Patrice Wendling

VIENNA — There are multiple genetic targets and combinations of therapies that hold great promise for changing the fate of melanoma patients, Christoph Höeller, M.D., said at the 10th World Congress on Cancers of the Skin.

A major focus of targeted therapies has been the protooncogene for Bcl-2, which is linked to chemoresistance, a problem in melanoma patients.

Antisense oligonucleotide therapy targeting Bcl-2 mRNA has increased tumor cell apoptosis and tumor response. But it has still not significantly improved the overall survival of these patients.

Small molecule inhibitors of Bcl-2 are entering phase I and phase III trials, and Bcl-2 RNA interference (RNAi) is in preclinical evaluation. But there's more to targeted therapies than Bcl-2, he said.

Dr. Höeller and colleagues at the Medical University of Vienna recently found that clusterin, a glycoprotein implicated in many cellular functions including apoptosis, varies in expression between melanocytes and melanoma cells (J. Invest. Dermatol. 2005;124:1300–7).

In tissue samples, 45% of melanomas stained positive for clusterin, whereas only 18% of nevi stained positive.

Antisense oligonucleotides directed against clusterin mRNA also significantly decreased the survival of human melanoma cells in mice in the presence of cytotoxic drugs, suggesting that downregulation of clusterin may be helpful in overcoming drug resistance in melanoma.

Mcl-1, another member of the Bcl-2 family that has been found to contribute to chemoresistance in melanoma in vivo, has potential for antisense therapy or combination therapy.

Combined Mcl-1 antisense oligonucleotides plus dacarbazine treatment led to significantly reduced mean tumor weight in severe combined immunodeficiency mice, compared with animals treated with saline plus dacarbazine or control oligonucleotide plus dacarbazine (J. Invest. Dermatol. 2003;120:1081–6).

Other treatment strategies include the use of histone deacetylase inhibitors such as tributyrin, sodium butyrate, and phenylbutyrate.

Histone deacetylase inhibitors are now in phase II studies, having been shown to be active against melanoma cells in in vivo and in vitro models, Dr. Höeller said at the meeting, which was cosponsored by the Skin Cancer Foundation.

Finally, he noted that bortezomib (Velcade), which is approved for patients with multiple myeloma and has a chemosensitizing effect when administered with other antitumoral drugs, may be useful in melanoma.

In a separate presentation, Eva-Bettina Bröcker, M.D., of the University of Würzburg (Germany), reported on a vaccine that targets the protein survivin.

Survivin is normally active only in growing embryos or rapidly dividing cells, but is turned on in a variety of malignancies.

It has become an increasingly popular target because downregulation or loss of expression of survivin is associated with impaired tumor progression.

Among five stage IV melanoma patients vaccinated with the human leukocyte antigen-A2 restricted survivin (96–104) epitope, four patients mounted strong T-cell responses to the epitope as measured by enzyme-linked immunospot assay (Vaccine 2005;23:884–9).

VIENNA — There are multiple genetic targets and combinations of therapies that hold great promise for changing the fate of melanoma patients, Christoph Höeller, M.D., said at the 10th World Congress on Cancers of the Skin.

A major focus of targeted therapies has been the protooncogene for Bcl-2, which is linked to chemoresistance, a problem in melanoma patients.

Antisense oligonucleotide therapy targeting Bcl-2 mRNA has increased tumor cell apoptosis and tumor response. But it has still not significantly improved the overall survival of these patients.

Small molecule inhibitors of Bcl-2 are entering phase I and phase III trials, and Bcl-2 RNA interference (RNAi) is in preclinical evaluation. But there's more to targeted therapies than Bcl-2, he said.

Dr. Höeller and colleagues at the Medical University of Vienna recently found that clusterin, a glycoprotein implicated in many cellular functions including apoptosis, varies in expression between melanocytes and melanoma cells (J. Invest. Dermatol. 2005;124:1300–7).

In tissue samples, 45% of melanomas stained positive for clusterin, whereas only 18% of nevi stained positive.

Antisense oligonucleotides directed against clusterin mRNA also significantly decreased the survival of human melanoma cells in mice in the presence of cytotoxic drugs, suggesting that downregulation of clusterin may be helpful in overcoming drug resistance in melanoma.

Mcl-1, another member of the Bcl-2 family that has been found to contribute to chemoresistance in melanoma in vivo, has potential for antisense therapy or combination therapy.

Combined Mcl-1 antisense oligonucleotides plus dacarbazine treatment led to significantly reduced mean tumor weight in severe combined immunodeficiency mice, compared with animals treated with saline plus dacarbazine or control oligonucleotide plus dacarbazine (J. Invest. Dermatol. 2003;120:1081–6).

Other treatment strategies include the use of histone deacetylase inhibitors such as tributyrin, sodium butyrate, and phenylbutyrate.

Histone deacetylase inhibitors are now in phase II studies, having been shown to be active against melanoma cells in in vivo and in vitro models, Dr. Höeller said at the meeting, which was cosponsored by the Skin Cancer Foundation.

Finally, he noted that bortezomib (Velcade), which is approved for patients with multiple myeloma and has a chemosensitizing effect when administered with other antitumoral drugs, may be useful in melanoma.

In a separate presentation, Eva-Bettina Bröcker, M.D., of the University of Würzburg (Germany), reported on a vaccine that targets the protein survivin.

Survivin is normally active only in growing embryos or rapidly dividing cells, but is turned on in a variety of malignancies.

It has become an increasingly popular target because downregulation or loss of expression of survivin is associated with impaired tumor progression.

Among five stage IV melanoma patients vaccinated with the human leukocyte antigen-A2 restricted survivin (96–104) epitope, four patients mounted strong T-cell responses to the epitope as measured by enzyme-linked immunospot assay (Vaccine 2005;23:884–9).

VIENNA — There are multiple genetic targets and combinations of therapies that hold great promise for changing the fate of melanoma patients, Christoph Höeller, M.D., said at the 10th World Congress on Cancers of the Skin.

A major focus of targeted therapies has been the protooncogene for Bcl-2, which is linked to chemoresistance, a problem in melanoma patients.

Antisense oligonucleotide therapy targeting Bcl-2 mRNA has increased tumor cell apoptosis and tumor response. But it has still not significantly improved the overall survival of these patients.

Small molecule inhibitors of Bcl-2 are entering phase I and phase III trials, and Bcl-2 RNA interference (RNAi) is in preclinical evaluation. But there's more to targeted therapies than Bcl-2, he said.

Dr. Höeller and colleagues at the Medical University of Vienna recently found that clusterin, a glycoprotein implicated in many cellular functions including apoptosis, varies in expression between melanocytes and melanoma cells (J. Invest. Dermatol. 2005;124:1300–7).

In tissue samples, 45% of melanomas stained positive for clusterin, whereas only 18% of nevi stained positive.

Antisense oligonucleotides directed against clusterin mRNA also significantly decreased the survival of human melanoma cells in mice in the presence of cytotoxic drugs, suggesting that downregulation of clusterin may be helpful in overcoming drug resistance in melanoma.

Mcl-1, another member of the Bcl-2 family that has been found to contribute to chemoresistance in melanoma in vivo, has potential for antisense therapy or combination therapy.

Combined Mcl-1 antisense oligonucleotides plus dacarbazine treatment led to significantly reduced mean tumor weight in severe combined immunodeficiency mice, compared with animals treated with saline plus dacarbazine or control oligonucleotide plus dacarbazine (J. Invest. Dermatol. 2003;120:1081–6).

Other treatment strategies include the use of histone deacetylase inhibitors such as tributyrin, sodium butyrate, and phenylbutyrate.

Histone deacetylase inhibitors are now in phase II studies, having been shown to be active against melanoma cells in in vivo and in vitro models, Dr. Höeller said at the meeting, which was cosponsored by the Skin Cancer Foundation.

Finally, he noted that bortezomib (Velcade), which is approved for patients with multiple myeloma and has a chemosensitizing effect when administered with other antitumoral drugs, may be useful in melanoma.

In a separate presentation, Eva-Bettina Bröcker, M.D., of the University of Würzburg (Germany), reported on a vaccine that targets the protein survivin.

Survivin is normally active only in growing embryos or rapidly dividing cells, but is turned on in a variety of malignancies.

It has become an increasingly popular target because downregulation or loss of expression of survivin is associated with impaired tumor progression.

Among five stage IV melanoma patients vaccinated with the human leukocyte antigen-A2 restricted survivin (96–104) epitope, four patients mounted strong T-cell responses to the epitope as measured by enzyme-linked immunospot assay (Vaccine 2005;23:884–9).

CHICAGO — Cosmetic dermatology is a rapidly moving and rewarding area of dermatology for those with the right mind set, Gerald N. Bock, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

An elective procedures practice offers the gratification of learning new procedures, recognition as having specific expertise, and less stress as a result of upfront payments and fewer insurance hassles. Staff can be used to amplify income, and fewer patients can generate the same or greater income, he said.

"We're in the golden age of minimally invasive procedures," reported Dr. Bock.

That being said, a cosmetic practice is not for everyone.

"If you don't enjoy working with these patients, who can sometimes be more demanding, don't do it," he said. "If your sole motivation is financial gain, don't do it. This will lead you to make bad decisions. And if you just don't have the flexibility or want to learn new things or take risks, this is not for you."

Dr. Bock acknowledged that his views are colored by the fact that he established a private elective procedures practice in the unlikely Central Valley location of Stockton, Calif., a conservative agricultural community far from the aesthetically obsessed hills of Hollywood. He offered the following tips from his experiences:

▸ Set realistic expectations. It's best to underpromise and overdeliver on your services. Have a humble attitude and offer great service. "You really want to be Wal-Mart with Nordstrom practices," Dr. Bock said. Put everything in writing to avoid misunderstandings. Explain that retreatment may be necessary and failures can occur. Consent forms should list the worst-case scenario for each procedure. Dr. Bock's Botox disclosures note that death can occur.

▸ Follow-up and photographs are essential. New patients should be seen 2–3 weeks after their first treatment to make sure they're satisfied or to offer them additional treatments if the result is less than satisfactory. Photograph all patients, every time. Photographs improve patient satisfaction and can resolve issues that may arise later. One patient complained of eyelid ptosis from her Botox injections until she was shown pretreatment photographs that helped her to realize the ptosis was there beforehand.

▸ Proper positioning is key. Pricing your services below what people expect is one way to exceed their expectations. Start out with very reasonable pricing. You can always raise your prices later. At lower prices, patients will want more frequent and extensive treatments, leading to better results and earlier retreatment. You'll get bigger and better faster, and this may intimidate potential competitors. "Just because you're better doesn't mean people will pay more for your services," he explained. "I've had patients in the past who've had their Botox done by the plastic surgeon's nurse, even though they know I was doing a better job."

▸ Little details are important. Dr. Bock strongly recommends using Air-Tite SteriJect 31-gauge needles for Botox injections. "Everybody tells us that our Botox injections are significantly less painful than injections they get elsewhere, and that's because of these needles," he said. Consider using vibration anesthesia, a technique developed by dermatologist Kevin Smith (Dermatol. Online J. Oct 15, 2004;10:1) to reduce discomfort during dermatologic procedures, particularly for needle-phobic patients.

▸ Consider used equipment. There are a lot of good machines available if you're willing to do the research. One source is the Aesthetic Buyers Guide (www.miinews.com

▸ Keep up your training. Botox, microdermabrasion, and hair removal generate the greatest revenue in Dr. Bock's practice. But patients will demand what they can't get elsewhere. Dr. Bock gained an edge, albeit temporary, by becoming the only practice in his area to offer soft tissue augmentation with Sculptra.

CHICAGO — Cosmetic dermatology is a rapidly moving and rewarding area of dermatology for those with the right mind set, Gerald N. Bock, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

An elective procedures practice offers the gratification of learning new procedures, recognition as having specific expertise, and less stress as a result of upfront payments and fewer insurance hassles. Staff can be used to amplify income, and fewer patients can generate the same or greater income, he said.

"We're in the golden age of minimally invasive procedures," reported Dr. Bock.

That being said, a cosmetic practice is not for everyone.

"If you don't enjoy working with these patients, who can sometimes be more demanding, don't do it," he said. "If your sole motivation is financial gain, don't do it. This will lead you to make bad decisions. And if you just don't have the flexibility or want to learn new things or take risks, this is not for you."

Dr. Bock acknowledged that his views are colored by the fact that he established a private elective procedures practice in the unlikely Central Valley location of Stockton, Calif., a conservative agricultural community far from the aesthetically obsessed hills of Hollywood. He offered the following tips from his experiences:

▸ Set realistic expectations. It's best to underpromise and overdeliver on your services. Have a humble attitude and offer great service. "You really want to be Wal-Mart with Nordstrom practices," Dr. Bock said. Put everything in writing to avoid misunderstandings. Explain that retreatment may be necessary and failures can occur. Consent forms should list the worst-case scenario for each procedure. Dr. Bock's Botox disclosures note that death can occur.

▸ Follow-up and photographs are essential. New patients should be seen 2–3 weeks after their first treatment to make sure they're satisfied or to offer them additional treatments if the result is less than satisfactory. Photograph all patients, every time. Photographs improve patient satisfaction and can resolve issues that may arise later. One patient complained of eyelid ptosis from her Botox injections until she was shown pretreatment photographs that helped her to realize the ptosis was there beforehand.

▸ Proper positioning is key. Pricing your services below what people expect is one way to exceed their expectations. Start out with very reasonable pricing. You can always raise your prices later. At lower prices, patients will want more frequent and extensive treatments, leading to better results and earlier retreatment. You'll get bigger and better faster, and this may intimidate potential competitors. "Just because you're better doesn't mean people will pay more for your services," he explained. "I've had patients in the past who've had their Botox done by the plastic surgeon's nurse, even though they know I was doing a better job."

▸ Little details are important. Dr. Bock strongly recommends using Air-Tite SteriJect 31-gauge needles for Botox injections. "Everybody tells us that our Botox injections are significantly less painful than injections they get elsewhere, and that's because of these needles," he said. Consider using vibration anesthesia, a technique developed by dermatologist Kevin Smith (Dermatol. Online J. Oct 15, 2004;10:1) to reduce discomfort during dermatologic procedures, particularly for needle-phobic patients.

▸ Consider used equipment. There are a lot of good machines available if you're willing to do the research. One source is the Aesthetic Buyers Guide (www.miinews.com

▸ Keep up your training. Botox, microdermabrasion, and hair removal generate the greatest revenue in Dr. Bock's practice. But patients will demand what they can't get elsewhere. Dr. Bock gained an edge, albeit temporary, by becoming the only practice in his area to offer soft tissue augmentation with Sculptra.

CHICAGO — Cosmetic dermatology is a rapidly moving and rewarding area of dermatology for those with the right mind set, Gerald N. Bock, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

An elective procedures practice offers the gratification of learning new procedures, recognition as having specific expertise, and less stress as a result of upfront payments and fewer insurance hassles. Staff can be used to amplify income, and fewer patients can generate the same or greater income, he said.

"We're in the golden age of minimally invasive procedures," reported Dr. Bock.

That being said, a cosmetic practice is not for everyone.

"If you don't enjoy working with these patients, who can sometimes be more demanding, don't do it," he said. "If your sole motivation is financial gain, don't do it. This will lead you to make bad decisions. And if you just don't have the flexibility or want to learn new things or take risks, this is not for you."

Dr. Bock acknowledged that his views are colored by the fact that he established a private elective procedures practice in the unlikely Central Valley location of Stockton, Calif., a conservative agricultural community far from the aesthetically obsessed hills of Hollywood. He offered the following tips from his experiences:

▸ Set realistic expectations. It's best to underpromise and overdeliver on your services. Have a humble attitude and offer great service. "You really want to be Wal-Mart with Nordstrom practices," Dr. Bock said. Put everything in writing to avoid misunderstandings. Explain that retreatment may be necessary and failures can occur. Consent forms should list the worst-case scenario for each procedure. Dr. Bock's Botox disclosures note that death can occur.

▸ Follow-up and photographs are essential. New patients should be seen 2–3 weeks after their first treatment to make sure they're satisfied or to offer them additional treatments if the result is less than satisfactory. Photograph all patients, every time. Photographs improve patient satisfaction and can resolve issues that may arise later. One patient complained of eyelid ptosis from her Botox injections until she was shown pretreatment photographs that helped her to realize the ptosis was there beforehand.

▸ Proper positioning is key. Pricing your services below what people expect is one way to exceed their expectations. Start out with very reasonable pricing. You can always raise your prices later. At lower prices, patients will want more frequent and extensive treatments, leading to better results and earlier retreatment. You'll get bigger and better faster, and this may intimidate potential competitors. "Just because you're better doesn't mean people will pay more for your services," he explained. "I've had patients in the past who've had their Botox done by the plastic surgeon's nurse, even though they know I was doing a better job."

▸ Little details are important. Dr. Bock strongly recommends using Air-Tite SteriJect 31-gauge needles for Botox injections. "Everybody tells us that our Botox injections are significantly less painful than injections they get elsewhere, and that's because of these needles," he said. Consider using vibration anesthesia, a technique developed by dermatologist Kevin Smith (Dermatol. Online J. Oct 15, 2004;10:1) to reduce discomfort during dermatologic procedures, particularly for needle-phobic patients.

▸ Consider used equipment. There are a lot of good machines available if you're willing to do the research. One source is the Aesthetic Buyers Guide (www.miinews.com

▸ Keep up your training. Botox, microdermabrasion, and hair removal generate the greatest revenue in Dr. Bock's practice. But patients will demand what they can't get elsewhere. Dr. Bock gained an edge, albeit temporary, by becoming the only practice in his area to offer soft tissue augmentation with Sculptra.

VIENNA — Teledermatology is expanding in Europe through an online international dermatology community that provides open-access consultations, H. Peter Soyer, M.D., reported at the 10th World Congress on Cancers of the Skin.

The consultations are free of charge for now, and they are available in five different languages. Physicians can send in patient pictures and information, and may request a consultation with a specific clinician from a team of dermatologists. Discussion can be added from about 500 participating dermatologists worldwide.

The idea (www.telederm.org

The first world congress on teledermatology will be held in November 2006 in Graz.

Dr. Soyer said teledermatology provides not only a second opinion, but also greater access to care and disease monitoring in remote areas and third world countries. European dermatologists have also gained valuable experience about unfamiliar skin conditions reported by dermatologists in Pakistan and China.

Audience members responded positively to the presentation, but many Americans suggested that malpractice insurance will be needed for telemedicine to grow in the United States.

American physicians have been successfully sued for consulting on nondermatologic cases from states where they didn't hold a license.

"We do it bona fide, with good trust," Dr. Soyer said at the meeting, which was cosponsored by the Skin Cancer Foundation. "If you are taking care of the patient, you are responsible, and I am your assistant."

Dr. Soyer said liability is an unresolved issue and that a legal platform may need to be established to address liability for online consultations.

Reasonable liability insurance for telemedicine has been slow to happen in the United States, in large part because of limited reimbursement, Hon S. Pak, M.D., a member of the American Academy of Dermatology Telemedicine Task Force and vice president of the American Telemedicine Association, said in an interview.

Although third-party payers are increasingly reimbursing for telemedicine, the Centers for Medicare and Medicaid Services currently reimburses only for rural patients—defined as patients who live in non-metropolitan statistical areas—if teledermatology takes place in a live, interactive mode.

Except in federally designated clinics in Hawaii and Alaska, reimbursement does not exist for store-and-forward consultations that allow for asynchronous communication between clinicians via the Internet.

"It's not that teledermatology increases liability; it's just that insurers don't know enough about it and how to put a risk score on it," Dr. Pak said. "Enough volume has to be generated to get a risk profile, and that requires reimbursement."

Members of both the AAD task force and the ATA appeared on Capitol Hill this spring to educate legislators on the value of teledermatology and to push for reimbursement for store-and-forward teledermatology.

A teledermatology forum is also planned for the AAD annual meeting in 2006. The forum is seen as a way to encourage dermatologists to use the technology to enhance their practices, said Dr. Pak, who is a dermatologist with the Telemedicine and Advanced Research Center at Fort Detrick in Frederick, Md.

Other hurdles still exist for teledermatology. Transmission of multimedia streams has remained a major challenge for real-time consultations, and some asynchronous consultations may or may not provide clinical information, depending on what is requested.

VIENNA — Teledermatology is expanding in Europe through an online international dermatology community that provides open-access consultations, H. Peter Soyer, M.D., reported at the 10th World Congress on Cancers of the Skin.

The consultations are free of charge for now, and they are available in five different languages. Physicians can send in patient pictures and information, and may request a consultation with a specific clinician from a team of dermatologists. Discussion can be added from about 500 participating dermatologists worldwide.

The idea (www.telederm.org

The first world congress on teledermatology will be held in November 2006 in Graz.

Dr. Soyer said teledermatology provides not only a second opinion, but also greater access to care and disease monitoring in remote areas and third world countries. European dermatologists have also gained valuable experience about unfamiliar skin conditions reported by dermatologists in Pakistan and China.

Audience members responded positively to the presentation, but many Americans suggested that malpractice insurance will be needed for telemedicine to grow in the United States.

American physicians have been successfully sued for consulting on nondermatologic cases from states where they didn't hold a license.

"We do it bona fide, with good trust," Dr. Soyer said at the meeting, which was cosponsored by the Skin Cancer Foundation. "If you are taking care of the patient, you are responsible, and I am your assistant."

Dr. Soyer said liability is an unresolved issue and that a legal platform may need to be established to address liability for online consultations.

Reasonable liability insurance for telemedicine has been slow to happen in the United States, in large part because of limited reimbursement, Hon S. Pak, M.D., a member of the American Academy of Dermatology Telemedicine Task Force and vice president of the American Telemedicine Association, said in an interview.

Although third-party payers are increasingly reimbursing for telemedicine, the Centers for Medicare and Medicaid Services currently reimburses only for rural patients—defined as patients who live in non-metropolitan statistical areas—if teledermatology takes place in a live, interactive mode.

Except in federally designated clinics in Hawaii and Alaska, reimbursement does not exist for store-and-forward consultations that allow for asynchronous communication between clinicians via the Internet.

"It's not that teledermatology increases liability; it's just that insurers don't know enough about it and how to put a risk score on it," Dr. Pak said. "Enough volume has to be generated to get a risk profile, and that requires reimbursement."

Members of both the AAD task force and the ATA appeared on Capitol Hill this spring to educate legislators on the value of teledermatology and to push for reimbursement for store-and-forward teledermatology.

A teledermatology forum is also planned for the AAD annual meeting in 2006. The forum is seen as a way to encourage dermatologists to use the technology to enhance their practices, said Dr. Pak, who is a dermatologist with the Telemedicine and Advanced Research Center at Fort Detrick in Frederick, Md.

Other hurdles still exist for teledermatology. Transmission of multimedia streams has remained a major challenge for real-time consultations, and some asynchronous consultations may or may not provide clinical information, depending on what is requested.

VIENNA — Teledermatology is expanding in Europe through an online international dermatology community that provides open-access consultations, H. Peter Soyer, M.D., reported at the 10th World Congress on Cancers of the Skin.

The consultations are free of charge for now, and they are available in five different languages. Physicians can send in patient pictures and information, and may request a consultation with a specific clinician from a team of dermatologists. Discussion can be added from about 500 participating dermatologists worldwide.

The idea (www.telederm.org

The first world congress on teledermatology will be held in November 2006 in Graz.

Dr. Soyer said teledermatology provides not only a second opinion, but also greater access to care and disease monitoring in remote areas and third world countries. European dermatologists have also gained valuable experience about unfamiliar skin conditions reported by dermatologists in Pakistan and China.

Audience members responded positively to the presentation, but many Americans suggested that malpractice insurance will be needed for telemedicine to grow in the United States.

American physicians have been successfully sued for consulting on nondermatologic cases from states where they didn't hold a license.

"We do it bona fide, with good trust," Dr. Soyer said at the meeting, which was cosponsored by the Skin Cancer Foundation. "If you are taking care of the patient, you are responsible, and I am your assistant."

Dr. Soyer said liability is an unresolved issue and that a legal platform may need to be established to address liability for online consultations.

Reasonable liability insurance for telemedicine has been slow to happen in the United States, in large part because of limited reimbursement, Hon S. Pak, M.D., a member of the American Academy of Dermatology Telemedicine Task Force and vice president of the American Telemedicine Association, said in an interview.

Although third-party payers are increasingly reimbursing for telemedicine, the Centers for Medicare and Medicaid Services currently reimburses only for rural patients—defined as patients who live in non-metropolitan statistical areas—if teledermatology takes place in a live, interactive mode.

Except in federally designated clinics in Hawaii and Alaska, reimbursement does not exist for store-and-forward consultations that allow for asynchronous communication between clinicians via the Internet.

"It's not that teledermatology increases liability; it's just that insurers don't know enough about it and how to put a risk score on it," Dr. Pak said. "Enough volume has to be generated to get a risk profile, and that requires reimbursement."

Members of both the AAD task force and the ATA appeared on Capitol Hill this spring to educate legislators on the value of teledermatology and to push for reimbursement for store-and-forward teledermatology.

A teledermatology forum is also planned for the AAD annual meeting in 2006. The forum is seen as a way to encourage dermatologists to use the technology to enhance their practices, said Dr. Pak, who is a dermatologist with the Telemedicine and Advanced Research Center at Fort Detrick in Frederick, Md.

Other hurdles still exist for teledermatology. Transmission of multimedia streams has remained a major challenge for real-time consultations, and some asynchronous consultations may or may not provide clinical information, depending on what is requested.

PARIS — Light-emitting diode phototherapy improves tissue quality and leads to accelerated wound healing after cosmetic and medical surgical procedures, Mario Trelles, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Dr. Trelles uses combination light-emitting diode (LED) therapy with both near-infrared and visible red LED extremely narrowband (plus or minus 3- to 8-nm) arrays.

LED therapy promotes the anti-inflammatory process, activates blood circulation, and realigns collagen fibers. It reduces scabbing and erythema, without promoting keloids, he said.

Dr. Trelles is a pioneer of this application of LED energy. "It is not yet widespread because LED therapy is just at the beginning of its clinical practice, and like all 'new' therapies, it will take time to overcome the inherent 'conservatism' of many clinicians, particularly in the United States," Dr. Trelles told this newspaper.

In a series of 22 patients who underwent full face resurfacing and subsequent LED therapy, 12 patients experienced complete healing of facial tissue in 7 days, and the remaining 10 experienced complete healing in 9–11 days.

Several kinds of aesthetic procedures benefit from subsequent LED therapy, including surgical face-lifting, facial resurfacing, nonablative laser or intense pulsed light skin rejuvenation, upper eyelid blepharoplasty, breast augmentation or reduction, and removal of abnormally pigmented or nonpigmented cutaneous lesions.

Results are less dramatic with diabetic ulcers or chronic ulcers caused by vascular conditions.

"All surgical wounds respond well, but in general the more extensive the wound, the better the response," said Dr. Trelles, a plastic surgeon with the Institut Mèdic Vilafortuny in Cambrils, Spain.

Dr. Trelles outlined his treatment protocol: a 633-nm wavelength treatment and an 833-nm treatment in the first week; three treatments at 830 nm in the second week; and one treatment at 633 nm in the third week, followed by a 1-month treatment-free rest period and a single treatment at 633 nm.

The 20-minute sessions deliver a radiant flux of approximately 96 J/cm

Postprocedural maintenance is not usually required if patients are compliant in using skin moisturizers and photoprotection, he said.

Dr. Trelles currently uses no pretreatment preparation of the skin, even with antiherpes medication. In more than 300 resurfacing cases, his rate of herpes infection was "virtually nil," he said.

PARIS — Light-emitting diode phototherapy improves tissue quality and leads to accelerated wound healing after cosmetic and medical surgical procedures, Mario Trelles, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Dr. Trelles uses combination light-emitting diode (LED) therapy with both near-infrared and visible red LED extremely narrowband (plus or minus 3- to 8-nm) arrays.

LED therapy promotes the anti-inflammatory process, activates blood circulation, and realigns collagen fibers. It reduces scabbing and erythema, without promoting keloids, he said.

Dr. Trelles is a pioneer of this application of LED energy. "It is not yet widespread because LED therapy is just at the beginning of its clinical practice, and like all 'new' therapies, it will take time to overcome the inherent 'conservatism' of many clinicians, particularly in the United States," Dr. Trelles told this newspaper.

In a series of 22 patients who underwent full face resurfacing and subsequent LED therapy, 12 patients experienced complete healing of facial tissue in 7 days, and the remaining 10 experienced complete healing in 9–11 days.

Several kinds of aesthetic procedures benefit from subsequent LED therapy, including surgical face-lifting, facial resurfacing, nonablative laser or intense pulsed light skin rejuvenation, upper eyelid blepharoplasty, breast augmentation or reduction, and removal of abnormally pigmented or nonpigmented cutaneous lesions.

Results are less dramatic with diabetic ulcers or chronic ulcers caused by vascular conditions.

"All surgical wounds respond well, but in general the more extensive the wound, the better the response," said Dr. Trelles, a plastic surgeon with the Institut Mèdic Vilafortuny in Cambrils, Spain.

Dr. Trelles outlined his treatment protocol: a 633-nm wavelength treatment and an 833-nm treatment in the first week; three treatments at 830 nm in the second week; and one treatment at 633 nm in the third week, followed by a 1-month treatment-free rest period and a single treatment at 633 nm.

The 20-minute sessions deliver a radiant flux of approximately 96 J/cm

Postprocedural maintenance is not usually required if patients are compliant in using skin moisturizers and photoprotection, he said.

Dr. Trelles currently uses no pretreatment preparation of the skin, even with antiherpes medication. In more than 300 resurfacing cases, his rate of herpes infection was "virtually nil," he said.

PARIS — Light-emitting diode phototherapy improves tissue quality and leads to accelerated wound healing after cosmetic and medical surgical procedures, Mario Trelles, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Dr. Trelles uses combination light-emitting diode (LED) therapy with both near-infrared and visible red LED extremely narrowband (plus or minus 3- to 8-nm) arrays.

LED therapy promotes the anti-inflammatory process, activates blood circulation, and realigns collagen fibers. It reduces scabbing and erythema, without promoting keloids, he said.

Dr. Trelles is a pioneer of this application of LED energy. "It is not yet widespread because LED therapy is just at the beginning of its clinical practice, and like all 'new' therapies, it will take time to overcome the inherent 'conservatism' of many clinicians, particularly in the United States," Dr. Trelles told this newspaper.

In a series of 22 patients who underwent full face resurfacing and subsequent LED therapy, 12 patients experienced complete healing of facial tissue in 7 days, and the remaining 10 experienced complete healing in 9–11 days.

Several kinds of aesthetic procedures benefit from subsequent LED therapy, including surgical face-lifting, facial resurfacing, nonablative laser or intense pulsed light skin rejuvenation, upper eyelid blepharoplasty, breast augmentation or reduction, and removal of abnormally pigmented or nonpigmented cutaneous lesions.

Results are less dramatic with diabetic ulcers or chronic ulcers caused by vascular conditions.

"All surgical wounds respond well, but in general the more extensive the wound, the better the response," said Dr. Trelles, a plastic surgeon with the Institut Mèdic Vilafortuny in Cambrils, Spain.

Dr. Trelles outlined his treatment protocol: a 633-nm wavelength treatment and an 833-nm treatment in the first week; three treatments at 830 nm in the second week; and one treatment at 633 nm in the third week, followed by a 1-month treatment-free rest period and a single treatment at 633 nm.

The 20-minute sessions deliver a radiant flux of approximately 96 J/cm

Postprocedural maintenance is not usually required if patients are compliant in using skin moisturizers and photoprotection, he said.

Dr. Trelles currently uses no pretreatment preparation of the skin, even with antiherpes medication. In more than 300 resurfacing cases, his rate of herpes infection was "virtually nil," he said.

PARIS — Add the curl lift technique to the growing list of so-called lunchtime face-lifts.

First popularized in the 1970s by René Guillemain, M.D., in Paris, the curl lift technique is being rediscovered, thanks to the use of a double-bevel needle like those used by upholsterers, according to Jean-Luc H. Vigneron, M.D., of the Centre Villabianca Dermatologie, Saint Paul de Vence, France.

The needle has two tips and a central eye that allow the surgeon to place stitches or long portions of threads subcutaneously, without an incision. The curl lift uses one loop of thread to lift selected parts of the face and a second loop of the same thread to anchor it to the more resistant tissues of the scalp, typically the galea. The procedure is done under local anesthetic, with little downtime, and leaves only a small scar in the scalp near the hairline.

"The future of the curl lift is clearly the lateral part of the neck," Dr. Vigneron told SKIN & ALLERGY NEWS. "My first five cases are really amazing."

The first line of polypropylene threads is placed in the upper subcutaneous layer. The needle is rotated 180 degrees and then moved upward in a second line parallel to the first. The 230-mm to 250-mm threads are knotted once the desired tension is obtained, then the knot is slipped 5 mm below the skin surface.

The main problem encountered using this technique is dimpling at the lifted area of the face, Dr. Vigneron said at the 4th International Academy of Cosmetic Dermatology World Congress. The dimples tend to disappear after 3 months, he said.

About 200 dermatologic and plastic surgeons have been trained in the curl lift technique in the last year through the American Society of Aesthetics and Mesotherapy or the Vitality Institute, both of Miami Beach.

ASAM chair and president Abdala Kalil, M.D., said in an interview that he has performed more than 300 curl lifts in the last 2 years, and that dimpling occurred only once or twice when he first began. He has modified the technique to carry his institute's name, Vitality Lift, and said it offers dramatic, lasting results that are far superior to those seen with Aptos threads.

The Aptos threads or FeatherLift technique is more widely known in the United States and gained Food and Drug Administration approval in March 2005.

Both procedures take about 1 hour, require good vascularization in the skin, and are best suited to patients without heavy ptosis.

Dimpling is seen 8 days after a curl lift was done from the hair of the temple to the cheek. Courtesy Dr. Jean-Luc H. Vigneron

PARIS — Add the curl lift technique to the growing list of so-called lunchtime face-lifts.

First popularized in the 1970s by René Guillemain, M.D., in Paris, the curl lift technique is being rediscovered, thanks to the use of a double-bevel needle like those used by upholsterers, according to Jean-Luc H. Vigneron, M.D., of the Centre Villabianca Dermatologie, Saint Paul de Vence, France.

The needle has two tips and a central eye that allow the surgeon to place stitches or long portions of threads subcutaneously, without an incision. The curl lift uses one loop of thread to lift selected parts of the face and a second loop of the same thread to anchor it to the more resistant tissues of the scalp, typically the galea. The procedure is done under local anesthetic, with little downtime, and leaves only a small scar in the scalp near the hairline.

"The future of the curl lift is clearly the lateral part of the neck," Dr. Vigneron told SKIN & ALLERGY NEWS. "My first five cases are really amazing."

The first line of polypropylene threads is placed in the upper subcutaneous layer. The needle is rotated 180 degrees and then moved upward in a second line parallel to the first. The 230-mm to 250-mm threads are knotted once the desired tension is obtained, then the knot is slipped 5 mm below the skin surface.

The main problem encountered using this technique is dimpling at the lifted area of the face, Dr. Vigneron said at the 4th International Academy of Cosmetic Dermatology World Congress. The dimples tend to disappear after 3 months, he said.

About 200 dermatologic and plastic surgeons have been trained in the curl lift technique in the last year through the American Society of Aesthetics and Mesotherapy or the Vitality Institute, both of Miami Beach.

ASAM chair and president Abdala Kalil, M.D., said in an interview that he has performed more than 300 curl lifts in the last 2 years, and that dimpling occurred only once or twice when he first began. He has modified the technique to carry his institute's name, Vitality Lift, and said it offers dramatic, lasting results that are far superior to those seen with Aptos threads.

The Aptos threads or FeatherLift technique is more widely known in the United States and gained Food and Drug Administration approval in March 2005.

Both procedures take about 1 hour, require good vascularization in the skin, and are best suited to patients without heavy ptosis.

Dimpling is seen 8 days after a curl lift was done from the hair of the temple to the cheek. Courtesy Dr. Jean-Luc H. Vigneron

PARIS — Add the curl lift technique to the growing list of so-called lunchtime face-lifts.

First popularized in the 1970s by René Guillemain, M.D., in Paris, the curl lift technique is being rediscovered, thanks to the use of a double-bevel needle like those used by upholsterers, according to Jean-Luc H. Vigneron, M.D., of the Centre Villabianca Dermatologie, Saint Paul de Vence, France.

The needle has two tips and a central eye that allow the surgeon to place stitches or long portions of threads subcutaneously, without an incision. The curl lift uses one loop of thread to lift selected parts of the face and a second loop of the same thread to anchor it to the more resistant tissues of the scalp, typically the galea. The procedure is done under local anesthetic, with little downtime, and leaves only a small scar in the scalp near the hairline.

"The future of the curl lift is clearly the lateral part of the neck," Dr. Vigneron told SKIN & ALLERGY NEWS. "My first five cases are really amazing."

The first line of polypropylene threads is placed in the upper subcutaneous layer. The needle is rotated 180 degrees and then moved upward in a second line parallel to the first. The 230-mm to 250-mm threads are knotted once the desired tension is obtained, then the knot is slipped 5 mm below the skin surface.

The main problem encountered using this technique is dimpling at the lifted area of the face, Dr. Vigneron said at the 4th International Academy of Cosmetic Dermatology World Congress. The dimples tend to disappear after 3 months, he said.

About 200 dermatologic and plastic surgeons have been trained in the curl lift technique in the last year through the American Society of Aesthetics and Mesotherapy or the Vitality Institute, both of Miami Beach.

ASAM chair and president Abdala Kalil, M.D., said in an interview that he has performed more than 300 curl lifts in the last 2 years, and that dimpling occurred only once or twice when he first began. He has modified the technique to carry his institute's name, Vitality Lift, and said it offers dramatic, lasting results that are far superior to those seen with Aptos threads.

The Aptos threads or FeatherLift technique is more widely known in the United States and gained Food and Drug Administration approval in March 2005.

Both procedures take about 1 hour, require good vascularization in the skin, and are best suited to patients without heavy ptosis.

Dimpling is seen 8 days after a curl lift was done from the hair of the temple to the cheek. Courtesy Dr. Jean-Luc H. Vigneron

CHICAGO — Add facial rejuvenation to the growing list of indications for topical photodynamic therapy.

Short-contact, broad-area application of 20% 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) can enhance or improve all parameters of facial rejuvenation—skin tone, texture, fine wrinkles, telangiectasis, and pore size, Kevin Pinski, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

There's little pain or downtime associated with the combination therapy, and it appears to shorten the number of intense pulsed light (IPL) treatments needed to achieve results.

The only approved indication for ALA-PDT is nonhyperkeratotic actinic keratoses on the face and scalp, requiring 14- to 18-hour drug incubation and blue-light therapy.

Investigators have experimented with shorter drug incubation periods and found no difference in efficacy in actinic keratosis with as little as 1 hour incubation, said Dr. Pinski of Northwestern University in Chicago.

New vascular lasers and IPL devices have also virtually eliminated the pain previously associated with the therapy.

Now ALA-PDT is being used off label in a variety of indications from basal and squamous cell carcinoma to Bowen's disease, acne vulgaris, hidradenitis suppurativa, and port-wine stains.

Split-face comparison trials in facial rejuvenation have been done for the first time, and they demonstrated that clinical improvement scores were higher on the sides treated with combination ALA-IPL, compared with areas treated with IPL alone (J. Drugs Dermatol. 2005;4:35–8). Mild edema, erythema, and desquamation were reported with the use of combination therapy.

The most recent study (J. Cosmet. Laser Ther. 2005;7:21–4) showed that ALA-IPL increased the production of type I collagen, compared with IPL monotherapy.

Dr. Pinski prepares patients for facial rejuvenation with an acetone scrub to increase the penetration of the ALA (Levulan Kerastick, DUSA Pharmaceuticals Inc.) before exposure with an N-Lite laser. Levulan comes in two glass ampules that must be mixed thoroughly for 2–3 minutes or results will be inconsistent, he said.

Levulan should incubate on the skin for a minimum of 1 hour for facial rejuvenation and actinic keratoses, and for up to 1 hour for acne vulgaris.

It's imperative that patients avoid sun exposure for 72 hours post treatment to avoid a phototoxic reaction, he said. Iron chelating agents are being developed that may reduce this potential reaction.

Finally, mounting evidence from animal models suggests that ALA-PDT could be used for skin cancer prevention, he said.

Data from hairless mice models suggest that protoporphyrin IX, an effective photosensitizer that is converted from 5-ALA, is activated by visible light, and that highly carcinogenic ultraviolet radiation may be filtered out by blue-light therapy.

"Hypothetically, we could treat large surface areas in patients that are at risk of developing skin cancer, such as our renal transplant cases, and thereby prevent them from developing actinic keratoses and squamous cell carcinomas," he said.

Dr. Pinski reported that he has no relevant conflicts of interest.

CHICAGO — Add facial rejuvenation to the growing list of indications for topical photodynamic therapy.

Short-contact, broad-area application of 20% 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) can enhance or improve all parameters of facial rejuvenation—skin tone, texture, fine wrinkles, telangiectasis, and pore size, Kevin Pinski, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

There's little pain or downtime associated with the combination therapy, and it appears to shorten the number of intense pulsed light (IPL) treatments needed to achieve results.

The only approved indication for ALA-PDT is nonhyperkeratotic actinic keratoses on the face and scalp, requiring 14- to 18-hour drug incubation and blue-light therapy.

Investigators have experimented with shorter drug incubation periods and found no difference in efficacy in actinic keratosis with as little as 1 hour incubation, said Dr. Pinski of Northwestern University in Chicago.

New vascular lasers and IPL devices have also virtually eliminated the pain previously associated with the therapy.

Now ALA-PDT is being used off label in a variety of indications from basal and squamous cell carcinoma to Bowen's disease, acne vulgaris, hidradenitis suppurativa, and port-wine stains.

Split-face comparison trials in facial rejuvenation have been done for the first time, and they demonstrated that clinical improvement scores were higher on the sides treated with combination ALA-IPL, compared with areas treated with IPL alone (J. Drugs Dermatol. 2005;4:35–8). Mild edema, erythema, and desquamation were reported with the use of combination therapy.

The most recent study (J. Cosmet. Laser Ther. 2005;7:21–4) showed that ALA-IPL increased the production of type I collagen, compared with IPL monotherapy.

Dr. Pinski prepares patients for facial rejuvenation with an acetone scrub to increase the penetration of the ALA (Levulan Kerastick, DUSA Pharmaceuticals Inc.) before exposure with an N-Lite laser. Levulan comes in two glass ampules that must be mixed thoroughly for 2–3 minutes or results will be inconsistent, he said.

Levulan should incubate on the skin for a minimum of 1 hour for facial rejuvenation and actinic keratoses, and for up to 1 hour for acne vulgaris.

It's imperative that patients avoid sun exposure for 72 hours post treatment to avoid a phototoxic reaction, he said. Iron chelating agents are being developed that may reduce this potential reaction.

Finally, mounting evidence from animal models suggests that ALA-PDT could be used for skin cancer prevention, he said.

Data from hairless mice models suggest that protoporphyrin IX, an effective photosensitizer that is converted from 5-ALA, is activated by visible light, and that highly carcinogenic ultraviolet radiation may be filtered out by blue-light therapy.

"Hypothetically, we could treat large surface areas in patients that are at risk of developing skin cancer, such as our renal transplant cases, and thereby prevent them from developing actinic keratoses and squamous cell carcinomas," he said.

Dr. Pinski reported that he has no relevant conflicts of interest.

CHICAGO — Add facial rejuvenation to the growing list of indications for topical photodynamic therapy.

Short-contact, broad-area application of 20% 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) can enhance or improve all parameters of facial rejuvenation—skin tone, texture, fine wrinkles, telangiectasis, and pore size, Kevin Pinski, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

There's little pain or downtime associated with the combination therapy, and it appears to shorten the number of intense pulsed light (IPL) treatments needed to achieve results.

The only approved indication for ALA-PDT is nonhyperkeratotic actinic keratoses on the face and scalp, requiring 14- to 18-hour drug incubation and blue-light therapy.

Investigators have experimented with shorter drug incubation periods and found no difference in efficacy in actinic keratosis with as little as 1 hour incubation, said Dr. Pinski of Northwestern University in Chicago.

New vascular lasers and IPL devices have also virtually eliminated the pain previously associated with the therapy.

Now ALA-PDT is being used off label in a variety of indications from basal and squamous cell carcinoma to Bowen's disease, acne vulgaris, hidradenitis suppurativa, and port-wine stains.

Split-face comparison trials in facial rejuvenation have been done for the first time, and they demonstrated that clinical improvement scores were higher on the sides treated with combination ALA-IPL, compared with areas treated with IPL alone (J. Drugs Dermatol. 2005;4:35–8). Mild edema, erythema, and desquamation were reported with the use of combination therapy.

The most recent study (J. Cosmet. Laser Ther. 2005;7:21–4) showed that ALA-IPL increased the production of type I collagen, compared with IPL monotherapy.

Dr. Pinski prepares patients for facial rejuvenation with an acetone scrub to increase the penetration of the ALA (Levulan Kerastick, DUSA Pharmaceuticals Inc.) before exposure with an N-Lite laser. Levulan comes in two glass ampules that must be mixed thoroughly for 2–3 minutes or results will be inconsistent, he said.

Levulan should incubate on the skin for a minimum of 1 hour for facial rejuvenation and actinic keratoses, and for up to 1 hour for acne vulgaris.

It's imperative that patients avoid sun exposure for 72 hours post treatment to avoid a phototoxic reaction, he said. Iron chelating agents are being developed that may reduce this potential reaction.

Finally, mounting evidence from animal models suggests that ALA-PDT could be used for skin cancer prevention, he said.

Data from hairless mice models suggest that protoporphyrin IX, an effective photosensitizer that is converted from 5-ALA, is activated by visible light, and that highly carcinogenic ultraviolet radiation may be filtered out by blue-light therapy.

"Hypothetically, we could treat large surface areas in patients that are at risk of developing skin cancer, such as our renal transplant cases, and thereby prevent them from developing actinic keratoses and squamous cell carcinomas," he said.

Dr. Pinski reported that he has no relevant conflicts of interest.

CHICAGO — Dermatologists shouldn't shy away from sclerotherapy to treat facial and even periocular veins, David Green, M.D., reported at the American Academy of Dermatology's Academy 2005 meeting.

Although sclerotherapy is widely used to remove varicose and telangiectatic veins on the lower extremities, it is underutilized at other sites, such as the face, hands, chest, and feet, he said.

Physicians are particularly reluctant to remove periocular veins.

"Everyone seems to have this universal caveat: 'Don't treat them because there's a risk it may cause blindness or stroke,'" he said, "but there are no reports of anyone ever having such an adverse event."

More to the point, such complications are unlikely because the periocular veins treated by sclerotherapy do not directly communicate with the orbital and cerebral venous systems, said Dr. Green, who is in private practice in Bethesda, Md.

Preseptal veins of the eyelid drain into the superficial temporal vein or the anterior facial vein, which themselves drain into the external jugular vein and the internal jugular vein, respectively.

Postseptal veins more directly join the orbital veins, but these are not visible on the eyelid and, as such, are never treated by sclerotherapy.

For sclerosant to drain into the superior ophthalmic vein, the flow would have to be toward the top of the head from the angular vein. This is hemodynamically unlikely because a liquid tends to follow the course of least resistance. Sclerosant travels in an antegrade direction into progressively larger veins.

Even if some sclerosant entered the superior ophthalmic vein, it would be rapidly diluted, making it increasingly harmless to the endothelial and mural layers, he said. As a precaution, Dr. Green injects laterally away from the angular vein and applies pressure just above the angular vein during the infusion.

Injections should never be made into the angular vein, he said.

Injections also are made under low pressure to minimize the risk of retrograde flow into smaller diameter veins and to prolong the duration of contact between the sclerosant and the mural layers of the targeted veins.

A concentration of 0.5%–1% sodium tetradecyl sulfate is used for facial veins, compared with a 0.25% solution usually required for lower-extremity veins of comparable diameter. The volume infused is 1–6 mL, depending upon the length of the veins and number of tributaries present.

"It's counterintuitive based upon gravitational hydrostatic pressures and vein wall diameters, but if we infuse the same concentration on facial veins as we use on the lower extremities, full mural denaturation is apparently not achieved and the veins persist," he explained.

Hypertonic saline should not be used for periocular sclerotherapy because it is quite painful and causes significant muscle cramping because of its high sodium concentration.

Complications such as linear hyperpigmentation and capillary telangiectatic matting—which occur in about 30% and 16%, respectively, of lower-extremity sclerotherapy cases—are rare after treating periocular veins.

Although capillary telangiectasias on the nose or face respond well to a variety of lasers, venous telangiectasias in these areas are more effectively treated with sclerotherapy. The amount of light from a laser needed to heat the volume of blood in a venous telangiectasia and achieve full mural denaturation may be high enough to burn the skin, Dr. Green noted.

Unlike lower-extremity sclerotherapy, posttreatment compression is not necessary in the periocular area.

If a vein is visually gone at 6 months, it can be safely assumed that it has been permanently ablated and will not reappear, he said.

CHICAGO — Dermatologists shouldn't shy away from sclerotherapy to treat facial and even periocular veins, David Green, M.D., reported at the American Academy of Dermatology's Academy 2005 meeting.

Although sclerotherapy is widely used to remove varicose and telangiectatic veins on the lower extremities, it is underutilized at other sites, such as the face, hands, chest, and feet, he said.

Physicians are particularly reluctant to remove periocular veins.

"Everyone seems to have this universal caveat: 'Don't treat them because there's a risk it may cause blindness or stroke,'" he said, "but there are no reports of anyone ever having such an adverse event."

More to the point, such complications are unlikely because the periocular veins treated by sclerotherapy do not directly communicate with the orbital and cerebral venous systems, said Dr. Green, who is in private practice in Bethesda, Md.

Preseptal veins of the eyelid drain into the superficial temporal vein or the anterior facial vein, which themselves drain into the external jugular vein and the internal jugular vein, respectively.

Postseptal veins more directly join the orbital veins, but these are not visible on the eyelid and, as such, are never treated by sclerotherapy.

For sclerosant to drain into the superior ophthalmic vein, the flow would have to be toward the top of the head from the angular vein. This is hemodynamically unlikely because a liquid tends to follow the course of least resistance. Sclerosant travels in an antegrade direction into progressively larger veins.

Even if some sclerosant entered the superior ophthalmic vein, it would be rapidly diluted, making it increasingly harmless to the endothelial and mural layers, he said. As a precaution, Dr. Green injects laterally away from the angular vein and applies pressure just above the angular vein during the infusion.

Injections should never be made into the angular vein, he said.

Injections also are made under low pressure to minimize the risk of retrograde flow into smaller diameter veins and to prolong the duration of contact between the sclerosant and the mural layers of the targeted veins.

A concentration of 0.5%–1% sodium tetradecyl sulfate is used for facial veins, compared with a 0.25% solution usually required for lower-extremity veins of comparable diameter. The volume infused is 1–6 mL, depending upon the length of the veins and number of tributaries present.

"It's counterintuitive based upon gravitational hydrostatic pressures and vein wall diameters, but if we infuse the same concentration on facial veins as we use on the lower extremities, full mural denaturation is apparently not achieved and the veins persist," he explained.

Hypertonic saline should not be used for periocular sclerotherapy because it is quite painful and causes significant muscle cramping because of its high sodium concentration.

Complications such as linear hyperpigmentation and capillary telangiectatic matting—which occur in about 30% and 16%, respectively, of lower-extremity sclerotherapy cases—are rare after treating periocular veins.

Although capillary telangiectasias on the nose or face respond well to a variety of lasers, venous telangiectasias in these areas are more effectively treated with sclerotherapy. The amount of light from a laser needed to heat the volume of blood in a venous telangiectasia and achieve full mural denaturation may be high enough to burn the skin, Dr. Green noted.

Unlike lower-extremity sclerotherapy, posttreatment compression is not necessary in the periocular area.

If a vein is visually gone at 6 months, it can be safely assumed that it has been permanently ablated and will not reappear, he said.

CHICAGO — Dermatologists shouldn't shy away from sclerotherapy to treat facial and even periocular veins, David Green, M.D., reported at the American Academy of Dermatology's Academy 2005 meeting.

Although sclerotherapy is widely used to remove varicose and telangiectatic veins on the lower extremities, it is underutilized at other sites, such as the face, hands, chest, and feet, he said.

Physicians are particularly reluctant to remove periocular veins.

"Everyone seems to have this universal caveat: 'Don't treat them because there's a risk it may cause blindness or stroke,'" he said, "but there are no reports of anyone ever having such an adverse event."

More to the point, such complications are unlikely because the periocular veins treated by sclerotherapy do not directly communicate with the orbital and cerebral venous systems, said Dr. Green, who is in private practice in Bethesda, Md.

Preseptal veins of the eyelid drain into the superficial temporal vein or the anterior facial vein, which themselves drain into the external jugular vein and the internal jugular vein, respectively.

Postseptal veins more directly join the orbital veins, but these are not visible on the eyelid and, as such, are never treated by sclerotherapy.

For sclerosant to drain into the superior ophthalmic vein, the flow would have to be toward the top of the head from the angular vein. This is hemodynamically unlikely because a liquid tends to follow the course of least resistance. Sclerosant travels in an antegrade direction into progressively larger veins.

Even if some sclerosant entered the superior ophthalmic vein, it would be rapidly diluted, making it increasingly harmless to the endothelial and mural layers, he said. As a precaution, Dr. Green injects laterally away from the angular vein and applies pressure just above the angular vein during the infusion.

Injections should never be made into the angular vein, he said.

Injections also are made under low pressure to minimize the risk of retrograde flow into smaller diameter veins and to prolong the duration of contact between the sclerosant and the mural layers of the targeted veins.

A concentration of 0.5%–1% sodium tetradecyl sulfate is used for facial veins, compared with a 0.25% solution usually required for lower-extremity veins of comparable diameter. The volume infused is 1–6 mL, depending upon the length of the veins and number of tributaries present.

"It's counterintuitive based upon gravitational hydrostatic pressures and vein wall diameters, but if we infuse the same concentration on facial veins as we use on the lower extremities, full mural denaturation is apparently not achieved and the veins persist," he explained.

Hypertonic saline should not be used for periocular sclerotherapy because it is quite painful and causes significant muscle cramping because of its high sodium concentration.

Complications such as linear hyperpigmentation and capillary telangiectatic matting—which occur in about 30% and 16%, respectively, of lower-extremity sclerotherapy cases—are rare after treating periocular veins.

Although capillary telangiectasias on the nose or face respond well to a variety of lasers, venous telangiectasias in these areas are more effectively treated with sclerotherapy. The amount of light from a laser needed to heat the volume of blood in a venous telangiectasia and achieve full mural denaturation may be high enough to burn the skin, Dr. Green noted.

Unlike lower-extremity sclerotherapy, posttreatment compression is not necessary in the periocular area.

If a vein is visually gone at 6 months, it can be safely assumed that it has been permanently ablated and will not reappear, he said.

PARIS — A new device that uses vacuum suction in combination with radio frequency painlessly treats facial lines and wrinkles, Michael H. Gold, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Radio frequency (RF) devices have been used successfully over the last 5 years to improve skin texture and laxity, but their use has been limited because patients complain the treatments are too painful, said Dr. Gold of Nashville, Tenn.

Efforts have been made with varying degrees of success to reduce the pain by changing machine parameters, using multiple passes at lower power, or by incorporating RF with intense pulsed light devices. General anesthesia or intravenous medications have been used, but few patients have been willing to incur the associated risks.

The new bipolar RF device, Aluma Skin Renewal System (Lumenis Inc.), uses vacuum suction to pull the skin about one-quarter inch into the vacuum, where there are RF electrodes on either side.

The device holds the skin for 1 second of vacuum at 20-mm Hg suction and delivers about 10 W of RF energy, he said. The overall treatment takes 15–30 minutes and treatments occur once weekly for 5–8 weeks. How the device reduces pain is unclear.

"I think because we're taking up the skin and compressing the nerves or the circulation affecting those nerves, we're doing something. We're just not sure what, but it is effective and doesn't hurt," Dr. Gold said in an interview.

In a study of 46 patients aged 30–65 years with periorbital and nasal labial wrinkles, 1%–2% of patients reported pain with the first two treatments. Patients reported pain of 0 or 1 on a 4-point scale, with 0 being no pain and 4 being intractable pain, he said. Seven patients were lost to follow-up. No one dropped out of the study because of pain or an adverse event, said Dr. Gold. All of the 39 patients who completed the study had at least a 50% improvement in wrinkling based on evaluation by blinded clinicians. Patients were able to maintain the improvements 6 months posttreatment.

The maximum benefit is seen after the fifth or sixth treatment. The optimal number and best interval between treatments have yet to be determined. Studies are planned to evaluate the device to reduce tissue laxity on the jowls, upper arms, stomach, and thighs. The device will be launched in the United States and Europe this month.

Dr. Gold is an investigator, advisory board member, consultant, and stockholder with Lumenis Inc., and has received honoraria to speak on behalf of the company.

PARIS — A new device that uses vacuum suction in combination with radio frequency painlessly treats facial lines and wrinkles, Michael H. Gold, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Radio frequency (RF) devices have been used successfully over the last 5 years to improve skin texture and laxity, but their use has been limited because patients complain the treatments are too painful, said Dr. Gold of Nashville, Tenn.

Efforts have been made with varying degrees of success to reduce the pain by changing machine parameters, using multiple passes at lower power, or by incorporating RF with intense pulsed light devices. General anesthesia or intravenous medications have been used, but few patients have been willing to incur the associated risks.

The new bipolar RF device, Aluma Skin Renewal System (Lumenis Inc.), uses vacuum suction to pull the skin about one-quarter inch into the vacuum, where there are RF electrodes on either side.

The device holds the skin for 1 second of vacuum at 20-mm Hg suction and delivers about 10 W of RF energy, he said. The overall treatment takes 15–30 minutes and treatments occur once weekly for 5–8 weeks. How the device reduces pain is unclear.

"I think because we're taking up the skin and compressing the nerves or the circulation affecting those nerves, we're doing something. We're just not sure what, but it is effective and doesn't hurt," Dr. Gold said in an interview.

In a study of 46 patients aged 30–65 years with periorbital and nasal labial wrinkles, 1%–2% of patients reported pain with the first two treatments. Patients reported pain of 0 or 1 on a 4-point scale, with 0 being no pain and 4 being intractable pain, he said. Seven patients were lost to follow-up. No one dropped out of the study because of pain or an adverse event, said Dr. Gold. All of the 39 patients who completed the study had at least a 50% improvement in wrinkling based on evaluation by blinded clinicians. Patients were able to maintain the improvements 6 months posttreatment.

The maximum benefit is seen after the fifth or sixth treatment. The optimal number and best interval between treatments have yet to be determined. Studies are planned to evaluate the device to reduce tissue laxity on the jowls, upper arms, stomach, and thighs. The device will be launched in the United States and Europe this month.

Dr. Gold is an investigator, advisory board member, consultant, and stockholder with Lumenis Inc., and has received honoraria to speak on behalf of the company.

PARIS — A new device that uses vacuum suction in combination with radio frequency painlessly treats facial lines and wrinkles, Michael H. Gold, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Radio frequency (RF) devices have been used successfully over the last 5 years to improve skin texture and laxity, but their use has been limited because patients complain the treatments are too painful, said Dr. Gold of Nashville, Tenn.

Efforts have been made with varying degrees of success to reduce the pain by changing machine parameters, using multiple passes at lower power, or by incorporating RF with intense pulsed light devices. General anesthesia or intravenous medications have been used, but few patients have been willing to incur the associated risks.

The new bipolar RF device, Aluma Skin Renewal System (Lumenis Inc.), uses vacuum suction to pull the skin about one-quarter inch into the vacuum, where there are RF electrodes on either side.

The device holds the skin for 1 second of vacuum at 20-mm Hg suction and delivers about 10 W of RF energy, he said. The overall treatment takes 15–30 minutes and treatments occur once weekly for 5–8 weeks. How the device reduces pain is unclear.

"I think because we're taking up the skin and compressing the nerves or the circulation affecting those nerves, we're doing something. We're just not sure what, but it is effective and doesn't hurt," Dr. Gold said in an interview.

In a study of 46 patients aged 30–65 years with periorbital and nasal labial wrinkles, 1%–2% of patients reported pain with the first two treatments. Patients reported pain of 0 or 1 on a 4-point scale, with 0 being no pain and 4 being intractable pain, he said. Seven patients were lost to follow-up. No one dropped out of the study because of pain or an adverse event, said Dr. Gold. All of the 39 patients who completed the study had at least a 50% improvement in wrinkling based on evaluation by blinded clinicians. Patients were able to maintain the improvements 6 months posttreatment.

The maximum benefit is seen after the fifth or sixth treatment. The optimal number and best interval between treatments have yet to be determined. Studies are planned to evaluate the device to reduce tissue laxity on the jowls, upper arms, stomach, and thighs. The device will be launched in the United States and Europe this month.

Dr. Gold is an investigator, advisory board member, consultant, and stockholder with Lumenis Inc., and has received honoraria to speak on behalf of the company.

PARIS — Resection can't be too early or too aggressive when treating neurofibroma in children, reported McKay McKinnon, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

Neurofibroma is a usually benign tumor of the peripheral nerves caused by abnormal proliferation of Schwann cells.

The development of neurofibromas, multiple café au lait spots, and freckling in the armpits or groin area are common symptoms of neurofibromatosis 1 (NF1), which occurs in 1 in 4,000 births.

There is no way to tell which patients will develop a mild case and which patients will have serious complications such as painful or disfiguring tumors.

Tumors may grow back and in greater numbers, and they could be fibrosarcoma, said Dr. McKinnon, a plastic and reconstructive surgeon with the University of Chicago. Early surgery, even in infancy, may be indicated.

“In my experience, a very aggressive surgery can often produce nonrecurrence for many years or forever,” he said. “That's hard to prove, but I think that should be the principle.”

Viable structure may remain after excision of large tumors from the ear. But ocular tumors pose a wide range of problems, particularly if the tumor extends into the extraocular muscles.

If at all possible, surgeons should not sacrifice the important structures of the face or the facial nerve, he said.

A careful and early diagnosis of neurofibroma is important and can help distinguish NF1 from neurofibromatosis 2 (NF2), which is rarer, occurring in 1 in 40,000 births.

NF2 is characterized by multiple tumors on the cranial and spinal nerves and by other lesions of the brain and spinal cord. Its primary characteristic is bilateral tumors of the eighth cranial nerve, resulting in hearing loss beginning in the patient's teens or early 20s.

Because patients with neurofibroma may have recurrence throughout life and/or develop neurosarcoma, they need continued surgical surveillance, Dr. McKinnon said.

The National Institutes of Health is launching a study to investigate whether genetic differences explain differences in disease severity among patients with NF1. Participants must be at least 16 years old. For more information, write to jsloan@mail.nih.gov

PARIS — Resection can't be too early or too aggressive when treating neurofibroma in children, reported McKay McKinnon, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

Neurofibroma is a usually benign tumor of the peripheral nerves caused by abnormal proliferation of Schwann cells.

The development of neurofibromas, multiple café au lait spots, and freckling in the armpits or groin area are common symptoms of neurofibromatosis 1 (NF1), which occurs in 1 in 4,000 births.

There is no way to tell which patients will develop a mild case and which patients will have serious complications such as painful or disfiguring tumors.

Tumors may grow back and in greater numbers, and they could be fibrosarcoma, said Dr. McKinnon, a plastic and reconstructive surgeon with the University of Chicago. Early surgery, even in infancy, may be indicated.

“In my experience, a very aggressive surgery can often produce nonrecurrence for many years or forever,” he said. “That's hard to prove, but I think that should be the principle.”

Viable structure may remain after excision of large tumors from the ear. But ocular tumors pose a wide range of problems, particularly if the tumor extends into the extraocular muscles.

If at all possible, surgeons should not sacrifice the important structures of the face or the facial nerve, he said.

A careful and early diagnosis of neurofibroma is important and can help distinguish NF1 from neurofibromatosis 2 (NF2), which is rarer, occurring in 1 in 40,000 births.

NF2 is characterized by multiple tumors on the cranial and spinal nerves and by other lesions of the brain and spinal cord. Its primary characteristic is bilateral tumors of the eighth cranial nerve, resulting in hearing loss beginning in the patient's teens or early 20s.

Because patients with neurofibroma may have recurrence throughout life and/or develop neurosarcoma, they need continued surgical surveillance, Dr. McKinnon said.

The National Institutes of Health is launching a study to investigate whether genetic differences explain differences in disease severity among patients with NF1. Participants must be at least 16 years old. For more information, write to jsloan@mail.nih.gov

PARIS — Resection can't be too early or too aggressive when treating neurofibroma in children, reported McKay McKinnon, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

Neurofibroma is a usually benign tumor of the peripheral nerves caused by abnormal proliferation of Schwann cells.

The development of neurofibromas, multiple café au lait spots, and freckling in the armpits or groin area are common symptoms of neurofibromatosis 1 (NF1), which occurs in 1 in 4,000 births.

There is no way to tell which patients will develop a mild case and which patients will have serious complications such as painful or disfiguring tumors.

Tumors may grow back and in greater numbers, and they could be fibrosarcoma, said Dr. McKinnon, a plastic and reconstructive surgeon with the University of Chicago. Early surgery, even in infancy, may be indicated.

“In my experience, a very aggressive surgery can often produce nonrecurrence for many years or forever,” he said. “That's hard to prove, but I think that should be the principle.”

Viable structure may remain after excision of large tumors from the ear. But ocular tumors pose a wide range of problems, particularly if the tumor extends into the extraocular muscles.

If at all possible, surgeons should not sacrifice the important structures of the face or the facial nerve, he said.

A careful and early diagnosis of neurofibroma is important and can help distinguish NF1 from neurofibromatosis 2 (NF2), which is rarer, occurring in 1 in 40,000 births.

NF2 is characterized by multiple tumors on the cranial and spinal nerves and by other lesions of the brain and spinal cord. Its primary characteristic is bilateral tumors of the eighth cranial nerve, resulting in hearing loss beginning in the patient's teens or early 20s.

Because patients with neurofibroma may have recurrence throughout life and/or develop neurosarcoma, they need continued surgical surveillance, Dr. McKinnon said.

The National Institutes of Health is launching a study to investigate whether genetic differences explain differences in disease severity among patients with NF1. Participants must be at least 16 years old. For more information, write to jsloan@mail.nih.gov

Greater adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective, according to the largest study to date of verified gout cases.

Investigators for the Health Professionals Follow-Up Study prospectively analyzed body mass index (BMI) measured at age 21 years, baseline, and updated every 2 years in a population of mostly (91%) white men with no previous history of gout. The participants were aged 40 through 75 years at baseline in 1986.

During the 12-year follow-up, there were 730 confirmed incident cases of gout in 47,150 men (Arch. Intern. Med. 2005;165:742–8).

Weight gain since young adulthood was strongly associated with the risk of gout, even after adjustment for initial weight and other risk factors, according to lead author Hyon K. Choi, M.D., Massachusetts General Hospital, Boston.

The relative risk of gout for men who had gained 30 pounds or more since age 21 was 2.47 compared with men who maintained their weight.

The relative risk of gout was 1.57 for those men who gained 20–29 pounds.

Weight gain since baseline and increasing waist-to-hip ratio also were significantly associated with increased risk of gout.

After adjustment for age, the relative risk of developing gout among men in the highest waist-to-hip ratio quintile (0.98–1.39) compared with those in the lowest quintile (0.70–0.88) was 2.39.

In contrast, men who had lost 10 pounds or more since the study's baseline had a 39% lower risk of gout compared with men who had maintained weight.

“To our knowledge, our study is the first to document this important potential benefit of weight loss,” Dr. Choi wrote.

The investigators also found that the presence of hypertension was strongly associated with the incidence of gout, independent of diuretic use and chronic renal failure.

The relative risks of gout were 2.31 for the presence of hypertension and 1.77 for diuretic use.

“Since more than half of the gout cases in our cohort occurred among those with hypertension, the potential impact of the prevention of hypertension on the incidence of gout is substantial,” he wrote.

Greater adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective, according to the largest study to date of verified gout cases.

Investigators for the Health Professionals Follow-Up Study prospectively analyzed body mass index (BMI) measured at age 21 years, baseline, and updated every 2 years in a population of mostly (91%) white men with no previous history of gout. The participants were aged 40 through 75 years at baseline in 1986.

During the 12-year follow-up, there were 730 confirmed incident cases of gout in 47,150 men (Arch. Intern. Med. 2005;165:742–8).

Weight gain since young adulthood was strongly associated with the risk of gout, even after adjustment for initial weight and other risk factors, according to lead author Hyon K. Choi, M.D., Massachusetts General Hospital, Boston.

The relative risk of gout for men who had gained 30 pounds or more since age 21 was 2.47 compared with men who maintained their weight.

The relative risk of gout was 1.57 for those men who gained 20–29 pounds.

Weight gain since baseline and increasing waist-to-hip ratio also were significantly associated with increased risk of gout.

After adjustment for age, the relative risk of developing gout among men in the highest waist-to-hip ratio quintile (0.98–1.39) compared with those in the lowest quintile (0.70–0.88) was 2.39.

In contrast, men who had lost 10 pounds or more since the study's baseline had a 39% lower risk of gout compared with men who had maintained weight.

“To our knowledge, our study is the first to document this important potential benefit of weight loss,” Dr. Choi wrote.

The investigators also found that the presence of hypertension was strongly associated with the incidence of gout, independent of diuretic use and chronic renal failure.

The relative risks of gout were 2.31 for the presence of hypertension and 1.77 for diuretic use.

“Since more than half of the gout cases in our cohort occurred among those with hypertension, the potential impact of the prevention of hypertension on the incidence of gout is substantial,” he wrote.

Greater adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective, according to the largest study to date of verified gout cases.

Investigators for the Health Professionals Follow-Up Study prospectively analyzed body mass index (BMI) measured at age 21 years, baseline, and updated every 2 years in a population of mostly (91%) white men with no previous history of gout. The participants were aged 40 through 75 years at baseline in 1986.

During the 12-year follow-up, there were 730 confirmed incident cases of gout in 47,150 men (Arch. Intern. Med. 2005;165:742–8).

Weight gain since young adulthood was strongly associated with the risk of gout, even after adjustment for initial weight and other risk factors, according to lead author Hyon K. Choi, M.D., Massachusetts General Hospital, Boston.

The relative risk of gout for men who had gained 30 pounds or more since age 21 was 2.47 compared with men who maintained their weight.

The relative risk of gout was 1.57 for those men who gained 20–29 pounds.

Weight gain since baseline and increasing waist-to-hip ratio also were significantly associated with increased risk of gout.

After adjustment for age, the relative risk of developing gout among men in the highest waist-to-hip ratio quintile (0.98–1.39) compared with those in the lowest quintile (0.70–0.88) was 2.39.

In contrast, men who had lost 10 pounds or more since the study's baseline had a 39% lower risk of gout compared with men who had maintained weight.

“To our knowledge, our study is the first to document this important potential benefit of weight loss,” Dr. Choi wrote.

The investigators also found that the presence of hypertension was strongly associated with the incidence of gout, independent of diuretic use and chronic renal failure.

The relative risks of gout were 2.31 for the presence of hypertension and 1.77 for diuretic use.

“Since more than half of the gout cases in our cohort occurred among those with hypertension, the potential impact of the prevention of hypertension on the incidence of gout is substantial,” he wrote.