Laser 2013

BOSTON – Sequential application of pulsed dye and Nd:YAG lasers is safe and effective for treating small basal cell carcinomas, based on data from a prospective study of patients with nodular and superficial BCC subtypes on the trunk and extremities.

The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 10 patients with BCC, 7 of the 12 lesions treated with pulsed dye laser followed by Nd:YAG laser showed completed clinical and histologic clearance, said Dr. H. Ray Jalian of Massachusetts General Hospital in Boston.

"Targeting the microvasculature of BCC offers a promising new treatment approach. These tumors have large caliber feeding vessels; oftentimes these vessels are larger than the surrounding stroma," he said.

Data from a previous study (Lasers Surg. Med. 2009;41:417-42) showed a 92% regression rate of BCC lesions smaller than 1.5 cm treated with a 595 nm pulsed dye laser, Dr. Jalian noted.

The rationale for the sequential laser therapy is that pulsed dye laser energy is well absorbed by hemoglobin, which generates methemoglobin that in turn absorbs 1064 nm Nd:YAG energy, allowing the energy to penetrate to deep vessels.

"We hypothesized that targeting the vasculature of basal cells at two levels may be able to selectively destroy deeper vessels and perhaps achieve a higher cure rate," he said.

The investigators conducted a prospective study with 10 patients who had a total of 13 BCC of nodular and superficial subtypes on the trunk and extremities (1 patient with a single lesion was not available for follow-up).

The treated lesions were less than 2 cm with clearly visible margins that would be suitable for treatment with standard surgical excision. Patients with scars or infections in the area to be treated were excluded, as were those who were immunocompromised or pregnant.

The participants underwent four laser treatments 2-4 weeks apart with a 585-nm PDL set for a 7-mm spot size, 8-J/cm², 2-ms pulse duration, followed by a 1064-nm Nd:YAG laser set with a 7-mm spot, 40-J/cm², 15-ms pulse duration.

A total of 7 of the 12 lesions available for follow-up were completely cleared on both clinical and histologic evaluation. Of the eight tumors under 1 cm in size, six were completely cleared by sequential laser therapy,

Of the four patients with 5 lesions with residual disease after four laser sessions, three were on anticoagulation therapy with aspirin, and one with warfarin.

"We did see a clearance of the nodular component in most cases, but there was persistent residual superficial BCC in these patients," Dr. Jalian said.

Anticoagulation may hamper the laser effect by reducing laser-induced vascular injury, he noted.

Treatment-related side effects included erythema, scarring, and hyperpigmentation. Erythema and scarring decreased from the first treatment to the last follow-up visit, while hyperpigmentation increased slightly from the first to the third treatment, and then plateaued.

Biopsy scars improved with sequential treatments, Dr. Jalian noted.

Possible explanations for the lower success rate treating BCC compared to previous studies include the use of a slightly lower wavelength laser (585 vs. 595), and lower energy settings (8 J/cm² for 2 ms, vs. 15 J/cm² for 3 ms), and by mix of histologic subtypes, said Dr. Jalian.

"Superficial subtypes present in residual lesions suggest there may be a different vascular pattern in these lesions."

The findings also suggest that anticoagulation therapy may need to be suspended before treatment with pulsed dye, Nd:YAG, and other vascular-specific lasers, he added.

The study was internally supported. Dr. Jalian reported having no financial disclosures.

surgerynews@frontlinemedcom.com

BOSTON – Sequential application of pulsed dye and Nd:YAG lasers is safe and effective for treating small basal cell carcinomas, based on data from a prospective study of patients with nodular and superficial BCC subtypes on the trunk and extremities.

The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 10 patients with BCC, 7 of the 12 lesions treated with pulsed dye laser followed by Nd:YAG laser showed completed clinical and histologic clearance, said Dr. H. Ray Jalian of Massachusetts General Hospital in Boston.

"Targeting the microvasculature of BCC offers a promising new treatment approach. These tumors have large caliber feeding vessels; oftentimes these vessels are larger than the surrounding stroma," he said.

Data from a previous study (Lasers Surg. Med. 2009;41:417-42) showed a 92% regression rate of BCC lesions smaller than 1.5 cm treated with a 595 nm pulsed dye laser, Dr. Jalian noted.

The rationale for the sequential laser therapy is that pulsed dye laser energy is well absorbed by hemoglobin, which generates methemoglobin that in turn absorbs 1064 nm Nd:YAG energy, allowing the energy to penetrate to deep vessels.

"We hypothesized that targeting the vasculature of basal cells at two levels may be able to selectively destroy deeper vessels and perhaps achieve a higher cure rate," he said.

The investigators conducted a prospective study with 10 patients who had a total of 13 BCC of nodular and superficial subtypes on the trunk and extremities (1 patient with a single lesion was not available for follow-up).

The treated lesions were less than 2 cm with clearly visible margins that would be suitable for treatment with standard surgical excision. Patients with scars or infections in the area to be treated were excluded, as were those who were immunocompromised or pregnant.

The participants underwent four laser treatments 2-4 weeks apart with a 585-nm PDL set for a 7-mm spot size, 8-J/cm², 2-ms pulse duration, followed by a 1064-nm Nd:YAG laser set with a 7-mm spot, 40-J/cm², 15-ms pulse duration.

A total of 7 of the 12 lesions available for follow-up were completely cleared on both clinical and histologic evaluation. Of the eight tumors under 1 cm in size, six were completely cleared by sequential laser therapy,

Of the four patients with 5 lesions with residual disease after four laser sessions, three were on anticoagulation therapy with aspirin, and one with warfarin.

"We did see a clearance of the nodular component in most cases, but there was persistent residual superficial BCC in these patients," Dr. Jalian said.

Anticoagulation may hamper the laser effect by reducing laser-induced vascular injury, he noted.

Treatment-related side effects included erythema, scarring, and hyperpigmentation. Erythema and scarring decreased from the first treatment to the last follow-up visit, while hyperpigmentation increased slightly from the first to the third treatment, and then plateaued.

Biopsy scars improved with sequential treatments, Dr. Jalian noted.

Possible explanations for the lower success rate treating BCC compared to previous studies include the use of a slightly lower wavelength laser (585 vs. 595), and lower energy settings (8 J/cm² for 2 ms, vs. 15 J/cm² for 3 ms), and by mix of histologic subtypes, said Dr. Jalian.

"Superficial subtypes present in residual lesions suggest there may be a different vascular pattern in these lesions."

The findings also suggest that anticoagulation therapy may need to be suspended before treatment with pulsed dye, Nd:YAG, and other vascular-specific lasers, he added.

The study was internally supported. Dr. Jalian reported having no financial disclosures.

surgerynews@frontlinemedcom.com

BOSTON – Sequential application of pulsed dye and Nd:YAG lasers is safe and effective for treating small basal cell carcinomas, based on data from a prospective study of patients with nodular and superficial BCC subtypes on the trunk and extremities.

The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 10 patients with BCC, 7 of the 12 lesions treated with pulsed dye laser followed by Nd:YAG laser showed completed clinical and histologic clearance, said Dr. H. Ray Jalian of Massachusetts General Hospital in Boston.

"Targeting the microvasculature of BCC offers a promising new treatment approach. These tumors have large caliber feeding vessels; oftentimes these vessels are larger than the surrounding stroma," he said.

Data from a previous study (Lasers Surg. Med. 2009;41:417-42) showed a 92% regression rate of BCC lesions smaller than 1.5 cm treated with a 595 nm pulsed dye laser, Dr. Jalian noted.

The rationale for the sequential laser therapy is that pulsed dye laser energy is well absorbed by hemoglobin, which generates methemoglobin that in turn absorbs 1064 nm Nd:YAG energy, allowing the energy to penetrate to deep vessels.

"We hypothesized that targeting the vasculature of basal cells at two levels may be able to selectively destroy deeper vessels and perhaps achieve a higher cure rate," he said.

The investigators conducted a prospective study with 10 patients who had a total of 13 BCC of nodular and superficial subtypes on the trunk and extremities (1 patient with a single lesion was not available for follow-up).

The treated lesions were less than 2 cm with clearly visible margins that would be suitable for treatment with standard surgical excision. Patients with scars or infections in the area to be treated were excluded, as were those who were immunocompromised or pregnant.

The participants underwent four laser treatments 2-4 weeks apart with a 585-nm PDL set for a 7-mm spot size, 8-J/cm², 2-ms pulse duration, followed by a 1064-nm Nd:YAG laser set with a 7-mm spot, 40-J/cm², 15-ms pulse duration.

A total of 7 of the 12 lesions available for follow-up were completely cleared on both clinical and histologic evaluation. Of the eight tumors under 1 cm in size, six were completely cleared by sequential laser therapy,

Of the four patients with 5 lesions with residual disease after four laser sessions, three were on anticoagulation therapy with aspirin, and one with warfarin.

"We did see a clearance of the nodular component in most cases, but there was persistent residual superficial BCC in these patients," Dr. Jalian said.

Anticoagulation may hamper the laser effect by reducing laser-induced vascular injury, he noted.

Treatment-related side effects included erythema, scarring, and hyperpigmentation. Erythema and scarring decreased from the first treatment to the last follow-up visit, while hyperpigmentation increased slightly from the first to the third treatment, and then plateaued.

Biopsy scars improved with sequential treatments, Dr. Jalian noted.

Possible explanations for the lower success rate treating BCC compared to previous studies include the use of a slightly lower wavelength laser (585 vs. 595), and lower energy settings (8 J/cm² for 2 ms, vs. 15 J/cm² for 3 ms), and by mix of histologic subtypes, said Dr. Jalian.

"Superficial subtypes present in residual lesions suggest there may be a different vascular pattern in these lesions."

The findings also suggest that anticoagulation therapy may need to be suspended before treatment with pulsed dye, Nd:YAG, and other vascular-specific lasers, he added.

The study was internally supported. Dr. Jalian reported having no financial disclosures.

surgerynews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – The appearance of mature burn scars significantly improved after treatment with a nonablative fractional laser, based on data from a randomized controlled trial.

In a split-lesion study, laser-treated skin appeared smoother than did adjacent untreated control sites, and within 3 months both patients and clinicians rated laser-treated areas as significantly improved, said Dr. Merete Haedersdal of the University of Copenhagen, Denmark.

"We consider this as a safe treatment, we now have long-term clinical and histological efficacy, and we do have documentation that the efficacy improves over time. We are operating with an intact skin barrier, which may give us a good potential for when we are going to treat patients with large areas of burn scars," she said at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Haedersdal and her colleagues in Denmark, Germany, and Belgium examined long-term outcomes from the treatment of burn scars using a 1,540-nm fractional nonablative laser with compression handpieces to deliver energy to deep and superficial tissues.

Twenty patients (median age, 38 years) were enrolled, and 17 completed the study. The patients, all Fitzpatrick skin types II or III, had mature burn scars from fires (75%) or scalding (25%), and 75% had previously received skin grafts. The mature scars, with a median duration of 7 years, involved the trunk and/or extremities.

Side-by-side areas of each lesion were randomly assigned to receive three monthly deep and superficial treatments with Palomar Medical Technologies’ 1,540-nm nonablative fractional laser or to serve as untreated controls.

With the deep (XD) handpiece, the energy was applied with 15-ms pulses at 70 mJ per microbeam in three stacks for 10 passes. The compression tip of the handpiece squeezes moisture away from the applicator end, allowing delivery of energy into deep tissues.

The superficial (XF) handpiece was then used to deliver 50 mJ per microbeam in a 15-ms pulse for one stack with two passes.

"By ultrasound, we saw that we were able to deliver the energy into the deep layers of the skin," Dr. Haedersdal said. She cited the example of one patient whose scar was 1.08 mm thick before treatment, and immediately after treatment it was 3.52 mm thick from edema in the mid and deep dermal layers.

On-site clinical evaluations at 6 months performed by blinded observers rated 15 of 18 treated areas as improved, 3 as showing no response, and none as worsening. In contrast, all 18 control sites were rated as having no response.

The investigators also used the Patient and Observer Scar Assessment Scale (POSAS), which rates vascularity, pigmentation, thickness, relief, pliability, and surface area, as well as overall impression. The scale ranges from 1 for "normal skin" to 10 for "worst scar imaginable." The baseline median score was 7 (range, 3-8) for both groups.

At 1 month after treatment, there was no significant difference in POSAS score between the treated and untreated sides of the scars, but by 3 months the untreated sides were rated as a median of 7, compared with 5 for the treated sides (P = .0185). At 6 months the difference had increased slightly, with a median rating of 7 for the untreated sides and 4 for the treated sides (P = .0008).

The researchers also observed significant improvements in laser-treated (but not control) scars from baseline to 3 months (P = .0185), baseline to 6 months (P = .0008), and from 3 to 6 months (P = .0092), "which actually supports for the first time that when giving these nonablative fractional treatments, there is a continued improvement over time," Dr. Haedersdal said.

The researchers found that meshed (transplanted) skin tended to respond better than nontransplanted skin. Preliminary histology showed treatment-induced remodeling of the stratum corneum, frequently with a thicker epidermal compartment. In addition, post-treatment collagen deposition appeared closer to that found in normal skin, Dr. Haedersdal noted.

The immediate post-treatment responses included edema in 17 of 20 patients, erythema in 18, and purpura in 15, but there was no blistering of skin, and the skin barrier remained intact.

During the study period, 6 of 20 patients had hyperpigmentation, which resolved gradually over time.

"We also saw a grid pattern in three of the patients using these parameters, but we softened up the treatments afterward by giving following treatments with the XF handpiece," Dr. Haedersdal said.

The study was supported by an equipment loan and research grant to Dr. Haedersdal from Palomar Medical Technologies.

BOSTON – The appearance of mature burn scars significantly improved after treatment with a nonablative fractional laser, based on data from a randomized controlled trial.

In a split-lesion study, laser-treated skin appeared smoother than did adjacent untreated control sites, and within 3 months both patients and clinicians rated laser-treated areas as significantly improved, said Dr. Merete Haedersdal of the University of Copenhagen, Denmark.

"We consider this as a safe treatment, we now have long-term clinical and histological efficacy, and we do have documentation that the efficacy improves over time. We are operating with an intact skin barrier, which may give us a good potential for when we are going to treat patients with large areas of burn scars," she said at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Haedersdal and her colleagues in Denmark, Germany, and Belgium examined long-term outcomes from the treatment of burn scars using a 1,540-nm fractional nonablative laser with compression handpieces to deliver energy to deep and superficial tissues.

Twenty patients (median age, 38 years) were enrolled, and 17 completed the study. The patients, all Fitzpatrick skin types II or III, had mature burn scars from fires (75%) or scalding (25%), and 75% had previously received skin grafts. The mature scars, with a median duration of 7 years, involved the trunk and/or extremities.

Side-by-side areas of each lesion were randomly assigned to receive three monthly deep and superficial treatments with Palomar Medical Technologies’ 1,540-nm nonablative fractional laser or to serve as untreated controls.

With the deep (XD) handpiece, the energy was applied with 15-ms pulses at 70 mJ per microbeam in three stacks for 10 passes. The compression tip of the handpiece squeezes moisture away from the applicator end, allowing delivery of energy into deep tissues.

The superficial (XF) handpiece was then used to deliver 50 mJ per microbeam in a 15-ms pulse for one stack with two passes.

"By ultrasound, we saw that we were able to deliver the energy into the deep layers of the skin," Dr. Haedersdal said. She cited the example of one patient whose scar was 1.08 mm thick before treatment, and immediately after treatment it was 3.52 mm thick from edema in the mid and deep dermal layers.

On-site clinical evaluations at 6 months performed by blinded observers rated 15 of 18 treated areas as improved, 3 as showing no response, and none as worsening. In contrast, all 18 control sites were rated as having no response.

The investigators also used the Patient and Observer Scar Assessment Scale (POSAS), which rates vascularity, pigmentation, thickness, relief, pliability, and surface area, as well as overall impression. The scale ranges from 1 for "normal skin" to 10 for "worst scar imaginable." The baseline median score was 7 (range, 3-8) for both groups.

At 1 month after treatment, there was no significant difference in POSAS score between the treated and untreated sides of the scars, but by 3 months the untreated sides were rated as a median of 7, compared with 5 for the treated sides (P = .0185). At 6 months the difference had increased slightly, with a median rating of 7 for the untreated sides and 4 for the treated sides (P = .0008).

The researchers also observed significant improvements in laser-treated (but not control) scars from baseline to 3 months (P = .0185), baseline to 6 months (P = .0008), and from 3 to 6 months (P = .0092), "which actually supports for the first time that when giving these nonablative fractional treatments, there is a continued improvement over time," Dr. Haedersdal said.

The researchers found that meshed (transplanted) skin tended to respond better than nontransplanted skin. Preliminary histology showed treatment-induced remodeling of the stratum corneum, frequently with a thicker epidermal compartment. In addition, post-treatment collagen deposition appeared closer to that found in normal skin, Dr. Haedersdal noted.

The immediate post-treatment responses included edema in 17 of 20 patients, erythema in 18, and purpura in 15, but there was no blistering of skin, and the skin barrier remained intact.

During the study period, 6 of 20 patients had hyperpigmentation, which resolved gradually over time.

"We also saw a grid pattern in three of the patients using these parameters, but we softened up the treatments afterward by giving following treatments with the XF handpiece," Dr. Haedersdal said.

The study was supported by an equipment loan and research grant to Dr. Haedersdal from Palomar Medical Technologies.

BOSTON – The appearance of mature burn scars significantly improved after treatment with a nonablative fractional laser, based on data from a randomized controlled trial.

In a split-lesion study, laser-treated skin appeared smoother than did adjacent untreated control sites, and within 3 months both patients and clinicians rated laser-treated areas as significantly improved, said Dr. Merete Haedersdal of the University of Copenhagen, Denmark.

"We consider this as a safe treatment, we now have long-term clinical and histological efficacy, and we do have documentation that the efficacy improves over time. We are operating with an intact skin barrier, which may give us a good potential for when we are going to treat patients with large areas of burn scars," she said at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Haedersdal and her colleagues in Denmark, Germany, and Belgium examined long-term outcomes from the treatment of burn scars using a 1,540-nm fractional nonablative laser with compression handpieces to deliver energy to deep and superficial tissues.

Twenty patients (median age, 38 years) were enrolled, and 17 completed the study. The patients, all Fitzpatrick skin types II or III, had mature burn scars from fires (75%) or scalding (25%), and 75% had previously received skin grafts. The mature scars, with a median duration of 7 years, involved the trunk and/or extremities.

Side-by-side areas of each lesion were randomly assigned to receive three monthly deep and superficial treatments with Palomar Medical Technologies’ 1,540-nm nonablative fractional laser or to serve as untreated controls.

With the deep (XD) handpiece, the energy was applied with 15-ms pulses at 70 mJ per microbeam in three stacks for 10 passes. The compression tip of the handpiece squeezes moisture away from the applicator end, allowing delivery of energy into deep tissues.

The superficial (XF) handpiece was then used to deliver 50 mJ per microbeam in a 15-ms pulse for one stack with two passes.

"By ultrasound, we saw that we were able to deliver the energy into the deep layers of the skin," Dr. Haedersdal said. She cited the example of one patient whose scar was 1.08 mm thick before treatment, and immediately after treatment it was 3.52 mm thick from edema in the mid and deep dermal layers.

On-site clinical evaluations at 6 months performed by blinded observers rated 15 of 18 treated areas as improved, 3 as showing no response, and none as worsening. In contrast, all 18 control sites were rated as having no response.

The investigators also used the Patient and Observer Scar Assessment Scale (POSAS), which rates vascularity, pigmentation, thickness, relief, pliability, and surface area, as well as overall impression. The scale ranges from 1 for "normal skin" to 10 for "worst scar imaginable." The baseline median score was 7 (range, 3-8) for both groups.

At 1 month after treatment, there was no significant difference in POSAS score between the treated and untreated sides of the scars, but by 3 months the untreated sides were rated as a median of 7, compared with 5 for the treated sides (P = .0185). At 6 months the difference had increased slightly, with a median rating of 7 for the untreated sides and 4 for the treated sides (P = .0008).

The researchers also observed significant improvements in laser-treated (but not control) scars from baseline to 3 months (P = .0185), baseline to 6 months (P = .0008), and from 3 to 6 months (P = .0092), "which actually supports for the first time that when giving these nonablative fractional treatments, there is a continued improvement over time," Dr. Haedersdal said.

The researchers found that meshed (transplanted) skin tended to respond better than nontransplanted skin. Preliminary histology showed treatment-induced remodeling of the stratum corneum, frequently with a thicker epidermal compartment. In addition, post-treatment collagen deposition appeared closer to that found in normal skin, Dr. Haedersdal noted.

The immediate post-treatment responses included edema in 17 of 20 patients, erythema in 18, and purpura in 15, but there was no blistering of skin, and the skin barrier remained intact.

During the study period, 6 of 20 patients had hyperpigmentation, which resolved gradually over time.

"We also saw a grid pattern in three of the patients using these parameters, but we softened up the treatments afterward by giving following treatments with the XF handpiece," Dr. Haedersdal said.

The study was supported by an equipment loan and research grant to Dr. Haedersdal from Palomar Medical Technologies.