Aesthetic Dermatology

SAN DIEGO — Direct, honest, and consistent communication between a Mohs surgeon and his or her technician is necessary for a high-functioning, organized partnership, said Alex Lutz at a meeting sponsored by the American Society for Mohs Surgery.

Neither party should rely on assumptions regarding procedure. The physician should not assume that the technician has understood instructions and followed the proper process each time, nor should the technician assume that the physician has conducted the surgery the same way each time, said Mr. Lutz, a Mohs technician in Torrance, Calif.

The technician must be able to tell the surgeon that the technician has made a mistake and be honest enough to admit it, Mr. Lutz said. Likewise, the physician must be able to tell the technician if something went wrong—if the technician didn't get enough of a base for the specimen or did something differently from the agreed-upon standards. "Without that sort of communication, errors will be made," Mr. Lutz said. "It's all about checks and balances."

With this kind of communication in place, the Mohs surgeon and the technician can keep the surgical practice organized by agreeing upon a standard way to process specimens. If something about a specimen doesn't make sense, both parties must feel comfortable asking questions in order to avoid errors. For example, the surgeon who usually puts double hatch marks to indicate 12:00 on a specimen may put them at 3:00 for some reason, causing confusion for the technician.

He offered several standardization tips to enhance physician-technician harmony.

For the physicians:

▸ Choose a method to denote a true 12:00; it can be a pattern of marks or something else.

▸ Bring specimens to the technician in a petri dish of saline to avoid dehydration.

▸ Develop a standard inking format and a standard staining regimen.

▸ Send the Mohs map to the technician along with the slides. "Don't get into the habit of making the map later; the technicians need it," Lutz said.

For the technicians:

▸ Pick up slides the same way each time, and determine the surgeon's preference as to whether they want the first cut closer to the frosted edge or the opposite.

▸ Note the time and location of all tissue cuts on the Mohs map.

▸ Process multiple specimens in an organized fashion. Technicians should label slides and place them in the cryostat the same way each time.

SAN DIEGO — Direct, honest, and consistent communication between a Mohs surgeon and his or her technician is necessary for a high-functioning, organized partnership, said Alex Lutz at a meeting sponsored by the American Society for Mohs Surgery.

Neither party should rely on assumptions regarding procedure. The physician should not assume that the technician has understood instructions and followed the proper process each time, nor should the technician assume that the physician has conducted the surgery the same way each time, said Mr. Lutz, a Mohs technician in Torrance, Calif.

The technician must be able to tell the surgeon that the technician has made a mistake and be honest enough to admit it, Mr. Lutz said. Likewise, the physician must be able to tell the technician if something went wrong—if the technician didn't get enough of a base for the specimen or did something differently from the agreed-upon standards. "Without that sort of communication, errors will be made," Mr. Lutz said. "It's all about checks and balances."

With this kind of communication in place, the Mohs surgeon and the technician can keep the surgical practice organized by agreeing upon a standard way to process specimens. If something about a specimen doesn't make sense, both parties must feel comfortable asking questions in order to avoid errors. For example, the surgeon who usually puts double hatch marks to indicate 12:00 on a specimen may put them at 3:00 for some reason, causing confusion for the technician.

He offered several standardization tips to enhance physician-technician harmony.

For the physicians:

▸ Choose a method to denote a true 12:00; it can be a pattern of marks or something else.

▸ Bring specimens to the technician in a petri dish of saline to avoid dehydration.

▸ Develop a standard inking format and a standard staining regimen.

▸ Send the Mohs map to the technician along with the slides. "Don't get into the habit of making the map later; the technicians need it," Lutz said.

For the technicians:

▸ Pick up slides the same way each time, and determine the surgeon's preference as to whether they want the first cut closer to the frosted edge or the opposite.

▸ Note the time and location of all tissue cuts on the Mohs map.

▸ Process multiple specimens in an organized fashion. Technicians should label slides and place them in the cryostat the same way each time.

SAN DIEGO — Direct, honest, and consistent communication between a Mohs surgeon and his or her technician is necessary for a high-functioning, organized partnership, said Alex Lutz at a meeting sponsored by the American Society for Mohs Surgery.

Neither party should rely on assumptions regarding procedure. The physician should not assume that the technician has understood instructions and followed the proper process each time, nor should the technician assume that the physician has conducted the surgery the same way each time, said Mr. Lutz, a Mohs technician in Torrance, Calif.

The technician must be able to tell the surgeon that the technician has made a mistake and be honest enough to admit it, Mr. Lutz said. Likewise, the physician must be able to tell the technician if something went wrong—if the technician didn't get enough of a base for the specimen or did something differently from the agreed-upon standards. "Without that sort of communication, errors will be made," Mr. Lutz said. "It's all about checks and balances."

With this kind of communication in place, the Mohs surgeon and the technician can keep the surgical practice organized by agreeing upon a standard way to process specimens. If something about a specimen doesn't make sense, both parties must feel comfortable asking questions in order to avoid errors. For example, the surgeon who usually puts double hatch marks to indicate 12:00 on a specimen may put them at 3:00 for some reason, causing confusion for the technician.

He offered several standardization tips to enhance physician-technician harmony.

For the physicians:

▸ Choose a method to denote a true 12:00; it can be a pattern of marks or something else.

▸ Bring specimens to the technician in a petri dish of saline to avoid dehydration.

▸ Develop a standard inking format and a standard staining regimen.

▸ Send the Mohs map to the technician along with the slides. "Don't get into the habit of making the map later; the technicians need it," Lutz said.

For the technicians:

▸ Pick up slides the same way each time, and determine the surgeon's preference as to whether they want the first cut closer to the frosted edge or the opposite.

▸ Note the time and location of all tissue cuts on the Mohs map.

▸ Process multiple specimens in an organized fashion. Technicians should label slides and place them in the cryostat the same way each time.

SAN DIEGO — Certain areas of the body are more challenging than others when it comes to Mohs surgery: the nose, ears, and eyelids, as well as urology cases and orthopedic cases on the hands and feet.

These are the places where surgeons, especially beginners, are more likely to get into trouble and where tumors tend to be more aggressive. "Anywhere the skin is closer to bone, the tumor is more likely to spread in an unpredictable manner," Dr. Roger I. Ceilley said at a meeting sponsored by the American Society of Mohs Surgery.

To tackle the tough Mohs surgery cases, physicians need a lot of experience and time spent working with other surgeons, said Dr. Ceilley, a Mohs surgeon and dermatologist in practice in Iowa.

Cancers in the nose, which tend to be deeply invasive and can be hard to detect, have a higher recurrence rate, compared with cancers in other areas, he said. Particularly tricky areas around the nose are the columella, nasolabial groove, supra tip area, and lateral nasal dorsum. Before performing Mohs surgery on tumors of the nose, physicians should conduct a scouting biopsy to determine the extent of the lesions and to remove all scar tissue. Be aware that a tumor of the nose could be the tip of a larger iceberg, and prepare in advance for possible collaboration with a head and neck surgeon, he advised.

Treating cancer of the ear with Mohs surgery may involve working around the parotid gland, as well as around many nerves. Skin cancers of the ear have a 16%–47% recurrence rate, which is higher than that of skin cancers elsewhere. For these cases, it is important to know the anatomy of the ear, especially the nerve distribution and nerve supply. The anatomy of the ear is complex, and the surgeon must anticipate that the tumor may be much larger than it appears clinically. That said, the back of the ear is a good place to perfect one's skin flap technique, he noted.

Most surgeons can handle procedures on the lower eyelid, but upper eyelid tumors require an immediate repair and the use of an eye shield to protect the cornea and prevent corneal dryness.

"I wouldn't tackle tumors on the upper eyelid if you think it will be full thickness because you need to do an immediate repair, and you have to keep a corneal shield in place on the eye to prevent drying of the cornea. A little carbon char can cause a corneal abrasion. Make sure you use plenty of ointment before and after surgery," he said.

If you plan to perform Mohs surgery in the genital area, arrange ahead of time to work with a urologist. Dr. Ceilley discussed a patient with penile cancer who was slated for a penectomy, but was not enthusiastic about that idea and wanted to try Mohs surgery. (See photo.)

The surgery involved use of a catheter, and the tumor had to be followed into the urethra. After excision of the tumor, the wound was not sutured, but allowed to heal by second intention. The patient has had no recurrence of cancer to date. "He has to watch where he points, but he has a functional penis," Dr. Ceilley said.

Mohs surgery also may be used to successfully treat cancer, especially squamous cell carcinoma, on the extremities. In the case of a verrucous squamous cell carcinoma, "the tumor went nearly through to the other side of the foot," he said. Dr. Ceilley collaborated with an orthopedic surgeon, who amputated several toes. The surgeon used the skin from those toes to create skin flaps and give the patient a functional foot. (See photo.)

Expect the unexpected in Mohs cases. "You can find tumors that look like a basal cell carcinoma and turn out to be a Merkel cell carcinoma," he said.

Microcystic adnexal carcinoma, a rare but deeply infiltrating tumor, can be treated by an experienced Mohs surgeon. Characteristic features of microcystic adnexal carcinoma include a bland appearance, ambiguous histopathology with bizarrely shaped parent cells, and aggressive clinical behavior. Permanent horizontal sections are highly useful in these cases, Dr. Ceilley said.

Lentigo maligna also can be treated with Mohs surgery, and surgeons can use imiquimod (Aldara) to decrease the size of the area prior to surgery and to facilitate healing after surgery.

Finally, for challenging or complex cases, Dr. Ceilley recommends getting permanent paraffin-embedded sections, in addition to the multiple frozen sections that may be needed.

A squamous cell carcinoma of the penis was successfully excised.

After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley

Tips to Ensure Successful Mohs Surgery

I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.

Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.

Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.

After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."

A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.

If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.

Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."

SAN DIEGO — Certain areas of the body are more challenging than others when it comes to Mohs surgery: the nose, ears, and eyelids, as well as urology cases and orthopedic cases on the hands and feet.

These are the places where surgeons, especially beginners, are more likely to get into trouble and where tumors tend to be more aggressive. "Anywhere the skin is closer to bone, the tumor is more likely to spread in an unpredictable manner," Dr. Roger I. Ceilley said at a meeting sponsored by the American Society of Mohs Surgery.

To tackle the tough Mohs surgery cases, physicians need a lot of experience and time spent working with other surgeons, said Dr. Ceilley, a Mohs surgeon and dermatologist in practice in Iowa.

Cancers in the nose, which tend to be deeply invasive and can be hard to detect, have a higher recurrence rate, compared with cancers in other areas, he said. Particularly tricky areas around the nose are the columella, nasolabial groove, supra tip area, and lateral nasal dorsum. Before performing Mohs surgery on tumors of the nose, physicians should conduct a scouting biopsy to determine the extent of the lesions and to remove all scar tissue. Be aware that a tumor of the nose could be the tip of a larger iceberg, and prepare in advance for possible collaboration with a head and neck surgeon, he advised.

Treating cancer of the ear with Mohs surgery may involve working around the parotid gland, as well as around many nerves. Skin cancers of the ear have a 16%–47% recurrence rate, which is higher than that of skin cancers elsewhere. For these cases, it is important to know the anatomy of the ear, especially the nerve distribution and nerve supply. The anatomy of the ear is complex, and the surgeon must anticipate that the tumor may be much larger than it appears clinically. That said, the back of the ear is a good place to perfect one's skin flap technique, he noted.

Most surgeons can handle procedures on the lower eyelid, but upper eyelid tumors require an immediate repair and the use of an eye shield to protect the cornea and prevent corneal dryness.

"I wouldn't tackle tumors on the upper eyelid if you think it will be full thickness because you need to do an immediate repair, and you have to keep a corneal shield in place on the eye to prevent drying of the cornea. A little carbon char can cause a corneal abrasion. Make sure you use plenty of ointment before and after surgery," he said.

If you plan to perform Mohs surgery in the genital area, arrange ahead of time to work with a urologist. Dr. Ceilley discussed a patient with penile cancer who was slated for a penectomy, but was not enthusiastic about that idea and wanted to try Mohs surgery. (See photo.)

The surgery involved use of a catheter, and the tumor had to be followed into the urethra. After excision of the tumor, the wound was not sutured, but allowed to heal by second intention. The patient has had no recurrence of cancer to date. "He has to watch where he points, but he has a functional penis," Dr. Ceilley said.

Mohs surgery also may be used to successfully treat cancer, especially squamous cell carcinoma, on the extremities. In the case of a verrucous squamous cell carcinoma, "the tumor went nearly through to the other side of the foot," he said. Dr. Ceilley collaborated with an orthopedic surgeon, who amputated several toes. The surgeon used the skin from those toes to create skin flaps and give the patient a functional foot. (See photo.)

Expect the unexpected in Mohs cases. "You can find tumors that look like a basal cell carcinoma and turn out to be a Merkel cell carcinoma," he said.

Microcystic adnexal carcinoma, a rare but deeply infiltrating tumor, can be treated by an experienced Mohs surgeon. Characteristic features of microcystic adnexal carcinoma include a bland appearance, ambiguous histopathology with bizarrely shaped parent cells, and aggressive clinical behavior. Permanent horizontal sections are highly useful in these cases, Dr. Ceilley said.

Lentigo maligna also can be treated with Mohs surgery, and surgeons can use imiquimod (Aldara) to decrease the size of the area prior to surgery and to facilitate healing after surgery.

Finally, for challenging or complex cases, Dr. Ceilley recommends getting permanent paraffin-embedded sections, in addition to the multiple frozen sections that may be needed.

A squamous cell carcinoma of the penis was successfully excised.

After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley

Tips to Ensure Successful Mohs Surgery

I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.

Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.

Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.

After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."

A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.

If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.

Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."

SAN DIEGO — Certain areas of the body are more challenging than others when it comes to Mohs surgery: the nose, ears, and eyelids, as well as urology cases and orthopedic cases on the hands and feet.

These are the places where surgeons, especially beginners, are more likely to get into trouble and where tumors tend to be more aggressive. "Anywhere the skin is closer to bone, the tumor is more likely to spread in an unpredictable manner," Dr. Roger I. Ceilley said at a meeting sponsored by the American Society of Mohs Surgery.

To tackle the tough Mohs surgery cases, physicians need a lot of experience and time spent working with other surgeons, said Dr. Ceilley, a Mohs surgeon and dermatologist in practice in Iowa.

Cancers in the nose, which tend to be deeply invasive and can be hard to detect, have a higher recurrence rate, compared with cancers in other areas, he said. Particularly tricky areas around the nose are the columella, nasolabial groove, supra tip area, and lateral nasal dorsum. Before performing Mohs surgery on tumors of the nose, physicians should conduct a scouting biopsy to determine the extent of the lesions and to remove all scar tissue. Be aware that a tumor of the nose could be the tip of a larger iceberg, and prepare in advance for possible collaboration with a head and neck surgeon, he advised.

Treating cancer of the ear with Mohs surgery may involve working around the parotid gland, as well as around many nerves. Skin cancers of the ear have a 16%–47% recurrence rate, which is higher than that of skin cancers elsewhere. For these cases, it is important to know the anatomy of the ear, especially the nerve distribution and nerve supply. The anatomy of the ear is complex, and the surgeon must anticipate that the tumor may be much larger than it appears clinically. That said, the back of the ear is a good place to perfect one's skin flap technique, he noted.

Most surgeons can handle procedures on the lower eyelid, but upper eyelid tumors require an immediate repair and the use of an eye shield to protect the cornea and prevent corneal dryness.

"I wouldn't tackle tumors on the upper eyelid if you think it will be full thickness because you need to do an immediate repair, and you have to keep a corneal shield in place on the eye to prevent drying of the cornea. A little carbon char can cause a corneal abrasion. Make sure you use plenty of ointment before and after surgery," he said.

If you plan to perform Mohs surgery in the genital area, arrange ahead of time to work with a urologist. Dr. Ceilley discussed a patient with penile cancer who was slated for a penectomy, but was not enthusiastic about that idea and wanted to try Mohs surgery. (See photo.)

The surgery involved use of a catheter, and the tumor had to be followed into the urethra. After excision of the tumor, the wound was not sutured, but allowed to heal by second intention. The patient has had no recurrence of cancer to date. "He has to watch where he points, but he has a functional penis," Dr. Ceilley said.

Mohs surgery also may be used to successfully treat cancer, especially squamous cell carcinoma, on the extremities. In the case of a verrucous squamous cell carcinoma, "the tumor went nearly through to the other side of the foot," he said. Dr. Ceilley collaborated with an orthopedic surgeon, who amputated several toes. The surgeon used the skin from those toes to create skin flaps and give the patient a functional foot. (See photo.)

Expect the unexpected in Mohs cases. "You can find tumors that look like a basal cell carcinoma and turn out to be a Merkel cell carcinoma," he said.

Microcystic adnexal carcinoma, a rare but deeply infiltrating tumor, can be treated by an experienced Mohs surgeon. Characteristic features of microcystic adnexal carcinoma include a bland appearance, ambiguous histopathology with bizarrely shaped parent cells, and aggressive clinical behavior. Permanent horizontal sections are highly useful in these cases, Dr. Ceilley said.

Lentigo maligna also can be treated with Mohs surgery, and surgeons can use imiquimod (Aldara) to decrease the size of the area prior to surgery and to facilitate healing after surgery.

Finally, for challenging or complex cases, Dr. Ceilley recommends getting permanent paraffin-embedded sections, in addition to the multiple frozen sections that may be needed.

A squamous cell carcinoma of the penis was successfully excised.

After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley

Tips to Ensure Successful Mohs Surgery

I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.

Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.

Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.

After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."

A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.

If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.

Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."

ATLANTA — A novel technology that combines diode laser and radiofrequency energy may be safe and effective for treating leg veins, Dr. Neil Sadick reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In a two-center study involving 50 women with lower extremity red or blue leg veins up to 4 mm in diameter, the Polaris LV system (Syneron Inc., Richmond Hill, Ont.) provided at least 50% vessel clearance in 76% of patients. The clearing persisted at 6 months of follow-up, said Dr. Sadick of Cornell University, New York.

The system uses a 915-nm laser. Patients were treated with one to three passes at each of three treatment sessions scheduled at 2-week intervals.

Pre- and posttreatment photographs were graded by patients and an independent physician at a 2-month follow-up visit to determine the level of vessel clearance, and a score was generated by a novel computer-based assessment system. Independent observer analysis was corroborated by the computer imaging analysis.

Biopsy specimens also were provided for histologic assessment, which showed signs of coagulation and prominent endothelial degeneration in all treated vessels, said Dr. Sadick, who is a research consultant for Syneron.

A subsequent study showed that the Polaris LV system's effects were comparable histopathologically with those of the 1064-nm wavelength laser.

Complications with the Polaris LV system were minimal. A slight increase in the amount of hyperpigmentation and bruising was noted, compared with the 1064-nm laser, but pain was considerably less with the 915-nm laser.

ATLANTA — A novel technology that combines diode laser and radiofrequency energy may be safe and effective for treating leg veins, Dr. Neil Sadick reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In a two-center study involving 50 women with lower extremity red or blue leg veins up to 4 mm in diameter, the Polaris LV system (Syneron Inc., Richmond Hill, Ont.) provided at least 50% vessel clearance in 76% of patients. The clearing persisted at 6 months of follow-up, said Dr. Sadick of Cornell University, New York.

The system uses a 915-nm laser. Patients were treated with one to three passes at each of three treatment sessions scheduled at 2-week intervals.

Pre- and posttreatment photographs were graded by patients and an independent physician at a 2-month follow-up visit to determine the level of vessel clearance, and a score was generated by a novel computer-based assessment system. Independent observer analysis was corroborated by the computer imaging analysis.

Biopsy specimens also were provided for histologic assessment, which showed signs of coagulation and prominent endothelial degeneration in all treated vessels, said Dr. Sadick, who is a research consultant for Syneron.

A subsequent study showed that the Polaris LV system's effects were comparable histopathologically with those of the 1064-nm wavelength laser.

Complications with the Polaris LV system were minimal. A slight increase in the amount of hyperpigmentation and bruising was noted, compared with the 1064-nm laser, but pain was considerably less with the 915-nm laser.

ATLANTA — A novel technology that combines diode laser and radiofrequency energy may be safe and effective for treating leg veins, Dr. Neil Sadick reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In a two-center study involving 50 women with lower extremity red or blue leg veins up to 4 mm in diameter, the Polaris LV system (Syneron Inc., Richmond Hill, Ont.) provided at least 50% vessel clearance in 76% of patients. The clearing persisted at 6 months of follow-up, said Dr. Sadick of Cornell University, New York.

The system uses a 915-nm laser. Patients were treated with one to three passes at each of three treatment sessions scheduled at 2-week intervals.

Pre- and posttreatment photographs were graded by patients and an independent physician at a 2-month follow-up visit to determine the level of vessel clearance, and a score was generated by a novel computer-based assessment system. Independent observer analysis was corroborated by the computer imaging analysis.

Biopsy specimens also were provided for histologic assessment, which showed signs of coagulation and prominent endothelial degeneration in all treated vessels, said Dr. Sadick, who is a research consultant for Syneron.

A subsequent study showed that the Polaris LV system's effects were comparable histopathologically with those of the 1064-nm wavelength laser.

Complications with the Polaris LV system were minimal. A slight increase in the amount of hyperpigmentation and bruising was noted, compared with the 1064-nm laser, but pain was considerably less with the 915-nm laser.

BALTIMORE — Lasers and light therapies have a limited role in the treatment of skin cancers and pigmented lesions, but their judicious use may be appropriate when standard treatments would be time consuming or provide poor cosmetic results, Dr. James Spencer said at a meeting sponsored by the Skin Disease Education Foundation.

Dr. Spencer, director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, presented information to help physicians determine when it may be acceptable or unacceptable to use lasers or photodynamic therapies on skin lesions.

CO₂ Laser

Use of a CO₂ laser in continuous wave mode produces rapid and bloodless thermal destruction of tissue, but this mode has not been shown to be an effective treatment for skin cancer, he said. In a study of 24 basal cell carcinomas (BCCs) treated this way, 50% recurred after 1 year and healing after the procedure produced hypopigmentation and atrophy (J. Dermatol. Surg. Oncol. 1979;5:803–6).

Some studies have tested the theory that treatment of superficial skin cancers with the CO₂ laser in ultrapulsed mode could destroy the tumor and avoid scarring. In a series of 51 BCCs that were treated with the CO₂ laser in ultrapulsed mode, dermatologic surgeons were able to ablate 21 superficial BCCs reliably if the level of ablation penetrated to the midreticular dermis or deeper. Attempts to use this method with 28 nodular and 2 infiltrating BCCs were not successful (Br. J. Plast. Surg. 2000;53:286–93).

In another study, two or three passes of an ultrapulsed CO₂ laser on 17 superficial BCCs and 13 squamous cell carcinomas (SCCs) in situ with 3-mm margins onto normal skin left an unacceptably high rate of lesions positive for cancer when they were excised and examined in serial sections. For superficial BCCs, two passes left five of eight lesions positive and three passes left zero of nine lesions positive. Treatment of in situ SCC with two passes yielded two of six lesions positive while three passes resulted in three of seven lesions being positive (Arch. Dermatol. 1998;134:1247–52).

Dr. Spencer said that he did not think CO₂ lasers should realistically be a part of a dermatologist's armamentarium against skin cancer, but he suggested that the CO₂ laser may be considered to treat actinic cheilitis and basal cell nevus syndrome, "where your role is not cure, but control, and you're trying to avoid too much mutilating surgery."

Intravenous and Topical PDT

Intravenously administered photodynamic therapy (PDT) with agents such as porfimer sodium (Photofrin) is being studied for a variety of cancers, but its side effect of photosensitivity for 4–6 weeks through the skin and eyes creates a problem in using it for skin cancers. "If you're dying of a stomach cancer, you will hide in a dark room for a month, but if you've got some basal cell skin cancers, I don't think you will," Dr. Spencer said.

In a prospective study, PDT with intravenous Photofrin and red light yielded a complete response rate of 88% after an average follow-up of 29 months in 37 patients who had a total of 151 BCCs (most patients had basal cell nevus syndrome). Tumors recurred, however, in 36% of lesions on the nose and in 89% of morpheaform tumors (Arch. Dermatol. 1992;128:1597–601).

PDT researchers are studying shorter-acting light-sensitizing compounds that preferentially accumulate in malignant cells to avoid the problem of persistent photosensitivity with Photofrin. Verteporfin, an intravenously administered agent approved for ophthalmologic use that photosensitizes patients for only a few days, is undergoing clinical trials to test its efficacy in skin cancer, he said.

Topical PDT agents such as delta-aminolevulinic acid (ALA), which avoid the photosensitizing problem altogether, have had reported recurrence rates of 44% in 95 superficial BCCs and 69% in 35 superficial SCCs after 19 months of follow-up (Arch. Dermatol. 1998;134:821–6). "You should not be doing this in your practice," said Dr. Spencer, who also has a private practice in St. Petersburg, Fla.

Eyelid tumors may represent the best opportunity to try topical ALA because it is usually desirable to avoid surgery in that area and ALA may be able to more fully penetrate the thin skin of the eyelid, he suggested. In one study, topical PDT ALA treatment clinically resolved 8 of 19 nodular BCCs on the eyelids and periocular skin, while the other lesions had partial or no response (Acta Ophthalmol. Scand. 1999;77:182–8).

In a study of topical PDT with methyl-5 ALA, 79% of 350 nodular BCCs that were curetted before treatment with PDT were clinically clear. After 2–4 years' follow-up, 11% of the clinically clear lesions recurred (Br. J. Dermatol. 2001;145:467–71).

Lasers That Target Melanin

Lasers should not be used as a substitute for surgical removal of lentigo maligna, Dr. Spencer said.

In 11 patients with lentigo maligna who were treated with the Q-switched ruby laser on four occasions in a 6-month period, 6 of 13 biopsies taken after treatment were still positive for the lesion. Studies of lentigo maligna treatments with 532-nm and 1,064-nm Q-switched Nd:YAG lasers have shown similar results.

Some people may want to undergo laser removal of common acquired nevi for cosmetic reasons. There is a variable response to such treatment, in which nevi partially or completely lighten in color. This "debulks" and superficially removes the nevus from the epidermis but leaves residual nevus cells in the dermis, he said.

It is unclear if laser treatment of dysplastic or congenital, especially giant, nevi reduces the risk of melanoma. Treatment of atypical-appearing melanocytic lesions with lasers can provide an excellent cosmetic result, but it may run the risk of promoting malignant transformation. Lasers strip a lesion of its outer layer of UV-protecting melanin and create a scar in the papillary dermis that may clinically mask a deeper component, Dr. Spencer said.

"These concerns are very real," he said, but "people have been cautiously trying lasers on nevi for 20 years, and we haven't seen any malignant transformation."

Dr. Spencer said that laser removal of nevi "should be studied in a more formal way, but people have been very afraid to do this."

Clinicians have widely accepted the removal of nevi of Ota with lasers for only cosmetic improvement, so laser removal of large congenital and common acquired nevi should be considered, he said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

BALTIMORE — Lasers and light therapies have a limited role in the treatment of skin cancers and pigmented lesions, but their judicious use may be appropriate when standard treatments would be time consuming or provide poor cosmetic results, Dr. James Spencer said at a meeting sponsored by the Skin Disease Education Foundation.

Dr. Spencer, director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, presented information to help physicians determine when it may be acceptable or unacceptable to use lasers or photodynamic therapies on skin lesions.

CO₂ Laser

Use of a CO₂ laser in continuous wave mode produces rapid and bloodless thermal destruction of tissue, but this mode has not been shown to be an effective treatment for skin cancer, he said. In a study of 24 basal cell carcinomas (BCCs) treated this way, 50% recurred after 1 year and healing after the procedure produced hypopigmentation and atrophy (J. Dermatol. Surg. Oncol. 1979;5:803–6).

Some studies have tested the theory that treatment of superficial skin cancers with the CO₂ laser in ultrapulsed mode could destroy the tumor and avoid scarring. In a series of 51 BCCs that were treated with the CO₂ laser in ultrapulsed mode, dermatologic surgeons were able to ablate 21 superficial BCCs reliably if the level of ablation penetrated to the midreticular dermis or deeper. Attempts to use this method with 28 nodular and 2 infiltrating BCCs were not successful (Br. J. Plast. Surg. 2000;53:286–93).

In another study, two or three passes of an ultrapulsed CO₂ laser on 17 superficial BCCs and 13 squamous cell carcinomas (SCCs) in situ with 3-mm margins onto normal skin left an unacceptably high rate of lesions positive for cancer when they were excised and examined in serial sections. For superficial BCCs, two passes left five of eight lesions positive and three passes left zero of nine lesions positive. Treatment of in situ SCC with two passes yielded two of six lesions positive while three passes resulted in three of seven lesions being positive (Arch. Dermatol. 1998;134:1247–52).

Dr. Spencer said that he did not think CO₂ lasers should realistically be a part of a dermatologist's armamentarium against skin cancer, but he suggested that the CO₂ laser may be considered to treat actinic cheilitis and basal cell nevus syndrome, "where your role is not cure, but control, and you're trying to avoid too much mutilating surgery."

Intravenous and Topical PDT

Intravenously administered photodynamic therapy (PDT) with agents such as porfimer sodium (Photofrin) is being studied for a variety of cancers, but its side effect of photosensitivity for 4–6 weeks through the skin and eyes creates a problem in using it for skin cancers. "If you're dying of a stomach cancer, you will hide in a dark room for a month, but if you've got some basal cell skin cancers, I don't think you will," Dr. Spencer said.

In a prospective study, PDT with intravenous Photofrin and red light yielded a complete response rate of 88% after an average follow-up of 29 months in 37 patients who had a total of 151 BCCs (most patients had basal cell nevus syndrome). Tumors recurred, however, in 36% of lesions on the nose and in 89% of morpheaform tumors (Arch. Dermatol. 1992;128:1597–601).

PDT researchers are studying shorter-acting light-sensitizing compounds that preferentially accumulate in malignant cells to avoid the problem of persistent photosensitivity with Photofrin. Verteporfin, an intravenously administered agent approved for ophthalmologic use that photosensitizes patients for only a few days, is undergoing clinical trials to test its efficacy in skin cancer, he said.

Topical PDT agents such as delta-aminolevulinic acid (ALA), which avoid the photosensitizing problem altogether, have had reported recurrence rates of 44% in 95 superficial BCCs and 69% in 35 superficial SCCs after 19 months of follow-up (Arch. Dermatol. 1998;134:821–6). "You should not be doing this in your practice," said Dr. Spencer, who also has a private practice in St. Petersburg, Fla.

Eyelid tumors may represent the best opportunity to try topical ALA because it is usually desirable to avoid surgery in that area and ALA may be able to more fully penetrate the thin skin of the eyelid, he suggested. In one study, topical PDT ALA treatment clinically resolved 8 of 19 nodular BCCs on the eyelids and periocular skin, while the other lesions had partial or no response (Acta Ophthalmol. Scand. 1999;77:182–8).

In a study of topical PDT with methyl-5 ALA, 79% of 350 nodular BCCs that were curetted before treatment with PDT were clinically clear. After 2–4 years' follow-up, 11% of the clinically clear lesions recurred (Br. J. Dermatol. 2001;145:467–71).

Lasers That Target Melanin

Lasers should not be used as a substitute for surgical removal of lentigo maligna, Dr. Spencer said.

In 11 patients with lentigo maligna who were treated with the Q-switched ruby laser on four occasions in a 6-month period, 6 of 13 biopsies taken after treatment were still positive for the lesion. Studies of lentigo maligna treatments with 532-nm and 1,064-nm Q-switched Nd:YAG lasers have shown similar results.

Some people may want to undergo laser removal of common acquired nevi for cosmetic reasons. There is a variable response to such treatment, in which nevi partially or completely lighten in color. This "debulks" and superficially removes the nevus from the epidermis but leaves residual nevus cells in the dermis, he said.

It is unclear if laser treatment of dysplastic or congenital, especially giant, nevi reduces the risk of melanoma. Treatment of atypical-appearing melanocytic lesions with lasers can provide an excellent cosmetic result, but it may run the risk of promoting malignant transformation. Lasers strip a lesion of its outer layer of UV-protecting melanin and create a scar in the papillary dermis that may clinically mask a deeper component, Dr. Spencer said.

"These concerns are very real," he said, but "people have been cautiously trying lasers on nevi for 20 years, and we haven't seen any malignant transformation."

Dr. Spencer said that laser removal of nevi "should be studied in a more formal way, but people have been very afraid to do this."

Clinicians have widely accepted the removal of nevi of Ota with lasers for only cosmetic improvement, so laser removal of large congenital and common acquired nevi should be considered, he said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

BALTIMORE — Lasers and light therapies have a limited role in the treatment of skin cancers and pigmented lesions, but their judicious use may be appropriate when standard treatments would be time consuming or provide poor cosmetic results, Dr. James Spencer said at a meeting sponsored by the Skin Disease Education Foundation.

Dr. Spencer, director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, presented information to help physicians determine when it may be acceptable or unacceptable to use lasers or photodynamic therapies on skin lesions.

CO₂ Laser

Use of a CO₂ laser in continuous wave mode produces rapid and bloodless thermal destruction of tissue, but this mode has not been shown to be an effective treatment for skin cancer, he said. In a study of 24 basal cell carcinomas (BCCs) treated this way, 50% recurred after 1 year and healing after the procedure produced hypopigmentation and atrophy (J. Dermatol. Surg. Oncol. 1979;5:803–6).

Some studies have tested the theory that treatment of superficial skin cancers with the CO₂ laser in ultrapulsed mode could destroy the tumor and avoid scarring. In a series of 51 BCCs that were treated with the CO₂ laser in ultrapulsed mode, dermatologic surgeons were able to ablate 21 superficial BCCs reliably if the level of ablation penetrated to the midreticular dermis or deeper. Attempts to use this method with 28 nodular and 2 infiltrating BCCs were not successful (Br. J. Plast. Surg. 2000;53:286–93).

In another study, two or three passes of an ultrapulsed CO₂ laser on 17 superficial BCCs and 13 squamous cell carcinomas (SCCs) in situ with 3-mm margins onto normal skin left an unacceptably high rate of lesions positive for cancer when they were excised and examined in serial sections. For superficial BCCs, two passes left five of eight lesions positive and three passes left zero of nine lesions positive. Treatment of in situ SCC with two passes yielded two of six lesions positive while three passes resulted in three of seven lesions being positive (Arch. Dermatol. 1998;134:1247–52).

Dr. Spencer said that he did not think CO₂ lasers should realistically be a part of a dermatologist's armamentarium against skin cancer, but he suggested that the CO₂ laser may be considered to treat actinic cheilitis and basal cell nevus syndrome, "where your role is not cure, but control, and you're trying to avoid too much mutilating surgery."

Intravenous and Topical PDT

Intravenously administered photodynamic therapy (PDT) with agents such as porfimer sodium (Photofrin) is being studied for a variety of cancers, but its side effect of photosensitivity for 4–6 weeks through the skin and eyes creates a problem in using it for skin cancers. "If you're dying of a stomach cancer, you will hide in a dark room for a month, but if you've got some basal cell skin cancers, I don't think you will," Dr. Spencer said.

In a prospective study, PDT with intravenous Photofrin and red light yielded a complete response rate of 88% after an average follow-up of 29 months in 37 patients who had a total of 151 BCCs (most patients had basal cell nevus syndrome). Tumors recurred, however, in 36% of lesions on the nose and in 89% of morpheaform tumors (Arch. Dermatol. 1992;128:1597–601).

PDT researchers are studying shorter-acting light-sensitizing compounds that preferentially accumulate in malignant cells to avoid the problem of persistent photosensitivity with Photofrin. Verteporfin, an intravenously administered agent approved for ophthalmologic use that photosensitizes patients for only a few days, is undergoing clinical trials to test its efficacy in skin cancer, he said.

Topical PDT agents such as delta-aminolevulinic acid (ALA), which avoid the photosensitizing problem altogether, have had reported recurrence rates of 44% in 95 superficial BCCs and 69% in 35 superficial SCCs after 19 months of follow-up (Arch. Dermatol. 1998;134:821–6). "You should not be doing this in your practice," said Dr. Spencer, who also has a private practice in St. Petersburg, Fla.

Eyelid tumors may represent the best opportunity to try topical ALA because it is usually desirable to avoid surgery in that area and ALA may be able to more fully penetrate the thin skin of the eyelid, he suggested. In one study, topical PDT ALA treatment clinically resolved 8 of 19 nodular BCCs on the eyelids and periocular skin, while the other lesions had partial or no response (Acta Ophthalmol. Scand. 1999;77:182–8).

In a study of topical PDT with methyl-5 ALA, 79% of 350 nodular BCCs that were curetted before treatment with PDT were clinically clear. After 2–4 years' follow-up, 11% of the clinically clear lesions recurred (Br. J. Dermatol. 2001;145:467–71).

Lasers That Target Melanin

Lasers should not be used as a substitute for surgical removal of lentigo maligna, Dr. Spencer said.

In 11 patients with lentigo maligna who were treated with the Q-switched ruby laser on four occasions in a 6-month period, 6 of 13 biopsies taken after treatment were still positive for the lesion. Studies of lentigo maligna treatments with 532-nm and 1,064-nm Q-switched Nd:YAG lasers have shown similar results.

Some people may want to undergo laser removal of common acquired nevi for cosmetic reasons. There is a variable response to such treatment, in which nevi partially or completely lighten in color. This "debulks" and superficially removes the nevus from the epidermis but leaves residual nevus cells in the dermis, he said.

It is unclear if laser treatment of dysplastic or congenital, especially giant, nevi reduces the risk of melanoma. Treatment of atypical-appearing melanocytic lesions with lasers can provide an excellent cosmetic result, but it may run the risk of promoting malignant transformation. Lasers strip a lesion of its outer layer of UV-protecting melanin and create a scar in the papillary dermis that may clinically mask a deeper component, Dr. Spencer said.

"These concerns are very real," he said, but "people have been cautiously trying lasers on nevi for 20 years, and we haven't seen any malignant transformation."

Dr. Spencer said that laser removal of nevi "should be studied in a more formal way, but people have been very afraid to do this."

Clinicians have widely accepted the removal of nevi of Ota with lasers for only cosmetic improvement, so laser removal of large congenital and common acquired nevi should be considered, he said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LONDON — Excimer laser treatment with minigrafting offers a new approach to repigmentation in vitiligo, according to Dr. Ludmila Nieuweboer-Krobotova of the Netherlands Institute for Pigment Disorders, University of Amsterdam.

The excimer laser has been used alone and in conjunction with topical therapies including tacrolimus and 8-methoxypsoralen. In the first preliminary study using this 308-nm laser with minigrafting in 20 patients with stable vitiligo, nine patients (45%) had 75%–99% repigmentation after 3 months, Dr. Nieuweboer-Krobotova reported in a poster session at the 14th Congress of the European Academy of Dermatology and Venereology.

Minigrafting was performed using 1.5-mm full-thickness punch grafts that were removed from a normally pigmented donor site. Grafted areas then were irradiated with the excimer laser twice weekly for 3 months.

The beginnings of repigmentation were visible after only 2 weeks, which is earlier than when narrowband UVB is used after minigrafting. At 3 months, three patients had 51%–74% repigmentation, four had 25%–50%, and four had 0%–24%.

LONDON — Excimer laser treatment with minigrafting offers a new approach to repigmentation in vitiligo, according to Dr. Ludmila Nieuweboer-Krobotova of the Netherlands Institute for Pigment Disorders, University of Amsterdam.

The excimer laser has been used alone and in conjunction with topical therapies including tacrolimus and 8-methoxypsoralen. In the first preliminary study using this 308-nm laser with minigrafting in 20 patients with stable vitiligo, nine patients (45%) had 75%–99% repigmentation after 3 months, Dr. Nieuweboer-Krobotova reported in a poster session at the 14th Congress of the European Academy of Dermatology and Venereology.

Minigrafting was performed using 1.5-mm full-thickness punch grafts that were removed from a normally pigmented donor site. Grafted areas then were irradiated with the excimer laser twice weekly for 3 months.

The beginnings of repigmentation were visible after only 2 weeks, which is earlier than when narrowband UVB is used after minigrafting. At 3 months, three patients had 51%–74% repigmentation, four had 25%–50%, and four had 0%–24%.

LONDON — Excimer laser treatment with minigrafting offers a new approach to repigmentation in vitiligo, according to Dr. Ludmila Nieuweboer-Krobotova of the Netherlands Institute for Pigment Disorders, University of Amsterdam.

The excimer laser has been used alone and in conjunction with topical therapies including tacrolimus and 8-methoxypsoralen. In the first preliminary study using this 308-nm laser with minigrafting in 20 patients with stable vitiligo, nine patients (45%) had 75%–99% repigmentation after 3 months, Dr. Nieuweboer-Krobotova reported in a poster session at the 14th Congress of the European Academy of Dermatology and Venereology.

Minigrafting was performed using 1.5-mm full-thickness punch grafts that were removed from a normally pigmented donor site. Grafted areas then were irradiated with the excimer laser twice weekly for 3 months.

The beginnings of repigmentation were visible after only 2 weeks, which is earlier than when narrowband UVB is used after minigrafting. At 3 months, three patients had 51%–74% repigmentation, four had 25%–50%, and four had 0%–24%.

ATLANTA — A new device that combines pulsed light and radiofrequency energy is proving highly effective for the treatment of acne vulgaris, Dr. Neil Sadick reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In 32 patients with moderate acne who were treated twice a week for 4 weeks, the combined use of optical and conducted bipolar radiofrequency energy reduced the average lesion count by 47%. Of patients surveyed, 59% rated overall improvement as good, 32% rated it as very good, and 4.5% rated it as excellent. Another 4.5% had mild or no improvement, said Dr. Sadick, clinical professor of dermatology at Cornell University, New York.

Biopsies were performed on four of the patients prior to treatment, 1 week after the initial treatment, and 1 month after the initial treatment. Compared with the baseline biopsy, the last biopsy showed a lower percentage of follicles with perifolliculitis (58% vs. 33%, respectively) and a reduction in the size of sebaceous glands (0.092 mm

The patients were treated using the Aurora AC device (Syneron Inc., Richmond Hill, Ont.). Those with Fitzpatrick skin types I-IV were treated with pulsed light of 8–10 J/cm

The combined use of optical energy and conducted bipolar radiofrequency current affects Propionibacterium acnes directly by photochemical activation of porphyrins, and by selective hyperthemia of the sebaceous glands. The radiofrequency energy supplements the optical energy and raises the temperature of the sebaceous glands, severely damaging the bacteria, Dr. Sadick explained.

Dr. Sadick is a research consultant for Syneron Inc.

Patient is shown at baseline and after 1 month of twice weekly treatments. Photos courtesy Dr. Neil Sadick

ATLANTA — A new device that combines pulsed light and radiofrequency energy is proving highly effective for the treatment of acne vulgaris, Dr. Neil Sadick reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In 32 patients with moderate acne who were treated twice a week for 4 weeks, the combined use of optical and conducted bipolar radiofrequency energy reduced the average lesion count by 47%. Of patients surveyed, 59% rated overall improvement as good, 32% rated it as very good, and 4.5% rated it as excellent. Another 4.5% had mild or no improvement, said Dr. Sadick, clinical professor of dermatology at Cornell University, New York.

Biopsies were performed on four of the patients prior to treatment, 1 week after the initial treatment, and 1 month after the initial treatment. Compared with the baseline biopsy, the last biopsy showed a lower percentage of follicles with perifolliculitis (58% vs. 33%, respectively) and a reduction in the size of sebaceous glands (0.092 mm

The patients were treated using the Aurora AC device (Syneron Inc., Richmond Hill, Ont.). Those with Fitzpatrick skin types I-IV were treated with pulsed light of 8–10 J/cm

The combined use of optical energy and conducted bipolar radiofrequency current affects Propionibacterium acnes directly by photochemical activation of porphyrins, and by selective hyperthemia of the sebaceous glands. The radiofrequency energy supplements the optical energy and raises the temperature of the sebaceous glands, severely damaging the bacteria, Dr. Sadick explained.

Dr. Sadick is a research consultant for Syneron Inc.

Patient is shown at baseline and after 1 month of twice weekly treatments. Photos courtesy Dr. Neil Sadick

ATLANTA — A new device that combines pulsed light and radiofrequency energy is proving highly effective for the treatment of acne vulgaris, Dr. Neil Sadick reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In 32 patients with moderate acne who were treated twice a week for 4 weeks, the combined use of optical and conducted bipolar radiofrequency energy reduced the average lesion count by 47%. Of patients surveyed, 59% rated overall improvement as good, 32% rated it as very good, and 4.5% rated it as excellent. Another 4.5% had mild or no improvement, said Dr. Sadick, clinical professor of dermatology at Cornell University, New York.

Biopsies were performed on four of the patients prior to treatment, 1 week after the initial treatment, and 1 month after the initial treatment. Compared with the baseline biopsy, the last biopsy showed a lower percentage of follicles with perifolliculitis (58% vs. 33%, respectively) and a reduction in the size of sebaceous glands (0.092 mm

The patients were treated using the Aurora AC device (Syneron Inc., Richmond Hill, Ont.). Those with Fitzpatrick skin types I-IV were treated with pulsed light of 8–10 J/cm

The combined use of optical energy and conducted bipolar radiofrequency current affects Propionibacterium acnes directly by photochemical activation of porphyrins, and by selective hyperthemia of the sebaceous glands. The radiofrequency energy supplements the optical energy and raises the temperature of the sebaceous glands, severely damaging the bacteria, Dr. Sadick explained.

Dr. Sadick is a research consultant for Syneron Inc.

Patient is shown at baseline and after 1 month of twice weekly treatments. Photos courtesy Dr. Neil Sadick

CHICAGO — A single 10 minimal erythema dose from an excimer laser can safely and effectively treat moderate to severe plaque psoriasis, Kevin D. Cooper, M.D., said at the 11th International Psoriasis Symposium sponsored by the Skin Disease Education Foundation.

The 308-nm XTRAC excimer laser treatment system (PhotoMedex, Montgomeryville, Pa.) is the first laser treatment approved for psoriasis.

It offers an obvious advantage over conventional phototherapy because it can target lesional skin with a higher initial dose of ultraviolet radiation, he said.

What hasn't been known is the optimal dose needed to treat moderate to severe psoriasis.

A minimal erythema dose (MED) of 4–16 has been used. But crusting of the involved skin can occur if the dose exceeds 10 MED, said Dr. Cooper, professor and chair of dermatology at Case Western Reserve University, Cleveland.

In a study that was led by his former colleague Mark Kagen, M.D., 15 patients with a mean Psoriasis Area and Severity Index (PASI) score of 18.9 and a lesional thickness of 168 μm were treated on the trunk and extremities with a single dose of 10 MED from the XTRAC excimer laser.

Patients responded rapidly at 2 and 4 weeks post treatment. On average, PASI scores were reduced from 18.9 at baseline to 8 by week 8.

"What's remarkable is that this is a single dose," Dr. Cooper said.

The response was limited to the area treated, but improvement was noted in patients of all skin types, including Fitzpatrick skin type V.

Biopsies were performed on lesions in eight patients. Lesion thickness decreased, and depletion of epidermal and dermal T cells also was observed. T-cell counts decreased from 50–55 at baseline to 15 at 8 weeks post treatment.

Dr. Cooper and Dr. Kagen, now in private practice in Orlando, do not have a relevant conflict of interest.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

CHICAGO — A single 10 minimal erythema dose from an excimer laser can safely and effectively treat moderate to severe plaque psoriasis, Kevin D. Cooper, M.D., said at the 11th International Psoriasis Symposium sponsored by the Skin Disease Education Foundation.

The 308-nm XTRAC excimer laser treatment system (PhotoMedex, Montgomeryville, Pa.) is the first laser treatment approved for psoriasis.

It offers an obvious advantage over conventional phototherapy because it can target lesional skin with a higher initial dose of ultraviolet radiation, he said.

What hasn't been known is the optimal dose needed to treat moderate to severe psoriasis.

A minimal erythema dose (MED) of 4–16 has been used. But crusting of the involved skin can occur if the dose exceeds 10 MED, said Dr. Cooper, professor and chair of dermatology at Case Western Reserve University, Cleveland.

In a study that was led by his former colleague Mark Kagen, M.D., 15 patients with a mean Psoriasis Area and Severity Index (PASI) score of 18.9 and a lesional thickness of 168 μm were treated on the trunk and extremities with a single dose of 10 MED from the XTRAC excimer laser.

Patients responded rapidly at 2 and 4 weeks post treatment. On average, PASI scores were reduced from 18.9 at baseline to 8 by week 8.

"What's remarkable is that this is a single dose," Dr. Cooper said.

The response was limited to the area treated, but improvement was noted in patients of all skin types, including Fitzpatrick skin type V.

Biopsies were performed on lesions in eight patients. Lesion thickness decreased, and depletion of epidermal and dermal T cells also was observed. T-cell counts decreased from 50–55 at baseline to 15 at 8 weeks post treatment.

Dr. Cooper and Dr. Kagen, now in private practice in Orlando, do not have a relevant conflict of interest.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

CHICAGO — A single 10 minimal erythema dose from an excimer laser can safely and effectively treat moderate to severe plaque psoriasis, Kevin D. Cooper, M.D., said at the 11th International Psoriasis Symposium sponsored by the Skin Disease Education Foundation.

The 308-nm XTRAC excimer laser treatment system (PhotoMedex, Montgomeryville, Pa.) is the first laser treatment approved for psoriasis.

It offers an obvious advantage over conventional phototherapy because it can target lesional skin with a higher initial dose of ultraviolet radiation, he said.

What hasn't been known is the optimal dose needed to treat moderate to severe psoriasis.

A minimal erythema dose (MED) of 4–16 has been used. But crusting of the involved skin can occur if the dose exceeds 10 MED, said Dr. Cooper, professor and chair of dermatology at Case Western Reserve University, Cleveland.

In a study that was led by his former colleague Mark Kagen, M.D., 15 patients with a mean Psoriasis Area and Severity Index (PASI) score of 18.9 and a lesional thickness of 168 μm were treated on the trunk and extremities with a single dose of 10 MED from the XTRAC excimer laser.

Patients responded rapidly at 2 and 4 weeks post treatment. On average, PASI scores were reduced from 18.9 at baseline to 8 by week 8.

"What's remarkable is that this is a single dose," Dr. Cooper said.

The response was limited to the area treated, but improvement was noted in patients of all skin types, including Fitzpatrick skin type V.

Biopsies were performed on lesions in eight patients. Lesion thickness decreased, and depletion of epidermal and dermal T cells also was observed. T-cell counts decreased from 50–55 at baseline to 15 at 8 weeks post treatment.

Dr. Cooper and Dr. Kagen, now in private practice in Orlando, do not have a relevant conflict of interest.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ATLANTA — A novel anchored rotation flap for infraorbital cheek reconstruction allows full defect repair without causing lower-lid ectropion, Dr. Kord Honda said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The technique involves the use of an anchoring suture to allow an inferiorly based rotation flap for horizontal defects of the midpupillary and medial infraorbital cheek. The suture allows horizontal redirection of the flap tension vectors, which helps prevent ectropion, explained Dr. Honda, a dermatology resident at the University of Washington, Seattle.

In four patients with defects ranging in size from 1.4 by 2.9 cm to 2.4 by 3.4 cm, outcomes at up to 3 months were excellent, with no evidence of lower-lid ectropion, he said.

The long axes of the defects in all four patients were horizontally oriented: Two were centered on the midpupillary line, and two were located medially.

The patients first underwent Mohs surgery for complete skin cancer removal; then the edges of the defect were made perpendicular. An incision was made to the midsubcutaneous fat at a 90-degree angle along the nasofacial sulcus and extended into the melolabial fold if necessary.

The flap, designed to rotate tissue from the inferior aspect of the defect, was undermined with sharp dissection in the midsubcutaneus fat. The anchoring suture was placed first and served as the key stitch. This suture was placed from the superior medial portion of the flap into the periosteum of the superior nasal sidewall or medial maxilla, Dr. Honda reported.

Testing for ectropion and eclabium was performed. The wound edges were approximated with a running 5–0 or 6–0 nylon suture with tension placed horizontally to prevent ectropion.

This anchored rotation flap is a one-stage procedure that preserves the eyelid margin and is ideal for horizontally oriented defects, he said.

ATLANTA — A novel anchored rotation flap for infraorbital cheek reconstruction allows full defect repair without causing lower-lid ectropion, Dr. Kord Honda said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The technique involves the use of an anchoring suture to allow an inferiorly based rotation flap for horizontal defects of the midpupillary and medial infraorbital cheek. The suture allows horizontal redirection of the flap tension vectors, which helps prevent ectropion, explained Dr. Honda, a dermatology resident at the University of Washington, Seattle.

In four patients with defects ranging in size from 1.4 by 2.9 cm to 2.4 by 3.4 cm, outcomes at up to 3 months were excellent, with no evidence of lower-lid ectropion, he said.

The long axes of the defects in all four patients were horizontally oriented: Two were centered on the midpupillary line, and two were located medially.

The patients first underwent Mohs surgery for complete skin cancer removal; then the edges of the defect were made perpendicular. An incision was made to the midsubcutaneous fat at a 90-degree angle along the nasofacial sulcus and extended into the melolabial fold if necessary.

The flap, designed to rotate tissue from the inferior aspect of the defect, was undermined with sharp dissection in the midsubcutaneus fat. The anchoring suture was placed first and served as the key stitch. This suture was placed from the superior medial portion of the flap into the periosteum of the superior nasal sidewall or medial maxilla, Dr. Honda reported.

Testing for ectropion and eclabium was performed. The wound edges were approximated with a running 5–0 or 6–0 nylon suture with tension placed horizontally to prevent ectropion.

This anchored rotation flap is a one-stage procedure that preserves the eyelid margin and is ideal for horizontally oriented defects, he said.

ATLANTA — A novel anchored rotation flap for infraorbital cheek reconstruction allows full defect repair without causing lower-lid ectropion, Dr. Kord Honda said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The technique involves the use of an anchoring suture to allow an inferiorly based rotation flap for horizontal defects of the midpupillary and medial infraorbital cheek. The suture allows horizontal redirection of the flap tension vectors, which helps prevent ectropion, explained Dr. Honda, a dermatology resident at the University of Washington, Seattle.

In four patients with defects ranging in size from 1.4 by 2.9 cm to 2.4 by 3.4 cm, outcomes at up to 3 months were excellent, with no evidence of lower-lid ectropion, he said.

The long axes of the defects in all four patients were horizontally oriented: Two were centered on the midpupillary line, and two were located medially.

The patients first underwent Mohs surgery for complete skin cancer removal; then the edges of the defect were made perpendicular. An incision was made to the midsubcutaneous fat at a 90-degree angle along the nasofacial sulcus and extended into the melolabial fold if necessary.

The flap, designed to rotate tissue from the inferior aspect of the defect, was undermined with sharp dissection in the midsubcutaneus fat. The anchoring suture was placed first and served as the key stitch. This suture was placed from the superior medial portion of the flap into the periosteum of the superior nasal sidewall or medial maxilla, Dr. Honda reported.

Testing for ectropion and eclabium was performed. The wound edges were approximated with a running 5–0 or 6–0 nylon suture with tension placed horizontally to prevent ectropion.

This anchored rotation flap is a one-stage procedure that preserves the eyelid margin and is ideal for horizontally oriented defects, he said.

ATLANTA — Fractional photothermolysis for skin rejuvenation provides results similar to those achieved with ablative laser resurfacing, but without the downtime, Dr. Tina Alster said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The new fiber laser technology is particularly good for treating dyspigmentation and rhytides, and can be used on areas other than the face, such as the arms, neck, chest, and hands, said Dr. Alster, director of the Washington Institute of Dermatologic Laser Surgery.

Of about 20 lasers that she uses in her practice, the Fraxel laser (Reliant Technologies Inc., Palo Alto, Calif.) is one of those she uses most often.

According to information from Reliant, the Fraxel laser system—which is approved for the treatment of melasma but also has been used for surgical and acne scars, striae, and actinic keratoses—treats the skin fractionally, with patterns of microscopic laser spots that are 70–100 μm in diameter. Each laser spot is called a microthermal zone, or MTZ, and the laser can deliver 2,000 MTZs per cm

The use of the MTZs with adjacent untreated tissue allows fractional wound healing with rapid reepithelialization of the epidermis and collagen remodeling to depths of 400–700 μm. This is compared with the 200-μm depth achieved with traditional ablative laser treatments.

Histology following treatment shows that the stratum corneum remains intact and epidermal tissue is coagulated. Collagen remodeling is also demonstrated, explained Dr. Alster, who reported no financial interest in the device.

"You see reepithelialization of the whole site within 24 hours," she said.

Her treatment protocol involves skin cleansing and application of a blue tint, which is required for the laser to work. About 30–60 minutes prior to the procedure, she also applies a topical anesthetic containing 30% lidocaine.

Dr. Alster said she usually uses 8–10 MJ per cm

Patients usually require two to four treatments at 2− to 4-week intervals. Most come back monthly to complete the series of treatments, she said. The skin is erythematous immediately after each treatment and remains so for approximately 2 days. On day 2 or 3, a variable amount of peeling occurs, resulting in rough-feeling skin.

Results are incremental, with additional improvement seen after each treatment. Most patients will achieve 50% improvement when being treated for dyspigmentation and/or rhytides. Although the laser is not marketed as a skin tightening device, it does provide some skin tightening, Dr. Alster noted.

The results are better than what she has experienced with trichloroacetic acid peels, particularly for fine lines, she said, and the recovery time is much quicker than with ablative resurfacing.

Dr. David Goldberg of Skin Laser and Surgery Specialists of New York and New Jersey agreed that fractional photothermolysis has several applications and a relatively good safety profile, but he cautions that adverse events are still possible. Scarring, for example, can occur when the device is held in one place for too long.

Dr. Goldberg also noted that many of the effects of this laser can be achieved with other modalities.

"It clearly works," he said, but it's not the "end all and be all."

For example, acne scarring responds well to the Fraxel laser, but it can also be treated effectively with the CoolTouch or Smoothbeam lasers. Crow's-feet can be treated effectively with botulinum toxin, and lentigines can be treated effectively with the Q-switched laser and intense pulsed light, Dr. Goldberg said.

"This is not a system that you buy simply to treat lentigines; this is not a system you buy simply to treat crow's-feet … but I think that you can't argue the fact that when you put the whole picture together, it's got tremendous diversity, and that diversity has led to its popularity," he said.

Dr. Goldberg has received a research grant from Reliant Technologies Inc.

ATLANTA — Fractional photothermolysis for skin rejuvenation provides results similar to those achieved with ablative laser resurfacing, but without the downtime, Dr. Tina Alster said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The new fiber laser technology is particularly good for treating dyspigmentation and rhytides, and can be used on areas other than the face, such as the arms, neck, chest, and hands, said Dr. Alster, director of the Washington Institute of Dermatologic Laser Surgery.

Of about 20 lasers that she uses in her practice, the Fraxel laser (Reliant Technologies Inc., Palo Alto, Calif.) is one of those she uses most often.

According to information from Reliant, the Fraxel laser system—which is approved for the treatment of melasma but also has been used for surgical and acne scars, striae, and actinic keratoses—treats the skin fractionally, with patterns of microscopic laser spots that are 70–100 μm in diameter. Each laser spot is called a microthermal zone, or MTZ, and the laser can deliver 2,000 MTZs per cm

The use of the MTZs with adjacent untreated tissue allows fractional wound healing with rapid reepithelialization of the epidermis and collagen remodeling to depths of 400–700 μm. This is compared with the 200-μm depth achieved with traditional ablative laser treatments.

Histology following treatment shows that the stratum corneum remains intact and epidermal tissue is coagulated. Collagen remodeling is also demonstrated, explained Dr. Alster, who reported no financial interest in the device.

"You see reepithelialization of the whole site within 24 hours," she said.

Her treatment protocol involves skin cleansing and application of a blue tint, which is required for the laser to work. About 30–60 minutes prior to the procedure, she also applies a topical anesthetic containing 30% lidocaine.

Dr. Alster said she usually uses 8–10 MJ per cm

Patients usually require two to four treatments at 2− to 4-week intervals. Most come back monthly to complete the series of treatments, she said. The skin is erythematous immediately after each treatment and remains so for approximately 2 days. On day 2 or 3, a variable amount of peeling occurs, resulting in rough-feeling skin.

Results are incremental, with additional improvement seen after each treatment. Most patients will achieve 50% improvement when being treated for dyspigmentation and/or rhytides. Although the laser is not marketed as a skin tightening device, it does provide some skin tightening, Dr. Alster noted.

The results are better than what she has experienced with trichloroacetic acid peels, particularly for fine lines, she said, and the recovery time is much quicker than with ablative resurfacing.

Dr. David Goldberg of Skin Laser and Surgery Specialists of New York and New Jersey agreed that fractional photothermolysis has several applications and a relatively good safety profile, but he cautions that adverse events are still possible. Scarring, for example, can occur when the device is held in one place for too long.

Dr. Goldberg also noted that many of the effects of this laser can be achieved with other modalities.

"It clearly works," he said, but it's not the "end all and be all."

For example, acne scarring responds well to the Fraxel laser, but it can also be treated effectively with the CoolTouch or Smoothbeam lasers. Crow's-feet can be treated effectively with botulinum toxin, and lentigines can be treated effectively with the Q-switched laser and intense pulsed light, Dr. Goldberg said.

"This is not a system that you buy simply to treat lentigines; this is not a system you buy simply to treat crow's-feet … but I think that you can't argue the fact that when you put the whole picture together, it's got tremendous diversity, and that diversity has led to its popularity," he said.

Dr. Goldberg has received a research grant from Reliant Technologies Inc.

ATLANTA — Fractional photothermolysis for skin rejuvenation provides results similar to those achieved with ablative laser resurfacing, but without the downtime, Dr. Tina Alster said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The new fiber laser technology is particularly good for treating dyspigmentation and rhytides, and can be used on areas other than the face, such as the arms, neck, chest, and hands, said Dr. Alster, director of the Washington Institute of Dermatologic Laser Surgery.

Of about 20 lasers that she uses in her practice, the Fraxel laser (Reliant Technologies Inc., Palo Alto, Calif.) is one of those she uses most often.

According to information from Reliant, the Fraxel laser system—which is approved for the treatment of melasma but also has been used for surgical and acne scars, striae, and actinic keratoses—treats the skin fractionally, with patterns of microscopic laser spots that are 70–100 μm in diameter. Each laser spot is called a microthermal zone, or MTZ, and the laser can deliver 2,000 MTZs per cm

The use of the MTZs with adjacent untreated tissue allows fractional wound healing with rapid reepithelialization of the epidermis and collagen remodeling to depths of 400–700 μm. This is compared with the 200-μm depth achieved with traditional ablative laser treatments.

Histology following treatment shows that the stratum corneum remains intact and epidermal tissue is coagulated. Collagen remodeling is also demonstrated, explained Dr. Alster, who reported no financial interest in the device.

"You see reepithelialization of the whole site within 24 hours," she said.

Her treatment protocol involves skin cleansing and application of a blue tint, which is required for the laser to work. About 30–60 minutes prior to the procedure, she also applies a topical anesthetic containing 30% lidocaine.

Dr. Alster said she usually uses 8–10 MJ per cm

Patients usually require two to four treatments at 2− to 4-week intervals. Most come back monthly to complete the series of treatments, she said. The skin is erythematous immediately after each treatment and remains so for approximately 2 days. On day 2 or 3, a variable amount of peeling occurs, resulting in rough-feeling skin.

Results are incremental, with additional improvement seen after each treatment. Most patients will achieve 50% improvement when being treated for dyspigmentation and/or rhytides. Although the laser is not marketed as a skin tightening device, it does provide some skin tightening, Dr. Alster noted.

The results are better than what she has experienced with trichloroacetic acid peels, particularly for fine lines, she said, and the recovery time is much quicker than with ablative resurfacing.

Dr. David Goldberg of Skin Laser and Surgery Specialists of New York and New Jersey agreed that fractional photothermolysis has several applications and a relatively good safety profile, but he cautions that adverse events are still possible. Scarring, for example, can occur when the device is held in one place for too long.

Dr. Goldberg also noted that many of the effects of this laser can be achieved with other modalities.

"It clearly works," he said, but it's not the "end all and be all."

For example, acne scarring responds well to the Fraxel laser, but it can also be treated effectively with the CoolTouch or Smoothbeam lasers. Crow's-feet can be treated effectively with botulinum toxin, and lentigines can be treated effectively with the Q-switched laser and intense pulsed light, Dr. Goldberg said.

"This is not a system that you buy simply to treat lentigines; this is not a system you buy simply to treat crow's-feet … but I think that you can't argue the fact that when you put the whole picture together, it's got tremendous diversity, and that diversity has led to its popularity," he said.

Dr. Goldberg has received a research grant from Reliant Technologies Inc.