Aesthetic Dermatology

SAN DIEGO — European experts in foam sclerotherapy have updated their recommendations regarding how to perform foam sclerotherapy. Those recommendations include one that foam as viscous as possible should be used, and that only a 2%-3% mixture of polidocanol is needed for the greater saphenous vein, Dr. Nick Morrison said at the annual meeting of the American Venous Forum.

At the second European Consensus Meeting on Foam Sclerotherapy in April 2006, 26 European experts and 1 American expert were surveyed about their practices, and the survey was used to update recommendations originally made in 2003, said Dr. Morrison, president-elect of the American College of Phlebology and a surgeon who practices in Scottsdale, Ariz.

Dr. Morrison said the document that emerged from that survey included consensus statements on the following:

▸ Access material. The majority of experts use direct puncture to access the great saphenous vein, and for the great and small saphenous vein, most use a needle or a short catheter for access, though some use larger needles or a long catheter for larger veins.

▸ Access location. For the great saphenous vein accessed by direct puncture, the preferred access location of most experts is the proximal thigh. When a long catheter is used, however, access below the knee is preferred. For the small saphenous vein, access is preferred at the proximal or middle part of the calf.

▸ Foam. Foam should be made as viscous as possible, and the amount of foam used should be small and limited, even if that means a second procedure, the experts concurred. The average amount of foam used by the experts per puncture was up to 6 mL, and the maximum volume was up to 8 mL. Eighty-five percent of the experts used less than 10 mL per session. The consensus was that 10 mL was the maximum amount of foam that should be used per leg and per session. Most experts use 2%-3% polidocanol, and most use liquid rather than foam for telangiectasias.

▸ Foam preparation. For the preparation of foam, the Tessari and the DSS/Tessari methods are recommended in all indications. Most experts are using a 4:1 liquid:gas ratio, with air being the most commonly used gas component, though CO2 and O2 can also be used.

▸ Safety. Most of the experts do not use a catheter with a balloon to control the flow of foam; in fact, some believe it is better to have some minor seep rather than a large bolus released at once when the balloon is deflated. A slight majority of the experts uses a limited amount of foam per puncture and per session to increase safety.

Most advise that the puncture site be a minimal distance of 8–10 cm from the saphenofemoral and saphenopopliteal junctions. Immediate compression over the puncture site should be avoided, and most experts use echographic control of foam location.

▸ Contraindications. A relative contraindication is a patent foramen ovale. Patients with a known, asymptomatic foramen ovale should rest in a supine position longer, from 8 to 30 minutes.

▸ Compression. The great majority of experts see a need for compression after treatment of a saphenous vein, its tributaries, perforating veins, and vascular malformations. About half of the experts use compression for treated reticular veins and telangiectasias.

SAN DIEGO — European experts in foam sclerotherapy have updated their recommendations regarding how to perform foam sclerotherapy. Those recommendations include one that foam as viscous as possible should be used, and that only a 2%-3% mixture of polidocanol is needed for the greater saphenous vein, Dr. Nick Morrison said at the annual meeting of the American Venous Forum.

At the second European Consensus Meeting on Foam Sclerotherapy in April 2006, 26 European experts and 1 American expert were surveyed about their practices, and the survey was used to update recommendations originally made in 2003, said Dr. Morrison, president-elect of the American College of Phlebology and a surgeon who practices in Scottsdale, Ariz.

Dr. Morrison said the document that emerged from that survey included consensus statements on the following:

▸ Access material. The majority of experts use direct puncture to access the great saphenous vein, and for the great and small saphenous vein, most use a needle or a short catheter for access, though some use larger needles or a long catheter for larger veins.

▸ Access location. For the great saphenous vein accessed by direct puncture, the preferred access location of most experts is the proximal thigh. When a long catheter is used, however, access below the knee is preferred. For the small saphenous vein, access is preferred at the proximal or middle part of the calf.

▸ Foam. Foam should be made as viscous as possible, and the amount of foam used should be small and limited, even if that means a second procedure, the experts concurred. The average amount of foam used by the experts per puncture was up to 6 mL, and the maximum volume was up to 8 mL. Eighty-five percent of the experts used less than 10 mL per session. The consensus was that 10 mL was the maximum amount of foam that should be used per leg and per session. Most experts use 2%-3% polidocanol, and most use liquid rather than foam for telangiectasias.

▸ Foam preparation. For the preparation of foam, the Tessari and the DSS/Tessari methods are recommended in all indications. Most experts are using a 4:1 liquid:gas ratio, with air being the most commonly used gas component, though CO2 and O2 can also be used.

▸ Safety. Most of the experts do not use a catheter with a balloon to control the flow of foam; in fact, some believe it is better to have some minor seep rather than a large bolus released at once when the balloon is deflated. A slight majority of the experts uses a limited amount of foam per puncture and per session to increase safety.

Most advise that the puncture site be a minimal distance of 8–10 cm from the saphenofemoral and saphenopopliteal junctions. Immediate compression over the puncture site should be avoided, and most experts use echographic control of foam location.

▸ Contraindications. A relative contraindication is a patent foramen ovale. Patients with a known, asymptomatic foramen ovale should rest in a supine position longer, from 8 to 30 minutes.

▸ Compression. The great majority of experts see a need for compression after treatment of a saphenous vein, its tributaries, perforating veins, and vascular malformations. About half of the experts use compression for treated reticular veins and telangiectasias.

SAN DIEGO — European experts in foam sclerotherapy have updated their recommendations regarding how to perform foam sclerotherapy. Those recommendations include one that foam as viscous as possible should be used, and that only a 2%-3% mixture of polidocanol is needed for the greater saphenous vein, Dr. Nick Morrison said at the annual meeting of the American Venous Forum.

At the second European Consensus Meeting on Foam Sclerotherapy in April 2006, 26 European experts and 1 American expert were surveyed about their practices, and the survey was used to update recommendations originally made in 2003, said Dr. Morrison, president-elect of the American College of Phlebology and a surgeon who practices in Scottsdale, Ariz.

Dr. Morrison said the document that emerged from that survey included consensus statements on the following:

▸ Access material. The majority of experts use direct puncture to access the great saphenous vein, and for the great and small saphenous vein, most use a needle or a short catheter for access, though some use larger needles or a long catheter for larger veins.

▸ Access location. For the great saphenous vein accessed by direct puncture, the preferred access location of most experts is the proximal thigh. When a long catheter is used, however, access below the knee is preferred. For the small saphenous vein, access is preferred at the proximal or middle part of the calf.

▸ Foam. Foam should be made as viscous as possible, and the amount of foam used should be small and limited, even if that means a second procedure, the experts concurred. The average amount of foam used by the experts per puncture was up to 6 mL, and the maximum volume was up to 8 mL. Eighty-five percent of the experts used less than 10 mL per session. The consensus was that 10 mL was the maximum amount of foam that should be used per leg and per session. Most experts use 2%-3% polidocanol, and most use liquid rather than foam for telangiectasias.

▸ Foam preparation. For the preparation of foam, the Tessari and the DSS/Tessari methods are recommended in all indications. Most experts are using a 4:1 liquid:gas ratio, with air being the most commonly used gas component, though CO2 and O2 can also be used.

▸ Safety. Most of the experts do not use a catheter with a balloon to control the flow of foam; in fact, some believe it is better to have some minor seep rather than a large bolus released at once when the balloon is deflated. A slight majority of the experts uses a limited amount of foam per puncture and per session to increase safety.

Most advise that the puncture site be a minimal distance of 8–10 cm from the saphenofemoral and saphenopopliteal junctions. Immediate compression over the puncture site should be avoided, and most experts use echographic control of foam location.

▸ Contraindications. A relative contraindication is a patent foramen ovale. Patients with a known, asymptomatic foramen ovale should rest in a supine position longer, from 8 to 30 minutes.

▸ Compression. The great majority of experts see a need for compression after treatment of a saphenous vein, its tributaries, perforating veins, and vascular malformations. About half of the experts use compression for treated reticular veins and telangiectasias.

SAN DIEGO — Foam sclerotherapy will soon be considered the standard of care for treating varicose veins, if it isn't already, Dr. John Bergan predicted at the annual meeting of the American Venous Forum.

"We have reached the point where foam has taken over," said Dr. Bergan, professor of surgery at the University of California, San Diego. "Put your laser on eBay because you are not going to be told this, but foam can do everything."

Insurance companies still generally consider foam sclerotherapy an investigational technique. But over the last 10 years, there have been at least 50 articles dedicated to some aspect of, or experience with, the technique, Dr. Bergan said.

Those publications indicate efficacy of immediate and primary venous occlusion of better than 80%, and that foam is 10 times stronger than liquid. They suggest that repeating the procedure when it fails the first or second time produces a success rate approaching 95%, and recurrence occurs only about 20% of the time, at 5 years.

In at least 70% of cases with saphenous vein reflux, there is no need to treat or strip the saphenous vein, because treating the varicose veins with foam will resolve the reflux or cause the saphenous vein to occlude.

Moreover, severe complications are extremely rare and allergic reactions to polidocanol just do not occur, he added.

A couple of years ago, his group was planning to buy a laser, but their experience with foam changed their minds, Dr. Bergan said.

Since January 2002, his group has treated 869 patients with foam sclerotherapy, and the vein-closure success rate at 1 year, with one or two treatments, has been 90%. And that group of patients has included 66 patients with active leg ulcers, unstable healed ulcers, or disabling lipodermatosclerosis.

There have been 13 adverse events total, of which 4 were ocular symptoms (which resolved), 3 were cases of dry cough, 2 were cases of migraine, 2 were cases of chest pain, and 2 were myoclonus and giddiness. In addition, there were three cases of deep vein thrombosis (two gastrocnemius thrombi, one posterior tibial thrombosis). Since last year, the group has instituted a policy of keeping the treated legs elevated at 45 degrees for 10 minutes after injection, and in 134 patients, there have been no adverse events.

Foam is as effective as laser or radiofrequency ablation, he said. The big difference is cost, with the generator for laser or radiofrequency costing about $30,000 and foam costing about $10.

"The literature is here," he said. "If your insurance company gives you a hard time, call me. I'll give you 50 references, or you can find them yourself on PubMed."

SAN DIEGO — Foam sclerotherapy will soon be considered the standard of care for treating varicose veins, if it isn't already, Dr. John Bergan predicted at the annual meeting of the American Venous Forum.

"We have reached the point where foam has taken over," said Dr. Bergan, professor of surgery at the University of California, San Diego. "Put your laser on eBay because you are not going to be told this, but foam can do everything."

Insurance companies still generally consider foam sclerotherapy an investigational technique. But over the last 10 years, there have been at least 50 articles dedicated to some aspect of, or experience with, the technique, Dr. Bergan said.

Those publications indicate efficacy of immediate and primary venous occlusion of better than 80%, and that foam is 10 times stronger than liquid. They suggest that repeating the procedure when it fails the first or second time produces a success rate approaching 95%, and recurrence occurs only about 20% of the time, at 5 years.

In at least 70% of cases with saphenous vein reflux, there is no need to treat or strip the saphenous vein, because treating the varicose veins with foam will resolve the reflux or cause the saphenous vein to occlude.

Moreover, severe complications are extremely rare and allergic reactions to polidocanol just do not occur, he added.

A couple of years ago, his group was planning to buy a laser, but their experience with foam changed their minds, Dr. Bergan said.

Since January 2002, his group has treated 869 patients with foam sclerotherapy, and the vein-closure success rate at 1 year, with one or two treatments, has been 90%. And that group of patients has included 66 patients with active leg ulcers, unstable healed ulcers, or disabling lipodermatosclerosis.

There have been 13 adverse events total, of which 4 were ocular symptoms (which resolved), 3 were cases of dry cough, 2 were cases of migraine, 2 were cases of chest pain, and 2 were myoclonus and giddiness. In addition, there were three cases of deep vein thrombosis (two gastrocnemius thrombi, one posterior tibial thrombosis). Since last year, the group has instituted a policy of keeping the treated legs elevated at 45 degrees for 10 minutes after injection, and in 134 patients, there have been no adverse events.

Foam is as effective as laser or radiofrequency ablation, he said. The big difference is cost, with the generator for laser or radiofrequency costing about $30,000 and foam costing about $10.

"The literature is here," he said. "If your insurance company gives you a hard time, call me. I'll give you 50 references, or you can find them yourself on PubMed."

SAN DIEGO — Foam sclerotherapy will soon be considered the standard of care for treating varicose veins, if it isn't already, Dr. John Bergan predicted at the annual meeting of the American Venous Forum.

"We have reached the point where foam has taken over," said Dr. Bergan, professor of surgery at the University of California, San Diego. "Put your laser on eBay because you are not going to be told this, but foam can do everything."

Insurance companies still generally consider foam sclerotherapy an investigational technique. But over the last 10 years, there have been at least 50 articles dedicated to some aspect of, or experience with, the technique, Dr. Bergan said.

Those publications indicate efficacy of immediate and primary venous occlusion of better than 80%, and that foam is 10 times stronger than liquid. They suggest that repeating the procedure when it fails the first or second time produces a success rate approaching 95%, and recurrence occurs only about 20% of the time, at 5 years.

In at least 70% of cases with saphenous vein reflux, there is no need to treat or strip the saphenous vein, because treating the varicose veins with foam will resolve the reflux or cause the saphenous vein to occlude.

Moreover, severe complications are extremely rare and allergic reactions to polidocanol just do not occur, he added.

A couple of years ago, his group was planning to buy a laser, but their experience with foam changed their minds, Dr. Bergan said.

Since January 2002, his group has treated 869 patients with foam sclerotherapy, and the vein-closure success rate at 1 year, with one or two treatments, has been 90%. And that group of patients has included 66 patients with active leg ulcers, unstable healed ulcers, or disabling lipodermatosclerosis.

There have been 13 adverse events total, of which 4 were ocular symptoms (which resolved), 3 were cases of dry cough, 2 were cases of migraine, 2 were cases of chest pain, and 2 were myoclonus and giddiness. In addition, there were three cases of deep vein thrombosis (two gastrocnemius thrombi, one posterior tibial thrombosis). Since last year, the group has instituted a policy of keeping the treated legs elevated at 45 degrees for 10 minutes after injection, and in 134 patients, there have been no adverse events.

Foam is as effective as laser or radiofrequency ablation, he said. The big difference is cost, with the generator for laser or radiofrequency costing about $30,000 and foam costing about $10.

"The literature is here," he said. "If your insurance company gives you a hard time, call me. I'll give you 50 references, or you can find them yourself on PubMed."

GRAPEVINE, TEX. — A single laser device that can sequentially deliver both 585-nm and 1,064-nm laser pulses was effective for treating thick port-wine stains, facial telangiectasias, and leg veins in three separate studies reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The Cynergy multiplex laser marketed by Cynosure is approved by the Food and Drug Administration, and is "clearly a nice advance," commented Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass., and cochairman of the session where the three reports were presented.

Many dermatologists have just begun to work with this device, which can sequentially fire a pulsed dye laser beam followed by an Nd:YAG beam with an intervening delay of as little as 50 milliseconds. "The marvel of this technology is to have two wavelengths in one box that fire sequentially and not fail. It's technically tricky," said Dr. Dover, who is also on the dermatology faculties at Yale University, New Haven, Conn., and Dartmouth Medical School, Hanover, N.H. He had no disclosed relationships with Cynosure.

Deciding how to optimally use this capability is "very complex, with a lot of parameters to choose from. It will take time to get the ideal settings," Dr. Dover said. "We've seen some port-wine stains that were stuck but then started to clear with this new laser. I think that in a year we'll see some very nice data" from use of the new laser.

The rationale behind the dual laser system is that an initial pulse from a pulsed dye laser at 585 nm generates heat within blood-containing vessels that converts oxyhemoglobin to methemoglobin. Methemoglobin is 3–5 times better able to absorb energy from an Nd:YAG laser at 1064 nm, which makes the sequential laser treatment more efficient than either of these two light energies is on its own.

The port-wine stain study reported at the meeting included 20 adults with lesions that had failed to improve by more than 20% following at least two treatments with a conventional pulsed dye laser at 595 nm.

Dr. Ashraf Badawi and his associates at the Laser Institute at Cairo (Egypt) University used the multiplex laser to first deliver 7.0–7.5 J/cm2 from the pulsed dye laser, followed by 60–80 J/cm2 from the Nd:YAG laser. Patients received an average of four treatments given at 3- to 4-week intervals. At the end of treatment, all patients had at least a 70% improvement, said Dr. Badawi, a dermatologist at Cairo University. Dr. Badawi did not have any financial disclosures for this study.

The study of facial telangiectasias enrolled 20 patients who were treated on a split-nose basis. One side of each nose was treated with sequential laser energy, first with a 10-millisecond pulse from the pulsed dye laser, using a 7-mm spot size and fluence of 10 J/cm2. This was followed after a 100-millisecond delay by a 15-millisecond pulse from the Nd:YAG laser at a fluence of 70 J/cm2. The other side of each nose was treated with either a pulsed dye or an Nd:YAG laser only.

After a single treatment, 18 of the sides treated with both lasers had at least 50% improvement in their telangiectasia appearance, compared with 4 of the 20 sides treated with a single laser reaching this level of improvement, reported Dr. Syrus Karsai, a dermatologist at the Laser Clinic in Karlsruhe, Germany. Dr. Karsai had no financial disclosures for this study.

The study of patients with leg veins included 25 patients. After two treatments with the multiplex laser, 19 patients had at least 50% clearance of their visible leg veins, and the remaining 6 patients had at least 25% clearance, reported Dr. Robert Adrian, a dermatologist in private practice in Washington. His regimen involved treatment with a 10-millisecond pulse of the pulsed dye laser with a 7-mm spot size and 7–8 J/cm2. After a 50–150-millisecond delay, the Nd:YAG was fired for 40 milliseconds with a 7-mm spot size and 60–70 J/cm2. Dr. Adrian received equipment from Cynosure.

'We've seen some port-wine stains that were stuck but then started to clear with this new laser.' DR. DOVER

GRAPEVINE, TEX. — A single laser device that can sequentially deliver both 585-nm and 1,064-nm laser pulses was effective for treating thick port-wine stains, facial telangiectasias, and leg veins in three separate studies reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The Cynergy multiplex laser marketed by Cynosure is approved by the Food and Drug Administration, and is "clearly a nice advance," commented Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass., and cochairman of the session where the three reports were presented.

Many dermatologists have just begun to work with this device, which can sequentially fire a pulsed dye laser beam followed by an Nd:YAG beam with an intervening delay of as little as 50 milliseconds. "The marvel of this technology is to have two wavelengths in one box that fire sequentially and not fail. It's technically tricky," said Dr. Dover, who is also on the dermatology faculties at Yale University, New Haven, Conn., and Dartmouth Medical School, Hanover, N.H. He had no disclosed relationships with Cynosure.

Deciding how to optimally use this capability is "very complex, with a lot of parameters to choose from. It will take time to get the ideal settings," Dr. Dover said. "We've seen some port-wine stains that were stuck but then started to clear with this new laser. I think that in a year we'll see some very nice data" from use of the new laser.

The rationale behind the dual laser system is that an initial pulse from a pulsed dye laser at 585 nm generates heat within blood-containing vessels that converts oxyhemoglobin to methemoglobin. Methemoglobin is 3–5 times better able to absorb energy from an Nd:YAG laser at 1064 nm, which makes the sequential laser treatment more efficient than either of these two light energies is on its own.

The port-wine stain study reported at the meeting included 20 adults with lesions that had failed to improve by more than 20% following at least two treatments with a conventional pulsed dye laser at 595 nm.

Dr. Ashraf Badawi and his associates at the Laser Institute at Cairo (Egypt) University used the multiplex laser to first deliver 7.0–7.5 J/cm2 from the pulsed dye laser, followed by 60–80 J/cm2 from the Nd:YAG laser. Patients received an average of four treatments given at 3- to 4-week intervals. At the end of treatment, all patients had at least a 70% improvement, said Dr. Badawi, a dermatologist at Cairo University. Dr. Badawi did not have any financial disclosures for this study.

The study of facial telangiectasias enrolled 20 patients who were treated on a split-nose basis. One side of each nose was treated with sequential laser energy, first with a 10-millisecond pulse from the pulsed dye laser, using a 7-mm spot size and fluence of 10 J/cm2. This was followed after a 100-millisecond delay by a 15-millisecond pulse from the Nd:YAG laser at a fluence of 70 J/cm2. The other side of each nose was treated with either a pulsed dye or an Nd:YAG laser only.

After a single treatment, 18 of the sides treated with both lasers had at least 50% improvement in their telangiectasia appearance, compared with 4 of the 20 sides treated with a single laser reaching this level of improvement, reported Dr. Syrus Karsai, a dermatologist at the Laser Clinic in Karlsruhe, Germany. Dr. Karsai had no financial disclosures for this study.

The study of patients with leg veins included 25 patients. After two treatments with the multiplex laser, 19 patients had at least 50% clearance of their visible leg veins, and the remaining 6 patients had at least 25% clearance, reported Dr. Robert Adrian, a dermatologist in private practice in Washington. His regimen involved treatment with a 10-millisecond pulse of the pulsed dye laser with a 7-mm spot size and 7–8 J/cm2. After a 50–150-millisecond delay, the Nd:YAG was fired for 40 milliseconds with a 7-mm spot size and 60–70 J/cm2. Dr. Adrian received equipment from Cynosure.

'We've seen some port-wine stains that were stuck but then started to clear with this new laser.' DR. DOVER

GRAPEVINE, TEX. — A single laser device that can sequentially deliver both 585-nm and 1,064-nm laser pulses was effective for treating thick port-wine stains, facial telangiectasias, and leg veins in three separate studies reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The Cynergy multiplex laser marketed by Cynosure is approved by the Food and Drug Administration, and is "clearly a nice advance," commented Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass., and cochairman of the session where the three reports were presented.

Many dermatologists have just begun to work with this device, which can sequentially fire a pulsed dye laser beam followed by an Nd:YAG beam with an intervening delay of as little as 50 milliseconds. "The marvel of this technology is to have two wavelengths in one box that fire sequentially and not fail. It's technically tricky," said Dr. Dover, who is also on the dermatology faculties at Yale University, New Haven, Conn., and Dartmouth Medical School, Hanover, N.H. He had no disclosed relationships with Cynosure.

Deciding how to optimally use this capability is "very complex, with a lot of parameters to choose from. It will take time to get the ideal settings," Dr. Dover said. "We've seen some port-wine stains that were stuck but then started to clear with this new laser. I think that in a year we'll see some very nice data" from use of the new laser.

The rationale behind the dual laser system is that an initial pulse from a pulsed dye laser at 585 nm generates heat within blood-containing vessels that converts oxyhemoglobin to methemoglobin. Methemoglobin is 3–5 times better able to absorb energy from an Nd:YAG laser at 1064 nm, which makes the sequential laser treatment more efficient than either of these two light energies is on its own.

The port-wine stain study reported at the meeting included 20 adults with lesions that had failed to improve by more than 20% following at least two treatments with a conventional pulsed dye laser at 595 nm.

Dr. Ashraf Badawi and his associates at the Laser Institute at Cairo (Egypt) University used the multiplex laser to first deliver 7.0–7.5 J/cm2 from the pulsed dye laser, followed by 60–80 J/cm2 from the Nd:YAG laser. Patients received an average of four treatments given at 3- to 4-week intervals. At the end of treatment, all patients had at least a 70% improvement, said Dr. Badawi, a dermatologist at Cairo University. Dr. Badawi did not have any financial disclosures for this study.

The study of facial telangiectasias enrolled 20 patients who were treated on a split-nose basis. One side of each nose was treated with sequential laser energy, first with a 10-millisecond pulse from the pulsed dye laser, using a 7-mm spot size and fluence of 10 J/cm2. This was followed after a 100-millisecond delay by a 15-millisecond pulse from the Nd:YAG laser at a fluence of 70 J/cm2. The other side of each nose was treated with either a pulsed dye or an Nd:YAG laser only.

After a single treatment, 18 of the sides treated with both lasers had at least 50% improvement in their telangiectasia appearance, compared with 4 of the 20 sides treated with a single laser reaching this level of improvement, reported Dr. Syrus Karsai, a dermatologist at the Laser Clinic in Karlsruhe, Germany. Dr. Karsai had no financial disclosures for this study.

The study of patients with leg veins included 25 patients. After two treatments with the multiplex laser, 19 patients had at least 50% clearance of their visible leg veins, and the remaining 6 patients had at least 25% clearance, reported Dr. Robert Adrian, a dermatologist in private practice in Washington. His regimen involved treatment with a 10-millisecond pulse of the pulsed dye laser with a 7-mm spot size and 7–8 J/cm2. After a 50–150-millisecond delay, the Nd:YAG was fired for 40 milliseconds with a 7-mm spot size and 60–70 J/cm2. Dr. Adrian received equipment from Cynosure.

'We've seen some port-wine stains that were stuck but then started to clear with this new laser.' DR. DOVER

GRAPEVINE, TEX. — Reduced laser energy can be effective and more acceptable to patients who are being treated for pseudofolliculitis barbae, based on results from a study with 11 evaluable patients.

"Lower fluences offer hair modulation without permanent hair reduction," Dr. Rafael A. Schulze said at the annual meeting of the American Society for Laser Medicine and Surgery.

The hair follicles become smaller and weaker, and less prone to cause pseudofolliculitis barbae. Lower laser fluences also mean less conductive heating and therefore less pain. Treatment with lower energy, at less than half the power usually used for hair removal, also means that the laser device can be smaller and potentially more portable, said Dr. Schulze, a dermatologist at Brooke Army Medical Center, Fort Sam Houston, Tex.

Pseudofolliculitis barbae, caused by the curling and growth of hair follicles into adjacent skin, occurs primarily in African Americans and causes inflammatory papules and pustules. It can also cause skin discoloration, hypertrophic or keloidal scarring, and secondary infections. Standard treatments include topical steroids, chemical depilatories, electrolysis, and laser hair reduction.

Standard laser hair reduction is done with a high-fluence device, usually at a dose of 22–40 J/cm2, which delivers a total power of 940 watts at an energy level of 24 J/cm2. This approach is painful in patients with darker skin and can cause pigmentation changes, scarring, or blistering. The laser device needed to deliver this energy is large and expensive, and at least two or three treatments are usually needed, at 4- to 6-week intervals. This treatment is designed to permanently destroy hair follicles.

Dr. Schulze and his associates examined the efficacy and safety of treatment with a 1064-nm Nd:YAG StarLux laser that delivered 12 J/cm2 with a 10-mm spot size and 20-millisecond pulses, producing a total power dose of 390 watts.

The Lux handpiece contained a water-cooled sapphire window; no topical anesthesia was used.

The treatment was designed not to destroy hair follicles but to cause a slight insult in them and make the hairs weaker and smaller, said Dr. Schulze, who had no financial conflicts to disclose for this study.

The study enrolled 21 men and 1 woman with pseudofolliculitis barbae and skin type IV-VI who were scheduled to receive weekly low-fluence laser treatments for 5 weeks, followed by 4 weeks of follow-up. Their age range was 21–42 years, with an average of 24. The participants were told to continue whatever grooming methods they had used before laser treatment, including clipping their facial hair and using a chemical depilatory.

Photographs of the necks of each patient were assessed before and after treatment by a panel of 10 dermatologists, who scored the outcomes based on papule counts, dyspigmentation, cobblestone appearance, and global assessment. Thirteen of the 22 patients completed the study. Two of the 13 completers failed to follow the protocol and changed their grooming method during the study, so they were excluded from the final analysis.

Among the 11 evaluable patients, none developed pigmentation changes, crusting, blistering, or scarring.

The global efficacy assessment showed an average 83% improvement for the composite of papule number, dyspigmentation, and cobblestone appearance, a statistically significant difference, compared with baseline.

Each of the individual assessments was also significantly improved at follow-up, compared with baselines. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GRAPEVINE, TEX. — Reduced laser energy can be effective and more acceptable to patients who are being treated for pseudofolliculitis barbae, based on results from a study with 11 evaluable patients.

"Lower fluences offer hair modulation without permanent hair reduction," Dr. Rafael A. Schulze said at the annual meeting of the American Society for Laser Medicine and Surgery.

The hair follicles become smaller and weaker, and less prone to cause pseudofolliculitis barbae. Lower laser fluences also mean less conductive heating and therefore less pain. Treatment with lower energy, at less than half the power usually used for hair removal, also means that the laser device can be smaller and potentially more portable, said Dr. Schulze, a dermatologist at Brooke Army Medical Center, Fort Sam Houston, Tex.

Pseudofolliculitis barbae, caused by the curling and growth of hair follicles into adjacent skin, occurs primarily in African Americans and causes inflammatory papules and pustules. It can also cause skin discoloration, hypertrophic or keloidal scarring, and secondary infections. Standard treatments include topical steroids, chemical depilatories, electrolysis, and laser hair reduction.

Standard laser hair reduction is done with a high-fluence device, usually at a dose of 22–40 J/cm2, which delivers a total power of 940 watts at an energy level of 24 J/cm2. This approach is painful in patients with darker skin and can cause pigmentation changes, scarring, or blistering. The laser device needed to deliver this energy is large and expensive, and at least two or three treatments are usually needed, at 4- to 6-week intervals. This treatment is designed to permanently destroy hair follicles.

Dr. Schulze and his associates examined the efficacy and safety of treatment with a 1064-nm Nd:YAG StarLux laser that delivered 12 J/cm2 with a 10-mm spot size and 20-millisecond pulses, producing a total power dose of 390 watts.

The Lux handpiece contained a water-cooled sapphire window; no topical anesthesia was used.

The treatment was designed not to destroy hair follicles but to cause a slight insult in them and make the hairs weaker and smaller, said Dr. Schulze, who had no financial conflicts to disclose for this study.

The study enrolled 21 men and 1 woman with pseudofolliculitis barbae and skin type IV-VI who were scheduled to receive weekly low-fluence laser treatments for 5 weeks, followed by 4 weeks of follow-up. Their age range was 21–42 years, with an average of 24. The participants were told to continue whatever grooming methods they had used before laser treatment, including clipping their facial hair and using a chemical depilatory.

Photographs of the necks of each patient were assessed before and after treatment by a panel of 10 dermatologists, who scored the outcomes based on papule counts, dyspigmentation, cobblestone appearance, and global assessment. Thirteen of the 22 patients completed the study. Two of the 13 completers failed to follow the protocol and changed their grooming method during the study, so they were excluded from the final analysis.

Among the 11 evaluable patients, none developed pigmentation changes, crusting, blistering, or scarring.

The global efficacy assessment showed an average 83% improvement for the composite of papule number, dyspigmentation, and cobblestone appearance, a statistically significant difference, compared with baseline.

Each of the individual assessments was also significantly improved at follow-up, compared with baselines. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GRAPEVINE, TEX. — Reduced laser energy can be effective and more acceptable to patients who are being treated for pseudofolliculitis barbae, based on results from a study with 11 evaluable patients.

"Lower fluences offer hair modulation without permanent hair reduction," Dr. Rafael A. Schulze said at the annual meeting of the American Society for Laser Medicine and Surgery.

The hair follicles become smaller and weaker, and less prone to cause pseudofolliculitis barbae. Lower laser fluences also mean less conductive heating and therefore less pain. Treatment with lower energy, at less than half the power usually used for hair removal, also means that the laser device can be smaller and potentially more portable, said Dr. Schulze, a dermatologist at Brooke Army Medical Center, Fort Sam Houston, Tex.

Pseudofolliculitis barbae, caused by the curling and growth of hair follicles into adjacent skin, occurs primarily in African Americans and causes inflammatory papules and pustules. It can also cause skin discoloration, hypertrophic or keloidal scarring, and secondary infections. Standard treatments include topical steroids, chemical depilatories, electrolysis, and laser hair reduction.

Standard laser hair reduction is done with a high-fluence device, usually at a dose of 22–40 J/cm2, which delivers a total power of 940 watts at an energy level of 24 J/cm2. This approach is painful in patients with darker skin and can cause pigmentation changes, scarring, or blistering. The laser device needed to deliver this energy is large and expensive, and at least two or three treatments are usually needed, at 4- to 6-week intervals. This treatment is designed to permanently destroy hair follicles.

Dr. Schulze and his associates examined the efficacy and safety of treatment with a 1064-nm Nd:YAG StarLux laser that delivered 12 J/cm2 with a 10-mm spot size and 20-millisecond pulses, producing a total power dose of 390 watts.

The Lux handpiece contained a water-cooled sapphire window; no topical anesthesia was used.

The treatment was designed not to destroy hair follicles but to cause a slight insult in them and make the hairs weaker and smaller, said Dr. Schulze, who had no financial conflicts to disclose for this study.

The study enrolled 21 men and 1 woman with pseudofolliculitis barbae and skin type IV-VI who were scheduled to receive weekly low-fluence laser treatments for 5 weeks, followed by 4 weeks of follow-up. Their age range was 21–42 years, with an average of 24. The participants were told to continue whatever grooming methods they had used before laser treatment, including clipping their facial hair and using a chemical depilatory.

Photographs of the necks of each patient were assessed before and after treatment by a panel of 10 dermatologists, who scored the outcomes based on papule counts, dyspigmentation, cobblestone appearance, and global assessment. Thirteen of the 22 patients completed the study. Two of the 13 completers failed to follow the protocol and changed their grooming method during the study, so they were excluded from the final analysis.

Among the 11 evaluable patients, none developed pigmentation changes, crusting, blistering, or scarring.

The global efficacy assessment showed an average 83% improvement for the composite of papule number, dyspigmentation, and cobblestone appearance, a statistically significant difference, compared with baseline.

Each of the individual assessments was also significantly improved at follow-up, compared with baselines. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GRAPEVINE, TEX — Hair removal by intense pulsed light is a useful adjunctive treatment for refractory hidradenitis suppurativa, based on experience with 10 patients at one center.

Five of the treated patients had clear improvement in their clinical status after 3–4 hair-removal treatments, with reduced or resolved lesions in the treated area. The remaining five patients had improvement after four to eight treatments, Dr. Agneta Troilius said at the annual meeting of the American Society of Lasers in Medicine and Surgery. The treatment also resulted in less scarring than usually occurs when hidradenitis suppurativa (HS) lesions resolve.

"Hair removal is one element of treatment" for a disease that affects as many as 4% of women, said Dr. Troilius, head of the laser and vascular anomaly section of the department of dermatology at Lund University in Malmö, Sweden.

The series included women aged 21–45 years with skin type II or III who had active HS for several years and had lesions that had affected their social lives.

Treatment was with an intense pulsed light (IPL) device, the Ellipse model made by Danish Dermatologic Development, using the hair applicator to deliver 645- to 950-nm light. Treatment was with a fluence of 17–19 J/cm2, delivered as 20- to 40-microsecond pulses with a 1.5-microsecond delay. Treatments were at 1-month intervals. For pain control, treated areas were pretreated with a eutectic mixture of lidocaine and prilocaine (EMLA), and also were treated with contact cooling.

"One drawback to this treatment is that it is painful to treat in the affected areas," Dr. Troilius said. Treatment of HS may be further refined by combining hair removal with photodynamic therapy or anti-inflammatory therapy with newly available biologic drugs.

GRAPEVINE, TEX — Hair removal by intense pulsed light is a useful adjunctive treatment for refractory hidradenitis suppurativa, based on experience with 10 patients at one center.

Five of the treated patients had clear improvement in their clinical status after 3–4 hair-removal treatments, with reduced or resolved lesions in the treated area. The remaining five patients had improvement after four to eight treatments, Dr. Agneta Troilius said at the annual meeting of the American Society of Lasers in Medicine and Surgery. The treatment also resulted in less scarring than usually occurs when hidradenitis suppurativa (HS) lesions resolve.

"Hair removal is one element of treatment" for a disease that affects as many as 4% of women, said Dr. Troilius, head of the laser and vascular anomaly section of the department of dermatology at Lund University in Malmö, Sweden.

The series included women aged 21–45 years with skin type II or III who had active HS for several years and had lesions that had affected their social lives.

Treatment was with an intense pulsed light (IPL) device, the Ellipse model made by Danish Dermatologic Development, using the hair applicator to deliver 645- to 950-nm light. Treatment was with a fluence of 17–19 J/cm2, delivered as 20- to 40-microsecond pulses with a 1.5-microsecond delay. Treatments were at 1-month intervals. For pain control, treated areas were pretreated with a eutectic mixture of lidocaine and prilocaine (EMLA), and also were treated with contact cooling.

"One drawback to this treatment is that it is painful to treat in the affected areas," Dr. Troilius said. Treatment of HS may be further refined by combining hair removal with photodynamic therapy or anti-inflammatory therapy with newly available biologic drugs.

GRAPEVINE, TEX — Hair removal by intense pulsed light is a useful adjunctive treatment for refractory hidradenitis suppurativa, based on experience with 10 patients at one center.

Five of the treated patients had clear improvement in their clinical status after 3–4 hair-removal treatments, with reduced or resolved lesions in the treated area. The remaining five patients had improvement after four to eight treatments, Dr. Agneta Troilius said at the annual meeting of the American Society of Lasers in Medicine and Surgery. The treatment also resulted in less scarring than usually occurs when hidradenitis suppurativa (HS) lesions resolve.

"Hair removal is one element of treatment" for a disease that affects as many as 4% of women, said Dr. Troilius, head of the laser and vascular anomaly section of the department of dermatology at Lund University in Malmö, Sweden.

The series included women aged 21–45 years with skin type II or III who had active HS for several years and had lesions that had affected their social lives.

Treatment was with an intense pulsed light (IPL) device, the Ellipse model made by Danish Dermatologic Development, using the hair applicator to deliver 645- to 950-nm light. Treatment was with a fluence of 17–19 J/cm2, delivered as 20- to 40-microsecond pulses with a 1.5-microsecond delay. Treatments were at 1-month intervals. For pain control, treated areas were pretreated with a eutectic mixture of lidocaine and prilocaine (EMLA), and also were treated with contact cooling.

"One drawback to this treatment is that it is painful to treat in the affected areas," Dr. Troilius said. Treatment of HS may be further refined by combining hair removal with photodynamic therapy or anti-inflammatory therapy with newly available biologic drugs.

GRAPEVINE, TEX. — Facial-hair removal with laser energy can backfire and trigger hypertrichosis if the regimen is not optimized, Dr. Andrea Willey said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a review of more than 500 women who underwent photoepilation, it was found that paradoxical hair stimulation occurred in about 10%, much more common than previously reported.

A reliable way to prevent this outcome is to cool the surrounding skin with ice packs during laser treatment, along with using the maximum tolerated laser fluence and employing a double-pass technique, said Dr. Willey, who is a dermatologist at Oregon Health and Science University, Portland.

She and her associates reviewed before and after photos of 543 women who were treated for facial hair at a laser center in Spain from December 1998 to December 2003. The women were aged 16–52 years; 68% had type III skin, and the remaining women had either type II or type IV skin.

About 80% were treated with an alexandrite laser, whereas the others were treated with either an Nd:YAG laser or intense pulsed light. They received 3–23 treatments.

At follow-up, an average of 10% of the women had increased facial hair, 8% had no change, 78% had reduced hair growth, and 3% had complete hair removal. The remaining 1% had incomplete information and weren't included in the analysis.

Women with hypertrichosis after treatment had the extra hair predominantly in their beard area. All of the affected women had prominent vellus hair before treatment, noted Dr. Willey.

No apparent link between skin type and hair growth was found. Of the 57 women with hair growth, 16 had polycystic ovary syndrome or irregular menses.

The cause of paradoxical hypertrichosis in this setting is not clear, and several mechanisms probably play a role, she said.

One possibility is that subtherapeutic laser energy injures hair follicles, thus stimulating growth rather than killing the follicles. To prevent this, dermatologists in Spain began to use ice packs, high fluence, and a double-pass technique.

Since this method started in late 2003, there have been no additional cases of paradoxical hypertrichosis in any patients treated with this approach, Dr. Willey said.

Several dermatologists who heard the report at the meeting said that their own anecdotal experience confirmed Dr. Willey's report.

"You can predict which women will have this. They all have fine, almost downy hair on dark skin that is type III or higher," said Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass.

"I don't treat thin, wispy hairs on the neck because the likelihood of hypertrichosis is so high," added Dr. E. Victor Ross, director of the laser and cosmetic dermatology unit at Scripps Clinic in San Diego.

ELSEVIER GLOBAL MEDICAL NEWS

GRAPEVINE, TEX. — Facial-hair removal with laser energy can backfire and trigger hypertrichosis if the regimen is not optimized, Dr. Andrea Willey said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a review of more than 500 women who underwent photoepilation, it was found that paradoxical hair stimulation occurred in about 10%, much more common than previously reported.

A reliable way to prevent this outcome is to cool the surrounding skin with ice packs during laser treatment, along with using the maximum tolerated laser fluence and employing a double-pass technique, said Dr. Willey, who is a dermatologist at Oregon Health and Science University, Portland.

She and her associates reviewed before and after photos of 543 women who were treated for facial hair at a laser center in Spain from December 1998 to December 2003. The women were aged 16–52 years; 68% had type III skin, and the remaining women had either type II or type IV skin.

About 80% were treated with an alexandrite laser, whereas the others were treated with either an Nd:YAG laser or intense pulsed light. They received 3–23 treatments.

At follow-up, an average of 10% of the women had increased facial hair, 8% had no change, 78% had reduced hair growth, and 3% had complete hair removal. The remaining 1% had incomplete information and weren't included in the analysis.

Women with hypertrichosis after treatment had the extra hair predominantly in their beard area. All of the affected women had prominent vellus hair before treatment, noted Dr. Willey.

No apparent link between skin type and hair growth was found. Of the 57 women with hair growth, 16 had polycystic ovary syndrome or irregular menses.

The cause of paradoxical hypertrichosis in this setting is not clear, and several mechanisms probably play a role, she said.

One possibility is that subtherapeutic laser energy injures hair follicles, thus stimulating growth rather than killing the follicles. To prevent this, dermatologists in Spain began to use ice packs, high fluence, and a double-pass technique.

Since this method started in late 2003, there have been no additional cases of paradoxical hypertrichosis in any patients treated with this approach, Dr. Willey said.

Several dermatologists who heard the report at the meeting said that their own anecdotal experience confirmed Dr. Willey's report.

"You can predict which women will have this. They all have fine, almost downy hair on dark skin that is type III or higher," said Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass.

"I don't treat thin, wispy hairs on the neck because the likelihood of hypertrichosis is so high," added Dr. E. Victor Ross, director of the laser and cosmetic dermatology unit at Scripps Clinic in San Diego.

ELSEVIER GLOBAL MEDICAL NEWS

GRAPEVINE, TEX. — Facial-hair removal with laser energy can backfire and trigger hypertrichosis if the regimen is not optimized, Dr. Andrea Willey said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a review of more than 500 women who underwent photoepilation, it was found that paradoxical hair stimulation occurred in about 10%, much more common than previously reported.

A reliable way to prevent this outcome is to cool the surrounding skin with ice packs during laser treatment, along with using the maximum tolerated laser fluence and employing a double-pass technique, said Dr. Willey, who is a dermatologist at Oregon Health and Science University, Portland.

She and her associates reviewed before and after photos of 543 women who were treated for facial hair at a laser center in Spain from December 1998 to December 2003. The women were aged 16–52 years; 68% had type III skin, and the remaining women had either type II or type IV skin.

About 80% were treated with an alexandrite laser, whereas the others were treated with either an Nd:YAG laser or intense pulsed light. They received 3–23 treatments.

At follow-up, an average of 10% of the women had increased facial hair, 8% had no change, 78% had reduced hair growth, and 3% had complete hair removal. The remaining 1% had incomplete information and weren't included in the analysis.

Women with hypertrichosis after treatment had the extra hair predominantly in their beard area. All of the affected women had prominent vellus hair before treatment, noted Dr. Willey.

No apparent link between skin type and hair growth was found. Of the 57 women with hair growth, 16 had polycystic ovary syndrome or irregular menses.

The cause of paradoxical hypertrichosis in this setting is not clear, and several mechanisms probably play a role, she said.

One possibility is that subtherapeutic laser energy injures hair follicles, thus stimulating growth rather than killing the follicles. To prevent this, dermatologists in Spain began to use ice packs, high fluence, and a double-pass technique.

Since this method started in late 2003, there have been no additional cases of paradoxical hypertrichosis in any patients treated with this approach, Dr. Willey said.

Several dermatologists who heard the report at the meeting said that their own anecdotal experience confirmed Dr. Willey's report.

"You can predict which women will have this. They all have fine, almost downy hair on dark skin that is type III or higher," said Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass.

"I don't treat thin, wispy hairs on the neck because the likelihood of hypertrichosis is so high," added Dr. E. Victor Ross, director of the laser and cosmetic dermatology unit at Scripps Clinic in San Diego.

ELSEVIER GLOBAL MEDICAL NEWS

GRAPEVINE, TEX. — Fractional splitting of a laser beam has been combined with selective photothermolysis to produce a new tool for dermatologic surgery.

By combining the spatial selectivity of fractional technology with wavelength selectivity, fractional photothermolysis "offers a new and unique opportunity for precise targeting of hemoglobin and melanin-containing targets" using a Nd:YAG laser with a 1,064-nm wavelength, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery. He predicted that the new laser will be extremely useful for treating resistant melasma, nevus of Ota, tattoos and—most likely—port-wine stains.

The investigational device is made by Palomar Medical Technologies Inc. as part of their StarLux series. Dr. Ross has received equipment, consulting fees, research grants, and honoraria from Palomar.

As of April, Dr. Ross and his associates had treated only a few patients, but with good results. Treated lesions included blood vessels that had not responded to conventional laser treatment, and port-wine stains.

He emphasized that the settings for various clinical applications had not yet been optimized.

The system uses a 10-mm spot size, with a 1-mm or 1.3-mm pitch beam array. The system can deliver a maximum fluence of 600 mJ/microbeam, but for the clinical applications so far, Dr. Ross used 430 mJ/microbeam, with a 30-ms pulse duration.

The high microbeam energy level allows deep beam penetration, which should be helpful for treating port-wine stains, said Dr. Ross, director of the laser and cosmetic dermatology unit at Scripps Clinic, San Diego.

GRAPEVINE, TEX. — Fractional splitting of a laser beam has been combined with selective photothermolysis to produce a new tool for dermatologic surgery.

By combining the spatial selectivity of fractional technology with wavelength selectivity, fractional photothermolysis "offers a new and unique opportunity for precise targeting of hemoglobin and melanin-containing targets" using a Nd:YAG laser with a 1,064-nm wavelength, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery. He predicted that the new laser will be extremely useful for treating resistant melasma, nevus of Ota, tattoos and—most likely—port-wine stains.

The investigational device is made by Palomar Medical Technologies Inc. as part of their StarLux series. Dr. Ross has received equipment, consulting fees, research grants, and honoraria from Palomar.

As of April, Dr. Ross and his associates had treated only a few patients, but with good results. Treated lesions included blood vessels that had not responded to conventional laser treatment, and port-wine stains.

He emphasized that the settings for various clinical applications had not yet been optimized.

The system uses a 10-mm spot size, with a 1-mm or 1.3-mm pitch beam array. The system can deliver a maximum fluence of 600 mJ/microbeam, but for the clinical applications so far, Dr. Ross used 430 mJ/microbeam, with a 30-ms pulse duration.

The high microbeam energy level allows deep beam penetration, which should be helpful for treating port-wine stains, said Dr. Ross, director of the laser and cosmetic dermatology unit at Scripps Clinic, San Diego.

GRAPEVINE, TEX. — Fractional splitting of a laser beam has been combined with selective photothermolysis to produce a new tool for dermatologic surgery.

By combining the spatial selectivity of fractional technology with wavelength selectivity, fractional photothermolysis "offers a new and unique opportunity for precise targeting of hemoglobin and melanin-containing targets" using a Nd:YAG laser with a 1,064-nm wavelength, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery. He predicted that the new laser will be extremely useful for treating resistant melasma, nevus of Ota, tattoos and—most likely—port-wine stains.

The investigational device is made by Palomar Medical Technologies Inc. as part of their StarLux series. Dr. Ross has received equipment, consulting fees, research grants, and honoraria from Palomar.

As of April, Dr. Ross and his associates had treated only a few patients, but with good results. Treated lesions included blood vessels that had not responded to conventional laser treatment, and port-wine stains.

He emphasized that the settings for various clinical applications had not yet been optimized.

The system uses a 10-mm spot size, with a 1-mm or 1.3-mm pitch beam array. The system can deliver a maximum fluence of 600 mJ/microbeam, but for the clinical applications so far, Dr. Ross used 430 mJ/microbeam, with a 30-ms pulse duration.

The high microbeam energy level allows deep beam penetration, which should be helpful for treating port-wine stains, said Dr. Ross, director of the laser and cosmetic dermatology unit at Scripps Clinic, San Diego.

GRAPEVINE, TEX. — Purpura-free treatment of facial lesions was achieved by combining a modified-pulse format of a pulsed dye laser with skin compression to blanch out blood during treatment.

With this technique "the risk of purpura was virtually eliminated" when treating telangiectasias and lentigines, Dr. Kenneth J. Galeckas said at the annual meeting of the American Society for Laser Medicine and Surgery.

The study used a new type of 595-nm pulsed dye laser that was designed to deliver energy as a series of eight sequential micropulses, in which no single pulse exceeds the temperature threshold within a blood vessel for causing purpura. This laser is marketed as the Vbeam by Candela Corp. Dr. Galeckas and his associates received equipment from Candela.

The second element of the protocol was to use a compression handpiece that allows the physician to compress a small area of target skin just before the laser is fired. The compression squeezes blood from the tissue, providing less of a target for stray energy absorption that could result in purpura.

The technique was tested on 20 patients with skin types I-III. Each patient received three treatments, involving two passes, at 3–4 week intervals. The first pass used a 10-mm spot size and 6.5–8.0 J/cm2 with a 1.5-ms pulse duration. The second pass used a 10-mm spot size with 9.5–10.0 J/cm2 and a 20-ms pulse duration, with cryogen-spray cooling.

Purpura occurred in 8 of the 20 patients during their first round of treatment, but it did not occur in any patient during the subsequent two rounds. In total, purpura occurred in 8 of 60 (13%) treatments. All of the purpura episodes occurred when patients were treated too quickly, before the compression handpiece had an adequate opportunity to blanch out surface blood. Once excess treatment speed was recognized as a problem, no additional purpura occurred, said Dr. Galeckas, a dermatologist at the Naval Medical Center San Diego.

Treatment response was assessed after the third treatment. The appearances of dark lentigines and small telangiectasias each were improved by 85%. Light lentigines were improved by 63%, and large telangiectasias were improved by 42%.

GRAPEVINE, TEX. — Purpura-free treatment of facial lesions was achieved by combining a modified-pulse format of a pulsed dye laser with skin compression to blanch out blood during treatment.

With this technique "the risk of purpura was virtually eliminated" when treating telangiectasias and lentigines, Dr. Kenneth J. Galeckas said at the annual meeting of the American Society for Laser Medicine and Surgery.

The study used a new type of 595-nm pulsed dye laser that was designed to deliver energy as a series of eight sequential micropulses, in which no single pulse exceeds the temperature threshold within a blood vessel for causing purpura. This laser is marketed as the Vbeam by Candela Corp. Dr. Galeckas and his associates received equipment from Candela.

The second element of the protocol was to use a compression handpiece that allows the physician to compress a small area of target skin just before the laser is fired. The compression squeezes blood from the tissue, providing less of a target for stray energy absorption that could result in purpura.

The technique was tested on 20 patients with skin types I-III. Each patient received three treatments, involving two passes, at 3–4 week intervals. The first pass used a 10-mm spot size and 6.5–8.0 J/cm2 with a 1.5-ms pulse duration. The second pass used a 10-mm spot size with 9.5–10.0 J/cm2 and a 20-ms pulse duration, with cryogen-spray cooling.

Purpura occurred in 8 of the 20 patients during their first round of treatment, but it did not occur in any patient during the subsequent two rounds. In total, purpura occurred in 8 of 60 (13%) treatments. All of the purpura episodes occurred when patients were treated too quickly, before the compression handpiece had an adequate opportunity to blanch out surface blood. Once excess treatment speed was recognized as a problem, no additional purpura occurred, said Dr. Galeckas, a dermatologist at the Naval Medical Center San Diego.

Treatment response was assessed after the third treatment. The appearances of dark lentigines and small telangiectasias each were improved by 85%. Light lentigines were improved by 63%, and large telangiectasias were improved by 42%.

GRAPEVINE, TEX. — Purpura-free treatment of facial lesions was achieved by combining a modified-pulse format of a pulsed dye laser with skin compression to blanch out blood during treatment.

With this technique "the risk of purpura was virtually eliminated" when treating telangiectasias and lentigines, Dr. Kenneth J. Galeckas said at the annual meeting of the American Society for Laser Medicine and Surgery.

The study used a new type of 595-nm pulsed dye laser that was designed to deliver energy as a series of eight sequential micropulses, in which no single pulse exceeds the temperature threshold within a blood vessel for causing purpura. This laser is marketed as the Vbeam by Candela Corp. Dr. Galeckas and his associates received equipment from Candela.

The second element of the protocol was to use a compression handpiece that allows the physician to compress a small area of target skin just before the laser is fired. The compression squeezes blood from the tissue, providing less of a target for stray energy absorption that could result in purpura.

The technique was tested on 20 patients with skin types I-III. Each patient received three treatments, involving two passes, at 3–4 week intervals. The first pass used a 10-mm spot size and 6.5–8.0 J/cm2 with a 1.5-ms pulse duration. The second pass used a 10-mm spot size with 9.5–10.0 J/cm2 and a 20-ms pulse duration, with cryogen-spray cooling.

Purpura occurred in 8 of the 20 patients during their first round of treatment, but it did not occur in any patient during the subsequent two rounds. In total, purpura occurred in 8 of 60 (13%) treatments. All of the purpura episodes occurred when patients were treated too quickly, before the compression handpiece had an adequate opportunity to blanch out surface blood. Once excess treatment speed was recognized as a problem, no additional purpura occurred, said Dr. Galeckas, a dermatologist at the Naval Medical Center San Diego.

Treatment response was assessed after the third treatment. The appearances of dark lentigines and small telangiectasias each were improved by 85%. Light lentigines were improved by 63%, and large telangiectasias were improved by 42%.

PHOENIX — Consider keeping hyaluronidase for injection on hand for repairing problems caused by hyaluronic acid fillers and not relying on compounded forms of hyaluronidase, Dr. Alastair Carruthers advised at a clinical dermatology conference sponsored by Medicis.

"Vitrase [hyaluro-nidase for injection] is a pure form of hyaluronidase, and it is of consistent efficacy," said Dr. Carruthers, clinical professor of dermatology at the University of British Columbia in Vancouver.

Compounded products might contain ingredients that cause reactions, he warned. They also are inconsistent in their activity.

"You can have up to a 10-fold difference in the activity, and clearly that is important," he said. "If you are using 10 units to get rid of a lump or 100 units—that is a big difference."

A naturally occurring protein enzyme, hyaluronidase makes connective tissue more permeable through hydrolysis of hyaluronic acid. "It eats hyaluronic acid," Dr. Carruthers said. Ista Pharmaceuticals in Irvine, Calif., manufactures Vitrase from the purified testicular hyaluronidase of sheep.

The Food and Drug Administration approved Vitrase for use in increasing the absorption and dispersion of other injectable drugs in 2004. The FDA reported the rate of adverse events, including allergic reactions, to be less than 1%. Because the drug could spread infection or inflammation, the FDA advised that it not be used in areas that are swollen by bites, stings, infection, or inflammation.

Using too much hyaluronidase for injection to correct a bump or other problem is not a concern, Dr. Carruthers said.

Hyaluronidase comprises only about 3% of human skin and it turns over in about 24 hours. "You can put in as much as you feel like, but typically maybe 20 units is enough to get rid of almost everything," he said.

Having hyaluronidase for injection on hand in the dermatology office "prevents problems," said Dr. Carruthers. He noted that vascular occlusion has been reported in rare cases with hyaluronic acid fillers.

Though cause and effect was not proven, he said occlusions have cleared after injection of large doses of hyaluronidase. "That is one of the reasons I have hyaluronidase in my office."

'You can putin as much [hyaluronidase] as you feel like, but typically maybe 20 units is enough.' DR. CARRUTHERS

PHOENIX — Consider keeping hyaluronidase for injection on hand for repairing problems caused by hyaluronic acid fillers and not relying on compounded forms of hyaluronidase, Dr. Alastair Carruthers advised at a clinical dermatology conference sponsored by Medicis.

"Vitrase [hyaluro-nidase for injection] is a pure form of hyaluronidase, and it is of consistent efficacy," said Dr. Carruthers, clinical professor of dermatology at the University of British Columbia in Vancouver.

Compounded products might contain ingredients that cause reactions, he warned. They also are inconsistent in their activity.

"You can have up to a 10-fold difference in the activity, and clearly that is important," he said. "If you are using 10 units to get rid of a lump or 100 units—that is a big difference."

A naturally occurring protein enzyme, hyaluronidase makes connective tissue more permeable through hydrolysis of hyaluronic acid. "It eats hyaluronic acid," Dr. Carruthers said. Ista Pharmaceuticals in Irvine, Calif., manufactures Vitrase from the purified testicular hyaluronidase of sheep.

The Food and Drug Administration approved Vitrase for use in increasing the absorption and dispersion of other injectable drugs in 2004. The FDA reported the rate of adverse events, including allergic reactions, to be less than 1%. Because the drug could spread infection or inflammation, the FDA advised that it not be used in areas that are swollen by bites, stings, infection, or inflammation.

Using too much hyaluronidase for injection to correct a bump or other problem is not a concern, Dr. Carruthers said.

Hyaluronidase comprises only about 3% of human skin and it turns over in about 24 hours. "You can put in as much as you feel like, but typically maybe 20 units is enough to get rid of almost everything," he said.

Having hyaluronidase for injection on hand in the dermatology office "prevents problems," said Dr. Carruthers. He noted that vascular occlusion has been reported in rare cases with hyaluronic acid fillers.

Though cause and effect was not proven, he said occlusions have cleared after injection of large doses of hyaluronidase. "That is one of the reasons I have hyaluronidase in my office."

'You can putin as much [hyaluronidase] as you feel like, but typically maybe 20 units is enough.' DR. CARRUTHERS

PHOENIX — Consider keeping hyaluronidase for injection on hand for repairing problems caused by hyaluronic acid fillers and not relying on compounded forms of hyaluronidase, Dr. Alastair Carruthers advised at a clinical dermatology conference sponsored by Medicis.

"Vitrase [hyaluro-nidase for injection] is a pure form of hyaluronidase, and it is of consistent efficacy," said Dr. Carruthers, clinical professor of dermatology at the University of British Columbia in Vancouver.

Compounded products might contain ingredients that cause reactions, he warned. They also are inconsistent in their activity.

"You can have up to a 10-fold difference in the activity, and clearly that is important," he said. "If you are using 10 units to get rid of a lump or 100 units—that is a big difference."

A naturally occurring protein enzyme, hyaluronidase makes connective tissue more permeable through hydrolysis of hyaluronic acid. "It eats hyaluronic acid," Dr. Carruthers said. Ista Pharmaceuticals in Irvine, Calif., manufactures Vitrase from the purified testicular hyaluronidase of sheep.

The Food and Drug Administration approved Vitrase for use in increasing the absorption and dispersion of other injectable drugs in 2004. The FDA reported the rate of adverse events, including allergic reactions, to be less than 1%. Because the drug could spread infection or inflammation, the FDA advised that it not be used in areas that are swollen by bites, stings, infection, or inflammation.

Using too much hyaluronidase for injection to correct a bump or other problem is not a concern, Dr. Carruthers said.

Hyaluronidase comprises only about 3% of human skin and it turns over in about 24 hours. "You can put in as much as you feel like, but typically maybe 20 units is enough to get rid of almost everything," he said.

Having hyaluronidase for injection on hand in the dermatology office "prevents problems," said Dr. Carruthers. He noted that vascular occlusion has been reported in rare cases with hyaluronic acid fillers.

Though cause and effect was not proven, he said occlusions have cleared after injection of large doses of hyaluronidase. "That is one of the reasons I have hyaluronidase in my office."

'You can putin as much [hyaluronidase] as you feel like, but typically maybe 20 units is enough.' DR. CARRUTHERS