Atlas de Dermatologie Cosmetica PDF

Color Atlas of
osme
-.,
erma o o
ZEINA TANNOUS
SANDY TSAO
MATHEW M. AVRAM
MARC R. AVRAM
___
Color Atlas of
Cosmetic
Dermatology
This page intentionally left blank
Color Atlas of
Cosmetic
Dermatology
Second Edition
Ze ina Tannous, M D
Chief, Mohs/Dermatologi c Surgery, Boston VA Medical Center
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Affiliate Faculty, Wellman Center for Photomedicine
Faculty Director for Dermatopathology, Department of Dermatology, Harvard Medical School
Assistant Professor in Dermatology, Harvard Medical School
Boston, Massachusetts
Mathew M . Avram, M D, JD
Director
Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School
Affiliate Faculty, Wellman Center for Photomedicine
Sandy Tsao, M D
Director of Procedural Dermatology
Harvard Medical School
Marc R . Avram, M D
Clinical Professor of Dermatology
Weill Cornell Medical School
Private Practice-905 Fifth Avenue
New York, New York
B Medical
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2011
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D E D I CATI O N
I wou ld l i ke t o ded icate this book t o the memory of m y beloved father,

who a l ways gave me h is u lti mate love a n d s u p port.
Zeina Tannous, MD
I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morre l l a n d

M a ria Avra m . You have provided me u ncond itional love a n d end less
s u p po rt s i n ce the day I was born . I love yo u .
Mathew M. Avram, MD, JD
To my h us ba n d , Hensi n . You a re my stre ngth a n d i n s p i ration. You r l ove, wisd o m a n d

encou ragement h e l p m e rea l ize a nyth i n g is poss i b l e . You a re a wo n d e rfu l h us ba n d ,
father a n d best fri e n d . I wi l l love y o u a lways . To my sons, Se basti a n a n d H u nter. You r
u nconditional love, enthusiasm a n d sense o f adventure h e l p me remem ber what is truly
i m porta nt. Yo u brighten my days a n d fi l l my l ife with h a p p i n ess and love .
Sandy Tsao, MD
T h i s book is ded icated to my wife R o b i n a n d my two sons Robert a n d J a c o b .

I tha n k t h e m f o r the love a n d s u p port t h a t they give me every day.
Marc R. Avram, MD
CONTENTS
ix
Preface
SECTION THREE: DISORDERS OF ECCRINE GLANDS
Chapter 16: Hyperhidrosis.... .... ... .. 86

.
SECTION ONE: PHO TOAGING
Chapter 1: Analysis of the Aging Face and

Non-Facial Regions
.
.
SECTION FOUR: DISORDERS OF HAIR FOLLICLES
Chapter 17: Hirsutism

Chapter 2: Topical Treatment Options.
92
99
7
Chapter 18: Pseudofolliculitis ....
Chapter 3: Soft Tissue Augmentation
... 14
Chapter 19: Male Pattern Hair Loss .... .... 103
.
Chapter 4: Botulinum Toxin
21
Chapter 20: Female Pattern Hair Loss
126
Chapter 5: Chemical Peels .. ...... .. ... 29

.
Chapter 6: Nonablative Laser Resurfacing
Chapter 7: Ablative Laser Resurfacing
39
43
Chapter 21: Low Level Light Therapy (LLLT)

and Hair Loss. .
..
..
.
. 133
SECTION FIVE: DISORDERS OF PIGMENTATION
Chapter 22: Cafe Au Lait Macule ... ...... 136

.
Chapter 8: Nonablative Fractional Laser

Resurfacing .............. .... 52
Chapter 23: Ephelides

Chapter 9: Ablative Fractional Laser
Resurfacing
.
Chapter 10: Tissue Tightening
57
Chapter 24: Lentigines
62
Chapter 25: Melasma . .. ...
Chapter 11: Dermatochalasis........
Chapter 26: Nevus of Ota
Chapter 12: Poikiloderma of Civatte
..... 64
. .
67
. .
.
139
.. 144
. . . 149
.
154
Chapter 27: Postinflammatory

hyperpigmentation ............ 158
Chapter 28: Vitiligo.... ....
SECTION TWO: DISORDERS OF SEBACEOUS
. .
.
.. .. 163
.
GLANDS
Chapter 13: Acne Vulgaris ...... .. ... .. 72

.
SECTION SIX: VASCULAR ALTERATIONS
Chapter 14: Rosacea
76
Chapter 29: Angiokeratoma
Chapter 15: Sebaceous Hyperplasia ......... 81
Chapter 30: Cherry and Spider Angiomas ....
vi i
168
170
Chapter 31: Granuloma Faciale
. .
.
Chapter 32: Infantile Hemangioma
..
. .
.
Chapter 33: Keratosis Pilaris Atrophicans
Chapter 34: Port-wine Stains
Chapter 35: Pyogenic Granuloma
. 177
183
188
192
Chapter 39: Warts
. .
Chapter 41: Becker's Nevus
.203
. . 206
Chapter 42: Epidermal Inclusion Cyst
Chapter 43: Epidermal Nevus
.248
252
. .
256
Chapter 54: Lichen Planus
Chapter 55: Morphea
Chapter 56: Psoriasis
262
265
267
272
. .. .
276
Chapter 59: HIV Lipodystrophy/Facial

Lipoatrophy
Chapter 60: Striae Distensae
SECTION TEN: ADIPOSE TISSUE ALTERATIONS
SECTION NINE: INFLAMMATORY DISORDERS
Chapter 58: Cellulite
198
. .. .
Chapter 53: Squamous Cell Carcinoma
SECTION SEVEN: BENIGN GROWTHS

.
Chapter 52: Basal Cell Carcinoma
Chapter 57: Gynecomastia
Chapter 40: Angiofibroma
Chapter 38: Venous Lakes
Chapter 51: Actinic Keratosis
. .181
Chapter 37: Lower Extremity Telangiectasias,

Reticular and Varicose Veins
SECTION EIGHT: CUTANEOUS CARCINOMAS
Chapter 36: Facial Telangiectasias
174
. .. ..
.
.212
.. 216
219
222
280
285
SECTION ELEVEN: WOUND HEALING ALTERATIONS
Chapter 44: Lipoma
Chapter 61: Hypertrophic Scars, Keloids,

and Acne Scars
226
290
298
Chapter 63: Tattoo Removal.
300
Chapter 64: Torn Earlobe
308
Index
311
Chapter 45: Milium
Chapter 47: Seborrheic Keratosis
Chapter 48: Syringoma
Chapter 49: Dermatosis Papulosa Nigra
Chapter 50: Xanthelasma
Chapter 46: Neurofibroma
. .
.
229
231
234
SECTION TWELVE EXOGENOUS

CUTANEOUS ALTERATIONS
Chapter 62: Ear Piercing
. .238
.
241
.243
viii
PREFACE
There has been a revol ution in the treatment of med ical a n d cos
go these proced u res. The decision as to when not to treat a patient
m etic d isord ers of the s ki n . I n la rge part, this is d u e to the ava i l
is perha ps the m ost i m porta nt i n this fie l d .
a b i l ity o f procedu res a n d tec h nologies t h a t prod uce clear, cosmet
With t h i s i n m i n d , Color Atlas o f Cosmetic Dermatology, Second
ic benefit with few side effects a n d l ittle downti m e . With the advent
Edition seeks to provide a succ i n ct yet broad overview of cosmetic
of lasers and l ight sou rces over the past 20 yea rs, cosmetic
thera py. There a re a plethora i l l ustrations and gra phs to e l u c i date
i m prove ment is a m atter of q u ic k , relatively pa i n less proced u res.
consu ltati o n , management, treatment and side effects of n u m e r
N on-laser treatments such as soft tissue fi l l ers, botu l i n u m tox i n
ous cos metic proced u res. Its pra ctica l format is gea red to the busy
i njections, sclerothera py, h a i r tra ns p l a n tation a n d others have a lso
practitioner or tra i nee who seeks a q u ic k , comprehensive refer
d ra matica l ly expa nded the scope of this field . These procedu res
ence fo r a pproa c h i n g the cosmetic patient. It a lso e m p h asizes
coincide with the busy l ifestyle of many patients who seek a n
pitfa l l s of treatment in ord e r to ed ucate the reader as to potenti a l
i m prove ment i n a p pea ra nce that does n ot interfere with t h e i r pro
p r o b l e m s w i t h certa i n treatments. It serves as a n i nva l ua ble
fessiona l , soc i a l or perso n a l obl igati o n s .
resource to both the experienced a n d novice.
These proced u res, however, a re n ot without potentia l side

effects o r co m p l icati o n s . Physicians who perform these treatments
Zeina Ta n nous, M D
in the a bsence of tra i n i ng or ed u cation a re certa i n to encou nter
M athew M . Avra m , M D , J D
poor resu lts , c o m p l ications and i rate patie nts . Beca use patients
Sandy Tsao, M D
a re p u rs u i ng el ective treatments fo r cosmetic benefit, a ny worsen
M a rc R . Avra m , M D
i ng o f a p pea ra n c e wi l l u n d e rsta n d a bly a nger patients who u n d e r-
ix
ACKNOWLEDG M E NTS
We wou l d l i ke to tha n k two people who provided sign ificant h e l p i n the

prod uction of this textbook, D r. R ox Anderson a n d Dr. G a ry Lask. In add iti o n , we wo u l d
l i ke t o tha n k t h e office staff at the M assa c h u setts Genera l H os pita l Dermato l ogy
Laser & Cosmetic Center a n d the office staff of Dr. M a rc Avra m for their h a rd work a n d
d ed ication i n o bta i n i ng high-q u a l ity photogra ph s .
F i n a l ly, w e wou l d l i ke t o tha n k the professiona l staff at M c G raw- H i l l for

t h e i r great h e l p and d evotion in p rod u c i n g this book. Tha n k you for push i n g us to
strive for the best possi ble Atlas.
ONE
Photoaging
Color Atlas of Cosmeti c Dermatology
CHAPT E R 1
A n a lysis of the Agi ng Face a nd No n-Facial R eg i o ns
The face is the foc a l point of h u m a n bea uty. Although

va rious factors i nfluence fac i a l bea uty, the aging process
is the m ost common as pect prom pt i n g non-s u rgica l
a n d/or s u rgica l i n tervention. Agi ng is a dyna m i c a n d con
tinual process . D iffe rent c u lt u ra l , eth n i c , a n d ge nder
norms (Ta ble 1 . 1 ) of bea uty exist; however, there a re cer
ta i n featu res w h i c h globa l ly tra nscend these d ifferences
to d ete r m i n e what is perceptua l l y pleas i n g . H ered ity a n d
environ mental fa ctors ( e g , s u n expos u re , w i n d , tra u ma )
a re t h e m a i n determ i n a nts o f aging. I n a d d ition , ciga rette
smoking a n d estrogen loss ca n accelerate the aging
process. As one ages, c h a nges c a n be o bse rved i n a l l
fac i a l a n d non-fa c i a l a nato m i c a l com pa rtments, i n c l u d
i n g t h e ski n , s u bcuta neous fat, m uscle, a n d b o n y struc
tu re . Use of a systematic a p proach i n the a n a lysis of
fac i a l a n d n o n -fac i a l aging wi l l a l low for the selection of
a p propriate, safe, a n d effective thera p ies.
TAB L E 1 . 1
Fac ial Age-Related Contour Cha nges
M a l a r c rescent
Cheek d e p ression
Nasola b i a l fold formation
P rej owl s u l c u s
P latys m a ! ba nds
J owl formation
ANATO M I C CO N S I D ERAT I O N S
S uccessfu l
rej uve nation o f the face a nd
non-fa c i a l
regio n s req u i res a thorough u n d e rsta n d i n g o f age-related

conto u r cha nges ( u nderlying soft tissue aging) a n d tex
tu ra l cha nges (skin aging) (Ta bles 1 . 1 a n d 1 . 2 ) .
TAB L E 1 . 2
Age-Re lated Textura l Changes
S u perficia l a n d deep rhytides

Pigmenta ry d istu r b a n ces
Te la ngiectasia fo rmatio n
Loss o f s k i n elastic ity
Acti n ic ke ratoses
A youthfu l face can be d ivided i nto th ree facial zones:

u p per, m id d le, and lower zones, as wel l as the u pper neck.
The u p per face incl udes the forehead , tem ple, a n d peri
orbita l region . Agi ng resu lts i n flatte n i ng of the brow a rc h ,
eyelid s k i n red u nda ncy, pseudo fat hern iation , a n d forma
tion of dyna m i c rhytid es at the latera l canthus. Horizonta l
forehead s k i n creases develop secondary t o sustai ned con
traction of the fronta l is m uscle i n a su bconsc ious atte m pt to
elevate the sagging brows. A ri m sulcus d eformity d evelops
between the cheek and the eyelid with u p per cheek
Figure 1.1 A&B G/ogau type 1 photoaging. Minimal signs of aging present
Secti o n 1: Ph otoa g i n g
th i n n i ng. This sulcus is exacerbated by a preexisti ng tea r

trough deform ity. Orbicula ris oc u l i m uscle ptosis can create
a malar fu l l ness, referred to as a malar crescent.
The m i d face i n c l u d es the cheekbones that form a
s mooth conti nuous convexity fro m the eyeli d to the l i p .
T h e m e l o l a b i a l fol d re prese nts a flat, smooth j u n ction
between the lowe r cheek a n d the u p per lip. The aging
face res u lts i n a downward m igration of the malar soft tis
sue, accentuati ng skeleto n i zation of the orbital
ri m .
Centra l cheek fat ptos is c reates a fu l l n ess latera l to the

melola b i a l fol d , refe rred to as nasola b i a l fo lds.
The lower face possesses a wel l-defi ned mand i b u l a r bor
der and a well-defi ned cervicomental a ngle. With aging,
platysma! m uscle ptosis a nd cheek fat ptosis a long the
mandi ble prod uce "jowls" overlyi ng the jawl ine. Soft tissue
atrophy a nterior to the jowls creates a " prejowl sulcus"
which accentuates the skeleton ized a ppea ra nce. P latysma!
ptosis of the u pper neck blu nts the cervico-mental a ngle,
creati ng platysma! ba nds or a "turkey neck" d eformity.
Facial textu ra l cha nges i n c l u d e su perfi c i a l a nd deep
rhytides, pigme nta ry d istu rba nces, telangiectasia forma
tion, loss of s k i n elasticity, a n d acti n i c keratoses .
P R EOPERAT IVE EVALUAT I O N

A n individual ized treatment plan designed to m i n i m ize sur
gica l risk is essenti al . The goa l is a youthfu l and natura l post
operative result. A strategy should be formu lated for eac h of
the three facial zones as well as each ind ividual non-facial
regio n , as each a natomic region req ui res a specific man
agement which influences the rema i n i ng a natomic regions.
A systematic eva l uation s h o u l d i n c l u d e the d egree of
textura l c h a n ges, rhyti d format i o n , pigmenta ry c h a nges,
loss of su bcuta neous fat, cha nges in fac ia l m usculature,
c a rti lagi n o u s a n d bony structu res, a nd elastic ity l oss.
G l oga u P h otoag i n g C l ass i f i c at i o n
Wri n k l e Sca l e
The G loga u P h otoagi ng Classification has been d evised
w h i c h b road ly d efi nes the cha nges that may be seen at
d ifferent ages with c u m u lative sun exposure.
Type 1 -"no wri nkl es" (Fig. 1 . 1 )
Ea rly photoaging
- M i ld pigme nta ry cha nge
- N o ke ratoses
- M i n i m a l wri n kles
Patient age : twenties o r t h i rties
M i n i ma l or n o m a keu p use
Type 2-"wrinkles i n motion" (Fig. 1 .2)
Ea rly to moderate photoaging
Figure 1.2 A&B Glogau type 2 photoaging. Fine lines barely visible.
- Ea rly se n i l e lentigines visi ble
Minimal pigmentary changes noted
- Keratoses pa l pa ble but not visi b l e

- Para l lel s m i l e l i nes begi n n i ng t o a ppea r
Patient age : late t h i rties or forties
U s u a l l y wea rs some fou n dation
Type 3-"wrinkles at rest" (Fig. 1 .3)
Adva nced photoaging

- O bvious dysc h ro m i a , tela ngiectasia
- Visi ble keratoses
- Wrin kles eve n when n ot movi ng
Patient age: fifties o r older
Always wea rs heavy fo u ndation
Type 4-"on l y wrinkles" (Fig. 1 .4)
Severe photoaging
- Yel l ow-gray [A3l color of skin
- Prior s k i n m a l igna nc ies
- Wrin kled throughout, n o normal s k i n
Patient age : sixties or seventies
Ca n n ot wea r m a k e u p-" ca kes and cracks"
P i g m e nta ry C h a n ges
A vita l as pect of the patient eva l uation is the dete r m i n a
tion o f the patie nt's s k i n res ponse t o eryth ema-prod ucing

d oses of u ltraviolet l ight. Fitz patrick's classifi cation of
skin types prov i d e s a stro ng i n d i ca t i o n of t h e pote nt i a l
f o r post- i nfla m mato ry h y p e r p i g m e n ta t i o n a n d hypopig
m e n ta t i o n and pote n t i a l fo r d ysc h ro m i a u po n e p i d e r
m a l a n d/or pa p i l l a ry d e r m a l i n j u ry ( Ta b l e 1 . 3 ) .
TAB LE 1 . 3
S k i n type
Fitzpatrick's Classification of Skin Types
Color
Reactio n to s u n
Always b u r n s
Very wh ite or frec kled
II
Wh ite
U s u a l ly b u rns
Ill
Wh ite to ol ive
Someti mes b u rns
IV
B rown
R a rely bu rns
Dark brown
Very ra rely b u rns
VI
B la c k
N ever b u rns
A patient's treatment res ponse c a n be d ete rm i n ed

by assess i ng both t h e d egree of p h otod a mage p resent
and the p i g m e nta ry skin type. A proced u ra l risk
benefit ratio wi l l d iffer, d e pe n d i ng on the patient's i n d i
vid u a l fi n d i n gs ( F igs . 1 . 5 a n d 1 . 6 ) . I n ge n e ra l , patie nts
with Fitzpatrick s k i n types I -I I I can tolerate more e p i d e r
m a l a n d d e r m a l i n j u ry with m i n i ma l risk of res i d u a l
d ysc h ro m i a . Patie nts w i t h Fitz patrick s k i n types I V-V
have a h igh risk of res i d u a l d ysc h ro m i a with i n c reased
s k i n i nj u ry that may p rec l u d e the use of m a n y treatm e n t
Figure 1.3 A&B G/ogau type 3 photoaging. Dyspigmentation and wrinkles
m od a l ities.
are evident
Secti o n 1 : Ph otoa g i n g
S u b c u ta n e o u s Fat At ro p h y
Agi ng resu lts i n a sign ifica nt d egree of loss or red istri bu
tion of su bcuta neous fat, espec i a l ly of the forehea d , tem
pora l fossae , periora l a rea , c h i n , a n d pre m a l a r a reas.
This leads to a skeleton ized a p pea ra nce. R estorati o n of
vol u m e loss resu lts i n the res h a p i n g of the face for a
fu l ler, ro u nder a p peara nc e .
Fac i a l M u sc u l at u re C h a n ges
Agi ng a l so res u lts i n m uscu l a r atrophy, contri buti ng to
vol u m e loss. As wel l , dyna mic rhyti d es, which a re m uscu
lar i n origi n , often create a n a ngry, t i re d , or aged a p pea r
ance. Selective c h e m ical denervation provides ma rked
relaxation of these l i nes.
C h a n ges i n Ca rt i l age , B o n y
S t r u c t u res, a n d U n d e r l y i n g
S u p po rt i ve S t r u c t u res
Agi ng resu lts i n sagging and loss of res i l iency. Red ra pi ng,
repositio n i ng, and j u d icious rem ova l of skin and soft tis
sue assist i n the restoration of a youthfu l a p pea ra n c e .
Once a syste m i c a p p roach has b e e n fol l owed , the fou r
Rs of fac i a l rej uvenation-relax, refi l l , red ra pe, a n d res u r-
face-can be a ppl ied solely or in combi nation to h e l p

restore a m ore youthfu l a p pea ra nce.
B I B L I OG RAPHY
C h u ng J H , E u n H C . Angiogenesis i n s k i n a g i n g a n d pho
toaging. J Dermatol. 2007 ;34(9) : 593-600 .
Davis R E. Facelift and a n c i l l a ry facial cosmetic surgery pro
Techniques in
Dermatologic Surgery. Lond o n : Mosby; 2003, pp. 333-344.
ced u res. I n : Nouri K, Leai-Nouri S, eds.
Fitzpatrick T. The va l i d ity a n d practica l ity of sun-reactive

ski n types I through V I . Arch Dermatol. 1 998 ; 1 24:869-87 1 .
G l oga u R . Aesthetic a n d a nato m i c a na lys is of the aging
ski n . Semin Cutan Med Surg 1 996; 1 5( 3 ) : 1 34- 138.
Epidermal and
Dermal Histological Markers of Photodamaged Human
Facial Skin. Shelto n , CT: R i c h a rdson-Vicks; 1 988.
M ontagna W, Carlisle K, Kirchner S .
Paes EC, Teepen H J , Koop WA, et a l . Periora l wrin kles:

H i stologic d iffere nces between men and wom e n . Aesthet
Surg J. 2009 ; 29(6) :467-472.

S haw RB J r, Katzel E B , Koltz P F, et al. Agi ng of the
m a n d i ble a n d its aesthetic i m pl ications. Plast Reconst
Surg 2010; 12 5 (9 1 ) :332-342 .

B
Figure 1.4 A&B Glogau type 4 photoaging. Extensive wrinkles and

prominent dyspigmentation
Figure 1.5 Female patient who avoided sun exposure throughout her life.
Her skin reflects only minimal signs of photoaging
Figure 1.6 Female patient with a history of extensive sun exposure in her
life. Her skin reflects extensive photodamage with dyspigmentation and
extensive wrinkle formation
CHAPT E R 2
Topica l Treat m e nt Optio ns
M ECHAN I S M OF ACT I O N
S u n sc reen
- The u ltraviolet ( U V) wave lengths of l ight associated
with c uta neous da m age a re UVB ( 290-320 n m ) a n d
UVA (320-400 n m ) l ight.
- UVB a bsorption by DNA res u l ts i n a p53 tumor s u p
pressor ge ne m utation res u lting i n pyri m i d i ne d i mer
fo rmatio n , w h i c h is m utage n i c a n d l i n ked to cuta
neous carc i n ogenesis.
- Acute UVB expos u re resu lts i n a s u n b u r n ( Fig. 2 . 1 ) .
- Re peat ac ute UVB exposu res over t i m e have been
assoc iated with the formation of basa l cell carc i noma
a n d melanoma .
- Chronic UVB exposure has been l i n ked to the develop
ment of acti nic keratoses and squamous cell carcinoma.
- UVA is u naffected by wi n d ow glass, a ltitude, time of
d ay, or season and can prod uce a ta n and dyspig
mentation without preced i n g eryt h e m a .
- UVA l ight penetrates d eeply i n to the dermis, prod uc
i n g m a ny of the c l i n ical fi n d i ngs associated with
photo d a mage ( Fig. 2 . 2 ) .
- UVA a bsorptio n b y D N A res u lts i n fo rmation o f oxy
gen free rad icals, thought to contr i bute to ca rc i n o
genesis. It c auses i m m u nosu ppress ion through the
Figure 2 . 1 Patient with an acute sunburn. There is marked swelling and

redness present. The upper back scar is the site of a previous superficial
spreading melanoma (Courtesy of Richard Johnson, MD)
d e pletion of La ngerhans' cells and red uced a ntigen

prese nti ng cell activity.
- UVA expos u re has been l i n ked to the d eve l o pment of
melanoma in a n i ma l models.
Chem ica l s u n sc reen (Ta ble 2 . 1 )-a bsorbs l ight i n the
UV wave length of l ight ( UVB 290-320 nm) and UVA
TAB L E 2 . 1
Chemical Sunscreen: Active Ingred ients
Avobenzone
C i n oxate
Dioxybenzone
H omosa late
M ethyl a nt h ra n i late
M exoryl SX
M exoryl XL
Octocrylene
Octyl m ethoxyc i n n a mate
Octyl sa l i cylate
Oxybenzone
Pad i mate 0
Pa ra-a m i nobenzoic acid ( PABA)
Phenyl benzi m idazole su lfo n i c acid
S u l isobenzone
Tro la m i ne sa l i cylate
Figure 2 . 2 Patient with marked photodamage due to chronic sun exposure.
The patient was an avid golfer and reported only occasional sunscreen use
320-400 n m ) , tra n sfo r m i n g this l ight i nto h a r m less long
First Generation (Nonaromatics)
wave rad iation and re-e m itti ng as heat en ergy.

Physica l screen ( Ta b le 2 . 2 )-scatters or reflects UV
heat.
TAB L E 2 . 2
Retinol
Physical Su nscreen: Active I ngredients
Tita n i u m d ioxide
Zinc oxide
COOH
Tretinoin
S u n protective factor-opt i ma l ly a s u nscreen wo u l d p ro

vide protection aga i n st the fu l l spectr u m of UV rad iation .
CH20H
rad iati o n . C a n a l so a bsorb U V l ight and release it as
Isotretinoin
OOH
The s u n p rotective factor ( S P F ) is the only i nternationa l ly

sta ndard ized measure of a sunsc reen's a bi l ity to filter UV
Second Generation (Mono-Aromatics)
rad iatio n . It is the ratio of the UV e nergy needed to prod uce

a m i n i ma l erythema d ose ( M ED ) on su nscreen-protected
skin to the UV energy req u i red to prod uce an M ED on
c u rrently recom mends the d a i ly use of sunscreen with
.l.Ql.
-
u n protected ski n . The American Academy of Dermatology

Etretinate
COOH
H3CO
S P F 30 o r greater.
Antioxida nts-theoretica l ly work to red uce a n d neutra l

i z e free rad icals t h a t d a mage DNA, cytoskeleta l struc
tu res, and cel l u l a r proteins. They a lso possess a nti-i
nflammatory effects a n d m a n y play a role in pigment
red ucti o n .
Acitretin
Third Generation (Poly-Aromatics)
- I n ord e r to be b i o l ogica l ly effective, th ese prod ucts

m ust be a ble to penetrate i nto the s k i n a n d rema i n
biologica l l y active l o n g enough t o exert t h e desired
benefits . A majority of the c u rrently ava i la b l e a ntioxi
Arotinoid
d a nt prod ucts a re very u n sta ble, with oxidation m a k

i n g them c hem ically i n a ctive. M o l e c u l a r formation
and packagi ng a re key factors i n the sta b i l izatio n of
these prod u cts.
- Antioxida nts may work synergistica l l y to provide thei r
Adapalene
greatest benefit.
.) IAlf)(
COOH
- Vita m i n C-the only a ntioxi d a nt to date to have

prove n benefit for wri nkle i m p rovement due to its
a b i l ity to i n c rease col lagen formation rather than its
a ntioxidative effects .
- Vita m i n E-d emo nstrated to i n h i b it UV-i nd uced ery
thema a n d edema in a n i ma l s . It has h igh contact
d e rmatitis risk.
rings has made third-generation retinoids more stable for more targeted
therapy with less potential side effects. (Reproduced, with permission,
from Baumann L. Cosmetic Dermatology: Principles and Practice, 2nd ed.
New York: McGraw-Hill; 2009)
- Coenzyme Q l O-natu ra l l y occ u rring n utrient a d d ed

to m a n y over-the-cou nter prod ucts . C u rrently t h ere
a re no stud ies ava i la ble to docu m ent its long-te rm
benefits on skin aging.
- l d ebeno n e-synthetic a na l og of Coenzyme Q l O .
Tazarotene
Figure 2 . 3 Chemical structures of retinoic acids. The addition of aromatic
Reti noic ac i d-reti noids a re natu ra l ly occ u rr i n g d e riva

tives of I)-ca rotene and la beled as vita m i n A and its
derivatives . I n cl uded a re reti n o l , reti n a l d ehyd e , reti nyl
este rs, and retinoic acid ( Fig. 2.3). Its benefits a re both
preve ntative a n d repa rative .
- UVB exposu re res u lts in the u p-regu lation of severa l

col lagen-degra d i ng matrix meta l l o protei nases, includ
ing col lagenase, gelatinase, and stromelys i n , which
TAB L E 2 . 3
Ski n Lighte n i n g Agents
Hyd roq u i none
cause collagen degradation. Reti noids act to i n h i bit the
Aloes in
i n d uction of th ese meta l lo p rote i n ases.
Arbuti n
- UVB exposu re a lso dec reases collagen prod ucti o n .
Ascorbic acid
Reti noids work t o i n h i bit t h i s loss o f pro-co l lagen syn
Flavonoids
thesis.
Gentisic a c i d
- Tret i n o i n-a fi rst-ge neration reti n o i d which was the
H y d roxyco u m a r i n s
fi rst ava i l a b l e to pica l reti n o i d . I t is a nonsel ective
Koj ic acid
ret i n o i d , a ctiva t i n g a l l reti n o i c a c i d pathways . I t is
Licorice extract
n ot p h oto-sta b l e . I t is ava i l a b le i n a ge neric fo r m , as

we l l as i n bra nd for m u lations s u c h as R e n ova a n d
M u l berry extract
Avita . C u rre ntly R e n ova is F D A a p proved fo r p h o
M e l a n ocyte tra nsfer i n h i bition

Lec ith i n s
toa g i n g . Treti n o i n is a lso ava i l a b l e in com b i nation a s
N ia c i n a m i d e
treti n o i n 0 . 02 5 % w i t h c l i n d a myc i n f o r patie nts seek
Soybea n/m i l k extracts
ing benefits fo r both acne and p h otoa g i n g and as
M e l a n ocyte cytotoxic agents
treti n o i n 0 . 2 5 % i n com b i nation with 4% hyd ro
Azela i c acid
q u i none a n d
M eq u i nol
0 . 0 5 % f l u o c i n o l o n e aceto n i d e fo r
hyperpigme ntation .
M on o benzone
- Reti nol-this prod uct m u st be converted to reti na lde

hyde a n d then to a l l -tra ns-retinoic acid with i n the ker
Skin turnover acce l e ration

G lyco l i c a c i d
atinocyte in order to become a ctive, t h u s d isplayi ng
La ctic a c i d
less activity than treti noi n . I t is thought to be a p p roxi
Linoleic acid
mately 20% less potent than retinoic acid . It is not as
Reti noic a c i d
freq uently assoc iated with i rritation or e rythema . It is

pri m a ri ly fo u n d i n over-the-cou nter prod u cts at va ri
o u s concentratio ns.
- Ad a pa l e n e-a t h i rd -ge neration reti noid wi t h selective
affi nity for specific ret i n o i c a c i d rece ptors, w h i c h
a l lows for m ore targeted benefit a n d red uction of
potentia l si d e effects . It is m ore c h e m i c a l l y sta ble
t h a n tret i n o i n a nd d oes not brea k d own i n the pres
ence of l ight. C u rrently ava i la b l e as D ifferin in a 0. 1 %
a n d a 0 . 3 % concentrati o n .
I t i s c u rrently FDA
a p proved for to pica l acne thera py.

- Taza rotene-a t h i rd-ge neration retinoid with sel ective
affi n ity for s pecific retinoic rece ptors for more tar
geted benefit. Has been associated with sign ificantly
h igher i rritati o n than othe r retinoids. I t is ava i l a ble in
0 . 1 % and 0.05% gels and in 0 . 1 % and 0.05%
c rea m s . It is c u rrently FDA a p proved for topica l acne
thera py a n d plaque psoriasis.
Tyrosi nase i n h i bitors
Skin l ighte n i ng agents-these prod ucts act to i n h i bit

one o r more ste ps in the mela n i n biosynthesis pathway.
The m a i n target is tyrosi nase, wh i c h is the rate- l i m iting
step i n mela n i n prod uction (Ta ble 2 . 3 ) .
- Hyd roq u i none-phenolic c o m p o u n d fo u n d natu ra l ly
in m a ny pla nts , coffee, tea , bea r, a n d w i n e .
I n h i bits conversion o f tyrosi nase t o m e la n i n .
Decreases tyrosi nase activity b y 90% .
May i n h i b it D N A synthesis.
M ay i n h i b it RNA synthesis.
10
Color Atlas of Cosmetic Dermatology
Ca n be cytotoxi c to mela n ocytes prod u c i n g i rre

vers i b l e cel l d a m age with monobenzyl ether of
hyd roq u i none.
Concern rega rd ing carci n ogen i c potentia l-cu rrently
heavily regulated a n d/or ba n ned i n E u rope, As i a ,
a n d severa l African cou ntries.
Ava i l a ble i n over-the-cou nter prod u cts up to 2%
and by presc r i ption i n 3 % to 4% concentrations.
Ca n be c o m p o u n d ed u p to 1 0 % concentration .
C u rrently ava i l a ble
in
Table 2.4 Use of the ''teaspoon rule" for su nscreen application can be
benefi c i a l i n educating patients on the proper of amount of sunscreen
that shou l d be appl ied with each appl ication.
Use of m ore tha n h a lf a teaspoon each on:
Head a n d neck region
R ight a rm
Left a r m
Use o f m ore than a teaspoon e a c h o n :
Anterior torso
c o m b i nation with to pica l
Posterior torso
reti noid acid a n d to pical stero i d a n d with other s k i n
R ight leg
l ighte n i ng agents.
Left leg
- Reti noic a c i d
( Data from D raelos ZD. P roced u res i n Cosmetic Dermatology Cosmeceuticals.
Acce lerate e p i d e r m a l turnover res u l t i n g i n i n c re

ased keratin ocyte s h ed d i n g lea d i ng to pigment loss
May i n h i bit tyrosi nase i n d uction
May res u l t in keratinocyte pigment d ispersion
May i nterfere with kerati n ocyte pigment tra nsfer
- Natu ra l cosmeceuticals
Koj ic a c i d-d e rived from va rious fu nga l species
suc h as Aspergillus and Penicillium. Primari ly used
as a food preservative and to promote the redd e n
i n g o f u n r i pe strawberries . Genera l ly u s e d i n 1 % t o
4 % conce ntration . N oted t o have h igh sensitizi ng
potentia l .
Licorice extract-derived from the root of G/ycyrrhiza
g/abra
I ts
linneva.
main
active
i ngred ient
is
gla brid i n . It i n h i bits tyros i nase activity with associ

ated cytotoxicity. It has been shown to be 1 6 x
m ore efficacious t h a n hyd roq u i none.
Azelaic a c i d-d e rived from Pityros poru m ova l e . I ts
mec h a n is m of action i n not fu l l y u nd e rstood . I t
works best on active melanocytes.
Aloes i n-d e rived from a l oe vera . I t a cts as a com
petitive i n h i bitor o n DOPA oxidation and noncom
petitive
i n h i bitor
on
tyros i n e .
When
used
in
c o m b i nation with a rbuti n , it has been demon

strated to i n h i bit UV- i n d uced melanogenesis.
Arbut i n -derived from the bea rbe rry. I t a cts to
i n h i bit mela noso m a l tyrosi nase activity. Ava i l a ble as
a mono treatment o r i n 1% conce ntration with other
d e pigme nti ng agents.
Paper m u l berry-derived from the roots of an orna
mental tree, Broussonetia papyrifera.
Soy-acts
to
phagocytosis,
i n h i bit
th us
kerati nocyte
red ucing
melanosome
m e la n i n
tra nsfer.
Cos meceutica l effect noted on ly with fresh soy m i l k .

N ia c i n a m i d e-acts t o i n h i bit m e l a n ocyte tra n sfer.
Also exh i bits anti- i nfla m matory a n d a nti-oxidant
properties.
Saund ers, 2005 . )
Sect i o n 1 : Ph otoa g i n g
Ascorbic a c id-acts at va rious oxidative steps

in mela n i n synth esis by i nteracting with copper ions
at the tyros i nase a ctive site a nd red u c i n g d o pa
q u i none.
G lyco l i c acid-has a n epidermal d iscohesive effect,
res u lti n g
in
i n c reased
epidermal
turnover
fo r
i n c reased shed d i ng of pigme nted kerati n ocytes.

S h o u l d be used i n lower concentrations to avoid
s k i n i rritation .
I N D I CAT I O N S
Red uce t h e occu rrence o f acti n i c keratoses a n d nonmelanoma s k i n cancer
Red uce the formation of s k i n aging
R hytides
Ephelides
Lentigin es
Melasma
Postinfla m matory hyperpigme ntation
P R ET R EAT M E NT EVALUAT I O N
Eva l uation of pre-existing a l lergies t o a n y active i ngred ient
Past prod u ct use a nd res ponse
I D EAL CAN D I DATE
A l l patients benefit from the d a i ly a ppl ication of a topi

cal s u nsc ree n , SPF 30 or greater
Patie nts with rea l istic expectations that topica l medica

tions may provide preve ntative benefits a n d a re less
l i kely to red uce moderate to d eep rhytides
LESS THAN I D EAL CAN D I DATE
U n real istic patient expectations

Patients with ma rked ly d ry or sensitive ski n-topical
treatments may exa cerbate cond ition
CONTRA I N D I CAT I O N S
P re-existing a l lergy t o active i ngred ient

Use of topical treti n o i n , sa l i cyl i c acid, and s k i n l ighten
i n g agents i n pregnant a n d lactati ng women
APPLI CAT I O N TECH N I QU ES
A su nscreen shou ld be a p p l ied a m i n i m u m of 30 m i n

utes prior t o s u n expos u re .
1 1
12
A p p roxi m ate ly 35 m l is the average a m o u nt of s u n

screen t h a t s h o u l d be a ppl ied t o t h e average-sized
a d u lt with each a p p l icati o n . T h i s tra nslates to a tea
spoon ( a p proxi mately 6 mU of s u n screen to each leg,
back, a n d chest a n d h a l f a teaspoon ( a pproxi mately
3 m l) a p pl ied to the a rms, face, a nd neck for fu l l cover
age (Ta ble 2 . 4 ) .
Topical retinoic acid prod u cts s h o u l d b e a pp l ied spa r

i ngly to treatment a reas 30 m i n utes after was h i n g to
m i n i m ize pote ntia l for i rritation .
B l eac h i ng c rea ms s h o u l d
be a p p l ied to hyperpig
mented treatment a reas on ly, with efforts made to avoid

u n i nvolved ski n .
COM P L I CAT I ON$
Conta ct a l lergic dermatitis
Conta ct i rritant dermatitis
Ac ne fla re
S k i n pee l i ng
Xerosis
Erythema
P h otoa l lergic rea ction
Ph ototoxic reacti on
Theoreti c a l red uction i n vita m i n D a bsorption with s u n screen use
Hyperpigmentation with blea c h i ng crea m use
Exogenous ochro n osis with bleac h i ng crea m
Hypopigm entation with blea c h i ng c rea m
Potentia l carc i n oge n i c risk of hyd roq u i no n e use
POSTTREAT M E N T CAR E
Strict photo protection s h o u l d b e fol l owed d a i ly, i n c l u d

i n g s u n avo i d a n ce as m u c h as possi ble, t h e u s e o f a
d a i l y s u nscreen S P F 30 or greater, use of a wide
bri m med hat, a n d s u n protective c l oth i n g
PEARLS FOR T R EATM ENT S U CCESS
M i n i m ize the n u m ber o f prod ucts a ppl ied d a i ly t o avo i d

the potentia l fo r i rritation .
Check the expi ration d ates of a l l prod u cts a p pl ied . Th i s

is pa rti c u l a r k e y fo r s u n sc reens, as the active i ngred i
ents may not provi d e benefit beyo nd the recommended
d ate of use.
Topical retinoic a c i d prod u cts shou l d be d isconti n u ed

2 weeks prior to fac i a l proced u res such as wax in g or
tweezi n g i n order to avo i d s k i n d esq ua mati o n .
B leac h i n g agents s h o u l d be d i sconti n ued if red ness or

i rritation d evelops, as they may worse n existing pig
mentatio n .
I t is usefu l t o d isconti n ue t h e use o f a hyd roq u i none

c rea m every 3 to 4 months to dec rease the risk of
exogenous och ronosis a n d to preve nt s i de effects .
B I B L I OG RAPHY
B ruce S . Cosmeceuticals for t h e atten uation o f extrinsic
a n d i ntrinsic dermal aging. J Drugs Dermatol, 2008;
7(2 S u p p l ) : s 1 7-s22 .
Colven R M , P i n n e l l S R . To pica l vita m i n C in aging. Clin
Dermatol. 1 996; 1 4 : 227-234.
Dreher F, M a i bach H. Protective effects of topica l antioxi
da nts i n h u mans. Curr Probl Dermatol. 2000;29: 1 57- 1 64.
Fisher GJ , Ta lwa r H S , Lin J, et al. M o l ec u l a r mechanisms
of photoaging i n human s k i n i n vivo a n d their prevention
by a l l -tra ns reti noic acid . Photochem Photobiol. 1 999;69 :
1 54- 1 5 7 .
Gensler H L, Aickin M , Peng Y M , e t a l . I m porta nce o f the
fo rm of to pica l vita m i n E for prevention of ph otoca rcino
genesis. Nutr Cancer. 1 996;26 : 1 83- 1 9 1 .
G u eva ra I L, Panda AG . Melasma treated with hyd ro
q u i none, treti noin a n d a fluori nated steroid . lnt J Dermatol.
200 1 ;30: 2 1 2 -2 1 5 .
Ka ng S , Voorhees J J . P h otoaging thera py with topica l
treti n o i n :
An
eviden ce-based
a n a lysis.
J Am Acad
Dermatol. 1 998;39 : S 55-S6 1 .

Kligman A M . The growi ng i m porta nce of topica l reti noids
i n c l i n ic a l dermato l ogy: A retros pective a nd prospective
a n a lysis. JAmAcad Dermatol. 1998;39:S2-S 7 .
L i n HW,
N aylor M ,
H o n igma n n H , e t a l . America n
Aca demy of Dermato l ogy Consensus Confe rence on UVA

protection of s u nscree ns, s u m m a ry a n d reco m menda
tions. JAmAcad Dermatol. 2000;44: 505-508 .
Naylor M , Boyd A, S m ith D, et a l . H igh s u n protection
factor su nscreens i n the s u p pression of acti n i c neoplas i a .
Arch Dermato/. 1995; 1 3 1 : 1 70- 1 7 5 .
Ogden S , Sa m u e l M , G riffiths S E . A review o f taza rote ne
i n the treatment of ph otoda maged s k i n . Clin lntervAging.
2008;3( 1 ) : 7 1 - 7 6 .
P i ca rd M , Ca rrera M . N ew a n d experi menta l treatments
of c h loasma a n d oth er hypermela noses. Dermatol Clin.
2007 ; 25 : 3 53-362 .
Schneider J . The teaspoon rule of a p plying s u n sc ree n .
Arch Dermatol. 2002; 138:838-839.
Solano F, B riga nti S , Picard o M, et al. Hypopigmenti ng
agents : An u pd ated review on biologica l , c h e m i c a l a n d
c l i n ical as pects . Pigment Cell Res. 2006; 1 9 : 550-57 1 .
13
14
CHAPT E R 3
Soft Tissue Aug m e ntatio n
Use of a synthetic or biologica l prod uct or s u rgical restruc
turing for the replacement of vol u m e loss and en h a nce
ment of derma l , su bcuta n eous, and m usc u l a r d eficiencies
that resu lt from tra u m a , s u rgical defects, l i poatrophic con
d itions, photoaging, or c h ronological aging.
I D EAL F I LLER (Table 3.1)
B iocom pati b l e
N o n i m m u noge n i c
Noncarc i noge n i c , nonte ratogen i c
N o n resorba b l e
N o n m igratory
I nexpensive
Eas i l y o bta i n ed a n d stored
Easy to a d m i n ister
P rovid es re prod u c i ble cosmetica l ly benefi c i a l res u lts
FDA a p p roved if not a utologous
Demonstrates m u lt i p u rpose use
N o side effects
Easy to re m ove in the event of a poor cosmetic outcome
TAB L E 3 . 1
Com monly Used F i l l ing Agents
Name
Com position
FDA approval
Skin testing req u i red
Longevity
Adatos i l 5000 ( Dow-Cor n i ng, M i d l a n d , M l )
S i l icone
No
No
Permanent
Al loderm ( Life C e l l Cor p . , B ra n c h b u rg, N J ;
Ace l l u l a r processed h u ma n
Yes
No
1-2 yr
O baj i M e d i ca l , C h i cago, I L)
cadaveric dermal a l l ograft
Aq u a m i d (Contu ra I nternatio na l , Soe bora ,
Po ly-a c ryl a m i d e gel
No
No
Permanent
Artefi l l (Canderm P h a r m a , I n c . , Quebec,
Bovi n e col lagen with poly( methyl
No
Yes
Perma nent
Ca n a d a ; Medical I nternational BV, B red a ,
methacrylate) beads
No
No
4-6 mo
Den mark)
The N etherla nds)

B elotero Soft; B e l otero Basic ( M e rz
Non-a n i m a l hya l u ro n i c a c i d d e rived
P h a rma , Fra n kfu rt, Germa ny)
from bacteria l fe rmentation
B i o-Aica m i d ( B ri n d is, Italy)
Poly-a c ryla m i d e
No
Yes
Perma nent
Ca pti que ( l named Corp, Sa nta
Non-a n i ma l-sta b i l ized hya l u ronic
Yes
No
4-6 m o
Monica, CA)
acid ( NASHA) d e rived from plant
Cosmoderm , Cosmoplast (AIIerga n ,
Recom b i na nt h u m a n col lagen
Yes
No
4-6 m o
No
4-6 m o
I rvine, CA)
Cymetra Life Cell Corp. , B ra n c h b u rg, N J ;
Ace l l u l a r processed lyo p h i l ized
O baji M e d i ca l , C h icago, I L
h u m a n cadaveric tissue
(continued)
TAB L E 3 . 1
15
Commonly Used F i l l ing Agents (Continued)
Name
Com position
Fasc i a n ( Fascia B iomaterials, B everly
H u m a n cadaveric preserved
H i l ls, CAl
pa rticu late fascia lata
Fat, su bcuta neous
Auto logous
Hylaform ( B iomatrix I n c . , R i d gefi e l d , N J ;
H ya l u ro n i c acid derived from
! na med Corp . , Santa M o n i c a , CAl
dom estic fowl coxcom bs
l solagen ( l so l agen I n c . , H o u sto n , TXl
FDA approva l
Skin testing req u i red
Longevity
No
3-4 mo
N/A
No
9-1 2 m o
Yes
No
4-6 mo
Autologous f ibro blasts
Yes
No
1-2 y r
J uved erm U ltra , U ltra XC, U ltra Pl us,
N on-a n i m a l-sta b i l ized hya l u ro n i c
Yes
No
6-9 mo
U ltra P l u s XC (AIIerga n , I n c . , I rvi n e , CAl
acid ( N AS HAl d erived from
Yes
No
4-6 mo
bacteria l fe rmentation . XC
formu lations with 0.3% lidoca ine
P reve l l e Silk ( M entor Corporat i o n , Sa nta
N o n -a n i ma l -derived hya l u ro n i c
B a r ba ra , CAl
a ci d w i t h 0. 3% l i d oc a i n e
Rad iesse ( B ioform Med ica l , San
Synthetic calci u m hyd roxyla patite
Yes
No
9- 1 2 m o
Non-a n i ma l-sta bil ized hya l u ro n i c
Yes
No
6- 9 mo
S i l i cone
No
No
Perma nent
G ore-Tex
N/A
No
Perma nent
Lyop h i l ized poly- L-Iactic acid
Yes
No
1-2 y r
Bovin e col lagen
Yes
Yes
3-4 mo
Mateo, CAl
Restylane, Restylane-L, Perlane,
Perlane L (Q-Med AB, Swed e n ;
a c i d ( N AS H A l derived fro m
bacterial fe rmentation .
M e d i c i s , Phoenix, AZl
L form u l ations with 0 . 3 % l i d ocaine

S i l i kone- 1 000, Adatos i l-5000 (Alcon La bs,
I n c , Fo rt Wort h , TXl
Softform ( McGhan Med ica l , Santa
Barbara , CAl
Scul ptra ( B iotech I n d ustry, SA,
Luxe m bo u rg; Derm i k , Berwy n , PAl
Zyd erm , Zyplast (AIIerga n , I rvi n e , CAl
I d entify the a ppropriate patient and treatment region

- Sign ificant past medical h istory, i n c l u d i ng h istory of
b l eed i ng or c l otti n g d isord e rs; keloid formation ; exist
ing d rug a l l ergies; i m m u nocom p ro m i sed state
- Cu rrent med ication use; past or c u rrent isotreti noin use
- Past s u rgica l
i nterventions,
yea r,
and
treatment
res ponse
- C l i n ic a l eva l u ation to d eterm i n e if the d esi red treat
ment a reas a re a me n a b l e to correction; outl i ne base
l i n e structu ra l i rregula rities
- Discuss l i ne softe n i ng versus vol u m e re placement for
fi l le r selection
- Discuss med ications to avo i d 1 0 days p reoperatively
when med ica l l y safe , i n c l u d i n g aspiri n , nonsteroid a l
med icati ons, vita m i n E s u p plements, S t . J o h n 's Wort,
a n d other herbal m e d i cations that have an a nticoagu
lative effect
16
Disc uss the risks a n d benefits of the treatment

- Al lergic reacti o n , loca l ized versus system i c
- P roced u ra l a n d posto perative d iscomfort
- Postoperative edema
- Posto perative bru ising
- Sca r formation
- I nfection
- Reactivation of herpes s i m plex virus
- I n complete a ugme ntation
- I rreg u l a r co nto u r/textu re
I d e ntify contra i n d ications to treatment

- Active i nfection at the treatment site
- Nond iste nsi ble, rigi d , or icepick sca rs
- Extensive jowl formation, prom i nent folds, a n d furrows
- U n d e rlying connective tissue d isord e r
- I m m u nologic d isease
- Prior a l le rgic reaction to fi l le r/re lated fi l l e r/positive
s k i n test
- Use of isotretinoin with i n the preced ing 6 to 12 m onths
- Pregna n cy
- U n real istic expectations
O utl i n e the pred icted outcome and l i m itations to the

treatment
- D u ration of co rrection
- Posto perative recovery period
- Tissue sou rce
- Expense
Figure 3.1 Massager utilized during filler placement to minimize treat
ment discomfort
S K I N TESTI N G (WH E N APP L I CAB LE)
I n itial test d ose-two s k i n tests recom me n d ed

- I nj ected in tu berc u l i n m a n n e r i nto vol a r forea rm
- Fou r-week o bservation period for fi rst test
- Re peat s k i n test placed in o pposite forea rm
- Two-week o bservation period fo r second test
Retest d ose-si ngle test recommended

- For new patients who have received treatment by
a n other physic i a n or patients who have not received
treatment for more than 1 yea r
- Two-week o bservation period recom mended
Positive fi l l e r reaction
- Swe l l i ng, i n d u rati o n , ten derness , o r erythema that
pe rsists o r occ u rs 6 h o u rs or longer after test i m p l a n
tation
- A pos itive s k i n test is a n a bsol ute contra i n d ication to
fi l l e r use
Figure 3 . 2 Clinical findings after EMLA application to skin. Expected
blanching lasts approximately 2 to 3 hours after application
17
AN ESTH ES I A
I njection of soft tissue fil lers may b e pa i nfu l , espec ia l ly

with treatment of the l i ps . M ost patients req u i re some
form of a n esthesia to m i n i m ize treatment d iscomfort.
Epidermis
"Ta l kesthesia , " h a n d - h o l d i ng, v i b ratory massager nea r

the treatment s ite a re usefu l for patient d istraction
( Fig. 3 . 1 ) .
Topica l a n esthesia ca n b e uti l ized fo r s m a l l treatment

a reas .
Commonly
used
agents
include
Betaca i n e
E n h a n ced G e l ( C a n d e r m , Quebec, Canada ) , Betaca i n e

P l us
( Ca n d e r m ,
Quebec,
Canada ) ,
L- M -X-4
and
5 ( Ferndale La bs, Fernd a l e , M l ) , E M LA (AstraZeneca,

Boston , MA), and ice ( Fig. 3 . 2 ) .
Lidoca i n e i ntegrated d i rectly i nto t h e fi l l e r m a y e l i m i

nate the need fo r a lternate forms of a n esthesia .
Regiona l n e rve blocks a re eas i l y a d m i n istered prior to

treatment. The patient s h o u l d avoid extremely hot or
cold beverages a n d foods for 2 to 3 h o u rs after menta l
a n d/or i nfraorbita l n e rve blocks t o avoid m u cosa l i nj u ry
d ue to i n a b i l ity to d etect tem pe rature a cc u rate ly.
Loca l ized tumescent a n esth esia
is util ized fo r fat
Fat
Figure 3 . 3 Recommended filler injection depths. (A dapted from Keyvan
N, Susana L-K, eds. Techniques in Dermatologic Surgery. United

Kingdom: Mosby; 2003.)
extraction with a utologous fat tra n sfer.
I nfi ltrative a n esthesia is to be avo i ded to o bviate tissue

d i sto rtion of the treatment site .
PROCEDU RAL M E D I CAT I O N S
Va ltrex 500 mg B I D
5 t o 7 days i n itiated 1 day prior
to the proced u re for patients with a h i story of h erpes

s i m plex virus in or nea r the treatment site
Keflex 500 mg B I D
7 days i n itiated 1 day prior to the
proced u re for patients u n d e rgoi n g a uto l ogo us fat trans

fe r o r Gore-Tex i m pla ntation
D iazepa m 5 to 1 0 mg can be offe red to a nxious

patients 30 m i n utes prior to the proced u re
LEVEL OF I NJ ECT I O N (Fig. 3.3)
S u perfi c i a l dermis: fi ne l i nes; verm i l ion bord e r l i p a ugmentation
Zyd erm I,
I I ; Cosmoderm I, I I ; Restylane Fine L i n e ;
Hylaform F i n e L i n e
M i d t o deep d e r m i s : s u perficial t o moderate rhyti des,

sca rs, and d efects; lip a ugm entation
Ca ptiq ue;
Cosmoderm
II,
Cosmoplast;
Hylafo r m ;
J uved erm U ltra ; P reve l l e S i l k ; Restylane; Zyder m I I ,

Zyplast
Deep dermis, s u bc uta neous fat, and m uscle: dee per,

more su bsta ntia l defects a n d rhytides ( Fig. 3 . 4 )
Autologous
fat
tra n sfe r;
Gore-Tex;
Hylaform
J uved erm U ltra P l u s ; Perla ne; Rad iesse; S c u l ptra
Figure 3.4 (A) Prominent nasolabial folds prior to augmentation with

P l us ;
hyaluronic acid. ( B ) Softening of folds after 3 c hyaluronic placed into

treatment sites
18
Com bi nation
derm a l ,
s u bcuta neous,
and
m uscle:
defects with both a su perfi c i a l a n d a d ee p com ponent

uti l ize both a su perfi c i a l and deep fixer for opti m a l a u g
m entation ( Fig. 3 . 5 )
I NJ ECT I O N TECH N I QU E (Fig. 3.6)
Seria l pu nctu re : c l osely spaced p u n ctu res created

a long l i nes, folds ( Fig. 3 . 7 ) .
Li nea r t h rea d i ng: withd rawa l o f fi l l e r a long t h e length

of the fac i a l d efect as a conti n uous th read of material
( Fig. 3 . 8 ) .
Fa n n i ng: s i m i l a r t o l i near threa d i ng. N eed le d i rection is

conti n ua l ly cha nged without with d rawing the need le
tip.
U sefu l for ora l com m issu res, u p per nasola bia l
folds.
C ross-hatc h i ng: similar to l i near t h rea d i ng. M aterial is

i nj ected at right a ngles to the fi rst i nj ecti ons. U sed for
s h a p i n g fac i a l conto u rs .
DEG R E E O F COR R ECT I O N
Dependent o n the fi l l e r used . I n ge nera l , ove rcorrection

is not reco m m ended . The m ost com mon tec h n i q u e
error is u n d e r-correctio n .
M u lti p l e treatment sessions a re genera l ly req u i red for

vol u m e re placement agents, i n c l u d i ng s i l icone a n d
poly-L-Iactic a c i d .
D U RAT I O N OF COR R ECT I O N

Dependent on t h e material i m pl a nted , i m p la ntation tec h
n i q ue, a n d a m o u nt i m pl a nted , the type o f d efect a n d
Figure 3 . 5 (A) Facial lipoatrophy with "sunken cheek appearance " prior
mec h a n ical stresses at the i m p l a ntation sites.
to Cymetra treatment. ( B ) Improvement of cheek volume after Cymetra

treatment, 2. 0 cc total volume
ADV E R S E R EACT I O N S
H y pe rse n s i t i ve
Prolonged e rythema a n d edema at i njection sites

Cyst/a bscess formation-long-lasti ng; can persist for
m ore than 2 to 3 yea rs
G ra n u loma formation
Ana phylaxis
N o n - H y p e rse n s i t i ve
B i ofi l m
B r u ising
I nfection-i n c l udes reactivation of h erpes s i m plex virus

a n d bacteri a l i nfection
19
Necrosis-d ue to vasc u l a r com pro m i se at the treat

ment site
N od u l e formation/bea d i ng
Pa rtial vision loss-d ue to vasc u l a r comprom ise at the
treatment site
U lceration
Tec h n i q u e C o m p l i cat i o n s
I rreg u l a r texture-d ue to u neven placement
Bea d i ng-d ue to too superficia l p lacement ( Fig. 3 . 9 )
I m p la nt rejectio n -d u e t o too s u perficia l placement
Necrosis-d u e to vasc u l a r i njection o r vasc u l a r com

pression
PEARLS FOR T R EAT M ENT S UCCESS
With fi l l e rs, the affected treatment sites should be fu l ly

a ugme nted to ensu re an eve n , c o m p l ete a ugmentati o n .
U n der-correction w i l l l e a d t o a n i nadeq uate a ugmenta
tion a n d patient d issatisfaction . With m ost tem pora ry
fi l lers, this is o bta i ned at the fi rst treatment. Permanent
fi l lers req u i re repeat treatments fo r correctio n comple
tio n .
With tem pora ry fi l lers, patie nts m u st u n d e rsta n d that

the treatment res ponse is va riable and can last less
t h a n or greater tha n the ave rage expected t i m e . Re peat
treatment w i l l be req u i red over t i m e .
Figure 3 . 6 Injection techniques A . Linear threading technique B. Serial

puncture technique. (Adapted from Keyvan N, Susana L-K, eds.
Techniques in Dermatologic Surgery. United Kingdom: Mosby; 2003.)
Patient expectations m u st be tem pered t o m i n i m ize

u n rea l istic expectations a bout fi l l e r benefits . Patie nts
m ust be awa re that the treatment e n d point is a soften
i n g of the affected a reas .
Posto perative bea d i ng is ge nera l ly responsive t o local

ized massage over 5 to 7 days. Persiste nt bead i n g can
be corrected by i njecting 2 mg/m l of tria mci nolone
a ceto n i d e i nto the bead o r by 1 1 -blade i n cisional
extraction of the fi l ler materi a l .
A thorough preoperative eva l uation is necessa ry to

e n s u re that there a re no contra i nd i cations to fi l l e r use,
espec i a l ly when using perm a nent fi l lers.
Conservative a ugm entation of the gla bel l a r region is

c ritica l to avoid vasc u l a r necrosis.
B I B L I OG RAPHY
B e e r K, S o l i c h N . H ya l u ron ics for soft tissue a ugmenta
tion : Practical considerations and tec h n ical recom m e n
d a t i o n s . J Drugs Dermatol. 2009;8( 1 2 ) : 1 086- 1 09 1 .
C l a rk D P, H a n ke CW, Swa nson N . Derma l i m p l a nts:
Safety of prod ucts i nj ected for soft tissue a ugmentation . J
Am Acad Dermatol. 1 989;2 1 :992-998.
Figure 3 . 7 Serial puncture method of injection
20
Cohen J L. U n dersta n d i ng, avoid i ng a n d ma naging d er

m a l fi l l e r c o m p l icati o n . Dermatol Surg. 2008; (34 S u ppl
1 ) : S92-S93 .
Colem a n S R . Fac i a l reconto u ring with l i posc u l pture. Clin
Plast Surg. 1 997;24( 2 ) :347-367 .

G l a i c h AS, Cohen J L, G o l d berg LH . I njection nec ros is of
the gla bel l a : P rotocol for prevention a n d treatment after
use of d e r m a l fi l lers. Dermatol Surg. 2006 ;32 ( 2 ) : 276281 .
J ones D H . Sem i perman ent a nd perma nent i njecta ble
fi l lers. Dermatol C!in. 2009;27(4) :433-444.
Mata rasso S L . I njecta ble collagens: Lost but not forgot
ten-a review of prod u cts, i n d ications a n d i njection tec h
n i q ues.
Plast Reconstruct Surg. 2007; 1 20(6 S u p pl ) :
1 7S-26S .
S c h u l l e r- Petrovic S. I m p rovi ng the aesthetic aspect of soft
tissue defects on the face usi ng a utologous fat tra nsplan
Figure 3.8 L inear threading method of injection
tation . Facial Plast Surg. 1997 ; 1 3 ( 2 ) : 1 9-24.
Figure 3.9 Filler beading due to too superficial placement
CHAPT E R 4
B otulinum Toxi n
PHARMACOLOGY
Botu l i n u m tox i n is a prote i n prod uced by the bacteri u m
Clostridium botulinum. Seven serotypes exist, designated
as A, B, C 1 , D, E, F, a n d G. Eac h one of them is a pro
tease with a l ight c h a i n l i n ked to a h eavy c h a i n by a d is u l
fide bond .
Ea c h is a ntigen ica l ly d isti n ct. H owever, botu l i n u m tox i n
A ( BTX-A) , B ( BTX-B ) , a n d F a re the on ly serotypes c u r
rently ava i la b l e for c l i n ical use (Ta b le 4 . 1 ) .
TAB L E 4 . 1
Bot u l inum Toxin Preparations
Type
U n its toxi n/bottle
Dos i n g eq u iva le nts
D i l ution
Botox Cosmetic (AIIerga n I n c . , I rvine,
1 00 U lyo p h i l ized powder
1 U Botox
Average 1-4 mL in
4 U Dysport
CA)-type A
prese rvative-free or
prese rved sa l i n e
R e l ax i n ( M edicis Esthetics, Scottsdale,
500 U i n lyo p h i l ized
AZ), Dys port ( I psen L i m ited , Berks h i re ,
powde r
1 U Botox
2 . 5-4 U
U K)-type A
R e l oxi n/Dys port
Average 1-2 . 5 m L i n
prese rvative-free o r
prese rved sa l i n e
Myobloc (Soltice N e u rosciences, San
2 , 500, 5,000, a n d
N ot we l l esta bl ished for
M a y b e used as is or d i l ute
F ra n c i sco, CA)-type B
10,000 U/m L a q ueous
cosmetic use
with sa l i n e
solution
Xeo m i n ( M erz P h a rmaceutica ls,
1 00 U via l
F ra n kfu rt, Germa ny)-type A

N e u ro n ox ( M edy-Tox, I n c , Seo u l ,
1 00 U vial
South Korea )-type A

P rosigne ( La nzhou I nstitute of B i ologica l
Reported 1 U B otox
1 U
N ot wel l esta bl ished
1 U
N ot wel l esta b l is hed
Xeo m i n
Reported 1 U B otox
N e u ronox
50 U vial a n d 100 U vial
P rod ucts, La nzhou, C h i n a )-type A
I n h i bition of acetyl c h o l i n e release at the n e u rom uscu l a r
j u n ction res u lting i n m usc u la r f l a c c i d pa ra lysis. Receptor
site b i n d i n g is med iated by the h eavy c h a i n portion of the
toxi n , is spec ific for the toxin serotype, and is i rrevers i b l e .
O n c e bou n d , the recepto r-neu rotoxi n comp lex is i n ter
n a l ized i nto the nerve term i n a l a n d the tox i n l ight c h a i n
acts as a protease t o c l eave specific syn a ptic prote i n
peptide bonds req u i red for acetylc h o l i n e formati o n . The
ta rget of BTX-A is the syna ptasome-associated prote i n of
25 k Da , S N A P-25. BTX- B a n d B TX-E cleave the vesicle
associated mem b ra n e prote i n , syna ptob rev i n .
N ot wel l esta b l ished
N ot we l l esta blished
21
22
DI LUTION
Procerus
m usc l e
BTX-A i s stored i n lyo p h i l ized vials. It ca n b e reconsti

tuted in prese rved sa l i n e or preservative-free sa l i n e .
D i l utions va ry accord i n g t o physicia n preference a n d
expe rience with BTX . A d i l ution ra nges from 1 m l
( 1 0 U/0 . 1 cc) t o 4 m L ( 2 . 5 U/0 . 1 c c ) . Dysport d i l uted to
2 . 5 ml wi l l atta i n a conce ntration of 20 U/0 . 1 cc. The
N asal i s
m usc l e -+++--=-==:..___;-
i njected vol u me m ust be sufficiently sma l l to provide

a c c u rate toxin d e l ivery without a n excessive vo l u me
effect or del ivery of tox i n to s u rro u n d i ng m u scles other
tha n the targeted m uscles. The vo l u me m ust be suffi
c i ently l a rge to permit a cc u rate i njection i nto the targeted
Levator lab i i
s u perioris
alaeq ue nasi
m uscle
-+--- Zygomaticus
major m u sc l e
m uscles.
CONTRA I N D I CAT I O N S
I\
A b so l u te
Levator
superioris muscle
U nderlying n e u rom usc u l a r cond ition s u ch as myasthen ia gravis or a myotro p h i c late ra l sclerosis
P regnan cy/breast-feed i n g-pregna ncy category C
Active i nfection in treatment a rea
U n rea l istic patient expectations
Figure 4.1 Anatomical illustration of the upper and midfacial muscula
ture
R e l at i ve
Ca l c i u m c h a n n e l bloc kers use-may pote ntiate effect
A m i n oglycosi d e a nti b i otic use-may potentiate effect
Patie nts who a re d e pend ent on fac i a l expression for

t h e i r l i ve l i hood (eg, actors)
P ro m i n e nt eye l i d ptosis, heavy b row or ectropion
P R EOPERATIVE EVALUAT I O N
Patient expectations m u st b e d efi ned a n d matched

with the expected treatment outcomes
Patient med ical h i story
Past treatment h i sto ry a n d outcome
C l i n ical eva l uation
Determ i n e location and extent of i nvolvement of the

treatment site
Doc u ment asy m m etries n oted ; presence of ptosis/l i d
laxity/brow prom i nence
Lowe r Eye l i d " S n a p B a c k " Test to
Assess Lower L i d Lax i ty
The m i d d l e of the lower l i d is grasped between the i n d ex

fi nger a n d the th u m b a n d p u l led forwa rd a n d u pwa rd .
Figure 4.2 Approximate injection sites for the forehead to obtain a more
The l i d is then released a n d a l l owed to "sna p " back
horizontal brow. This pattern is most frequently used to create a more

masculine brow
aga i nst the globe. A q u ic k return to its norma l state i n d i

cates m i n i m a l laxity. Botu l i n u m toxin t o t h i s region c a n
provide benefit. A slow return o f s k i n t o its nat u ra l posi
tion i n d icates sign ifica nt laxity. Botu l i n u m toxin s h o u l d
not be u s e d i n these patients, as it may accentuate t h e
l i nes present.
P ROCEDU R E
Patient consent o bta i ned

P reope rative pictures ta ken at rest and with targeted
m usc le grou ps contra cted
P retreatment with topica l a n esthetic or ice for pa i n
Patient placed u p right
Treatment a reas wi ped with a l cohol
red uction
I njections a d m i n istered . Use of 1 ml syri nges with a 30

to 32 ga uge need l e is freq uently u t il ized . Use of i nsu l i n
syringes with a n i n tegrated 30-ga uge syri nge a n d a
h u b less system may hel p to red uce toxin vol u m e loss
M U SCLE G RO U PS
A thorough knowledge of the fac i a l m uscu latu re a n d
fac i a l a natomy is req u i red for the proper u s e a n d place
ment of botu l i n u m toxin ( Fig. 4. 1 ) .
Fore h ea d - F ro n ta l i s M u sc l e
( F i gs .
4.2
and
4.3)
Insertion: Originates at fro nta l bone ga lea a poneurotica

and i nserts i nto fibers of the procerus, corrugator, a n d
orbic u l a ris oc u l i
Function: O pposes depressor m uscles o f t h e g la be l l a r
com plex a n d brows t o elevate the brow a n d fo rehead
Lines noted: H o rizonta l l i nes ac ross the fo rehead
Injection technique: 2 to 3 u n its ( U ) added at 1 . 5-cm
i nterva ls ac ross the m idforehea d , a m i n i m u m of 2 e m
a bove t h e u pper brow
Dose injected: Average 12 to 20 U
Avoid:
Excess treatment of this m uscle; u n o pposed d e p ressor

fu nction wi l l res u l t in loss of u pper fac i a l express i o n , a
"ti red " a p pea ra nce, a n d risk of b row ptos is.
Treatment of this m uscle if the fronta l i s is s u p porting a

ptotic u pper eye l i d or if the patient has low-set brows
a n d/or excess u pper eye l i d s k i n .
I nject 1 e m a bove the eye b rows t o red uce t h e r i s k of

b row ptos i s . Patient m ust be awa re that res i d u a l l i nes
wi l l be present after the treatment if low fore head wrin
kles a re present.
Figure 4.3 (A) Forehead lines prior to B TX-A treatment. (B) Forehead
lines 1 month following B TX-A treatment
23
24
I njection too c l ose to the med i a l orbita l ri m ; toxin d iffu
sion t h rough the orbital sept u m to the levator pa l pebrae

su perioris a n d orbicula ris m uscles may lead to d i plopia .
X
X
G l a b e l l a r Co m p l ex-T h e C o r r u gator
S u p e rc i l i i , the Proce r u s , M ed i a l
O r b i c u l a r i s O c u l i , a n d F r o n ta l i s
M u sc l es ( F i gs .
4.4
and
4. 5)
Insertion: Originates a t the nasa l process of the fronta l

bone a n d extends latera l l y a n d u pward to i nsert i nto the
m id d le t h i rd of the eye b row
Function: O p poses el evator m uscles of the fronta l i s for
b row a d d uction a n d brow/s k i n d ownward a n d med i a l

m ove ment
Lines noted: Frown l i nes; "a ngry" or "worried " a p pea r
a n ce
Injection technique: Fema les have a rc hed eye brows ;
ma les have flatter or horizonta l eyebrows ; tec h n i q ue ta i
lored to match the b row sha pe; 3 to 1 0 U i nto the pro
cerus; 4 to 6 U in the i nfe rior and s u perior bel l i es of the
Figure 4.4 Approximate injection sites for the glabellar frown lines.
(A) Female brow. (B) Male brow
corrugators; 2 to 3 U i nto the medial orbic u l a ris oc u l i

Dose injected: 1 5 t o 4 0 U ( d e pendent on m uscle mass)
Avoid:
U nd e rtreatment of t h i s region
Too low of a n i njection resu lting i n tox i n d iffusion i nto
the orbital se ptu m a n d orbit with resu lta nt l i d ptos is.
Pal pation of the su perior bony orbita l ri m with i nj ection
1 e m or more a bove this l a n d mark h e l ps to m i n i m ize
t h i s risk
Con c u rrent treatment of the forehead if a heavy brow is

noted
Pe r i o r b i t a l R eg i o n-O rb i c u l a r i s Oc u I i
( F igs.
4.6
and
4. 7)
Insertion: Enc i rcles the periorbita l region a n d i nserts i nto

the m e d i a l a n d latera l canthal te ndons as wel l as i nto the
fibers of the fronta l , proce rus, a n d corrugator su perc i l i i
m usc les
Function: Forcefu l closure of the eyes a n d d e p ression of
the brows a n d eye l i d s
Lines noted: Late ra l c a n t h a l l i nes; " c rows feet"
Injection technique: 3 to 5 U a re i njected i nto th ree
poi nts in a vertica l l i n e 1 em from the latera l canth us; if a
strong sna p test is n oted , 2 to 4 U c a n be placed 3 e m
below the m i d p u p i l lary l i ne
Dose injected: 22 to 38 U
Figure 4 . 5 (A) Glabellar complex before BTX-A injection and (B) 3 weeks
following B TX-A injection
Avoid:
I njecti on of the i nfraorbita l region if a d e layed s n a p test
is n ote d ; ectropion of the i njected l i d may d eve l o p
Overtreatment o f this a rea ; i m proper eye c l os u re, brow
..
An i njection a i med too low at the lower periorbita l wrin

kles. Wea ken i n g of the levator labii su perioris m uscles
with a n u p per l i p d roop and a bnorma l s m i l e may be
U p p e r N a sa l R oot ( F i g .
, '
.:
observed
ptosis, or l i d ptosis may ensue
X
X
Figure 4.6 Approximate injection sites for periorbital lines
4 . 8)
Insertion: Encircles the periorbita l regio n a n d i nserts i nto

the m e d i a l a n d latera l ca ntha l te ndons as wel l as i nto the
fibers of the fronta l , proce rus, and corrugator su perc i l i i
m usc les
Function: Nasa l wri n k l i ng

Lines noted: U p per nose fa n n ing rhytides; " b u n n y l i nes"
I njection tec h n iq u e : 2 to 4 U is i nj ected i nto each latera l
nasa l wa l l i nto the be l l y of the u p per nasa l i s as it traverses
the d o rs u m of the n ose
Avoid: I njection i nto the u p per nasofa c i a l groove may
resu lt i n lip ptosis
Use of botu l i n u m toxin i n the lowe r face is m i n i ma l ly
benefi c i a l . Other treatment modal ities a re l i kely to be
m ore benefic i a l with fewer potentia l side effects. A stro ng
u ndersta n d i n g of the lower fa ce and neck a natomy is c rit
ical for i njection placement ( Fig. 4 . 9 ) .
N a so l a b i a l Fo l d ( F i gs .
4. 1 0
and
4. 1 1)
It is key to weigh the l i m ited benefit of BTX-A in t h i s

region com pa red w i t h the i n c reased risk o f compl ica
tions. F i l l i ng agents may provide greater benefit with

fewer side effects.
Insertion: Result of s k i n laxity, gravitatio n a l ptosis, a n d

su bc uta neous fat loss overlying t h e c uta neous atta ch
ment i n the zygomaticus m a jor a n d m i nor, levator la bi i
su perioris, a n d
levator l a b i i s u perioris a laeq ue n a s i
m usc les
Function: Associated with mouth a n d l i p movement

Lines noted: Pro m i nent c rease, med i a l c heek; " g u m m y
show"
Injection technique: 1 to 2 U i njected i nto the u p per

aspect of the nasola b i a l fold 2 to 3 m m latera l to its i n ser
tion with the n ose
Avoid:
Complete re laxation of this a rea ; u p per l i p ptosis c reat

i n g a sad a p pea ra nce may occ u r
Figure 4.7 (A) Periorbital lines prior to treatment with B TX-A. (B)
Periorbital lines 6 weeks following B TX-A treatment
25
26
U n even pa ra lysis; a n asy m m etric s m i l e or d ispro por

tionate l i p may be seen
Per i o ra l R eg i o n-O r b i c u l a r i s O r i s
w i t h C o n t r i b u t i n g F i bers f r o m
t h e B u c c i n ator, C a n i n u s , a n d
Tr i a n g u l a r i s M u sc l es ; D e p ressor
A n g u l i O r i s ; M e n ta l i s M u sc l e
( F igs.
4. 1 2
and
4. 1 3)
l
X
Figure 4.8 Approximate injection sites for upper nasal root rhytides
Insertion: O r b i c u l a ris oris origi nates fro m the maxi l l a ry

a lveol a r bord e r ru n n i ng c i rc u mferentia l l y a ro u n d the
mouth to the overlyi ng cuta n eous attach me nts; d epres
sor a ngu l i oris ( DAOl a rises from the m a n d i b u la r o b l i q u e
l i n e , i nserting i nto the a ngle o f t h e mouth . I t is conti n uous
with the pl atysm a m uscle; menta l is m uscle origi nates
from the m a n d i b u l a r i n c i sive fossa and d escends to a
c uta neous i nsertion
Function: Op position a n d protrusion of the l i ps; mouth

a ngle d e p ression; lower lip protrusion a n d chin d i m p l i ng
Lines noted: Deep a n d s u p e rfic i a l rhyt id es, u p per a n d

lower l i p ; pro m i nent a n g u l a r folds, " s a d a p pea ra n c e " ;
c h i n wri n kl i n g
Injection technique: 0 . 5 t o 1 . 0 U i njected 2 t o 3 m m

a bove t h e verm i l i on bord er i n fou r a reas each for the
u pper and lowe r lip; 1 to 2 U i njected at the i ntersection
of a line d rawn from the naso l a b i a l fol d and a n a rea 1 e m
a bove the jawl i n e a ngle; 5 t o 1 0 U i nto the i nfe rior m id
chin
Dose injected: 4 t o 8 U for t h e u p per a n d lower l i ps ; 2 to

4 U for the DAO; 5 to 10 U for the menta l i s m usc le
Avoid:
Overtreatment of this a rea ; s peech d iffi c u lties, a n

asym metric s m i le, i n a b i l ity t o c l ose t h e m o u t h , d rooling
a n d a ltered fac i a l expressions may ensue
Deep i nj ecti ons; i n c reased risk of side effects
Too h igh of an i nj ecti on for the DAO; i n a b i l ity to raise
A u r i c u l ar i s su perior m u sc le
A u r i c u l a r i s anterior m usc le
the corner of the mouth may d evelop
N ec k- P l atys m a M u sc l e Co m p l ex
( F ig.
4 . 1 4)
Insertion: Origi nates on the fascia of the u p per pectora l i s
su perioris
muscle
-"71--'T-=-''-----T-+- 0 r b i c u l a r i s o r i s m usc l e
:.dr!'J-f- Depressor angu l i oris m usc l e
Depressor l a b i i i nferioris m uscle
major a n d de ltoid m uscles a n d proceeds u pwa rd a n d

med ia l ly a long t h e s i d es o f t h e neck. Fi bers a re i n serted
i nto the m a n d i ble, su bc uta neous tissue of the lower face,
periora l m uscle, and s k i n
Function: Fac i a l a n i mati o n ; lower jaw depressio n ; lowe r

l i p d e p ression
Lines noted: Neck wri n k l i ng; centra l ba nds
Figure 4.9 Anatomical illustration of the m usculature of the lower face

and neck
Injection technique: 2 to 5 U i njected from the s u perior to

i nferior portion of each platys m a ! ba nd at 1 to 1 . 5 e m
i nterva ls w i t h the patient's teeth c l e n c hed to contract t h e
m usc le d u ri n g i njection
Dose injected: 20 to 1 00 U
Avoid: Too deep an i njection; neck wea kness, l a ryngea l
m usc le wea kness, or dysphagia may d evelop
POSTOPERAT I V E CO N S I D E RAT I O N S
I c e or cold compresses may b e a p plied to red uce pos

s i b l e bruising a n d edema
Active co ntraction of the treated m uscles for 20 to 30

seco nds every 30 m i n utes for 4 h o u rs afte r treatment
may exped ite tox i n u pta ke
Physical a ctivity s h o u l d be l i m ited for 4 h o u rs after
Figure 4. 1 0 Approximate injection sites for nasolabial folds
treatment to avoid the th eoretica l poss i b i l ity of u nto

wa rd toxin d iffusion
CO M P L I CAT I O N S
Tra nsi ent pa i n
Eye l i d ptosis
Eye brow ptosis
Bruising
Headache
I nc o m p l ete or asy m m etric chemical denervation
D i plo pia
D ry eyes
Ectro pion
Asym metrical s m i l e
Droo l i ng
Decreased p uc ke r
Dysphagia
P u n ctate keratitis
Mask- l i ke expression less face
Anti body resista nce
F l u - l i ke sym ptoms
Figure 4. 1 1 Approximate injection sites for the perioral muscles
T R EAT M E N T B E N E F I TS
R ecovery from B TX-A paralysis gen e ra l ly begins at 3 to
4 months after i njection . Patients who routinely receive
BTX-A may note the recovery time to exte nd to 4 to
6 months over ti m e . Side effects i n c l u d i ng eye l i d a n d
eye b row ptos is a n d b r u i s i n g ge nera l ly resolve with i n 2 to
3 weeks of onset. Treatment benefits may be lengthened
with concom ita nt conservative use of a fi l l e r fo r soft tissue
Figure 4. 1 2 Approximate injection sites for the depressor anguli oris
a ugme ntati o n .
muscle
27
28
Patie nts w i t h known neutra l iz i ng a nti bod ies aga i nst

Botox-A may res pond to Myo b l oc given the la ck of sig
n ificant c ross reactivity between the two tox i n s .
O n l y F DA-a pproved botu l i n u m prod ucts s h o u l d be uti

l i zed . U n l icensed botu l i n u m toxin may res u lt i n seve re,
l ife-th reate n i ng bot u l i s m .
I n the eve nt of an eye l i d ptos is, use of (a.-ad re nergic

agon ist eyed rops suc h as a p raclon i d i n e hyd roc h l oride
0.5% eyed rops ( l e p i d i n e , Alco n , Fort Wort h , TXl may
be used to provide tem pora ry lid elevation .
Patie nts s h o u l d be i nformed that the maxi m u m benefit

of Botox ca n ta ke up to 4 weeks to d eve l o p .
D e e p fu rrows w i l l o n l y pa rtia l l y respond to botu l i n u m
Figure 4 . 1 3 Approximate injection site for the mentalis muscle
treatment. C o m b i nation thera py with a filler su bsta nce

may provide the best c l i n ical end poi nt.
I t s h o u l d be em phasized to patients that a s i ngle botu

l i n u m treatment wi l l not be c o m p l etely effective i n e l i m
i nating a l l treated l i nes a n d wri n kles. A s we l l , it s h o u l d
be expla i ned t h a t s o m e res i d u a l m usc u l a r movement is
the desired treatment end point.
B I B L I OG RAPHY
Alam M , Dove r J S , Arndt KA . Pa i n associated with i njec
tion of botu l i n u m A exotoxin reconstituted using isoto n i c
sod i u m c h l o r i d e w i t h a n d without preservative: A dou ble
blind,
ra n d o m i zed
control led
tria l . Arch
Dermatol.
2002; 1 38 : 5 1 0- 5 1 4 .
Alste r T, L u pton , J . Botu l i n u m tox i n type B f o r dyna m i c
glabel l a r rhyti d es refractory t o botu l i n u m tox i n type A .
Dermatol Surg 2003 ; 29 ( 5 ) : 5 1 6- 5 1 8 .
B l itze r A, B i n der WJ , Aviv J E, e t a l . The ma nagement of
hyperfu nctional fac i a l l i nes with botu l i n u m tox i n . A col
la borative study of 210 i njection sites in 1 62 patients .
Arch Otolaryngol Head Neck Surg. 1 997 ; 1 23 : 389-392 .
B ra n d t F S , Boeker A . Botu l i n u m tox i n for t h e treatment of
neck l i nes a n d neck ba nds. Dermatol C l i n . 2004 ; 2 2 : 1 59166.
Carruthers A, Bogie M , Carruthers JD, et al. A ra ndom
ized , eva l u ator- b l i nded two-center stu dy of the safety and
effect of vo l u me on the d iffusion a n d efficacy of botu
l i n u m toxi n type A in the treatment of latera l orbita l
rhytides. Dermatol Surg. 2007;33: 567-57 1 .
Carruthers A , Kiene K, Carruthers J . Botu l i n u m A exo
tox i n use in c l i n ical d ermato l ogy. J Am Acad Dermatol.
1 996;34: 788-797 .
Carruthers J , Carruthers A . Botu l i n u m tox i n A i n t h e m i d
a n d lowe r face a n d nec k . Dermatol Clin. 2004;22 : 1 5 1 1 58 .
Figure 4.1 4 Approximate injection sites for the platysma muscle complex
Carruthers J , Mata rraso S ;
Botox Consensus G ro u p .
Consensus recom mendation on t h e u s e o f botu l i n u m

tox i n type A i n fac i a l aesthetics. Plastic Reconstruct Surg.
2004; 1 1 4 : 1 S-22S.
Chertow DS, Ta n ET, Masla n ka S E , et al. Botu l ism i n
4 a d u lts fol lowi ng cosmetic i njections with a n u n l icensed ,
h ighly
conce ntrated
botu l i n u m
prepa rati o n .
JAMA.
2006 ; 296:2476-2479.
H s u TS, Dover J S , Arndt KA. Effect of vol u m e a n d con
centration on the d iffusion of botu l i n u m exotoxi n . Arch
Dermatol. 2004; 140: 135 1 - 1 354 .
Lelouarn C. Botu l i n u m tox i n A a n d fac i a l l i nes: The va ri
able concentratio n . Aesth Plast Surg. 200 1 ;2 5: 73-84.
Z i m bler MS, Holds J B , Ko l oska MS, et a l . Effect of botu
l i n u m tox i n p retreatment on laser res u rfa c i ng res u lts: A
p rospective, ra nd o m ized , b l i nded tria l . Arch Facial Plast
Surg. 200 1 ;3 : 1 6 5- 1 69 .
CHAPT E R 5
Che mical Peels
M ECHAN I S M O F ACT I O N
T h e a ppl ication o f a wou n d i ng agent t o i n d uce epidermal
a n d/or dermal slough i n g .
I N D I CAT I O N S
Epiderm a l d efects-e p h e l i des, melasma

Epiderm a l a n d dermal defects-melasma, lentigi nes,
post- i nfla m matory
hyperpigme ntati o n ,
acti n i c
ker
atoses, s u perfi c i a l rhytides, acne vu lga ris
Dermal d efects-deep rhytid es, acne sca rring, sca rs

Peel i n g agents a re selected based o n t h e patient's
l i festyle, defect d e pth , s k i n cha racteristics, a n d defect
location (Ta bles 5 . 1 -5 .3 ) .
Past med ical h i story

- Past rad iation h i story-decreased a d nexa l structu res
l i kely
- H i story of ora l herpes s i m p lex virus-rea ctivation
may occ u r
- Pregna ncy-peels contra i n d i cated with t h e exception
of glyco l i c a c i d
- H i story o f k e l o i d formation-moderate a n d d eep
d e pth peels should be avoided
29
30
TAB L E 5 . 1
C l inical I n d ications and Peel Types
I n d i cation
Peel d e pth/treatment e n d po i n t
Peel type
A c n e vu lga ris
S u perficia l when active
Localized epidermal peel i n g req u i red ; lesion a l i m p rovement
Ephelides; lentigines
S u perfic i a l or m ed i u m
Tota l epidermal pee l i ng req u i red for com plete remova l ; l ighte n i ng
Post-i nflam matory i nfla m mation
S u perfi c i a l or med i u m
Tota l epidermal pee l i ng req u i red ; l ighte n i n g with either strength
Melasma
S u perficia l or m ed i u m
Tota l epidermal pee l i ng req u i red ; l ighte n i ng with either strengt h ;
S u perficial rhytides
S u perficia l
Loca l i zed e p i d e r m a l pee l i ng req u i red ; softe n i ng
with s u perfi c i a l a pp l ication
i nconsistent res ponse

Moderate rhytid es
M ed i u m or deep
Tota l epiderma l a n d pa p i l l a ry d e r m a l peel ing req u i red ; softe n i ng
Deep rhytides
Deep
Tota l epidermal to reti c u l a r d e rma l peel req u i red ; softe n i ng
Acti n ic ke ratoses
M ed i u m
Tota l epidermal to pa p i l l a ry dermal pee l i n g req u i red ; lesio n a l cleara n ce
Depressed sca rs
M ed i u m o r deep
Les i o n a l ed ges targeted ; tota l epidermal a n d pa rtia l d e r m a l

pee l i ng req u i red; l esional flatte n i ng; va riable res ponse
TAB L E 5 . 2
Woun d i ng Depth of Superfi c i a l , Medium-Depth, and Deep-Depth Strength Peels
S u perfic i a l peel
M ed i u m -d e pth peel
Deep peel
a- Hyd roxy a c i d
G lyco l i c acid a n d TCA
Ba ker's Gordon phenol , u n occ l u d ed
M od ified U n na 's resorc i n o l paste
J essner's and TCA
Ba ker's Gordon phenol , occ l uded
J essner's
Solid carbon d ioxide a n d TCA
Sal icyl ic acid
50% TCA
Solid carbon d ioxide s l u s h
Pyruvic a c i d
Treti n o i n
8 8 % F u l l -strength p h e n o l
1 0%-25% TCA; 35% va ria b l e
TAB L E 5 . 3
Pee l i ng Agent Characteristics

Safe for
Peel type
Color end poi nt
G lyco l i c a c i d
Confl uent erythema
1-2 coats
1-2 h
A l l s k i n types
J essner
Pale wh ite
Coats a re a pp l ied singly a n d
4-5 d ; m i l d epidermal
A l l s k i n types
Appl ication
e n d point mon itored for
H ea l i n g time
d esq u a mation noted
3-4 m i n prior to repeat

a p pl ication
TCA (30% or greater)
Sol i d wh ite
Si ngle even a p pl icati o n ;
1 0-14 d ; severe
loca l i zed a p p l ications for
s u n b u rn - l i ke pee l i n g
l ighter wh ite a reas may
observed
I a n d I I ; caution
with I l l and I V
be considered
Phenol
G ray wh ite
S i ngle even a p p l icatio n ; can

be conservatively rea p p l ied
Past s u rgica l h i story

- Prior cosmetic proced u res-prior face l ift, blep h a ro
plasty, carbon d ioxi d e resu rfa c i ng, o r derma b rasion
may affect peel o utcome . I nc reased ectropion risk
prese nt.
Medication use
- Previous isotreti n o i n use and yea r
- To pica l med ications such as tret i n o i n a n d a-hyd roxy
acids may potentiate peel penetration
- Couma d i n use
1 0-14 d ; su perfi c i a l
b u r n a p pea ra n ce
I and I I
31
Fitz patric k s k i n ph ototype

- Skin p hototypes I-I I I patients respond to a l l peel types.
- S k i n ph ototypes IV a n d V patients a lso respond to a l l
peel types, b u t the risk o f post-treatment dyspigmen
tation is greater.
- A test site may be wa rra nted for d a rker s k i n types to
eva l uate peel outco me .
Degree o f acti n i c d a mage a n d p h otoaging

- A wh ite l i ne of d e m a rcation between peeled a n d
u n peeled s k i n m a y b e pro m i nent i n t h e p resence of
moderate to severe dermatohel iosis.
Wood's lamp eva l uation

- H e l pfu l i n ascerta i n i ng pigmentation type p rese nt
- Epiderm a l
origi n :
lesional
color
e n h a ncement
( Fig. 5. 1 )
- Dermal o r c o m b i nation epidermal a n d derma l : n o
lesional color e n ha ncement to l ight
- Exa m i nation d oes not acc u rately pred ict c l i n ical peel
res ponse
- Epidermal pigment may res pond better to pee l i ng
agents com pared with d e r m a l or c o m b i nation p ig
ment d e position
Medical cleara n ce
- A rece nt electroca rd iogra m is necessa ry to serve as a
base l i n e for phenol peels in the event of ca rd i otoxicity.
- Liver fu nction a n d ren a l function tests s h o u l d be eva l
uated t o e n s u re adequate he patorenal fu n ction fo r
phenol pee ls.
I D EAL CAN D I DATE
S k i n p h ototype I or I I
Acti n i c d a maged s k i n
Static rhytides associated w i t h s u n expos u re
LESS I D EAL CAN D I DATE
Dyn a m i c rhyti d es-a c h i eved benefits a re tem pora ry i n

natu re
Exte nsive gravitati o n a l folds a n d fu rrows- l i kely to

req u i re s u rgica l i nterve ntion in conj u n ction with c h e m i
cal peels
Deep rhytides
Boxc a r a c n e o r mod erate d e pth atro p h i c sca rring
CONTRAI N D I CAT I O N S
U n rea l i stic patient expectations
Patient u n a b l e to perform necessa ry postoperative ca re
Figure 5 . 1 Thirty-one-year-old female with melasma. Wood's lamp accen
tuated her facial pigmen tation
32
Patients with ice p i c k sca rs or d ee p atro p h i c sca rs
Patients with d i lated , la rge pore size
H i story of o ra l isotret i n o i n use with i n 1 yea r prior to p ro

ced u re
H i story of keloid formation

Patient with u n d e rlying ca rd iac a rrhyth m ias (for deep
peels)
Coumad i n use (for deep pee ls)
Skin p hototypes I l l-V I (fo r deep pee ls)
M E D I CAT I O N S
P reo perative a ntivi ra l medications a re reco m m e n d ed .

Va ltrex 500 mg B I D or Acyc lovir 400 mg T I D i n itiated
o n the day of p roced u re and conti n ued for 5 to 1 4 days
is a d m i n istered depend i n g on peel d e pt h .
Topical retinoic a c i d a n d a-hyd roxy a c i d prod ucts a re

d isconti n ued 48 h o u rs prior to a glycol i c acid peel a n d
1 wee k prior t o a deeper peel a n d n ot rei n itiated for
1 week post treatment.
WOU N D DEPTH
Determ i ned b y m u lt i p l e factors.
Anato m i c consid e rations

Fac i a l skin d iffers from non-fa c i a l s k i n i n the relative
n u m be r of p i l osebaceous u n its per cosmetic u n it a n d
t h i c kness. P ro m i nent a d nexa l structu res a re req u i red
to promote re-e pith e l i a l ization post treatment.
- The nose a n d forehead have more sebaceo us g l a n d s
t h a n d o the c h eeks or tem ples.
- The face has m o re sebaceous glands tha n the n o n
fac i a l a reas i nc l u d i n g the neck.
- M o re a cti n i c a l l y d a maged s k i n is t h i n n e r with fewer
p i l osebaceous u n its prese nt.
Body location and prese nce of acti n i c a l l y d a m aged
ski n sign ificantly affects the selection of the wo u n d i n g

agent. The pee l i ng agent m a y be m o re d estru ctive i n
a reas with fewer a d nexa l structu res a n d th i n ne r ski n ;
therefore a less aggressive pee l i ng agent s h o u l d b e uti-
1 ized in these a reas.
Prepeel s k i n d efatt i ng-use of acetone to d efat the

treatment a rea res u lts i n a deeper penetrati ng peel
Wo u n d i ng agent strength-a n i n c reased stre ngth wi l l
A m o u nt o f agent a p pl ied-deeper s k i n penetration with
resu lt i n d eeper s k i n peel i n g

each peel layer a p p l ied
Figure 5.2 (A) Epidermal melasma unresponsive to topical bleaching
creams.
P E E L TYP ES
S u perfi c i a l peels-pa rtia l o r complete epidermal i nj u ry;

may exten d i nto the pa p i l l a ry dermis ( Fig. 5.2A a n d B)
M ed i u m-d e pth peels-i nj u ry exten d s i nto the pa p i l l a ry

to u p pe r reti c u l a r dermis ( Fig. 5.3A a n d B )
Deep
peels-i nj u ry exte nds
i nto the
m id - reti c u l a r
dermis
PROCED U R E
P reoperative written consent o bta i ned .
P reoperative p i ctu res ta ke n .
Patie nt's m a ke u p rem oved a nd face c l ea nsed with a n

a n tise ptic wash (eg, c h lorhexid i n e ) .
Scru b t h e treatment a rea with a cetone on cotton ga uze

for 2 to 3 m i n utes.
The pee l i ng agent s h o u l d be pou red i nto a glass c u p .
T h e pee l i ng agent is a p p l ied t o t h e treatment site .

- A pai ntbrush or cotton ba l l may be used to a p ply gly
colic a c i d .
- A sa ble b r u s h is rec o m m e nded f o r J essner peel for
i n c reased penetration .
- Cotton-ti p ped a p p l icators or cotton ga uze may be
used to a p ply tri c h l o roacetic a c i d
(TCA)
peel i n g
agents .
- One or two s m a l l cotto n-ti p ped a p p l icators a re used
fo r phenol a p p l icati o n .
- A rou n d toot h p i c k or wood en porti on o f a broken
cotton -ti p ped
a p p l icator
may
be
used
to
treat
i n d ivid u a l rhytides a n d icepick a cn e sca rs.

- The n u m be r of a p p l icators used and the p ressu re
a p plied to the treatment site with agent a ppl ication
will affect solution del ivery a n d d e pth of penetration
( Figs. 5.4 a n d 5 . 5 ) .
A fa n is req u i red t o h e l p red uce t h e associated patient

d iscomfort.
P retreatment with J essner o r glyc o l i c acid prior to a

TCA peel a l l ows for d ee per peel penetrati o n .
Feathering i nto t h e h a i r l i n e a n d at the jawl i n e con cea ls

the poss i b l e line of d e m a rcati o n . Feathering s h o u l d
a lso be performed when the periora l a rea is treated
a lone to p reve nt l i nes of d e m a rcation ( Fig. 5 . 6 ) .
The periorbita l tissue s h o u l d b e treated fi rst with TCA

peels, fol l owed by the n ose, c h eeks, peri o ra l a rea , a n d
forehead for best patient tolera n c e . The u pper a n d
lower eye l i d s m a y b e treated . Extension 2 t o 3 m m o nto
the periora l verm i l l ion is benefi c i a l for rhytid es red uc
tio n .
A sa l i n e syri nge s h o u l d b e ava i l a b l e i n t h e case o f i na d

verte nt i ntrod uction o f the pee l i ng agent i nto the eye .
Figure 5.2 (continued) (8) Mild improvement noted following two 50%
glycolic acid peels
33
34
The a pp l icator should be wrung out a n d sem i-d ried to

p reve nt d ri p p i ng. The glass conta i ner s h o u l d be h e l d
away from the patient to avoid d i rect s pi l l i ng o n t o t h e
patient.
J essner
pee l ,
TCA,
and
phenol
peels
a re
self
neutra l izi ng. G lycol i c a c i d pee ls m ust be neutra l ized

with water o r bica rbonate solution .
Cool was h c l oth is a p p l ied to the treated a reas.
Vase l i n e is a p plied to the treatment site fo r J essner,

TCA, a n d phenol peels. G lyco l i c a ci d peels req u i re a
I ight moistu rizer.
Deep peels have i n h erent card ia c , rena l , a n d h e patic

toxicities. F u l l -face a p p l ication req u i res i ntravenous f lu
ids, sedation , cardiac mon itoring, p u lse oxi meter, a n d
blood pressu re mon itoring.
COM P L I CAT I ON$
G reater d e pth of peel provided than expected ( Fig. 5 . 7 )
I nfection-vira l , bacteria l , funga l
Tem po ra ry o r perma nent hyperpigme ntation o r d e pig

mentation
Prolonged e rythema
Sca rring-atro p h i c , hypertro p h i c , keloida l ; ectro p i o n ,
d e layed hea l i n g
Conta ct dermatitis
Text u ra l c h a n ges
Acne
M i l ia
Figure 5.3 (A) Pseudo-ochronosis. The pigmentary changes persisted
Cardiac a rrhyth m ias (deep phenol pee l )
despite discontinuation of the inciting medication.
La ryngea l edema ( d e e p p h e n o l pee l )
POSTOP E RAT I V E CAR E
A l ight moistu rizer i s a p p l ied twice d a i l y for glyco l i c a c i d

peels.
Vase l i n e is ke pt o n rou n d the clock with twice d a i ly

c l ea n s i ng soa p a n d water, J essner, TCA, a n d phenol
peels.
Strict photoprotection is stressed fo r a m i n i m u m of

1 month after a glycol i c acid peel and 2 to 3 months for
the re m a i nd e r of peels.
Patie nts a re i n structed to a l low nat u ra l slough i n g of the

treated ski n . The skin m ust n ot be m a n u a l ly removed .
Ca refu l patient selection a n d p e e l selection is n eces

sa ry for treatment s uccess. I t is best to u nd e rtreat with
a less potent peel i n g agent in non-fa c i a l a reas to m i n i
m ize the risk of sca r formati o n .
35
Patie nts m u st be awa re of the expected recovery time

with each chemical peel a n d the n ecessa ry posto pera
tive wou n d care they wi l l n eed to perform to exped ite
hea l i ng . Although one deep peel may provide the great
est benefit, l ifestyle or work constrai nts make seria l
su perfi c i a l or med i u m -d e pth peels a bette r long-te rm
goa l .
T h e m a rgi n o f safety is m u c h n a r rower a n d t h e risk of

c o m p l ications
much
greate r
with
i n c reased
peel
strengths .
Patients w i t h s k i n ph ototypes I l l a n d I V h a v e a greater

risk of d eve l o p i n g pregna n cy- i n d uced hypertension
after a chemical peel . Consideration of a test site is wa r
ra nted for m ed i u m-depth pee l s .
C h e m i c a l pee ls w i l l n o t a lter pore s i z e a n d may i n fact

i n c rease thei r size.
B I B L I OG RAPHY
Ba ker TJ , Gordon H L, M osienko P, e t a l . Long-term h i sto
logica l study of s k i n after c h e m i c a l fac i a l pee l i ng. Plast
Reconstr Surg 1 9 74;53: 522-52 5 .

B rody HJ . M ed i u m-depth c h e m i c a l pee l i ng o f the s k i n : A
va riation of su perfi c i a l che mosu rgery.
Adv Dermatol.
1 988; 3 : 205-220.
G r i mes PE. Melasma : Etio l ogic and therapeutic consid e r
ations. Arch Dermatol. 1 997; 1 3 1 : 1453-1457.
G ross D . Ca rd iac a rrhyth m i a d u ri n g phenol face pee l i ng.
Plast Reconstr Surg 1 984; 73: 590-594.
Kligman A M , B a ker TJ , Gordon H L. Long-term h isto logic
Figure 5.3 (continued) (B) Marked pigment lightening after three Jessner
35% TCA peels
fo l l ow- u p of phenol face peels . Plast Reconstr Surg.

1 985 ; 7 5 : 652-659 .
La n d a u M . Com bination of c h e m i c a l pee l i ngs with botu
l i n u m toxi n i njections and
dermal fi l l ers . J Cosmet
Dermatol. 2006; 5(2 ) : 1 2 1 - 1 26.

M a c Kee G M , Ka rp FL. The treatment of post-a c n e sca rs
with p h e no l . Br J Dermatol. 1 9 52 ; 64( 1 2 ) :456-459 .
Mata rasso SL, G loga u R G . C h e m i c a l face peels. Dermatol
C!in. 1 99 1 ;9 : 1 3 1 - 1 50.
M o n h eit
G.
The J essner's-tric h l o roacetic
acid
pee l .
Dermatol Clin. 1995 ; 1 3 ( 2 ) : 2 77-283 .

M u ra d H , S h a m b a n AT, Premo PS. The use of glycol i c
acid as a pee l i ng agent. Dermatol Clin. 1995; 1 3 ( 2 ) : 285307 .
Que SK, Bergstrom KG . Hyperpigmentati o n : O l d p roblem,
new thera pies. J Drugs Derma tal. 2009;8(9 ) : 879-882 .
R u l l a n P, Ka ra m A M . Chemical peels for d a rker skin types.
Facial Plast Surg Clin North Am. 2010; 1 8( 1 ) : 1 1 1- 1 3 1 .

Szzc h owicz E H , Wright W K . Delayed hea l i ng after fu l l
face c h e m i c a l pee ls. Facial Plast Surg. 1 989;6( 1 ) :6- 1 3 .
36
Figure 5.4 Fine white color immediately following a 20% salicylic acid
peel
Figure 5 . 5 Pale white color immediately following a Jessner peel
Figure 5.6 Solid white color immediately following a Jessner/35% TCA
peel
37
38
Figure 5.7 Patient with line of demarcation between the Jessner/35%
TCA peel treated perioral area and untreated skin. Patient appears
hypopigmented in the treatment site. A subsequent medium-depth peel
to the remainder of the face resulted in a more even facial appearance
Figure 5.8 Localized frosting following application of a 50% glycolic acid

peel. The localized peel resulted in some mild desquamation for 3 days
CHAPT E R 6
No n a blative Lase r R esu rfaci n g
I N TRODUCT I O N
There a re m u lti ple laser a n d l ight sou rce treatments for
p h otoaging. These treatme nts ra nge in effi cacy a n d side
effects . Typical ly, there is a trad e-off between c l i n ica l
i m prove ment a n d a concom ita nt i n c rease i n s i de effects
a n d d ownt i m e fro m work a n d soc i a l activities . Oth e r
cha pte rs have foc used o n s u c h treatments as n o n a b l a
tive fra ctional resu rfaci ng, a blative fractional res u rfa c i ng,
and tra d itional res u rfa c i ng. This c h a pter exa m i nes non
a b lative laser resu rfa c i n g a n d , i n partic u la r, the use of
m id-i nfra red lasers . Other d evices such as i ntense pu lsed
l ight, n o n a b lative fractional res u rfa c i ng lasers, and vas
c u l a r lasers a lso ach ieve n o n a b l ative benefits, a n d a re
add ressed i n d eta i l i n oth er cha pters .
P h otoaging encom passes a l l the cha nges prod uced by
expos u re to u ltraviolet ( UV) rad iation, i n c l ud i ng tela ngiec
tasias, rhyti d es, poor skin text u re, and tone as we l l as
ski n laxity (see Dermatohel iosis c h a pter) . N o n a b l ative
rej uve nation treats s u n -da maged s k i n by heati ng d e r m a l
Figure 6.1 Vesicles appeared 1 day after treatment with a 1 4 50-nm
col lagen w i t h the a i m o f sti m u lating n ew collagen growt h .
diode laser with a Fitzpatrick skin type 1 patient. These vesicles com
pletely cleared without sequelae 3 days later
I t is a lso effective i n t h e treatment o f a c n e scars.

Epiderma l cool i n g is p rovid ed to e n s u re that thermal
heati ng is ta rgeti n g the dermis, a n d n ot the e p i d e r m i s .
The best adva n tage o f nona b lative treatme nts is t h a t they
req u i re l ittle, if a n y, d ownti me from work a n d soc i a l activ
ities. This is i n contrast to a blative and fra ctional a b lative
treatm ents . In s k i l led h a n d s , side effects a re typ i ca l ly
m i l d a n d tem pora ry ( Fig. 6. 1 ) .
Ofte n , they p rod uce s u btle o r m i l d ben efits , eve n after
m u ltiple treatments. U nfort u nately, the p red icta b i l ity of
i m prove ment is u ncerta i n . Some patients d o not experi
ence a ny d iscern i b l e ben efit even after m u ltiple treat
ments. In the past few yea rs, nona blative fractional lasers
have p rod uced e n h a nced results from other forms of
n o n a b l ative res u rfa c i ng, with m u ltiple treatments. Th ese
lasers have a lso p roven to be safe in s k i l led h a n d s . With
the advent of nona b lative fractional lasers, trad itio n a l
n o n a b l ative laser res u rfa c i n g has decl i n ed i n popula rity.
In add ition to i ntense p u l sed l ight sou rces a n d vasc u l a r
lasers, there a re m a n y n o n a b lative devices t h a t util ize vis
i b le, nea r- i nfra red , and m id - i nfra red wavelengths with
e p i d e r m a l skin coo l i n g . These wavele ngths target the
water that is a b u nda nt in dermal tiss u e. The skin cool i ng
p rotects aga i n st epidermal da mage. T hese lasers p ro
d uce d ee pe r dermal penetrati o n , greate r a bsorption , a n d
d e r m a l therma l i nj u ry t h a n vasc u l a r lasers. F u rther, there
is sign ifica ntly decreased risk of pigme nta ry c h a nges i n
d a rker s k i n phototypes a t these wavelength s . W h i l e the
best ca n d id ates for treatment a re those with m i ld to mod
e rate static rhytides, the d egree of i m provement after
treatment is d iffic u lt to q ua ntify.
39
40
N o n a b lative lasers
Su btle i m provement of rhyti d es, pa rti c u l a rly when com

pa red to a blative d evices
- Best for patients with m i l d to moderate p h otod a m
age, s k i n laxity, a n d s k i n coa rseness
Req u i res m u ltiple treatments to p rovide m i l d i m p rove

ment of s k i n text u re, tone, a n d rhytides
Little to no posto perative d ownti me compared to tra d i

t i o n a l a blative d evices
Patient can return to work o r soc i a l activities the sa me

day as the proced u re
Ca n treat cosmetic u n its effective ly without l i nes of

dema rcation
I N D I CAT I O N S
I n d ications
- M i l d rhyt id es
- P h otoda mage, i n c l u d i n g s k i n texture a n d tone
- Acne sca rs, i n c l u d i n g boxca r, atro p h i c , ro l l i n g sca rs
- S u btle benefit
- M i ld i m provement in s k i n laxity
- N ot effective for dyna m ic or deeper rhyti des
S k i n type (can treat d a rker s k i n types with m id-i nfra red

lasers, but req u i res caution with s k i n coo l i ng)
Sun exposu re
H istory of ke loids
Figure 6 . 2 (A) Patient with EMLA under occlusion prior to treatment of
l sotret i n o i n use i n past 6 months
acne scars. (B) Treatment with 1 4 50-nm diode laser with DCD cooling
Patie nts with u n rea l istic expectations

A consu ltation is req u i red before this treatment to
assess the patient as wel l as a p p ro p riately prepare the

patient for the proced u re . The patient s h o u l d be fully
educated as to the risks a n d benefits of the proced u re . I t
is i m perative t h a t expectations a re s e t rea l i stica l ly i n
te rms o f t h e m i l d d egree of i m provement that w i l l often
be seen for rhytides . The patient s h o u l d a lso be i nfo rmed
that the ben efits of rhytid treatment accrue 3 to 6 months
after treatment.
PROPHYLAX I S/AN ESTH ES I A

M a y i nc l u d e a n y o f t h e fol l owi ng:
Antiviral prophylaxis
Topical a n esthetic
- 23% Lidoca i n e!? % tetraca i n e
- 7 % Lidoca i n e/7 % tetra ca i n e
- Eutectic m ixtu re o f loca l a n esthetic ( E M LA)
41
Beca use some of m id-i nfra red laser treatme nts c a n be

pa i n fu l , some form of a n esthesia is ofte n req u i red . It wi l l
va ry accord i ng t o t h e aggressiveness o f treatment, the
pa rti c u l a r suscepti b i l ities of the patient, a nd the physi
c i a n 's comfort with va rious a n esthetic reg i m e n s .
M i d - i n fra red Lasers

The 1320- n m N d :YAG laser ( Coolto u c h I n c . , Rosevi l le ,
CAl featu res a t h e r m a l feed back system t h a t measu res
e p i d e r m a l tem peratu re to more precisely ta rget dermal
collage n . Thus, the laser s u rgeon can control h eati ng
with more p recision . I t is theorized that n ew col lagen
sti m u lation is caused by i nfla m matory cyto k i n es after
d e r m a l heati ng.
The 1450-n m d iode laser ( S m ooth bea m , Candela
Corp . , Wayl a n d , MAl a lso targets dermal water, while
p rotecti ng the e p i d e r m i s with a c ryoge n s p ray d evice
( Fig. 6 . 2 ) . There is n o tem peratu re feed back device. With
either device, aggressive coo l i ng can p rod uce tem pora ry
pigmenta ry c h a nges.
LAS E R SAFETY
Eye protection : m eta l eye goggles

- All perso n n e l p resent at the time of treatment m ust
wea r safety glasses/goggles to avoid
i nadverte nt
cornea l d a mage.
Figure 6.3 Pretreatment and immediate posttreatment photos of non
ADV E R S E S I DE EFFECTS
Adverse side effects: fa r less co m mo n than a blative pro
ced u res, but do occ u r with h igher fl u e n ces as we l l as
i nadvertent pu lse sta c k i n g ( ie, fi r i ng twice in ra p i d s u c
cession over the sa me a real
Sca rring
B u l lae ( Fig. 6 . 2 )
Posti nfla m matory
hyperpigme ntation
( us u a l l y
from
ove rly aggressive s k i n cool i ng)
Posto perat i ve C a re ( F i g .
6. 1)
Little postp roced u re pa i n .
A n y e rythema i s m i l d a n d resolves sh ortly after treat

ment.
There is no req u i rement for a fol l ow- u p visit afte r treat

ment.
N o posto perative c a re is req u i re d .

Patient s h o u l d b e i nstru cted t o ca l l if erythema persists
or if vesic les or b u l lae d evel o p ( Fig. 6 . 1 ) .
bruising pulsed dye laser treatments. There is mild erythema after treat
ments. Many patients note an improvement in the texture and tone of
skin after a series of treatments
42
Postoperative erythema resolves q u ic kly. Strict s u n

avoidance is recom mended .
The fol l owing practices a l l sign ifica ntly i n c rease the
risk of sca r:
Aggressive treatments i n c rease risk of sca r
Poor tec h n iq u e, ie, excess ive overla p ( p u lse stacking)

In sum, nona b lative laser resu rfa c i n g proced u res offer
the adva ntage of q u ic k , safe treatments that p rod uce

m i l d i m provement of photoda maged ski n . U s u a l ly, they
can be performed on the sa m e day as work a n d soc i a l
o b l igation s. N o n etheless, the treatment has i t s d raw
backs s u c h as
Resu lts a re usua l ly modest.
D u ration of benefit, if a n y, is n ot known .
Best resu l ts often req u i re more m u ltiple treatments.

Beca use the i m provement i s often s u btle and u n p re
d icta b le, eve n after m u lt i p l e treatme nts, other proce

d u res s u c h as nona blative fract i o n a l resu rfa c i ng have
i n c reasingly s u p pla nted the a p pea l of trad iti o n a l nona bla
tive p roced u res.
B I B L I OG RAPHY
Ta nzi EL, W i l l i a m s C M , Alster TS. Treatment o f fac i a l
rhytides with a nona b lative 1450- n m d iode laser: A con
trol led c l i n ic a l a n d
h istologic study.
Dermatol Surg.
2003 ; 2 9 ( 2 ) : 1 24- 1 28 .
Ta nzi E L , Alster TS. C o m pa rison o f a 1450- n m d iode
laser and a 1320- n m N d :YAG laser i n the treatment of
atro p h i c fa c i a l scars: A prospective c l i n ical and h isto logic
stu d y. Dermatol Surg. 2004;30(2 Pt 1 ) : 1 52- 1 57 .
CHAPT E R 7
A b l ative Lase r R es u rfaci ng
U t i l i z i n g t h e p r i n c i ples of selective photothermolysis,
a b lative rem ova l of s k i n i n a precisely control led fas h i o n
w i t h resu lta nt m i n i ma l s u rro u n d i n g t h e r m a l d a m age is
ach ieved . The d e pth of tissue penetration is dependent
on sel ective a bsorptio n of water. I m med iate tissue effects
a re d e pendent on the s pot s ize a n d power uti l ized as we l l
as t h e s peed o f treatment a d m i n istration . T h e ti me of
laser-tissue i nteraction is the critical factor for res i d u a l
thermal da mage. Epidermal o b l iteration a n d (or pa rtia l
a b lation o r coagu lation o f t h e u pper d e r m i s is t h e en d
point. Re-epith e l i a l ization resu lts fro m the m igration of
cells that a rise from su rro u n d i ng fol l i c u l a r ad nexae .
N o r m a l com pact col lagen a n d elastic fibers re place the
a m orphous elastotic dermal com pone nts, a n d norma l ,
we l l-orga n ized epith e l i a l cells replace t h e d i sorga n ized
p hotoda maged epidermis. Col lagen re mode l i n g is n oted
both i ntraoperatively via therm a l s h r i n kage and contrac
tion and postoperatively with i n the re mod e l i ng phase of
wo u n d hea l i ng.
C a r b o n D i ox i d e Laser
( C 0 2 R es u rfac i n g)
Conti n uo u s
wave
( 10,600 n m ) ,
s u per- p u lsed ,
and
sca n ned C0 2 lasers a re util ized for res u rfa c i ng. A rela
tively b l ood less su rgery with red uced swe l l i ng is a c h ieved
via the p h otocoagu lative effect on blood vesse ls and lym
phatics. The risk of sca rring, u n p red icta b l e level of th er
mal d a mage, a n d d e layed hea l i ng of the conti n uous wave
laser l i m it its c l i n ical use. The sca n n ed a n d p u lsed C0 2
lasers d e l iver high pea k fl u en ces in less tha n 0.001 sec
onds to a c h i eve tissue va porizatio n of 20 to 30 1-1m per
pass . Approxi mately 40 to 120 1-1m of res i d u a l thermal
d a mage is n oted per pass ( Fig. 7 . 1 ) .
E r b i u m : Ytt r i u m - A i u m i n u m G a r n et
Laser ( E r : YA G )
A laser o f wave length 2 ,490 n m i s uti l ized for more
s u perfic i a l
resu rfa c i ng.
It
is
16x
m ore
selectively
a bsorbed by water. It a c h i eves tissue va porization of 1 to

5 1-1m per pass. It res u l ts in a na rrower zon e of res i d u a l
t h e r m a l da mage ( 5-30 1-J m ) . A s a z o n e o f therm a l d a m
a g e o f 50 1-1 m o r greate r is req u i red f o r ph otocoagulati o n ,
Er:YAG treatment resu l ts i n a s l ightly b l oody s u rgica l fie l d .
The t h e r m a l d a mage is a lso i n s ufficient t o prod uce
i m med iate
c o l l agen
contra cti o n .
re model i ng is l i m ited ( Fig. 7 . 2 ) .
Long-term
col lagen
Figure 7 . 1 (A) A 58-year-old woman with extensive actinic damage.
43
44
I N D I CAT I O N S
Ablative lasers have been util ized as a c utti ng too l a n d
va poriz i n g tool t o treat epidermal a n d su perfi c i a l d e r m a l
lesions.
Cutting too l :
keloids, acne kelo i d a l i s n uchae, cyst
remova l , basa l carc i n o m a , b u r n , a n d u l ce r d e b ri d e

ment; h a i r tra nspla ntat i o n ; b l e p h a ro p lasty; other i n c i
sional s u rgeries where control led hemostasis is desi red
or where e p i n e p h r i n e is contra i nd icated or a pacer pre
c l udes use of e l ectrosu rgery.
Va porizi ng tool : treatment of n u merous cond itions

i n c l u d i ng static and dyna m ic rhyt id es, boxca r, c rateri
form and hypertro p h i c acne sca rs, pox scars, wa rts,
lentigines, adenoma sebace u m , a ngi okeratomas, pyo
gen i c
gra n u l o m a ,
lym pha ngioma
c i rc u mscri ptu m ,
Bowe n 's d i sease, eryt h roplasia o f Queyrat, o ra l florid

pa p i l l om atosis, acti n i c c h e i l itis, acti n i c keratoses , epi
d e r m a l n evi , syri ngomas, gra n u loma faciale, n e u rofi
b romas, xa nthelasma , and tattoos.
N ot i n d icated for the treatment of icepick acne sca rs .
Sign ifi cant past med ical h istory i nc l udes a h istory o f her
pes l a b ia l is; u n derlyi ng a uto i m m u ne d i sease or i m m u n e
d eficiency; u nd e rlyi ng koe bnerizing/i nfectious cond itions
i n c l u d i ng psoriasis, verrucae, and m o l l u sc u m ; h i story of
keloid or hypertro p h i c sca r format i o n ; u n derlying card ia c
o r p u l m o n a ry cond itions t h a t may be exacerbated by t h e
u s e o f a n esthetic medications; existi ng d rug a l le rgies;
tobacco use; a ctive acne vu lga r i s .
Sign ifica nt past s u rgica l h i story i n c l udes prior s u rgica l
treatments to the treatment sites, s u rgica l dates, a n d
patient response.
The patient m ust be awa re of the lengthy recovery
period that w i l l req u i re extens ive h a n d s-on patient care
for o pti m a l treatment resu lts . Re-epit h e l i a l ization req u i res
7 to 10 days with associated pa i n , ed e m a , a n d e rythe m a .
Posto perative erythema resolves over a n ave rage period
of 3 to 5 months. Strict sun avoida nce m u st be fol l owed
for a m i n i m u m of 1 yea r posto peratively to avoid pigmen
ta ry cha nges a n d p h otose nsitivity. Rea l istic expectations
a re the m ost i m porta nt d ete r m i n a nts of treatment suc
cess . The patient m ust be aware that the treatment wi l l
i m prove b u t d oes n ot e l i m i nate a l l or even m ost rhytides
or sca rs a n d that dyna m i c rhytides a re l i kely to rec u r
with i n a few months postoperative ly.
P roced u ra l
risks to em phasize i n c l u d e tem pora ry
a n d/or perma nent hyperpigme ntation a n d d e pigme nta

t i o n , i nfection (vi ra l , bacteria l , yeast ) , a n d sca r (atro p h i c ,
hypertro p h i c , keloi d a l ) fo rmati o n ; a c n e fla re; eczema
last i n g 1 to 2 months. Pred icta ble side effects i n c l u d e
proced u ra l a n d posto perative d iscomfort; edema , oozi ng,
Figure 7.1 ( continuedJ (B) A marked reduction in rhytides and dyspig
mentation is noted 2 months after full-face carbon dioxide resurfacing
45
a n d crusti ng lasting 1 to 2 weeks; e ryth em a , s k i n tight

ness, a n d pruritus lasti ng u p to 3 to 4 months.
I D EAL LAS E R CAN D I DATE
Fa i r s k i n type ( Fitzpatrick phototypes I-l l )
Laser-a menable lesions
M i n i ma l assoc iated dyspigme ntation of neck a n d c h est
Abl e to tole rate exte n d ed period of conva lesce nce post

operatively
Able to fo l low and exec ute necessa ry posto perative s k i n

ca re regi men
Rea l istic treatment expectations
LESS THAN I D EAL LAS E R CAN D I DATE
Da rker s k i n type ( Fitzpatrick ph ototypes I l l , IV, a n d Vl;

treat with cauti o n , d ue to sign ifica nt risk of tem po ra ry
a n d/or permanent pigmenta ry a lterations
Moderate associated d ys p igme ntation of neck and

c h est
U na b l e to fol low a n d execute necessa ry postoperative

s k i n care regi m e n
P r i o r fac i a l s u rgica l proced u res performed

P ro m i nent fac i a l pore pattern-laser treatment may
exacerbate the i r a ppea ra nce
ABSOLUTE CONTRA I N D I CATI O N S
Use of o ra l treti n o i n with i n 1 yea r o f su rgery
S k i n p h ototypes V a n d V I
Active cuta neous i n fection
P reexisti ng ectropion
Poor patient c o m p l ia nce
U n re a l istic patient expectations
R E LAT IVE CO NTRA I N D I CAT I O N S
Exte nsive u nderlying dyspigmentation of face a n d

su rrou n d i n g neck a n d c h est-risk o f d e m a rcatio n l i ne/
d ifference in s k i n color of treated vers us u ntreated s k i n
S k i n p h ototypes I l l a n d I V
U n d erlying connective tissue
U n d erlying koebnerizing cond ition
U n d erlying i m m u nologic d i sease
P revious lower lid a n d/or blepha roplasty (for i nfraorbita l

resu rfa c i ng)
Figure 7.2 (A) A 45-year-old woman with facial photoaging and mild acne
scarring.
46
Previous ablative resurfacing, derma brasion, cryosu rgery;

face l i ft or phenol peel
H i story of fac i a l rad iation treatment
M E D I CAT I O N S
Anti bacterial thera py: t o avoid i m petigi n i zation a n d

bacterial i nfection o f t h e treatment sites, prop hylactic
a nti biotics a re i n itiated 1 day p reo peratively.
- Dic loxa c i l l i n 500 mg PO B I D or Keflex 500 mg PO
B I D for 1 0 to 14 days is presc ri bed .
- I n pen i c i l l i n-a l lergic i n d ivi d ua ls, Ci profloxa c i n 500 mg
PO B I D
PO
10 to 14 d ays or azith romyc i n 500 mg
1 day fo l l owed by 250 mg d a i ly for 5 days is
reco m m e n d ed .
Antiviral thera py: laser resu rfa c i n g may trigger a herpes

s i m p l ex outbrea k that can spread to the treatment sites
with an i n c reased risk of sca r fo rmation .
- Prop hylactic a ntiviral medications a re i n itiated 1 day
p reoperatively.
- Va lacyc lov i r 500 mg PO B I D for 14 days or acyc l ovi r
400 mg PO T I D for 14 d ays is reco m m ended .
Topical treti n o i n
- Use o f treti n o i n prior t o C02 l a s e r res u rfa c i n g h a s
b e e n shown c l i n ica l ly a n d v i a b i o c h e m i c a l a na lysis to
not provide e n h a n ced collage n formati o n , acceler
ated re-e pithe l i a l izati o n , or q u icker resol ution of post
operative erythema.
- Use of this med ication is o ptiona l .
- Use o f this medication postoperatively s h o u l d be
postponed u n t i l a l l associated e rythema and i nfla m
mation have resolved .
B l eac h i ng c rea ms: no p u b l ished , control led trials have
Figure 7 . 2 ( continued) (B) Improvement of photoaging 3 weeks after full
demonstrated the ben efits of preo perative bleac h i ng
face erbium treatment
c rea ms to red uce the risk of postinfl a m matory hyper

pigme ntati o n . To possi bly red uce this risk, patients with
skin p h ototypes I l l and I V a re presc ri bed a blea c h i ng
c rea m to be a ppl ied twice d a i ly for 6 to 7 weeks prior to
treatment. As we l l , strict s u n avo i d a n ce is m a n d atory.
AN ESTH ES I A
Cold-a i r cool i n g ( Z i m mer) may b e a d eq uate for loca l

ized or si ngle-pass C0 2 treatment or Er:YAG treatment.
Topical a n esthesia may be adeq uate for loca l ized or

si ngle-pass C0 2 treatment o r Er:YAG treatment.
Regio n a l n e rve b l oc ks with su pple menta l i nfi ltrative

a n esth esia a re ge nera l ly a d m i n istered for m u lti ple- pass
C0 2 treatment.
- Site-dependent b l ocks i n c l u d e s u p raorbita l , s u p ra

troc h lea r, i nfraorbita l , and menta l blocks.
- Lid oca i ne (1 % ) with 1 : 1 00,000 o r 1 :200, 000 epi
n e p h r i n e , a tota l of 0 . 5 to 1 . 0 ml is a d m i n istered per
site .
- S u p plementa l i nfi ltrative a n esthesia consisting o f a n
eq u a l m ixtu re o f 1 % l idoca i n e , 0 . 5 % b u pivaca i n e ,
a n d 1 : 1 0 sod i u m bica rbonate is ge nera l ly req u i red ,
espec ia l ly for the jawl i n e , u pper eyel ids, a nd te m ples.
- Hya l u ro n i dase (Wyd ase) 7 5 U for tissue d iffusion
may be a d d ed to the i nfi ltrative a nesthes i a .
- Treatment is delayed 1 0 t o 1 5 m i n utes to a l low for
c o m plete a n esthetic effect.
Conscious i ntravenous sed ation a n d gen e ra l a n esthesia

have been e m p l oyed by tra i ned physicians i n ce rtified
fac i l ities i n patients u n a b l e to tolerate the i njections or
for la rger proced u res.
SAFETY M EAS U R ES
Eye protection
- One o r two d ro ps of 0 . 05% to pica l pro pa raca i n e
(Aica i n e ) or 0.05% topica l tetra ca i n e ( Pontoca i n e )
a re placed i nto e a c h eye o f the patient, fol l owed by
the a ppl ication of to pica l e ryth romyc i n oi ntment o r
o p htha l m i c l u bricant ( e g , Lacri-Lu be) a n d non reflec
tive m eta l l ic ocu l a r shields (eg,
Byron
Medica l ,
Tucso n , AZ; Ocu lo-Piasti k , M o ntrea l , Canad a ) .

- A l l perso n n e l m ust wea r clea r p lastic safety glasses to
avo i d i nadve rtent cornea l d a mage .
Operative field
- All reflective su rfaces and windows m ust be covered
to avoid inadve rtent treatment of a reflective s u rface.
- The treatment room door m u st be la beled properly to
wa rn others not to enter d u ri n g laser treatm ent.
- A l l fla m ma ble materials and a nesthetic gases m ust
be kept away fro m the operative field .
- Wet d ra pes a n d sponges a re pla ced a ro u n d the s u r
gica l s ite to preve nt accide nta l i rrad iation of s u r
ro u n d i ng s k i n a n d to m i n i m ize potentia l fi re risk.
- A nonfla m m a b l e oi ntment (eg, S u rgi l u be; KY J e l ly)
m ust be placed ove r the exposed h a i r l i n e and eye
brows to avoid h a i r si nge i n g . S u rgi l u be s h o u l d not be
used over the eyelas hes to avoid the risk of cornea l
keratitis.
- All s u rgica l tools uti l ized m ust possess a non reflective
or ro ughened black coati ng to preve nt laser bea m
d eflection .
- A laser smoke evac uator that fi lters pa rticles as s m a l l
as 0. 1 2 m i n d ia meter a n d laser-gra d e s u rgica l
masks m ust be used to red uce potenti a l s p read of
i nfectious pa rtic l es in the laser p l u m e .
Figure 7.3 (A) A female patient who was most bothered by her perioral
rhytides, but was also noted to have moderate dermatoheliosis with
n umerous lentigines and actinic damage of the remainder of her face.
47
48
- Use of H i biclens, isopropyl a lc o h o l , a n d acetone is

proh i bited due to their fla m ma bl e nature. All m a keu p
a n d h a i rs pray a re to be removed , as they a re poten
tia l ly fla m m a b l e .
- The l a s e r s h o u l d be ke pt i n the sta n d by m o d e at a l l
ti mes other than a ctive treatment t o avo i d accid ental
fi ri ng.
- Oxygen s h o u l d be avoid e d , but if need ed, s h o u l d be
c l osely mon itored a n d o n ly used in conj u nction with a
c l osed gas system that i n c l udes either en dotracheal
i n t u bation of l a ryngea l mask a i rway.
PROCEDU R E
A thorough review of the risks a n d benefits i s perform ed .
Patient written consent is o bta i n ed .
R e p rese ntative preoperative pictu res a re o bta i ned .
P retreatment preparation is performed.
The choice of laser and laser pa ra meters va ries,

d e pend i ng on the c l i n ica l situation .
- The C0 2 laser is prefe ra ble for d ee per l i nes a n d
sca rring p rocesses a n d for fa i r-sk i n ned patients
( Fig. 7 . 1 ) .
- The Er:YAG laser is beneficia l for s u perfic i a l l i nes a n d
dyspigme ntation a n d for da rker s k i n ned patients
( Fig. 7 . 2 ) .
- T h e patient's postope rative considerations a lso affect
the choice of laser. The C02 laser wi l l have a n
expected longer recovery c o m pa red with t h e Er:YAG
laser.
I n ge nera l , treatment of a cosmetic u n it or fu l l face is

best to m i n i m ize the risk of text u ra l mismatch between
nontreated a n d treated a reas. I n an isolated treatment,
one m ust treat the entire lesion or line to their end
rather than rema i n with i n a cosmetic u n it .
The ve rm i l ion border can be treated conservatively t o

m i n i m ize l i pstic k " bleed i n g . "
Treatment s h o u l d extend beyond the a nato m i c a l u n it

being treated with a feathering tec h n i q u e (decreased
fluence) e m p l oyed to blend i nto the untreated ski n .
For d e p ressed scars, a d d iti o n a l passes with a s m a l l e r

s pot s i z e o n t h e d efect edge a l l ow for more sign ifica nt
flatte n i ng of the sca r.
Sca r contraction wi l l occ u r with hea l i ng. To avo i d

atro p h i c sca r formati o n , a d m i n iste r treatment to the
l evel of nea r normal adjacent s k i n on ly.
Ab lative resu rfa c i n g of dyna m i c rhytides provides o n l y

tem pora ry benefit. Consideration o f c o m b i nation ther
a py with botu l i n u m toxi n or a fi l l e r su bsta nce s h o u l d be
enterta i ned to a c h i eve maxi m u m benefit.
Figure 7 . 3 ( continuec!J (8) Same patient immediately after perioral
carbon dioxide laser resurfacing and a Jessner/35% trichloroacetic acid

peel to the remainder of her face.
M i n i m a l mechanical tra u ma tec h n i q u e : fewer C0 2

passes performed with reta i n ment of the last pass
esc h a r to exped ite hea l i ng a n d m i n i m ize sca r risk a n d
pigme nta ry cha nges. T h i s tec h n i q u e is o pti m a l for
you nger patients with more s u perfic i a l lesions a n d fo r
d a rker s k i n types.
With any treatment m od a l ity, the presence of l a rger col

lagen b u n d les hera l d entry i nto the deep retic u l a r d e r
m is a n d wa rn of the poss i b i l ity of scar formation .
Treatment s h o u l d be d i sconti n ued i m med iately.
Res u rfa c i n g of nonfa c i a l rhyti d es is associated with a

h igh risk for textura l a n d pigmenta ry cha nges d u e to
the red uction in a d nexa l stru ctu res a n d poor vasc u l a rity
in compa rison to the face. The C0 2 laser s h o u l d n ot be
util ized for the treatment of nonfa c i a l rhyti d e s . The
Er:YAG laser should be util ized with extre me caution .
Combi nation thera pies of ca rbon d i oxide res u rfa c i n g

a n d c h e m i c a l pee ls, botu l i n u m tox i n , or soft tissue a ug
mentation may p rovide the greatest benefit ( F ig. 7 . 3 ) .
POSTOPERAT I V E CAR E
An open wou n d tech n i q u e or c l osed tec h n i q u e may be

fo l l owed .
Posto perative d iscomfort is cha racterized by moderate

b u r n i ng with i n the fi rst 24 h o u rs . T h i s is m i n i m ized with
the use of an occ l usive d ressi ng. I t can genera l ly be
controlled with ice pac ks , cold c o m p resses, a n d a ceta
m i no p h e n , as we l l as freq uent wo u n d ca re.
Posto perative edema d evelops 24 to 48 h o u rs postop

eratively and c a n be contro l l ed with ice packs and head
e l evati o n . O ra l steroids a re e m ployed when ma rked
swe l l i ng d eve lops i ntraoperatively or i m med iately post
operative ly.
Re-epith e l i a l izati on occ u rs with i n 3 to 10 days a nd is

d e pendent on the laser util ized , the n u m ber of laser
passes exec uted , and the s u rgica l ca n d i d ate. You nger
patients, patients who u nd e rgo Er:YAG treatment, a n d
fewer passes show faste r h ea l i ng. Delayed h ea l i ng is
observed i n older patie nts, sm okers, and i nc reased
laser passes.
Topica l a nt i b i otics and Aq u a p h o r H ea l i ng O i ntment

should be avoided d ue to the risk of a l lergic co ntact
d e rmatitis.
C l ose fol l ow- u p is m a n d a tory to ensure p ro per care a n d
Prophylactic a ntibiotics a n d a ntivira l med ications a re
hea l i ng o f t h e treated sites ( Figs. 7 . 4 a n d 7 . 5 ) .

conti n ued for 10 to 14 days posto pe rative ly to avoid
infecti o n .
Strict s u n avo i d a n ce is m a i nta i ned fo r 1 yea r postopera

tively to avoid photose nsitivity and to m i n i m ize the risk
of posti nfla m matory hyperpigmentation.
Figure 7.3 ( continued) (C) Same patient 6 months following her treat
ment. A marked reduction in both her rhytides and dyspigmentation is

appreciated.
49
50
P EARLS FOR T R EATM ENT S U CCESS
P reoperative wou nd c a re i n structions a r e critica l for

treatment su ccess. The patient a n d sign ificant others
m ust be pre pa red fo r the exten sive ca re that w i l l be
req u i red fo r exped ient a n d
safe
hea l i ng.
Patients
s h o u l d be shown postoperative pictures to prepare

them for how they wi l l a p pea r. Posto perative s u p p l i es,
i n c l u d i n g wo u n d ca re s u p p l ies and d esi red ca m ouflage
fou ndation, s h o u l d be o bta i ned prior to the treatment
date. Patie nts with you nger c h i l d re n m ust prepare
them for the sign ificant c h a nges that wi l l be noted d u r
i ng the hea l i ng period . Any posto perative assista nce the
patient may req u i re should be a rra nged prior to treat
ment if possi b l e .
Patients req u i re freq uent postoperative eva l uation for

the fi rst 14 d ays to e n s u re proper wo u n d ca re is being
e m ployed , pred icted hea l i ng is noted , and no side
effects s u c h as sca r formation or i nfection occ u r.
Patients s h o u l d be eva l u ated on posto perative day 2 ,
posto perative d a y 5 t o 7 , a n d postoperative day 1 0 to
1 4 a n d a nyti m e the patient exp resses a concern of
need for eva I uation .
Patie nts' expectations m ust be ta i l o red to the expected

be nefits . Patients s h o u l d be i nfo rmed that the greatest
benefits w i l l not be a p p reciated for 6 to 12 months
posto peratively.
Strict ph otoprotection a n d s u n protection a re c ritical i n

red u c i n g t h e occ u rrence o f posti nfla m m atory hyperpig
m entation and s u n b u r n and should be fo l l owed for a
m i n i m u m of 1 yea r after treatment.
Treated skin is sensitive to a majority of fac i a l prod u cts,

perfu mes, a n d to pica l medications for an average of 1 2
weeks posttreatment. B l a n d p rod u cts, i n c l u d i ng a s u n
block, a re recom mended d u ri n g this hea l i ng t i m e .
Persistent a reas o f erythema s h o u l d ra ise concern

rega rd i ng sca r formation or i nfection . A c u lture is rec
o m m ended to rule out bacterial or yeast i nfectio n . Use
of a pote nt topical corticosteroid a n d/o r pu lsed dye
laser is crucial with close fol low- u p to ensure resol ution .
B I B L I OG RAPHY
Alster
TS. C uta neous resu rfa c i n g with C0 2 a n d

erbi u m : VAG lasers : P reoperative, i ntraoperative a n d post
operative
consid erations.
Plast
Reconstr
Surg.
1 999; 1 03 : 6 1 9-634.
Anderson R R , Parrish JA. Selective photothermolysis:
P recise m i c rosu rgery by selective a bsorption of p u l sed
rad iatio n . Science. 1 983 ;220: 524-527 .
Carruthers J , Carruthers A , Zelichowska A. T h e power of
c o m b i ned thera pies: Botox a n d a blative laser res u rfac
ing. Am J Cosmet Surg. 2000; 1 7 : 129- 1 3 1 .
Figure 7.4 Under aggressive wound care. A substantial amount o f crust
ing is observed. Proper wound care was demonstrated in-office and with
repeat written instructions reviewed
David I, R u i z- Es pa rza J . Fast hea l i n g after laser s k i n

resu rfa c i ng . The m i n i ma l mecha n ical tra u ma tec h n i q u e .
Dermatol Surg. 1997;23:359-36 1 .

Dover J S , H ruza GJ , Arndt KA . Lasers i n s k i n resu rfa c i n g .
Semin Cutan Med Surg. 1 996; 1 5: 1 7 7 - 1 88 .

D u ke D, G reve l i n k J M . Ca re before a n d a ft e r l a s e r s k i n
resu rfa c i ng .
A s u rvey a n d
review o f the
l iterature.
Dermatol Surg. 1 998;24:201 -206.

Fitz patrick RS, G o l d m a n M P, Sat u r N M , Tope WD. P u lsed
ca rbon d i oxide laser resu rfa c i ng of p h otoaged fac i a l s ki n .
Arch Dermatol. 1996 ; 1 32 : 395-402.

Fitzpatrick R E, To pe W D , Gold m a n M P, et al. P u lsed
ca rbon d ioxid e laser, tric h l o roacetic a c i d , Backer-Gordon
phenol and derma b rasi o n : A com pa rative c l i n ical a n d
h istologic study o f cutaneous res u rfa c i n g i n a porc i n e
model . Arch Dermatol. 1 996; 132:469-47 1 .
N a n n i CA, Alster TS. Com pl ications of ca rbon d ioxi d e
l a s e r res u rfa c i n g : An eva l uation o f 5 0 0 patients. Dermatol
Surg. 1 998;24: 3 1 5-320.

Orringer JS, Ka ng S, J o h nson TM, et al. Treti n o i n treat
ment before carbon-dioxide laser res u rfacing: A c l i n ica l
and
biochemical
a n a lysis.
Am
Acad
Dermatol.
Decem ber 2004; 5 1 ( 6 ) : 940-946.

R a u l i n C , G rema H. S i ngle-pass carbon d ioxid e laser s k i n
resurfa c i ng com bined w i t h cold-a i r cool i ng: Efficacy a n d
patient satisfaction o f a pros pective side-by-side study.
Arch Dermatol. 2004; 140( 1 1 ) : 1 333- 1336.

R u iz-Esparza J, Ba rba G o m ez J M , Gomez de Ia To rre OL.
Wou n d ca re after laser skin res u rfa c i ng. A combi nation of
open a n d c l osed methods using a new polyethylene
mask. Dermatol Surg. 1 998;24: 79-8 1 .
Figure 7 . 5 Postinf/ammatory hyperpigmentation 6 weeks after perioral

carbon dioxide resurfacing. This pigmentation resolved with the use of
4 % hydroquinone twice daily for 2 months
51
52
CHAPT E R 8
N o n a b l at i ve F ract i o nal Lase r R esurfaci ng
Fract i o n a l p h otothermolysis
Nona blative fractio n a l res u rfa c i ng ( N A F R ) is a n ovel con

cept of skin rej uvenation that ca n ta rget both e p i d ermal
Laser
---
I I I
I I I
a n d d e r m a l cond iti ons. NAFR p rod uces a u n iq ue thermal
I I I
d a mage patte rn consisti ng of m u ltiple col u m n s of th er
I I I
I I I
I I I
m a l coagu lative da mage, refe rred to as m i c rothermal

treatment zones ( M TZs) ( Fig. 8. 1 ) . N A F R c h a racteristi
I I I
I l l
Epidermis
c a l l y spares the tissue su rrou n d i n g each MTZ, thus a l l ow
I I I
'fiN
i n g fast epidermal repa i r d u e to m ic rosco pic size of the

wou nd s a n d short m igratory d ista nce fo r the via b l e ker
atinocytes p resent at the MTZ epidermal m a rgins. On ly a
fractio n of the s k i n of the s u rface a rea is treated .
D E R M ATOPAT H O LOGY
M TZ revea ls homogen ized col u m ns of dermal matrix a n d
t h e formation o f m i c roscopic e p i d e r m a l nec rotic d e bris
( M EN D ) ( Fig. 8 . 2 ) . M E N D formation is thought to re p re
sent the p rocess of e l i m i nation of the therma l ly d a m aged
S u bc uta neous fat
--
Figure 8 . 1 Schematic of microscopic treatment zones (MTZJ created by
fractional resurfacing laser (note the characteristic sparing of the sur

rounding tissue between the treatment zones)
epidermis conta i n i ng pigment by the ra p i d l y m igrati ng

via ble kerat i n ocytes at the MTZ ma rgi ns. M E N D may a lso
conta i n d e r m a l structu res s u ch as the elastic fi bers .
Vesse ls i n t h e M T Z regions can be therm a l ly d estroyed i n
a nonselective m a n ner. H igher energies res u l t i n deeper
and wider MTZs. H igher energies resu l t i n deeper a n d
wider M TZs. N A F R can b e hel pfu l i n t h e treatment o f epi
d e r m a l pigmentation suc h as melasma a n d lentigi nes
d ue to the process of M EN D formatio n . N A F R can a lso
be h e l pfu l in i m p rovi ng rhytides and sca rring due to the
p rocess of col lagen remod el i ng and n ew col lagen forma
tion, i nd uced by the dermal thermal da mage.
I N D I CAT I O N S
N A F R c a n b e a n effective treatment o f fine-to- moderate
rhytides; acne scars, s u rgica l , tra u matic, a n d burn sca rs;
melasm a ; dysc h ro m i a ; and d e rmatohel iosis ( Fig. 8 . 3) .
Sign ificant past medical history i n c l udes h i story o f h e r

pes l a b i a l is, keloid or hypertro p h i c scar formatio n , ora l
treti n o i n i ntake (d ate last cou rse com pleted ) , to pical
retinoid use, tobacco use, a n d k n own d rug a l lergies
i n c l u d i n g l i doca ine a l lergy.
Sign ificant past s u rgica l h i story i n c l udes prior s u rgical

treatments to the treatment sites, the dates of the p ro
ced u res, the pati ent's res ponse, and the associated
side effects.
Figure 8.2 H & E histology of microthermal treatment zone (MTZ) 1 day

after fractional resurfacing treatment (note the microscopic epidermal
necrotic debris (MEND) overlying a column of homogenized dermis)
53
The patient s h o u l d be awa re of the fol lowi ng:

- Proced u ra l d iscomfort.
- S u n burn-l i ke sensation for severa l h o u rs after the
proced u re.
- S u n b urn- l i ke postoperative erythema that may per
sist for 3 to 7 days ( Fig. 8.4 l .
- Posto perative edema, ge nera l ly m i l d , that usually
resolves with i n 2 to 3 days.
- Posto perative bronzing that is ge nera l ly noted o n the
t h i rd posto perative day and often persists for 3 to
4 days .
- Posto perative su perfi c i a l pee l i ng t h a t is often m i l d
a n d is noted t o sta rt o n the th i rd postoperative day
a n d to persist for 3 to 4 days .
- Rea l istic expectations f o r the proced ure: the patient
s h o u l d be awa re that the treatment wi l l i m prove fine
to-moderate wri n kles, pigmentati o n , a n d s u perficial
sca rs
but d oes
not e l i m i nate
moderate-to-deep
rhytides. A modest benefit may be noted for d eeper
Figure 8.3 Periorbital rhytides (A) following one fractional resurfacing
treatment and (B) following four fractional resurfacing treatments. An

appreciable softening is noted (Courtesy of R. Fitzpatrick, MDJ
wri n k l es.
- Proced u ra l risks: a lthough these adverse eve nts a re
u ncommon a n d a re m u c h less freq uent than those
assoc iated with a blative resu rfa c i ng, they sti l l exist.
They i n c l u d e te m pora ry posti nfla m mato ry hyperpig
mentation
( Fig.
8.5),
b l i ste ri ng,
c rusti ng,
m i l ia
( Fig. 8 . 6 ) , acn eiform e r u ption , p i n po i nt hemorrhage

( Fig. 8 . 7 ) , herpes s i m plex reactivati o n , a n d ra rely
hypertro p h i c sca rri ng. This is in a d d ition to the p re
d icta b l e side effects that i nc l u d e proced u ra l d iscom
fo rt, posto perative e rythema, bronzing, and edema .
There is usua l l y no assoc iated oozing or c rusti ng
u n l ess very h igh energies a n d/or h igh densities a re
util ized .
The i d ea l ca n d i d ate is a fa i r-s k i n patient ( Fitzpatrick

p hototypes 1-1 1 1 ) . H owever, NAFR can be safe and
effective i n d a rker s k i n types ( F itz patrick p h ototypes I V
a n d V ) . I t is a lso safe t o u s e o n nonfa c i a l a reas i n c l u d
i n g the n e c k , tru n k , a n d extrem ities, provided that
decreased fluences and d e nsities a re uti l i zed .
CO NTRAI N D I CAT I O N S
Ora l treti n o i n use with i n 6 months t o 1 yea r o f su rgery
Active c uta neous i nfection
U n real istic patient expectations
P regnant or lactating wom a n
M ED I CAT I O N S
Anti bacterial therapy: prophylactic a nti biotics a re gen

era l l y n o t req u i red
Figure 8.4 Mild sunburn-like erythema immediately following Fraxel laser
treatment with 6 to 8 mJ, 250 M TZ!cm2 , eight passes. This erythema

may persist for 3 to 7 days
54
Antiviral thera py
- Fracti o n a l resu rfac i ng may trigger reactivation of her
pes s i m plex that ca n s p read to the treatment sites .
- Prophylactic
a ntivi ra l
m ed i cations
a re
i n itiated
1 d a y prior to the proced u re . Va la cyc lovir 500 mg

PO B I D o r acyc l ovi r 400 mg PO T I D fo r 7 d a ys is
u s u a l l y recom m e n d ed . An a l ternative is va l acyc l ov i r
2 PO B I D f o r 1 d a y t o be sta rted t h e m o rn i ng o f t h e
proced u re .
Treti noi n : i t is advised t o d isconti n u e treti n o i n c rea m at

severa l days before N A F R to preve nt s k i n i rritation at
the treatment sites.
AN ESTH ES I A
Cold-a i r cool i ng (Zi m mer) i s very effective i n decreasi n g

the proced u ra l d iscomfort.
Topical a n esthesia (oil or crea m base) a ppl ied at least
Figure 8 . 5 Postinflammatory hyperpigmentation following fractional

resurfacing treatment to the upper lip
1 hour before the proced u re is genera l ly adeq uate, espe

cially in combi nation with cold-a i r cool ing ( Z i m mer) .
Regio n a l n e rve blocks ca n be effective to red uce the

d iscomfort for patients with low pa i n t h resholds, espe
c i a l l y when uti l i z i n g higher fl u ences a n d d e nsities .
I nfraorbita l a n d menta l b l oc ks can be h e l pful when
treati ng periora l wrin kles, but a re usually not necessa ry.
P R EOPERATIVE P R E PARAT I O N
Ex p l a i n t h e risks a n d benefits o f the proced u re .
O bta i n t h e patient's writte n consent.
Wash the a rea to be treated with soa p and water.
O bta i n preo perative pictu res .
A p p l y a t h i c k layer of topical a n esthetic i n an o i l or

c rea m base to the treatment site .
Wa it at l east 6 0 m i n utes t o a c h i eve o pti m a l a nesthetic

effect.
Wi pe off the to pical a n esthetic with a d a m p c l oth .
PROCEDU RAL T I PS
The laser pa ra meters a re c h osen accord i n g to the c l i n i

cal ta rget.
- For e p i derma l cond itions s u ch as p h otod a mage,
lentigi nes, melasma, and dysc h ro m i a : lowe r f lu ences
and h igher densities a re u s u a l l y uti l ized .
- For deeper processes such a s rhytid es or a cn e sca r
ring: h igher fl uences a re uti l ized .
Lower percent coverage of s k i n su rface a rea ; that is,

lower d e nsities a re i n d icated i n d a rker s k i n types to
avoid postinfl a m matory hyperpigme ntation .
Figure 8.6 Milia on the chin 1 day after NAFR
55
Caution s h o u l d be exerted when treating s m a l l e r a reas

s u c h as u p per l i p , nose, and tem ple in ord e r to avoid
b u l k heating that can res u l t in bl istering and sca rri ng.
- Al l ow adequate time between passes for the heat to
d issi pate and the s k i n to cool d own before the next
pass .
- When treati ng the u pper l i p, a l ternate the treatment
between the right side and the left side, and sta rt
each pass from the sa m e point.
Th ree to six treatment sessions ( d e pe n d i ng o n the i n d i

cation for treatment) a re a d m i n istered 3 to 4 weeks
a pa rt . Longer period between treatments is a dvised i n
d a rker-s k i n patients t o avo i d o r decrease t h e i nc i dence
of posti nfla m m atory hyperpigmentation ( P I H ) .
POSTOPERAT I V E CAR E
Posto perative d i scomfo rt is genera l ly m i l d a n d tra n

sient. The patient wi l l experience a s u n b u rn sensatio n
for seve ra l h o u rs .
Patie nts may a p p ly m a ke u p i m med iately after the treat

ment.
Patie nts a re encou raged to use m i ld moisturize rs fo r

severa l days after the p roced u re .
Posto perative e d e m a is u s u a l l y m i n i ma l but can be

controlled with ice packs a n d head elevatio n . I n ra re
i n sta nces of ma rked swe l l i ng, o ra l p red n isone ca n be
p resc ri bed for 3 to 7 days.
Sun avo i d a nce is m a i nta i ned for at least 4 to 6 weeks

after the proced u re to m i n i m ize the risk of posti nfla m
matory hyperpigmentation . S u n sc reens with a m i n i
m u m S P F of 30 a re reco m mended .
Typical ly, patie nts can retu rn to work on the fi rst post
operative day.
PEA R LS FOR TREAT M ENT S UCCESS
Patient selectio n is the key. Treating rhyti d es o r sca rs

that a re too deep w i l l p rove d isa ppointing to the patient
a n d physic ia n . The patient m u st be awa re of the need
for m u ltiple treatments to o bta i n the d esi red c l i n ical
benefit.
NAFR ca n res u lt i n serious side effects such as sca r

ri ng when used at very h igh fl uenc ies by i n experien ced
physicia ns o r health ca re workers. Caution s h o u l d be
ta ken to stay with i n the recom m e nded pa ra meters a n d
a p ply a p propriate
ove r l a p p i n g tec h n i q u e t o avoid
potentia l com p l i cations.
Patients m ust be awa re that benefits may be s h o rt last

i n g a n d may req u i re m a i nte na nce treatments for con
t i n ued c l i n i c a l benefit.
Figure 8.7 A patient with rosacea who developed pinpoint hemorrhage
1 day after Fraxel Restore treatment. Pinpoint hemorrhage can occur with
higher energies and usually resolves in few days with no sequelae
56
Effective N A F R treatment i n patients with ski n ph oto

types I l l to V c a n be a c h ieved . An i n c reased i n c i d e n ce
of posti nfla m matory hyperpigmentation
is genera l ly
noted . Patients m u st be aware of the poss i b i l ity of P I H

with each treatment. Decreasing t h e density o f treat
ment red uces the risk of PI H .
DEV I CES
The m ost c o m m o n l y used N A F R d evices t h a t a re ava i l
a b le i n t h e ma rket a re Fraxel R estore (Solta Medica l , I n c . ,
Haywa rd , C A ) , L u x 1 , 540 n m laser ( Pa l o m a r Medical
Tech n ologies, B u rl i ngto n , M A ) , a n d Affi rm 1 ,440 nm
N d : YAG laser ( Cynos u re, Westford , MAl (Ta ble 8. 1 ) .
Fraxel R estore util izes the sca n n i ng tec h n o l ogy whereas
Lux 1 , 540 nm and Affi rm 1 ,440 nm lasers uti l ize the
sta m p i n g tec h nology and d o not usually req u i re to pical
a n esthesia or d isposa ble tips.
TAB L E 8. 1
Nonab lative Fractiona l Lasers
Com pany
Laser d evice
Laser
M od e
wavelength ( n m )
Sa lta Medical
F raxel R estore
1 , 550
Sca n n i ng
Cynosure
Lux 1 , 540
Affi rm 1 ,440 N d : YAG
1 , 540
1 , 440
B I B L I OG RAPHY
La u bach HJ , Ta n nous Z , Anderson R R , M a nste i n D . S k i n
res ponses t o fra ctional photothermolysis. Lasers Surg
Med. 2006;38(2 ) : 142- 149 .

M a nste i n D , H e rro n G S , S i n k R K , Ta n n e r H , And erson
R R . F ractiona l ph otothermolysis: A new concept fo r c uta
neous remod e l i ng u s i n g m i c rosco pic patterns of thermal
i nj u ry. Lasers Surg Med. 2004;34( 5) :426-438.
N a r u rka r VA . N o n a b lative fracti o n a l laser resu rfa c i ng.
Dermatol Clin. 2009 ;27(4) :473-478, vi.

Ta n n o u s Z . Fractio n a l res u rfa c i ng. Clin Dermatol. 2007;
2 5 ( 5 ) : 480-486 .
M a x energy/MTZ
d i a meter ( m m )
or m ic ro bea m ( mJ )
d e l ivered ( c m 2 )
70
1 2-4,000 ( 5-48% )
Density
15
( Fraxel SR 1 , 500)
Pa l o m a r
Ti p
Sta m ping
Sta m ping
10
1 00
1 00
15
15
320
10
8 J/cm 2/pu lse
1 , 000
CHAPT E R 9
A b l ative Fract i o nal Lase r R esu rfaci ng
I N TRODUCT I O N
Treatme nts for photoaging ra nge fro m nona blative laser
resu rfa c i ng to a blative laser res u rfa c i n g . Both of these
tec h n i q ues a re d escri bed in d eta i l in previous cha pters.
Put s i m ply, the m ost effective lasers, carbon d ioxi d e
a n d e r b i u m a blative res u rfa c i ng lasers , provid e the m ost
d ra matic benefit for photoaging a n d other s k i n co n d i
t i o n s , but a lso ca rry t h e h ighest r i s k f o r adverse effects.
They rema i n the gol d sta n d a rd treatment for photod a m
aged ski n . Dramatic res u l ts, however, ca n be seen with
one treatment. Side effects i n c l u d e prolonged erythema
(fo r months ) , perma nent hypopigmentat i o n , te m pora ry
hyperpigmentat i o n ,
i nfect i o n ,
and
sca r.
Ad d itional ly,
d ownt i m e from work a n d soc i a l a ctivities is sign ifica nt.

For this reaso n , the po p u l a rity of a blative lasers has
decreased d ra matica l ly over the past seve ra l yea rs
a mong patients a n d physicians.
By contrast, nona blative lasers, with m u ltiple treatment
sessions,
p rovide a safe method for provid i ng m i ld
i m prove ment of m i l d -to- moderate p h otoda mage with l it

tle risk of si d e effects. U nfortu nate ly, the p red icta b i l ity of
i m prove ment is u ncerta i n . Some patients do n ot experi
ence a n y d iscern i b l e benefit even after m u ltiple treat
ments. In the past 5 years, nona blative fractional lasers
have prod uced e n h a nced results from other forms of
n o n a b l ative res u rfaci ng with m u lt i p l e treatm e nts . These
lasers have a lso p roven to be safe in s k i l led h a n d s . Sti l l ,
thei r efficacy is l i m ited , espec ia l ly w h e n c o m p a red to
a b lative laser resu rfaci ng.
M ore rece ntly, fractional a blative lasers, both carbon
d ioxid e and erb i u m va riants, have been d evelo ped to pro
vide e n h a nced res u l ts with relatively good safety. The
concept is to provi d e the more aggressive tec h nology of
a b lati o n , but to confi ne potential d ownt i m e a n d s i de
effects b y e m p l oying a fra ctional pattern of tissue d a m
age, w h i c h encou rages more ra pid h ea l i ng t i m e s with
fewer side effects. O n ly a fraction of the skin is a blated at
each treatment, as o p posed to trad iti o n a l a b lative res u r
fac i ng proced u res . F u rther, the d e pth of a blation is
d ee pe r tha n with tra d iti o n a l a blative resu rfa c i n g proce
d u res.
Adva ntages of fractional a blative lasers a re as fo l l ows :
Better i m provement of deeper rhyti des t h a n nona bla

tive d evices
Sign ificant benefit with one treatment
Ca n provid e some i m p rovement for s k i n laxity, pig
Sign ificant red uction i n posto perative d ownti m e com
mented lesions, a n d vasc u l a r dysc h ro m i a as we l l

pa red to tra d itio n a l a b lative devices
Figure 9 . 1 Immediate endpoint of pixilated damage pattern with an

erbium fractional ablative device
57
58
Ca n treat cosmetic u n its effective ly without l i nes of

d e m a rcation often seen with trad itional a blative proce
d u res, that is, perioral/periorbita l a reas
I N D I CAT I O N S
R hytides, espec i a l ly moderate-to-severe periora l a n d

periorbita l rhytid es
P h otoda m age, i nc l u d i ng s k i n text u re a n d tone
Acne sca rs, i n c l u d i ng boxca r, atro p h i c , ro l l i n g sca rs
S u rgical a n d b u r n sca rs
M i l d i m provement in s k i n laxity
N ot effective for dyna m i c rhytid es
P R EOPERATI V E EVALUAT I O N
S k i n type ( I-I I I a re best ca n d i d ates )
S u n exposu re
H istory of ke loids
System ic i nfections
Prior plastic s u rgery, espec i a l ly neck l ifting p roced u res

a n d face lifts
l sotret i n o i n use i n past 6 months
Patients with u n rea l istic expectations

A consu ltati on is req u i red before this treatment to
assess the patient as wel l as a p p ro p riately prepa re the

patient for the proced u re . The patient s h o u l d be fu l ly
educated as to the risks a n d benefits of this proced u re.
The patient m u st be awa re of the recove ry period of 4 to
7 days (on average ) . The patient should be shown post
operative pictu res to prepa re them fo r h ow they w i l l
a p pea r. Any posto perative assista nce the patient m a y
req u i re s h o u l d be a rra nged prior t o treatment if poss i b l e .
The patient s h o u l d a lso be i nformed t h a t the ben efits of
the treatment accrue 3 to 6 months after treatment. A
patient who is u n a ble to fol l ow a n d execute necessa ry
postoperative s k i n ca re regi men s h o u l d n ot be treated .
PROPHYLAX I SIAN ESTH ES lA

May include any of the fol lowi ng:
Antiviral and a nti biotic prophylaxis
Topical a n esthetic
- 23% Lidoca i n e/7 % tetra ca i ne
Oral pa i n med ication a n d a nxiolytic

- Vicod i n/a ceta m i n o p hen/ativa n/not h i n g
N e rve blocks/1 M Torad o l
Genera l a n esth esia
Figure 9.2 Patient immediately after C0 ablative fractional resurfacing
2
treatment. Note erythema, edema, and pinpoint hemorrhage
Beca use this proced u re is pa i nfu l , some form of

a n esthesia is req u i red .
It wi l l va ry accord i ng to the
aggressiven ess of treatment, the pa rt i c u l a r suscepti b i l i

ties o f t h e patient, a n d the p hysi c ia n 's co mfort with
va rious a n esthetic reg i me n s . R egio n a l nerve blocks with
s u p plementa l i nfi ltrative a n esthesia a re ge n e ra l l y h e l pfu l .
S ite-d ependent b l ocks i nc l u d e su praorbita l , i nfraorb ita l ,
a n d menta l b l ocks. Lid oca i ne ( 1 % ) with 1 : 1 00, 000 o r
1 : 200,000 e p i n e p h r i n e , at a tota l o f 0 . 5 to 1 .0 m l c a n b e
i njected at eac h site .
LAS E R SAF ETY
Eye protect i o n : m eta l eye s h ields

- One o r two d ro ps of 0 . 05% to pica l p ropa raca i ne
(Aica i n e ) or 0.05% topica l tetra ca i n e ( Po ntoca i n e )
a re placed i nto e a c h eye o f the patient, fol l owed by
the a p pl ication of to pical e ryth romyc i n oi ntment o r
ophth a l m i c l u bricant ( e g , Lacri-Lu be) a n d non reflec
tive meta l oc u l a r s h ields.
- A l l perso n n e l present at the treatment m ust wea r
safety glasses/goggles to avo i d i nadverte nt cornea l
d a mage .
Due to the pa i n , bleed i ng, a n d pa i n med ications assoc i
ated with this treatment, it is i m perative that the patient be

acco m pa n ied by a friend , spouse or relative who can d rive
or accompany the patient home after the proced u re .
Posto p e rat i ve C a re ( F i g .
9. 1)
I nterestingly, l ittle postp roced u re pa i n ( Fig. 9 . 2 )
Best expla nati o n : heat release th rough a blated c h a n n e l s
I m perative t o give ora l a n d written wou n d care i nstruc

tions to patient
Ga uze soa ks and e m o l l ie nts i m med iately posto perative

Room tem peratu re sterile water soa ks for 20 m i n utes,
every 3 to 4 h o u rs fol l owed by Aq u a p horNase l i n e a pp l i
cation for 2 to 3 days
Fo l l ow- u p at
( Fig.
9.3)
48
to
72
h o u rs
Re-epith e l i a l izati on i s usually com plete .
Eryt h e m a , edema, a n d resi d u a l p i n po i n t h e morrhagic

crusting a re expected .
M i l i a a re com m o n a n d often clear with i n a few days .
Assess fo r vesicles, b u l la e , p ustu les.
E m o l l i ents twice d a i ly for 3 to 7 days.
I nstructions to ca l l if a n y concerns or cha nges i n wou n d

hea l i ng .
Postoperative e rythema
resolves over a
period of
wee ks. Strict s u n avo i d a n ce m u st be fol l owed fo r a
Figure 9.3 Patient at 72-hour follow-up. Note that hemorrhage is no
longer present, but edema and erythema persist
59
60
m i n i m u m of 3 mo nths postoperatively to avoid pigmen

ta ry c h a nges and p h otosensitivity.
Adve rse S i d e Effects
Delayed onset hypopigmentation
Sca rring
Posti nfla m m atory hyperpigme ntation
Persistent erythema
I nfection
The side effects for fractional a blative resu rfa c i ng a re
the same as those for trad itiona l a blative res u rfaci ng

proced u res, a l beit fa r less freq uent or severe i n s k i l l ed
hands.
As
with
nonablative
fractional
resu rfaci ng,
post-i nfla m matory hyperpigmentation ( P I H ) is more l i kely

to occ u r with h igher treatment densities, pa rtic u l a rly in
da rker ski n phototypes ( Fig. 9.4). Hypertrophic sca rring of
the neck is a sign ifica nt a nd potentially permanent com
p l ication of fractionated C0 2 laser res u rfacing ( Fig. 9 . 5 ) .
Caution is req u i red for these proced u res .
The fol l owing p ractices a l l sign ificantly i nc rease the
Figure 9.4 Test spot treatments with a C0 ablative fractional resurfacing
2
device in a young male with Fitzpatrick skin type 5. The test spots are
not arranged in order of aggressiveness. The darker areas of PIH coincide
with increased treatment density. Increasing pulse energies do little to
worsen PIH
risk of sca r:
Aggressive treatments i n c rease risk of sca r
Poor tec h n iq u e , that is, excessive overl a p
Postoperative wo u n d i nfection
H i story of face lift o r neck l ifti n g proced u res
Treatment of nonfa c i a l ski n , espec i a l l y the neck
I n fect i o n ( F i g .
9.6)
The key to treating i nfection i s to recogn ize i t at its i n cep

tion . I nfections a re d iagnosed c l i n i c a l ly. C u ltures can
confi rm a d iagnosis. E m p i ric a nti biotics a n d c l ose c l i n ical
fo l l ow- u p a re the keys to treatment. Persistent a reas of
e rythema s h o u l d raise concern rega rd i ng sca r formation
o r i nfection . A c u lture is rec o m m e n d ed to r u l e out bacte
rial o r yeast i nfection . Do not perform these proced u res if
you can n ot recogn ize a n d treat bacteria l , v i ra l , fu nga l
i nfections.
N o n fa c i a l S k i n
Nonfa c i a l s k i n i s more v u l nera b l e to thermal energy d u e
t o u n derprivileged wo u n d h ea l i ng c a pa b i l ities. Th ere a re
fewer p i l osebaceous u n its on the neck a n d more l i m ited
c uta neous vasc u latu re to s u p port wou nd h ea l i ng. T h i s is
espec ia l ly true where there is a h i story of prior plastic
su rgery. Face/neck l ifti ng proced u res place neck s k i n
onto the face; t h u s , y o u may be treating " neck" s k i n o n
the fa ce. If there is a h i story o f p r i o r plastic s u rgery, it i s
best to treat at lowe r setti ngs .
Beca use of the risks of serious side effects, it is
strongly a dvised
that fractional
a blative
res u rfa c i ng
Figure 9 . 5 Hypertrophic scar after treatment with a C0 fractional abla

2
tive device
61
s h o u l d only be performed by a n a p p ro p riately tra i ned

phys i c i a n experien ced i n postoperative wou n d ca re fol
lowi ng resu rfa c i n g p roced u res.
In s u m , a b lative fractio n a l res u rfa c i n g p roced u res offer
the adva ntage of good res u lts with one treatment as wel l
as offering sign ifica nt i m p rovement where nonablative
fra ctional a n d n onfractional d evices do not, such as mod
e rate a n d severe rhytides. At the sa me time, it offers the
flex i b i l ity of treati ng s m a l l e r a reas than tra d itional resu r
faci ng p roced u res beca use it d oes not typica lly leave
l i nes of d e m a rcati o n . Ad d itional ly, there is sign ifica ntly
red uced c l i n ic a l and soc i a l d ownt i m e com pared to fu l l
s u rface a b lative proced u res. N o n etheless, t h e treatment
has its d rawba c ks s uc h as
lighte n i n g is usual l y modest.
D u ration of benefits i s not known .
Best resu l ts often req u i re more than one treatment.

- Espec i a l l y acne sca rs .
- Req u i res 1 wee k away fro m w o r k a n d soc i a l activities.
- Series nona blative treatments may be more tolera ble
a n d practical for m a n y patients.
Figure 9.6 Localized minute pustules, edema, and erythema representing

a localized pseudomonas infection in the setting of post-C0 fractional
2
ablative resurfacing for a burn scar. It cleared fully without sequelae after
oval antibiotic treatment.
62
CHAPT E R 1 0
Tissue Tighte ning
There have been a va riety o f n o n i nvasive d evices that

p u r port to l ift a n d tighten " l oose" necks, jawl i nes, a n d
eyes . These d evices work b y del iveri ng monopolar, bi po
l a r, or i nfra red energy to the d ee p dermis a n d su bc uta
neous tissue, resu lting in tighte n i ng a n d l ifti ng of s k i n a n d
c reation o f new collage n . T h e c h ief o bstacle for th ese
d evices has been i nconsistent c l i n ica l resu lts . Some
patients have had d ra m atic res u l ts i n com pa rison to tra
d itional i nvasive s u rgery a nd oth e rs have seen l ittle or no
i m provement. Patients who u n d e rsta n d the risks before
the proced u re a re ha ppy with excellent resu lts a n d not
d isappoi nted by lack of i m p rovement.
There a re d iffe rent rad i ofreq uency ( R F) tec h n o l ogy a n d
i nfrared d evices that del iver vol u m etric h eat t o t h e deep
dermis and s u bcuta neous tissue wh i c h tightens existi ng
col lagen and h e l ps c reate new collage n .
CAN D I DATE S E LECT I O N

A s with a l l proce d u res, ca n d i d ate selection i s vita l t o the
success of the proced u re . These devices wi l l n ot treat epi
dermal cha nges of aging such as lentigo, tela ngiectasia,
or ro ugh ski n . Ca n d idates should have deep cuta neous
signs of aging such as "saggi ng" skin in the neck, jaw, or
around the eyes. Some physicians have re ported good
success in treating a reas off the face i n c l ud i ng u pper
arms, a bdomen , and b reasts . All patients m u st be awa re
that the a m o u nt of c l i n ic a l i m prove ment is h ighly va riable
not pred icta b l e before the proced u re. Patients that d o not
u n d e rsta nd this should not u n d e rgo the proced u re .
Figure 10.1 (A) Prior to treatment skin laxity is observed in the jowl
region.
THE PROCEDU R E
When fi rst i ntrod uced t h e c h ief c o m p l a i n t with
RF
d evices was i ntolera b l e pa i n . The proced u re was done

with a single pass at h igh energy settings. Over the yea rs
the trend has been towa rd more passes with lower fluen
cies. T h i s has greatly red u ced the pa i n associated with
the proced u re. M u ltiple passes, lowe r fl uenc ies, and d if
fe rent s pot sizes have resu lted i n greater i m med iate tis
sue tighte n i n g o bserved
in
patie nts
and
h igher
percentage of patients with i m provement after 6 months.
P re p roced u re C h ec k l i st
Remove a l l m a ke u p .
Remove a l l jewel ry.
No pacema ker or d efi bri l lator.
A l l patients with fac i a l i m pla nts s h o u l d have the mater
63
ial of the i m p l a n t i d e ntified before the proced u re . If it is

u n kn own , d o not treat d i rectly over the i m p la nt.
A p p l y thick layer of topica l a n esthetic 30 m i n utes

before p roced u re .
Determ i n e a p p ro priate s pot size a n d fl uence.

Kee p the h a n d piece even with the s k i n t h roughout the
p roced ure.
After the proced u re patie nts c a n res u m e reg u l a r a ctivi

ties i m med iately.
Patie nts s h o u l d com m u n icate with their phys i c i a n i n

case o f a n y q u estions or concerns.
I m provement occ u rs fo r u p to 6 months after the p ro

ced u re .
S I DE EFFECTS
The a m o u nt of serious side effects has been red uced
ove r the yea rs as treatment protocols have been refi ned .
With l ower fluences the risk of side effects has been s u b
sta ntia l ly red uced .
Pote n t i a l S i d e Effects
Atro phoderma which may be tem pora ry or perm a nent
B u rn
Erosion/ulcer
Sca r
Dysc h ro m i a
N e rve da mage
Oc u l a r da mage
Figure 10. 1 (continued) (B) Six months after treatment appearance of the
CLI N I CAL PEARLS
A l l patients s h o u l d be wa rned before a n y proced u re

that the a m o u nt of c l i n ic a l i m provement va ries from
person to person . I m prove ment can ra nge from d ra
matic to N O i m provement at a l l . Any patient who d oes
not u nd e rsta n d
the
potenti a l for n o i m prove ment
should not have the proced u re performed .
W h i le treating each patient conti n u ously, observe the

skin and ask the patient to inform the physici a n if there is
a partic u l a r s pot with i n c reased pa i n or u n usual sym p
toms. If a patient complains of u n usual pa i n or sym p
toms, sto p the p roced u re a n d reeva l uate the setti ngs.
M a ke s u re a u n iform a m o u n t of energy is d e l ivered with

each pu lse. This is done by usi ng the a p propriate spot
size a n d a pplyi ng u n iform gentle but firm p ress u re to
the ski n .
D o not perform t h e p roced u re o n a patient with a ctive

s u n burn or ta n .
jowl and neck is improved slightly. (Reproduced, with permission, from

Hirsch R, Sadick N, Cohen JL. Aesthetic Rejuvenation: A Regional
Approach. New York: McGraw-Hill, 2009: 97. )
64
CHAPT E R 1 1
D e r m atochalasis
Dermatoc ha lasis is a cond ition cha racterized by u p per

a n d/or lowe r eye l i d s k i n , m uscle red u n d a ncy a nd laxity,
a n d fat pad hern iation . It is m a i n ly attri buta b l e to c h rono
logica l aging a n d c h ro n i c s u n expos u re .
EPI D E M I O LOGY
Incidence: ve ry c o m m o n
Age: m ost freq uently o bserved i n i n d iv i d u a l s older tha n
50 yea rs
Sex: no pred i l ectio n

Race: most common i n fa i r-s k i n ned i n d ivi d u a ls (skin
phototypes I a n d I I ) ; l ess common in da rker-s k i n ned i nd i vid u a l s (ski n p hototypes IV-V I )
Precipitating factors: c h ronologica l aging; c h ro n i c s u n

expos u re ; thyroid d isease
PATHOG E N ES I S
U p per a n d/o r lower eye l i d s k in a n d m uscle hypertro phy
and prola pse; fat pad d escen s ion .
PHYS I CAL EXAM I NAT I O N

Ea rly fi n d i ngs i n c l u d e a d o u b l e l i d c rease with o n l y mod
est hood i ng. Severe fi n d i ngs i n c l u d e pro m i nent eye l i d
Figure 11.1 (A) A 59-year-old female concerned about her sunken eyes
and forehead wrinkles. (B) Improvement of the blepharloptosis, sunken
eyes, and forehead wrinkles 9 months following upper lid blepharop/asty
and leavator aponeurotica advancement. (Reproduced, with permission,
from Harue Suzuki, MD, Kyoto, Japan.)
h ood i n g w i t h u pper a n d latera l v i s u a l f i e l d obstruction .

Coexisting b row ptosis may f u rther c o m p rom ise the
peri phera l visio n .
Tests for lower l i d laxity h e l p determ ine i f a l id-tighte n i ng
proced u re is needed .
Lower l i d horizonta l laxity is measu red by the d istrac
tion test that req u i res p u l l i ng the lowe r lid a nteriorly away
from the globe. A greater than 7-mm lid excu rsion i n d i
cates laxity.
Orbic u l a ris oc u l i tone is measu red by the s n a p test that
is performed by p u l l i ng the lowe r lid i nfe riorly. If the l i d
d oes not sponta neously retu rn t o the n o r m a l position
prior to the next b l i n k , the test is positive i nd icati ng l ower
lid laxity.
D I F F E R E N T I A L D I AG N OS I S
B l e p h a rochalasis ( recu rrent i d i o path ic eye l i d i nfla m ma
tion with resu lta nt re laxation of the u p per lid ski n ) ; u p pe r
eye l i d hood i n g seco ndary t o eye b row ptos is.
Epidermal aca nthosis with flatte n i ng of the derma l
e p i derma l j u ncti o n ; dermal col lagen brea kd own with
fo rmation of a m orphous masses and i n c rease i n gly
cosa m i noglyca ns.
CO U RS E
C h ro n i c p rogressive cou rse ; visual eye fields may be

affected .
KEY CO N S U LTAT I V E QU EST I O N S
A n y assoc iated sym ptoms i n c l u d i n g visual o bstruction,

d ry eyes, excessive tea ring
U nderlying medical cond itions, espec i a l l y eye d i sease

a n d thyroid cond itions
Prior treatment and response
MANAG E M ENT
P reventi o n : strict s u n avoida nce
Control u n derlying thyro i d d isease
TREATM ENT
Topica l thera py: d a i ly su nscreen a pp l ication with UVB/

UVA coverage
S u rgical thera py
- Coro n a l browlift-u pper face rej uvenation
- Trichophytic browlift-u pper face rej uvenation
- Blepha roplasty-u p per and lower eye l i d rej uve nation
( Fig. 1 1 . 1 )
Laser thera py
- Placement of protective eye s h i e l d s prior to laser
treatment if pa ra m o u nt.
- Conservative treatment is necessa ry to avoid ectropion formation a n d/or sca r formatio n .
- Carbon d i oxide laser resu rfa c i ng.
- Erbi u m : YAG laser.
- Fractionated a b lative carbon d ioxide laser resu rfacing.
P I T FALLS TO AVO I D
A conservative a pproa c h to s u rgica l rem ova l of this s k in

is vita l to prevent a " sta rtled " a ppea ra nce o r ectropion .
65
66
Retention of a l l or portions of a ny hern iated fat pads

h e l ps m i n i m ize the skeleto n ized a p pea ra nce ofte n
noted to d eve l o p with age a n d loss of fa c i a l vol u m e .
D i rect visual ization o f t h e i nferior o b l i q u e m uscle is vita l

t o avoid m uscle i nj u ry.
Treatment with l u brica nts a n d ta p i n g l i d s may h e l p pre

vent keratoconj u n ctivitis.
B I B L I OG RAPHY
A n c o n a D , Katz B E . A p ros pective study o f the i m prove
ment in periorbita l wrin kles a n d eye brow elevation with a
n ovel fractiona l C0 2 laser-th e fractional eye l ift. J Drugs
Dermatol. 20 10;90 ) : 1 6-2 1 .
Ca rte r S , Seiff S, Chao P. Lower eye l i d C02 laser rej uvena
A
ra n d o m ized
p rospective
c l i n ic a l
stu dy.
tion :
Ophthalmology. 200 1 ; 1 08:437-44 1 .

Cod ner MA, Wo lfl i J N , Anza rut A . P r i m a ry transc uta
neous lower b l e p h a roplasty with routi ne latera l canthal
s u p po rt: A com prehensive 1 0-yea r review. Plast Reconst
Surg. 2008; 1 2 1 : 1 24 1 - 1 250 .
J u nzeker C M , We iss ET, Geron e m us R G . Fractionated
C0 2 laser res u rfa c i ng: Our experience with m o re t h a n
2000 treatments. Aesthet Surg J. 2009 ; 29(4) : 3 1 7-32 2 .
K o r n B S , Ki kkawa DO, Cohen S R . Tra nscuta n eous lower
eye l i d
b l e p h a roplasty
with
orbitomala r
suspensio n :
Retros pective review o f 2 1 2 consecutive cases. Plast

Reconstr Surg. 20 1 0 ; 12 5 ( 1 ) : 3 1 5-323 .
Lee D, Law V. S u bbrow blepha roplasty for u p per eye l i d
rej uve nation i n Asia n s . Aesthet Surg J . 2009 ;29(4): 284288 .
Le m ke B N , Stasior OG . T h e a n atomy o f eye l i d ptosis.
Arch Ophthalmol. 1 932 ; 1 00:981 -986 .
Levine
MR.
Manual
of
Oculoplastic
Surgrery.
P h i la d e l p h i a : B utterworth H ei n em a n n ; 2003 .
Shorr N , Enzer Y. Considerations i n aesthetic eye l i d
su rgery. J Dermatol Surg Oneal. 1992 ; 1 : 1 08 1 - 1 09 5 .
CHAPT E R 1 2
Poi kilod e r m a of Civatte
Poi k i l oderma of Civatte ( POC) is a cond ition that is attri b

uta ble to chronic sun expos u re of the neck and the c h est.
The seve rity of fi n d i ngs is d e pend ent on the d u ration a n d
i ntensity
of
sun
expos u re,
constitutive
skin
color
( Fitzpatrick s k i n type ) , and the capac ity to ta n .
EPI D E M I O LOGY
Incidence: common
Age: most freq uently o bserved i n persons older than
40 yea rs
Sex: sl ight fem a l e pred o m i na nce

Race: m ost common in fa i r-s k i n ned i n d ivid u a l s ( s k i n
p hototypes I a n d I l l ; rarely seen i n da rker-s k i n ned i n d i
vid u a l s (ski n p hototypes I V-V I )
Precipitating factors: c h ro n i c s u n expos u re i n c l u d i n g

i ntentio n a l s u n exposu re s i n ce youth a n d occ u pationa l
expos u re; tra u m a ; c h ronologica l aging
PATHOG E N ES I S
U ltraviolet B ( U V B ) i s the m ost d a maging U V rad iati o n ,
with h igh d ose u ltraviolet A ( U VA) contri buting t o t h e
n oted cha nges . I n a d d it i o n , vis i b l e a n d i nfra red ra d iations
have been shown to a ugment the action of UVB .
PHYS I CAL EXA M I NAT I O N

Te langiectases, m i l d atrophy, ret i c u l ated hyperpigmenta
tion , a n d hypopigm entation affect i n g the late ra l a n d pos
teri or as pect of the neck, a nterior c h est, a n d jawl i n e .
S u b menta l neck is s pa re d . Perifo l l i c u l a r s p a r i n g noted
( Figs. 1 2 . 1 a n d 1 2 . 2 ) .
D E R M ATOPATHOLOGY
Epiderma l a ca nthosis with flatte n i ng of the d e r m a l
e p i d e r m a l j u ncti o n . Foca l i n c rease i n e pi d e r m a l basa l
c e l l m e l a n ocytes; i rreg u l a r basa l c e l l hyperpigme ntati o n .
Dermal c o l lagen brea kdown with fo rmation o f a m o r
p h o u s m asses a n d i nc rease i n glycosa m i n oglyca ns.
Te l a ngiectasia noted .
D I F F E R E N T I AL D I AG N OS I S
R oth m u n d-Thomson syn d ro m e ; ra d iation dermatitis;
Ki n d l e r
syn d ro m e ;
tela ngiectasi a .
B l oo m 's
syn d ro m e ;
Ataxia
Figure 1 2 . 1 Poikiloderma of Civatte. Reticulated pigmentation, ery
thema, and atrophy can be seen with characteristic sparing of the sub
mental area. The erythematous component is more prominent in this
patient. (Courtesy of Richard A. Johnson, MO. )
67
68
COU RS E
C h ro n i c p rogressive cou rse with conti n u ed s u n expos u re .
Past a n d c u rrent s u n expos u re h i story
Occu pation
H o b b i es/sporting activities
U nd e rlying medical cond itions
H/o rad iation thera py
Past treatments a n d response
MANAG E M E N T
P revention : strict s u n avo i d a n ce .
Figure 1 2 . 2 Poikiloderma o f Civatte-the pigmented component is more

prominent in this patient.
TREAT M ENT
Topical
thera py:
d a i ly
su nscreen
a p p l ication
with
UVB/UVA cove rage .
Laser thera py: great caution m ust be fo l l owed with a ny

laser treatment a d m i n istered to m i n i m ize the risk of
sca r formati o n , dyspigmentati o n , "finger- p r i nting" o r
treatment s k i p a reas, a n d text u ra l cha nges. The neck i s
pa rtic u l a rly p r o n e t o sca rring given fewer pi losebaceous
u n its. A test site is recom mended . M u lt i p l e sess ions a re
genera l ly req u i red .
Laser fl ue nces should be lowered by a pproxi mately
25% to 30% of fac i a l pa ra m eters to avoid adve rse

effects .
- Pu lsed dye laser-low flue nces util ized (eg, Vbea m
595 n m , 0.45- 1 . 0 ms, J/cm 2 , 7- 1 0-m m spot,
DCD 30/20). I m p rovement in te langiectasia a n d atro
phy see n . L i m ited benefit for dyspigmentatio n .

- I ntense
p u lsed
l ight
(eg,
Sta rLux,
20-30
ms,
28-34 J/d m 2 , 1 0 % pass overla p )-i m provement of
a l l com pon ents may be poss i b l e .

- Versa P u lse 532-n m laser-l ow fl ue nces necessary
( Fig. 1 2 . 3 ) .
- Fractionated n o nab l ative a n d a blative laser-a l l com
ponents may be targeted . Can be safely util ized in
affected body a reas, though conservative laser pa ra
meters a re req u i red to avoid potenti a l sca rring.
A conservative a p proac h m u st be fo l l owed with a ny

treatment used for POC, given the sign ifica nt risk of
u n even remova l of the pigmentation a n d e rythema
res u lting i n a "footprint" - l i ke a p pearance ( Fig. 1 2 . 4 ) .
Figure 1 2 . 3 (A) Poikiloderma of Civatte pretreatmen t. (B) Poikiloderma of
Civatte following three VersaPulse 532-nm laser treatments. Marked

reduction in erythematous component is observed.
69
T h i s m ottled a p pea ra nce can occ u r norma l ly d u ri ng the

cou rse of treatment. The patient m ust be awa re of t h i s
poss i b i l ity. Cont i n ued treatment t o the resid ua l lesions
genera l ly res u l ts i n a resol ution of t h i s side effect.
Patients m u st be awa re of the d ifficu lty in i m provin g

t h i s condition. M u lt i p l e treatments a re expected for end
point of l ighte n i ng. Textural c h a nges a re l i kely to per
sist.
POC with a p r i m a ry e rythemato us com ponent typica l ly

res ponds better than POC with a primarily hyperpig
mented com ponent.
B I B L I OG RAPHY
B a tta K, H i n d s o n C , Cotte r i l l J A , Fo u l d s I S . Trea t m e n t
of poi k i l od e r m a o f C i va tte with t h e potass i u m tita nyl
p h o s p hate ( KT P ) laser. Br J Dermatol. 1 999 ; 1 40( 6 ) :
1 19 1 - 1 192.
Gero n e m u s R . Po i k i loderma o f Civatte . Arch Dermatol.
1 990; 1 26(4) : 547-548.
Kato u l is AC, Stavria neas N G , Panayiotides J G , et a l .
Poi k i loderma of Civatte : A h i stopathologica l a n d u ltra
struct u ra l study. Dermatology. 2007 ; 2 14(2) : 1 7 7 - 1 82 .
La nge l a n d J . Treatment o f poiki loderma o f Civatte with
the p u lsed d ye laser: A series of seven cases. J Cutan
Laser Ther. 1 999; 1 (2 ) : 1 2 7 .

R uscia n i A, Motta A, F i n o P, Men i c h i n i G . Treatment of
poi k i l oderma of C ivatte u s i n g i ntense p u lsed l ight sou rce:
7 yea rs of experience. Dermatol Surg. 2008;34( 3 ) : 3 1 43 19 .
Ti erney EP, H a n ke CW. Treatment o f poi k i loderma of
Civatte
with
a b lative
fractional
laser
res u rfa c i ng :
P ros pective study a n d review o f the l i teratu re . J Drugs
Dermatol. 2009;8(6) : 527-534.

Ti erney EP, Kou ba DJ , H a n ke CW. R eview of fractional
photothermolysis: Treatment i n d ications a n d effi cacy.
Dermatol Surg. 2009 ;35( 1 0 ) : 1 445- 146 1 .
Figure 1 2 .4 "Footprinting" o f the anterior neck after a single intense

pulsed light (!PL) source treatment for Poikiloderma of Civatte. This sub
sequently resolved with continued IPL treatments
TWO
D isord e rs of S e baceo u s G l and s
72
CHAPT E R 1 3
Ac n e Vulga ris
Acne vu lga ris is a c h ro n i c i nfla m m atory d isease of the

pi losebaceous u n it. Ac ne lesions favor the face, neck,
u pper ba ck, c hest, a n d u pper arms. M u lti ple c l i n ical va ri
a nts exist and they i nc l u d e comedonal acne, pa p u l opus
tular acne, nod u l ocystic a c n e , a cn e conglobata , a n d
a c n e fu l m i na n s .
EPI O E M I O LOGY
Incidence and age: pred o m i n a ntly a d isord e r of adoles
cence; affects 85% of i n d ivid u a l s between
12 a n d
2 4 yea rs o f age; m a y affect a l l age grou ps
Race: lowe r i nc i d e n ce in Africa n-America ns a n d Asi a n s

Sex: more severe forms i n m a l es
Precipitating factors: ge netic p red isposition, endocri ne
d isord e rs, stress, mec h a n ical factors (fricti o n , p ress u re,
occ l usion ) , contact with a cnege n i c materials ( o i l s , c h lori
nated hyd roca rbons, cosmetics) , a n d d rugs (steroids,
l ith i u m , a n d rogens, hyda ntoi n )
PATHOG E N E S I S
Many patients with nod u locystic acne have a fi rst-degree
relative with a history of severe acne. The primary patho
physiology i nvolves a ltered fol l i c u l a r keratin ization resu lting
i n o bstruction of sebaceous fol l ic les, increased seb u m pro
d uction, hyperprol iferation of Propion i bacteri u m acnes,
and i n c reased prod uction of chemotactic factors which
resu lt i n i nfla m matio n .

Comedones ( c l osed a n d open ) , erythematous pa p u les,
p ustu les, nod u les, and cysts. May resolve with res i d u a l
hyperpigmentation or sca rri ng.
Ac n e
rosa cea ,
ste roid
acne,
acne
mecha n i c a ,
P ityros poru m fol l i c u l itis, a n d bacteria l fol l i c u l it i s .
LABORATORY DATA
E n d oc r i n e St u d i es
No routi n e stu d i es a re needed . If h i story a n d physical
exa m i nation ra ise concerns then consider ordering
screen for free a n d tota l testosterone, d e hyd roe p ia n d ros
terone,
and
fo l l ic l e
sti m u lating
hormone/l ute n i z i n g
Figure 13.1 An 1 8-year-old male with cystic acne being treated with
1 , 450-nm diode laser
Sect i o n 2 : D i so rd e rs of Sebaceous G l a n d s
73
hormone ( FS H/LH ) ratios to exc l u d e polycystic ova ry syn

d rome or other hormonal a bnorma l ities espec i a l l y in
wo men with mode rate-to-severe a c n e , h i rsutism , i rregu
l a r menses, a n d weight ga i n . D i et may play a role i n fla res
of a c n e . H igh glyce m i c d i ets may exacerbate a c n e .
F u rther stu d ies a re need ed .
D e r m at o p at h o l ogy
Pathology of early lesion (comedone) revea ls o bstruction
of the fol l i c u l a r i nfu n d i b u l u m by corn ified cells lead i ng to
d i latation . Later lesions revea l fol l i c u l a r r u pt u re with lym
p hocytes, neutro p h i l s , and macrophages . Sca rring may
be see n .
COU RSE
T h i s d isease dem onstrates a c h ro n i c cou rse a n d rem its
s ponta n eously in the early-to-mid-th i rd decade in the
majority of patients. However, a c n e may persist m u c h
longer i n some patients .
MANAG E M ENT
Ea rly treatment o f a c n e is essential for t h e preve ntion of
d ysc h ro m i a or assoc iated sca rring (see sca r treatment

cha pter 6 1 ) . M a ny acne patients benefit from c o m b i n a
tion thera pies. A thorough h i story a n d physical exa m i na
tion a re para m o u nt to a d m i n istering a maxi m a l ly effective
p la n . T h i s s h o u l d i n c l u d e c u rrent cosmetics a n d s u n
screens, s k i n type, l ifestyle, occ u pati o n , medications,
past treatments a n d res ponse, d i et, menstrua l and ora l
contraceptive h i story.
To p i c a l Treat m e n t
To pical treatment may b e req u i red for the d u ration o f t h i s
c o n d ition . To pical for m u l ations s h o u l d be a p pl ied t o the
lesions as wel l as to the adjacent a c n e-prone c l i n ica l l y
normal ski n .
Reti noids: treti noi n , a d a pa l e n e , taza roten e
Anti bacterial agents: benzoyl peroxide, c l i n d a m yc i n ,

e ryt h romyc i n
Kerato lytic agents: sa l icyl i c a ci d , hyd roxy a c i d , aze l a i c

a c i d , sod i u m su lfaceta m i d e , a n d s u lfu r
Syste m i c Treat m e n t
Ant i biotics: tetracyc l i ne , d oxycyc l i ne, m i nocyc l i n e a re

m ost
commonly
used .
Alternatives
i n c l ude
e ry
t h romyc i n , azith romyc i n , a n d a m oxic i l l i n .
Hormones: o ra l contraceptives or spi ronolacto ne for

women with persistent acn e on lowe r face, c h i n , a n d
neck.
Figure 13.2 (A) Facial inflammatory acne vulgaris unresponsive to multi

ple topical and oral treatment regimens. (B) Marked improvement of acne
6 months following five 1 , 450-nm diode laser treatments (Smoothbeam,
Candela Corp. , Wayland, MA), 6-mm spot, 1 4 J/cm 2 , DCD 30 ms
74
l sotreti n oi n : fo r severe n od u l ocystic acne that has fa i l ed

other to pical a n d syste m i c thera pies.
S u rg i c a l Treat m e n t
Comedone extraction : expression of kerati nous con

tents of open comedones by a pplying the comedone
extractor to the comedones and a pplying p ress u re .
A n i c k m a y b e m a d e t o t h e overlyi ng s k i n with a
# 1 1 - blade or 1 8-ga uge need le to ease in the extracti o n .
The
Scham berg,
Unna,
and
Saalfi e l d
comedone
expressors a re m ost com m o n l y uti l i zed . Comedone

extraction is contra i n d icated for i nfla m ed comedones
or pustu les d ue to i n c reased sca r risk.
l ntra l esional steroid i njection : tri a m c i nolone aceto n i d e

( 2-3 mg/m U is i njected i nto i nfla m ed cystic lesions
using a 30-ga uge need l e . Maxi m u m d ose i njected
s h o u l d not exceed 0 . 1 mL per lesion to avo i d atro phy.
Patients s h o u l d be wa rned that atrophy from an i nflam
m atory cystic lesion can occ u r with o r without an
i ntra lesiona l steroid i nj ectio n .
Chemical pee l s : seri a l sa l i cyl ic a c i d peels, glyco l i c a c i d

peels ( 20-70% ) , a n d tri c h loroacetic a c i d ( T C A ) peels
( 1 0-20) have been util ized to red uce the n u m ber of
comed ones a n d i m prove posti nfl a m m atory hyperpigmentation a n d persistent erythema . Peels may be per-
formed every 2 to 4 weeks, with i n c reasing strengths

and time a p p l ied as tol erated . M i ld i rritation may be
o bserve d . Adj u nctive thera py is genera l ly necessa ry.
M i c roderma b ras ion : this is prima rily effective for come

donal acne. It is usua l ly performed every 2 to 3 weeks.
M u lti ple treatments a re needed with va ria ble i m prove
ment.
L i g h t Trea t m e n t
Lasers: lasers a n d l ight sou rces a re not the fi rst-l i n e

thera py f o r a c n e b u t ca n b e a n effective a lternative o r
adj uva nt t o m e d i c a l thera py when req u i red .
- 1450- n m d i ode laser ( S m ooth bea m laser, Candela
Corp . , Wayla n d , M A ) : treatment fl u en cies from 8 to
14 J/c m 2 , 6-m m s pot size, a n d dyna m i c cool i n g
device setting o f 30-35 ms can res u lt i n m i ld t o d ra
matic i m provement of i nflam matory tru n k a n d fa c i a l
acne w i t h a sign ificant red uction i n l e s i o n count after
an ave rage of t h ree, sepa rated by 4-to-6-week i nter
va ls ( F igs. 1 3 . 1 a n d 1 3 . 2 ) . I t is i m porta nt to d e l iver
nonoverla p p i n g pu lses to red uce the risk of side
effects. To pical l i doca i ne c rea m a p p l ied prior to treat
ment is needed to m i n i m ize the treatment-assoc iated
pa i n . It is vita l to a p ply the c rea m over a l i m ited body
s u rface to l i m it a ny risk of l idoca i n e toxic ity.
Figure 13.3 (A) Severe acne before treatment. (B) A fter three treatments
of photodynamic therapy with topical 5-aminolevulinic acid and pulsed
dye laser, 7-mm spot, 6 J!cm 2 , 6-ms pulse duration (Courtesy of Mark
Nestor, MD, PhD)
- Lower fl u e n c ies of 8 J/c m 2 with two fu l l-face passes

versus a si ngle ful l-fa ce pass at h igher fluenc ies
( 1 0- 1 4 J/cm 2 ) have been used to red uce pa i n .
Sect i o n 2 : D i so rd e rs o f Sebaceous G l a n d s
75
- P u lsed dye laser ( P D U : stu d i es exa m i n i ng the effi

cacy of P D L for i nfla m mato ry acne have prod uced
conflicti ng data . P u lsed dye laser alone or i n c o m b i
n a t i o n w i t h long p u lsed 1 , 064- n m YAG l a s e r h a s
b e e n effective i n red u c i n g i nfla m matory a c n e . P D L
can i m p rove postacne erythe m a . F l u ences o f 5 . 5 t o
7 J/c m 2 , 7-m m spot s i z e w i t h pu lse d u rations o f 3 t o
6 ms a re most c o m m o n l y em ployed . Severa l treat
ments a re n eeded to ach ieve the greatest benefit.
P h ototh era py:
m u lt i p l e
l ight
sou rces
have
been
reported to sign ifica ntly i m prove acne with m i n i ma l side
Figure 1 3 .4 (A) Facial inflammatory acne prior to photodynamic therapy.
effects. These sou rces i n c l u d e h igh-i ntensity narrow
(8) Marked reduction of the inflammatory acne after three sessions of
ba nd b l u e l ight, h igh-i ntens ity meta l h a l i d e la m p, h igh
photodynamic therapy (Courtesy of Mark Nestor, MD, PhD)
energy b road-s pect r u m b l u e l ight, as wel l as m ixed

b l u e a n d red l ight.
P h otodyna m ic thera py ( P DT ) : PDT uti lizing the topica l

a d m i n istration of 5-a m i nolevu l i n i c acid (ALA, Levulan
Kerastick, D U SA Pha rmaceutica ls, I nc . , W i l m i ngto n ,
M A ) activated b y l ight exposure is a n other potentia l l y
effective modal ity t o treat acne ( Figs . 1 3 . 3 a n d 1 3 .4) .
Short contact A LA- PDT ( 1 5-60- m i n ute d rug i n c u bati o n )
w a s c a p a b l e o f i m p roving acne sign ifica ntly i n a va riety
of c l i nical stu d i es . Diffe rent l ight sou rces have been
uti l ized i ncl u d i ng b l u e l ight (405-420 n m ) , red l ight
(635 n m ) , long- p u lsed 595- n m pu lsed dye lasers, a n d
i ntense pu lsed l ight (430- 1 200 n m ) ( Fig. 1 3 . 5 ) .
B I B L I OG RAPHY
Bowe WP, J osh i SS, S h a l ita A R . D i et a n d a c n e . J Am
Acad Dermatol. 20 1 0 ; 63( 1 ) : 1 24- 14 1 .
Fried m a n P M , J i h M H , Ki mya i-Asa d i A , Gold berg LH .

Treatment of i nflam matory fac i a l acne vu lga ris with the
1 450- n m d iode lase r : A pilot stu d y.
Dermatol Surg.
2004;30(2 pt 1 ) : 147- 1 5 1 .
H a m i lton F L , C a r J , Lyons C , C a r M , Layton A , Majeed A .
Laser a n d oth e r l ight thera pies for the treatment of a cn e
vu lga ris: Systematic revi ew. Br J Dermatol. 2009 ; 1 60(6):
1 273- 1 285.
Leheta TM. Role of the 585- n m p u lsed dye laser i n the
treatm ent of a c n e in c o m pa rison with other topica l thera
peutic modal ities. J Cosmet Laser Ther. 2009; 1 1 ( 2 ) :
1 1 8- 1 24 .
P o l l o c k B , Tu rner D , Stringer M R , e t a l . Topical a m i n ole
vu l i n i c acid-photodyna m i c thera py for the treatment of
acne vulga ris: A study of c l i n ical efficacy a n d mec h a n ism
Figure 1 3 . 5 (A) Mild acne scarring and dyschromia prior to Er: YAG laser
of acti o n . Br J Dermato/. 2004; 1 5 1 (3 ) : 6 1 6-62 2 .

Yeu ng C K , S h e k SY, Yu CS, Ko no T, C h a n H H . Treatment
of i nfla m matory fac i a l ac n e with 1 ,450- n m d iode laser in
type I V to V Asia n skin using an o pti m a l c o m b i nation of
laser pa ra meters . Dermatol Surg. 2009;35(4): 593-600.
resurfacing. (B) Four months after Er: YA G laser resurfacing utilizing a

5-mm spot at 1 J with four passes results in significant improvement
(Reproduced, with permission, from Dover J, Arndt K, Geronemus R,
et a!. Illustrated Cutaneous & Aesthetic Laser Surgery. McGraw-Hi//,
Inc.; 2000)
76
CHAPT E R 1 4
R osacea
A c n e rosacea is a c h ro n i c vasc u l a r a n d a c neiform d isor

der of the p i l osebaceo us u n it that affects p red o m i n a ntly
the centra l face i n c l u d i ng the centra l c h eeks, n ose, a n d
c h i n . The eyes a n d the eye l i d s can occasiona l ly be
i nvolved . Typical ly, there is an i n c reased reactivity of cap
i l la ries to h eat, lead i n g to fl u s h i n g and u ltimately tela ng
iectasia .
S u btypes of
rosacea
include
(1)
vasc u l a r
rosacea (erythematotela ngiectatic), ( 2 ) pa p u l o pust u l a r

rosacea , (3) sebaceous hyperplasia ( phymatous rosacea )
i n c l u d i n g r h i nophyma ( nasa l sebaceous hyperplas i a ) ,
a n d ( 4 ) oc u l a r rosacea . G ra n u lomatous rosacea is a vari
a nt of rosacea .
EPI O E M I O LOGY
Incidence: common
Age: 30 to 50 yea rs; pea k i nc i d e n ce between 40 and
50 yea rs
Sex: fe male pred i lect i o n ; m a l e pred o m i n a nce for r h i n o

phyma
Race: m ost common in fa i r-s k i n ned i n d ivid uals (skin

phototypes I and I I ) ; rarely seen i n da rker-ski n ned i nd i
vid u a l s (ski n p hototypes IV-V I )
Precipitating factors: excessive s u n exposu re, caffe i n e ,
s picy food s , h ot foods a n d beverages, heat, a lcohol, seb

orrhea ,
topical
corticosteroid
use,
and
u n derlyi ng
Pa rkinso n 's d isease
PATHOG E N E S I S
M u ltiple facto rs a re i nvolved i n the pathogenesis of
rosacea i n c l u d i n g vasc u l a r hypera ctivity, Demodex fol
l i c u lorum m ites, H e l icobacter pyl ori, a n d hypersensitivity
to Pro p i o n i bacteri u m acnes.

Va riable c l i n ic a l featu res ca n b e p resent d e pen d i ng o n
the severity a n d t h e s u btype o f rosacea . Ea rly featu res
i n c l u d e tra nsient a n d nontra nsient f l u s h i ng, e rythema
to us pa p u les, a n d p ustu les. N o comedones a re n oted .
Late featu res i n c l u d e tela ngiectasias, sebaceous hyper
plasia, nasa l t h i c k e n i n g and e n l a rge ment ( r h i nophym a ) ,
a n d lym phedema . Oc u l a r i nvolvement is freq ue ntly see n .
Acne vu lga ris, seborrheic d e rmatitis, periora l dermatitis,
steroi d
rosacea, system ic l u pus erythematosus, a n d
B l u pu s m i l ia ris d isse m i natus fac ie i .
Figure 14. 1 A&B Severe rhinophyma prior to electrosurgery (Courtesy of
Suzanne Olbricht, MD)
Sect i o n 2: D i so rd e rs of Sebaceous G l a n d s
Vasc u l a r ectasia as wel l as perifo l l i c u l a r and perivasc u l a r
lym phoh istiocytic i nfi ltrates a re t h e most c o m m o n fi n d
i ngs. Demod ex fol l ic u l o r u m is usua l ly d etected i n the fol l i
c l es . N oncaseating epithelioid gra n u lomas a re seen i n
t h e gra n u lo matous va riant. Sebaceous hype rplasia a n d
fi b rosis a re seen i n rhi nophym a .
CO U RS E
C h ro n i c with freq uent rec u rre nces. May sponta n eously
resolve afte r several yea rs .
MANAG E M ENT
P reventi o n , red u ctio n , or e l i m i nation o f exacerba nts ; s u n
avoida nce.
To p i c a l T h e ra py
M etro n idazole (0. 7 5%- 1 % ) once or twice d a i ly, 1 0 %
sod i u m s u lfaceta m i d e w i t h 5 % sulfur o n ce d a i ly, a n d
aze l a i c a c i d o n c e d a i ly, a l o n e or i n c o m b i nati o n , a re h e l p
ful i n s u p p ressi n g the pa pu l o pustu l a r com ponent of
rosacea .
Syste m i c T h e ra py
Tetracyc l i ne, 1 ,000 to 1 , 500 mg d a i ly in d ivided d oses,

u nt i l clear; then ta per to a m a i nte n a n ce d ose of 250 to
500 mg d a i ly.
M i nocyc l i n e a n d d oxycyc l i n e , 50 to 1 00 mg twice d a i ly,

with a ta peri ng to once d a i l y use.
Oral
isotret i n o i n
is
'-- - """""'
reserved for severe cases not
res pond i ng to o ra l a nti biotics and req u i res c l ose fol low
u p . A low-dose regi men may be effective .
S u rg i c a l T h e ra py
Rh i nophyma
M u ltiple s u rgica l mod a l ities have been used to correct
the hypertro p h i c c h a nges of r h i nophyma . It is i m porta nt
to exa m i n e a ph otogra ph of the patient prior to the onset
of the r h i n o phymatous c h a nge in order to h e l p g u i d e the
s u rgeon i n the re mod e l i ng of the nose . A regional nerve
block with a d d itiona l loca l a n esthesia is suffic i ent in the
majority of cases fo r perioperative pa i n m a n agement.
D i rect i nj ection of a n esthesia req u i res m u lt i p l e i nfi ltra
tions a n d is less effective and fa r more pa i nfu l .
Electrosu rgery: electrosection (cutti ng) is very effective

in d e b u l k i ng a n d reconto u r i n g the r h i n o p hymatous
nose with the added adva n tage of a relatively b l ood less
fie l d . It is s i m i l a r in efficacy to C0 2 laser treatment a n d
less expensive ( Fig. 14. 1 ) .
Figure 14. 1 ( continued) C, D,&E Debulking and recontouring of the

rhinophymatous nose in a relatively bloodless field utilizing large wire
loop electrosurgery Impressive flattening of the rhinophymatous nose
after electrosurgery. The wound is left to heal by secondary intention
(Courtesy of Suzanne Olbricht, MDJ
77
78
The hypertro p h ied tissue is re moved with care to pre

serve the p i l osebaceous u n its .
Overcorrection wi l l prod uce sca rring a n d contractu res .

Wou n d contractu re with hea l i ng may p u l l the nasa l t i p
u pwa rd .
Perma n e nt d e pigmentation may res u l t from overvigo r

ous treatment.
- The El l m a n S u rgitron can be used with a la rge wi re
loop in
blended waveform "fu l l y rectifi ed" mode
which provides c utti ng with hem ostasis, at a powe r

control between 4 a n d 5 .
- A vac u u m evac uator s h o u l d be u t i l ized for e l i m i nat
ing p l u mes of smoke.
- Any rem a i n i ng b l eed i ng poi nts ca n be coagu lated at
t h e end of the proced u re by switc h i ng to t h e coagu l a tion " pa rtia l ly rectified " m o d e .
- The wo u n d is a l l owed to heal b y seco n d a ry i nte ntio n .
- The patients a re i n structed to kee p t h e wo u n d moist
by m u lt i p l e a p pl ications of petro l e u m j e l l y d a i l y u nt i l
re-epith e l i a l ization is com plete a p p roximately 2 weeks
postop .
Exc ision b y t h e fa r- i nfra red lasers ( i e , C0 2 o r Er:YA G )

fol l owed b y va porization is a lso ve ry effective w i t h a relatively blood less s u rgica l fie l d . A sca n n ed C0 2 laser is
t h e o pti m a l d evice given the need to d e b u l k la rge, t h i c k
a reas o f ski n . The pu lsed C0 2 laser can a lso b e used i n
t h e conti n u o u s wave mode t o rem ove t h e b u l k o f the
r h i n o phyma a n d i n t h e p u lsed mode to scu l pt and
resu rface t h e rem a i n d e r of the nose.
Te langi ectasias
Laser a n d flash la m p treatments based on selective l ight
a bsorption by he mogl o b i n a re usua l ly very effective for
re movi ng tela ngiectasias a n d pa rtia l ly effective in i n h i bit
ing f l u s h i n g . Patie nts m ust be awa re that over time they
a re l i kely to deve l o p more tela ngiectasias a n d back
grou n d erythema .
Laser treatment: m u lt i p l e effective o ptions a re ava i l

a ble.
- P u lsed d y e lasers ( P O L) a re the treatment o f c h o i c e
for fac i a l telangiectasias.
The tra d itiona l P O L with a short pu lse d u ration of
0.45 or 1 . 5 ms provides the m ost effective treat
ment for fac i a l te la ngiectasias. H owever, posttreat
ment p u r p u ra occ u rs w h i c h ge nera l ly lasts 1 0 to
14 days.
A va ria ble-pu lse POL ( 59 5 n m , Candela V-bea m ,

Wayla n d , M A ) with stuttered pu lse d u rations ( i e ,
0.45, 1 . 5, 3, 6, 10, 20, 30, 40 ms) can provide a
red uced p u r p u ra t reatm ent of fac i a l tela ngiec
tasias, b u t is somewhat less effective and usua l ly
req u i res m u lti ple treatments.
Figure 14.2 (A, B, C) Prominent facial erythema prior to treatment with
/PL .
79
0 C o m m o n ly, s u b p u rp u ric fl uences of less t h a n

1 0 J/cm 2 at pu lse d u ration of 1 0 ms wit h a 7 - m m
spot s i z e a re util ized .
0 Better efficacy of the va riable-pu lse P D L i n treat

ing fac i a l telangiectasias can be a c h ieved by uti
l iz i n g p u r p u ri c fl uences or with a p u lse sta c k i n g
o f s u b p u r p u ric pu lses (sta c ked 2-4 s u b p u rpuric
p u l ses at a 1 . 5- H z repetition rate, 7.5 J/c m 2 ,
1 0-ms pu lse d u rati o n , 1 0- m m spot size, D C D of
30/20).
0 Facial edema, eryth em a , a n d d isco mfort c a n

occ u r after exte nsive treatment w i t h the p u r p u ra
free va ria ble-pu lse P D L. H owever, these u nde
si red effects a re ge nera l l y better tolerated when
compared to a p u r p u ra- i n d u c i ng laser treatment.
- I ntense pu lsed l ight ( I PL) can be h ighly effective in

treating backgro u n d erythema while P O Ls work bet
te r for i n d ivid u a l telangiectasia . I P L fl uenc ies of 30 to
40 J/c m 2 with a 20 msec p u lse d u ration a re usua l ly
effective ( Sta r l u x Lux G h a n d piece, Pa lomar Med ical
Tec h n o logies, B u r l i ngton , M A J . The treatment end
point is i m med iate vessel clearance or selective ves
sel d a rke n i ng. M u lt i p l e treatments may be req u i red
fo r the greatest treatment benefit.
- The va riable pu lse width 1 , 064- n m N d : YAG laser
has proven to be effective i n the treatm ent of fac i a l
te la ngiectasias. S h o rter p u lse widths with h igher f lu
en ces m ight be n ecessa ry for effective treatment of
s m a l l e r vessels but have a n increased risk of b l i ster
and sca r formatio n .
- Freq uency-d o u bled 532 n m N d : YAG laser, a lso
cal led potass i u m-tita nyl-phosphate ( KT P ) laser, pro
vides effective a bsorptio n of hemogl o b i n with a pu lse

d u ration of 1 to 50 m s m a k i ng it idea l ly su ited to treat
su perfi c i a l vessels without p u r p u ra formati o n . Tra c i n g
o f i n d iv i d u a l vessels is a usefu l tec h n iq ue for patients
with a cou nta b l e n u m be r of d iscrete , visi ble vesse ls.
Flashla m p
( p u lsed
l ight)
treatment:
IPL
provides
a n othe r effective, p u r p u ra-free method for red ucing

fa c i a l tel a ngiectasias a n d erythema ( Figs . 1 4 . 2 and
14.3 ) .
B I B L I OG RAPHY
Afe rzon M , M i l l ma n B . Exc ision o f r h i n o phyma with h igh
freq u ency electrosu rgery. Dermatol Surg. 2002 ; 28(8 ) :
735-738.
Alam M, Dover JS, Arndt KA. Treatment of fac i a l telang
iectasia
Figure 14.2 (continued) (0, E, F) Reduction of the facial erythema after
with
va r i a b l e- p u lse
h igh-fl uence
pu lsed-dye
laser: Com pa rison of efficacy with fl uences i m med iately

a bove and below the p u r p u ra t h reshold . Dermatol Surg.
2003 ; 29 ( 7 ) : 68 1 -684 . D iscussion 685 .
two treatments with /PL, Starlux L ux G handpiece
80
Bernste i n EF, Kligm a n A. R osacea treatment using the

new-gen eratio n ,
d u ration
h igh-energy,
p u l sed-dye laser.
595
nm,
long
pu lse
Lasers Surg Med. 2008;
40(4): 233-239 .
Del Rosso J Q . Anti-i nfla m matory d ose d oxycyc l i n e in the
treatment of rosacea . J Drugs Dermatol. 2009 ; 8( 7 ) :
664-668 .
J a s i m Z F, Woo WK, H a n d ley J M . Long-p u lsed (6-ms) d ye
laser
treatment
of
rosacea-associated
te la ngiectasia
using s u b p u rp u ric c l i n ica l t h reshold . Dermatol Surg.

2004;30( 1 ) : 37-40 .
Mark KA, S pa racio R M , Voigt A, M a re n u s K, Sa rnoff D S .
O bjective a n d
q u a ntitative i m prove ment o f rosacea
assoc iated erythema after i ntense p u l sed l ight treatment.
Dermatol
Surg.
2003 ; 29(6) : 600-604;
1 63- 1 6 7 .
Discussion 1 6 7 .
N e u h a u s I M , Za ne LT, Tope W D . Comparative efficacy of
n o n p u r p u rage n i c p u l sed dye laser a n d i ntense p u lsed
l ight fo r erythematotela ngiectatic rosacea . Dermatol Surg.
2009 ;35(6):920-928.
Sa rradet DM,
H ussa i n M , Gold berg DJ .
M i l l isecond
1 064- n m neodym i u m : YAG laser treatment of fa c i a l

tela ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58.
T h i boutot D M , Fleisc h e r AB, Del Rosso JQ, R i c h P.
Re lated Articles 7: A m u lticenter study of topical aze l a i c
a c i d 1 5% gel i n c o m b i nation with ora l d oxycyc l i n e as i n i t i a l th era py a n d azela ic a c i d 1 5 % g e l as m a i nte nance

monothera py. J Drugs Dermatol. 2009;8( 7 ) : 639-648.
Figure 14.3 (A) Prominent facial telangiectasias prior to treatment with
/PL . (B) Posttreatmen t erythema immediately after IPL treatment
CHAPT E R 1 5
Se baceous H ype rp l a s i a
Sebaceous hyperplasia a p pea rs a s 1 -to-3-m m ye l l ow

u m bi l icated pa pu les with overlying te la ngiectasias on the
face of m id d le-aged i n d iv i du a ls ( Fig. 1 5 . 1 ) . They re p re
sent a benign prol iferation of sebaceous glands. The
lesions a re someti mes m i sta ken for basa l cell carc i n o m a .
E P I D E M I O LOGY
Incidence: very common
Age: m ost c o m m o n l y middle age a n d elderly but can
a p pea r i n you ng i n d ivid u a l s as wel l
Race: more common in Caucasians
Sex: eq ual
Precipitating factors: orga n tra nspla ntation is a ra re p re
c i pita nt
PATH OG E N ES I S
U n known .
PATHOLOGY
I nc reased n u m bers of l a rge, matu re sebaceous l o b u les
a re c l u stered a ro u n d a centra l d u ct in the u p per d e r m i s .
The lobu les l i e closer tha n normal t o the e p i d e r m i s .
PHYS I CAL LES I ON S

There a re si ngle or m u lti p l e 1 -to-3-m m ye l low u m b i l i
cated pa p u les with overlying telangiectasias t h a t a p pea r
on the face. The forehea d , c h eeks, a n d nose a re the
m ost common locatio ns. I t can rarely present on the
a reo l a .
D I FFERENTIAL D I AG N OS I S
M ost c o m m o n l y m ista ken for basa l cel l carci n o m a .
LABO RATORY EXA M I NAT I O N

N o n e i s i n d icated . B i o psy i f consideri ng basa l cell carci
noma.
CO U RS E
Ben ign , but d o not regress o r resolve without thera py.

Any h i story of the lesion bleed i ng.
Figure 1 5 . 1 Large sebaceous hyperplasia on the forehead
81
82
MANAG E M ENT
There i s no me d i c al i n d ication t o treat sebaceo us hyper
plasia . Sti l l , some i n d ivid u a l s a re sign ifica ntly bothe red by
its a p pea ra nce a n d req uest re mova l , pa rticula rly in the
c i rc u msta nce of m u ltiple lesions. Treatme nts i n c l u d e
o ra l , destructive, laser, a n d photodyna m ic thera p ies.
Eac h has its side effects and risk of rec u rrence.
TREAT M ENTS
A l l patie nts s h o u l d be i nformed before a ny treatment
modal ity that i m prove ment is va ria b l e and i n the futu re
new lesions may a rise req u i ri n g fol low- u p treatme nts.
Dest r u ct i ve M o d a l i t i es
" Light" c ryothera py a n d electrosu rgery a re q u ic k , i n ex
pens ive means of treating sebaceo us hyperplasia .
Laser T h era py
The
1 ,450- n m
d iode
laser has
been stu d i ed
in
1 0 patients for the treatment of sebaceous hyperplasia

( Figs. 1 5 .2 and 1 5 . 3 ) .
- Ea c h patient was treated 1 t o 5 times.
- F l u e n ces of 1 6 to 17 J/c m 2 were em ployed , with cooli n g d u rations of 40 to 50 ms.
- After two to th ree treatm ents with the d iode laser,
84% of lesions d ec reased in size greate r t h a n 50%,
a n d 70% decreased greate r tha n 75%. Patient a n d
phys i c i a n satisfaction was h igh .
- Side effects i n c l uded one case of a n atro p h i c sca r
a n d one case of hyperpigme ntati o n .
Pu lsed d y e laser ( P D U ( 585 n m ) h a s been shown to

i m prove sebaceous hyperplasia .
- Su ccessful treatment has been shown with t h ree
sta c ked 5-mm p u lses at fl u e n ces of 7 a n d 7 . 5 J/cm 2 .
- M ost lesions respond after one treatment with flatten
i ng, s h r i n k i ng, o r resol ution .
- Seve n percent of lesions rec u rred com p l ete ly.
- One study s h owed cleara n ce i n two patients treated
with the P D L at 585 n m , 6 . 5 to 8 J/cm2 , a n d a p u lse
width of 300 to 450 seconds. Two to t h ree treatments
were performed .
Erbi u m : YAG or C0 2 laser a b lation c a n a lso i m p rove

sebaceo u s hyperplasia .
Laser-assisted photodyna m i c thera py with topica l 20%

5-a m i no l evu l i n ic acid and PDL i rrad iation (595 n m ) ,
b l u e l ight or i ntense p u lse l ight; 1 t o 4 treatme nts a re
needed with va ria b l e i m provement a n d futu re recu r
rence a c h i eved m ore effective i m provem e nt of seba
ceous hyperplasia than P D L a l one.
Figure 1 5 . 2 (A) Patient with sebaceous hyperplasia on the right temple
and forehead. (8) Improvement 1 month after treatment with 1 , 4 50-nm

diode laser (Smoothbeam, Candela Corp., Wayland, MA) utilizing a 6-mm
spot with a f/uence of 1 4 J/cm 2 and a pulse duration of 35 ms
- Treatme nts were performed at 1 -to-6-week i nterva l s .

- B o t h thera pies showed greater i m provement t h a n no
thera py at a l l . There were no long-term res u lts.
- Side effects were l i m ited to m i l d tem po ra ry red ness,
edema, and crusting.
P I T FALLS TO AVO I D/O UTCO M E

EXPECTAT I O N S/CO M P L I CAT I O N S/
MANAG E M ENT
Patie nts should b e i nfo rmed that com p l ete resol ution i s
d iffic u lt a n d n ot a l ways permanent.
Destructive modal ities su ch as c ryothera py a n d electrod es iccation can prod uce pigmenta ry c h a n ges a n d
eve n sca rring if done too aggressively. Recu rrences a re
co m m o n .
Loca l exc ision leaves a sca r.
Ora l thera py with isotret i n o i n is clearly an a lte rnative

treatment a n d is n ot as efficacious as other mod a l ities
and ca rries with it the risk of sign ifica nt side effects
s u c h as teratogen icity, d ry s k i n a nd m ucous mem
b ra n es,
h igh
skeleta l
hyperostosis,
triglycerides and
l iver
c h oleste ro l ,
fu nction
d iffuse
a bnormal ities,
red uced n ight vision, pse u d otu m o r cere b r i , l e u ko pe n i a ,

possi ble d e p ress i o n , a n d s u i c i d a l i d eati o n . To pical
treti n o i n can p rod uce s k i n i rritation .
Laser thera py m ust be used with caution, especially i n

dark s k i n phototypes, given t h e risk o f hyperpigmentatio n .
There ca n be sca rri ng, red ness, e d e m a , a n d c rusti ng,

as shown i n Figure 1 5 . 3 . Recu rrence is n ot u ncom m o n .
Figure 1 5.3 (A) Sebaceous hyperplasia-before. (8) Improvement one
B I B L I OG RAPHY
Aghassi D, Gonza l ez E, And erson R R , R ajad hya ksha M ,
Go nza lez S . E l u c i d ati ng t h e p u lsed -dye laser treatment of
sebaceous hyperplasia in vivo with rea l-ti me confoca l
sca n n i ng laser m ic roscopy. J Am Acad Dermatol. 2000;
43 ( 1 pt 1 ) :49-53 .
Alste r TS, Ta nzi EL. P hotodyna m i c thera py with topical
a m i nolevu l i n ic acid and pu lsed dye laser i rra d iation for
sebaceous hyperplas i a . J Drugs Dermatol. 2003 ; 2 ( 5 ) :
50 1 - 504.
Kim SK, Do J E, Ka ng H Y, Lee ES, Kim YC. Combi nation of
topica l 5-a m i nolevu l i n ic a c i d - photodyna m i c thera py with
carbon d ioxi d e laser for sebaceous hyperplasia. J Am
Acad Dermatol. 2007 ; 56(3 ) : 523-524.

R i c hey D F. A m i n o l evu l i n ic acid photodyna m i c thera py for
sebaceous gla nd hyperplasia . Dermatol Clin. 2007 ;25( 1 ) :
59-65. Review.
Schonermark M P, Sc h m id t C , Ra u l i n C. Treatment of
sebaceous gland hyperplasia with the p u lsed dye laser.
Lasers Surg Med. 1997 ; 2 1 (4) :3 13-3 1 6 .
month after treatment with 1 450 nm diode laser 1 4 . 5 J/cm 2 , 35 ms

cooling, single pulse per lesion
83
TH RE E
D isord e rs of Ecc rine G l and s
86
CHAPT E R 1 6
H ype rhid ros is
Hyperh i d rosis is t h e secretion o f excessive a m o u nts of

sweat from the ecc ri ne sweat glands at rest a n d at normal
room tem peratu re . It pro d u ces both physica l a n d soc i a l
d iscomfort. The m ost com m o n l y affected a reas a re the
axi l lae, pa l m s , a n d pla nta r feet. I t can present i n a b i lat
eral o r sym m etric fas h i o n . The m ost c o m m o n cause of
hyper h i d rosis is i d i o path i c .
EPI DEM I O LOGY

Incidence: no good e p i d e m i ologic stu d i es of p reva lence.
Age: pa l mo p l a nta r: b i rt h ; axi l l a ry: p u be rty.
Race: no rac i a l pred i l ection .
Sex: eq ua l .
Precipitating factors: i d i o path ic, emotiona l , centra l nervous
system injury/d isease, d rug, s u rgica l i nj u ry a re the most
common ca uses. In most cases, there is a fa m i ly h i story.
Figure 1 6 . 1 An example of the starch-iodine test in the left axilla. Note
PATHOG E N E S I S
Ecc rine glands a re primarily i n nervated b y sym pathetic
fibers that a re c h o l i n ergic rather t h a n ad renergic in
n e u ra l response.
PHYS I CAL F I N D I N G S
Pa l m o pla nta r: excessive sweat a n d sweat d roplets p ro

d uc i n g a moist a p pea ra n ce a n d c l a m m y feel
Axi l l a ry: sta i n i ng of s h i rts i n the u nd e ra r m a rea
C l i n ical a p pea ra nce d oes n ot s u ggest other d isord ers .
LABORATORY EXAM I NAT I O N

Sta rch-iod i n e or n i n hyd rin test a re usefu l i n d efi n i ng
a reas of sweati ng ( Fig. 1 6 . 1 ) .
N o c h a racteristic fi n d i ngs . B i o psy plays no ro le i n m a n
agement.
COU RS E
Does n ot remit sponta neously; may i m p rove sl ightly with
age .
the prominent dark blue-black discoloration at sites of hyperhidrosis
Sect i o n 3 : D i so rd e rs of Ecc ri n e G l a n d s
Med ication h i story
Assess fo r syste m i c a bnormal ity
Recent s u rgery
HYPERHIDROSIS
Antipersp i rant
Botox
M e d i cation
Antipersp i ra nt
F i rst l i n e t reatment
A l u m i n u m c h l or i d e (20%-25%)
S u rgery
a p p l ied in the eve n i ng 2-4 t i m es per week
MANAG E M ENT
Effective for many patie nts
Dryness and i rritat i o n are m a i n s i d e effects
Botox
T h e goa l o f the treat m e n t is t o s u bsta ntia l l y d e c rease

sweat p rod u c t i o n to i m p rove p h ys i ca l a n d soc i a l d i s
Botu l i n u m tox i n type A ( Botox)
most com m o n l y used .
co mfort, n ot c o m p l ete e l i m i nati o n . T h e re a re m u lt i p l e
Average dose, 50- 1 00 u n i ts per axi l l a
Safe, h i g h l y effect ive 3-9 months
treat m e nts fo r h y pe r h i d ros i s ( F i g .
Expensive if not covered by i n surance
1 6 . 2 ) . Botu l i n u m
tox i n A i s a very effective treat m e n t p rov i d i ng tem po

ra ry red uction in sweati n g . To p i c a l a n d ora l m e d i c a
t i o n s a re o n l y m o d estly effective . S u rg i c a l t h e ra py,
i n c l u d i ng l i pos u c ti o n , is m o re effective tha n to p i ca l
t h e ra py.
M e d i cati ons
Com pensatory hyperh id rosis sec o n d a ry to sym pathec
Antich o l i nergics; h igh
i n c i d e nce of side effects
tomy l i m its its use at present except as a fi n a l therapeutic

modal ity.
.
. . . .. . . . . . . . . ..
TOP I CAL M E D I CATI O N S
A l u m i n u m c h loride hexahyd rate .
hyd rate solution in etha nol with o r without occ l usion

to u nshaven sk i n for 6 to 8 h o u rs n ightly for 3 to
4 days ca n be benefi c i a l but is com pl icated by loca l
i rritati o n . R etreatment once or twice wee kly for m a i n
tenance is reco m m e n d e d . Treated s k i n s h o u l d b e
washed t h e fol lowi ng m o r n i n g .
- I n the axillae, it is a p pl ied at n ight to u nshaven s k i n
a n d washed off i n t h e morn i n g .
- Freq u ency o f a p pl ication d i m i n ishes w i t h i m p rove
ment.
Ta p water iontophoresis can be effective.
- The proced u re req u i res conti n u a l a p p l i cation for 1 5
t o 2 0 m i n utes 2 t o 3 ti m es per wee k .
- B l istering a n d b u r n i ng have been reported as s i d e
effects.
- Contra i nd ications i n c l u d e p regnancy, ca rd iac pace
m a kers, and m etal i m pl a nts.
ORAL M E D I CATI O N S
Oral a ntichol i n e rgics i n c l u d i ng born a p r i n e , glycopyrro
nium
brom i d e ,
propa nth e l i ne,
and
metha ntha l i ne
b rom ide a re of l i m ited efficacy. They prod uce d ose

related a ntichol i n ergic side effects.
Consider if a l l other t h e ra py fa i l s
E n d osco p i c thora c i c sympath ecto my; m ost
effect ive for pa l mar or fac i a l hyper h i d rosis
- Appl ication of 1 0 % to 30% a l u m i n u m c h loride hexa
S u rgery
H ig h l y effect ive proced u re w h e n performed by a
s k i l l ed spec i a l i st
Figure 16.2 Hyperhidrosis treatment diagram
87
88
S U RG E RY
N o r m a l i n n ervat i o n
Eccr i n e
S u rgica l proced u res i nc l u d e the fol lowi ng:
Endoscopic
or
c l assic
sym path ecto my
Sympathet i c n erve
is
Acety l c h o l i n e
usua l ly
sweat
gland
reserved as a fi n a l therapeutic option for pa l m a r hyper

h i d rosis. S u rgery p rovides long-lasting control . Genera l
a n esth esia is req u i red . S i d e effects i n c l u d e bleed i ng,
I n nervat i o n b l oc ked by Botox
sca r formatio n , i n fectio n , reaction to a n esthes i a , com

pensatory hyperh i d rosis, gustatory sweating,
pneu
moth orax, a n d Horner's syn d ro m e .
Li posuction for axi l l a ry hyperh id rosis i n volves su bder
Acety l c h o l i n e
--+ X
Selective g l a n d rem ova l is reserved f o r axi l l a ry hyper

h i d rosis.
--IIII X
Sym pathet i c n e rve
Figure 16.3 Mechanism of action of Botox in hyperhidrosis. Blocking

acetylcholine release from cholinergic presynaptic vesicles
m a l l i posucti on . The l i posuction ca n n u la is held with

the bevel side up at the s u bdermal level for sucti o n i ng
of this regi o n .
BOTU L I N U M TOX I N A
Botu l i n u m tox i n A provides tem pora ry effective treatment
fo r this cond ition . I t is a bacterial tox i n that dec reases
sweating by i rrevers i bly blocking a cetyl c h o l i n e release
from c h o l i n e rgic p resyna ptic vesicles ( F ig. 1 6 . 3 ) .
A n e st h es i a
Topical a n esthetic c rea m a nd/or ice ge nera l ly ca n p ro

vide sufficient a n esthetic effect.
Sti l l , nerve blocks s h o u l d be considered prior to pla nta r

a n d pa l m a r treatme nts to m i n i m ize the associated pa i n .
- P l a nta r: s u ra l a n d posterior ti b i a l nerves
- Pa l m a r : u l n a r a n d med i a n nerves
Treat m e n t
A sta rc h - i od i n e test perfo rmed prior t o treatment can

h e l p d e l i n eate the a reas to be injected . Iodine is placed
on the affected a rea , fol l owed by the a pp l ication of
cornsta rch p rod u c i n g a pro m i nent d a rk bl u e- bla ck d is
colorat i o n . The sta rch-iod i ne paste s h o u l d be washed
off prior to Botox i njections.
Effective Botox d i l utions va ry. A Botox A ( 1 00 U/via l )

d i l ution o f 2 . 0 U/0 . 1 c c i s effective .
I njecti ons a re performed at 1 to 2 em i nterva ls i ntra d e r

m a l l y t h roughout the affected a rea ( Figs. 1 6.4, 1 6 . 5
a n d 1 6 . 6 ) . Two u n its s h o u l d b e i njected p e r site .
A tota l d ose ra nging from 50 t o 1 00 U/axi l l a , pa l m , o r

s o l e can be i njected , for a tota l d ose o f 1 00 t o 200 U for
both treatment sites. A decreased d ose can be used for
l oca l i zed hype r h i d rosi s.
Tem po ra ry h a n d a n d fi nger m uscle wea kness may be a
Figure 1 6.4 Appropriate injection sites of botulinum toxin A for
c o m p l ication of pa l m a r botu l i n u m tox i n A i njections,
treatment of (A) palmar hyperhidrosis and (B) axillary hyperhidrosis. Each

injection should be approximately 1 to 2 em apart
especia l ly with i n c reasi n g d osages . Patie nts should use
Sect i o n 3: D i so rd e rs of Ecc ri n e G l a n d s
89
caution when ho l d i ng c u ps a n d other o bj ects s u p

ported by the thenar m uscle w h i l e the wea kness is p re
sent. T h i s wea kness ge nera l ly d issi pates with i n 3 to
4 weeks .
Decreased sweati n g is o bserved with i n 1 to 2 weeks .
Side effects may i n c l u d e loca l m uscle wea kness for pal
Benefits ge nera l ly a re n oted between 3 a n d 9 months.

m a r i njections, bru isi ng, a nti body resista nce, a n d ra rely
an a n a phylactic reactio n .
T h e efficacy o f botu l i n u m tox i n i njections is not affected

by laser h a i r rem ova l in the sa me a rea of treatment.
M ed i c at i o n s
Antichol i ne rgics; h igh i n c i d ence of s i de effects
Figure 16.5 Injection sites marked on right axilla of a male prior to botu
Tem porary h a n d a n d fi nge r m usc l e wea kness may be a

c o m p l ication of pa l m a r i njections of botu l i n u m tox i n A,
espec i a l ly with i n c reasing d osages .
Botox i nj ecti ons are contra i n d i cated i n patients with

u n d erlyi ng n e u ro m u sc u l a r cond itions as wel l as in
p regna nt and lactating patie nts.
Decreased d oses s h o u l d be consid ered fo r patients on

a ngiotensin-converting enzyme (ACE) i n h i bitors, wh i c h
ca n potentiate Botox effects.
It is i m porta nt to cou nsel that the benefits of Botox a re

te m po ra ry a n d req u i re repeat treatments.
None of the thera pies is u n iversa l ly efficacious. The

patient m u st be awa re that the treatm ent end point is a
red uction i n sweating a n d n ot c o m p l ete e l i m i nation .
Treatment side effects may be considera ble d e pend i n g

on the treatment c h ose n , a n d m ust b e revi ewed a t
d e pth with t h e patient prior t o a n y treatment i n itiati o n .
B I B L I OG RAPHY
Ca m panati A, Laga lla G , P e n n a L, Gesu ita R , Offi d a n i A .
Loc a l n e u ra l block at t h e wrist for treatment o f pa l m a r
hyperh id rosis with botu l i n u m toxi n : Tec h n ical i m prove
ments . J Am Acad Dermatol. 2004 ; 5 1 (3) :345-348.
G laser
DA.
Treatment
of
axi l l a ry
hyperh i d rosis
by
c h e modenervation of sweat gla nds using botu l i n u m tox i n

type A . J Drugs Dermatol. 2004;3 ( 6 ) : 627-63 1 .
G o h C L . A l u m i n u m c h l oride hexa hyd rate versus pa l m a r
hyper h i d rosis. lnt J Dermatol. 1 990;29:368-370.
G regoriou S , R igo pou los D, M a kris M , et al. Effects of bot
u l i n u m toxi n-a thera py for pa l m a r hyperhid ros is in p l a n
ta r
sweat
496-498.
prod uctio n .
Dermatol Surg.
201 0;36(4) :
linum toxin A injection
90
H a m m H . The place of botu l i n u m tox i n type A in the

treatment
of
foca l
hyperh i d rosis.
Br
Dermatol.
2004; 1 5 1 (6) : 1 1 1 5- 1 1 2 2 .
Heckma n n
M,
Ceba l l os- Ba u m a n
AO,
Plewig
G.
Bot u l i n u m tox i n A f o r axi l l a ry hyperh i d rosis (excessive

sweat i n g ) . N Eng/ J Med. 200 1 ;344:488-493.
H erbst F, Plas EG, Fuggo R, F ritsch A . Endoscop i c tho
racic sym pathectomy for pri m a ry hyperh i d rosis of the
u pper l i m bs : A critical a na lysis and long-term res u lts in
480 operations. Ann Surg. 1 994;220: 86-90.
Lowe N, Ca m pa nati A, Bodokh I, et a l . The use of topical
glycopyrrolate i n the treatment of hyperh id rosis. Clin Exp
Dermatol. 1998;23: 204-205.
Pa u l A, Kra nz G, Sc h i n d l A, Kra n z G S , Auff E, Syc ha T.
Diode laser h a i r rem ova l d oes not i nterfere with botu
l i n u m tox i n A treatment aga i n st axi l l a ry hyperh i d rosis.
Lasers Surg Med. 2010;42(3 ) : 2 1 1 -2 1 4.
R e i n a uer S , N uesser A, Schauf G , H olzle E . I o ntophoresis
with a lternati ng c u rrent and d i rect c u rrent offset (A/C ion
to phoresis): A n ew a p p roac h fo r treatment of hype r h i d ro
sis. Br J Dermatol. 1993 ; 1 29 : 1 66- 1 69 .
Figure 1 6 . 6 The sites of hyperhidrosis
FOUR
D isord e rs of H air Fo l l ic l es
92
CHAPT E R 1 7
Hirsutis m
H i rsutism rep rese nts a male pattern overgrowth of term i

n a l a n d vel l us h a i rs i n women . Fa r fro m be i n g solely a
cosmetic concern , h i rsutism can be a n i m porta nt m a n i
festation of an u nderlying endocrine d isord e r a rising from
i n c reased a n d roge n i c activity. Ofte n , it res u l ts from a n
ove rprod uction of a d re n a l a n d ova ri a n hormones a n d
m a y acco m pa ny oth e r s i g n s o f v i r i l izatio n . I ts a ppea ra nce
prod u ces soc i a l a nxiety,
d i stress,
and
ostracism
in
affected patients. I t a l so merits a n a p pro p riate med ical

work u p . By contrast, hypertrichosis feat u res fi ne h a i rs in
a n d roge n-sens itive as wel l as a n d rogen-i nsensitive a reas.
Normal ra c i a l and eth n i c va riations may cause confusion
with these d isord ers .
EPI O E M I O LOGY
Incidence: com m o n .
Age: u s u a l l y postpu berta l b u t age o f o nset ca n va ry i n t h e
setti ng o f med icati o n , t u m o r, or endocrine a b normal ity.
Race: rac i a l a n d c u ltura l factors affect the perception of

what constitutes a bnormal h a i r growt h . S k i n type affects
treatment options as wel l .
Sex: fe m a l e .
Precipitating factors: h i rsutism is ca used b y a h ost of
endocrine
a bnorma l ities.
Ad rena l
ca uses
include
C u s h i ng's d isease, ecto pic ad renocorticotropic hormone

(ACT H J prod ucti o n , p r i m a ry a n d rogen-prod u c i n g neo
Figure 1 7 . 1 Spot size, 8 mm versus 1 5 mm. Larger spot sizes penetrate
plasms, and congen ita l a d re n a l hyperplasia . Ova r i a n
deeper and allow quicker treatments
causes can be related to polycystic ova ri a n synd rome

a n d p r i m a ry t u m o rs a m o ng oth e r causes. F i n a l ly, med
ications
suc h
as
o ra l
contrace ptive
pills,
a n a bo l i c
steroids, a n d a n d roge ns may ca use h i rsutis m .

There i s a n overgrowth o f h a i r i n a n d rogen-sensitive h a i r
fo l l icles. C o m m o n sites i n c l u d e t h e bea rd a rea o f the
face, c h i n , prea u ri c u l a r face, l i nea a l ba , pe r i a reola r a rea ,
a n d c hest. Depend i ng on the severity of the cond ition ,
other signs of v i r i l ization such as i nc reased m uscle mass,
deep vo ice, male pattern h a i r loss, and c l itora l e n l a rge
ment may be prese nt.
W h i l e both h i rsutism a nd hypertric h osis featu re h a i r over
growt h , these conditions ca n be d iffe re ntiated by the
location and q u a l ity of the hair growth . H i rsutism is c h a r
a cterized
by term i n a l
h a i r overgrowth
i n a n d rogen
d e pendent a reas, wh i l e hypertrichosis featu res fi ne h a i rs
Figure 1 7 . 2 Hair trimmed prior to treatment
Sect i o n 4 : D i so rd e rs o f H a i r Fo l l i c l es
in a n d roge n-sensitive as wel l as a n d rogen-i nsensitive

a reas. Normal rac i a l a n d eth n i c va riations may cause
confusion with these d isorders.
LABO RATORY TESTS

The la boratory workup should be gu ided by the patient's
c l i n ical fi n d i ngs as wel l as by a deta i l ed patient h istory.
Testing ca n hel p esta blish if there is an a d renal or ova ria n
sou rce of the h a i r growth . Ova ria n , a d re n a l , a n d pitu ita ry
tu mors should be ruled out in cases of ra pid onset by a n
endocri n ologist a n d/or a gynecologist. Tota l testosterone
levels, dehyd roepiand rosterone su lfate levels, u r i n a ry free
cortisol levels, d exa methasone s u ppression test, prolacti n
levels,
ACTH
sti m u lation,
l ute i n izing
hormone/foll icle
sti m u lating hormone ( LH/FS H ) ratio, 1 7- hyd roxy proges

terone levels, a n d pelvic u ltrasou n d may a l l present i m por
ta nt com ponents of a thorough endocri nologic work u p .
CO U RS E
Cou rse i s dependent o n t h e etiology o f t h e h i rsutism .
Menstru a l h istory-reg u l a r or i rreg u l a r
O nset a n d p rogression of sym pto ms
Fa m i ly h i story of i nfla m m atory cystic acne and h a i r loss
H istory of endocrine a bnorma l ities
Figure 17.3 Laser light firing
MANAG E M ENT
T h e pri m a ry goa l o f t h e treatment is t o d eterm i n e the
u nderlying cause of h i rsutism a nd treat. After d eterm i n
i n g t h e ca use a n d e n s u r i n g a pp ropriate med ical thera py,
the goa l ca n tra n s ition to reversi n g the a bn o r m a l h a i r
growth . There a re m u lti ple mea ns b y w h i c h tem po ra ry
a n d perma nent h a i r rem ova l can be ach ieved .
C o n s u l t at i o n w i t h E n d oc r i n o l ogy
I n cases of h i rsutism, the fi rst priority is to u n cove r the
sou rce of the a be rra nt hair growth . N u merous la boratory
i n vestigatio n s, as d eta i led a bove,
may be req u i red .
Consu ltation a nd referra l to a n en docri n ologist is stro ngly

recom men d ed as pa rt of such a worku p .
N o n l a ser T h e ra p i es
There a re severa l tem pora ry means to con cea l h a i r ove r
growth . They i n c l u d e m a ke u p , b l ea c h es, a n d hyd roge n
perox i d e . S havi ng a lso c a n te m pora ri l y h id e h a i r growt h .
Figure 1 7.4 Characteristic posttreatment perifollicular erythema
93
94
H a i r remova l can be ach ieved with d e p i lati o n , e p i l a

t i o n , l a s e r thera py, e l ectrolysis, a n d to pical eflorn ith i n e .
Depi lation
Depi lation is the process of removing pa rt of the h a i r
shaft. Its effects a re tem pora ry. There a re c h e m i c a l a n d
mec h a n ical methods o f d e p i lati o n . C h e m i c a l depi latories,
such as th ioglycolate sa lts and su lfides of a l ka l i m eta ls,
d issolve hair shafts. They can prod uce loca l ized i rritati on
at the site of treatment. Mecha n i c a l depi lation c a n be
q u ite crude i n c l u d i ng shaving of h a i r as we l l as r u b b i n g
h a i r w i t h a p u m ice stone.
E p i lation
Epi lation is the process of removing the enti re hair shaft.
I t provides more longevity tha n d e p i lation but is not per
manent. It i n c l udes waxi ng, p l u c k i ng, t h rea d i ng, a n d
e l ectrical d evices t h a t re move t h e h a i r shaft. Eac h of
th ese o ptions is relatively i n expensive but can prod uce
pa i n and irritation as side effects . P l u c k i n g can res u lt in
loca l ized i nfection , i ngrown h a i rs, and even sca rring.
Eac h of these treatm ents can be used i n com bi nation
with topical eflorn ith i n e on the face of wo m e n .
Top i c a l eflorn i th i ne (Va n i qa)

To pical eflorn ith i n e twice d a i ly has been a p proved by the
U . S . Food a n d Drug Ad m i n istration ( F DA) for tem pora ry
h a i r remova l on the face of wome n . It s h o u l d o n l y be
used on the face a n d not on other pa rts of the body. It
decreases the rate of hair growth by i n h i biti ng ornith i n e
d eca r boxylase . I t s h o u l d be used i n conj u nction with
other h a i r remova l methods, such as shaving, waxing, or
p l u c k i ng.
Patie nts
should
use the
med ications for
Figure 1 7 . 5 Bizarre growth of back hair on a male due to poor technique
8 weeks to j u dge its efficacy. If there is n o i m provement

after 8 weeks, the med ication should be d isconti n ued . If
the
med i cation
works,
it
should
be
conti n ued .
Disconti n uation of treatment resu l ts in a res u m ption of

h a i r growt h . S i d e effects i n c l u d e loca l irritation . It s h o u l d
n ot be used d u ri n g pregnancy.
E l ectro l ys i s
Remova l can be permanent.

El ectrolys i s uses d i rect e l ectrica l c u rrent to d estroy the
dermal pa p i l l a of t h e h a i r fo l l ic l e . A fi ne need le placed
d i rectly i nto the h a i r fo l l i c l e d e l ivers the e l ectri c a l
c u rrent to the fo l l i c l e's b a s e w i t h o u t p rod u c i ng sca r
r i n g . T h e site of treatment is shaved severa l d ays prior
to thera py and to pica l a n esthetic c rea m ca n be used
1 hour prior to the p roced u re to red uce pa i n . Side
effects i n c l u d e sca r, hy po-/hyperpigmentat i o n , and
i nfecti o n . I t i s m ost a p p ro p r i ate fo r s m a l l a reas of
treatment.
Need for m u lt i p l e treatm ents for l i m ited treatment zon e .
G reater r i s k o f side effects, pa i nfu l .
N ot practical fo r la rge a reas o f the body.
Figure 1 7 . 6 Extensive dyschromia secondary to inappropriate fluence and

pulse duration
Sect i o n 4 : D i so rd e rs of H a i r Fo l l i c l es
95
Laser h a i r re m ova l
Lasers a re the treatment of choice for permanent red uc
tion of u nwa nted , pigmented term i n a l hair fol l icles. Laser
h a i r remova l is q u ic k , relatively n o n pa i nfu l , espec i a l l y
compared to e l ectrolysis. Fu rthermore, it ca n cover a fa r
m ore exte nsive a rea of affected s k i n with less pa i n in less
( i e , i m proper spaci ng and overla p) time. An average of
five to seven treatments a re needed for greater tha n 50%
red ucti o n .
Mechan ism of a cti on

Lasers a re based on the selective p h otothermo lysis. The
l ight is a bsorbed
by the
pigment i n
hair fol l i c les.
Therefore, if h a i r fol l i c l es have no pigment ( ie , blond or

gray h a i r ) , lasers d o n ot work. Lasers work best o n t h i c ke r
h a i r fol l ic l es .
.._______________________....,
Pat i e n t Co n s u l tat i o n
H a i r color.
S k i n type-a l l s k i n types ca n benefit from laser h a i r

remova l .
Past med ical h i story.
Med ications.
Past treatments .
E m p hasize the n e e d for five t o seven treatments on a n

average t o re move t h e majority o f u nwa nted h a i r.
I m provement is va r i a b l e .
Low risk o f no i m p rove ment or i n c reased h a i r (es pe
c i a l ly in fe ma les of Med iterra nea n he ritage ) .
Figure 1 7 . 7 (A) Appearance of skin prior to laser hair removal. (B) Hair on
R isk o f hyper- or hypopigme ntation that m a y last
lateral cheeks
months; rarely perma nent.
Sca rring is ra re.

Like l i hood of at l east some pa i n ; the a m o u nt of pa i n
assoc iated with t h e proced u re is a refl ection o f t h e cal
i be r a n d d e nsity of hair i n the treated regio n .
Ideal ca n d idate h a s d a r k cou rse h a i r a n d l ight s k i n

phototype.
Average ca n d i d ate-fi ne/l ight brown h a i r

Poor ca n d i date-blond/gray h a i r s h o u l d n ot b e treated
with
8 1 0-n m
d iode
laser
with
c u r rent
lasers .
Ad d itional ly, pati ents with u n rea l i stic expectations or

med ic a l contra i n d i cations should not be treated .
Pat i e n t Co n s u ltat i o n P r i o r to
Treat m e n t
S u n avoidance is crucia l . If a patient is ta n ned , t h e pro

ced u re s h o u l d be postponed u nt i l the ta n com pletely
Figure 17.8 Appropriate clinical endpoint of perifollicular erythema in
fa des. If the proced u re is performed on ta n ned ski n ,
this 24-year-old female with type VI skin and polycystic ovarian syndrome
treated with the long-pulsed 1 , 064-nm Nd: YA G laser
t h e risk o f dysc h ro m i a i s ma rked l y i n c rease d .
96
Shave h a i r prior to a rrivi ng i n the offi ce. Alte rnatively,

the h a i r can be tri m m ed in the office with a moustache
tri m mer. T h i s w i l l foc us the majority of energy to the
pigme nted hair fol l i c l es i n the ski n .
A topica l a n esthetic crea m ca n b e a p p l ied 1 h o u r prior

to thera py to decrease the pa i n d u ri n g the proced u re . I t
is i m porta nt t o advise the pati ent t o a p ply to pical a nes
thetic over a l i m ited s u rface of the s k i n to avoid a ny risk
of l i doca i ne toxicity.
H a i r waxing s h o u l d not be performed 2 to 3 weeks

before treatment.
If there is a h i story of recu rrent herpes s i m plex vi rus,

prophylaxis should
be
provided
before
laser
hair
remova l on face.
P regnancy: there a re no clear stud ies dem onstrating

safety or risk. I t is i m porta nt to edu cate pregn a n t
patients desi ri ng h a i r re mova l as t o this uncerta i nty.
M ost physicians wi l l not treat patients w h i l e pregna nt. If
treatment is p u rs ued , it is recommended to treat only
l i m ited a reas d u ri n g t h i rd tri meste r after m e d i ca l clear
a nce from an o bstetric ia n .
J u st P r i o r to Treat m e n t
Written consent
Ph otogra phy
Tri m h a i r
Laser H a i r R e m ova l Tec h n i q u e
( F igs.
1 7 . 1 - 1 7 . 8)
(Ta b l e
17. 1)
Key concepts for o pti m a l resu lts a re as fo l l ows :
For s k i n types I to I l l , use relatively h igh energy with a

shorter pu lse d u ration for o pti m a l resu lts.
TAB L E 1 7 . 1
Laser Hair Remova l Technique
Laser type
R u by
Safest s k i n type
I-I I I
Wavelength ( n m l
694
P u lse d u rati o n
Energy (J/cm 2 l
1-20 ms
1 0-40 J/c m 2
Comments
Fi rst laser used for
h a i r rem ova l ; slower to use
Al exa nd rite
I-I I I
755
Skin types I-I I I 3 ms;

skin types I l l and I V
Diode
1-V
810
S k i n types I-I I I
20-25 J/cm 2 ; s k i n
1 0-20 ms
type I V 1 5-20 J/cm 2
3- 100 ms
30-40 J/cm 2
3 ms and 1 0-20 ms
pu lse d u ration demonstrate
eq u a l efficacy
Longer p u lse d u ration for
treatment of s k i n types IV
and V
N d : YAG
I-V I
1 064
S k i n types I-I I I 1 0-20 ms;

ski n types IV-VI 25-100 ms
I ntense p u lsed
I ight-noncoherent
l ight
I-I V
550- 1 200
1 . 5-3 . 5 ms
Skin types I-I I I 30-50

J/c m 2 ; skin types
Safest d evice for

rem ovi ng h a i r i n s k i n
I l l-V I 25-35 J/c m 2
types I V-V I
25-50 J/cm 2
M ost va riable resu lts
LAS E R SAFETY
Hazard: o c u l a r
Da ngers
E n h a n c e Safety
Cornea , ret i n a , or lens
Base l i ne eye exam
can oc c u r
f r o m d i r e c t exposure
re f lec t ed beams, I . e .
equ a l to or greater t h a n
can be da m aged
Laser goggle optrcal
Damage
densrty (00) shou ld be

7 (c h ec k gogg l es)
or
I nspect goggles for vrsible damage or
pat ien t jewel ry, watches
degradation of t h e f i l ler med ia
Q-sw itc hed lasers are
Always c heck that appropriate gogg l es for
most hazardous, can
wavelength are used
cause b l i n d ness
Remove, e bon ize or cove r any ref lect iVe
r cornea
Lens
surfaces in laser room , i .e . m i r rors,

meta l l ic garbage cans
Remove pat ient jewe l ry, watches
H a z a r d : fire
Dangers
All lasers c a n pote n t i a l l y
cause fire hazards
su rfaces i n l a se r room , i.e. m irrors, metal l ic
Most common ly seen

w i t h C02
R emove . ebonrze. or cover any relfectrve
lasers
garbage cans
Avoi d alcohol or ensure that it i s f u l ly
vapori zed prior to st a rt of
Damage can oc c u r
f r o m d i rec t exposure or
ref lected beams
treatment
Drape treatment srte wrth wet

Remove a l l f lamm a b l e
t owe l s,
d rapes
gauze or
items, i . e .
dry
towe l s
gauze,
Coat exposed harr w i t h water-based j e l l y

Decrease F i02 t o
40%
e ndotrac heal t u bes
H a z a r d : p l ume,
sp l att e r, infection
Dangers
I n tact v i r rons and viral
Use mask
D N A such as
when treat r ng near
H PV
may
be present rn the p l u m e
of COz l asers
Smoke
evac uator
nssue part i c les can

splatter a n d aerosol ize
with Qswitched lasers
Hazard: el ectrocution
Dangers
Even
O n l y q u a l i f ied laser tec h n r c rans should
with power off,
ca n ca use shock/
e l ec t rocu t i o n
open l ase rs
Check for water s p i l ls, hose ruptures or

condensations
H a z a r d : general
Dangers
A n t i c i pate da ngers
Always r m mcd iatcly put laser on standby
mode when not treat rng pa t ren t

E n s u re proper srgn rs on the door of laser room
Ed ucate staff members as to laser safety
Figure 17.9 Laser safety. It is important to emphasize that lasers present special safety concerns for physicians, staff, and patients.
Among the risks are ocular injury, fire, electrocution, and dissemination of infectious disease. No lasers should be operated in the
absence of a detailed knowledge of laser safety issues between the physician and the staff. Educating staff members is an essential
component of safe laser practices. Periodic laser safety training is required by many hospitals and remains good practice for private
physician offices as well. (A) Patient and all personnel are wearing protective eyewear. Note gauze is moist to reduce the risk of fire.
(8) Smoke evacuator. (C) Safety sign placed outside appropriate laser room to ensure proper warning of laser use
98
S k i n types IV to VI m u st use l onger pu lse a n d lo nger

wavele ngth such as a 1 064- n m YAG .
If u n certa i n as to treatment pa ra m eters, perfo rm test
LASER A N D
EYE INJ U R I E S
sites with va ria ble fluencies a n d p u lse d u rations.
gen , contact coo l i ng, or ge l .
Opti m a l cool i n g setti ngs m ust b e util ized to lower the

risk of d ysc h ro m i a .
Wavel ength ( n ml Lasers
Use l a rger s pot s izes for d eeper penetration a n d m o re

Safety goggles for patient a n d med ical tea m .
Use the la rgest spot size possi ble for ta rget region .
Overla p laser p u lses 1 0 % over the enti re treatment

regi o n .
Postt reat m e n t I n st r u ct i o n s to Pat i e n t
Ex pect red ness fo r u p t o severa l h o u rs afte r treatment.
If red ness o r pa i n persists for m o re than 1 2 h o u rs, ca l l

t h e office. If there a re a n y c uta neous cha nges i n the
s k i n the day afte r the p roced u re o r beyo n d , the patient
m ust be to ld to conta ct the treati ng physic i a n .
O n c e red ness fades, patient may conti n ue t o wea r

m a ke u p .
Avoi d s u n for 4 8 h o u rs; no ta n n i ng.

Hair remova l is not entirely i m med iate . Some hair wi l l
fa l l o u t 1 t o 3 d ays after treatment.
Do not worry if some hair persists after treatment.
Ca l l the office if d iscoloration develops i n the treated sites.
Ca l l the office with q u esti ons or concerns.
P I T FALLS TO AVO I D/CO M PL I CATI O N S/

MANAG E M E N T ( F igs . 1 7 . 5-17 . 6)
There is no effective mecha n is m for laser remova l of

l ight or blond ha i r.
Excess ive fluenc ies or i ncorrect pu lse d u ration may

prod uce epidermal d a mage and dysc h ro m i a . These
effects a re typica l ly te m po ra ry but can be permanent. If
there is a n y d o u bt rega rd i ng laser pa ra m eters, pe rfo rm
a test site .
30().. 4 00 Exc 1 mer

(308 n m )
yes
: yes
400-600 Argon
(488 nm)
: yes
KTP
( 532 m n )
yes
Flash of the
em1 tted wavelength
fol l owed by
aften mage of a
complementary color
: yes
Pu lsed dye
laser
: yes
( 585-
600 nml
600- as N d : VAG
1 000 ( 532 n m )
: yes
as R u by
: yes
A lexa ndrite
: yes
D1ode
(694 n m )
(755 nm)
(810 nm)
yes
detected as reh na
lacks pam f i bers
a-switc hed lasers have

h ighest pote n t i a l to
c a u se b l i n d ness
May produce a popping
sou nd, then v1sual
: yes
N d : VAG
: yes
D1ode
( 1 320 n m )
( 1 4 50 n m )
yes
yes
CO:!
( 1 0,600 n m )
yes
B u r n mg pam at the site of
exposure on the cornea o r

sclera
Figure 1 7 . 1 0 Lasers and eye injuries
Coincident tattoos and lentigi nes may expe rience l ight
(http:!lwww. eyesafety. 4ursafety. com/laser-eye-safety. h tm l)
A lways kee p contact coo l i ng aga i nst the s k i n to avo i d

Overla p ( 10 % ) i n the treated zo n e . Do not leave "ga ps"
that can c reate biza rre h a i r growth patte rns as h a i r
regrows .
be
d i sorientation
1 000- as Nd: VAG

1 400 ( 1 064 n m )
1 4DO- Er: VAG

1 0000 (2940 n m )
Damage from a a-switc hed
N d : VAG l a se r m a y n o t
S k i n types IV to VI req u i re longer p u lse d u rations a n d
b u r n i ng.
yes
<300
l ower fl uenc ies.

e n i ng. Patie nts s h o u l d be i nformed of this poss i b i l ity.
Signs or symptoms
of injury
Eye injury
Cornea : lens : Retina
ra pid treatm e nt of l a rger a reas .
(:)-""
1 - Lens
--
A l l m a c h i nes util ize coo l i ng of epidermal s k i n via c ryo
Sect i o n 4 : D i so rd e rs o f H a i r Fo l l i c l es
For N d : YAG lasers, patie nts may expe rience pa i n eve n

after to pical a nesthes i a .
B I B L I OG RAPHY
Azziz R . The eva l uation a n d ma nagement o f h i rsutis m .
Obstet Gynecol. 2003 ; 1 0 1 ( 5 p t 1 ) :995- 1 007 .
Battle EF, H o b bs LM . Laser-assisted h a i r rem ova l for
d a rker s k i n types . Dermatol Ther. 2004; 1 7 ( 2 ) : 1 77 - 1 83 .
Bouzari N , Ta bata ba i H , A b basi Z , Fi rooz A, Dowlati Y.
Laser h a i r re m ova l : Com parison of long-pu lsed N d : YAG ,
long-pu lsed a l exa n d rite, a n d long-pu lsed d iode lasers .
Dermatol Surg. 2004;30(4 pt 1 ) :498-502 .
Gold berg
DJ .
Laser
hair
remova l .
Dermatol
Clin.
2002 ; 20(3) : 56 1 -567 .

Ta nzi EL, Alste r TS. Lo ng-pu lsed 1 064- n m N d : YAG laser
assisted h a i r remova l in a l l s k i n types. Dermatol Surg.
2004;30( 1 ) : 1 3- 1 7 .
CHAPT E R 1 8
Pseud ofoll icu I itis
Pseu d ofo l l i c u l itis is a com m o n , c h ro n i c i nfla m m atory d is

order that prese nts with i nfla m mato ry pa pu les a n d pus
tu les in the bea rd d istri bution of m a l es, pa rticularly those
with d a rker s k i n phototypes a n d tightly coiled h a i r.
N o n etheless, pse u d ofol l i c u l itis ca n present in a n y s k i n
t h a t is reg u l a rly sh aved a n d i n a l l s k i n p h ototypes . I n
fe ma les it is m ost commonly seen i n the axi l l a ry a n d
p u b i c a reas. It tends t o prese nt i n a more m i ld form i n
l ighter s k i n ph ototypes .
Incidence: ove r 50% of African American ma les
Age: begi ns with shaving or p l u c k i n g
Race: more common i n bea rd d istri bution o f ma les with
d a rker skin phototypes
Sex: male > fe ma les
Precipitating factors: shaving in any region of the body
PATH OG E N ES I S
T h i s d isord e r i s i n d u ced by shavi ng. Shaving sha rpens
c u rled h a i r. Sha rpened , tightly c u rled h a i rs pierce i nto the
ski n adjacent to the hair fo l l ic l e and i nvad e i nto the der
mis prod u c i ng a n i nfla m matory reactio n . I t c a n a lso fol
low hair p l u c k i ng, espec i a l ly i n fe m a l es with h i rsuti s m .
99
1 00
H a i r pe netration resu lts i n e p i d e r m a l i nvagi nation with
associated m i c roa bscess , m i xed i nfla m m atory i nfi ltrate,
and foreign body giant reaction at the tip of the i nvad i n g
h a i r. Dermal fi brosis m a y b e o bserved .
PHYS I CAL LES I O N S

M ost c o m m o n ly, i t presents with fol l i c u l a r pa p u les, pus
tu les, and posti nfla m matory hyperpigme ntation in the
bea rd a rea and a nterolatera l neck of ma les and u n d er
a rms a n d biki n i a reas of fe males. Pa p u les can d eve lop
i nto cysts. Sca r formation may be o bserved . The u p per
c uta neous lip is typica l ly spared .
Acne vu lga ris, fol l i c u l itis.

None.
COU RS E
Begi n s with shaving o r p l u c k i n g a n d conti n ues u nt i l
cessation o r mod ification i n the h a i r rem ova l tec h n i q ue .
MANAG E M ENT
Figure 18. 1 (A) A young male with type VI skin phototype and pseudofol
T h e goa l o f t h e treatment is t o prevent t h e formation of

the pa p u les, pustu les, sca rring, a n d posti nfla m matory
hyperpigmentation associated with this d isord e r. There
a re m u ltiple treatment options ava i la ble to acco m p l ish
this goa l . Cessation of shaving or p l u c k i ng is the m ost
successful treatment but it is i m p ractica l a n d u ndesira b le
fo r many patients . Laser thera py is h ighly effective with
h igh patient satisfactio n .
TREAT M ENT
S h a v i n g Cessat i o n
The most s i m ple, i nexpensive, a n d effective treatment for
pseu d ofo l l i c u l itis is the cessation of shaving.
Many
patients w i l l fi nd this o p t i o n u nd es i ra b l e o r i m practica l .
M o d i f i c at i o n of S h a v i n g Tec h n i q u e
A proper shaving tec h n i q u e may preve nt o r sign ificantly
decrease the risk of pse u d ofo l l i c u l itis. Among these prac
tices a re l ifti ng, n ot p l u c k i n g i ngrown h a i rs, thoroughly
liculitis barbae prior to treatment. (B) Same patient 3 months later after
several treatments with long-pulsed 1, 064-nm Nd: YAG laser. (Courtesy of
E. Victor Ross, MD)
Sect i o n 4 : D i so rd e rs o f H a i r Fol l i c les
wetti ng the a rea prior to a pplying shaving c rea m , using a

sharp razor, shaving i n the d i rection of the h a i r growth,
a n d avo i d i ng shaving i n more t h a n one d i rection i n the
sa m e a rea . The B u m p Fighter Razor p revents the shaved
h a i r from being cut too short . Additional ly, c utting the h a i r
twice d a i l y with h a i r c l i p pers p revents h a i rs from piercing
i nto the skin.
To pical a nti biotics a re effective i n treati ng the i nfla m ma
tion and occasional i m petigi n ization assoc iated with this
conditi o n . To pical treti noi n , benzoyl peroxide, and gly
colic acids can be h e l pfu l a dj u n cts.
Laser H a i r R e m ova l ( F i g s .
and
1 8.2)
18. 1
Laser h a i r remova l i s a safe, h ighly effective treatment

modal ity for short and long-te rm i m provement.
S k i n types I to I l l
- The long-pu lsed a lexa n d rite laser ( 755 n m ) , d iode
laser (810 n m ) , i ntense pu lse l ight ( 590-1 00 n m ) ,
Figure 18.2 Pseudofolliculitis-laser therapy: pigmented versus
a n d long- p u lsed N d : YAG ( 1 064 n m ) laser have the
unpigmented hair follicle
a p pro p riate wavele ngths to selectively ta rget the

c h ro m o p h ore mela n i n fou n d in the hair b u l b .
- M u ltiple treatme nts (average o f 5- 1 0 ) every 4 t o 8
weeks ach ieve a n average of 50% to 75% perma nent
red uction of fol l i c u l a r pa p u l es/pust u l es .
S k i n types I V to V I
- The long-pu lsed 1 , 064-n m N d : YAG l a s e r is the treat
ment of choice in s k i n p h ototypes IV to V I . It is safe
a n d effective . Long pu lse d u rations a re necessa ry
fo r epidermal p rotection . P u lse d u rations of 30 to
1 00 ms a re genera lly recom m ended . O pti m a l flue nces
ra nge from 20 to 40 J/cm 2 . Treatment is performed
with nonoverla p p i ng p u lses uti l i z i n g coo l i ng to the

epidermis via c ryoge n , contact coo l i ng, or gel .
- N ewer ge neration d iode lasers with longer p u lse
d u rations up to 400 ms can a lso be util ized with ca u
tion i n d a rker s k i n types.
- Typical ly, 5 to 1 0 treatments spaced every 4 to 8 weeks
a re needed for 50% to 75% perma nent red uctio n .

MANAG E M ENT
Ta n ned patients s h o u l d not b e treated with laser h a i r

remova l . O n ce the ta n/i nfl a m mation su bsides, h a i r
remova l can beg i n .
Do not p l u c k or wax h a i r prior t o o r d u ri ng t h e cou rse of

laser h a i r remova l .
Figure 18.3 Etiology of pseudofolliculitis
101
1 02
Patients with u n pigme nted h a i r ( b l o n d , gray, red ) wi l l

not benefit from laser h a i r rem ova l a n d s h o u l d n ot be
treated .
There is the risk of tra nsient a n d long-te rm hyperpig

m entation and hypopigmentatio n . Tra nsient erythema,
sca b b i ng, and risk of sca r formation also exist.
A majority of patients wi l l see 75% i m p rovement. A

sma l l m i n ority w i l l see l ittle or no i m provement .
Futu re m a i ntena nce treatments may be needed .

A s m a l l m i nority of patients w i l l experience a paradoxi
cal i n c rease i n hair growth, pa rt i c u l a rly fe ma les of
Med iterra nean descent.
Treatment may n ot benefit p reexisting hyperpigme nta

tion and wi l l n ot i m p rove sca rs.
I t is i m porta nt to i nform patients that side effects a re

often delayed in s k i n p hototypes IV to VI a n d may not
be o bserved for 1 to 2 weeks after treatment. Test s pot
is a dvised fo r these patients ( Figs . 1 8 . 3 a n d 1 8 . 4 ) .
B I B L I OG RAPHY
Battle EF J r, H o b bs LM . Laser-assisted h a i r remova l for
d a rker s k i n types. Dermatol Ther. 2004; 1 7 (2 ) : 1 77 - 1 83 .
B ridgema n-Shah S . T h e med ical a n d s u rgica l thera py of
pseu d ofo l l i c u l itis barbae. Dermatol Ther. 2004; 1 7 ( 2 ) :
1 58- 163.
Haedersd a l M , Wulf HC. Evi d e nce- based review of ha i r
remova l u s i n g lasers a n d l ight sou rces. J Eur Acad
Dermatol Venereal. 2006;20( 1 ) :9-20.
Kontoes P, Vlachos S , Konsta nti nos M, Anastasia L, M yrta
Figure 18.4 (A) Test spot treatment under chin and on cheek is advised
for darker skin phototypes before treating pseudofolliculitis. (B) Two
weeks after test spot treatment, some hair removal is achieved with no
pigmentary changes
S. H a i r i n d uction after laser-assi sted h a i r re m ova l a n d its

treatment. J Am Acad Dermatol. 2006; 54( 1 ) :64-67.
R oss EV, Cooke L M , Ti m ko AL, Overstreet KA, G ra h a m
B S , Barnette DJ . Treatment o f pse udofo l l i c u l itis ba rbae i n
s k i n types IV, V, a n d V I with a long-pu lsed neodym i u m :
Yttr i u m a l u m i n u m ga rnet laser. J Am Acad Dermatol.
2002 ;47 ( 2 ) : 888-893.
Sect i o n 4: D i so rd e rs of H a i r Fol l i c les
CHAPT E R 1 9
M a l e Patte r n H ai r Loss
M a l e pattern h a i r loss c lassica l ly presents with bite m pora l
IV
II
IVa
II a
Ilia
Va
III
VI
III vertex
VII
h a i r loss that progresses t o t h e loss o f h a i r o n t h e vertex,

fro nta l , a n d te m pora l sca l p . Parieta l a n d occi p ita l h a i rs
a re usually u naffected . It is a no nsca rring forrn of a l o pe
cia that occ u rs in gen etica l l y suscepti ble males. The
gra d u a l involuntary loss of hair d oes cha nge the natura l
fra m e h a i r provides a ro u n d o u r face. T h e gra d u a l loss of
h a i r resulting in an i nvol u nta ry cha nge in a ppea ra nce
c reates varyi ng d egree of emotional a nd psyc hologica l
stress. M a ny men seek treatment fo r m a l e patte rn h a i r
loss because o f u n ha ppi ness with its cosmetic a p pea r
a n ce a n d association with aging.
Incidence: 30% of ma les older than 30 yea rs; more t h a n
h a l f of m a l es o l d e r than 50 yea rs .
Age: begi ns after p u be rty.

Precipitating factors: polygenetic i n herited pred is positio n .
N o d iagnostic tests exist t o d eterm i ne t h e etio l ogy a n d
natura l progression .
PATH OG E N ES I S
The prec ise pathophysiology rema i n s u n k n own . This
process is bel ieved to res u lt from both a polygenetic
i n h erited suscepti b i l ity as we l l as a nd roge n i c sti m u lati o n .
T h e m ost i m porta nt a n d rogen i n t h i s process is d i hy
d rotestoste ron e .
There is a d i m i n ution i n the size o f affected term i n a l
fo l l i c les that regress t o become vei l u s fo l l icles that even
tua l l y d isa p pea r. There is a n i n c rease i n telogen h a i rs and
a decrease i n a nagen h a i rs .
PHYS I CAL EXAM I NAT I O N AN D

NATU RAL PROG R ES S I O N
Typica l ly, fronta l a n d tem pora l h a i r loss/th i n n i ng is pre
sent first. T h i s beg i ns in pu berty a n d progresses ove r
d ecades. The rate a n d extent of h a i r loss va ries from i n d i
vid u a l t o i n d ivid u a l . S o m e progress t o co m plete ba l d n ess
in early 20s a n d others grad u a l l y t h i n over decades.
I n ma les, the pattern of h a i r loss i s c h a racteristic s u ggest
i n g no other d iagnoses.
Figure 19. 1 Norwood classification of the natural progression of male

pattern hair loss
1 03
1 04
TAB L E 1 9 . 1
M i noxi d i l and Finasteride-The Only Two FDA-Approved Medications for Male Pattern Hair Loss
M ec h a n is m of action
Fi nasteride
M i n oxi d i l
5-a red uctase type II i n h i bitor blocking the conversion of
U n known
testostero ne to d i hyd rotestosterone

Key to success
E m p hasize m a i ntena nce ove r regrowth of h a i r and c o m p l i a n ce

fo r at least 6-8 months to see ben efit
E m p hasize m a i ntena nce over regrowth of

h a i r and com p l i a nce 6-8 months to
see benefit
2% of men expe rience sex u a l d ysfu ncti o n . Revers i b l e with i n
S i d e effects
days i f d iscont i n ued
D ryness and pru ritus of the sca l p . R a re

a l lergic reacti on
N o a l lergic reactions, bl ood m o n itori ng o r d rug i nteractions.

P re m e n o pa use of fe ma les should never h a n d le or take
medicati o n . Women may have some benefit
C l i n ical onset of action
6-8 months
6-8 months
Dose
1 mg q d with o r without food
Two to fou r d rops one to two t i m es d a i ly

to fronta l a n d vertex of sca l p
Ca n d i d ate selection
N o rwood I I- IV
H ighly effective
H igh l y effective
N o rwood IV-V I I
Somewhat effective
Somewhat effective

I n ma les, no laboratory work u p i s typica l l y req u i red .
M E D I CAL TH ERAPY
K ey C o n s u l tat i ve Q u est i o n s
Age of onset
Rate of h a i r loss
Past med ical h istory
Med ications used to date a n d success of thera py
Patient expectation of a ny med ical or s u rgical thera py
F DA-A p p roved M ed i c a l T h e ra py
(Ta b l e
19. 1)
M i noxid i l a n d fi nasteride a re the on ly two medications for

male pattern h a i r loss a p p roved by the U . S . Food & Drug
Ad m i n istration ( F DA).
HAI R TRA N S P LA N TAT I O N

Def i n i t i o n
All patients s h o u l d expect consistently natu ra l a p pea ri ng
tra nspla nted h a i r. Based on the theory of donor d o m i
na nce, h a i r fol l ic l es m a i nta i n t h e i r genetic d esti ny wher
ever they grow on o u r sca l p . H a i r tra nspla nted from the
posterior sca l p will grow fo r as long as it was ge netica l ly
progra m med to grow. For the vast majority of m e n , tra n s
pla nted h a i r wi l l grow for d ecades.
Figure 19.2 Unnatural "pluggy" hairline using 1 0 to 25 hair grafts.
Should never happen in twenty-first century
Sect i o n 4 : D i so rd e rs of H a i r Fol l i c les
1 05
H a i r nat u ra l ly grows in 1 to 4 h a i r fol l i c u l a r b u n d les.

Contem pora ry hair tra nspla ntation uti l izes a la rge n u m
b e r o f 1 t o 4 h a i r fol l i c u l a r gro u p i ngs . The res u lt is consis
tently nat u ra l a p pea r i n g tra nspla nted h a i r fo r men a n d
wo m e n .
THE CON S U LT
K ey Q u est i o n s
H ow long h ave you n oticed h a i r loss?
Rate of h a i r loss?
W h i c h m e d i cations, wheth er p rescri ption or a lternative,
Expectations?
have been tried and for h ow long?
P h ys i c a l Exa m i n at i o n
N o rwood stage ( F ig. 1 9 . 1 )
Donor density
Ca l i ber of h a i r fol l i c les

- I d ea l c a n d i d ate : h igh donor density, t h i c k ca l i be r h a i r
fo l l icle, rea l i stic expectation ( Figs . 1 9 . 3 a n d 1 9 .4)
- Poor ca n d idate: poor donor den sity, below average
h a i r ca l i ber, u n rea l istic ex pectations
Key P o i nts to E m p h a s i ze B efore H a i r
Tra n s p l a ntat i o n
Figure 19.3 Realistic expectations using 1 to 4 hair grafts. Before
N et perce ived dens ity fro m a h a i r tra ns p l a nt
the
Norwood V
n u m be r of hair fol l icles tra nspla nted-{)ngo i ng hair loss.
F i n e hair fol l icles will c reate th i n natu ra l coverage , a n d

t h i c k ca l i ber fol l icles wi l l c reate more perceived density.
O ngoi ng h a i r l oss w i l l affect the cosmetic a p pea ra nce of

a tra nspla nt.
Visible donor sca r o r sca rs if h a i r is shaved o r c l osely

c rop ped i n poste rior sca l p .
L i m ited d o n o r s u pply!
Key to success: phys i c i a n and pati ent have s i m i l a r
expectations o f what t h e proced u re w i l l a n d wi l l not

ach ieve over the short ( 1-3 yea rs) and
long term
( 1 0-20 yea rs ) .
M ed i c at i o n a n d Tra n s p l a n tat i o n
Med ication to m a i nta i n existi ng h a i r wi l l maxim ize the
density from a tra ns p l a nt but med ications should a l ways
rema i n elective . H a i r l i ne design a n d d istri bution of rec i pi
ent sites should a lways ass u m e ongoin g hair loss.
Figure 19.4 Realistic expectations using 1 to 4 hair grafts. A fter 1 , 1 00
1 to 4 hair grafts
1 06
S U RG I CAL PROCED U R E
P reo p e rat i ve I n st r u ct i o n s
N o s pecific b l ood tests
Medical clearance if a p p ropriate
Ph otogra phs
I nformed written consent sent to the patient for review

at least 1 week before the p roced u re
Day of P roced u re
Written consent with postoperative i nstructions reviewed
I ntrod uce h a i r tra ns p l a nt tea m
Review p roced u re a n d goa ls with patient
Figure 19.5 Trim donor region with moustache trimmer, and tape hair up
so donor suture will not be visible in the postoperative period
D o n o r R eg i o n -O n l y L i m i t i n g Factor
i n H a i r Tra n s p l a ntat i o n ( F i g s .
and
1 9 . 1 0)
19.5
An esth esia in donor region
1 % Lidoca i n e w i t h 1 : 200, 000 e p i n e p h r i n e
30 t o 6 0 cc sa l i n e
Sa l i ne i n d o n o r region p rovides
a nesthesia
hemostasis
less tra nsection of hair fol l i c les
less l i kely to tra nsect the occi pita l a rteries
Donor harvesting tec h ni ques (Ta b l es 1 9. 2

a n d 1 9.3)
El l i ptica l str i p h a rvesting: >95% of patients
Fol l i c u l a r u n it extractio n : <5% of patients ( Fig. 1 9 . 1 1 )
Figure 19.6 Patient in prone position
E l l i ptical stri p harvesting
Use ski n hooks to retract when re movi ng d o n o r e l l i pse

to m i n i m ize tra nsactio n of h a i r fol l ic les ( Fig. 1 9 . 1 2 )
TAB LE 1 9 . 2 Advantages and Disadva ntages of

Fol l icular Unit Extraction (FUE)
Adva ntage
Disadva n tage
-No l i nea r donor scar
-More t i m e consu m i ng
-Ofte n m i n i ma l ly visi ble
-More F U E sess ions to
sca rri ng i n tri m med
eq u a l d e nsity from
donor region ; adva n tage
e l l i pse
for patients with short

h a i rstyle
-Can be used for patients
with exte ns ive sca rri ng
-G reater tra nsection of

h a i r fo l l ic l es with
i n posterior sca l p from
potenti a l decreased
m u ltiple p revious s u rge ries
yield
Figure 1 9 . 7 Donor strip should not be more than 1 em wide. Strips
>1 em have an increased risk of creating a hypertrophic scar
TAB L E 1 9 . 3
Fol l i c u l a r u n it extraction
M i n i m a l tra nsection of donor h a i r
Yes
No
N u m ber o f 1-4 grafts safely ha rvested p e r proced u re
1 , 500-2, 000
200-500
Ti me to ha rvest donor h a i r
1 5-20 m i n
1-2 h
Visi b l e d o n o r sca r with h a i r length > 1 e m
No
No
Visi b l e d o n o r sca r with h a i r length <0 . 5 e m
Yes
Likely not
Overa l l percentage o f cases used
>95%
<5%
U nd e rm i n i ng donor region ra rely n ecessa ry
Dou ble layer of sutu res ra rely necessa ry
Sutures or sta p l es to close in si ngle layer
Sutu res or sta p l es out in 7 to 1 0 d ays
Keys to success in donor harvesting of e l l i pse
Donor str i p width <1 em
After l idoca i ne , add sa l i n e to donor region to provide

hemostasis, a nesthesia , a n d red uce tra nsection of h a i r
fo l l i c les
S k i n h oo ks to retra ct tissue w h i l e re moving e l l i pse
Do not rush!
Fo l l i c u l a r u n i t ext ract i o n
Defi n ition: re m ova l of fo l l ic u l a r gro u p i ngs from the poste
rior sca l p u s i ng 1 - m m p u nches.
Exce l lent treatment o ption for patients' ve ry short
donor h a i r that do want a visi ble donor sca r a n d for
patients with severely depleted donor regions from m u lti
p l e previous hair transpla nts .
G ra ft c reat i o n
A l l grafts should m i m ic the natu ra l 1 to 4 fol l i c u l a r b u n
d les t h a t natura l ly occ u r o n the sca l p .
Keys t o success i n creating 1 to 4 h a i r grafts

Good ergo n o m i cs a n d i n stru ments. Prep blades a n d
# 1 0 blades a re often used t o sepa rate fol l ic u l a r gro u p
i ngs from the donor e l l i pse. Magn ificatio n can a i d the
process i n sepa rating fol l ic u l a r gro u p i ngs from the
donor e l l i pse.
Do not a l low grafts to d ry. They m ust a l ways be i n

c h i l led sa l i n e .
1 07
Donor Harvesting Tec hniques: E l l i ptical Strip Harvesting Versus Fol l i c u l a r Unit Extraction
E l l i pse
We l l -tra i ned staff o f th ree t o fou r s u rgical assista nts .
Staff tra i n i ng
Enth usiasm/i nterest in proced u re
Patie nce; 6 to 1 2 months for an assista nt to learn to

c reate 200 to 300 grafts per h o u r
Figure 19.8 Closing donor region with staples
1 08
A n est h es i a i n R ec i p i e n t R eg i o n
Field block a n d loca l i nfi ltration with 1 % l idoca i n e with

1 : 200,000 e p i n e p h r i n e and
0.25%
M a rca i n e with
1 : 200,000 e p i n e p h r i n e .
S u p raorbita l a n d s u p ratroc h l ea r b l o c k is o ptio n a l .
Su perfi c i a l i nfi ltration i n d e r m i s , n o t su bc uta neous tis

sue, will c reate good hemostasis.
H a i r l i n e Des i g n
Defi n ition: a h a i r l i n e is a n i rregu l a r, i l l-defi ned tra nsition
zone from skin to i n c reas i n g dens ity of term i n a l pig
mented hair fol l icles.
Always consider the fronta l , te m pora l , and poste rior

h a i r l i nes.
The fronta l and poste rior h a i r l i nes should be i rregu l a r

a n d i n t h e sa me pla i n . T h i s m e a n s genera l ly avoid i ng
tra nspla nting
the
ve rtex,
partic u l a rly
in
you nge r
patients . The reason is the ever-expa n d i ng ba l d i ng s pot

in the ve rtex.
- When design i n g a fronta l tem poral h a i r l i ne, a l ways
assume p rogression of h a i r loss to N orwood stage V.
- Fronta l h a i r l i n e at least 9 em a bove gla be l l a .
- Be conservative .
R ec i p i e nt S i te C reat i o n ( F i g .
1 9 . 1 8)
Com m o n l y used need les to create rec i p ient sites a re
# 1 9 or #20 ga uge need le

- Magn ification to red uce tra nsaction of existing pigmented term i n a l h a i r
S P 8 8 t o 90 ga uge n eed le
0 . 5- to 1 . 0-m m cag need l e
Figure 19.9 A 2-cm-wide donor scar from 1 . 5-cm-wide ellipse
K e y p o i nts
D istri b ute rec i pient sites ra n d o m ly a n d c l osely together

a n d i n a d istri bution that will a p pea r nat u ra l if all hair is
lost i n the fro nta l two-t h i rds of the sca l p
Avo i d tra u ma t o existi ng h a i r fol l i c l es

- Magn ification in rec i pient sites
- Fol low the natura l 1 5- to 30-degree a ngle of h a i r fol l i c l es i n t h e fronta l two-th i rds o f t h e sca l p
Excellent he mostasis using 1 : 1 00,000 e p i n e p h r i n e

1 0 to 30 sites/cm 2 d e pend i ng on the a mo u nt o f existi ng
hair and a rea ( c m 2 ) to d i stri b ute grafts
G ra ft P l a c e m e n t ( F i g .
1 9 . 1 9)
Two or th ree s u rgical assista nts place the grafts i nto

reci pient sites u s i n g m i c rovasc u l a r forceps.
Figure 1 9 . 1 0 Follicular unit extraction using 1 -mm sites
1 09
Keys to success
H a n d l e grafts i n perifo l l i c u l a r tissue-never crush h a i r

fo l l i c les
Kee p a l l grafts in c h i l led sa l i n e-neve r a l low a graft to

desiccate
Staff tra i n i ng
Excellent h e mostasis using 1 : 1 00,000 e p i n e p h r i n e
Patience
Posto p e rat i ve P e r i od
Overnight d ress i ng t o protect grafts .

Ora l steroids 40 mg qd for 3 to 4 days to red uce fronta l
edema .
Tylenol #3, one ta b l et q 4 to 6 h o u rs for 1 day P R N .

There s h o u l d b e n o d iscomfort morn i n g afte r su rgery.
S h ower in morn i n g afte r s u rgery. Avoid tra u ma to tra ns

pla nted zo n e .
Figure 1 9. 1 1 Skin hooks to aid in removal of donor ellipse
- Perifo l l i c u l a r hemorrhagic c rusti ng rem a i ns 5 t o 8 days

- The vast majority of patients retu rn to work 2 to
3 days after the proced u re
N o r m a l a ctivities i m med iately. No heavy exe rcise for

5 to 7 days.
Topica l a nti biotic to donor wou n d for 7 to 1 0 days.
Sutu res or sta p l es rem oved 7 to 1 0 days after su rgery.
Co m m o n Post H a i r Tra n s p l a n t S i d e
Effects
Fronta l edema lasting 3 to 4 days posto peratively
Pru ritus in donor a n d/or rec i pient zone
Tra nsitory fol l i c u l itis
Te logen effl uvi u m i n patients with d iffuse t h i n n i ng
Figure 1 9 . 1 2 Donor ellipse with natural follicular bundles
R a re S i d e Effects
Hypertro p h i c sca rring i n donor region i n e l l i pses less

t h a n 1 em
Persistent n u m bness or d i sco mfort in donor or rec i p i ent zone
Cystic nod u les
Poor q u a l ity growth of tra ns p la nted h a i r
I nfection
Posts u rg i c a l Pe r i od after
S u t u res/Sta p l es R e m oved
Resume fu l l s ports 1 wee k after s u rgery
Dye h a i r 2 weeks after su rgery
Figure 1 9 . 1 3 Magnification helps visualize 1 to 4 hair bundles and mini
mize transection when separating with surgical prep blades
1 10
TAB L E 1 9 . 4
Treatment Options for Corrective H a i r Transplant Surgery
Treatment o ption
Adva ntage
Disadva n tage
Ad d i ng 1-3 h a i r grafts
Dra matica l ly soften h a i r l i n e and a d d further density to
Donor region may be depleted
between existi ng la rge
existing " pl ugs"
1 0-25 h a i r " pl ugs"

Pati ent not psyc hologica l ly a b l e to go
t h rough a nother h a i r tra ns p l a nt p roced u re
Patient req u esti ng "I wo u l d rather j u st be ba l d " Status
Exc ision of grafts
Potentia l visible e rythem atous sca r
quo a nte
for wee ks to months

Permanent sca r a n d/or d ysc h ro m i a
Laser h a i r remova l
N o n i nvasive
40-80% i m prove ment afte r-five to
Com bi nation
Red u ce " pl uggy" grafts
A s a bove
seven does not work on b l a n d h a i r

Majority of patients util ize a c o m b i nation of the a bove
for o pti m a l res u lts
I n itial fo l lowu p 8 to 1 2 months after su rgery
Fu l l cosmetic res u lt 9 to 15 months afte r s u rgery
Correct i ve H a i r Tra n s p l a n t S u rgery
(Ta b l e
1 9 .4)
For the majority o f m e n , corrective h a i r tra nsplant su rgery

is cosmetic a l l y a n d emotiona l ly m a n d atory, not elective .
Consult
Key q uestio n : what is yo u r c h ief concern a n d goa l for
poss i b l e corrective su rgery?
B I B L I OG RAPHY
Avra m M R . Polarized l ight-em itting d iode magn ification
fo r o pti m a l rec i pient site c reation d u ri n g hair transpla nt.
Dermatol Surg. 2005 ;3 1 (9 pt 1 ) : 1 1 24- 1 1 2 7 . Discussion
1 127.
Epste i n J S . The treatment o f fe male pattern h a i r loss a n d
other a p p l ications o f s u rgica l h a i r restoration i n women .
Facial Plast Surg Clin NorthAm. 2004; 1 2 ( 2 ) :24 1 -247 .
H a rris J A . Fol l ic u l a r u n it tra nsplantation : Dissecting a n d
p l a nting tec h n i q ues. Facial Plast Surg C!in North Am.
2004; 1 2 ( 2 ) : 225-23 2 .
Leavitt M, Pe rez- Meza D, Rao NA, et a l . Effects of finas
te ride
(1
mg)
on
h a i r tra nspla nt.
Dermatol Surg.
2005 ;3 1 ( 10) : 1 268- 1 276. Disc ussion 1276.

Li m m e r B L. E l l i ptical donor ste reosco pica l ly assisted
m icrografti n g as an a p p roach to further refi nement in ha i r
tra nspla ntation . J Dermatol Surg Oneal. 1994;20( 1 2 ) :
789-793 .
Figure 1 9 . 14 1 to 4 hair grafts
Figure 19. 1 5 1 to 4 hair grafts in chilled saline
Figure 1 9 . 1 6 Natural irregular frontal hairline
111
1 12
Figure 1 9 . 1 7 Magnification with polarized ligh t to create recipient sites
Figure 1 9 . 1 8 Placing 1 to 4 hair grafts with microvascular forceps
Figure 1 9 . 1 9 Preoperative Norwood Ill
1 13
1 14
Figure 19.20 A fter 2, 400 1 to 4 hair grafts
Figure 1 9 . 2 1 Preoperative Norwood Ill to I V
Figure 19.22 A fter 900 1 to 4 hair grafts
Figure 1 9.23 Preoperative Norwood I V to V
1 15
1 16
Figure 19.24 A fter 2, 030 1 to 4 hair grafts
Figure 19.25 Preoperative Norwood I V to V
Figure 19.26 A fter 1 , 000 1 to 4 hair grafts
Figure 19.27 Straight "pluggy" frontal hairline
1 17
1 18
Figure 19.28 A fter 650 1 to 3 hair grafts. Note improvement. Not com
pletely natural hairline
Figure 19.29 Straight "pluggy" hairline. Depressed scars
Figure 19.30 A fter 1 , 000 1 to 3 grafts
Figure 1 9 . 3 1 Preoperative Norwood IV to V
Figure 19.32 A fter an additional 700 hair grafts (second surgery)
1 19
1 20
Figure 1 9.33 Straight "pluggy" hairline
Figure 1 9 .34 A fter 500 1 to 3 hair grafts
I l l ustration 19. 1 Obsolete 4-mm "pluggy" grafts
S i te of
donor st r i p
E l l i p t i c a l d o n o r str i p
from poste rior sca l p
I l l ustration 19.2 Elliptical donor strip from posterior scalp
121
1 22
I l l ustration 19.3 1 to 3 hair follicular groupings within donor strip
I l l ustration 19.4 Versus 1 0 to 20 hair "pluggy" graft. Natural 1 to 3 fol
licular groupings
1 23
I l l ustration 1 9 . 5 Straight artificial "pluggy" hairline using 1 0 to 20 hair
grafts
I l l ustration 1 9 . 6 Recipient sites created at 1 5- to 45-degree angles not
90 degrees
1 24
I l l ustration 1 9 . 7 Corrective hair transplant adding 1 to 3 hair grafts
between and in front of "p/uggy" grafts
1 25
I l l ustration 19.8 Adding 1 to 3 hair grafts between large "pluggy" grafts
to improve cosmetic appearance
1 26
CHAPT E R 2 0
Fe m ale Patte rn H air Loss
Female patte rn h a i r loss p resents with a d iffuse th i n n i ng

of the m i d -sca l p with a cha racte ristic m a i ntenance of the
fronta l h a i r l i n e . I t may a lso p resent with the typical bitem
pora l h a i r recession seen i n male pattern h a i r loss.
Pa rieta l
and
occi pita l
h a i rs a re
usua l l y u naffected .
Female patte rn h a i r loss is pa rtic u larly p ro b l e m atic for

women for whom h a i r loss p rod u ces greater soc i a l a n d
self-esteem d ifficu lties t h a n for men with m a l e pattern
h a i r loss ( Figs. 20. 1 and 20. 2 ) .
EPI O E M I O LOGY
Incidence: nea rly 30% of fe ma les older than 30 yea rs .
Age: begins in second a n d in t h i rd decade.
Race: none reported i n fe ma les.
Precipitating factors: polygenetic i n h erited pred isposition
is p rese nt. It is n ot o n e pa rent's fa u lt!
Figure 20. 1 Preoperative L udwig Ill
PATHOG E N ES I S
There i s a d i m i n ution i n the size of affected term i n a l fol l i
c l es that regress t o beco me vei l us fo l l ic les that eventua l ly
d isa p pea r. There is an i n c rease in telogen h a i rs a n d a
decrease in a nagen h a i rs . Hormones play a rol e but the
exact path o physio l ogy is u n certa i n .
COU RS E
Begi ns i n twenties a n d p rogresses over decades. T h e rate
a n d extent of h a i r loss va ries.
D u ration o f h a i r loss
Menstrual h istory
Medication h i story
N utrition, d i eti ng, weight loss
H a i r ca re-blea c h i ng, b ra i d i ng
Fa m i ly h i story of h a i r loss
H istory of major u n expected e motional or p hysi cal

stress
Medical h istory, that is, thyroid d isease, i ro n d eficiency

N onsca rring a l o pecia-no erythem a , sca le, atro phy i n
s k i n with fe male pattern h a i r loss
Figure 20.2 After 900 1 to 4 hair grafts
Sect i o n 4 : D i so rd e rs of H a i r Fol l i c les
1 27
D I FFERENTIAL D I AG N OS I S OF FEMALE
PATTE R N HAI R LOSS
Te logen effl uvi u m
Poor h a i r sty l i ng-c h e m icals, excessive dying
I ron d efi ciency, thyro i d d i sease, c h ro n i c med ica l d is-
Med ication -related hair loss
ease, polycystic or oth er en docrine i m ba l a nce
Poor n utriti o n , weight loss
Tri c h oti lloma n ia
D iffuse a l o pecia a reata-ra re
KEY QU EST I O N S TO D I ST I N G U I S H
H ow long has you r h a i r loss persisted?
Changes in d iet or weight loss over past 6 to 12 months?
Any n ew presc ri pti o n , over-the-cou nter (OTCJ medica

tions, or s u pplements?
Any major su rgery or u n us u a l e m otional stress?
Any cha nge in h a i r ca re? Ch em icals to h a i r?
KEY PO I NTS
Patients may have a com bi nation of eti ologies .

If there is a ny q u estion i ng afte r h i story a n d physical
exa m i nati o n , sca l p bio psy is i n d icated .
Thyroid function tests, i ron stud ies, a nti n uclear a nti
Figure 20.3 Preoperative temporal scar-chief complaint: "I cannot wear

my hair back"
body ( A N A l , ra pid plasma reagin ( R P R J .
Referra l t o gynecologist a n d/or en docri nologist if a p p ro

priate on h i sto ry a n d/or exa m i nation .
M E D I CAL TH ERAPY
To pica l m i noxi d i l (2% and 5 % solution) a re the o n ly med
ications fo r fem a l e patte rn ha i r loss a pp roved by the U . S .
Food a n d D r u g Ad m i n istration ( F DA ) (Ta ble 20. 1 ) . The
mec h a n ism of action is u n known . It is safe fo r long-term
a p pl icati o n .
TAB L E 20. 1
M inoxi d i l
Mecha n is m o f action
U n known
Onset of action
6-8 months
Side effects
Dryness, pru ritus, "greasy h a i r "
Use with p regna ncy
No
or b reast-feed i ng
5% versus 2 %
5% sl ightly m o re effective b u t
m ore "greasy" sl ight
i n c reased risk of h i rsutism
1 28
M i noxi d i l 5% foa m is only a p proved for men but often

is used by wom e n . The reason is d ue to m i noxi d i l in s m a l l
pe rcentage o f wom e n , i n d u c i n g u nwa nted pigmented
term i n a l
h a i rs .
The
med icatio n - i n d u ced
h i rsutism
is
revers i b l e if the med ication is d iscont i n u ed .

M a n y women who d o get m i n oxi d i l - i n d uced h i rsutism
a lso get excellent growth of hair on their sca l p a nd opt to
conti n u e the m e d i cation and use lasers to re move the
u nwa nted hair on the face.
The foa m creates much less i rritation o n the sca l p
m a k i n g i t m uc h easier t o b e com p l i a nt tha n t h e sol utio n .
KEYS TO S U CCESS
Com pliance: m ust u s e for 6 t o 8 m o n t h s t o prod uce t h e

d esi red effect.
Em phasize mai ntenance over regrowth of h a i r. M i noxi d i l
Figure 20.5 Preoperative Ludwig I to II
stops h a i r loss i n t h e majority o f patients a n d grows bac k

pigmented term i n a l h a i r i n a m i nority of patients.
N O N - FDA APPROVED M E D I CAT I O N S
Fi nasteride, a type I I 5-a red uctase i n h i b itor, i s con

tra i nd i cated i n women of c h i l d bea ring age. Stu d i es
demonstrate
some
efficacy
in
postmenopausa l
fe males.
Oral a n d roge n receptor a ntago n i sts s u ch as s p i ronolac

tone and cyproterone a cetate a re other a lternatives with
l i m ited p roof of efficacy i n both p re m e n o pa usa l a n d
postmenopausal fema les. They a re contra i n d i cated i n
p regna nt patients, given t h e risk o f p rod u c i n g sexual
d efects i n a male fetus. T h ey shou l d , therefore , be d is
conti n u ed months prior to a pl a n ned p regnancy.
S U RG I CAL
C o n s u l tat i o n
C h i ef com pla i nt: "see t h rough" fronta l h a i r l i n e , " l i m ited
sty l i n g o ptions, " "fea r of windy days . "
K e y Q u est i o n s
H ow long has h a i r loss persisted on?
Medical work u p to d ate
Med ication used to treat h a i r loss a n d for how long
Patie nt's c h ief cosmetic concern
Patie nt's goa l fo r hair tra nspla ntation
Donor density
Ca l i be r of h a i r l oss
Exte nt of h a i r l oss
1 29
KEY PO I NTS
Em phasize u n pred icta ble donor density. The tra ns

p l a nted h a i r w i l l grow for as long as it was gen etica l ly
p rogra m m ed to grow.
I nc reased risk of posts u rgica l te logen effl uvi u m .

Ongoing h a i r loss wi l l affect perce ived den sity o f h a i r
tra nspla nt.
S U RG I CAL APPROACH :
FEMALE VERS U S MALE HAI R
TRA N S P LANTAT I O N (Table 2 0 . 2)
H a i r tra nspla ntation for men a n d wom e n util ize the same
donor ha rvesting tec h n i q u es, graft c reation , i n stru ments,
a n esthes i a , and p re- and postsu rge ry cou rse .
Figure 20.7 Preoperative L udwig I to II.
FE MALE S U RG I CAL PLAN N I NG

Tra nsplant fronta l one-t h i rd of sca l p on ly! Th i s wi l l
add ress c h i ef com p l a i n t a n d red uce the risk o f telogen
effl uvi u m .
C h i ef com p l a i nt: "see t h rough " fronta l h a i r l i n e
Sta ble fronta l , tempora l , a n d posterior h a i r l i nes
D iffuse th i n n i n g-no ba l d spots
R isk of telogen effl uvi u m

- U n pred icta ble long-te rm growth o f h a i r from the
donor region
TAB L E 20.2
Surgica l Approach : Female Versus M a l e Hair Transplantation

Male
Female
Donor density
M ore pred i cta b l e
Less p redicta b l e long term
H a i rl i ne design
U nsta ble a n d reced i n g fronta l tem pora l a n d poste rior

h a i r- l i n e
N eed t o design h a i r tra ns p l a nt f o r lo ng-term natu ra l
cosmetic a p pea ra nce ( > 1 0 yea rs)
Sta ble h a i r l i nes. Major cosmetic adva n tage

ove r men for s u rgica l pla n n i ng
Ca l i be r of ha i r
Va r i a b l e between i n d ivi d u a l s
Va r i a b l e between i n d ivid ua l s
M ed ication use with h a i r
If existi ng h a i r rem a i ns, med ication w i l l add dens ity
A l l women s h o u l d u s e m i n oxi d i l t o h e l p m a i nta i n
tra nspla ntation
by l i m iti ng fu rther h a i r loss

Med ication a lways rema i n s elective
N eed to d esign h a i r tra nsplant ass u m i ng ongoi ng
hair loss and reced i n g h a i r l i nes
Expectations
Key to su ccess
existi ng h a i r a n d decrease risk o f postsu rgery

te logen effl uvi u m
Density = n u m be r of h a i r fol l i c l es tra nspla nted
ongoi ng h a i r loss
Key to su ccess
1 30
P reo p e rat i ve I n st r u ct i o n s
- H u m a n c h o ri o n i c gonadotro p i n ( B- H C G ) i n a p p ropriate patient
Consent
Ph otos
Medical cleara n ce if a p p ro p riate
Ok to dye h a i r u p u nt i l day before p roced u re
P roced u re
I ntrod uce staff
Review s u rgica l plan
Review posts u rgica l care, a n esthes i a ,
i n stru m e nts,
donor ha rvesti ng, graft c reati o n , grafts placement a re

the sa me as for m e n
Posto p e rat i ve I n st r u ct i o n s
Figure 20.8 A fter 750 1 to 3 hair grafts.
Overnight d ressi ng to p rotect grafts a s they hea l .

Resume regula r a ctivities. Light exercise 2 t o 3 days
after
su rgery.
Full
exercise
when
sta ples/sutu res
removed 7 to 10 days posto peratively.
If any d iscomfo rt o r pa i n , ta ke Tylenol #3 with food q 4

to 6 h o u rs . Fifty percent of patients ta ke no pa i n med
ication and the other 50% take one or two ta blets . If a
patient has a ny d iscomfort or pa i n after the day of
su rgery, they s h o u l d co ntact thei r p hysicia n .
P red n isone 4 0 mg qd for 3 t o 4 d ays t o p revent fronta l

edema . If a patient can not or w i l l not ta ke p red n isone,
ice forehead for 1 0 m i n utes every 30 m i n utes over the
d ressin g for the fi rst afternoon/even i n g of su rgery to
red uce
but
n ot
e l i m i nate
edema .
Edema
begins
24 h o u rs after su rgery, pea ks 72 h o u rs postsu rgery,

a n d d i sa p pea rs 5 to 6 days postsu rgery. R a re perior
bita l ecchymoses.
The m o r n i n g after s u rgery the d ressing is rem oved . A l l

patients a re encou raged to shower to h e l p red uce post
s u rge ry h e morrhagic crusti ng. Patients s h o u l d NOT
pick or ru b scabs; t h i s may perma n ently d a m age trans
pla nted h a i r.
After shower, blow d ry with wa rm not h ot a i r on low
Apply topical a nti biotic or Aq u a p h o r to donor region
power.
twice daily for 7 days.
Resume m i noxi d i l 48 to 72 h o u rs post s u rgery.
Posto p e rat i ve Pe r i od
Conti n u e m i noxi d i l one to two t i m es d a i ly.
Telogen effl uvi u m may beg i n 2 to 3 weeks after su rgery

a n d conti n u e for 2 to 3 months.
If te logen effl uvi u m occ u rs, h a i r density wi l l decrease

but w i l l ra rely be cosmeti c a l l y n oticea b l e .
I I
Fema le
I l l
Ca n d y e h a i r 2 weeks a ft e r su rgery.
I n itial fol l ow u p 9 to 12 months after s u rgery a n d then
every 3 months u ntil 1 5 mo nths when fi n a l density from
the proced u re w i l l a p pea r.
KEYS TO S UCCESS W I T H FEMALE

H A I R TRA N S P LA N TAT I O N
Male
Em phasize ongo i n g h a i r loss wi l l affect long-term den

sity of h a i r tra ns p l a nt. The net perceived density of the
I I
hair tra ns p l a n t = n u m ber of hair fol l icles tra nspla nted

ongoi ng h a i r loss .
Patie nts with t h i c k ca l i be r h a i r w i l l a p pea r to have more

h a i r than a patient with a n eq u a l n u m ber of fine h a i r fol
l icles. The sa me effect w i l l occ u r with a h a i r tra ns p l a nt.
Discuss the risk of posts u rgica l telogen effl uvi u m .

M i noxid i l wi l l hel p red uce not e l i m i nate t h e risk o f te lo
ge n effl uvi u m and h e l p slow or sto p ongo i n g h a i r loss
for the majority of patie nts .
l l l
1 1 1
e r te x
U n p red icta b l e futu re loss of d o n o r h a i r. Tra nspla nted

h a i r w i l l grow for as long as it was geneti cally p ro
gra m med .
L i m i t the majority of tra nspla nted grafts to frontal one

t h i rd of sca l p for maxi m u m cosmetic i m pact.
We l l -tra i ned staff.
HAI R TRA N S P LA N TAT I O N TO COR R ECT

ALT E R E D T E M PORAL HAI R L I N E FROM
L I FT I N G PROCEDU R E
After fe m a l e patte rn h a i r l oss, tra nsplanting to correct
sca rs left from l ifting p roced u res s u ch as facel ifts a n d
b rowl ifts a re the m ost common reaso ns for h a i r tra ns
p l a ntation in wom e n .
I I
CH I E F CO M P LAI NT ( Figs . 20.3 AN D

2 0 . 4)
" I can not wea r my h a i r u p or bac k . "
CON S U LT ( Figs. 2 0 . 5-2 0 . 8)

K ey Po i n ts
After h a i r loss fol l owi ng a l i ft, wa it at least 12 months

before considering su rgery.
The loss may be a te logen effl uvi u m a n d the h a i r may

grow back o n its own .
I l l ustration 20. 1 Female versus male pattern hair loss
131
1 32
H a i r growth in sca r tissue is u n pred i cta b l e . The majority

of patie nts have excellent growth but a s ma l l m i nority
do not.
Em phasize greate r risk of fronta l and potenti a l ly perior

bita l ede m a . It is not med ica l ly concern i ng, but may
i m pact
postoperative cosmetic a ppea ra nce of the
patient.
P roced u re
P reo perative, i ntrao perative, a n d posto perative med ica
tion , tec h n iq ue, and wo u n d ca re a re the sa me fo r male
and fe m a l e hair tra nspla ntati o n . When creat in g rec i pient
sites, fo l l ow the natu ra l d i rection of hair growth i n the
te m po ra l regio n .
K eys to S u cc ess
Wa it at least 12 months after loss before considering

su rgery.
Fol l ow the nat u ra l a ngle of h a i r in the tem po ra l regio n ,

t h a t is, 1 5-degree a ngle pointing d own towa rd the
neck.
With a ppro priate patient sel ecti o n , there is h igh patient

satisfaction .
B I B L I OG RAPHY
Avra m M R . Accu rately com m u n icating t h e extent o f a
h a i r tra nsplant proced u re . A proposa l of a fol l ic u l a r- based
c lassification scheme. Dermatol Surg. 1997;23(9 ) :8 1 7818.
Avra m M R . Pola rized l ight-em itting d iode magn ifi cation
fo r o pti m a l rec i pient site c reation d u ri n g hair tra n splant.
Dermatol Surg. 2005 ; 3 1 ( 9 pt 1 ) : 1 1 24- 1 1 2 7 . Discussion
1 127.
Avra m M R , C o l e J P, G a n d e l m a n M , e t a l . The potentia l
ro le of m i noxid i l i n the h a i r tra nspla ntation setti ng.
Dermatol Surg. 2002 ;28( 1 0 ) : 894-900. Discussion 900 .
Epste i n J S . The treatment of fe male pattern h a i r l oss a n d
other a p pl ications o f s u rgica l h a i r restoration i n wome n .
Facial Plast Surg Clin NorthAm. 2004; 1 2 ( 2 ) : 24 1 -247 .
H a rris J A . Fol l ic u l a r u n it tra nsplantation : Dissecti ng a n d
p l a nting tec h n i q ues. Facial Plast Surg Clin North Am.
2004; 1 2 ( 2 ) : 225-23 2 .
Leavitt M , Perez- M eza D , Rao NA, Ba rusco M , Ka ufm a n
K D , Z i e r i n g C . Effects o f finasteride ( l m g ) on h a i r
tra nsplant.
Dermatol
Surg.
2005;3 1 ( 1 0 ) : 1 268- 1 276.
Discussion 1 276.
Limmer B L. E l l i ptica l d o n o r ste reosco pica l ly assisted
m ic rografti n g as an a p p roach to f u rther refi nement in h a i r
tra nspla ntation . J Dermatol Surg Oneal. 1 994;20( 1 2 ) :
789-793.
CHAPT E R 2 1
Low Leve l Light The rapy ( L L LT) a nd H air Loss
Low level l ight laser thera py ( LLLT) has been used to treat
a va riety of medical d isorders from u l ce rs to m uscu
loskeleta l d isord ers . In 200 7 , a low leve l l ight d evice was
a p proved by the U . S . Food a n d Drug Ad m i n istration
( FDA) to treat male patte rn hair loss ( Fig. 2 1 . 1 ; H a i rmax,
Boca Rato n , Flori d a ) . The laser co m b is a h a n d h e l d
d evice t h a t was a p p roved as a device w h i c h has a d i ffe r
ent sta n d a rd for FDA a pprova l than a medication . The
d evice is sold over the cou nter without phys i c i a n p re
scri ption o r physi c i a n mon itoring. There a re various other
m a n u factu rers of l ight thera py devices that a re sold to
physicia ns' offi ces that a re not h a n d h e l d , s u ch as the
S u n etics
d evice
( Figs.
2 1 .2
and
2 1 .3 ;
S u netics
I nternationa l , Las Vegas NV) .
Figure 2 1 . 1 Hand held LLLT device (hairmax lasecomb Boca Raton,
Florida)
M ECHAN I S M OF ACT I O N-U N KNOWN
Ca n d idate selection-a l l s k i n types . A l l h a i r colors .

M ost effective at ea rlier stages o f h a i r loss .
F DA
a p proved for male pattern h a i r loss. M a n y physicians

believe it may have a ro le i n treati ng fe m a l e pattern h a i r
loss.
APPROPR IATE U S E
T h e m a n ufa ct u re r reco m m e n d s slowly c o m b i n g the

device t h roughout the affected a reas of hair more t h a n
1 0 m i n utes three ti m es wee kly ( Fig. 2 1 .4 ) .
There a re n o p u b l ished stu d i es c o m pa r i n g d ifferent fre

q uency a n d time of use of the d evice.
PEARLS OF W I SDOM
A l l patients with h a i r loss s h o u l d be eva l uated b y a der

matologist to esta blish a d iagnosis before considering
a ny medical thera py.
M i noxi d i l for m e n a n d wo men a n d finasteride for m e n

rema i n the medical treatment o f c h o i c e for m a l e a n d
fe male pattern h a i r loss.
LLLT a p pea rs to be safe but long-term i n d ependent

stu d ies confi rm i n g efficacy over placebo have not been
done.
Corporate-fu nded stu d ies have demonstrated some

efficacy i n the treatment of male patte rn hair loss.
LLLT s h o u l d be considered after clear medical fa i l u re

with m i noxi d i l a n d/or fi nasteride.
Figure 2 1 .2 Office based LLLT device (Sunnetics, las Vegas, Nevada)
1 33
1 34
B I B L I OG RAPHY
Avra m M R , Leon a rd RT J r, Epste i n E S , Wi l l ia m s J L,
B a u m a n AJ . The c u rrent ro le of laser/l ight sou rces in the
treatment of male and fem a l e pattern hair loss . J Cosmet
Laser Ther. 2007;9( 1 ) : 27-28. Review.
Avra m M R , R ogers N E. H a i r tra ns p l a ntation fo r m e n . J
Cosmet Laser Ther. 2008; 1 0(3 ) : 1 54- 1 60. R eview.
Avra m M R , R ogers N E . The use of low-level l ight fo r h a i r
growth : P a rt I . J Cosmet Laser Ther. 2009 ; 1 1 ( 2 ) : 1 1 01 1 7.
H odson D S . C u rrent a n d futu re trends i n home laser
d evices. Semin Cutan Med Surg. 2008;27(4): 292-300.
Leavitt M, C h a rles G, H eyma n E, M ichaels D. H a i rMax
LaserCo m b laser p h otothera py d evice i n the treatment of
male a n d rogenetic a l o pec i a : A ra n d o m ized , dou ble
b l i n d , s h a m d evi ce-control led , m u lticentre tria l . Clin Drug
Figure 2 1 .3 Patient undergoing LLLT treatment for male pattern hair loss
lnvestig. 2009;29( 5 ) : 283-292.
in a physician office
Figure 2 1 .4 Patient performing home LLLT treatment
F I VE
D isord e rs of Pigm entation
1 36
CHAPT E R 2 2
Cafe Au Lait M acu l e
Cafe a u lait ma c u les (CALMs) a re benign we l l -demar

cated , l ight b rown ma c u les that typica l ly present in ea rly
c h i ld h ood . The pigmentatio n is typica l ly u n ifo r m . Lesions
may be m u lt i p l e or isolate d . They grow i n p roportion to
the growth of the c h i l d . They a re p resent i n as m a ny as
20% of the po pu lation a n d , ra rely, can be associated with
a h ost of ge nodermatoses.
EPI O E M I O LOGY
Incidence: 10% to 20% of the popu lation
Age: b i rth and early c h i l d hood
Race: more common in Africa n Americans than Caucasians
A
Sex: none
Precipitating factors: m ost commonly these a re ben ign ,
isolated fi n d i ngs in healthy c h i l d re n . M u lt i p l e CALMs can
be associated with genodermatoses s u c h as n e u ro
fi b romatosis,
tu berous
sclerosis,
B loom
synd rom e,
McCu ne-A l b right synd ro m e, R usse l l-Si lver synd rom e,

Watson synd rome, a n d Westerhof syn d rome
PATHOG E N E S I S
U n known .
PATH OLOGY
I n c reased mela n i n in basa l keratinocytes . C l i n ically da rker
lesions conta i n more melanocytes than l ighter ones.

Lesions a re wel l d e m a rcated , u n iformly pigmented mac
u l es that va ry i n color fro m h u es of tan to l ight b rown to
b rown . They ca n present a nywhere on the body but
spare m u cous m e m b ra nes. The i r size can ra nge from a
few m i l l i m eters to over 20 e m .
Posti nfla m m atory hyperpigmentation,
Bec ker's nevus,
melasma, lentigi nes, e p h e l i d es, berloq u e d e rmatitis, a n d

congen ita l nevus.

B i o psy i s not i n d i cated . Ad d itional laboratory work u p may
be a p p ro p riate i n the eve nt of suspicion of a n u n derlying
system i c d i sorder.
Figure 22. 1 (A) Cafe au lait macule on left cheek of a 1 7-year-old female
prior to treatment. (B) Erythema and lightening of cafe au Ia it macule
after one treatment with 694-nm Q-switched ruby laser. (C) Significant
clearing after four treatments with Q-switched ruby laser
Secti o n 5: D i so rd e rs of Pigmenta t i o n
1 37
CO U RS E
T h ey grow i n proporti o n t o t h e growth o f t h e c h i l d . O n c e
a c h i l d has fu l ly grow n , C A L M s d o n ot c h a nge i n size
o r c o l o r. T h e re is n o i n c reased risk of m a l ig n a n t tra ns
fo rmat i o n .
li m e o f onset
Fa i l u re to m eet m i l estones
Ph otosensitivity
I ntel lectual i m pa i rment
H i story of m u lt i p l e fractu res
Centra l nervous system d isord e rs or t u mo rs
Poor growth
Sco l iosis
O p hth a l m ologic i m pa i rment
MANAG E M ENT
CALMs d o not req u i re treatment u n less t h e i r a p pea ra nce
is d isfiguring or d istressi n g to the patient or parents.
M u ltiple lesions may suggest an u n d e rlying syste m i c d is
order. If there is a ny i n d ication of u n derlying system i c
a b normal ities i n t h e setti ng o f m u ltiple CALMs, referra l to
a p propriate pediatric spec i a l i sts is i n d icated . Laser ther
a py is often e m ployed as a treatment. CALMs te n d to be
m ore d iffic u lt to treat tha n other benign pigmented
lesions s u c h as e p h e l ides a nd lentigi nes. They req u i re
m u ltiple treatments a n d com plete reso l ution can be chal
lenging. Recu rrence is com m o n . Cryothera py a n d s u rgi
cal exc ision a re a l ternatives to laser thera py but carry the
risk of pigme nta ry a lterations, poor cosmesis, pa i n , a n d
sca rring.
LAS E R T R EAT M E N T ( Figs. 2 2.1-2 2 . 3)

Prior to treatment, a test s ite s h o u l d be performed to
assess for
efficacy
and
hyperpigme ntation .
CALMs
res pond va riably to m u ltiple modal ities of laser thera py.
Q-switc hed
lasers i n c l u d i n g the freq ue ncy-dou bled
Q-switc hed
N d : YAG
( 532
nm),
Q-switc hed
ru by
( 694 n m ) , a n d the Q-switc hed a l exa n d rite (755 n m ) a re

e m p loyed for selective pigment rem ova l .
It i s i m po rtant t o n ote that treatment with Q
switc hed lasers is not cookbook. Energy setti ngs va ry
fro m laser to laser. They a lso va ry before a n d after
m a i nte nance. T h u s , treatm ent s h o u l d be based on
a c h iev i n g
Figure 22.2 (A) Cafe au fait macule adjoining right lateral commissure of
Without
epidermal
epidermal
white n i ng
white n i ng,
u n I i kely to be effective .
after
the
treatm e nt.
treatment
is
lips. (B) Near clearance after three treatments with a 755-nm Q-switched
a/exandrite laser
1 38
H owever, it is i m porta nt to note that overly aggressive

treatments prod uce pigme nta ry cha nges s u ch as hypo
a n d hyperpigmentatio n .
- I n o n e study,
Q-switched
r u by a n d
fre q u e n cy
d o u b led Q-switc hed N d : YAG treatments , each at

6 J/cm 2 , prod uced va ria b l e responses i n c l u d i ng
Sign ificant l ighte n i ng, which was m ost freq uently
o bse rved
C l ea ra nce with rec u rrence
Da rke n i n g
- Q-switched lasers have a decreased r i s k o f text u ra l
cha nge versus other laser thera p ies, but sti l l ca rry the
risk of hyperpigmentation .
- Resu lts a re va r i a b l e with a pprox im ately 50%
of
lesions showing a res ponse.

- W h i l e fu l l
resol ution
ca n
be o bta i ned
with the
Q-switc hed lasers, th ere a re freq uent rec u rrences .

Frustratingly, rec u rrences may occ u r 6 months to
1 yea r after treatment. Someti mes l ighte n i ng, rather
t h a n fu l l resolution, is the best o bta i n a ble result. A l l of
these lasers prod uce equ iva lent resu lts i n the treat
ment of CALMs.
TOP I CAL T R EATM ENT

CALMs a re not res ponsive t o topical blea c h i ng c rea ms.

MANAG E M E N T
U nfortunately, despite their s u pe rfi c i a l nat u re, CALMs

can be d iffic u lt to treat completely.
The key c l i n ica l fi n d i ng is epidermal white n i ng after

Q-switc hed laser treatment.
Lighte n i ng, rather than fu l l clearance, is often the best

res u lt, even after m u lti ple treatments.
There is a h igh risk of rec u rrence of CALMs u p to 1 yea r

after treatment.
Stud ies i n d icate a risk for hyper- a n d hypopigmentation

associated with the Q-switc hed lasers, espec i a l ly in
d a rker s k i n p h ototypes.
Treating a bove the therapeutic t h res h o l d may result i n

prolonged hea l i ng a n d i n c reased risk o f pigme nta ry
cha nges.
Patie nts with d a rker s k i n types s h o u l d be treated cau

tiously a n d conservatively, given the lower therapeutic
t h reshold .
Laser treatment of ta n ned patients s h o u l d be avoided .
B
Figure 22.3 (A) Treatment of cafe au fait macule on the chin of a young
man with a 532-nm frequency-doubled Q-switched Nd: YA G laser.

(B) Completion of treatment of cafe au fait macule with the appropriate
clinical endpoint of tissue whitening and erythema
Secti o n 5 : D i so rd e rs o f Pigmenta t i o n
B I B L I OG RAPHY
Al ora M B , Arndt K A . Treatment o f a cafe-a u-lait macule
with the erbi u m : YAG
laser.
J Am Acad Dermatol.
200 1 ;45(4 ) : 566-568 .

G ross m a n M C , Anderson R R , Fa rinel l i W, Flotte TJ ,
G reve l i n k J M . Treatment of cafe au lait m a c u l es with
lasers: A c l i n i co patho l ogic correlatio n . Arch Dermato/.
1995; 1 3 1 : 1 4 1 6 - 1 420.
K i m JS, K i m MJ , C h o SB. Treatment of segmenta l cafe au
l a it macu les using 1 064- n m Q-switched N d : YAG laser
with l ow p u lse energy. C/in Exp Dermatol. 2009;34( 7 ) :
222-223 .
Levy J L, Mordon S, Pizzi-Anse l m e M . Treatment of i n d i
vid u a l cafe a u l a i t macu les with t h e Q-switched N d : YAG :
A c l i n i copathologic correlation . Cutan Laser Ther. 1 999;
1 (4) : 2 1 7-223 .
CHAPTE R 23
Ephelides ,
Ephe l id es
more c o m m o n l y known
as frec kles, a re
benign, s ma l l , wel l -d e m a rcated , b rown macu les fo u n d

on t h e s u n -exposed s k i n o f blon d , l ight brow n , a n d red
h a i red i n d ivid u a l s . They present in early c h i l d hood a n d
decrease i n older age . They can b e d isti ngu ished fro m
lentigi nes in that they da rken in t i m es of h igh s u n expo
s u re a n d fad e d u ri ng periods of l i m ited sun expos u re .
Incidence: very com m o n , pa rticula rly i n fa i r-s k i n ned
patients
Age: early c h i l d h ood

Race: more common in Caucasians, but a lso seen i n
As ians
Sex: eq ual
Precipitating factors: i n d ivi d u a ls with l ight hair a n d com
p lexion s u c h as blonds a n d red heads
PATHOG EN ES I S
The
b rown
pigm entation
assoc iated
with
ephel i d es
resu lts from i n c reased p rod uction of m e la n i n in s u n

exposed a reas o f the s ki n .
1 39
1 40
PATHOLOGY
Kerati nocytes d i s play an i n c rease in mela n i n especia l ly i n
the basa l layer, but there i s n o su bsta ntial i n c rease i n the
n u m be r of m e l a n ocytes i n e p h e l ides.

Ephelides a re wel l-dema rcated l ight brown to dark b rown
macu les of severa l m i l l i m eters d i a m eter that p resent i n
s u n-exposed a reas o f t h e ski n .
The d ifferentia l d iagnosis i n c l u d es other benign lesions
s u c h as lentigines a n d j u nctio n a l nevi .
LABORATORY EXA M I NAT I O N

None.
COU RS E
T hey p resent i n ea rly c h i l d hood . They d a rken i n periods
of h igh sun exposu re and l ighten d u ri ng periods of l i m
ited s u n exposu re .
KEY CON S U LTAT I V E QU EST I O N S
S u n expos u re .
MANAG E M ENT
There is no medical i n d ication t o treat e p h e l i d es . The
cosmetic a p pea ra n ce, however, may d i s please some
i n d ivi d u a ls.
Sun
avoidance
and
s u n sc reens
protect
aga i nst d a rken i n g of ephel ides. B leac h i n g c rea ms, s u ch

as hyd roq u i none, a nd topica l reti noids can prod uce l ight
e n i ng. C ryothera py a n d laser treatment a re a l so effective .
Recu rrence is freq uent, pa rti c u l a rly with s u n expos u re .
T R EAT M E NTS
To pical blea c h i ng c rea ms m a y p rovi d e some l ighte n i ng .
M u ltiple for m u lations a re ava i la b le d iffe ring i n t h e i r p rod
uct co ntents a n d stre ngths.
H yd roq u i n one (2-4 % ) c rea ms have tra d iti o n a l l y been

e m p l oyed .
- Twice d a i ly a p p l ication of the c rea m to the e p h e l i d es
ove r 3 months is ge nera l l y necessa ry to a c h i eve sig
n ificant, if n ot c o m p l ete, i m provement.
- Side effects i n c l u d e i rritatio n , pru ritus, pee l i ng, a n d
d ryness o f the treated a reas.
Figure 23. 1 (A) A 38-year-old male from Southern California with exten
sive ephelides. (B) Same patient with posttreatment whitening immedi
ately after frequency-doubled a-switched Nd: YA G (532 nmJ laser
therapy. (C) Significant improvement 2 weeks after single treatment with
frequency-doubled a-switched Nd: YA G (532 nmJ laser utilizing a f/uence
of 1 . 5 J/cm2 and a 2. 0 mm spot size
141
- If eryth ema a n d i rritation occ u r, exercise caution to

avo i d hyperpigme ntatio n , espec i a l l y in d a rker s k i n
phototypes .
- Patients m ust d isconti n u e the treatment if a ny l ight
e n i ng of non lesion a l s k i n is o bserved .
- B leac h i ng c rea ms a re contra i n d i cated in pregnant
a n d lactat i n g women .
- Prolonged treatment may prod uce s k i n d iscoloratio n
known as pseu d o-oc h ronosis.
Reti noids
- Retinoids have been added i n prod ucts such as Solage
(2%
meq u i nol and
O.Q l % treti n o i n ) a n d Tri l u m a
(0.0 1 % fluocinolone acetonide, 4% hyd roq u i none, a n d

0.05% tretinoi n ) t o provide a n exfol iative benefit.
- Appl ication of Tri l u ma m ust be l i m ited in d u ration
d ue to the poss i b i l ity of side effects with repeated
corticoste roid usage su ch as s k i n atrophy a n d a c n e .
Aze l a i c ac i d (20%) c rea m is u n pred i cta bly effective for

e p h e l i d es a n d le ntigi nes.
Koj ic a c i d 0-2 . 5% ) c rea m .
C h e m i c a l Pee l s
Chem ica l peels can b e h e l pful i n red u c i n g the a p pea r
a nce of ephel ides . Su perfi c i a l d e pth peels, med i u m
d e pth peels, a n d deeper pee ls a re a l l effective . A ca refu l
eva l uation of s k i n type, however, is esse ntia l prior to treat
ment. As the d e pth of the peel i n c reases, the c h a nce for
i m prove ment, a long with adverse s i de effects, i nc reases .
Over-the-co u nter a-hyd roxy acid peels a re a benefi c i a l

a dj u n ct to physician-strength c h e m i ca l pee ls. The c o n
t i n u a l exfol iation ach ieved from cons iste nt u s e o f t h e
peels wi l l res u lt i n m i ld l ighte n i ng.
G lyco l i c a c i d pee ls (35-70%) a re ad m i n istered every 2
to 3 weeks uti l iz i n g i n creasing strengths as to lerated .

Lighte n i ng of e p h e l i d es may be o bserved after fou r to
six pee ls. Strict photo protection is stressed . S a l icyl ic
a c i d peels ( 20-30% ) a re a lso effective . They can be
used safely in a l l s k i n types .
J essner pee ls ( resorc i n o l , lactic acid , a n d sa l icyl ic a c i d )

a re a d m i n istered every 6 t o 8 weeks.
- Strict photo protection fo r 2 to 3 months is advised .
- M u ltiple treatments a re reco m m e n d ed .
- Contra i n d icated i n pregnant a n d lactating women .
Com bi nation J essner/10% tri c h loroacetic (TCA) peels

may a lso be em ployed in a s i m i l a r fas h i o n as the
J essner pee l .
- The J essner pee l results i n exfol iation a l l owing fo r
greate r penetration of the TCA pee l .
- M u ltiple peels a re gen e ra l l y needed . Contra i n d i cated
in pregna n t a n d lactat i ng women .
Figure 23.2 (A) A 40-year-old Japanese female with ephelides and lentig
ines prior to 694-nm Q-switched ruby laser treatment. (8) Immediate

tissue whitening and erythema after treatment
1 42
Caution to avoid pigmenta ry cha nges, es pec i a l l y i n

d a rker s k i n types.
A test site can be considered .
C ryot h e ra py
C ryoth era py can prod uce l ighte n i ng of frec k l i ng.
Has a risk of hypo- or hyperpigmentation at a n d around

treated sites, especially i n da rker s k in phototypes and
ta n ned pati ents .
Recu rrence is com m o n .
Laser T h era py ( F i gs .
23 . 1
and
23 . 2 )
Laser a n d l ight sou rce thera py can be effective i n treating

ephel i d es .
I ntense p u l sed l ight, freq uency-d ou bled Q-switc hed

N d :YAG ( 532 n m ) , Q-switc hed a l exa n d rite (755 n m ) ,
Q-switc hed
r u by
(694
nm),
Q-switc hed
N d :YAG
( 1 064 n m ) , p u l sed dye ( 59 5 n m ) , fractional res u rfac

i ng, and KT P lasers ( 532 nm) a re all effective .
With Q-switched lasers:

- Perform a test s pot on d a rker skin types.
- Treatment end point for Q-switc hed lasers is i m med iate tissue whiten i ng. For the Q-switc hed N d : YAG
( 1 064 n m ) , sma l l p i n po i nt bleed i n g may be see n .
- A 7-to- 10-day hea l i n g t i m e c a n b e expected for crust
i n g to resolve with Q-switc hed lasers .
One
study
used
the
frequency-doubled
N d: YAG
(532 n m ) to treat ephel ides in 20 patients with type IV

ski n .
50%
Eighty percent of patients showed better than

i m provement.
Recu rrence
was
com mon .
Hypopigmentation, textura l changes, and hyperpigmenta

tion a l l resolved with i n 2 to 6 months after final treatment.
In a n other study, 197 Asians were treated with the
Q-switched a l exa nd rite (755 nm) at 7.0 J/cm 2 , with a

pu lse width of 100 ns at 8-week i nterva ls. C l i n ical fol-
lowu p after an average of 1 . 5 treatment sessions showed

a 76% decrease in the n u m ber of ephel ides. No sca rri ng,
textura l cha nges, or pigmentary cha nges were noted .
The Q-switc hed ru by ( 694 n m ) a n d a l exa nd rite lasers

(755 n m ) a re a l so effective.
- If the c l i n ical end point of im med iate whitening is
achieved , the ephel ides should clea r with one treatment.
Q-switc hed lasers a re m ost effective for d a rker lesions.

Fractiona l res u rfa c i n g ( F raxel Laser; Reliant tec h nologies, San Diego, CA) is a lso effective ( Fig. 23 . 3 ) .
- Treatment is ge nera l ly performed at su perficial d e pths
compared to treatme nts of rhytides and acne sca rs.
- H igh treatment dens ities a re m ost effective .
- M i ld -to-moderate e ryth e m a , rese m b l i ng a s u n b u r n
Figure 23.3 (A) Young male with ephelides on his left cheek at baseline.
reaction , is observed . Postproced u re swe l l i ng is a lso
(B) Improvement of ephelides after several nonablative fractional resur
com m o n .
facing treatments.
Secti o n 5 : D i so rd e rs of Pigmenta t i o n
- The erythema reso lves in 3 to 5 d ays a n d can be cov

ered with m a ke u p wit h i n a day of the treatment.
- Long-te rm d ata a re c u rrently lacking.
I ntense p u lse l ight is a lso effective.

- The c l i n ic a l end po i n t is da rken i n g of the lentigi nes.
Caution should be e m ployed when treating pati ents

with d a rker s k i n types to avo i d hyperpigme ntation that
may persist for months.
Recu rrence of frec k l i n g after treatment, however, is
S u n sc reen a n d s u n avo i d a n ce a re m a n d ato ry adj u n cts
com m o n .
to laser thera py.
P I T FALLS TO AVO I D/CO M P L I CATI O N S/

MANAG E M ENT
Laser treatment o f ephel i d es is freq uently su ccessful

but often tra nsient.
Patients should be i nformed that rec u rrence is h ighly

l i kely, espec i a l l y with s u n expos u re .
D a i l y strict photo protection with a s u n sc reen with

UVAIUVB p rotection a nd/o r a physica l block such as
tita n i u m d ioxi d e or z i n c oxi d e a re stressed as wel l as
sun avoidance.
I f blea c h i ng c reams prod uce erythema, ca ution is

advised as e rythema c a n prod uce i rritation and hyper
pigme ntation .
Patie nts s h o u l d be cou nseled rega rd i ng the poss i b i l ity

of posti nfla m m atory pigme ntatio n c h a nges after treat
ment. Laser remova l of ephel i d es may a lso prod uce a n
u nattractive, s potty hypopigmentation , espec i a l ly i n
d a rken s k i n phototypes .
B I B L I OG RAPHY
J a ng KA , C h u ng E C , Choi J H , S u n g KJ , M o o n K C , Koh
J K . S u ccessful remova l of freckles in Asia n skin with a Q
switc hed a lexa nd rite laser. Dermatol Surg. 2000; 26(3 ) :
23 1 -234.
M is h i m a Y, Ohyama Y, S h i bata T, et a l . I n h i bitory action of
koj ic acid on melanogenesis and its therapeutic effect for
va rious h u m a n hyperpigme ntation d isorders . Skin Res.
1 994;36( 2 ) : 134- 1 50 .
N a kagawa M , Kawa i K . Contact a l lergy t o koj i c a c i d i n
ski n ca re prod ucts . Contact Dermatitis. 1995;3 1 ( 1 ) : 9 - 1 3 .
Ngujen Q H , B u i T P. Azelaic a ci d : Pha rmacoki netic a n d
pha rmacodyn a m ic properties a n d its thera peutic role i n
hyperpigmenta ry d i sorders a n d acne. lnt J Dermatol.
1995;34( 2 ) : 75-84 .
R a s h i d T , H ussa i n I , H a i d e r M , H a roon TS. Laser thera py
of freckles a n d le ntigi nes with q uasi-conti n uous, fre
q uency-dou bled , N d : YAG (532 n m ) laser in Fitzpatrick
ski n type IV: A 24-month fol l ow-u p . J Cosmet Laser Ther.
2002 ;4(3-4 ) :8 1 -85.
1 43
1 44
CHAPT E R 24
Le ntigi n es
T h e re a re two major types of lentigines: lentigo s i m plex

and solar lentigos. They a re ben ign lesions. Although
both a re c l i n ica l ly i d e ntica l , they a p pear i n enti rely
d ifferent c l i n i c a l setti ngs. Lentigo s i m p l ex typi c a l l y fi rst
p resent
in
c h i l d hood
as
m u lti p l e wel l - d e m a rcated ,
b rown or b l a c k m a c u les that ca n a p pear on a n y pa rt of

the s k i n or m ucous m e m branes. T h ey a re c l i n i c a l l y
i n d isti n g u i s h a b l e fro m j u nctio n a l n evi . T h e re is n o a sso
ciation with s u n exposu re in t h i s type of lentigo . I n
co ntrast, sola r lentigos, m o re c o m m o n l y k n own a s " l iver
s pots , " a re we l l - d efi ned , b rown m a c u les that a p pea r o n
s u n -exposed s k i n o f a d u lts . T hey i n c rease i n n u m be r
w i t h a g e . T h ey m ost often a p pea r o n the d o rsa l h a n d s ,
s h o u l d e rs, a n d fa ce o f l ightly pigmented a n d red - ha i red
patients.
EPI OEM I O LOGY

Incidence: very com m o n , pa rt i c u l a rly i n fa i r-s k i n ned
pati ents
Age: bimodal d istri bution in c h i l d hood a n d i n s u n

d a m aged s k i n o f a d u lts
Race: m o re common in Caucasians

Sex: eq u a l
Precipitating factors: s u n expos u re is c l osely related to
sol a r lentigines. M u lti p l e lentig i n es a re associated with a
few ge nodermatoses
i n c l u d i ng
LEO PA R D synd ro m e ,
LAM B syn d rome, a n d Peutz-J eghers syn d rome
PATHOG E N E S I S
U n known .
PATHOLOGY
There is a u n iform elongation of the rete rid ges of the e p i
d e r m i s a long w i t h i n c reased mela n i n i n melanocytes a n d
basa l keratin ocytes. I n a d d it i o n , there a re a n i nc reased
n u m be r
of
mela nocytes
in
the
basa l
cell
layer.
M e l a n o p hages a re p resent in the pa p i l l a ry dermis.

Wel l -d efi ned b rown ma c u les. Le ntigo s i m p l ex m a c u l es
te nd to be evenly d i stri b uted a nd s m a l l , meas u r i n g o n ly a
few m i l l i mete rs . Solar lentigos have a p red i lection for the
Figure 24. 1 (A) Lentigo on left cheek of a female. (B) Significant
s u n-exposed a reas of the d o rsa l hands a n d face. They
improvement after one treatment with a 532-nm Q-switched Nd: YA G

laser at a fluence of 1 . 0 J/cm2 and a 2-mm spot size
can be l a rger tha n lentigo s i m plex.
1 45
Seborrheic keratosis, j u nctional nevi , ephel ides, lentigo
m a l igna , melanoma may a l l m i m i c lentigines.
TAB L E 24. 1
Solar Lentigo Versus Ephelid

Sola r lentigo
Ephel i d
P resents i n c h i l d h ood
No
Yes
Permanent
Yes
No
Dec reases with age
No
Yes
H igh rec u rre nce after treatment
Yes
Yes
I nc rease in m e la n i n
Yes
Yes
I nc rease in m e l a n ocytes
Yes
No
LABO RATORY EXAM I NAT I O N

B i o psy i s i n d icated i f there i s suspicion o f a le ntigo
m a l igna o r melanoma . Medical worku p is a ppropriate if
there is suspicion for a genode rmatosis.
CO U RS E
There i s a b i m od a l d istri bution for le ntigi nes. They a p pea r
in c h i l d hood a n d i n s u n -exposed a d u lts .
H a s there been a n y cha nge i n the color o r size o f the

lesion?
Does the lesion bleed?
Sun exposu re
S u n sc reen use
MANAG E M ENT
There is no med ica l i n d ication t o treat lentigi nes. T h e cos
metic a p pea ra nce, however, d ispleases m a ny d ue to the
perception that lentigines a re associated with aging.
Cryothera py a n d laser treatment a re the m a i n stays of treat
ment. Laser thera py is more effective than one-ti me a ppli
cation of cryothera py. C ryothera py, however, is a n effective
a n d less expensive o ption for the pati ent. Chemical peels,
topical tret i n o i n , l oca l derma brasio n , and topica l blea c h i ng
agents represent other treatment options.
TOP I CAL M E D I CATI O N S
B leac h i ng c rea ms suc h a s 4% hyd roq u i none can

l ighten lesions over a period of severa l months. A topical
com b i nation of hyd roq u i none, stero i d , a n d ret i n o i d , ie,
Tri l u ma (4% hyd roq u i none, 0.05% treti noi n , 0 . 0 1 %
Figure 24.2 Two examples of chrysiasis, a rare but well-described compli
cation of a-switched laser therapy in patients with a history of ingesting

gold salts. In both of these patients, the characteristic dark-blue pigmen
tation was produced after a-switched laser treatments of lentigines on
the (A) dorsal hand and (B) forehead, respectively
1 46
fluocinolone a cetonide) can be used as we l l . However,

blea c h i ng c rea ms a re often not completely effective.
Topical tret i n o i n ca n prod uce lighte n i ng, but not usua l l y

c l e a r a n c e o f l e s i o n s . It may a lso, i n c o m b i nation with
sun avoidance and s u n sc reen use, p revent the d evel
o p ment of lentigi nes.
Retreatment is often necessa ry.

If a n y of these to pical med ications prod uce sign ifica nt
i nfla m mation o r i rritat i o n , it is i m porta nt to d isconti n u e
t h e i r use t o avoid posti nfla m matory hyperpigmentatio n .
I n a d d it i o n , pseud o-oc h ro n osis m a y occ u r with contin
uous, l ong-term use of topica l hyd roq u i n o n e .
B l eac h i ng c rea m s a re relatively contra i n d icated
in
p regna nt a n d lactati ng women .
CRYOTH E RAPY
This is a cheap, swift, and effective mea ns for treating

lentigines.
A p p l ication of c ryothera py c a n be accom p l i shed with a

sma l l cotton -ti p a p p l i cator or with a cryoth e ra py gu n .
I t i s ofte n l ess effective th a n one-t i m e treatment with a

Q-switc hed laser.
There is a sign ifica nt risk of hypo pigmentation with
c ryothera py if it is a pp l ied excess ively, or on a ta n ned

patient.
C H EM I CAL P E E LS
S u perficial d e pth peels, med i u m d e pth peels, a n d deeper
peels a re all effective for lentigines. A carefu l eva l uation of
skin type, however, is essential to avoid pigmenta ry com pli
cations. As the d e pth of the peel i n c reases, the chance of
i m provement, a l ong with adverse side effects, i n c reases.
LAS ER AND LIGHT SOU RCE TREATMENT

M u ltiple d ifferent thera pies a re effective for treating lentig
i nes. In genera l , da rker lentigines fare best with Q-switched
lasers. Where there a re n u merous, fa inter lentigines,
i ntense pulsed l ight sou rces a n d , to a lesser extent, nonab
lative fractional resurfacing lasers a re very effective.
I ntense p u l sed l ight, freq uency-d o u bled Q-switc hed

N d :YAG laser (532 n m ) ( Fig. 24. 1 ) , Q-switched a l exa n
d rite laser (755 nm) ( F ig. 24. 2 ) , Q-switc hed r u by laser
(694 n m ) , Q-switc hed N d :YAG laser ( 1 064 n m ) , p u l sed
dye laser with pigmented lesion w i n d ow ( 595 n m ) , a n d
fractional resu rfa c i ng lasers a re a l l effective .
With Q-switched lasers:

- Perform a test s pot on d a rker skin types.
- Treatment end point for Q-switc hed lasers is i m med iate tissue white n i ng. For the Q-switc hed N d : YAG
( 1 064 n m ) , sma l l p i n po i nt bleed i n g may be see n .
- A 7-to- 1 0-day hea l i ng t i m e can be expected for c rust

i n g to resolve after Q-switc hed laser treatm ent.
- Legs res pond m o re s l owly than the face and h a n d s .
- C a u t i o n s h o u l d be t a k e n wh i l e treating lowe r legs as
they often hyperpigment.
Hyperpigme ntation may
persist for months.
The freq uency-d o u b led Q-switc hed N d : YAG (532 n m )

laser h a s been shown t o i m p rove le ntigi nes safely a n d
effective ly.
- In one study, 37 patients were treated once with a
fluence of 2 to 5 J/c m 2, a 2 . 0-m m s pot size, a n d a
1 0-ns p u lse width .
- H i gher fl ue n ces provided best resu lts with 60% of
patients showi ng 75% or better clea ra nces.
- M i n or, tra nsient hypopigmentati o n , hyperpigmenta
tion , and e rythema were noted in a few patients.
- Has been shown to prod uce bette r cleari ng t h a n
35% T C A peel .
- Has been shown to treat lentigi n es more effectively
t h a n cryothera py.
The Q-switched ruby (694 n m ) laser is a lso very effective.

- In one treatment, su bsta ntia l cleari ng occu rred at
fl uences of 4 . 5 a n d/or 7 . 5 J/c m 2 a n d a pu lse width of
40 ns.
- I f the c l i n ic a l end poi nt of i m m ed iate white n i n g is
a c h ieved , the lentigo should clear with one treatment.
Fractio nal res u rfa c i n g can also be effective .

- Treatment
is
ge nera l ly
performed
at
s u perfi c i a l
d e pths a n d lower e ne rgies c o m p a red to treatm ents of

rhytides a n d acne sca rs.
- H igh treatment d ensities a re m ost effective . Typical ly,
req u i res m u ltiple treatments .
- M i ld -to-mod erate erythema , rese m b l i ng a s u n bu r n
react i o n , is o bserved . Postproced u re swe l l i ng is a l so
co m m o n .
- T h e e rythema resolves i n 3 t o 5 days a n d ca n be
covered with m a keu p with i n a day of the treatment.
- Long-te rm d ata a re c u rrently lacking.
I ntense p u l se l ight is a lso effective.

- Seve nty-fo u r percent c l ea ra nce of lentigi nes in 18
patients with one treatment.
- The c l i n ic a l end point is da rken i ng of the lentigi nes.
P I T FALLS TO AVO I D/CO M P L I CAT I O N S/

MANAG E M ENTIOUTCO M E
EXPECTAT I O N S
Q-switc hed laser a n d l ight source treatment for le ntig

i n es is freq uently successfu l . N o n a b lative fractio n a l
res u rfa c i n g is the least effective o f t h i s grou p .
1 47
1 48
Patients should be cou nseled rega rd i n g the possi b i l ity

of posti nfla m matory pigmentation c h a nges after treat
ment, espec i a l l y on the lowe r legs.
Recu rrence after treatment is not u ncom mon .

B i o psy a ny lesion that demonstrates a n y c l i n ica l atypia
prior to treating with laser o r c ryothera py. Laser thera py
of a m a l ignant lesion s u ch as a lentigo m a l igna o r
m e l a n o m a may mask its c l i n i c a l a p pea ra nce a n d thus
cause a delay i n d iagnosis.
Avoi d using Q-switc hed lasers i n patie nts with a n y
p r i o r h i story o f g o l d i nta ke . C h rys iasis, p resenting as

b l ue-gray c i rc u l a r m a c u les on the skin, can occ u r after
Q-switched laser treatment of so l a r l e ntigi nes i n th ese
patie nts ( Fig. 24. 2 ) .
B I B L I OG RAPHY
Bjerring P, C h ristia nsen K. I ntense p u lsed l i ght sou rce for
treatment of s m a l l mela nocytic nevi a n d sol a r lentigines.
J Cutan Laser Ther. 2000; 2 : 1 7 7 - 1 8 1 .

G a l eckas KJ , R oss EV, U e b e l h oer N S . A p u lsed dye laser
with a 1 0- m m bea m d i a m eter and a pigmented lesion
wi n d ow for p u r p u ra-free photorej uvenat i o n .
Dermatol
Surg. 2008;34(3 ) :308-3 1 3 .

Geist D E , P h i l l i ps TJ . Development o f c h rysiasis afte r Q
switc hed ru by laser treatment of sol a r lentigines. Am
Acad Dermatol. 2006; 5 5 ( S u p p l 2 l : S 59-S60.
K i l mer SL. Laser e rad ication of pigme nted lesions a n d
tattoos . Dermatol Clin. 2002 ; 20( 1 ) :37-53.
K i l m e r SL, Whee l a n d RG, Gold berg DJ , Anderson R R .
Treatment of e p i derma l pigmented lesions with the fre
q uency-dou bled Q-switched N d : YAG laser. A control led ,
si ngle- i m pact,
d ose-res ponse,
m u lticenter tria l . Arch
Dermatol. 1 994; 1 30( 1 2 ) : 1 5 1 5- 1 5 1 9 .

L i YT, Ya ng KC . Compa rison o f t h e freq uency-dou b l ed Q
switc hed N d : YAG laser a n d 35% trichloroacetic acid for
the
treatment
of
face
lentigines.
Dermatol
Surg.
1 999 ; 25(3) : 202-204 .

Sadighha A, Saatee S, M u haghegh -Za hed G . Efficacy
and adverse effects of Q-switc hed r u by laser on sol a r
lentigi nes: A p rospective study o f 9 1
F itzpatrick skin type I I ,
I l l , and
I V.
patients with
Dermatol Surg.
2008;34( 1 1 ) : 1 465- 1468.

Ste rn RS, Dove r JS, Lev i n JA, Arndt KA. Laser therapy
vers us c ryothera py of lentigines: A com pa rative tri a l . J
AmAcad Dermatol. 1 994;30(6 ) : 985-987.
Taylor CR, Anderson RR. Treatment of ben ign pigme nted
epidermal
lesions
by Q-switc hed
ru by
laser.
tnt J
Dermatol. 1 993;32 ( 1 2) : 908-9 1 2 .

Todd M M , R a l l is T M , G e rwels J W, Hata T R . A com parison
of 3 lasers and l i q u id n itrogen in the treatment of solar
lentigi nes: A ra nd o m ized , control led , c o m pa rative tria l .
Arch Dermatol. 2000; 136( 7 ) : 84 1 -846.
CHAPT E R 2 5
M e lasma
M e l a s m a i s a n a cq u i red b rown m a c u l a r hyperpigm e n

tati o n u s u a l ly o f t h e fa c e . It is fa r m o re c o m m o n i n
fe m a l es t h a n i n m a les. I t u s u a l ly p resents b i latera l ly
a n d sym m etrica l l y on the fa c e , but exte nsor forea rms
may a lso be i nvolved . T h e re a re b e l i eved to be th ree
h i stologic va ria nts of m e l a s m a : e p i d er m a l , d e r m a l , a n d
m ixed d e r m a l a n d
epidermal .
Epiderma l
melasma
res ponds best to th e ra py. A l l fo rms have a h igh rate o f

rec u rre n c e , m a k i n g t h i s a frustrat i n g c o n d ition to treat.
S u n expos u re , pregn a n cy, a n d o ra l contraceptive pi l ls
a re a l l associ ated with its presentati o n a n d rec u rrence
( Fig. 25. 1 ) .
EPI D E M I O LOGY
Incidence: common
Age: you ng fem a l es
Race: Centra l a n d South America n , M i d d le Easter n ,
I nd i a n , East As i a n fe males a re most freq uently affected
Sex: fe ma les > m a les ( 9 : 1 )

Precipitating factors: pregna ncy, ora l contraceptive p i l ls ,
s u n expos u re, hormone rep lacement thera py
PATHOG E N ES I S
U n k nown .
In epidermal melasma, there is i n c reased mela n i n d e po
sition in the epiderm is, pa rti c u l a rly in the basa l a n d
su pra basa l layers . I n d e r m a l melasma, there a re perivas
c u l a r m e l a n i n-conta i n i ng macrophages i n the su perfi c i a l
a n d m iddermis. M ixed-type m e l a s m a exh i b its featu res of
each of the a bove fi nd i ngs.
PHYS I CAL L ES I ON S
Patients p rese nt with wel l -d e m a rcated l ight b rown to
d a r k b rown sym m etric m a c u l a r hyperpigmentati o n . I n
a p p roxi mately two-th i rd s of pat i e n ts i t a p pea rs o n
the centra l fa ce i n c l u d i n g t h e fo rehead , n o s e , u p per
c uta neous l i p, and c h i n . I t presents less freq u e n t l y o n
the m a l a r a reas a n d jawl i n e . M o re ra rely, it a p pea rs o n
t h e d o rsa l forea r m s . Derm a l m e l a s m a h a s m ore of a
b l u e-gray h u e . M i xed-type m e l a s m a has a brown-gray
c o l o rat i o n .
Figure 25. 1 Female with extensive melasma recalcitrant to m ultiple
topical regimens for several years
1 49
1 50
Postinfl a m matory hyperpigmentation, exogenous och rono
sis, d rug- i n d u ced/photo-hyperpigmentati o n , nevus of Ota ,
erythema dysc h ro m i c u m persta ns.

Wood 's la m p exa m i nation accentuates the i n c reased ep i
d e r m a l pigmentation i n me l a s m a but d oes not h ig h l ight
its dermal com ponent.
COU RS E
T h e p i g m e ntat i o n p rese nts over a period of weeks. I t
occ u rs m ost co m m o n ly i n s u m m e rti m e , with
h igh
estroge n states , d u ri ng preg n a n cy, and p r i o r to men

struat i o n . I t may fa d e c o m p letely months after d e l ivery
or afte r d i sconti n u ation of o ra l co ntrace ptive p i l l s . It
may rea p pea r in s u bseq u e n t preg n a n c ies a nd/o r s u n
expos u re .
P regna n cy
S u n exposu re
Ti m e of onset
P revious treatments
MANAG E M E N T
There
is
no
med ica l
i n d ication t o treat
melasma .
N evertheless, many patie nts u n dersta nd a bly a re d is

tressed by its a ppea ra nce a n d desire treatment. The goa l
of the treatment is to l ighte n or rem ove the pigmentati o n .
Treating melasma can b e q u ite frustrati ng. P r i o r t o i n itiat
ing thera py, it is esse nti a l for the physicia n to expla i n
melasma a n d its treatment i n d eta i l t o the patient. W h i l e
there a re many treatments for m e l a s m a , it s h o u l d b e
stressed t h a t many a re often only p a rti a l ly effective.
Recu rrences a re very c o mmo n .
I t is a lso i m porta nt t o d eterm i n e which fo rm of
melasma is being treated, that is, epidermal versus
m ixed -type versus d e r m a l melasma ( Fig. 2 5 . 2 ) . There
a re
m u lt i p l e
topica l
and
laser
thera pies
ava i l a b l e
( Fig. 2 5 . 3 ) . Treatment is frustrating a n d ofte n i n effective .

There is a h igh rate of rec u rrence. Derm a l a n d m ixed
type melasma a re least responsive to thera py. I n a l l
melasma patients, strict s u n avo i d a n ce is cr u cia l with a
s u n sc reen with UVNUVB protection a n d/or a physical
block suc h as tita n i u m d ioxide o r z i n c oxide d u ri n g and
after any treatment regi m e n .
Figure 25.2 (A) A female patient with therapy-resistant melasma.
(Courtesy of Howard Conn)
151
TOP I CAL TREAT M ENT (Table 2 5 . 1)

There a re a h ost of to pica l treatme nts for melasma .
N u merous for m u lations conta i n i ng blea c h i n g agents

s u c h as 4% hyd roq u i none a re effective treatments to
l ighten or resolve pigme ntation. They a re most effective
if used ove r a period of weeks to a few months. If the
skin becomes sign ificantly i rritated from treatm e nt, d is
conti n u e its use to avoid posti nfla m mato ry hyperpig
mentation . Prolonged usage of hyd roq u i none can res u lt
in a c h a racteristic s k i n d i scoloration k nown as pse udo
ochronosis.
Reti noids s u c h as topical 0 . 1 % treti n o i n a ppl ied once

d a i ly fo r 40 weeks has been shown to be effective, but
less effective tha n hyd roq u i none.
Com b i nation thera py of 0.05% treti noi n , 4% hyd ro

q u i none, a n d 0.0 1 % fluocinolone acetonide, that is,
Tri l u ma , prod uces favorable c l i n ica l resu lts for melasma
and postinflam matory hyperpigmentation with decreased
irritatio n . Treatment d u ration is l i m ited by side effects
of prolonged topical steroid use i nc l u d i ng skin atrophy
and acne.
Aze l a i c acid has also been shown to prod uce i m p rove

ment.
CH EM I CAL P E E LS
Chem ica l peels a re often effective for melasma .
I n one study, there was no d ifference i n resu lts when

comparing J ess ner's solution versus 70% glycol i c a c i d
peels after perfo r m i n g th ree peels 1 m o n t h a pa rt on
each side of the face.
G lyco l i c a c i d peels performed every 3 weeks i n co m b i
Figure 25.2 (B) ( Continued) Marked resolution in the melasma after four
nation with
treatment sessions with Fraxel laser. (Courtesy of Howard Conn)
TAB L E 2 5 . 1
d a i ly s u n sc reen
and
c o m b i nation
Treatment o f Pigmented Lesions o n the Face
Melasma
Ret i n o i d/hyd roq u i none
G lyco l i c a c i d peels
Q-switc hed laser
A blative res u rfa c i ng
Fractional resu rfa c i ng
Va r i a b l e i m provement
M u ltiple l ight pee ls in
No
Yes; but ca refu l
Yes in s k i n
conj u n ction with
patient selection
types 1-1 1 1 ;
su nscreen a n d
a n d l o n g postlaser
caution s k i n
topica l ret i n oid/
recovery
type IV
hyd roq u i none

Posti nfl a m matory
hyperpigmentation
Yes ; weeks to months
Va ria b l e i m prove ment
No
No
No
M i n i m a l/moderate
Yes; one to two
Yes;
M i l d/moderate
to see c l i n ica l
i m provement
Lentigo
M i n i m a l/mod erate
i m provement afte r
c h a nge with th ree
treatments a re
post-i nfla m matory
months of use
to fo u r peels
h igh ly s uccessfu l
erythema c h ief
o bstacle
N evus of Ota
None
Non e
Yes; m u lti ple

treatments res u lt
in i m provement
No
No
1 52
glyco l i c a c id/hyd roq u i no n e c rea m has been shown to

be effective .
Seria l su perfic i a l c h e m i c a l peels s u ch as sa l icyl ic a c i d

a n d glyco l i c acid pee ls a re the safest peels i n d a rker
skin phototypes.
Caution is req u i red for d a rker skin phototypes to avo i d
hyperpigmentati o n .
LAS ERS
Q-Sw i t c h e d Lasers
a-switched laser treatment for melasma is not recom
mended given its h igh i ncid ence of posti nflam matory
hyperpigmentation . Add itiona l ly, it is not d ra matica l ly effec
tive except in some cases of su perficial melasm a .
A
A b l at i ve Laser
I n cases refractory t o topica l crea ms and chem ica l peels,
erbium :YAG laser prod uced sign ificant, tem porary i m prove
ment in 10 patients in one study but was com p l i cated by
su bseq uent posti nfla m mato ry hyperpigme ntation in a l l
1 0 patie nts.
N o n -A b l a t i ve Fract i o n a l R e s u rfac i n g
N o n -A blative Fracti o n a l res u rfacing can be su ccessful for
some cases of melasma , espec i a l ly epidermal types
( Fig. 2 5 . 2 ) .
Long-term data a re lacking.
Treatment is ge nera l ly performed at su perfic i a l d e pth
Treatment is genera l ly performed at h igher densities.
relative to treatments for rhytid es and acne sca rs .
I t is m ost successfu l i n patients with l ighter skin p h o

totypes, suc h as s k i n types I a n d I I . I m provement is less
p red i cta b l e in sk i n type I l l , but is often a c h i eved .
S k i n ph ototypes IV a n d V often do not respond favor
a b ly to fra ctional resu rfa c i ng. Postinflam mato ry hyper
pigme ntation is a high risk.
P re- a n d posttreatment use of hyd roq u i none a n d l onger

i nterva ls between treatments may red uce postinflam
matory hyperpigme ntation i n d a rker s k i n phototypes.
P I T FALLS TO AVO I D/
COM P L I CAT I O N S/MANAG E M ENTI
O U TCO M E EXPECTAT I O N S
A l l forms o f melasma a re d iffic u lt a n d frustrating to

treat. Recu rrence is co m m o n .
Derm a l melasma is pa rticula rly d iffic u lt.
Patie nts should be a p prised of the reca lc itra nt nature of

t h i s condition in some cases .
Figure 25.3 (A) Young female with melasma. (B) Characteristic darkening
of melasma 1 -day post intense pulsed light treatment
Postpa rtu m state a n d d isconti n ua n ce of oral contra
Phys i c a l Exam
ce ptive p i l ls a re freq uently s uccessfu l thera pies .
Some treatme nts worse n its a p pea ra n c e .
Strict s u n avo i d a n ce is c r u cia l w i t h a su nscreen with
S u n exposed a rea-face more often t h a n arms
D i st r i b ut i on-cheeks, l ower face , med i a l face,
in any com b i nation

Wood 's Light to determ i n e e p i dermal vs.
d e r m a l d i stri b u t i o n of pigment
UVNUVB protection a nd/o r a physical block such as

tita n i u m d ioxide o r z i n c oxi d e d u ri n g a n d after a ny
treatment regi men .
C l i n ical
D ifferential Diagnosis
approach to
diagnosing
Post- i nf l a m matory hyperpigme ntat i o n
melasma
M e d i cation i n d uced hyperpigme ntat ion
B I B L I OG RAPHY
Risk Factors
F i n ke l U , D itre C M , H a m i lton TA, E l l is C N , Voorhees J J .

To pica l treti n o i n ( reti noic a c i d ) i m proves melasm a . A
veh i c l e-contro l l ed , c l i n i c a l tria l . Br J Dermatol. 1 993 ; 129:
4 1 5-42 1 .
G r i mes P E . M a nagement of hyperpigme ntation i n d a rker
Pregnancy
Oral contracepti ves
I ncreased p igme ntat i o n w i t h s u n expos ure
Figure 25.4 Clinical approach to diagnosing melasma
rac i a l eth n i c grou ps. Semin Cutan Med Surg. 2009 ;

28( 2 ) : 77-85.
Lawre nce N, Cox S E , B rody HJ . Treatment of melasma
with J essner's sol ution versus glycol i c acid : A com pa rison
of c l i n ic a l efficacy and eva l uation of the pred ictive a bi l ity
of Wood 's l ight exa m i nati o n . J Am Acad Dermatol.
1997;36: 589-593 .
Lee H S , Won C H , Lee D H , et a l . Treatment of melasma i n
As i a n s k i n using a fractional 1 , 550 n m laser: An open
c l i n ical study. Dermatol Surg. 2009;35( 1 0 ) : 1499 - 1 504 .
M a n a loto R M , Alser T M . Erb i u m :YAG laser resu rfa c i n g
MELASMA
f o r refractory melas m a . Dermatol Surg. 1999 ; 25 : 1 2 1 -
Vig i l a nt sunscreen is cruc ial
123.
S P F30 before , d u r i ng a n d after any therapy
R o k h s a r C K , Fitzpatrick R E. The treatment o f melasma
I m provem e n t i s var i a b l e a n d rec u rrence i s common
with fractional p h otothermo lysis: A p i lot study. Dermatol
Surg. 2005;3 1 ( 1 2 ) : 1 645- 1 650.

To ro k
HM,
J ones T,
Rich
P, S m ith
S,
Tschen
E.
Top i c a l
Mechanical
Lasers
H yd roq u i n o n e
Ret i n o i d s
to n i de 0 . 0 1 % : A safe a n d efficacious 1 2-month treat
S u perf i c i a l pee l s
A b l at i ve resorfa c i n g
ment for melasma . Cutis. 2005 ; 7 5( 1 } ; 57-62 .
Koj i c a c i d
Q-switched
Aze l a i c a c i d
lasers
Licorice extracts
Hyd roq u i none 4 % , treti n o i n 0 . 0 5 % , fl uocinolone ace
Vera l lo- Rowe l l V M , Ve ra lo V, G ra u pe K, Lo pez-V i l lafuerte

L, G a rcia Lopez M . Double- b l i n d com parison of azeleic
acid and hyd roq u i none i n the treatment of melasma .
M i crodermabras i o n
Fract i o n a l
photothermolysis
Acta Derm Venereal. 1 989 ; 143: 58-6 1 .
A com b i n at i o n of a topical s u c h as
Victor FC, G e l ber J , Rao B . Melasma : A revi ew. J Cutan
m i crodermabrasion for 6 months is a n
Med Surg. 2004; 8(2) :97- 1 02 .
effect ive a n d safe com b i n at i o n t h erapy
hyd roq u i n o n e , w i t h month ly pee l s a n d/or
Laser/l ight sou rces s h o u l d be u sed o n l y after c o m b i nation of topicals
a n d pee l s m i crodermabrasion fa i l
R i sk of post- i n f l a m matory hyperpigme ntat i o n from a n y l aser
( m ay persist for months)
Fract i o n a l photothermolysis has fewer s i d e effects a n d l ess down
time t h a n a b l at i ve lasers
A b l at i ve resorfa c i n g o n l y for t h e m ost refractory cases in patie nts
who can tolerate months of post i nf l a m m atory c h a n ges
Q-switched l asers a re ofte n not effect ive a n d often worsen m e l asma
Figure 25.5 Melasma treatment protocol
1 53
1 54
CHAPT E R 2 6
Nevus of Ota
N evus of Ota , a lso known as nevus fuscoceru leus oph

tha l momaxi l l a ris, represents a ben ign pa rtia l ly confl uent
mac u l a r
b rown- b l u e
pigme ntation
of the ski n
and
m ucous mem bra nes i n t h e d istri bution o f the fi rst a n d

second b ra n c hes o f t h e trige m i n a l nerve. It may b e u n i
late ra l o r bi latera l . The i psi latera l scl era is freq ue ntly
i nvolved .
Incidence: 0.4% to 0.8% of J a pa nese dermatology patients
Age: b i modal d istri bution at birth a n d p u berty
Race: m ore common in Asia ns a n d b l a c ks than wh ites
Sex: m ore fema les t h a n ma les seek treatment for this
cond ition ; u n known if there is a sex p red i lection
Precipitating factors: spora d i c , not a n i n h e rited d isord er
PATHOG E N E S I S
Hyperpigme ntation
a rises
as
res u l t
of
dermal
melan ocytes t h a t have n o t m igrated to the epid erm i s .
PATHOLOGY
H eavily pigme nted , e l ongated , d e n d ritic melan ocytes a re
located a mong the reti c u l a r dermal collage n . Most typi
c a l l y, these mela nocytes a re fo u n d i n the u p per one-t h i rd
of the reticu l a r dermis but a re a lso seen in the pa p i l l a ry
d e r m i s i n s o m e lesions.

I t presents a s confl uent o r pa rtia l ly co nfl uent b rown- b l u e
patches i n the d istri bution o f the fi rst a n d second
b ra n c h es of the trige m i n a l n e rve . G ray, black, and p u r p l e
coloration may be p resent i n s o m e lesions as wel l . I t can
be u n i latera l o r bi latera l . The magnitude of i nvolvement
can va ry fro m loca l perioc u l a r i nvolvement to much of the
side of the face. A p p roxi mately two-th i rd s of patie nts fea
t u re i psi latera l sclera l i nvolvement.
Melasma, cafe a u I ai t m a c u l e , H o ri's macule b l u e nevus,
bru ising, och ronosis, a rgyria ,
p h otod ermatoses, fixed
d rug eru ption, a n d other m ed ication-related eru ptions

should be considered i n the proper c l i n ical setting.
B
Figure 26. 1 (A) Nevus of Ota prior to treatment with Q-switched ruby
laser. (8) Significant clearance after serial treatments with Q-switched
ruby laser
1 55

B i o psy m a y b e i n d icated i f t h e d iagnosis i s i n q u estio n o r
t o exc l u d e the ra re case o f melanoma a rising i n this
lesion .
CO U RS E
There i s a b i modal d istri bution fo r n evus o f Ota , b i rth a n d
p u be rty. It rema i n s relatively s i m i l a r i n a p pearance after
i n itia l presentatio n .
O nset o f eru ption
MANAG E M ENT
There is no medical i n d ication t o treat nevus o f Ota .
Cosmetic a p pea ra n ce, however, is d istressi n g to patients.
W h i l e c ryothera py and topica l b l ea c h i n g treatments have
been util ized , the treatment of c h oice is Q-switc hed laser
treatment.

M a k e u p can camouflage o r assist i n ca mo uflag i n g nevus
of Ota . To pica l med ications a re less effective than laser.
Figure 26.2 Nevus of Ota. Periorbital blue-gray pigmentation with scleral
involvement (Kay K, Jen R, Richard J, et at eds. Color Atlas & Synopsis of

Pediatric Dermatology. McGraw-Hill, Inc. ; 2002)
T R EAT M E N T
N u merous stu d ies have s hown that nevus o f Ota i s

a m e n a b l e t o su ccessfu l reso l ution with Q-switc hed
laser
thera pies
i n c l u d i ng
the
Q-switched
ru by
( 694 n m ) , the a l exa n d rite (755 n m ) , a n d the N d :YAG

( 1 , 064 n m ) lasers ( Figs . 2 6 . 2 a n d 26 . 3 ) .
Test s pot ca n be performed prior t o treatment.

The Q-switc hed r u by laser has been shown to be effec
NEVUS OF OTA
tive at prod u c i n g 7 5 % or greater c l ea ra nce at fl uences

of 5 to 7 J/c m 2 , 4-m m s pot size, a n d a 30-ns pu lse
width at 3-to-4- month treatment i nterva ls.
- I n a study of 46 c h i l d ren a n d 107 a d u lts with nevus
of Ota , treatments were more s uccessfu l i n c h i l d ren
Topica l
Mechanical
Lasers
Camouflage
may be h e l pfu l
for some patients
M i croderma b rasi o n
s h o u l d not b e performed
H igh risk of dysc h rom i a
a n d/or scarr i ng
Q-switched l asers
are the t reat ment of
choice
A b l a t i ve-no
t h a n i n a d u lts.
- The mean n u m be r of treatment sess ions to a c h ieve

sign ifica nt cleari ng or better was 3 . 5 for the younger
age gro u p and 5.9 fo r the older age gro u p .

- Ad d itional ly, com p l i cations we re lowe r i n t h e c h i l d ren
t h a n ad u lts, that is, 4.8% as com pa red to 22.4% .
- One
retros pective study exa m i ned
101
M u l t i p l e t reatments with Q-switched l asers are needed

I m p rovement moderate to dramatic after m u lt i p l e treatments
Q-switched l aser treatment of lesions that arise in i nfancy may
respond better to l aser t h erapy than l ater in l ife
If a Q-switched VAG l aser is u sed a com b i n a t i o n of 532 n m/ 1 064 n m
m a y res u l t i n better c l i n i cal i m provement t h a n 1 064 n m a l o n e
pati ents
1 yea r after treatment with Q-switc hed r u by laser a n d
Figure 26.3 Treatment of nevus of Ota algorithm
1 56
fo u n d that 1 6 .8% d is played hypopigme ntation a n d

5 . 9 % showed hyperpigmentatio n . One patient w h o
had com plete resol ution d eve loped rec u rrence.
The Q-switched a lexa nd rite laser is a lso effective for the

treatment of nevus of Ota . Dermal white n i n g is the
key c l i n ica l end point when treati ng nevus of Ota with
Q-switc hed lasers .
- One gro u p reported the su ccessful treatm e nt o f
nevus
of
Ota
with
fractional
p h otothermo lysis.
N o n etheless, Q-switc hed laser is the treatment of

choice.
To p i c a l
Ca mouflage may be hel pf u l fo r some patients .
M ec h a n i c a l
M i c roderma b rasion s h o u l d not be performed .
H igh risk of dysc h ro m i a a n d/o r sca rring.
Lasers
Q-switched lasers a re the treatment of choice.
Ablative-no.
M u lt i p l e treatme nts with Q-switc hed lasers a re need e d .
I m provement moderate t o d ra matic after m u ltiple treat

ments.
Q-switched laser treatment of lesions that a rise i n

i nfa ncy may respond better t o laser thera py t h a n later
in l ife .
If a Q-switc hed YAG laser is use d , a c o m b i nation of

532 n m/ 1 , 064 nm may res u l t in better c l i n ical i m prove
ment tha n 1 , 064 nm a l o n e .
- One study treated 1 3 patients at fl uen ces ra ngi ng
between 6 a n d 8 J/c m 2 at 8-week i n terva ls. T h e
mea n
n u m ber o f treatments w a s a pproxi mately
seve n . Seve n patients ach ieved 75% or bette r l ight

e n i ng, th ree patie nts a c h ieved between 5 1 % a n d
7 5 % i m prove ment, one a c h ieved between 2 5 % a n d
5 0 % i m p rovement, a n d a noth e r a c h i eved less tha n
25% i m provement.
- Two patie nts experienced tra nsient hyperpigme nta
t i o n ; one ex perienced tra nsient hypopigme ntatio n .
T h e Q-switc hed N d : YAG ( 1 ,064 n m ) laser h a s a lso

prove n to be effective.
- Sl ightly less effective than other Q-switc hed lasers.
- I t is safer for use in dark skin types .
- Less risk of hypopigme ntatio n .

MANAG E M ENT
Laser treatment for nevus o f Ota is freq uently successfu l .
G iven t h e h igh proportio n o f patients with d a r k s k i n

phototypes, there is the r i s k o f hypo- a n d hyperpigmen
tatio n .
The r i s k o f suc h a n a dverse reaction s h o u l d be d is
Add itiona l ly, a test site can be treated before perform
Q-switc hed l a s e r treatment can be associated w i t h tra n
cussed with the patient prior to thera py.

i n g fu l l treatment of a n y les i o n .
sient hyperpigme ntation .
Recu rrence after treatment is i n freq uent.
B I B L I OG RAPHY
C h a n H H , Le u n g R S , Ying SY, e t a l . A retrospective a n a ly
sis of compl ications in the treatment of n evus of Ota with
the Q-switc hed a l exa n d rite and
Q-switched
N d : YAG
lasers . Dermato/ Surg. 2000;26( 1 1 ): 1 000- 1 006.

Chan H H , Ying SY, Ho WS, Kono T, King WW. An i n vivo
trial c o m pa ri ng the c l i n ic a l efficacy and c o m p l icati ons of
Q-switc hed 755 nm a lexa nd rite a n d Q-switched 1 064 n m
N d :YAG lasers i n t h e treatm e nt o f nevus o f Ota . Dermatol
Surg. 2000;26( 1 0 ) : 9 1 9-92 2 .
Ko no T , C h a n H H , Ercocen A R , e t a l . Use o f Q-switc hed
r u by laser in the treatment of nevus of Ota i n d i ffe rent age
gro u ps . Lasers Surg Med. 2003;32(5) :39 1 -395.
Ko no T, N oza ki M, Chan H H , M i ka s h i m a Y. A retrospec
tive study looking at the long-term com pl ications of
Q-switc hed r u by laser in the treatment of nevus of Ota .
Lasers Surg Med. 200 1 ;29(2) : 1 56 - 1 5 9 .
Ko u ba DJ , F i n c h e r EF, M oy R L. N e v u s o f Ota successfu l ly
treated by fractio n a l p h otothermo lysis u s i ng a fra ction
ated
1440- n m N d :YAG laser. Arch Dermatol. 2008;
144( 2 ) : 1 56- 1 58 .
R a d m a n esh M . Naevus o f Ota treatment w i t h c ryother
a py. J Dermatol Treat. 200 1 ; 1 2 (4) : 205-209 .
1 57
1 58
CHAPT E R 2 7
Posti nfl a m mato ry hype rpig m e ntatio n
Posti nfla m matory hyperpigmentation ( P I H ) is a c o m m o n

seq uela o f i nfla m matory dermatoses or i nj u ry t o the ski n .
It
occ u rs
most
commonly
in
d a rker
skin
types .
Depend i n g on the etiology of the hyperpigmentation , p ig

ment may be de posited in the dermis o r epidermis with
i m porta nt i m p l ications for treati ng the pigment c h a nges .
It is a c o m m o n seq uela of laser treatment, pa rti c u l a rly i n
d a rker s k i n p hototypes ( Fig. 27 . 1 ) .
EPI D E M I O LOGY
Incidence: com m o n , espec i a l ly in d a rker skin types
Age: a l l ages
Race: m ore common in d a rker s k i n types
Figure 27. 1 PI H seen after a series of treatments with nonablative
Sex: none
fractional resurfacing for a scar. The PIH resolved on its own within
3 weeks
Precipitating factors: a ny i nfla m m atory d isorder o r i nj u ry

to the ski n can p rod uce hyperpigmentatio n . It may a lso
res u lt from laser thera py, derma b rasi o n , c ryothera py, or
c h e m i ca l peels. I t p rese nts more exu bera ntly a n d with a
greate r d u ration i n d a rker s k i n ph ototypes
PATHOG E N ES I S
U n known .
Basa l cel l layer pigme ntatio n and dermal mela n o p hages
a re see n .

I n epidermal P I H , patients d isplay i n d isti nct ta n t o d a rk
b rown m a c u l es at s ites of previous s k in i nfla m mation . I n
d e r m a l P I H , there i s m o re of a brown-gray h u e .
M astocytosis, m a c u l a r a myloidosis, m i noc i n hyperpig
mentatio n , exogenous oc h ronosis, melasma, and ery
thema dysc h ro m i c u m persta n s .

None.
_____
Figure 27.2 (A) Pseudo-ochronosis seen after years of hydroquinone
treatment.
1 59
CO U RS E
P I H d oes not worse n i n the a bsence o f further i ns u lt o r
i nfla m mation a t the affected site . P I H usually resolves
ove r a period of a few months. In the case of dermal
hyperpigmentati o n , th ere may n ot be i m provement.
S u n expos u re, s u nscreen use
lime of onset
Recent rashes, i nj u ry, or treatment of s k i n
Med ication use
MANAG E M ENT
W h i l e there is no medical i n d ication to treat P I H , m a n y
patients a re as bothered by P I H as t h ey a re by t h e
Figure 27.2 (B) ( Continued) Significan t improvement after treatment with
a-switched laser
p rocesses that prod uced it i n itial ly. F u rthermore, P I H c a n

end u re fa r longer tha n the origi n a l e r u ptio n . There a re
m u ltiple treatments i n c l u d i ng to pica l , laser, a n d c h e m ical
peels ( Ta ble 2 7 . 1 ) . I t is essentia l to fi rst dete r m i n e the
cause of the hyperpigmentation . C u l prits ra nge from
hemosiderin to pigment to vasc u l a r. Without d eterm i n i ng
the etio l ogy correctly, treatment w i l l , at best, provide no
i m provement, o r worsen the P I H . Freq ue ntly, the safest
a n d most effective treatment is ti m e . Atte m pted treat
ment of P I H , espec ia l ly in da rker s k in ph ototypes, c a n
often worsen a n d prolong hyperpigmentatio n . N o r m a l ly,
e p i d e r m a l P I H w i l l resolve on its own ove r a period of
months.
Thera peutic o ptions i n c l u d e topical reti noids, bleach
i n g crea ms, chemical pee ls ( i nc l u d i ng glycol i c a c i d peels,
TAB L E 27. 1
Post- i nflammatory Hyperpigmentation treatment

Fractio n a l
Thera peutic
R eti n oid/
Peels/
o ptions
hyd roq u i none
m i c roderm a b rasion
Q-switc hed laser
Ablative lasers
resu rfa c i ng
Post-i nfla m m atory
N eeds to be used
20-70% glycol i c acid
No
No
No
hyperpigmentation
for weeks to
peels, jessner peels,
months for
c o m b i nation j essner
i m prove ment
TCNpee ls and Sa l ic i lyc

acid peels a n d/or
m ic roderma brasion
may h e l p i m prove
m ore q u ickly
Fa ce/u pper body
R i s k of pa rad oxic a l l y
i m proves more
m a k i ng posti nfla m matory
q u ickly t h a n lower
c h a nges worse if too
ha If of the body
m u c h i nf la m mation
is c reated
1 60
J essner peels, c o m b i nation J essnerfTCA pee ls, a n d sa l i

cyl i c a c i d pee l s ), a n d fractional laser treatment. There is
a risk of paradoxica l ly m a k i n g post- i nfla m matory c h a nges
worse if too m uc h i nfla m mation is created .
S U N P ROTECT I O N
S u n b l oc ks a n d s u n sc reens used d a i ly a re c r u c i a l t o pre
vent worse n i ng, as is sun avoid a n c e . Without their use,
other thera pies w i l l n ot be effective . If a patient d oes n ot
avoid s u n expos u re , P I H wi l l worsen . S u n avo i d a n ce
i n c l udes avoid i ng pea k s u n h o u rs , wea r i n g a hat out
d oors to protect the face from s u n exposu re a n d a n
awa re ness t h a t UVA rays pen etrates through w i n d ows
w h i l e d riving, w h i l e at work a n d wh i l e at home.
TOP I CAL T R EATM ENTS

T here a re a h ost of topical treatments fo r P I H that pro
d uce m i l d i m provement and may exped ite reso l ution .
Hyd roq u i none form u lations, pa rticu larly with su nscreens

- Hyd roq u i none ( 2 %-4% ) c rea ms a re effective, fi rst
l i n e treatment.
- Prolonged usage of hyd roq u i none can res u lt i n a
c h a ra cteristic s k i n d iscol oration known as pse udo

och ronosis ( Fig. 2 7 . 2 ) .
- B lea c h i ng c rea ms a re contra i n d i cated i n pregnant
a n d lactat i n g wo m e n .
Reti noids
- Solage ( 2 % meq u i nol a n d 0 . 0 1 % treti n o i n ) and
Tri l u ma ( 0 .0 1 % fluoc i nolone aceto n i d e , 4% hyd ro
q u i none, a n d 0.05% treti n o i n ) provide an exfol iative
benefit.
- Tri l u m a s h o u l d n ot be used i n defi n itely d ue to its cor
ticosteroid content and risk for atrophy.
Aze l a i c ac i d ( 20% ) c rea m a p pl ied twice d a i ly provides

slow l ighte n i ng of pigmentati o n .
Koj ic a c i d ( 1 %-2 . 5 % ) c rea m .

- The exact conce ntratio n of koj i c a c i d needed for
effective res u lts is u n known .
If any of these to picals prod uces sign ifi ca nt i nfla m ma

tion or i rritati o n , it is i m porta nt t o d isconti n u e its use to
avoid worse n i ng of P I H .
C H EM I CAL P E E LS
Chem ica l peels a re an effective treatment option for the
red uction of P I H .
Over-the-cou nter a-hyd roxy a c i d peels a re a benefi c i a l

adj u nct to phys i c i a n -strength c h e m i c a l
pee ls. The
conti n u a l exfoliation ach ieved from cons iste nt use of

the peels may res u l t i n m i l d l ighte n i ng.
Figure 27.3 (A) Hyperpigmentation on left side of face before treatment.

(8) Improvement after a series of salicylic acid peels and topical applica
tion of 4 % hydroquinone (Courtesy of Pearl E. Grimes, MDJ
1 61
G lyco l i c a c i d pee ls (20%-70% ) a re a d m i n istered every

2 to 3 weeks utilizing i n c reasing strengths as tole rated .
- The treatment end poi nt is m i ld confl uent e rythe m a .
- Treated a reas m ust b e f u l l y ne utra l ized with sod i u m
b i ca rbonate or wate r a t t h e com pletion o f t h e pee l .
- Lighte n i ng o f su perfi c i a l P I H m a y b e o bserved after
fo u r to six peels.
- Strict photoprotection for 1 m o nth is essential and
m u st be stressed .
J essner peels ( resorc i n o l , lactic acid , a n d sa l icyl ic a c i d )

a re a d m i n i stered every 6 t o 8 weeks.
- Treatment end point is a l ight white n i ng of the ski n .
- Strict photo protection for 2 t o 3 months i s advised .
- M u ltiple treatments a re reco m m e nded .
- Contra i n d icated i n p regnant a n d lactating women .
Com bi nation J essner/10% tri c h loroacetic (TCA) peels
may a lso be em ployed in a s i m i l a r fas h i o n as the

J essne r pee l . The J ess ner peel res u l ts i n exfo l iation
a l lowi ng for greater penetration of the TCA pee l .
- M u ltiple peels a re ge nera l ly needed .
- Contra i nd icated in p regnant a n d lactating wom e n .
- Deeper pee ls a re ra re ly e m ployed given t h e r i s k of
P I H exacerbation with h ea l i ng.
Caution m u st be used i n treating s k i n phototypes I l l to

VI, pa rti c u l a rly with med i u m-depth pee l s . Sa l i cyl ic a c i d
peels a re safest for d a r k s k i n phototypes ( Fig. 2 7 . 3 ) .
LAS ERS
Trad itiona l ly, laser treatment for P I H d oes n ot p rod uce
re l i a b l e i m provement and is n ot fi rst- l i n e thera py. In fa ct,
laser thera py may exacerbate P I H . In genera l , it is n ot
reco m m e n d ed .
F racti o n a l phototh ermolysis ( F P ) ca n , however, provide
i m prove ment of P I H ( Fig. 27 .4) . T h i s is espec i a l l y true for
patients with l ighter s k i n p h ototypes. I n d a rker s k i n types,
P I H often worsen s . I t s h o u l d not be recom m e nd ed as a
fi rst- l i n e thera py. Rather, blea c h i ng c reams a n d c h e m i c a l
p e e l s provide more consistent, reprod u c i ble resu lts.
Typical ly, F P treatments s h o u l d be d i rected toward
s u perfic i a l s k i n d e pth a n d avoid higher treatment densi
ties.

MANAG E M E NTIOUTCO M E
EXPECTAT I O N S
I t is i m porta nt t o reassu re patie nts that P I H w i l l resolve

on its own with t i m e , except if it is a dermal process .
Laser treatment is u n re l i a b l e a n d may prod uce worsen

i n g . It is u s u a l l y not reco m m e n d ed .
Figure 27.4 (A) Hyperpigmentation after a series of Q-switched laser tat
too treatments. (B) Improvement of PIH after two nonablative fractional

resurfacing treatments utilizing superficial depth and lower treatment
densities
1 62
It is i m porta nt to d isconti n u e a n y to pical m ed i cations

that prod uce i nfla m mation or i rritation to avoid wo rsen
i ng P I H .
C h e m i c a l peels a re l i kely to only l i ghten a n d not f u l l y

e l i m i nate the P I H . C a u t i o n s h o u l d be ta ken i n d a r ker
s k i n phototypes.
I t is bette r and safe r to uti l ize seri a l s u perfi c i a l peels

rather tha n a si ngle deeper peel to m i n i m ize the risk of
PI H .
P I H may not i m prove d espite seria l c h e m i c a l peel use.

P I H res u lt i n g from hemosiderin (ie, leg vei n treatme nts)
w i l l not res pond to lasers, pee ls, a nd bleac h i ng c rea ms.
In fact, treatment w i l l l i kely worsen the P I H .
B I B L I OG RAPHY
K i l mer S L . Laser erad ication o f pigme nted lesions a n d
tattoos . Dermatol. Clin. 2002;20( 1 ) :37-53.
M is h i m a Y, Ohyama Y, S h i bata T, et a l . I n h i b itory action of
koj ic acid on m e l a n ogenesis and its therapeutic effect for
va rious h u m a n hyperpigme ntation d isorders. Skin Res.
1 994;36( 2 ) : 1 34- 1 50 .
N a kagawa M , Kawa i K . Conta ct a l le rgy t o koj i c a c i d i n
s k i n c a re prod ucts . Contact Dermatitis. 1995;3 1 ( 1 ) :9- 1 3 .
Ngujen Q H , B u i T P. Azel a ic a c i d : Pha rmacoki netic a n d
pha rmacodyn a m i c properties a n d its therapeutic role i n
hyperpigmenta ry d isorders a n d a c n e . lnt J Dermatol.
1995;34( 2 ) : 75-84 .
CHAPT E R 28
Vitiligo
Viti l igo is an acq u i red i d i o path ic cond ition that prod u ces
sym metric d e pigm ented patc hes of the ski n . It is pa rtic u
larly d istress i n g a n d c l i n i ca l ly a p pa rent i n patients with
d a rker skin p h ototypes.
EPI D E M I O LOGY
Incidence: a p p roxi mately 2% of the world popu lation
Age: can present at a ny age but most commonly presents
in the second to fou rt h decade
Race: eq u a l
Sex: eq ual
Precipitating factors: i n h erita nce, tra u m a , i l l ness, emo
tional states
PATHOG EN ES I S
U n k nown .
There a re no melanocytes i n basa l cel l layer.

Patients
d isplay
wel l-demarcated ,
sym metric,
depig
mented , chal k-wh ite macules. Common locations include

el bows, knees, sacra l a rea , pen is, periora l a reas, a n d neck.
H a i r may also lose pigmentation ( Figs . 28. 1 and 28.2 ) .
Chem ical leukoderma, postinfl a m matory hypopigme nta
tion, nevus depigmentosus, nevus a nemicus, pityriasis
a l ba , l u pus erythe matos us, leprosy, and genodermatoses.

Wood 's l a m p exa m i nation i s h e l pfu l i n m a k i n g the d iag
nosis. In cases of u ncerta i nty, b i o psy s h o u l d be per
fo rmed of both lesiona l a n d n o n lesional s k i n in order to
d eter m i n e if there is an a bsence of melan ocytes in the
affected s ki n . Check thyro i d-st i m u lating hormone (TS H )
fo r hypothyro i d i s m .
CO U RS E
Viti l igo c a n p u rsue a va ria ble cou rse . After a n i n itial ra pid
p resentati o n , it te nds to sta bi l ize. Typical ly, it is a c h ro n i c
Figure 28. 1 Vitiligo on the trunk and neck of a young patient
1 63
1 64
d isease with periods of pa rt i a l re pigmentation but not res

ol ution . It may i m p rove in the s u m merti m e . I n some
cases, depigmentation beco mes extensive.
Age o f patient
Time of onset
Fa m i ly h i story
Occu pation
Chemical exposu res
MANAG E M ENT
There a re m u ltiple treatment modal ities for viti ligo.
U n fo rtu nately, treatment is frustrating a n d often i n effec
tive .
Patie nts u nd e rsta n d a bly a re d istressed
by the
a p pearance of viti l igo and desi re treatment. In exte ns ive

cases, it p rod u ces a stri ki ng a ppea ra nce, pa rti c u l a rly for
patients with darker s k i n ph ototypes .
P R EV E N T I O N
S u nscreens a n d s u n avoida nce protect viti l iginous s k in
from b u rn i ng a n d a re a n i m porta nt com ponent of ther
a py. F u rther, ta n n i ng u naffected s k i n wi l l accentuate the
contrast between normal a n d viti l iginous ski n , worse n i ng
the cosmetic a ppea ra nce of the d i sease .
TOP I CAL T R EAT M E N T

There a re a host o f topical treatments for viti l i go . T h ey
include
Corticosteroids
- To pica l
- l ntra lesi o n a l
Ca l c i n e u r i n i n h i bitors: tac ro l i m us, pi mecrol i m us

Monobenzylether of hyd roq u i none
- Prod u ces permanent d e pigmentation
- Twice d a i l y ove r 1-yea r period
- Permanent d e p igmentation is prod uced in less t h a n
50% o f patie nts
- Poor or no depigmentation in nearly h a lf of patients
- Caution prior to p u rs u i n g this permanent treatment
- Side effects i n c l u d e contact d ermatitis, e ryt h e m a ,
a n d pru ritus
- He ightened risk of s u n burn after this perma nent
treatment
Cam ouflaging m a ke u p and self-ta n n i ng agents to h i d e

depigmented m a c u l es
Figure 28.2 White forelock in the same patient
1 65
PH OTOTH E RAPY
P h otothera py is a m a i nstay of viti l igo treatment.
Psora len and u ltravio l et A ( P UVA) with topical o r o ra l

5-methoxypsora len or 8-methoxypsora len
N a rrowba n d UVB
ORAL T H E RAPY
Oral thera pies i n c l u d e
Ora l 5- or 8-methoxypsora len i n c o m b i nation w i t h gra d

u a l , l i m ited s u n exposu re
P u lse thera py with corticosteroi d s
S U RG I CAL TREATM ENTS

Autologous s k i n grafti n g can be a h e l pf u l treatment for
viti l igo reca lc itra nt to other thera p ies. I t is not a fi rst- or
seco n d - l i n e treatment. S p l it-t h i c k n ess grafts, epidermal
bl iste r grafts, c u ltu red melanocyte grafts, si ngle hair
grafts, a nd noncu ltu red epidermal suspension grafts
have a l l been exa m i n ed . Pa i n after graft p roced u res is
com m o n , pa rti c u l a rly at the ha rvest site ( Fig. 28. 3 ) .
A majority o f patients e m p loying t h e epidermal suction

graft tec h n i q u e sh owed i m prove ment.
S p l it-thi c k ness grafting and derma brasion have a lso

a c h i eved re pigmentation with i n an ave rage of 6 months
i n one stu dy of 22 patients .
Si ngle h a i r grafts a re m ost effective i n loca l ized or seg

mental viti l igo . Success in genera l i zed viti l igo is poor.
Both c u ltured p u re melanocyte suspension as wel l as

c u ltured epidermal grafting after treatment with C0 2 laser
have been shown to be successful in treating viti l igo .
- Resu lts were best i n loca l ized cases of viti l igo.
LAS ER T H E RAPY
Exc i m e r Laser
An exci mer laser em its UVB ra nge l ight a t 308 n m , close to
the wavelength of na rrow-ba nd UVB thera py that has been
used to successfu lly treat viti l igo. Begi n n i ng with a starting
d ose of 1 00 mJ/cm 2 , with i n c reasing d oses i n sta ndard

photothera py increments , there was good i m provement i n
reca lc itra nt viti l igo after 30 weeks o f treatments.
Acra l lesions were m ost refractory to treatment.
Few adverse effects.
Best res u l ts a re p rod uced on the face > neck, extre m i

ties, tru n k , a n d gen ita l i a > hands, feet.
M ore
expensive
tha n
m a ny
trad itiona l
thera pies.
Co m bi nation treatment with tacro l i m u s 0 . 1 % is more

effective than treatment with exc i m e r laser a l o n e .
B
Figure 28.3 (A) Depigmented patch of skin on right mandible.
(B) Significan t improvement after m ultiple 1 -mm punch grafts (Courtesy
of Pearl E. Grimes, MD)
1 66
P I T FALLS TO AVO I D/CO M PL I CAT I O N S/

MANAG E M E N T/O UTCO M E
EXPECTAT I O N S
Viti l igo is a d i ffi c u lt d isease to treat.
There a re m u ltiple fi rst- a n d secon d - l i n e therapies that

should be e m p loyed before seeking s u rgica l o r laser
treatments.
I t is es pec i a l ly d iffi c u lt to p rod uce long-term sign ifica nt

cosmetic i m provement i n extensive cases.
Freq ue ntly, re pigmentation may be confi ned to perifol

l i c u l a r a reas c reating a "spotty" a ppea ra n c e .
Patients n eed to be e d u cated t h a t a n y thera py m a y not

succeed .
The exc i m e r laser is not widely ava i la b l e , ma king its use

pa rtic u la rly d iffi c u lt.
B I B L I OG RAPHY
Chen Y F, Ya ng PY, H u D N , Kuo FS, H u ng CS, H u ng C M .
Treatment o f viti l igo by tra nspla ntation o f c u l t u red p u re
melanocyte suspensi o n : Ana lysis of 1 20 cases . J Am
Acad Dermato/. 2004; 5 1 ( 1 ) : 68-74.
H a d i S M , Spencer J M , Lebwo h l M . The use of the 308nm exc i m e r laser fo r the treatment of viti l igo . Dermatol
Surg. 2004;30 ( 7 ) :983-986 .
Koga M . Epidermal grafting u s i ng the tops of s uction b l is
te rs
in
the
treatment
of
viti l igo.
Arch
Dermatol.
1 988; 1 24( 1 1 ) : 1 656- 1 658.

Na GY, Seo SK, Choi SK. Single hair grafting for the treat
ment of viti l igo . JAmAcad Dermatol. 1 998;38(4): 580-584.
Ozd e m i r M, Ceti n ka l e 0, Wolf R, et a l . Com parison of two
s u rgica l a p proa c hes for treati ng viti l igo: A pre l i m i n a ry
study. lnt J Dermatol. 2002 ;4 1 ( 3 ) : 135-138.
Passeron T, Ostova ri
N,
Zakaria W, et al.
To pical
tacrol i m us a n d the 308 n m exc i m e r laser: A synergistic

c o m b i nation for the treatment of viti l igo. Arch Dermatol.
2004; 140(9 ) : 1 065- 1 069 .
Ta neja A, Tre h a n M , Taylor C R . 308- n m exc i m e r laser for
the
treatment of
loca l ized
viti l igo .
tnt J Dermatol.
2003 ;42(8) : 658-662 .

To riya ma K, Ka mei Y, Kazeto T, et a l . Combi nation of
s h o rt- p u l sed C02 laser resu rfa c i n g a n d c u l t u red epid er
mal sheet a utografting in the treatm e nt of vitil igo: A
prel i m i n a ry report. Ann Plast Surg. 2004 ; 53 ( 2 ) : 1 78- 1 80 .
va n G e e l N , Ongenae K, De M i l M , Haeghen YV, Vervaet
C, N aeyaert J M. Dou ble-b l i n d placebo-controlled stu dy of
a utologous tra nsplanted epidermal c e l l suspensions for
re pigmenting viti ligo. Arch Dermatol.
1 203- 1 208.
2004; 140( 1 0 ) :
S IX
Vasc u l a r A l te rat i o n s
1 68
CHAPT E R 29
Angio ke rato m a
Angioke ratomas a re te la ngiectasias with keratotic ele

ments . They present i n d i ffe rent c l i n ical scena rios i n c l u d
i n g ( a ) solitary or m u lt i p l e a ngioke ratomas occ urring
p red o m i n a ntly on lower extre m ities; ( b) a ngiokeratoma of
Fordyce affecti n g the sc rotu m a n d the vu lva ; ( c ) a ngiok
e ratom a of M i be l l i , a n a utoso m a l d o m i n a nt d isorder
affecti n g d o rs u m of h a n d s a n d feet, e l bows, a n d knees;
(d) a ngiokerato ma corporis d iffus u m associated with
Fa bry's d isease, an X- l i n ked recessive d isord e r c h a rac
terized by a.-ga lactosidase-A d eficie ncy and affecting
the lowe r a bd o m e n , buttoc ks, a n d ge n ita l ia ; a n d ( e )
a ngioke ratoma c i rc u mscri ptu m usua l ly grou ped on one
extre m ity.
Age: solita ry o r m u ltiple a ngiokeratomas u s u a l l y affect
you n g a d u lts , a ngiokeratomas of Fordyce affect m i d d le
aged and elderly i n d ivid u a l s . Angioke ratoma of M i be l l i
a n d a ngioke rato ma c i rc u msc r i ptu m a re u s u a l l y d iag
n osed in c h i l d h ood .
Sex: a ngiokeratoma of M i be l l i a nd a ngioke ratoma c i r

c u mscri pt u m exh i bit fem a l e pred o m i na nce. Otherwise,
there is no sex pred is position .

R ed t o violaceous, we l l - c i rc u m sc r i bed hyperke ratotic
pa p u les a n d p l a q ue s .
D I F F E R E N T I A L D I AG N OS ES
Sol ita ry lesions ca n be m ista ken for mela noma , a cq u i red
hemangioma, lym p ha ngio m a , seborrheic ke ratos is, a n d
wa rts .
LABORATORY DATA
D e r m atopat h o l ogy
M a rked d i lated , t h i n -wa l l ed blood vesse ls in the pa p i l l a ry
d e r m i s , associated with an overlying acanthotic hyperker
atotic epidermis.
COU RS E MANAG E M ENT
M a nagement o f a ngiokeratomas rema i ns a c h a l lenge.
Figure 29. 1 (A) Angiokeratomas on the abdomen of a young patient.
M a n y m od a l ities have been reported i n the l iterature with
(B) Angiokeratoma imaged through an epiluminescence microscope
va riable s uccess . Treatment m od a l ities i n c l u d e
(DermLite)
Sect i o n 6 : Va sc u l a r A l te rat i o n s
1 69
Lasers : a ngiokeratomas have occasionally been treated

successfu lly with lasers.
- The p u lsed dye laser ( P OL) is an effective d evice for
the i m provement of the vasc u l a r component of
a ngiokeratomas,
but
freq uently
some
keratosis
rema i n s . The target c h romophore is hemogl o b i n .

P O L has proven successful a t 595 n m , 5-to-7- m m
spot, 9 t o 1 1 J/c m 2 , O C O 30/20. Cove ring the a ngiok

e rato m a with a glass s l i d e , that is, d iascopy, is h e l p
fu l . The end point is lesional p u r p u ra . H ea l i ng occ u rs

in more than 10 to 14 days. M u lt i p l e treatments may
be req u i red ( Fig. 29 . 3 ) .
- Res u rfacing lasers s u c h as C0 2 and Er:YAG lasers ca n
be uti l ized for lesiona l va porizatio n . Patients genera l ly
req u i re local i nfi ltration with 1 % l id oca i n e with or with
out epinephrine prior to treatment. The U ltra Pu lse C0 2
( Lu men is, Sa nta Clara, CAl is employed using a 3-m m
col l i mated hand piece, with an energy of 300 to 500 mJ
with nonoverlapping pu lses . The va rious sca n ned C0 2
lasers such as the Sharplan FeatherTouch a re
Figure 29.2 Angiokeratoma on the left thigh resistant to m ultiple treat
ments with pulsed dye laser
em ployed using the 1 25-m m hand piece, 3-m m sca n

size at 14 to 40 W. The treatment end point is a blation
to
achieve
lesional
flattening
and
opalescence.
Treatment sites should be clea nsed with sa l i ne soa ked

ga uze
between
laser
passes.
Postoperative
care
req u i res twice d a i ly wash i ng with soa p and water a n d

a ppl ication o f a n a nti biotic oi ntment. Hea l ing occ u rs i n
more t h a n 2 t o 6 weeks. A s with a l l a blative proced u res, sca rring may be observed .
- Other lasers that have been used i n the past with
va riable success i n c l u d e potass i u m -tita nyl-phosphate
laser, a rgon laser, a n d copper va por lase r. Long
pu lsed N d : YAG ( 1 , 064 n m ) laser has been shown to
be effective in i m prov i n g a ngioke ratomas d u e to its
selectivity a nd its deeper penetration i nto the ski n .
Successfu l treatment with a d ua l -wave length laser
system (595 a n d
reported
1 , 064 n m ) has been rece ntly

( Cynergy with M u lti plex , Cynosu re,
Westford , MA, U S A ) .
O t h e r s u rgical treatments i n c l u d e excision , electro

ca utery, electrofu lgu ratio n , or c ryosu rgery.
Patients s h o u l d be advised that the P O L treatment wi l l

cause o bvious b r u i s i n g for u p t o 14 days.
Keratotic
featu res
may
persist
after
treatment.
I m provement is often el usive.
B I B L I OG RAPHY
Gorse SJ , J a mes W , M u rison M S . S u ccessful treatment of
a ngioke ratoma with potass i u m tita nyl phosphate laser. Br
J Dermatol. 2004; 1 50 ( 3 ) : 620-622.
Figure 29.3 (A) Biopsy-proven angiokeratoma on the thigh of a young
child. (B) Some resolution after one treatment with pulsed dye laser at a
wavelength of 595 nm with a 1 0-mm spot, pulse duration of 1 . 5 ms, a
fluence of 7. 5 J/cm2 , and DCD 30120
1 70
La pi ns J , Emtesta m L, M a rcusson J A . Angiokeratomas i n

Fa bry's d isease a n d Fordyce's d i sease : Successful treat
ment with copper va pour laser. Acta Derm Venereal.
1 993; 73 ( 2 ) : 1 33- 1 3 5 .
Occella C , B l e i d l D , R a m p i n i P, Schiazza L, R a m p i n i E.
Argon laser treatment of c uta neous m u lt i p l e a ngioker
atomas. Dermatol Surg. 1995;2 1 ( 2 ) : 1 70- 1 7 2 .
Ozd e m i r M , Baysa l I , Engi n B , Ozd e m i r S . Treatment of
a ngiokeratoma of Fordyce with long- p u lse neodym i u m
d o ped ytt r i u m a l u m i n i u m garnet laser. Dermatol Surg.
2009;35( 1 ) : 92-97 .
Pfi rrma n n G , R a u l i n C , Ka rsa i S . Angioke rato ma o f the
lower extre m ities: Successfu l treatment with a d ua l
wavele ngth laser system ( 595 a n d 1 064 n m ) . Eur Acad
Dermatol Venereal. 2009;23( 2 ) : 1 86- 187.
Sommer S , M e rc h a nt WJ , Shee h a n - Da re R . Severe p re
d o m i n a ntly acra l va riant of angiokeratoma of M i be l l i :
Response t o long-pu lse N d : YAG ( 1 064 n m ) laser treat
ment. JAmAcad Dermatol. 200 1 ;45 ( 5 ) : 764-766 .
CHAPT E R 3 0
Che r ry a nd Spid e r Angio mas
Cherry a ngiomas, a lso known a s r u by spots, se n i l e

hema ngiomas,
a cq u i red
ca p i l lary
hemangioma,
and
Ca m p bell d e Morga n spots a re very c o m m o n benign vas

c u l a r lesions that pred o m i n a ntly affect the tru n k . Spider
a ngiomas, a lso known as nevus a ra n eus, spider telangiec
tasia, a rteri a l spid er, and vasc u l a r spid er, re present loca l
ized
telangiectasias
rad iating
from
centra l
feed ing
a rterioles. They a re common vasc u l a r lesions that pre

d o m i n a ntly affect the face, u pper tru n k , a rms, and hands.
EPI OEM I O LOGY

Age: cherry a ngiomas-m i d d l e-aged a n d elderly peo ple;
s p i d e r a ngiomas-a l l ages
Sex: more common in fema les
Precipitating factors: cherry a ngiomas can e r u pt d u ri n g
p regnancy or w i t h h e patic d i sease. S pider a ngiomas a re
strongly associated with pregna n cy, i nta ke of ora l contra
ceptive p i l ls, a n d h e patoce l l u l a r d isease
PATHOG EN ES I S
U n known for both . Assoc iation with pregna n cy, o ra l con
traceptive use, a n d l iver d isease suggest a hormona l ly
med iated a ngioge n i c mecha n is m .
Sect i o n 6: Va sc u l a r A l te rat i o n s
171

Cherry a ngioma prese nts as a 1 -to-3-m m bright red to
violaceous,
s mooth ,
d o m e-sha ped
pa p u l e .
Spider
a ngioma d is plays a network o f d i l ated ca p i l l a ries rad iati ng

from a ce ntra l vessel . B oth may bleed when tra u matized .
PATHOLOGY
Che rry a ngiomas show loss of rete ridges as we l l as con
gested and ectatic ca p i l l a ries a n d postca p i l l a ry ven u les in
the pa p i l la ry dermis. S p i d e r a ngiomas revea l a centra l
asce n d i ng a rte riole that b ra nc hes a n d co m m u n icates
with m u lt i p l e d i lated c a p i l l a ries.
D I F F E R E N T I AL D I AG N OS ES
Cherry a ngiomas ca n be m ista ken for angiokerato m a ,
glomeruloid
hema ngioma ,
pyoge n i c
gra n u l o m a ,
and
n od u l a r mela noma . S p i d e r a ngiomas can be m i sta ken for

genera l i zed essentia l te langi ectasias a n d h ered ita ry h em
orrhagic tela ngiectasia .
CO U RS E
Che rry a nd spider a ngiomas a ri s i n g d u ri n g pregnancy
may regress postpa rt u m . S p i d e r a ngiomas a rising i n
c h i l d hood m a y a lso resolve sponta neous ly. Otherwise,
both lesions ten d to persist.
MANAG E M ENT
Although
med ica l l y
i nsign ifica nt,
c h e rry a n d
spider
a ngiomas a re freq u e ntly treated for cosmetic p u r poses .

M u ltiple
effective
s u rgica l
treatment
o ptions
exist.
Depend i ng on the proced u re selected , the cost to the

patient
may
va ry
sign ificantly.
Che rry
and
spider
a ngiomas that present d u ri ng pregnancy s h o u l d n ot be

treated u ntil seve ra l months after d e l ivery as they may
resolve on their own .
El ectrosu rgery
- El ectrod essication with coagulation ( monopolar set
ti ng, 1-2 W fol l owed by gentle c u rettage with end
point of lesional flatte n i ng a n d h em ostas is) has been
the trad itiona l treatment m od a l ity for th ese lesions.
- I t is effective and easi l y a ccess i b l e .
- The potential f o r sca r formation m ust b e considered .
Laser su rgery : d ifferent lasers have been used su ccess

fu l ly in treatment of c h e rry a n d spider angiomas.
- P u l sed dye laser ( P OL) is the treatm e nt of c h oice. A
Figure 30. 1 (A) Spider angioma, right nose. (B) Full resolution of spider
angioma after a single pulsed dye laser treatment to central vessel and
surrounding skin
s pot size s h o u l d be selected that matc h es d ia meter

of the a ngioma . With spider a ngiomas, the ce ntra l
1 72
feed i n g vessel as we l l as the s u r ro u n d i n g vessels

s h o u l d be treated . It is best to com press the lesion
with a m i c roscope s l i d e to b l a n c h all but the centra l
fee d i n g vesse l . A p u r p u r i c laser pu lse s h o u l d be
d e l ivered . The m i c roscope s l i d e shou ld be rem oved
to a l low for coo l i n g of the a rea . S u bseq uently, a p u r
p u r i c laser p u lse ca n be e m p l oyed to target the
te la ngiectasias rad iating from the feed i n g vesse l . The
p u r p u ric treatment end point re presents coagu lation
of the targeted vessels ( Figs . 30. 1 and 3 0 . 2 ) .
- The potass i u m -tita nyl-phosphate ( KT P ) 532-n m laser
prod u ces a favora b l e res ponse. S pot size s h o u l d
match the lesion d i a m eter. The vessels shou l d b e
traced out c o m p l etely for m ost effective treatment.
Treatment end point is lesional cleara nce or su perfi
c i a l white n i ng. E rythema ca n be expected posttreat
ment, last i n g 24 to 48 h o u rs .
- Ca rbon d ioxid e laser ( U itra P u lse 3-m m co l l i m ated

h a n d piece,
300-400
mJ/pu lse,
nonoverlapping
p u l ses; Sharplan FeatherTou ch 1 25- m m h a n d piece,

14-40 W, 3-mm sca n size, nonoverla p p i n g p u lses)
has been e m p l oyed as secon d-l i n e thera py with
su ccess . Treatment e n d po i n t is lesional flatte n i n g .
Potentia l sca r formation m ust be consid ered .
Light thera py
- I ntense p u l sed l ight ( I P L) has a lso been e m p l oyed
with some su ccess. As coagu lation is needed fo r
lesional reso l ut i o n , h igher fluences may be req u i red
for treatm ent efficacy.
S u rgical exc ision

- Excision should be reserved for lesions that a re resis
ta nt to other treatments. A posto perative sca r is
expected w h i c h may be less cosmetically pleasing
t h a n the a ngioma .
Figure 30.2 (A) Cherry angiomas on the trunk in a middle-aged female.

(B) The appropriate endpoint is purpura obtained after pulsed dye laser
treatment (wavelength of 595 nm, 7-mm spot. 1 . 5-ms pulse duration,

f/uence of 1 2 J/cm 2 , DCD 30120)
Patie nts need to be cou nseled as to the l i ke l i h ood of

o bvious p u r p u ra fo l l owi n g treatment with P D L that may
persist for 1 0 to 14 d ays , espec i a l l y off the face. Lesions
a re less l i kely to be com pletely treated at s u b p u r p u ric
fluences.
S i m ple electrocautery may be j u st as effective as P D L

at a red uced cost t o t h e patient.
Com press i n g the lesion with a glass slide d u ri n g PDL o r

K T P treatment is h e l pful t o m i n i mize its s i z e a n d a l low
i ng for greate r laser penetrati o n . This red u ces the tota l
energy needed for coagu lation a n d i n c reases the treat
ment success rate .
M u lt i p l e treatme nts may be req u i red , in pa rti c u l a r for

la rge spider a ngiomas.
Figure 30.3 (A) Cherry angioma, chest.
1 73
B I B L I OG RAPHY
Dawn G , G u pta G . Com pa rison o f potass i u m tita nyl p h os
p hate vasc u l a r laser a n d hyfrecato r in the treatment of
vasc u l a r
spiders
and
che rry
a ngiomas.
Clin
Exp
Dermatol. 2003 ; 28(6) : 58 1 -583 .

Fod or L, R a m o n Y, Fodo r A, Ca r m i N , Peled I J , U l l ma n n
Y. A side- by-side pros pective study o f i ntense p u l sed l ight
and N d : YAG laser treatment fo r vasc u l a r lesions. Ann
Plast Surg. 2006; 56(2 } : 1 64- 1 70 .
Figure 30.3 (ContinuedJ (B) Pulsed dye laser treatment to cherry angioma
utilizing diascopy (C) Purpura immediately post pulsed dye laser treat
ment. (D) Complete resolution of cherry angioma after one pulsed dye
laser treatment
1 74
CHAPT E R 3 1
G ra nu l o m a Facia l e
G ra n u loma fac i a l e ( G F ) was fi rst d escri bed by Wigley i n

1 945 w h o la beled t h e d i sease "eos i n o p h i l ic gra n u l o ma . "
P i n kus re n a m ed this d isorder gra n u loma fac i a l e i n 1952.
G F is a n i d i o pathic c h ro n i c c uta neous d isorder that usu
a l ly i nvolves the face, pa rt i c u l a rly the nose . It ca n prese nt
with a si ngle lesion or m u ltiple lesions.
Incidence: u n c o m m o n
Age: 30 t o 50 yea rs
Race: pri m a ri ly seen in Caucasians
Sex: ma les > fem a l es
Figure 3 1 . 1 Granuloma faciale on the scalp
PATH OG E N ES I S
U n k nown , but may b e mediated b y i m m u ne c o m p lex
d e position .

Si ngle i n d u rated facial brown ish-red pa pule o r plaque.
Some lesions may have telangiectasia . M u ltiple lesions may
be present. Extrafacial sites rarely observed . Lesions may
vary in size from m i l l i meters to centimeters ( Fig. 3 1 . 1 ) .
D I FFERENTIAL D I AG N OS ES
Cutaneous l u pus erythematos us, sa rco idosis, lym p h o m a ,
pseudolym phoma , c uta neous T-ce l l
lym p h o m a , fixed
d ru g e r u pti o n , rosacea .
Dense, polymorphous i nflam matory cell i nfi ltrate i n the
u pper two-t h i rds of the dermis. The i nfi ltrate is com posed
of n u merous eosinoph i ls, neutrophi ls, lym phocytes, a n d
h istiocytes . A pro m i nent grenz zone is c h a racteristica lly
present. Leu kocytoclastic vasc u l itis is freq uently observed .
CO U RS E
The lesions of G F a re usua l ly c h ro n i c a n d o n l y occasion
a l ly resolve s ponta neously.
1 75
MANAG E M ENT
Difficu lt t o treat with a ny modal ity. A n y s uccessfu l treat
ment often leaves sca rring.
Corticosteroids: topica l , i ntra lesio n a l
Tac ro l i m u s o i ntment (0. 1 % )
Da psone
Anti m a l a ri a l s
Colc h ic i n e
Cl ofaz i m i n e
G o l d i nj ecti ons
S U RG I CAL TREAT M E N T
C ryos u rgery:
m u ltiple
reports
i n d icati ng su ccessful
c l ea ra n c e . Resu lts a re u n pred icta ble ( Fig. 3 1 . 2 ) .
S u rgical excision .
Derm a b rasion .
El ectrosu rgery.
L i g h t Treat m e n t
Topica l psora len a n d u l traviolet A ( P UVA) rad iation

thera py
Laser thera py: d ifferent lasers have been used in the

treatment of GF with p ro m i s in g resu lts, either as an
a b lative thera py with ca rbon d i oxid e laser o r as a selec
tive thera py ta rget i n g the prom i n ent vasc u latu re in G F
lesions using the Q-switc hed a rgon laser, p u lsed dye,
d i ode laser, and potass i u m tita nyl phosphate ( KT P )
532-nm l a s e r ( F ig. 3 1 .3 ) .
P I T FALLS T O AVO I D
G F is often reca lc itra nt to thera py. Patie nts s h o u l d be

cou nseled that successfu l treatment is often el usive.
B I B L I OG RAPHY
A m m i rati CT, H ruza GJ . Treatment o f gra n u l o m a fac i a l e
w i t h the 585- n m p u l sed d y e laser.
Arch Dermatol.
1 999; 135(8) :903-905.

Apfel berg DB, Dru ker D , Maser M R , Las h H, S pence B
J r, Denea u D. G ra n u l o m a fac i a l e . Treatment with the
a rgon laser. Arch Dermatol. 1 983 ; 1 1 9 ( 7 ) : 573-576.
Figure 3 1 .2 (A) Multiple lesions of granuloma faciale on the face. (8) No

significant improvement detected after one treatment with cryotherapy on
a 4-month follow-up visit
1 76
Chatrath V, R o h rer TE. G ra n u loma fac i a l e successfu l l y

treated w i t h long-pu lsed t u n a b l e d y e laser. Dermatol
Surg. 2002 ;28( 6 ) : 527-529 .

Elston O M . Treatment of gra n u loma fac i a l e with the
p u l sed dye laser. Cutis. 2000;65(2 ) : 9 7-98.
Khaled A , J ones M, Zerma n i R, et a l . G ra n u loma fac i a l e .
Pathologica. 2007 ;99( 5 ) : 306-308.

M a i l l a rd H, G rogna rd C , Toled a n o C, J a n V, Mac het L,
Va i l la nt L. G ra n u l o m a fac i a l e : Efficacy of c ryosu rgery i n
2 cases. Ann Dermatol Venereal. 2000; 1 2 7 0 ) : 77-79 .
To mson N , Ste rl i ng J C , Sa lva ry I . G ra n u loma fac i a l e
treated successfu l l y w i t h topica l tac ro l i m us . Clin Exp
Dermatol. 2009;34(3) :424-42 5 .

Wheela nd R G , Ash l ey J R , S m ith O A , E l l i s O L, Wheela n d
O N . Ca rbon d ioxid e l a s e r treatment o f gra n u loma fac i a l e .
J Dermatol Surg Oneal. 1 984; 1 0 ( 9 ) : 730-733 .
Figure 3 1 .3 (A) Indurated brownish-red plaque on the left cheek of a

middle-aged female with granuloma facia/e. (B) Two-year follow-up show
ing resolution of granuloma faciale after m ultiple pulsed dye laser treat
ments
CHAPT E R 3 2
1 77
I nfa ntile H e m a ngio m a
I nfa nti le hema ngioma ( I H l , a lso known as strawberry,

ca p i l l a ry,
or
cavernous
hema ngiom a ,
is
benign
e n d oth e l i a l prol iferation that re presents the most com

mon tumor i n i nfa ncy. I t ca n be c lassified i nto su perfic i a l
hema ngioma ( S H , 55% o f cases ) , deep hema ngioma
( D H , 30% of cases ) , and m ixed su perfi c i a l and deep
hema ngioma ( M H , 1 5% of cases ) . They occ u r m ost com
m o n ly o n head a n d neck a reas .
EPI D E M I O LOGY
Incidence: 1% to 3 % a re p resent at b i rt h , 10% to 1 2 %
a re p resent b y 1 yea r o f age
Age: majority (80 % ) become a p pa rent between 2 a n d

5 weeks o f age; 2 0 % a re n oted at b i rt h .
Sex: fe ma les a re affected two t o fou r ti mes more t h a n

m a l es
Precipitating factors: prematu re i nfa nts a re more com

monly affected
PHYS I CAL EXA M I NAT I O N

The a p pearance depends o n t h e d e pth o f the heman
gioma a n d the phase of evol utio n . S H p resents as bright
red -colored p l a q u e . D H presents as a soft dermal o r s u b
c uta neous nod u l e with a b l u ish- p u r p l e col or. M H shows
featu res of both SH a n d D H . M u lt i p l e truncal heman
giomas
may
be
o bserved .
I nvol uting
hema ngiomas
demonstrate a flatter su rfa ce with a grayis h - p u r p l e h u e

t h a t begi ns ce ntra l l y a n d expa n d s outwa rd . The h e m a n
giomas
m ight
become
u lcerated
and
he morrhag i c .
Resi d u a l fatty tissue, atrop hy, tela ngiecta s i a , s c a r forma

tion , and hypertrophy may be observed .
D I F F E R E N T I AL D I AG N OS ES
Congen ita l hema ngiomas ca n be confused with a vasc u
lar
ma lformation
such
as
port-wi n e sta i n
at
b i rt h .
H ema ngiomas a re ge nera l ly present after b i rth versus

vasc u l a r ma lformations, which a re genera l l y present at
b i rth .
LABO RATORY TESTS

Prol iferations of p l u m p e n d oth e l i a l cel ls that may exte n d
fro m the su perfi c i a l d e r m i s t o the deep su bcuta neous
tiss u e , d e pen d i ng o n the hem a ngioma s u btype.
Figure 32. 1 (A) Left upper eyelid hemangioma in its early growth phase,
a lesion that may threaten the child 's vision. (B) Marked lightening and
flattening of the hemangioma after m ultiple pulsed dye laser treatments
1 78
A n c i l l a ry Tests
A n a bd o m i n a l u ltraso u n d s h o u l d be o bta i ned if m o re

t h a n fo u r tru ncal hema ngiomas a re noted prior to
4 months of age .
An electroca rd iogra m ( ECG) a n d a ca rd iac EC H O should

be considered for a n y concern of h igh ca rd iac output.
COU RS E
H ema ngiomas c h a racteristica l l y exh i bit th ree phases of
evol ution : ( a ) prol iferative phase, ( b ) i nvol uting phase,
and (c) i nvo l uted phase. The prol iferati ng phase is c h a r
a cterized by a ra p i d growth p hase that starts at 1 to
2 m o nths of age a n d lasts u nt i l 6 to 9 months of age. This
growth phase is fol l owed by the i nvol uting phase that
usua l l y starts i n the second yea r of l i fe a n d persists for
severa l yea rs. M ore than 90% of u ntreated hema ngiomas

i nvol ute, that is, atta i n maxi m a l regression by 9 yea rs of
age. U p to 30% of hema ngiomas leave posti nvol ution
cha nges i n c l u d ing hypopigme ntati o n , sca rring, tela ngiectasi a , and fi b rofatty tiss u e .
COM P L I CAT I O N S
B leed i n g a n d u lceratio n with seco n d a ry i nfection a n d
sca rring, espec ia l ly i n hema ngiomas i nvolvi ng t h e d i a pe r
a rea , a re c o m m o n l y see n . Oth er serious com pl ications
i n c l u d e orbital o bstruction and a m b lyo pia with periorbita l
hema ngiomas, u pper a i rway o bstruction with h e m a n
g i o m a s i n the bea rd d istri bution , s p i n a l a bnorma l ities
with l u m bosacra l hema ngiomas, posterior fossa ma lfor
mation in la rge fac i a l hema ngioma ( P H A C E syn d rome) ,
a n d h igh output c a rd ia c fa i l u re with m u lt i p l e c uta neous
hema ngiomas assoc iated with viscera l i nvolvement.
Figure 32.2 (A) Hemangioma on the left fifth toe pad, a location that
in terfered with the child's ability to ambulate. (B) Significant clearing and
near resolution of the hemangioma after multiple pulsed dye laser treat
ments
Onset o f lesion
N u m ber of lesions noted
U l ceration n oted
B l eed i ng noted
Prior treatm ents a n d res ponse
MANAG E M E N T
T h e treatment o f I H s is controve rsia l . G iven t h e natu ra l
cou rse o f I H with sponta neous reso l ution, m a n y physi
cians c h oose to ca refu l ly o bserve the a rea with no
i ntervention, espec i a l l y i n nonfacia l , sma l l , a n d u ncom
p l icated
hema ngiomas.
Ea rly i ntervention
is recom
m e n d ed for ( a ) all I H s that i nterfere with the function of

vita l
orga ns
(eg,
periorbita l
hema ngiomas,
a i rway
o bstruction with hema ngiomas i n the bea rd d istr i b ution,
1 79
h igh-output cardiac fa i l u re ) ; ( b ) la rge facia l hema ngiomas

that usua l ly i nvo l ute with permanent d i sfiguri ng; (c) u l cer
ated hema ngiomas; and (d) hema ngiomas in the d ia per
a rea that a re very l i kely to u lcerate causing severe pa i n .
Medica l treatment
- Steroids i n c l u d i ng topica l steroid a pp l i cation ( c lass 1
corticoste roid a p pl ied twice d a i ly with mon itoring
every 2 wee ks) , i ntra lesiona l steroids (tria m c i nolone
a ceto n i d e 1 0 mg!m L a d m i n istered monthly), and oral
steroids ( 1 . 5-2 mg/kg/d of pred n isone) a re the m a i n
stay o f treatment. Patie nts m ust be mon itored c l osely,
espec ia l ly with oral steroid use given the risk of sys
temic com p l ications i nc l u d i ng growth reta rdation a n d
g l u cose a lterations. Loca l ized side effects i n c l u d e
atrophy a n d yeast infect i o n .
- Other treatment options i nc l u d e to pica l i m i q u i mod
( a p p l ied d a i ly ) , i nterferon-a (3 m i l l ion u n its/m 2/d ,
S C ) , a nd v i n c ristine (0.05 mg/kg/d if less than 10 kg,

IV ), espec ia l ly in steroid-resista nt I H . As i nterferon-a
is associated with spastic d i plegi a , patients m u st be
mon itored c l osely.
P ro p ra nolol at a d ose of 2 mg/kg/d has been recently

reported to be ve ry effective i n treating severe I H s , even
in steroid-resista nt I H s . T h i s treatment is proposed to
re place ora l or i ntravenous steroids that a re associated
with sign ifica nt side effects. H owever, patients on p ro
pra n olol s h o u l d be c l osely m o n itored for bradyca rd i a ,
hypotension , a n d hypoglycemia espec ia l ly a t the o nset
of the treatment.
Laser treatment
- P u lsed dye laser ( P D U treatment i n d u ces sign ifi
ca ntly faster regression of the I H . Fl u e nces lower
than those of PWS a re effective and a re assoc iated
with lowe r risk of laser- i n d u ced sca rri ng ( Figs . 3 2 . 1 ,
3 2 . 2 a n d 3 2 . 3 ) . P D L has been used exte nsively i n
the treatment of I H i n th ree c l i n ical scena rios:
Figure 32.3 {A) Segmental hemangioma in volving the hand of a 1 -year
1. U l cerated hema ngiomas res pond effectively to

P D L. PDL ma rked ly dec reases the associated
pa i n a n d i n d uces ra pid hea l i ng of the u l ceration
(75% with i n 2 weeks) ( Fig. 32.4) . Res i d u a l sca r
fo rmation from the u l ce ration is expected .
2. S H s c a n respond wel l to P D L if sta rted either
before
or
early
in
the
prol ife rative
phase.
M u ltiple treatments, every 4 to 6 weeks, a re

req u i red in the prol iferative phase. T h e o n ly
exception is a ra pid ly prol ife rating fa c i a l hema n
gioma . P D L treatment may i n d uce u lceratio n of
these va ria nts so treatm ent s h o u l d be avoided .
I H with deeper components ( M H , D H J res pond
less effectively to PDL beca use of the l i m itation
of penetration of PDL to 1 . 2 mm i n the ski n .
3 . P D L ca n h e l p treat the res i d u a l erythema a n d
tela ngiectasias o n
hemangiomas.
the
s u rface o f i nvol uted
old girl. {B) Complete resolution of the hemangioma after four treatments
with 595-nm pulsed dye laser at low fluences
1 80
- Long-pu lsed N d : YAG lasers a re usefu l for photocoagu

lation of D H s but have a h igher incidence of sca rring.
Other
interventions
include
s u rgical
debulking
and
em bol ization . The risks and benefits of each s u rgica l

a pproach should be considered ca refu l ly before i nterven
tion since the sca r from spontaneous regression is usua l ly
better than the surgica l scar. Em bol ization is uti l ized in
hema ngiomas associated with h igh-output ca rd iac fa i l u re.
Use of excessive P O L fluences without s k i n coo l i ng ca n

cause sca r.
Pa rents a re u nd ersta n d a bly a nxious a bout their c h i l d 's

hema ngioma . A f u l l d iscussion of the natu ra l c o u rse of
hema ngiomas is m a ndatory prior to sta rt i n g thera py.

The option of foregoi n g treatm ent a n d c l i n ica l l y m o n i
toring a patient s h o u l d b e reviewed ca refu l ly p r i o r to
sta rt i n g treatment.
Pa rents s h o u l d a lso have a rea l i stic idea of the l i m ita

tions of thera py. La rge hema ngiomas res pond less suc
cessfu l ly
to
o ra l ,
s u rgica l ,
and
laser
thera py.
C o m p l icated hema ngiomas that may i n te rfere with the

c h i l d 's health s h o u l d be referred to an a p p ropriate
ped iatric spec i a l i st. P a re nts m ust be awa re that treat
ment wi l l provide an i m provement but may n ot res u lt i n
fu l l resol ution o f t h e h e m a ngioma .
Parents n eed to be ed ucated on proper wou n d care,

espec i a l ly for u lcerated hema ngiomas, i n order to
i m prove the c h i l d 's q u a l ity of l ife .
F i b rofatty c h a n ges a re ofte n a seq uela of resolved

hema ngiomas.
Such
c h a nges
can
be
i m p roved
sign ificantly with n o n a b l ative a n d a blative fract i o n a l

resu rfa c i ng.
B I B L I OG RAPHY
Batta K, G oodyea r H M , M oss C, Wi l l i a m s H C , H i l ler L,
Waters R. R a n d o m ised control led study of early p u lsed
dye laser treatment of u ncompl icated c h i l d hood haeman
giomas: Resu lts of a 1 -yea r a na lysis.
Lancet 2002 ;
360(9332 ) : 5 2 1 -527 .
Lea ute-La breze C, Du mas de Ia Roq ue E, H u biche T,
Bora levi F, Tha m bo J - B , Taleb A. Propranolol for severe
hema ngiomas of i n fa n cy. N Eng! J Med. 2008;358: 2649265 1 .
L i YC, McCa h a n E , R owe N A , M a rt i n PA, Wilcsek G A ,
Figure 32.4 (A) Ulcerated hemangioma, isolated nodular type, extremely

painful and hemorrhaging, treated twice with pulsed dye laser 6 Jlcm 2 ,
7-mm spot size, 590 nm. (B) At 2 months ' follow-up, significant healing
of the ulceration after a single treatment with pulsed dye laser. (C) Four
months after initial pulsed dye laser treatment and 2 months after
second pulsed dye laser treatment, there is complete healing of the
ulceration
M a rt i n FJ . S uccessfu l treatment o f i nfa nti le h a e m a n

g i o m a s o f the o r b i t w i t h pro p ra n olol . Clin Experiment
Ophthalmol. 2010;38(6): 5 54-559 .

More l l i J G , Ta n OT, Yoh n J J , Weston WL. Treatment of
u l cerated hema ngiomas i nfa n cy. Arch Pediatr Ado/esc
Med. 1 994; 148( 1 0) : 1 1 04- 1 1 0 5 .
CHAPT E R 33
1 81
Ke ratosis Pi l a ris At rophica ns
Ke ratosis p i l a ris atro p h ica ns ( K PA) is a gro u p o f i n he rited

d i so rd e rs with th ree su btypes i n c l u d i ng (a) keratosis
p i l a ris atro p h i ca n s fac i e i ( KPAF ) , (b) atrophoderma ver
m ic u latu m (AV ) , a n d (c) ke ratosis fo l l i c u l a ris s p i n u losa
d ecalva n s ( KFS D ) . KPA F a n d AV present m a i n ly on the
face with K FS D often a p pea r i n g o n the eye b row a n d AV
m ost com m o n l y seen on the c heeks, sparing the eye
brows a n d sca l p . KFSD can affect the face, sca l p , a n d
tru n k . I n herita nce pattern can b e a utosom a l d o m i na nt
( KPAF, AV) , recessive (AV ) , or X-l i n ked ( KFS D ) .
EPI D E M I O LOGY
Incidence: very ra re; KPAF is the m ost c o m m o n su btype
Age: KPAF a n d KFSD in i nfa ncy; AV in c h i l d h ood
Sex: ma les a re more seve rely affected in KFSD
Figure 33. 1 Keratosis pilaris: fine, sandpaper-like follicular papules on
PATH OG E N ES I S
the arm of a young man
Abnormal fol l i c u l a r keratin ization of the u pper sectio n of

the h a i r fol l icle that may later res u lt in atro p h i c fo l l i c u l a r
sca rring.

Fol l i c u l a r
pl u gging
with
erythema
in
early
stages
( Figu re 33. 1 ) . Atro p h i c fol l i c u l a r sca r fo rmation with

assoc iated a lopecia in later stages .
Ke ratos is p i l a ris, keratosis pila ris ru b ra , seborrheic der
matitis ( KPA F ) , atopic d e rmatitis ( KFS D ) , other etiologies
of sca rring a l o pecia ( KFS D ) , acne sca rri ng (AV), Rom bo
syn d rome (AV ) , a n d K I D syn d rome ( K FS D ) .
D i lated fo l l ic l es with fo l l i c u l a r hyperkeratosis and i nfla m
m a t i o n i n e a r l y stages . Fol l i c u l a r fi brosis a n d atrophy i n
later stages .
CO U RS E
The cou rse i s c h ro n i c with n o sponta n eous reso l ution .
With t i m e , the e ryt h e m ato u s fo l l i c u l a r hyperkeratotic
pa p u les i nvol u te i nto d e p ressed atro p h i c fo l l i c u l a r sca rs
with a l opec i a .
1 82
MANAG E M ENT
There is n o com pletely effective treatment for KPA.
M u ltiple treatment options have been tried with only va ri
a b le s uccess . Patients should be cou nseled that thera py
may not be effective.
Topical thera py may, at best, prod uce modest benefit.

- Lactic acid a n d a-hyd roxy acid lotions ( 1 0 %- 1 2 % )
a p plied twice d a i ly may i m p rove the text u ra l ro ugh
ness. H owever, they may p rod uce i rritatio n .
- R eti n o i d s (taza rote n e , reti n-A) a p p l ied n i ghtly may
i m p rove text u r a l ro ugh ness. T h ey may prod uce i rri
tati o n .
- Corticosteroids a p p l ied s pa ri ngly m a y show i m provement. R i s k of fac i a l atro ph y l i m its their use.
System i c thera py
- Other o ptions that have p rovided va ria ble su ccess
i n c l u d e o ra l reti noids a n d d a pso n e .
- They a re m ost h e l pfu l fo r the i nfla m m atory stage of
KPA, but provide m i n i m a l i m prove ment in the fol l ic u
l a r hyperkeratos is.
- They req u i re ca refu l mon itoring for potentia l side
effects.
Laser thera py
- P u lsed dye laser ( 59 5 n m , 7-m m spot, 7-1 0 J/cm 2 ,
D C D 40/20, p u lse d u ration of 1 . 5-3 ms) c a n be
effective in the treatment of the assoc iated e rythema
of KPAF but will not sign ifica ntly i m prove the text u ra l
rough n ess o f KPA ( Fig. 33 . 2A , B ) .
- Laser-assisted h a i r remova l with long- p u lsed n o n
Q-switc hed ru by l a s e r may be a n effective treatment
i n patients with KFS D .
P I T FALLS T O AVO I D
Pati ent expectations a re ge nera l ly very h i g h . They m ust
be cou nseled as to the c h ro n i c natu re of the cond ition
and m i n i m a l res ponse to ava i la ble thera pies.
B I B L I OG RAPHY
Baden H P, Byers H R . C l i n i c a l fi n d i ngs, c uta neous pathol
ogy, and response to therapy i n 21 patients with keratosis
p i l a ris atro p h ica n s . Arch Dermatol. 1 994; 130(4):469475.
C h u i CT, B e rger TG , P rice VH, Za c h a ry CB. R eca lcitra nt
sca rring fol l ic u l a r d isord e rs treated by laser-assisted h a i r
re mova l : A prel i m i na ry report. Dermatol Surg. 1 999 ;
25( 1 ) : 34-3 7 .
C l a rk S M , M i l l s C M , La n iga n SW. Treatment o f keratosis
p i l a ris atro p h i c a n s with the p u lsed tunable dye laser. J
Cutan Laser Ther. 2000 ; 2 (3 ) : 1 5 1 - 1 56.
Figure 33.2 (A) Keratosis pilaris atrophicans. Patient is emotionally both

ered by persistent erythema. (8) Marked lightening of erythema 2 years
following three pulsed dye laser treatments
Ka u n e K M , Haas E, E m m e rt S, Schon M P, Z utt M .

Successfu l treatment of severe keratos is p i l a ris ru bra with
a 595- n m pu lsed dye laser. Dermatol Surg. 2009 ; 3 5 :
1 592- 1 595.
M a rq ue l i ng AL, G i l l ia m AE, P rend ivi l l e J, et al. Keratosis
p i l a ris ru b ra : A c o m m o n but u n d errecogn ized conditi o n .
Arch Dermatol. 2006; 142( 1 2 ) : 1 6 1 1 - 1 6 1 6 .
R i c h a rd
G,
H a rth W . Keratosis fol l ic u l a ris s p i n u losa
d ecalva n s . T he ra py with isotret i n o i n and etreti nate in the

i nfla m matory stage. Hautarzt. 1 993;44(8) : 529-534.
CHAPT E R 34
Po rt-wi n e Stains
Port-wine sta i n s ( PWS) a re low-flow ca p i l lary m a lforma

tions. They represent the m ost common type of vasc u l a r
ma lformations. Any a rea o f t h e body can b e affected .
H owever, the head a n d neck a reas a re m ost co m mo n ly
affected .
EPI D E M I O LOGY
Incidence: 3 per 1 , 000 newborns
Age: prese nt at b i rt h i n the majo rity of patients ; rarely
a p pea r i n adolesce nce o r a d u lthood
Sex: no sex pred i l ection
Race: less common i n Asi a n s a n d African Americans
Associated syndromes: PWS can be a m a n ifestation of
severa l synd romes i n c l u d i n g Stu rge-We ber syn d rome,
K l i ppel-Tre n a u nay synd ro m e , P rote us syn d rome, and
pha komatos is pigmentovasc u la ris
P H YS I CAL EXA M I NAT I O N

PWS prese nts a t b i rth a s l ight p i n k , we l l-dema rcated
m a c u l a r lesions a n d patc hes usua l l y in a segmenta l d is
tri butio n . They ca n tra n sform with age i nto hypertro p h i c
d a r k r e d a n d/or p u r p u ric pla q u es w i t h nod u l a rity. PWS
i nvolves the face m ost c o m m o n l y a l ong the trigem i n a l
n e rve d istri bution : ophtha l m i c b ra n c h V 1 ( u pper eye l i d
a n d forehea d ) , maxi l l a ry b ra n c h V2 ( u pper l i p , cheek,
lower eye l id ) , a n d m a n d i b u l a r b ra n c h V3 .
PWS exh i bits c h a racteristic c l i n i cal featu res a n d i s sel
d o m m isd iagnosed . I t can be confused with the mac u l a r
stage o f h e m a ngioma at b i rth .
1 83
1 84
M u ltiple d i lated t h i n -wa l led vesse ls in the pa p i l l a ry a n d
reti c u l a r d e r m i s .
A N C I LLARY TESTS
The pa rents s h o u l d be cou nseled rega rd i n g the possi

b i l ity of Stu rge-We ber synd rome (SWS) i n lesions
l ocated i n a fac i a l Vl o r V2 dermatom a l d istri bution .
SWS is cha racterized by the prese nce of fac i a l PWS
with i psi latera l o c u l a r a n d lepto m e n i ngea l a n o m a l ies.
Ten to fifteen percent of pati ents with PWS i n the V l
d istr i b ution wi l l have SWS . Patients w i t h b i latera l PWS
h ave even a h igher risk of SWS . An ophthal mologic
exa m i nation to ru l e out gla ucoma a nd cata ract forma
tion with conti n ued fo l lowu p is necessa ry for these
patients . A head c o m p uted tomogra phy ( CT) or mag-
netic reson a n ce i maging ( M R I ) s h o u l d be o bta i ned to

r u l e out b ra i n i nvolvement that could affect menta l
development a n d res u l t i n sei z u res.
PWS overlyi ng the s p i n e ca n be associated with s p i n a l

a n o m a l y s u c h as s p i n a l dysra p h i s m o r tethered s p i n a l
cord . N e u ro l ogic eva l uation a n d a p p ro priate i maging
stu d ies a re recom m e n d ed .
Large extremity PWS should ra ise the consideration of

Kl i ppel-Trenau nay syn d rome, cha racterized by capillary
venous ma lformations or ca pil lary-lym phatic-venous mal
formations with hypertrophy of the affected extrem ity. Leg
girth and length should be measu red and followed over
time.
COU RS E
PWS grows proporti o n a l l y with the patient a n d gra d ua l ly
t h i c kens a n d d a rkens i n color from p i n k to d a r k red to
deep p u rple. Eleven percent may d eve l o p n od u l a rity a n d

2 4 % may d eve l o p pyoge n i c gra n u lomas. PWS may b e
associated with hypertro phy o f u n derlying soft tissue a n d
bone,
pa rtic u l a rly
in
Stu rge-We ber
syn d rome
and
K l i ppel-Tre n a u nay syn d ro m e .
On set o f lesion
Assoc iated c l i nical fi n d i ngs
Is the c h i l d m eeti ng d eve l o pmenta l m i lestones?
Has the c h i l d had an eye exa m i nation?
Has the c h i l d had a head M R I or CT?
B l eed i ng
B l ebs
(B) Significant lightening of the PWS after a single POL treatment.
G rowth of PWS
(C) Complete resolution of the PWS after POL treatments
Figure 34. 1 (A) PWS on the right inner thigh of an infant girl.
1 85
MANAG E M ENT
PWS d e m o nstrates progressive vasc u l a r d i latation a n d
hypertrophy with age, t h u s m a k i ng treatment d u ri ng
ea rly i nfa ncy esse ntial for a bette r res ponse. Treatment
ca n be sta rted as ea rly as 2 weeks of age . Treatment p ro
vides a red uction in the n u m be r of vessels a n d d oes n ot
c o m p l ete ly rem ove the enti re lesio n . T h e refore , the PWS
may exh i bit some d a rke n i n g a n d t h i c ke n i ng over t i m e
despite
i n terventio n .
G e n e ra l
a n esthesia
m ight
be
needed for treati ng la rge PWS i n c h i ld re n .
Laser treatm e n t ( F igs . 34. 1-34. 5 ) .

P u lsed dye laser ( P O L) rema i n s the gol d sta n d a rd for
the treatment of PWS . Effective P O L pa ra meters i n c l u d e

wavele ngths o f 5 8 5 t o 600 n m , flue nces o f 6 t o 1 5 J/c m 2 ,
p u l se d u rations of 0.45 or 1 . 5 ms with cryogen spray
cool i n g (CSC). Fou r to twe lve laser sessions with 4-to-8week i nterva ls a re u s u a l l y req u i red in order to ach ieve
sign ificant b la n c h i n g of the PWS . Lower fl uen ces a re i n itia l ly uti l i zed for PWS off the face a n d in d a rker s k i n
types . The use o f e s c concom ita ntly d u ri n g P O L treatment sign ificantly dec reases the pa i n associated with the
proced u re a n d the i n c i d ence of bl istering. esc protects
the epidermis a n d a l l ows for d e l ivery of h igher flu ences,
resulting in more effective b l a n c h i ng of the PWS . P O L
treatm ent is fo l l owed b y tem pora ry p u r p u ra that usua l ly
resolves in 7 to 14 days. Complete l ighte n i ng of PWS with
POL treatment is a c h i eved i n l ess than 20% of PWS .
Resista nce to
P O L treatment
is
more freq ue ntly
encou nte red in deeper and hypertro p h i c PWS . H e l pful

m a n e u ve rs to potentiate the efficacy of P O L i n c l u d e
i n c reasi n g t h e fl u e n ces with adeq uate c ryogen cool i n g to
p rotect the epidermis a n d i n c reas i n g the wavelength u p
to 600 n m to ta rget deeper vesse ls. A pi lot study demon
strated that PWS that a re treated with to pica l imiquimod
once d a i ly for 1 month after P O L exposu re m a n ifest
su perior b l a n c h i ng res ponse over time as compared to
P O L a l o n e . Another re port i n vestigated the c o m b i ned use
of POL and a topica l a n giogenesis i n h i bitor, rapamycin,
using the in vivo rodent wi n d ow c ha m ber mode l . There
was no reformation a n d reperfusion of blood vessels after
treatment with P O L fol l owed by topical ra pamyc i n for
14 d ays, i n contrast to P O L a l o n e . With extreme ca ution
to avo i d sca rring and dyspigmentatio n , it is poss i b l e to
treat P O L-resista nt PWS and deeper or hypertro p h i c
a d u lt P W S su ccessfu l ly w i t h longer wavele ngth lasers that
a l low d eeper penetration i nto the skin such as l ongp u l sed a l exa n d rite (755 n m ) laser, long-pu lsed N d :YAG
( 1 , 064 n m ) laser, and d u a l 595- n m P O L a n d 1 ,064- n m
N d :YAG laser cou pled w i t h adeq uate coo l i ng. U s e o f t h e
N d :YAG laser can be treac h e rous as there is a narrow
thera peutic ra nge. R isk of sca r ca n be sign ificant.
Light treatment: i ntense pu lsed l ight ( I P L ) may be effec

tive in treatment of PWS , i n c l u d i n g P O L- resista nt PWS .
A green-ye l l ow waveband a n d lowest ava i l a ble p u lse
B
Figure 34.2 (A) Extensive port-wine stain on the right face and forehead
of an infant male. (8) Significant resolution after multiple treatments

with pulsed dye laser
1 86
d u ration s h o u l d be used , with s k i n coo l i ng. A recent

ra ndom ized c l i n ical tria l com pa r i ng P O L a n d I P L side
by side revea led a better efficacy a n d h igher patient
preference after POL treatment. P h otodyna m ic thera py
may a lso prove to be an a lternative efficacious treat
ment for PWS .
Other treatment modal ities for PWS that can be effec

tive i n c l u d e tattooing a n d cosmetic m a keu p .
Patients s h o u l d be cou nseled that PWS d isplay a va ri

a b le response to treatment. M o re extens ive and th icker
lesions respond less wel l when com pa red to su perfi c i a l
lesions. Fac i a l PWS responds best. P W S treatment effi-
cacy decreases as one d escends from face to feet, with

the lower extre m ities d isplaying the least treatment
benefit.
M u lt i p l e treatment sessions may be req u i red . B r u i s i n g

is a necessa ry side effect t o o bta i n efficacious thera py.
Laser treatment may prod uce "footpri nti ng" or o n ly pa r

tial i m p rovement.
Treatme nts should be ceased when the patient is satis

fied with l ighte n i ng, o r when n o fu rther benefit has
been noted , that is, afte r two su bseq uent treatments.
B I B L I OG RAPHY
Alste r TS, Ta nzi EL. C o m b i ned 595- n m a n d 1 , 064- n m
laser i rrad iation o f rec a l c itra nt a n d hypertro p h i c port
wine sta i n s in
c h i l d ren a n d a d u lts.
Dermatol Surg.
2009 ; 3 5 ( 5 ) : 8 1 3-8 1 5 .
C h a n g CJ , Hsiao Y C , M i h m M C J r, N elson J S . P i lot stu d y
Figure 34.3 (A) Extensive port-wine stain on the right neck of a young
female. (B) Marked resolution of the port-wine stain after multiple treatments with pulsed dye laser
exa m i n i ng the com b i ned u s e o f p u lsed d y e l a s e r a n d topical l m i q u i mod versus laser a l o n e for treatment of port
wine sta i n b i rt h m a rks. Lasers Surg Med. 2008;40(9 ) :
605-6 1 0 .
C h a pas A M , Eickhorst K, G e ron e m u s R G . Efficacy of
early treatment of fac i a l port w i n e sta i n s in newborns: A
review of 49 cases. Lasers Surg Med. 2007;39 ( 7 ) : 563568 .
C h i u C H , C h a n H H , H o WS , Ye u ng C K , N e lson J S .
P ros pective stu d y o f p u l sed d ye laser i n conj u nction with
c ryogen s p ray coo l i n g fo r treatment of port wine sta i ns i n
C h i n ese patients. Dermatol Surg. 2003;29(9):909-9 1 5 .
Discussion 9 1 5 .
Fa u rsc h o u A , Togsverd- B o K , Zachariae C , Haedersdal
M. P u lsed dye laser vs . i ntense p u lsed l ight for po rt-wine
sta i ns : A ra nd o m ized side-by-side tria l with b l i n ded
res ponse eva l uati o n . Br J Dermatol. 2009 ; 1 60(2) :359-
Figure 34.4 (A) Port-wine stain on the lower mucosal and cutaneous lip.
1 87
Ho WS, Ying SY, C h a n PC, C h a n H H . Treatment of port

wine sta i n s with i ntense pu lsed l ight: A prospective study.
Dermatol Surg. 2004;30(6):887-890.

H u i keshoven M, Koste r P H , d e B orgie CA, Beek J F, va n
Gernert M J , va n d e r H o rst C M . Reda rken i n g of port-wine
sta i n s 1 0 years after p u l sed-dye-laser treatment. N Eng! J
Med 2007;356( 1 2 ) : 1 235- 1 240.

Li L, Kon o T, G roff WF, C h a n H H , Kitazawa Y, N oza ki M .
Com parison study of a long-pu lse p u lsed dye laser a n d a
long-pu lse p u lsed a lexa nd rite laser in the treatment of
port w i n e sta i ns . J Cosmet Laser Ther. 2008; 1 0( 1 ) :
12-15.
P h u ng T L , O ble D A , J ia W , B enja m i n L E , M i h m M C J r,
N elson J S . Can the wo u n d hea l i ng res ponse of h u ma n
s k i n b e mod u l ated afte r laser treatment a n d t h e effects of
exposu re exte nded? I m pl ications on the c o m b i ned use of
the p u l sed dye laser a n d a topical a ngioge nesis i n h i bitor
fo r treatment of port wine sta i n b i rth ma rks . Lasers Surg
Figure 34.4 (Continued) (B) Significant lightening of port-wine stain after
Med. 2008;40( 1 ) : 1-5.

Se l i m M M , Ke l l y K M , N e lson J S, We nd elsc hafe r-Cra b b G ,
Ke n n edy WR , Z e l i c kson B D. Confocal m i c roscopy stu d y
three treatments with a combination of pulsed dye laser to the cutaneous lip
and vermilion and long-pulsed 1 , 064-nm Nd: YAG laser to the inner
mucosa/ lip and vermillion
o f nerves a n d blood vessels i n u ntreated a n d treated

portwine sta i ns : Pre l i m i n a ry o bservati ons. Dermatol Surg.
2004;30:892-897.
Ya ng M , Ya roslavsky A , Fari n e l l i , e t a l .
Long-pu lsed
neodym i u m : Yttri u m -a l u m i n u m -ga rnet laser treatment

for port-wi ne sta i n s . J Am Acad Dermatol. 2005 ; 52(3):
480-490.
Figure 34.5 Hypopigmentation, which can be permanen t, after aggres

sive treatment of a PWS in an A frican-American patient
1 88
CHAPT E R 3 5
Pyoge nic G ra n ulo m a
Pyoge n i c gra n u l o m a ( PG ) c a n be rega rded a s a benign

vasc u l a r tu m o r o r a s a reactive vasc u l a r process a risi ng
at sites of prev i o u s tra u m a or i rritat i o n . PG is a lso k n own
as l o b u l a r ca p i l l a ry h e m a n g i o m a , gra n u l o m a tela ng
iectatic u m , a n d gra n u lo m a gravi d a r u m when p rese nting
o n t h e gi ngiva of preg n a n t wo m e n . I t commonly occ u rs
i n a reas of tra u ma i n c l u d i n g the face a n d finge rs .
EPI D E M I O LOGY
Incidence: c o m m o n
Age: most common i n c h i l d ren a n d yo u ng a d u lts
Precipitating factors: m i nor tra u ma , pregna n cy, laser treat
ment of port-wi ne sta ins, isotretinoin
Figure 35. 1 Classic hemorrhagic pyogenic granuloma
PATHOG E N E S I S
Reactive neovasc u l a rization suggested b y c o m m o n asso
c iation with preexisting tra u m a o r i rritation a n d l i m ited
growth ca pac ity.

Red t o violaceous, d o me-sha ped , friable
pa p u l e or
nod u le , 0.5 to 1 . 5 e m i n size, with s m ooth surfa ce that

freq uently ulcerates ( Figs. 35. 1 , 3 5 . 2 and 3 5 . 3 ) .
N od u l a r a me l a n otic m e l a n o m a , glomus tumor, h e m a n
gioma , sq u a m o us c e l l carci noma ( S C C ) ( F ig. 3 5 . 4 ) ,
nod u la r basa l cel l carc i n o m a , wa rt, bac i l l a ry a ngiomato
sis, Ka posi 's sa rco m a , and m etastatic cancer.
Wel l -circ u mscri bed exo phytic l o b u l a r pro l i feration of ca p
i l l a ries with flattened a n d someti mes e roded overlyi n g
epidermis w i t h pe r i p hera l epidermal "colla rettes . "
COU RS E
P G u s u a l l y grows ra p i d ly over the cou rse of weeks o r
months a n d then sta b i l izes. It b l eeds freq u e ntly with
m i nor tra u ma and ca n persist i n d efin itely if n ot treated .
Figure 35.2 Pyogenic granuloma on the palm of a pregnant woman,

bleeding frequently
1 89
MANAG E M ENT
Laser treatment
- Pu lsed dye laser (585--600 n m , 0.45- 1 . 5 ms, 7-10 m m ,
6-- 1 5 J/cm 2, O C O 20-40/20 with or without d iascopy) is
a safe and effective device for the treatment of small
lesions and for ped iatric patients. Seria l treatments are
usua l ly req uired . Treatment is wel l tolerated without
anesthesia. A recent report suggested shave excision
followed by immed iate pu lse dye laser ( P OLl for larger
lesions. POL has been also reported to be effective i n
gi ngival PG. Nd:YAG laser c a n also be effective.
- Carbon d ioxi d e is effective . Lesional flatte n i ng is the
c l i n ica l end point. l ntra l esional l i doca i n e 1% is neces
sa ry prior to treatment. Postoperative ca re req u i res
twice d a i ly cleansing with soa p a n d water a n d a p p l i
cation o f a nt i b i otic oi ntment over a 2 t o 6 wee ks heal
i n g t i m e . Sca r formation is l i kely. A low rec u rrence
rate is noted .
S u rgical treatment: a l l treatments may res u lt in sca r for
Figure 35.3 Pyogenic granuloma overlying a dermal nevus
mati o n .
- Shave exc ision fol l owed b y electrod essication o f t h e
base is t h e proced u re most c o m m o n l y e m p loyed .
Recu rrence is common ( Figs . 3 5 . 5 a n d 3 5 . 6 )
- El l i ptica l exc ision c a n be pe rformed w i t h l o w rec u r
rence but wi l l leave a sca r
- Ligation of the base
- C ryos u rgery
Alternative treatment options i n c l ud e

- l m iq u i m od 5 % c rea m h a s been recently reported to
be effective in ped iatric patients a n d in patients with
recu rrent PG
- l ntralesional i njection of a bsol ute etha nol
- Scleroth erapy with monoetha nola m i n e oleate
- To pica l a l itreti n o i n (9- cis-ret i n oic c i d ) ge l , a d rug that
is used for the treatment of Ka pos i 's sa rcoma
Patients s h o u l d be awa re that rec u rre nce is common

after treatment.
Patie nts s h o u l d be i nformed that all treatments may

result i n sca rring.
Amela notic melanoma as wel l as SCC and other skin can

cers can m i mic PG . A biopsy should be performed for
any suspicious lesions in the a ppropriate c l i nical setti ng.
B I B L I OG RAPHY
B o u rguignon
R,
Paq uet
P,
P i e ra rd - F ra n c h i mont
C,
P i e ra rd G E . Treatment o f pyogen ic gra n u lomas with t h e

N d-YAG laser. J Dermatolog Treat. 2006; 1 7(4) : 247-249 .
Figure 35.4 Pyogenic granuloma mimicking a squamous cell carcinoma
on the left lower mucosa/ lip of a patient with multiple nonmelanoma

skin cancers
1 90
Fa l l a h H , Fisc h e r G , Zaga re l l a S. Pyoge n i c gra n u loma i n

c h i ld re n : Treatment with to pical i m i q u i m od . A ustralas J
Dermatol. 2007;48(4) : 2 1 7-220

Kha n d p u r S , Sharma VK. S u ccessfu l treatment of m u lti
p l e gi ngiva l pyoge n i c gra n u lomas with p u lsed-dye laser.
Indian J Dermatol Venereal Lepra/. 2008; 74( 3 ) : 275-27 7 .

M a loney D M , S c h m idt J D , D u v i c M . A l itreti n o i n g e l to
treat pyoge n i c gra n u loma . J Am Acad Dermatol. 2002 ;
47( 6 ) : 969-970.
Mats u m oto K, N a ka n is h i H, Seike T, Koiz u m i Y, M i h a ra K,
Ku bo Y. Treatment of pyogen i c gra n u loma with a scleros
ing agent. Dermatol Surg. 200 1 ;27(6) : 52 1 -523 .
R a u l i n C, G reve B , H a m mes S. The combi ned conti n u
ouswave( pu I sed carbon d ioxide laser for treatment o f pyo
gen i c gra n u lo m a . Arch Dermatol. 2002 ; 138( 1 ) :33-3 7 .
S u d A R , Ta n ST.
Pyoge n i c gra n u loma c o m p l icating
p u lsed -dye laser thera py for c h e rry a ngioma . J Plast
Reconstr Aesthet Surg. 2010;63(8) : 1 364- 1368.
Figure 35.5 (A) Shaving a hemorrhagic and painful pyogenic granuloma

on the plantar foot with # 1 5 blade. The specimen was sent for histological
confirmation. (B) Electrodessication of the residual pyogenic granuloma
1 91
Figure 3 5 . 6 (A) Biopsy-proven pyogenic granuloma on the right chin of a

young female. (8) Shave excision of pyogenic granuloma with Derma
Blade (Personna Medical, Verona, VA)
1 92
CHAPT E R 3 6
Fac i a l
Facial Te l a ngiectasias
tela ngiectasias a re d i lated
vesse ls a p pea ring
su perfi c i a l l y i n the dermis m ostly on the a l a e nas i .

Te la ngiectasias a re a lso c o m m o n i n sca rs a n d va rious
s k i n lesions .
EPI O E M I O LOGY
Age: most common i n a d u lts and elderly peop le
Sex, race: n o se x o r ra ce pred isposition
Prec i p itati ng facto rs: c h ro n i c a cti n i c d a mage, rosacea,
and topical steroid use a re the m ost common preci pitat
ing factors. Other less c o m m o n etiologies i n c l u d e hered i ta ry hemorrhagic telengiectasia , Cockayne synd ro m e ,
ataxia telengiectasia ,
B l oo m 's syn d ro m e ,
Roth m u nd
Thomson synd rome, sclerod erma, C R EST syn d rome,

l u pus, a n d ra d iation dermatitis

Te la ngiectasias consist o f fi n e , tiny, e rythe matous l i n ea r
vessels, typica l ly 0 . 2 t o 2 m m i n d ia m eter, c o u rs i n g
a l ong the s u rface o f the ski n , w h i c h b l a n c h ea s ily u po n
press u re .
D i lated , t h i n-wa lled vessels i n the u p per d e r m i s .
COU RS E
Fac i a l telangiectasias a re usua l ly c h ro n i c i n natu re with
no sponta neous resol ution .
MANAG E M E N T
Fac i a l tela ngiectasias a re freq uently treated for cosmetic
p u r poses . M u ltiple effective treatment opti ons exist.
Laser treatment: m u lt i p l e effective options a re ava i l

a b l e . Patients m u st b e awa re that ove r t i m e they a re
l i kely to d eve l o p more te la ngiectas ias.
- Pu lsed dye lasers ( P D U a re the treatment of choice
for fac i a l telangiectasias ( Figs. 36 . 1-36 . 5) .
The trad itional P D L with a short pu lse d u ration of
0.45 or 1 . 5 ms provides the most effective treatment
for fac i al tela ngiectasias. However, posttreatment
p u r p u ra occ u rs which genera l ly lasts 7 to 14 days
Figure 36. 1 (A) Middle-aged male with multiple facial telangiectasias.

(B) Purpura observed immediately after pulsed dye laser treatment.
(C) Significan t reduction in telangiectasias after a single-pulsed dye
laser treatment
1 93
N ewer generation 595- n m P D L ( i e , V- bea m or

V- bea m Perfecta lasers, Ca ndela Corp . , Wayl a n d ,
M A l with va ria b l e pu lse d u rations ( 0 .45, 1 . 5, 3, 6,
10, 20, 30, 40 msl can provide a red u ced p u r p u ra
treatment of fac i a l tela ngi ectasias when longer
p u l se d u rations a re util ized , but is somewhat less
effective and u s u a l l y req u i res m u lt i p l e treatme nts
0 C o m m o n ly, s u b p u r p u ric fluences of less t h a n 1 0

J/c m 2 at pu lse d u ration o f 1 0 m s , with a 7-mm
spot size a re util ized .
0 Better efficacy of the va riable-pu lse P D L i n treat

ing fac i a l tela ngi ectasias can be a c h ieved by uti
l iz i n g p u r p u ric fl ue n ces o r by pu lse sta c k i n g with
s u b p u rpuric pu lses (stac ked 2-4 s u b p u p u ric
p u lses at a 1 . 5- H z repetition rate, 7 . 5 J/cm 2 ,
1 0-ms p u lse d u rati o n , 1 0- m m spot size, D C D of
30/20l or by perfo r m i n g m u ltiple passes d u ri n g

the sa m e session .
0 La rger t h icker l i near vessels can be treated with

the newest ge neration 595- n m long- P O L (V- bea m
Perfecta , Candela Corp . , Wayla n d , MAl using a
3
10 mm e l l i ptical spot size, 40- ms pu lse d u ra
tio n , 1 5 to 1 7 J/cm 2 , a n d DCD 30 to 40/20. The

end point is tra nsient b l u ish d a rke n i ng of the
vessel fol l owed by vessel b l a n c h i n g ( Figs . 36.4
and 36. 5 l . T h is treatment may res u lt in m i ld
p u r p u ra in a ro u n d 23% of patients .
Fac i a l edema , eryt h e m a , a n d d iscomfort c a n occ u r
after exte nsive treatment with the p u r p u ra-free va ri
a ble-pu lse PDL. H owever, these u nd es i red effects
a re ge nera l ly better tolerated when c o m pa red to a
p u r p u ra-i n d u c i ng laser treatment

- The va riable pu lse width 1 ,064-n m N d : YAG laser has
prove n to be effective i n the treatment of fac i a l
telangiectasias. S h o rter pu lse w i d t h s w i t h h igher fl u
en ces m ight be n ecessa ry for effective treatment of
s m a l l e r vessels but have an i n c reased risk of bl ister
and scar formati o n . The seq uential d e l ivery of 595and 1 , 064- n m wavelength has been re ported to be
more effective than a single wavelength treatment.
- Freq u e ncy-d o u bled
532- n m
N d :YAG
laser
a lso
cal led potass i u m-tita nyl-p hosphate ( KT P l laser pro

vides effective a bsorptio n of hemogl o b i n with a pu lse
d u ration of 1 to 50 m s m a k i ng it idea l ly su ited to treat
su perfi c i a l vesse ls without p u r p u ra formati o n . Tra c i n g
o f i n d ivid u a l vessels is a usefu l tec h n i q u e for patients
with a counta b le n u m be r of d iscrete , visi ble vesse ls.
Flashla m p ( i ntense pu lsed l ight [ I P Ll l treatment

- I P L provi des a n other effective, p u r p u ra-free method
fo r red ucing fac i a l tel a ngiectasias and
e rythema
( Fig. 36.6l . For exa m ple, fluences of 30 to 40 J/c m 2
with 20-ms pu lse d u ration a re effective with the Starlux

Lux G handpiece ( Palomar Medical Tech nologies,
Figure 36.2 (A) Telangiectasias prior to pulsed dye laser treatment. The
setting was 1 0-mm spot, 595 nm, 8 J!cm2 , 6-ms pulse duration.
(B) Immediately posttreatment. (C) Ten days after pulsed dye laser
treatment
1 94
B u rl i ngton, M A l . The treatment end poi nt is i m med iate

vessel cleara nce or selective vessel d a rken i ng. M u ltiple
treatments may be req u i red for the greatest treatment
benefit.
Other
treatment
options
include
electrosu rgery,
c ryothera py, a n d i nfi ltration of scleros i n g agents. These

a re less selective, often less effective, a n d more l i kely to
resu lt in sca rring than laser or I P L treatment
Treatment typica l l y is wel l tolerated

O bvious posttreatment p u r p u ra for 7 to 1 4 days with
p u r p u r i c setti ngs is expected
P u r p u ra ca n be avoided by uti l iz i n g non pu rpu ric set
ti ngs at the expense of dec reased efficacy
Fac ia l edema, erythema , a nd d isco mfort can occ u r after

extens ive treatment with the p u r p u ra-free va riable-pu lse
POL
Tela ngiectasias w i l l rec u r over yea rs
Caution in da rker s k i n types
B I B L I OG RAPHY
Bernste i n EF, Kligm a n A . R osacea treatment u s i n g the
new-generation , h igh-energy, 595 nm, long p u lse-d u ra
tion p u lsed -dye laser. Lasers Surg Med. 2008;40(4) : 233239 .
J 0rgensen G F, Hedel u nd L, Haedersda l M . Lo ng-pu lsed
dye laser versus i ntense pu lsed l ight for ph otodamaged

ski n : A ra n d o m ized spl it-face trial with b l i n d ed res ponse
eva l uation . Lasers Surg Med. 2008;40 ( 5 ) : 293-299.
Ka rsa i S , R oos S, R a u l i n C . Treatment of fac i a l te la ngiectasia using a d ua l -wavelength laser system ( 59 5 a n d
1 , 064 n m ) : A ra n d o m ized control led tri a l w i t h b l i nded
res ponse eva l uati o n . Dermatol Surg. 2008;34( 5 ) : 702708 .
R o h re r TE, C hatrath V, Iyenga r V . Does p u lse stacking
i m prove the res u lts of treatment with va ria ble-pu lse
p u l sed -dye lase rs? Dermatol Surg. 2004;30(2, pt 1 ) : 1 631 6 7 . Disc ussion 1 6 7 . 6 .
R oss EV, U e bel hoer N S , Doman kevitz Y . U s e o f a novel
p u lse d ye laser for ra pid s i ngle- pass p u r p u ra -free treatment of te la ngiectases. Dermatol Surg. 2007 ;33( 1 2 ) :
1 466- 1469 .
Sa rradet D M ,
1 064- n m
H ussa i n
M , Gold berg DJ .
neodym i u m :YAG
M i l l isecond
laser treatment of fa c i a l
te la ngiectases . Dermatol Surg. 2003 ;29( 1 ) : 56-58.
c
Figure 36.3 (A) Female with centrofacial telangiectasias and erythema
prior to pulsed dye laser therapy (B) Pulsed dye laser treatment at a
wavelength of 595 nm, 1 O-ms pulse duration, 7 J/cm 2 , 7-mm spot size.
(C) Appropriate clinical endpoint of erythema and slight edema at sites of
treatment. No purpura was produced
1 95
c
Figure 36.4 Telangiectasias prior to long pulse-duration pulsed dye laser
treatment. The settings were 40-ms pulse duration, 7-mm spot, 595 nm,
1 2J!cm2 . (B) Note the transient vasoconstriction with almost complete
disappearance of the telangiectasias immediately posttreatment.
(C) Slight decrease in diameter of the telangiectasias 1 month after one
treatment
1 96
B
Figure 36.5 (A) Large caliber nasal telangiectasias on the nose prior to
long-pulse duration pulsed dye laser treatment. (B) Decrease in the diam
eter of the telangiectasias after six treatments with PDL using long pulse
duration of 40 ms, 7-mm spot size, and f/uences up to 1 1 . 5 J/cm 2 .
1 97
c
Figure 36.5 ( Continued) {C) Marked resolution of the telangiectasias after
an additional four POL treatments utilizing short pulse duration of 1 . 5

ms, 7-mm spot size, and 1 2Jicm 2
Figure 36.6 Intense pulsed treatment with Starlux (Palomar Inc. ,
Burlington, MAJ of facial telangiectasias. The handpiece is in full contact

with the skin
1 98
CHAPT E R 3 7
Lowe r Extre mity Tela ngiectasias , R eticula r a nd

Va ricose Veins
Lower extrem ity telangiectasias, ret i c u l a r a n d va ricose

ve i n s d eve l o p as a res u lt of ve nous system i m pa i rment.
Incidence: very common and the i n c idence i n c reases
with age . R eti c u l a r vei n s can occ u r in up to 10% of c h i l
d ren 1 0 t o 1 2 yea rs old . The i n c id e nce o f va ricose vei ns
in the seventh d ecade is 72% i n wo men a n d 43 % in men
Age: m ore common i n a d u lts a n d e l d erly

Sex: more common i n wom e n
Precipitating factors: fa m i l ia l pred i s position, p reg n a n cy,
static gravitational p ressu res, dyna m i c m uscu l a r forces,
hormonal i nfl ue n ces
PATHOPHYS I OLOGY
Venous
pathology d evelops when
venous
ret u r n
is
i m pa i red for a n y reason .

I t can d evelop from venous o bstruction (thro m botic o r
nonthro m botic ) o r from ve nous va lvu l a r i n com petence.

Lower extrem ity te la ngiectasias a re red t o violaceous i n
color a n d u p t o 2 m m i n d i a m eter. R eti c u l a r ve i n s a re
b l u e to b l u e-green in color a n d u p to 4 m m in d i a meter.
Va ricose vei ns a re b l u e to b l u e-gree n in color with a
d ia meter greater than 3 to 4 m m .
LABORATORY DATA
D i lated vasc u l a r c h a n nels in the d e r m i s .
Vasc u l a r St u d i es
Doppler u ltraso u n d a n d/or d u plex sca n n i ng a re i n d i cated
in the fol l owing c l i n ical scenarios:
Asym ptomatic va ricosity greater tha n 4 mm i n d i a meter
Sym ptomatic vei n s
Reti c u l a r, perforati ng, a n d/or va ricose ve i n s
S i g n s o f ve nous i nsufficiency o r stasis c h a nges
Prior h istory of deep vei n throm bosis or t h rom boph leb itis
Prior h i story of sclerothera py with rec u rrences or bad

outcome
Figure 37. 1 (A) Sclerotherapy of spider veins. The needle is bent at a

45-degree angle and the vessel is canalized. (B) Immediate vessel
blanching seen after injecting the sclerosant agent
1 99
MANAG E M ENT
S c l e rot h e ra py ( F i gs .
37 1 37 3)
.
Sclerotherapy i s the treatment of c h oice fo r lowe r leg

tela ngiectasias a n d reti c u l a r ve i n s . It s h o u l d be repeated
at 6 to 8 week i nterva l s . Patients may req u i re two to six
scleroth e ra py sess ions to ach i eve the greatest treatment
benefit.
S c l erosi n g agents
An ideal sclerosing agent ca uses complete local endothe
l i a l d estruction of the vesse l wa l l with seco n d a ry fibrosis
and
l u men
obl iteratio n ,
with
no
system i c
toxicity.
Sclerosing agents a re classified i nto th ree gro u ps depend

i ng on their mecha nism of action of i n d ucing endoth e l i a l
i nj u ry. These i n c l u d e hyperosmotic agents, d etergents,
and chem ical i rrita nts (Ta bles 37 . 1 and 3 7 . 2 ) . The most
commonly used sclerosa nt agents in the U n ited States a re
hype rto n i c sa l i n e ( HS) a n d sod i u m tetradecyl su lfate
(STS ) . Both HS a n d STS a re FDA a p p roved a n d have low
est i n c idence of a l lergen i city. Sod i u m morrhuate a nd poli
d oca nol a re a lso FDA a p p roved .
S c l erothera py tec h n i q u e for te langiectasias a n d

reticular v e i ns
Fi l l the sclerosa nt agent i nto 3 c m 3 d isposa ble syri nges

with d isposa ble 30-ga uge h a lf i n c h need les.
Swa b the site to be treated with a lcohol to better visual

ize the vesse l s .
Treat l a rger vessels fi rst.
Bend the need le at a 30-d egree a ngle to 45-d egree

a ngle.
Figure 37.2 (A) Spider veins, prior to treatment with sclerotherapy.
Stretc h the s k i n overlying the vessels being treated .
(B) Marked resolution of the spider veins after sclerotherapy treatment
I nsert the need le slowly in the vessel wa l l . Yo u may use

the a i r bo l u s tec h n i q u e by i njecti ng less than 0.5 c m 3 of
a i r in the vessel o r the p u nctu re-fi l l tec h n i q u e relyi ng on
the feel associated with vessel wa l l perforation w h i l e
i nj ecti ng. The em pty vei n tec h n i q u e , performed b y e l e
vati ng the leg a n d gently knead i n g the vei n prior to
i nj ecti o n , a l lows for thro m b u s red uction a n d need fo r
s m a l l e r sclerosa nt vo l u mes. When treat i n g reti c u l a r a n d
va ricose vei n s , aspirate a sma l l a m o u nt o f blood t o con
firm i ntravasc u l a r locati o n .
I nject the sclerosa nt very slowly t o ensu re sufficient

co ntact of the sclerosa nt with the vessel endoth e l i a l wa l l
a n d t o preve nt d i stention a n d r u pture. I nject less t h a n
0 . 5 c m 3 per i njection at 3-cm i nterva ls.
Apply small circular band a i d s , ta ped cotton ba l ls o r

ro l l s at the i njection sites f o r com pression .
Foa m sclerotherapy
A treatment mod ification can be made for la rge r vesse ls
by vigorously foa m i ng a n a i r-sc l e rosa nt solution j ust prior
to i njection to i n d uce a solution that d isplaces b l ood a n d
re m a i n s for a n extended t i m e i n t h e ta rget vessel without
200
being fl ushed . Theoretical ly, lowe r sclerosa nt conce ntra

tions can be used with a lower i n c i d e nce of pigmentation
and matti ng (Ta b les 37.2 and 3 7 . 3 ) . The foa m i ng d eter
gent of either sotradechol or po l i d oca nol is prepa red by
m ixing the d etergent with a i r ( usua l ly 1 :4 ml ratio of
d eterge nt to a i r) i n a back a n d forth motion using a th ree
way sto p lock u n t i l a foa med e m u lsion is c reated . The
foa m sclerosa nt is i nj ected i n a m a n ner s i m i l a r to that
with other scl erothera py tec h n i q u es .
Postop erative care
Com pression i n c reases the efficacy of sclerothera py

a n d decreases the i nc i d ence of hyperpigme ntatio n .
Elastic com p ression stoc k i ngs ( 1 5-60 mm Hg) a re

h ighly recommended i m med iately fol lowi ng sclerothera py a n d u p to 2 to 3 wee ks after the proced u re , espec i a l l y posttreatment of la rger ca l i be r vesse ls. Fas h i o n
hose ( 1 5- 1 8 m m Hg) a n d Class I h ose (20-30 m m H g )
a re the m ost commonly u s e d grad uated com pression
h ose used postsc leroth erapy of te la ngiectasias and
reti c u l a r vei n s .
Encou rage wa l k i n g to avoid thromboe m bo l i c d iseases .
Avo i d s u n exposu re to m i n i m ize posttreatment hyper

pigme ntation .
C o m p l i cati ons (Ta b l e 37 .3)
Postsc lerothera py hyperpigme ntatio n ( PS H ) : The i nci
Figure 37.3 (A) Lower leg telangiectasias at baseline. (B) Marked resolu
dence of PSH can be u p to 30% d e pe n d i ng on the
tion of the telangiectasias 1 month after one sclerotherapy treatment.

Note the development of slight telangiectatic matting superior to the
treated area
tec h n i q u e used , the size of the treated vessels, the type

of sclerosi n g agent, a n d the solution conce ntratio n .
Postsc lerothera py c o m p ress ion decreases t h e i nc i
dence o f PS H . P S H is caused b y perivasc u l a r d e posi
tion of hemosiderin rather than mela n i n and fol l ows the
TABLE 3 7 . 1
Sclerosi ng Agents
Sclerosa nt c lass
Hyperosmotic agents
Sclerosa nt types
Mecha n ism
Hyperto n i c sa l i ne ( 1 0-30 % )
Dehyd ration
Hyperto n i c sa l i ne ( 1 0 % ) d extrose ( 2 5 % ) (Sclerodex)

Detergents
Sod i u m tetrad ecyl s u l fate (Sotradechol, Thromboinject)
S u rface tension c h a nge
Polid oca nol (Aethoxysc lero l , Aetoxisc l e ro l , Sclerove i n )

Sod i u m morrh uate (Scleromate)
Etha n o l a m i n e oleate
C h e m i c a l i rrita nts
Polyiod ide iod i d e (Va rigloba n , Va rigl o b i n , Sclerod i n e )
Corrosives
G lyceri n ( 7 2 % ) w i t h 8% c h rom i u m potass i u m a l u m ( C h ro m ex)
TAB L E 37.2
Recommended Sclerosa nt Concentration
Sclerosa nt/rec o m m e nded

concentratio n
Te la ngiectasias
Reti c u l a r vei n s
Va ricose ve i n s
Dose l i m itatio n
Hyperto n i c sa l i ne
1 1 . 7-23.4%
23.4%
N ot commonly used
6-1 0 m L o f 18-30%
Sod i u m tetrad ecyl su lfate
0 . 1 -0 . 5 %
0.3-0 . 5 % , 0 . 1 -0 . 2 5 % foa m
0 . 5-3 % , 0 . 5- 1 % foa m
1 0 ml of 3 % sol ution
solution
TAB L E 3 7 . 3
Com p l ications of Sclerotherapy
Sclerosa nt
Al lerge n i city
Hyperto n i c sa l i ne
C ra m pi n g
Pa i n
Hyperpigmentati on
Te la ngiectatic matting
S k i n necrosis
+ An a p hylaxis
Sod i u m tetrad ecyl s u l fate
( ra re, < 0.01 % )
cou rse of the treated site. The pigme ntation usua l ly

resolves in 6 to 12 months. It can i m prove with the use
of i ntense pu lsed l ight ( I P U .
Tel a n giectatic matting (TM ) : T h e i nc i d e n ce o f T M can

be up to 16%. It consists of a network of b l u s h - l i ke, fine
( <0 . 2 mml tela ngiectatic vessels s u rrou n d i n g a p revi
ously treated a rea , occ u rring with i n days to months
after sclerothera py. They u s u a l l y reso lve with i n 3 to
12 months. P red ispos i n g factors i n c l u d e pregna ncy,
o besity, hormona l thera py, a n d fa m i ly h istory of tela ng
iectasias. TM can i m p rove with p u lsed dye laser or I P L .
Ways t o avo i d thi s com p l ication i nc l ude
- Lower i njection pressu re
- Lower sclerosa nt vol u m e ( u p to 1 . 0 m L per i njection
site)
- Lower sclerosa nt concentration
- Li m iti ng blanching ( u p to 1-2 e m )
S k i n nec rosis a n d u l ce ration : Necrosis ca n occ u r sec

o n d a ry to extravasatio n of the scleros i n g agent i nto the
tiss u e , rega rd less of the tec h n i q u e used o r the scle
rosa nt type . To m i n i m ize extravasation, the s u rgeo n
s h o u l d sto p the i njection when encou nte r i ng
- Eve n sl ight resista nce to i njection
- Bleb formation
- I n c reased pa i n reported by the patient
If extravasation is recogn ized i m med iately, the s u rgeon
can i nject normal sa l i n e at the site o r a p ply 2 % n itroglyc

e r i n paste .
Other com pl ications i n c l u d e pa i n a n d c ra m pi ng (com

m on ) ,
20 1
a l l ergic
reactions
( ra re ) ,
su perfi c i a l
t h rom
boph l e b itis (up to 1 %), a n d t h ro m boe m bo l i c reactions

(very ra re ) .
Laser a n d I n te n se P u l sed L i g ht
T h e ra p i es ( F i gs .
37.4
and
3 7 . 5)
Lasers a n d I P L sou rces can occasionally be successful i n

t h e treatment o f lowe r extrem ity tela ngi ectasias a n d retic
u l a r vei ns, espec i a l l y when coupled with lo nger p u lse
d u ration a n d coo l i n g d evices. They a re considered sec
ond-line treatment after sclerothe ra py. Wavelengths in the
ra nge of 500 to 1 , 1 00 nm a re most effective , with shorter
wavelengths [eg, pu lsed dye laser ( P O l l , potassi u m tita nyl
phosphate ( KTP)l being used for red su perficia l blood
Figure 37.4 (A) Marked erythema immediately after pulsed dye laser
treatment to lower extremity spider veins.
202
vesse ls a n d longer wavelengths (eg, 755- n m Alexa n d rite

laser with around 60 ms pu lse d u ration , 1 064 N d : YAG
laser) for b l u ish deeper blood vessels. I n d ications for
laser/ I P L treatments i n c l u d e the fo l l owing:
Need le phobic patients
Vessels res ista nt to sclerothera py
Vesse ls located below the a n kle
TM
Propens ity f o r P S H or T M
A m b u l atory P h l e b ecto m y,
E n d ovasc u l a r Tec h n i q u e s , S u rg i c a l
L i gat i o n/Str i p p i n g
M u ltiple treatment options exist for va ricose vei n s i n c l u d
ing a m b u latory p h l e bectomy, endovasc u l a r laser a blatio n ,
endovasc u l a r rad iofreq uency obl iteratio n , as wel l as s u rgi
ca l l i gation and stri pping proced u res. A m b u latory ph le
becto my can be used for l a rge va ricosities. Endovenous
occ l usion ca n be ach ieved with rad iofreq uency ( R Fl or
laser sou rces . Either a laser fiber o r a n RF catheter is
i nserted i nto the sa phenous vei n at or j ust below the knee.
Laser systems i n c l u d e 8 1 0- n m d iode, 940- n m d iode,
980- n m d iode, and 1 ,320- n m N d :YAG lasers . These
d evices spa re the
need for genera l a n esthesia a n d
extended recovery t i m e associated with vei n stri p p i ng a n d

l igation . There is l ittle d owntime, with patie nts res u m i ng
normal activities on the same day of the proced u re .
B I B L I OG RAPHY
B a r rett
JM,
Allen
B,
Oc kelford
A,
Gold m a n
M P.
M ic rofoam u ltraso u n d-gu i ded scle rotherapy of va ricose
Figure 37.4 (Continued) (B) Mild reduction in spider veins after a single
vei n s in 1 00 legs. Dermatol Surg. 2004;30( 1 ) : 6- 1 2 .
pulsed dye laser treatment
Coleridge S m ith P. Sclerothera py a n d foa m scleroth e ra py

fo r va ricose ve i ns . Phlebology. 2009 ; 24( 6 ) : 260-269 .
Ka h l e B, Leng K. Efficacy of sclerotherapy i n va ricose
vei ns-prospective, b l i nded , placebo-controlled stu dy.
Dermatol Surg 2004;30( 5 ) : 723-728.

Kern P, Ra melet AA, WOtsc hert R, H ayoz D . Com pression
after sclerotherapy for tela ngiectasias a n d reticu l a r leg
vei n s : A ra nd o m ized control led stu dy. J Vase S u rg .
2007;45(6) : 1 2 1 2 - 1 2 1 6 .
Morrison N , Neuhardt DL. Foa m sclerothera py: Cardiac
and cerebra l mon itori ng. Phlebology. 2009;24(6) :252-259 .
R oss EV, Meehan KJ , G i l be rt S , Doman kevitz Y. O pti m a l
p u l se d u rations f o r the treatment o f l e g te la ngiectasias
with a n a lexa nd rite laser. Lasers Surg Med. 2009 ;4 1 (2 ) :
1 04- 109.
Figure 37.5 Postinflammatory changes after laser leg vein treatment
CHAPT E R 38
203
Ve n o us La kes
Venous la kes a re benign vasc u l a r lesions that resu lt from

d i lated ven u les. They commonly affect the l i ps , face, a n d
ears.
EPI D E M I O LOGY
Incidence: common
Age: m ost c o m m o n l y o bserved i n the e l d erly
Precipitating factors: may be related to sun exposu re
P H YS I CAL EXAM I NAT I O N

Venous Jake presents as dark b l u e t o violaceous, e l e
vated , soft, a nd easily compress i b l e papule or nodule.
D I FFERENTIAL D I AG N OS ES
Pyoge n i c gra n u lo m a , m e l a n o m a , labial melanotic mac
ule, atypical nevus, hema ngioma .
D i lated t h i n-wa l led ve n u l es in the s u pe rfi c i a l d e r m i s .
T h rom bosis may be o bserved .
EPI LU M I N ESCENCE M I CROSCO PY

Epi l u m i nescence m ic roscopy ( ELM ) revea ls erythema
tous glo b u l es with n o pigmenta ry network. It is hel pful in
d ifferentiati ng this vasc u l a r lesion from a m e l a n ocytic
lesion .
Figure 38. 1 (A) Venous like on the lower lip of an elderly man.
(B) Marked resolution of the venous Jake after m ultiple treatment ses
CO U RS E
They u s u a l l y persist for yea rs a nd c a n bleed afte r tra u m a .
MANAG E M ENT
Venous la kes a re freq u e ntly treated for cosmetic p u r
poses. M u ltiple treatment options exist.
Light treatment
- Lasers ( Figs . 38. 1-38.3 )
P u lsed d y e laser ( 585--5 95 n m , 0.45-- 1 . 5 m s , 5-1 0
m m s pot, 7- 1 0 J/cm 2 , D C D 30-40/20, with a n d
without d iascopy). Pulsed dye laser provides incon

sistent benefit for venous Jakes.
sions with the pulsed dye laser
204
Diode laser (800--8 1 0 n m , 30 ms, 30-50 J/c m 2 )

can a lso be a very effective treatment. It is h e l pfu l
to a l low 3 seconds of compression of the lesion with
the c h i l l tip prior to the laser p u lse. A physical
" k i c kback" is often felt by the laser s u rgeon at the
t i m e of the pu lsatio n . The c l i n ical e n d point is
i m med iate p u r p u ra .
Long- p u lsed N d : YAG laser a n d i ntense p u lsed l ight
( I P U have a lso been re ported to be effective .
Sc lerotherapy: I n one study, i ntra lesiona l i njections with

1% pol i d oca nol have been shown to be effective i n
clearing two ve nous la kes after two sessions o f scle
rothera py. A scar was noted to occ u r i n one patient.
Electrosu rgery, s u rgical excisio n , c ryothera py a re other

a lternate treatment o ptio n s . H owever, these modal ities
can res u lt i n a sca r.
P I T FALLS
Often req u i res seve ra l treatments with laser.
A l l thera peutic modal ities may prod uce a scar.
B I B L I OG RAPHY
B e k h o r PS.
Long- p u lsed
N d : YAG laser treatment of
venous l a kes: R e port of a series of 34 cases. Dermatol
Surg. 2006;32(9 ) : 1 1 5 1 - 1 1 54 .
Jay H , Borek C . Treatment o f a ve nous- l a ke a ngioma with
i ntense p u lsed light. Lancet. 1 998; 3 5 1 (9096) : 1 1 2 .
K u o HW, Ya ng C H . Ve nous l a ke o f t h e l i p treated with a
scleros i n g agent: Report of two cases. Dermatol Surg.
2003 ; 29(4) :425-428 .
Wa l l TL, G rassi A M , Avra m M M . Cleara n ce of m u lti p l e
ve nous la kes w i t h a n 800-n m d iode laser: A novel
a p proa c h . Dermatol Surg. 2007;33( 1 ) : 1 00- 1 03 .
Figure 38.2 (A) Venous lake on the upper lip. (B) Five-month follow-up
demonstrating complete resolution of the venous lake after a single treat

ment with an 800-nm diode lase, 30-ms pulse duration, at energy set
tings of 45 J!cm2 (one pulse), and 50 J!cm2 (one pulse)
205
(_ _)
C ross sect ion of l i p
Com press ion a p p l i e d
Figure 38.3 Clinical efficacy of pulsed dye laser for a venous lake with
compression of the vessels during treatment versus no compression
Diode
'
(800 nm)
Pu I sed d ye laser
( 59 5 n m )
Laser penetrat i o n : p u l sed dye vs d iode
Figure 38.4 Pulsed dye laser does not penetrate deep enough.
Compression is needed. Diode laser penetrates deeper and therefore is

more effective than PDL
206
CHAPT E R 39
Wa rts
V i ra l wa rts a re caused by h u ma n pa p i l lo maviruses ( H PV) .

Va rious types of H PV- i n d u ced wa rts exist i n c l u d i ng com
mon wa rts (70% of all wa rts ) , pa l m o p l a nta r wa rts, plane
wa rts, a n d ge n ita l wa rts .
EPI D E M I O LOGY
Age: c h i l d ren a n d a d u lts
Precipitating factors: s k i n tra u m a , i m m u nosu p p ression
( H IV a n d tra nsplant patients ) , genetic pred is position
( e p i dermodysplasia ve rruc iform is)
PATHOG E N E S I S
H PVs a re nonenvelo ped d o u ble-stra nded D N A vi ruses
that prod uce i nfection a n d i n d uction of hyperprol ife ratio n

w h e n the v i r u s enters prol ife rating basa l epithe l i a l c e l l s .
Avo ida nce o f h ost i m m u n e s u rve i l l a nce occ u rs . Exact
mec h a n isms of i nfectio n , latency, a n d reactivation of
H PV a re u n known .

Warts present as s i ngle o r m u lt i p l e hyperkeratotic, exo
p hytic , skin-colored pa p u les, nod u l es or plaq ues. They
can have finger- l i ke proj ections (fi l iform wa rts) or ca n be
flat-top ped ( p l a n e wa rts ) . B l a c k p u n ctate d ots re present
ing t h rom bosed ca p i l l a ries a re observed freq ue ntly. They
m ost commonly present on fi ngers, d o rsal h a n d s , pla nta r
su rfaces, a n d press u re a reas.
Hypertro p h i c
acti n i c
keratosis,
seborrheic
keratosis,
sq u a m o u s cell c a rc i n o m a , verrucous ca rc i n o m a , a n d
a c ra l a mela notic melanoma . Pla nta r warts can a lso be
m ista ken for corns o r call uses .
The e p i d e r m i s featu res hyperkeratosis, aca nthosis, pa p i l
lomatosis, with tiers o f pa ra ke ratos is, va l l eys o f hyper
gra n u losis and koi locytosis. The d e r m i s featu res d i lated
ca p i l l a ry loops and hemorrhage.
Figure 39. 1 (A) Verruca vulgaris on the left thumb immediately
posttreatment with pulsed dye laser, 590-nm wavelength, 7-mm spot

size, 1 0 J!cm2 , with pulse stacking. (B) Five-month follow-up with com
plete resolution of the wart after single pulsed dye laser treatment
207
CO U RS E
They ge nera l ly resolve sponta neously i n i m m u nocom pe
tent patients, but this may ta ke yea rs . They tend to per
sist a n d resist treatment in i m m u nosu p pressed patients.
Auto i n ocu lation by scratc h i ng may occ u r.
MANAG E M ENT
There is n o c u rrent s pecific a ntivi ra l thera py fo r H PV.
There a re m u ltiple treatment options that either i n d uce
loca l physical destruction of the warts or sti m u late the
i m m u ne
response
aga i nst
H PV
i nfection
or
both .
S q u a m o u s cell carc i noma ca n a rise from some lesions,

that is, condylomata a nd epidermodysplasia ve rruci
fo rmis and req u i re conti n uous mon itori ng. H i stologica l
eva l uation s h o u l d be considered for wa rts that a re u n re
spons ive to m u lt i p l e treatment modal ities to r u l e out

m a l i gna n cy.
Patients should b e ed ucated a s t o the vira l , i nfectious, a n d
recu rrent natu re o f H PV despite therapeutic i ntervention .
Patients m ust also be i nformed of the need for repetitive
treatments for a l l treatment modal ities employed . M u ltiple
effective topica l treatments exist. There is n o current treat
ment of choice.
Loca l ized tissue destructi o n : sa l icyl ic a c i d , 5% ca n

t h a rone, tric h loracetic a c i d , a n d 0 . 5 % pod o phyl lotox i n
a re e m p l oyed d a i ly. Loca l ized wa rt occ l usion w i t h d u ct
ta pe has d e m onstrated efficacy in a study. S u r ro u n d i ng
Figure 39.2 (A) Verruca vulgaris on the left middle finger resistant to
normal tissue may d e m onstrate te m po ra ry m aceration
multiple treatments with cryotherapy. (B) Marked resolution of the wart

after three POL treatments.
d u ring treatment.
Vi ra l cell d ivision a lterati o n : i ntra l es i o n a l bleomyc i n (0.4

mg/m U
in
normal
prese rved sa l i n e ;
5-fl uoro u ra c i l
crea m .
I m m u ne mod ulation : to pical i m i q u i m od has demon

strated effica cy.
S u rg i c a l Treat m e n t
Lasers (Ta b l e 39. 1 )

TAB L E 39 . 1
Laser Treatment of Wa rts

PDL
C02
Effective
Efficacy
Va r i a b l e
Average n u m be r of sessions
2-1 2
1-3
Anesthesia needed
Occasionally
Yes
Sca rring risk
Low
H igh
Dysc h ro m i a risk
Low
Moderate
I nfection risk
Low
Low
Pa i n
Moderate t o h igh
M i n i m a l to h igh
208
P u lsed d ye laser ( P D U ( Figs . 39 . 1-39.4)

- PDL is the m ost commonly e m p l oyed laser for wa rts .
It may i n d uce a therapeutic res ponse by vasc u l a r
a bsorption o f laser l ight prod u c i n g therma l nec rosis
of wa rt tissue as wel l as by i nd uction of a host
i m m u ne res ponse. C l i n ical i m provement is va ria b l e .
P D L is ge nera l ly uti l ized after fa i l u re o f fi rst- l i n e
thera pies.
- PDL protocol
P rotective laser masks, gloves , and gowns as wel l
as u s e o f a smoke eva c uator a re reco m mended to
avoid tra nsm ission of the wa rt virus.
The hyperkeratotic portion of the wart should be
pa red prior to treatment. B leed i ng is to be avoided, as
this w i l l m i n i m ize laser l ight a bsorption by the wa rt.
H igh fluences (585-595 n m , 0.45- 1 . 5 ms pu lse
d u rati o n , 8- 1 5 J/cm 2 ) a re typica l ly req u i red for

effective treatment. M u ltiple p u lses a re m ost effec
tive,
but
should
be
performed
with
caution .
Figure 39.2 (Continued) (C) Recurrence of the wart after six POL
treatments
Diascopy with p u lses s h o u l d be considered . Treat

1 to 2 m m of s u r ro u n d i ng healthy ski n .
Treat u n t i l lesiona l p u r p u ra i s a pparent.
Re petitive treatments spaced 3 weeks a pa rt a re
genera l l y o pti ma l . Longer i nterva ls between treat
ment sessions may fac i l itate wa rt regrowth a n d
shorter i nterva ls m a y preve nt com plete hea l i ng.
Carbon d i oxide laser (C0 2 )

- C0 2 laser treatment is gen e ra l ly reserved for reca lci
tra nt, widesprea d , pai nfu l , o r hyperke ratotic warts
- Adva ntages : h igh success rate u s u a l l y after one or
two sess ions, no bleed i n g
- Disadva ntages: u n known haza rd o f H PV i n laser
p l u me, risks of dysc h ro m i a , rec u rrence and i nfec
tio n ; pro l onged hea l i ng t i m e of weeks to months;
resid u a l sca rring that can be pa i nfu l ; risk of perma
nent nail dystrophy with peri u n g u a l treatment

- C0 2 protocol
P rotective laser masks, gloves, and gowns as we l l as

use of a sm oke evac uator a re reco m mended to avoid
tra n s m ission of the wa rt virus.
Ad m i n ister i ntra lesi o n a l i nfi ltrative a n esthesia or a d igi

ta l block ( 1 % l id oca i n e with or without 1 : 1 00,000 epi
nephrine).
Va porize the wart a n d a 2- t o 5-m m marg i n u nt i l t h e s u r

face is cha rred ( U itra pu lse CW defocused , 1 5-20 W;
Sharplan su perpu lsed mode, 1-2 mm spot, 5-1 5 W).
Remove the c h a r by r u b b i ng a sa l i ne-soa ked ga uze

pad . Al low the a rea to d ry.
Reva porize the wa rt as a bove with c h a r remova l

between passes u nt i l tissue sepa ration occu rs a n d nor
m a l tissue is observed .
Figure 39.3 (A) Plantar verruca with characteristic thrombosed capillaries.

(8) Paring of wart with # 1 5 blade prior to pulsed dye therapy
209
N o n laser surgi cal moda l ities
C ryothera py with l i q u i d n itrogen is the most com m o n l y

e m p l oyed
s u rgica l
treatment
modal ity
em ployed .
Treatment benefit is d e pendent on ice crysta l - i n d uced

cell death as wel l as the i n d u cti on of a host i m m u n e
res ponse.
- Treatment may be d e l ivered via a c ryos u rgica l u n it
( B ry m i l l C ryoge n i c Syste ms, E l l i ngto n , CTJ or via a
cotton -t i p ped a p p l i cator, d i psti ck , or forceps.
- A s i ngle o r d o u ble 5 to 15 seco nds freeze-thaw cycle
may be d e l ivered d e pe n d i ng o n the treatment s ite
a n d lesion thickness. T h i c ker lesions a n d pla nta r
lesions req u i re more aggressive treatment. M u ltiple
treatment sess ions a re genera l ly req u i red .
- Treatment
may
i n d uce te m pora ry or
pe rmanent
hyperpigmentatio n a n d hypopigmentati o n , bl istering

and sca r formatio n .
El ectrodessication a n d c u rettage a n d s u rgica l excision

have a lso been e m ployed with va ria ble res ponse.
Be very awa re of the d e pth of d estruction with C02

laser. As you go below the pa p i l l a ry dermis, the risk of
sca rri ng a n d d ysc h ro m i a i n c reases.
Patie nts m u st be awa re that sca r formation is l i kely a n d

m a y b e pa i nfu l . Pa i nful sca rring is m ost c o m m o n on
pressu re-bea ring a reas.
Recu rrences most freq uently occ u r at the wou n d edge .

Treating a m a rg i n of normal s k i n m i n i m izes t h i s risk.
- C ryothera py c a n prod uce pigment cha nges a n d sca r
- I m p rovement is va riable with a n y treatment modal ity
- Warts ca n rec u r after a n y treatment
B I B L I OG RAPHY
Pa rk H S , Choi W S . P u lsed dye laser treatm ent for v i ra l
wa rts : A stu dy o f 1 2 0 patients. J Dermatol. 2008;35(8) :
49 1 -498 .
Schell haas U , Gerber W , H a m mes S, Oc kenfels H M .
P u lsed dye laser treatment i s effective i n the treatment of
reca lc itra nt v i ra l wa rts . Dermatol Surg. 2008;34( 1 ) :67-72.
Sero u r F, Somekh E. S uccessfu l treatment of reca lcitrant
wa rts i n ped iatric patie nts with carbon d ioxid e laser. Eur J
Pediatr Surg. 2003; 1 3(4) : 2 1 9-223 .

Seth u ra m a n G , R i c ha rds KA, H i remaga lore R N , Wagner
A. Effective ness of p u lsed d ye laser i n the treatment of
reca lc itra nt wa rts i n c h i l d re n .
Dermatol Surg. 2 0 1 0 ;
36( 1 ) : 58-65.
S h u m er SM, O' Keefe EJ . B leomyc i n i n the treatment of
reca lc itra nt wa rts . J Am Acad Dermatol. 1 983 ;9 :9 1 .
Figure 39.4 Mechanism of action of pulsed dye laser treatment of
verruca. (A) The verruca is characterized by a rich vascular supply.

(B) The pulsed dye laser selectively targets the vascular component of the
verruca. (C) The laser light is selectively absorbed by the blood leading
to coagulation of the vessels (0) and resolution of the wart
S EVE N
B enign G rowths
21 2
CHAPT E R 40
Angiofi b ro m a
Angiofi broma is a d escri ptive te rm for a gro u p of lesions

with d iffe rent c l i n ical prese ntations but with the sa me
h istopathology. These lesions i n c l ud e fibrous pa p u l e ,
fac i a l a ngiofi broma ,
pea rly pen i l e
pa p u l e ,
adenoma
sebace u m , peri u ngual fibro m a , a n d Koe n e n 's tu mo r.

T h i s c h a pter w i l l foc us on fac i a l a ngiofi broma . Genera l ly,
an a ngiofi broma presents as a 1 to 5 mm s k i n -colored to
e rythematous d o me-sha ped pa p u le on the face. When it
presents as m u ltiple fac i a l lesions, it can be associated
with tu berous sc lerosis o r m u lt i p l e endocrine neoplasia
type 1 ( M E N 1 ) .
EPI D E M I O LOGY
Age: majority i n e a r l y t o m i d c h i ld hood
Figure 40. 1 Patient with n umerous facial angiofibromas. He is noted to
Race: none
have associated tuberous sclerosis
Sex: eq ual
Precipitating factors: tu berous sclerosis, MEN 1
PATHOG E N E S I S
U n known .
PHYS I CAL EXAM I NAT I O N (Fig. 40 . 1)

F i r m s k i n -colored to eryth ematous pa p u l es ( 1-5 m m ) o n
the nose, c h i n , a n d c h eeks, wh i c h may b e a rra n ged
b i latera l ly. I n d iv i d u a l s with tu berous sc lerosis can a lso
have peri u ngua l fi bromas, fi brous plaq ues, a n d ash -leaf
macu les.
I ntradermal
mela nocytic
nev i ,
a p pend agea l
t u mo rs,
basa l cell carc i n o m a , a c n e vu lga ris
A sym metric, we l l-c i rc u mscri bed pa p u l e with a normal to
sl ightly atro p h i c epidermis. The pa p i l l a ry and reti c u l a r
d e r m i s feat u res a prol iferation o f va ry i n g d egrees o f nor
mal b l ood vesse ls with i n a f ibrotic stro m a . The col lagen
fibers a re a r ra nged perpend i c u l a rly to the epidermis a n d
concentrica l ly a r o u n d t h e vessels a n d
h a i r fol l ic l es .
Ste l late-sha ped m u lti n u c l eated fibroblasts may be seen .
Sect i o n 7 : B e n ign G rowt h s
21 3

I n the sett i n g o f m u lti ple fac i a l a n d/or peri u ngual a ngiofi
b romas, tu berous scl erosis and M EN 1 m ust be i nvesti
gate d . This is best performed by refe rra l to ped iatric
spec i a l ists .
CO U RS E
M u ltiple fac i a l a ngiofi bromas typica l ly p resent i n c h i l d
hood a n d m a y be associated with tu berous sclerosis
( Fig. 40 . 2 ) . Isolated lesions rema i n u ncha nged . F u rther
a ngiofi bromas may d evelop i n a d u lthood .

A
Onset a n d location o f lesions
Fa m i ly h i sto ry of s i m i l a r lesions
Fa m i l y h i sto ry of cancer
Associated centra l nervous system d i sorders
MANAG E M ENT
There is no med ical i n d ication t o treat a ngiofi bromas.
Thei r cos metic a p pea ra nce, however, may be stri k i n g
a n d u n d e rsta nda bly concern i n g t o s o m e i n d ivid u a l s .
Treat m e n t
M u ltiple treatment modal ities a re ava i la bl e . Recu rre n ce
rate is high with the majority of the treatment option s .
Treatment o pti ons may be c o m b i ned for the best treatment outco m e .
S u rgical
- Shave excision-outl i n e lesion prior to a p plyi ng loca l
a n esthesia as the lesion may b l a n c h after the a nes
thesia is i nj ected
- P u n c h or e l l i ptical excision-l i m ited to isolated few
lesions. R es i d u a l sca r expected
- Electrod essication and c u rettage-may l eave resid u a l
scar
Laser su rgery-best fo r m u lti ple lesions

- P u lsed d ye laser-red u ces the erythematous com po
nent of the lesion on ly. Possi ble lesio n a l flatte n i ng
with use of 5-a m i no l evu l i n ic acid b l u e l ight photody
n a m i c thera py fo l l owed by p u lsed dye laser treatment
- Carbon d ioxide laser ( F ig. 40.3)--conti n uo u s wave
mode most effective . Long-term i m provement has
been see n . Adverse reactions i n c l u d i n g tem pora ry
in
Figure 40.2 (A) Fibrous plaques on the forehead in an adult patient with
F itzpatrick s k i n ph ototypes I l l a n d IV, as we l l as scar
tuberous sclerosis. (B) Fibrous plaques on the scalp. (C) Ash leaf macule
on the leg of the same patient
a n d/or
perma nent dyspigmentation
espec i a l l y
fo rmatio n . Lesional rec u rrence is expected ove r time
214
- KT P laser-sta c ked p u lses without cool i n g has been

uti l ized with some su ccess . Req u i res two to five
sessions fo r lesional flatte n i ng . Dyspigme ntation a n d
sca r formation a re poss i b l e . Les i o n a l rec u rrence i s
expected
Derma b rasion-s i m i l a r outcome to conti n uo u s wave

ca rbon d ioxi d e laser treatment
Though there a re many treatment modal ities for the

i m provement of a ngiofi bromas, the e n d point is genera l ly
lesion a l flatte n i ng a n d not c lea ra nce. Setting rea l isti c
expectations p r i o r t o treatment is key
Patients m u st be awa re of the l i ke l i hood of lesional rec u r

rence over time. With u n derlyi ng tu berous sclerosis, new
lesions a re l i kely to occ u r
Ab lative thera pies carry a r i s k o f sca rring a n d d yspig

mentatio n . U se of conservative pa ra m eters a re pa ra
mount to avoid potential s i de effects
B I B L I OG RAPHY
Bittencou rt R C , H u i lgol SC, Seed PT, Ca lonje E, M a rkey

AC, Ba rlow RJ . Treatment of a ngiofi b romas with a sca n
n i ng carbon d i oxide laser: a c l i n ico path ologic study with
long-te rm fol l ow- u p . J Am Acad Dermatol. 200 1 ;45 ( 5 ) :
73 1 -735.
Boixeda P, Sanc hez- M i ra l les E, Aza na J M , Arrazola J M ,
Moreno R , Ledo A . C0 2 , a rgo n , a n d pu lsed dye laser
treatment of a ngiofi bromas. J Dermatol Surg Oneal.
1 994;20( 1 2 ) :808-8 1 2 .
Papadavid E, Ma rkey A, B e l l a n ey G , Wa l ke r N P. Carbon
d i oxide and p u lsed dye laser treatment of a ngiofi bromas
i n 29 patients with tu berous sclerosis. Br J Dermatol.
2002; 147(2) :337 -342 .
Tope W D , Kageya m a N . " H ot" KTP-Iaser treatment of
fa c i a l a ngiomata . Lases Surg Med. 200 1 ;29( 1 ) : 78-8 1 .
Wei n berger, C H , End rizzi B . Hook KP, Lee P K . Treatment of
a ngiofi bromas of tu berous sclerosis with 5-a m i nolevu l i n i c
a c i d b l u e l ight photodyn a m ic thera py fol l owed by i m me
d iate pu lsed dye laser. Dermatol Surg. 2009;35( 1 1 ) : 1 849185 1 .
Figure 40.3 (A) Multiple angiofibromas on a 1 6-year-old male with tuber
ous sclerosis. (B) Improvement 2 months after single treatmen t with C02
laser.
Figure 40.3 (Continued) (C) Partial recurrence of angiofibromas noted
13 months after C02 laser treatment
215
21 6
CHAPT E R 4 1
B ecke r's Nevus
Bec ker's nevus i s a sharply dem a rcated ta n to brown

patch or sl ightly ra ised ve rrucous p l a q u e that most com
m o n l y a p pea rs o n the s h o u l d e r, c h est, o r u p per bac k . It
typica l l y prese nts u n i latera l ly and is freq u e ntly associated
with overlying hypertrichosis. It is a benign h a m a rtom a .
EPI D E M I O LOGY
Incidence: 0 . 5 % of ma les
Age: teens to t h i rties, ra rely conge n ita l , fa m i l ia l cases
reported
Race: a l l races
Sex: ma les > fem a l es ( 6 : 1 )
Precipitating factors: n o ne
PATHOG E N E S I S
U nclear etio logy. Post u l ated t o have a loca l ized i n c rease
in a n d rogen receptors a n d heightened sensitivity to
Figure 4 1 . 1 Becker's nevus. A slightly raised ligh t-tan plaque with

sharply defined and highly irregular border and hypertrichosis on the
chest of a 35-year-old male (Wolff K, Johnson RA, Suurmond D.
Fitzpatrick's Color A tlas & Synopsis of Clinical Dermatology, 5th ed. New
York: McGraw-Hill; 2005)
a n d roge ns.
PATHOLOGY
There is pa p i l lomatosis, hyperke ratosis, aca nthosis, a n d
basa l layer hyperpigmentati o n . Th ere is a n i nc rease i n
t h e m e l a n i n content o f kerati n ocytes with l ittle or n o
cha nge i n t h e n u m be r o f m e l a n ocytes. A s mooth m uscle
h a m a rto ma is frequently present in the d e r m i s .

They occ u r m ost often on t h e u p per tru n k as a we l l
dema rcated u n i latera l ta n t o d a r k b rown patc h with a
block- l i ke configuration ra nging fro m a few to > 1 5 e m .
Hypertrichosis usua l ly d eve l o ps afte r t h e hyperpigme nta
tion ( Figs. 4 1 . 1 and 4 1 . 2 ) . Ac neiform lesions strictly l i m
ited to a reas of hyperpigmentati on have been reported .
Congen ita l nevus, cafe a u lait m a c u l e , e p i d e r m a l nevus,
p l exiform neu rofi broma

Physical exa m i nation should b e performed t o r u l e out
associated hypoplasia of the i psi late ra l arm, b reast, a re
o l a , or i psi latera l arm shorte n i n g as wel l as pectus c a r i n a
tu m o r thorac i c scoliosis.
Figure 4 1 .2 Becker's nevus. Large brown plaque that becomes noticeable

at puberty with increased pigment followed by hair growth (Wolff K,
Johnson RA, Suurmond D. Fitzpatrick's Color A tlas & Synopsis of Clinical
Dermatology, 5th ed. New York: McGraw-Hill; 2005)
217
CO U RS E
It m ost c o m m o n l y p resents a t p u berty a s a u n i late ra l ta n
patc h . Over t i m e , it may develop i nto a plaque a n d d is
play a d a rker b rown h u e . H a i r growth , which becomes
d a rker
and
coarser
over
time,
fol l ows
pigme nta ry
cha nges. They tend to e n l a rge slowly fo r a few yea rs, then
rema i n sta b l e over t i m e . The color may fad e with time;
h owever, the hair growth usua l ly persists.

Onset o f lesion?
I s the lesion sta ble?
I s the pigme nt, the h a i r growt h , or both cosmetica l ly trou
b l i ng?
MANAG E M ENT
T here is n o med ical i nd ication t o treat Becke r's nevus.
The cosmetic a p pea ra nce, however, may d isplease some
i n d ivi d u a ls-most often fem a l es who note its hypertri
chosis. Treatment options a re m u ltiple, but n ot a l ways
effective
i n c l u d i ng camo uflage
m a ke u p ,
electrolysis,
waxi ng, laser thera py, a n d s u rgica l excision . S u rgica l

exc ision is i m practica l for la rger lesions. Laser thera p i es
can be ta i l o red for h a i r rem ova l or pigment resol ution
( Fig. 4 1 . 3 ) .
Laser Treat m e n t
A test site i s reco m m e n d ed before i n itiati ng a n y laser

thera py to assess for efficacy and side effects .
Pigment:
nm),
Q-switc hed
N d : YAG (532 nm or 1 , 064 n m ) , and
Q-switc hed
r u by
(694
Q-switc hed
a lexa n d rite (755 nm) lasers have been reported effec

tive in treating the pigmenta ry com ponent of a Bec ker's
nevus ( Fig. 4 1 .4) .
- I n genera l , res ponse is poor. M u lt i p l e treatments a re
usua l l y req u i red for l ighte n i ng.
- There is a h igh rate of re pigmentation . T h i s is l i kely
d ue to deep hair fo l l ic l e mela nocytes .
Fractionated laser treatm ent: the 1 , 550- n m wave length

fractionated laser has been shown to safely and effec
tively red uce the pigmenta ry com ponent. M u ltiple treat
ments s paced 4 weeks a p a rt were e m p l oyed .
Hair
remova l :
long- p u lsed
a lexa nd rite
a nd
d iode
(800 n m ) lasers can prod uce hair red uction but a re

less effective with long-term pigment l ighte n i ng.
Ablative thera py: Erb i u m : YAG laser (2,940 nm) has

been demonstrated to be more effective than long
pu lsed N d : YAG laser ( 1 ,064 n m ) in s i de by side com
parison treatment of Bec ker's
nevus.
B oth
lasers
Figure 4 1 . 3 Incomplete improvement of Becker's nevus on upper buttock

after three treatments with Q-switched ruby laser. Associated pigmentary
changes noted
21 8
prod uce e rythema which clears with i n 1 5 days. The
BECKER'S NEVUS
l ong-term c l i n ica l a n d h i stological clearance has been
Therapy di rected toward
noted .
- It is i m porta nt to note that there is a h igh risk of tex
P igmentati o n
Excessive h a i r with i n the lesion
t u re cha nge a n d/or scar formation associated with

a b lative thera py.
I ntense pu lsed l ight has dem o nstrated m ixed success
Pigment reduction
H a i r reduction
Lasers
Lasers
Q-switched R u by, N d : VAG a n d

A l exand rite l asers most effective
Var i a b l e i m provement
R i sk u n even pigment red uction
creat i n g poor cosmet ic res u l t
A b l ative lasers have h igher risk
of side effects
Long p u l sed N d : VAG ( 1 064)

i s t h e least l i kely h a i r
re mova l l aser to cause post
i nflam matory changes.
Long-p u l sed ru by, a l exa nd rite
a n d d iode l asers are more
l i ke l y to cause hypo p igmentati o n
i n a Becker's nevus
in i m prov i n g pigmentation a n d h a i r loss .
P I T FALLS TO AVO I D/CO M PL I CAT I O N S/

EXPECTAT I O N S
Treatment o f t h e pigme nta ry com ponent o f t h e nevus is

often i neffective and rec u rrences a re common
S u rgical
Laser h a i r remova l ca n i m prove overlyi ng hypertrichosis

and is genera l ly perm a n ent i n natu re
Postinfl a m m atory hypo- a n d hyperpigme ntation occ u r

fre q u e ntly, therefore a conservative laser a p p roach is
vita l to m i n i m ize a ny assoc iated pigme nta ry c h a nge
Patie nts with d a rk s k i n p h ototypes (types I V a nd V)

s h o u l d be treated ca utiously and at lowe r fl ue nces, as
t h e i r t h reshold res ponse occ u rs at lower en ergies . A
S e r i a l exc i sion should only be

pursued in lesions of I i m i ted s i ze
Perman e n t hair red uction i s a n effective safe opt i o n for

i m prov i ng a Becker's nevu s. A long p u l sed N d : VAG l aser shou l d
be used .
Laser red uct i o n of t h e p i gmented component is less effecti ve
a n d may prod uce worse cosmetic appeara nce
Any i m provement with l asers a n d pigment red uction may be
tem porary with future recu rrence
conservative laser a p proach is best to avoid posti nfl a m

matory hyperpigme ntation a n d/or hypopigmentation
Figure 4 1 .4 Becker's nevus treatment diagram
Laser treatment should be l i m ited to nonta n ned i n d ivid

u a l s to avo i d tem pora ry or perm a n e n t dyspigme ntation
S u rgical exc ision is d e pendent o n the size and locatio n

o f a l e s i o n a n d is ge nera l ly l i m ited to ve ry sma l l lesions
B I B L I OG RAPHY
Choi J E, Kim J W, S e a S H , S o n SW, A h n H H , Kye Y C .
Treatment o f Becke r's N evi with a Long- p u lse A l exa n d rite
laser. Dermatol Surg 2009;35( 7 ) : 1 105- 1 1 08 .
G l a i c h AS, G o l d berg L H , Da i T, K u n ish ige J H , Fried m a n
P M . Fractio n a l Res u rfa c i n g : A n ew thera peutic modal ity
fo r Bec ker's nevus. Arch Dermatol. 2007 ; 143 ( 1 2 ) : 14881 490.
Kopera
D,
H o h e n l eutner
U,
La ndthaler
M.
Qu a l ity
switc hed ru by laser treatment of sola r lentigi nes a n d

Bec ker's nevus : A h istopathologic a l a n d i m m u n oh isto
c h e m i c a l study. Dermatology. 1997 ; 1 94(4) :338-343 .
N a n n i CA, Alster TS. Treatment of a Becker's nevus u s i ng
a
694- n m
long- p u lsed
ru by
laser.
Dermatol Surg.
1 998;24(9 ) : 1 032- 1 034.

Tre l les
MA,
Allones
I,
M o ren o-Arias
GA,
Ve lez
M.
Becker's nevus: A c o m pa rative study between erbi u m :

YAG
and
Q-switc hed
neodym i u m : YA G ;
h istopathologica l fi n d i ngs .
( 2 ) :308-3 1 3 .
c l i n ic a l
and
B r J Dermatol. 2005; 1 52
CHAPT E R 42
Epid e rm a l I nclusio n Cyst
The epidermal i n c l usion cyst ( EI C ) , a lso known as seba

ceous cyst and epidermoid cyst, is the m ost common
cyst of the ski n . I t ra nges i n size from a few m i l l i m ete rs to
a few centi meters a n d origi nates fro m the fol l ic u l a r
i nfund i b u l u m . Its contents a re a c h eesy, malodorous m ix
t u re of d egraded l i p i d a n d kerati n . It ofte n ru ptu res, with
associated pa i n and i nfla m matio n .
Age: a d u lts
Race: none
Sex: eq u a l
Precipitating factors: deve l o p sponta neously o r as a res u lt
of tra u m a
PATHOG E N ES I S
Arise from epidermal cells i n the d e r m i s . T h ese cells may
be i m pla nted as a res u lt of tra u ma o r a rise fro m fo l l i c u l a r
i nfund i b u l a r c e l l s . These c e l l s m a y prol iferate as a res u lt
of p i l osebaceous occ l usio n . M u lt i p l e lesions have assoc i
ated with G a rd ner synd rome a n d basa l cell nevus syn
d ro m e .
PATHOLOGY
With i n the dermis o r s u bcuta neous fat, there is a wel l
dema rcated cyst conta i n i ng la m i n ated kerati n debris.
The cyst wa l l is l i ned by stratified sq u a m ous epithel i u m
featu ri ng a gra n u la r c e l l laye r. I n ru ptu red cysts, there i s a
fo reign body gra n u lo matous reaction with m u lt i n u c l eated
giant cells.
An E I C i s a d o m e-s ha ped , s m ooth , fi r m , we l l -c i rc u m
scri bed m o b i l e nod u l e freq u e ntly protru d i ng a bove the
s k i n s u rfa ce with a ce ntra l pore ( Fig. 42 . 1 ) . T h ey ra nge
in size from a few m i l l i m eters to a few centi m eters . They
ty pica l l y present on h a i r- b ea r i ng s ki n , s u c h as the u p per
tru n k , neck, e a r l o bes, and face. After ru ptu re, th ese
cysts deve l o p a stro ng i nfla m matory reaction as a resu lt
of the s p i l lage of cyst co ntents i nto the d e r m i s . I n t h i s
sett i n g , the cysts become red , i nfla m ed, te n der, a n d
e n l a rged . Periles i o n a l fi b rosis may d evelop with c h ro n i c
i nfla mma ti o n .
Figure 42 . 1 (A) Elliptical excision around epidermal inclusion cyst

punctum. (8) Cyst sac being "delivered" from excision site.
219
220
P i l a rs cyst, dermoid cyst, bra n c h i a l c l eft cyst, nod u l a r
f i b r o m a , a n d d e r m a l tu mors m a y c a u s e confusion with
E I Cs . Of these lesions, only E I Cs feature centra l pores.

I n t h e event o f u n ce rta i nty o f d iagnosis, a bio psy c a n be
performed to r u l e out neoplas m .
COU RS E
E I Cs may i n c rease i n size over ti m e , especia l ly with phys
ical
m a n i p u latio n .
These
lesions freq ue ntly become
i nfla med , resu lti ng i n d iscomfort. Fra n k puru lence may

a rise, req u i ri n g i n c ision and d ra i nage.
I s t h e lesion recu r rently i nfla med a nd pa i nful?
I s the l esion sym ptom atic?
I s the l esion i n c reasing in size?
Has the lesion been i nflamed before?
Has the lesion been d ra i n ed or exc ised in the past?
Wo u l d the patient prefe r a s u rgica l sca r rather than

kee p i n g the cyst?
Figure 42.2 (A) Removal of cyst with punch biopsy, (B) dissection of cyst
from surrounding skin, (C,O) extrusion of cyst sac
MANAG E M E N T
There is no medical i n d ication t o treat E I Cs i f they a re not
sym ptomatic . The cosmetic a p pea ra nce, however, may
d isplease some i n d ivid u a l s . I n these i nsta nces, s u rgica l
exc ision is the treatment of choice. R u ptu red E I Cs can
prod uce rec u rrent d iscomfort a n d repeated i nfections fo r
some patients. For these lesions, s u rgica l remova l is ben
eficia l . Cyst recu rrence is highest for cysts that have been
i nflamed with the d evelopment of associated fi brosis.
TREAT M ENT
Patient e d u cation is pa ra mount t o avo i d cyst e n l a rge

ment. Disconti n uation of cyst m a n i p u lation red uces the
risk of cyst e n l a rge ment and cyst r u pt u re
S u rgical excision is the treatment of choice for cyst

re mova l
For n o n i nflamed E I Cs
- The cyst m a rgins s h o u l d be pa l pated a n d d e l i n eated
prior to a n esthesia
- The s u rgica l i ncision l i ne s h o u l d tra nsect the epid er
mal pore as poss i b l e
22 1
- Typica l ly, a s m a l l e l l i ptical-sha ped excision or a sma l l

p u n c h bio psy is performed ove r t h e cyst a ro u n d the
ce ntra l pore ( F igs . 42. 1 and 42 . 2 )
- The cyst s a c is t h e n identified a n d ca refu l l y d i ssected
to kee p the sac i ntact
- Sac remova l may req u i re latera l com p ress ion to
extru d e the cyst. A portion of the cyst co ntents may
be removed to assist i n sac re mova l
- It is i m porta n t to note that short of fu l l remova l of the
entire sac wa l l , there is a l i ke l i hood of rec u rrence.
Consider i r rigation of the wo u nd with sa l i ne if cystic
contents a re noted i n the wou n d
- T h e patient m ust b e awa re o f t h e potentia l dead
space that may resu l t fro m cyst remova l . H ea l i n g in
these i nsta nces may res u lt i n a n i n d e ntatio n of the
affected s k i n
F o r i nflamed E I Cs
- I n the eve nt of an i nfla m ed , i nfected , or newly r u p

tu red cyst, s u rgica l remova l s h o u l d be postponed
u nt i l the i nfection a nd i nflam mation have resolved
- I nflamed E I Cs a re more d iffic u lt to exc ise as they
become more fi rmly a d herent to the s u rrou n d i n g d e r
ma I structu res
- D ra i nage of contents is i m porta nt prior to treating
la rge r i nflamed cysts
- l ntralesional corticoste roids, wa rm com p resses , a n d
a nti biotics ( i n t h e eve nt o f i nfection) c a n a i d i n
decreasi n g i nfl a m mation
- When the i nfla m mation has su bsi d e d , s u rgica l exc i
sion c a n proceed
- Consider a cou rse of postexc isiona l o ra l a nt i b i otics
when cysts a re i nflamed or have d ra i nage

MANAG E M ENT/O UTCO M E
EXPECTAT I O N S
I t i s i m porta nt to d iscuss with t h e patient that w h i l e s u r

gica l exc ision of a n E I C is a routi ne s u rgical p roced u re,
the sca r left from the s u rgery may be m o re cosmetica l ly
d istu r b i n g tha n the E I C itse lf.
Patie nts m ust be awa re that cyst rec u rrence may occ u r.
C h ro n i ca l ly i nflamed E I Cs s h o u l d be exc ised to avoid

further i nfl a m mation/i nfectio n .
B I B L I OG RAPHY
M e h ra bi D , Leon h a rdt J M , B rodell RT. R e mova l o f kerati
nous and p i l a r cysts with the p u n c h i ncision tec h n i q u e :
Ana lysis o f s u rgical outcomes. Dermatol Surg. 2002 ; 28:
673-677 .
Figure 42.3 (A) Epidermal inclusion cyst prior to punch biopsy

(B) Epidermal inclusion cyst immediately following removal. An intact
cyst sac decreases the risk of cyst recurrence.
222
Rao K, Teh ra n i H . Exc ision of epidermoid cysts with a

minimal
l i nea r
incision.
Dermatol Online J.
2006;
1 2( 1 ) : 2 1 .
S m oot EC . R e mova l of la rge i n c l usion cysts with m i n i ma l
i n c ision sca rs. Plast Reconstr Surg. 2007; 1 1 9 (4) : 1395.
Wad e C L , H a l ey JC, H ood AF. The util ity of s u b m itti ng
epidermoid
cysts
fo r
h i stologic
exa m i nation .
lnt J
Dermatol. 2000;39 : 3 1 4-3 1 5 .
CHAPT E R 43
Epidermal
nevus
(EN)
is a
Epid e r m a I Nevus
ben ign
h a m a rtomato u s
growth . I t presents as a gro u p o f verrucous, c l osely

grou ped , skin-colored to b rown pa p u l es often in a l i near
a rra ngement fol l owing the Lines of B lasc h ke ( F ig. 43 . 1 ) .
It d eve lops p r i m a r i l y i n c h i l d h ood . There a re severa l va ri
ations of EN i nc l u d i n g loca l ized nevus u n i us lateris, sys
tematized
EN,
EN
synd rome,
and
i nfla m m atory
verrucous epidermal nevus ( I LV E N ) ( F ig. 43 . 2 ) .
EPI O E M I O LOGY
Incidence: 0 . 1 % of b i rths
Age: majority in the fi rst yea r of l ife; few d evelop in
p u berty
Race: none
Sex: fe male pred o m i n a nce i n I LV E N
Precipitating factors: u s u a l l y spora d i c ; fa m i l ia l cases
reported
PATHOG E N E S I S
E N i s c reated b y overprod u ction of kerat i nocytes from
p l u ri potent e m b ryon i c epidermal basa l kerat i n ocytes.
Genetic mosa i cism is thought to be respons i b l e for most
epidermal nevi .
PATHOLOGY
Pa p i l lomatosis, aca nthosis, epidermal hyperplasia , a n d
hyperkeratosis a long with elongated rete ridges a re p re
sent. In some lesions, epidermolytic hyperkeratosis a n d
va ria ble pa ra keratosis m a y b e prese nt. If t h i s fi n d i n g i s
m a d e i n t h e setting o f m u ltiple epidermal nev i , ge n etic
cou nsel i n g s h o u l d be offered i n o rd e r to ed ucate patients
as to the risk of e p i d e rm olytic hype rkeratosis in offspring.
Neoplasms s u c h as keratoacanthoma , basa l cell carci
n o m a , and sq u a m o u s cell ca rc i noma may rarely d evelop
i n assoc iation w i th epidermal nevi .
Figure 43 . 1 Young man with epidermal nevus limited to his neck nape
Sect i o n 7: B e n ign G rowt h s
223

Com m o n ly p resent a s a si ngle l i n ear les i o n , a lthough
u n i latera l o r b i latera l l i ne a r plaq ues may be prese nt.
M ost cons ist of m u lt i p l e , we l l - d efi ned , c l osely gro u ped
l i n ea r, yel l ow, p i n k , or b rown verrucous pa p u les on a n y
b o d y s i t e . E N often fol l ows the L i n es o f B lasc h ko on t h e
tru n k a n d travels longitu d i na l l y on the extre m ities. Size
ca n va ry from a few m i l l i meters to m u ltiple centi m eters .
May t h i c ken a n d become m o re ve rrucous over t i m e ,
espec i a l l y i n flex u ra l regions. Erythema is a c o m m o n fea
t u re of I LVEN .
N evus sebaceo us, seborrheic ke ratos is, ve rruca vu l
ga ris, l ich e n striatus, m e l a n ocytic nevus, l i c h e n p l a n u s ,
psoriasis.
Figure 43.2 An extensive epidermal nevus on the left face and left ear

A biopsy m a y b e i n d icated t o d isti nguish fro m nevus
sebaceo u s o r l i c h e n striatus. Ra rely, basa l cel l and sq u a
mous c e l l ca rc i n o m a may a rise i n E N .
E P I DERMAL NEVUS
U n known et i o l ogy; rare

R a rely, pat ients have an assoc i ated syn d rome with C N S ,
oc u l a r, m uscu l oskeletal cha nges
Deta i l ed rev i ew of systems and eva l uation by ped i atrics w i t h
appropri ate d i agnostic tests shou l d be performed to r u l e out E N
syn d rome
CO U RS E
A n E N ge nera l ly presents a t b i rt h o r c h i l d h ood a s mac
u les i n itia l l y wh i c h th icken ove r time. Eighty percent of
E N s a p pea r with i n the fi rst yea r of l ife . At p u berty, they
te n d to e n l a rge, d a rke n , a n d becom e more verruco u s .

I LVEN may be pru ritic i n nature.
Treatment of an epidermal nevus

Cosmeti c i m provement i s var i a b l e
w i t h a l l treatments
Age o f onset
C N S a bnorma l ities
Skeleta l d efects
Pru ritus
Fa m i ly h i story
P u l sed carbon d ioxide

laser, treatment of choice
with moderate to exce l l e n t
i m provement depen d i ng on
depth of lesion
Les i o n s may part i a l l y rec u r
over t i me
R i sk of dysc h ro m i a or sca rring
MANAG E M ENT
Mechanical
Derma brasi o n- a b lat i ve l asers

provide better contro l
S u rgical excision
L i m ited
Var i a b l e scar fo l lowi ng exc i s i o n
Figure 43.3 Epidermal nevus treatment diagram
I n pati e n ts with m u lti p l e E N s , a thorough exa m i nation

fo r syste m i c a b n o rm a l ities is i n d icated . Th ere is n o
med i c a l i n d ication t o treat E N . The cosmetic a p pea r
a nce, h oweve r, may be both erso m e to the affected i n d i
vid u a l or pa re nts of c h i l d re n with d isfigu r i n g growt h s .
T h e re a re m u lt i p l e treatment m od a l ities for E N i n c l u d i n g
su rgery, d e r m a b ras i o n , to pica l t h era py, a n d laser ther
a py ( F ig. 43 . 3 ) . Patients s h o u l d be c o u nseled that treat
m e n t res u lts a re va r i a b l e . The phys i c i a n
I
Lasers
needs to
c o n s i d e r whether treatment wi l l p rod uce a su perior
224
o utco m e to n o n i nterve n ti o n . T h e m ost aggressive fo rms

of thera py, laser a b lation and s u rgica l exc i s i o n , ca rry a
h igh risk of sca r fo rmation a n d/or dyspigm entati o n
( Fig. 43 .4) .
TOP I CAL T R EATM E NTS

The fo l lowi ng topica l thera pies provide l i m ited su ccess
for lesional i m provement a n d
may best util ized for
sym ptomatic re l i ef of pru ritus: h igh-potency corticos

teroids, treti n o i n , a n t h ra l i n , 5-fl u o ro u ra c i l , podophyl l i n ,
calci potrio l , a n d 5 % 5-fl uoro u ra c i l .
S U RG E RY
F u l l-th ickness s u rgical excision of EN is c u rative
Postoperative sca r is expected
Cosmesis is va riable
Poss i b i l ity of hypertro p h i c or kel o i d a l sca rring
S u rgical outcome is best for smaller lesions
Excision may be d iffi c u l t for yo u n g c h i l d re n to tolerate
Shave biopsy a n d c u rettage may be too su perfi c i a l ,

rec u rrences l i kely
CRYOT H E RAPY/E LECTROCAUTERYI

D E R MAB RAS I ON
C ryoth era py, e l ectrocautery, a n d dermabrasion have l i m
ited efficacy, a h igh rate o f rec u rrence, a nd h igh r i s k o f a
perma nent pigmenta ry a lteration a n d sca rring.
LAS E R T R EAT M E N T
Laser thera py ca n b e effective i n treat i n g E N . A test site is
reco m m e n d ed prior to treatment
C0 2 laser ( Fig. 43 . 5 )
- Laser a blation c a n p rovide good control o f the d e pth
of treatment
- Treatment d e pth is l i m ited to the pa p i l l a ry dermis i n
order to avoid sca r fo rmation
Erbi u m : YAG laser

Fractio nated a blative laser
- M ost effective for more su perfi c i a l lesions
- Treatment d e pth is l i m ited to the pa p i l l a ry dermis
With a blative laser treatment, there is a na rrow m a rgi n

between successful treatment a nd h a rmfu l side effects
s u c h as sca rri ng a n d perma nent d yspigmentation
Recu rrences a re common after laser treatment
Q-switched lasers
Figure 43.4 (A) Young patient with epidermal nevus syndrome. Note the
extensive nature of these lesions even after several surgical procedures
225
The Q-switc hed a lexa nd rite ( 7 5 5 n m l a n d fre q u e n cy

d o u bled Q-switc hed N d : YAG 532- n m lasers may be
effective for i m p rovement of th i n E N s .
I t is i m po rta nt to i nform patients that treatment may

o n ly be pa rti a l ly successful and may rec u r
Laser treatment o f t h e epidermis a l o n e w i l l res u l t i n

i n c o m plete remova l
Laser treatment beyon d the pa p i l l a ry d e r m i s may res u lt
There is a lways the risk that treatment wi l l prod uce an
Adve rse side effects as d escri bed a bove m ust be
in sca r formation a n d/or d yspigmentation

i nferior res u l t to n o n i nterve ntion
expl a i ned i n d eta i l to patients for rea l istic expectations
rega rd i ng treatment outcom e
B I B L I OG RAPHY
Boyce S , Alster TS. C02 laser treatment o f e p i derma l
nevi : Long-te rm su ccess. Dermatol Surg. 2002 ; 28( 7 ) :
6 1 1 -6 1 4 .
K i m J J , C h a n g MW, Schwayd er T . To pica l tret i n o i n a n d
5-fl uoro u rac i l i n t h e treatment o f l i n ea r verrucous epid er
mal nevus. J Am Acad Dermatol. 2000 ;43 ( 1 pt 1 ) : 1 29132.
Lee BJ , M a n c i n i AJ , R e n u cc i J , Pa l l e r AS, B a u e r B S . F u l l
t h i c kness s u rgica l excision fo r t h e treatment o f i nfla m ma
tory l i near verrucous epidermal nevus. Ann Plast Surg.
200 1 ;47 ( 3 ) : 285-29 2 .
M itsu h a s h i Y , Katagi ri Y , Ko n d o S . Treatment o f i nfla m
matory l i n e a r ve rrucous e p i d e r m a l naevus w i t h to pical
vita m i n 03. Br J Dermatol. 1997 ; 1 3 6( 1 ) : 1 34- 1 3 5 .
M o reno Arias GA, Ferra n d o J . I ntense pu lsed l ight for
mela nocytic lesions. Dermatol Surg. 200 1 ; 27(4) :397-400.
Pa nagioto po u l os
A,
C hasa p i
V,
N i kolaou
V,
et
naevi .
Acta Derm
Venereal.
Figure 43.4 (Continued) (B) and after greater than 30 subsequent surgical
procedures including flaps and skin grafts (Courtesy of Richard Bennett,
Muba Taher, and Mathew A vram)
al.
Assessment o f c ryosu rgery for t h e treatm e nt o f verrucous

epidermal
2009 ; 89 ( 3 ) :
A b l a t ive
C02 lase r
292-294.
Pa rk J H , Hwang ES, Kim S N , et a l . Er:YAG laser treat
ment of verrucous epidermal n evi . Dermatol Surg. 2004;
30(3 ) : 3 78-38 1 .
Derm a l
compon e n t
re m a i n s
Toyozawa S , Ya m a m oto Y, Ka m i n a ka C , Kishi oka A , Yo nei

N . , F u r u kawa F. S u ccessfu l treatment with tric h loroacetic
acid pee l i ng for i nfla m m atory l i nea r verrucous epidermal
nevus. J Dermatol. 2010;37(4):384-386.
Zvu l u nov A , G r u nwa l d M H , H a lvy S . To pical calci potriol
fo r treatment of i nfla m m atory l i nea r verrucous epidermal
nevus. Arch Dermatol. 1 997 ; 1 33 ( 5 ) : 567-568.
Figure 43 . 5 Effect of ablative C02 laser on removing an epidermal nevus.
With the dermal component remaining, there is a risk of recurrence
226
CHAPT E R 44
Lipo m a
Li poma i s a benign t u m o r of matu re fat . I t presents a s a

soft s u bcuta n eous flesh-colored t u m o r that freely moves
aga i n st overlying s ki n . M ost often , it presents as a sol i
ta ry l e s i o n on the tru n k , n e c k , a n d prox i m a l extre m ities
( Fig. 44 . 1 ) . I nfreq u e n tly, i n d iv i d u a l s may present with
m u lt i p l e l i po m a s , ra rely as a pa rt of an i n h e rited syn
d ro m e .
EPI DEM I O LOGY

Age: can present at a n y age but m ost com m o n ly i n the
fo u rth decade
Race: none
Sex: eq u a l
Precipitating factors: m ost freq uently, there is n o p rec i p i
tati ng factor. M u lt i p l e l i pomas c a n be associated with
syn d romes such as Derc u m 's d i sease, fa m i l i a l m u ltiple
l i pomatosis, M a d e l u ng's d i sease, G a r d n e r's syn d rome,
B a n naya n-Zo nana a n d P roteus syn d rome
PATHOG E N E S I S
U n known .
PATHOLOGY
Wel l -c i rc u mscri bed , l o b u lated t u m o r of u n iform , mat u re
a d i pocytes in the s u bcuta neous fat, often with a th i n s u r
ro u n d ing fi brous ca ps u l e a n d eccentric n uc l e i .

A l i poma p resents as a soft, freely m o b i l e flesh-colored
ova l or rou n d su bcuta n eous nod u le with a norma l overly
ing epidermis. I ts size can va ry greatly from m i l l i m eters to
many centi meters . It is nontender u n l ess prese nting as
pa rt of Derc u m 's d isease, as an a ngiol i poma o r if i m p i ng
i n g on a nerve .
Epidermal i n c l usion cyst, p i l a r cyst, h i bernoma, angi
o l i po m a , a n d other fatty t u m o rs i n c l u d i ng l i posa rcoma
m ust be considered . If the lesion is greater than 1 0 e m or
fixed , m a l igna ncy should be considered .
Figure 44 . 1 A middle-aged female with two lipomas on her arms

I n normal c i rc u msta nces, no wo rku p i s i n d icated . I n the
eve nt of ra p i d or extensive growt h , however, biopsy may
be i n d icated if m a l igna n cy is suspected . Caution is i n d i
cated i n the eve nt of exc i s i n g a l i poma located i n the m i d
l i n e sac rococcygea l
regio n .
I t may re present s p i n a l
d ysra p h ism . I n t h i s c i rc u msta nce, consider rad iologica l

a n d neu ros u rgica l eva l uati o n . Do n ot perform a b i opsy.
CO U RS E
They te n d t o grow s l owly t o a certa i n size a n d d o not i n vo
l ute without i nterventi o n .
N u m ber a n d location o f l i pomas
Fa m i ly h i sto ry of s i m i l a r lesions
H i story of keloids/hypertro p h i c sca rring
Associated pa i n
Recent lesiona l growth
MANAG E M ENT
There is no medical i n d ication t o treat l i pomas u n l ess
they p rod uce
pa i n or constriction of movement or
demonstrate accelerated growth . M a ny patients, h ow

ever, req uest treatm ent for cosmesis. S u rgica l rem ova l ,
via exc ision or l i pos uction , is t h e m a i nstay of thera py. I f
t h e lesion is located i n t h e m i d l i ne sac rococcygea l reg i o n ,
c o n s i d e r s p i n a l dysra ph i s m .
TREATM ENT
S u rgical excision : best for s m a l l l i pomas ( F igs . 44. 2 a n d

44 . 3 )
- Depe n d i ng on t h e size o f t h e l i po m a , a s ma l l e l l i ptical
excision is performed over the tu mor. Once the
l i poma is encou ntered , it is d i ssected from its s u r
ro u n d i ng tissue.
- Afte r remova l , a laye red closure with su bcuta neous
sutu res is ge n e ra l ly req u i red to repa i r the cavity pro
d uced by the proced u re .
- Recu rrence is c o m m o n d u e t o t h e d ifficu lty o f d isti n
g u i s h i ng t u m o r fro m n o r m a l su bcuta n eous fat .
- S u rgica l exc ision is preferred f o r s m a l le r l i pomas a n d
is less expe nsive than l i posuction .
Li posuctio n : best for la rge l i pomas

- A sma l l i ncision is c reated with i n the center of the
l i poma after regional a n esth esia and l i pos u ction of
the l i poma is performed .
Figure 44.2 (A) Lipoma on posterior neck prior to surgical excision.

(8) Excision of lipoma.
227
228
- The entire t u m o r is not necessa rily removed . Rather,

porti ons of the l i poma a re removed u n t i l the affected
a rea l ies flush with the s u rrou n d i ng ski n .
- Postproced u re f i b rosis c a n ensu re a persistent flat
te n ed conto u r of the rema i n i ng l i poma tiss u e .
- The advantage o f l i pos u ction over excision is t h a t i t
prod uces a s m a l ler sca r.
- It is more expe nsive tha n sta n d a rd excisio n .
Low conce ntration d eoxych olate i njections have been
s h own to be effective for the treatment of l i pomas in a
l i m ited study. These i njections o bviate the need fo r
su rgery, a n d thus sca rring. N o netheless, further study is
reco m m e n d ed before this a l te rn ative treatment can be
reco m m e n d ed .
P I T FALLS T O AVO I D/CO M P L I CATI O N S/

EXPECTAT I O N S
T h e phys i c i a n s h o u l d i nfor m t h e patient that a l l s u rgica l

i nterventions prod uce some d egree of sca rri ng.
Sca rring may bother patients more t h a n the l i poma

itse lf.
Ad d itiona l ly, re m ova l of la rge l i pomas freq uently resu lts

in a posto perative s k i n d e p ressio n .
Recu rrence is com m o n , espec i a l ly with l i posucti o n .
B I B L I OG RAPHY
H a rri ngton A C , Ad m ot J , Chesser R S . I nfi ltrati n g l i pomas
of the u pper extrem ities. J Dermatol Surg Oneal. 1 990;
1 6 : 834-836.
R ot u n d a AR, Ablon G, Ko lod ney MS. Lipomas treated
with s u bcuta neous deoxyc holate i njections. Dermatol
Surg. 53 ( 6 ) : 73-78.
Salasche SJ , McCollough M L, Ange l o n i VL, G ra bski WJ .
Fronta l is-assoc iated l i poma of the forehead . J Am Acad
Dermatol. 1 989 ;20:462-468 .

Sanc h ez M R , Golom b FA , M oy J A , Potozk i n J R . G ia n t
l i po m a : c a s e report a n d review o f the l iteratu re . J Am
Acad Dermatol. 1 993;28: 266-268 .

Tru h a n A P, G a rd e n J M , et a l . Fac i a l a n d sca l p l i pomas:
case reports a n d study of preva lence. J Dermatol Surg
Oneal. 1 985; 1 1 : 9 1 .
Figure 44.2 ( Continued) (C) Subcutaneous suture for closure. (D) Gross
path specimen of lipoma
CHAPT E R 45
M iliu m
M i l ia a re benign su perficial wh ite-ye l low kerati naceo u s

cysts t h a t typ ica l l y prese nt on the eye l i d s , forehea d , a n d
face but may present a nywhere ( Fig. 45. 1 ) . They occ u r a t
a l l ages a n d a re very co m m o n .
EPI DEM I O LOGY

Age: a ny age; m ost common i n newborns a n d a d u lts
Race: none
Sex: eq u a l
Precipitating factors: These a re most freq uently spora d i c
lesions but they can be assoc iated with s u bepidermal
b l istering d i seases s u c h as porphyria cuta n ea ta rda , ep i
derm olysis b u l losa acq u isita , va ricella zoster vi rus, b u l
lous pem ph igo i d , a n d b u l lous l i c h e n pla n u s . T h e y a re
a lso associated with s k i n tra u ma s u c h as a brasions,
b u rns, dermatologic s u rgery, a blative a n d n o n a b l ative
fractional res u rfa c i ng, C02 res u rfa c i ng, a n d ra d iation
thera py. They may a lso occ u r fol lowi n g treatm ent with
topical 5-fl uoro u rac i l , topical corti costeroids, and m i c ro
derma brasion
PATHOG EN ES I S
M i l ia a re believed to b e retention cysts d erived from vel
Ius h a i r fo l l ic l es . M i l i a seco n d a ry to tra u ma or b u l lous d is
eases a rise from ecto pic h a i r fol l icles.
PATHOLOGY
They re present s m a l l epidermoid cysts and feature c h a r
acteristic stratified sq u a m o us epithe l i u m with l a m i nated
kerat i n debris. A gra n u l a r layer is p resent in the cyst wa l l .
P H YS I CAL LES I ON S
M i l i a present as 1 t o 4 m m s u perfi c i a l wh ite-yel low cysts
that m ost c o m m o n l y a p pea r on the eye l i d s , cheeks, a n d
fo reh ea d .
T h e i r c l i n ic a l a ppea ra nce i s c h a racteristi c .

None.
Figure 45 . 1 Small milia on face of a 3 7-year-old female
229
230
COU RS E
They c a n present a t a n y age a n d d o n ot resolve without
i n tervention.

I s there a n y h i story o f bl istering or tra u ma?
MANAG E M ENT
There is no med ica l i n d ication t o treat m i l ia . T h e cosmetic
a p pea ra n ce, however, may d isplease some i n d ivid u a l s .
TREAT M ENT
I ncision a n d exp ress i o n : treatment o f choice ( Fig. 4 5 . 2 )
- Local a n esthesia m a y b e req u i red .

- I n cision with a # 1 1 blade a n d remova l of kerati n a ceous d e b ris w i t h press u re from comedone extractor,
m i c rovasc u l a r force ps, or cotton swa b ti ps.
- The proced u re is fast, s i m ple, and effective .
Topical medications
- To pica l treti n o i n c a n be effective for m u ltiple m i l i a .
Other treatments
- Electrica l fulgurati o n .
- Ab lative o r fractional a b lative lasers c a n b e effective
but a re fa r more expensive with a h igher rate of side
effects a n d recovery time.
EXPECTAT I O N S
Treatment o f m i l ia is stra ightforwa rd . I ncision a n d exp res

sion is fast, s i m ple, a n d successfu l . It rem a i n s the treat
ment of choice.
In
cases of m u lt i p l e m i l i a , topica l
treti n o i n is a good choice, partic u larly if the lesions a re

s m a l l ( F ig. 45. 1 ) . Laser plays no practical ro le in the
treatment of m i l i a .
B I B L I OG RAPHY
M a rra D E , Pourra bba n i S, F i n c h e r EF, M oy R L. Fractional
photothe rmolysis for the treatment of a d u lt colloid m i l
i u m . Arch Dermatol. 2007 ; 143 ( 5) : 572-574.
D movsek-O i u p B, Ved l i n B. Use of Er:YAG laser fo r
benign s k i n d i sorders. Lasers Surg Med. 1997;2 1 ( 1 ) :
13-19.
Figure 45.2 (A) Lancet piercing a milium on the left lower anterior neck
of a patient. (B) Comedone extractor extruding keratinaceous debris from
milium. (C) Postprocedure resolution of milium after comedone extraction
CHAPT E R 46
Neu rofi b ro m a
N e u rofi bromas ( N Fs) a re ben ig n , soft, p i n k , neu romes

enchymal tu mors
that
can
be
sol ita ry o r
m u ltiple
( Fig. 46. 1 ) . Sol ita ry tumors a re n ot associated with sys

te m i c fi n d i ngs. M u lt i p l e N Fs a re assoc iated with neu rofi
b romatosis types I and I I , both neu roc uta neous d isord e rs
with i m porta nt system i c m a n ifestations i n c l u d i ng m a l ig
na ncies. P l exiform N Fs a re seen in patients with n e u rofi
bromatosis type I .
EPI DEM I O LOGY

Incidence: common
Age: you ng a d u lts
Race: none
Sex: eq u a l
Precipitating factors: m u ltiple N Fs a re s e e n i n assoc iation
with n e u rofi b romatosis I and I I . There a re n o p rec i p itati ng
factors for sol ita ry N Fs
Figure 46. 1 Multiple nonracial neurofibromas
PATH OG E N ES I S
The pathogenesis of sol ita ry lesions i s u n known . M u ltiple
germ l i n e a nd somatic m utations have been i d entified for
patients with n e u rofi b romatosis types I a n d I I .
PATHOLOGY
NF is c h a ra cteri zed by a wel l -c i r c u mscri bed , u nenca ps u
lated dermal a n d s u bc utic u l a r collection o f s m a l l nerve
fibers a n d loosely a rra nged s p i n d l e cells possessi ng wavy
n uclei in an eos i n o p h i l i c matrix. M ast cells a re c o m m o n l y
see n . M itoses a re a bsent.
N Fs p rese n t as s k i n c o l o red t o p i n k t o b rown soft o r
ru b b e ry, pa p u les o r nod u les ( Fi g . 46 . 2 ) . T h e a b i l ity to
e a s i l y i nvag i n ate the l e s i o n with press u re , k n ow n as
" b utto n h o l i n g , "
is a c h a racteristic p h ys i c a l fi n d i n g.
T h ey ra nge i n size fro m a few m i l l i m eters to a few c e n

t i m eters. P l exifo r m N Fs a re c h a racterized by la rge ,
bag- l i ke m a sses that may have associ ated hyperpig
m e ntati o n .
Derma l nevi ; congen ita l nevi ; dermatofi bromas; neu ro
mas; a n d fi bromas
Figure 46.2 Multiple neurofibromas on the left face
23 1
232
N E U ROFIBROMA
C l i n i c a l exa m
A sol ita ry N F d oes not merit a work u p . Biopsy may b e i n d i

cated o f a c l i nica l ly atypical N F. M u ltiple N Fs merit refe rra l
to n e u rologic, ophth a l mologic, genetics, a n d orthoped ic
Soft, s k i n -col ored , red/brown papu l e/nod u l e

S o l i tary lesion more common t h a n m u l t i p l e
special ists to assess for neu rofi bromatosis I or I I . Complete

skin a n d eye exa m i nation of the patient a n d i m med iate
relatives is i n d icated as wel l . Skin exa m i nation should
assess for axi l l a ry freckl i ng, cafe a u Ia it macu les, plexiform
N Fs, j uven i le xa nthogra n u lomas, a n d Lisch nod u les.
Sol i tary l e s i o n ( most com m o n )

S u rgical shave or exc i s i o n ,
treatment of choice
No rol e for lasers
Figure 46.3 Neurofibroma diagram
COU RS E
They tend t o grow i n d o lently a n d pa i n lessly. Plexiform N F
req u i re conti n u ous mon itoring for potentia l m a l ignant
cha nge .
N u m ber o f lesions
Fa m i ly h i story
Centra l nervous system ( C N S J a bnorma l ities
Sco l i osis
Eye a bnorma l ities
Bone defects
Loss of hea r i n g
MANAG E M ENT
There is no med ical i n d ication t o treat N Fs u n less they
prod uce pa i n or a re cosmeti cally d isfigu ring or a re
cha nging in growt h . M a ny patients , however, req u est
treatment for i m provem e nt of cosmetic a p pea ra nce.
T R EAT M ENT (Fig. 4 6 . 3)
S u rgical exc ision

- W h i l e there a re many methods for removing N Fs,
s u rgica l excision is the m ost common and efficient
means of rem ova l . Recu rrence is l i kely if the NF is
not completely excised
- El l i ptica l exc ision is an effective, i n expens ive treat
ment and is pa rti c u la rly a ppropriate for management
of a few n u m ber of lesions. As with a ny s u rgery, an
expected sca r will resu l t ( Fig. 46 .4)
Laser a b lation
- N ot fi rst- l i ne thera py
- Carbon d ioxid e (C02 ) laser res u rfa c i n g can be util ized for fac i a l lesions. C0 2 laser treatment of no nfa
c i a l l e s i o n s is ge nera l ly n o t reco m men ded given r i s k
o f hypertro p h i c sca r/ke loid formation
I f m u lt i p l e les i o n s , r u l e out
assoc i ated n e u rof i bromatosi s
S u rgical shave or exc i s i o n ,
treatment of choice
Lasers: seco n d - l i n e therapy
233
A cutting tec h n i q u e ca n be uti l i zed to exc ise

tu mors. C0 2 treatment in a foc used conti n u o u s
wave bea m , 1 5 to 30 W is performed a long the
m a rked m a rgi n . R e i n cise a l o n g the m a rg i n u ntil the
d esi red d e pth is o bta i ned . Tissue u n d e rm i n i ng a n d
hemorrhage control ca n b e o bta i ned uti l i z i n g the
sa m e laser pa ra m eters with the h a n d piece held
away from the wou n d to defoc us the bea m . Wo u n d
c l osu re is performed i n a sta n d a rd fas h i o n
A va porization tec h n iq ue may be uti l i zed t o flatten
and remove t u m ors. C0 2 treatment with a d efo
c u sed bea m a n d 3 to 6 W is performed to the level
of adjacent normal ski n . I t may be necessa ry to
m a n u a l ly extract la rge resi d u a l dermal tumor once
visual ized .
Char
should
be d e brided
between
passes with a wet ga uze a n d d ried f u l l y prior to con

t i n u i ng treatment
Seve ra l treatment sessions may be req u i red for
pati ents with n u merous N Fs
Posti nfl a m matory
hyperpigmentati o n ,
atro p h i c
sca rring, hypertro p h i c sca rring, a n d i ncom plete

remova l have been reported as side effects. A test
site s h o u l d be considered , in partic u l a r in patients
with Fitzpatrick s k i n phototypes I l l-V I
- Erbi u m : ytt ri u m a l u m i n u m ga r n et laser res u rfa c i n g
can be util ized fo r fac i a l lesions
S u rfa ce va porization to flatte n t u m o rs . This treat
ment modal ity is less effective t h a n the C0 2 laser i n
l es i o n a l re m ova l . H owever, t h i s laser m a y b e m o re
a p pro priate for patie nts with d a rker Fitz patrick s k i n
p hototypes t o m i n i m ize posti nfla m m atory pigmen
ta ry cha nges
I nterstiti a l ph otocoagu lation ca n be performed for
the treatment of b u l kier lesions, i n c l u d i ng nonfacial
lesions

EXPECTAT I O N S
T h e physicia n shou l d i nform t h e pati ent that a n y s u rgi

cal o r laser i n tervention p rod uces some d egree of scar
ring.
Remova l
of N Fs via
laser a blation
may prod uce
posti nfla m matory hyperpigmentation a n d/or sca rri ng.

Recu rrence is com mon .
C0 2 laser i n cisiona l treatm ent ca n lead to decreased

te nsile wou n d strength d u ri ng the wou n d hea l i ng phase
when com pa red to sta n d a rd s u rgica l exc ision due to
laser therma l d a m age at the wou nd m a rg i n . S utu res
s h o u l d be left in for an a d d itiona l wee k to assist i n
wou nd hea l i ng.
Figure 46.4 (A) Solitary neurofibroma preop. (8) Solitary neurofibroma
following simple excision. This is the treatment of choice for solitary neu
rofibromas. It is also a good option for removal of limited neurofibromas
234
C0 2 laser va porization treatment s h o u l d be l i m ited to

fac i a l N Fs, given an i nc reased risk of sca r formation
with use o n nonfa c i a l sites .
B I B L I OG RAPHY
Cole
R P,
Widd owson
D,
M oore
JC.
Outcome
of
erbi u m : yttri u m a l u m i n u m ga rnet laser resu rfa c i n g treat

ments . Lasers Med Sci. 2008;23(4) :427-433.
Elwa k i l T F, Samy N A , E l basiouny M S . N on-exc ision treat
ment of m u lt i p l e c uta neous neu rofi bromas by laser pho
tocoagu lation . Lasers Med Sci. 2008;23 ( 3 ) : 30 1 -3 1 6 .
M oren o J C , Mathoret C , La ntieri L, Sel ler J , Revuz, J ,
Wol kenste i n P. Carbon d ioxi d e laser for remova l o f m u lti
p l e c uta neous n e u rofi bromas. Br J Dermato/. 200 1 ;
144 ( 5 ) : 1 096- 1 098.
N evi l l e H L, Sey m o u r-Dem psey K, Slopis J, et al. The role
of s u rgery in c h i l d ren with neu rofi b ro matosis. J Pediatr
Surg. 200 1 ;36( 1 ) : 2 5-29 .
CHAPT E R 47
Se b o r rhe ic Ke ratosis
Seborrheic ke ratosis ( S K) a re the m ost common be n ign

c uta neous t u m ors, and i n a d u lts S K a re wa rty, ke ratotic
skin growth that fi rst present after the fou rth d eca d e . The
mea s u re from a few m i l l i meters to centi mete rs The color
ra nges fro m p i n k to ta n to dark b row n . Lesions can be
sol ita ry or m u lt i p l e ( Fig. 47. 1 ) .
Over time,
patients
d eve l o p a nywhere from a few to h u n d reds of S Ks . M a n y

patients req u est rem ova l o f S Ks, pa rticula rly w h e n m u lti
p l e or la rge , beca use of their u nsightly a p peara nce.
EPI D E M I O LOGY
Age: usua l l y i n fou rth decade a n d become more n u mer
ous in m i d d l e age a n d beyon d
Race: m ore common i n Ca ucasi a n s

Sex: eq u a l
Precipitating factors: fa m i ly h i story w i t h l i kely a utoso m a l
d o m i n a nt i n he rita nce
PATHOG E N ES I S
U n known .
PATHOLOGY
C lassica l ly, S Ks a re wel l -c i rc u mscri bed epidermal growths
that rise a bove the s u rface of the s u r ro u n d i ng ski n . A l l
featu re hyperke ratos is, pa p i l l o matosis, a n d acanthosis.
The epidermis conta i ns basa loid cells that show sq ua
mous d ifferentiati o n . Sq u a m ous edd ies may be prese nt.

There a re m a n y c l i n ica l va ria nts o f S Ks . They range i n
size from a few m i l l i m eters t o a few centi m eters a n d m ost
c o m m o n l y occ u r on the fa ce, neck, a nd tru n k . They typi
ca l ly fi rst present as we l l-demarcated ta n o r l ight b rown
macu les. With time, they rise to becom e p l a q u es a n d
d eve l o p a wa rty a n d stu c k-on a p pea ra n c e . H o r n cysts
become a p pa rent with i n the lesions. They ca n occ u r a ny
where on h a i r-bea ring sk i n a n d a re not seen on the pa l m s
a n d soles.
Lentigi nes, verruca , a c rochordons, condyloma a c u m i na
tum, a c rokeratosis verruciformis, dermatosis pa pu losa
n igra , Bowe n 's d isease, nevus, epidermal nevus, lentigo
m a l igna, m e l a n oma , a n d sq u a m ous c e l l carc i n o m a . The
c l i n i c a l a p pea ra nce and prese nce of horn cysts in S Ks
ma kes the d iagnosis stra ightforwa rd .

N o n e ; s k i n b i o psy i f sus pect m a l igna ncy.
CO U RS E
They present i n t h e fou rth decade a n d persist for yea rs .
Over time, they becom e la rger, more pigmented a n d fea
t u re a
m o re verrucous a p pea ra nce.
They typ ica l ly
become more n u m erous with age. I nfreque ntly, they can

regress sponta neous ly.
Fa m i ly h istory o f s k i n ca ncer
H istory of bleed i ng
li m e of onset
Was there a ra p i d o nset of n u merous S Ks?
MANAG E M ENT
There is n o medical i n d ication t o treat S Ks, u n l ess they
a re i rritated . Sti l l , the cosmetic a p peara n ce bothers many
patients. There a re m u ltiple modal ities for treating S Ks
Figure 47. 1 Multiple seborrheic keratoses on back of elderly male
235
236
i n c l ud i ng c ryothera py, el ectrodesiccati o n , c u rettage, a

switc hed a n d a blative laser thera py. M ost often , the tra d i
t i o n a l methods o f treati ng S Ks a re m ost a p propriate . If
there is a ra pid onset of widespread lesions, perform a
review of systems a n d consider a fu l l physical exa m i na
tion to rule out a n y u n d e rlyi ng medical cond ition or carci
noma (Sign of Leser Tre let ) .
TRA D I T I ONAL T R EATM ENTS

E m p has ize r i s k o f i ncom plete remova l a n d recu rrence
with a ny treatment modal ity.
C ryothera py
- Light c ryothera py is a q u ic k , i n expensive , a n d effec
tive method of treating S Ks . R i s k hypo- or hyperpig
mentation and low risk of sca rring
- If the lesion d oes n ot resolve, retreatment is neces
sa ry in 3 to 4 weeks
C u rrettage and light cautery

- El ectrod esiccation of S Ks is a n other q u ic k a n d effec
tive method of treatment. Sl ight d iscomfort assoc i
ated with loca l a nesthesia
- C u retti n g the lesion after electrodesiccation can
e n s u re remova l
- Light, q u ic k e l ectrod esiccation of the base may a lso
e n ha nce effi cacy a n d preve nt rec u rre nce
- Postproced u re wo u n d care is needed with e m o l l ient
for 7 to 1 0 days
Shave excision
- Shave excision ca n effectively remove S Ks
LAS ER T R EAT M E NTS

Laser is not a fi rst- l i n e treatment for S Ks . Rather, it s h o u l d
be considered a n a lternative treatment a n d only u s e d i n
the correct c l i n ical setting.
M e la n i n ta rget i n g lasers fo r t h i n S Ks
- Q-switched ru by (694 n m ) a n d Q-switc hed a l exa n
d rite (755 n m ) , a n d the long-pu lsed 5 3 2 n m lasers
ca n effectively treat t h i n S Ks ( Fig. 47 . 2 )
- Somet i m es
i n effective,
espec i a l l y
as
t h i c kness
i n c reases; repeat treatments may be req u i red

- R isk of hypopigmentation
- Expensive compared to tra d itional thera p ies, but may
be more tolera ble to a patient with m u lti ple lesions
Ab lative lasers
- C0 2 a n d erbi u m : YAG lasers can a blate S Ks
- Repigmentation of S Ks occ u rs i nfreq ue ntly after
treatment
- Expensive com pa red to tra d itional thera p ies
Figure 47.2 Posttreatment whitening of seborrheic keratoses after
treatment with a 755-nm Q-switched alexandrite laser with a fluence of

10 J!cm2 and a 3-mm spot size. The procedure was performed after
fractional resurfacing, which explains the blue dye remnants apparent
on his face
237

EXPECTAT I O N S
S Ks c a n b e treated with a n u m ber o f d ifferent a n d

effective modal ities.
The phys i c i a n s h o u l d ed ucate the pati ent that a ny ther

a py has poss i b l e adverse effects such as pigmenta ry
cha nges, sca rring, a n d rec u rre nce.
Tra d iti o n a l thera pies s u c h as l ight c ryothera py or c u ret

tage a re s i m p l e , q u ick, a n d effective ( Fig. 47 . 3 ) .
Laser thera py is a n a lternative treatment at a h igher

expense.
B I B L I OG RAPHY
B rodsky J . M a nagement o f benign s k i n lesions com
mon ly affecti n g the face: acti n i c keratos is, seborrheic
keratosis, a n d rosacea . Curr Opin Otolaryngo/ Head Neck
Surg. 2009 ; (4) : 3 1 5-320.
C u l bertson G R . 532-nm d i ode laser treatment of sebor
rheic
ke ratoses with
color e n h a ncement [ p u b l ished
o n l i n e a head of print J a n u a ry 29, 2008] . Dermatol Surg.

2008;34(4 ) : 525-528; d iscussion 528 .
K i l m e r SL. Laser erad ication of pigme nted lesions a n d
tattoos. Dermatol Clin. 2002 ; 200 ) :37-53.
M e h ra bi D, B rod e l l RT. Use of the a lexa nd rite laser for
treatm ent
of
seborrheic
keratoses .
Dermatol
Surg.
2002 ; 28 ( 5 ) : 43 7-439.
Figure 47.3 (A) Curettage of seborrheic keratosis. (B) Immediately after
curettage of seborrheic keratosis. (C) Postinflammatory erythema 1 month

after curettage of seborrheic keratosis
238
CHAPT E R 48
Sy ringo m a
Syri ngomas a re c o m m o n benign a d nexa l neoplasms of

eccri ne d uct d e rivation that present most freq uently
i n fem a l es on the face, espec i a l ly a ro u n d the eyes
( Fig. 48. 1 ) . They may also be seen on the c h est, u m bi l i
c u s , a x i l l a e , a n d vulva .
EPI D E M I O LOGY
Age: usua l ly prese nt at puberty
Race: none
Sex: fe m a l e > m a l e
Precipitating factors: m o re common i n Dow n 's synd rome
PATHOG E N ES I S
Figure 48. 1 Infraorbital syringomas being treated with low setting elec
trocautery on a young female. The treatment was not effective.
U n known .
PATHOLOGY
T hese
benign
sym metric, wel l - c i rc u mscri bed d e r m a l
tu mors a re com posed o f m u lt i p l e s m a l l d ucts w i t h two

layers of c u bo i d a l epithel i u m , often with a "ta i l " givi ng a
"ta d pole, " or comma-l i ke a p peara nce i n the u p per d er
m is . These d u cts a re someti mes d i lated a n d a re l i ned by
an eosi n o p h i l i c cuticle. There is a s u r ro u n d i n g dense
fi b rous eos i n o p h i l i c stro m a .

Ski n-co l o red t o yel l ow, 1 - t o 3-m m firm pa pu les. They a re
seen most freq u ently a ro u n d the eyes, espec i a l ly the
lower eyel i d . Typical ly, they a re m u ltiple and sym m etric .
They c a n a lso be seen on t h e chest, u m bi l icus, axi l la e ,
a n d genita l i a ( Fig. 48 . 2 ) . Acra l lesions a re seen in e r u p-
tive syri ngomas.
M i l i a , sebaceous hyperplasia, basa l cell carci n o m a , tri
c h oepith e l i o m a , fi brous pa p u le,

B i o psy may b e i n d icated i f basa l ce l l carc i noma i s sus
pected . N o other la borato ries a re i n d icate d .
Figure 48.2 (A) Infraorbital syringomas in a young female. (8) Follow-up
picture at 1 week after ablative fractional C0 2 laser resurfacing showing

improvement of the syringomas. This improvement is attributed mostly to
the postprocedure edema. No significant improvement was noted at a
later follow up
CO U RS E
They present a t p u berty a n d d o n ot resolve without i n ter
ventio n .

Ti me o f onset
MANAG E M ENT
There is no me d i c a l i nd ication t o treat syringomas. M a n y
patients,
however,
req uest
treatment
for
cosmetic
a p pea ra nce. Syri ngomas a re thera peutica l l y c h a l lenging.

Although there a re m u ltiple treatment modal ities ava i l
a b l e , n o n e is co m p letely su ccessful i n c o m p l ete or
permanent remova l of syri ngomas. Ofte n , the s i de effects
of treatment w i l l bother patients more than the syr i n go
mas the mselves. Ideal ly, the treatment of syri ngomas
s h o u l d prod uce destruction of the tumor with m i n i m a l
sca rring a n d n o rec u rrence. There a re no effective topical
med ications.
TREATM ENT
S u rgical excision : best rese rved for sol ita ry lesions.

- Sca r will be prod uced
El ectroca utery : can be successfu l

- Loca l i zed a n esthes ia with 1 % l idoca i n e with or with
out e p i n e p h r i n e may be em ployed .
- Low-energy setti ng electroca ute ry performed at 1 to
2 W with the el ectrode placed in the center of the
syri ngo m a .
- C l i n ic a l end point is lesiona l flatte n i ng.
- Light setti ngs a re a dvised
to avoid
pigmenta ry
cha nges or sca rring.

- Gentle c u rretage is reco m m en ded to e n s u re that
effective
remova l
of
the
syri ngoma
has
been
obta i n ed .
Carbon d i oxide (C02 ) laser i s a n effective means of

i m proving these lesions. The goa l is to flatten rather
t h a n re m ove the lesio n s.
- Li m ited to patients w i th s k in p hototypes I-I I I .
- I n d iv i d u a l lesions o r m u ltiple syri ngomas with the
sa m e cosmeti c u n it may be treated .
- C0 2 treatment in a d efocused mode, 3 to 6 W, 3- m m
spot, 0 . 1 to 0 . 2 seconds may be e m p loyed .
- M u ltiple passes a re performed with remova l of resid
u a l char between passes with sa l i n e-soa ked ga uze
pads. Lesions a re treated to the l evel of adjacent nor
m a l s ki n .
Figure 48.3 Multiple syringomas on the chest of a female
239
240
- Les i o n a l rec u rrence is com m o n . Posti nfla m matory
SYRINGOMA
hyperpigmentation a n d sca rring may occ u r.
cacy a n d sid e-effect profi l e .
( Figs. 48 .3 a n d 48.4 ) .
Caution s h o u l d b e exercised w i t h e a c h o f t h e a bove
l isted modal ities .
Patie nts m ust a lso be i nformed that the side effects of

treatment may be more cosmetica l l y u ndesira b l e tha n
the syri ngomas themselves. These side effects i n c l u d e
sca rring,
hyperpigmentation ,
rec u rrence,
and
ery
thema .
When treati ng syri ngomas, ca re s h o u l d be ta ken to not

ove rtreat the l esions. I t is n ot n ecessa ry to complete ly
e l i m i nate the lesions, as some d e r m a l fi b rosis is
expected with hea l i ng, with res i d u a l lesions beco m i ng
l ess a p pa rent over t i m e .
Mechanical
Lasers
N o effective
topical therapy
Local a nesthes i a
w i t h l ight el ectro
desi ccati o n
A b l a t ive-Pu l sed C02 the

most effective moda l ity.
Post-l aser erythema for 1 -2
weeks . Apply emo l l i e n t over
treated area for opt i m a l
hea l i n g.
Although there a re m u ltiple treatment modal ities, they

a re often resista nt to thera py. Recu rrence is c o m m o n
Topical

EXPECTAT I O N S
Other treatme nts: i n c l u d e c ryos u rgery a n d derma bra

sio n . There is l ittle d ata with w h i c h to j u dge thei r effi
D i ff i c u l t to treat with a n y moda l i ty

C l i n i cal i m provement is var i a b l e
G reat ca re s h o u l d be given t o the treatment o f patients

with s k i n p h ototypes IV a n d h igher to avo i d tem porary
and perma nent pigmenta ry cha nges .
B I B L I OG RAPHY
Akita H , Ta kasu E, Was h i m i Y , Sugaya N , N a kazawa Y,
Mats u naga K. Syri ngoma of the fa ce treated with frac
tional photothermolys i s . J Cosmet Laser Ther. 2009 ;
1 1 (4) : 2 1 6-2 1 9 .
Frazier CC, Ca macho AP, Coc kere l l CJ . The treatm ent of
eru ptive syri n gomas in an Africa n America n patient with
a combi nation of trich lo roacetic acid and C02 laser
d estruction . Dermatol Surg. 200 1 ; 2 7 ( 5 ) :489-49 2 .
Ka ng W H , Km N S , K i m Y B , S h i m WC. A n ew treatment
fo r syri ngo m a . Com bi nation of carbon d ioxide laser a n d
trichloroacetic a c i d . Dermatol Surg. 1998; 24( 1 2 ) : 1 3701374.
Ka ra m P, B ened etto AV. Syri ngomas: new a p proa c h to an
o l d tec h n i q u e . lnt J Dermatol. 1 996;35( 3 ) : 2 1 9-220.
Saj ben FP, R oss EV. The use of the 1 .0 mm h a n d piece i n
h igh e n e rgy, pu lsed C02 laser d estructi o n o f fa c i a l
a d nexa l t u m ors. Dermatol Surg. 1 999;25( 1 ) : 4 1 -44.
Wa ng J l , Roenigk H H J r. Treatment of m u lti ple fac i a l
syri ngomas with the ca rbon d i oxide (C02 ) laser. Dermatol
Surg. 1 999;25( 2 ) : 136-139.
L-------+
Figure 48.4 Diagram of syringoma treatment
H igh rec u rrence rate

w i t h any mod a l ity i n
1 2-36 months
CHAPT E R 49
D e r m a tosis Papu l osa Nig ra
Dermatosis pa pu losa n igra ( D P Ns l a re very common

ben ign brown warty pa p u les that a p pea r i n African
Americans a n d othe r patients with d a rk ski n phototypes,
D P N s usually affect the cheeks, neck, a n d u p per c hest
( Fig. 49 . 1 ) . D P N s a re a type of seborrheic keratosis. M a ny
patients req uest re m ova l of D P N s, pa rtic u larly when m u l
tiple or l a rge, d ue to their u nsightly a p pea ra nce.
Incidence: very common in Africa n Americans and Asians
Age: second decade to m i d d le age
Race: more common in Africa n America ns a n d Asi a n s
Sex: fe males > m a l es ( 2 : l l
Precipitating factors: strongly associated with fa m i ly history
Figure 49 . 1 Dermatosis papulos nigra on the forehead of an A frican
American female
PATH OG E N ES I S
U n known .
PATHOLOGY
D P N s featu re hyperkeratosis, pa p i l lo matosis, and acan
thosis as seen i n seborrheic keratoses . N o sq ua mous
edd ies a re present.

They present i n a sym m etric fas h i o n as s m a l l brown
s mooth sess i l e pa pu les o n the face, neck, a n d u p per
tru n k of African America ns and Asia n s . They range from
1 to 5 mm in d ia meter and a re often ped u n c u lated .
Seborrheic
ke ratosis,
lentigo,
ve rruca ,
acrochord o n ,
m e l a n ocytic nevus, a n giofi bro m a , a n d ad nexa l tumors

a re a l l in the d iffe rential d iagnosis.

None.
CO U RS E
They present d u ri ng teenage yea rs . Over t i m e , they
become la rger and m ore n u m erou s , pea king i n m id d l e
age. They d o n ot regress sponta neously.
24 1
242

Fa m i ly h i story o f D P N s .
MANAG E M E N T
There is no med ical i n d i cation t o treat D P N s , u n less they
a re i rritated . Sti l l , the cosmetic a p peara n ce bothers m a n y
patients pa rti c u l a rly when n u mero u s . Th ere a re m u lti p l e
modal ities f o r treating D P N s i n c l u d i ng c ryothera py, elec
trodessicatio n , gra d l e scissor remova l , c u rettage, a n d
a b lative laser thera py. P r i m a ry consideration befo re treat
ment s h o u l d be the effective remova l of the D P N s without
prod u c i n g pigmenta ry cha nge .
TREAT M ENTS
Shave or gra d l e scissor excision c a n effectively re move

DPNs
- Local i nfi ltration with loca l a n esthesia fol l owed b y gra
dle scissor rem ova l is safe, fast and has the lowest
risk of posti nfla m m atory dysc h ro m i a
C ryothera py
- Light c ryothera py is a q u ic k , i nexpensive, s l i ghtly
pa i nfu l , and effective method of treating D P N s
- Cautio n : cryothera py can p rod uce hypopigmentation
by d estroyi ng m e l a n ocytes. Hyperpigme ntation ca n
a lso occu r
Light electrodesiccation a n d c u rettage

- Light electrod esiccation of D P N s is a n other q u ic k
a n d effective m ethod o f treatment. There is a r i s k of
posti nfla m matory dysc h ro m ia
- With l ight electrodesiccati o n , the lesion w i l l turn wh ite
O n ly l ight e l ectrod esiccation s h o u l d be e m p l oyed to

decrease the risk of pigme nta ry cha nges
LAS E R T R EAT M E NTS
M e la n i n ta rgeting lasers fo r t h i n D P N s
- Q-switched ru by (694 n m ) a n d Q-switc hed a l exa n
d rite ( 7 5 5 n m ) c a n someti mes effectively treat t h i n
ner D P N s .
- S pot size s h o u l d b e l ess tha n the size o f the lesion .
- R e peat treatme nts may be req u i red .
- R isk of hypopigmentation a n d hyperpigme ntation
should be exp l a i ned ca refu l l y to patient.
- Expensive com pa red to tra d it i o n a l thera p ies.
Ab lative lasers
- C0 2 , fractional a blative a n d erbi u m :YAG lase rs can
a b late these epidermal lesions.
- Expensive compared to tra d itional thera p ies.

- R isk of hypopigmentation and
hyperpigmentation
should be exp l a i n ed ca refu l ly to the patient.

EXPECTAT I O N S
A n y thera py h a s poss i b l e adverse effects s u ch a s pig

menta ry c h a n ges, sca rring, a n d rec u rre nce. G ra d l e
scissor remova l has the lowest r i s k o f dysc h ro m i a .
D P N s ca n be treated with a n u m ber o f d iffe rent a n d

effective moda l ities.
Tra d iti o n a l thera p i es such as scissor excision, c u rettage,

or l ight c ryothera py a re s i m ple, q u ick, a n d effective.
Laser thera py is more expensive a nd ca rries a h igher

potential for hyper- o r hypopigmentation . Test spot may
be a p p ropriate.
B I B L I OG RAPHY
K i l m e r S L . Laser eradication o f pigme nted lesions a n d
tattoos. Dermatol Clin. 2002 ;20( 1 ) :37-53.
Sc hweiger ES , Kwa s n i a k L, Ai res OJ . Treatment of d e r
matosis pa p u l osa n igra with a 1 064 nm N d : YAG laser:
Report of two cases. J Cosmet Laser Ther. 2008; 1 0(2 ) :
1 20- 1 2 2 .
CHAPTE R 50
Xa n t h elas m a
Xanthelasmas, a lso referred to as xa nthelasma pa l pe

b ra r u m , a re pla n e xa nthomas, occ u rring on the eye l i d s .
Incidence: relatively com mon
Age: m id d le-aged a d u lts
Precipitating factors: hyperl i p i d e m i a prese nt in 50% of
patients with xa nthelasmas, fa m i ly h i story of hyperl i ped
i m a , and xa nthelsma . Yo u nger a d u lts who p resent with
xa nthelasma a re more l i kely to have l i pid a bnormal ities
PATHOG E N ES I S
Abnorma l ities of a po l i poprote i n E phen otypes o r oth e r
l i poprote i n s .
243
244

Xanthelasmas commonly present a s m u ltiple soft sym met
rical ova l yel l owish pa pu les a n d pla q u es on the eyelids.
Syri ngomas, sebaceo us neoplasms, m i l i a , necrobiotic
xa nthogra n u l o m a .
Col lections of foa m cells i n the superfi c i a l d e r m i s .
COU RS E
T hey a re ge n e ra l l y perma nent with tendency t o i n c rease

in n u m be r a n d coa lesce with t i m e .
MANAG E M ENT
Xa nthelasmas often
rec u r after treatment with a ny
modal ity.
S u rg i c a l Exc i s i o n
S u rgica l excision i s the treatment of choice fo r xa nthelas
mas. The lesion is l ifted and then exc ised using a blade
o r a G ra d l e scissor. The d efect is either left to heal by
second i ntentio n o r sutu red using silk o r eth i l o n sutu res
( Fig. 50. 1 ) . This proced u re u s u a l l y res u lts in a ve ry cos
metica l l y acce pta ble outco m e .
Loca l i zed Ti ss u e Dest r u ct i o n

C02 o r erb i u m laser va porization, tric h l o roacetic a c i d ,
el ectrosu rgery, o r c ryothera py.
Although
50%
of patients with xa nthelasmas a re
normoli p e mi c , it is c r u c i a l to screen new patients with

xa nthelasmas fo r the p resence of hyperl i p i d e m i a . This
is pa rti c u l a rly i m porta nt i n you nger patie nts who pre
sent with xa nthelasma s i n c e they a re more l i kely to
have assoc iated l i p i d a bnorma l ities.
Patie nts m ust be made awa re that complete remova l of

the xa nthelasmas d oes not preve nt futu re d evelopment
of new lesions.
Extre me caution should be exerted when operati ng o n

the eye l i d s i n o r d e r t o avoid eye i nj u ry.
Figure 50. 1 Xanthelasma on the left upper medial eyelid in a middle

aged woman. (B) The resulting defect is sutured using ethilon sutures.
This procedure produced a very good cosmetic result
B I B L I OG RAPHY
Eedy DJ . Treatment o f xa nthelasma b y excision with sec
o n d a ry i nte ntion h ea l i ng. Clin Exp Dermatol. 1 996;2 1 :
273-27 5 .
G h osh YK, Pra d h a n E, A h l uwa l ia H S . Exc ision o f xa nthe
lasm ata-c la m p , shave, and suture. lnt J Dermatol.
2009 ;48 ( 2 ) : 1 8 1 - 18 3 .
Hawk J L. C ryothera py ma y be effective f or eyel i d xa nthe
las m a . Clin Exp Dermatol. 2000;25:35 1 .
M a n n i no G ,
Pa pa le A , D e Bella
F, et a l .
Use of
erbi u m : YAG laser in the treatment of pa l pe b ra l xa nthelas

mas. Ophthalmic Surg Lasers. 200 1 ;32: 129-133.
N a has T R , M a rq u es J C , N i coletti A, Cunha M, N is h iwa ki
Da ntas M C , Filho JV. Treatment of eye l i d xa nthelasma
with 70% tri c h l o roacetic a c i d . Ophtha/ P/ast Reconstr
Surg. 2009;25(4): 280-283 .
U l l m a n n Y, H a r-Shai Y, Peled IJ . The use of C0 2 laser fo r
the treatment of xa nthelasma pa l pe b ra r u m . Ann Plast
Surg. 1 993;3 1 : 504-507
245
E I GH T
C utaneo u s Ca rcino mas
248
CHAPT E R 5 1
Acti nic Ke ratosis
Acti n ic keratos is (AK) present as si ngle or m u ltiple d is

c rete, sca ly lesions, fou n d m ost freq uently in ha bitua l ly
s u n-exposed sk i n of ad u lts .
Age: m ost c o m m o n l y noted i n m id d le age, occasionally
occ u rs i n patients u n d e r 30 yea rs
Sex: more common in m a les

Incidence: very c o m m o n ; i n Austra l i a 1 : 1 ,000 persons
Race: s k i n phototypes I-I I I , rarely seen i n s k i n phototypes

I V-V I
Occupation: outdoor workers (eg, fa rmer, ra ncher, sa i lor)
and outdoor sports (golf, te n n is, sa i l i ng)
PATHOG E N E S I S
Prolonged a n d re peated s u n expos u re i n suscepti ble per
sons resu lts in c u m u lative kerati n ocyte d a mage. The
p r i n c i p l e sun d a m age is secondary to u ltravoi l et B ( UV B )
( 290-320 n m l l ight.

AKs present as s i ngle o r m u ltiple ski n-colored , e rythema
to us, o r b rown sca ly patc hes. There is a pred i lection for
s u n-exposed a reas i n c l u d i ng the fa ce, ears, neck, fore
a rms, and dorsa l h a n d s . A Ks may become t h i c kened,
fo rm i n g a cuta neous horn . M o re easily pa l pated t h a n
see n . They a re genera l ly asym ptomatic but may be ten
d e r o r pru riti c . Act i n i c c h e i l itis d eve lops o n the verm i l i o n

bord e r as d iffuse sca l i ng o r d ryn ess . Associated tela ng
iectasia, so l a r elastosis, and lentigi nes a re freq uently
o bse rved .
Epidermal pro l iferation with m i l d -to- moderate bas i l a r ker
atinocyte pleomorph i s m , pa ra ke ratosi s , and dyskeratotic
keratinocytes. Cytologica l ly, atypical kerati n ocytes a re
usua l l y confi ned to the epidermal basa l laye r.
Eczematous d e rmatitis
Extra m a m m a ry Paget's
Sq u a m o u s cell ca rc i n o m a
Basa l cell carc i noma
Figure 5 1 . 1 (A) Numerous facial actinic keratosis pre-Aidara treatment.

(B) Expected erythema and crusting during A ldara treatment. (C) Facial
actinic keratosis post-Aidara treatment applied twice weekly for 4 weeks

(Courtesy of Richard Johnson, MDJ
Secti o n 8 : C u ta n eo u s Ca rc i n o m a s
249
CO U RS E
A Ks ca n self-resolve, b u t genera l l y a re persistent i n
natu re . T h e progress ion t o s k i n cancer with i n preexist i n g
A Ks is u n known but is estimated at less t h a n 1 % o f i n d i
vid u a l lesion s . B i o psy wa rra nted for pigme nted A Ks
( s u perfi c i a l
pigme nted a cti n i c
ke ratosis)
or
nod u la r
ke ratosi s .
D u ration o f lesion(s)
Lesiona l rate of growth
Prior treatment for lesions a nd response
Perso n a l and fa m i ly h i story of prior s k i n ca n ce rs
H i story of prior rad iation treatment to the a rea
Cu rrent med ica l h i story
Med ication use
Evidence of i m m u n os u ppression
P red ispos i n g synd romes
MANAG E M ENT
Assess ment o f t h e n u m be r, size, location, freq uency of
deve l opment, a n d any u nderlying i m m u nosu ppressed
state s h o u l d be o bta i n ed . A b i o psy should be o bta i ned of
any
lesion
that
is
suspicious
for
skin
c a n cers .
Consideration m a y t h e n b e given t o treatment o f i n d ivid

ual or m u lt i p l e lesions, prophylactic thera py, and deter
m i nation of the n eed for c l i n ical fol low- u p .
Figure 5 1 .2 (A) Actinic cheilitis, lower lip. Patient complained of fre
quent peeling that was poorly responsive to cryosurgery and efudex.
T R EATM ENT
(8) Reduction in actinic damage following carbon dioxide resurfacing.
Patient reported complete resolution of peeling
P reve ntion
- A p p l ication of da i ly s u n s creen with U VN U V B pro
tectio n
- To pica l treti n o i n a pp l ied n ightly
Topica l
- Once d a i ly ( Ca ra c ) or twice d a i ly ( Efudex) a p pl ication
of 5-fl u o ro u ra c i l fo r 3 to 4 weeks
- Twice weekly o r every th i rd
day a p p l ication
of
i m i q u i nod (Aida ra 3M St. Pa u l , M N ) for 4 weeks

( Fig. 52 . 1 )
- D i c l ofenac (Sola raze) 3% sod i u m topica l gel twice
d a i ly for 2 to 3 m o nths
- l ngenol mebutate a p p l ied on 2 su bseq uent days or
twice 1 week a pa rt
Gentle c ryosu rgery with a si ngle freeze-thaw cyc l e .

B l ister formation poss i b l e . R e peat treatment may b e
req u i red . R isk o f tempora ry hyperpigmentation a n d
250
permanent depigme ntation m ust be a d d ressed with the

patient. T hi s modal ity is best for isolated n u m ber of
lesions
System ic
- Long-te rm low-dose oral retinoid has been used , t h i s
treatment req u i res c l ose fol low- u p to avo i d pote ntial
side effects. Benefi c i a l o n l y while on m ed i cation
- O ra l vita m i n A has been used , req u i res close fol l ow
up to avoid potentia l side effects. Benefi c i a l o n l y
w h i l e on med ication
S u rgica l
- Photodyna mic thera py with topical a m i nolevu linic acid
( Levu len , Dusa Pharmaceutica ls, I nc . , Wilmi ngton, MAl
has been successfu lly uti l ized . The pu lsed dye laser
595 nm, blue l ight 415 n m , nea r-infrared 830 n m ,
i ntense pu lsed light sou rce, a n d l ight-em itting d iode
have been e m ployed for del ivery of treatment. M ulti ple
treatments a re usually req u i red . Topica l levu lan appl ied
1
hour
prior
to
l ight treatment
may
be
used .
Photosensitivity posttreatment promi nent

- C h e m i c a l pee ls-seria l med i u m-depth peels i n c l u d
i n g J essner/10% t o 35% tri c h loroacetic a ci d peels
a re
h ig hl y
beneficia l
Postoperative
in
red u c i n g
lesion
cou nt.
pee l i ng may last u p to 2 weeks
d e pe nd i ng on the strength util ized

- Fractionated a b l ative carbon d i oxi d e laser-seria l
treatments may be req u i red to reac h treatment e n d
point o f lesio n a l red uction
- P u lsed ca rbon d ioxide laser-h ighly effective i n m a n
agement o f acti n i c c h e i l itis ( Fig. 5 2 . 2 ) . The ve rm i l io n
bord e r is outl i n ed p r i o r t o the ad m i n istration o f m e n
ta l block a n d/or loca l ized i nfi ltrative a n esthesia with
1% l i d oca i n e with 1 : 100,000 e p i n e p h ri n e . Passes
a re performed u nt i l remova l of epidermis is o bse rved .
Area wi ped with sa l i ne soa ked spo nges between the
passes . Posto perative care req u i res soa king the treat
ment site with water a n d a clean wash c l oth to rem ove
a n y crusti n g a n d a p pl icati o n of vase l i n e th ree to fou r
ti mes a day. R i s k of sca r formation a n d i nfection m ust
be consid ered
With acti n i c c h e i l itis, it is esse ntia l to avo i d vaporiza

ti on of the verm i l io n
bord e r to p reve n t sca rring.
D e l i n eati n g the bord e r prior to a d m i n istration of a n es

thesia is h e l pfu l .
Patients m u st b e awa re that a ny treatment a d m i n istered

d oes not e l i m i nate the d evelopment of fut u re pre m a l ig
nant a nd m a l igna nt growths. Strict photoprotection a n d
s u n avoida nce is m a n d atory.
Patients uti lizing to pica l treatments m ust be made awa re

of the expected erythema, crusti ng, a n d d iscomfort that
w i l l persist d u ri ng the d u ration of treatment a nd for 1 to

2 weeks posttreatment. A m i ld topica l corticosteroid may
be prescri bed posttreatment completion to assist i n the
resol ution of these fi ndi ngs.
B I B L I OG RAPHY
A l be rts D , Ra nger- M oore J , Einspa h r J , e t a l . Safety a n d
efficacy o f d ose-i ntens ive o ra l vita m i n A i n s u bjects with
su n-da maged ski n . Clin Cancer Res. 2004; 10(6) : 1 8751 880 .
Ericson
MB,
Sand berg
C,
Stenq u ist
B,
et
al.
P h otodyna m i c thera py o f acti n i c keratosis a t va ry i n g flu

ence rates : Assessment of photo b l ea c h i ng, pa i n a n d pri
m a ry c l i n i cal outcome. Br J Dermatol. 2004; 1 5 1 (6 ) :
1 204- 1 2 1 2 .
H a d ley G , Derry S , M oore R A . l m iq u i m od for acti n c ker
atosis: Syste m i c review a nd
meta-a na lysis. J Invest
Dermatol. 2006; 1 26(6) : 1 2 5 1 - 1 255

J a rvis B , Figgitt D P. To pical 3 % d i c l ofenac i n 2 . 5 %
hya l u ro n i c ac i d ge l : A review o f its u s e i n patients with
acti n i c ke ratosis. Am J Clin Dermatol. 2003 ;4( 3 ) : 2032 13 .
J orizzo J , Weiss J , F u rst K, Va n d e Pol C . Effect o f a
1 -wee k treatment with 0 . 5 % to pical fl uoro u ra c i l o n
occu rrence o f acti n i c keratosis afate r c ryos u rgery: A ra n
d o m ized , veh i c le-contro l l ed c l i n ical tria l . Arch Dermatol.
2004; 140( 7 ) : 8 1 3-8 1 6 .
Rolf-Ma rkus S , M atheson R , Davis S , e t a l . To pica l methyl
a m i nolevu l i nate photodyna m i c thera py using red ! l ight
emitting d iode l ight for m u lt i p l e a cti n i c ke ratosis: A ra n
d o m ized study. J Dermatol Surg. 2009 ;35(4): 586-59 2 .
S i l le r G , G e ba ue r K, Wel b u rn P , Katsa mas J , Ogbo u rn e
S M . P EP005 ( i ngenol me b utate) ge l , a n ovel agent fo r
the treatment of acti n i c keratosis: Resu lts of a ra ndom
ized , d o u ble- bl i n d , ve h icle-control led , m u l tice ntre phase
l l a study. Australas J Dermatol. 2009 ; 50( 1 ) : 1 6-22.
Thai KE, Ferg i n P, F ree m a n M, et a l . A pros pective stu dy
of the use of c ryosu rgery fo r the treatment of acti n i c ker
atosis. lnt J Dermatol. 2004;43 ( 9 ) : 687-69 2 .
25 1
252
CHAPT E R 5 2
B asal Cell Ca rci n o m a
Basa l cel l carc i noma ( BCC) i s a slow-growing m a l ignant

skin tumor that presents i n d isti nct h isto l ogica l s u btypes
i n c l u d i ng nod u l a r, su perfi c i a l , m i c ronod u la r, i nfi ltrati ng,
and morpheafo r m . N od u la r BCC is the most common
type occ u rring pred o m i n a ntly on the head a n d neck
regions.
EPI OEM I O LOGY

Incidence: the m ost com mon skin cancer i n Ca ucasia ns
with a p proxi mately 800,000 cases/year d i agnosed i n the
U n ited States
Age: most common in patients over 40 yea rs

Race: m ost c o m m o n in Caucasians
Sex: h igher i n c idence i n ma les
Precipitating factors: c h ro n i c u lt raviolet ra d iation a n d
fa i r s k i n a re t h e m ost s i g n ificant p red isposing fa ctors .
Oth e r fa ctors i n c l u d e i o n i z i n g ra d i ati o n , a rs e n i c expo
s u re , i m m u n os u p p ress i o n , P U VA , and ge netic p red is
positi o n .
PATHOG E N E S I S
T h e m ost c o m m o n a ltered gene i n B C C i s t h e PTCH
tumor
s u ppressor
ge ne
with
res u lta n t
a ltered
H edgehog signa l i ng pathway lea d i ng to u n reg u lated cel l

prolife ration a n d a l te red c e l l d ifferentiatio n . M u tations i n
t h e p53 t u m o r s u p p ressor gene a re a lso freq uently
o bserved lea d i ng to cel l u l a r i m m o rta l ity a n d resista nce
to a po ptos i s .

P i n k , e rythematous, pea rly tra nsl ucent pa p u l e , nod u l e ,
o r pla q u e with a ro l led bord e r a n d overlying tela ngiec
tasias ( Fig. 52 . 1 ) . S u perfi c i a l B CC p resents as a p i n k or
e rythematous thin sca ly plaq u e . The center may become
u l cerated and covered by a c rust, that is, " rodent u lcer. "
Morpheaform B C C exh i bits a scar- l i ke a p pea ra nce with
i l l-defi ned borders. They m ost commonly present in pho
tod istri buted a reas.
Dermal m e l a n ocytic nevi , sebaceous hyperplasia, sq ua
mous cel l c a rc i noma (SCC).
Figure 52. 1 Large BCC on the face. Note the characteristic rolled bor
ders, overlying telangiectasias, and the central ulceration
Secti o n 8: C u ta n eo u s Ca rc i n o m a s
253
LABO RATORY DATA

Lo b u les, nests, or cords of neoplastic basa loid cells with
peri phera l pa l isa d i ng, c lefti ng, and m u ci n o u s stroma .
CO U RS E
Loca l ly i nvasive a n d slow growi ng over m o nths a n d even
yea rs. M etastasis is an exceed i ngly ra re occ u rre nce.

Excessive s u n expos u re a n d other pred ispos i n g factors,
prior h istory of BCC or SCC, perso n a l a n d fa m i ly h i story of
s k i n cancer, i m m u nos u p pressio n .
MANAG E M ENT
There a re m u lti ple methods for treating B C C . Treatment

selectio n should be based u po n the age, hea lth, a n d
prefe rences o f t h e patient after a fu l l d iscussion o f treat
ment options, risks, a n d benefits. G iven the loca l ly
d estructive nature of B C C, h istologica l confi rmation of
com plete remova l is o pti m a l . S u rgica l excision a n d h i sto
logical eva l uation rem a i n the treatment of choice in most
cases. Tu m o rs fixed to u nd e rlying bone, espec i a l ly the
sca l p , merit rad io l ogica l work u p prior to s u rgica l excision
o r M o h s m i c rogra ph i c su rgery. Topical thera pies req u i re
c l ose fo l l ow- u p for a n y evidence of treatment fa i l u re or
recu rrence. Patient ed ucation rega rd i n g the benefits of
sun avoida nce, s u n sc reen use, and reg u l a r self-exa m i na
tions a re i m porta nt preventive measures.
F i rst- l i n e T h e ra p i es
Exc isional s u rgery: ge n e ra l ly with 4-m m m a rgins is the

treatment of choice for nonsu perficia l BCC that d o n ot
meet the criteria of Mohs m i c rogra p h i c s u rgery
Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice

for h igh-risk a nato m i c a l locations (ie, " mask" a rea of
the face), locations where tissue conservati o n is c r u c i a l
for fu n ctional o r cosmetic reasons, rec u rrent tu mors, i l l
d efi ned c l i n ical m a rgi ns, h i stologica l l y aggressive s u b
types , t u m o rs in i m m u nosu ppressed patients, t u m o rs
Figure 52.2 (A) BCC on the nose with very ill-defined clinical margins.
la rge r than 2 e m , i rrad iated ski n , a n d peri n e u ra l i nva
(B) Large defect after Mohs micrographic surgery. Mohs micrographic

surgery is the ideal treatment for this type of skin cancer providing the
highest cure rate among all other treatment modalities
sion on biopsy ( Figs . 52 . 2-52.4) . M o hs m i c rogra ph i c

su rgery has the h ighest c u re rate o f a n y treatm ent of
BCC
El ectrodessication a n d c u rettage
Cryothera py
254
Rad iation thera py is a nother treatment option espe

c i a l ly when su rgery i s not feasible or contra i n d icated . It
can a lso be used as a n adj uva nt thera py when per
i n e u ra l i nvasion is i d e ntified
A l te r n ate T h e ra p i es
Topical i m i q u i mod , a p p l ied five t i m es a week for a tota l

d u ration of 6 wee ks . It is FDA a pproved for treatment of
su perfi c i a l B C C .
Recu rrence
rates a re sign ifica ntly
h igher than s u rgica l excision .
Topical 5-fl uoro u ra c i l is primarily reserved for treatment

of su perfi c i a l B C C . H owever, rec u rrence rates a re h i g h .
P h otodyn a m i c
thera py
prod u ces
p h otoc h e m i c a l
reaction t h a t req u i res the prese nce o f a p h otosensitiz

i ng agent, tissue oxyge n , a n d l ight with ph otoactivating
wavelength . The m ost common to pical photosens itizer
is 5-a m i nolevu l i n i c acid (5-ALA ) . 5-ALA is a precu rsor
of the i ntri nsic i ntrace l l u l a r hemebiosynthetic pathway,
w h i c h resu l ts in the prod uction of a photoactive porphyri n , protoporphyri n IX. The m ethyl d e rivative of 5ALA, methyl a m i nolevu l i n ic acid ( M AL) is a lso very
c o m m o n l y used a n d demonstrates a bette r sel ectivity

for m a l igna nt cells. The l ight sou rces a re usua l ly in the
visi ble l ight ra nge and they i n c l u d e laser (coherent)
l ight sou rces (eg, pu lsed dye lasers) or noncoherent
l ight sou rces ( red, blue l ight) . Red l ight provides the
dee pest penetration of these l ight based treatment
modal ities. PDT ca n provide 76% to 97% clearance
rates for su perficia l BCC. I t is pa rticula rly useful i n
patients who a re poor s u rgica l ca n d i d ates or those who
h ave m u ltiple BCCs that req u i re m u ltiple s u rge ries.
C l ose c l i n ical fol l ow- u p after treatment is req u i red for
a n y evidence of rec u rrence or i ncom plete remova l
l ntra lesi o n a l i n te rfe ron is ra re ly performed
Carbon d ioxi d e laser-may be effective for s u perfi cia l

B C C a n d patients w i th m u lt i p l e s h a l l ow tumors s u c h as
i n basa l cell nevus synd rome
- I nfecti o n , bleed ing, pa i n , nerve da mage, poor cosme
sis fo l lowi ng surgical repa i r, hypertro p h i c or atrophic
sca rring, a n d rec u rrence a re all com mon pitfa l ls of
BCC s u rgica l thera py a n d should be fu l ly d iscussed
with the patient prior to treatment.
- Nonsurgica l thera pies may provide better cosmesis but
sign ificantly h igher rates of recu rrence. Fu rthermore,
nonsurgical i nterventions d o not provide the opportu
n ity for h istological confi rmation of complete remova l .
They a re best for patients w h o have n u merous BCCs
and i n those who a re poor surgica l candidates.
Figure 52.3 (A) Surgical defect after Mohs micrographic surgery of BCC
on the right forehead. (B) Repair of the defect with an A to T advance
ment flap. Notice that the horizontal incision line is hidden within the
eyebrow hairs for a better cosmetic outcome
Secti o n 8: C u ta n eo u s Ca rc i n o m a s
B I B L I OG RAPHY
Atti l i S K, Lesa r A, M c N e i l l A , e t a l . An o p e n pilot study of
a m bu latory photodyn a m i c thera py u s i ng a wea ra ble low
i rrad ia nce orga n i c l ight-e m itti ng d iode l ight sou rce in the
treatment of n o n m e l a noma s k i n cancer. Br J Dermatol.
2009 .
M u ller
FM,
Dawe
RS,
M oseley
H,
Fleming
CJ .
R a n d om ized com pa rison of mohs m ic rogra p h i c s u rgery

a n d s u rgica l excision fo r s m a l l nod u la r basa l c e l l carci
n o m a : Tissue-sparing o utco m e. Dermatol Surg. 2009 .
R owe D E , Carro l l RJ , Day CL J r. Long term rec u rrence
rates in previously u ntreated ( pr i m a ry) basa l ce l l carci
n o m a : I m pl ications for patient fol l ow- u p . J Dermatol Surg
Oneal. 1989; 1 5 : 3 1 5-328 .
Ti erney E, Ba rker A, Ahdout J , H a n ke CW, M oy R L,

Ko u ba DJ . P h otodyna m i c thera py for the treatment of
c uta neous neoplasia , i nfla m matory d isord e rs , a n d p h o
toaging. Dermatol Surg. 2009;35(5): 725-746.
Wolf DJ , Zite l l i JA. S u rgica l m a rg i n s for basa l cel l carci
noma. Arch dermatol. 1987 ; 1 23 : 340-344 .
Figure 52.4 (A) Nodular basal cell carcinoma on the left preauricular
area. (B) Clearance of basal cell carcinoma after Mohs surgery.

(C) Primary closure of the Mohs defect with dog-ear repair
255
256
CHAPT E R 53
Sq u a m ous Cell Ca rci n o m a
S q u a m ous cell c a rc i noma (SCC) m ost c o m m o n l y origi

nates from kerati nocytes i n su n-da maged skin either d e
novo or from a preexisting a cti n i c keratosis o r sec i n situ
(a lso known as Bowe n 's d isease ) , predom i na ntly affect
ing the h ea d , neck, a n d a r m s . I t can a l so a rise in non
su n-exposed s k i n most commonly from c h ro n i c leg
u l ce rs a n d b u rn sca rs .
EPI DEM I O LOGY

Incidence: it is the seco n d most common skin cancer in
Caucasians and the most common skin cancer i n d a rkly
pigmented s ki n . A p proxi mately 1 50,000 cases/year a re
d iagnosed in the U n ited States
Age: most common in patients over 55 yea rs

Race: m a i n ly affects Caucasians
Sex: h igher i n c idence i n ma les
Precipitating factors: c h ro n i c u ltravio l et rad iation and fa i r
Figure 53 . 1 Invasive squamous cell carcinoma on the right neck
s k i n a re the most significant pred ispos i n g factors . Other

factors i n c l u d e i m m u nos u p press i o n , h u ma n pa p i l loma
virus
i n fection ,
ge netic
ionizing
d isord e rs
ra d iati o n , a rse n i c expos u re ,
(epidermodysplasia
verruc iform is,
a l b i n i s m , xerod erma pigmentos u m , epid ermolysis bul

losa ) , P U VA expos u re, smoki ng, a n d c h ro n i c i nfla m m a
t i o n ( u lcers, b u rn scars, d iscoid l u pus)
PATHOG E N E S I S
The most common a ltered gene i n SCC i s the p53 tu mor
s u p p resso r gene, res u lting i n keratinocyte i m m orta l iza
tion and u n reg u l ated c e l l prol ife ratio n .

Hyperkeratotic ski n-col ored t o erythematous
pa p u l e ,
p l a q u e , or nod u le ( Figs . 53 . 1 a n d 53 . 2 ) . I t can b e u l ce r

ated , fria ble, or exo p hyti c . It m ost commonly presents
with i n su n-da maged ski n .
Keratoacanthoma ( F ig. 53 . 3 ) , hypertro p h i c acti n ic ker
atosis, basa l cell carc i n o m a ( B C C ) , i nfla med seborrh eic
keratosis.
Figure 53.2 Recurrent squamous cell carcinoma on the chest of an
elderly woman
257
LABO RATORY DATA

Prol iferation of atypical kerati nocytes with va ria b l e d iffer
entiation of the epidermis a n d va riably sized n ests a n d
islands i nvad i ng t h e d e r m i s . Foci o f kerat i n izatio n a re
n oted i n we l l-diffe rentiated va ria nts . Peri n e u ra l i nvolve
ment may be o bse rved .
CO U RS E
SCC tends t o b e more aggressive t h a n B CC, with a
reported
2%
to
3%
i nc i d e n ce
of
metastasis.
M ucocuta neous SCC has a h igher rate of m etastasis, as

h igh as 1 1 % . M ore aggress ive forms of SCC a re o bserved
in i m m u n os u p p ressed patients o r sec that a rises with i n
previously i rrad i ated sites, sca rs, b u rns, a n d a reas of
i nfla m mati o n . There is a h igher m etastatic potential for
sec a rising on the ea r a n d the l i p.
Figure 53.3 Giant keratoacanthoma on the chest. Many authors regard
keratoacanthomas as variants of well-differentiated squamous cell

carcinoma

Eva l uate fo r past h i story o f bl istering s u n b u rns a n d
c h ro n i c s u n expos u re . Determine i f other pred ispos in g
factors a re present s u c h as perso n a l a n d fa m i ly h istory of
ski n cancer a n d i m m u n os u p pression , especia l ly orga n
tra nspla ntatio n .
MANAG E M ENT
P reventative measu res, s u c h as s u n avoi da nce a n d d a i l y
s u n sc reen u s e , a re c ritica l for lo ng-term preventio n .
Treatment selection s h o u l d be based u pon the age,
hea lth , and preferences of the patient after a fu l l d iscus
sion of treatment options, risks, and benefits . G iven the
m etastatic potentia l of sec, h i stologica l confi rmation of
complete remova l is a l ways advised . S u rgica l excision
and
h i stological eva l uation
rema i n the treatment of
choice i n m ost cases . Tu m o rs fixed to u nderlying bone,

espec ia l ly the sca l p, merit ra d iological work u p prior to
s u rgica l excision o r Mohs m i c rogra p h i c su rgery. Prior to
treatment, lym p h node pa l pation is a p propriate for la rge
sec, sec in i m m u n osu p pressed patients, a n d h igh-risk

SCCs. To pica l thera pies req u i re c l ose fol l ow- u p fo r any
evidence of treatment fa i l u re o r rec u rrence.
F i rst- L i n e T h e ra p i es
Exc isional s u rgery: 4-m m m a rgins a re ge nera l ly recom
Mohs m ic rogra ph i c s u rgery is the treatment of c h o ice
for high-risk a nato m i c a l locations (ie, " mask" a rea of
Figure 53.4 (A) Defect on the ear after Mohs excision of a squamous cell
the face ), locations where tissue conservation is c r u c i a l
carcinoma.
mended
258
for fu nctional or cosmetic reasons, rec u r rent t u m o rs, i l l

defined c l i n i cal m a rgins, h i stologica lly aggressive s u b
types, t u m o rs in i m m u n osu ppressed patients, t u mo rs
la rge r than 2 e m , i rrad iated ski n , a n d per i n e u ra l i nva
sion on biopsy ( Figs. 53.4 a n d 53 . 5 ) . C u re rates of SCC
depend o n size, h isto l ogica l gra d e, peri n e u ra l i nvasion,
a n d i m m u nos u p pressi o n . La rge r lesions, less d iffe renti
ated va ria nts with per i n e u ra l i nvolvement, and lesions
i n i m m u noco m p ro m ised patie nts demonstrate lowe r
c u re rates
Electrodessication a n d c u rettage ( usua l ly not recom

mended d u e to lack of h i stologic confi rmation of
remova l )
C ryothera py ( u s ua l ly not reco m m e nded d u e t o l a c k of

h isto l ogica l confi rmation of remova l )
Rad i othera py ( a p p ropriate for poor s u rgical ca n d i d ates)
Figure 5 3 . 4 ( Continued) {8) The Mohs defect is repaired with a
A l te r n ate T h e ra p i es
full-thickness skin graft
Topical 5-fl uorouraci is l i m ited to SCC in situ
Topical i m i q u i m od is l i m ited to SCC i n situ
l ntra lesional i n terfe ron
P h otodyn a m i c thera py ( P DT) u s i n g topica l o r syste m i c

photosensitize rs with lasers or noncoh erent red l ight
a re m ost effective for SCC in situ . Clearance rates ra nge
from 72% to 94% . PDT can act as an a lternative treat
ment for la rge lesions, espec i a l l y for those patients who
a re poor s u rgica l c a n d i d ates. It can serve as a n a lterna
tive treatment i n patients with m u ltiple SCCs. For these
patients, P DT and c l ose c l i n ical fol l ow- u p may o bviate
the need for m u lti p l e s u rgeries. P DT is a lso effective for
decreasing the n u m ber of acti n i c keratosis, t h us acting
as a preventative of future sec development
Carbon d ioxide laser is h ighly effective fo r a cti n i c chei l i

t i s . It can a l so b e used t o treat S C C i n situ
I nfection , bleed i ng, ne rve d a mage, pa i n , hypertro p h i c
sca rring, p o o r cosmesis fol lowi n g s u rgica l repa i r, a n d
recu rrence a re a l l c o m m o n pitfa l ls o f S C C treatm ent a n d
s h o u l d b e fu l l y d iscussed with the patient p r i o r t o treat
ment. Nonsu rgica l thera pies may provide better cosme
sis
but
sign ifica ntly
h igher
rates
of
rec u rre nce.
F u rthermore, nonsu rgica l i nterve ntions d o not provide

the o p portu n ity for h i sto logica l confi rmation of complete
remova l . T h i s is pa rti c u l a rly cr u cia l given the potential of
metastatic s p read with SCC. T h u s , sta n d a rd or Mohs
m ic rogra p h i c s u rgica l exc ision with h istologica l confi rma
tion of clear m a rg i n s is a l ways the treatment of choice for
sec.
Figure 53.5 {A) Surgical defect after Mohs micrographic surgery of an

sec on the left cheek.
259
B I B L I OG RAPHY
Covadonga M a rtinez-G onza lez M , d e l Pozo J , Paradela S ,
Fernandez-J orge B , Fern a n dez-Torres R , Fonseca E .
Bowe n 's d i sease treated b y ca rbon d i oxide laser. A series
of 44 patients. J Dermatolog Treat. 2008; 1 9 ( 5 ) : 293-299 .
M orton CA, McKenna KE, R hodes LE. B ritish Assoc iation
of
Dermatologists
Thera py
G u i d e l i nes
and
Aud it
S u bcomm ittee and the B ritish P hotod ermatology G rou p .

G u i d e l i nes for to pical p h otodyna m i c thera py : Update. Br
J Dermatol. 2008; 1 59 ( 6) : 1 245- 1 246.

P reston DS, Ste rn RS. N o n melanoma cancers of the ski n .
N Eng/ J Med. 1 992;327 : 1 649- 1 662.

R owe D E , Carro l l RJ , Day C L J r. P rognostic factors for
loca l rec u rre nce, m etastasis, a n d s u rviva l rates in sq ua
mous cel l carc i n o m a of the skin, ear, a n d l i p. I m p l ications
fo r treatment m od a l ity selecti o n . J Am Acad Dermatol.
1992;26:976-990.
Figure 5 3 . 5 (Continued) (B) The Mohs defect is repaired with a transposi
tion flap. (C) A fter suture removal 1 week later
NINE
I nf l a m matory Disord e rs
262
CHAPT E R 54
Liche n Pla nus
Lichen p l a n u s ( LP ) is a c o m m o n i nfla m m atory d isease

i nvo lvi ng the s k i n a n d m u cous m e m b ra nes. M a n y c l i n ical
va ria nts exist that include atro p h i c , u lcerative, b u l lous,
a n n u la r, l i nea r, i nverse , hypertro p h i c , l i c h e n pla n o p i l a ris,
acti n i c LP and LP pigme ntos u s .
EPI D E M I O LOGY
Incidence: About 0 . 5 %
Age: 30 t o 6 0 yea rs
Race: A l l races a re affected eq u a l ly i n m ost va riants
Sex: H igher i n c i d e n ce in fe ma les
Precipitating Factors: M ost c o m m o n l y i d iopath ic medica
tions may i nd uce a LP- I i ke e r u ption
PATHOG E N E S I S
Primari ly, a T- hel per cell-med iated reaction

Most common ly, primary lesions consist of m u ltiple viola
ceous,
polygo n a l ,
flat-topped ,
grou ped
pa pu les,
and
plaq ues that a re usually pru ritic. T h e i r su rface is s h iny o r

tra nspa rent a n d m a y exh i b it small gray-white punctae o r
reticular fine wh ite li nes known as Wickha m 's striae . T h e
lesions favor t h e oropharynx, flexural wrists, dorsa l hands,
med i a l th ighs, s h i ns, tru n k , a n d gen ita l i a . Posti nfla m matory
hyperpigmentation is com mo n . Acti nic LP a n d LP pigmen
tosus can present with melasma - l i ke hyperpigmented
patc hes on the forehead and the face ( Figs. 54. 1-54.3) .
D I F F E R E NT I A L D I AG N OS I S
Psoriasis, l ic h e n s i m plex, l ic h en oid graft-versus-host d is
ease, c h ro n ic c uta neous l u pus e rythe matos us, l i chenoid
d rug e r u ptio n , melasm a .
LABORATORY DATA
G iven the association with h e patitis B a n d C , h e patitis
serologies can be i nvestigated .
Pathology reveals l i chenoid i nterface dermatitis, hyperk
e ratosis, hypergra n u losis, saw-tooth aca nthosis, associ
ated with colloid o r civatte bodies.
Figure 54. 1 Actinic LP on the forehead, temples, and lateral cheek,

mimicking melasma
Secti o n 9 : I nfla m m atory D i so rd e rs
263
CO U RS E
S ponta neous re m ission of cuta n eous L P occ u rs with i n
1 yea r o f onset i n t h e majority o f patients. O ra l LP persists
for many yea rs . Sq u a m o u s ce l l carc i noma may a rise from
these
lesions,
pred o m i n a ntly from
the
oral
va riant
( Fig. 54.4).
MANAG E M ENT
Corticosteroids, topica l , i ntra lesi o n a l
l m m u n omod u lators, s u c h as tac rol i m us
Cyc losporine retention mouthwash for o ra l LP
Corticoste roids
Figure 54.2 Generalized lichen planus in a patient with skin type 1 V-V
in volving the trunk and buttocks with postinflammatory hyperpigmentation
Reti n o i d s : isotret i n o i n a n d acitreti n . Acitret i n is the

only syste m i c treatment that has been eva l uated i n a
d o u b l e - b l i n d , p l a cebo-contro l led study
G riseofu lvi n , metro n i d azole, a ntima l a ri a l s , m ethotrex

ate, cyc l ospori ne, a n d mycophenolate m ofet i l
L i g h t Treat m e n t
N a rrow B a n d UVB
P U VA
308- n m UVB exc i mer laser for o ra l LP
C0 2 laser for o ra l L P : va ria b l e resu lts with i n c reased

risks of side effects
Extracorporea l photophoresis
B I B L I OG RAPHY
Da m m a k A , Masmoud i A , Bou daya S , Bouassida S ,
M a rrekc h i S , Tu rki H . C h i l d h ood acti n i c l i c h e n pla n u s
( 6 cases) [ p u b l ished o n l i ne a head o f p r i n t J a n u a ry 18,
2008] . Arch Pediatr. 2008; 1 5( 2 ) : 1 1 1 - 1 14.
La u rberg G , Geiger J M , Hjorth N , et al. Treatment of
l i c h e n p l a n us with a c itreti n . A d o u ble-bl i n d , place bo
contro l l ed study in 65 patients. J Am Acad Dermatol
1 99 1 ; 24(3):434-437 .
Tre h a n M , Taylor C R . Low-dose exc i mer 308- n m laser for
the treatment of o ra l l i c h e n pla n us . Arch Dermatol
2004; 140(4) :41 5-420.
va n der Hem PS, Egges M, va n der Wa l J E, Rooden b u rg
J L. C0 2 laser eva poration of oral l i c h e n p l a n u s . tnt J Oral
Maxillofac Surg. 2008; 3 7 ( 7 ) : 630-633.
Figure 54.3 Hypertrophic lichen planus on the legs of 4 years duration
resistant to topical and intralesional steroid therapy. The patient

improved markedly after 1 month treatment with acetretin
264
Figure 54.4 (A) Ora/ lichen planus at baseline. (B) Two month follow-up
after 1 8 treatments with excimer laser administered weekly (Courtesy of
Charles Taylor, MDJ
Secti o n 9 : I nfla m m atory D i so rd e rs
CHAPT E R 5 5
265
M o rphea
M orphea is l oca l ized scleroderma confi ned t o the ski n . It

m ost commonly affects the tru n k but a lso occ u rs on the
face and extre m ities. The fo u r c l i n ical va ria nts i n c l u de
p l a q u e-type morphea, gen e ra l ized morphea, l i near mor
phea (en cou p de sabre), a n d pa nsclerotic morphea of
c h i l d re n ( morphea profu n d a ) .
Incidence: ra re
Age: m ost com m o n l y occ u rs i n the seco n d to fifth
d eca d e . Li nea r scleroderma a nd morphea profu nda a re
more c o m m o n i n c h i l d ren
Race: sl ightly more common in Caucasians

Sex: fe ma les more than ma les (2-3 : 1 )
Precipitating factors: Borrelia c a n trigger morphea i n
some cases, pred o m i n a ntly i n E u ro pe
PATHOG EN ES I S
Overprod uction of col lagen (types I , I I , I l l ) a n d gly
cosa m i noglyca ns by s k i n fi broblasts a nd vasc u l a r d a m
age. Proba ble T-cell med iated phenomeno n .

I l l-d efi ned p i n k t o violaceous, i nd u rated 2 - t o 1 5-cm
plaq ues that tra n sform to sm ooth sclerotic ivory-colored
plaq ues with a l ight violaceous bord e r a n d a s h i n y s u r
face. Posti nfla m matory hyperpigmentation is p reva lent
( Fig. 55. 1 ) . Linear morphea presents with a l i nea r e rythe
matous i nfla m matory streak that may progress to form a
sca r- l i ke ba n d i nvolvi ng u n d e rlying fasc i a , m usc le, a n d
te ndons.
Acrod ermatitis c h ron ica atro p h icans, eos i n o p h i l i c fasc i
itis, l i c h e n sclerosus et atro p h i c u s , sclered e m a , sc l e
ro myxed e m a , a n d n e p h roge n i c system i c fi b rosis.
LABO RATO RY DATA

S e ro l ogy
Check for Borre l i a a n t i bodies.
Figure 5 5 . 1 (A) Early morphea on the left leg presenting as an erythema
tous plaque. (B) Same patient with late stage morphea on the right leg
presenting as linear depressed yellowish to white hard plaques with ery
thematous margins
266
D e r m atopat h o l ogy
H omogen ization a n d thickening of derma l col lagen b u n
d l es, tra p ped a n d atro p h i c eccrine glands, perivasc u l a r
mononuclear i nfi ltrate o f lym p h ocytes a n d plasma cells
with normal o r atro p h i c overlying epidermis. U n d erlying
su bcuta neous fat may a lso be i nvolved with sclerosis in
adva n ced cases.
COU RS E
Cou rse i s va ria b l e . M a ny patients re m it s ponta n eously
but others have a p rogress ive cou rse.
MANAG E M ENT
Treatment for t h i s cond ition ca n b e frustrating d ue t o fre
q uent treatment fa i l u re . Patients s h o u l d be cou nseled
that thera py may not be effective .
Topical treatment
- Corticosteroids
- Calci potriene
System i c treatment
- Corticosteroids, D-penicillami ne, vitamin 03, methotrexate
Light treatment
- U ltraviolet A l photothera py
- P u lsed dye laser ( 585 n m , 5 J/cm 2 twice monthly),
reported to be effective i n s i ngle case report
S u bc i s io n : s u bcision with a N okor 18G need le may
help to elevate the b o u n d -down ski n . It is m ost effec
Figure 5 5 . 2 (A) Morphea with significant epidermal, dermal, and subcu
tive
taneous atrophy. (8) Elevation of the atrophic plaque of morphea after a

single autologous fat transfer. The associated telangiectasias were subse
quently treated with the pulsed dye laser with substantial improvement
for
l i nea r
m o r phea
and
fa c i a l
h e m iatro p h y.
S u bc i s i o n is performed u n d e r loca l i nfi ltrative a n esthe

sia
to the affected
s ite with
1%
l i d oca i n e with
1 : 1 00,000 e p i n e p h ri n e . The Nokor need le is i ntro

d uced at a 45-degree a ngle i nto the skin uti l i z i n g a
swee p i n g
motion
to
release
a ny tethered
a reas.
M u lt i p l e entra nce sites should be performed fo r opti

m a l benefit. F i r m press u re is a p pl ied to the treatment
sites fo r h e m ostasis
Soft tissue a ugmentatio n : va rious fi l lers have been

e m ployed with va riable s uccess to a ugment the scle
rotic sites . They a re m ost com monly uti l i zed for l i near
morphea a n d fac i a l h e m i atrophy. Te m pora ry fi l l e rs c u r
rently rec o m m e n d ed given the u n p red i cta ble c o u rse of
morphea . Autologous fat tra n sfer can provi d e sign ifi
cant a ugme ntation of the affected sites ( Fig. 5 5 . 2 ) .
R e peat i njections genera l ly req u i red . En bloc a u tolo
gous dermal fat graft re ported to be effective i n one
case re port.
Secti o n 9: I nfla m m atory D i so rd e rs
P I T FALL TO AVO I D
Patients must be awa re of the u n pred icta ble natu re of mor
phea, therefore the u n pred icta ble nature of the treatment.
B I B L I OG RAPHY
Eisen D , Alster TS. U s e o f 5 8 5 n m p u lsed dye laser fo r
the treatment of morphea . Dermatol Surg. 2002 ; 28( 7 ) :
6 1 5-6 1 6 .
La piere J C , Aasi S , Cook B , M onta lvo A . S u ccessful cor
rection of d e p ressed sca rs of the forehead seco n da ry to
tra u ma a n d morphea e n cou p de sa b re by en b l oc a utol
ogous d e r m a l fat graft. Dermatol Surg. 2000 ; 26(8) : 793797.
N i stico
S P,
Saraceno
R,
Sc h i pa n i
C,
Costa nzo
A,
C h i menti S . Differe nt a p pl ications o f m on oc h romatic

exc i mer l ight i n skin d iseases. Photomed Laser Surg.
2009 ; 27(4) : 647-654 .
CHAPTER 56
Pso riasis
Psoriasis is a c o m m o n c h ron i c i nfla m m atory d isease of

the s ki n . They a re sym metric in d istri bution a n d favor
e l bows, knees, sca l p , retroa u r i c u l a r ski n , and i nte rtrigi
nous a reas. Many c l i n ical va riants exist and i n c l u d e
p l a q u e psoriasis, pustu l a r psoriasis, guttate psoriasis,
i nve rse psoriasis, and eryth rod ermic psoriasis, with the
plaque va riant bei ng the m ost common type ( Figs . 56. 1
and
56 . 2 ) .
N a i ls a n d
m ucous mem bra n es can
be
affected . Psoriasis is associated with psoriatic a rth ritis i n

a t least 5 % o f patients .
EPI DEM I O LOGY

Incidence: About 1 . 5 % to 2 % of the wor l d 's population
Age: can occ u r at a n y age. Two pea ks of onset, the sec
ond
and sixth decades. Onset is ea rlier in wo m e n .
U ncom m o n ly affects c h i l d ren
Race: lower i n c idence i n African Ame rica n s , Native

America ns, a n d Asians
Sex: eq ual
Precipitating factors: bacterial i nfections, especia l ly strepto
cocca l i nfection (guttate psoriasis), tra u m a ( Koebner p he
nomenon ) , stress, ge netic pred isposition, a nd med ication
use ( m ost com monly l it h i u m , beta blockers, antimalarials) .
Rapid corticosteroid ta pers may ind uce pustu lar psoriasis
Figure 56. 1 Classic psoriatic plaques on the knees
267
268
PATHOG E N E S I S
Polyge n i c d i sease with a 4 1 % risk for a c h i l d to d evelop
psoriasis if both the pa rents a re affected . The p r i m a ry
pathophysiology i nvolves hyperprol iferation a n d a b nor
m a l d ifferentiation of epidermal kerati nocytes as well as
a b normal cel l u la r i m m u n e res ponse.

P l a q u e va riant with we l l-demarcated , p i n k t o erythema
to us pa pu les a n d plaq ues with overlyi ng s ilvery-wh ite
sca l e . P i n po i n t bleed i n g o bserved with sca le re mova l
(Ausp itz sign ) . G uttate va riant with tea r d rop-sha ped
lesions. Erythe mato u s genera l ized pustu les a re seen with
p ustu l a r pso riasis.
Figure 56.2 Psoriatic plaques koebnerizing vitiligo patches
Ti nea corporis, seborrheic d e rmatitis, eczematous d er

matitis, mycosis fu ngoides, pa ra pso riasis, l i c h e n s i m plex
c h ro n i c us ,
p ityriasis
ru bra
pila ris,
Reiter's
d isease,
Bowe n 's d isease.
LABORATORY DATA
S e ro l ogy
Antistrepto lys i n O(ASO) titer for guttate psoriasis.
Regu l a r psoriasiform epidermal hyperplasia with a bsent
gra n u la r cell layer and th i n n i ng a bove the dermal pa p i l
l a e . Othe r c h a racteristic featu res i n c l u d e col lections of
ne utro p h i l s in epidermis as wel l as tortuous blood vessels
i n the pa p i l l a ry d e r m i s .
COU RS E
T h i s d isease d e mo nstrates a c h ro n i c cou rse with m u ltiple
exacerbations a n d re m issions, w h i c h ca n be season a l or
related to stress.
MANAG E M ENT
There a re m u lt i p l e thera peutic options for treatm e nt of
psoriasis. C hoos i n g an a p pro p riate thera py d e pen ds o n
the a g e , h e a l t h , a n d prefe ren ces o f the patient. It a lso
d e pends on the exte nt of the psoriasis. The costs of ther
a py va ry d ra m atically as we l l . Alternative thera pies a re
m ost a pprop riate in refractory cases. Assessing the side
effect profi le of treatments is a n other cruc i a l com ponent
Secti o n 9: I nfla m m atory D i so rd e rs
269
of thera py. Com bi nation thera p i es a re gen e ra l ly m ost

effective to decrease inflam mation a n d red uce sca le p ro
d ucti o n .
Topica l Treatment
- Corticosteroids, to pical a n d i ntra l es i o n a l
- Calci potriene
- Taza rotene
- Coa l ta r
- Anthra l i n
- Sa l icyl ic acid
System i c Treatment
- M ethorexate
- Reti noids, p red o m i n a n etly a c itret i n
- Cyc lospori ne
- B i o logics suc h as a l efa cept, eta ne rcept, efa l uz i m a b ,
a n d i nfl ixi m a b
Laser a n d Light Treatme nts

- Psora len with U ltraviolet A ( P UVAJ
- U l travio l et B ( U V B ) , 3 1 1 - n m na rrowba nd-UVB ( N BUVBJ
- 308- n m UVB exc i m e r laser
An a lternative fo r treatment of m i ld-to- moderate
psoriasis, where m o re conventi o n a l t h era pies have
fa i led . It is espec i a l l y h e l pfu l for loca l i zed refractory
p l a q u e psoriasis
Stu d i es have demonstrated that this local ized UVB
treatm ent provides much lowe r c u m u lative d oses of
UVB to i n d uce cleara n ce of psoriatic plaq u es com
pa red to N B-UVB thera py
The exc i mer laser m ight a lso prod uce longer re m is
sion periods, with m i n i m ization of UVB expos u re to
healthy su rrou n d i ng s k i n
Exc i m e r l a s e r has proved t o be effective a n d safe i n
treating refractory sca l p psoriasis
D rawbacks of exc i m e r laser in psoriasis treatment
i n c l u d e l i m ited ava i l a b i l ity, treatment expense and
exte ns ive treatment time n eeded per session
Ph otodyna m i c thera py has been shown to i m prove pso

riasis
in
m u lt i p l e stud ies.
The
major side effects
i n c l uded pa i n a n d b u r n i n g sensation associated with

PDT
Pu lsed dye laser (0.45- 1 . 5 m s , 7-mm s pot, 7-9 J/c m 2 ,

D C D 30-40/20) has been e m p l oyed to ta rget the vas
c u la rity assoc iated with psoriatic lesions with noted
benefit. I n a recent study, P D L p roved to be effective i n
t h e treatment o f n a i l psoriasis ( Fig. 56.3)
In a recent study, N d : YAG laser ( 1 ,064 nm) fa i led to

i m prove loca l ized p l a q u e type psoriasis
T
Figure 56.3 Improvement in treated psoriatic plaque 3 months after
pulsed dye laser treatment (585 nm, 1 0-mm spot size, 5 J/cm 2 , no cool
ing, 0. 45-ms pulse duration), as compared to the control site
(Reproduced, with permission, from Brian Zelickson, MD)
270
P I T FALLS
Patients s h o u l d be cou nseled t h a t psoriasis is a c h ro n i c

cond ition with fla res a n d re m issions. Laser th era py,
such as the exc i m e r laser, is an a l ternative treatment
that should o n ly be considered afte r a pati ent has fa i led
m u ltiple other treatment reg im en s .
Patients s h o u l d be awa re t h a t any treatment a d m i n is

tered , it may res u l t in s p read of the psoriasis ( Koebner
phenomenon ) . They should a lso be awa re that s u rgica l
treatments performed for a ny reason may a lso res u lt i n
si m i l a r s p rea d .
B I B L I OG RAPHY
Ferna n dez-G u a r i n o
M,
H a rto A ,
Sanc hez- Ronco
M,
Ga rcfa - M o ra les I , J a e n P. P u lsed dye laser vs . p h otody

n a m i c therapy in the treatm e nt of refractory n a i l pso ria
sis: A comparative p i lot study. J Eur Acad Dermatal
Venereal. 2009 ; 23(8) : 89 1 -895 .
Gattu S , R a s h i d R M , Wu JJ . 308- n m exci mer laser i n
psoriasis vu lga ris, sca l p psoriasis, a n d pa l m o p l a nta r pso
riasis. J EurAcad Dermatal Venereal. 2009; 23( 1 ) :36-4 1 .
N o borio
R,
Ku rokawa
M,
Kobaya s h i
K,
Morita
A.
Eva l uation o f t h e c l i nica l a n d i m m u n o h istologica l efficacy

of the 585- n m p u lsed dye laser in the treatment of psori
asis. J Eur Acad Dermatal Venereal. 2009 ;23(4) :420424 .
S m its T, Klei n pe n n i ng M M , va n Erp P E , va n de Ke rkhof
P C , Ge rritsen
MJ .
A placebo-controlled
ra n dom ized
study on the c l i n ic a l effectiveness, i m m u noh istoc h em ica l

cha nges a n d p rotoporphyri n I X accu m u lation i n fraction
ated 5-a m i nolaevu l i n i c a c i d - p hotodyn a m i c th era py in
patients with psoriasis. Br J Dermatal. 2006; 1 55 ( 2 ) :429436
Taylor C R , Racette AL. A 308- n m exc i m e r laser for the
treatment
of
sca l p
psoriasis.
Lasers
Surg
Med.
2004;34(2) : 1 36- 140.

Va n Li ngen RG, d e J ong EM, va n Erp P E , va n M eeteren
WS, va n De Kerkhof PC, Seyger M M . N d : YAG laser
( 1 , 064 n m ) fa i l s to i m prove loca l ized p l a q u e type psoria
sis: A c l i n ic a l and i m m u n oh i stoc h e m i c a l pi lot study
[ p u b l ished o n l i n e a h ead of p r i nt Octo ber 2 7 , 2008] . Eur
J Derma tal. 2008; 18(6) :67 1 -676.
TE N
Ad i pose Ti ss u e A l te ratio n s
272
CHAPT E R 5 7
G y n eco m astia
Gynecomastia is the i nc reased p resence of benign gla n

d u l a r tissue, i n the form of a firm mass, a r o u n d the n i pple
i n m a l es ( Fig. 5 7 . 1 ) . I t is accom pa n i ed by i n c reased fat
d e position . I n contrast, i nc reased fat de position a lone, i n
the a bsence of gla n d u l a r prol ife ratio n , i s known as
pseudogyn ecomasti a . It ca n be b i l atera l or u n i latera l . I t is
common at b i rt h , p u berty, m id d l e age, a n d i n elderly
a d u lts. M a ny cases a re i d i o path i c . M u ltiple prec i pitat i n g
factors exist i n c l u d i n g hormonal a bn or m a lities, m ed ica
tion , c i rrhosis, hypogo n a d i s m , test i c u l a r t u m o rs, hyper
thyro i d i s m , a n d c h ro n i c re n a l i n s uffi c i e n cy.
For t h i s
reason , i n the a p p ropriate c l i n ical setting, the a ppea r

a n ce of gynecomastia d e m a n d s a med ical work u p .
Incidence: most common i n newborns but a lso c o m m o n
i n p u berty a n d o l d e r ma les
Age: b i rth (0-3 weeks ) , p u be rty ( 1 0- 1 7 yea rs) , m i dd le

aged and elderly age gro u ps ( 50-80 yea rs)
Race: none
Sex: ma les
Precipitating factors: hormonal i m ba l a nces, hormonal
thera py for prostate ca ncer, d rugs s u c h as, finasteride,
c i rrhosis, hypogonad i s m , testic u l a r tu mors, hyperthy
roid i s m , c h ro n i c re n a l i n s ufficiency. About one-q u a rter of
cases a re id iopath ic
PATHOG E N E S I S
I n cases of hormonal
B
i m ba l a n ces, the fu n d a m enta l
defect is a decrease in a n d rogen levels with a concomi

ta nt i n c rease i n estroge n levels.

A fi rm su bcuta neous n o d u l e extends con centrica l ly from
the n i p pl e . It may be u n i latera l or bi latera l . I n pse u d ogy
necomastia, the exa m i ned a rea is less firm as there is no
excess gla n d u l a r tissue.
B reast ca ncer, pse ud ogynecom asti a , b reast hypertrophy.

Seru m h C G , L H , testosteron e , estra d i o l leve ls s h o u l d be
i n vestigated in the setti n g of pa i n , tenderness, o r recent
Figure 57. 1 Characteristic appearance of gynecomastia in a middle-aged
male
Sect i o n 1 0 : Ad i pose Ti s s u e Alterati o n s
onset or c l i n ica l suspicion of endocrine a b normal ities.

F u rther worku p i s i n d icated i n the eve nt of u n i latera l
b reast e n l a rgement.
CO U RS E
T h i s depends on t h e etio l ogy. N ewborn gynecomastia
persists for a few weeks. In tee nagers, it may last a few
yea rs .
D i sconti n u a nce of med ication w i l l a m e l io rate
sym ptom s in d rug- i n d u ced cases. In cases of hormonal

i m ba la n ce, k i d n ey d isease, a n d hyperthyroid ism , correc
tion of the u n d e rlying i l l ness w i l l prod uce i m provement.
Medication h i story
Hormonal c h a nges
R e n a l or thyroid d i sease
Hormonal thera py for prostate cancer
Assoc iated sym pto ms
U n i latera l or b i latera l
MANAG E M ENT
M ost gynecomastia is tem pora ry a n d wi l l resolve without
thera py. If it is related to p u be rty, c l i n i ca l o bservation and
fo l l ow- u p wi l l l i kely be all that is needed . Disconti n uation
of a n offe n d i ng med i cation is typi c a l l y a l l that is req u i red
to treat d rug- i n d uced gynecomastia . U n i latera l gyneco
m astia req u i res a m a m mogra m with a p propriate fo l low
u p as needed . Med ica l a n d s u rgica l opti ons a re ava i la ble
for patients who have persistent gynecomastia i nto late
p u be rty p rod ucing e m otional d istress, pa i n , or tend er
ness . Ben ign psued ogynecomastia is the m ost c o m m o n
cause o f m a l e b reast e n l a rgement.
T R EATM ENT
O ra l M e d i cat i o n s
Medical thera py for gynecomastia i s beyond the scope of
this textbook. It is best performed by a physician who is
tra i ned in internal med icine or endocri nology. Med ications
include androgens, a ntiestrogens, and aromatase i n h i bitors .
P ro p h y l ax i s i n P rostate C a n c e r
B reast rad iation c a n b e performed prophylactica l ly i n
pati ents u n d e rgoing a ntiand rogen thera py or orch iec
tomy for prostate c a ncer. Concom ita nt ta m oxifen a d m i n
istration with f i nasteride/fl uta m i d e thera py ca n a lso be
prophylactic for gynecomastia .
273
274
S u rge ry
I n the event of medical treatment fa i l u re , s u rgica l thera py
is the next o pti o n . It is reserved for pati ents with refra c
tory gyn eco mastia that has fa i led medical thera py. The
treatments depend on the exte nt of gyn ecomastia . A few
options a re descri bed bel ow.
S u rgical excision i n c l u d i ng sta n d a rd el l i ptical excision

as we l l as s u bcuta neous mastectomy.
Conventiona l a n d u ltraso u n d -assisted l i posucti o n , that

is, l oca l ized rem ova l of gla n d u l a r tissue a n d/o r excess
fat . T h i s is part i c u l a rly successfu l in early stage a n d
l i m ited gyn ecomastia .
- Li posuction is performed th rough s m a l l incisions i n
t h e axilla a n d ste rn u m t o m i n i m ize sca rring
- Li posuction is less effective i n longsta n d i ng a n d s u b
sta ntial gynecomastia
- In prostate cancer patie nts, ea r l i e r i nte rvention is
more efficacious
- Resid u a l pe ri areola r fat may be n oted postl i pos uction
that can be i m p roved with local ized d issection of fat
via a s m a l l peria reo l a r i n cision
- Postproced u re s k i n laxity may be n oted
Com bi nation of s u rgica l excision a n d t u m escent l i po

sucti o n . T h i s i nvolves l i posuctio n , open excision , a n d
s k i n red uction for laxity. Li posuction h a s a lso been
c o m b i ned with su bcuta neous mastectomy.
S u rgical excision with plastic s u rgica l repa i r, p a rticu

la rly i n the event of b reast tissue sagging. Excessive fat,
gla n d u l a r tiss u e , and loose skin a re exc ised via e l l i ptica l
excision ,
i n c l u d i ng
the
ni pple
and
a reola.
The
n i p ple/a reola co m pl ex is then p laced i n the a p p ro priate

a nato m i c position as a fu l l t h i c k n ess s k i n graft after the
excess gla n d u l a r tissue is re m oved .
Psuedogynecomastia c a n be treated with l i posuction .

M a l e b reast fat tends to be re latively fi b rous, a n d t h us
more d ifficult to treat. F u rther, ca re m ust be ta ken to
avoid i nj u ry to the pectora lis m uscle. I n true gynecos
m asti a , excess gla n d u l a r tissue ren ders the p roced u re
eve n more c h a l lenging.
W h i l e tra d itiona l l i posuction a n d t u m escent l i posuction

have d o m i nated l i posuction treatment of gynecomastia
and pse u d ogynecomast i a , laser-assisted l i posuction is
a recent a d d ition to this fie l d . Th ere is no evidence to
show that laser-assisted l i posuction is su perior to either
of these forms of I i posucti o n .

EXPECTAT I O N S
I t is i m porta nt t o recogn ize that gyn ecomastia h a s m u l

t i p l e etio l ogies before atte m pting t o treat it.
I n most cases, watc hfu l wa iti ng is the best thera py.

I n cases of a n u nd e rlying syste m i c ca use, referral to the
a p propriate spec i a l ist is m a n dated .
I n cases of d rug- i n d uced gyn ecomasti a , d isconti n ua

tion of the med ication is the best ma nagement.
In cases of refractory to medical manage ment, there a re

severa l s u rgica l options. C o m p l i cations from these pro
ced u res i n c l ude a poor cosmetic res u lt, posto perative
sca rring, i ncom plete re mova l , postproced u re s k in laxity,
perma nent n u m bness i n the a rea , a n d he matoma for
mation .
B I B L I OG RAPHY
As i a n G , Tu n ca l i D , Te rziogl u A, B i ng u l F . Peria reolar
tra nsa reol a r-perithe l i a l i n cision for the s u rgica l treatment
of gyn eco mastia . Ann Plast Surg. 2005; 54( 2 ) : 1 30-134.
B e m bo SA, Ca rlson H E. Gynecomasti a : I ts features, and
when a n d h ow to treat it. Cleve Clin J Med. 2004; 7 1 (6 ) :
51 1-517.
G a b ra
HO,
M o ra bito
A,
Bianchi
A,
B owen
J.
Gynaecomastia i n t h e adolescent: A surgica lly releva nt

cond ition . Eur J Pediatr Surg. 2004; 1 4( 1 ) :3-6.
Gaspero n i C , Sa lgare l l o M, Gaspero n i P. Tec h n ic a l refi ne
ments in the s u rgica l treatment of gyn ecomasti a . Ann
Plast Surg. 2000;44(4) :455-458
lwuagwu OC, Calvey TA, l lsley D, D rew PJ . U ltraso u n d
g u ided m i n i m a l ly i nvasive breast s u rgery ( U M I BS ) : A
s u perior tec h n i q u e for gynecom asti a . Ann P/ast Surg.
2004 ; 52( 2 ) : 1 3 1 - 1 3 3 .
R o h rich
RJ ,
Classificatio n
Ha
RY,
and
Ken kel
JM,
ma nagement
Ad a m s
of
WP
J r.
gynecomasti a :
Defi n i ng the ro le o f u ltraso u n d -assisted l i posucti o n . Plast

Reconstr Surg 2003 ; 1 1 1 ( 2 ) : 909-923.
G raf R, Auersva ld A, Da masio R C , R i ppel R, d e Ara ujo
LR, B iga re l l i LH, F ra n c k CL. U ltraso u n d-assisted l i posuc
tion : An a na lysis of 348 cases. Aesthetic Plast Surg.
2003 ; 2 7 ( 2 ) : 146- 1 53 .
Z e l i c kson B D , Dresse l T D . Discussion o f laser-assisted
l i pos u ction . Lasers Surg Med. 2009;4 1 ( 1 0 ) : 709-9 1 3 .
275
276
CHAPT E R 58
Cellulite
Cel l u l ite d escri bes an orange peel type d i m pl i ng of s k i n i n

t h e u p per poste rior th ighs a n d buttoc ks ( Fig. 58. 1 ) .
Although there i s n o assoc iated morbid ity o r morta l ity, i t is
a mong the m ost common cosmetic com p l a i nts a mong
fe male patients . I t is present i n nearly all post p u berta l
fe males, rega rd less of weight. It is best thought of as a
fe male
seco n d a ry sexua l
cha racteristic .
I m po rta ntly,
treatments for fat remova l a n d cel l u l ite s h o u l d be consid

e red d isti nct. Effective treatments fo r fat remova l typica l ly
have no benefit for cel l u l ite .
EPI D E M I O LOGY
Incidence: 85% to 98% of postpu be rta l fe ma les, fa r less
c o m m o n in ma les
Age: begins in fem a l es after p u be rty

Race: m ore common in Caucasians
Sex: fa r more c o m m o n i n fem a les, ra re i n m a l es
Precipitating factors: fe m a l e ge nder, a n d roge n deficiency
in m a les ( ra re)
PATHOG E N E S I S
U n known .

There is a n ora nge peel o r cottage c h eese type d i m p l i n g
o f t h e u p per a n d outer th ighs a n d buttoc ks. Other com
mon locations i n c l u d e the breasts, lowe r a bd o m e n ,
u pper a rms, a n d n a pe o f neck.
None.

None i n d icated a s the c l i n ic a l a p pea ra nce is class i c .
COU RS E
Begi ns i n p u berty i n fe males a n d persists t h roughout l ife .
I n m a l es with a n d rogen d eficienc ies, the c l i n i c a l a p pea r
a n ce worsens as the a n d rogen d eficie ncy becom es m o re
severe . It may p resent de novo in m a l es u n d e rgoing hor
m o n a l thera py for prostate cancer.
Figure 58. 1 Classic appearance of cellulite

I n m a l es, i n q u i re a s t o a n y poss i b i l ity o f endocrine a b n or
m a l ities. T hi s is a very rare assoc iation of cel l u l ite i n
males.
MANAG E M ENT
There is no med ica l i n d ication t o treat cel l u l ite. Sti l l , many
patients req uest thera py. C u rrently, there a re n u merous
p u r ported thera pies, none of which have proven to be
very effective . I nteresti ngly, despite the lack of sci entific
evi dence of i m provement, many patients report su bjective
i m provement a n d satisfaction with thera py.
T R EATM ENTS
D i et
We ight has o n l y a m i nor association with ce l l u l ite
I t is c o m m o n in t h i n fe m a l es a n d ra re in o bese m a l es
There is no d ata to s h ow that d i et a n d exe rcise a re

effective treatme nts
To p i c a l Treat m e nts
A m i nophyl l i ne, reti noids, lactic a c i d , xa nth i n es, a n d

many others have a l l b e e n used w i t h l ittle evi d e nce o f
efficacy
Some c rea m s may prod uce more harm t h a n benefit

In fact, one study i n d icated 25% of cel l u l ite c rea ms
exa m i ned conta i ned known contact a l l erge ns
I n t e rve n t i o n a I Treat m e nts
Liposucti o n
There a re a few pu bl ished re ports o f i m prove ment;
I n some cases, it accentuates the a p pea ra nce of cel
however, typica l l y it d oes n ot i m p rove ce l l u l ite

l u l ite
Prior to perfo r m i n g a l i posuction proced u re, it is usefu l

to i n form patients that their cel l u l ite wi l l not reso lve .
T h i s wi l l protect aga i n st postproced u re d is a p poi ntment
Endermologie
Endermologie is a n FDA cleared device to i m prove the

a p peara nce of cel l u l ite
S k i n is kneaded by a h a n d held m a c h i n e
I t is rol led over affected a reas o f the body t h a t a re cov
ered by a nylon s u it
It p u r ports to i m prove blood a n d lym phatic flow as wel l

as s k i n a rc h itect u re
Figure 58.2 VelaSmooth laser treatment of thigh of young female
277
278
Twice wee kly treatm e nts of 10 to 45 m i n utes each a re

reco m m e n d ed
There is a l ittle evi d e nce to s u p po rt its efficacy
Subcision
Req u i res l o c a l a n esthesia

U s i n g a sca l pel or special 1 6-ga uge need le, the fat septae a re cut i n the deep s u bcuta n eous fat
Side effects i n c l u d e pa i n , bruisi ng, sca r, a n d puckering
Little d ata to su pport tem pora ry effi cacy
M esotherapy
P h os p h ati d y l c h o l i n e i njecti o n s : n ot a reco m m e n ded
t h e ra py.
I njecti on of c o m b i nations of i ngredie nts d i rectly i nto

su bc uta neous fat
P h osp hatidylchol i ne a n d d eoxycho late prepa rati ons a re

most c o m m o n ly used
- Deoxyc holate is the a ctive i ngred ient
N o p u b l ished d ata to show efficacy
Laser
Ve laSmooth system (Syneron
I nc.,
R i c h m on d
Hill,
O nta rio, C a n a d a ) com b i n es near-i nfra red l ight a t a

wavele ngth of 700 to 2 , 000 n m , conti n u o u s-wave rad io
freq u ency, a n d mecha n ic a l suction ( Fig. 58 . 2 )
- Twice wee kly treatments fo r a tota l o f eight t o t e n ses
sions have been recommended
- Th ere a re no long-term d ata to su pport its efficacy i n
patients
The TriActive Laserdermology (Cynosure, I nc, Chel msford,

Massachusetts) combi nes six near-infrared d iode lasers at
a wavelength of 810 nm, loca l ized cooling, and mechani
ca l massage
- Th ree wee kly treatments fo r 2 weeks a n d then
b iweekly treatme nts for 5 weeks a re suggested
- Th ere a re no long-term d ata to s u p po rt its effi cacy i n
patients
Other FDA clea red devices include a u n i polar rad i ofre

quency device (Alma Accent, Alma, I n c . , B uffa l o G rove,
I l l . ) a n d a d ua l wavelength laser system (SmoothSha pes,
Eleme Med ica l , I nc . , Merri mack, N ew H a m ps h i re)

EXPECTAT I O N S
Patients s h o u l d b e i nformed that there a re no truly effec
tive treatments fo r cel l u l ite. It is a lso i m porta nt to d isti n
guish treatments for body conto u r i n g and fat re m ova l
from those of cel l u l ite. M ost of the positive resu lts relati ng
to ce l l u l ite treatment a re a n ecd ota l or reported i n sma l l ,
u nscientific stud ies . M a n y of the thera p i es a re expensive,

espec ia l ly given the i r lack of efficacy. Some may even
prod uce more harm than benefit. There may be a more
p ro m ising futu re for laser a n d l ight sou rce treatments.
B I B L I OG RAPHY
Avra m M M . Cel l u l ite; A review o f i t s physiology a n d treat
ment. J Cosmet Laser Ther. 2005 ; 7 : 1 -5 .
Gold berg DJ , Faze l i A , Berl i n AL. C l i n ica l , la boratory, a n d
MRI
a n a lysis o f cel l u l ite treatment with a
u n i po l a r
rad i ofreq uency device. Dermatol Surg. 2008;34( 2 ) : 204209 .

K i n ney B M . Cel l u l ite treatment: A myth or rea l ity: a
p rospective ra ndom ized , controlled tria l of two thera pies,
endermologie a nd a m i nophyl l i n e c rea m . Plast Reconstr
Surg. 1999 ; 1 04: 1 1 1 5- 1 1 1 7 .

Lis-Ba l c h i n M . Pa ra l lel-placebo-control led c l i n ica l study
of a m ixtu re of herbs sold as a remedy for cel l u l ite.
Phytother Res. 1999 ; 1 3 : 627-629 .

P i era rd-Fra n c h i mont C , P i era rd G E, H e n ry F, Vroome V,
Ca uwen bergh G . A ra ndom ized , place bo-control led tria l
of topical reti n a l in the treatment of cel l u l ite . Am J Clin
Derma to/. 2000; 1 :369-37 4 .

Rao J , Gold M H , G o l d m a n M P. A two-center, dou ble
b l i nded , ra n d o m ized tria l testi ng the to lera b i l ity a n d effi
cacy of a novel thera peutic agent for cel l u l ite red ucti o n .
J Cosmet Dermatol. 2005;4(2) :93- 1 02

R ossi A R , Vergna n i n i A L . Cel l u l ite: A review. J Eur Acad
Dermatol Venereal. 2000; 14:25 1 -262 .

va n V l i et M , O rtiz A, Avra m M M , Ya m a u c h i PS. An
assessm e nt of traditional a n d n ovel thera p ies fo r cel l u l ite.
J Cosmet Laser Ther. 2005; 7 ( 1 ) : 7- 1 0 .

Wa n ne r M , Avra m M M . An evi d ence-based assessment
of treatments fo r cel l u l ite . J Drugs Dermatol. 2008 ; 7 (4) :
341 -345
279
280
CHAPT E R 59
H IV Lipod ystrophy/Facia l Lipoatrophy
H IV l i podystrophy d escri bes a conste l lation of cha nges i n

su bcuta neous a n d viscera l fat d istri bution i n patients on
a nti retrovira l
thera py.
In
d isti nction
to
" l i poatrophy"
(wh ich descri bes local fat loss ) , l i podystro phy refers to
both the acc u m u lation of fat as wel l as the loss of fat in
other a reas. I n H I V l i postro phy, the fi n d i ngs i n c l u d e s u b
cuta n eous fat loss in the m a l a r a n d b u cca l fat pads, ie,
fa cial l i poatrophy, as wel l as o n the extre m ities. It a l so fea
tu res fat a cc u m u lation on the d o rsocervica l fat pad ,
( Fig 59 . 1 ) ie, buffa l o h u m p, b reasts, a n d i ntra-a bdom i n a l
cavity. Its c h a racteristic a p pearance is sign ificant, i n t h a t i t
red uces patient com plia nce with a nti retrov i ra l thera py
a n d d e prives patients of H I V status privacy, pa rti c u l a rly i n
com m u n ities where H IV rates a re h ig h . T h i s d isord er is
a lso associated with a host of meta bol ic d isord e rs with
long-term i m pa ct on health
hyperl i pi d e m i a ,
and
i n c l u d i ng hyperglyc e m i a ,
hypertriglycerid e m i a .
Treatments
va ry accord i n g to the c l i n ical fi n d i ngs.
Incidence: 25% to 83 % of patients treated with a nti retro
virals depend i ng on c riteria used
Age: A l l ages , but older age is p red i ctive of severity

Race: N o n e
Sex: Eq u a l , severe fi n d i ngs m ore freq uent i n fem a les
P R EC I P I TAT I NG FACTORS
Anti retrov i ra l thera pies a re the prec i p itating factor. It a lso
presents i n freq ue ntly in H IV patients na'lve to H I V ther
a py. Typical ly, pati ents a re on com b i nation thera pies.
PATHOG E N ES I S
Path oge nesis rem a i ns u n known . I t i s a m u ltifactorial d is
order that va ries a ccord i ng to the med ications ta ke n .
Com p l ete or nea r complete loss of fat. J uxta position of
the dermis a n d fascia may be see n . Ad i pocytes a re
ma rked ly red uced in n u m be r a n d size.

Fat a cc u m u lation a n d fat loss a re d isplayed .
Fat acc u m u lation
Figure 59. 1 (A) "Buffalo h ump " in dorsocervical back of HIV-infected
male. (8) Substantial reduction in size of buffalo h ump after liposuction

procedure
Sect i o n 10: Ad i pose Tissue Alterati o n s
- Dorsocervica l fat pa d , ie, buffa l o h u m p

- B reasts
- I ntra-a bdo m i n a l cavity, ie, Crix bel ly
Fat loss
- M a l a r a n d bucca l fat pads
- Extrem ities and buttocks
Other l i podystrop h i es fac i a l l i poatrophy from aging, H IV
wasting synd rome, C u s h i ng's d i sease, m a l n utrition states,
a n o rexia nervosa , meta bolic X synd ro m e , cachexia sec
o n d a ry to cancer, m a l a bsorptio n synd romes, thyrotoxico
sis, and m u lt i p l e sym metric l i pomatosis.

B i o psy i s not usefu l . T h e c l i n ical fi n d i ngs a re sufficient to
make a d iagnosis. La boratory work u p s h o u l d i n c l u d e
assessm e nt o f blood g l u cose, l i pids, a n d triglycerides. If
C u s h i ng's is c l i n ica l ly suspected , la boratory exa m i nation
should be performed .
CO U RS E
H I V l i podystro phy d oes n ot sponta neously regress i n the
a bsence of treatment or medication cha nge .

M ed ication use
Com p l i a nce
H I V status
D u ration of l i podystoprhy
Associated hyperglycem i a , hyperl i p i d e m i a , a n d hyper
triglycerid e m i a
P R EV E N T I O N
Once a patient h a s been treated fo r t h e H IV virus, there i s
no prevention o f H IV l i podystro phy.
MANAG E M ENT
Cosmetic i m provement ca n b e essentia l t o promoting a
patient's ad herence to their H IV med ication regimen. There
a re several means by which the cosmetic a ppea ra nce of
H IV l i pcdystrophy ca n be i m proved . These include medica
tion cha nges, filler su bsta nces, and l i posu ctio n . Diet and
exercise can be helpfu l both for cosmesis a n d meta bolic
28 1
282
dera ngements. Treating the meta bolic derangements is

best referred to physicians skilled in treating hyperl i pi
demia, hypertriglyceridemia, and i nsu l i n resista nce.
T R EAT M E NTS
There a re severa l treatme nts that can
i m p rove the
cosmetic a p pea ra n ce of these d isord ers . They ca n be

d ivided i nto two sections: treatment of l i poatrophy a n d
treatment o f fat accu m u lati o n . Ad d itional ly, cha nges i n
med ications c a n b e p u rsued . T h i s i s best entrusted t o a
p hysic i a n who spec i a l i zes in the care of patients with H I V.
O ra l M e d i cat i o n s
A l l c h a n ges to a n a nti retrov i ra l reg i m e n a re best h a n d led
by physic i ans who spec i a l ize i n H I V treatment. These
cha nges can i m prove the a p pea ra nce of H I V l i podystro
p hy. Med ication cha nges i n c l u d e
D isconti n ua n ce o f a nti retrovira l thera py

- O bvious risks of d i sconti n u i ng med ications for a l ife
t h reate n i n g i l l ness
Cha nge H IV medications

- Other H IV med ications prod uce the sa me cond ition
- Some a ntiretrov i ra ls have a
lower i n c id e nce of
l i podysto phy
Treat m e n t of Fac i a l L i poatro p h y
Tempora ry fi l l ers
Poly-L-Iactic a c i d , Scu l ptra , is FDA cleared for the treat

ment of H IV fac i a l l i poatro phy
- Synthetic, biodegra d a b l e polymer
The materi a l used i n Vicry l sutures
- Seve ra l treatme nts a re req u i red , d e pend i ng on sever
ity of l i poatrophy
Benefits a re n ot seen u nt i l weeks after each treat
ment
- 18 to 24 month d u ration of fi l l e r material
- N o n eed for a l lergy testing
Ca l c i u m hyd roxyla patite, Rad iesee , is FDA cleared for

the treatment of H IV fac i a l l i poatro phy
- I m med iate correction
- D u ration up to 1 8 months
- N o need for a l lergy testing
Perma nent fi l l ers
S i l icone
A h ighly pu rified 1 , 000-cSt s i l icon o i l has been exa m
- N ot FDA c l ea red
i n ed i n 77 patients
The data showed that the n u m be r of treatments a n d

a m o u n t o f s i l icone req u i red for fu l l treatment was corre
lated to the i n itia l seve rity of fa c i a l l i poatrophy
The i n vestigato rs n oted no adverse events but cau

tioned that long-term effi cacy a n d safety a re yet to be
determ i ned
Treat m e n t of Fat Acc u m u l a t i o n
L i p osucti o n/l i pectomy
Loca l ized l i posuction/li pectomy uses tu mescent loca l

ized a n esthesia rather t h a n ge nera l a n esthesia
U ltraso u n d assisted l i posuction has a lso been em ployed

It is effective in rem ovi ng excess fat in the d o rsocervical
regi o n , that is, buffa lo h u m p
P I T FALLS T O AVO I D/CO M PL I CAT I O N S/

EXPECTAT I O N S
It is i m porta nt t o m a ke certa i n that t h e m u ltiple med ica l
issues
a re
being
mon itored
a p p ropriately
in
th ese
patients. It is a lso i m porta nt to e m p hasize the l i m ited

a b i l ity of th ese treatments in the fa ce of exte nsive H I V
l i podystro phy. General ly, however, patients a re ve ry eager
to see i m p rovement and gratefu l for the h e l p they
receive.
F i l lers can be very effective for i m proving fac i a l l i poat
rophy. Tem pora ry fi l l e rs, s u c h as Scul ptra or R a d i esse,
have the adva ntage of FDA clearance and stu d i es docu
menting the i r efficacy.
F u rt h er, thei r
non permanent
nature a l lows for tem pora ry side effects i n the eve nt of

poor resu lts or gra n u l oma fo rmatio n . U nfortu nately, tem
pora ry fi l l e rs req u i re perpetua l treatment sessions a n d
expense .
Permanent fi l l ers such as s i l icone a re attractive i n
these patients because t h e i r d isord e r is perm a nent. Data
a re pro m i s i ng, but fu rthe r lo ng-term stud ies a re n eeded
to assess lo ng-term efficacy and safety concerns. After a
series of i njections, fu rther treatment a n d expense is n ot
req u i red . U nfo rtunately, poor tec h n i q u e a n d gra n u loma
formation a re haza rds . W h i l e gra n u lomas a re i nfreq uent
side effects, they prod uce o bvious cosmetic d isfigu re
ment. Th e re is the potenti a l of gra n u loma formation m a ny
years afte r i n itial treatment as wel l . These gra n u lomas do
n ot resolve with the relative ra pid ity of n o n perm a nent
fi l l e r s u bsta nces.
F u rthermore,
s i l icone
is
n ot
F DA
cleared for the treatment of H IV l i podystro phy.

Li posuction can be very effective in patients with buf
fa lo h u m ps . Local ized l i posu ction/l i pectomy uses t um es
cent loca l ized a n esthesia rather t h a n ge nera l a n esthes i a ,
w h i c h dec reases the possi b i l ity o f s e r i o u s adverse eve nts.
Sti l l , l i posuction can be expensive and
res u lts va ry
accord i ng to the experience of the p ractitioner.
283
284
Fac i a l plastic s u rgica l proced u res ca n be effective, but

req u i re major i nvasive s u rgery with its atte n d a n t risks of
morbid ity. There is also i n c reased d own t i m e , pa i n , a n d
t h e r i s k o f ge neral a n esthes i a .
B I B L I OG RAPHY
B o i x V . Polylactic acid i m p l a nts . A n e w s m i l e f o r l i poat
ro p h i c faces? AIDS. 2003 ; 1 7 ( 1 7 ) : 2533-253 5 .
Carruthers A , Ca rruthers J . Eva l uation o f i nj ecta ble c a l
c i u m hyd roxyla patite f o r the treatment o f fac i a l l i poatro
phy associated with h u m a n i m m u n od efi ciency virus.
Dermatol Surg 2008;34( 1 1 ) : 1486- 1 499 .
Carruthers A, Liebeskind M , Carruthers J , Fo rster B B .
Rad iogra p h i c a n d com puted tomogra p h i c stud ies of cal
cium hyd roxyla patite for treatment of H IV-associated
fac i a l l i poatro phy a n d correction of naso l a b i a l fol d s .
Dermatol Surg 2008;34( S u p p l 1 l : S 78-S84
Con nolly N , M a n d e rs E, R id d ler S. Sh ort com m u n icati o n :
S uctio n -assisted l i pectomy for l i podystro phy. AIDS Res
Hum Retroviruses. 2004;20(8 ) : 8 13-8 1 5 .
H a d iga n C , Yawetz S , Thomas A , Havers F, Sax P E ,
G r i nspoon S . Meta bo l i c effects o f rosigl itazo ne i n H IV
l i podystro phy; A ra ndom ized , control led tria l . Ann Intern
Med. 2004; 786-794.
J ones D H , Carruthers A , O rentrei ch D, et a l . H ig h ly p u r i
f i e d 1 000 est s i l icon o i l f o r treatment o f h u ma n i m m u n
odeficiency virus-assoc iated fac i a l l i poatro phy: A n open
p i l ot tria l . Dermatol Surg 2004;30( 1 0) : 1 279-1 286 .
Koutkia P, Canava n B, B reu J , Torria n i M , Kissko J ,
G r i nspoon S . G rowth hormone-releasing h o r m o n r i n H I V
i n fected m e n with l i podystro phy: A ra n d om ized con
trol led tria l . JAMA. 2004;292 ( 2 ) : 2 1 0-2 1 8 .
Levy R M , Red bord KP, H a n ke CW. Treatment o f H IV
l i poatro phy a n d l i poatro phy of aging with poly-L-Iactic
a c i d : a prospective 3-yea r fol l ow- u p study. J Am Acad
Dermatol. 2008;59( 6 ) : 923-933.
P i lero PJ , H u bbard M , King J, Fa ragon J J . Use of u ltra
sonogra phy-assisted
l i posuction for the treatment of
h u m a n i m m u n odefi c i ency vi rus-assoc iated e n l a rgement

of the d o rsocervica l fat pad . Clin Infect Dis. 2003 ; 3 7 :
1374- 1 3 7 7 .
Vl egga a r D ,
Bauer U.
Fac i a l e n h a ncement a n d the
E u ropean experience with Scu l ptra ( poly-L-Iactic a cid ) .

J Drugs Dermatol. 2004;3 ( 5 ) : 542-547 .
CHAPT E R 60
285
Str i a e Diste nsa e
Striae d istensae, m ore com m o n l y known as " stretch

marks, " a re atro p h i c l i nea r ba nds of skin that a p pear
after certa i n p rec i p itati ng factors such as pregna ncy,
steroid use, a n d d ra matic cha nges i n weight or m uscle
mass ( F ig. 60. 1 ) . At prese ntatio n , they feature a pu rple or
p i n k color (striae ru bra) that fad es to a pa ler wh ite (striae
a l ba ) over time. They a re most common in a d u lt women .
Incidence: common
Age: pu berty, pregna ncy
Race: more common in Ca ucasians
Sex: fe males > ma les (associated with pu berty a n d preg
na ncy)
Precipitating factors: to pical
and
o ra l
ste roid
use,
C u s h i ng's synd rome, p regna ncy, b reast-feed i ng, pu berty,

genetic col lagen d efects,
and
d ra matic c h a nges
in
weight, height, or m uscle mass
PATHOG E N ES I S
There a re cha nges i n the extrace l l u l a r dermal matrix
i n c l u d i ng fi b ri l l i n , elasti n , a nd collage n , resulting from
p rolonged stretc h i ng of the s ki n .
PATHOLOGY
There a re sca r- l i ke featu res . Typica l ly, there is an atro p h i c
epidermis w i t h na rrow col lagen b u n d l es a rra nged pa ra l lel
to the ski n s u rface. The rete ridges a re effaced . I n early
striae, there is a s u perficia l , deep, a nd i nterstitia l lym p h o
cytic perivasc u l a r i nfi ltrate a n d occasional eos i n o p h i l s .
The i nfi ltrate fades i n older lesions.
M u ltiple sym metric l i nea r ba nd-l i ke plaq ues o f atro p h i c
ski n t h a t present most commonly i n the outer thighs,
b reasts, a n d buttocks of wo men a long the l i nes of cleav
age. They p resent with a p i n k/purple h ue (striae ru bra )
a n d become pa ler with fi ne wri n kl i n g over time (striae
a l ba ) . Striae a re la rgest a n d m ost a b u nd a nt i n pati ents
with C u s h i ng's d isease. I n preg n a ncy, striae a re m ost
a b u n d a nt on the a bd o m e n . In weight l ifters, they a re
m ost p ro m i nent on the s h o u l d ers. To pical corticoste roid
use most c o m m o n l y produces striae on the face, ge n i
ta l i a , flex u ra l a reas, a n d body folds.
Figure 60. 1 (A) Striae alba at baseline. (B) Striae alba at 1 1 months
follow-up after four treatments with a 1 450-nm diode laser

(Smoothbeam, Candela Corp., Wayland, MAJ at energy settings of 1 3 to
1 4 J!cni2 , using a 6-mm spot size with a pulse duration of 30 ms.
Treatment was performed at intervals of 2 to 3 months
286
Linear foca l elastosis.

T h e c h a ra cteristic c l i n i c a l a p pea ra n c e of striae n egates
a ny n eed fo r s k i n b i o psy. Ad d itional la boratory work u p to
rule out C u s h i ng's d i sease is i n d icated in the a p p rop riate
c l i n ica l setting.
COU RS E
Striae beg i n a s p i n k o r pu rple atro p h i c lesions that
becom e pa ler and less o bvious ove r t i m e .
D u ration
S k i n phototype
P regna n cy
Assess for sym ptoms of Cush i ng's d isease
Use of corticostero i d s
H istory o f weight cha nge
H istory of weight l ifti n g
MANAG E M E N T
There is no medical i n d ication t o treat stria e . Sti l l , ma ny
i n d ivi d u a ls a re sign ifica ntly bothered by the i r a p pea ra nce
and req u est treatment. There a re n u m e rous options to
treat stria e . U nfort u n ately, none of the treatments is com
p l etely successfu l . In fact, m ost treatme nts provide mod
est or no benefit. Thus, prior to treatment, patie nts'
expectations n eed to be tem pered . C o m b i nation treat
ment i nvolving laser and
topical regimens s u c h as
treti n o i n is often a hel pfu l method of treatment. More

recently, nona blative a nd a b lative fractional treatm ents
have emerged . Fort u nately, the a p pea ra nce, parti c u la rly
the color of striae, i m proves with t i m e . Patients with s k i n
phototypes 1-1 1 1 respond better t h a n those w i t h types
I V-VI to laser thera py. Test sites prior to thera py a re rec
om mended . There is some data to show that treatments
i m prove striae over n o n i nterventio n . The fi rst priority is to
esta bl ish whether stria r u b ra or stria a l ba a re be i n g
treated , as the i r treatments d iffe r sign ifica ntly.
TREAT M ENT (Fig. 6 0 . 2)
Stria ru bra : the pu lsed dye laser (585 n m ) with a 7- or 10mm spot size and 2 to 4 J/cm 2 fluence has been shown
to i m prove the erythema of striae, but is associated with
Figure 60.2 (A) White striae, axilla. Prominent atrophy, textural changes,
and depigmentation are observed. (B) White striae, axilla, following three
fractional resurfacing laser treatments. Mild improvement of the atrophy
and textural changes are noted. Mild post-inflammatory hyperpigmenta
tion is observed, which resolved 3 weeks after the last laser treatment
Sect i o n 10: Ad i pose Ti s s u e Alterati o n s
287
the risk of hyperpigmentation in da rker skin phototypes.

A c l i n ica l end point of deep erythema o r l ight purpura is
o pti m a l . In o u r experience, lower fluences a re more suc
cessful than h igher fluences ( Fig. 60. 3 ) .
- P u lsed d y e l a s e r treatments d o l ittle, if a nyth i ng, to
i m prove the textu re a n d atro phy of striae.
- I m p rovement ca n be seen even i n cases of poor i n i
ti al res ponse 6 months afte r treatment.
- Stu d ies recom mend aga i n st treating s k in phototypes
V-V I .
- Some d ata casts d o u bt on the effectiveness of pu lsed
dye laser.
Stria a l ba : nona blative fractional resurfa c i ng has been

s h own to provide some benefit for striae a l ba e . Stud i es
show a ra nge of efficacy with these treatments.
There is l ittle data to suggest whether deep d e pth , h igh
coverage treatme nts a re more effective t h a n lower d e pt h ,

lower coverage treatme nts.
I n o u r experience, m ost
patients see a modest benefit from treatment. A m i no rity

sees more sign ificant resu lts .
S hort- p u l sed erbi u m :YAG a n d C0 2 lasers can be mod

estly effective but a re no lo nger commonly used due to
s u c h side effects as prolonged , d iffic u lt h ea l i ng and
pigme nta ry a lte rat i o n . They a re n ot reco m mended .
The exc i m e r laser (308 n m ) has been exa m i ned for

treatment of striae a l ba
and
sca rs in
31
a d u lts .
Treatme nts bega n at t h e M i n i ma l Erythema Dose

( M ED l m i n us 50 mJ/cm 2 to affected a reas a n d were
performed biweekly for 1 0 weeks. An i m prove m ent i n
coloratio n , b y visual i n s pection ( 60-70% ) a n d colorimetric a na lysis ( 1 00% ) , was n oted and correlated
strongly with the n u m ber of treatme nts performed . The
pigment correctio n , h owever, retu rned c l ose to base l i n e
after a 6-month fol l ow- u p . N o bl iste r i ng or pigmenta ry
d istu r ba nces were noted .
Figure 60.3 (A) Numerous striae rubra and alba on the abdomen of a
young woman . (8) Immediate endpoint of purpura following low energy,
short pulse duration treatment with a pulsed dye laser
Ea rly striae
- Tre n i n o i n (0. 1 %) crea m can i m prove the a ppea ra nce
of striae, partic u l a rly early stria e , wh i l e decreasi ng
t h e i r length a n d width .
Matu re striae
- Treti n o i n (0.05 % ) and 20% glyco l i c acid ca n i m prove
striae.
- G lyco l i c a c i d (20 % ) a n d 10% L-ascorbic acid can
i m prove striae.
M I CRODERMABRAS I O N
M icrod erma brasion ca n
prod uce sma l l
i m provement
after six to ten treatments . M ic roderma brasion ca n also
288
be used i n assoc iation with laser thera py given its fa irly

benign sid e-effect profi l e .

MANAG E M ENT
Patients s h o u l d b e i nformed that com p l ete resol ution i s

not rea l isti c . Rather, m i l d-to-moderate benefit is most
rea l istic . Thus, h ighly motivated patients with rea l istic
expectations a re the best ca n d i dates for treatment.
Laser thera py m ust be used with caution i n dark s k i n

phototypes given the r i s k o f hyperpigme ntati o n .
Topical treti n o i n can prod uce s k i n i rritati o n .
B I B L I OG RAPHY
Alexiades-Arme n a kas M R , Bernste i n U , Fried m a n P M ,
Gero n e m u s R G . The safety a nd efficacy o f t h e 308- n m
exc i mer laser for pigment correctio n o f hypopigme nted
sca rs a n d striae a l ba . Arch Dermatol. 2004; 1 40(8) : 955960.
Ash K, Lord J, Z u kows ki M, M c Da n iel D H . Comparison of
to pical thera py fo r striae a l ba (20% glycol i c a c id/0.05%
treti n o i n versus 20% glyc o l i c acid/10% L-ascorbic a cid ) .
Dermatol Surg 1 998;24( 8 ) : 849-856.
Bak H, Kim BJ , Lee WJ , et a l . Treatment of striae d i sten
s a e w i t h fractional
phototherm olysis.
Dermatol Surg.
2009 ; 3 5 ( 5 ) : 826-83 2 .
Gold berg OJ , Sa rradet D , H ussa i n M . 308- n m Exc i m e r
laser treatment o f mature hypo pigmented striae. Dermatol
Surg. 2003 ;29(6): 596-598. Discussion 598-599.
J i menez G P,
Flores
F,
Berman
B,
G u nja-S m ith
Z.
Treatment of striae ru bra and striae a l ba with the 585-n m

p u l sed-dye laser. Dermatol Surg. 2003 ;29(4) :362-365 .
M c D a n iel D H , Ash K, Z u kowski M . Treatment of stretc h
ma rks with the 585- n m flash la m p- p u m ped pu lsed dye
laser. Dermatol Surg 1 996;22(4) :332-33 7 .
Nehal
K S , Lichte nste i n
DA,
Ka m i no
H,
Levi n e VJ ,
As h i n off R . Treatment of matu re striae with the p u lsed

dye laser. J Cutan Laser Ther. 1 999; 1 ( 1 ) : 4 1 -44.
N o u ri K, R o magosa R, C h a rtier T, Bowes L, Spencer J M .
Com parison of the 585 n m pu lse dye laser a n d the short
p u l sed C02 laser i n the treatment of striae d istensae in
s k i n types IV a n d VI. Dermatol Surg. 1 999 ; 2 5 ( 5 ) : 368370.
Stotla n d M, Cha pas AM, B rightm a n L, et al. The safety
a n d effi cacy of fra ctional p h otothermolysis for the correc
tion of striae d i stensae. J Drugs Dermatol. 2008; 7 ( 9 ) :
857-86 1 .
E L EVE N
Wo und H ea l ing A l te rations
290
CHAPT E R 6 1
H ype rtrop hic Sca rs , Ke l oids , a nd Ac n e Sca rs
I NTRODUCT I O N
Hypertro p h i c sca rs a n d keloids a re both c h a ra cte rized by
excess fibrous tissue at a site of i nj u ry in the s ki n .
Hypertro p h i c sca rs a re confi ned t o t h e origi n a l wou n d
site, whereas keloids, b y contrast, exten d beyond the
origi n a l wou n d site (Ta b l e 6 1 . 1 ) . Both a re common a n d
freq u e ntly d istu r b patients greatly, both as a n u n s ightly
sca r as wel l as a rem i nd e r of p revious tra u ma o r s u rgery.
Acne sca rs res u l t from the loss of u n d erlying col lage n
a n d elastic tissue from d e r m a l i nflam mation assoc iated
with a c n e , pa rti c u larly cystic acne. Ac ne sca rs a re a lso
very c o m m o n a n d a sou rce of d istress to the patient, both
fo r thei r obvious a p pea ra nce o n the face as wel l as a
re m i nder of p revious a c n e .
HYPERTROPH I C SCARS AND KELO I DS :

Hypertro p h i c sca rs prese nt as thick, firm l i nea r plaq ues
at the site of tra u m a . I n itial ly, they may be erythematous
Figure 6 1 . 1 Dermal injection of hypertrophic scar that resulted from a
shave biopsy
but often become s k i n -colored with time. Ke loids a re

fi r m , fibrous p l a q u es that exte nd outside the s ite of i nj u ry
with claw- l i ke projectio ns.
Dermatofi broma , sca r sarco i d , d ermatofi b rosa rcoma pro
tu bera ns, gra n u lo m a .

N o n e . If, however, a keloid i s u n res ponsive t o m u lti p l e
thera pies, s k i n b i o psy t o rule out d e rmatofi b rosa rcoma
protu bera ns is i n d icated .
TABLE 6 1 . 1
Hypertrophic Scars Versus Keloids
Defi n ition
Ke loid
Hypertro p h i c sca r
Excess fibrous tissue formation i n a wo u n d that
Excess fi brous tissue formation in a wo u n d that
exte nds beyon d the orig i n a l wou n d site
re m a i n s with i n the origi n a l wo u n d site
Cou rse
Does n ot sponta neously regress

May a rise weeks or months afte r i nj u ry
U s u a l l y a rise with i n weeks of i nj u ry
Prec i p itati ng factors
Fa m i ly h i story, s u rgery, tra u m a , b u r n , a c n e , earlobe
Fa m i l y history, su rgery, tra u m a , b u r n , acne; may
pierc i ng; most common in skin types I V-V I ,
Often sponta neous regression months after the i nj u ry
a rise in a n y patient at all ages
but may a rise in a l l s k i n types a n d a l l ages

I n cidence
Co m mo n ; M a les = fe ma les
Com m o n ; M a les = fe ma les
Ste rn u m : most c o m m o n location
Ste rn u m : most common location
Sect i o n 1 1 : Wo u n d H ea l i ng A lte rat i o n s
29 1
MANAG E M ENT
There a re
m u ltiple thera pies that a re effective for
decreasing the u nsightly a p peara n ce of ke loids a n d

hypertro p h i c sca rs . N o n e is complete ly satisfactory a n d
n o n e ca n be designated as a treatment o f choice.
Patients s h o u l d be ed ucated as to the refractory natu re of
keloids a n d hypertro p h i c sca rs a n d that m u ltiple treat
ments ove r months a re typ ica l l y req u i red for effi cacy.
Ke loids tend to be more resista nt to thera py than hyper
tro p h i c scars.
These treatment opti ons i n c l u d e i ntra l es i o n a l tri a m c i
n o l o n e aceto n i d e , i ntra lesiona l 5-fl uoro u ra c i l ( 5- F U ) ,
s i l icone s h eeti ng, i m i q u i m od , rad iati o n , e l l i ptical exc i
sion, fractio n a l res u rfa c i ng, a n d p u lsed dye laser ( P D U
( 59 5 n m ) . These treatme nts provide d iffe rent ben efits.
Some red uce eryth e m a , others flatten lesions, a n d some
perform both the functions. M ost ofte n , i ntra l esio n a l
Figure 6 1 .2 Mild purpura after pulsed dye laser treatment of keloidal
stero ids a re a good i n itia l th era py t h a t ca n b e com bi ned
acne on back of a teenager. lntralesional kenalog was also used to

produce eventual clinical improvement after a series of treatments
with o r fol l owed by oth e r thera pies. Treatments can

be b roa d ly d ivided i nto laser and non laser thera p i es
(Ta b l e 6 1 . 2 ) .
TAB L E 6 1 . 2
Non laser Treatment Options
l ntra les ional 1

tri a m c i nolone
Dose
I nterva l of time
Hypertro p h i c sca r
Keloids
Com ments
5-40 mg!m l
Every 2-6 weeks
For m ost scars,
Va ria ble su ccess; m ost
Effective, safe,
(site dependent)
aceto n i d e
moderate to d ra matic
successful with
i nexpensive; ca re
i m prove ment
early i ntervention
to avoid atrophy
( Fig. 6 1 . 1 )
I ntra lesional
50 mg/m l
5-fl u o ro u rac i l
1 -3 ti mes wee kly

for t h e fi rst
Ca n be effective;
Va riable success
No clea r adva ntage

ove r tria m c i nolone
secon d - l i n e thera py
1-2 wee ks;
aceto n i d e
then every
2-5 weeks
1 2 h o u rs per
S i l icone sheeti ng
Va ria b l e i m provement
Va riable i m p rovement
Safe
N ot stud ied
Study showed no
N o lo ng-term
day for
1 2 weeks
l m i q u i mod
I n d u ces t u m o r
N ightly
necrosis facto r
a p pl ication for
recu rrences u p to
stud ies for
a l pha a n d
6- 8 weeks
6 months; risk
rec u rre nce rates
i n terfero n a l pha
sta rti n g the
hyper pigmentation
and ga m m a
d a y o f su rgery
i n sca r. F u rther
study needed to
confi rm these results
Excision s u rgical
M ostly u n s u ccessfu l ,
Very high rec u rre nce
I m med iate
n ot recom mended
rate without adj u n ct
gratification but
without adj uva nt
thera py. All patie nts
i nc reased risk of
thera py
m ust be awa re
rec u rrence
rec u rrent keloid may

be worse than original
292
LAS E R
P D L ( 595 n m lhas e me rged as a n i m porta nt adjuvant for
treatment of ke loids a n d hype rtro p h i c sca rs ( Fig. 6 1 . 2 ) .
G ive n its selective ta rgeting o f su perfi c i a l b l ood vessels,
PDL can d ra matica l l y i m prove the erythema assoc iated
with
hypertro p h i c
sca rs
and
keloids
(Ta ble
6 1 .3).
I nteresti ngly, lowe r fluence treatments at short pu lse

d u rations te n d to be more successfu l than higher fl uence
treatments. It has a lso been shown h e l p to flatten lesions
as wel l .
Ab lative a n d n o n a blative fractio n a l res u rfa c i n g res u r
fac i ng has been shown to provide moderate i m provement
for acne, s u rgica l , hypertro p h i c , a n d b u r n sca rs . It is sti l l
u n k n own wh eth er h igh-d e nsity treatments a re m o re
effective than
re m od e l i ng
low-density treatments. Typical ly, sca r
with
nona blative
fra ctional
res u rfa c i n g
req u i res six t o eight treatments t o a c h i eve a bout 50%

benefit ( Fig. 6 1 .3) . S ig n ificant i m prove ment is seen with
one to two treatments with a b lative fractio n a l resu rfa c i n g .
C0 2 l a s e r treatment o f these lesions, w h i l e reported
successful in some of the l iteratu re, is not reco m me n d ed
d ue to a h igh rate of rec u rre nce. l ntra l esional corticos
teroids a re a h e l pf u l adjuva n t to laser thera py to h e l p flat
ten lesions and red uce pru ritus.
STU D I ES
One study exa m i ned the effect of a flash la m p p u m ped

P D L at 585 nm o r a flash l a m p P D L at 5 1 0 nm o n
1 5 patients with red hypertro p h i c scars. After a n aver
age of nea rly two treatme nts, 77% i m provement was
noted . After th ree treatm e nts, 7 of the 1 5 patients had
complete reso l ut i o n .
Another stu d y u s i n g the 585- n m P D L treated one h a lf
Figure 6 1 .3 (A) Pre- and (B) postappearance of a traumatic scar after a

series of fractional resurfacing treatments. There is some m ild residual
PIH that faded within 1 to 2 weeks
of m e d i a n ste rnotomy hypertro p h i c sca rs/ke loids i n 1 6

patients a n d l eft t h e other s i de u ntreated . Patients
received two treatm ents every 6 to 8 weeks a n d we re
exa m i ned after 6 months. B l i nded o bserve rs a nd pho
togra phy revea led "significant i m p rovement" in red
ness, sca r height, skin s u rface texture , and pru ritis i n
laser-treated sca r a reas after 6 m onths .
TAB LE 6 1 .3 Pu lsed Dye Laser for Hypertrophic

Scars/Keloids
Mecha n is m of action
U n k n own
Expectation
I m proves erythema ,
t h i c kness, a n d p l ia b i l ity
by u p to 30-90%
PDL setti ngs
3-7 J/cm 2 , 7 or 1 0-m m

spot, 0.45- or 1 . 5-ms
p u lse d u ration
Average n u m ber of
treatments
4-6; but may req u i re fa r

m ore
Figure 6 1 .4 (A) Erythematous deep acne scars.
293
C L I N I CAL EXPER I E NCE
Avo id elective su rgery i n patie nts with a h istory of
Consider begi n n i ng therapy at the t i m e of su rgery o r at
keloids/hypertro p h i c sca rring.

suture remova l .
Keloids a re more d iffi c u lt t o treat a n d more u n pre

d i cta b l e in the i r res ponse tha n hypertro p h i c sca rs.
Hypertro p h i c sca rs often i m prove with no treatment i n

6 months.
P O L a n d fractional res u rfa c i ng lasers a re effective in
i m proving hypertro p h i c sca rs,

F ra ctio n a l res u rfa c i ng can i m prove the text u re a n d
a p pearance o f s u rgica l a nd b u r n sca rs
AC N E SCARS
Acne sca rring is a co m mon seq uela of severe i nfla m ma
tory o r cystic a c n e . It can present i n a m i ld o r cosmeti
ca l ly d i sfigu ri ng fo rm . The best prevention of acne
sca rring is aggressive treatment of a c n e vu lga ris at the
time
of
presentati o n ,
i n c l u d i ng,
when
a p propriate,
isotretinoi n . Acne sca rs have severa l va rieties i n c l u d i ng

atro p h i c , ice-pick, ro l l i ng, a n d boxca r sca rs. Treatme nts
va ry accord i ng to the type of sca r being treated . I n fact, a
c o m b i nation of treatments is ofte n m erited , that is, P O L
fo r sca r erythema a n d s u bseq u e nt n o n a b l ative fractional
resu rfa c i ng for a c n e sca rs ( Fig. 6 1 .4) They a lso va ry in
terms of d u ration of efficacy a n d expe nse. Prior to s u rgical o r a blative thera py, it is i m porta nt to e l icit a ny recent
h istory of Acc uta ne use with i n the previous 6 months as

we l l as a h istory of hypertro p h i c or keloida l sca rring to
avo id poor wou n d hea l i ng a n d sca rring after thera py.
P h ys i c a l Les i o n s
Atro phic sca rs a re d e p ressed from the s k i n s u rface a n d

result from loca l loss o f tissue from i nfla m mati o n ,
i ntra lesi o n a l stero ids, s k i n s u rgery, weight loss, or ra pid
growth (Ta ble 6 1 . 4 ) .
Ice-pick sca rs a re na rrow, d e e p , vertica l , cyl i n d rica l

de pressions at the site of the i n fu n d i bu l u m . G iven t h e i r
d e pth , they a re more resista nt t o l a s e r thera py. P u n c h
excisions, fol l owed b y nona b lative fractional resu rfac
i ng, can be h e l pfu l ( Fig. 6 1 . 5 ) .
R ol l i ng sca rs a re s h a l low de pressions that a re best

a p preciated with a c h a nge in surface l ighti ng. They c a n
va ry i n s i z e a n d often coa l esce w i t h n e i g h b o r i n g rol l i n g
sca rs . They a re w i d e r tha n
ice-pick sca rs. T h e i r
de pressed a p pearance reflects a n u n d erlyi ng fi b rosis of

the d e r m i s a n d su bcuta neous fat.
Boxc a r sca rs a re wider than ice-pick sca rs but less

deep. They have a wel l-defi ned c i rc u l a r o r ova l s h a pe .
Figure 6 1 .4 (Continued) (8) Improvement in acne scar erythema after a

series of pulsed dye laser treatments. (C) Further improvement with acne
scars with subsequent nonablative fractional resurfacing
294
TAB L E 6 1 .4
Treatment Options for Atroph ic Scars
Thera py
Type of thera py
Cou rse
C o m m ents
To pical
Tret i n o i n 0 . 0 5-1 % n ightly
Sl ight i m provement after
S l ight i m provement as monothera py. M ost
6-- 1 2 months
effective as an a dj u nct with other modal ities.

If i n it i a l i rritation , a p ply every other n ight u nti l
better tolerated
Laser
1 ,450-n m d iode: 1 2- 13 J/c m 2 ,
1 0-30% i m p rovement
M i l d i m provement
6-m m s pot size 30-40-ms

c ryogen coo l i ng spray, th ree to
fou r treatments over 4-6 months;
treats active acne as we l l
Safe in a l l s k i n types
R isk of transito ry hyperpigmentatio n ; postlaser
erythema weeks to months; may cause acne
fla re
Fractional resu rfa c i ng: five t o six
N o n a b l ative : moderate
treatments; d eeper d e pth of
i m provement afte r five to six
treatment is more effective,
treatm ents
u nclear if h igher or lower density

of treatment is m ore effective
S i d e effects i n c l u d e tem po ra ry erythema,

edema, crusti ng, a n d mild pa i n
A blative: moderate i m provement

after two treatme nts
Some m a y d evelop bronzing a n d m i ld fla k i n g
at 5-7 days
H igher i n c idence of hyperpigmentation i n
d a rker s k i n p hototypes
Low risk for lo ng-term adve rse side effects;
except that scarri ng may occ u r with a blative
fractional d evices
U ltra p u lsed pu lse carbon d ioxide

laser
40---{)0 % i m provement; m ore

effective than nona blative
M o re d ownti m e a n d side effects t h a n

nona blative laser
laser
Postlaser erythema lasting weeks to months;
risk of hyperpigmentatio n , i n fect i o n , sca r, a n d
permanent hypopigmentation
Best for s h a l l ow, wide sca rs such as boxcar sca rs
Antivi ra ls for patients with history of H SV
F i l l e rs
R estylane ( h ya l u ro n i c a c i d )
D ra matic i m provement
Te m po ra ry
6--8 months
Low-risk a l lergy, gra n uloma; do not overcorrect
sca rs
F i l l e rs
Auto logous fat
D ra matic i m provement a n d
Longer d u ration
longer d u ration t h a n other

fi l lers
N o risk of a l lergy, gra n u loma
M ore d iffic u lt to master effective tec h n i q u e
F i l l e rs
Bovine collage n : Zyd erm I ,

Zyd erm I I , Zyplast
Good , tem pora ry i m provement
Req u i res test site for a l l e rgy
fo r 2-3 months
H igher risk of a l lergy ( ie , 1-3 % )
Tec h n i q ue: overcorrect sca rs
Easier proced u re for i nexpe rienced practitioners
t h a n other fi l le rs
Adverse effects: s h o rter d u ration
F i l l e rs
H u ma n col lagen
Good , tem pora ry i m provement

fo r 2-3 months
TAB L E 6 1 .4
295
Treatment Options for Atrophic Scars ( Continued)
Thera py
Type of thera py
Cou rse
C o m m e nts
Mecha n ical/
M icoderma b rasi o n , glyco l i c a n d
M i ld i m p rovement
M ic rod e r m a b rasion/glyc o l i c a c i d peels a re safe;
chem ical
sa l icyl ic acid pee ls safe in s k i n types I V-V I ;
sa l i cyl ic acid peels ( Fig. 6 1 .4)
derma brasion s h o u l d n ot be performed
TCA peels; derma b rasion
except i n extremely expe rienced h a n d s

S u rgica l
S u bcision ( i ncision i nto dermis with
M i l d i m p rovement
Safe
Good i m provement
Ti me cons u m i ng. M u ltiple treatme nts. Better
mec h a n ical tra u ma i n d u c i n g

fi b rosis)
S u rgica l
P u n c h exc ision Fig. 6 1 . 6 ) , p u n c h

grafting, p u n c h a utografti ng,
for ice- p i c k sca rs
punch elevation
K ey P o i nts i n Treat i n g Ac n e S c a rs
Em phasize i m provement rather tha n complete reso l u

tion as a n o bta i n a bl e res u lt .
D iscuss a l l treatment o ptio n s . A l l o ptions have adva n

tages a n d d isadva ntages .
M a n y patients w i l l benefit from a com bination of ther

a py.
O bta i n com plete medical h i sto ry a n d med ication use,

that is, Accuta ne with i n 6 months of a ny s u rgica l/a bla
tive treatment.
M a ke s u re a c n e is being o r has been treated to p revent

futu re sca rs .
B I B L I OG RAPHY
Alste r T S , W i l l ia m s C M . Treatment o f kel o i d sternotomy
sca rs with 585 nm flash la m p-pu m ped p u l sed -dye laser.
Lancet. 1 995;345(8959) : 1 1 98- 1 200 .

Avra m M M , Tope W D , Yu T, Szacowicz E, Nelson J S .
Hypertro p h i c sca rring o f the neck fo l l owi n g a blative fra c
tional carbon d ioxide laser res u rfa c i n g . Lasers Surg Med.
2009 ; 4 1 ( 3 ) : 185-188.
Berma n B , Ka ufm a n J. P i lot study of the effect of posto p
e rative i m i q u i mod 5% c ream on the rec u rre nce rate of
exc ised keloids. J Am Acad Dermatol. 2002;47(su ppl
4 ) : S209-S2 1 1 .
Berma n B, Via l l A. l m iq u i mod 5% c rea m fo r keloid m a n
agement. Dermatol Surg. 2003 ;29( 1 0) : 1 050- 1 05 1 .
C h u a S H , Ang P, Khoo LS , Goh C L . N o n a b lative 1450 n m
d iode laser i n treatment o f fac i a l atro p h i c a c n e sca rs i n
type IV Asian ski n . Dermatol Surg. 2004 ; ( 1 0) : 1 287- 1 29 1 .
Fitzpatrick R E. Treatment of i nfla med hypertro p h i c sca rs
using i ntra lesi o n a l 5 - F U . Dermatol Surg. 1 999 ; 2 5 ( 3 ) :
224-23 2 .
Figure 6 1 . 5 (A) Ice pick scars prior to punch excisions. (8) Improvement
of ice pick scars 1 week after suture removal. Further improvement was
achieved with nonab/ative fractional resurfacing
296
G l a i c h AS,
R a h m a n Z, Gold berg L H , Fried m a n P M .
Fracti o n a l resurfa c i ng for the treatment of hypopig

mented sca rs: A p i lot stu dy. Dermatol Surg. 2007;33 ( 3 ) :
289-294 .
Haedersd a l
M,
M o rea u
KE,
Beyer D M ,
Nyma n n P,
Alsbjorn B . Fractional nona blative 1 540 n m laser resu r

fac i ng or thermal b u r n scars: A ra ndom ized control led
tri a l . Lasers Surg Med. 2009 ;4 1 ( 3 ) : 1 89 - 1 9 5 .
Jacob C l , Dover J S , Ka m i n e r M S . Ac ne sca rring: A c lassi
fication system and review of treatment o ptio n s . J Am
Acad Dermato/. 200 1 ;45( 1 ) : 1 09- 1 1 8 .

N iwa A B , M e l l o AP, Toreza n L A , Oso rio N . Fractional p h o
tothermolysis for the treatment o f hypertro p h i c sca rs:
C l i n ical experience of eight cases. Dermatol Surg. 2009 ;
35( 5 ) : 773- 7 7 7 .
N o u ri K, J i menez G P, Ha rriso n - B a l estra C , Elga rt GW.
585 nm p u l sed d ye laser in treatment of s u rgical sca rs
sta rti ng on suture remova l day. Dermatol Surg. 2003 ;
29( 1 ) : 65-73
Wa i bel J, Beer K. Fractional laser resu rfa c i n g fo r thermal
Figure 6 1 .6 Patient after numerous punch excisions. Sutures are

removed 5 to 7 days after the procedure
burns. J Drugs Dermatol. 2008; 7 ( 1 ) : 59-6 1 .
TAB L E 6 1 . 5
I ce-Pick/Boxcar Scar
Adva ntage
P u n c h h a rvesting and suture or

punch ha rvest a n d i m p l a nt full
thickness graft
Low cost, potentia l d ra m atic i m p rovement;

best fo r na rrow, deep sca rs s u c h as
D isdva ntage
U n p red i cta b l e , risk of m a k i ng cosmetic
a p pea ra nce worse; time consu m i ng
ice-pick sca rs or deep boxcar sca rs; p u n c h

exc ision ca n b e fo l l owed b y a blative or
nona b lative fractional resurfa c i ng treatments
Ablative C0 2/Erbi u m : YAG
Potentia l 40-60% long-term i m provement;

best for s h a l l ow boxcar sca rs
Postlaser erythema weeks to months; risk

of hyperpigmentati o n , i n fectio n , sca r, and
permanent hypopigmentation
Q u i c k , sign ificant i m p rovement

Antivi ra ls for patients with history of H SV
No perma nent i m p rovement
F i l l e rs, ie, R estylane, collage n ,

etc . (see Ta ble 6 1 .4)
Low risk
N eed to repeat at least twice a n n ua l ly
Lasts 4-8 m o nths

N o n a b lative laser
ie, 1 ,450- n m d iode
1 2- 1 3 J/c m 2 (one pass)
l ower fl uenc ies (two passes)
m u ltiple monthly treatme nts
Low risk of serious side effects

No d ownti m e
Treats a ny a ctive a cn e
I m prove ment 1 0-30 %
TWE LVE
Exogeno u s C utaneo u s A l te rat i ons
298
CHAPT E R 62
Ea r P i e rei ng
Ea r pierc i ng i s performed t o fac i l itate a n i n d ivid u a l 's

desire to wea r earri ngs. By having the proced u re per
formed in a medical fac i l ity by a physic i a n , the patient is
reassu red that the proced u re is being performed i n a
safe , control led environment.
Contact a l le rge ns t o meta ls
H istorY of ke loids or hypertro p h i c sca rri ng
Desi red site of pierc i ng

Assess the thickness of ea rlobes.
MANAG E M ENT
There a re two common methods for ea r pierc i n g . It c a n
b e performed with a need le b y h a n d or with t h e h e l p of
an a utomatic ea r-pierc i n g g u n ( Fig. 62 . 1 ) . Before per
fo rm i n g either proced u re , it is i m porta nt to m a ke certa i n
that the correct location for pierc i ng h a s been selected .
Sym metrY with the contra late ra l ear is esse ntia l for a good
cosmetic a ppea ra n c e . The patient s h o u l d review the sites
using a m i rror prior to treatment.
TREAT M E N T
Steril ize a l l i n stru me nts
Ste r i l ize a n d a nesthetize both ea r lobu les
Identify the exact sites to be pierced with a marking pen

on the a nterior and posterior portions of the ear lobule.
Confirm proper placement with patient before proceed ing
U s i n g slow press u re, adva n ce a 1 4- to 18-ga uge need le

t h rough the poste rior lobule i nto the a nterior l o b u l e
If a n a utomatic ea r-pierc i n g g u n is used , the g u n is

advanced from the a nterior l o b u l e towa rd the poste rior
lobule
Use a steril ized ea rring w i t h a sta i n l ess steel post
A n ickel-free post of the ea rring is adva n ced with the

needle a n d the tip is p u l led back t h rough the ea r
The clasp is put on the posterior post

Leave the ea rring in place for a pproxi mately 14 days
u ntil re-epithe l i a l ization of the tra c k
C l e a n t h e site with hyd rogen peroxide a n d topical

a nti biotic oi ntment twice d a i ly
Figure 62. 1 Ear-piercing gun being used on earlobe of a young female
Sect i o n 1 2 : Exoge n o u s C u ta n eo u s A ltera t i o n s

EXPECTAT I O N S
T h i n ea rlo bes m a y spl it, espec ia l ly with heavier earri ngs

P lace earri ngs o n the sa m e level horizonta l ly to assu re
sym metry
A good clean steri l e tec h n iq u e c a n avoid postproced u re

i nfections
I t is i m porta nt to el icit a n y h i story of hypertro p h i c scars

or ke loids i n these patients ( Fig. 62 . 2 ) . Ea r pierc i ng
s h o u l d not be performed on th ese patients
Any h i story of n i c kel or other m eta l a l lergens s h o u l d be

e l i c ited prior to a ny proced u re as wel l
Ed u cate patients as t o wou n d care a n d t h e need to

co ntact you in the event of i nfection
In the event of co ntact dermatitis or a l le rgy, topical

steroids a re the m a i nstay of treatment
Figure 62.2 Keloid on posterior earlobe secondary to ear piercing
(Courtesy of Tomi Panda/fino, MD)
B I B L I OG RAPHY
Atk i n D H , Lask G P. E a r pierc i n g a n d s u rgica l repa i r o f the
earlobe .
In:
Lask G P, M oy R L, ed s .
Principles and
Techniques of Cutaneous Surgery. N ew York: M c G raw

H i l l , I n c ; 1 996.
299
300
CHAPT E R 63
Tattoo R e m ova l
Tens of m i l l ions of Am erica ns have tattoos . Over t i m e ,

many d e c i d e t h a t they wa nt the tattoo t o be re moved .
Qual ity-switched
( Q-switc hed ) lasers a re effective i n
re movi ng most tattoo pigme nts safe ly ( Figs . 63 . 1-63 . 3 ) .

T h e a p propriate laser wave length is determ i ned b y the
tattoo i n k's a bsorption s pectru m . It is bel i eved that laser
p u l ses in the n a n osecond range target tattoo pigments
a n d brea k them i nto s m a l l e r pa rticles, there by fac i l itati ng
remova l
of
the
pigment
tra nse piderma l l y
or
via
macro phages and loca l scave nger cells. In order to treat

m u lticol ored tattoos, seve ra l Q-switched
laser wave
lengths m ust be e m p l oyed .
Was the tattoo placed b y a n a mate u r or a profess ional

tattoo a rtist?
Was the tattoo placed for the p u rpose of rad iation thera py?
Is the tattoo the res u l t of tra u m a or i nj u ry?
What colors a re conta i ned with i n the tattoo? (Ta ble 63 . 1 )
P revious treatments
Use of isotret i n o i n with i n 6 months
H istory of keloids/hypertro p h i c sca rs
D u ration of tattoo
S k i n p hototype
H istory of H SV at site of treatment
H istory of a l le rgic or gra n u l omatous reactio n to tattoo

pigment
TABLE 63 . 1
B
Figure 63 . 1 (A) Tattoo on left earlobe prior to therapy. (8) Resolution after
six treatments with 1 , 064-nm Q-switched Nd: YA G laser
Laser Therapy by Tattoo Color
Tattoo pigment
Light s pectrum
M ost effective lasers
Comment
Red
G reen
Freq uency-d ou bled Q-switc hed N d :YAG
May cause pigment a lteration i n da rker s k i n
( 532 n m )
Ye l l ow
G reen
Freq ue ncy-d ou bled Q-switc hed N d :YAG
G reen
Red/nea r i nfra red
Q-switc hed ru by ( 694 n m )
Least pa i nfu l o f Q-switc hed lasers

N ot very effective
( 532 n m )
May ca use hypopigme ntation in da rker s k i n
Q-switc hed a l exa nd rite ( 7 5 5 n m )

Light b l ue
Q-switc hed ru by (694 n m )
May ca use hypopigme ntation i n da rker s k i n
Q-switc hed a l exa nd rite ( 7 5 5 n m )

Dark blue
a-switc hed ru by (694 n m ) : l ight s k i n

types o n l y
B la c k
Q-switc hed a l exa nd rite (755 n m ) : l ight

skin types on ly
Q-switc hed N d : YAG ( 1 , 064 n m ) : a l l
s k in types
Q-switched N d : YAG ( 1 ,064 n m ) safe i n

a l l s k i n types. Less p i g m e n t loss
30 1
Is the tattoo placed over or covering a nother tattoo?
H i story of go ld i n gestion
Does the tattoo conta i n rust-col ored o r wh ite pigment?
MANAG E M ENT
It is i m porta nt t o a s k t h e patient w h o placed t h e tattoo .
P rofessional tattoo pigments a re denser a n d placed
d ee per in the dermis than most a mate u r tattoos. This
re nders these tattoos m o re refractory to treatment, partic
u l a rly those that a re m u lticolored and conta i n meta l l ic
pigments . It is i m porta nt to i nform the patient prior to
treatment that c o m p l ete resol ution is not a l ways fea s i b l e .
It is a lso i m porta nt to cou nsel t h a t m u ltiple treatments
ove r 1 to 2 yea rs may be req u i red for maxi m a l i m prove
ment. There is no fixed a n swer as to the n u m be r of treat
ments for tattoo rem ova l .
P R ET R EAT M E NT ASS ESS M E NT
Patients w i t h da rker s k i n types a re m o re l i kely t o suffer

pigme nta ry cha nges
Professional tattoos req u i re more treatm ents than a ma

te u r tattoos
O l d e r tattoos res pond m o re favora bly than new tattoos

B la c k a n d d a r k b l u e tattoos res pond more effectively
t h a n yel l ow tattoos
Assess for s u nta n . If patient is ta n ned , delay treatment

u nt i l ta n resolves
M u lticolored tattoos a re more d ifficult to su ccessfu lly

clear than si ngle-color tattoos. D u ri ng treatment, some
patients may be frustrated at the n o n u n iform i m p rove-
ment of these tattoos
Assess for sca rring with i n the tattoo . If p resent, s how

the patient a n d doc u ment prior to treating
N U M B E R OF T R EAT M E NTS
Professional tattoos req u i re a bout 6 to 20 treatments

prior to rem ova l ; not i nfreq ue ntly, more than 20 treat
ments a re needed for max i m a l i m p rovement
Amate u r tattoos conta i n less dense pigment particles

a n d usua l ly req u i re a bout fou r to six treatments
Rad iation tattoos a n d tra u matic tattoos a re more su per

ficia l and less de nse than professiona l tattoos, req u i ri n g
o n l y a few treatments for resol ution ( Fig. 63 .4)
In genera l , rad iation tattoos can be removed i n one to

th ree treatme nts. Someti mes, they req u i re a d d itional
treatments
Figure 63.2 (A) Tattoo on arm with underlying port-wine stain. (B) Note
Lower fluences a n d la rger s pot sizes can be as effective
the selective removal of the tattoo, while the port-wine stain persists.
as s m a l ler spot s izes a n d i n c reased f l u ences
(C) Tattoo clearance
302
Test spot may be a p pro priate i n d a rker s k i n phototypes

if concern i n g
Test spots a re c l ea rly i n d icated f o r cosmetic tattoos ,

rust-colored tattoos, a n d wh ite tattoos
TATTOO TREATM E NT
Ph otogra ph of tattoo prior to treatment
Topical a n esthesia o r 1% l i d oca i n e, i n the form of l oca l

i njection or nerve block, w i l l m a ke the treatment more
comforta ble for the patient
Treat the affected a reas with the a p propriate a-switc hed
The c l i n ica l e n d po i n t is i m med iate tissue wh iten i ng. For
laser a l lowi ng for up to a 10% overlap (Ta ble 63 .2)
the 1 ,064-n m a-switc hed N d :YAG , i n a d d ition to tissue

white n i ng there may be a sma l l a m o u nt of p i n point
bleed i n g at the site of treatment ( Figs. 63 . 5 a n d 63 .6)
Tissue "splatter" (ie, epid erma l/dermal d isruption a n d

bleed i ng) m a y prod uce sca rring. If this occ u rs, decrease
the fluence
If the tattoo is m u lticolored , treat the red pigment fi rst.

E rythema a n d i nfl a m mation from other treated sites
may o bsc u re vis u a l ization of red tattoo pigment
Apply to pical hyd rated petrolatu m a n d a nonad herent

d ressing after completing the treatment
Counsel s u nscreen a n d sun avoi da nce to the treatment

a rea
B
Figure 63.3 (A) Left shoulder tattoo with inferior scar resulting from prior
POSTTREAT M E N T CAR E
S u n avoida nce, s u n sc reens
Telfa d ress i n g and hyd rated petrolatu m o i ntment with
treatment with dermabrasion. (B) Improvement after six treatments with

1 , 064-nm Q-switched Nd: YA G laser. While improvement is not complete,
the cosmetic result is far superior to that of dermabrasion
paper ta pe
If tattoo is located in belt-l i n e a rea o r a bove a n kles, cau

tion patients from wea ring tight belts o r boots that may
prod uce friction aga i nst the treated a rea
Retu rn for treatment in 6 to 8 weeks
TAB L E 63.2
Laser Therapy by Qual ity-Switched Lasers
Laser
I n itial setti ngs
Effective aga i n st th ese tattoo i n ks
Freq uency d o u b l ed a-switc hed N d : YAG (532 n m )
1 . 5-5 .0 J , 4 . 0-8 . 0 mm spot size
Red , orange, ye l l ow
a-switc hed r u by (694 n m )
3 . 0-8 . 0 J, 6.5 mm s pot size
G ree n , b l u e , black
a-switc hed a lexa nd rite ( 7 5 5 n m )
5 . 0-6 . 5 J, 2 . 0-4. 0 mm spot size
G reen , blue, b l a c k
a-switc hed N d : YAG ( 1 , 064 n m )
3 . 0- 1 2 . 0 J, 2 .0-8. 0 mm s pot size
B l ue , b l a c k (safest i n d a rk s k i n types)
303
ADV E R S E EFFECTS/PR ECAUT I O N S
Pigmenta ry a lterati o n
B l iste r i ng ( es pec i a l ly, Q-switc hed a l exa n d rite a n d r u by)
( Fig. 63 . 7 )
Sca rring ( Fig. 63.8)

In a patient with a n a l lergic reaction to tattoo ink i n the
past ( Fig. 63 . 9 ) , th ere is the poss i b i l ity of a rec u rre nce
seco nd ary to the re lease of tattoo ink fol lowi ng laser
thera py. A l l e rgic p reca utions s h o u l d be ta ke n . Syste m i c
a l lergic reactions c a n occ u r with Q-switc hed lasers
( u n l ike d estructive modal ities-derma brasion, etc . )
R u st-co lored a n d wh ite tattoos s h o u l d b e treated ca re

fu l l y as wel l as red a n d flesh-colored cosmetic tattoos,
for exa m ple, l i p l i ner. Someti mes wh ite i n k is m ixed with
other pigme nts ( Fig. 63 . 1 0)
- The tattoo may d a rken as a result of oxidation of i ron
o r tita n i u m oxi d e pigment with i n the tattoo
- A test site can be performed 4 to 8 weeks prior to
Figure 63.4 Traumatic tattoo on knee of a female that has persisted

30 years after childhood bicycle fall. a-switched 1 , 064-nm Nd: YA G
cleared the tattoo i n three treatments
treatment for possible d a rke n i ng

- This d a rken i n g ca n someti mes be treated with lasers
or may req u i re excision
- They respond slowly to laser thera py
Perform a test s pot prior to treating patie nts with h i story

of gold salt i n gestio n . C h rys iasis, m a n i fested as da rk
b l u e pigmentation , can res u lt fro m treatment with Q
switc hed lasers
Ra rely, patients w i l l experience a tra nsient i m m u n e

res ponse fol l owi ng a
laser tattoo treatment. S u c h
responses i n c l u d e fl u - l i ke sym ptoms a n d e n l a rged

lym ph nodes

EXPECTAT I O N S
Response t o tattoo treatment is dependent u pon the

d e pth of pigment, the color of pigment, and the size of
pigment pa rticles. I t c a n va ry d ra matica l l y fro m one to
tattoo to a nother
Effective treatment for a professional tattoo may req u i re

u p to a 20 or more treatment sessions over a period of 1
to 2 yea rs . F u rt h e rmore, complete remova l is often not
fea s i b l e
A su ccessful treatment often leaves s o m e res i d u a l tat

too pigment. T hi s can be i m proved with n o n a b l ative
fractiona l res u rfa c i n g
Physicians s h o u l d c o u n s e l patients t h a t sign ifica nt

l ighte n i ng may be the best feasible c l i n ical resu l t
Tattoo treatment can prod uce hyper- a n d hypopigmen

tation i n a ny patient, espec i a l l y those with da rker skin
types
Figure 63.5 Tissue whitening after treatment with the 532-nm frequency
doubled a-switched Nd: YAG and 694-nm a-switched ruby laser. Tissue
whitening is the appropriate endpoint when treating tattoos with a
switched lasers. Pinpoint bleeding resulted from injection of lidocaine
with epinephrine prior to treatment
304
Treatment of tattoos in a reas of h a i r growth ( i e , eye
b rows ) may prod uce tem porary h a i r remova l

The freq uency-dou bled Q-switc hed N d : YAG , Q-switc hed
ru by, and Q-switched a l exa nd rite lasers a re more l i kely to

ca use d u ra ble pigmenta ry cha nges than the Q-switc hed
N d : YAG ( 1 ,064 n m )
M ost freq uently,
pigment
a l teration
is
te m pora ry.
Hyperpigme ntation typ i ca l ly resolves more q u i c kly

Lower fl uences and a d d itio n a l time between treatments
s h o u l d be e m ployed i n da rker s k i n p h ototypes
B I B L I OG RAPHY
Alster T . Q-switched a l exa n d rite laser ( 7 5 5 n m ) treatment
of
professiona l
a nd
a mate u r
tattoos .
J Am Acad
Dermatol. 1 995;33 : 69-73.

Ferguson J E, August PJ . Eva l uation of the Nd/YAG laser
Figure 63.6 Purpura immediately after treatment of an eyebrow tattoo
fo r treatment of a m ateu r and profess iona l tattoos. Br J
with a Q-switched Nd: YAG laser
Dermatol. 1996; 135(4) : 586-59 1 .

F itzpatri ck R E, G o l d m a n M P. Tattoo re m ova l using the
a l exa n d rite laser. Arch Dermatol. 1994 ; 1 30 : 1 508- 1 5 14.
G reve l i n k J M ,
M u las
MW,
Hata
TR,
Goldman
M P,
F itzpatrick R E, G reve l i n k J M . Laser treatment of tattoos i n

d a rkly pigme nted patients : Efficacy a n d side effects .
J Am Acad Dermatol. 1 996;34: 653-656.

l z i kson
L,
Avra m
MM,
Anderson
RR.
Tra nsient
i m m u noreactivity after laser tattoo remova l : Re port of two

cases. Lasers Surg Med. 2008;40(4) :23 1 -232.
K i l mer S L, Anderson R R . C l i n ical use of the Q-switc hed
r u by and the Q-switc hed N d : YAG ( 1 064 nm and 532 n m )
lasers fo r treatment o f tattoos . J Dermatol Surg Oneal.
1 993; 1 9 (4) : 330-338.
Levine VJ , Gero n e m u s RG. Tattoo remova l with the Q
switc hed r u by laser and the Q-switc hed N d : YAG laser: A
comparative study. Cutis. 1 995; 55:29 1 -296.
Figure 63.7 Blistering after tattoo treatment. This reaction is common

and usually resolves completely within a week with routine topical skin
care
Figure 63.8 Scarring after treatment with a Q-switched ruby laser
(Courtesy of Teresa Soriano, MD)
305
306
B
Figure 63.9 (A) Allergic hypersensitivity reaction to tattoo (see elevated
portions of tattoo). (B) To avoid systemic allergic reaction with traditional

Q-switched laser treatment of the entire tattoo, focal treatment with an
ablative fractional erbium laser was performed. Note focal improvement
after several treatments
307
B
Figure 63. 1 0 (A) Tattoo prior to test spot treatment. (B) Test spot treat
ment of tattoo with a 694-nm Q-switched ruby laser produces discol

oration. Tattoo ink combined blue and white inks
308
CHAPT E R 64
To r n Ea rl o be
Torn earlobe a n d e n l a rged p ierced earlobe canals a re a

c o m m o n conseq u e n ce of wea ring heavy earri ngs for a
pro l onged pe riod of t i m e ( F ig. 64 . 1 ) as we l l as other fac
tors such as tra u ma , heavy earri ngs, i nfecti o n , low place
ment of pierc i ng, pressu re necrosis, etc . It occ u rs most
easi ly in t h i n ear l o b u les. D roo p i n g or easily torn ea rlobes
may also be secondary to a congen ita l d efect o r tra u m a .
K E Y CO N S U LTAT I V E QU EST I O N S
P rec i pitating event of earlobe tea r
H istory of ke loids or hypertro p h i c sca rri ng
Does patient desire to wea r ea rri ngs aga i n after the

repa i r?
MANAG E M ENT
There a re n u merous s u rgica l methods t o repa i r com

p l etely a n d pa rti a l ly torn earlo bes. D iffe rent tec h n i q ues
a re su ited for d iffe re nt tea rs. Partial tea rs a re m o re easily
treated a n d c a n be corrected via sid e-to-s ide closure as
we l l as punch exc ision and repa i r.
T R EAT M E NTS ( Figs . 64 . 1-64 . 3)

Com plete tea rs a re m ore d iffic u lt to treat tha n pa rtial
tea rs . There a re n u merous d iffe rent tec h n i q ues that ca n
be successfu l . M ost c o m m o n ly, the Z-plasty repa i r o r
i nterloc k i n g L s repa i r prod uce the best res u lt .
Sterile pre paration a n d tec h n i q u e
Loca l a n esthesia s h o u l d be i njected i nto t h e repa i r site
The epidermis of the opposing edges of the tea r wo u n d
s h o u l d b e exc ised
- Sca l pel
Figure 64. 1 (A) Female with large tear defect of earlobe at the site of
- Scissors
heavy earring. (B) Torn earlobe reconstructed by primary repair
I nterru pted 6-0 epidermal sutures a pproxi mate a n d

eve rt t h e wou n d edges o f t h e a nte rior a n d posterior
lobe
- Be certa i n to a p prox i mate the wou n d ed ges of the
i nferior r i m of the ea r ca refu l ly to avoid d istortion o r
m isa l ignment
- The wo u n d edges s h o u l d be u n d e r m i n i ma l tension
N o su bcuta n eous sutu res a re used
Z-plasty re pa i r ( Fig. 64 . 2 ) or i nterloc k i n g Ls repa i r on

the rim wi l l prod uce tissue a p p roxi mation wh i l e pre
venting the d i m pl i ng of the i nferior rim of the earlobe
309
Patients should be cou nseled to refra i n from wea ring

earrings for 3 months fol l owi n g the repa i r

EXPECTAT I O N S
M eti c u lous attention t o a p p roximating t h e wou n d edges

a n d the i nfe rior r i m of the ea r a re esse ntia l for a satis
fa ctory resu lt. N otc h i ng of the i nfe rior rim of the earlobe
ca n occ u r easi ly, sign ifica ntly compromising a esthetic

a p pea ra nce
Caution i n a patient with a h i story of keloids or hyper

tro p h i c sca rs
Patient s h o u l d n ot wea r earrings for 2 to 3 m o nths after

s u rgery
Wou n d strength is less than the origi nal strength of the

lobe. Avoid wea ring heavy earri ngs to prevent rec u rrence
B I B L I OG RAPHY
Ti pton J B . A s i m ple tec h n iq u e for red uction o f the ea r
lobe. Plast Reconstr Surg. 1 980;66: 630-63 2 .
Figure 64.2 Repair of complete earlobe tear utilizing a Z-plasty to pre
vent dimpling of the inferior aspect of earlobe
31 0
Figure 64.3 One stage preauricular flap to repair earlobe deformities
INDEX
N ote : I n this i ndex, the letters "f" and "t" denote figu res and ta bles, respectively.
pathogenesis, 72
1, 450-nm diode laser, 82, 82f, 83f
physical exa m i nation, 72
5-a m inolevu l i n i c acid (5-ALA), 75, 254

5-fl uorouraci l , 207, 224, 229
Acq u i red ca p i l l a ry hema ngioma, 1 70-1 73
1320-nm N d : YAG laser, 4 1

1 450- n m diode laser, 4 1 , 74
Acra l amela notic melanoma, 206

Acti n i c c h e i l itis, 248
Actinic keratosis (AK), 248
consu ltative q uestions, 249
cou rse, 249
Ablative fractional laser resu rfaci ng, 39, 57
dermatopathology, 248
adva ntages of, 57

ind ications, 58
d ifferential d iagnosis, 248

epidemiology, 248
laser safety, 59
ma nagement, 249
adverse side effects, 60, 601
pathoge nesis, 248
fol low- u p , 59-60, 59f
i nfectio n , 60, 6 1 1
pitfa l l s , 250-2 5 1
nonfacial skin, 60-6 1

postoperative care, 57f, 58f, 59
treatment, 249-250
Acti n i c keratoses
vs. wa rts, 206
preoperative eva l uation, 58
Acyclovir, 32, 46, 54
prophylaxis/a nesth esia, 58-59

Ablative laser res u rfacing, 1 5 11, 1 52
Ada palene, 9, 73
a bsol ute contra i nd ications, 45
Adatosil 5000, 14t, 1 5t
a n esthesi a , 46-47
for Becker's nevus, 2 1 8
Adenoma sebaceu m , 2 1 2
Affirm 1 , 440 n m N d : YAG laser, 56, 56t
for epidermal nevus, 224
Age-related textural cha nges, 2t
ideal laser candidate, 45
Agi ng, 2
i n d ications, 44
Aging face and non-facial regions, a na lysis of
less than ideal laser cand idate, 45
a natomic consid erations, 2-3 , 2t
mecha n ism of action, 43

ca rbon d i oxide laser, 43, 43f, 44f

ca rti lage, bony structures, and s u p portive structures,
Er:YAG, 43, 45f
cha nges in, 5
medications, 46
facial m uscu lature cha nges, 5
for m i l ia , 230
G l oga u Photoaging Classification, 2f, 3-4, 3f, 4f, 5f
postoperative care, 49, 501, 5 1 1
pigmenta ry cha nges, 4, 6f
preoperative eva l uation, 44-45

proced ure, 48-49, 49f
su bcuta neous fat atrophy, 5

AK. See Acti nic keratosis
relative contra ind ications, 45-46
A LA . See 5-a m i n olevu l i n i c acid
safety mea s u res, 47-48
Alca i ne. See Topica l proparaca ine
for seborrheic keratosis, 236
Alcon, 28
treatment pearls, 50
ACE i n h i bito rs . See Angiotensi n-converting enzyme (ACE) i n h i bitors
Alcon La bs, 1 5t
Al lerga n , 1 4t, 1 5t, 2 1 1
Aceta m i nophen, 58
Allergic reactions
Acetone, 48
to sclerothera py, 20 1
Al loderm , 14t
Acne scars, 290, 293
Aloe vera , 10
physica l lesions, 293-295

treatment, 295
Acne vu lga ris, 72, 76, 1 00
Aloesi n , 9t, 10
a-hyd roxy acid, 32
lotions, 182
vs. angiofi broma, 2 1 2
for posti nfl a m matory hyperpigmentation, 1 60
cou rse, 73
peels, 1 4 1
epidemiology, 72
A l u m i n u m c h l oride hexa hydrate, 8 7
la boratory data
A m b u latory phle bectomy, 202

American Academy of Dermatology, 8
endocrine stud ies, 72-73
Amoxici l l i n , 73
ma nagement, 73
Amyotro phic latera l sclerosis, 22
l ight treatment, 72f, 73f, 74-75, 75f
Anesthesia , 88
s u rgica l treatment, 74
for a blative fractional laser resu rfaci ng,
systemic treatment, 73-74

topical treatment, 73
58-59
for a blative laser resu rfaci ng, 46-47
31 1
31 2
I ndex
for a ngiofi broma, 2 1 3

for l i poma treatment, 227
for neurofi broma, 236
for nonablative fractional laser resu rfaci ng, 54
for nonablative laser resu rfa c i ng, 40
m i d - i nfrared lasers, 40f, 4 1
for soft tissue augmentation, 1 6f, 1 7
for wa rt remova l , 207t, 208
Angiofi broma, 2 1 2-2 1 5
consu ltative q uestions, 2 1 3
cou rse, 2 1 3 , 2 1 3f
de rmatopathology, 2 1 2
d ifferenti a l d iagnosis, 2 1 2
epidemiology, 2 1 2
laboratory data , 2 1 3
ma nagement, 2 1 3-2 14, 2 1 4f, 2 1 5f
pathogenesis, 2 1 2
physical exa m i nation, 2 1 2 , 2 1 2f
pitfa l l s , 2 1 4
Angiokeratoma, 1 68
vs. angiomas, 1 7 1
cou rse ma nagement, 1 68-1 69, 1 69f

de rmatopathology, 1 68
differentia l d i agnoses, 1 68
epidemiology, 1 68
physical exa m i nation, 1 68
pitfa l l s to avo i d , 1 69
Angio l i poma, 226
Angiomas, cherry and spider, 170
cou rse, 1 7 1
differentia l d i agnoses, 1 7 1
epidemiology, 1 70
ma nagement, 1 7 1 - 1 7 2
pathogenesis, 1 70
pathology, 1 7 1
physical exa m i nation, 1 7 1
pitfa l l s to avo i d , 1 7 2
Angiotensi n-converti ng enzyme (ACE)
i n h i bitors, 89
Anth ra l i n , 224
Anti bacterial agents, 73
Anti bacteria l thera py, 46, 53
Anti biotics, 73
Antima la ria ls, 1 75
Antioxida nts, 8
Anti pers p i ra nt, 89
Antivira l med ications, 49
Antivira l thera py, 46, 54
Apraclo n i d i n e hydrochloride, 28
Aq ua m i d , 1 4t
Aquaphor H ea l ing O i ntment, 49
Arbuti n , 9t, 1 0
Artefi l l , 1 4t
Arterial spider, 1 70- 1 73
Ascorbic acid , 9t, 1 1
B
B l u pu s m i l iaris d isse m i natus faciei, 76
B - H C G . See - H u m a n chorionic gonadotropin

B a n naya n-Zonana synd rome, 226
Basa l cell carci noma ( BCC), 81, 252-254
epidermal nevus a n d , 222, 223
cou rse, 253
de rmatopathology, 252
d ifferential d iagnoses, 252
epidemiology, 252
la boratory data, 253
ma nagement, 253-254, 253f, 254f, 255f
pathogenesis, 252
physical exa m i nation, 252, 252f
pitfa l l s , 254
B ea rberry, 1 0
B ecker's nevus, 2 1 6--2 1 8
consu ltative q uestions, 2 1 7
cou rse, 2 1 7
d ifferential d iagnosis, 2 1 6
epidemiology, 2 1 6
la boratory exa m i nation, 2 1 6
ma nagement, 2 1 7-2 18, 2 1 7f
pathogenesis, 2 1 6
pathology, 2 1 6
physical exa m i nation, 2 1 6, 2 1 6f
pitfa l l s , 2 1 8
B e l otero Basic, 1 4t
B e l otero Soft, 14t
Benign growths
a ngiofi broma, 2 1 2-2 1 5
Becker's nevus, 2 1 6--2 1 8
epidermal i nclusion cyst, 2 1 9-22 1
epidermal nevus, 222-225
Benzoyl peroxide, 73
- H u ma n
chorionic gonadotropin ( B- H C G )
Betaca ine Enha nced Gel, 1 7

B etaca ine P l u s , 1 7
B io-Aica m i d , 14t
B i oform M e d i ca l , 1 5t
B iomatrix I nc . , 1 5t
B i o psies
epidermal i nclusion cysts, 220
epidermal nevus a n d , 223
l i poma, 227
neurofi broma, 232
seborrheic keratosis, 235
B i otech I n d u stry, 1 5t
B laschke, l i nes of, 222
B leac h i n g crea ms, 46
B l e p h a rochalasis, 64
B loom's synd rome, 67, 136
Bornaprine, 87
Ash leaf macule, 2 1 2, 2 1 3f
Botox, 89 . See also Botu l i n u m toxin A
Aspergillus, 1 0
AstraZeneca , 1 7
Botu l i n u m toxin
Botox Cosmetic, 2 1!
Ataxiatela ngiectasia, 67
com pl ications, 27
Ativa n , 58
contra i n d ications
Atro p h i c scars, 294-295

Atrophoderma verm iculatu m (AV), 1 8 1
a bsol ute, 22
relative, 22
Avila , 9
Avobenzone, 7t
d i l ution, 22
Azelaic a c i d , 9t, 10, 73, 77, 1 4 1 , 1 5 1 , 1 60
m uscle gro u ps, 22f, 23
Azit h romyc i n , 46, 73
mecha nism of action, 21

forehea d , 22f, 23-24, 23f
I n d ex
gla bellar com plex, 24, 24f
Cavernous hemangioma, 1 77-1 80
nasolabial fol d , 25--2 6, 27f
Cel l u l ite, 276-279, 276f
neck, 26-27, 28f
periora l region, 26, 27f, 28f

periorbital regio n , 24-25, 25f
course, 276
u pper nasal root, 25, 26f
epidemiology, 276
la boratory exa m i nation, 276
pharmacology, 2 1 , 2 1 !
ma nagement, 277
postoperative considerations, 27
physical lesions, 276
preoperative eva l uatio n , 22
pitfa l l s , 278--279
lower eyelid snap back test, 22-23

prepa rations, 2 lt
treatments, 277-278, 277f
proced u re, 23
Centrofacial te la ngiectasias, 194f

Chem ical peels, 30, 74, 1 4 1
treatment benefits, 27
compl ications, 3 4 , 38f
contra i n d ications, 3 1-32
B otu l i n u m toxin A ( BTX-Al , 2 1 , 22, 87, 88, 88f

a n esthesi a , 88
antipers p i ra nt, 89
ideal ca n d i d ate, 3 1
less ideal ca n d idate, 3 1
med ications, 32
Botox, 89
peel types, 33
hyperh i d rosis, mechanism of action i n , 88f
postoperative care, 34
i njection sites of, 88f, 89f
proced ure, 33-34, 36f, 37f
med ications, 89
treatment pearls, 34-35
su rgery, 89
treatment, 88-89, 88f, 89f
wou n d depth, 32
Chem ical su nscreen, 7-8, 7t
Botu l i n u m toxin B ( BTX- B l , 2 1
Cherry a ngiomas, 1 70-- 1 73 , 1 72f
B otu l i n u m toxin E ( BTX-E), 2 1
Cinoxate, 7t
B r i n d is, 14t
C i p rofloxa c i n , 46
Broussonetia papyrifera, 1 0
C l i ndamyc i n , 73
B ucci nator, 2 6 , 27f, 28f
Clofazimine, 1 7 5
C02 l a s e r a b lation, 82
C02 resu rfacing. See Carbon d ioxide (C02 ) laser
Coenzyme Q10, 8
Clostridium botulinum, 2 1
Cafe au lait macu les (CALMs), 136

vs. B ecker's nevus, 2 1 6
Colchicine, 1 7 5
cou rse, 137
Col lagen, i n a ngiofi broma, 2 1 2

Col lagenase, 9
Comedone extractio n , 74
epidemiology, 136
Common wa rts, 206-209

laser treatment, 1 37-138
Compression stocki ngs, 200
ma nagement, 137
Complete tea rs, 308
vs. neurofi bromas, 232
Congen ital ad renal hyperplasia, 92

Congen ita l hema ngiomas, 1 7 7
pathogenesis, 136
Congen ita l nevus, 2 1 6
pathology, 136
Contu ra I nternationa l , 1 4t
physica l lesions, 136

pitfa l ls, 138
Cooltouch I n c . , 4 1
Corrugator s u perc i l i i , 24, 24f

Corticosteroids, 1 64, 1 75
Calci potriol, 224
Corrective h a i r transplant su rgery, 1 10, 1 1 0t
Campbell de Morga n spots, 1 70--1 73
for epidermal nevi , 224
Candela Corp . , 4 1
for epidermal i ncl usion cysts, 22 1
Canderm, 1 7
Canderm Pharma, I n c . , 1 4t
Ca n i n us, 26, 27f, 28f
for m i l ia , 229
Cosmod ermrM , 14t
Cantharone, 207
Cosmoplas(TM , 14t
Cross-hatch ing, 18
Ca p i l l a ry, 1 77
Cryogen spray coo l i n g (CSC ) , 185
Ca ptiq uerM , 1 4t
Cryosu rgery, 175
Carbon d ioxide (C02 ) laser, 43, 43f, 48, 49, 57, 1 7 2 , 239
Carbon d ioxide laser resu rfacing
Cryothera py
for a ngiofi broma, 213, 2 1 4-2 1 5f

for a ngiomas, 1 72
for de rmatosis pa pu losa n igra , 242

for ephelides, 142
for basa l cell ca rcinoma, 254
for lentigines, 146

for neu rofi broma, 232
for sebaceous hyperplasia, 83
for sq uamous cell carcinoma, 258
for sq uamous cell carcinoma, 258

for venous la kes, 208
for venous lakes, 204

for wart remova l , 209
for wa rts, 207t, 208
for seborrheic keratosis, 236, 237, 237f
313
314
I ndex
C u rettage
Dyschromia

for wa rt remova l , 209
from wart remova l , 207t, 208, 209

Dysport, 2 lt
Cushi ng's d isease, 92, 285

Cutting tool , 44
Cymetra Life Cell Corp., 14t
Cynosure, 56, 56t
Ea r piercing, 298
Cyproterone acetate, 1 28
Cysts

ma nagement, 298, 298f
epidermal incl usion cysts, 2 1 9-2 2 1
h o r n , 235
m i l i a , 229-230
pitfa l l s , 299, 299f
pilar cysts, 220
treatment, 298
Ectopic ad renocorticotropic hormone prod uction, 92
Electroca utery, 239
Electrodesiccation, 83
for a ngiofi bromas, 2 1 3
DAO. See Depressor angu l i oris
for seborrheic keratoses, 236
Dapsone, 1 75
Deep-depth strength peels, 30t, 33
Electrolysis, 94, 2 1 7
Electrosection, 7 7
Deep hema ngioma ( D H ) , 1 7 7
Electrosu rgery, 76f, 7 7 , 77f, 8 2 , 1 7 5
Deep vei n throm bosis, 198
Demodex fol l ic u l o ru m , 77
El l i ptical excision, 2 1 3 , 2 1 9f, 227, 2 132
Depilation, 94
El l i ptical strip h a rvesti ng, 1 06
Depressor angu l i oris ( DAO), 26, 27f, 28f

Derc u m 's d i sease, 226
vs. fol l i c u l a r unit extraction ( F U E) , 107, 107t

E l l m a n S u rgitro n , 78
Derma brasion , 1 75
Em bol ization, 180

Endermologie
for cel l u l ite, 277-278
Derm a l melasma, 149
Endocrine stud ies, of acne v ulgaris, 72-73
Dermatochalasis, 64
Endocrinology, consu ltation with, 93

End osco pic/classic sym pathectomy, 88
cou rse, 65
Eosi noph i l ic gra n u loma, 1 74
Ephelides, 139
differentia l d iagnosis, 64
consu ltative q uestions, 1 40
epidemiology, 64
course, 140
ma nagement, 65
pathogenesis, 64
d ifferential d iagnosis, 1 40
epidemiology, 1 39
pitfa l ls, 65-66
ma nagement, 140
treatment, 65
Dermatosis pa pu losa n i gra ( D P N s ) ,
pathogenesis, 139
pathology, 140
24 1 , 24lf

vs. solar lentigo, 1 45t
cou rse, 24 1
treatments
chemical peels, 14 1-142
epidemiology, 241
cryothera py, 1 42
laboratory exa m i nation, 241
laser thera py, 1 42- 143
laser treatments, 242-243

ma nagement, 242
pitfa l l s to avoid/com plications/ma nagement, 143

topical treatment, 1 40- 1 4 1
pathogenesis, 241
E p i d e r m a l acanthosis, 6 5 , 6 7
pathology, 24 1
E p i d e r m a l inclusion cysts ( EI C ) , 2 1 9-22 1
pitfa l ls, 243
cou rse, 220
Derm ik, 1 5t
Destructive modal ities, 83
of sebaceous hyperplasia
Diazepa m , 17

epidemiology, 2 1 9
ma nagement, 220
Dicloxa c i l l i n , 46
pathogenesis, 2 1 9
Diode laser treatments
pathology, 2 1 9

for venous la kes, 204
Dioxybenzone, 7t
physical exa m i nation, 2 1 9, 2 19f

pitfa l l s , 22 1
treatment, 220-22 1 , 2 1 9f, 220f
Dow-Corn ing, 1 4t
Epidermal melasma, 32f, 1 49
Doxycyc l i ne, 73, 77
Epidermal nevus ( E N ) , 222
D P N s . See Dermatosis pa pu losa n igra
vs. Becker's nevus, 2 1 6
I n d ex
medical thera py, 1 27-1 28
course, 223
non-FDA a p p roved medications, 1 28
d ifferentia l d iagnosis, 223
pathogenesis, 1 26
epidemiology, 222
physical exa m i nation, 1 26, 1 28-129

su rgery, 128
pathogenesis, 222
Female s u rgica l pla n n i ng, 129
pathology, 222
postoperative i n structions, 130
physica l exa m i nation, 223
postoperative period , 130- 1 3 1
pitfa l ls, 225

vs. seborrheic keratosis, 223, 235
treatment, 224-225
Epidermis
a n d epidermal i n c l usion cysts, 2 1 9
preoperative i n structions, 1 3 0
Fern d a l e La bs, 1 7
Fi brous pa pu les, 2 1 2
F i l iform wa rts, 206
F i l lers
permanent, 282-283
i n l i poma, 226
Epidermoid cyst, 2 1 9
E pi l u m i nescence microscopy ( E L M ) , 203
Epinephrine, 59
tem porary, 282

Finasteride, 104, 104t, 1 28, 1 33
Fitzpatrick skin phototype, 3 1
Er:YAG . See Erbi u m : Yttr i u m-Al u m i n u m Ga rnet Laser
Fitzpatrick's classificatio n , of skin types, 4t
Erbi u m ablative resu rfacing lasers, 57
Flash l a m p , 78f, 79, 79f, 801
Erbi u m : Yttriu m-Ai u m i n u m Garnet ( Er:YAG) laser
treatment, 193
and a blative laser resu rfacing, 43, 451, 48, 49
Flavonoids, 9t
a n d epidermal nevus, 224

and seborrheic keratos is, 236
Foam sclerothera py, 199-200

Follicular i nfu n d i b u l u m , 2 1 9
Erythematotela ngiectatic rosacea . See Vasc u l a r rosacea
Follicular u n it extraction ( FU El , 1 06t, 1 0 7 , 1 08!

vs. e l l i ptica l strip ha rvesting, 1 07t
Eryth romyc i n , 73
Eutectic m i xture of loca l a n esthetic (EM LA), 17, 40
Fo l l i c u l itis, 1 00
Exci mer laser, 1 65, 287
Forehea d , 22f, 23-24, 24f
Excision su rgica l , 253, 257, 29 1 , 29 11

Eye i nj u ries
m i l i a , 229-230
Fractional photothermolysis ( F P )
and lasers, 981
Fractional res u rfaci ng, 1 5 11, 152, 1 53f

Fraxel Restore, 56, 56!
Freckles. See Ephel ides
Fronta l i s m u scle, 221, 23-24, 23f
F
Facial age-related conto u r changes, 2t
Fronta l i s m u scles, 24, 24f

F U E . See Follicular u n it extraction
Facia l m uscu lature changes, 5

Facial telangiectasias, 192, 192f
cou rse, 192
epidemiology, 192
Gelatinase, 9
ma nagement, 192-194
Genita l wa rts, 206-209

Gentisic acid , 9t
pitfa l l s to avo i d , 194
G l a be l l a r com p l ex, 24, 24f
prior to long p u l se-d u ration pu lsed dye laser
G la brid i n , 1 0
treatment, 1 951
prior to p u l sed dye laser treatment, 1 931
Fa n n i ng, 18
Fascia B iomateria ls, 1 5t
Fascia n, 1 5t
Fat accu m u lation
treatment of, 283
G l oga u Photoaging Classification, 2f, 3 -4 , 3f, 4f, 51

G lycolic acid , 9t, 30!
G lycolic acid pee l , 32, 331, 74, 1 60
and e p h i l ides, 1 4 1
and melasma, 1 5 1 , 1 5 1 t
G lycopyrro n i u m bromide, 8 7
G/ycyrrhiza g/abra linneva, 1 0
F DA-a pproved med ications, for male pattern h a i r loss, 104, 1 04t
G o l d i njections, 1 7 5
Female pattern h a i r loss, 126, 1 26f. See also M a l e pattern hair loss
c h i ef com pla i nt, 1 3 1
G rafts, s k i n , 2251
G ra n u loma faciale, 1 74, 1 741, 1 76f
consult, 1 3 1-132
cou rse, 1 74
consu ltative q u estions, 1 26
de rmatopathology, 17 4
course, 126
d ifferential d iagnoses, 1 74
d ifferentia l d iagnosis, 1 2 7
epidemiology, 1 74
epidemiology, 1 26
female hair transplantation, 1 3 1
l ight treatment, 1 75
ma nagement, 175
t o correct a ltered tem pora l h a i r l i ne, from l ifting proced u re, 1 3 1

female surgica l pla n n i ng, 129
postoperative i n structions, 130
postoperative period , 130- 1 3 1
preoperative i n structions, 1 30
vs. male pattern h a i r loss, 1 29, 1 29t, 1 3 1 1
m u ltiple lesions of, 1 75f

pathogenesis, 1 74
pitfa l l s to avoid, 1 7 5
syste m i c treatment, 1 75
topical treatment, 1 7 5
31 5
31 6
I ndex
G ra n u loma gravida r u m , 1 88- 1 9 1
botu l i n u m toxin A, 88, 88f
G ra n u loma tela ngiectaticu m , 188- 1 9 1
anesthesi a , 88
G ra n u lomatous rosacea , 7 6
antipers p i ra nt, 89
Gynecomastia, 2 72-275, 272f

consu ltative q u estions, 273
botox, 89
medications, 89
cou rse, 273
su rgery, 89
treatment, 88-89, 88f, 89f
epidemiology, 272
laboratory exa m i nation, 272-273
cou rse, 86
ma nagement, 273
pathogenesis, 272
epidemiology, 86
pitfa l ls/com p l ications/outcome expectations, 274-275
la boratory exa m i nation, 86, 86f
treatment, 273-274

ora l med ications, 87
pathogenesis, 86
physica l fi ndi ngs, 86
H
H a i r loss. See Female pattern h a i r loss; M a l e pattern h a i r loss
H a i r remova l , 2 1 7
H a i r tra nspla ntation, 1 04-1 05
H a i r l i n e design , 1 08
H a rn a rto rna , 2 16, 222
Hemangioma, segmenta l , 1 80f
Hemangioma, u l cerated , 1 79f
Herna ngiornas, 1 7 7
H i bernoma, 226
H i biclens, 48
H i rsutism, 92
cou rse, 93
differentia l d iagnosis, 92-93
epidern iology, 92
laboratory tests, 93
ma nagement, 93
electrolysis, 94
endocrinology, consultation with , 93
j ust prior to treatment, 96
laser h a i r remova l tech n i q ue, 95, 96-98
non laser thera p ies, 93-94
patient consu ltation, 95-96
posttreatment i n structions to patient, 98
pitfa l l s , 89-90
su rgery, 88
topical med ications, 87
Hyperh i d rosis
sites of, 90f
treatment d iagra m , 87f
Hyperpigrnentation
a n d cryotherapy, 209
and post-sclerothera py, 200
Hype rsensitive rea ctions, of soft tissue augmentation , 18
Hypertonic sa l i n e , 199, 200t, 201t
Hypertrichosis, 2 1 6, 2 1 7
Hypertrophic sca rs, 290
c l i n ical experience, 293
vs. keloids, 290!
laser, 29lf, 292, 292f

ma nagement, 291
pu I sed dye laser, 292t
stud ies, 292
Hypopigmentation, 67, 187f
and cryothera py, 209 , 236
and laser treatments, 2 1 8
pitfa l l s , 94f, 98-99

H IV l i podystrophy/facial l i poatrophy, 280-284
cou rse, 28 1
Ice-Pick/Boxcar Sca r
dermatopathol ogy, 280

lcod i n , 58
l d e benone, 8
epidemiology, 280
l m i q u imod , 1 79 , 207, 29 1 , 29 1 T
l named Corp, 14t
l named Corp. , 1 5t
pathogenesis, 280
physical lesions, 280-281
I nfa nti le hemangioma ( I H ) , 1 7 7 , 1 7 7f, 1 78f
pitfa l ls, 283-284
a n c i l l a ry tests, 1 78
com pl ications, 1 78
prec i pitating factors, 280
course, 1 78
prevention, 28 1
de rmatopathology, 1 7 7
treatments, 282-283
Homosalate, 7t
Hormones, 73
d ifferential d iagnoses, 1 7 7
epidem i ology, 1 7 7
H u ma n pa pil lomavirus ( H PV), 206-209
la boratory tests, 1 77
ma nagement, 1 78-180
Hya l u ronidase, 47
physical exa m i nation, 1 7 7
Hyd roq u i none, 9 , 9t, 13, 140, 146, 15 1!, 160,

Hyd roxy acid, 73
Hyd roxycou marins, 9t
Hylaform , 1 5t
Hyperhid rosis, 86
pitfa l l s t o avo i d , 180

I ntense pu lsed l ight lasers
for pseudofo l l i c u l itis, 1 0 1
for cherry and spider a ngiomas, 1 72
I n d ex
for port-wine sta i ns, 185
and h i rsutism , 95
for postsclerothera py hyperpigmentatio n , 201-202, 20lf, 202f
and pseudofolliculitis, 1 001, 1 0 1 , 1 0 l f
tech niq ue, 9&-98
I nterferon-a, 179
Laser l ight firing, 93f
I nterlocking Ls repa ir, 308

l ntra lesional 5-fl uoro u racil (5-FU ) , 29 1 , 29 lt
Laser safety, 97f
l ntra lesional steroid i njection, 74
nona b lative laser resu rfaci ng, 41

for a blative fractional laser resurfaci ng, 59
l ntra lesional tria mcinolone acetonides, 29 1 , 29 lt
adve rse side effects, 60, 601
l o p i d i n e , 28
fol low- u p , 59-60, 59f
I PL. See I ntense pulsed l ight
i nfection, 60, 6 1 f
I psen L i mited, 2 1 t
lsolage n , 1 5t
nonfacial ski n, 60-6 1
Isopropyl a lcohol , 48
lsotreti n o i n , 40, 58, 74, 77
postoperative care, 57f, 58f, 59

Laser thera py
for d ermatochalasis, 65
for gra n u loma faciale, 1 75
for Poiki loderma of Civatte, 68, 68f
for sebaceous hyperplasia, 82--83, 82f, 83f
J essner, 30t, 35f
Laser-assisted photodynamic thera py, 82
J essner peels, 14 1 , 160
Lasers, 74
J uvedermrM , 1 5t
Lecithins, 9t
Lentigines, 144
chem ical peels, 146
consu ltative q uestions, 1 45-146
K
Keflex, 1 7 , 46
Keloids
vs. hypertrophic scars, 29ot
vs. keloids, 290t

laser, 29lf, 292, 292f
ma nagement, 29 1
pulsed dye laser, 292t
stud ies, 292
Keratinocytes, 1 40, 222
Keratolytic agents, 73
Keratoses
seborrheic, 223
Keratosis fol liculari s s p i n u losa deca lva ns ( KFSD), 1 8 1
Keratosis p i l a r i s atroph ica ns ( KPA), 1 8 1 , 1 8lf, 1 82f
cou rse, 1 8 1
dermatopathology, 1 8 1
d ifferential d iagnosis, 1 8 1
epidemiology, 1 8 1
ma nagement, 1 8 2
pathogenesis, 1 8 1
physica l exa m i nation, 1 8 1
pitfa l l s t o avoid , 182
Keratosis pila ris atroph ica ns faciei ( KPA F ) , 181
Keratoses
actinic, 206
seborrheic, 206, 234-237
Kindler synd rome, 67
Koenen's tumor, 2 1 2
Koj ic acid , 9t, 1 0 , 1 4 1
KTP laser. See Potass i u m -tita nyl-phosphate laser
cou rse, 1 45
cryothera py, 146
epidemiology, 144
laser and l ight sou rce treatment, 146-147
ma nagement, 1 45
pathogenesis, 1 44
pathology, 144
pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations,
147-148
vs. seborrheic keratosis, 235
topical med ications, 1 45-146

Lentigo sim plex, 144
LEOPA R D synd rome, 1 44
Lichen planus ( L P ) , 262-264
course, 263, 264f
epidemiology, 262
la boratory data , 262
ma nagement, 263
pathogenesis, 262
physical exa m i nation, 262, 262f, 263f
Lichen striatus, 223
Licorice extract, 9t, 10
Lidoca i ne, 47, 59, 107
for wart removal , 208
Life Cell Corp. , 1 4t
Light treatment, of acne vu lgaris, 72f, 73f, 74-75, 75f
Light cryothera py, 82
Linear foca l elastosis.
Linear th readi ng, 1 8
Linoleic acid, 9t
L
L- M -X-4 a n d 5, 1 7
Li pectomy, 283
Lipoma, 22&-228
Lactic acid, 182
cou rse, 227
Lactic acid, 9t
d ifferentia l d iagnosis, 226

epidemiology, 226
LAM B synd rome, 1 44

La nzhou I nstitute of B iologica l Prod ucts, 2 1t
Laser h a i r remova l

pathology, 226
31 7
31 8
I ndex
physical exa m i nation, 226, 226f, 227f, 228f

pitfa l l s , 228
treatment, 227-228, 227f, 228f
Melanin
i n post-sclerothera py hyperpigmentation , 200
in seborrheic keratosis, 236
Li posa rcom a , 226
M ela nocyte cytotoxic agents, 9t
Li posucti o n , 88
for cel l u l ite, 277
Melanoma
Melanocyte tra nsfer i n h i bition, 9t
for gynecomasti a , 274
for HIV l i podystrophy/facial l i poatrophy, 283
venous la kes a n d , 203
for l i poma, 227
warts a n d , 206
Liver s pots. See Solar lentigos
M elanophages, 1 44
LLLT. See Low level l ight laser therapy

Lob u l a r ca p i l l a ry hemangioma, 188-- 1 9 1
M elasma, 1 4 9 , 1 49f
a blative laser, 152
Long- p u lsed alexa nd rite laser, 1 0 1
chemical peels, 1 5 1- 152
Long- p ulsed N d : YAG laser, 1 0 1
Low level l ight laser thera py ( LLLT), 1 33, 1 33f, 1 34f
cou rse, 1 50
mecha nism of action , 133

pea rls of wisd o m , 1 33
use of, 1 33
epidemiology, 149
Lower extremity telangiectasias, 198--202
fractional resu rfaci ng, 1 52 , 1 53f
Lower eye l i d snap back test, 22-23
la boratory exa m i nation, 1 50
Lower face, 3
ma nagement, 1 50, 1 50f, 1 5 11, 1 52f
Lower lid horizonta l laxity, 64

LP. See Lichen planus
pathogenesis, 1 49
Lux 1 , 540 n m laser, 56, 56t
pitfa l l s , 1 52-153

Q-switched laser, 1 52
topical treatment, 1 5 1 , 1 5 lt
M EN D . See M icroscopic epidermal necrotic debris
Macu les, 2 1 6, 223

Madelu ng's d i sease, 226
M enta l i s m uscle, 26, 27f, 28f
Male pattern hair loss, 1 03 . See also Female
M eq u i n o l , 9t
pattern hair l oss

consult, 105
Mentor Corporation, 1 5t
M e rz Pharma, 1 4t, 2 lt
M esothera py
for cel l u l ite, 278
epidemiology, 1 03
vs. fem a l e pattern h a i r loss, 129, 1 29t, 1 3 1 1
M ethanthel i u m bromide, 87
h a i r transpla ntation, 1 04- 1 05
M ethyl a nthra n i late, 7t
M etron idazole, 77
M exoryl SX, 7t
medica l thera py, 1 04, 1 04t
M ethyl a m i nolevu l i nic acid ( MAL), 254
natural progression, 1 03
M exoryl XL, 7t
pathogenesis, 103
physical exa m i nation, 1 03 , 1 03f, 1 05f
M icroderma brasion, 74, 229, 287
s u rgica l proced u re
M icroth ermal treatment zones ( MTZs ) , 52
M icrosco pic epidermal necrotic debris ( M E N D ) , 52
corrective h a i r transplant su rgery, 1 10, 1 10t
M idface, 3
day of proced u re, 1 06
M id-i nfrared lasers, 401, 4 1
donor h a rvesti ng tec h n i q ues, 1 06, 1 06f, 106t, 107t
M i ld atrophy, 67
donor regi o n , a n esthesia i n , 1 06

fol l i c u l a r unit extraction ( F U E) , 107, 107t
M i l i a , 229-230
graft creation, 107
cou rse, 230
graft placement, 108--1 09, 1 13f
epidemiology, 229
h a i r l i n e design , 1 08
pathogenesis, 229
post h a i r tra n splant side effects, 109
pathology, 229
postoperative period , 109

postsu rgica l period after sutu res/sta ples
physica l exa m i nation, 229, 229f, 2301
removed , 1 09-1 1 0
treatment, 230, 2301
pitfa l l s , 230
M i n i m a l erythema d ose ( M ED ) , 8
ra re side effects, 1 09
M i nocyc l i ne, 73, 77
reci pient region, anesthesia i n , 1 08
M i noxid i l , 104, 1 04t, 1 2 7-1 28, 1 2 7t, 1 3 1 , 133
reci pient site creation, 1 08, 1 12f

McCune-A l bright syndrome, 136
M c G h a n Medica l , 1 5t
M ixed dermal melasma, 149

M ixed su perficial a n d deep hema ngioma ( M H ) , 177
Mohs microgra p h i c surgery, 254, 257-258
M ED. See M i n i m a l erythema d ose
M onobenzone, 9t
Medial orbicularis ocu l i , 24, 24f
Morphea, 265--267
M ed icis, 1 5t
cou rse, 266
Medicis Esthetics, 2 l t
M ed i u m -d e pth pee l , 30t, 3 3 , 34f, 35f
M edy-Tox, Inc, 2 l t
epidemiology, 265
I n d ex
la boratory data, 265-266
med ications, 53-54
postoperative care, 55
pathogenesis, 265
preoperative eva l uation, 52-53, 53f, 54f
physica l exa m i nation, 265, 265f

pitfa l l , 267
preoperative pre paratio n , 54
M TZs. See M icrothermal treatment zones
proced ura l tips, 54-55

M u l berry extract, 9t
Nonablative fractional lasers, 57
M uscle grou ps, 23
Nonablative fractional resu rfacing, 39, 60
forehea d , 23-24
Nonablative laser resurfaci ng, 39, 39f
glabellar com p l ex, 24, 24f

nasola bial fol d , 25-26, 27f
adve rse side effects, 4, 4 1 f l
neck, 26-27 , 28f
postoperative care, 4 1 -42

i n d ications, 40
periora l region, 26, 27f, 28f
laser safety, 4 1
periorbita l regio n , 24-25, 25f
u pper nasal root, 25, 26f
prophylaxis/a nesthesia , 40
M yasthenia gravis, 22
Myobloc, 2 l t
m i d - i nfra red lasers, 40f, 4 1

N onfacial s k i n , 60--6 1
N o n - F DA approved med ications, for fe male pattern h a i r loss, 128
Non-hypersensitive reactions, of soft tissue augmentation, 18-19
Non laser thera py, 93
N A F R . See Nona blative fractional laser res u rfacing

Nasal sebaceous hyperp lasia . See R h i nophyma
Nasolabial fol d , 25-26, 27f
N d :YAG laser, 99, 1 93
depi lati o n , 94
topical eflorn ith i n e , 94
Norwood classification, 103f
N eck, 26-27 , 28f
N e u rofi bromas ( N F) , 23 1-234
Octocrylene, 7t

cou rse, 232
epidemiology, 2 3 1
Octyl methoxycinna mate, 7t

Octyl sa l i cylate, 7t
Ocular rosacea , 76
Oral medications
i n hyperh i d rosis, 87
ma nagement, 232
Oral thera py, 1 65
pathogenesis, 231
Orbicularis ocu l i , 24-25, 25f
pathology, 23 1
physica l exa m i nation, 23 1 , 23lf
pitfa l ls, 223-224
Orbicularis ocu l i tone, 64

Orbicularis oris, 26, 27f, 28f
Oxybenzone, 7t
treatment, 232-233, 232f

N e u rofi bromatosis, 136
N e u ronox, 2 l t
N e v u s a ra neus, 1 70- 1 73
N evus, Becker's, 2 1 6-2 1 8
N evus, epiderma l , 222-225, 235
p
rf>3 tumor suppressor gene,
252
PABA. See Pa ra-a m i n o benzoic acid

Padi mate 0, 7t
Nevus fuscoceruleus ophtha l momaxilla ris, 1 54
Palmoplanta r warts , 206-209
Nevus of Ota , 1 54
Palomar Medical Tec h nologies, 56, 56t, 79

Paper m u l berry, 1 0

cou rse, 155
epidemiology, 1 54
ma nagement, 1 55
pathogenesis, 1 54
pathology, 1 54
physical lesions, 1 54
pitfa l ls, 1 57
treatment, 1 55- 1 56
Papu les
in angiofi bromas, 2 1 2
i n epidermal nevus, 223
i n warts, 206
Papu lopustular rosacea, 76
Pa ra-a m i n o benzoic acid ( PABA), 7t
Partial tears, 308
Patient consu ltation, 95
prior to treatment, 95-96
P D L. See Pu lsed d ye laser
P DT. See Photodyna mic thera py
Nevus sebaceous, 223
Pearly pen ile pa p u l es, 2 1 2
N ia c i n a m i d e , 9t, 10
Nonablative fractional laser resu rfacing ( N A F R )
Peel types, 33
and c l i n ica l i n d ications, 30t
a n esthesia, 54
Pee l i ng agent characteristics, 30t
contra i n d i cations, 53
dermatopathology, 52, 52f
Penici l l i u m , 1 0
Perifo l l i c u l a r erythema, cha racteristic posttreatment, 93f
devices, 56, 56t
Periora l dermatitis, 76
i n d ications, 52
mecha nism of action, 52, 52f
Periorbita l region, 24-25, 25f, 26, 27f, 28f

Periorbita I rhyti d es, 55f
31 9
320
I ndex
Peri u ngua l fibromas, 2 1 2
pathogenesis, 1 58
Perlane, 1 5t
physica l lesions, 1 58
Perla ne LrM , 1 5t
pitfa l l s to avoid/co m p l ications/ma nagem ent/outcome
Peutz-Jeghers syndrome, 144

P H A G E synd rome, 1 78
Phenol, 30!
expectations, 1 6 1
s u n p rotection, 1 59
topical treatment, 1 60
Phenyl benz i m i d azole su lfonic acid , 7t
Postsclerotherapy hyperpigmentation ( P S H ) , 200
Photodyn a m i c thera py ( P DT ) , 75
Potass i u m -tita nyl-phosphate laser, 79, 193
Photodyn a m i c thera py, 254, 258, 269
Pred nisone, 130, 1 79
Photothera py, 75, 1 65

P hymatous rosacea . See Sebaceous hyperplasia
Pregna ncy
P hysical screen , 8, 8t
and telangiectasias, 1 98, 201

Pregna ncy-ind uced hypertension ( P I H ) , 60
Pigmentary cha nges, i n face, 4, 6f
Prevelle s i l k , 1 5t
P I H. See Posti nflam matory hyperpigmentati o n ; Pregna ncy-ind uced

hypertension
Primary and rogen-prod ucing neoplasms, 92

Procerus, 24, 24f
Pilar cysts, 220, 226

P i mecro l i m u s, 1 64
Propanth e l i ne, 87
Prophylactic anti biotics, 49 , 53
P ityros poru m ova l e , 1 0
Propranolol, 1 79
P l a n e warts, 206--209
Prosigne , 2 1 !
Pla ntar wa rts, 206
Prostate cancer
Plaques
in a ngiofi broma, 2 1 2
i n Becker's nevus, 2 1 6
i n seborrheic keratosis, 235
P latysma m uscle co m p l ex, 26--27, 28f
prophylaxis in, 273

Proteus syn d rome, 226
Pseudofollicul itis, 99
course, 100
POC. See Poiki loderma of Civatte
d ifferentia l d iagnosis, 1 00
Podophyl l i n , 224
epidemiology, 99
Podophyllotox i n , 207
Poiki loderma of Civatte ( POC), 67

ma nagement, 1 00
pathogenesis, 99
course, 68
de rmato pathology, 67
pitfa l l s , 1 0 1-102, 1 0 11, 1 02f
epidemiology, 67
treatment
ma nagement, 68
laser hair remova l , lOOt, 1 0 1 , 1 0 1 1

shaving cessation, 100
pathogenesis, 67
shaving tech n i q ue , mod ification of, 10(}- 1 0 1
physical exa m i nation, 67, 67f, 68f
topical treatment, 1 0 1
pitfa l ls, 68-69, 69f

pretreatment, 68f
treatment, 68, 68f
Pseudofo l l i c u l itis, a n d etrology, 1 0 1 1

Pseudogynecomasti a , 272
Polidoca n o l , 199, 200, 200!
Pseudo-och ronosis, 34, 1 59f

Psora len a n d ultraviolet A ( P UVA ) , 1 65, 1 75
Poly-L-Iactic acid, 1 8
Psoriasis, 267-270, 267f, 268f
Pontoca i n e . See Topica l tetraca ine

Port-wine sta i n s ( PWS), 1 83 , 1 84f, 1 85f, 1 86f
ancil lary tests, 1 83
course, 183
course, 268
epidemiology, 267

ma nagement, 268-269, 269f
differentia l d iagnosis, 1 83
pathogenesis, 268
epidemiology, 183
ma nagement, 1 83
Post hair tra nsplant side effects, 109
Post i nfla m matory erythema
a n d cu rettage, 237f
Post i nfla mmatory hyperpigmentation ( P I H ) , 1 58, 1 58f
chemical peels, 1 6(}- 1 6 1
pitfa l l s , 270
Psuedogynecomastia, 274
P u l sed carbon d i oxide laser, 250
Pu lsed dye laser ( P OL)
for acne vulga ris, 75
for a ngiokeratomas, 1 69
for cherry and spider a ngiomas, 1 7 1
for facial telangiectasia, 203, 203f, 205f
course, 1 59
for facial tela ngiectasias, 192
dermato pathology, 1 58
for hypertrophic scars/ke loids, 292t
differentia l d iagnosis, 1 58
for i nfa ntile hema ngiomas, 1 79
epidemiology, 1 58
for keratosis pila ris atrophicans, 182
laboratory exa m i nation, 1 58

lasers, 1 6 1
for m orphea , 266

for Poiki loderma of Civatte, 68
treatment, 2 18, 233

ma nagement, 1 59
for port-wine sta ins, 185

for psorias, 269
I n d ex
for pyogenic gra n u lo m a , 189
Rete ridges
in epidermal nevus, 222
for rosacea , 78
for sebacious hyperplasia, 82
for striae d i ste nsae, 287
for telangiectasias, 201
Reticular veins, 198-202

Reticulated hyperpigmentation , 67
for venous la kes, 203, 205f
Reti n-A, 1 82
Reti naldehyde, 8, 9
for warts, 206f, 208, 208f, 209f
Reti noic acid, 8-9, 9t, 10, 1 2

chemical structu res of, Sf
for warts, 208

P u n c h excision, 2 1 3
Reti noids, 73, 1 4 1 , 1 5 1 , 1 5 1!, 1 60, 182
Pu rpura, 204, 208

PUVA. See Psora len a n d u ltraviolet A
Reti n o l , 8
Pyogenic gra n u loma ( PG ) , 1 88, 188f, 1 89f
Retinyl esters, 8
R F technology. See Radiofreq uency ( R F) tech nology
biopsy-proven , 1 9 l f
R h i nophyma, 76, 76f, 77-78
cou rse, 188
R hytides, 58
dermatopathology, 1 88
R osacea , 76
cou rse, 77
d ifferential d iagnoses, 1 88
epidemiology, 188
laser treatment, 1 89
ma nagement, 1 89
epidemiology, 76
pathogenesis, 1 88
ma nagement, 77
physica l exa m i nation, 1 88
surgica l thera py, 77-79

s u rgica l treatment, 189
systemic thera py, 77

topical thera py, 77
pathogenesis, 76
vs. venous la kes, 203

Roth m u nd-Thomson synd rome, 67
R u by spot, 1 70-1 73 . See also Cherry a ngiomas
Q-M ed AB, 1 5t
Q-switched lasers, 1 52
R ussell-Silver synd rome, 1 36
alexa nd rite
for Becker's nevus, 2 1 7, 2 1 8f
for cafe au Ia it macules, 1 3 7 , 138
Sa l icyl ic acid , 73, 207
for dermatosis pa pu losa n igra , 242

Sa l i n e
for nevus of Ota , 1 55, 1 56

a rgon
and gra n u loma faciale, 1 75
N d :YAG
a n d warts, 2 0 7 , 208
and tela ngiectasias, 201
Scarring
from a n giofi broma treatment, 2 1 4
from surgica l i ncision, 224, 228
from wart remova l , 207t, 208, 209
for cafe au Ia it macules, 1 3 7 , 138
SCC . See Squamous cell carcinoma

Sclerothera py, 199-20 1 , 1 98f, 1 99f, 200f, 200t, 201t, 204
a n d e p h i l ides, 142
Scoliosis, 232
a n d lentigines, 1 46
Sc u l ptra TM , 1 5t
for nevus of Ota , 155
Se baceo us cyst, 2 19
for tattoo remova l , 300!, 302

r u by
Se baceo us hyperplasia, 76, 77, 8 1 , 8lf

cou rse, 8 1
for dermatosis pa p u l osa n igra , 242
for e p h i l ides, 1 42
epidemiology, 8 1
for lentigines, 1 46, 1 47
for seborrheic keratosis, 236f
for nevus of Ota , 155

for tattoo remova l , 300!, 302t

ma nagement, 82
pathogenesis, 81
pathology, 8 1
R
Rad iation dermatitis, 67
Rad iation thera py, 2 54
Radiesse TM , 1 5t
pitfa l l s , 83
treatments, 82
destructive modal ities, 82
laser thera py, 82-83, 82f, 83f
Radiofreq uency ( R F) tech nology, 62
Seborrheic dermatitis, 76
Rad iothera py, 258
Seborrheic keratosis, 234--2 37. See also Dermatosis pa pulosa n igra
R e-epithe l i a l ization, 49
Relaxi n , 2 1 !
cou rse, 235
Renova , 9
R estylane, 1 5t

epidemiology, 234
R estyla ne-L, 1 5t
vs. epidermal nevus, 223, 235
32 1
322
I ndex
pathology, 235
d ifferential d iagnosis, 256, 257f
epidemiology, 256
pitfa l l s , 237
treatment, 236
vs. epidermal nevus, 223

vs. wa rts, 206
ma nagement, 257-258, 258f, 259f
Segmenta l hemangioma, 1801
pathogenesis, 256
Senile hema ngiomas, 1 70-1 73
physical exa m i nation, 256, 256f
Seria l p u n ctu re, 18
pitfa l l s , 258
Seria l sa l icylic acid peels, 74

Sharplan FeatherTouch, 1 69
Shave biopsies a n d excisions
vs. wa rts, 206, 207
Sta rch-iod ine test, 88
for a ngiofi bromas, 2 1 3
Sta rlux Lux G hand piece, 79
Steroid rosacea , 76
for l i poma, 227, 227f
Stockings, elastic com pression, 200
for n e u rofi bromas, 236

Strawberry, 1 77- 1 80
Stretch marks. See Striae d i stensae
Shaving cessation, 100
Stria a l ba , 287
Shaving tech n i q u e , mod ification of, 1 00-1 0 1
Stria ru bra , 286-287, 287f
Short-pu lsed erbi u m , 287
Striae d i stensae, 285, 285f
S i l icone, 18
S i l icone sheeti ng, 29 1 , 29 lt

S i l i kone- 1 000, 1 5t
cou rse, 286

Skin grafts, 225f
epidemiology, 285
Skin l ightening agents, 9-1 1
Skin testi ng, 1 6
ma nagement, 286
Skin turnover acceleration, 9t
m icroderma brasion , 287
Skin types
a n d Becker's nevus, 2 1 8
pathogenesis, 285
pathology, 285
Smooth bea m , 4 1
physica l lesions, 285
SNAP-25, 2 1
pitfa l l s , 288
Sod i u m morrh uate, 199
Sod i u m sulfaceta mide, 73, 77

Sod i u m tetradecyl su lfate, 199, 200t, 20lt
Soft tissue a ugmentation
adve rse reactions
treatment, 286-287
Stromelysi n , 9
Stu rge-Weber syndrome (SWS) , 184
S u bcision, 278
hypersensitive, 18
Su bcuta neous fat, i n l i poma, 226
non-hypersensitive, 1 8- 1 9
Su bcuta neous fat, 1 5t
tec h n i q u e compl ications, 1 9

a n esthesia, 1 6f, 1 7
Su bcuta neous fat atro phy, 5

Su lfu r, 73
degree o f correction, 1 8
S u l isobenzone, 7t
d u ration o f correction, 18
S u n expos ure
ideal fil ler, 14, 14t- 1 5t

i njection tech n i q ue, 18, 1 8f, 19f
level of i njection, 1 7- 18, 1 7f, 18f
mecha n ism of action , 14
and sclerothera py, 200

and venous lakes, 203
Sun protective factor ( S P F ) , 8
Su nscreen , 7-8, 7f, 7t
preoperative eva l uation, 1 5- 1 6
Su perficial hemangioma ( S H ) , 1 77 , 1 79
proced ura l medications, 1 7
Su perficial pee l , 30t, 32f, 33, 33f
skin testi ng, 1 6
Su rgery
Softform, 1 5t
Solar le ntigo vs. ephel i d , 145t
Solar le ntigos, 144
in hyperhidrosis, 88
S u rgica l excision, 1 75
S u rgica l proced u re, for hair tra nsplantation
corrective hair tra nsplant su rgery, 1 10, 1 10t
Solta Medica l , I n c . , 56, 56t
day of proced u re, 1 06
Soltice Neu rosciences, 2 lt
donor h a rvesti ng tec h n i q ues, 1 06, 1 06f, 106t, 107t
Sotradechol, 200
donor region, a nesthesia i n , 1 06
Soy, 1 0
Soybea n/m i l k extracts, 9t
fol l i c u l a r u n it extraction ( F U E) , 107, 107t

graft creation, 107
S P F. See S u n protective factor
graft placement, 108-1 09, 1 1 3f
Spider a ngiomas, 1 70-173, 1 7 11
hairline design , 1 08
Spider tela ngiectasia, 1 70-1 73
post h a i r tra n s plant side effects, 109
S p i n a l dysra p h i s m , 227
postoperative period , 109
Spi ronolactone, 73, 1 28

Squamous cell carcinoma (SCC), 256-258
postsu rgica l period after sutu res/sta ples

removed , 1 09-1 1 0
cou rse, 257
rare side effects, 1 09
I n d ex
checkl ist, 62-63

side effects, 63
S u rgica l thera py
of acne vu lgaris, 74
for Dermatochalasis, 64f, 65
Topica l 5-fl uorou raci l , 254

Topica l eflorn ith ine, 94
Topica l i m iq u i m od , 254
Topica l med ications, in hyperh i d rosis, 87
for epidermal i ncl usion cysts, 220
Topica l proparaca ine, 47, 59
for epidermal nevus , 224
Topica l retinoic acid , 32
for l i poma, 227, 227f, 228f
Topica l tetraca ine, 47, 59

Topica l thera py
for neu rofi broma, 232-233, 232f

of Rosacea , 76f, 77-79 , 79f, 80f
of acne vu lgaris, 73
for dermatochalasis, 65
for wa rt remova l , 207-209
for Poiki loderma of Civatte, 68

of pseudofo l l i c u l itis, 1 0 1
Syri ngoma, 238, 238f

cou rse, 239
o f Rosacea , 77
Topica l treatment options
a p p l ication tec h n i q ues, 1 1- 1 2
epidemiology, 238
com pl ications, 1 2
contra i n d icatio ns, 1 1
ma nagement, 239
ideal ca ndidate, 1 1
pathogenesis, 238
pathology, 238
i nd ications, 1 1
less than ideal ca ndidate, 1 1
physica l lesions, 238, 238f
mecha nism of action , 7-1 1
pitfa l ls, 239f, 240, 240f
posttreatment care, 1 2
treatment, 239-240
System i c l u pus erythematosus, 76
System i c thera py
of acne vu lgaris, 73-74
323
proced ure, 62
reci pient region, a nesthesia i n , 1 08

reci pient site creation, 1 08, 1 12f

pretreatment eva l uation, 1 1

Topica l treti n o i n , 46, 146
Torn earlobe, 308
of Rosacea , 77
key consu ltative q uestions, 308

ma nagement, 308
pitfa l l s to avoid/co m p l ications/ma nagement/outcome expectations, 309
T
Tacro l i m us, 1 64
treatments, 308-309, 308f, 309f, 3 1 0f

Trad ition a l P D L, 78
Tacro l i m u s oi ntment, 1 75
Trad ition a l resu rfaci ng, 39
Ta l kesthesia, 1 7
Tretinoi n , 9, 46, 54, 73
Ta p water iontophoresis, 87
and epidermal nevus, 224
Tattoo remova l , 300, 300f
and m i l i u m , 230
adverse effects/preca utions, 303, 304f, 305f, 306, 307f

consu ltative q uestions, 300-301
TriActive Laserd ermology, 278

Tria mci nolone aceton ide, 1 79
laser thera py, 300t
Triangula ris m uscles, 26, 27f, 28f
ma nagement, 301
Trich l o racetic acid (TCA) peels, 301, 74
pitfa l ls, 303-304
for wart removal , 207
posttreatment care, 302
Tri l u ma , 1 46
pretreatment assessment, 30 1
tattoo treatment, 302, 302t, 303f, 304f
Trola m i n e sa l i cylate, 7t
TS H . See Thyroid-sti m u lating hormone
treatment, 30 1-302, 303f
Tu berous sclerosis, 136
Tazarotene, 9, 73, 1 82
Tu berous sclerosis, 213, 2 1 3f
TCA peels. See Trichloroacetic acid peels
Tu rnors, 220
Telangiectases, 67
Tylenol, 109
Tela ngiectasias, 78-79, 78f, 79f, 80f

lower extremity, 198-202
Tyrosinase, 9
Tyrosi nase i n h i b itors, 9t
epidemiology, 198
laboratory data, 198
ma nagement, 199-202, 1 98f, 1 99f, 200f
pathophysiology, 198
physical exa m i nati o n , 198
Telangiectatic matting rM , 201
u
U l cerated hemangioma, 1 79f
U ltra , 1 5t
U ltra P l u s , 1 5t
Telogen effl uvi u m , 1 29, 130-13 1
U ltra P l u s XC, 1 5t
Tetracycl i ne, 73, 77
U ltra XC, 1 5t
T h ro m boph lebitis, 198
U ltrasou n d , 198
U ltraviolet A ( U VA), 67
Thyroid-sti m u lating hormone (TS H ) , 1 63

Tissue tighte n i ng, 62
ca n d idate selection, 62
c l i n ical pea rls, 63
mecha n ism of action, 62
U ltraviolet B ( U V B ) , 67
U p per a n d m idfacial m uscu latu re, a natom ical i l l u stration
of, 22f
U p per face, 2-3
324
I ndex
U p per nasal root, 25, 26f
la boratory exa m i nation, 1 63
U .S . Food a n d Drug Ad m i n istration, 94
laser thera py
exci mer laser, 1 65
UVA. See U ltraviolet A

UVB exposu re, 9
ma nagement, 1 64
U V B . See U ltraviolet B
oral thera py, 1 65

pathoge nesis, 1 63
photothera py, 165

pitfa l l s to avoid/co m p l ications/managem ent!
Valacyclovir, 46
outcome expectations, 1 66
Valacyclovir, 54
preventi o n , 1 64
s u rgica l treatments, 1 65
Valtrex, 1 7 , 32
Va n iqa . See Topica l eflorn ith i n e
topical treatment, 1 64
Va porizi ng tool , 44
Variable-pu lse P D L, 78
Varicose veins, 198-202
Vascular a lterations
lower extremity telangiectasias, 198-202
reticular and va ricose veins, 198-202
w
Warts, 206-209
cou rse, 207
venous lakes, 203-205
warts, 206-209

epidemiology, 206
Vascular a lterations
pathogenesis, 206
venous lakes, 203-205
warts, 206-209
Vasc u l a r ectasia, 77
pitfa l l s , 209
treatment, 207-209, 206f, 207f, 205f, 209f
Vascular lasers, 39
Vascular rosa cea , 76
Vascular spid er, 1 70- 1 73
Watson's syndrome, 136

Westerhof's syndrome, 136
Vaseli ne, 34
Wickha m 's striae, 262
Vei ns, reticular a n d varicose, 198-202

VelaSmooth system , 278
Wood's l a m p eva l uation, 3 1 , 3 1 1, 1 63

Wydase. See Hya l u ron idase
Venous lakes, 203-205

cou rse, 203
de rmato pathology, 203
d ifferenti a l d iagnosis, 203
epidemiology, 203
e p i l u m i n escence m i c roscopy ( EL M ) , 203
X
Xa nthelasma pa l pebraru m . See Xa nthelasrnas
Xa nthelasmas, 243
cou rse, 244
ma nagement, 203-204, 203f, 204f, 205f
pitfa l ls, 204
epidemiology, 243
ma nagement, 244
Venous o bstruction, 198

Venous va lvular incom petence, 198
Verruca , 223, 235
pathoge nesis, 243

Vincristine, 1 79
Vita m i n C, 8
Vita m i n E, 8
pitfa l l s , 244
Xeom i n , 2 1 !
Vitiligo, 1 63
cou rse, 1 63-1 64
dermato pat hology, 1 63
Z-plasty repa i r, 308

Zyd erm , 1 5t
epidemiology, 1 63
Zyplast , 1 5t

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Color Atlas of

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The McGrowH/11 Companies

I wou ld l i ke t o ded icate this book t o the memory of m y beloved father,

I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morre l l a n d

Mathew M. Avram, MD, JD

To my h us ba n d , Hensi n . You a re my stre ngth a n d i n s p i ration. You r l ove, wisd o m a n d

T h i s book is ded icated to my wife R o b i n a n d my two sons Robert a n d J a c o b .

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SECTION THREE: DISORDERS OF ECCRINE GLANDS

Chapter 16: Hyperhidrosis.... .... ... .. 86

SECTION ONE: PHO TOAGING

Chapter 1: Analysis of the Aging Face and

SECTION FOUR: DISORDERS OF HAIR FOLLICLES

Chapter 17: Hirsutism

Chapter 3: Soft Tissue Augmentation

Chapter 4: Botulinum Toxin

Chapter 5: Chemical Peels .. ...... .. ... 29

Chapter 6: Nonablative Laser Resurfacing

Chapter 7: Ablative Laser Resurfacing

Chapter 21: Low Level Light Therapy (LLLT)

SECTION FIVE: DISORDERS OF PIGMENTATION

Chapter 22: Cafe Au Lait Macule ... ...... 136

Chapter 8: Nonablative Fractional Laser

Chapter 23: Ephelides

Chapter 10: Tissue Tightening

Chapter 24: Lentigines

Chapter 25: Melasma . .. ...

Chapter 11: Dermatochalasis........

Chapter 26: Nevus of Ota

Chapter 12: Poikiloderma of Civatte

Chapter 27: Postinflammatory

Chapter 28: Vitiligo.... ....

SECTION TWO: DISORDERS OF SEBACEOUS

Chapter 13: Acne Vulgaris ...... .. ... .. 72

SECTION SIX: VASCULAR ALTERATIONS

Chapter 14: Rosacea

Chapter 29: Angiokeratoma

Chapter 15: Sebaceous Hyperplasia ......... 81

Chapter 30: Cherry and Spider Angiomas ....

Chapter 31: Granuloma Faciale

Chapter 32: Infantile Hemangioma

Chapter 33: Keratosis Pilaris Atrophicans

Chapter 34: Port-wine Stains

Chapter 35: Pyogenic Granuloma

Chapter 39: Warts

Chapter 41: Becker's Nevus

Chapter 42: Epidermal Inclusion Cyst

Chapter 43: Epidermal Nevus

Chapter 54: Lichen Planus

Chapter 55: Morphea

Chapter 56: Psoriasis

Chapter 59: HIV Lipodystrophy/Facial

Chapter 60: Striae Distensae

SECTION TEN: ADIPOSE TISSUE ALTERATIONS

SECTION NINE: INFLAMMATORY DISORDERS

Chapter 58: Cellulite

Chapter 53: Squamous Cell Carcinoma

SECTION SEVEN: BENIGN GROWTHS

Chapter 52: Basal Cell Carcinoma

Chapter 57: Gynecomastia

Chapter 40: Angiofibroma