Faculty Bibliography

BACKGROUND: The success of Mohs surgery relies on the ability to histologically differentiate tumor from the normal background tissue of the patient. In most cases of basal cell carcinoma and nonmelanoma skin cancer, this is a relatively straightforward process. However, in distinction, when only subtle histopathologic features differentiate the background tissue from the tumor of interest, the determination of a tumor-free margin becomes more challenging. OBJECTIVE: Our objective is to highlight the histopathologic features that we used to differentiate our patient's near-confluent background of trichoepitheliomas from the basal cell carcinoma that we were extirpating. METHODS: Case report. RESULTS: A 41-year-old white female with a history of familial multiple facial trichoepitheliomas presented for removal of a basal cell carcinoma on her right lower cutaneous lip. Mohs surgery was used to remove the tumor. The characteristic features of basal cell carcinoma and trichoepithelioma were used to differentiate the basal cell carcinoma that we were removing from the surrounding trichoepitheliomatous neoplasia. CONCLUSION: Mohs surgical extirpation of a basal cell carcinoma in a patient with multiple familial trichoepitheliomas requires a clear understanding of the histopathologic features that differentiate a trichoepithelioma from a basal cell carcinoma

BACKGROUND AND OBJECTIVES: Many pediatric dermatological conditions may be successfully treated with laser surgery. STUDY DESIGN/MATERIALS AND METHODS: The clinical approach to various pediatric dermatological conditions utilizing laser treatment options is discussed. RESULTS: Clinical uses of various modalities such as pulsed dye laser, KTP laser, Nd-YAG laser, Q-switched ruby laser, erbium-YAG laser, diode laser, non-coherent blue light sources, and fractional resurfacing are presented with successful parameters, developed over 22 years, utilized on a daily basis in a laser surgery clinic. CONCLUSION: Laser surgery can make a significant improvement in many pediatric skin lesions, thanks to the unique properties of pediatric skin and a vast array of laser technologies

OBJECTIVE: To ascertain the immediate and short-term side effects of fractional photothermolysis for the treatment of a variety of skin disorders involving the face, neck, chest, and hands. METHODS: Physician-administered questionnaires were given during 60 follow-up visits for fractional photothermolysis treatment for a variety of facial skin disorders in patients with skin types ranging from I to IV. The questionnaire addressed 14 possible side effects, pain, and limitation of social activities. In addition, all patients were asked about any additional side effects not mentioned in the survey. An analysis of the data was performed once 60 surveys had been collected. RESULTS: All patients (100%) undergoing fractional photothermolysis had transient post-treatment erythema. Other frequently reported post-treatment side effects were transient and included facial edema (82%), dry skin (86.6%), flaking (60%), a few (one to three) small, superficial scratches (46.6%), pruritus (37%), and bronzing (26.6%). Other more rarely reported effects included transient increased sensitivity (10%) and acneiform eruption (10%). Most patients reported that the pain level was easily tolerated, with an average pain score of 4.6 on a scale of 10. Most patients (72%) reported limiting social engagements for an average of 2 days after treatment. There were no long-lasting adverse events noted in our survey. CONCLUSION: Fractional photothermolysis to treat dermatologic conditions on the face, neck, chest, and hands is a well-tolerated and safe procedure with several immediate, and slightly delayed, post-treatment side effects. In our experience, these side effects were transient and limited to erythema, edema, dry skin, flaking skin, superficial scratches, pruritus, increased sensitivity, and acneiform eruption. Importantly, we did not see the development of post-treatment scarring, herpetic activation, hypopigmentation, hyperpigmentation, persistent erythema, persistent edema, or infection

OBJECTIVE: To assess the analgesic effect of a handheld forced cold air device during fractional photothermolysis. METHODS: Twenty patients who were being treated with full-face fractional photothermolysis were asked to rate their pain level with and without the handheld air-cooling device. Pain was rated on a scale of 1 to 10, with 10 being the worst. RESULTS: Nineteen of 20 patients noted decreased pain with the addition of handheld cooling. The mean level of pain without air-cooling was 6.95 +/- 2.0. The mean level of discomfort with air cooling was 4.0 +/- 1.8. The mean decrease in pain with the addition of air-cooling was 2.9 +/- 1.8. CONCLUSION: The addition of a handheld forced cold air device to cool the skin before and after fractional photothermolysis treatment is an effective adjunctive analgesic modality

OBJECTIVE: To share our current experience and review the current literature concerning the use of radiofrequency for the treatment of facial laxity. METHODS: We discuss our experience and review the current literature. RESULTS: Radiofrequency can impart mild tightening of mid- and lower facial laxity as well as periorbital laxity. In addition, it may help acne scars and acne. CONCLUSIONS: Radiofrequency appears to impart mild improvement to facial laxity and is a viable nonsurgical option for patients with mild facial laxity. There is, however, a need for blinded, randomized controlled studies to further validate these claims

BACKGROUND: Light-emitting diode (LED) photomodulation is a novel nonthermal technology used to modulate cellular activity with light. OBJECTIVE: We describe our experience over the last 2 years using 590 nm LED photomodulation within a dermatologic surgery environment. METHODS: Practical use of nonthermal light energy and emerging applications in 3,500 treatments delivered to 900 patients is detailed. RESULTS: LED photomodulation has been used alone for skin rejuvenation in over 300 patients but has been effective in augmentation of results in 600 patients receiving concomitant nonablative thermal and vascular treatments such as intense pulsed light, pulsed dye laser, KTP and infrared lasers, radiofrequency energy, and ablative lasers. CONCLUSION: LED photomodulation reverses signs of photoaging using a new nonthermal mechanism. The anti-inflammatory component of LED in combination with the cell regulatory component helps improve the outcome of other thermal-based rejuvenation treatments

Brooke-Spiegler syndrome (BSS), familial cylindromatosis (FC), and multiple familial trichoepithelioma (MFT), originally described as distinct entities, share overlapping clinical findings. Patients with BSS are predisposed to multiple skin appendage tumors such as cylindroma, trichoepithelioma, and spiradenoma. FC, however, is characterized by cylindromas and MFT by trichoepitheliomas as the only tumor type. These disorders have recently been associated with mutations in the CYLD gene. In this report, we describe three families with BSS, one with FC, and two with MFT phenotypes associated with novel and recurrent mutations in CYLD. We provide evidence that these disorders represent phenotypic variation of a single entity and lack genotype-phenotype correlation

BACKGROUND: Topical anesthetics are important tools for many dermatologic procedures. The S-Caine Peel is composed of a 1:1 (w:w) eutectic mixture composed of lidocaine base 7%, USP, and tetracaine base 7%, USP. It is applied as a cream, dries on exposure to air, and forms a flexible membrane, which can be easily peeled off. OBJECTIVE: To evaluate the effectiveness of the S-Caine Peel in providing clinically useful local dermal anesthesia for laser-assisted tattoo removal and to monitor the nature and frequency of adverse events associated with the safety of the S-Caine Peel. METHODS: Thirty adult patients undergoing laser-assisted tattoo removal were enrolled in this multicentered, randomized, double-blind, placebo-controlled study. Each subject received both the S-Caine Peel and placebo simultaneously for 60 minutes. The primary efficacy parameter was a 100 mm visual analog scale (VAS) for patient self-assessment of pain. Secondary efficacy parameters included both the investigator's and an independent observer's evaluation of subject pain (4-point categorical scale: no pain through severe pain) and the patient's and the investigator's overall impression of the local anesthetic. RESULTS: Mean VAS scores were 42 mm for the S-Caine Peel and 66 mm for placebo treatment sites (p=.001). Patients received adequate pain relief in 50% of S-Caine Peel sites versus 7% of placebo sites (p=.002). The percentage of those who would like to use the S-Caine Peel again were 43% for the S-Caine Peel compared with 7% for placebo (p=.005). Investigators' evaluations revealed that 70% of patients had less pain at S-Caine Peel treatment sites compared with 10% with less pain at placebo sites (p<.001), and 70% of the S-Caine Peel-treated sites achieved adequate anesthesia versus 10% of placebo sites (p<.001). The independent witness assessed less pain in 67% of S-Caine Peel-treated sites versus 10% of the placebo sites (p=.002). One occurrence of moderate to severe erythema was noted at both an S-Caine Peel and a placebo treatment site on removal of the S-Caine Peel after 60 minutes, which self-resolved quickly. There was no statistical difference between the two groups. Other side effects were limited to local mild, transient erythema at the application sites. CONCLUSION: Administration of the S-Caine Peel for 60 minutes prior to laser-assisted tattoo removal was effective in significantly reducing pain levels associated with the procedure

BACKGROUND AND OBJECTIVES: Photomodulation has been described as a process which modifies cell activity using light sources without thermal effect. The objective of this study was to investigate the use of a non-thermal low dose light emitting diode (LED) array for improving the appearance of photoaged subjects. STUDY DESIGN/MATERIALS AND METHODS: This prospective study investigated a random cohort of patients (N = 90) with a wide range of photoaged skin treated by LED photomodulation using a full panel 590 nm non-thermal full face LED array delivering 0.1 J/cm(2) with a specific sequence of pulsing. Subjects were evaluated at 4, 8, 12, 18 weeks and 6 and 12 months after a series of 8 treatments delivered over 4 weeks. Data collected included stereotactic digital imaging, computerized optical digital profilometry, and peri-ocular biopsy histologic evaluations for standard stains and well as collagen synthetic and degradative pathway immunofluorescent staining. RESULTS: Digital imaging data showed a reduction of signs of photoaging in 90% of subjects with smoother texture, reduction of peri-orbital rhytids, and reduction of erythema and pigmentation. Optical profilometry showed a 10% improvement by surface topographical measurements. Histologic data showed markedly increased collagen in the papillary dermis of 100% of post-treatment specimens (N = 10). Staining with anti-collagen I antibodies demonstrated a 28% (range: 10%-70%) average increase in density while staining with anti-matrixmetalloproteinase (MMP)-1 showed an average reduction of 4% (range: 2%-40%). No side effects or pain were noted. CONCLUSIONS: Photomodulation to reverse photoaging is possible with a specific array of LEDs with a specific fluence using a precise pulsing or 'code' sequence. Skin textural improvement by digital imaging and surface profilometry is accompanied by increased collagen I deposition with reduced MMP-1 (collagenase) activity in the papillary dermis. This technique is a safe and effective non-painful non-ablative modality for improvement of photoaging

Photomodulation is a process that manipulates or regulates cell activity using light sources without thermal effect. Previous studies of LED photomodulation have shown skin textural improvement accompanied by increased collagen deposition with reduced MMP-1 (collagenase) activity in the papillary dermis. The purpose of this study was to investigate a separate cohort of patients (N =93) with a wide range of Fitzpatrick skin types treated by LED photomodulation using the Gentlewaves full panel 590 nm high energy LED array with a specific sequence or code of pulsing in the millisecond domain. Results showed improvement of signs of photoaging in 90%. The majority of patients demonstrated improvement in peri-ocular wrinkles, reduction in Fitzpatrick photoaging classification, global skin texture and background erythema, and pigmentation. No side effects were noted. LED photomodulation is a safe and effective non-painful non-ablative modality for improvement of photoaging