Faculty Bibliography

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

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

Actinic cheilitis (AC) is a common precancerous condition for which a safe, effective, rapid, and cosmetically favorable treatment is needed. The objective of this study was to assess the safety and efficacy of the long-pulsed pulsed dye laser (LP PDL) (595 nm) with photodynamic therapy (PDT) for the treatment of AC. This study was designed to be a prospective, proof-of concept pilot study to assess safety and efficacy of LP PDL in conjunction with topical 20% 5-aminolevulinic acid solution PDT for the treatment of AC. Control patients received LP PDL alone. The setting was an outpatient clinical research center. A volunteer sample of 21 patients with biopsy-proven AC was enrolled (age range, 42-86 years; skin types I-III). All patients were refractory to prior therapies. Patients with a history of herpes labialis were pre-treated with famcyclovir. Nineteen patients received one-to-three treatments of topical 20% 5-aminolevulinic acid for 2-3 hours, followed by LP PDL (595 nm) at monthly intervals. Two control patients received one treatment with LP PDL alone. Patients in the ALA-LP PDL group were followed at 1, 2, 3, 6, 9, and 12 months. Clearance of AC was assessed by clinical evaluation. Control patients were followed to the one month interval. We observed none-to-mild pain; slight-to-moderate erythema; no crusting, purpura, or scarring; treatment time of less than one minute; and complete resolution of post-operative erythema by day three. Complete clearance was achieved in 13/19 (68%) of patients following a mean of 1.8 treatments (7/13 (37%) after one, 2/13 (11%) after two, and 1/13 (21%) after three treatments). Patients were followed for a mean of 4.1 (range 1-12) months. Among the remaining cases, partial clearing was achieved in two patients, recurrence during the follow-up interval was observed in one patient, and failure to follow-up occurred in three patients. Post-operative impetiginization occurred in three patients with erosive AC, which resolved with dicloxacillin therapy. Among the control patients, no clearing was observed. Treatment of AC using LP PDL (595 nm) at nonpurpuric parameters following topical application of 5-aminolevulinic acid at short incubation times is safe and effective. It may offer the advantages of rapid incubation, treatment, and recovery times, minimal discomfort, excellent cosmetic outcome, and good efficacy rates. Patients with erosive AC should receive antibacterial prophylaxis. Multiple treatments may be required for complete clearing

OBJECTIVES: To quantitatively assess improvement in acne scarring after a series of nonablative laser treatments and to determine efficacy at 1-, 3-, and 6-month follow-up after treatment. DESIGN: Before-after trial of consecutively selected patients. SETTING: Private practice at the Laser and Skin Surgery Center of New York, New York. PATIENTS: Eleven patients with mild to moderate atrophic acne scarring were treated. INTERVENTIONS: A 3-dimensional optical profiling imaging system was used to assess skin topography before, during, and after treatment. Patients were treated with a 1064-nm Q-switched Nd:YAG laser and reassessed after 3 treatment sessions and at 1, 3, and 6 months after the fifth treatment session. MAIN OUTCOME MEASURES: The skin roughness analysis was quantified at baseline and at each follow-up interval. Pain, erythema, and petechiae formation were assessed on 3-point scales. RESULTS: At midtreatment (1 month after the third treatment session), an 8.9% improvement in roughness analysis was seen. This improvement increased to 23.3%, 31.6%, and 39.2% at 1, 3, and 6 months after the fifth treatment, respectively. Patients reported mild to moderate pain with treatment. The only adverse effects noted were transient erythema and mild pinpoint petechiae. CONCLUSIONS: Treatment with the nonablative 1064-nm Q-switched Nd:YAG laser results in significant quantitative improvements in skin topography in patients with mild to moderate atrophic acne scars. Continued incremental improvements were noted at 1-, 3-, and 6-month follow-up, indicating ongoing dermal collagen remodeling after the treatment

BACKGROUND: Multiple modalities have been described for skin rejuvenation, including ablative and nonablative therapies. Because of the prolonged recovery period associated with ablative procedures that injure the epidermis, nonablative skin treatments have grown increasingly popular. Various laser- and light-based systems have been designed or applied for promoting skin remodeling without damage to the epidermis. METHODS: Studies investigating the use of nonablative procedures for facial rhytids or acne scarring with clinical, histological, and objective quantitative measurements are systematically reviewed. RESULTS: Nonablative treatments are associated with clinical and objective improvements for the treatment of facial rhytids and acne scarring. Dermal remodeling seems to occur as a result of thermal injury, leading to dermal fibrosis without epidermal disruption. CONCLUSIONS: Although results are not as impressive as those of ablative treatments, nonablative procedures are effective in the treatment of photoaging and acne scarring. As technology in nonablative therapies continues to evolve, future laser and light sources may yield even more favorable results

OBJECTIVE: To assess the safety and efficacy of the 308-nm excimer laser in pigment correction of hypopigmented scars and striae alba. DESIGN: Institutional review board-approved randomized controlled trial. SETTING: Private research center. PATIENTS: Volunteer sample of 31 adult subjects with hypopigmented scars or striae alba distributed on the face, torso, or extremities. INTERVENTIONS: Lesions were randomized to receive treatment or not, with site-matched normal control areas. Treatments were initiated with a minimal erythema dose minus 50 mJ/cm(2) to affected areas. Subsequent treatments were performed biweekly until 50% to 75% pigment correction, then every 2 weeks thereafter until a maximum of 10 treatments, 75% increase in colorimetric measurements, or 100% visual pigment correction. MAIN OUTCOME MEASURES: Pigment correction by visual and colorimetric assessments compared with untreated control lesions and site-matched normal skin before each treatment and at 1-, 2-, 4-, and 6-month follow-up intervals. Occurrence of erythema, blistering, dyspigmentation, or other adverse effects was monitored. RESULTS: The percentage pigment correction by both assessments increased in direct proportion to the number of treatments. The mean percentage pigment correction by visual assessment relative to control of 61% (95% confidence interval [CI], 55%-67%) for scars and 68% (95% CI, 62%-74%) for striae was achieved after 9 treatments. The mean percentage pigmentation by colorimetric measurements relative to control of 101% (95% CI, 99%-103%) for scars and 102% (95% CI, 99%-104%) for striae was achieved after 9 treatments. Both sets of values gradually declined toward baseline levels during the 6-month follow-up. No blistering or dyspigmentation occurred. CONCLUSIONS: Therapy with the 308-nm excimer laser is safe and effective in pigment correction of hypopigmented scars and striae alba. Mean final pigment correction rates relative to control sites of approximately 60% to 70% by visual assessment and 100% by colorimetric analysis were observed after 9 treatments administered biweekly. Maintenance treatment every 1 to 4 months is required to sustain the cosmetic benefit

BACKGROUND: Increases in complications resulting from the nonphysician practice of dermatologic procedures have been reported nationally. This investigation was initiated owing to growing concern regarding the nonphysician practice of medicine in Texas. OBJECTIVE: The objective was to survey dermatologists in Texas to determine the number of patients seeking corrective treatment owing to complications from dermatologic procedures performed by nonphysicians. METHODS: A total of 488 dermatologists in Texas were surveyed and seven patients who experienced complications were interviewed by phone. RESULTS: Nearly 53% of responding physicians noted increased complications resulting from nonphysician practice of medicine. Approximately 33% of responding physicians reported that complications were known to have occurred in the absence of an on-site supervising physician. CONCLUSION: The increase in the number of complications owing to nonphysician practice of medicine in Texas mirrors the increases that have been reported nationally. The serious complications reported underscore the need for improved awareness and regulatory changes by state boards of medicine