Aesthetic Dermatology

SAN DIEGO – A man goes into full cardiopulmonary arrest in the waiting room. A patient coughs up pink frothy sputum during a Mohs surgical procedure. Another pops two ibuprofen 20 minutes before a biopsy and goes into anaphylaxis once the procedure is underway.

These aren’t scenarios concocted for an emergency training film, but real-life events that transpired in the private practice of Dr. Alexander Miller, a Mohs surgeon in private practice in Yorba Linda, Calif.

"Stuff happens," he said during the meeting sponsored by the American Society for Mohs Surgery. "You’ve got to be prepared."

Preparedness begins with a preoperative consultation, said Dr. Edward H. Yob, a Mohs surgeon in private practice in Tulsa, Okla., who noted that it’s an "odd week" when he doesn’t find at least one prospective patient with a systolic blood pressure well over 200 mm Hg.

Mohs surgeons who meet their patients for the first time during the surgical appointment might never realize that the patient in his 50s with nitroglycerine on his medication list actually requires the medication 1-2 times a day. Dr. Yob sent this patient for a cardiac consultation, eventually deciding to schedule his procedure in a hospital operating room.

"You have to decide how far you’re going to take this, whether you’re going to monitor patients. In our office, we don’t monitor. We take blood pressure, pulse oximetry, and pulse. [Beyond that], we have our cutoff and say, ‘We won’t operate on this patient in the office,’ " he said.

However, an occasional medical emergency is bound to strike, regardless of how thorough the preoperative workup might be, both surgeons agreed.

For that, planning is the key.

"Designate a 911 caller," suggested Dr. Miller. "[While the staff is] sort of scared and wide-eyed and gaga, [someone needs] to actually call 911."

Likewise, he said, "Train yourself to maintain composure and calmness, and do the steps that are required."

Maintain CPR certification and proficiency, and have the right equipment on hand, he recommended.

Dr. Yob said the extent of equipment required will depend not only on the complexity level of patients accepted for Mohs surgery, but also the practice’s proximity to the hospital.

"How long does it take for an ambulance to get there?" he asked.

At a minimum, an office performing Mohs surgery should have available oxygen, Benadryl, atropine, epinephrine, intravenous supplies, and oral and intravenous dextrose.

An automated external defibrillator is an element of state-of-the-art care, said Dr. Yob.

A review of internet sites found that such units are available for about $2,400 and up, and come with simple instructions designed to be easily followed even in the pressure of an emergency.

Dr. Yob and Dr. Miller reported no disclosures pertaining to their talks.

SAN DIEGO – A man goes into full cardiopulmonary arrest in the waiting room. A patient coughs up pink frothy sputum during a Mohs surgical procedure. Another pops two ibuprofen 20 minutes before a biopsy and goes into anaphylaxis once the procedure is underway.

These aren’t scenarios concocted for an emergency training film, but real-life events that transpired in the private practice of Dr. Alexander Miller, a Mohs surgeon in private practice in Yorba Linda, Calif.

"Stuff happens," he said during the meeting sponsored by the American Society for Mohs Surgery. "You’ve got to be prepared."

Preparedness begins with a preoperative consultation, said Dr. Edward H. Yob, a Mohs surgeon in private practice in Tulsa, Okla., who noted that it’s an "odd week" when he doesn’t find at least one prospective patient with a systolic blood pressure well over 200 mm Hg.

Mohs surgeons who meet their patients for the first time during the surgical appointment might never realize that the patient in his 50s with nitroglycerine on his medication list actually requires the medication 1-2 times a day. Dr. Yob sent this patient for a cardiac consultation, eventually deciding to schedule his procedure in a hospital operating room.

"You have to decide how far you’re going to take this, whether you’re going to monitor patients. In our office, we don’t monitor. We take blood pressure, pulse oximetry, and pulse. [Beyond that], we have our cutoff and say, ‘We won’t operate on this patient in the office,’ " he said.

However, an occasional medical emergency is bound to strike, regardless of how thorough the preoperative workup might be, both surgeons agreed.

For that, planning is the key.

"Designate a 911 caller," suggested Dr. Miller. "[While the staff is] sort of scared and wide-eyed and gaga, [someone needs] to actually call 911."

Likewise, he said, "Train yourself to maintain composure and calmness, and do the steps that are required."

Maintain CPR certification and proficiency, and have the right equipment on hand, he recommended.

Dr. Yob said the extent of equipment required will depend not only on the complexity level of patients accepted for Mohs surgery, but also the practice’s proximity to the hospital.

"How long does it take for an ambulance to get there?" he asked.

At a minimum, an office performing Mohs surgery should have available oxygen, Benadryl, atropine, epinephrine, intravenous supplies, and oral and intravenous dextrose.

An automated external defibrillator is an element of state-of-the-art care, said Dr. Yob.

A review of internet sites found that such units are available for about $2,400 and up, and come with simple instructions designed to be easily followed even in the pressure of an emergency.

Dr. Yob and Dr. Miller reported no disclosures pertaining to their talks.

SAN DIEGO – A man goes into full cardiopulmonary arrest in the waiting room. A patient coughs up pink frothy sputum during a Mohs surgical procedure. Another pops two ibuprofen 20 minutes before a biopsy and goes into anaphylaxis once the procedure is underway.

These aren’t scenarios concocted for an emergency training film, but real-life events that transpired in the private practice of Dr. Alexander Miller, a Mohs surgeon in private practice in Yorba Linda, Calif.

"Stuff happens," he said during the meeting sponsored by the American Society for Mohs Surgery. "You’ve got to be prepared."

Preparedness begins with a preoperative consultation, said Dr. Edward H. Yob, a Mohs surgeon in private practice in Tulsa, Okla., who noted that it’s an "odd week" when he doesn’t find at least one prospective patient with a systolic blood pressure well over 200 mm Hg.

Mohs surgeons who meet their patients for the first time during the surgical appointment might never realize that the patient in his 50s with nitroglycerine on his medication list actually requires the medication 1-2 times a day. Dr. Yob sent this patient for a cardiac consultation, eventually deciding to schedule his procedure in a hospital operating room.

"You have to decide how far you’re going to take this, whether you’re going to monitor patients. In our office, we don’t monitor. We take blood pressure, pulse oximetry, and pulse. [Beyond that], we have our cutoff and say, ‘We won’t operate on this patient in the office,’ " he said.

However, an occasional medical emergency is bound to strike, regardless of how thorough the preoperative workup might be, both surgeons agreed.

For that, planning is the key.

"Designate a 911 caller," suggested Dr. Miller. "[While the staff is] sort of scared and wide-eyed and gaga, [someone needs] to actually call 911."

Likewise, he said, "Train yourself to maintain composure and calmness, and do the steps that are required."

Maintain CPR certification and proficiency, and have the right equipment on hand, he recommended.

Dr. Yob said the extent of equipment required will depend not only on the complexity level of patients accepted for Mohs surgery, but also the practice’s proximity to the hospital.

"How long does it take for an ambulance to get there?" he asked.

At a minimum, an office performing Mohs surgery should have available oxygen, Benadryl, atropine, epinephrine, intravenous supplies, and oral and intravenous dextrose.

An automated external defibrillator is an element of state-of-the-art care, said Dr. Yob.

A review of internet sites found that such units are available for about $2,400 and up, and come with simple instructions designed to be easily followed even in the pressure of an emergency.

Dr. Yob and Dr. Miller reported no disclosures pertaining to their talks.

NEW ORLEANS – The American Medical Association’s House of Delegates has passed a resolution urging physician organizations to push for stricter state regulation of medical spas. The vote came at the Delegates’ interim meeting, held in New Orleans.

The resolution seeks to ensure that cosmetic medical procedures have the same safeguards as do medically necessary procedures. That includes appropriate training, supervision, and oversight.

The resolution also stated that cosmetic procedures, including botulinum toxin injections, dermal filler injections, and laser and intense pulsed-light procedures, should be considered the practice of medicine.

The Medical Student Section of the House brought the resolution forward, stating that patient safety was a growing concern. The resolution also urged the AMA to increase public awareness about potential dangers presented by unregulated spas and to work to help create a formal complaint procedure for patients.

NEW ORLEANS – The American Medical Association’s House of Delegates has passed a resolution urging physician organizations to push for stricter state regulation of medical spas. The vote came at the Delegates’ interim meeting, held in New Orleans.

The resolution seeks to ensure that cosmetic medical procedures have the same safeguards as do medically necessary procedures. That includes appropriate training, supervision, and oversight.

The resolution also stated that cosmetic procedures, including botulinum toxin injections, dermal filler injections, and laser and intense pulsed-light procedures, should be considered the practice of medicine.

The Medical Student Section of the House brought the resolution forward, stating that patient safety was a growing concern. The resolution also urged the AMA to increase public awareness about potential dangers presented by unregulated spas and to work to help create a formal complaint procedure for patients.

NEW ORLEANS – The American Medical Association’s House of Delegates has passed a resolution urging physician organizations to push for stricter state regulation of medical spas. The vote came at the Delegates’ interim meeting, held in New Orleans.

The resolution seeks to ensure that cosmetic medical procedures have the same safeguards as do medically necessary procedures. That includes appropriate training, supervision, and oversight.

The resolution also stated that cosmetic procedures, including botulinum toxin injections, dermal filler injections, and laser and intense pulsed-light procedures, should be considered the practice of medicine.

The Medical Student Section of the House brought the resolution forward, stating that patient safety was a growing concern. The resolution also urged the AMA to increase public awareness about potential dangers presented by unregulated spas and to work to help create a formal complaint procedure for patients.

WASHINGTON – When it comes to news coverage of dermatology, aesthetic issues get much more attention than oncologic, surgical, or medical topics, according to a recent analysis of the nation’s top newspapers.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," Dr. Kristina Collins, a fellow in dermatologic surgery in the department of dermatology at Harvard Medical School, Boston, and Lahey Clinic, Burlington, Mass., said in an interview. "I think that many dermatologists find that patients or even colleagues in other specialties are not aware of the important medical diseases that the field of dermatology encompasses, and many people are under the false impression that most of a typical dermatologist’s time is dedicated to cosmetics."

In fact, according to Dr. Collins, national practice data shows that the average dermatologist spends only about 10% of his or her time on cosmetic procedures.

To conduct the study, Dr. Collins and her colleagues analyzed the contents of 1,669 dermatology-related articles gathered from the top 10 most widely circulated newspapers over a 10-year period ending on Jan. 1, 2011.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," said Dr. Kristina Collins.

Cosmetic procedures received 32% of the coverage, followed by skin diseases and disorders at 24%, skin cancer/tanning/sun protection at 22%, skin care at 12%, and acne and hair loss at 5% each.

Comparing the percentage of cosmetic vs. noncosmetic articles, the New York Post took the top spot with 72% cosmetic articles. It was followed by the New York Daily News (57%) and USA Today (55%). The Philadelphia Inquirer and the Denver Post had the lowest percentage of cosmetic articles at 37% and 29%, respectively.

Botox topped the chart when the articles were analyzed by topic (105 articles), followed by lasers (64), popularity of procedures (63), and sun protection tips (61). Botox for hyperhidrosis, smallpox/vaccine complications, epidermolysis bullosa, and tanning laws and restrictions took the bottom spots with 15 articles each.

A handful of other studies have also arrived at the same conclusion, with one focusing on the iconic TV sitcom Seinfeld and its reference to dermatologists. "Selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers," the authors wrote. (Dermatol. Online J. 2010;16:1).

Dr. Collins said that, with the aging population and the cultural shift in beauty norms, "people are genuinely interested in some of the cosmetic procedures that are available and that interest, in turn, drives the news media." But, "Somehow as a profession, we need to find ways to make important skin health information compelling both to the media and their target audiences.

"All of the aspects of our field have a place in the news, whether we are talking about Botox or basal cell carcinoma. We owe it to our patients to try to get them vital health information any way we are able," she said in an interview.

Dr. Collins had no disclosures.

WASHINGTON – When it comes to news coverage of dermatology, aesthetic issues get much more attention than oncologic, surgical, or medical topics, according to a recent analysis of the nation’s top newspapers.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," Dr. Kristina Collins, a fellow in dermatologic surgery in the department of dermatology at Harvard Medical School, Boston, and Lahey Clinic, Burlington, Mass., said in an interview. "I think that many dermatologists find that patients or even colleagues in other specialties are not aware of the important medical diseases that the field of dermatology encompasses, and many people are under the false impression that most of a typical dermatologist’s time is dedicated to cosmetics."

In fact, according to Dr. Collins, national practice data shows that the average dermatologist spends only about 10% of his or her time on cosmetic procedures.

To conduct the study, Dr. Collins and her colleagues analyzed the contents of 1,669 dermatology-related articles gathered from the top 10 most widely circulated newspapers over a 10-year period ending on Jan. 1, 2011.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," said Dr. Kristina Collins.

Cosmetic procedures received 32% of the coverage, followed by skin diseases and disorders at 24%, skin cancer/tanning/sun protection at 22%, skin care at 12%, and acne and hair loss at 5% each.

Comparing the percentage of cosmetic vs. noncosmetic articles, the New York Post took the top spot with 72% cosmetic articles. It was followed by the New York Daily News (57%) and USA Today (55%). The Philadelphia Inquirer and the Denver Post had the lowest percentage of cosmetic articles at 37% and 29%, respectively.

Botox topped the chart when the articles were analyzed by topic (105 articles), followed by lasers (64), popularity of procedures (63), and sun protection tips (61). Botox for hyperhidrosis, smallpox/vaccine complications, epidermolysis bullosa, and tanning laws and restrictions took the bottom spots with 15 articles each.

A handful of other studies have also arrived at the same conclusion, with one focusing on the iconic TV sitcom Seinfeld and its reference to dermatologists. "Selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers," the authors wrote. (Dermatol. Online J. 2010;16:1).

Dr. Collins said that, with the aging population and the cultural shift in beauty norms, "people are genuinely interested in some of the cosmetic procedures that are available and that interest, in turn, drives the news media." But, "Somehow as a profession, we need to find ways to make important skin health information compelling both to the media and their target audiences.

"All of the aspects of our field have a place in the news, whether we are talking about Botox or basal cell carcinoma. We owe it to our patients to try to get them vital health information any way we are able," she said in an interview.

Dr. Collins had no disclosures.

WASHINGTON – When it comes to news coverage of dermatology, aesthetic issues get much more attention than oncologic, surgical, or medical topics, according to a recent analysis of the nation’s top newspapers.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," Dr. Kristina Collins, a fellow in dermatologic surgery in the department of dermatology at Harvard Medical School, Boston, and Lahey Clinic, Burlington, Mass., said in an interview. "I think that many dermatologists find that patients or even colleagues in other specialties are not aware of the important medical diseases that the field of dermatology encompasses, and many people are under the false impression that most of a typical dermatologist’s time is dedicated to cosmetics."

In fact, according to Dr. Collins, national practice data shows that the average dermatologist spends only about 10% of his or her time on cosmetic procedures.

To conduct the study, Dr. Collins and her colleagues analyzed the contents of 1,669 dermatology-related articles gathered from the top 10 most widely circulated newspapers over a 10-year period ending on Jan. 1, 2011.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," said Dr. Kristina Collins.

Cosmetic procedures received 32% of the coverage, followed by skin diseases and disorders at 24%, skin cancer/tanning/sun protection at 22%, skin care at 12%, and acne and hair loss at 5% each.

Comparing the percentage of cosmetic vs. noncosmetic articles, the New York Post took the top spot with 72% cosmetic articles. It was followed by the New York Daily News (57%) and USA Today (55%). The Philadelphia Inquirer and the Denver Post had the lowest percentage of cosmetic articles at 37% and 29%, respectively.

Botox topped the chart when the articles were analyzed by topic (105 articles), followed by lasers (64), popularity of procedures (63), and sun protection tips (61). Botox for hyperhidrosis, smallpox/vaccine complications, epidermolysis bullosa, and tanning laws and restrictions took the bottom spots with 15 articles each.

A handful of other studies have also arrived at the same conclusion, with one focusing on the iconic TV sitcom Seinfeld and its reference to dermatologists. "Selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers," the authors wrote. (Dermatol. Online J. 2010;16:1).

Dr. Collins said that, with the aging population and the cultural shift in beauty norms, "people are genuinely interested in some of the cosmetic procedures that are available and that interest, in turn, drives the news media." But, "Somehow as a profession, we need to find ways to make important skin health information compelling both to the media and their target audiences.

"All of the aspects of our field have a place in the news, whether we are talking about Botox or basal cell carcinoma. We owe it to our patients to try to get them vital health information any way we are able," she said in an interview.

Dr. Collins had no disclosures.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

LISBON – Two of 10 nonmelanoma skin cancers are misdiagnosed as being of a nonaggressive tumor subtype at initial biopsy, according to Dr. Nathalie Zeitouni.

This raises concern that a substantial number of biopsied squamous and basal cell carcinomas are being treated suboptimally, Dr. Zeitouni said at the congress.

She presented a consecutive series of 513 patients referred for Mohs micrographic surgery for biopsy-proven BCC or SCC. Based upon routine Mohs intraoperative evaluation of all histologic tumor layers, 21.1% of the cancers were of aggressive subtypes that went undiagnosed on initial biopsy.

Aggressive subtypes of nonmelanoma skin cancer include basosquamous carcinoma, invasive SCC, and morpheaform, infiltrating, keratinizing, and micronodular BCC. Nonaggressive subtypes include follicular, nodular, adenoid cystic, and superficial BCC, as well as SCC in situ, according to Dr. Zeitouni, chief of dermatologic surgery at the Roswell Park Cancer Institute, Buffalo, N.Y.

In only 51% of cases was there concordance between the preoperative and the definitive intraoperative diagnosis of a nonmelanoma skin cancer as being of an aggressive or nonaggressive subtype.

In 21% of cases the intraoperative evaluation showed no residual tumor present, only scar. In 5.5% of cases, intraoperative histologic tumor layer evaluation resulted in downgrading of the nonmelanoma skin cancer from an aggressive to a nonaggressive subtype.

Dr. Zeitouni stressed that dermatologists need to have a low threshold for suspecting that a nonmelanoma skin cancer is of an undiagnosed aggressive subtype. If the lesion is clinically atypical or it responds poorly to standard excision or simple destructive measures, that possibility becomes distinctly more likely. Aggressive subtypes, she added, are best managed by Mohs surgery.

She said she had no relevant financial disclosures.

LISBON – Two of 10 nonmelanoma skin cancers are misdiagnosed as being of a nonaggressive tumor subtype at initial biopsy, according to Dr. Nathalie Zeitouni.

This raises concern that a substantial number of biopsied squamous and basal cell carcinomas are being treated suboptimally, Dr. Zeitouni said at the congress.

She presented a consecutive series of 513 patients referred for Mohs micrographic surgery for biopsy-proven BCC or SCC. Based upon routine Mohs intraoperative evaluation of all histologic tumor layers, 21.1% of the cancers were of aggressive subtypes that went undiagnosed on initial biopsy.

Aggressive subtypes of nonmelanoma skin cancer include basosquamous carcinoma, invasive SCC, and morpheaform, infiltrating, keratinizing, and micronodular BCC. Nonaggressive subtypes include follicular, nodular, adenoid cystic, and superficial BCC, as well as SCC in situ, according to Dr. Zeitouni, chief of dermatologic surgery at the Roswell Park Cancer Institute, Buffalo, N.Y.

In only 51% of cases was there concordance between the preoperative and the definitive intraoperative diagnosis of a nonmelanoma skin cancer as being of an aggressive or nonaggressive subtype.

In 21% of cases the intraoperative evaluation showed no residual tumor present, only scar. In 5.5% of cases, intraoperative histologic tumor layer evaluation resulted in downgrading of the nonmelanoma skin cancer from an aggressive to a nonaggressive subtype.

Dr. Zeitouni stressed that dermatologists need to have a low threshold for suspecting that a nonmelanoma skin cancer is of an undiagnosed aggressive subtype. If the lesion is clinically atypical or it responds poorly to standard excision or simple destructive measures, that possibility becomes distinctly more likely. Aggressive subtypes, she added, are best managed by Mohs surgery.

She said she had no relevant financial disclosures.

LISBON – Two of 10 nonmelanoma skin cancers are misdiagnosed as being of a nonaggressive tumor subtype at initial biopsy, according to Dr. Nathalie Zeitouni.

This raises concern that a substantial number of biopsied squamous and basal cell carcinomas are being treated suboptimally, Dr. Zeitouni said at the congress.

She presented a consecutive series of 513 patients referred for Mohs micrographic surgery for biopsy-proven BCC or SCC. Based upon routine Mohs intraoperative evaluation of all histologic tumor layers, 21.1% of the cancers were of aggressive subtypes that went undiagnosed on initial biopsy.

Aggressive subtypes of nonmelanoma skin cancer include basosquamous carcinoma, invasive SCC, and morpheaform, infiltrating, keratinizing, and micronodular BCC. Nonaggressive subtypes include follicular, nodular, adenoid cystic, and superficial BCC, as well as SCC in situ, according to Dr. Zeitouni, chief of dermatologic surgery at the Roswell Park Cancer Institute, Buffalo, N.Y.

In only 51% of cases was there concordance between the preoperative and the definitive intraoperative diagnosis of a nonmelanoma skin cancer as being of an aggressive or nonaggressive subtype.

In 21% of cases the intraoperative evaluation showed no residual tumor present, only scar. In 5.5% of cases, intraoperative histologic tumor layer evaluation resulted in downgrading of the nonmelanoma skin cancer from an aggressive to a nonaggressive subtype.

Dr. Zeitouni stressed that dermatologists need to have a low threshold for suspecting that a nonmelanoma skin cancer is of an undiagnosed aggressive subtype. If the lesion is clinically atypical or it responds poorly to standard excision or simple destructive measures, that possibility becomes distinctly more likely. Aggressive subtypes, she added, are best managed by Mohs surgery.

She said she had no relevant financial disclosures.

'In this month's podcast, Reporter Sherry Boschert talks to Dr. Libby Edwards about how best to manage genital itching in female patients, while Reporter Jeff Evans catches up with Dr. Darrell Rigel on what dermatologists can expect now that MelaFind has received FDA approval.

Vincent DeLeo reminds dermatologists that they need to tell patients how much sunscreen to use during application because most aren't using enough.

And last but not least, Dr. Alan Rockoff shows off his ability to say "fungus" in multiple languages.

Don't miss another episode of The Skinny Podcast; subscribe on iTunes!

'In this month's podcast, Reporter Sherry Boschert talks to Dr. Libby Edwards about how best to manage genital itching in female patients, while Reporter Jeff Evans catches up with Dr. Darrell Rigel on what dermatologists can expect now that MelaFind has received FDA approval.

Vincent DeLeo reminds dermatologists that they need to tell patients how much sunscreen to use during application because most aren't using enough.

And last but not least, Dr. Alan Rockoff shows off his ability to say "fungus" in multiple languages.

Don't miss another episode of The Skinny Podcast; subscribe on iTunes!

'In this month's podcast, Reporter Sherry Boschert talks to Dr. Libby Edwards about how best to manage genital itching in female patients, while Reporter Jeff Evans catches up with Dr. Darrell Rigel on what dermatologists can expect now that MelaFind has received FDA approval.

Vincent DeLeo reminds dermatologists that they need to tell patients how much sunscreen to use during application because most aren't using enough.

And last but not least, Dr. Alan Rockoff shows off his ability to say "fungus" in multiple languages.

Don't miss another episode of The Skinny Podcast; subscribe on iTunes!