Aesthetic Dermatology

BOSTON — The ability to shift wavelength emissions "on the fly" makes infrared flashlamp technology a safe and effective option for hair removal in all skin types, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 63 patients ranging in age from 16 to 50 years with Fitzpatrick skin types I-VI, laser hair removal with the Cutera ProWave 770 cooled sapphire infrared flashlamp handpiece resulted in a mean hair reduction 2 months after the final treatment of 35%–67%, depending on skin type, said Dr. Ross of the Naval Medical Center in San Diego, who authored the study with Dr. Min-Wei Christine Lee of Walnut Creek, Calif.

Study participants underwent hair removal treatment without anesthesia in the bikini area, axillae, lower legs, upper lip, and/or chin, with the axillae and facial regions being the most commonly treated zones.

Hair thickness ranged from medium to coarse across all skin types and hair color ranged from light brown in skin types I and II to brown, dark brown, and/or black in all skin types.

Depending on hair type and amount, patients underwent one to four treatments at 4-week intervals.

A touch screen interface on the flashlamp handpiece enabled clinicians to automatically select the most appropriate treatment mode, which corresponds to different current densities, based on skin type.

"The ability to control spectral emissions in this way enables rapid and precise parameter titration for specific hair and skin types," Dr. Ross said. "The objective is to optimize treatment to destroy the hair follicle while sparing surrounding tissue."

Treatment efficacy was evaluated by global assessment of hair counts from photographs taken immediately before each treatment session and 2 months following the final treatment. For skin types I and II, the mean hair reduction 2 months after the final treatment was 67%, compared with 55% for skin types III and IV and 35% for skin types V and VI.

In terms of side effects, "there was some mild crusting, mostly in darker skin types, that resolved quickly," Dr. Ross said.

The ability to optimize wavelength ranges to specific skin types enables "a nice balance between safety and efficacy," and produces results similar to those seen with Nd:YAG lasers or with very long pulse 810-nm diode lasers, he added.

Dr. Ross reported receiving equipment and research support from Cutera.

BOSTON — The ability to shift wavelength emissions "on the fly" makes infrared flashlamp technology a safe and effective option for hair removal in all skin types, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 63 patients ranging in age from 16 to 50 years with Fitzpatrick skin types I-VI, laser hair removal with the Cutera ProWave 770 cooled sapphire infrared flashlamp handpiece resulted in a mean hair reduction 2 months after the final treatment of 35%–67%, depending on skin type, said Dr. Ross of the Naval Medical Center in San Diego, who authored the study with Dr. Min-Wei Christine Lee of Walnut Creek, Calif.

Study participants underwent hair removal treatment without anesthesia in the bikini area, axillae, lower legs, upper lip, and/or chin, with the axillae and facial regions being the most commonly treated zones.

Hair thickness ranged from medium to coarse across all skin types and hair color ranged from light brown in skin types I and II to brown, dark brown, and/or black in all skin types.

Depending on hair type and amount, patients underwent one to four treatments at 4-week intervals.

A touch screen interface on the flashlamp handpiece enabled clinicians to automatically select the most appropriate treatment mode, which corresponds to different current densities, based on skin type.

"The ability to control spectral emissions in this way enables rapid and precise parameter titration for specific hair and skin types," Dr. Ross said. "The objective is to optimize treatment to destroy the hair follicle while sparing surrounding tissue."

Treatment efficacy was evaluated by global assessment of hair counts from photographs taken immediately before each treatment session and 2 months following the final treatment. For skin types I and II, the mean hair reduction 2 months after the final treatment was 67%, compared with 55% for skin types III and IV and 35% for skin types V and VI.

In terms of side effects, "there was some mild crusting, mostly in darker skin types, that resolved quickly," Dr. Ross said.

The ability to optimize wavelength ranges to specific skin types enables "a nice balance between safety and efficacy," and produces results similar to those seen with Nd:YAG lasers or with very long pulse 810-nm diode lasers, he added.

Dr. Ross reported receiving equipment and research support from Cutera.

BOSTON — The ability to shift wavelength emissions "on the fly" makes infrared flashlamp technology a safe and effective option for hair removal in all skin types, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 63 patients ranging in age from 16 to 50 years with Fitzpatrick skin types I-VI, laser hair removal with the Cutera ProWave 770 cooled sapphire infrared flashlamp handpiece resulted in a mean hair reduction 2 months after the final treatment of 35%–67%, depending on skin type, said Dr. Ross of the Naval Medical Center in San Diego, who authored the study with Dr. Min-Wei Christine Lee of Walnut Creek, Calif.

Study participants underwent hair removal treatment without anesthesia in the bikini area, axillae, lower legs, upper lip, and/or chin, with the axillae and facial regions being the most commonly treated zones.

Hair thickness ranged from medium to coarse across all skin types and hair color ranged from light brown in skin types I and II to brown, dark brown, and/or black in all skin types.

Depending on hair type and amount, patients underwent one to four treatments at 4-week intervals.

A touch screen interface on the flashlamp handpiece enabled clinicians to automatically select the most appropriate treatment mode, which corresponds to different current densities, based on skin type.

"The ability to control spectral emissions in this way enables rapid and precise parameter titration for specific hair and skin types," Dr. Ross said. "The objective is to optimize treatment to destroy the hair follicle while sparing surrounding tissue."

Treatment efficacy was evaluated by global assessment of hair counts from photographs taken immediately before each treatment session and 2 months following the final treatment. For skin types I and II, the mean hair reduction 2 months after the final treatment was 67%, compared with 55% for skin types III and IV and 35% for skin types V and VI.

In terms of side effects, "there was some mild crusting, mostly in darker skin types, that resolved quickly," Dr. Ross said.

The ability to optimize wavelength ranges to specific skin types enables "a nice balance between safety and efficacy," and produces results similar to those seen with Nd:YAG lasers or with very long pulse 810-nm diode lasers, he added.

Dr. Ross reported receiving equipment and research support from Cutera.

ORLANDO — The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."

Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've found—in terms of bleeding and bruising—tend to be the least technically difficult parts of the surgery," he said.

Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.

There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.

He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.

"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.

A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.

There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."

For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.

The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen

ORLANDO — The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."

Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've found—in terms of bleeding and bruising—tend to be the least technically difficult parts of the surgery," he said.

Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.

There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.

He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.

"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.

A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.

There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."

For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.

The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen

ORLANDO — The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."

Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've found—in terms of bleeding and bruising—tend to be the least technically difficult parts of the surgery," he said.

Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.

There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.

He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.

"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.

A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.

There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."

For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.

The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen

BOSTON — Monopolar radiofrequency energy delivered to the eyelids through a shallow treatment tip is an effective noninvasive option for rejuvenating both upper and lower eyelid skin, Dr. Brian S. Biesman said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a multicenter clinical trial, Dr. Biesman, who is in private practice in Nashville, Tenn., and his colleagues evaluated the efficacy of the ThermaCool radiofrequency system from Thermage outfitted with the newly designed shallow tip for tightening the eyelid skin of 72 patients ranging in age from 23 to 58 years.

Of the 72 patients treated at four medical centers, 64 underwent treatment of both upper and lower eyelids, 7 underwent upper eyelid treatment only, and 1 underwent only lower eyelid treatment. All of the patients were evaluated at 1 hour, 1 week, 1 month, 2 months, 4 months, and 6 months after treatment.

Based on physician assessment at the 6-month follow up, significant reductions in both upper eyelid hooding and skin tightening were noted in, respectively, 86% and 88% of the patients who underwent the procedure. The physicians reported lower eyelid tightening in 83% of the patients who had the procedure done.

In terms of adverse events, two patients at one center sustained burns that resolved without problem, and there were no ocular injuries.

The key to the "impressive results after only one treatment," said Dr. Biesman, was the shallow tip delivery device that he and his colleagues previously tested in a series of animal and experimental models.

The standard Thermage treatment tip is 1 cm by 1 cm. "The center heating zone [with that tip] is too far beneath the skin's surface to be safely used on the thin skin of an eyelid," Dr. Biesman noted.

The new shallow tip, at 0.5 cm by 0.5 cm, is a quarter of the size of the standard tip, which results in a treatment area of 0.25 cm

"By using a smaller electrode, the treatment is done more superficially," he said. "In the eyelid area, this means impacting the dermis without injuring the epidermis or the eyelid muscle."

The results of this trial suggest that the ThermaCool TC device with the shallow treatment tip is a viable option for eyelid tightening.

"The obvious benefits are that the procedure is quick, painless, and requires no anesthesia or downtime," Dr. Beisman commented.

Dr. Beisman reported receiving consulting fees, a research grant, and honoraria from Thermage.

BOSTON — Monopolar radiofrequency energy delivered to the eyelids through a shallow treatment tip is an effective noninvasive option for rejuvenating both upper and lower eyelid skin, Dr. Brian S. Biesman said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a multicenter clinical trial, Dr. Biesman, who is in private practice in Nashville, Tenn., and his colleagues evaluated the efficacy of the ThermaCool radiofrequency system from Thermage outfitted with the newly designed shallow tip for tightening the eyelid skin of 72 patients ranging in age from 23 to 58 years.

Of the 72 patients treated at four medical centers, 64 underwent treatment of both upper and lower eyelids, 7 underwent upper eyelid treatment only, and 1 underwent only lower eyelid treatment. All of the patients were evaluated at 1 hour, 1 week, 1 month, 2 months, 4 months, and 6 months after treatment.

Based on physician assessment at the 6-month follow up, significant reductions in both upper eyelid hooding and skin tightening were noted in, respectively, 86% and 88% of the patients who underwent the procedure. The physicians reported lower eyelid tightening in 83% of the patients who had the procedure done.

In terms of adverse events, two patients at one center sustained burns that resolved without problem, and there were no ocular injuries.

The key to the "impressive results after only one treatment," said Dr. Biesman, was the shallow tip delivery device that he and his colleagues previously tested in a series of animal and experimental models.

The standard Thermage treatment tip is 1 cm by 1 cm. "The center heating zone [with that tip] is too far beneath the skin's surface to be safely used on the thin skin of an eyelid," Dr. Biesman noted.

The new shallow tip, at 0.5 cm by 0.5 cm, is a quarter of the size of the standard tip, which results in a treatment area of 0.25 cm

"By using a smaller electrode, the treatment is done more superficially," he said. "In the eyelid area, this means impacting the dermis without injuring the epidermis or the eyelid muscle."

The results of this trial suggest that the ThermaCool TC device with the shallow treatment tip is a viable option for eyelid tightening.

"The obvious benefits are that the procedure is quick, painless, and requires no anesthesia or downtime," Dr. Beisman commented.

Dr. Beisman reported receiving consulting fees, a research grant, and honoraria from Thermage.

BOSTON — Monopolar radiofrequency energy delivered to the eyelids through a shallow treatment tip is an effective noninvasive option for rejuvenating both upper and lower eyelid skin, Dr. Brian S. Biesman said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a multicenter clinical trial, Dr. Biesman, who is in private practice in Nashville, Tenn., and his colleagues evaluated the efficacy of the ThermaCool radiofrequency system from Thermage outfitted with the newly designed shallow tip for tightening the eyelid skin of 72 patients ranging in age from 23 to 58 years.

Of the 72 patients treated at four medical centers, 64 underwent treatment of both upper and lower eyelids, 7 underwent upper eyelid treatment only, and 1 underwent only lower eyelid treatment. All of the patients were evaluated at 1 hour, 1 week, 1 month, 2 months, 4 months, and 6 months after treatment.

Based on physician assessment at the 6-month follow up, significant reductions in both upper eyelid hooding and skin tightening were noted in, respectively, 86% and 88% of the patients who underwent the procedure. The physicians reported lower eyelid tightening in 83% of the patients who had the procedure done.

In terms of adverse events, two patients at one center sustained burns that resolved without problem, and there were no ocular injuries.

The key to the "impressive results after only one treatment," said Dr. Biesman, was the shallow tip delivery device that he and his colleagues previously tested in a series of animal and experimental models.

The standard Thermage treatment tip is 1 cm by 1 cm. "The center heating zone [with that tip] is too far beneath the skin's surface to be safely used on the thin skin of an eyelid," Dr. Biesman noted.

The new shallow tip, at 0.5 cm by 0.5 cm, is a quarter of the size of the standard tip, which results in a treatment area of 0.25 cm

"By using a smaller electrode, the treatment is done more superficially," he said. "In the eyelid area, this means impacting the dermis without injuring the epidermis or the eyelid muscle."

The results of this trial suggest that the ThermaCool TC device with the shallow treatment tip is a viable option for eyelid tightening.

"The obvious benefits are that the procedure is quick, painless, and requires no anesthesia or downtime," Dr. Beisman commented.

Dr. Beisman reported receiving consulting fees, a research grant, and honoraria from Thermage.

PARK CITY, UTAH — Make sure that patients treated with nonablative lasers have reasonable expectations of what their skin will look like after rejuvenation therapy, Dr. Thomas E. Rohrer said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

"Improvement is gradual and subtle, but it is real," Dr. Rohrer said, warning that patients expecting dramatic skin changes after each treatment could be disappointed.

Dr. Rohrer, a Mohs and dermatologic surgeon in Chestnut Hill, Mass., described nonablative skin rejuvenation as one of the fastest-growing areas of dermatologic surgery, with a 60% increase in 2 years' time.

"What we're talking about is creating a controlled dermal injury—a thermal injury 100–400 microns deep—to get collagen remodeling," he said at the meeting, which was also sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Infrared lasers heat the dermis to get this effect, according to Dr. Rohrer. Heating the dermis results in a wound-healing response: inflammation, proliferation, and remodeling. The process can take months.

"You are effectively changing the dermis without affecting the epidermis," he said.

The infrared lasers available today vary only slightly and have produced similar outcomes in the studies reported so far. The amount of improvement varies from patient to patient, but most do improve, he noted.

Despite the use of anesthetic creams and cryogenic cooling, infrared laser treatment does hurt, he said. In his practice, attempts to limit pain have involved vibratory anesthesia, the application of anesthetic cream for about an hour, and the Zimmer cooler, which he said was the most effective.

Multiple tactile pass techniques—going over the same area twice at a lower fluence—also can reduce pain. "It hurts a little bit less at each pass, but you are doubling treatment time," he said, "so I am not sure how effective or practical that is going to be."

In what may be the longest study of a nonablative therapy, patients were followed for 35 months. The investigators found that improvement peaked at 6 months after the last treatment, but at 35 months patients still had almost 30% improvement in the texture of the skin, Dr. Rohrer said.

Many patients are combining nonablative lasers with botulinum toxin treatments. Because Botox is known to work, this has raised a question as to the role of the lasers in any improvement that is seen.

"Certainly Botox works faster than nonablative [therapy] and jump starts" rejuvenation, he said, showing photographs of patients whose improvements lasted months after the Botox effect would have worn off.

He recommended infrared lasers for the treatment of scars, but again cautioned that patients have to understand that improvement will require multiple treatments over a long time. "We should let our patients know they cannot expect a whole lot after just three treatments," he said.

Visible light lasers are another nonablative option that has improved pigment and vasculature. They also have produced histologic changes and changes in skin texture over time.

Intense pulsed light systems deliver a broad band of wavelengths, some of which help with pigment while others increase collagen, according to Dr. Rohrer. He said that he is preparing to publish a series of studies on this option.

Photomodulation light-emitting diodes offer another nonablative therapy that has produced improvement in most patients studied. "Improvement is subtle, but it is there if you measure it," he said.

Dr. Rohrer disclosed that he receives compensation for research from laser manufacturers Candela Corp., Laserscope, and Palomar Medical Technologies Inc.

"We should let our patients know they cannot expect a whole lot after just three treatments." DR. ROHRER

PARK CITY, UTAH — Make sure that patients treated with nonablative lasers have reasonable expectations of what their skin will look like after rejuvenation therapy, Dr. Thomas E. Rohrer said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

"Improvement is gradual and subtle, but it is real," Dr. Rohrer said, warning that patients expecting dramatic skin changes after each treatment could be disappointed.

Dr. Rohrer, a Mohs and dermatologic surgeon in Chestnut Hill, Mass., described nonablative skin rejuvenation as one of the fastest-growing areas of dermatologic surgery, with a 60% increase in 2 years' time.

"What we're talking about is creating a controlled dermal injury—a thermal injury 100–400 microns deep—to get collagen remodeling," he said at the meeting, which was also sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Infrared lasers heat the dermis to get this effect, according to Dr. Rohrer. Heating the dermis results in a wound-healing response: inflammation, proliferation, and remodeling. The process can take months.

"You are effectively changing the dermis without affecting the epidermis," he said.

The infrared lasers available today vary only slightly and have produced similar outcomes in the studies reported so far. The amount of improvement varies from patient to patient, but most do improve, he noted.

Despite the use of anesthetic creams and cryogenic cooling, infrared laser treatment does hurt, he said. In his practice, attempts to limit pain have involved vibratory anesthesia, the application of anesthetic cream for about an hour, and the Zimmer cooler, which he said was the most effective.

Multiple tactile pass techniques—going over the same area twice at a lower fluence—also can reduce pain. "It hurts a little bit less at each pass, but you are doubling treatment time," he said, "so I am not sure how effective or practical that is going to be."

In what may be the longest study of a nonablative therapy, patients were followed for 35 months. The investigators found that improvement peaked at 6 months after the last treatment, but at 35 months patients still had almost 30% improvement in the texture of the skin, Dr. Rohrer said.

Many patients are combining nonablative lasers with botulinum toxin treatments. Because Botox is known to work, this has raised a question as to the role of the lasers in any improvement that is seen.

"Certainly Botox works faster than nonablative [therapy] and jump starts" rejuvenation, he said, showing photographs of patients whose improvements lasted months after the Botox effect would have worn off.

He recommended infrared lasers for the treatment of scars, but again cautioned that patients have to understand that improvement will require multiple treatments over a long time. "We should let our patients know they cannot expect a whole lot after just three treatments," he said.

Visible light lasers are another nonablative option that has improved pigment and vasculature. They also have produced histologic changes and changes in skin texture over time.

Intense pulsed light systems deliver a broad band of wavelengths, some of which help with pigment while others increase collagen, according to Dr. Rohrer. He said that he is preparing to publish a series of studies on this option.

Photomodulation light-emitting diodes offer another nonablative therapy that has produced improvement in most patients studied. "Improvement is subtle, but it is there if you measure it," he said.

Dr. Rohrer disclosed that he receives compensation for research from laser manufacturers Candela Corp., Laserscope, and Palomar Medical Technologies Inc.

"We should let our patients know they cannot expect a whole lot after just three treatments." DR. ROHRER

PARK CITY, UTAH — Make sure that patients treated with nonablative lasers have reasonable expectations of what their skin will look like after rejuvenation therapy, Dr. Thomas E. Rohrer said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

"Improvement is gradual and subtle, but it is real," Dr. Rohrer said, warning that patients expecting dramatic skin changes after each treatment could be disappointed.

Dr. Rohrer, a Mohs and dermatologic surgeon in Chestnut Hill, Mass., described nonablative skin rejuvenation as one of the fastest-growing areas of dermatologic surgery, with a 60% increase in 2 years' time.

"What we're talking about is creating a controlled dermal injury—a thermal injury 100–400 microns deep—to get collagen remodeling," he said at the meeting, which was also sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Infrared lasers heat the dermis to get this effect, according to Dr. Rohrer. Heating the dermis results in a wound-healing response: inflammation, proliferation, and remodeling. The process can take months.

"You are effectively changing the dermis without affecting the epidermis," he said.

The infrared lasers available today vary only slightly and have produced similar outcomes in the studies reported so far. The amount of improvement varies from patient to patient, but most do improve, he noted.

Despite the use of anesthetic creams and cryogenic cooling, infrared laser treatment does hurt, he said. In his practice, attempts to limit pain have involved vibratory anesthesia, the application of anesthetic cream for about an hour, and the Zimmer cooler, which he said was the most effective.

Multiple tactile pass techniques—going over the same area twice at a lower fluence—also can reduce pain. "It hurts a little bit less at each pass, but you are doubling treatment time," he said, "so I am not sure how effective or practical that is going to be."

In what may be the longest study of a nonablative therapy, patients were followed for 35 months. The investigators found that improvement peaked at 6 months after the last treatment, but at 35 months patients still had almost 30% improvement in the texture of the skin, Dr. Rohrer said.

Many patients are combining nonablative lasers with botulinum toxin treatments. Because Botox is known to work, this has raised a question as to the role of the lasers in any improvement that is seen.

"Certainly Botox works faster than nonablative [therapy] and jump starts" rejuvenation, he said, showing photographs of patients whose improvements lasted months after the Botox effect would have worn off.

He recommended infrared lasers for the treatment of scars, but again cautioned that patients have to understand that improvement will require multiple treatments over a long time. "We should let our patients know they cannot expect a whole lot after just three treatments," he said.

Visible light lasers are another nonablative option that has improved pigment and vasculature. They also have produced histologic changes and changes in skin texture over time.

Intense pulsed light systems deliver a broad band of wavelengths, some of which help with pigment while others increase collagen, according to Dr. Rohrer. He said that he is preparing to publish a series of studies on this option.

Photomodulation light-emitting diodes offer another nonablative therapy that has produced improvement in most patients studied. "Improvement is subtle, but it is there if you measure it," he said.

Dr. Rohrer disclosed that he receives compensation for research from laser manufacturers Candela Corp., Laserscope, and Palomar Medical Technologies Inc.

"We should let our patients know they cannot expect a whole lot after just three treatments." DR. ROHRER

ORLANDO — Combining intense pulsed light and heat energy appears to be an effective hair removal technique for individuals with dark skin, according to a study presented by Dr. Neil S. Sadick at the annual meeting of the American Academy of Cosmetic Surgery.

"By using two different energies … you can use less light energy, which means there is less chance of burning the skin," said Dr. Sadick, professor of dermatology at Cornell University, New York.

This is especially important when treating dark-skinned individuals, because using intense pulsed light alone can cause burning hyperpigmentation. "We try to use two energies to deliver more energy more gently," he said.

For his study, Dr. Sadick recruited 23 women and 3 men. Of these, 8 participants had Fitzpatrick skin type V and 18 had skin type VI. The participants' mean age was 36 years.

Patients underwent one treatment and were seen again at 6- and 12-week follow-ups, he said.

Mean hair clearance at 6 and 12 weeks was 42% and 36%, respectively. On average, hair removal after a single treatment was 36%. Hair clearance rates at 6 and 12 weeks were "lower than those seen with other, more classic, chromophore-targeting technologies, such as lasers of the past, but still were much more efficient than anything else in the past," Dr. Sadick explained.

In terms of side effects, "when you look at hypo- and hyperpigmentation, there was actually quite a low percentage—much lower than was noted using laser sources for dark-skinned individuals," he said. There were two cases of hypopigmentation noted at 6 weeks, which resolved by week 12.

Erythema and edema were transient, with 11 patients experiencing erythema and 2 experiencing edema at the time of treatment. Erythema and edema resolved by week 6.

For use in this study, Dr. Sadick used the Radiancy SkinStation, which utilizes a broad spectrum of light wavelengths (500–900 nm). Heat output for the device ranges between 8 and 55 J/cm

The light and heat energy are emitted from a lamp, targeting specific skin structures based on selective photothermolysis plus direct heat conduction. There is targeting of melanin in the hair follicle, along with nonspecific heating by the thermal component. The advantage of this technique is that there is an additive effect and less competitive melanin absorption in the epidermis.

Dr. Sadick is now conducting a study looking at multiple treatments in a larger group of individuals.

Right forearm of a male with skin type VI is shown at baseline.

The same patient is shown 6 weeks post treatment. Photos courtesy Dr. Neil Sadick

ORLANDO — Combining intense pulsed light and heat energy appears to be an effective hair removal technique for individuals with dark skin, according to a study presented by Dr. Neil S. Sadick at the annual meeting of the American Academy of Cosmetic Surgery.

"By using two different energies … you can use less light energy, which means there is less chance of burning the skin," said Dr. Sadick, professor of dermatology at Cornell University, New York.

This is especially important when treating dark-skinned individuals, because using intense pulsed light alone can cause burning hyperpigmentation. "We try to use two energies to deliver more energy more gently," he said.

For his study, Dr. Sadick recruited 23 women and 3 men. Of these, 8 participants had Fitzpatrick skin type V and 18 had skin type VI. The participants' mean age was 36 years.

Patients underwent one treatment and were seen again at 6- and 12-week follow-ups, he said.

Mean hair clearance at 6 and 12 weeks was 42% and 36%, respectively. On average, hair removal after a single treatment was 36%. Hair clearance rates at 6 and 12 weeks were "lower than those seen with other, more classic, chromophore-targeting technologies, such as lasers of the past, but still were much more efficient than anything else in the past," Dr. Sadick explained.

In terms of side effects, "when you look at hypo- and hyperpigmentation, there was actually quite a low percentage—much lower than was noted using laser sources for dark-skinned individuals," he said. There were two cases of hypopigmentation noted at 6 weeks, which resolved by week 12.

Erythema and edema were transient, with 11 patients experiencing erythema and 2 experiencing edema at the time of treatment. Erythema and edema resolved by week 6.

For use in this study, Dr. Sadick used the Radiancy SkinStation, which utilizes a broad spectrum of light wavelengths (500–900 nm). Heat output for the device ranges between 8 and 55 J/cm

The light and heat energy are emitted from a lamp, targeting specific skin structures based on selective photothermolysis plus direct heat conduction. There is targeting of melanin in the hair follicle, along with nonspecific heating by the thermal component. The advantage of this technique is that there is an additive effect and less competitive melanin absorption in the epidermis.

Dr. Sadick is now conducting a study looking at multiple treatments in a larger group of individuals.

Right forearm of a male with skin type VI is shown at baseline.

The same patient is shown 6 weeks post treatment. Photos courtesy Dr. Neil Sadick

ORLANDO — Combining intense pulsed light and heat energy appears to be an effective hair removal technique for individuals with dark skin, according to a study presented by Dr. Neil S. Sadick at the annual meeting of the American Academy of Cosmetic Surgery.

"By using two different energies … you can use less light energy, which means there is less chance of burning the skin," said Dr. Sadick, professor of dermatology at Cornell University, New York.

This is especially important when treating dark-skinned individuals, because using intense pulsed light alone can cause burning hyperpigmentation. "We try to use two energies to deliver more energy more gently," he said.

For his study, Dr. Sadick recruited 23 women and 3 men. Of these, 8 participants had Fitzpatrick skin type V and 18 had skin type VI. The participants' mean age was 36 years.

Patients underwent one treatment and were seen again at 6- and 12-week follow-ups, he said.

Mean hair clearance at 6 and 12 weeks was 42% and 36%, respectively. On average, hair removal after a single treatment was 36%. Hair clearance rates at 6 and 12 weeks were "lower than those seen with other, more classic, chromophore-targeting technologies, such as lasers of the past, but still were much more efficient than anything else in the past," Dr. Sadick explained.

In terms of side effects, "when you look at hypo- and hyperpigmentation, there was actually quite a low percentage—much lower than was noted using laser sources for dark-skinned individuals," he said. There were two cases of hypopigmentation noted at 6 weeks, which resolved by week 12.

Erythema and edema were transient, with 11 patients experiencing erythema and 2 experiencing edema at the time of treatment. Erythema and edema resolved by week 6.

For use in this study, Dr. Sadick used the Radiancy SkinStation, which utilizes a broad spectrum of light wavelengths (500–900 nm). Heat output for the device ranges between 8 and 55 J/cm

The light and heat energy are emitted from a lamp, targeting specific skin structures based on selective photothermolysis plus direct heat conduction. There is targeting of melanin in the hair follicle, along with nonspecific heating by the thermal component. The advantage of this technique is that there is an additive effect and less competitive melanin absorption in the epidermis.

Dr. Sadick is now conducting a study looking at multiple treatments in a larger group of individuals.

Right forearm of a male with skin type VI is shown at baseline.

The same patient is shown 6 weeks post treatment. Photos courtesy Dr. Neil Sadick

A new physician-maintained Web site provides information on the causes of acne, acne treatments, and acne prevention. The site also includes an acne glossary, physician referrals, and an acne news feed. For more information, visit www.acnesource.org

A new physician-maintained Web site provides information on the causes of acne, acne treatments, and acne prevention. The site also includes an acne glossary, physician referrals, and an acne news feed. For more information, visit www.acnesource.org

A new physician-maintained Web site provides information on the causes of acne, acne treatments, and acne prevention. The site also includes an acne glossary, physician referrals, and an acne news feed. For more information, visit www.acnesource.org

MIAMI BEACH — Consider whether antimicrobial prophylaxis is needed for cosmetic procedures by evaluating the nature and extent of any wound that may result, as well as the patient's history of herpes simplex infection, Dr. Mark S. Nestor said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Prophylaxis is a must for ablative procedures such as CO₂ and erbium laser resurfacing, but clinical judgment is needed for other procedures. More aggressive nonablative procedures such as Fraxel laser treatment can cause superficial wounds that last 2–7 days; judicious use of antibiotics may be indicated, he said.

For photodynamic therapy and Thermage, antibiotic prophylaxis is generally not needed unless the patient has risk factors such as diabetes or immune suppression or is malnourished, he said.

The antibiotic used for prophylaxis should be sufficiently broad spectrum to cover not only gram-positive streptococcal and staphylococcal infections, but also the important gram-negative pathogens. A useful choice is cefdinir (Omnicef), which has excellent skin penetration and can be used even in penicillin-allergic patients, he said.

"You are going to get calls from the pharmacist about using a cephalosporin in penicillin-allergic patients, but there is no problem with this whatsoever," he said. The reason for this lies in the structure of the drug: Cefdinir's side chains are different from those of penicillin or ampicillin.

Antiviral prophylaxis should be considered for susceptible patients. "For patients who get frequent cold sores, there really is no reason not to give these drugs because they are safe and easily tolerated," he said. Either famciclovir or valacyclovir can be used.

Prophylaxis is not required with the use of injectable fillers, but antiviral treatment may be needed if the lips are the site of injection and the trauma results in reactivation, said Dr. Nestor, who is in private practice in Aventura, Fla.

Antiviral prophylaxis can begin 2 days before the procedure, while antibiotic prophylaxis should begin the night before or the morning of the procedure. Both should continue for about 10 days, until the patient is fully reepithelialized, he said.

Prophylaxis can prevent many, but not all, infections. Early signs of bacterial infection include increasing redness, pain, and new formation of ulcerations. Cultures and a change of antibiotic are often necessary, and vigilance is needed because scarring can occur, he said.

If a viral infection occurs while the patient is on an antiviral drug, the dosage can be increased. "If the patient is on 250 mg of famciclovir twice a day, I will double it or even give 500 mg three times a day," he said.

Certain patients Dr. Nestor has seen over the years have experienced what he refers to as a nonhealing syndrome. They initially have an infection, but it is followed by an autoimmune phenomenon that prevents the wound from healing. "If you culture them, you will grow out everything. They can be treated with everything in the book but don't get better," he said. The approach he has used is to give them a judicious course of antibiotic treatment along with a short course of betamethasone dipropionate ointment. "We have had some amazing results because this cuts down the autoimmune response," he said.

Dr. Nestor disclosed that he is a member of the speakers' bureau for Abbott Laboratories, manufacturer of cefdinir.

Prophylaxis should continue for about 10 days, until the patient is fully reepithelialized. DR. NESTOR

MIAMI BEACH — Consider whether antimicrobial prophylaxis is needed for cosmetic procedures by evaluating the nature and extent of any wound that may result, as well as the patient's history of herpes simplex infection, Dr. Mark S. Nestor said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Prophylaxis is a must for ablative procedures such as CO₂ and erbium laser resurfacing, but clinical judgment is needed for other procedures. More aggressive nonablative procedures such as Fraxel laser treatment can cause superficial wounds that last 2–7 days; judicious use of antibiotics may be indicated, he said.

For photodynamic therapy and Thermage, antibiotic prophylaxis is generally not needed unless the patient has risk factors such as diabetes or immune suppression or is malnourished, he said.

The antibiotic used for prophylaxis should be sufficiently broad spectrum to cover not only gram-positive streptococcal and staphylococcal infections, but also the important gram-negative pathogens. A useful choice is cefdinir (Omnicef), which has excellent skin penetration and can be used even in penicillin-allergic patients, he said.

"You are going to get calls from the pharmacist about using a cephalosporin in penicillin-allergic patients, but there is no problem with this whatsoever," he said. The reason for this lies in the structure of the drug: Cefdinir's side chains are different from those of penicillin or ampicillin.

Antiviral prophylaxis should be considered for susceptible patients. "For patients who get frequent cold sores, there really is no reason not to give these drugs because they are safe and easily tolerated," he said. Either famciclovir or valacyclovir can be used.

Prophylaxis is not required with the use of injectable fillers, but antiviral treatment may be needed if the lips are the site of injection and the trauma results in reactivation, said Dr. Nestor, who is in private practice in Aventura, Fla.

Antiviral prophylaxis can begin 2 days before the procedure, while antibiotic prophylaxis should begin the night before or the morning of the procedure. Both should continue for about 10 days, until the patient is fully reepithelialized, he said.

Prophylaxis can prevent many, but not all, infections. Early signs of bacterial infection include increasing redness, pain, and new formation of ulcerations. Cultures and a change of antibiotic are often necessary, and vigilance is needed because scarring can occur, he said.

If a viral infection occurs while the patient is on an antiviral drug, the dosage can be increased. "If the patient is on 250 mg of famciclovir twice a day, I will double it or even give 500 mg three times a day," he said.

Certain patients Dr. Nestor has seen over the years have experienced what he refers to as a nonhealing syndrome. They initially have an infection, but it is followed by an autoimmune phenomenon that prevents the wound from healing. "If you culture them, you will grow out everything. They can be treated with everything in the book but don't get better," he said. The approach he has used is to give them a judicious course of antibiotic treatment along with a short course of betamethasone dipropionate ointment. "We have had some amazing results because this cuts down the autoimmune response," he said.

Dr. Nestor disclosed that he is a member of the speakers' bureau for Abbott Laboratories, manufacturer of cefdinir.

Prophylaxis should continue for about 10 days, until the patient is fully reepithelialized. DR. NESTOR

MIAMI BEACH — Consider whether antimicrobial prophylaxis is needed for cosmetic procedures by evaluating the nature and extent of any wound that may result, as well as the patient's history of herpes simplex infection, Dr. Mark S. Nestor said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Prophylaxis is a must for ablative procedures such as CO₂ and erbium laser resurfacing, but clinical judgment is needed for other procedures. More aggressive nonablative procedures such as Fraxel laser treatment can cause superficial wounds that last 2–7 days; judicious use of antibiotics may be indicated, he said.

For photodynamic therapy and Thermage, antibiotic prophylaxis is generally not needed unless the patient has risk factors such as diabetes or immune suppression or is malnourished, he said.

The antibiotic used for prophylaxis should be sufficiently broad spectrum to cover not only gram-positive streptococcal and staphylococcal infections, but also the important gram-negative pathogens. A useful choice is cefdinir (Omnicef), which has excellent skin penetration and can be used even in penicillin-allergic patients, he said.

"You are going to get calls from the pharmacist about using a cephalosporin in penicillin-allergic patients, but there is no problem with this whatsoever," he said. The reason for this lies in the structure of the drug: Cefdinir's side chains are different from those of penicillin or ampicillin.

Antiviral prophylaxis should be considered for susceptible patients. "For patients who get frequent cold sores, there really is no reason not to give these drugs because they are safe and easily tolerated," he said. Either famciclovir or valacyclovir can be used.

Prophylaxis is not required with the use of injectable fillers, but antiviral treatment may be needed if the lips are the site of injection and the trauma results in reactivation, said Dr. Nestor, who is in private practice in Aventura, Fla.

Antiviral prophylaxis can begin 2 days before the procedure, while antibiotic prophylaxis should begin the night before or the morning of the procedure. Both should continue for about 10 days, until the patient is fully reepithelialized, he said.

Prophylaxis can prevent many, but not all, infections. Early signs of bacterial infection include increasing redness, pain, and new formation of ulcerations. Cultures and a change of antibiotic are often necessary, and vigilance is needed because scarring can occur, he said.

If a viral infection occurs while the patient is on an antiviral drug, the dosage can be increased. "If the patient is on 250 mg of famciclovir twice a day, I will double it or even give 500 mg three times a day," he said.

Certain patients Dr. Nestor has seen over the years have experienced what he refers to as a nonhealing syndrome. They initially have an infection, but it is followed by an autoimmune phenomenon that prevents the wound from healing. "If you culture them, you will grow out everything. They can be treated with everything in the book but don't get better," he said. The approach he has used is to give them a judicious course of antibiotic treatment along with a short course of betamethasone dipropionate ointment. "We have had some amazing results because this cuts down the autoimmune response," he said.

Dr. Nestor disclosed that he is a member of the speakers' bureau for Abbott Laboratories, manufacturer of cefdinir.

Prophylaxis should continue for about 10 days, until the patient is fully reepithelialized. DR. NESTOR

MIAMI — "The new endovenous techniques such as foam sclerotherapy have made small dysfunctional veins easy to obliterate," said Dr. John J. Bergan of Scripps Memorial Hospital, La Jolla, Calif., who gave a presentation about foam sclerotherapy for the treatment of varicose veins at the annual meeting of the American Venous Forum.

"Foam can be used for nearly anything. Unlike laser radiofrequency treatment, foam will go into any peripheral vein and flow into the accessory saphenous vein," Dr. Bergan said.

"Ultrasound-guided foam sclerotherapy is very good. The small saphenous veins are very easy to close," agreed Dr. Neil S. Sadick of Cornell University in New York.

The foam for the procedure can be made from detergent agents such as Sotradecol and polidocanol at any concentration from 0.25% to 3% with a mixing ratio of 1:4 using room air.

It can be used from the skin down to any vein segment. "One of the easiest procedures there are is the treatment of the tangle of superficial veins underneath ulcers, that can best be treated using foam sclerotherapy," said Dr. Bergan.

Foam heals ulcers in weeks, he explained, referring to this new procedure as a "dramatic change in treatment."

Increasing numbers of patients are appearing who have recurring symptoms after previous laser therapy.

"About one-third of patients with laser therapy will need to have treatment for recurring varices," Dr. Bergan noted. "But about one-third will have a return of symptoms—these can be successfully treated with foam."

Another great advantage of foam sclerotherapy is the avoidance of surgery to the small saphenous vein and prevention of sural nerve injury.

Severe complications that occur as a result of foam sclerotherapy are rare, and can include migraine from bits of foam reaching the extracranial circulation to the brain.

The usual side effects of sclerotherapy include matting, superficial thrombi, and residual pigmentation, he said at the meeting.

Dr. Bergan stressed the need to carefully evaluate for abnormal vein segments in each patient before commencing treatment, especially in those with Turner's or Klippel-Feil syndrome, who have a higher chance of presenting with venous malformations.

"You must also be very careful with other patients who may have other conditions," he cautioned.

"Sclerosant foam is cheap, painless, simple, and not disabling," Dr. Bergan explained.

He stressed the need for standardization of treatment methods with the advent of such new therapies that are being proved efficacious.

MIAMI — "The new endovenous techniques such as foam sclerotherapy have made small dysfunctional veins easy to obliterate," said Dr. John J. Bergan of Scripps Memorial Hospital, La Jolla, Calif., who gave a presentation about foam sclerotherapy for the treatment of varicose veins at the annual meeting of the American Venous Forum.

"Foam can be used for nearly anything. Unlike laser radiofrequency treatment, foam will go into any peripheral vein and flow into the accessory saphenous vein," Dr. Bergan said.

"Ultrasound-guided foam sclerotherapy is very good. The small saphenous veins are very easy to close," agreed Dr. Neil S. Sadick of Cornell University in New York.

The foam for the procedure can be made from detergent agents such as Sotradecol and polidocanol at any concentration from 0.25% to 3% with a mixing ratio of 1:4 using room air.

It can be used from the skin down to any vein segment. "One of the easiest procedures there are is the treatment of the tangle of superficial veins underneath ulcers, that can best be treated using foam sclerotherapy," said Dr. Bergan.

Foam heals ulcers in weeks, he explained, referring to this new procedure as a "dramatic change in treatment."

Increasing numbers of patients are appearing who have recurring symptoms after previous laser therapy.

"About one-third of patients with laser therapy will need to have treatment for recurring varices," Dr. Bergan noted. "But about one-third will have a return of symptoms—these can be successfully treated with foam."

Another great advantage of foam sclerotherapy is the avoidance of surgery to the small saphenous vein and prevention of sural nerve injury.

Severe complications that occur as a result of foam sclerotherapy are rare, and can include migraine from bits of foam reaching the extracranial circulation to the brain.

The usual side effects of sclerotherapy include matting, superficial thrombi, and residual pigmentation, he said at the meeting.

Dr. Bergan stressed the need to carefully evaluate for abnormal vein segments in each patient before commencing treatment, especially in those with Turner's or Klippel-Feil syndrome, who have a higher chance of presenting with venous malformations.

"You must also be very careful with other patients who may have other conditions," he cautioned.

"Sclerosant foam is cheap, painless, simple, and not disabling," Dr. Bergan explained.

He stressed the need for standardization of treatment methods with the advent of such new therapies that are being proved efficacious.

MIAMI — "The new endovenous techniques such as foam sclerotherapy have made small dysfunctional veins easy to obliterate," said Dr. John J. Bergan of Scripps Memorial Hospital, La Jolla, Calif., who gave a presentation about foam sclerotherapy for the treatment of varicose veins at the annual meeting of the American Venous Forum.

"Foam can be used for nearly anything. Unlike laser radiofrequency treatment, foam will go into any peripheral vein and flow into the accessory saphenous vein," Dr. Bergan said.

"Ultrasound-guided foam sclerotherapy is very good. The small saphenous veins are very easy to close," agreed Dr. Neil S. Sadick of Cornell University in New York.

The foam for the procedure can be made from detergent agents such as Sotradecol and polidocanol at any concentration from 0.25% to 3% with a mixing ratio of 1:4 using room air.

It can be used from the skin down to any vein segment. "One of the easiest procedures there are is the treatment of the tangle of superficial veins underneath ulcers, that can best be treated using foam sclerotherapy," said Dr. Bergan.

Foam heals ulcers in weeks, he explained, referring to this new procedure as a "dramatic change in treatment."

Increasing numbers of patients are appearing who have recurring symptoms after previous laser therapy.

"About one-third of patients with laser therapy will need to have treatment for recurring varices," Dr. Bergan noted. "But about one-third will have a return of symptoms—these can be successfully treated with foam."

Another great advantage of foam sclerotherapy is the avoidance of surgery to the small saphenous vein and prevention of sural nerve injury.

Severe complications that occur as a result of foam sclerotherapy are rare, and can include migraine from bits of foam reaching the extracranial circulation to the brain.

The usual side effects of sclerotherapy include matting, superficial thrombi, and residual pigmentation, he said at the meeting.

Dr. Bergan stressed the need to carefully evaluate for abnormal vein segments in each patient before commencing treatment, especially in those with Turner's or Klippel-Feil syndrome, who have a higher chance of presenting with venous malformations.

"You must also be very careful with other patients who may have other conditions," he cautioned.

"Sclerosant foam is cheap, painless, simple, and not disabling," Dr. Bergan explained.

He stressed the need for standardization of treatment methods with the advent of such new therapies that are being proved efficacious.

Extramammary Paget's disease (EMPD) is an uncommon clinical condition. However, cases of EMPD increasingly have been reported in recent years because of advancements in diagnostic technique and increased awareness of the disease. There are 3 patterns of EMPD: (1) cutaneous in situ epithelial with no associated underlying cancer; (2) epithelial with an associated underlying adnexal cancer; and (3) disease associated with underlying organ involvement (ie, genitourinary, gastrointestinal, or another distant site). Treatment of EMPD is problematic because the disease is associated with a high rate of recurrence. Preliminary results with topical imiquimod monotherapy demonstrate that this treatment may serve as a potential nonsurgical cure for the disease. We report a case of a patient who failed to respond to surgery or imiquimod monotherapy but who responded to imiquimod combination therapy with 5-fluorouracil (5-FU) and retinoic acid. 

Case Report
A 68-year-old Chinese man presented with a pruritic rash in the scrotal area of 7 years' duration (Figure 1). Results of a skin biopsy revealed diffuse clusters of malignant pagetoid intraepidermal epithelial proliferation that stained positive with colloidal iron, mucicarmine, and periodic acid-Schiff with diastase (Figure 2). The results were diagnostic for EMPD. Results of detailed clinical and laboratory examinations showed no evidence of malignancy in other sites.

The patient underwent a large surgical excision with skin flap repair. One year later, he complained of an itchy rash within the surgical scar. Results of a repeat biopsy confirmed EMPD. The patient refused further surgery. As an alternative treatment, imiquimod 5% cream was applied nightly (Monday through Friday) for 6 weeks; because of moderate irritation, the application was decreased to every other day for the next 4 weeks. In general, the patient tolerated the treatment well and only reported erythema, burning, and some tenderness in the affected area. At the end of the 10-week treatment, histologic evaluation results revealed residual epidermal EMPD. The patient was then treated with imiquimod, 5-FU, and retinoic acid combination chemotherapy. The protocol involved applying 5-FU 5% cream every morning, retinoic acid 0.1% gel every afternoon, and imiquimod every evening. After 12 days, the patient complained of severe burning and pain in the affected area, and results of an examination showed severe erosive erythema (Figure 3). At that point, topical chemotherapy was discontinued. Zinc oxide 2% and polysporin ointment were applied alternatively 4 times daily for 2 weeks.

In the third week after the topical chemotherapy, results of multiple punch biopsies on several sites revealed no residual malignancy. The patient remained asymptomatic, and the results of a repeat biopsy revealed no residual microscopic malignancy at the 2-year follow-up visit. 

Comment EMPD is a multifocal epidermal malignancy that possibly is related to the proliferation of pleuripotential epithelial stem cells. EMPD follows an unpredictable clinical course, ranging from indolent skin disease to aggressive malignancy. In general, EMPD appears in individuals aged 50 to 80 years, particularly in those who are white. Typical anatomic sites involve the vulvar, perianal, perineal, scrotal, and penile regions. Less common sites include the thighs, buttocks, axilla, eyelids, and external ear canal. The lesions of EMPD present as well-defined erythematous plaques that usually are accompanied by pruritus. The main differential diagnoses of EMPD include psoriasis, contact dermatitis, fungal infection, lichen sclerosis, atopic dermatitis, Bowen's disease, melanoma, histiocytosis, pagetoid basal cell carcinoma, and mycosis fungoides. The nonspecific presentation of EMPD often leads to a misdiagnosis, and an average of one year may pass before a biopsy is performed and a definitive diagnosis is made. Microscopically, the margins of EMPD are multicentric and vague, with skip areas that frequently extend beyond the clinically detectable lesion, which results in the high rate of recurrence of EMPD. In addition, there is a lack of clinical experience with cutaneous EMPD because the disease has a relatively rare occurrence. Case reports constitute the majority of literature on EMPD. The successful management of EMPD is compromised by the multifocal nature of the disease; recurrence of lesions after conventional surgical management is high, ranging from 44% to 75%. Even with Mohs micrographic surgery, the lesions have a reported recurrence rate of 27%.1-2 Imiquimod is an immodulator that stimulates the production of a wide range of cytokines, including interleukins 1, 6, 8, and 12; interferon; and tumor necrosis factor. Imiquimod activates B-cell responses by increasing the expression of class II major histocompatibility complex markers, which increase immunoglobulin production. Imiquimod also may enhance Langerhans cell migration from the skin to the lymph nodes, thus improving antigen presentation.3 An in vitro study has demonstrated that imiquimod inhibits tumor-associated angiogenesis and diminishes tumor burden in transplantable murine carcinoma.4 Results of a biopsy specimen from one melanoma patient also showed apoptosis after treatment with topical imiquimod cream and systemic dacarbazine.5 We identified 5 cases (in 4 reports) in which the effect of topical imiquimod monotherapy applied to the perianal/genital area of patients with EMPD was evaluated.6-9 All 5 cases showed a clinical and histologic cure, with minimal functional disturbance. In the study with the longest follow-up period, the patient remained disease free at the 14-month follow-up visit.7 In the study with the most frequent dosing interval, the medication was applied once daily.9 Treatment duration ranged from 6 to 16 weeks (Table).6-9

5-FU has selective toxicity in premalignant and malignant epithelial lesions. 5-FU is a chemotherapeutic drug that induces notable regression in advanced locally progressing EMPD.10,11 The mechanisms of action of 5-FU are based on the drug's steric similarity to uracil and its irreversible binding to thymidylate synthetase, which prevents the synthesis of thymidine from uridine. Consequently, RNA and DNA synthesis are inhibited, faulty RNA is produced, and cell toxicity ensues. Paget's cells have a high metabolic activity that requires abundant RNA. This high demand for RNA synthesis may be responsible for the sensitivity of Paget's cells to 5-FU. Six cases (in 6 reports) published in the English literature evaluated the effect of 5-FU monotherapy in the treatment of EMPD.11-16 Four reports showed clinical cure after treatment with 5-FU.12-14,16 In 2 of the reports, microscopic evidence of disease persisted after treatment12-13; in one report, no follow-up biopsy was performed14; in another report, no microscopic evidence of disease after treatment was identified.16 In the case report by Del Castillo et al,16 the patient applied topical 5-FU 5% intermittently (at the patient's discretion) to the affected axilla region for one year. The surgical removal of the lesion after one year of intermittent treatment showed no evidence of EMPD. In the case reports by Bewley et al11 and Eliezri et al,15 application of 5-FU 5% increased the disease margins. In summary, these reports demonstrate that topical 5-FU cannot be considered a safe and effective first-line choice of treatment due to its erosive feature and false impression of total clinical resolution. Retinoic acid has antiproliferative activity and induces apoptosis by its selective binding activity to the γ receptor in the nuclear receptor–independent pathway in neoplastic cells.17-18 We identified no published reports of topical retinoic acid for the treatment of EMPD. The most common use of retinoid antitumor agents is in the treatment of leukemia. In our case report, the tumor recurred after initial surgery and remained after 10 weeks of monotherapy with imiquimod. The reason imiquimod therapy failed in this case may relate to the presence of the tumor in the area of scar tissue; imiquimod by itself could not achieve adequate tissue penetration to induce the appropriate immune response. Consequently, we applied 5-FU cream in the morning to induce a selective toxicity in the Paget's cell, and retinoic acid gel in the afternoon to promote an antiproliferative apoptosis and to facilitate the penetration of imiquimod, which was applied in the evening. This combination therapy could potentiate a stronger stimulation of cytokines and interferon, which would then lead to the activation of T and B cells, natural killer cells, and a macrophage host response, all of which could be responsible for the destruction of the intraepithelial EMPD. In conclusion, we have demonstrated that a combination treatment of topical imiquimod, 5-FU, and retinoic acid may serve as an effective treatment option for patients who have failed imiquimod monotherapy. Acknowledgments—The authors would like to thank their colleagues John O'Dea, MD; Tony Chin, MD; Robert Uyeda, MD; and Simon Chan, MD, for reviewing and critiquing this manuscript. The authors also would like to thank Irma Marques for editing the manuscript.

Extramammary Paget's disease (EMPD) is an uncommon clinical condition. However, cases of EMPD increasingly have been reported in recent years because of advancements in diagnostic technique and increased awareness of the disease. There are 3 patterns of EMPD: (1) cutaneous in situ epithelial with no associated underlying cancer; (2) epithelial with an associated underlying adnexal cancer; and (3) disease associated with underlying organ involvement (ie, genitourinary, gastrointestinal, or another distant site). Treatment of EMPD is problematic because the disease is associated with a high rate of recurrence. Preliminary results with topical imiquimod monotherapy demonstrate that this treatment may serve as a potential nonsurgical cure for the disease. We report a case of a patient who failed to respond to surgery or imiquimod monotherapy but who responded to imiquimod combination therapy with 5-fluorouracil (5-FU) and retinoic acid. 

Case Report
A 68-year-old Chinese man presented with a pruritic rash in the scrotal area of 7 years' duration (Figure 1). Results of a skin biopsy revealed diffuse clusters of malignant pagetoid intraepidermal epithelial proliferation that stained positive with colloidal iron, mucicarmine, and periodic acid-Schiff with diastase (Figure 2). The results were diagnostic for EMPD. Results of detailed clinical and laboratory examinations showed no evidence of malignancy in other sites.

The patient underwent a large surgical excision with skin flap repair. One year later, he complained of an itchy rash within the surgical scar. Results of a repeat biopsy confirmed EMPD. The patient refused further surgery. As an alternative treatment, imiquimod 5% cream was applied nightly (Monday through Friday) for 6 weeks; because of moderate irritation, the application was decreased to every other day for the next 4 weeks. In general, the patient tolerated the treatment well and only reported erythema, burning, and some tenderness in the affected area. At the end of the 10-week treatment, histologic evaluation results revealed residual epidermal EMPD. The patient was then treated with imiquimod, 5-FU, and retinoic acid combination chemotherapy. The protocol involved applying 5-FU 5% cream every morning, retinoic acid 0.1% gel every afternoon, and imiquimod every evening. After 12 days, the patient complained of severe burning and pain in the affected area, and results of an examination showed severe erosive erythema (Figure 3). At that point, topical chemotherapy was discontinued. Zinc oxide 2% and polysporin ointment were applied alternatively 4 times daily for 2 weeks.

In the third week after the topical chemotherapy, results of multiple punch biopsies on several sites revealed no residual malignancy. The patient remained asymptomatic, and the results of a repeat biopsy revealed no residual microscopic malignancy at the 2-year follow-up visit. 

Comment EMPD is a multifocal epidermal malignancy that possibly is related to the proliferation of pleuripotential epithelial stem cells. EMPD follows an unpredictable clinical course, ranging from indolent skin disease to aggressive malignancy. In general, EMPD appears in individuals aged 50 to 80 years, particularly in those who are white. Typical anatomic sites involve the vulvar, perianal, perineal, scrotal, and penile regions. Less common sites include the thighs, buttocks, axilla, eyelids, and external ear canal. The lesions of EMPD present as well-defined erythematous plaques that usually are accompanied by pruritus. The main differential diagnoses of EMPD include psoriasis, contact dermatitis, fungal infection, lichen sclerosis, atopic dermatitis, Bowen's disease, melanoma, histiocytosis, pagetoid basal cell carcinoma, and mycosis fungoides. The nonspecific presentation of EMPD often leads to a misdiagnosis, and an average of one year may pass before a biopsy is performed and a definitive diagnosis is made. Microscopically, the margins of EMPD are multicentric and vague, with skip areas that frequently extend beyond the clinically detectable lesion, which results in the high rate of recurrence of EMPD. In addition, there is a lack of clinical experience with cutaneous EMPD because the disease has a relatively rare occurrence. Case reports constitute the majority of literature on EMPD. The successful management of EMPD is compromised by the multifocal nature of the disease; recurrence of lesions after conventional surgical management is high, ranging from 44% to 75%. Even with Mohs micrographic surgery, the lesions have a reported recurrence rate of 27%.1-2 Imiquimod is an immodulator that stimulates the production of a wide range of cytokines, including interleukins 1, 6, 8, and 12; interferon; and tumor necrosis factor. Imiquimod activates B-cell responses by increasing the expression of class II major histocompatibility complex markers, which increase immunoglobulin production. Imiquimod also may enhance Langerhans cell migration from the skin to the lymph nodes, thus improving antigen presentation.3 An in vitro study has demonstrated that imiquimod inhibits tumor-associated angiogenesis and diminishes tumor burden in transplantable murine carcinoma.4 Results of a biopsy specimen from one melanoma patient also showed apoptosis after treatment with topical imiquimod cream and systemic dacarbazine.5 We identified 5 cases (in 4 reports) in which the effect of topical imiquimod monotherapy applied to the perianal/genital area of patients with EMPD was evaluated.6-9 All 5 cases showed a clinical and histologic cure, with minimal functional disturbance. In the study with the longest follow-up period, the patient remained disease free at the 14-month follow-up visit.7 In the study with the most frequent dosing interval, the medication was applied once daily.9 Treatment duration ranged from 6 to 16 weeks (Table).6-9

5-FU has selective toxicity in premalignant and malignant epithelial lesions. 5-FU is a chemotherapeutic drug that induces notable regression in advanced locally progressing EMPD.10,11 The mechanisms of action of 5-FU are based on the drug's steric similarity to uracil and its irreversible binding to thymidylate synthetase, which prevents the synthesis of thymidine from uridine. Consequently, RNA and DNA synthesis are inhibited, faulty RNA is produced, and cell toxicity ensues. Paget's cells have a high metabolic activity that requires abundant RNA. This high demand for RNA synthesis may be responsible for the sensitivity of Paget's cells to 5-FU. Six cases (in 6 reports) published in the English literature evaluated the effect of 5-FU monotherapy in the treatment of EMPD.11-16 Four reports showed clinical cure after treatment with 5-FU.12-14,16 In 2 of the reports, microscopic evidence of disease persisted after treatment12-13; in one report, no follow-up biopsy was performed14; in another report, no microscopic evidence of disease after treatment was identified.16 In the case report by Del Castillo et al,16 the patient applied topical 5-FU 5% intermittently (at the patient's discretion) to the affected axilla region for one year. The surgical removal of the lesion after one year of intermittent treatment showed no evidence of EMPD. In the case reports by Bewley et al11 and Eliezri et al,15 application of 5-FU 5% increased the disease margins. In summary, these reports demonstrate that topical 5-FU cannot be considered a safe and effective first-line choice of treatment due to its erosive feature and false impression of total clinical resolution. Retinoic acid has antiproliferative activity and induces apoptosis by its selective binding activity to the γ receptor in the nuclear receptor–independent pathway in neoplastic cells.17-18 We identified no published reports of topical retinoic acid for the treatment of EMPD. The most common use of retinoid antitumor agents is in the treatment of leukemia. In our case report, the tumor recurred after initial surgery and remained after 10 weeks of monotherapy with imiquimod. The reason imiquimod therapy failed in this case may relate to the presence of the tumor in the area of scar tissue; imiquimod by itself could not achieve adequate tissue penetration to induce the appropriate immune response. Consequently, we applied 5-FU cream in the morning to induce a selective toxicity in the Paget's cell, and retinoic acid gel in the afternoon to promote an antiproliferative apoptosis and to facilitate the penetration of imiquimod, which was applied in the evening. This combination therapy could potentiate a stronger stimulation of cytokines and interferon, which would then lead to the activation of T and B cells, natural killer cells, and a macrophage host response, all of which could be responsible for the destruction of the intraepithelial EMPD. In conclusion, we have demonstrated that a combination treatment of topical imiquimod, 5-FU, and retinoic acid may serve as an effective treatment option for patients who have failed imiquimod monotherapy. Acknowledgments—The authors would like to thank their colleagues John O'Dea, MD; Tony Chin, MD; Robert Uyeda, MD; and Simon Chan, MD, for reviewing and critiquing this manuscript. The authors also would like to thank Irma Marques for editing the manuscript.

Extramammary Paget's disease (EMPD) is an uncommon clinical condition. However, cases of EMPD increasingly have been reported in recent years because of advancements in diagnostic technique and increased awareness of the disease. There are 3 patterns of EMPD: (1) cutaneous in situ epithelial with no associated underlying cancer; (2) epithelial with an associated underlying adnexal cancer; and (3) disease associated with underlying organ involvement (ie, genitourinary, gastrointestinal, or another distant site). Treatment of EMPD is problematic because the disease is associated with a high rate of recurrence. Preliminary results with topical imiquimod monotherapy demonstrate that this treatment may serve as a potential nonsurgical cure for the disease. We report a case of a patient who failed to respond to surgery or imiquimod monotherapy but who responded to imiquimod combination therapy with 5-fluorouracil (5-FU) and retinoic acid. 

Case Report
A 68-year-old Chinese man presented with a pruritic rash in the scrotal area of 7 years' duration (Figure 1). Results of a skin biopsy revealed diffuse clusters of malignant pagetoid intraepidermal epithelial proliferation that stained positive with colloidal iron, mucicarmine, and periodic acid-Schiff with diastase (Figure 2). The results were diagnostic for EMPD. Results of detailed clinical and laboratory examinations showed no evidence of malignancy in other sites.

The patient underwent a large surgical excision with skin flap repair. One year later, he complained of an itchy rash within the surgical scar. Results of a repeat biopsy confirmed EMPD. The patient refused further surgery. As an alternative treatment, imiquimod 5% cream was applied nightly (Monday through Friday) for 6 weeks; because of moderate irritation, the application was decreased to every other day for the next 4 weeks. In general, the patient tolerated the treatment well and only reported erythema, burning, and some tenderness in the affected area. At the end of the 10-week treatment, histologic evaluation results revealed residual epidermal EMPD. The patient was then treated with imiquimod, 5-FU, and retinoic acid combination chemotherapy. The protocol involved applying 5-FU 5% cream every morning, retinoic acid 0.1% gel every afternoon, and imiquimod every evening. After 12 days, the patient complained of severe burning and pain in the affected area, and results of an examination showed severe erosive erythema (Figure 3). At that point, topical chemotherapy was discontinued. Zinc oxide 2% and polysporin ointment were applied alternatively 4 times daily for 2 weeks.

In the third week after the topical chemotherapy, results of multiple punch biopsies on several sites revealed no residual malignancy. The patient remained asymptomatic, and the results of a repeat biopsy revealed no residual microscopic malignancy at the 2-year follow-up visit. 

Comment EMPD is a multifocal epidermal malignancy that possibly is related to the proliferation of pleuripotential epithelial stem cells. EMPD follows an unpredictable clinical course, ranging from indolent skin disease to aggressive malignancy. In general, EMPD appears in individuals aged 50 to 80 years, particularly in those who are white. Typical anatomic sites involve the vulvar, perianal, perineal, scrotal, and penile regions. Less common sites include the thighs, buttocks, axilla, eyelids, and external ear canal. The lesions of EMPD present as well-defined erythematous plaques that usually are accompanied by pruritus. The main differential diagnoses of EMPD include psoriasis, contact dermatitis, fungal infection, lichen sclerosis, atopic dermatitis, Bowen's disease, melanoma, histiocytosis, pagetoid basal cell carcinoma, and mycosis fungoides. The nonspecific presentation of EMPD often leads to a misdiagnosis, and an average of one year may pass before a biopsy is performed and a definitive diagnosis is made. Microscopically, the margins of EMPD are multicentric and vague, with skip areas that frequently extend beyond the clinically detectable lesion, which results in the high rate of recurrence of EMPD. In addition, there is a lack of clinical experience with cutaneous EMPD because the disease has a relatively rare occurrence. Case reports constitute the majority of literature on EMPD. The successful management of EMPD is compromised by the multifocal nature of the disease; recurrence of lesions after conventional surgical management is high, ranging from 44% to 75%. Even with Mohs micrographic surgery, the lesions have a reported recurrence rate of 27%.1-2 Imiquimod is an immodulator that stimulates the production of a wide range of cytokines, including interleukins 1, 6, 8, and 12; interferon; and tumor necrosis factor. Imiquimod activates B-cell responses by increasing the expression of class II major histocompatibility complex markers, which increase immunoglobulin production. Imiquimod also may enhance Langerhans cell migration from the skin to the lymph nodes, thus improving antigen presentation.3 An in vitro study has demonstrated that imiquimod inhibits tumor-associated angiogenesis and diminishes tumor burden in transplantable murine carcinoma.4 Results of a biopsy specimen from one melanoma patient also showed apoptosis after treatment with topical imiquimod cream and systemic dacarbazine.5 We identified 5 cases (in 4 reports) in which the effect of topical imiquimod monotherapy applied to the perianal/genital area of patients with EMPD was evaluated.6-9 All 5 cases showed a clinical and histologic cure, with minimal functional disturbance. In the study with the longest follow-up period, the patient remained disease free at the 14-month follow-up visit.7 In the study with the most frequent dosing interval, the medication was applied once daily.9 Treatment duration ranged from 6 to 16 weeks (Table).6-9

5-FU has selective toxicity in premalignant and malignant epithelial lesions. 5-FU is a chemotherapeutic drug that induces notable regression in advanced locally progressing EMPD.10,11 The mechanisms of action of 5-FU are based on the drug's steric similarity to uracil and its irreversible binding to thymidylate synthetase, which prevents the synthesis of thymidine from uridine. Consequently, RNA and DNA synthesis are inhibited, faulty RNA is produced, and cell toxicity ensues. Paget's cells have a high metabolic activity that requires abundant RNA. This high demand for RNA synthesis may be responsible for the sensitivity of Paget's cells to 5-FU. Six cases (in 6 reports) published in the English literature evaluated the effect of 5-FU monotherapy in the treatment of EMPD.11-16 Four reports showed clinical cure after treatment with 5-FU.12-14,16 In 2 of the reports, microscopic evidence of disease persisted after treatment12-13; in one report, no follow-up biopsy was performed14; in another report, no microscopic evidence of disease after treatment was identified.16 In the case report by Del Castillo et al,16 the patient applied topical 5-FU 5% intermittently (at the patient's discretion) to the affected axilla region for one year. The surgical removal of the lesion after one year of intermittent treatment showed no evidence of EMPD. In the case reports by Bewley et al11 and Eliezri et al,15 application of 5-FU 5% increased the disease margins. In summary, these reports demonstrate that topical 5-FU cannot be considered a safe and effective first-line choice of treatment due to its erosive feature and false impression of total clinical resolution. Retinoic acid has antiproliferative activity and induces apoptosis by its selective binding activity to the γ receptor in the nuclear receptor–independent pathway in neoplastic cells.17-18 We identified no published reports of topical retinoic acid for the treatment of EMPD. The most common use of retinoid antitumor agents is in the treatment of leukemia. In our case report, the tumor recurred after initial surgery and remained after 10 weeks of monotherapy with imiquimod. The reason imiquimod therapy failed in this case may relate to the presence of the tumor in the area of scar tissue; imiquimod by itself could not achieve adequate tissue penetration to induce the appropriate immune response. Consequently, we applied 5-FU cream in the morning to induce a selective toxicity in the Paget's cell, and retinoic acid gel in the afternoon to promote an antiproliferative apoptosis and to facilitate the penetration of imiquimod, which was applied in the evening. This combination therapy could potentiate a stronger stimulation of cytokines and interferon, which would then lead to the activation of T and B cells, natural killer cells, and a macrophage host response, all of which could be responsible for the destruction of the intraepithelial EMPD. In conclusion, we have demonstrated that a combination treatment of topical imiquimod, 5-FU, and retinoic acid may serve as an effective treatment option for patients who have failed imiquimod monotherapy. Acknowledgments—The authors would like to thank their colleagues John O'Dea, MD; Tony Chin, MD; Robert Uyeda, MD; and Simon Chan, MD, for reviewing and critiquing this manuscript. The authors also would like to thank Irma Marques for editing the manuscript.

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA