe ach eved.

Ski hototpes IV ad V ofte do ot respond avor

ab to fractional resurfaci ng. Postinla mmator hper

pigmentation is a high r sk.

Pre a d ostteatment use of hdroqu i noe and ogenteas betwee treatmets ma reduce ostiflam

mator hpegmentaton n da rker sk hototes.

PTFALLS TO AVOD/COMPLCATONS/MANAGEMENTIOUTCOME EXPECTATONS

Al orms of melasma are diicut and frustratng to

treat. Recurrence s commo

Dermal melasma is pat icu ar d icu t .

Patents shoud be apprised of te recacitrat nature o

this codit o some cases.

A

BFigure 23 () Young female with melasma (B) Characteristic darkeningof melasma 1 -day post intense pulsed light treatmen t



Postpartum state and discontinuace of ora contra

cetve pi s a re reque ntl successul terapi es

Some treatments worsen ts apearance

Strict sun avodance is crucial wit a sunscree wt

UVUVB protecto and/or a pscal bock such ast itaum d ioxide or z inc oxide dur ig and aer an

treatment regimen

BBLOGRAPHY

inke Ditre CM amiton TA, E is CN Voorees JTocal tretinoin (retioc acid) improves measma A

veic econtro led , c l ica tr ia l J m 1993 129

41 5 42 1

Gr imes P E Management of per gmentat on in darker

racia etnic grous Smi Md Sg 2009;28(2) 77-85

Lawrence N, Cox SE Brod HJ Treatmet of melasmawith Jessners solutio versus gco c acd : A com parisonof c n ica eicac and evaluation o the predictive abi l it

of Woods l ight examnatio J Am Ad m.1997;36:589-593

Lee S Won C , ee D , et al reatment o melasma i

Asa skn us g a ract iona l 1 550 nm aser : An open

ciical stud m S 200935(10) :14991504

Manaoto RM Aser M Erb um:YAG laser resurfac ing

for refractor melasma m Sg 1999;25121-

123

Rokhsar CK, Ftzatrck RE Te treatmet o melasma

with ractiona potothermosis: A lot stud mSg. 200531 (12) 16451650

Torok M, oes T Ric P, Smth S, Tscen E

Hdroquione 4% tret no 005%, f luoc no lone acetonde 001%: A safe and efficacious 12month treat

ment for measma i. 200575(1} 5762

Veral o-Rowel VM Verao V Graue K Loez-V l auerteL, Garc ia opez M Double-b l ind comar son of azele ic

acd ad droqunone in te treatment of melasmaA m 198914358-61

Victor C, Gelber J, Rao B Measma: A revew J Md Sg. 20048(2) :97102

Cl ca apoac todagnosg

easma


Pyscal Exa Sun exposed areaface moe often tha ars Distrbt onceeks, lowe face, meda facein any combat on

Wood's Light to deteme epiea vs.dera d s bu o of p gment

erenta iagnosis Post nf amatory hypepgetaon

Medcao indce hyperpgmentatio

Rsk Factos Pregnancy Oa contracepves

Iceased pigmentation wth sun exposre

Fgue 2 Cinicl ppch t dignsing msm

ELASA

Vgant sunsce s ccal

SPF30 before du ing an d afte any teapyImpoveen s va abe and ecurence is comon

opica echanical Hydroquinoe Microerabraso Re nods

Supef c ia pees Koj ic acd Azea c acd

Lico rce exacs

I

+ +A combnato of a topca such as

hydouone wth onthy pees ad/ormcoemabrason fo 6 monts s aneffecte and safe com bn ation th erapy

Lasers Fraconapototheroyss

Aba e resofac g Q-swtched

ases

+

Lase/ g souces shoud be used ony afte combnation of topcasand peesmcodemabrason fa

Ri sk of post- inf am matoy hypepigmentation fom an y ase(may persst fo monts) Fracona potohermoysis as fewer sde effects and ess down

time than aba ive ases Abae resofacg ony for the mos efactoy cases in patents

who can toeate onhs of post infammato canges

Q-swched asers are often not effecive and ofen worsen measa

Fgue 2 Msm ttmnt ptcl




CHAPTER 26 Nevus of Ota

Nevus of Ota aso known as nevus uscoceruleus o

thamomaxi ar s represents a bengn ata coflent

macuar brow-blue gmentat on of the skn andmucous membraes in the d istr but ion of the irs ad

second brances of the tr igemin a nee. I ma be un ilatera or bi aeral. e isiateral scera is fequentl

involved

EPDEMOLOGY

cic 0.4% t o 08% of Jaanese dematoo paients

g bmodal dst ibuon at b and bert

Rc: moe common in Asans and blacks tha whites

Sx moe females than maes seek treament o thiscondit ion u nknown if ere is a sex redi lection

rciiig cors: soradc not an ierted dsorde

PAHOGENESS

Hperigmentaton arises as a resut of dermal

mean oces tha have ot m grated to the epid emis .

PAHOLOGY

Heav igmented eongated dendrtic meanoctes arelocated among the reticla dema collage. Mos tp

call these mela noctes are ound n te u er onethrd

of he recular derms but are aso see in the pa la

dermis i n some es ions.

PHYSCAL LESON S

I t p resens as couen or paa l conlue b rown-blu epatches in the dsr ibuton of the rst and second

branches o the tr gemina nerve. Gra back and urpecoloratio ma be resent in some lesons as well It can

be nilatera or b latera . The magntude of ivovementcan var from local eriocua r i nvolvement o much of hesd e of the face Ap roximate twoth ds of atie nts ea

tre ipsi latea sceral ivolvement.

D FFERENTAL DAGNOSS

Measma caf au I ai t macule Hor i s macue b l ue nevus

brusng ochroosis agra oodemaoses fixed

drug erupto and oter medcaion-reated erutonsshoud be consdered in the roer c i n cal setting

A

Bigure () Nvus of Ota rior to tratmnt with Q-switchd rublsr 8 ignificnt claranc ar srial trtmnts with Q-switchdrub lasr



LABORAORY EXAMNAON

Bios ma be id caed i f th e d iagosis is i n qu es ion or

to exc lude te are case of meanoma ar is ing n th sleso.

COURSE

Thee s a bmo da d isti buion for nevus of Ota b ith an dube. It remains eatve similar aearance afte

in it a resetato

KEY CONS ULAVE QU ESON S

Onse of erutio

Medication histo

MANAGEMENThee is no medcal idcaion to trea nevus o Ota.Cosmetc a earance howeve s dstessg to aents

Wh le cohea and toica beachi g reatmes havebeen uized the teatment of choice is Qswched ase

treatment

OPCAL REAM EN

Mak eup can cam ouflage or asss in cam oulagng nevus

of Ota To ca med icatio ns are less effecive tha ase.

REAMEN

N ume rous sudes have sow that evus of Ota i s

ameabe to successfu esoluion with Q-swtced

aser teraes icudig the Q-switched ub

(694 nm) the aexandrte (755 nm) and te Nd:YAG( 1 064 m) lases (F gs . 26.2 ad 26.3) .

est sot can be perormed pro o teatmen t

he Qswched ub lase has b een sh own to be effec

tive a poducin g 75 % o geate cearance at luences

of 5 to 7 J/cm 4mm sot size and a 30s pulse

wdth a 3to4mot treament inteals In a stud of 46 c l dren ad 107 adu lts wi evus

of Ota treatments were moe successu in cidren

than n adu ts

The mean nu mber of treament sessions to ach eve

sgnficant cearing or better was 35 fo the ouger

age goup and 5.9 for the oder age group

Addit onal complications were lower n e childen

than ad ults that s 48% as compaed to 22.4%.

Oe erospectve stud examined 101 patens1 ea ater teament wit Q-swtched ru b aser ad


Figure Nevs of Ota Periorital legray pigmentation ith scleralinvolvement Kay K Jen ichard J, et a eds Color Atlas & ynopsis ofPediatric ermatolo McGraHill, Inc; 00

Topca Caoagea e e o soe aies

NEVUS OF OTA

echancal iodeaasoso o e eoed g is o soaa/or sag

Lasers Qswied asesae e eae ooie Alaeo

li le reaes wi Qswie ases ae eeded I oee oerae o draa aer e eaes Qswie ase reae o esios a aise ia aresod eer o laser ea a lae i l ie a Qswie A ase is se a oaio o 532 /106 a resl ee al ioee a 1 06 aloe

Figure Treatment of nevs of Ota algorithm




ound ha 168% dsplayed hypopgmenaon ad

5.9% showed hyperpigmeaio One paen whohad com pee resouio developed recurrence

he Qswched a lexand ie laser s a so efecve or he

reamen o nevus o Oa Dermal when g is hekey c in ca endpon when reaing nevus o Oa wih

Qswched lasers Oe group reored he successu reamen o

nevus o Oa wih racional phoohemoysis

oeheess Qswched aser s he reame ochoice

• To ica

Camoulage may be he ul or some paens.

• M e c h a n c a

Mi crodemabrason shoul d no be perormed

H igh r isk o dyschromi a ad/or scaing

• asers

Q-swiched asers are he reamen o choice

Ablaiveno

Muipe reamens wh Q-swched lases are needed

m povemen moderae o dramaic aer m u iple ea

mens.

Qswiched aser reamen o lesons ha arise nnancy may respond bee o lase heray han aer

n le

a Q-swched YAG aser is used a combinaion o

532 nm/1,064 nm may resu n beer cncal impove

men han 1 064 nm alone

Oe sudy reaed 13 paes a luences ragng

beween 6 and 8 /cm a 8week inevas he

mea number o reamens was approximaey

seven Seven paiens acheved 75% or beer igh

enng hree paiens acheved beween 51% and75% impoveme one achieved bewee 25% and

50% improvemen and anoher achieved less han25% mprovemen.

wo paens experenced ransien hyperpigmena

ion one experienced rasien hypopigmenaion

he Q-swched NdYAG (1 064 nm) laser has a lso

proven o be eecve

S ighy ess eecve han ohe r Qswched lasers.

I is saer o use n dark sk ypes

Less risk o hypopigmenaion.



PFALLS O AVOD/OUCOMEEXPECAONS/COMPLCAONS/MANAGEMEN

Lase treatment for nevus o Ota is requently su ccessfu

Given te igh proportion o patents wit dark ski

phototypes, there is the isk of hypo an d hyperpigmentat io.

he r isk of such an advese eact o shou d be d scussed with the patient prior to therapy.

Additionay, a test site can be teated befoe peform

ing u l treatment of any eso.

Qswtced ase r treatment can be associated with tran

sient hypepgmentation.

Recurence ater treatment s ifequent.

BBLOGRAPHY

Cha n H eung RS, Ying SY et al . A retospective aa y

sis of complcations in the treatment of nevus of Ota wth

the Qswitched aexandite ad Qswtched d:YAGlasers erm Surg 200026( 1 1 ) 10001006.

Chan H H Y ng SY, Ho WS, Kono T King An i v ivotr ia l comparing te cl in ical efficacy and compcatos of

Q-switched 755 nm alexandte and Q-swtched 1064 nm

Nd :YAG lases i n t e treatment of evus of Ota. erml

Surg 200026( 10 ) 91 9-922.

Kono Cha n H , Ercocen AR , et a l . Use of Q-swtced

ru by laser n the teatment of nevus of Ota i n di ferent age

groups. Lsers Surg Med 200332(5) 391395.Kono ozaki M, Cha H Mkashima Y. A retrospec

tve study ooking at the ong-tem compications of

Qswitched uby aser in the treatment of nevus of Ota.

Lsers Surg Med 2001 29(2) 156159.

Kou ba D Fin che EF, M oy RL e vus o Ota successful y

treated by fractional potothemoyss using a fraction

ated 1440nm d:YAG aser Arch erml 2008

144(2) : 156158.

Radmanesh M aevus o Ota treatment with cryothe

apy. J erml Tre 200112(4)205-209.





CHAPTER 27 ost nf a m ma tory hyperpg me ntaton

Posinlam mator hergmenaion (P I ) is a commo n

sequea o i nflammato dermatoses or inju r to the ski.

It occrs mos common n darker sk tpes.Deendng on the etolog of the hergmenaon, pig

ment ma be deposed n the dermis or epdermis wthimorant micatons for teatng the gmen changes.

It s a common seqel a of ase eatmen art ic ar i ndarker sk n hototpes ( ig 27 . ) .

EPDEMOLOGY

ee: comm on, esecia l n da rke skn tpes

e a l ages

Rae: moe common in da rker skin tpesSex: none

rea ars an inlammato disorder or injuto the skin ca rodce hperigmentatio. It ma aso

result rom lase thera, demabrasion, crothera or

chemcal pees It resents more exberatl and with agreaer duraon in daker skn photoes

PAHOGENESS

Unknown.

DERMAOPAHOLOGY

Basa cel laer pigmentaton and dermal meanophages

are seen.

PHYSCAL LESON S

In epidermal P H, at ents d ispa nd ist ic an o dakbrown macles a sies of prevos skin inflammaon In

derma l P here s more o a browngra he

D FFERENAL DAGNOSS

Masoctosis, macular amoidosis, minoci herg

mentaion, exogenos ochronosis, melasma and er

thema dschromicm pesans

LABORAORY EMNAON

None .

Figure 27 PIH seen aer a seres o treatments wth nonablatveractonal resurfacn or a scar The PIH resolved on ts own wthn

weeks

A_

_

Figure 27 2 () Pseudo-ochronoss seen aer years o hydrqunone

treatment



COURSE

P I H does not wosen i n he absence o uther n sult o

infla mmation at he aected sie. PI H usuall resovesover a eiod of a few mohs. In he case o demal

herpigmeaton thee ma not be im ovemet


Su n exosue susceen use

me of onset

Recet rashes injur or treatment of skin

Medication use

MANAGEMEN


Whle tere s o medica ndication to treat P manatents ae as botheed b PI as the ae b the

rocesses that produced i i it ia l Furtermoe PIH ca

endue ar longe than he original eruption here are

mu t ip le teatmens nc ud i ng to ica l lase ad chemica leels (able 271) It is essenia o rst determne he

cause of the heigmentaton Culits ange romhemosidei n o igment to vascul ar Wihout detemi ing

the etioog correct reatmen wll at best rovide no

imoveme or worsen the PH Frequent the safestand most eecive teament is time Attemted teat

ment of P esecia n daker skin hotoes caoen wose and olong hergmetato ormall

ederma PIH wi l resolve on its own over a eriod omonths

Figure 272 (B) (Continue ignificant improvement aer treatment with

switched laser

Theaeutc otions include toical retioids bleac

ing ceams chemica l pee s ( i nc ud ing glcol c ac id eels

TLE 27 • Post-fammatory Hypepigmetatio teatmet

Theaeutic Retinoid/ Peels/otons hdoqui none mic rodemabrasion

Pos-iflammator

herigmenatio

eeds to be used

for weeks to

months fomovemet

ace/ue bod

moves more

qui ck than owe

ha If of he bod

2070% glcoc acid

ees jessner ees

combinaton esserTCees and Saic c

acid ees and/omicrodermabason

ma hel imrove

moe qu ck Risk o aadoxica l l

mak ng ostnam maor

changes wr if oo

much inf ammat on

is ceated

Qswitched lase Ablat ve ases

o o

Fractiona

resufacing

o




essne peels, combinatio JessneTCA pees and sali

cl c ac d peels) a nd factiona lase teatmet Tee sa isk o paadoxcall making posnammato changes

rs f oo much inam mation s ceated

SUNPROTECTON

S n bocks and sunsceens used dai l ae cucal to pe

vent wosenng as s sun avoidance Wot thei se,

ohe eapies wll not be eectve f a patent does notavod sn expose P IH w l l wosen Sun avodance

incudes avodng peak sn hos weaing a at otdoos to potect the face om sn expose and an

awaeness at UVA as peetaes though wdows

wi e d iv ng, wh e at wok ad wi le at home

TOPCAL TREAMENTS

hee ae a ost of topcal eatments o PIH tha pod ce ml d mpovement and ma expedite eso ion

Hdoq inone omlaios paticla l wh su nsceens

Hdoqunone (2%4%) ceams ae effective fist

i ne teatment

Poonged usage o hdoqone can eslt in a Achaacteist ic skn dscooaion known as psedo

ochonosis (F ig 272 )

Bleacing ceams ae contaidicated in pegnant

and lactat ng wome

Ret io ids

Solage (2% meqno l ad 0.01% te ino in) andT ma (001% f loc no lone aceton ide 4% do

qinone and 005% tetinon) povide an exfoliat ive

benefit

T ma s hol d not be used i ndefinitel due o its co

ticoseod conet and sk fo atoph

Azeac acd (20%) ceam app ed twce dai povides

slow l ghtening of pigmentation

Koj c ac id ( 1 %2 . 5% ) ceam

The exac concenaion of kojc acid eeded foefective eslts is nknow

f an o hese topicals poduces sgnficant inflamma

ton o i itat ion, it s i mpoant o di scotin e ts use to

avoid wosening of PI H

CH EM CAL PEELS

Chemca peels ae an effective eatment opton fo theedct ion o P I H

Ovethecounte dox acd peels ae a beneficial

adunct to phsicanstenh chemcal peels econtna exfo ia ion achieved fom cosistet se o

the peels ma esu lt n m l d l ighten g

BFigure 27 3 () Hyperpigmentation on le side of face before treatment

8 Impvement aer a series of salicylic acid peels and topical application of 4% hydroquinone Courtesy of Pearl E Grimes, M



Gco ic ac id ees (20%70 % ) are adminisered ever

2 to 3 weeks ui zg icreasng sreghs as olerated

The reatme edpoint is m d con en eema .

Treaed aeas ms be u l neua zed wih sodium

bcabonae o waer at h e comeo o f the ee l .

Ligheni g o suefc a l P ma be o bserved ateror o six peels.

Srict photooection o 1 monh s essetal and

ms be stressed.

essner eels (resocnol, acic acd and salc ic acd)

are ad mi i seed ever 6 o 8 weeks.

Treament edon s a l igh whiten ng o the skin .

Strict photoproecon for 2 o 3 monhs s advsed.

Mu ile eatmes are recommended .

Conta id caed i n regant and lacang women.

Combnao Jessne/0% r choroacec (TCA) ees

ma also be emoed i a sim a fashion as heesser pee . The Jessne eel esuts in exoa oalowing for geae peneaion o he CA ee.

Mu ile eels are genea l needed.

Conaid caed i regant and lacang women.

Deee eels ae ael emploed gven the sk ofP exacebaion wh healing

Caution must be used n reaig skin hototpes I oVI pa icu la with medi m-deth ees Sa l ic c ac d

pees are safes or dark skin photoes (Fig. 27.3).

LASERSTraditiona, aser reament fo PI does no roduce

relab e mpovemen and s no firs l i e hera. n aclaser thea ma exacerbae PI. n geeral i is not

recommendedFraciona l hoothemolsis (FP) can however ovde

im oveme of P ( F ig 274) . h s is esecia l l re o

atens wh gter skin hotoes. I da rke skin es,PI oe worsens. I shoud no be recommended as a

rs l ne hera Rahe beac hing creams and chemi caeels rovide more consse eoduc ble esus

Ticall FP reatmes shoud be directed owad

suerficia skn deh ad avod hgher eatme densi es .

PFALLS O AVOD/COMPLCAONS/MANAGEMENOUCOMEEXPECAONS

I t is im orant o reassure aiens ha P H w l resove

on is own wh tm e excet f it is a de ma ocess

Lase treatme is u eliab e and ma produce worse

ing. I is usua l l no recommended


A

BFgure 27 () Hyperpigmentation aer a series of Qswitched laser tattoo treatments (B) Impvement of PIH after two nonablative fractionalresurfacing treatments utilizing superficial depth and lower treatment

densities




t is important o disconinue an topca medications

that poduce nfammation o ta on to avoid worse

ng P IH

Chemical peels ae l ike to onl l ghte and not ful l

e l iminate the PIH Caut io should be ake n dake

skin pototpes

t is beer and safer o ut l ize seria supecial peelsathe than a si nge deepe pee o mi n mize the isk ofP I H .

PH ma ot improve despite serial cemca pee use

P I H result ng fom hemosidein ( ie, leg vei eatments)wi not respond to asers, peels and beach ing creams

In fact, teatment wi i kel worse the PI H .

BBLOGRAPHY

Kime SL Lase eradicaton of pgmented lesions and

tattoos Drmal. li. 200220() 37-53

Mis i ma Y Ohama Y, Sh baa T et a l n h i b ior acion ofkojic acd o melanogenesis and its herapeutic effect fo

vaious huma hperpigmentation disoders Ski Rs.994;36(2) 134-150.

Nakagawa M Kawai K Contact a lerg to koj ic acid n

sk in care poducs a Drmaiis. 1 995 3 ( ) 9 3 .

Ngujen QH, Bu i P. Azela ic ac d : Phamacokinet c ad

phamacodamic propertes ad its erapeuic role n

hperpigmea disodes and ace l J Drmal.995;34(2) 75-84.



CHAPTER 28 Vtgo

Vt igo is a acquired idiopathic condt ion that produces

smmetic deigmented patches of the skn It s art icu

la dstressng and cl ica apparet i patets wthdarker skin phototpes

EPDEMOLOGY

i ap roxmatel 2% o the world popu lation

Ag: can reset at an age but most commonl presents

in the secod to ourth de cade

Ra: equal

Sx equa

riiig ars nher itance trauma i ess, emo

to a states

PAHOGENESS

Unkown

DERMAOPAHOLOGY

Thee are no melaoces n basal ce ae

PHYSCAL LESONS

Patents dispa weldemarcated smmetic, depigmented, chakwite macues Common locatios icudeelbows, kees, sacra area penis, peroa areas and neck

Hai r ma also ose pigmentaton ( Figs. 28. 1 and 282).

DFFERENAL DAGNOSS

Chemical eukoderma ostnflammato hopgmentaton, nevus deigmetosus, evus aemicus, ptr iasis

alba, upus erhematosus, lepros, and geodermatoses

LABORAORY EXMNAON

Wood's amp exam iat io s he pfu i making the d iag

nosis In cases of uceaint, bios should be eormed o both esional and onesioa skin in oder to

determine i there s an absence of meanoctes i the

aected skn Check trod-stmuatng ormone (S)or hothrodism

COURSE

Vit igo can p ursue a variabl e course After an i t ia ra id

presentation , it tends to sta bi ize Tpica , it is a ch ronic


Fgure 28 Vitiig n th trunk and nck f a yung patint




dsease with eriods of artial regmentaton but ot res

outon . It ma im rove in the sum mei me. In somecases degmetation becomes extensive

KEY CONSULATVE QUESONS

Age of ati ent

me of oset

aml histor

Occuato

Chemcal exosures

MANAGEMEN

hee are mult ile treatment modalt ies or vit i igo

Unortuate treatment is frustratng and ofte nefec

tive Patients understandabl are dstressed b the

aearance of vtil igo ad desie treatment extensvecases t roduces a str ki g aearance aticu ar oatents wit darker skn hototes.

PREVENON

Sunscreens and sun avodance rotect vit l iginous skinfrom burn ng and are an imortant comoent o ter

a Furter tannng unafected skin wil accentuate thecontrast between norma l ad vt i ig nous sk worseing

the cosmetc a earance o the disease.

OPCAL REATME N

hee are a h ost of toi cal treatmets fo vti i go. he

inc lude

Cotcosterods

oica

ntra les iona l

Calc ineur i n ib itors tacro l mus imecro l mus

Moobenzlether of hdroqu noe

Produces ermanet deigmetation

wce dal over 1-ear eriod

Permanent degmetato is roduced n ess than

50% of atients

Poor or no deigmetaton n eal haf of atents

Caution or to u rsuig ths erma net treatment

Side efects nclude contact demattis erthema

and rur itus

eighteed sk of sunbur ate ts ermanent

treatment

Camouagng makeu and self-tanning agents to hde

deigmented macues

Figure 28 2 White forelock in the same patient



PHOTOTHERAPY

Photothera is a ma insta of vii l i go eatmen

Psoraen and utravioet A (PVA) with toical or oral

5methoxsoalen or 8meoxsoraen

Narrow-band UVB

ORAL TH ERAPY

Oral thera es ic l ude

Ora 5 o 8methoxsoa en n combinat on wth grad

ual l mited sun exosue

Pu lse era with co costeods

SU RG CAL TREATM ENTS

Autologous skin gang can be a eu teatme for

vi i go recalctant o othe theaies It s not a first orsecond-l ie teatment Si-hickness gafs, eidemal

blister gas cutued melanocte grats single hairgrats and noncutured eidermal susesio gas

have a been examned Pai aer grat rocedues s

comm on aicu ar l at e ha rvest site (g 28 3)

A majoi of ates em oing the ede ma sucto

grat techni que showed m ovemet

Sit-ckess gaig and dermabasio have aso

achieved eigmenation within an average o 6 months

in one stud of 22 atients

Single a gras ae mos efectve in localized o seg

menta vit l igo Success n genera zed vt i go is oor Both cultured ure meanoce susenson as wel as

cuued eidermal gaig ae treatmet with C asehave bee sown to be successful in teating vitiigo

Resu s were best in l oca ized cases of viti igo

LASER THERAPY

Excie Lase

An excime laser em is UVB rage igt at 308 nm cl ose tothe wavelegt of aowband UVB tea that has been

used to successful teat vtil igo Begin ni ng wih a staingdose o 100 m/cm wt increasing doses in sandadhotothera in cements hee was good m rovement n

recalc itrant viti igo ater 30 weeks of teatmets

Acal lesons were most efracto to treament

ew a dvese eects

Bes esuts are roduced on the ace > neck extem

t ies tunk a nd genita i a > hands eet

Moe exensive than ma tradt iona theraies

Combnat ion treament with aco l imus 01% s more

eectve tha treament wi excim er ase alon e


A

BFigure (A) epigmented patch of sin on right mandible

(B) ignificant improvement aer multiple 1 -mm punch gras Courtesyof Pearl E Grimes, M




PFALLS O AVOD/COMPLCAONS/MANAGEMEN/OUCOMEEXPECAONS

Viti go is a difficut dsease to treat

here ae mu lt ip le f irst and secod l n e theraies tat

shoud be emloed befoe seeking surgical or lasertreatments

t is esecal dfficut to roduce ongterm signficant

cosmetic improvement in extesve cases

Fequentl, eigmentaton ma be cofied to erio

cul ar areas creating a spott" appeaace.

Patients need to be educated that a therap ma not

succeed

he excim er ase s not wdel avai ab e, m aki g its use

paicu lar d ifficu lt

BBLOGRAPHY

Chen Y, Yag PY, u D, Kuo FS, ung CS, Hug CM

reatment of vt i l igo b transantation of cutured puremeanocte susenso Analsis o 120 cases J Am

Aad Dermao 200451(1) 6874

Hadi SM, Spence M ebwohl M. The use of the 308-

nm excimer ase or the treatment o vitil igo Dermaol

Surg 200430(7)983-986.

Koga M Epide rma grating us ig te tops o suctio b is

ters in the treatmet o vitil igo Arh Dermaol

1988; 1 24(1 1 ) : 1 656-1658.

Na GY Seo SK, Choi SK Sigle hair graing for the treatment of viti igo JAmAad Dermaol 1998;38(4):580584

Ozdemi r M, Cetnkae , Wolf R et a . Comparson of twosugical aroaches or treatng vit i igo: A e iminar

stud ln J Dermaol 200241(3) 135-138.

Passeon , Ostovar N Zakaia W, et al opicatacro mus and te 308 nm excimer laser A snegistic

comb ination or the treatment o vit i l igo Arh Dermaol

2004; 140(9) : 1065-1 069

aneja A, reha M , alo CR. 308nm excim er aser fo

the treatment of localized vt l igo n J Dermaol

2003;42(8)658-662.

oriama K, Kamei Y, Kazeto T, et al Combinato of

short-ulsed C aser resurfacing and cutured epiderma sheet autogating in the treatment o vit l igo: A

preiminar reort Ann Plas Surg 200453(2) 178-180.

va Geel , Ongeae K, e Ml M, Haegen YV, Vervaet

C, aeaert M oubleb l d aceboconto led stud of

autologous transpanted epidemal cel suspensions or

repgmentng vit igo. Arh Dermaol 2004;140(10):

12031208.



S IX

Vascu lar A l terat i ons




CHAPER 29 Angokeatoma

Angokeratomas are teagectasias wt keratotic ele

mets. Te esent dierent c in ca scearios inc lud

ing (a) so ita or mult i le agiokeratomas occrr ingredomi nantl o owe extemit es; ( b) a ngiokeratoma o

ordce aectng the scrotum ad the vuva (c) angio keratoma o Mibe l l i a autosomal domiant d isorde

afectg dorsum o ands ad eet ebows ad knees(d) angiokeatoma cororis dsum associated wth

abs disease an liked ecessive dsorder caracterzed b gaactosidaseA decienc and afecting

the ower abdomen bttocks ad genia ia; ad (e)

angiokeraoma crcumsctum sua groued o one

exremit.

EPDEMOLOGY

Ae: solitar or mut ile angiokeratomas usal aect

oug aduls angiokeratomas o ordce aect mddle

aged ad edel individas. Agokeratoma o Mibe iand angiokeratoma circmscritm are sal diag

nosed i cildhood.

Sex angiokeratoma o Mibel and angokeratoma cir

cmscrtum exhbit emale redominance. Otherwse

there is n o sex redsosit ion

PHYSCAL EXAMNATONRed to v io aceous wel l- c ircm scr ibed herkeratot icau es and aques

DFFERENTAL DAGNOSES

Soliar esos can be mistaken or melanoma acqed

hemagoma mhagioma seborrhe c keratos s and

wars.

LABORATORY DATA

• Dematopathoogy

Maked di ated inwaed bood vesses i te ai ar

derms associated wit an overlig acanthotic herker

atotic eidemis.

COURSE MANAGEMENT

Maagemet o agiokeratomas emans a ca ege.Ma m oda it ies have bee reoed in the iteraure with

variabe success. Treatment modai ies icde

A

BFgure 29 () Aniokeratomas on the abdomen of a youn patient(B) Aniokeratoma imaed thuh an epiluminescence micscopeermLite



Lasers angiokeraomas have occasiona been treaed

successfu wih asers

The p used de aser ( P) is an eective device for

the mprovement of the vascuar component of

angiokeraomas but frequentl some keraosis

remais The targe chromophore is hemogobin

P has proven successful at 595 m 5to7mmspo 9 to 1 1 J/cm, C 30/20 Covering the angiok

eratoma with a glass s ide that is, diascop, is hel p

u The endpoin is es iona p urpura eal i ng occursin more than 10 o 14 das Muipe reaments ma

be requ red (F ig 293 )

Resurfacn g lasers such as C and ErYAG lasers canbe utilzed fo lesiona vaporzation Paiens general

require local infilration wi 1% idocaine with or without epine pr ne prior to treatmet The Utra Puse C (umenis, Santa Cara, CA is empoed usng a 3mm

colimated hadpiece wi an eerg o 300 to 500 mJ

wh ooverlapping pulses The varous scanned C lasers such as the Sharplan FeaherTouch areempoed using the 125mm handpiece, 3-mm scan

size a 14 to 40 W he treatment endpoint is abation

to achieve esional flattenng and opaesceceTreamen sites shoud be ceansed with sa i ne soaked

gauze betwee aser passes Postoperative care

requires wice dail washing wit soap and waer and

app icaon of a a ntibiot c ointment eal ing occurs nmore than 2 o 6 weeks As with a abative proce-

dures scarrig ma be observed

Oer asers that have been used in the past wthvarabe success i ncud e potassiu mtitanp hospate

laser argon laser ad coppe vapor laser og

pulsed NdYAG (1064 nm) aser as been shown obe eective in improving angokeratomas due o is

selectivit ad is deeper peneraion ito the skin

Section 6: Vascula r A lerat ions 6

Fgure 29 2 Angiokeratoma on the le thigh resistant to multiple treatments with pulsed dye laser

Successu reatmen wih a dual-waveength laser Asstem (595 and 1064 nm) has been recent

repoed (Cnerg with Mutplex™ CnosueWestford MA SA)

Other surgical reatmets incude excision eectro

cauter elecrofulg uratio n or crosurger

P TFALLS O AVO D Patients shoud be advised that the PL reatme wil l

cause obvious brui s ng or u p to 14 das

Keratotic features ma pesis after treatmen

mp rovement s oen eusive

BBLOGRAPHY

Gorse SJ J ames W, M urson MS S uccessfu treament ofangiokeraoma wih poassium titanl phospate aser rJ Dermal 2004150(3)620-622

BFgure 293 (A) iopsyproven angiokeratoma on the thigh of a youngchild (B) ome resolution aer one treatment with pulsed dye laser at awavelength of 55 nm with a 1 0mm spot, pulse duration of 1 5 ms, a

uence of 5 cm and C 00




Lais Emtestam M arcusso JA A ngiokeaomas n

abs disease and odces dsease: Successful teatmet wth coe vaou ase Aca Derm Venerel

993; 73(2) 133-135.

Occe la C B le id l D Ramin i P Sch iaa L Rami i EArgo ase teatmet of cutaeous mul i e agioker

atomas. Dermaol Surg 1 9952 (2 ) 70 72 Odemir M Basal I Eg B Odemi S. eament oangiokeaoma of Fodce with log-use eodmium

doed iu m al um iu m gaet ase. Dermaol Surg

2009;35() 92-97

Pirman G Rau l in C arsa i S. Angiokeratoma o the

lowe extremi ies Successul treatment with a dualwaveegt laser ssem (595 ad 064 nm). Eur Acad

Dermaol Venerel 200923(2) 86-87.

Sommer S Merchat WJ SheehaDae R Sevee edomiant aca l va iant of angiokeatoma of Mibe l i

Resose to long-use NdYAG (064 nm) aser teat

ment . JAmAcad Dermaol 20045(5)764-766

CHAPTER 30 Cherry and Spder Angomas

Che agiomas a so kow as rub sots seni e

hemagiomas acqued cai la hemangioma ad

Cambe de Moga sots are ve commo benign vascula esions that edomant afect te tuk. Side

agiomas aso know as nevus aaneus side teangiectasa arteia sider ad vascuar side eeset local

ied teagectasias adaig rom ceta feedig

ateroes. The ae commo vascula esions hat edom ina tl aect the face u er runk arms and ha nds.

EP EM O LOGY

Incidence ve commo

Age che agiomasmid d eaged ad ederl eole;s ider agomasa l ages

Sex moe commo in females

Precipiaing facors che agomas ca erut duing

regac o with heatc disease Side agiomas ae

stog associated wth eganc ntake of oal cota

cetive ls and heatocelu ar disease

PAHOGENESS

Ukown fo both. Associaion wth egac ora con

taceive use and live dsease suggest a omonallmediated angiogenic mechaism .



PHYSCAL EM NATON

Cherr agoma presents as a 1-o-3-mm bright ed o

voaceous smooth dome-shaed apule Spderangioma d isplas a network of d lated ca l lar es radiai ng

rom a central vesse Bo ma bleed when taumaized

PAHOLOGY

Cherr angomas show oss of rete ridges as wel as congested and ectatic cap l ar ies and postca l a venules i

the ap la demis Sider angiomas revea a centalascendg arerole at banches and commucates

with m ult i e d lated ca la ies

D FFERENTAL DAGNOSES

Cherr agiomas can be mstaken fo agokeratoma,

gomeru o d hemangioma pogenic granuoma andnodular melanoma S ider angiomas can be m sake for

geera zed essetial telagiectasas and heredta hemorrhagic ea ngiectasia

COURSE

Cherr and spide angomas ais ng duig pregnancma egress pospaum Spider angomas aris ng in

ch dhood ma aso esolve spoaneous Otherwise

both esions ted to pesst

MANAGEMEN

Althoug medica l ns ign f cant cerr and spider

angiomas ae fequen teaed for cosmeic purposes

Mutple effecive surgica teatment otions exstDependig on the rocedure selected he cost to he

patent ma va sgical Cer and spider

angiomas a pesen durng egnanc shoud no be

treated unt severa mohs afte delve as the ma

resolve o th ei own

Electrosurger

Eectrodessicao wth coagulaion (monoolar set

t ing 12 W followed b gele cueage wth endpoin of lesional atteing and hemosass) has bee n

the rad ioa reatme moda it for hese lesi ons

I is eecive and easil accessib e

The potenial for sca ormation m ust be considered

Laser surger: d fferent lases ave been used success

fu i treament o cerr and spde agom as

Pulsed de aser (PL) is the treamen of choice A

so size should be seected that matches diameter

of the angioma Wh sider angomas the centra

Section 6: Vascul ar Alerations 7

A

BFigure 3 () pide angioma, ight nose (B) Full esolution of spideangioma ae a single pulsed dye lase teatment to cental vessel and

suounding skin




eedng vesse as wel as he surroundg vesses

sho uld be reaed I is bes o com press he esion

wh a mcoscoe s ide o banch al l but he cenral

eedng vessel. A purpuric laser pulse shoud be

deiveed he microscoe sl de shoud be removed

o aow fo coong of he aea. Subseque, a pu

puric laser pulse can be emploed o arget heeagecasias adiatig from he eedig vessel The

purp uc eamen end poin represens coaguaonof he argeed vessels (gs. 301 ad 30.2)

The poassum-ianlhosae (KTP) 532 m laser

produces a avorabe resonse Spo size shoudmach he leson diamee. he vessels shoud be

raced ou complee or mos effectve reamen

Treame endpoi s lesional cleaace or supeicia whienng Erhema can be expeced osrea

men lasng 24 o 48 hous

Carbo d oxide lase (UraPu se 3mm col l imaed

handece 30000 mJ/puse, nonoverlappgpulses Sharpan eaherTouch 125-mm andpece140 W, 3mm scan size, nonoverlaping puses)

has been empoed as secondl ine hera wih

success. Treame edpon s esoa atenng.Poena sca fomaion mus be consdeed

Lgh hera

nese pused l igh ( P) has aso been emploedwih some success. As coagulaion s eeded or

esional esoluion, hghe fluences ma be equredo reamen ecac

Sugica excson

Excsion should be eseved fo lesons ha are ressan o oher reamens A posopeaive sca s

expeced which ma be less cosmeica peasig

han he angioma .

PTFALLS TO AVOD

Paties eed o be counseed as o the kelhood o

obvious pu rpu ra fol l owing eamen wh P DL tha ma

perss o 1 0 o 14 das, espec ial l off he ace esios

are ess ikel o be comeel eaed a subpurpuric

uences

Smple elecrocaue ma be us as effecve as PD

a a educed cos o he paie

Com essng he esion wh a glass sl ide du ring PD o

KP eamen is he lpfu l o mi i mize s s ze and a l ow

ng for greaer laser eetrao. This reduces he oa

eneg needed fo coagulaio and increases he reamen success ae.

M u p e reamens ma be requ ied , i a ic u a for

age spde angomas.

A

BFgue 3 2 () Cher angiomas on the trunk in a middle-aged female(B) The appropriate endpoint is purpura obtained after pulsed dye lasertreatment wavelength of 55 nm, -mm spot 1 5-ms pulse duration,uence of 1 Jm C 00

AFgue 33 () Cher angioma, chest



BBLOGRAPHY

Daw G G uta G Com arson of otassium ttanl hos

hate vascuar aser and frecator in e treament ovascular siders ad cherr angiomas. l pDermaol 200328(6)581-583.

Fodor , Ramo Y, Fodor A, Carmi , Pe ed IJ , U mannY. A sdebside rosecve stud o tense ulsed ght

and dYAG aser reatment or vascuar esions. Alas Sr 200656(2}164-170.


B

c

Figure 33 (Continue (B) Pulsed dye laser treatment to cher angioma

utilizng diascop (C) Purpura immedately post pulsed dye laser treatment (D) Complete resolution of cher angioma aer one pulsed dyelaser treatment




CHAPTER 3 G a nuoma Faca e

Graloma facae (GF) was first described by Wigey i

1945 wo labeled the d isease eos inop l c gra o ma "

Pin ks reamed th s d isorder gran loma fac a le n 1952.GF s a id iopat c croic ctaeos d isorder that s

a ly ivolves e face pac lar y the ose. ca presetwith a sige leso or mt iple esos

EPDEMOLOGY

idee: ncommo

Ae: 30 to 50 years

Rae: prmar ly see in Cacasas

Se males > femaes

PATHOGENESS

U kown bt may be mediated by im m ne compledeposit o

PHYSCAL EM NATON

Sige idraed acal browisred apule or paqe.Some lesions may have telagiectasa tple es ons may

be preset Etrafacia stes rarely observed. esios may

vay i size from milimeters o cetmeters (Fig. 311)

D FFERENAL DAGNOSES

Ctaneos ps erytematoss sarcodoss ymomapseudoympoma ctaneos Tce lymoma fed

d rg erupto rosacea

DERMATOPATHOLOGY

Dense oymoros iflammatoy cel fltrate i te

er words of te derms. e ifltrate s comosedof nmeros eosophis erophils ymocyes ad

istiocyes. A promient grenz zone s caraceriscalypreset ekocyocastc vascl s is frequety observed

COURSE

Te lesions of GF are usaly croic ad only occasoaly resolve sontaeosly

Fgre 3 Granuloma faciale on the scalp



MANAGEMEN

Dicl to reat wi any modaiy Any successul teat

ment often leaves scar ing

• Topica Teaet

Corticoserods topica ntralesional

acro l mus o ntme (0 1 %)

• Systec Teaet

Dasone

Ant malar a ls

Coc c e

Cofazimine

Gold n ect ions

SU RGCAL REATMENT

Cryosrgey: mt iple eports indcatig successl

c earance Resuts are n predictab le ( F g 3 2)

Sgica ecison

Dermabasio

Electrosurgery

• igh Teae

opca psorae and ltravioe A (PUVA) radatonteray

Laser e ray d ierent ase rs ave been sed in e

treatment o GF wit romsing rests eter as an

ab laive terapy wt carbo doide aser or as a seec

tive teray tagetng te prominet vasclature i GF

esions sing te Qswitced argon laser pulsed dye

dode laser and otassm ttany pospate (KP)532nm laser (F ig 31 3)

P FALLS TO AVO D

GF s oen recalcitan to eray Patents sold beconseled tat successful teatment is often elusive

BBLOGRAPHY

Am m rati C rza G reament of grau oma aciae

wit te 585nm pulsed dye laser Dema.1999; 35 (8) 903-905

Apelbeg D Dker D Maser MR Las H Spence

Denea D Granoma aciae reamen wit eargo ase Dema. 1983119(7) 573-576


A

BFgure 3 2 () utipe esions of ganuoma faciae on the face (8) Nosignificant impvement detected ae one teatment with cotheapy ona 4month foowup visit




Catrat V Rorer TE Grauoma facale successfuly

treated wt longused tunable dye aser DermalSrg. 200228(6)527529.

Eson Teament of grauloma facae wt te

pused dye laser is 200065(2)97-98

Ka ed A oes Zerma R et a l Grau loma fac ia le

algia. 200799(5)306-308.

ail lard Grogard C Toedano C a V acet Vai la Grauloma facae: Eicacy of cryosurgery

2 cases Ann Dermal Venerel 200027)77-79.

omson N Ser ing JC Sa lvay I . Grau loma fac a etreated successfully wit opical tacro mus li Dermal. 200934(3)424425

Weead RG Asley R Smit A E is WeeandN Carbo d ioide aser treatmet o granu loma fac a le

J Dermal Srg Onl 19840(9) 730-733. A

BFigure 33 (A) Indurated brwnishred laque on the le cheek of amiddleaged female with granuloma facia/e (B) Twoyear followu showing resolution of granuloma faciale after multile ulsed dye laser treat

ments



Section 6: Vascul ar Aleration s 77

CHAPTER 32 Inante emangoma

Infani le emangoma ( aso kow as srawbery

cail ay or cavernos hemangioma is a benign

endoeia rolieraon ha epreses e mos common mor in inacy. I can be classfied no serfic a l

hemagioma (S 55% o cases) dee hemangioma(D 30% o cases) ad mixed se c a l and dee

hemagioma ( M 15% o cases) . hey occur m os commony on ead ad neck areas .

EPDEMOLOGY

i % o 3% are rese at brh 0% o 12%

are rese by yea o age

Ag majoriy (80%) become aaren bewee 2 and

5 weeks o age 2 0% a re noed a birhSx emaes ae aected wo o fo mes more hanmales

ripiig faors remaure nans are more com

mon ly aeced

PHYSCA EXAMNATON

The aearance deends on th e deh of he heman

goma ad he ase o evoion S eses as brgh

redcolored aqe D resens as a so derma or sub

caeos nodule wi a bishrle coo M shows

eares o boh S and D Mu ile ruca hemangomas may be observed Involtng hemagiomas

demosrae a flatte sface with a grayishre heha begins cenra ly and exads oward. he heman

gomas migh become uceaed and emorhagc

Residu a fay issue arohy eangectasia scar omaon and hyerohy may be observed

D FFERENA DAGNOSES

Congenal hemangomas can be confsed wi a vascu

la mafomaion sch as owne san a bh.emangiomas are geneay prese aer br vesus

vasclar malormaions whch ae geeray preset abrh.

LABORATORY TESTS

• Demaopahoogy

Po iferaons o m endohea l ce s ha may exendrom he serfca l dems o he dee sbcaneous

ssue deendi ng on he hemangioma su bye

A

BFgure 32 () Le upper eyelid hemangioma in its early gwth phase

a lesion that may threaten the ch ild vision (B) Marked lightening andattening of the hemangioma aer multiple pulsed dye laser treatments





ig-opt cardac fa lre); (b) large acial emagiomas

a sally vote wit permaent dsfgring; (c) cerated emagomas; ad (d) emangomas e daper

area at are very i kely to ce rate causi g severe pai

edic a treament

Serods ncluding opica sterod applcaion (class 1

corcoseroid applied twce da y wit montorigevery 2 weeks) iralesional seroids (r iamciooneaceoide 10 mgm administered monly) ad oral

seroids (52 mg/kg/d o prednsoe) are e mainsay of treatment Patents m ust be mon tored cosey

especay wit oral serod se give te rsk o sys

emc comp ications c di ng grow reardato andgcose alterations ocaized sde effecs incde

aropy ad yeas ifeco

Oer treamet opt ons nc de topica mq imod

Section 6: Vascula r A lerat ions

(appl ied da ly) inteeron (3 mi l l on uits/m /d ASC) and v icris ine ( 005 mg/kg/d if less ta 0 kg

IV) especia y in steroid-resstant As iterfero-is associaed wi spastic diplega patiens ms be

moniored cosey

Propranool a a dose of 2 mg/kg/d as bee recently

reported o be very effecive n reating severe I s eve

in seroidresistat Is Tis treatmen s proposed torepace ora or nraveos sterods ta are associated

w signfica side eecs owever paiens on propraoo sold be cosey motored or bradycarda

ypoension a d ypogycemia especal y a e onse

of e treatment

Laser treatme

Plsed dye laser (PD treamen iduces signficanly aser regresson of te Fences ower

tan tose o PWS are effective ad are assocatedw ower r sk of laserindced scarr ig (Fgs 321

322 a d 323) P D L as bee sed eens ivey ine reame of I in tree c l in ica scenar os :

1 Uceraed emagomas respond eecively o

PD PD markedly decreases te associated

pai ad idces rapd ealg o e lcerato(75% witn 2 weeks) (Fg 324) Residal scar

ormation from te ceratio is epeced

2 Ss ca respond well o PDL f stared eier

before or eary n te proleraive paseiple reames every 4 to 6 weeks are

reqired in te proliferative pase e ony

ecepon s a rapi dy prol iferang faca e ma goma PD treamet may idce lceration of

tese varans so treatmen sould be avodedI wit deeper compones (M D respond

less effecvely to PD becase o te lmtaion

of penetraton o PDL o 12 mm n te ski n

3 PD can e p rea e res idua l erema and

telagiectasas on te srface of ivoluted

emagiomas

BFigure {A) egmental hemangioma involving the hand of a 1 yearold girl {B) Complete resolution of the hemangioma afer four treatmentswith 55nm pulsed dye laser at low fluences




Log-plsed Nd:YAG asers ae sef or potocoag

atio o DHs bt ave a ger cdece of scarrg

Oter tervetios icde srgica debkg ad

embolizaio. Te risks ad beets of eac srgcal

approach sold cosidered carely before iteetio sice te scar rom spotaeos regresso s sualy

beter ta te sgica scar Embolizatio is tiized nhemagiomas associated wt gotpt cardiac fail re

PTFALLS TO AVOD

Use of ecessve P fle ces withou ski cool g ca

ca se scar

Paes are desadaby aous abot ter ci ld's

emagioma. A fl l d iscsson o te atral course of

emagiomas is madatory prior o start ig herapy

Te opio of foregog treamet ad cl ica ly mo

tor g a patiet sold be revewed careflly pr or to

sta g reatme

Pares sod aso ave a realist ic dea of te mta

tons o erapy arge emagomas respod less sccesslly to ora srgcal ad lase terapy

Complicated emagiomas at may iterfere wi te

c ld's healt sod be referred to a appropiaepediatrc specialis Parets mst be awae ta teat

met wil provide a im provemet bt may ot eslt

l reso lt o of t e emagoma.

Paes need to be edcated o prope wod care

especial ly or lcerated emagiomas order omprove te chids quality o lfe.

ibrofaty cages ae oe a seqea of esolved

hemagiomas Sc chages ca be mproved

sig catly wt noabave ad ablat ve actona

resracig

BBLOGRAPHY

Batta K, Goodyear HM Moss C Wi l ams HC i e

Waers R Radomised cotrol led sudy o eary psed

dye laser reatme o co mp icaed ci ld ood aema gomas Results of a 1year aalysis. ae 2002

360(9332):521527.

Lat-abrze C Dmas de Ia Roqe E Hubche

Boraevi am bo B Ta·eb A. Proprao o for sevee

emangomas o iacy N g J Med 20083582649

2651

L YC McCa E Rowe NA Mar PA W lcsek GA

Mati Sccess reatmet of ifati le aemagomas o te orb it wi propraolo l . li peimepalmol 201038(6)54-559.

Moe i G a O Yo J Westo WL Treatmet ofcerated emagomas facy. A edia Ado/esMed 1994148(0) 04-05.

A

B

cFigure 32 () Ulceated hemangioma, isolated nodula type, extemelypainful and hemohaging, teated twice with pulsed dye lase 6 m,mm spot sie, 50 nm (B) At months ' followup significant healingof the ulceation ae a single teatment with pulsed dye lase (C) Foumonths ate initial pulsed dye lase teatment and months afte

second pulsed dye lase teatment, thee is complete healing of theulceation




CHAPTER 33 Keatoss ars Atrophcans

Keratoss p lar i s atrop icas ( KPA) s a grop of n erted

disorders wit tree sbtypes cludg (a) keratoss

p lar is aropcas facie (KPA) (b) atropoderma vermiclatm (AV) ad (c) keratos s o ic ar s spnlosa

decavas (KSD) KPA and AV preset many on teace wit KSD oen appearig on te eyebrow ad AV

mos commoy see o te ceeks sparig e eyebrows ad scap KSD can aect te ace scap ad

trk Iner tace patte can be atosoma domiant( KPAF AV) recessve (AV) or i ked ( KSD)

EPDEMOLOGY

id very are KPA is te most commo sbtype

Ag KPA and K SD ifacy AV c i doodSx males a re more severely aected in KSD

PAHOGENESS

Aborma fol l clar keratization of te pper secio of

te air fo l c le tat may ater eslt i aropic fol l clar

scarr ig

PHYSCAL EXAMNAON

o iclar pgging wt eyema early stages( gre 331) Atropic fo icu ar scar ormat ion wtassociated aopecia i aer stages

D FFERENAL DAGNOSS

Keratoss pi ar s keratosis p ar is rbra seborreic der

mati s (KPAF) atopic dermatt is (KFSD) oter etiologesof scarr g aopecia (KFSD) ace scar ng (AV) Rombo

syndrome (AV) and K D sydrome (KFSD)

DERMAOPAHOLOGYDilated fo l ic les wit fo l car yperkeratosis ad iam

mat ion i e ar ly sages o ic a r bros is ad atropy n

later stages

COURSE

Te corse s cron ic wit o spotaeos resolt on

Wit t me te erytemaous fo l l ic ar yperkeratot c

papu les voute into depressed atrop c fo ic l ar scarswit a lopeca

Fgue 33 Kratosis pilaris fin sandpaprlik follicular papuls onth arm of a young man




MANAGEMEN

Thee s no cometely effective teatment for KPA

t ie treatmet otions have bee t ied wth oly varab le success Patiets shold be conseled that theay

may ot be effective

Topical theapy may at best prodce modest beefit Lactc acd ad ydoy acid lot ions (0% 2% )

aled twce da ly may mrove the texra rog

ess oweve tey may rodce rtation

Ret ino ds (tazarotene ret inA) ap ed n ight y may

mpove texta rougness Tey may podce r i

tat io

Cortcosteoids a l ied sa gly ma y show mp ove

ment Rsk of facal atrohy l m its the se A Systemi c te ray

Oter otions that ave rovded vaable sccess

nc ude ora et io ids ad da psone

They are most hel for te inflammatoy stage of

KPA bt ovde minima movemet in te ol icu

a yekeratoss

They eqre caref motoring o potential side

eects

Lase theay

Plsed dye aser (595 m 7-mm sot 710 /cmDCD 40/20 pse datio o 53 ms) ca be

eective in th e teatmet o te assocated erythem a

of KPAF bt wi l not sigicaty im rove te textarogness o KPA ( ig 332A, )

Lase-assisted ai remova wit og-lsed noQ-swtched by ase may be a effective treatmentn patents wit KFSD

P FALLS O AVO D

Patet exectatos ae genealy very high hey mustbe conseed as to te conc natre o te codt ion

ad mimal esose to ava able therapes

BBLOGRAPHY

ade HP yers R Clca idngs cutaneous patology and response to te ay n 2 atets wt keatoss

p la is atroicans Ar Dra. 1994 30(4) :469

475

Chi CT erge TG Prce V Zacary C Recalcitrant

scag ol cul ar d isodes treated by ase-asssted hai remova: A prelmnary eor Dra Srg. 999;

25( ) :34-37

Clak S i s C aiga SW Treatmet o keatossp la is atophicas wit te sed tnable dye ase Ja asr r. 20002(3) 5-56

BFgure 33 2 () Kratosis piaris atphicans Patint is otionaly both

rd by prsistn t rythma (8) Markd ightning of thma yarsfoowing thr pusd dy lasr tratnts



Kane , Haas E Emme S Scn P Ztt

Successfl treatment of severe keratoss p i ars r bra wta 595- pulsed dye aser Dermaol Surg 200935

15921595

arqel ing AL Gi l am AE Prendiv le et a Keratos spi lar is rubra A common bt ud errecognized codt ion

Arch Dermaol 2006142 12 16 1 1- 161 6

Ricard G, Hart W. Keratos is o l icu ar s spnlosadecavans erapy wt sotretnoi and etretinate in te

inflammatory stage. Haur 1993448 529-534

CHAPTER 34 Pot-wne Stans

Powie stans (PWS) are owfow capi lary maforma

tons. Tey represet te most common type of vascu ar

malformatios. Any area of te body can b e affected

However te ead and neck areas are most commoyaffected

EPDEMOLOGY

Incidence 3 per 1000 newborns

Age present at brt n te majorty of patets rarely

appear i n adolescence or ad ltood

Sex no se pred ectionRace ess common As ians and Afr ca Amer cans

Associaed syndmes PWS can be a manfestaton ofseveral syndromes icudig SturgeWeber syndrome

K ippe lrenanay syndrome, Protes syndrome andpakomatosis pig mentovasc lars

PHYSCAL EXAMNATON

PWS presents at birt as l gt pk, welldemarcated

macuar esios and patces sualy n a segmental ds

tr ibto. Tey can transform wit age into ypertropc

dark red ad/or purprc paqes wt noduar ity. PWS

involves te face most commony aong te tr igemina

nerve distr bton: optalmic branc 1 (upper eyel d

and foreead) ma l la branc 2 (upper l p ceeklower eye id) and m andi bu ar branc 3

D FFERENTAL DAGNOSS

PWS ebts caracterist ic cl n cal features and s sel

dom misdiagosed It can be confsed wt te macuar

stage o emangioma at b .





DERMAOPATHOLOGY

t ip e d i ated t n-wal ed vesses n te ap l lary and

ret car dermis

ANCLLARY ESS

Te parents sod be conseed regardng te ossi

bi l ty o StrgeWeber syndome (SWS) n lesions

ocated n a facia Vl or V2 dematoma distr btionSWS is caracterized by te presence o facial PWS

wit si latera oclar and eptomeingea aomalesTen to fifeen percent of patients wit PWS n te Vldistr btion wi ave SWS Patents wit b atea PWS

ave even a ige risk of SWS An optamoogiceaminaton to le out gacoma ad cataract oma

ton wit contined ollowup s ecessay fo tesepatents A ead compted tomograpy (CT) o mag Aet c resonace magng (RI) sold be obta ned to

rue ot bran invovement tat cold aect mentadeveopment and eslt n se izres

PWS oveying te spie can be associated wit s nalanomay sc as spina dysrap sm or tetered spa

cod Neuroogc evaato and approriate imagg

stdies are recomme nded

Large etremity PWS sod raise te consdeaton of

KippeTrenaay syndrome caracterzed by capilaveos ma lormations or cap laymaticvenos mal

ormato ns w t ytrop y of te affected eremty eg

gi and legt sod be meased ad foowed overtime

COURSE

PWS grows propooaly wit te patet and gada y

tickens and darkes in colo rom pnk to dark ed to

dee ppe Eleven percent may deveop noda ty and24% may develop pyogenc granomas PWS may be

associated wit ypertopy of n deryg soft t sse a d

bone part iclar ly i SturgeWeber syndome andKippeTenaay syndrome

KEY CONSULTAVE QUESTONS

Onset of esion

Assocated cl iical fndgs

s te c d meetng deveopm eta m iestones?

Has te cd ad an eye eamiatio?

Has te c d ad a ead R I o CT?

Past teatments ad response

eedng

ebs

Growt of PWS

B

cFgure 3 (A) PW on the right inner thigh of an infant gir(B) ignificant lightening of the PW aer a single P treatment(C) Complete resolution of the PW aer P treatments



MANAGEMEN

PWS demostrates progressve vascar d latato ad

yperopy wt age s makg treatmet drigeary ifacy essetal fo a better respose Treame

ca be staed as ear y as 2 week s of age. Treatmet p ro

vdes a edctio i te um ber of vessels ad does otcom petey remove te etire lesio . ereore t e PWS

may eib t some dakeg ad ickeig ove t imedespite nteveo Genera aestesa migt be

eeded for rea g lage PWS in c i ldren .

Laser treatmet (gs 34.134.5) .

Plsed dye aser (P) remais te gold stadard for

te treamet of PWS. Effectve P parametes icde

waveegts o 585 to 600 m fle nces of 6 to 1 5 /cm,


pse dratios of 0.45 or 1.5 ms wt coge spay Acooli g ( CSC) our to tweve laser sessios wit 4to8week itevals are usaly eqired i order to acieve

sgifca t bla ci g o te PWS. Lowe fleces are ii-

taly utlized for PWS of te face ad i darker ski

types. e se o s cocomitatly dig PL teat-

met sgificay decreases te pai associated wi eprocedure ad e cidece of bl serg s protects

te epiderms ad a ows for delivery of iger fleces

result g more eective bacig of e PWS. P

treatmet s fo lowed by temporay p rp ra tat usa ly

resolves n 7 to 14 days. Complete lgteig of PWS wtP treatmet is acieved i ess ta 20% of PWS.

Resistace to PL teatmet s more feqetly

encotered deeper ad yperropic PWS. elplmaeuvers to potetiate e efficacy o P incde

i ceasg t e flue ces wt ad equate cryoge cool g toprotec te epidermis ad creasig te waveegt p

to 600 m to arget deepe vessels. A pilo stdy demon

staed tat PWS ta are treated wt topcal imiimonce daiy fo 1 mot afer PL eposre maiest

speror bacig respose over t ime as compared toP aloe . Aoter report i vestgated te com bined se

of P ad a topica agiogeesis bor raamyisg te vvo odet widow camber model. ere

was o reformatio a nd reperfsio o blood vessels aer

treatment wt PL folowed by topcal rapamycn for14 days cotras o P alo ne Wt ereme cauio

to avod scarr g ad dyspigmetao t s possbe otreat PL-resstat PWS ad deeper or ypeopc

ad l P WS sccess y wi l oger wavelegt lasers tat

a low deeper peetatio io te ski suc as og-psed aleadrie (755 m) laser ong-pulsed NdYAG

( 1 064 m) aser ad dua l 595-m P ad 1 064-mNd YAG ase coped wit adeqate coo i g Use o te

NdYAG aser can be reacerous as tere is a arrow

terapeutc rage Ri sk of scar ca be sgifcat.

Lgt treatmet i tese p sed l igt ( I P) may be effec

tive reatmet of PWS incdig PL-resisat PWS.

A gree-yeow wavebad ad lowest ava lable pse

BFigure (A) tensive ort-wine stain on the right face and foreheadof an infant male (8) ignificant resolution aer m ultile treatmentswith ulsed dye laser




drato shold be sed wi skin cooling A recet

randomized c l i ica tr a compar ng PL and IPL s deby side reveaed a better efcacy ad hgher paet

preferece afer PL treatmet Potodyamc herapy

may aso prove to be a alterative eficacios reat

ment or PWS

Other treatment modaties for PWS that can be efectve icl de tattooing and cosmetic make p

PTFALLS TO AVOD

Patients sold be coseled that PWS dsplay a vari

abe respose o treatmet More extesive and thcker

esons respod ess well wen com pared to sperfic a l

esons acia PWS respods best PW S treamet effi- Acacy decreases as oe d esceds from face to fee wth

the ower etremiies dispayg he eas treatment

beefit

Mt ipe treatmet sessions may be reqired ruisings a necessary sde efect o obta n eicac ous t erapy

Laser treatment may prodce footprntig" or oy par

t a mprovemet

reamets sould be ceased when the paient is sais

ed with ghteng or we no ther benefit has

been noted tha is afer two sbseqent treatmets

BBLOGRAPHY

Alster S anzi E Combied 595-m and 064-nm

laser irradiatio of recactrant and ypertropic portwine sa ns ch i ldre ad adts Deral Srg.2009;35(5) 813815.

Chang CJ s iao YC Mi m M C r N elso JS P i ot stdyexam n i g the combi ned se o plsed dye laser ad op-

ical lmqimod verss laser alone for treatmet o po

wine stai brhmarks asers Srg Me. 200840(9)

60560.

Chapas AM Eickhors K Geroems RG Efcacy of

eary treatment of facal po wne stas i newbors A

revew o 49 cases asers Srg Me 200739(7) 563568.

Ch C Ca o WS Yeg CK Ne lso SProspective sudy of p sed dye aser i conj ction withcryogen spray coolg for treatment o pot wne stas in

Chese patients Deral Srg 2003;29(9) 90995.

Discsso 95.

arscho A ogsverd-o K Zachariae C Haedersdal

M P sed dye aser vs iense pulsed l igt for port-wine

stais: A randomized sidebysde tr ia l wt bl indedrespose evalatio r Deral. 200960(2) 359

BFigure 33 () tensive portwine stain on the right neck of a young

feale (B) Marked resolution of the port-ine stain aer ultiple treat-ents with pulsed dye laser

�. Figure 3 () Portine stain on the lower ucosal and cutaneous lip



Ho WS, Yng SY Can PC, Ca HH. Treament of port

wine stans wt ntense psed g A prospective sudy.

Derma Srg. .

Hkesoven , Koser P, de oge CA eek F, van

Geert van der Horst C Redarkenig o port-winestans years after lseddyea ser treame N g J

e.L Kono T Goff WF Can H, Kazawa Y, ozak Com parison sdy o a ong-p lse p sed dye aser and a

longpse psed aleadrte laser n te reatmet oport wine sains. J sme ser Ter. .

Png TL , Ob e DA a W, enamin E im C r Neso S Can te wond heang response o uman

sk in e mod aed aer laser treament and t e eecs oeposre eended? I mp icaons on e combi ned use o

te psed dye laser and a opcal agogenesis nhibior

or teament o po wne stain tmarks asers Srg

e. Se m , Ke ly K e son S, Wendelscaer-Crabb G

Kennedy WR, Zeckson D. Cooca microscoy sdy

of nerves and bood vesses n reated and treaed

portwne sains Prelmna obseatos. Derma Srg.

Yang , Yarosavsky A Farie i et al Longpsed

neodymim Yttr iuma mnumgane laser treamentor portwne stains J Am Aca Derma. .

Section 6: Vascular Alerations 87

BFigue 3 (Continue (B) igniicant ightening o powine stain aer

three treatments with a combination o pused dye aser to the cutaneous ipand vermiion and ongpuse 1 064nm Nd YAG aser to the innermucosa/ ip and vermiion

Figure 3 Hypopigmentation, which can be permanent, aer aressive treatment o a PWS in an AricanAmerican patient




CHAPTER 3 5 yogenc Granuoma

Pyogenic gra loma ( PG) can be regaded a s a begn

vasc a tmo r or as a eact ve vascula pocess ar is g

at stes of pevos trama or r itat on. PG is aso kowas ob a r cap i l la y hemang oma gan oma te lag

iectat cum and gra lom a grav dam when present ing

on te gingiva of pregnant wome. t commonly occrs

in areas of trau ma inc ld ing the ace and iges

EPDEMOLOGY

iee: common

Ae: most common ch i de and yong ad ts

Preiii ars m o tama p regnancy lase treat

met o otwne stai ns sotretn on

PAHOGENESS

Reactve neovascuarizatio sggested by commo asso

cato wit peexistig trama or i itat on and mted

growth caacty.

PHYSCAL EXAMNAON

Red to voaceos domesaped f able pale o

node 0.5 to 15 m i sze wth smoot sace tatfreqent ly u lceates (F igs . 35 352 ad 35.3 )

DFFERENAL DAGNOSES

Nodua amelaot c melanoma g loms tmo eman

goma sqamos ce l carc inoma (SCC) (F ig 354)nodar basa cel cacinoma wart bac lary angiomato

ss aposi's sarcoma and metastatc cacer

DERMAOPAHOLOGY

Wellci cumscibed exophytc lo bl a prol eato of cap

i l ar es wit flatteed and sometmes eroded oveyigepidermis with per iphea l epiderma co l larettes ."

COURSE

PG sualy grows rapdy over te cose o weeks or

monts ad the stab l zes It b eeds freqety wit

mi nor tra ma and ca persist nd efntely i not treated.

Fgre 3 Classic hemorrhaic pyoenic ran uloma

Fige 3 2 Pyoenic ranu loma on the palm of a prenant womanleein frequently



MANAGEMEN

Laser treatmet

Pulsed dye aser (58600 m 04 5 s 70 m

5 /cm, C 20/20 wt or wtou diascopy) isa safe ad efecive device for te treatmen of small

esos ad for pedatrc patens Sera reatets aresally requred Treatme s wel tolerated wtot

anestesia A recet repor sggested save ecson

oowed by immediate pulse dye laser (PL for largeresos P as been a lso repoted to be effective i

ggva PG NdYAG laser ca also eectve

Carbo doide s efectve esioal faeing s e

c i ca l edpont tra es ioa l l idoca ne % is eces

sary pror o reatme Postoperave care requrestwce da ly cleasig wit soap ad water and appli

catio o atbi oic ointmet over a 2 to 6 weeks ealig t ime Scar ormaton s l kely A ow recurrece

rate is noted

Surgica reame: all reatmes may res i scar for

ma io

Save ecison fo owed by eectrodessicato of te

base is te procedre most commony empoyedRecrrence s commo ( igs 35 5 ad 356)

El ipt ical ecso ca be performed wt low recur

rence bt wil leave a scar

Lgatio of te base

Cryosrge

Aterave reame optos n c ude

lmiqumod 5% cream as bee recety repoted tobe efective i edatric patets ad i paties wt

recrret PG

lntralesoal injecto of absote etao

Scleroterapy wt mooeaolam e ol eate

Topica a tretoi (9 retno c cid ) gel a drug at

is sed for te treatment of Kaos 's sarc oma

P FALLS O AVO D

Paets sould be aware at recrrece s commo

ater reatme

Paets sold be iformed tat al l reamets may

resu scarr g

Amelaoc meanoma as well as SCC ad oter sk ca

cers ca mimic PG A bopsy soud be performed forany sspic ous esos i te app roprae cln ical seig

BBLOGRAPHY

Borggon R, Paqet P P rardracimot C,Pirard GE reamet of pyogeic graulomas wt e

NdYAG laser J Draolog ra. 20067(4)247249


Figure 3 3 Pyogenic granuloa overlying a deral nevus

Figure 3 Pyogenic granuloa iicking a squaous cell carcinoaon the le lower ucosa/ lip of a patient with ultiple non elanoaskin cancers




al a iscer G Zagare a S Pyogenc gran oma n

c i dren: Treatment wt to ica imiqmod Asralas Jrmaol 200748(4)27220

Kand S, Sama VK Sccessf treament of mlt i

e gingiva yogenc granomas wi lsed-dye aser

ia J rmaol rl / 200874(3)275277

aloney Scmdt vic Al ite ino n ge l totreat yogenc granoma J Am Aca rmaol. 200247(6):969-970

atsmoto Nakanis i Se ke T Ko zm Y Mi hara K

Kbo Y Treatment o yogenc granloma wt a sclerosing aget rmaol Sr 20027(6) 521523

Ra in C Greve ammes S Te combined continoswave( sed ca rbon d oide laser for treatmet o yo

genic gran oma Arc rmaol. 2002;138() :3337

Sd AR Tan ST Pyogenc granloma comcatingsed-dye aser teray for cerry angoma J las

Rcosr As Sr 201063(8)364368

A

BFgu 3 (A) having a hemorrhagic and ainful yogenic granulomaon the lantar foot with # 1 5 blade he secimen was sent for histological

confirmation (B) Electdessication of the residual yogenic granuloma




A

BFigue 3 (A) Biopsyprven pyogenic granuloma on the right chin of ayoung female (8) have excision of pyogenic granuloma with ermaBlade Personna edical, Verona, VA




CHAPTER 36 Faca Te a ngectasas

acia telangiectasias are d lated vesses appearing

sperf c a y n te derms most ly o te a lae as i

Teangectasias are aso common scars and variosskin les ions

EP E M OLOGY

iee: very commo

Ae most common n adts ad elderly peope

Sex re no se or race predsposit ion

Precipiat ng factors cronic actinic damage rosacea,

and topcal steroid se are te most commo precipitat

ing factors Oter ess common etooges ic d e ered

tary emorragic telengiectasa, Cockayne syndrome, Aataia telegiecasa, loom's syndrome, Rotmnd

Tomson sydrome scleroderma, CREST syndrome,l ps, and rad aton dermat tis

PHYSCAL EXAMNATON

Tea ngiectasas consis of fin e, t i ny erytematos l i ear

vessels typca l ly 02 o 2 mm in d iameter cors ing

a ong te sace of te skin , wic b anc eas i ly ponpressre

DERMAOPATHOLOGY

Dilated, ti-wa ed vessels in e pper dermis

COURSE

acia telangiectasias are sua y cronic n atre wit

no sponaneos resoluion

MANAGEMENT

acia telangiectasas are reqenly treated for cosmetic

pr poses. t ipl e eective treament optons eist

Laser treatmet: mlt pe eective options are availabe Patients ms be aware tat over t ime tey are

kely to deveop more tela ngiectasas

Plsed dye asers (PD are te treament o coceor facia telangectasias ( igs 36 136 . 5) .

Te radtioal PD wit a sort plse dration o

0.45 or .5 ms provides te mos eecive treametor facial eangiecasias owever posttreatmet

pr pra occ rs wc generaly asts 7 o 4 days

B

cFigure 3 () Middleged mle wih muliple fil elngiesis(B) Purpur observed immediely er pu lsed dye lser remen(C) ignifin reduion in elngiesis er singlepulsed dyelser remen



Newer geeratio 595-nm PD (ie V-beam or

V-beam Pefecta asers Candea Corp, Wayad,A w va iab e p lse d a ions (045 5, 3, 6

0, 20, 30, 40 ms can provde a redced prpratreatmen of facal telangiectasas wen onger

pse duraions are ti zed, bt is somewa ess

effecve ad sa y requ ires m l pl e reamens Commoly, spurpurc feces o ess tan 0

/cm at pse dra on of 0 ms w a 7-mm

spo size ae ti l zed

Beer eicacy of e variable pse PD n tea

ing faca teangecasias can be aceved by ti

iz ing p urp rc fluences or y pse stack ng wisbpurpuric plses (stacked 2 sbppric


plses at a 5Hz repett on rae, 75 /cm, A0ms pse dratio 0mm spot size DCD of

30/20 or by peormng mlt pe passes dring

te same sessio

Large cke inear vesses ca be treaed wte ewest generaon 595-m ong-PL (V-beamPefecta Candea Corp, Wayland A sng a

3 x 0 mm eiptical spot size 40ms pse dra

t ion , 5 to 7 /cm, and DCD 30 to 40/20 Teendpoi is transient blis darkening of te

vessel followed by vessel blancig (Figs 364

and 365 is treatment may res in m ld

prpra in arond 23% of paiens

Facia edema, eryema, and dscomot ca occurae exensive teament wi e p rp ra-ree vari

able-pse PDL oweve, tese ndesed eects

are generally better tolerated wen compared o aprpra-ndcng laser teamet

Te varable pse wd ,064nm Nd:YAG laser as

proven o be eecive in e reament of acalteagectasias Sorer pulse wids wit iger fl

ences mig be necessary for eective reament ofsmale vesses bt ave an increased sk o bster

and scar formatio Te seqenal delivery of 595-

and ,064-nm wavelengt as been repoed to bemore effectve a a sg le waveeng treament

Freqecydoubed 532nm NdYAG laser asocalled potassimtanyl-pospate (KP aser pro

vdes effective absorption of emoglobin wit a psedratio of 1 to 50 ms makng i idealy sied to treas perfic a l vesses wiot pr pra fomaion acn g

of id vda l vesses is a sefl eci qe for paientswt a counabl e n m ber of discree, vis i ble vessels

Flas amp ( i nense plsed g [ IP L eatmen

IPL povides aoe effective, purpura-free meod

or redcg acial eangiecasias and erytema

( Fig 36 6 For examp le, f leces of 30 o 40 /cm

w 20-ms pse dratio ae effective wi e StarlxLx G adpece (Paomar edical Tecnologies

B

cFgure 3 2 () Telangiectasias prior to pulsed dye laser treatment Thesetting was 1 0-mm spot 55 nm J!m 6-ms pulse duration

(B) Immediately posttreatment (C) Ten days afer pulsed dye lasertreatment




Blgo, A T tratmt dpoit is immdia

vss caac or sctiv vssl dark g ltip tams may b rqrd for t grast tatm

bit

Otr tratmt optios icd ctrosrgy,

cryohrapy, ad lrato of scrosg agts Ts

ar ss slctiv of ss fctv, a d mor i ky orst scarr g tha lasr or P L tratm

PTFALLS TO AVOD

Tatmt ypcaly is wl oad

Obvios postatmt ppa or 7 to 4 days wit

prprc sgs is pctd

Prpra ca b avoidd by i z g oprpric st

tgs a t ps o dcrasd ficacy

Facia dm a rytma, a d d scomort ca occr ar

tsiv tatmt wit t p r p afr vaiabl p lsP

Ta gctasias wi l cr ov yars

Catio i dakr ski typs

BBLOGRAPHY

Brst EF, igma A Rosaca tamt sig tw-gatio, hig-rgy, 595 m, log pls-dra

to pusd-dy asr asers Srg Me. 200840(4)233-

239.

A

rgs GF, Hdd Hadrsda ogpsd

Bdy lasr vrsus ts psd ligt or potodamagd

ski A radomizd spli-fac tr ia l wt bl idd rsposvaatio asers Srg Me. 200840(5)293-299.

Karsai S Roos S, Ral C Tratmt o facia lagic

tasia sig a dalwavlgt asr sysm (595 ad

064 m): A adomzd coro d r ia wit b l idd

rspos vaato Dermal Srg 200834(5) 702708.

Rohrr TE, Catrath V Iygar V. Dos ps sackig

impov t rss o tatmt with variablplspsddy asrs? Dermal Sr 200430(2 pt ) 63

67. Discsso 676

Ross EV, U bor N S Doma kvtz Y Us of a ov

ps dy lasr for apid sig-pass prpa- trat-

mt o tlagictass Dermal Srg. 2007 33( 2 )466469.

Sarradt D Hussa Goldbrg D l iscod

064nm odymimYAG lasr tatmt of facal

tagictass Dermal Srg. 200329( ) 5658.

cFigue (A) Female with centfacial telangiectasias an erythemaprior to pulse ye laser therap (B) Pulse ye laser treatme nt at awavelength of 55 nm, 1 -ms pulse uration Jm, -mm spot size

(C) Apppriate clinical enpoint of ethema an slight eema at sites oftreatment No purpura was prouce




A

B

cFigure Telangiectasias prior to long pulseduration pulsed dye lasertreatment The settings were 40ms pulse duration, mm spot, 55 nm,1!m (B) Note the transient vasoconstriction with almost completedisappearance of the telangiectasias immediately posttreatment(C) light decrease in diameter of the telangiectasias 1 month aer onetreatment




A

BFigue (A) Large caliber nasal telangiectasias on the nose prior tolong-pulse duration pulsed dye laser treatment (B) ecrease in the diameter of the telangiectasias aer six treatments ith PL using long pulse

duration of 40 ms mm spot sie, and uences up to 1 1 5 Jm



Section 6: Vascul ar Aleration s

cFigure (Continued) {) Marked resolution of the telangiectasias aeran additional four PL treatments utilizing short pulse duration of 1 5ms, mm spot size and 1 Jm

Fgue 3 Intense pulsed treatment with tarlux Palomar Inc ,

urlington MA of facial telangiectasias he handpiece is in full contactwith the skin




CHAPTER 3 7 ower Extremty Teangectasas, Retcuar andVarcose Vens

Lower eemy eagecasias recula and varicose

veins deveop as a resu l of venos sysem mpai rmen

EPDEMOLOGY

Iiee: very common ad he icdece icreases

wh age Reicar vens can occr i p o 0% of chil

dren 10 o 1 2 years od Te i ncd ence of varicose veins

in e seve decade is 72% n women ad 43% i men

Age more common i n adu s and e der ly

Sex more common in wome

reiiig ars: amil a l predispos io regnancy

sac graviaional ressures, dyamc msclar forceshormonal i lences

PAHOPHYSOLOGY

Veos paology develops when venos reurn sim ared for ay easo

I ca develop rom venous obscion (hromboc or

nonomboic) o r from venos valvu a in compeence

PHYSCAL EXAMNATON

Lower eremiy elagiecasias are red o violaceos nco lor and p to 2 m m in d iameer R e cu lar ve ins arebe o buegreen color and up o 4 mm in diameter

Varicose ves are blue o ble-green n coor wt ad ameer greaer an 3 o 4 mm

LABORATORY DATA

• Dematopathoogy

Dilaed vascuar cannes in e dermis

• Vasc l a Stu esDopper lrasond and/or duple scannig are idcaedin e fol owing c in cal scearios

Asympomac varicosy greaer an 4 mm in diameer

Sympomaic ves

Reicua perforang and/or varicose veis

Sg ns of venous isffc ency or sasis c anges

Prior sory of deep ven r ombosis or hrombop eb s

Prio hisory of scleroeray wih recurences o badocome

A

BFigure 37 () clertherapy of spider veins The needle is bent at a45degree angle and the vessel is canalized (B) Immediate vesselblanch ing seen aer injecting the sclerosant agent



MANAGEMEN

Sce otheapy (F gs 3 7 3 7 3 )

Sc erotherapy i s the reatme of c oice for ower egtelagiectasas ad retcu ar veins It sould be repeated

at 6 to 8 week ntervas Paiets may reqre two to s

scleroterapy sessions o acheve the geatest teatmetbeeft

Scl eosng agentsAn ideal sclerosg agen causes complete loca edotela desruction of he vesse wall wit secondary fboss

and men oblterato wit no systemc toicity

Sce rosi g agets are cassfied nto tree go ps depedig on te r mecasm of act o of id c ig endothel ia l

ijry These cde hypeosmotc agets, deegents,and cemical rr itants (Tables 37 ad 372) The most

com mo y used scerosant agets n the U ied States ae

hypertoic sa ine (S) ad sodim tetradecy sfate

(STS) Bot S ad STS are FDA approved and have owest c idence of a ergeic ity Sod m morhuate and pol

docaol a re also FDA ap proved

Scleotheapy technique fo teangectasas andetcu la ei ns

Fil l the sclerosant aget nto 3 cm disposable syri ges

wth d isposabe 30gage half i c eedles

Swab te ste to be teated with a coo to beer vis al

ize te vesses

Trea larger vessels first

Bed the neede at a 30degree angle to 45degree

ag e

Stetc te sk in overying the vessels be g reated

Isert the eedle sowly i the vesse wa Yo may se

the air bo s echni que by jectig ess ta 05 cm ofa in te vessel or the pctrefi l echnque re yig o

the feel assocated wth vessel wa peforato wheinectig Te em pty vei teci q e performed by ee

vaig the eg and gely kneadg the ven prior to

inectio a lows for thombus reductio and eed forsma le sc leosant vo mes Whe treat g et ic ar ad

varicose ves, asprate a smal am o of blood to con

f irm itravascular loca ion

ject the sclerosat very sowly to ensre sucet

contact of the scerosa wi e vessel e dothelia l wa l

ad to prevet disento ad rpure ec less tan

0 5 c m per i jeco at 3cm i ervals

Appy smal c irclar bad aids taped cotton balls orro ls a the injecto sites for com presson

Foam sc leotheapyA reatmet mod ifcato can be made o arger vesselsby vigorosly foam ng a a r-scerosat soto j st pr or

to injecton to ndce a soltion at displaces bood ad

remas fo an etended t m e te arget vessel witot


A

B

igure 372 (A) pider veins, prir t treatment with sclertherap(B) arked reslutin f the spider veins aer sclertherapy treatment




being fl sed Teoretical ly, ower scerosant concentra

tions can be sed with a ower cidence o pigmentatioad mattg (Tables 372 ad 373) Te oamig deter

gent o eiter sotradecol or polidocanol is prepared by

ming e deergen wt ar (sa y 1:4 m ratio of

deterget o ar) i a b ack and fort moton us ing a tree

way sop ock t l a foamed emsion s creaed Thefoam sclerosant s injected in a manner similar to tat

wth oer sceroerapy tech q es

Postopeatve cae

Compresso ncreases te ecacy of sceroterapyand decreases te ncidence of yperpigmetation AElastc co m pression stocki gs ( 1560 mm g) arehigy recommeded immediaely folowing sceroter

apy and p to 2 to 3 weeks aer te procedre, espe-

cia ly posreatmet o arger ca iber vessels Fasio

hose ( 8 m m Hg) ad C ass I ose (2030 mm g)

are the mos commoy sed gradaed compresso

hose sed possclerotherapy o telagectasas andret cu lar veins

Encorage wak ng to avoid tromb oembo c d seases

Avod sn eposure to minimze posttreatmet yper

pigmentation

Comp licatons (Tabe 37 .3) B Postscleroterapy hyperpgmentatio (PSH): Te ici

dece of PS can be p to 30% dependig o te

tec q e sed t e sze of the treaed vesses, the type

of sclerosing agent and e sotion concentrationPosscerotherapy compressio decreases e inc

dece of PS . PS s cased by perivascular deposit on of emosider i rater than me a ad fol lows the

Figure 37.3 (A) Lowe leg telangiectasias a t asel ine (B) Maked esolution of the telangiectasias 1 m onth afte one scleotheapy teatment Note the development of slight telangiectatic matting supeio to the

teated aea

TLE 3 7. 1 • Scerosing Agents

Sclerosat class

Hype rosmotc agets

Detergens

Chemcal irr itants

Sc erosant types

Hypeonc sa ie ( 130%)Hypeonc sa ie (10%) detrose (25%) (Sclerode)

Sodi m tetradecy sfate (Soradeco, Trom boinject)

Pold ocano (Aethoysclero Aetosce rol, S ceroven)

Sodim morrae (Scleromate)

Ethanolamie oeatePoly iod de od ide (Var ig loban , Var g lob n Sc erod e)

Gycer i ( 72%) wi 8% chromum potass m a um ( Chrome)

TLE 37.2 • Recommended Scerosant Concentration

Sclerosant/recommededconcetratio eagectasas Ret icu ar ve s Varicose veins

Hypertonic sane 7234% 234% Not commoy sed

Sodi m tetradecy s fae 0 5% 035% 025% foam 053% 0 51% oam

ecaism

Dehydrato

S rface tenson ca nge

Corrosves

Dose mtation

60 m of 830%

sotion0 m of 3% so t on



LE 3 7.3 • Compications o Sclerotherapy

Scerosa Aergeniciy Cram ng

Hyeonc sa l ie

Sodi um eradecyl s lfae + Anahyais

(rare < 001 %)

+

corse of e eaed site he igmenaon usaly

resoves 6 o 2 mons. I ca improve w the se

of inense u lsed ig ( P

Telangecta c maing (M ) The nc idence of M ca

be o 6% t cosiss of a nework of blsh ke fine

(<0.2 mm elangecaic vessels surroudng a revi

osy reaed area occrrng wihin days o monts

after scleroerapy They usaly resove wihin 3 o

2 monhs Pedisosg facors incde pregnacy

obesity hormoa eray and family story o elang

iecasas ca mrove w psed dye aser or PWays to avoid hs com p icao ncl ude

Lower njecon pressre

Lower sclerosa volume ( to 10 m er ijecion

se)

Lower scerosan concerato

L im ing b lachg ( o 2 m)

Skin ecrosis and ceraio: Necrosis ca occr sec

ondary o eravasaion of te sclerosing age no the

isse regardless of he eciqe used or e sce

rosa ype o miimize etravasaion the sgeon

soul d so he injecon wen econteri g Even sg resstance o necio

Beb formaon

Increased ai reorted by e patien

eravasaion is recogzed immediatey e srgeon

ca i njec ormal sal ne at e sie or aply 2% itrogycerin ase

Oer comp ca os nc lude pa i and cramig (com

mo) a l ergic react ons (rare) sef c a l hrombohleb is (u o %) and thromboembo ic reac ios

(very rare)

Lase a tese Pu se L ghtThea ies ( gs 3 7 . 4 a d 37 .5

Lasers ad IP L soces ca occasioally be sccessf i

th e reatment of lower eremiy telag ectasas a d reclar ves eseca ly wen coped wh longer plse

draio and cooling devices ey are considered sec

od -i ne reamen after sceroerapy Waveegs in erange of 500 o 100 nm are mos effecive wi sorer

wavelengs eg plsed dye ase (Pl otassm ianyl

osate (KTP) beig used for red sercial bood

Pa

A

+

+

yerpgmeato

+

+


Teagiectatic mang

+

+

Skn necrosis

+

+

Fgure 37.4 (A) Marked erythema immediately aer pulsed dye lasertreatment to lower extremity spider veins




vessels ad longer wavelengts (eg 755-m Aeadrte

laser wi arod 60 ms pse drao 1064 NdYAGlaser) or buis deepe bood vessels ndcatons or

laser/I PL reames inc d e e fol lowig

Needle p obic paties

Vesses ressant o sc eroerapy

Vesses located beow e ankle

M

Propesty or PS or T M

• Abulaoy Ph lebecoy,Endovascu la echn ques , Sug ica lL ga io/S pp ng

M l pe treatmet optios eist for varicose vens ic d

ing am bulaor p lebecomy e ndovascular laser abaio

endovasca r radiofreqency ob ierato as wel as sgi

cal l gato and spping procedres. Amblato plebectomy ca be sed or arge varicoses. Edoveosocclso can be acieved wt radioreqency (RF or

laser sorces. Eter a laser fiber or a RF caeer is

in seted no te sapen os vei a or st beow te kneeLaser systems clde 810nm dode 940-m diode

980m diode and 1320nm dYAG asers esedevices spare te eed or genera aesesia ad

etended recovery t me associated wi vei strip pi g and

igation ere is ittle dowme wi patets esmignorm a acivites o te same day of te poced re

BBLOGRAPHY

Barre M A e B Ockeford A Goldma P.

icrofoam rasoud-gded sceroteapy o varicoseveis i 100 legs Demal Sr 200430(1) 6-12

Coerdge Smi P Scleoerapy and foam scleroterapy

for varicose ves lel 200924(6)260269.

Kae B Leg K. Eficacy of sceroteapy varicose

veisprospectve binded pacebocontoled sdy.Demal S 200430(5)723-728.

Ker P Ra meet AA Wtscet R ayoz D Comp resson

ae sceroterapy for telangiectasas ad reclar leg

veins A randomzed controled stdy Vas Srg2007;45(6) 1 212-121 6

Morrison Neuard D Foam sceoterapy Cardacand cerebral motorig lel 200924(6)252259

Ross EV Meea K Gi lbe S Doma kevitz Y. Opma l

pse duraons for te reatmen of eg eangecasiasw a aleadrite aser. ases Sr Med 200941(2)

104-109.

BFigure 37.4 (Continue (B) Mld educton n spder vens aer a snlepulsed dye laser teatment

Figure 375 ostnflammato changes afer laser le ven treatment



CHAPTER 38 Venos akes

Veos la kes are begn vasc ar l esons a res rom

di laed ven les ey commo y aec e ps face and

ears

EPDEMOLOGY

iee common

Age mos commo ly observed i e el derly

reiiaig ars may be relaed o su eposre

PHYSCAL EM NATON

Ves ake rese as dark b ue o v o aceous e e

vaed so ad easiy compressible ale r le

D FFERENTAL DAGNOSES

Pyogenc graloma meaoma laial melai male aial es emagioma

DERMATOPATHOLOGY

Di aed h i-wa led vees n e superf c a dermis rombosis may be observed

EP LUM N ESCENCE M CROSCOPY

Ep mescence microscopy (EL) reveas eryema

os globes w o pigmeary etwork s elpful dierenia ig s vascar esion rom a melaocyic

leso

COURSE

ey sa ly perss for years and c a bleed aer ra ma

MANAGEMEN

Veos lakes are freqeny reaed or cosmec pur

poses ip e reame opions eis

Lgh reamen

Lasers (gs 38 38 3)

P sed dye aser (8 9 m 04 . ms 0

mm spo 70 J/cm DCD 3040/20 w ad

wiho diascopy) lse ye laser ies i

sise eei r es akes.

Section 6: Vascu la r Alerations 203

A

Bigure 3.1 (A) Venous like on the lower li of an elerly man(B) Marke resolution of the venous ake aer multile treatment sessions with the ulse ye laser




Diode laser (80010 nm 30 ms 3050 /cm)

can aso be a ve eecve teatment t is elpto a low 3 secods of compresso of e es ion wit

te c l p pror to te laser pse. A pysicakickback" s ofe el by te ase surgeon a te

t me o te pu sa ion Te c l ca edpont is

immediate prpra .Long-plsed NdYAG aser and intense psed ig

(IP ave aso been repoed to be eectve.

Scleroterapy I one stdy ntralesional i njectios wit% poidocao ave been sow to be effective i

clearng two veos lakes after two sessons o sce

roteapy sa was noted to occu r i one pate

Eectrosurge srgcal ecision cryoterapy are oter

alteate eatmen opons owever tese modalites

can rest in a scar

PTFALLS

Ote req i res severa reatmes w aser

Al teapetic mod alit ies may prodce a sca.

BBLOGRAPHY

Beko PS Long-psed dYAG aser teatment ofvenos akes Repot o a series of 34 cases DeaolSg. 200632(9) 151-54

ay Borek C Treamet of a venos ake agioma wintense plsed igt. ae 199835(9096) 2

K o W Yang C Veous l ake o t e i p reated wi a

sclerosig agent Report o wo cases Deaol Sg.2003;29(4)425-428

Wal l T Grass i A Avram . Cleaance o ml ip e

venos lakes wit an 800-nm dode aser A ovelappoac Deaol Sg. 200733( ) 00-03

A

BFgue 32 (A) Venous lake on the uppe lip (B) Five-onth follow-up

deonstating coplete esolution of the venous lake ae a single teatent with an 00-n diode lase 0-s pulse duation at enegy settings of 45 J! one pulse and 50 J! one pulse




�_

o o o p

opo p l d

Fgure 3.3 Clinical efficacy of pulsed dye laser for a venous lake withcompression of the vessels during treatment versus no compression

Dioe

n '

P Isd dye asr • •

n m) :

Las pnetaon uls dy vs d oe

Figure 3.4 Pulsed dye laser does not penetrate deep enoughCompression is needed iode laser penetrates deeper and therefore ismore eective than PL




CHAPTER 39 Warts

Vral warts are cased by h ma pa p lo mavrses (H PV)

Varios types o H PV- dced warts eist ic udi g com

mo warts (70% of a wars), palmopatar warts paewarts, ad geta warts

EPDEMOLOGY

ee commo

Ae ch l dre ad adu lts

re r sk trama, immosuppress io

(IV ad rasplat pates), geetc predisposit io

(ep demodysplasa verrcfom is)

PAHOGENESS

H PVs are oeveoped do be-straded DN A vrses Athat prodce ectio a d d co of yperprolieratio

we the v ir s eters pro iferat ig basa l epe ia ce s

Avoidace o host imme sel lace occrs Eactmecasms o ifecto, latecy ad reacivato of

HPV are ukow

PHYSCAL EXAMNAON

Wars peset as sgle or ml ipe hyperkeratoic eo

phytic sk-colored paples odes or paqes eyca have ger-lke proectios (filiform warts) o ca beflat-topped (p la e warts) la ck p ctate dots represet

ig thrombosed caplaries are observed reqetly ey

mos commo y preset o figers, do rsal ads platarsraces ad pressre areas

DFFERENAL DAGNOSES

Hypertropic actic keraoss, seborreic keaosis,sqamos ce l l carc ioma verrcos carc oma ad

acal amelaotic melaoma Platar wats ca aso be

mistake fo cos or ca l ses

DERMAOPAHOLOGY

he epd erms feaures yperkeratosis, aca tosis pap l

lomatoss, wth tiers of parakeratoss, valeys o yper

gralosis ad ko ocytosis Te dermis eatres di latedcapil ary loops ad emorrage

BFgure 39.1 (A) Verruca vulars on the le thumb mmedately

posttreatment wth pulsed dye lase 50-nm wavelenth, -mm spotsze, 1 0 J!m, wth pulse stackn (B) Fve-month follow-up wth complete resoluton of the wart afer snle pulsed dye laser treatment






Plsed dye aser (P D ( F igs . 39 394)

PDL s te mos commonly e mpl oyed aser for was.t may idce a terapetc response by vascula

absorption of lase l igt podcng terma ecross

of wart tisse as wel as by ndcon of a ostmmne respose. Cl i ica improveme is va iab e .

PDL is generaly t ized aer a ure of first l ineterapes.

PDL potoco

Protective laser masks gloves and gowns as we

as us e of a sm oke evacaor are recomme ded oavod rasmisson of e wart virs.

Te yperkeatotic poon of te wart sold be

pared pri or to treatmet eedi g is to be avoided a s

ts w l m m ize laser g absorpton b y te wa.

Hig ences (58595 nm 0451.5 ms plsedrat on 15 J/cm) are ypicay reqred or

eectve teatment. ltple pulses are mos effec

tve bt sold be performed wt cauon.Diascopy wt pses sod be consdered. Teat

to 2 mm of suroudig ealy ski

Trea nt i es oa pur pura s appaent .

Repettive treamets spaced 3 weeks apart ae

general y opima Loger iervas between treament sessios may fac itate wa egrow ad

soer inervals ma y prevent compete ea i g.

Cabo dode ase (C)

C aser treatmet is geerally eseved fo recacitrant wdespead panf or ypekeratotc warts

Advatages ig sccess rate usay after one owo sessios o bleedi g

Dsadva ages: known azard o PV in aser

pme isks of dyscromia ecurrece and nection prologed ea ng t me of weeks to mons

resida scarr g tat ca be pa nfl r isk of perma

en na dystropy w per ngu a eatmen

C proocol

Protective aser masks goves and gows as we as

se of a smoke evacaor are recommeded to avoidtransmssion of e wart vs.

Admiister ntraesiona nfi ltraive anestesia or a digita l b lock ( % idoca ne wit o wtot 1 : 100000 epep ine )

Vaporize te wart and a 2 to 5mm margn u l te sr

ace s carred (Utaplse CW defocsed 1520 W

Sarpa sperpu sed mode 12 mm spot 515 W)

Remove e car by rbbng a saline-soaked gauze

pad. A low e area o d.

Revaporze e wart as above wit ca removal

between passes unt tssue separatio occrs and ormal t isse is obseed.

cFgure 39 .2 Continue () ecurrence of the wart after sx PL

treatments

A

BFigure 39.3 (A) Plantar verruca wth characterstc thrombosed capllares(8) Parng of wart wth # 1 blade pror to pulsed dye therapy



Nonase surgica moda t ies

Cryoerapy with l iqd ntrogen s te most commolyemployed surgica teatment moda ty empoyed

Treatmet beeft s depedent on ce cystalndcedcell death as well as e dcto of a host imme

respose

Treamet may be deliveed via a cryosrgca unit(ml l Cryogenc Sysems E igton CT or via a

cottonipped applcator, dipsck or forceps

A sngl e or do be 5 to 15 seconds freezethaw cycemay be delvered depending o te teatment ste

ad les ion ickess T cker les ons ad paarlesions reqire moe aggessve treament t ipe

treatmet sessions are geeally req ed

Treamet may dce empoa o permanent

yperpigmenation ad ypopigmentaion b isteing

ad scar fomao

Electrodesscation and creage and sgica ecson

ave also been em poyed wi varia be espose

P TFALLS O AVO D

Be ve aware of te dept of destructio wt Claser As you go below te papllary dermis te rsk oscarig ad dyschromia ncreases

Patets mst be aware that scar fomation s lkey ad

may be pa n Pa ifu l scarr ig is most common opressrebeaig areas

Rec ences mos req enly occ at the won d edge

Treating a ma rgi of norma ski mi n mzes this r sk Cryoterapy ca p rodce pgmen cha nges and scar

I mp roveme s varable wi an y teamet moda ity

Wars can rec ate any treatmen

BBLOGRAPHY

Park S Coi WS Plsed dye aser treatmet fo val

wars A stdy of 120 patients Dermaol. 200835(8)

491-498.

Scel laas U Gerber W ammes S Ockene ls

P sed dye aser teatmet s eective i te reamen orecactan vral was Dermaol Srg 2008;34(1) 67-72.

Sero Somek E S ccessfl treament of recalctrat

wars pediatr ic patients with carbo dioide laser r eiar Srg 200313(4)219223.

Sethaman G Richads K i remagalore R N Wagner

A Effectiveess of psed dye ase in e reatmen ofreca lc itan was i ch i dren Dermaol Sr 2010

36(1 ) 5865.

Sme S O'Keefe E Beomycin i te treatment ofrecacitan wa rts Am Aa Dermaol 1983991 .


igure 39.4 Mechanism of action of pulsed dye laser treatmen of

verruca (A) The verruca is characerized by a rich vascular suppl(B) The pulsed dye laser selectively targes the vascular component of theverruca (C) The laser light is selectively absorbed by the blood leading

o coagulation of he vessels (0) and resolution of the wart






SEENBenign Gowhs




CHAPER 40 Angofboma

Agofbroma s a descipve erm or a goup of lesos

with differet c ical presetatios but wt the same

hsopatoogy Tese esios cude fbrous papulefac a agiof broma pea ly pei e papue adeoma

sebaceum peiugual f boma ad Koees tumor.

Ths capter w l l focus o faca agiofibroma. Geeral y

a agiofiboma presets as a to 5 mm sk-colored toerytematous dome-saped papu le o the face Whe t

preses as mut iple aca lesos it ca be associatedwh tubeous sceosis or mu ipe edocre eopasa

type (E )

EPDEMOLOGY

commoAg major ity i ear ly to m d c h d hood

Ra oe

Sx equa

rg ars tuberous scleoss E

PAHOGENESS

Ukow.

PHYS CAL EXAM NATO N (Fig 40 1)rm skicolored to eythematous papules (5 mm) o

the ose c i ad cheeks wc may be aaged

b atea ly Id v idua s wi uberous sc eros s ca a lso

ave perugual fromas fibous paques ad asleaf

macules .

D FFERENAL DAGNOSS

Itradermal meaocytic evi appedagea tumors

basa ce l carc oma ace vu lgar is

DERMAOPAHOLOGY

A symmetic wellc rcumscr bed papul e wt a orma to

s ight y aroph c epidemis Te pap l lary ad et icu ar

derm s eaures a prol feaio of vayig degrees of or

ma bood vesses wii a fibrotic stoma. Te collage

fibes are arraged perpedi cua r y to the epdermi s adcocetr ica y aroud te vessels ad a r o l c es .

Ste late-saped m ult i uc eated fibroba sts may be see .

Fgure 40.1 Patent th numerous faca angofbmas He s noted to

have assocated tuberus sceross



LABORAORY EXAMNAON

I e seig of m lt ip le ac a a d/or e iga agof i

bromas uberos sceross ad MEN 1 mst be ivestigated is s best perormed by reerra to pediatrc

secal ists

COURSE

Mt ip le fac a ago bomas ty ica l ly prese c i dood ad may be associaed wit tberous scleoss

(F g 40.2) . Iso aed es ios remai caged. Fteragiofibomas may develop i adltood.


Ose a d ocatio o lesos

ami y story of sm a esos

ami y story of cacer

Associated cea ervos system di sorders

MANAGEMEN

Tee s o med ca i d icaio to treat agobomas.

Teir cosmetic appeaace owever may be strkigad udersadably coceig o some d iv ida l s .

Teatmet

Mt ple treatmet modalit ies ae ava able. Recrrecerate s ig wit te majoty o e treatmet optos.

Secion 7 Benign Growhs 1 3

A

Treatmet opos may be combed for te bes treamet otcome

Srgica

Save ecisouie leso prior to apyg ocalaestesia as e leso may blac after e aes

tesa is ected

Pc o e l l t ca ec s ioimited to isoated fewlesios Resd a scar epected

Eectodessicatio ad cretagemay eave resida

sca

Laser s rgerybest or m ult e lesios

P lsed dye laserredces e eytematos como

et of e esio oly Possible esioal fatteigwt se o 5amioevli ic acid be igt otody

amic terapy folowed by psed dye laser teatmet

Carbo diode ase (Fig 40.3)otios wavemode most effective og-tem imovemet as

bee see Adverse eactios icdig tempoaryad/o ermaet dyspigmeatio esecial y i

tzpatr ick ski ototypes l l a d V as wel as scar

ormatio esioa recurece s epected over me

cFgue 40.2 (A) Fibrous paques on the forehead in an adut patient with

tuberous scerosis (B) Fibrous paques on the scap (C) Ash eaf macueon the eg of the same patient




KTP aserstacked p lses wio coolig has bee

tized wi some sccess Requires wo o fivesessos for lesioa latteig Dyspgmeaio ad

scar ormaio are possible esioal recrrece is

epeced

Dermabrasiosimilar ocome o couos wave

carbo d oide l aser reamet

PTFALLS TO AVOD

og here are may reame modalies for hem roveme of agofibromas he e doin s geera y

esioal faeg ad o cearace Seg realis cepecaios ri or o reame s key

Paies ms be aware of he ike i hood of esio al recr

rece over m e Wh deryi g berous sclerosis ewesios are key o occur

Ablaive erapies carry a r isk of scarr g ad dyspig

meaio se of coservave parameers are para

mou t o avoid oeti al s de effecs

BBLOGRAPHY

Becor RC uilgo SC Seed PT Caoje E arkey

AC a row R Treame of ang ofbroma s wt a sca

g carbo d ode laser a c copatoogic sdy wi

log-erm olow-up J m a Dermao. 2001 ;45(5) 731735

Boeda P Sacezira es E Azaa Arrazola

oreo R Ledo A C argo ad lsed dye laserreame o agofibromas J Dermao Srg 1994;20(12) 808812

Papadavid E, arkey A Belaey G Walker NP Carbod ode ad plsed dye aser reame of agiofibromas

i 29 paies wt berous sceross r J Dermao2002; 147(2) 337342

oe WD Kageyama N o" KTP-aser reame of

ac a l a giomaa ases Srg Me. 2001 29(1 ) 78-81

Weberger C Ed rizi B Hook KP Lee P K Treame ofagoibromas of beros sceross wi 5amoeviic

acid ble l ig poodyamic erapy fol owed by imme

d ae used dye laser Dermao Sr 2035(11) 1849-

A

1 8 51 BFigure 403 (A) Mutipe angiofibrmas on a 1 6yearo mae with tuberous scerosis (B) Improvement mon ths aer singe treatment with aser




cFgue 40 .3 Continue () Partial recurrence of angiofibmas noted months aer C laser treatment




CHAPER 4 1 Becker's Nevs

Beckers evus i s a sar py dem arcated ta o brow

patc o s igty raised verrucos la qe tat mos com

moly appears o te solder ces or upper back. Ittyca ly presets i atera y ad is reqely associated

wth oveyig hypercosis It s a beig amaroma.

EPDEMOLOGY

cidece: 05 % o maes

Ae tees to trt es rarely cogetal am ia cases

reported

Rce: all races

Sex: males > ema es (6 1 )

reciii crsoe

PAHOGENESS

Uclear etioogy. Posulated to ave a locaized crease

i adroge receptors ad egteed sesitvity toadroges

PAHOLOGY

hee is pap l lomatosis yperkeratosis acatosis ad

basal layer yepigmetaio. ere s a icrease i

te meai cotet o keratiocytes wt l e or ochage the mber o melaocytes. A smoo muscleam artoma is reqely preset i the derms.

PHYSCAL LESON S

hey occr most oe o te pper trk as a wel

demarcated latera ta o dark brow patc wt a

bock ike coguaio ragg rom a ew to >5 m.Hypertr cosis sua y deveops ater e yperpigmeta

t io ( gs . 4 ad 4 .2) Aceorm les ios stricty i m

ited to areas o yperpgm etato have bee reported

D FFERENAL DAGNOS S

Cogeita evs ca au a it mace epderma evs

peiorm eroibroma


Pysica eamiat io shoud be erormed to r e otassociated ypolasia o te silatera arm breas ae

oa o is aeral arm sorte g as well as pectus cara

tm o r toracc scolioss.

Figure 4 1 . 1 Becker's nevus A slihly rised lihn plque wihshrply defined nd hihly irreulr border nd hyperrichosis on heches of 5yerold mle Wolff K, Johnson A, uurmond

Fizpricks Color Als & ynopsis of Clinicl ermolo 5h ed NewYork McGrw-Hill; 005

Figure 412 Becker's nevus Lre bwn plque h becomes noiceble pubery wih incresed pimen followed by hir wh Wolff K,

Johnson A, uurmond Fizpricks Color Als & ynopsis of Cliniclermolo 5h ed New York McGrwHill; 005



COURSE

I t most commol y presets at p bey as a un latera ta

patc Ove t e, it may develo to a plaque and dsay a darker brow e ar gro, wic becomes

darker ad coaser over tie, follows getary

ca nges ey ted o en a rge sowly for a few years, tenremai stab e ove t me e co lor ay fade wit t ime;

owever, te a gro saly persists


Oset of lesio?

Is te esio stable?

Is te pgm ent te ai r gro or bot cosmetcally trou

blig?

MANAGEMENee is o edica ndicatio to treat eckers evs

e cosmetc apearace, owever, may di slease soe

id v da smost ofe females wo ote its yertricoss reatment otos are mt iple, bt not always

effectve incdng camofage makeup eectrolyss,waig, laser teapy and sgical ecision Srgical

ecso is imactcal for arge esions Laser terapies

ca be ta loed for ar remova or get resoto

(F g 4 3 )

Lase Teame A test site s recommended before iit at g any aser

teray to assess fo eicacy ad side efects

Pgmet Qswtced rby (694 n), Qswtced

Nd:YAG (532 m o 1064 ), ad Qswtcedaeandrite (755 nm) asers ave bee repoed effec

tive i treatng te p igme tary com oent of a ecker'snevus (F ig 41 4)

I geera, esponse is oor l pe treatments ae

saly reqired for gteg

hee is a ig ae of egmeaton is s lkely

d e to dee ar fo l ic le el anoces

actoaed aser treatmet: the ,550nm waveegt

fractioated aser as been sown to safey ad efec

tivey redce te pgmetary componet t le treat

ets spaced 4 weeks apa rt were e m oyed

Har remova : log-sed a leadr te ad d ode

(800 m ) lasers ca oduce air redcto bt areess eective wt longterm pigmet igening

Abative teray Erbim YAG lase (2,940 m) has

bee demostrated to be more efectve ta logplsed NdYAG laser (,064 n) i sde by side com

pariso treatment of ecker's evs ot lasers


Figure 4 1 3 Incomplete improvement of eckers ne vus on upper buttockafer three treatments with Q-switched ruby laser Associated pigmentachanges noted




produce ethema whch clears witn 15 days The

og-term c in ical ad istoogcal clearance has beenoted

t is important to ote tat tee s a hg risk o te

tre change and/o scar formatio associated witabative terapy

ntese pulsed ight as demonstrated med sccessn improving pigmetato and air oss

PTFALLS TO AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS

Treatment o t e pigmentary component of th e nevus s

often ineffectve and recrrences are commo

Lase ar remova can impove overlyng ypertricosis

and s general y permanent n natre

Postinfla mmatory ypo ad yperpigmentation occrreqently, terefore a conseatve aser approac s

vital to miimize any associated pgmentary cange

Patents wit dak skin pototypes (types IV and V)

sod be treated cautosy ad at lower fluences, as

ther treshold espose occrs at ower enegies Aconservative laser approach s best to avod postinlam

matory yperpigmentaton and/o ypopigmentaton

Lase treatment sod be mited to notanned d vd

a s to avoid tem porary or permane nt dyspgmentation

Srgica ecison is depedent on the sze and ocaton

of a lesi on ad s generaly im ited to very smal lesions

BBLOGRAPHY

Cho E, m JW Se SH So SW, Ahn HH ye YC

Treatment o eckers Nev wit a Longpuse Aeandrite

laser Drmal Sr 200935(7) 105-08

Gla c AS, Goldberg , Da i T n ish ge H Fr iedman

P Fractioa Resrfacng A new therapeutc moda tyor ecker's nevs Ar Drmal 2007143(2) 488

490

opera D, oeetner U andthaer . Qality

swtced rby laser treatmet o solar letgnes adBeckers nevs A stopathologica and immnosto

chem cal study Drmal 199794(4)338343

Na CA Alster TS Treatment of a eckers nevs sng

a 694-m ong-psed rby lase Drmal Srg998;24(9) : 1032-1034

Treles A, Alones , orenoArias GA, Velez

eckers nevs A comparative study between erbm

YAG ad Q-switched neodymimYAG c l n ica l andstopatologica f ndigs r J Drmal 200552

(2) 308-33

BECKER'S NEVUS

Therapy d irected towa geao xessie a w e esio

Pigment reducti

Lasers Qswied R d A adAlexad re asers os eee arae roee Rs ee ge edoeaig oo ose esl Alaie lasers ae iger iso sde ees

Surgcal

Seal exso sold ol esed i esios o ed si e

Ha educton

Lasers og sed d A (06)s e eas i e l areoal lase o ase osaao agesogsed r alexadiead dode asers ae oe el o ase ogeao a ees es

erae air redo s a eee sae oio o roi g a eers es A og sed d A ase solde sed ase redio o e geed ooe is less eeiead a rode wose osei aearae A roee wi ases ad ge edio a eeoar w e reree

Figure 41.4 Bckr's nvus tratmnt diagram



CHAPTER 42 Epd e m a ncuson Cys

Te epderma nclusion cyst (EC), a lso kow as seba

ceous cyst and epidermoid cyst, s te most common

cyst o te skin t rages siz e from a ew mi l m eters toa ew cetimeters and orignates rom the oicuar

inf ndi bu m ts contets are a ceesy, malodorous mitre o degraded pd and kerati t oen rptures, wit

assocated pa and n lammaton.

EPDEMOLOGY

ciece very commo

Age adlts

Rce none

Sex eqa

Preciiig cr deveop spontaneosly or as a reslt

of t rauma A

PAHOGENESS

Arise from epiderma ce l s i n te dermis ese ce l s may

be m planted as a res t o trama o r ar ise rom foll cul ar

infndibuar cels . Tese ce s may pro ierate as a resuto p losebaceous occson. lt pe esions ave assoc

ated wit Gardner sydrome ad basa cel nevus syn

drome .

PAHOLOGY

B

Secion 7 Benign Growhs 1

Wit the dermis or subctaneos at, tere s a wel

demarcated cyst contaiing amated kerati debrs

Te cyst wal is l ined by stratf ied squamos epitelium

eatri ng a gra ua r ce layer I ru ptured cysts tere is a

oreign body gran l omatous reacto wit m lt nuc eatedgat ce l ls Figue 42.1 (A) lliptical exciio arud epidermal icluio cyt

puctum (8) Cyt ac beig "delivered from exciio ite

PHYSCAL LESONS

A EIC s a dome-saped smoot f irm, we l-c rcmscr bed mob le node frequet y protrud g above te

ski s urace wt a centra l pore (F ig 42 ) Tey range

in sze from a few m meters to a few centimeters. Teytypca y preset on hair-bearig skin, sc as te upper

truk eck, earobes and face After rptre, these

cysts develop a strong ammatory reactio as a resuto te spi age o cyst contents ito te dermis. n ths

settng, te cysts become red, named tender, and

enl arged Per i les oa l ibros s may develop wth c ron c

in lammat io




D FFERENAL DAGNOSS

Piars cyst dermod cyst bracal cle cyst odar

f ibroma ad derma tmors may cause cofus o wtEICs. O tese lesios oly EICs featre cetra pores

LABORAORY EMNAON

I t e evet of ceaty of d agoss a b iopsy ca be

peormed to rue ot eopasm

COURSE

E Cs may crease i sze over t me especial ly wit pys

ical maipato Tese lesos freqety become

if lamed res t ig d iscomfo. Frak pr lece may

ar ise requ r ig c is io ad dra iage


s the es o recurret ly f lamed ad pa f l?

s the eso symptomatic?

s the eso creasig i size?

Has te eso bee amed beore?

Has te eso bee draied or ecised te past?

Wold te patet prefer a surgcal scar rater takeep g te cyst?

MANAGEMENTere s o medca d icatio to treat EI Cs tey are otsymptomatic. Te cosmetc appearace however may

dsplease some idvidals tese staces srgical

ecso s te treamet o coice. Rptred EICs caprodce recrret dscomfo ad repeated ifecios for

some pates. For tese esos srgcal removal s beeca l Cyst recu rrece s i ges or cysts tat ave bee

iflam ed wit th e developmet of assocated i brosis.

REAMEN

Patet edcao s paramot to avoid cys eargemet Dscotiatio of cyst ma p atio redces te

rsk of cyst e la rgeme t ad cyst ru pture

Srgica ecso is te treatmet of coce for cys

remova

For oflamed ECs

Te cyst margs sold be papaed ad delieated

pror o aestesia

The srgica cisio l ie sold trasect te epider

mal pore as possbe

A B

Fgure 422 (A) emoval of cyst with punc h biops (B) dissection of cystfrom surunding skin (C,) extrusion of cyst sac



Typica y a small el t ical-shaped eciso or a small

p nc h bo psy is erformed over he cyst arond thecentra ore (Figs. 42 ad 422)

The cyst sac s the deti ed a d care y dissected

to kee the sac intact

Sac removal may reqire lateal compresson to

etrude the cys A porto o the cyst contes maybe removed to assist i n sac rem oval

It s m poant to note tha shor o l remova o he

etire sac wall thee is a ke ihood o recurece.

Consider irr gato of the wond with sale if cystccontents are oted n e wond

The patient mst be aware of the potea dead

space that may reslt rom cys remova eaig in

these nstaces may resl n an ndetato of the

aected ski

For if lamed E ICs

I the event of a nflamed ifected or ewly rtred cyst srgica remova shold be postoednt the nfection and inf ammati on have resolved

Iflamed EICs are more diclt to ecise as hey

become more irm y aderet to the surround g derma I st rct res

Dranage of contes is impoant pror to treatig

larger iflamed cysts

ltralesonal cocosterods warm comresses and

at ib iot cs ( in he evet o iect on) can a d n

decreasg ammation

When the inlammaton has sbsded sgcal eci

son ca n proceed

Consider a corse of postecisiona ora atboics

wen cysts are inlamed or have dranage

PFALLS O AVOD/COMPLCAONS/MANAGEMEN/OUCOMEEXPECAONS

t i s mortant to d scss wi the pat ient tha whi e sugca ecson o a EIC is a rote srgica rocede

the scar let om the s rgery may be mo re cosmetica y

dsurbig ha he EIC itsef. Patents m ust be aware tat cyst recu rrece may occ r

Chroicaly iflamed ECs should be ecsed o avod

her ammation/inecton

BBLOGRAPHY

eh rabi D eoha rd M rodel RT Remova of kerati

nos and p lar cysts with the pch icis o techiqe

Analysis o sgcal otcomes erml Srg 2002;28673677


A

BFgue 423 (A) Epiderml inclusion cyst prior to punch biopsy(B) Epiderml inclusion cyst immeditely following removl An intctcyst sc decreses the risk of cyst recurrence




Rao K Tran . Ecsion of pdrmoid cysts with a

min ima nar ic s on rmal li J 2006; 2 ( ) : 2

Smoo EC. Rmoval of larg clsion cysts wt mnmal

incsio scars la Rr Srg 2007 9(4) 395

Wad CL Hay C ood A. T ut l ty of submtt ing

pidrmod cysts or sologic amation. l Jrmal 20003934-35

CHAPTER 43 Epdema I Nevus

Epdrma vs (EN) s a big amartomatos

groh. It prsns as a grop of vrrcos c osygropd skncolord to brown paps oftn a nar

arrangmnt fo l owing L ins of lasck ( g 43 ) It dvlops primari y c ldood. Tr ar svra vari

atios o E ncding localizd vs ns latris sys

tmazd E E syndrom ad flammatoryvrrcos pdrma vs ( I LVE ) ( g . 432) .

EP E M OLOGY

i: 0 % of b rts

Ag majorty i t frst yar of f fw dvlop i

pby

Ra: o

Sx ma prdomnanc i VE

riiig ar: sa ly sporadic fam l ia l cass

rportd

PAHOGENESS

EN s cratd by ovrprodcto of kratnocyts rom

pr pont mbryonc pidrmal basal kratnocyts.Gtc mosa csm s toght to b rsposib or most

pidrma v .

PAHOLOGY

Pap l omatos is acanosis pidrmal yprplas a and

yprkratosis along wt longatd r ridgs ar prsn n som sions pidrmolic yprkratoss ad

var ab parakratos is may b prsnt . f th is f id n g smad n t sng o mt ip l pidrmal v gnt c

consl g s od b ord n ordr to d cat pats

as to t risk of pi drm olytc yprkraoss n ofspr ng .

Nopasms sch as kratoacantoma basa cll carci

noma ad sqamo s c l carc ioma may rarly dvlopin association wth pidrmal nv

Figre 4 3. 1 Youg ma with pirmal vus limit to his ck ap



PHYSCAL LESONS

Commonly presen as a s gle near les on a log

n aera l or b laera l l inear p aqes may be prese os conss o m pe, wel-defied closey groped

liear, yelow pnk or brow verrcos paples o ay

body sie . E N oen fol l ows e Lnes o lasc ko o erunk ad raves ongid na ly o e erem ies Sze

can vay from a ew mil l meers o ml ple cenimeesay cke and become more vercos over me,

especal l y in leura egios Eyema s a comm o ea

re o VEN

D FFERENAL DAGNOSS

Nevs sebaceos, seborreic keraoss verca vlgar s cen sr as melaocy c evs ce pans

psoiasis


A bopsy may be indcaed o dis ingis rom nevs

sebaceos or ce s iaus Raely basa ce ad sqa

mos ce cac noma may ar se in E N

COURSE

An EN geea y peses a b i or c i dhood as mac

les in i a y wc icken over me Egy percen of

ENs appear w he frs year o ife A pbey, hey

end o enlage, darken, and become more vercosILVEN may be prr ic i naure

KEY CONS ULTATVE QU ESON S

Age of o se

CNS a bnormal i es

Skeea deecs

Prr is

Famiy sory

MANAGEMEN

I pa iens w mul p le ENs a orogh eamina onor sysemic aboma es s indicaed Tere s no

medca ind ca on o rea E Te cosme c appear

ance, owever may be boersome o e afeced indiv da l or parens of c dre wi d s gr g grows

Tere are m p le reame moda ies for EN inc l d n gsrgery demabrason, opica erapy, ad aser e

apy ( F ig 433) . Pa ens should be conseled a rea

me ress are varabe Te pyscan needs ocons der weer reame wi l l prodce a sper ior


Fgue 432 An extensive epidema nevus on the eft face and e ea

EPIDERMA NEVUS

ow eiolog rare Rae aes ae a assoaed sdroe wi CNSoa sloselea ages eaed eew o sses ad eaaio ediars wiaroae dagos ess sold e eored o e o Nsdoe

I

Lasers

I

eame of an epea nevus Cose ioee s araewi al l eaes

echaicalI

l sed aro doxdeaser eae o oew odeae o exee roee deedg ode o lesio

eaaso aa e lasesroide ee oo

esos a ara eoer ie R s o dsroa o sarg

Sugcal exciso ied arae sa ol lowig exisi o

Fgue 433 pidema nevus teatment diagam




ocome o noinervetio The mos aggressive forms

o theray laser abla on and sugcal ecsio carry ag r isk o sca ormaion and/or dyspigmenaon

(F g 43.4) .

TOPCAL TREATMENTSe following oical eraes provde l imted sccess

for esoa improvemet and may bes ui l ized fosympomaic rele of prurs: g-otency cocos

ero ids ret ino i atra 5f lororac i l odophy l

ca lc iotrio a d 5% 5 ororac i

SURGERY

ltickness srgical ecso of E is craive

Posoerave scar is epected

Cosmess is var able

Possib i l y of hyperoc o keod al scarr ig

S gica otcome s best for smale esions

Ecsio n may be d ffic t for yog ch i dre o toerate

Save bosy ad cretage may be too sefcialrecrences kely

CRYOTHRAPY/ELECTROCAUTRYIDERMABRASON

Cryoterapy eectrocaery and demabasio have m

ited efficacy a hg rae o rec rrence a nd ig isk of a

permanen ig mentary alteraion a d scaring.

LASR TRATE NT

Laser he ray can b e effecve n reag EN A tes se s

recommeded rio to reament

C aser (F ig 435)

Laser ablaton ca rovde good cono of te de of reatmen

Treament deh is imied to te api ary dermis in

orde o avod sca formaon

EbimYAG aser

acionated ablatve aser

os efective or more s eric a esos

Treamet depth is l m ied to he pa i l a derms

Wit abave aser treatme here is a narrow margbetween sccessfu treatmet ad a rml sde effecs

sc as scaig and emaent dyspgmetato

Rec rences ae com mon aer laser reament

Qswiced asers

AFigure 43.4 (A) Young patient with epidermal nevus syndrome Note theetensive nature of these lesions even afer several surgical procedures



T Q-swcd alandrt (755 nm and frqncy

dobd Qswtcd NdYAG 532-nm asrs may bctv or m rovmt of tn ENs

P TFALLS O AVO D

t is i mpoant to norm patins ta tratmnt mayonly b artia ly sccssl and may rc

Lasr tratmnt o t pdrmis a lon w l l rslt n

inc omp t rmoval

Lasr ratm byond t pai ary drms may rsltin sca omation and/or dyspgmato

r is a lways t sk ta tratm wil odc aninior rst o no ni ntvntio

Advrs sid cts as dscribd abov must b

paind n dtail o patins or rastc ctationsrgadg tratmnt otcom

BBLOGRAPHY

Boyc S Astr TS C lasr tramnt of idrma

nvi Longrm sccss Dral Srg 200228(7) 6 6 4

Kim Cang W Scwaydr oca rtnoin ad

5- oouracil n t tatmnt of l nar vrcos pdmal vs A Acad Dral. 200043(1 t ) 29-

132

L BJ Manc in A Rncci Pa l r AS Ba S F l ltic knss srgca cision for ratm of inflam ma

to l inar vrrcous pidrmal nvs A la Srg.20047(3) 285292

itsasi Y Katagr Y Kondo S ratmnt of in am

matory nar vrrucos pidrmal avs wt to ca lv tami 3 r Dral. 997 36 (1 ) 34 35

orno Aras GA Frrado J Intns lsd ligt fo

mlanocytc sons Dral Srg. 227(4)397-4

Panagiotooos A Casai V kolao V al

Assssmnt of cryosrgry for t tratmnt o f vrrcos

drma navi Aca Dr rl. 200989(3)292294

Park wang ES Km SN t a ErYAG asr tratmnt of vrcos idrmal nvi Dral Srg. 2004

30(3) 37838

Toyozawa S Yamam oto Y Kami na ka C K isoka A Yon

N Fr kawa F Sccssf tramnt wit tr c ooactc

acd i ng fo nfamm atory l nar vrrcos drma

nvus Dral 201037(4)384386

Zvlnov A Grwad M Ha lvy S opca ca c ot o l

or ratmn of nfamm atory l nar vrrcos idrma

nvus Arc Dral 199733(5) 567568


Bigure 434 (Continued) (B) and aer greater than 0 subsequent surgicalprcedures including aps and skin gras Curtesy f ichard ennett,

Muba Taher, and Mathw Avra

AbveC02 lser

ecoe

ems

igue 435 ffect f ablative C laer n reving an epideral n vus

With the deral cpnent reaining, there is a risk f recurrence




CHAPER 44 poma

L poma s a beg tumor of maue at I t presets as a

sof subcutaeous les-coored tumo tat eey moves

agast ovelyg sk. ost ofte t presets as a solitary es o o te uk, eck, ad proma eremit ies

(F ig . 441) . Ifreqet ly , id v idua s may preset wmut pe pomas, rarey as a pa of a iherted sy

drome

EPDEMOLOY

ee: very commo

Ae ca prese at ay age but most commoly te

fo decade

Rae: oe

Sex eqa

re ar most frequetly, tere is o precipi

tatig factor ul ipe l pomas ca be associated wsydromes suc as Dercums disease, famil ia l mut iple

ipomatoss adelugs disease Garders sydome,Ba ayaZoaa a d roteus sydrome

PATHOENESS

Ukow

PATHOOY

Well-circumscribed, obuaed tmo o ufom, matureadipocytes i e subctaeos fat, ofe wit a ti sr

roudg bous capsle ad eccetric uc e i

PHYSCAL ESON S

A lipoma presets as a sof reely moble escolored

ova o oud s bcutaeous odul e wit a orma l ovely

ig epidermis Its size ca va greaty from millmeters tomay cetimeters. is oede uess presetig as

pa o Dercums dsease, as a agiol ipoma or i impgig o a eve.

D FFERENTAL DANOS S

Epderma c lus o cyst , p i a cyst , iberoma agi

o ipoma, ad oer faty tumos icludg posarcomamus be cosidered I te lesio s greate tha 10 m o

fied, maigacy sold be cosdered

Fgure . 1 A mddleaed female th to lipomas on her arms




I omal c icumstaces o workp s d cated the

evet o rapd or etesve growth, however biopsy maybe dicated maigacy is sspected Cauto s di

cated e evet o ecsig a l ipoma located i the mi d

l e sacrococcygea egio t may epreset spiadysraphism. th s c cumstace, cosder rad io ogca

a d e rosurgica evalato Do ot peorm a bi opsy

COURS

They ed t o grow sowly to a cetai sze a d d o ot vo

lte without teveto

KEY CONS ULTATVE QU STON S

Nu mbe ad locat io o pomas

Fami y hstory of sm a esios

Hi story o keods/hypetroph ic scarr g

Assocated pai

Recet lesioa growth

MANAGEMENT

Thee is o medca idcatio o teat l ipomas uess

they produce pa or costco o movemet or

demostrate accelerated growt ay patiets ow

ever reques reatme for cosmesis Surgica removal,

va ecisio or l iposucto is te maistay o erapy. Ithe esio is located i th e mid i e sacrococcygeal egio

cos der spia dysraphi sm.

TREATMENT

Su rgica ecsio best for smal l pomas (F igs 442 a d

3)

Depedg o the size o he l poma a sma e l pt cal

ecsio s perormed over te tmor. Oce thelipoma s encoutered is disseced fom its su

rodg t ssue.

Aer remova, a layered close with subctaeossutures is geerally required to repair the cavty pro

d ced by the procedue

Recrrece s com mo due to te d iicty of d ist igish g tmor rom orma l su bctaeos at .

S rgica ecso is preerred o sma ller ipomas a dis less epesive tha iposuctio

Lposuctio best or age ipomas

A smal cisio is created wthi te ceter o he

lipoma ae egoa aesthesia ad iposctio of

the l ipoma s perormed


A

BFgure 2 (A) Lipoma on posterior neck prior to surgical excision(8) cision of lipoma




The entre tmor is ot necessarily removed Raer

portons o te lpoma are removed ntil the affectedarea es s with e srrondig skin

Postprocedre brosis can esre a persisten at

tened cotor of the remai n ng i poma tisse

The advantage of posction over ecso s tat it

prodces a sma ler scar

It is more epensive tan stadard ecsion

Low concentraton deoycoate injectons have been

sown o be eecive for te treatment of lpomas in a

limied study hese injectios obviate the need forsrgery and tus scarr ng oneeess frter stdy is

recommended before ts aternaive treament can berecommended

P TFALS TO AVO D/CO PL CATO NS/ cANAGEENT/OUTCOEEPECTATONS

e pysc an sod inform te patient that a l srgica lnterentos prod ce some d egree of scarr i ng

Scarrng may bother patents more tan te l poma

tself

Addtionaly removal o large ipomas frequenty reslts

n a postoperative skn depression

Recrrence is comm on especia l ly wi i posct on

BBLOGRAPHY

Harrigton AC Admot Cesser RS nf lrat ng l ipomas

of the pper eremt ies J Dmal Sg On 990;

6834836.

Rotnda AR Abon G Kolodey S ipomas reatedwth subctaneos deoychoate iecions Dmal

Sg 53(6)73-78.

Salasce S McCollog M Angeoni V Grabsk W

rontalisassociaed lipoma o te foreead J m a

Dmal. 198920462468

Sancez R Golomb A Moy A Potozkin R Gia ipoma: case report ad revew of te l iteratre J m

a Dmal 199328266268

ran AP Garden et a l ac ia l and sca lp pomas:

case reports ad stdy of prevalence J Dmal SgOn 1 9 8 5 9 .

Fgure 2 (Continue (C) ubcutanus sutu f clsu (D) Gsspath spcimn f lipma



CHAPTER 45 Mum

ia are beign supericia l wieye ow kerainaceos

cyss tha ypcal y prese on e eyelids, oreead and

ace bu may prese aywhere (Fg. 45 . 1) . hey occr aa l ages ad a re very comm on

EPDEOLOGY

i: very commo

Ag: ay age; mos commo i newborns ad a du lts

Ra: oe

Sx eqa

Priiig ar: These are most reqely sporadic

lesons bu ey ca be assocaed w sbepderma

bl isering diseases sc as porphyria cuaea arda epidermolyss bulosa acqisia varcella zoser virus, bl

los pempgoid , and bl os ce planus . hey areaso associaed wi ski trama sc as abrasos

brns dermaologc srgery abat ve ad onabave

ractiona resrfacg resrfacg and radiaiotherapy Tey may also occr folowig reame wh

opcal 5-fluororac l , opcal coicoserods, and mcro

dermabras ion

PAHOGENESS

ia are believed o be retenio cysts derived rom velIs a r fo l l c les . i a secodary o tra ma or bu l los d s

eases arse rom ecopc air olicles

PAHOLOGY

They represen smal epdermod cyss ad eatre char

acers c srai ed sqamous epihelium wi laminatedkerai debris A gra ua r ayer is present i e cys wal

PHYSCAL LESONS

i a presen as 1 o 4 m m su pericia wieyelow cysstha mos commonly appear on the eyelids cheeks and

oreead.

D ERENTAL DAGNOSS

her c i ica l a ppearace is cha racer is ic .

LABORAORY EXANAON

Noe .


Fgure 4 5 . 1 mall milia on face of a yearold female




COURSE

They ca p rese a a y age ad do o resove wiot

itevetio

KEY CONS ULATVE QU ESON S

Is there a y h i story of b se g o rama?

MANAGEMENT

Tee s o medica d icato to treat m l a T e cosmetic

ap peaace owever may dspease some d ividua s

TREATMENT

c s io a d epess io: treatmet of choice ( F ig 452 )

Local a estesia ma y be req ed cisio wi a #1 bade ad emova of kerata-

ceous deb ris with pressre from comedo e etracormcrovasclar foceps or cotto swab tps

The procedure is fast simpe, ad eecive

Topical medcatios

Topica retoi ca be eective for mt iple mi a

Ohe reatmes

Eectr ica fgratio

Ablative or ractoa abative lases ca be effecivebt ae fa moe epesve wit a ger rae of side

efects ad recovery tme

EPECTATONS

Treatmet o m ia is straightfoard I cis o ad epresso s as s mpe, ad sccessl It emas the tea

met o choce I cases o ml pe mi ia opicalteto is a good coce part icar ly f e esios ae

smal (Fig 451) aser pays o paccal roe i te

teatmet of m ia

BBLOGRAPHYara DE Poabba i S, F ce EF oy R ract oa

photoermolysis or te treatmet of adlt colo d m li m rc ermao. 2007143(5) 572-574

DmovsekOp Ved i se of Er:YAG laser or

beig ski d sordes asers Sr e. 9 9 7 2 ( )

39

A

B

cFgure 452 (A) Lancet piercin a milium on the left ower anterior neck

of a patient (B) Comedone extractor extrudin keratinaceous debris from

miium (C) Postprocedure resolution of milium aer comedone extraction



CHAPTER 46 Neurofbroma

Neuroibromas (NFs) are benig, soft pnk eromes

encyma tmos at ca be soitary or m iple

(Fg 461) Soltary tmors are not assocated with systemic findigs. l iple NFs are assocated with nerof

bromatoss pes I ad I bo e roctaneos disorderswit impotan sysemc maifestatios incding malg

naces Peiform NFs are see i paients wt neurobromatoss type I .

EPDOLOGY

iee common

Age youg ad lts

Rae oe

Sex eqa

Peiiig fas mltpe NFs are seen n assocatio

with ne rofbromatoss I and I I Tere are no precip tatingactors for sol iary N Fs

PAHOGENSS

Te paogenesis of so tary lesions s k nown ut ip le

germline ad somac mutatos ave been deiied orpatets wi neroi bromaoss ypes I a nd I I

PAHOLOGY

NF s caracerzed by a we circ mscribed, nencapsulated dema ad subct icu ar co l lect io of sma l nerve

bes and oosely arraged sp d e ce l s possessng wavy

ncle n a eosnopi c matr ast cels are commoy

seen itoses are abset

PHYSCAL LESONS

Ns present as skin co lored to p nk to brown soft or

rbbey papules or nodles (F g . 462) Te ab i i ty toeasily vagate he esio w pressue known as

buttoo ing" s a caracter ist ic pys ca l d igTey rage in size from a ew m meters to a ew ce

timeters Pleiform s are caracterzed by large

bag ike masses tat may ave associated yperpg

metat ion .

D ERENTAL DAGNOSS

Derma evi cogeial evi dermatofibromas; eromas ad f bomas


Figue 46.1 Multiple nonacial neurofibromas

Fgue 46.2 Multiple neurofibromas on the le face





A soltary NF does not merit a workp iopsy may be di

cated o a c nca ly atypca N F. ltip e N s mert reerrato neroogc ophtalmoogc genetcs ad ortopedic

special ists to assess or nerofibromatosis or I C ompete

sk and eye eaminaton o the patet and mmediaterelatives is idicated as wel . Ski eamation shod

assess for al a ry reckl ing caf a a it mac ues peormN Fs jveie antogra lomas an d sc odu es

COURS

hey tend to grow indoenty and pan lessly Peform N F

reqire contnos motoring or potenta magnantchange.

KEY CONSULTAVE QUESTONS

Nu mber o es ios

amly history

Cetal nevos system (CN S a bnorma it es

Scoiosis

Eye abnorma lt ies

one deects

Loss of earig

MANAGEMNT

hee is o medica indcation to treat NFs ness tey

prodce pa or are cosmetcally dis iguring or arechanging i growt any patients owever equest

treatment or mprovement of cosmetc appearace

TREATMEN (Fig. 46.3)

Sgica ecson

Whie tere are many metods or emovng Ns

sgcal ecson is te most common ad ecent

meas o remova Recurrence is key if the NF is

not completely ecised Elptical ecsion is an eectve nepensve treat

ment and is part ic lay appropriate or maagement

o a ew nmber o lesios As wit any srgery, an

epected scar w l l reslt ( Fg 46.4)

Laser a blatio

Not irst-line therapy

Carbon d ioide (C ) laser resacig can be ti-

ized for acial lesions C laser treatment of nona

cia esions is genera ly ot recommended gve r isk

of ypertopi c scar/kelod omatio

EUROFBRMA

C ial exa

So siooed ed/o ale/odle Sol ia leso oe oo a lle

So a esio (os oo) Sgial sae o exisoeae o oie No ole o ases

Figure 46.3 Neurofibroma diagram

I l i le les os e oassoaed eooaoss Sgial sae o exis oeae o oie ases seode ea



A cttig teciqe ca be t l ized to ecise

tmos C treatmet a focsed cotouswave beam 15 to 30 W s erformed aog the

maked margi Re ic ise a log te margi t tedesred det s obtaied Tisse demiig ad

emorage cotol ca be obtaied t iz g the

same laser arameters wit te adiece eldaway fom the wod to defocus the beam Wo d

cos re is eformed i a stad ard fashio

A vaozatio tecque may be t l ized to atte

ad emove tmors C treatmet wt a defo

csed beam ad 3 to 6 W s eformed to the eveof adjacet oma ski It may be ecessary to

maa y etact age resdua dema tmor oce

visa ized Char sold be debded betweeasses wit a wet gaze a d d ied l ly pri o to co

tig teatmet

Several teatmet sessios may be reqed for

atets wit meros N FsPostiflammatoy yegmetato atophicscarrg yeroic scarr ig, ad complete

remova ave bee reoted as sde effects A test

site shold be cosidered i aicua patietswith Fitzatick ski ototyes I V I

Erb m ytr im a lmim garet laser esfac ig

ca be ut l ized for facial esios

Srface vaozatio to flate tumors hs teat

met modaity s ess effectve ta the C aser i

esoa emoval However, this ase may be morea oiate o atets wt daker Ftzpatr ck s ki

hototyes to mmze ostammato gmetay cages

Itestita photocoagulatio ca be perormed for

the teatmet o bkie lesios cldg oacalesos

PTFALLS O AVOD/COMPLCATONS/MANAGEMENOTCOMEEPECTATONS

e ysic ia sod iform t e patet tat ay sg

cal or aser itevetio rodces some degee o scarr ig

Removal of NFs via laser ablatio may podce

postfammatoy hyperpgmetato ad/o scag

Recrrece s commo

C aser ics oa treatmet ca ead to deceasedtes le wod stregt d ig te woud eali g phase

we comaed to stadard srgica ecso de toaser thema damage at the wod magi. Stres

sould be le o a addtioa week to assist

wod eal g


BFigure 464 (A) olita neurofibrma preop (8) olitary neurofibrma

following simple excision This is the treatment of choice for solita neurofibromas It is also a good option for removal of limited neurofibromas




C lasr vaporzation tratmnt should b l imitd to

acia NFs gvn an ncrasd risk of scar fomationwith us o nonfacia s its

BBLOGRAPHY

Co RP Wddowson D Moor JC Outcom orbumyttr ium alumnum garnt asr sracig tramnts ases Me Si. 200823(4)427-433.

Ewaki Samy A Ebasouny MS Non-csion trat

mnt o mul p ctanos nrofibromas by asr p otocoaguaton ases Me Si. 200823(3)30316

Mono JC atort C Lant r L S lr Rvuz

Wolknstin Carbo doid lasr fo rmoval of mt

p cutaous nrofibromas J Dema/. 2001

44( 5) 096098

Nv l H Symour-Dmpsy K Sops J t al rol

of srg c dn wi nuofibromatoss J eiaS. 20036(1) 2529

CHAPTER 47 Seborrhec Keratoss

Sboric kratosis (SK) ar t mos common bignctanos tumors and in adts SK ar warty kratotic

ski growt that irst prsnt aftr th fourt dcad T masr rom a fw mllmtrs to ctimrs Th coor

rangs rom pnk to ta to dark brown sions can b

sol tay or mut p l ( g 47) Ovr t m pat intsdvop aywh from a fw to undrds o SKs any

patts rqst rmova of SKs part icar y whn m lt ip or la rg bcaus of tir un sigty apparac

EPDEMOLOGY

iee: vry common

Ae usuay in oth dcad and bcom mor numr

os in m ddl ag and byondRae: mo common i Caucasias

Sex: qa

eiii as amily story wt iky atosomadomi nat inr itanc

PATHOGENESS

Unknow



PATHOLOGY

Cassca ly, S Ks are wel -crcumscrbed ep dermal growts

tha rse above te srface of te srroudg skn. Aleatre yperkeratoss, pap omatoss, and acaoss.

Te epderms coans basaod cells that sow squa

mous dereao Squam os eddes may be preset

PHYSCA LESONS

Tee are many clcal varats o SKs. ey rage sze rom a few m l meers to a few cetm eters ad mos

comm oly occr o te face, eck, a nd tru k. Tey typ

caly frst preset as weldemacaed ta or lgt brown

macues Wt t me ey r se to become plaques and

deveop a warty ad sucko appearace. or cystsbecome appare wt te l esos Tey can occr ay

were o arbeang sk ad ae ot see o te palms

and soles

D ERENTA DAGNOSS

Letges, verruca, acrochodos, codyoma acuma

tm, acrokeratoss verrcforms dermaoss paposa

ga Bowes dsease evs epdermal evs ego

mal gna meanoma, ad sqamos ce l cac oma The

ccal appearace ad presence of orn cysts SKs

makes e dagoss stragorward


Noe; sk n b opsy f sspect ma gacy.

COURS

Tey presen t e forh decade a d persst for years.

Ove tme, hey become larger, more pgmented ad eatre a more verrcos appearace. Tey typcaly

become more m erous wth age Infreqently tey caregress spoa eous ly


Fam y hstory of sk cacer

Hstory o b leedng

m e of onset

Was there a rapd ose of merous SKs?

MANAGEMENT

Tee s no medca dcato to treat SKs, less tey

are rr tated St l l , e cosmetc appeaace boters may

patets There are ml ple modalt es fo treatg SKs


igure 47.1 Multiple seborrheic keratoses on back of elderly male




including cryoterapy, electodesccato, ceage

swtced and ablative laser terapy ost ote te tradt io na metods of treatg S s are most appropiate I

there s a rapid oset of wdespread esons, perform a

revew of systems and cosder a f l pyscal eamna

t ion to r e ot ay uder ly ing medica l cond ion or carc

noma (Sign of eser Telet).

TRADT ONA TRATM NTS

Emphasze r sk of incompete remova and recurece

with any reatmen modalty

Cryoerapy

Lght cryoerapy is a quck epesve ad efec

tive metod of reating Ss Ris k hypo or ypepg

mentato ad low rsk o scarig

f the lesio does no resove retreatment s neces

sary i 3 o 4 weeks

C rrettage ad ig ht catey

Eectrodesccaton of Ss is anoer q c k an d effec

tive meod o treatment Slg dscomfot assoc

ated wh oca anestesa

Creng the leso ate electrodesccao ca

ensre emoval

Lgt, qck eectodesccation of e base may alsoenhace eficacy and prevent ecrrence

Posprocedre wond cae is eeded with emo ent

or 7 to 0 days

Save eciso

Shave ecso n ca efectivey remove Ss

ASR TRATMNTS

Laser s ot a fst l n e treatment for Ss Rather, it sould

be cosdered a alerative treament and oly sed n

the correct c n ca l sett ng

ea n n targeng asers for tin S s

Qswtced by (694 nm) ad Qswtced aean

dr te (755 nm), and te longpsed 532 nm lasers

can eectvely treat thn S s (Fg. 47 2)

Somemes neective especial ly as thickness

nceases repeat treatmets may be reqred

Rsk of hypopgmentato

Epensve compared o tradit iona terap es, but maybe more toleab e o a patient wit m t i pe l esions

Ablaive lases

C and erbi m :YAG asers can abate Ss

Repgmentato of Ss occrs nfreqetly ae

treatment

Epensive compa red o tradt iona terapes

Figure 472 Posttreatment whitening of seborrheic keratoses atertreatment with a 55-nm Q-switched alexandrite laser with a uence of

10 J!m and a mm spot size The procedure was performed aferfractional resurfacing, which explains the blue dye remnants apparenton his face



PTFALLS O AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS

SKs ca be treated wi a mber of d eret ad

eectve modalities

Te pysca so ld edcae te paet tat ay terapy as possbe adverse eects suc as pigmetarychages scarr ig ad recrece

Tradi o al terapies sc as gt cyotheapy o curet

tage ae simpe qck ad effectve (Fg 473)

Laser terapy is a alterative treatmet at a higerepese

BBLOGRAPHY

Brodsky J aageme of beg sk lesos commoy afecg e face: actc keratoss seborrec

keraoss ad rosacea Curr Opin Otolaryngo/ Head Neck

Surg 2009(4) 35320.

Cbeso GR 532m dode laser treatmet of sebo

rec keratoses wit coor eacemet pblised

oe aead o pi aary 29, 2008 Dermatol Surg

2008;34(4):525-528 discssio 528.

Kilmer SL Laser eradicato of pigmeted esios ad

tattoos Dermatol Clin. 200220)37-53

erabi D Bodell RT se of e aeadrte laser for

treatmet of seborrec keratoses Dermatol Surg

2002;28(5):437-439


cFgue 47.3 (A) Curettage of seborrheic keratosis (B) Immediatel aercurettage of seborrheic keratosis (C) Postinammato erthema 1 monthafer curettage of seborrheic keratosis




CHAPER 48 Syrngoma

Syrigomas are common beign adea neoplasms of

eccrie duct dervaion at preset mos freqety

in females o the ace especa y arod e eyes( Fig 48 ). ey may aso be seen on te cest u m b i

cs a lae and v va .

EPDEMOLOGY

cidece: commo

Ae saly present at pubey

Rce: oe

Sex ema e > ma le

Preciii crs: more common i Dows sydrome

PAHOGENESS

Unkown.

PAHOLOGY

hese beign symmetric wel-crcumscrbed dermaltmors are composed of mt ple smal ducts wt two

layers of cubodal eptelm ote wit a ta l" gvg atadpole" or comma- ike appearace in e pper der

mis Tese ducts are sometimes di ated a d are l ned by

a eos inop l ic ct c le ere s a srrodig denseibros eos iop i l c stroma

PHYSCAL ESON S

Ski coored to yel ow to 3mm rm pap es ey aresee most reqely arond the eyes especal y the

lower eyeld. Typica y tey are mut ple ad symmetric

hey can a so be seen on te ces mbi l cs ai ae

Figure 41 nfraorbital syrinomas bein treated with low settin electrocaute on a youn female The treatment was not eective

ad geital ia (Fig. 482). Acral esions are seen n erp At ive syrngomas.

D FFERENTAL AGNOSS

il a sebaceos yperpas a basa l ce l l carc ioma tr i

choepithe oma f i brous pap le

LBORATORY EXAMNATON

Biopsy may be d cated i basa ce carc noma s ss

pected. No oter laboraories are ind cated

BFgue 42 (A) Infraorbital syrinoms in a youn female (8) Followuppicture at 1 week afer ablative fractional C laser resurfacin showinimprvement of the syrinomas This improvement is attributed mostly to

the postprocedure edema No sinificant improvement was noted at alater follow up



COURSE

Tey prese a pbey and do o resolve wot ite

ve ion


Time o f onse

MANAGEMENT

Tee is o medica ndicato to treat syrgomas. ay

patens owever reqes reament for cosmecapearace Syrngomas are eraeuica y callengig.

Altog ere are ml ple reame modalt ies avail

abe one is comeely sccessl compee orperm aen emoval of syringom as Oen te s de efects

of reamen wi boter atets more tha te syrigo

mas emselves Ideally e treament of syrgomassoud rodce destrcton of e tmo wi mnmal

scarr ing an d o ec rence Tere are no effecive opicalmedca ios .

TREATMENT

Srgica ecison bes reserved for solay lesos

Scar wi l be prodced

Electrocaery can be sccessfl

Locazed aesesia w % l docaine w or wit

ot epiepr i ne may be emoyed Low-energy seng elecrocaery eformed at to

2 W w e electrode aced i e center of e

syringoma.

C i cal endon s lesioal faeng.

Lg seings are advsed to avoid pigmenta

cages o scarr i g.

Getle curetage s recommeded o esre at

eectve removal o e syrgoma as bee

obta ned.

Carbo d ode (C ) lase s an effectve meas of

imoving ese lesons. The goal is to flae raer

a remove e lesons

Lmed to patients wt skin ootypes I I I .

Ind v ida l les os or m p le syr ingomas w te

same cosmec nit may be reated

C treatmen in a deocused mode 3 to 6 W 3mm

spo 01 o 02 secods may be eml oyed

tiple passes are peormed wt remova of resdal car bewee asses w saliesoaked gaze

pads. Leso s are treated to e evel of adjace no

ma l s k n


Fgue 4.3 Multiple syringomas on th e chest of a female




Lesonal recurence s common Postinfammatory

hyergmenatio a nd scarrg may occr

Oher eames nclde cryosrgey and dermaba

sio hee s l itt le data wit whc o judge their efi

cacy ad sideeect prole

PTFALS TO AVOD/COPLCATONS/ANAGEENT/OUTCOEEPECTATONS

Atough tere ae mlt pe reamen modal ies tey

are oten ressant o therapy Recrrece s common(F gs 483 and 484)

Ca io sou d be eerc sed wi ea c o the a bove

sted modal ies

Patens must aso be ormed ta e sde eecs of

reame may be moe cosmetca ly udesabe a

he syrngomas hemseves ese side efecs incldescarrng yerigmenaion recurence ad ery

thema

We teatng syrigomas care shoud be take to ot

overreat e esios I is not ecessary to completey

e l imiate e es ios as some dermal bros is sepected wi ealng with esidual lesons becoming

ess aaren over m e

Great care so d be given to the treatmet of aetswih skn ootyes V and higher o avoid tempora

and permanen ig mentary canges

BBLOGRAPHY

Akta H Takasu E Wasmi Y Sgaya N Nakazawa Y

atsaga K Syingoma of he face reated with frac

tiona photoermolysis J sme ase e 2009 (4) 2 6 -2 9 .

Frazier CC Camach o AP Cockere l C The treamet o

eruive syrgomas n a Afrcan Amercan atent wita combinaio of r icoroacetic acid ad C laser

desructon Demal S 20027(5) 489492.

Kag WH Km NS Km Y S im WC A new reatmeor syrgoma Comnation of carbo dode aser and

tr icloroacetic acd Demal Sg 99824( 2) 370

374

Karam P eedetto AV Syrigomas ew aoach o an

o d tecn iqe l J Demal 99635(3)29-220

Sajbe FP Ross E e se of e 0 mm adpece in

hg eergy ulsed C aser destructo of facal

adneal tmos Demal S 99925() 444

Wang Roeigk H Jr reame of mut p le fac a

syrigomas wh he carbo doide (C) ase DemalSg 99925(2) 3639

Topica o eeeopial ea

SYNGOMA

l o ea t a oda Cial ioee is aae

Mechaical oal aesesiai ig eleo

desiaio

asers Aaielsed C eos eeie oda i

os ase eea o 1 ees Ap eol i et oeeaed aea o oaea g

ig eee aeL a oda i

1 36 os

Fgure 44 iagam of syingoma teatment




CHAPTER 49 Dermaoss apuosa Nga

Dermaoss papulosa ngra (DPNs are very common

benign brown way papules a appear n Afrca

Americas and oher patens wi dark skn pooypesDPNs usualy afect e ceeks neck and pper cest

(g. 49 ) DPN s are a type of seborrheic keratosis anypatiens request removal of DPNs paclary wen mul

t p e or large de to ther unsigtly appearance.

EPDEOLOGY

iee very commo i Afrca Americans ad Asians

Ae: second decade to mi dd e age

Rae: more common in Africa Americans ad Asans

Sex emales > maes (2:

reiii a srongy assocated wth famly sory

PAHOGENESS

Unknown

PAHOLOGY

DPNs feature yperkeraosis papi lomatosis and aca

thosis as see in seborrhec keraoses o squamos

eddies are prese

PHYSCA LESONS

Tey presen n a symmerc fashio as sma l browsmoot sess e papues on te face neck ad upper

trun k of Afr can Amercans ad Asians Tey range rom to 5 mm n dameter and are ofen pednculated.

D FFERENTA DAGNOSS

Seborrec keraoss entigo verrca acrocordon

melanocyic evus angiofibroma and adnexa tumors

are al l in te dierential dagnoss

LABORAORY EANAON

Noe .

COURSE

Tey present drig teeage years. Over time ey

become larger and more nmerous peakg in middle

age T hey do no regress spontaneo sly.

Figure 4 9 1 ermatosis papulos igra o the forehead of a AfricaAmerica female





ami h isor of DPNs

MANAGEMENT

hee is no medcal ndicaton to teat DPNs uless theare ir r ated St l l , he cosmeic appeaance bothes manpatents atclar when numeous hee are ml ipe

moda it es or treag DPN s in cl d ng crothera elec

trodesscatio, gadle scissor emoval, cuettage and

ablaive lase hea Primar considerato before teatment sou d be e eectve removal of e DP Ns wihout

prodcig pigmenar change

TREATMENS

Shave or grade scissor ecision ca efectvel emove

D P Ns Local ifi traton wth oca aesthesia o owed b gra

de scissor emoval s safe, fas and as the owesrisk o postnflamm ao dschom a

Cohera

Lght croera is a qick, inepensive sl ightlpa nfu , ad eectve method of eatig D PN s

Cation cotheap can oduce hpopigmentation

b destoing melanoctes pergmenation cana lso occ

Lght electrodesccaon and crettage

Lght eecodesiccation of DPNs s another quickan d eective method o treatment hee s a r sk of

posnammato dscroma

Wth ight electrodesiccato the lesion w l tn whe

On l ght eectrodesccaio should be emploed todecease the rsk of gmena ca nges

LASER TREATMENTS

ea n n argeng asers for thin DPN s

Qswitched ub (694 nm) ad Qswtced aean

drte (755 nm) can someimes eecvel eat thiner DPNs

Sot size shoul d b e ess han the size o e leson

Repea reatments ma be requied

Risk o hoigmenation and hpergmenaion

should be e ained ca refull to pate

Epensive compa red o tadit i ona theap es

Ablaive lases

C, factioal ablative and erbimYAG asers can

abae these ederma esons



Epensive comp ared o radi onal terapies

Rsk o ypopigmenaion and yperpigmenaionsould be epla ned careflly o e paien.

PTFALLS O AVODCOMPLCATONS

MANAGEMENOUTCOMEEXPECTATONS

An y erapy a s possibl e advese eecs sc a s p gmenary canges scarr ing and recurrence Grade

scissor removal as e lowes r isk of dyscromi a

DPNs can be reaed wi a mbe of deren ad

eecve modaliies

radi io nal herapies sc as scissor ecson cu retage

or l ig cryoherapy are sim pe qu ck and eecve

Laser herapy is more epensive ad carres a ger

poena for yper or ypopi gmenaio es spo may

be app ropiae

BBLOGRAPHY

Kilme SL Laser eradicao o pigmened esons and

aoos. Dermatol Cln. 20022013753

Schweiger ES Kwasnak L Aires Treamen of dermaosis paplosa ngra wt a 10 nm NdYAG lase:

Report of wo cases J Cosmet Laser Ther 2008 10 2

120122

CHAPTER 50 Xanteasma

anteasmas also reerred o as anhelasma palpe

brarm are pane aomas occrr ng on he eyelds

EPDEMOLOGY

Incidence reavely common

Age mddeaged adls

Precipiting factors hyperl ipidema presen n 50% of

paens w aneasmas fam ly sory of yperl iped

ima and anesma Yonger adls who presen waneasma are more i key o have l i pid a bnoma i es

PATHOGENESS

Abnorma ies of apol poproein E phen oypes or oer

l poproe ins





PHYSCA EM NATON

ateasm as comm oy present as m l ipl e soft symmet

rca oval yelowis papes and plaqes o e eyelds

D FFERENTA AGNOSESSyrgomas, sebaceos neoplasms m l ia ecrobotcatoganuoma

DERMAOPATHOOGY

Coectios of foam cel s n te superficia de rms .

COURSE

ey are geerally permaent wt tedecy to i crease

in m ber ad coa esce wt ime

MANAGEMENT

anteasmas ofte recr aer treatment wit any

modality

• S u g i c a E x c s o

S rgica ecsio s te treatment of coice for ateas

mas Te esion s lited ad e ecised usg a bade

or a Grade scissor Te defect s eter et o eal bysecond tenio or stred sig s k or eti lon stes

(Fig 50) Tis pocedre sa ly reslts n a very cos

metically accepabl e otcome

• Loca ze Tssue Destruct io

C or erb m aser vapor iza io tr ic oroacet ic ac id

eectrosurgery or cryoteapy

PTALS TO AVOD

Atog 50% o paiets wi anelasmas areormolpemc it is crca o scree ew pates w

aeasmas for e presece of yperl pidema Tis

s part icuar y mportant i yoger paiets wo pre

se wt atelasma sice tey are moe kely to

ave assocated l ipd abormat ies

Patents mst be made aware at complee removal of

te antelasmas does ot prevet fte develome

of ew lesos

Etreme cation sold be eerted wen operating on

te eyeli ds i ord e to avoid eye nry

A

BFigure 50.1 Xanthelasma on the le upper medial eyelid in a middleaged woman (B) The resulting defect is su tured using ethilon suturesThis pcedure produced a very good cosmetic result



BBLOGRAPHY

Eedy J Treae o xaneasa by excsion w sec

ondary ieno eang Clin p Dermatol 1 996 2 :273275

Gosh YK, Pradan E Auwa ia HS Exc is ion o xahe

lasaacap shave a sre lnt J Dermatol2009;48(2) : 81 183

Hawk . Cryohera py ay be eecve for eye d xahe

lasa Clin p Dermatol 200025:35

anio G Papale A e Bel a F e a se o

erb YAG aser n he reaen o pa pebra xanhelas

as Ophthalmic Surg Lasers 20032: 2933

Naas TR arques JC co e i A Cunha s wai

aas C Fi lho JV reaen o eyeid xanelasa

wih 70% r cloroacec acd Ophtha Past Reconstr

Surg 200925(4)280283

llann Y HarSai Y Pele I J . The use o C laser or

he reae o xaeasa papebraru Ann PlastSurg 19933:504507






EIGHTCutaneous Carcinoas




CHAPER 51 Actnc Keatoss

Acnc keraosis (AK) presen as snge or ul iple is

cree scay esions oun os requenly in habiually

sun-exposed sk o au ls

EPDEMOLOGY

A os cooly noed n idle age occasona y

occurs n paens nder 30 years

Sx ore coon in ales

Icidece very coo i n Ausra l ia 1 1 000 persons

Ra skin phooypes I I rarely seen n s kn phooypes

I VVI

Occuptio ouoor workers (eg arer rancher salor)

and ouoor spors (go enn s sai l ng) A

PAHOGENESS

Proonged an repeaed su exposre i n suscepible per

sons resuls n culaive kerainocye daage he

princple su daage is secondary o uravo e B (UVB)(290320 n igh

PHYSCAL EXAMNAON

AKs presen as sngle or u iple ski n-colored, eryhea

ous or brown scaly paches There is a predilecion orsun-exposed areas ncuing he ace ears neck ore

ars an orsa hands. AKs ay becoe hickeneoring a cuaeous horn. ore eas ly palpaed han

seen. They are genera ly asypoac bu ay be ender or pru r i c Ac n c cei l is deveops on he ver l i on

borer as dise scalng or ryness. Assocae elang

iecasia solar easosis an lenignes are requeyobserve

DERMAOPAHOLOGY

Epdera pro ieraon wih il-ooerae bas ar kerainocye pleoorphs parakeraoss an yskeraoc

kerainocyes Cyologcaly aypical keranocyes areusua y conne o he epider al basa ayer.

D FFERENTA DAGNOSS

Eczeaous derai is

Exra a a ry Pages

Squaous ce carc inoa

Basal cel carcnoa

B

cFigure 51.1 (A) Numerus facal actc keratoss pre-Adara treatmet(B) pected erythema ad crust dur Aldara treatmet (C) Facalactc keratoss post-Adara treatmet appled twce weekly for 4 weeksCourtesy of Rchard Johso, M



COURSE

AKs can self-resove b geeral y are perssen in

nare e progress on o sk n cancer w preexis ngAKs is know bu s esiae a less a 1% o ini

val esios Bopsy warane for pgene As

(speic a l p igene ac n ic keraos is) or olarkeraoss

KEY CONS ULTATVE QU STON S

ra o of les on(s)

Lesoa rae of grow

Prio reae for esions an response

Persoal an faily isory of pror skn cancers

Hi sory o pri or rai aion reae o he area

Crre eica isory

eicaion se Evience o iuosppresson

Preisposng syn roes

MANAGEMEN

Assessen o e ber s ze ocaon freqency oeveopen an any elyng uosppresse

sae sol be obae A b opsy so be obaine o

any leson ha s sspicos or skn caces

Consiera ion ay en be gven o reaen of in iv i

a o l pe lesions propylacc erapy a eeriaon o e nee for c iical fol lowp

TREATMENT

Preveo

Appl ica io o a y sunscree wi VVB pro

ecion

Topica reioi appie ngly

opca

Oce a ly (Carac) or wice aily (Efex) applcaion

of 5-fl oro acil for 3 o 4 weeks

Twice weekly or every ir ay applcaion ofi iq u no (Aara 3 S Pa ) or 4 weeks

(F ig 52 )

cofenac (Solaraze) 3% soi opica ge wceaily for 2 o 3 ons

lgeol ebae applie o 2 sbseqe ays or

wice 1 week apar

Genle cryosrgey w a single freezeaw cyce

B iser oraon possibe Repea reaen ay be

reqire Rsk of eporary yperpigenaon an

Secion 8 Caneos Carcinomas 249

A

BFigue 512 (A) Actinic cheil itis, lower lip Patient complained of frequent peeling that was poorly responsive to cosurge and efudex(8) eduction in actinic damage following carbon dioxide resurfacingPatient repoed complete resolution of peeling





wl perss urng he uraon of reae an for o

2 weeks posreae A opica coicoseroi ay

be prescribe posreaen copleion o assis in he

resouion of hese fin ngs

BBLOGAPHYAlbers , Rager-oore J, Einspahr J e al Safey aefficacy o ose-inesve o ra via in A in subjecs wih

sunaage skin Clin Cancer Res. 20040(6)875880

Ercson B, Sanberg C, Senqus B, e al

Phooyna ic herapy of acin c eraosis a varyng fluence raes: Assessen of phoobeachi ng pa n a pri

ay c n cal oucoe. Br Dermatol. 20045 (6) :204-22

Haley G erry S, oore RA l iqu o for ac inc er

aosis Sysec revew an eaaalysis nvest

Dermatol 200626(6) : 25-255

Jarvis B, Figgi P opcal 3% icofenac n 25%

hyaluroic aci ge: A revew of s use in paens whacc keraosis Am Clin Dermatol. 2003;4(3)203-

2 3

Jorzo J, Weiss J Furs K, VaePo C Efec of a

-wee reae wih 05% opical uorouraci on

occurrence of acinc eraoss afaer cryosurgey: A ranoze, ve ic le-coro l le c l n ica l r a Arch Dermatol.

2004; 40(7) :8 3-86

Rofarus S, aheson R, avs S, e a opica eyainolevulinae pooynac herapy using re ! l gh

eing oe l gh for ul ple aciic keraoss: A ra

oze suy Dermatol Surg. 200935(4)586592.

S l ler G, Gebauer K, Welburn P, Kasaas J Ogbourne

S PEP5 (ngeo ebuae) ge, a nove age or

he reaen of acinc eraoss: Resus of a raoize, oublebin, vehicecorol le u icenre phase

lla suy Australas Dermatol. 200950() :622

hai KE, Fergi P Freean , e a A prospecive suyof he use of cryosurgery or e reae of aci ic er

aosis lnt Dermatol. 200443(9)687692





CHAPER 52 Basa Ce Ca cn om a

Basa ce l carc inoa ( BCC) s a s low-growng al gna

skin or a preses i d s inc hisoogica subypes

inc lud ing odlar sperf c a croodar n ra ngand opeafor Nodar BCC is e os coon

ype occr ig predonany o e ead and neck

regons.

EP M OLOGY

dee: e os coon skn cancer in Caucasans

wih approxaey 800000 cases/year dagnosed in e

ned Saes

Age os coon n paes over 40 years

Rae: os coon in Cacasans

Sex higer inc idence i a es

reag ars: cron c rav o le ad a ion and

fa r ski are he os s ign if ican ped sposing facors Oher acors inc lde on z ing rad a on arseic expo

sre iuosuppress ion PVA ad gene c pred s

pos i on

PATHOGENESS

e os coon a ered gene in BCC s e or sppressor gee w a resuan alered

Hedgeog signaling pahway eadng o reglaed ce pro l ifera io and a lered ce l l d ifferenia io ua ons n

e 5 uo suppressor gene ae a lso freqen ly

observed ead ng o ce l l u a r i o ra y ad res isance

o apoposis.

PHYSCAL EXAMNATON

Pn eryeaos pea ly ras lcen paple nodu e

or paqe wi a ro led border and overlyng eangec

as ias (F ig 52 ) S perf ic ia B CC presens as a p i k or

eryeaous scaly paq e. e ceer ay becoe

ceraed and covered by a crus a s roden cer"opheaor BCC exhibis a scal ke appearance wh

i l dened borders. Tey os coonly pesen in po

odsr ibed aeas.

DFFRNTAL DAGNOSS

eral eanocyic nevi sebaceos yperpasia sqa

os ce l carc noa (S CC)

Figure 52.1 Large B o th e fae Note th e haraterst rolled borders, overlyg telagetasas, ad the etral ulerato



LABORATORY DATA

Demaopahoogy

Lobes ess, or cords of eoplasic basaloid cels w

perpera pa isadg, ce ig ad cos sroa.

COURSE

Loca y i vasve ad sow growig over ohs a d eve

years easass is a exceedgly rare occrrece


Excessve s exposre a d oer predis posg acors

pr or h isory of BCC or SCC persoal a d a iy i so o

ski cacer osppresso.

MANAGEMENT

Tere are pe eods for reag BCC reae

selecio shold be based upo e age heal, ad

prefereces o e paie aer a ful l dscsso of rea

e opios r isks ad bees Gve e loca ly

desrucive aure of BCC, isologica cofiraio ocopee reoval s opa Surgca excso ad so

logcal eval uao rea i he reae of choce i os

cases Tors ixed o deryg boe especia ly hescap er radioogca workp prior o srgca excsio

or os icrograpc srger opcal herapes require

cose fo ow-p or ay evdece of reae fai lre orrecrrece Paie edcao regardg e bees ofs avoidac e suscree use ad regul ar seexa a

os a re i poa preveve easres

F i rs e Therap es

Excsoa surgey: geerally w 4 argis s e

reae of choce for o sperfcia l BCC ha do oee e crier ia of os crograp c s rgery

os crograpic surgery s e reae of coce

or grs aaoica ocaios (ie, ask" area of

e ace) ocaos where issue coservao is c ruca l

or f coal or coseic reasos recrre ors l

defied c ical args soogcally aggressive sbypes ors i iosuppressed paes, ors

arger ha 2 , ir rad iaed ski ad per iera l ivaso o bopsy (Figs 52 2524) Mos crograpic

srgery as he ges cre rae o ay reae of

BCC

Elecrodesscaio ad cureage

Cyoerapy


A

BFgue 522 (A) on the nose with very ill-defined clinical margins(B) Large defect aer Mohs micrgraphic surge Mohs m icgraphicsurge is the ideal treatment for this type of skin cancer providing thehighest cure rate among all other treatment modalities




Radaion heapy is aohe reaen opio espe

cia ly we surgery s o feasible o conraid caed Ican also be used as an aduvan erapy we per

neu ra l i vas o s ide ied

• Aerae heap es

opical iiquod applied ive ies a wee or a oal

d urao o 6 wees. is F A ap proved for reaen osuperficia l BCC Recurece raes are sigificanly

higer an su gcal excsio

opical 5uorouraci is priaily reserved o reaeof su pecal BCC Howeve ecurrence aes are igh .

Phoodyac erapy produces a poocecal

reacon a requires e presence o a poosensizng agen ssue oxygen ad gh wi phooacvaing

waveeng e os coon opica phoosens izers 5anolevuliic acid (5ALA) 5AA is a precurso

of e i n insic iracell u a r e ebiosynec pawaywich resuls i e producio of a phooacive por

pyri prooporphyn . Te eyl dervave o 5 AALA eyl aoevuliic acd (MAL) s aso very

coony used ad deosaes a beer seecviy

or aliga cells . Te l g souces are usua y n evisbe ig rage ad ey incude ase (coeren)

g sources (eg pulsed dye lases) or oncohere

g sources (ed blue l g). Red g povides edeepes peerao of hese lg based reae

odali es P can provde 76% o 97% clearaceraes or supeficia l BCC. is paicuar y useul i

paens wo are poor surgca canddaes or ose who

have u iple BCCs ha requre u iple sugeries

Close cl in ca o owup afer reaen is required fo

any evdence of recurrece or icopee reoval

alesio al ineferon is arey perored

Cabo dioxide laseay be eecve for superfcial

BCC a d paiens w u p le sa ow uos such as

n basal cell nevus sydroe

PTFALLS TO AVOD

nfecion bleedg pan n erve daage poor cose

sis fol lowig su gcal epair yperopic or aopicscarr ig, and recurrece are al l coon pfa ls of

BCC surgcal eapy ad shoud be u ly discussed

wi e paie por o reae

Nonsurgca erapies ay provide beer cosess bu

sgnficanly iger raes o recurrece uerore

osugica nervenos do no provide e opporu

y o isoogical confirao of coplee reoval.

They are bes or paens wo have uerous BCCs

ad i ose wo are poor surgca c anddaes.

Fgure 52.3 (A) urgical defect aer Mohs micrgraphic surge of BCCon the right forehead (B) epair of the defect with an A to T advancement ap Notice that the horizontal incision line is hidden within theeyebw hairs for a better cosmetic outcome



BBLOGRAPHY

A i S K Lesar A cNe l A e a An op en p o sy o

a bulaory phooynaic herapy si ng a wearable ow

irraiance orgaic l gei ing iode ig sorce i hereaen o noeaoa ski cancer J Dem.

2009. ler F awe RS oseley F eg C Radoize coparison of ohs crographic surgery

and surgca exciso for sa odar basa ce carcnoa isse-sparing oucoe Dem S 2009

Rowe E Carrol RJ ay C Jr og er recrrence

raes n previously ureae (prary) basa cel carci

noa Ipcaions for pae fo low-up J Dem Sg. 199;535-32

Terney E Barker A Ahdo Han ke CW oy RKoba J Phooynaic erapy for e reaen of

caeos neoplasa nflaaory disorers ad pho

oagig Dem Sg. 2009;35(5)72574Wolf J Zie i JA Srgcal argis or basal cel carc

noa A em 197;2334034.


A

B

cFigure 52.4 (A) Nodua basa ce cacinoma on the e peauicuaaea (B) Ceaance of bas ce cacinoma ae Mohs suge

(C) Pimay cosue of the Mohs defect with dogea epai




CHAPER 53 Sqamous Ce Carcnoma

Sqaos ce carc ioa (SCC) os cooy or ig

aes o keraiocyes i s-daaged sk eie de

ovo o ro a preexsg acc keraosis or s s i(aso kow as Bowe's disease) predoiay aec

ig e ead eck ad ars. I ca aso aise i os-exposed sk os cooly ro croic eg

cers ad br scars.

EPDEMOLOY

Iee: s e secod os coo ski cacer

Cacasas ad e os coo ski cacer darkly

pgeed ski Appoxiaey 50000 cases/year aredagosed e ied Saes

Age: os co o i paes ove 55 yearsRae: ai y afecs Cacasia s

Sex iger ic idece i a es

reag ar: croic ravoe adiaio ad far

ski are e os sig ica predsposig acos. Oefacors c de iosuppress io ua pap loa

vs ecio iozig rada o arseic exposre

geec dsoders (epderodysplasia verucifoisa b i is xerodea pgeos epdeoys is b

losa) PVA expose sokig ad croc if laa io ( cers b scars d isco id ps)

PATHOENESS

e os coo a eed gee i SCC s e o

sppressor gee esl ig keaiocye ioa iza io ad ureglaed cell po feraio.

PHYSCAL EM NATON

Hyperkeraoic skicoored o eeaos papep aque o odu e (F igs . 53 ad 532) I ca be cer

aed friabe or exopyc os cooly preses

wi s-daaged ski .

DFERENTAL DANOSES

Keraoacaoa (Fig 533), ypeopc acic ke

aoss basa ce l cacioa (BCC) iflaed seboec

keaoss

Fgure 5 3 1 Inase squamou cell carcnoma on the rght nec

Figure 532 ecurrent squamous cell carcnoma on the chest o f an

elderly woman



LABORATORY DATA

Demaopahoogy

Proliferaon of aypical keranocyes wi variabe derena on o he epders and varably sized ness and

is lands invadng he deris Foc i of era n za ion are

noed n well-dferenaed varias Perneral ivolveen ay be observed

COURSE

SCC eds o be ore aggressive an BCC wih a

repored 2% o 3% icdence of easass cocaneos S CC as a ger rae of easasis as

g as % ore aggressve ors of SCC are observedin unosppressed paens or s a arses win

prevosly irradiaed ses scars brns and areas of

inflaaion Tere s a ger easac poenial for

s arising on he ear and e ip


Evalae for pas hisory o bl isering snbrns and

chronc su exposure eerie if oher pred sposing

acors are presen sc as personal and faily isory of

skin cancer and inosppression especal y organransplanaon

MANAGEMENT

Preveave easres sc as sn avodance and da ysnscree se are cri cal or longer prevenion

Treaen selecion sould be based pon he age

ealh ad preferences of e paien afer a fl discsson of reae opions rss and benefs Gven he

easaic poenial o s sologcal coniraion ofcopee reova is aways advised Surgical excsion

and sologica evaluaio rean e reaen of

choice i os cases Tuors fixed o nderlying boneespecia ly e scalp eri radologcal workp prior o

srgca excision or os icrograpic srgery Prior oreaen lyp node palpaion is appropriae or arge

s s n nosppressed paiens and hig-rskSCCs opica erapes reqre cose fol ow-p or anyevidence of reaen fai re or recrrence

F i rs-L e Therap es

Excsio na su rgery: 4- argins are general ly reco

ended

os crograpc surgery s e reaen of coce

or g-r s aaoica ocaions (ie, as" area of

e face) ocaons where issue coservaion is cr ca l


Figure 53.3 Giant keratoacanthoma on the chest Many authors regardkeratoacanthomas as variants of elldifferentiated squamous cellcarcinoma

AFigure 534 (A) efect on the ear aer Mohs excision of a squamous cellcarcinoma




or unciona or cosec reasons recurren uo rs i

dened cln ical argins h sologica y aggressive subypes uors n unosuppressed paiens uors

arger ha 2 ir rad ae skin ad per ieura nvasion o biopsy ( Figs. 53.4 an 53 .5 ) Cu re aes o SCC

depe on sze hisoogica grae perneural nvasio

and iuosuppression. arger esons less dierenaed varas wih perieural involvee and esions

n unocoprosed paiens eonsrae ower

cure raes

Eecrodessicaion and cureage (usually no reco

ene due o ac o hisologic conirao oreova)

Cryoherapy (usually no recoened ue o lack o

hisoogica coniraon o reova)

Rad oherapy (ap propriae or poor surgca can di aes)

• Aeae heap es opical 5uorouraci s e o SCC in siu

opica l q u i o is l ed o SCC in s iu

nalesion al inereron

Phoodynac erapy (P) using opical or sysecphoosensizers wh lasers or oncoeren red g

are os eecive or SCC n siu C leara nce aes range

ro 72% o 94%. PT can ac as an aernave reaen or large esos especially or hose paens who

are poor surgca c andid aes can serve as an a erna ve reae paiens wi u ip le SCCs For ese

paens PT an close c n cal ol ow-up ay obviae

he eed or uipe surgeries PT s aso eecive ordecreasig he nu ber o acn c eraosis us acing

as a prevenave o uure s evelope

Carbo d oxe laser is h ighy eecive or acini c chei l i s can a so be used o rea SCC s u

PTFALLS TO AVOD

Inecion beeng nerve daage pan yperropc

scarr ing poor cosess o lowng surgca repair and

recurrence are a co on pa s o SCC reaen a

sou d be u ly d scusse wi he pa en pr io r o reaen. Nonsurgcal erapies ay provie beer cose

ss bu sgniicany igher raes o recurrence.uherore nonsurgical inervenons do no provide

he op porun y or h soogica coraion o cop lee

reova . Th is s parcul ar y crucial gve he poenial oeasaic sprea wh SCC Tus sanard or Mohs

i crograp hic su rgical excsion wih hisoogica conir aion o clear argns s al ways e reaen o choce or

BFgure 534 (Continue {8) The Mohs defect is repaired ith a

fullthickness skin gra

s AFgure 53.5 {A) urgical defect aer Mohs micrgraphic surge of an on the lef cheek



BBLOGRAPHY

Covadonga M arnez-Gonzez M , de Pozo J, Paradela S

ernnez-Jorge B ernnez-ores R, Fonseca EBowen's disease reaed by carbon doxide aser A seres

of 44 pai ens J Drmalg ra 20089(5)293299

Moon CA McKenna KE Rodes LE. Bri s Associaionof eraologss Terapy Gudelines an Audi

Subcoiee ad e Br is Pooeraoogy Group.

Gudeies o opca pooynaic erapy: pa rJ Drmal 200859(6)245246

Preson S Sern RS. Non elan oa cancers of e ski n g/ J M. 992327649662

Rowe E, C arrol RJ ay CL Jr. P rognosic facors fo

local recurence easasis, and srviva aes in squaous ce l l cac oa o e skn , ear, an i p . p ica os

or reae oay seecion J Am Aa Drmal.992;26:976990


B

cFgure 53.5 (Continue (B) The Mhs defect is repaired with a traspsiti flap (C) Ater suture remval 1 week later






IEInfammaoy Disoders




CHAPER 54 chen anus

Lche paus (LP) s a coo aaoy dsease

ivolvg e sk ad cous ebraes a y c i i ca l

varas exs ha clde aropc lcerave b lousauar ear iverse hyperrophic l chen paopilar s

acc P ad LP pigeoss

EPDEMOLOGY

Abo 05%

g: 30 o 60 years

Ra: All races are aeced eqally os varas

Sx Higer cdece i eales

rg ars: os cooly id iopah ic edica

os ay dce a LP- ike erupo

PATHOGENESS

Pri ai ly a he per ce ed aed reaco

PHYSCAL XMNATON

os cooly piay lesios consis o uiple vioa

ceos poygoa la-opped grouped papules ad

plaques ha are sal y pur ic heir surace s shiy or

aspare ad ay exhbi sal gaywhe pcae or

reicar ie whie ies kow as Wckha's srae Telesios avor he oroparyx exal wrss dorsa hads

edial hghs s s r k a d geal a . Posaaoyhyperpigeaion is coon. Aciic LP ad LP pge

osus ca prese w easa-ike hyperpigeed

paches o he oreead ad he ace ( Figs. 54. 54. 3)

D ERENTAL DAGNOS S

Psoriass che splex l icheoid gra-verss-hos ds

ease chroc caeos ups eryheaoss l cheod

drug erup io elasa

BORATORY DATA

Gve he assocao wih hepa is B ad C hepai s

serologes ca be vesigaed

• Dematopathoogy

Pahology reveals l icheoid ieace dera is hypek

eraosis ypegrauosis saw-oo acahoss associaed wih col o id o r civae bodes

Figure 54.1 Actnc LP on the forehed temples, nd lterl cheekmmckng melsma



COURSE

Sponaeous reission of cuaeous P occurs wihin

year of onse in he aory of paens Ora LP pesiss

or any years Sq ao s ce c arcinoa ay arse fo

hese lesions predoanly fro e oral varian

(F g 544)

MANAGEMEN

• Topica Teamet

Coricoserods opica nralesional

l u ooduaors such as acro l i us

Cycosporne reeion ohwas for ora P

• Sysem c Teamet

Coricoserods Re ino ids : isore io in and ac ire in Ac re in is he

only sysec eaen ha has been evaaed in a

doubleb nd p laceboconro l led sudy

Griseolvn eronidazoe aniaar ia s eorex

ae cycosporne a d ycopeoae ofe l

• Ligh Teame

Narrow Band VB

PVA

308 VB excie aser for oral P

C aser for oral LP: vaiabe resuls wih ncreased

risks of sde eecs

Exracorporea phooporesis

BBLOGRAPHY

aak A asoudi A Boudaya S Bouassda S

arekch S Turki Ch ldood ac in ic ichen planus

(6 cases) [p b shed on ne ahead of pr in Januar 8,2008 Ar ediar. 2 008 5(2 ) : 4

Laurberg G Geige J orh , e al reaen of

l cen paus wih aciren A doubleblid placeboconroled sudy n 65 paens Am Aad Derma99;24(3) :434437

Trehan Tayor C R Low-dose excie r 308 laser for

he reae of ora cen panus Ar Derma2004; 40(4) :4 5420

van de He PS Egges M van der Wal JE Roodeburg

J C laser evaporaon o ora ichen paus raaxila Srg. 200837(7)630633

Secon Inf lammaory Dsorders 263

Fgure 54.2 Generaized lichen planus in a patient ith skin type 1 VV

invoving the trunk and buttocks ith postinammato hyperpigmentation

Figue 54.3 Hypertphic lichen panus on the legs of 4 years durationresistant to topica and intraesiona steroid therap The patientimproved markedly aer 1 month treatmen t ith acetretin




A

BFigure 54.4 (A) Ora/ lichen planus at baseline (B) Two month followupafter 1 treatmen ts with excimer laser admin istered weekly Courtesy of

Charles Taylor, M



CHAPTER 55 Morphea

orphea s ocalzed sclerodera cofied o he sk.

os cooly affecs e ru k bu also occ rs o he

ace ad exrei es. Te for c ica varias cludepaqueype orpea geera ized orpea iear or

pea (e coup de sabre) ad pascleroic orpea ofch dre (orpea proda) .

EPDOLOGY

iee rare

Age os cooly occurs he secod o ff

decade. iear scerodera ad orpea profuda are


ore coo i c i dre ARae slgly ore coo i Caucasias

Sex eaes o re a ales (23 : )

reiiig aors orrelia ca r gger orpea i

soe cases predoay i Europe

PAHOGENESS

Overproduc io of co l lage (ypes , I l l ) ad gly

cosaioglycas by sk fibroblass ad vascuar daage Probable Tcel edaed peoeo.

PHYSCAL EXNATONI defed p k o v io laceos iduraed 2 o 5c

paques a rasor o soo scleroic vorycolored

plaques wih a g voaceous border ad a siy sur

ace Posflaaory yperpgeao is prevae

(Fg 55). iear orpea preses wi a ear eryeaous iflaaory sreak a ay progress o for a

scar ike bad volv ig uder y g fasc a scle adedos.

DERENTAL DAGNOSES

Acrodera is croica arophcas eosiophil ic asci s ce scerosus e aropcus scleredea sce

royxedea a d ep rogec syseic fibrosis

LABORATORY DATA

Seroogy

Ceck for Borrel a aibodes.

Bigure 551 (A) Early morphea on the let leg presenting as an ethematous plaque (B) ame patient with late stage morphea on the right legpresenting as linear depressed yellowish to white hard plaques with ethematous margins




• Dematopathoogy

Homogezaion and hickeng o erma colage bu

des apped and arophic eccine gads perivasclarmonocear inf lrate o lyhocyes ad asma cells

wih norma or aroic over ly ig edermis ner ly ing

subcaneos fat may aso be nvoved wit scleross iadvanced cases

COURSE

Course is vaiabe. Many paies remit soaneously

bt oers have a rogessve course.

MANAGEMENT

reatmen or this conit ion can be rusaing ue o re

qen reatme fai re Paens shoud be couseled

that era y ay ot be eectve

opical treament

Cocoseroids

Calcpot ee

Systemic reatme

Coicoseroids penciane vitan ethotrexate

Lght reate

ravolet A ooheapy

Plsed ye lase (585 n 5 J/cm twice monly)

repoted to be efective n s ngle cas e report

Subcs on : subcis o wit a okor 18G needle mayhep o eevate the bound-down skin It s most efecve for l ear orpea and facia hearohy

Subcsio is pefored under loca ini trat ve aneste

sa to he afeced ste wit % l idocaie wih

:00000 epinephr e . Te Nokor neede s inro

duced at a 45degee age into te skin i l zing a

sweeping moio o eease any eheed areas.

Mu ipe enrance sites soud be eomed or opi

a benefit r pressre is aplied to te treatment

stes or emosasis

Sof tissue agmetaion: varous fi es ave bee

emloyed wh varabe success to augmen e scerotc sies. Tey are most commoly l ized fo l inearophea an d acia hemi atropy Tepoar i l le rs cu

rently recomm ende give e unp red cable course o

ophea. Atologous at asfer can povde significant augmentation of e afected sies (g 55.2)

Repeat iections genea y equred En bloc atoogous derma a gat repoe o be efecive in one

case repo

A

BFigure 55.2 (A) Morhea wth sgnfcant edermal dermal and subcutaneous atrhy 8 Elevaton of the atrhc laque of morhea aer asngle autologous fat transfe The assocated telangectasas were subsequently treated wth the ulsed dye laser wth substantal mrovement



P TFALL TO AVO D

Paens ms be awae o he nredcable nae o mo

hea, hereore he nredcabe nae o e eame

BBLOGRAPHY

Esen , Alser S se o 585 nm sed dye lase ohe eamen o morhea Dermal Sr 2002;28(7)

6566

Laiee JC Aasi S Cook B Moao A Sccessl cor

recion o deessed scars o he oehead seconday o

ama and morhea en co de sabe by e boc aologos dema a gra Dermal Sr 200026(8)793-

797

Nisic SP Saaceno R, Sciani C, Cosazo A,

Chmeni S een alcaios o monochromac

excme l gh in skn diseases Pme aser Sr

2009;27(4)647654

CHAPTER 56 Psoass

Psoiass s a commo choc n ammaoy dsease ohe skin They are symmeic in ds ibo and ao

ebows, knees, sca, reroaica sk and ner iginos aeas May cl in ical arians exis and incdeaqe sorass sa soasis, gae soiass,

inerse soass, and eyrodemic sorass, wh he

aqe aria being e mos common ye (gs 56

and 562) Na i ls and mcos membanes can be

aeced Psorasis is associaed wh soriac arhis ina eas 5% o aens

EPDEOLOGY

cece Abo 1 5% o 2% o he word 's olaio

Age can occ a any age Two eas o onse, he second and sixh decades Onse s ear ie in women

U ncomm ony aecs chi ld re

Race owe ncidence in Aican Ameicans, aie

Amer icans, and Asas

Sex eqa

Precg acrs baceal necions, esecaly seococca ineco (gae sorasis) ama (Koebner he

nomenon), sess genec edisosion, and medicaionse (mos commonly ihim bea blockes aimaaals)

Ra id coicoseroid aers may in dce sar soriasis


igure 56.1 Claic poriatic plaque on the knee




PATHOGENESS

Poygenc dsease wih a 4% isk fo a ch ld o develop

psoiass boh he paens ae aeced he piaypahophysoogy nvoves hypepofeaion and abno

a difeeniaon of epidea keainoces as we as

abnoal ce l u la im un e espose

PHYSCAL EXAMNATON

Paque vaian wih welldeacaed pn o eea

ous papules ad paques wih ovelyig si veywiescae Pinpoin bleeding obseved wih scae eoval

(Ausptz sign) Guae vaian wih ea dopshaped

lesons Eheaos genealized pusues ae seen whpsula psoass

DFFERENTAL AGNOSES

inea copois sebohec deai is eczemaos de

ai is ycosis fugodes paapsoass chen smpexchonics piy ass uba pi a is Ree's dsease

Bowen's disease

ABORATORY DATA

• Serology

Ansepolysi O(ASO) ie fo guae psoasis

• Dematopathoogy

Regua psoiasifo epdea hypepasa wih absen

ganu la ce l l laye ad h ni ng above the deal pap lae Ohe chaaceis ic feaues incude colecos of

neuopi s in epde mis as well as ouous blood vessels

in e pap lay des

COURSE

h s dsease deonsaes a chon c couse wi u ip le

exacebaions and essons wich can be seasonal o

eaed o sess

MANAGEMENT

hee ae mul pe heapeuic opions fo eamen o

psoiasis Coosng an appopiae heapy depends onhe age eah ad pefeences of he paten It a so

depe ds o he exent of he psoias s Te coss of he

apy vay damacal ly as wel Aenaive theapies aeos appop iae efacory cases Assessng he side

efec pofle of eamens is anohe cucal componen

Figure 56.2 Psoriatic plaques koebnerizing vitiligo patches



o theray Combiatio terapes are geeraly most

eectve to decrease ilammato a reuce scae roduct io

opca reatmet

Coicosterods toica a itraesioal

Calcipotiee

Tazarotee

Coa tar

Athra l i

Sal cy ic ac

Systemc Treatmet

Metorexate

Retods redomaety acitret

Cycosore

Bioogcs suc as aleacept etaercept eauzimab,

ad i x mab

Laser ad igt Treatmets

sorae wt ltravoet A (PVA

ltrav io et B (V) 3nm arowbaVB (B

V

308-m VB excimer laser

A ateative or treatmet o mdtomoerate

soriasis where more covetoa t eraies havefailed It s eseciay hepfu fo localze eractory

aque soriass

Studes ave emostrate that tis ocalize VBtreatmet provides muc lower cumulative doses o

VB to uce clearace o soriat c laques compare to BVB te rapy

The exci mer laser migt also produce oge rems

sio eriods wth m i im izato o VB exosure tohealthy surrouig sk

Excme aser has proved to be eective a sae i

treatig reracto scal psoriass

rawbacks of excme aser sorasis teatmet

clude l mted ava labi ty treatmet exese a

extes ive treatmet tme eee e sessio

hotoyami c therapy has bee sh ow to m rove so

riasis i mult le stues The maor side efectsic luded pa ad burig sesat io assocated witT

ulsed ye aser (0455 ms 7mm sot 79 J/cm

C 30/20) has bee empoyed to target the vas

cularity associated wit soiatic esos with ote

beeit I a ecet study L roved to be eective

t e treatmet o a l soras s ( ig 563)

a recet study AG lase (064 m) ai le to

im ove local ized paq ue type soriass


T

Fgue 563 Improemen t in treated psoriatic plaque months after

pulsed dye laser treatme nt 55 nm, 1 0mm spot size, 5 Jm, no cooling, 0 45ms pulse duration, as compared to the con trol siteeproduced, with permission, from rian Zelickson, M




PTFALS

Patiens sou d be couseed at psoiasis is a cronc

condi ion wi lares ad reissions Laser terapysuc as te excie aser s a aeaive treaent

ha sould ony be considered aer a paen has ailed

u lt ipl e oher reaen regimens

Patiens shoud be awae a any treate adiis

ered i ay esu in spread o e psoasis (Koeber

penom enon) Tey sould a so be aware ha surgicalreatens peormed or any reason ay also resu in

s ii a spread .

BBLOGRAPHY

ernndez-Guar no M Haro A Snchez-Ronco M

Garca-Moraes , Jan P Pused dye ase vs poody

naic erapy in te treate o reracoy nail psoria

sis A coparave pilo study J Eur Acad DermalVenerel 200923(8)89895

Gattu S Rash id RM Wu JJ 308-n exce lase n

psoiasis vugaris scalp psoiasis and paloplantar pso

r ias is J EurAcad Dermal Venerel 200923() 36-4.

Noborio R Kuokawa M Kobayasi Moia AEvauat ion o e c l in ica and im uno iso ogica eicacy

o the 585 pulsed dye laser in he treaent o psoras is J Eur Acad Dermal Venel 200923(4)420

424

Ss T Kepennng MM va Erp PE va de KerkoPC Gerr sen MJ A paceboconro led randoized

sudy o e cl n ica eeciveness iunoisocheicalchanges ad prooporpyrin I accuulaion in acton

aed 5ainoaevuln ic acdphoodynaic herapy n

patens wi psoriasis Br J Dermal 200655(2) 429436

aylor CR Racee A. A 308-n exce laser or thetreaent o scalp psorasis. Lasers Surg Med

200434(2) 136-140.

Van ingen RG de Jong EM van Ep PE va M eeerenWS van De Kerkho PC Seyger MM Nd AG laser

(064 ) a s to ipove loca zed plaque type psoa

s is A c l in ica ad unosocheica l p i lo sudy

[pu bl ished o n i ne ahead o pr i Ocober 27 2008] EurJ Derma l 2008 8(6) 67 -676



TEN

Ad pose T ssue A l terations








• Sugey

I n e even o edc a reaen a l ue s gcal era

is e nex oon I is reserved or aens w reacor gnecoasia a has ailed edca era he

reaens deen d o he exen o gnecoasa A ew

oons are descrbed beow

Sugca excsion incldng sadard el ical excision

as we as subcuaeous maseco

Conveniona and lrasoundasssed ioscion a

s ocalzed eova o gland ua r issue and/or excess

a Tis is arcal successul in ear sage and ied gnecomasa

Losucon is eormed hrough small cis ons n

e ax la and sernu o n ze scar r ing

Losucon is less eecive n ongsandi g and s ubsaial gecomasia

n rosae cace aiens earier erveion s

ore ecacous

Resdu a eraeolar a a be noed osl osucon

a ca be imroved w loca ized dissecon o a

v ia a sma l er areo ar nc s o

Posrocedue skin laxi a be noed

Cobnaion o surgica excisio and uescen l o

sucion is nvoves l iosuco, oen excson adskin reducon o ax osuco as also been

comb ned wi s bcuaneous aseco

Sugica excisio wih lasic surgical rea , ar ic

a r i n he eve o breas issue saggi g Excessive a,

gla du ar issue, and loose skn ae excsed va el l icalexc is on nc lud ng e i e ad areola e

ni le/areoa co ex is e aced e aroriaeanaoic os ion as a u l ck ness skn gra ae e

excess ga nd la sse s eoved

Psuedognecoasia ca be reaed wih liosuconMale breas a ends o be elaive ibrous ad s

ore dcul o rea uher care us be aken oavoid nur o e ecoralis scle n rue gnecos

asa excess glan du ar issue enders e rocedure

even ore calenging

We adi oa iosucio and umescen osucion

have domnaed losucon reaen o gnecoasiaand seudognecoasa laseassised iosucon s

a ecen add io o s e d Tee is no evidece o

sow a laserassised iosucon is sueor o eiero ese os o i osucio n

P TFALLS TO AVO D/CO PL CAT ON S/ANAGEENT/OUTCOEEXPECTATONS

s oan o recognze ha gnecoasa a s ml

e eooges beore aeing o rea i



n mos cases wacu waing s e bes heap.

n cases o an unde rlig ssemc ca use eerra o e

ap opae specia is s man daed

n cases o drugnduced gnecomasia dsconua

ion o e medcaion is e bes managemen.

n case s o eraco o me dica ma ageme hee areseveral surgcal opions Compicaions rom ese o

cedures incude a poor cosmeic esu osoperavescarrng incomplee eova posprocede skin laxi

peane numbness n e aea and eaoma o

a on

BBLOGRAPHY

Asan G Tuncal i D Ter ogl A B ngu l F . Per iaeo la

ransareoarpeeal incision o e sugca reaeno gnecomasia Ann Plast Surg 200554(2) 30-34.

Bebo SA Cason Gnecoasia Is eaures andwen and ow o ea i. Clee Clin Med 2004;(6) 5 5

Gabra O Morabio A B iac A Bowe

Gnaecomasa n e adolescen A sugica reevancond ion Eur Pediatr Sur 20044() 36

Gaseon C Sagael o M Gasperon P. Technca eine

mens in e srgical reamen o gnecomasia. Ann

Plast Sur 200044(4)455-458

lwuagwu OC Cave A ll sle D Drew P . U lrasound

guded mn mal invas ive beas suger (UMIBS) Asuperor ecnique or gecomasia Ann Past Surg

2004;52(2) 31 33Rohr c R a R Kenke M Adams WP r .

Class icaion and managemen o gecomasia

Den ng e roe o ulrasound asssed l i posucon Plast

Reconstr Sur 2003 (2 ) 909923.

Gra R Auersva d A Damaso RC Rippel R de Arajo

LR Bigae i H Franck CL lasound-asssed l posucon: A anass o 348 cases Aesthetic Plast Surg

2003;2( 2) 461 53

Zeckson BD Dessel TD Discssion o aseassisedloscon. Lasers Surg Med 20094(0)0993.

Secion 1 : Adipose Tssue Aleaons 275






I maes qu re as o a poss b l i o edocr ie abo

malies Ts is a ve ae assocao of celle males .

MANAGEMEN

Tere is o medca dicaio o ea ce l l ie S l l ma

paies reques herap Crrel here ae meosprpored erapies oe of whc ave prove o be

ver eecive. Ieresigl despie e ack o scecevde ce of im poveme ma paies repo sbecve

im proveme a d sasfacio wi erap

TREATMENTS

• Det

Weig has ol a mi o associaio wih cell u l ie

s commo femaes ad rae i obese maes

ee s o daa o sow a de ad exercse are

eecve eames

• Topca Treaets

Amoph l ie e o ids lac c ac id xa es adma oers have a bee sed w i le evidece o

ecac

Some ceam s ma podce moe ham a bene

fac oe sd dicaed 25% of ceue creamsexam ed coaed kow coac al erges

• I tervet oa I Treatets

Lposucton

ee are a few pbised epors o mproveme

owever pical i does o improve celuie

some cases acceaes he appearace o cel

i e

Prio o perform g a l posco procedure i s se

o orm paies ha er ce u e w l l o esolveThi s wil proec agai s pospoced re disappoi me

Endemooge

demologe is a FA cleaed devce o mprove he

appearace o ce e

Ski is keaded b a had eld machi e

i s rol led over aeced a reas of he bod a are cov

ered b a o s

prpos o mprove bood ad lmp ac fow as we l

as sk a rchiecre


Figure 5.2 Velamooth laser treatment of thigh of young female




wce weekly teatmes of 10 o 45 mintes eac ae

ecommended

hee is a ie evde nce to sp po s efficacy

Subcis on

Req es oca aestesa

Usin g a scapel o special 16gauge neede he fa septae are c n e deep su bctaeos fa

Sde effecs icde pa bsing sca and puckeig

Lie data to sp po tempoa y eicacy

MesotherapyPospha idy co ne in ec ions ot a ecommended

herapy

neco of combinatons of igedents decty nosbcaneos fat

Phosphatidyco i ne and deoxycholae peparaios ae

mos commony used

eoxychoate s the acve gredie

No publised data o show efficacy

aser

VeaSmooh system (Syneon nc Rchmond Hi l l Oario Canada) combes neanfrared ight a a

waveength o 700 o ,000 m coninos-wave ado

freqecy ad mechanca scion (Fg 58)

Twce weekl y reatmes for a ota o f eght to ten ses

sions have been ecommended

Thee ae o long-em daa o spo is effcacy ipaiens

e TrAcive asedeolo (Cynose I nc Chel msod

Massacses) com bi nes six neanfared d iode asers a

a waveengh of 810 m locaized coolg and mecha

cal massage

Three weekly eamens for weeks and then

bweeky teatments fo 5 weeks ae sggested

Thee ae no long-em daa o spo is ecacy i

paiens

Oter FA cleaed devices iclde a nipoa adiofe

qency device (Alma Accent A ma c Buffalo G oveIll ) ad a dal waveegt laser sysem (SmootShapes

Eleme Medca Inc Merimack New Hampse)

PTFALS TO AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS

Paes so ld be i nfomed tha hee ae o ly eec

tive eames for cell ie t is also mpoan to ds n

gish teaments fo body conog and fat emovafom hose of cellie Mos of he posive esls reaing

to cellu l ie treamen ae aecdota o repoted n sma






CHAPER 59 V Lpodystrophy/Faca poatrophy

HI liodsro descibes a coselaio o chages i

subcaeous ad visceral a dis ibuio aies o

areovira heap dscio o l poaro"(wic descrbes local a loss) liodsro reers o

bo he accu u lao o a as well as he oss o a ioer areas I HI l iosroh he idigs icde sb

cuaeous a loss i e alar ad bccal a ads eaca l i oaoph as we as o e exremi es I a lso ea

res a accuulao o he dorsocevcal a ad( g 59 ) e balo hum p breass ad raabdoia l

cav s caraceis ic apearace s sigica i h a i

reduces aie coliace wi airerovira eraad derives aies o HI saus ivac paricularl i

comu es were I raes are ig s disoder isaso associaed w a hos o meaboic disorders wi

logerm iac o eah cdig ergcea Aherl deia ad eriglcerdema reaesvar accord g o e c ica digs

EPDEMOLOGY

cdece: 25% o 83% o aes reaed wi a rero

vias deed g o crier a used

e A ages b u older age is redcve o seve

Race: Noe

Sex Eqa severe d igs more reque i eales

PRECPTATNG FACTORS

Arerovra eraies are e recpiag acor. I aso

preses requel i HI aies ave o I er

a Tica aies are o combaio eraies.

PATHOGENESS

Pahogeess reais u kow I i s a u iacoria l dis

orde ha vaies accordg o e ed caios ake .

DERMATOPATHOLOGY

Coee o ear coee loss o a Jxaosiio o

he deris ad ascia ma be see Adioces ae

aked redced ber ad s ize

PHYSCAL ESONS

a accu mu laio a d a loss are disp laed

a accmuao

Figure 59.1 (A) "uffalo hump n dorsocervcal back of HI V-nfectedmale (8) ubstantal reducton n se of buffalo h ump after lposuctonpcedure



Dorsocervcal at pad, ie, ualo hp

Beasts

Intra-abdonal cavi e Crx bell

a l oss

Mal ar ad bcca fat pads

Exeites and buocks

D ERENTA DAGNOSS

er ipodstrophes facial l poatroph fro agng IVwastg sdroe C si ngs disease, al uit o sates

anoexa nevosa etabolic sndoe cacexa sec

onda to cancer aasoption sndoes, otoxico

ss, and ut pe setic poatosis

LABORATORY EAMNATON

Bio ps s not sefl e c n cal n di gs ae sfc e toake a dagoss. Laorato wokup shod clde

assesset of bood gcose l pids ad tr gcedes f

Csig's s cl in ica sspected aoator exaaio

soud be pefored

COURSE

IV lipodstop does o spotaneous egress i eabsence of treate o edcato cage


Medcatio se

Cop iance

HIV staus

Du aton of podstopr

Associated peglceia pe ipdea, ad pe

tr iglceideia

PREVENTON

ce a patie as ee teaed for t e IV vus, thee so pevetion o IV l i podstop

MANAGEMENT

Cosetc poveent can e essetia to prootg a

patets aderece to ter V ed icato regi e ere

ae severa eans wich te cosetc appeaace of

IV l pdstop can be proved ese inc de edca

tio changes fil ler sstances and liposuction Diet adexercise can e hepfl boh or cosesis ad etabolc

Secion 1: Adipose Tssue Aleaons 281




deangemes. eaing te meaboc deagemens s

bes efeed o ysicians sklled in eag hyelidemia yeiglycedema and nsuin essance.

TREATMENTS

hee ae sevea eamens a can imove hecosmetc aeaance of hese dsodes. They can bedvided ino wo secions eament o l ioaohy and

eamen o a accum ulato n. Add i ional ly ca nges i n

medica os ca n b e usued. h s s bes entused o a

hysician who secializes in he cae o aies with HIV.

• O r a M e i c a i o s

A chages to a a netoval egime n ae bes handed

by hysicians who seca ze HIV eame hese

changes ca move he aeaance of HIV odyso

hy edicao chages icude scontn uance o f aneova heay

Obvous sks of disconinung medcaions fo a l ife

heateng less

Change HIV medicaions

Oe HIV medicaions oduce he same cod io

Some aeovas have a owe incdence of

iodysohy

• Teame of Fac a l i poaopy

Temporary fi ers PolyLacic ac d Scul a s A c eaed o he ea

men of HV faca l l oaohy

Syeic bodegadabe oyme

he mateial used n Vicyl suues

Sevea eamens ae equied deedng on sevey of ioaohy

Benefs ae o seen u weeks ae eac teament

8 o 24 moth d uao of f l e maeal

No need fo al legy esing

Calcium ydoxylaaie Radiesee s A cleaed ohe eame of HIV aca l oaohy

m mediae coecon

uaion u o 8 mons

No need fo all egy tesing

Permanen fi ers

S l icoe

No A cleaed

A highy uf ied 000cS s icon o has been exam

n ed in 7 7 aens






acial plastc sugcal proceures ca be eectie, but

reqi e ao i ase srge wt ts aedat r sk s oobity Tee s also iceased ow t e, pai, a

te r isk o geera l aesesia

BBLOGRAPHYBox Po ly act ic ac i pas A ew s e or l ipoatrophic aces?AIDS 2003 7 7 ) 2533-2535

Carrutes A, Carutes J Eaatio o ectabe ca

cum yoxyapatie o te reate o acia l l i poaropy assocate wi a iuodececy us

Dermaol Sur 200834 ) 486-499

Carrutes A ebesk , Carthes oster B

Radiograpic a copute toograpc stuies o ca

cum ydoxyapatite o eate o associatedaca poatopy ad coectio o asoabal olds

Dermaol Sur 200834Supp S78-S4

Conol ly , Maders E R d le S Shot cou icat o:Sctio-assse lpectoy o lipoystropy AIDS Res

Hum Rerviruses 2004208)8385

Haiga C Yawe S, Toas A, aers , Sax PE,Gispoo S etaboc eecs o osig itazoe i

ipoysopy A raoze, corol le tr a Ann Ine

Med 2004786-794

oes , Cates A, Oere c e a g ly p

ie 000 st s l ico o i l or treatet o ha i m u

odeicecy irusassocate aca l ipoatropy: A ope

p ot t ia l Dermaol Sur 2004300)279286

Koutkia P Caaa B, Beu J To iai , Kissko Grispoo S Growt omoe-eleasg oror

iected e wit l ipoystophy: A raomized cotro ed t ia l JAMA 20042922) 2028

Ley RM Redbo KP, ake CW Treatet o

lipoatopy ad l poaropy o agig wit poly--Iacc

aci a prospectie 3year ollowup stdy J Am Acad

Dermaol 2008596)923-933

Pileo P bbad , g J, arago J se o ulta

soogapyassiste iposuctio or te teaet o

ua muoeiciecy irus-associate elagemeto te dorsocecal at pad Clin Infec Dis 200337:

374377eggaa , Bauer ac ia eaceet ad teEuropea expeiece wit Sclpra polyLIacc aci)

J Drugs Dermaol 200435)542547




CHAPTER 60 Stiae Dstensae

Strae istesae moe commol kow as setch

maks" ae atoic ear bas o ski tha apear

ae cea recptating actos sch as pregacsteo use a amatc canges n weight o muscle

mass (g 60 1) A esetaton the eatre a pu le op k coo (st ae uba) at aes to a aer whie (st iae

a ba) over t ime. The ae most commo a ut women.

EPDEOLOGY

iee common

Age pube pregac

Rae moe commo in Caucasias

Sex emales > males (associate wth ubet a preganc)

reiiig ar toica a ora seroi use ACushgs snrome reganc breasteeig ubegeetic colage eecs a ramatic canges i

weght height o m usce mass

PAHOGENESS

Thee are changes in the extracellu la ermal matrix

inc ing ibr i i e last an co l agen res lt g rom

rooge sretchng o the ski

PAHOLOGY

Thee ae sca-ke eatures cal ee s a atrohic

ee rmis wit h arow coage bu les aage aa e

to the skin surace. e ete riges are eace earlst ae there is a supeca eep a n ntest ia l lm ho

ctc pervasclar i i trate a occasoa eosioh ls The i n lae aes i oe es os.

PHYSCAL LESONS

u t ip le smmetric near ban-l ike laq ues o atohcskin that esent mos commo the oute thighsbreasts an bttocks o wome a log the l i es o cleav

age The resent wi a pik/ure hue (str iae rubra)an become aler wit e wkl g ove t ime (str ae

aba) Str iae are largest a mos abuat i patets

with Cshigs sease. In regac stiae ae mostabuat o he abomen. weght ites the ae

mos romie o he souers. Topica cotcoseroiuse most common oces st ae o the ace geni

tal i a lexual aeas a bo os

BFigue 601 (A) triae alba at baeline (B) triae alba at 1 1 month

follow-up aer four treatment with a 1 450-nm diode laermoothbeam Candela Corp ayland M at energy etting of 1 to

1 4 J! uing a 6mm pot ize with a pule duration of 0 m

Treatment wa performed at interval of to month




D ERENTAL DAGNOSS

Lnear oca el astoss

LABORATORY EMNATON

he characers c cl in ica appeaance o str ae negatesany need or sk biopsy. Addtona aboatoy workup torle o Cshngs dsease s ndicate in te appropriae

cin ical sett ng

COURS

Str ae begn as pink o purple atop c es ions at

becoe pae and less obvos over t ime

KEY CONS ULTAVE QU ESTON S

rat on

Skin pootype

Pregnancy

Assess or sypos o Cs ng's d isease

Use o cortcosteods

H stoy o wegt c ange

H stoy o weg litin g

MANAGEMNT

hee is no edca n icaton o treat stiae St l l a nyind vid als are signiicany botered by ter appeaance

and request treatment hee ae nerous optios to

treat stiae. notun aey non e o e teatents is copetey sccess n ac ost teaents provde o

es o o beneit hs pro to eatmen patientsexpectaions need o be epeed Cobnaton eat

ent volving laser an topcal regimens sc as

tretnon s oten a hepl method o eatme Moereceny nonablative and ablaive actiona eatents

have eerged. Founatey te appearance, paticlaythe color o striae poves wit e Patets w skn

photoypes espond bette than those wit types

IVVI to laser the apy est stes p ro to therapy a re ec

oeded hee is soe data to show tat eates

impove siae ove noninteentio he ist prioity s toesabsh whete stra rbra o stra alba are being

treated as ter teaens er signiicanty

TRATM EN (Fig 60 2)

Sria bra te psed dye ase (585 n ) wit a 7 o 10m spot size and 2 to 4 /c uece as been sown

to ipove the eea o striae bt s associated wit

A

BFigure 60.2 (A) White striae axilla Pminent atrph textural changesand depigmentation are obsered (B) White striae axilla following threefractional resurfacing laser treatments Mild improement of the atphyand textural changes are noted Mild postinammato hyperpigmenta

tion is observed which resoled wees after the last laser treatment



e risk of ypepgmeo i dke sk ooypes

A clcl edpoin of deep eye or ig pu soil In or exeriece owe flences re more sc

cess n ge fuences g 63)

lsed dye lse emens do i le if nyg oim ove e exue n d ropy of sie

I ovee cn be see even n cses of poo in i i l esponse 6 o s fe een

Sdies ecommed gns reing skin pooyes

VVI

Some d css doub on e eeciveness of ulseddye lse

Si lb onblve rcionl esufcng s been

sown o povide some benefi for sie be Sudessow ge o efficcy w ese emes

Secion 1: Adipose Tssue Aleaons 287

Tee is ie d o sgges wee dee d ep g Acoverge remens e moe effecive n ower de

lower coverge emens In o experience mospens see odes benei fom emen A mioriysees more sgnficn ress

Soulsed erbim:AG nd C sers c be mod

esly efecve b e o onger comoy used de osuc side eecs s proonged dicl eling d

pgmenry lero ey re no ecomended

e excmer se 38 m) s been exmied for

emen of srie b d scrs n 3 dls

Temens begn e Mnim Eyem oseE s 5 /cm o eced res nd wee

peormed biweeky fo weeks An povee n

co lo io by v su sec on 67%) nd coor ieic nyss 1%) ws noed nd coreled

sogy w e numbe of eens efomed Te

pgmen corecon owever euned cose o bsene

fer 6o fol owup o bl iseing o pigmery

dsbnces wee noed

TOPCA TREATM ENT

Erly s ie

Treno in %) ce cn mrove e p perce

of s e cully erly s ie wile decresing

ei eg d wid Mre srie

Treo n 5% ) d 2% glycoli c cid cn im povesie

Gyco c c id 2%) d % Lscob ic c id cn

im ove s e

MCRODERMABRASON

Micodebson cn poduce sml mpovemen

e six o e emens Mcodebson cn so

BFgure 60.3 (A) Numerous striae rubra and alba on the abdomen of ayoung woman (8) Immediate endpoint of purpura following low energshort pulse duration treatment with a pulsed dye laser





ELEVEN

Wound Healing Alteraions




CHAPER 61 ypertropc Scars, Keods, and Acne Scars

NTROUCTON

Hyperophic scas ad keoids a re boh ch aracerzed by

excess fibros isse a a sie of ry in he skn

Hyperrophic scas are cofied o h e oiginal ou d

se hereas eoids by coas exed beyod he

o ig ia l oud s e (Tab e 6 ) Boh ae coon ad

reqenly disurb paes greay bo as a usighly

sca as ell as a emi der of prevous ra a o r srgeAce scars resu fo he loss o udelyig coage

ad easic sse fro deral in amao assocaed

ih ace par icuar y cysc ace. Ace scars ae aso

very co o a d a sou ce o dsress o he pae boh

fo heir obvios appearace on he ace as e as are nde o pevos ace

HYPERTROPH C SCARS AN KELO DS:PHYSCAL EAMNATO

Hypertrophic scas prese as hick nea plaques

a he sie of rauma. Iiay hey ay be eheaos

b oe becoe sk-coloed i me. Keods arefir bos paq es ha exed ousde he se of i ury

h cla-ie poecions.

Figure 6 1 1 ermal injection of hypertrophic scar that resulted from a

shave biopsy

ERENTAL DAGOSS

Dermaofibroma scar sacod deaoibrosarcoma po

beas graoa.


Noe I hoever a eoid is uresposive o l ipeherapies ski biopsy o rue o deaobosarcoa

poberas is dicaed

TLE 611 • yperophc Scars Vesus Keloids

Den io

Corse

Pecipiang facors

Ic dece

Keo id

Excess fibro s isse foaio i a ou d a

exeds beyod e orign al ou d seDoes o spoa eousy regess

ay arise ees or os ae ry

aiy hsor surge raa br ace earobepiercig; mos como in sin types IVV I

b ay arise i al l sn ypes ad al agesCoo aes = feales

Sern os coon ocao

Hyperophic scar

Excess fibros issue foraio i a ond ha

eais ih n e or ig ia ond s eOfe spoaeos regresso ohs ae he ury

sa ly ar ise hi eeks o iur

amiy hso srgery rauma burn ace; ayarse ay pae a al l ages

Coo aes = feales

Sern os coon locaion



MANAGEMEN

Thee are multple erapies at are eective or

decreasig the usightly appeaace o keloids ahypertrophic scars oe s com petely satsacory a

oe ca be esigated as a treatmet o choice

Pates sho uld be eucate as to the reracory ature okeoids ad hypetrophic scars ad hat mult pe reat

mets over moths are typcaly requred or eicacyKeoids ted to be more resstat to therapy tha yper

trophc scars.

These treatmet opt ios i c lu de i tra les oa l tr amci

o loe acetode a les ioa 5 luorourac (5),

s l icoe shee ig, imiqu imod rad at o, e l ipt ca exc s o rac oa l resurfac ig, a pu lsed ye laser (PD

(595 m) These treatmets povde deret beeitsSome reduce eryhema, others ae lesios, ad some

perorm both te uctios ost ofte itraesoa

steois are a good ii ia heapy that ca be combie

wih or ol lowed by oer herapies Treatmets cabe broadly dvie io ase ad oase therapies

(Tab e 6 2)

TABLE 6 1 . 2 • Nonaser Treatent Options

Dose Iteva o time

ltralesoa 50 mgm Every 26 weeks

tr amco loe (sie depedet)aceoe

( g 6 )I tra lesoa 50 mg/m 3 times weekly

5-luorouraci or the i rst2 weeks

the every

25 weeksS l icoe sheet ig 2 hours per

day o

2 weeks

lmqu imod d uces umor ight yecosis actor app icatio or

a pha a 8 weeks

iteeo apha start g he

ad gamma day o su rgery

Excisio surgical

Section 1 1 Wond Hea ing A lteat ions 291

Fgure 61.2 ild purpura aer pulsed dye laser treatment of keloidal

acne on back of a teenager lntralesional kena log was also used to

pduce e ventual clin ical improvement after a series of treatmen ts

yperophic sca Keoids Commes

or mos scas, Variabe success most Eectve, sae

moderate to dramatic successul with iexpesive ca reim proveme ealy iterveto to avoi atrophy

Ca be eecive Variable success o cea adva tage

secod-l ie erapy over t iamciooeaceode

Vaiabe impovemet Variable mprovemet Sae

o studed Study sowed o o logterm

recureces u p to studies or

6 moths r isk ecurrec e rates

hyper pgmetato scar Further

study eede tocoirm these resus

osy usuccessul, Very hgh recurrece Immedate

ot recommede rate without ad u ct grat icatio b ut

without aduvat therapy All patiets icreased risk o

therapy must be aware ecurrecerecuret keod may

be wose tha oigal




ASER

PD (595 mas eerged as a imprtat adjuva fr

treatmet keds ad pertrpc scars (Fig. 612).Give is selecive targeig sperficial bd vessels

PD ca draaica l mprve e eema asscated

wih hperrpc scars ad keids (Table 613)Ieresg wer lece treatmes a sh plse

d rats ted be mre sccessf ta hi ger uecetreatmets t as als bee sw elp t fatte ess

as wel l

Abative ad abave racial resrfacig resrfacig has bee sw prvde mderae impvemet

fr ace srgica perrphic ad bur scas I s sti ukw weter ghdesi reames are mre

efecve a wdesi treamets. pcal scar Aredeg w ablatve ractia resacig

reqires sx t eig reames t aceve abut 50%

beeit (Fg. 63). Sgi ca prveme is see wi

e t w treatmets wi ablative fractial resuracigC laser reatme ese lesis wile reped

successu i sme te literare s t recededde t a gh rate f recrrece traesial ctics

terids are a elpul aduva t laser terap t hep flate lesis ad reduce puitus.

STUDES

Oe stud exa ied te efec f a fasa p p m ped

PD a 585 m r a f las amp PD at 50 m 5 paies wih red perpic scars. Afer a aver

age ear tw reates 77% iprveme wased Afer tree reaes 7 te 5 paies ad

cplee reslti

Ater sd sig the 585 PD reaed e al

f media stert pepic scas/keds 6

paets ad e te er sde teaed. Paties

receved w reaes ever 6 t 8 weeks ad were

examied aer 6 ts. B ided bservers ad ph

gap eveaed sgifca prvemet" i redess scar egt sk surface textue ad prurit s i

asertreaed scar areas ater 6 ts.

TABE 61.3 • Pulsed Dye aser for HyperophicScars/Keloids

Mecasm f aci

xpectati

PD setigs

Average be

reatmes

kw

Iprves erea

ckess ad pl iab i l i b p t 3090%

37 /cm 7 r 0-mm

sp 045 r 5ms

plse durai

46 bu ma requre arme

BFigure 61.3 (A) Pre and (B) postappearance of a traumatic scar aer aseries of fractional resurfacing treatments There is some m ild residualPIH that faded within to weeks

AFigure 61.4 (A) Ethematous deep acne scars



CLN CAL EPE ENCE

Avoi elecive srgery in paens w a hsoy of

kelos/hyperop c scarr ig .

Cose beginn ng erapy a e m e o srgery or atsure remova

Kelois are more iffc o ea a more pre cab e in eir response an yperopc scars.

Hyperopic scars ofe improve wi no reamen n

6 monhs.P an fracional resrfacing asers ae efecive i

impovng hyperopc scars

racional resfacng can improve e exre aappearance of sgical an burn scas

ACNE SCARS

Acne scarrg is a common seqea o severe namma

ory or cysc acne t can presen i a m or cosmecaly sfigring form. e bes pevenon of acne

scarrng is aggressive reamen o acne vlgars a heme of presenaio, icing, wen appoprae

isoreion. Acne scars ave seveal vare es icig

arophic, icepck ro l ing a boxcar scars reamensvary accoi g o he ype o scar b en g reae I n ac, a

combnaon o reames s oen merie ha is PLor sca eryhema a subseqe n onabl aive fracoal

resracing for acne scars (ig 61) hey also vay ierms of urao of ecacy an expense P rior o srg


ca o r ablaive terapy s im poran o el ic ay recen B

isory o Accae se wihin e previos 6 mos aswe as a sory o yperopic o keloial scarr ng o

avoi poor wo hea ng an scarr ing afe erapy

• y s c a e s o s

Arophi c scars are epresse from te ski n s race a

resu rom local oss o ssue rom nam matioinralesiona l serois s kin s rgey wegh oss or rap

groh (able 61.)

ce-pick scars are narrow eep verica cyl inica

epessons a e s ie of he inn b l m. Gven e ir

ep hey are more resisa o laser therapy. Pucexcsions fo lowe by onablaive fracional resrac

ing can be e lpf l ( ig 61 .5) .

Roll ing scars are shallow epessions a are bes

appeciae wh a change i srface ightng hey can

vay sze a ofen coaesce wh negborng ro l ingscars ey are wer an cepick scars eir

epesse appearance reecs an neying brosis of

e er ms an sbcuaneos a.

Boxcar scars ae wier han ce-pick scars but less

eep hey ave a wel lefine c ircul ar or oval sha pe

cFigue 614 (Continue () Impvement in acne scar ehema afer aseries of pulsed dye laser treatments (C) Further improvement with acne

scars with subsequent nonablative fractional resurfacing




TABE 61.4 • Teatment Options fo Atophic Scas

h ea y Tye o te ray Cou rse

oca

Laser

l lers

l lers

l lers

l lers

Tetino 0.05% nigtly

450 dode: 2 3 /c

6m sot size 3040scryoge coo g s ay, t ee to

fou treatets oer otstreats actie ace as wel

ractioal resrac g ie o six

treatets deeer d et o

treatet s ore effecteuce ar g er o owe desity

o reate is oe efectie

raulsed ulse carbo doxdeaser

Resty lae ( ya lu ron ic ac d)

Auoogous fat

Boine co agen: Zyde I ,Zyder I Zylast

u a co lage

Sl gt roeent aer

612 onts

030 % proement

Noa blatie: od erate

i oee afer e o sx

treatesAblatie: oderate oeent

ae wo treatents

40% i oee oreeectie ta noablatie

laser

Draatic roeent

8 oths

Draatic roeent andoger durao a other

f lers

Good eoay ioementfor 23 oths

Good e oay i roement

for 23 oths

Coes

S i ght roeme as mootheay. Mosteecte as a adjuct wh oer odalites

If i it a l itao a ly eey oer ight ut

better toleratedMd imroeent

Sae in all skin yes

R sk o trasiory hyergetatio ostlase

ethea weeks to ohs m ay case acne

fareSide eecs nclude temoray ehea

edema crst g ad i ld a i

Soe ay deeo brozig ad ld ak ig

at 7 days

gher incdence o yerigmetaio idarke s k n ototyes

Low rsk for loger aderse side eects

excet tat sca g ay occr with a batie

fractioal deices

oe dowtie a d side eects tha oa batie lase

Posaser etea asti g weeks o onthsr isk o hyerigetatio iecto sca, a d

peraet yogetaoBest or sha low wid e scars such as boxcar scas

Antii rals or atents wi h stor o HSVTeoray

Lowrisk ale graloa do not oercorec

scars

Loger du raon

No r isk of a legy gra lo aMore dicut o aster eecte technique

Req u res test ste fo all ergy

g er r sk o a legy (ie 3%)

Tecique: oercorrec scars

Easier pocedue o inexereced acttioes

than othe fi l ersAderse efecs: s hoe d uratio



TABLE 61.4 • Teatent Otions fo Atophc Scas (ontinue

Th ea y Tye of he ray Cou rse

ecaica / codermabras io, g yco ic ad i d im rovemechemica sa cy ic ac d ees ( F ig 6 4)

TCA eels demabraso

Surgca Subcis io ( i c s o to demis with d moveme

mecaca tauma ducig

ibross)

Surgca Puch excis io ig 61 6) uchgraftig uc h a utogafig,

Good improvemet

puch elevatio

Key Po ts Teat g Ac e Scars

Emhasize improvemet rathe tha complete esou

t io as a oba i ab e resu lt . scuss al l treatmet otios A l otios have adva

tages ad disadvaages

ay patiets wil beefit fom a combato of ther

ay

Obtai comlete medical h story ad medcato use,

that s Accutae withi 6 moths of ay surgica/ab ative treatmet.

ake sure ace s beig or as bee reated o preve

future scars.

BBLOGRAPHY

Aster TS Wl l ams CM Treatmet o kelod sterotomy

scars wh 585 m flashlamumed ulsed-dye laser.

ace. 1995345(8959): 98200.

Avram M Tope W Yu Szacowicz E Nelso S

Hyetrohc scar g o f he eck ollowg a blaive fac

toa carbo dioxde laser resufacg ae Sg Me.2009;4 1(3) 85188

Berma B auma . Pi o sudy o the efect o ostoeraive imquimod 5% cream o he recurrece rate of

excised kelods J m ca Demal. 2002;47(supl

4) S209S2 Berma B, Vial l A. miqumod 5% cream for keod ma

agemet Demal Sg. 200329(0) 05005 .


Commes

crodermabaso/gycoic ac id peels are safesal cy ic acd ees safe sk types IVVI

derma braso shou d ot be erformed

excet extremely exerieced ad sSafe

Tme cosumig. u ie teatmes. Bette

or ce-ick scars

Chua SH Ag P oo S, Go CL. Noablative 450 mdiode aser treatmet of faca atrohic ac e scars

tye IV Asia sk Demal Sg. 2004;(10) 28729 .

Fgue 61.5 (A) Ice pck scas po to punch excsons (8) Impvement

of ce pck scas 1 week ae sutue emoval Futhe mpovement wasacheve wth nonabatve factonal esufacng

itzpatrck RE. reamet o flamed hyperrohc scarsus ig ta es oa 5- F . Demal Sg. 999;25(3) :

224232.




Gla c AS Raha Z Goldberg Fr eda PM.

Fractona resracing for he eaet o hypopigeted scars A piot sdy Dermal Srg. 200733(3)

289294

Haedersdal M Morea KE Beyer DM ya PAsbjor B. Fractioal onablave 1540 aser resr

facig or eral br scars A radozed corol ledr ia aer Srg e 20094(3) 8995

acob Cl Dover S Kainer M S. Acne scarr ng A c ass

icaion syse and revew of reae optos. J AmAa Derma/ 200 45( ) 098

iwa A Me o AP Toreza A Osorio . Fracioal pho

toherolyss or he reae o ypertrophc scars:

Cliical eperece o eig cases Dermal Srg. 2009

35(5) 773777

ouri K ieez GP ar isonBaesra C Egart GW585 n pused dye aser n reaen o srgica scars

saring o sre reoval day Dermal Srg. 2003

29( ) 65-73

Waibel Beer K. Fracioal laser resrfaci g for era

brns J Drg Dermal 20087( ) 596

Fgr 61.6 Patient aer numerus punch excisions utures areremoved 5 to days afer the pcedure

TLE 61 5 • I-Pkxa Sar

Pn ch arvesig ad suure orpnch harvest and ipla f

hickness ga

Abatve C/Erb i:AG

Fl lers e Restylane co lageetc (see Tabe 6 4)

Noablaive lase

e 1 450- d ode 23 /cm (oe pass)

owe fecies (wo passes)

lt pe onhl y eates

Advaage

ow cost poetial draaic provemen;

best for a rrow dee p scars such as

ice-pck scars or deep bocar scars pn c

ecson can be o owed b y abla ve oroablaive fracioal resracg reaes

Poea 460% ongter iprovee;bes or shal ow bocar scars

Quick s ign if can proveet

ow rsk

asts onthsow r sk o seious side effecs

o downeTreas ay active ace

Disdvanage

U predcabe r sk of ak ing cosetcappearace worse t e cons ng

Postlaser eryea weeks o ons; risk

of ypepigeaion inecon scar and

peraen ypopg eaon

Anivi rals for paens wi h sor of HSV

No peranent i proveet

Need o repea a least wce an na ly

Iprovee 1030%



TWELEExogenos Ctaneos Ateaons




CHAPER 62 Ea r Pie r ng

Ear pierc ng is perormed o fac l iae an id ivd a 's

desre to wear earrings. By avng e procedre per

ormed in a medical aci y by a pyscan e paien sreassred a te procedre s beig perormed in a

sae conrol led enviromen


Conact al ergens o meas

H sor o keoids or yperropic scar ng

esred se of pecing

PHYSCAL EAMNATON

Assess e ckness of earobes

MANAGEMENT

ere are wo commo meods for ea piecng I can

be peormed wit a needle by ad or wi e elp o

an auomaic ear-piercig gn (Fig. 62.) Before per

forming eter procedure i is mpoan o make ceraina e correc locaio or piercng as been seeced

Symm er wi e conralaera ear s essenia o a good

cosmetc a ppearance. Te paent sou d revew e sies

usi g a m irror prior o treamen.

TREATMENT

Seri ize a l nstruments

Seri ize ad a neseze bo ear lobu les

dent te exac sies o be pierced wit a makng pe

on e anteror and posteror porions of e ear lobue.

Conirm proper pacemen wit paiet beore proceeding

Usin g slow pressure advance a - o 8-gage needle

rog e poseror lobe no te anteror lob le

an aomaic ear-piecng g is sed e gn isadvanced rom e anerior l obu e oward e poserior

ob e

Use a sei zed earring wi a sainess steel pos

A nckefree pos of te earng s advanced w te

neede and e p s p lled back rog e ear

e cla sp is p t on e poseror pos

Leave te earrng in place for approximaely 1 days

ni l re-epelia l zaion of e rack

Cean e sie w ydogen peroxide and opcalan bo c onmen wice daily

Fgr 62.1 Ear-piercing gun being used on earlobe of a young female



PTFALLS O AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS

i earo be ma y pl i epecal y i eavier ear ing

Pace eaig on e ame level oizoaly o aue

ymme A good c ean tei e ecni que c an avoi potpocedu re

inecon

i m poa o e ic any ioy of yperropc ca

o kelod in ee paen (Fig 62.2) a pecing

old o be pefomed o ee paie

Any toy of nickel or ote mea alege oud be

e c e pro o ay procee a e

ucate paient a o ound cae an e nee o

conac you in te even of inecon

n e event of conac ematii o allergy topica

teoid ae e m a nay of reamen

BBLOGRAPHY

Akn ak GP. E ar p ierc ing ad ugca epa r o e

ealobe. n : ak GP Moy R ed. Principles and

echniques of Cuaneous Surger Ne ork McGa

H i l c ; 1 996 .

Secon 1 2 Exogenous Cuaneous Aeaons 299

Fg 62.2 Keloi on posterior earlobe secona to e ar piercingCourtesy of Tomi Pan/fino M




CHAPTER 63 Tatoo Removal

ens of mi ions of Ameicans have attoos. Ove tmeany ecie that they want the tatoo to be removed

Qality-swtched (Q-switched) lases are eective nremoving ost atoo igments saey ( Fgs 63. 13.3 )he aoriate ase wavelegth s etere by the

tattoo nks absorpion spectru t is be eve that lase

puses in te nanosecon range taget tattoo gents

and beak them into smaler patic les hereby acil tat ing

reova of the igment tanseermaly o via

acophages a local scavenger ces I ore to reat

muticooed tattoos severa Qswitche ase wavelenghs must be em oye

KEY CONS ULTAVE QU ESTON S

Was the attoo place by an amateu o a oessiona

tattoo aist?

Was the tattoo lace o te urose of raaion te

ay?

s the tattoo the esu t o tam a o ny?

What colos are containe wthn te taoo? (abe 63.1)

Prevos teamen ts

Use of soetnoi with 6 months

H sto o keois/hyperohc scars

Duraton of tatoo

Skin hootype

Hstoy o HSV a ste o teatment

A

B Hstoy of aergc or ganomatos reaction to tattoo

igment Fgr 63.1 (A) Tattoo o le earlobe rior to theray (8) esolutio aer

six treatmets ith 1,064m Qsitched NdYG laser

TLE 631 • Lasr Thrapy b Ta lr

aoo ge nt ight sectum

Red Geen

ellow Geen

Geen Red/near infrae

Lgh b ue Re/near rared

Dark b le Re/near rare

B lack

Most eecve ase s

requency-dobled Q-swiche NAG(532 nm)

requency-dobled Q-swche NAG

(532 nm)Q-swiched by (694 nm)

Qswitche aexante (755 n)Q-swtche uby (694 nm)

Q-switche aexante (755 n)

swtche uby (694 nm) l igt skntyes ony

Qswitche alexante (755 n) ightskin tyes oly

Qswitche N AG ( 1 064 nm ): a l

skin tyes

Comen

ay cause gment alteaion i n aker sknLeast pai nfu l of Q-swtched lases

No vey eecve

ay cause hyoigmentation i da ker skin

ay cause yoigmenaion i daker skin

Qswitched d:AG (0 nm) sae inal sk n yes ess g en oss



s the tattoo ace over or coveig aother attoo?

History of go ingesto

Does te taoo contai rst-coore or wte pget?

MANAGEMENTI t s i poa to ask te at iet wo pace t e taoo.

Professoa tattoo pgets are eser a lace

deeer n the eis tha ost aateur tattoos Ts

rees es e attoos m ore refacory to treaent aic

lar ly those ta are icoore a cotain etal ic

igets. It is iorant to ior the atet pror to

treatent at colete resouto s ot always fease.

It s a so iotat o counsel at ut ile eates

over to 2 years ay e requre or axal iproveet. Tere s o fxe aswer as to te er of trea

ets for tattoo emoval .

PRETREATMENT ASSESSMENT

Patients wt a ker s types are ore ey to sue

pgentary cages

Proessoa tattoos reqre ore reatets tan aa

te r attoos

Ol er attoos reso ore favora y an ew tattoos

Back a ark e taoos reso ore effectvely

ta ye ow taoos

Assess for snta f ate is ta e eay reate

untl ta resoves Mlicoore attoos are oe clt to sccessy

cear tha siglecoor tattoos D uri g treatent soe


A

patiets ay e frustrate at the oniorm imrove en t of ese tattoos

Assess for scaring wt e taoo I resent show

te patiet a oc ent ri or to treang

N UM BER OF TREATME NTS

Professoa tattoos reque aout 6 o 20 treatents

prior to reova o inrequely ore tha 20 reatets are eede for ax ma i rovee

Aateur attoos coain less ense get aces

an usual y req ire aout four to sx teatets

Ra iaio tattoos an d tram atc tattoos are o re su er

fic ia a ess ense an professioa tatoos equ r in g

only a few reates or resolutio (g 634)

n geeral raaton tattoos ca e eove i oe to

tree treatents Soees ey reqire at ioaltreatents

Lower uec es a arger sot sizes can e as eective

as sa er spot szes an nc rease feces

cgr 63.2 (A) Tattoo on arm wit underlying portwine stain (B) Notete seletive removal of te tattoo wile te portwine stain persists

(C) Tattoo learane




est spot may be appropriate i darke sk pototypes

f concerng

est sos are clearly ndicated fo cosmetic taoos

rustcolored tattoos a d w ie taoos

TATTOO TREATMENT Photograph o tattoo prior o teatmet

opical aestesia or 1% docaine i te orm of ocal

njectio or erve bock w l make te teament more

comfortable for e patiet

reat the affeced areas wit te apopriae -swtced

aser alowg fo up o a 10% overlap (abe 632)

e c l ica e dpot is m mediate t issue wteing or

the 1 064m swtced Nd AG i ad dit o to ssue

witeng there may be a small amount of ppot

b leeding at te s ite of reatme ( F igs. 635 a d 63.6)

issue spater" ( e, edermal/demal dsrpo adbleedg) may p roduce scarr ig. If this occurs decrease

te fluence

f te aoo is mutcoored teat te red pgmet first

Erytema and fammato from oter treated sitesmay obscue vsazao of red taoo pigme

Appy tocal hydrated eroatum ad a noaderent

d ressig ater co mpetig te treamet

Couse su scee a d su avodace o te teament

area

POSTTREATM EN T CAR E

Su avoidace sscrees

ela dressng ad hydrated petrolatum otme wit

paper tape

f tattoo is ocaed i belt l ine a rea or above akles cau

to patets from wearg tight bets or boots that may

prod ce frco aga ist e treated area

Retrn or eatmet 6 to 8 weeks

A

B

Fgr 63.3 (A) Le shoulder tattoo with inferior scar resulting from priortreatment with dermabrasion (B) Improvement aer six treatments with

1 064nm Qswitched Nd YAG laser While improvement is not completethe cosmetic result is far superior to that o f dermabrasion

TLE 6 3.2 • Lasr Thrapy b Qa y-Sw Lasrs

Laser

Frequecy dobed switced dAG (532 m)

-swtched ruby (694 m)-switched aexadrte (755 nm)

-swtched NdAG (1064 m)

I t ia settgs

. 55 0 J 4. 00 mm spot size

3 00 J 6.5 mm spot size5 06 5 J 2 .00 mm spo size

3.0120 J 2.00 mm spot size

Eecive agais these attoo inks

Red orage, yel ow

Gree b lue b lack

Gree b le b ack

Ble back (saes i dak sk ypes)



ADVERS E EECTS/PRECAUTO NS

Pgmentay aterato

Blistering (especia ly, Qswtched alexadite and rby)

(F ig 63.7 )

Scarr ng (F g 638)

n a patet with an allergic reaction to tattoo k n thepast ( Fg 639) , thee s the possibi ty o a rec rrenceseconday to the elease o tattoo nk folowng laser

therapy A ergic recations sho uld be taken System calergic reactions ca occr wth Qswtched ases

(un ke destrctive modalit eserabasio etc)

Rstcooed and white tattoos should be teated cae

ly as wel as ed and fleshcooed cosmetc tattoos

or exam ple, i er Sometimes whte n k is xed with

othe p gments (F ig 63 0)

The tattoo may darken as a esult o oxidation of iron

or t tan u m oxide pgment withi the tattoo

A test site can be efored 4 to 8 weeks pio totreatment fo possibe darken g

This darkenig can sometimes be treated wth lases

or may reqie excsion

They espod s lowly to lase theapy

Peom a test spot pi or to treati g atie nts wth istory

of gold salt ngestion Chysiasis, afested as darkbe pigmetaton can esult fo treatment with Q

switched ases

Rarely, patets wl expeence a trasient immune

resonse folowng a ase tattoo treatment Suc

resonses incude flu ike symtoms and enagedlymph nodes

PTFALLS TO AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEPECTATONS

Response to tattoo treatment is dependent upo thedeth of pgmet, the color o pigment and the size o

pgment part ces It ca vay damatcal y o one to

tattoo to anoter

Efectve teatent for a rofessional tattoo may reqe

p to a 20 or more treatment sessons ove a period of 1

to 2 years Fheroe compete reova s oe not

feas b e

A successf treatment often eaves some resdua tat

too igent hs can be impoved wth noabatve

ractiona resfacng

Physic ians shod couse pat ients that s gn f icant ighteni ng may be the best feasbl e c n cal result

aoo treatent can produce ye- ad hypogmen

tatio in any patiet especa y those wth daker skntypes


Fg 63.4 Taumatic tatt n knee f a female that has pesisted

0 eas afe childhd biccle fall switched 1 064nm Nd YAG

cleaed the tatt in thee teatments

Fg 63.5 ssue whitening afte teatment with the 5-nm fequenc

dubled switched Nd YAG and 64-nm -switched ub lase ssuewhitening is the apppiate endpint when teating tatts with switched lases Pinpint bleeding esulted fm injectin f lidcainewith epinephine pi t teatment




emen o oos in res of hi growh (ie eye

brows) my poduce empo hi remov

he eqencydoubled Qswched :AG Qswiched

uby nd Qswched lexndie lses e moe key o

cuse durbe pigmenry chnges hn he Q-swched

AG ( ,064 nm)

Mos eqely pigmen eion is emoy.Hypergmenon yc y esolves oe qu ic kly

Lowe leces nd diionl me beween emens

shou d be employed i n ke ski n h ooyes

BBLOGRAPHY

Alse T. Q-swiched exnd e se (7 55 n ) reeo pofessionl d eu oos J m Dmol. 199533:6973

eguson E Augus P Evl ion of he d/AG lse

or remen of meu nd poessio oos JDmol. 199635(4) 58659

zpck RE Goldm MP oo eovl using he

exn die ser Dmol. 199430: 5085 4

Gevel nk M Mu ls MW H R Go m n M Pzpck RE Greve in k JM . Lse reen of oos n

dkly igmened ens Eccy nd side eecs.

J m Dmol. 199634:653656

lzikso L, Avr MM Anderson RR nsien

i mm uno recivty er ser oo emovl Re o o wo

cses Sg . 200840(4)23232

Ki me SL Anerson RR . C l in ic l se of he Q-swiche

rby nd he Qswche d AG ( 1064 m nd 532 n m)lsers or een of oos. J Dmol Sg Ol.993; 9(4) :330338

Levne V Geoneus RG. oo emov wih he Qswced uby ser nd he Q-swiched d AG lse A

com pve sudy. i. 199555:29296

Fgr 63.6 Pp immeitely fte tetment of n eyebow tttoowith Qswitche N YG lse

Fgr 63.7 listeing e tttoo tetment Thi ection is commonn slly esolves completely within week with tine topicl skince




Fg 63. carring aer treatmen t ith a Qsitched rub laserCourtes of Teresa oriano, M




A

BFgr 639 (A) Allergic hypersensitivity reaction to tattoo see elevatedportions of tattoo (B) To avoid systemic allergic reaction with traditional

Qswitched laser treatment of the en tire tattoo focal treatment with anablative fractional erbium laser was performed Note focal impvementafter several treatments




A

BFg 63.10 (A) Tattoo prior to tst spot tratmnt (B) Tst spot tratmnt of tattoo with a 64-nm Q-switchd ruby lasr producs discoloration Tattoo ink combind blu and whit inks




CHAPER 64 Torn Ea obe

o ealobe ad eaged peced ealobe caals ae a

commo cosequece o weaig heavy eaigs o a

pooged peiod o me ( g 1 ) as wel as ohe acos suc as auma eavy ea gs i eco ow place

me o pecig pessue ecosis, ec I occus moseas y i i ea obues oopig o easily o ealobes

may also be secoday o a cogea deec o auma


Pecipiaig eve o ealobe ea

H so o keoids o hypeopc sca g

oes paie desie o wea eaigs agai ae he

epa?

MANAGEMNT

hee ae umeous sugcal mehods o epai com

peey ad paia ly o eaobes ee echiquesae sued o dee eas Paal eas ae moe easiy

eaed ad ca be coeced via sde-o-side closue as

we as puc excsio ad epa

TR EATM EN TS (Fgs 64 1-643)

Compee eas ae moe dicul o ea ha paialeas Thee ae u meous diee ec q ues ha cabe successul Mos commoy e Z-pasy epai o

ielocig s epa poduce he bes esul

Sei e pepaaio ad echique

Local a eshesia shou d be i eced io he epa sie

he epid emis o he opposi g edges o he ea woud

shou d be excsed

Sca pe

Scissos

euped 60 epidema suues appoximae ad

ever e woud edges o e aeo ad poseioobe

Be ceai o appoximae he wod edges o e

eo im o e ea caeu y o avod dso io omsa igme

The woud edges sou d be ude m i ma es io

o su bcuaeous suues ae used

Z-pasy epai ( ig 2) o i e loc ig s epai o

he im wi poduce issue appoxmao whie pe

veig he di mp ig o he eio m o e eaobe

A

BFgr 64. 1 (A) Female with large tear defect of earlobe at the site ofheavy earring (B) To earlobe reconstructed by prima repair



aes shold be counsee o efrai fom wearig

eangs for 3 monhs fol owing he reai r

P TFALLS O AVO D/COM PL CAT ON S/MANAGEMENOUTCOM

EPECTATONS Mec os aeon o a roxma g he woud edges

ad he infero rm of e ea ae esseial for a sasfacory resu ocig o he iferio rm of e earlobe

can occr easi y s ignficay comromisg aeshecaearace

Cauio n a paen wih a hisoy of keods or yer

rohic scars

aie sh o l o wear ear ngs for 2 o 3 m ohs aersugery

Wond sreg is less an e oigna sreng o he

obe Avoid wearg eavy earrigs o reve recrece

BBLOGRAPHY

on B A sm le ech niq e for redcio of he ea

lobe Plast Reconstr S 198066630632


b

gr 64.2 epai of complete ealobe tea utilizing a Z-plas to pevent dimpling of the infeio aspect of ealobe




Fgr 64.3 One stage preauricular ap to repair earlobe deformities



I N D E X

ote: this n e te letes " n " enote figes n tbes espectively.

1 50nm ioe ser 8 8f 83f

5olevl nic c (5ALA) 75 5

5foroci, 07 4 9

130m :YAG se 41150nm ioe lser 4 7

AAbtve rcton lser resrfcing 39, 57

vntges o 57ictions, 58

ser sfey 59

vese sie eects 60 60

foloup, 59-60, 59

nfection, 60, 61nonfcil skin 601posoperive cre 57f, 58f 59

preopetve evlution 58

pohylis/neshesi 58-59

Abtve se escing, 151, 15

bsolte cotctions, 5

estes 67for Becker's nevs 18

for ee nevs 4

e lser cnite, 5

ictions,

ess t iel ser cnte, 45

echnis of co 3cbo ioie lse 3 3f, 4f

EYAG 3 5feictos 6

for i i, 30

posoertve cre 9 50 51

peopetve evlution 5pocere 89 9f

etve conr inicios 56

sfety meses 47-8

for seboec ketosis 36

tetmet pes, 50AC i bitos See Angioesicovetng ezye (ACE) iibitors

Acetminope 58

Acetoe 48

Acne scrs 90, 93

pysc lesos 93-95

tetet 95Acne vgis 7 76 00

vs. giofibro,

course, 73

ifeeni ignoss 7

eeioogy 7

botory tetoptoogy 73

enocrie stues 773

geent, 73

igh retmen, 7f 73f 7-75 75f

sgic tretmet 74

sysemc reten, 73-7topicl tretent, 73

3

ptogeesis, 7

pyscl eminto 7

Acqire cpil ry emgio, 170-73

Ac elnotc elno 06Actnic ceil tis 8

Actnic kertosis (AK) 48

consttve qestios 9

corse, 9

etopthology 48

ifeenil ignoss 8eeiology 8

mgement, 9

ptogeesis 8

pyscl eminto, 8

pitls, 50-51tetet 49-50

Actnc kertoses

vs s 06

Acycovi 3 6 5

Apene 9 73

Atos 5000 1t, 15t

Aeom sebcem Affi 1, 40 n :YAG ser 56 56t

Ageelte tetl chges t

Agg

Agg fce n nonci egos nyss o

toic consi etios 3, t

preopetve evltion 3ctige bony stctures, s potive strctres

cnges 5fci musctre cnges, 5

Glog Potoging Cssficton f 3, 3f, 5f

pigeny cnges , 6f

sbcteos ft tohy 5AK See Actin ic kertoss

AA See 5iolevul inic c

Acne See Topc prorcine

Acon 8

Acon bs 5A lergn 1t 15t 1

Alergic ectons

to scleotey, 0

Aloerm, 1t

Aoe ver 0

Aoesin 9t 10hyoy ci 3

otos, 18

for posinfl tory yperpigmetton 160

pees 1

Ai cloe hehyrte 87

Abloy plebectomy 0Aeicn Acemy of Demtology 8

Aoic l in 73

Ayorophc ltel scleosis

Aestesi, 88

for btve fcton l lser resrfcng

5859for btve ser resufcg 46-7



3 1 2 I nd ex

or angioiroa 23

or l oma reatmen 227

or neuroiroma 236

or nonalaie fational lase esuaing 54or nonalaie laser resuang 40

dinared lases 40 41

or sot tssue augentation 6f 7

or wa reoal 207t 208

Angioroma 212215

onsultat e q uestions 2 3ourse 2 3 2 13

dermatoathoog 212

difeenia agnoss 2 2

eiemioog 212

aoator data 23

anagement 21 3214 21 4f 2 5fathogeness 2 12

hsia exaination 21 2 2 2

ita s 214

Angiokeraoa 168

vs angiomas 71

ourse anagement 681 69 69dermatoathoog 68

dieenia agnoses 168

eiemioog 68

hsia exaination 68

itas o aoid 69

Angiol ipoa 226Angiomas er and sder 170

ourse 171

difeenia agnoses 171

eiemioog 70

anageent 1772athogeness 170

atholog 171

phsia exaination 71

ita s o aoid 72

Angioesinoneting ene ACE)

nhios 89Antha in 224

Antiaeial agens 73

Antiaeial thera 46 53

Antiiotis 73

Antialarias 75

Antioxidants 8Antierspirant 89

Antira edatons 49

Anti ra tera 46 54

Aaodne hdrohlode 28

Aquamd 14t

Aquao H ea g Ointent 49Arutin 9t 0

Aefl l 4t

Aeria spide 17073

Asor aid 9t 1

Ash ea maue 2 12 2 13

Aspergilus, 10AstraZeea 7

Ataxatelangietasa 67

Atan 58

Atoph sas 294295

Atohodera emiuau AV) 8

Aa 9Aoenone 7t

Aela aid 9t 0 73 77 14 51 160

Aithon 46 73

BB l uus mi ar s dsseminatus aei 76

BHCG. See �um an hoi oni gonaooin

BannaanZonana snroe 226

Basa e l arnoa CC) 8 252254

ederma neus and 222 223

onsultatie questons 253

ourse 253dematoatholog 252

dierenial d iagnoses 252

edemoog 252

aoator data 253

aagement 253254 253 254 255f

pathogenesis 252phsal exaination 252 252

pitals 254

Bearer 10

Bekers neus 22 1 8

onsultatie questons 2 17

ourse 217

dierenial d iagnosis 21 6

edemoog 21 6

aoator examinaton 26aagement 2 1728 2 7

pathogenesis 216

patholog 26

phsal exai nation 2 6 2 6

pital s 218

Beotero Basi 14t

Beotero So 4t

Bengn growths

angioroma 21225

Bekers neus 22 1 8

ederma lusion st 2922

eerma neus 222225

Beno eroxide 73

�uman hoioi gonaooin BHCG)

Betaaine nha ned Ge 7Betaaine lus 17

BoAaid 14t

Boo edal 1 5t

Bomatix n. 15t

Bosies

ederma nlusion sts 220

eerma neus and 223

ioma 227

neurofroma 232

seorhe keraoss 235

Bioeh Indust 5

Bashk ies o 222

Beahing reas 46

Beaohalasis 64

Booms sndrome 67 136Bonane 87

Botox 89 See also Botu in um oxin A

Botox Coseti 2

Botu i u oxin

opliations 27

ontra in daons

asoute 22

elatie 22

di lut ion 22

ehanism o aon 21

usle grous 22f 23

forehea 22 2324 23



glabella copex 4 4f

nasolabia fold 6, 27f

neck 627, 28

peioa egion, 6, 7 28fpeioba egion, 5, 5f

ue nasal oo 5 6f

phaacolog, 2 1, 1!

posoeae consideaons, 7

peopeae ealuaion, 2

owe eeld s nap back es 3peaaions, 2

pocedue, 3

eaen benefis 7

eaen peas, 28

Bou n u oxin A BXA, 1 87 88, 88f

aneshesa, 88anipespian 89

Boox 89

pehidoss ecanis of acon in, 88f

necion ses of, 88f, 89f

edicaons 89

sge, 89eaen 8889 88f, 89f

Boul inu oxn BX 1

Bou nu oxin BX), 1

Bndis 4

Boussoneta papyfea, 10

Bcc nao, 6, 7f, 8

cCa au la acues CAMs) 136

vs Beckes neus, 6

consulae qesons 37

couse, 137

diffeenial diagnoss, 136

edeoog, 36

aboao exainaon 136ase eaen, 137138

anageen, 137

vs. neuofboas 23

pahogeness, 136

paholog, 136

phsca lesions 136pifa s, 138

opical eaen 138

Cacpool , 4

Capbel de Mogan sos 170173

Candea Cop . , 4

Cande, 17Cande haa nc. , 14

Cannus, 6, 27f, 8f

Canaone 07

Capl a 177

Capque, 14

Cabon dioxide C) ase, 43, 43f 49 57, 17 39Cabon dioxide ase esfacing

fo angoiboa, 13 115f

fo angioas 17

fo basa ce cacnoa, 254

fo epdea nes, 4fo neuofiboa 3

fo sebohec keaosis 36

fo squaous cel cacinoa 58

fo enous akes, 08

fo was 07 08

Caenos heangoa 77180

Cele, 779 76f

consulae quesions, 77

couse, 276

edeiolog, 76aboao exainaon, 76

anageen, 77

phscal lesions, 76

pial s, 779

eaens, 27778, 77f

Cenofacal eangi ecasas 194fCheica peels 30, 74, 141

colcaions 34, 38f

conaindcaions, 33

deal canddae, 31

ess idea canddae, 3edcaions 3

pee pes 33

posoeaie cae 34

pocedue 3334 36f, 37f

eaen peals, 3435

wound deph 3Cheica sunsceen 78 7

Che angioas, 1773 17f

Cnoxae, 7

Cpofoxacn, 46

Cl indacin, 73

Cofazine, 75Clostdum botulnum 21

C ase abaon 8

C esufacing. See Cabon doxde C) ase

Coenze 10 8

Cocic ne, 1 75

Colagen, in angofboa, 1Coagenase 9

Comedone exacion, 74

Comon was 0609

Complee eas 308

Compession sockngs, 00

Congenial adenal hpeplasia 9Congenial heangoas, 177

Congenial neus, 1 6

Conua Inenaional, 14

Cooouc nc, 41

Coece a ansplan suge 1 10 10

Cougao suecil 4 4fCoicoseods 164 175

fo epdea nei, 4

fo epdea ncusi on css, 1

fo ia, 29

Cosode 4

Cosoplas, 14Cosshaching, 18

Cogen spa coong CSC), 185

Cosuge, 175

Cohea

fo deaoss pauosa n ga 4

fo epe des 14fo epdea neus, 24

fo lenignes, 146

fo sebaceous peplasia 83

fo seboheic keaosis 36

fo squaous cel cacinoa 58

fo enous lakes, 04fo wa emoa, 09

fo seboeic keaosis 36, 37, 37f

ndx 1



3 1 4 I nd ex

Ceage

or edeal nes, 224

or wat reoal, 209

Cshngs dsease, 92, 285

Cng too, Cera ie Cel Co, 4

Cnose, 56, 56

Croerone aetae, 28

Css

D

eidera inlsion sts, 21922

orn, 235ia, 229230

ilar sts, 220

DAO. See Deresso angl i ois

Dasone, 75Deedeh srength eels, 30t, 33

Dee eangoa D), 77

Dee en hrombosis, 198

Deodex ol ilor, 77

De lat on, 94

Deresso angli oris DAO), 26, 27, 28Des disease, 226

Deabrasion, 75

or edeal nes, 224

or angioibroa, 24

Dea easa, 19

Deatohalasis, onsltate qestions, 65

orse, 65

deratoatoog, 65

dieenia dagnoss, 6

eidemioog, anageent, 65athogeness, 6

hsia exaination, 64

itas, 666

teatent, 65

Deatosis alosa ngra DNs),

24, 2onsltate qestions, 242

orse, 2

dieenia dagnoss, 21

eidemioog, 2

aboator examinaton, 241

aser teaents, 24223anageent, 22

athogeness, 21

atholog, 241

hsia esions, 241

ita s, 243

Deik, 5Destie oda ities,

o sebaeos heasia

Diazea, 17

Diloxai l n, 46

Diode ase teatents

or Bekes nes, 218or enos akes, 20

Dioxbenzone, 7t

DowCorning, 4t

Doxne, 73, 77

Ds See Deratosis a losa n igra

Dsroia

o war emoal , 207, 208, 209

Dsort, 2t

EEa iering, 298

ons ltatie qestons, 298anageent, 298, 298hsal exaination, 298

itals, 299, 299

teatent, 298

Eto a denooiotro horone rodtion, 92

Eletoate, 239or edea nes, 224

Eletodesiaton, or angioibroas, 213

or sebohe keatoses, 236

Eletolss, 9, 2 17Eletoseion, 77

Eletosge, 76, 77, 77, 82, 175

or enos lakes, 204

El l t al exsion, 23, 29, 227, 2132

Ell tal sti aestng, 06

vs. ol ilar nit extaion F UE), 07, 107tEl la n Sgitron, 78

Embol ization, 180

Endeologie

or ee, 277278

Endone stdies, o ane lgaris, 7273

Endonolog, onsltation wt, 93Endoso/assi satheto, 88

Eosinohl i granloa, 174

Eedes, 139

onsltatie qestons, 40

orse, 140

dierenial diagnosis, 40edeolog, 39

aboator exainaton, 140

anageent, 140

athogenesis, 139

atholog, 140

hsal lesons, 140vs soar lentigo, 145

teatents

heial eels, 4142

rotea, 42

aser thea, 1213

ital s o aoid/o iatons/anageent, 43toial treatent, 4041

Edera aanhosis, 65, 67

Edera nlson ss C), 219221

onsltatie qestons, 220

orse, 220

dierenial diagnosis, 220edeioog, 219

aboator data, 220

anageent, 220

athogeness, 219

atholog, 29

hsal exai nation, 21 9, 2 9itals, 22

teatent, 22022 , 2 19, 220

Edera elasa, 32, 149

Edera nes E), 222

vs. Bekers nes, 26



consultatie qestons, 3

corse, 3

difeenial diagnoss, 3

ed emoogy, aboatory data, 3

pathogeess,

pathology,

physica exaination, 3

pitas, 5

vs. seborhec keaosis, 3, 35teatent, 45

Ederis

and epdera cl sion cysts, 19

n l ipoa, 6

Ederod cyst, 9

El i escence croscoy E LM ), 03Enehrne, 59

Er:YAG. See Eb m :Ytr uAlm n Garnet Lase

Erbm abate resufacing lasers, 57

Erbm:YrumAminu Garnet EYAG) laser

and a blatie ase resurfacng, 43, 45, 48, 49

ad epidera neus, 4and seborrhec keratoss, 36

Eyhematoteagectatc rosacea See Vasca rosacea

Eryhomycn, 73

Etecc m xture of loca an esthetc M LA), 7, 40

Excime aser, 65, 87

Excison sgcal , 53, 57, 9 , 9Eye nj r ies

and ases, 98

FFacial ageelated conto changes,

Facial musclate changes, 5Facial eangecasias, 19, 19f

corse, 9

dematopathoogy, 9edemoogy, 9

anagement, 1994physca exai nation, 9

pitfa s o aoid, 94

prior to ong p sedurato p sed dye laser

treatent, 95

prior to sed dye ase teatent, 93

Fang, 18Fascia Bioaeals, 15t

Fascian, 5

Fat accumulaion

teatent of, 83

FDAapoed med caions, for mae patern ha r loss, 04, 04t

Feale pater ha oss, 16, 16f See also Male pattern ha oss

chef coplaint, 31consult , 133

consultatie qestons, 6

corse, 6

dieenial diagnoss, 17

edemioogy, 6femae har tansantation, 31

to corect altered tepoal ha i ine, fom li ng procedre, 3 1

femae surgica plan ing, 19

posoperae stuctions, 30

posoeraie eriod, 13031

preopeate n sructions, 30vs. ale pattern hai oss, 19, 9t, 3

edca theray, 178

nonFDA aproed medicatons, 8

pathogenesis, 6

physcal exa naton, 16, 819suger, 8

Feae sugica panning, 19

posoeraie instuctons, 130

posoeraie eriod, 3031

preopeate nsructions, 130

Fendae abs, 7Fibrous paples, 1

Fl om was, 06

Fl lers

pemanent, 883

temporary, 8

Finasede, 104, 104, 8, 33Ftzatrick ski phooype, 3

Ftzatricks cassifcatio, of skin types, 4t

Flashlap, 78f, 79, 79f, 80

teatent, 93

Flaonoids, 9t

Foam scleotheapy, 9900Fo l ic lar infundb u, 9

Fol icla r nit extraction F E, 06, 07, 108

vs ell ptcal sti aestng, 07t

Fol icul is, 00

Foeead, f, 34, 4f

a, 930Fractona phototemolysis F)

Fractiona esrfacing, 5, 5, 53f

Fraxel Restoe, 56, 56!

Freckes See Eheides

Frotas muscle, , 34, 3

Frontas muscles, 4, 4fFUE See Fol icular nit extracton

GGelatinase, 9

Genita was, 009Gentsic acid, 9t

Glabellar comex, 4, 4f

G lab id n , 0

Gloga hotoaging Ca ssifcato, f, 3, 3f, 4, 5

Glycolc acid, 9, 3

Glycoic acid peel, 3, 33, 74, 60and eph ides, 41

and melasa, 5 , 5t

Glycoyroi um bomide, 87

G/ycyhza g/aba linneva, 10

Gold inectons, 75

Grafts, skin, 5

Granuoma faciale, 174, 74, 76course, 174

dematopat hol og, 17 4

differenial diagnoses, 74

edemiology, 174

g reatmen, 175anagement, 175

ut pe esons of, 175f

pathogenesis, 174

physcal exainaton, 174

pitfals o aoid, 175

sysemc reatmen, 75toca teatment, 175

ndx 3 5



3 1 6 I nd ex

Grauloma gaidarum 119

Grauloma elagiectaicu 18891

Graulomatos rosacea 76

Gnecomasa 272275 272fconsultate qesions 273

corse 273

diffeenia agnoss 272

eiemioog 272

aoator exam nat on 272273

aagement 273pathogeness 272

phsca lesios 272

pifas/comlications/oucoe exectaons 274275

teatet 273274

HHar loss. See Female pate ha oss; Mae paten hai loss

Har emoa 217

Ha r ranspantaon 04105

Har ne desig 108

Haaoa 216 222

Heagioma segmenal 180fHeangioma lceated 79f

Heangioas 177

Heoma 226

H c lens Hrsism 92

consultate qesions 93corse 93

diffeenia agos s 9293

ei e io og 92

aoator tess 93

aageent 93

elecoss 94eocroog cons uaon wi 93

jus por o reamen 96

aser ha eoal technqe 95 9698non lase heap ies 9394

patient consaon 9596

posteaet instrucons to aient 98phsica exaination 92

pifas 94f 9899

H IV ipodsroh/faca l i poatoph 280284

consultate qesions 281

corse 28

dematopatoog 280diffeenia agnoss 281

eiemioog 280

aoator examnaton 281

aagement 281282

pathogeness 280

phsica l esios 28028pifas 283284

precitatg facors 280

preetion 281

teatets 282283

Hoosaae 7tHomones 73

H man pap i loaius V) 206209

Haurodase 47

Hdroquinone 9 9 13 140 146 151! 160

Hdrox aci 73

Hdroxcomarins 9tHaform® 15tHerhosis 86

oul um oxin A 88 88f

aesthesa 88

atiperspirant 89

otox 89edcaos 89

sger 89

teaet 8889 f 89f

consultatie qesons 87

corse 86

dematopaholog 86differenial diagnosis 86

eemoog 86

aoaor examinaon 86 86f

aagement 87 87f

oal edcaons 87

pathogenesis 86phscal findings 86

pitfals 8990

sger 88

topical medicatons 87

Hehosis

ses of 90fteaent dagram 87f

Hepgetaton

ad cohera 209

ad ostsclerothera 200

Hpesensite reacions of so tssue a gentaon 18

Hetoc saine 199 200 201tHetichosis 216 217

Herophic scas 290

clinica expeence 293

differenial diagnosis 290

vs keoids 290!aoator exam inat on 290

aser 29f 292 292f

aagement 291

phscal exainaion 290

pu

se de aser 292

suies 292Hpogmenao 67 187f

ad cothera 209 236

ad ase teaets 218

Iceick/Boxcar Scar

lcoin 58deeoe 8

l imod 179 207 291 29

lnamed Cop 4

lnamed Cop. 15t

Infai e hemangoma I) 177 177f 178f

acia tests 78coplications 78

corse 178

dematopatholog 177

differenial iagnoses 177

eemoog 77

aoaor tess 77aagement 17880

phscal exai naion 1 77

pitfal s o aoid 180

Intese puse ligh asers

for pseudofol i cul t is 01

for Beckers neus 218for cher an spder agiomas 172



for potwine sta ns, 85

for posscerotherapy hyerpigmenation, 201-202, 20f, 202f

for veous akes, 204

Inteeon, 179

Interockng Ls repir, 308lntaesona 5foroacil (5FU), 291, 29t

lntaesona seroi inecton, 74

lntaesona tr iacinoone aceonides, 291, 29t

lopine, 28

I L See ntense pse ght

Ipsen Limite, 21tlsolagen, 15t

Isopopyl acohol, 8

lsotreino, 0, 58, 7, 77

JJessner, 30t, 35f

Jessner peels, 141 , 60

Jveder, 5

KKeex, 17, 46

Keos

dieeia iagnoss, 290

vs hyperropic scas, 29t

vs. keoids, 290t

boatory exa iat on, 290aser, 29, 292, 292

ngeent, 291

physc exaination, 290

pse dye aser, 292t

sues, 292

Ketnocyes, 40, 222Keatoyc gens, 73

Keatoses

seborrhec, 223Keatoss fo icla s sn losa decalvans ( KFSD), 81

Keatoss pi lais aropcans (KPA), 181, 18f, 182f

course, 18deatopatoogy, 181

difeeil iagnoss, 181

eeoogy, 81

ngeet, 182

pathogeess, 181

physc exaination, 181pitfa s o voi, 182

Keatoss plais ropcans face (KPAF), 181

Ketoses

ctic, 206

seborrhec, 206, 23-237

Kiner syome, 67Koees to, 212

Kojic acid, 9t, 10, 141

KT laser. See Potassumtanylphosphate lase

LLMX an 5, 7

Lacc acid, 82

acc aci, 9t

AB syndroe, 14

Lanzou stiute o Biologica roducs, 21tase ha r emova

n sus, 95

n pseuofo ic it is, 100, 10, 10

technq ue, 9&98

Lase l ght frig , 93f

Lase safety, 97f

nonbtve laser resucg,

for ab tve facol lser resacng, 59

vese si e effects, 60, 60

followp, 59-60, 59f

nfection, 60, 6

nonfca skin, 60

posoperive care, 57f, 58f, 59Lase therpy

for demtochaasis, 65

for ganuoma aciale, 75

for Poikiodema of Civtte, 68, 68f

for sebaceous yperplasi, 8283, 82f, 83f

Laseasssted photoyamic terapy, 82

Lases, 74

Lecitins, 9

Lentgnes, 1

checa peels, 46

consuttve questions, 4146course, 45

cryoteapy, 16

differeil iagnoss, 145

epeiology, 4

aboatory exiaton, 145

aser an ght soce treatmet, 146147mngement, 45

pathogenesis, 1

pathoogy, 14

physcl lesions, 14

ndx 3 7

pitfal s o void/cop icatios/mnageent/oucome expections,

147-48

vs seborhec keraosis, 235

topica medicatons, 15-146

Lentgo sex, 4LEOPARD syndroe, 1

Licen pans (L), 262-264

corse, 263, 264f

dematopathology, 262

differenil agnoss, 262

epeiology, 262

aboratory data, 262mngement, 263

pathogenesis, 262

physcl examiaton, 262, 262f, 263f

Licen striaus, 223

Licorce extract, 9t, 10

Liocaine, 47, 59, 107

for war remova, 208

Life Cell Corp., 1tLigt teament, of ace vulgaris, 72f, 73f, 74-75, 75f

Light cyotheapy, 82

Liear foca elastosis

Lier headig, 1 8

Lioleic c, 9

Lipecomy, 283

Lipoma, 22&228

consutatve qestions, 227

course, 227

diffeeil ignoss, 226epe iology, 226

aboatory data, 227

pathoogy, 226



3 1 8 I nd ex

hysi exintion 226 226 227 228

its, 228

tetet 227-228 227 228

Liosom 226

Liosuion 88or elul e 277

or gyneost, 274

or IV podystrophy/il i orohy 283

or l o 227

Liver sots See Sor lentigos

LLL See Low leve ight lse theryLobu i ly emngo 8819

Longpused exdrite ser 0

Longpused Nd:YAG lse 10

Low leve gt ser hery (T 33 133 134

enis o io 33ers o wisdom 33

use o 33

Lowe exreity tengetasis 9-202

Lowe eye sn k tes 2223

Lowe e 3

Lowe lid oizon xity 64L See Lihe nus

Lux 540 n lse 56 56t

MMules 216 223Melugs disese 226

Mle ttern hir oss 03 See also Femle

ten h ir oss

onslt 05

diereni gnoss 103

epieioogy 03vs ee ttern hir loss 29 129t 13

ir trnspnio, 04105

bortory exnton 104

ei terpy, 04 104tntu ogressio, 103

togeness 103hysi exintion 03 103 105

surg roedue

oretive hi r trnspl n surgery 10, 10t

dy o roedure 06

dono hvesting enques 106 06 106t 107t

dono egion nesthes in 06ol iulr unit extio ( F E) 107 07t

grt eton 07

grt lemet 1 081 09 1 13

ir l ne design, 08

os i tns t side eets 1 09

osopeive perod 109

ossugi eiod te sutures/stlesreoved, 109-10

eoetve in srutions 06

e side eets 109

reient regon nesthesi in 08

reient site eton 1 08 1 2MuneAbrig sydroe 36

MGhn edil , 5t

MED See M ni eryte dose

Mel oiulis oul i , 24 24

Meis 15t

Meiis Estets 2tMeumdet eel 30t 33 34 35

Meyox In 2t

Me ln in

ostserohery hyperigmenton, 200

seorrei kertosis, 236

Mel noyte ytotoxi gens 9t

Melnoyte tnser hio, 9

Melno

vs. seborrhe kerosis 235

venous kes d 203

ws d 206

Meloges 1

Melsm, 149 49

tve ser 152

hemil eels 5152

onslttive questions 50

ourse, 150detothology 49

dieenil igosis 150

epeology 49

ton resurng 52 153

botory exminton 150

geent, 150 50 151 152

thogenesis, 149

hysl lesios 149

itl s 52-53

swhe lse 52

toil tretment, 5 5

M E N D See Mirosoi eperl neot ebis

Mets se 26 27 28

Metor orporion 5t

Mequino 9t

Merz hr 4 2t

Mesohery

or eue 278

Mehnhel u omide 87

Mehy molevu ini id (MA) 254

Mehy ntrite 7

Meronzole 77

Mexory SX 7tMexory X 7t

Miroerrsion 74 229 287

Mirosoi eper nerot ebs ( ME D) 52

Mirother retment zoes (MZs), 52

Mide 3

Midnrred sers 40 41

Mid trohy 67

Mi , 229-230

onsulttive questons 230

ourse, 230

epe iology 229

togeness, 229

thology 229

ysl exintio 229 229 230

itls 230tetet 230 230

Mii erythe dose (ED) 8

Mioylne 73 77

Minoxidi l 04 04 27 28 127t , 13 33

Mixed derm els 49

Mixed supel nd dee hegio () 177Mohs rogh surgey 254 257258

Mooenzone 9t

Morhe 265267

ourse, 266

detothology 266

dierenil dignosis 265

epdeology 265



aboatory data 265-266

aageent 266 266

pathogeess 265

physca exaination 265 265fpita 267

MTZs See M croheal eatent zoes

Mubery extac 9t

Muscle grops 23

forehea 23-24

glabella copex 24 24nasoabia od 25-26 27f

neck 26-27 28

peioal egion 26 27 28f

peioa egion 2-25 25f

upe asal root 25 26

Myastheia gavis 22Myobloc 2t

NNAFR See Noalatve factoa aser resuacg

Nasa sebaceous hypepasa See Rhophyma

Nasoabia fol 25-26 27Nd:YAG ase 99 193

for sebohec keatosis 236

Neck 26-27 28

Neofroas ( F) 231-234

consltative qestos 232

course 232difeenial iagnoss 231

eeoogy 231

aboatory data 232

aageent 232

pathogeess 231

pathology 231physca exaination 231 23f

pitas 22322

teatet 232233 232Neofroatosis 36

Neoox 2

Nevus aaneus 170-73Nevus Becker's 216-218

Nevus edea 222-225 235

Nevus uscoceules ophthaomaxl lais 154

Nevu s of Ota 154

consltatve qestos 55

course 155difeenial agnoss 154

eeoogy 5

aboatory exaiaton 155

aageent 55

pathogeess 154

pathology 154physca lesos 15

pitas 157

topical teatent 155

teatet 5156

Nevus seaceos 223

Nacade 9t 10oaative factona aser resuacg ( AF R)

aesthesa 54

contandcaos 53

deatopathoogy 52 52f

devices 56 56t

d catios 52echanis o acio 52 52

ecatios 53-54

posoeraive care 55

preopeatve evaluation 52-53 53f 54f

preopeatve preparato 54

proceural ips 54-55teatet peals 55-56

Nonalatve factioal lasers 57

Nonalatve factoal esracig 39 60

Nona latve aser resacng 39 39

avese side eects 41

posoeraive care 2ndicatos 40

aser saey 4

preopeatve evaluation 40

prohyaxis/aneshesia 40

dfaed ses 4 41Nonfacal sk n 60

ndx 3 9

NonFDA aprove edications or feae patten hai oss 128

Non hypesesitive eactions of soft tsse augentato 1819

Nonlaser theapy 93

depiat on 94

topca elohe 94Noood cassficato 103

0Octocrylene 7t

Octy ethoxycamae 7t

Octy sa cyate 7

Ocla r rosacea 76Oral edicatons

n hyerhidrosis 87

Oral heapy 65

Orbclars oci 225 25f

Orbcuar s oci tone Orbcars os 26 27f 28fOxybezoe 7t

p3 to supresso gene 252

ABA. See aaai obezoc acid

adiae 7t

aoplantar arts 206209

aoa Medcal echnooges 56 56t 79ape ubery 10

apules

n angiofioas 212

n epidea evs 223

n arts 206

apulopstuar osacea 76aaamnobenzoic acid (ABA) 7t

aial ears 308atet consultato 95

pror to teatet 95-96

DL See ulse dye aserDT. See hotodya c theray

eary e le papues 212

eel tyes 33

ad c ca d icatons 30t

eelng aget characteistcs 30t

enic i l 10eifoll cu la eryhea chaacestc postteatet 93

eioa deatis 76

eioba egio 2-25 25f 26 27f 28f

eioba hytes 55f



320 I nd ex

Peigal fibroas, 212

Pelane, 15t

Pelane 15

Pet-eghers syndome, PAE syndrome, 78

Pheno, 30

Phenyl benzm dazole sonic acid, 7

Photodynaic theray ( PDT), 75

Photodynaic theray, 25, 258, 269

Phototeapy, 75, 165Phyatos rosacea. ee Sebaceos hyerplasia

Physica sceen, 8, 8

Pigenay cages, n face, , 6f

P . ee Postinfaatory hyerpigenation; Pregnancyindced

yperesion

Piar cysts, 220, 26Pimecro ms, 16

Pityrospom ovae, 10

Pla e was, 20 209

Platar was, 06

Plaes

n angofbroma, 212n Becke's evs, 2 6

n seborrheic keatoss, 235

Playsa scle co ex, 2627, 28f

POC. ee Poki odera of Civatte

Podoy in, 22

Podoyotox, 207Poklodea of Cvatte (POC), 67

consltatve estions, 68

corse, 68

deratopatoogy, 67

diffeenia agnos s, 67eieioogy, 67

manageent, 68

pathogeness, 67

physica examination, 67, 67f, 68f

pitfas, 68-69, 69

prereaten, 68fteatmet, 68, 68f

Poidocanol, 199, 200, 00

PoyIacc ac, 18

Pontocane ee Toca tetacae

Porwne sains (PWS), 83, 18f, 185f, 186f

aclary tests, 83corse, 183

deatopatoogy, 183

diffeenia agnoss, 183

eieioogy, 83

maagement, 183

physica examination, 83pitfa s o avoid , 83

Post ha i tans at si de efects, 109

Postnfaatoy erythea

ad crettage, 237f

Postnfaatoy hyerpigenation ( PI H) , 158, 158f

cheical peels, 166consltatve estions, 159

corse, 159

deratopatoogy, 158

diffeenia agnoss, 158

eieioogy, 58

aboatory exanaton, 58asers, 161

teatmet, 218, 233

maageent, 159

pathogenesis, 158

physcal lesos, 158

pitfal s o avoid/cop icatons/manageent/ocome

expectaios, 61

snotecio, 159topical treatent, 160

Postsceroeapy hyperigenatio (P SH) , 200

Potasstaylphoshate lase, 79, 93

Prenisone, 130, 79

Pregnancy

ad telangecasias, 98, 201Pregnancydced hyeension ( PI ) , 60

Prevel le si k, 5t

Prmary andogenprodcng neoplass, 92

Procers, , 2f

Proanthelne, 87Proyacic antbotcs, 9, 53

Proranolo, 179

Prosgne, 2!

Prostate cace

proylaxis in, 273

Proes synd ome, 226Psedofol icts, 99

corse, 100

deatopatology, 00

diffeenial diagnosis, 00

ed eiology, 99

aboatory exainaton, 100maageent, 100

pathogenesis, 99

physcal lesos, 100

pitfal s, 101-02, 101, 102f

teatment

aser ha emoval, 101 , 0shavng cessato, 100

shavng technie, odifcaio o, 1001

topical teatent, 10

Psedofoll icits, and erology, 01

Psedogyecoasia, 272

Psedoochronoss, 3, 159fPsoralen and tavioet A (PVA), 65, 75

Psorass, 267270, 67f, 268f

corse, 268

diffeenial d iagnosis, 268

edeiology, 67

aboatory data, 268maageent, 268-269, 269f

pathogenesis, 268

physcal examination, 268

pitfals, 270

Psedogyecoasia, 27Psed carbon doxide laser, 250

Psed dye aser (PL)

for acne vlgas, 75

for angiofibroma, 213

for a ngiokeratoas , 169

for cery a spider agioas, 17 1for facia telagiectasa, 203, 203f, 205f

for facia telagiectasas, 192

for hypetroic scars/keloid s, 292t

for nfantile hemagioas, 79

for keatoss ais atroicans, 182

for orhea, 266for Po kiode ma of Civatte, 68

for powine stans, 85

for psorias, 69



for pyogec ganloa 89

for rosacea 78

for seacious yperpasa 82

for strae distensae 287for telagiectasias 201

for venous aes, 203 205f

for wars 206f 208, 208f 209f

for wars 208

Pnch excsion 213

Pura 204 208PVA See Psora len and ultravioet A

Pyogenc gan loa ( PG) 88, 88f 89f

Q

iosyproven 9f

corse 88

deatopathoogy 188

diffeenial iagnoses 88eeioogy 88

aser teatent, 89

aageent 89

pathogeness 88

physca exaination 88

pitfas o avoid 89sgica treatmet 189

vs venos aes 03

Med AB 5tswche lasers 52

R

alexandite

for Becers nevs 27 28f

for caf a Ia it acles 37 138

for deatosis palosa n igra 242for epdera nevs 25

for nevs of Oa 55 56

for seorrheic eatosis 236

argon

and ganu loa facae 175

d:YAGfor Becers nevs 27 28f

for caf a Ia it acles 37 138

and eph ides 4

and ent gines 146

for nevs of Oa 55

for tattoo eoval 300 302uy

for Becers nevs 7 28f

for deatoss palosa nigra 42

for epil des 42

for etigies, 46 47

for nevs of Oa 55for seorrheic eatosis 23 6

for taoo eoval 300 302t

Radiato deatis 67

Radia ton terapy 25RadiesseTM, 15t

Radiofeqecy (RF) echology 62

Radi oteapy 258

Reepithel ial izat on 9

Rex in

Renova 9Restylane 15

RestylaneL 5

Rete rdges

n epidera evs 222

Reticar veins 98-202

Reticated ypepigentaio 67

RetinA 82Retinadehyde 8 9

Retioc acid 8-9 9 0 2

cheica structues of f

Retinods 73 41 5 51! 60 182

Retino 8

Retinyl esters 8R F technoogy See Radi ofeqecy ( RF ) echoogy

Rhophya 76, 76f 77-78

Rhes 58

Rosacea 76

course 77deatopathology 77

differeial diagnoss 76

epdeiology 76

aageent, 77

sgca terapy 7779

sysec herapy 77topica teapy 77

pathogeesis, 76

physcal exainaton 76

Rothud-oson syndome 67

Ry sot, 70-73 See also Chery angioas

Rssel-Silver synoe 36

sSaicylic aci 73 207

Sa ie

ad warts 207 208ad teangecasias, 20

Scarig

fo angiofioa treaten 24

fo surgical ncision 22 228

fo wa eoval 207 208 209

SCC See Squamos ce carcinoa

ndx 321

Sceroteapy 199-20 98f 99f 200f 200t 20t 204

Scoioss 232

Sculpa 15t

Seaceos cyst 2 9

Seaceos hyperplasa 76 77 8 8f

consutatve qestios 8course, 81

differeial diagnoss 8

epeiology 8

for seoeic keatosis 236f

aoratory exai naton 8

aageent, 82pathogeesis, 81

pathoogy 8

physcal lesios 8

pitfal s 83

teatets, 82

descive oda ies 82aser terapy 82-83 82f 83f

Seorhec eratitis 76

Seorh ec eraosis 23237 See also Deatosis paplosa gra

consutatve qestions 235

course 235

differeial dagnoss 235epde iol ogy 234

vs edera nevs 223 235



322 I nd ex

anageen 235-236

pahology 235

physica exainaion 235

pifas 237eaen 236

s. was 206

Segena eangioa 8

Senie eangoas 170-173

Seia puncue 8

Seia saicyic acid peels 74Sharpan FeaherToch 169

Shave biopsies and excisons

for angiofiboas 21 3

for epdeal nevs 224

for l poa 227 227f

for neuofiboas 236for seboheic keaosis 236

Shaving cessaon 100

Shaving echnque odifcaion of 10010

Shoplsed eb 287

Sil cone 18

Sil cone sheeing 29 29S l kone1000 5

Skin gafs 225f

Skin l ghenng agens 9-1

Skin esng 16

Skn unove acceeaon 9

Skin ypesand eckes nevus 218

Soohbea 41

SA25 21

Sodiu ohuae 199

Sodiu slfacetaide 73 77Sodiu eadecy su fae 99 200 20

Sof issue agenaion

avese eacions

hypesensive 8

nonhypesensive 18-9

echniq ue copicaions 9aneshesa 16f 7

degree of coecion 18

duaion of coecon 18

dea fl e 4 14-15

necion echnque 18 18f 19f

evel of injecion 1718 17f 18fechans of acion 4

peopeave evauaion 15-16

pocedral edicaons 17

skin esng 6

eaen peas 19

Soffo 15Sola lenigo s epheid 145

Sola lenigos 44

Soa edical Inc 56 56

Soice euosciences 2

Soadecho 200

Soy 10Soybean/k exacs 9

SF See Su n poecive facor

Spe angoas 170-73 17

Spe elangecasa 170-73

Spnal dysaphs 227

Sponolacone 73 28Saous cell carcnoa (SCC) 256-258

conslave quesions 257

course 257

deaopahology 257

diffeenial diagnosis 256 257f

epe iology 256

s. epea nevus 223aboaoy daa 257

anageen 257-258 258f 259f

pahogenesis 256

physcal exainaion 256 256f

pifals 258

s. sebohec keaoss 235s. was 206 207

Sachod ine es

Saux Lux G handpiece 79

Seoi rosacea 76

Sockings eas c copesson 200

Sawbery 77180Sech aks. See Sae di sensae

Sa aba 287

Sia ruba 286-287 287f

Siae disensae 285 285f

conslaive quesons 286

course 286diffeenial iagnosis 286

epdeiology 285

aboaory exa ina on 286

anageen 286

icroerabasion 287

pahogenesis 285pahology 285

physcal lesons 285

pifal s 288

opical eaen 287

eaen 286-287Soeysn 9

Sge-Webe syndroe (SWS) 184

Subcision 278

Sbcaneos fa n ipoa 226

Subcaneous fa 5

Sbcaneos fa arophy 5Sfu 73

Sisobenzone 7

Sn exposue

and sceoheapy 200

and venos akes 203

Sn poecive facor (SPF) 8Snscreen 7-8 7f 7

Speficial heangoa (S) 177 179

Speficial peel 30 32f 33 33f

Sgery

n hypehidoss 88

Sgca excsion 175Sgca pocede for hai anspanaon

coecive ha ans pan sugey 10 1 10

day of pocedue 06

dono avesing echnques 106 06f 106 107

dono egion a neshesa in 06

fol icula n i exacon (F E) 107 07gaf ceaion 07

gaf paceen 108-109 13f

a in e desgn 108

pos ha i anspa n side effecs 109

posopeaive period 109

possugca peiod afe sues/stapleseoved 09- 10

peopeave nscions 06

ae sde effecs 109



ecipen regio aeshesia in 08

ecipen se ceaio 08 2f

Sgca hera py

of ace vu gars 7

for angioibroma 23for Becker's nevs 27

for Deraochaasis 6f 65

for epdea nclsio cyss 220

for epdea nevs 22

for ipoa 227 227f 228f

for neuofibroa 232-233 232fof osacea 76f 77-79 79f 80f

for veous akes 20

for wa emova 207-209

Syigoma 238 238f

conslave quesons 239course 239

diffeeial iagnoss 238

epe ioogy 238

aboaory exa ia on 238

maageen 239

pahogeess 238pahology 238

physca lesios 238 238f

pifas 239f 240 20f

eaen 239-20

Sysec l ps erytheaoss 76

Sysec heapy

T

of ace vugars 73-7

of osacea 77

Tacrols 6

Tacrols oe 75

Takeshesa 7

Tap wae ionophoresis 87

Taoo reoval 300 300f

averse eecs/pecaos 303 30 305 306 307fconslave quesons 300-30

aser heapy 300

maageen 30

pifas 303-304

posteamen ca e 302

pereaen assesse 30aoo reame 302 302 303f 30f

eamen 30-302 303f

Tazaoene 9 73 82

TCA pees See Trichl ooacec acid peels

Teangecases 67

Telangiecasas 7879 78f 79f 80fower exremty 98-202

epeioogy 98

aboaory daa 9 8

maageen 99202 98f 99f 200f

pahophysoogy 98

physical exami naion 98Teangecaic mattg rM 20

Telogen efuvi 29 30-3

Teracycine 73 77

Tombophlebi s 98

Thyroidsi a g homone (TS) 63

Tsse ghening 62canddae seecio 62

cl in ca pears 63

mechanis of acon 62

procere 62

checklis 62-63

side eecs 63

Topica 5foroacil 25Topica eflornihine 9

Topica m ui od 25

Topica mecaions i hypehdrosis 87

Topica proparacane 7 59

Topica eioic acd 32

Topica eacae 47 59Topica herapy

of ace vu lgaris 73

for demaochaasis 65

for Poikioema of Civate 68

of pseudofol cul i s 0

of osacea 77Topica reame opi ons

app caion echq ues - 2

compica ons 2

conandcaios

deal can dae

nd icaos ess ha dea can ae

mechani s of aco 7-

poseamen cae 2

prereaen evaao

eame pearls 2-3

Topica reio 6 6Tor ea obe 308

key consaive quesions 308

maageen 308

ndx 323

pifal s o avoid/cop icaios/manageent/oucome expecaios 309

eames 308-309 308f 309f 30fTraoa PDL 78

Tradoa resuacig 39

Treno 9 6 54 73

ad epidermal evs 22

ad l i u 230

TriAcive Laserdeoogy 278Triamcoone aceoe 79

Triaguais mscles 26 27 28f

Trichloaceic acd (TCA) peels 30 7

for war remova 207

Tri ma 6

Trolame sacylae 7TS See Tyroidsilaing horone

Tuberos scerosis 36

Tuberos scerosis 23 23f

Tuors 220

Tyleno 09

Tyosinase 9Tyosinase i h biors 9

uUlceaed hemagioa 79fUla 5

Ula Plus 5

Ua Plus XC 5

Ua XC 5

Ulaso 98Ulaviole A (UA) 67

Ulaviole B (UB) 67

Upper and idfacia usculaue aaoca i srao

of 22f

Up per face 2-3

Documents

atlas de dermatologie cosmetica.pdf