Faculty Bibliography

BACKGROUND: With the emergence of new laser and dermatologic procedures, the need for more effective topical anesthesia continues to grow. There are now several topical anesthetics that are being used prior to laser and surgical procedures. OBJECTIVE: To compare the degree and duration of anesthesia produced by four commonly used topical anesthetics, we performed a prospective study investigating the efficacy of EMLA (eutectic mixture of local anesthetics), ELA-Max, 4% tetracaine gel, and betacaine-LA ointment (formerly eutectic-LA). METHODS: Equal amounts of the above topical anesthetics plus a control (eucerin cream) were applied to 10 test sites under occlusion on the volar forearms of 12 adult volunteers. After a 60-minute application time, the degree of anesthesia was assessed immediately by a Q-switched Nd:YAG laser at 1064 nm. Pain testing was also performed 30 minutes after the 60-minute application period. Volunteer responses to pain stimuli were recorded using an ordinal scale of 0 (no pain) to 4 (maximal pain). The mean scores for the time intervals were obtained. Analysis of the data was performed using analysis of variance (ANOVA), Newman-Keuls test, Friedman rank order test, and paired t-tests. RESULTS: ELA-Max, EMLA, and tetracaine were statistically superior to control after the 60-minute application period. Thirty minutes later, ELA-Max, EMLA, tetracaine, and betacaine-LA were all statistically superior to the control. Comparing individual anesthetics, ELA-Max and EMLA were the superior anesthetics at both time intervals. Although the mean pain scores for each anesthetic were lower 30 minutes after their removal, the differences did not reach statistical significance. CONCLUSION: This is the first prospective study comparing the efficacy of several new topical anesthetic agents. Using the methodology of this study, in which the anesthetics were applied under occlusion, ELA-Max and EMLA were the superior anesthetics after a 60-minute application time and 30 minutes later. In addition, there was a clinical increase in efficacy suggested with all of the anesthetics 30 minutes after their removal

BACKGROUND: Warts are a therapeutic challenge. New studies indicate that pulsed dye laser therapy may be effective, with clearance rates of 72 to 93%. OBJECTIVE: To determine clearance rate in pulsed dye laser treatment of warts and compare our rate to those of other published studies. METHODS: Thirty-three patients with 96 warts received pulsed dye laser treatment for recalcitrant plantar, digital, peri- and subungual, and body warts. RESULTS: Forty-eight percent of patients had complete wart clearance; 45% partially cleared. Sixty-nine percent of those who cleared remained wart-free for an average of 11 months. Mean fluence was 9.4 J/cm2, with an average of 3.4 treatments. Body and palmar warts responded best, digital and peri- and subungual next, and plantar lesions worst. No significant side effects were observed. CONCLUSION: Pulsed dye laser is an effective treatment option for recalcitrant warts with an excellent side effect profile. However, our response rates were not as high as those previously reported, and we feel that further studies would be useful

INTRODUCTION: Striae are a common cosmetic problem with no effective treatment options. A recent study has shown improvement in the appearance of mature striae following a single 585-nm pulsed dye laser (PDL) treatment at low fluence. OBJECTIVE: To evaluate the effectiveness of treating mature striae with the 585-nm PDL. METHODS: Five patients with mature striae on the abdomen were prospectively treated with the 585-nm PDL at 2-month intervals for 1-2 years. The response of the striae to laser treatment was evaluated in each patient through sequential clinical, photographic, textural, and histologic assessment. RESULTS: All five patients reported a slight overall improvement in the appearance of the striae following multiple PDL treatments. Comparison of pre- and post-treatment photographs, however, failed to reveal improvement in any patients. Optical profilometry performed on striae impressions showed mild improvement in the surface texture of striae in three patients. Histologic comparison of pre- and post-treatment biopsy specimens failed to reveal normalization of skin architecture. CONCLUSIONS: Serial treatment of mature striae with the PDL results in mild, subjective, clinical improvement but no significant photographic, textural or histologic improvement

BACKGROUND: Basal cell carcinomas (BCC) arising on the genitalia are exceedingly rare with an unclear pathogenesis. OBJECTIVE: To better understand risk factors, tumor characteristics, and the possible role of human papillomavirus (HPV) in the development of BCC of the genitalia. METHODS: 1543 records of Mohs micrographic surgery performed during a 6-year period were reviewed to identify cases of BCC arising on the genitalia. Tumor tissue was analyzed for HPV DNA by in situ hybridization. RESULTS: Four patients with BCC of the genitalia were treated with Mohs micrographic surgery. The malignancies were located on the scrotum, perineum, and perianal areas in the three male patients and on the vulva in the female patient. The mean age was 67 years. None of the patients had prior history of skin cancers. Histologic evaluation of the tumors revealed two nodular subtypes, one superficial subtype, and one with follicular differentiation. In situ hybridization failed to reveal DNA of HPV types 6, 11, 16, 18, 30, 31, 33, 35, 45, 51, and 52. CONCLUSION: In this small series, genital BCC occurred in an older age group with no identifiable predisposing risk factors and did not show evidence of HPV infection

BACKGROUND: Both dermabrasion and high-energy pulsed carbon dioxide (CO2) laser resurfacing can improve the appearance of surgical scars. Although the results of these two procedures have been compared using historical data, a prospective evaluation has never been performed in humans. OBJECTIVE: To prospectively compare the clinical effects of dermabrasion and high-energy pulsed CO2 laser resurfacing in the revision of surgical scars. METHODS: Facial surgical scars in four patients were prospectively revised using a split scar model. One half of the scar was dermabraded and the other half was resurfaced with the high-energy pulsed CO2 laser. Comparisons of the two treatment modalities were performed through clinical assessment, photographic evaluation, and textural analysis of the scars. RESULTS: The high-energy pulsed CO2 laser-resurfaced halves of the scar were bloodless with less postoperative crusting in comparison with the dermabraded halves. Reepithelialization time and degree and duration of postoperative erythema were similar for both treatment halves. Photographic evaluation and textural analysis showed comparable improvement in the clinical appearance and surface texture of the scars with both treatment modalities. CONCLUSIONS: Both the high-energy pulsed CO2 laser and dermabrasion can achieve comparable clinical improvement in the revision of surgical scars. The high-energy pulsed CO2 laser offers the advantage of a bloodless field and a more precise method of tissue ablation. Postoperative erythema, however, is an expected finding with both treatment modalities

Squamous cell carcinoma of the penis is most frequent in uncircumcised men. Other contributing factors include human papillomavirus infection, phimosis, balanitis, and smoking. We present a patient, circumcised at birth, who showed penile squamous cell carcinoma in situ and was treated with carbon dioxide laser ablation. Squamous cell carcinoma rarely presents in patients circumcised as infants. Factors contributing to chronic inflammation may predispose to this disease. Carbon dioxide and neodymium:YAG lasers are two modalities that are successful in the treatment of in situ and probably early invasive penile carcinoma. Optimal treatment includes coordination with a urologist if urethral disease is present

BACKGROUND: Previous studies have shown the efficacy of short-pulse carbon dioxide (CO2) lasers in the treatment of rhytides and scars. To date, there have been few studies examining the histological aspects of these treatments. OBJECTIVE: The purpose of this study was to perform a prospective clinical and histopathological study of CO2 laser resurfacing for improvement of facial rhytides and scars. METHODS: A total of 23 patients were studied. Clinical improvement was evaluated both pre- and postoperatively using photographs and optical profilometry. Skin biopsies of rhytides were also obtained. RESULTS: Postoperatively, rhytides and scars both demonstrated significant increases in clinical improvement scores. Results from optical profilometry studies reflected these results. Skin biopsies from rhytides posttreatment demonstrated increases in collagen layer thickness. Improvement was sustained as late as 1 year following treatment. CONCLUSIONS: Histopathological studies suggest improvement of rhytides and scars by CO2 laser resurfacing may be attributed to new collagen formation following treatment

Several quasi-continuous wave and pulsed lasers can effectively treat a variety of vascular lesions. The PDL follows the theory of selective photothermolysis, is safe for infants and children, and has a low incidence of side effects. It is successful in treating telangiectasias, spider and cherry angiomas, pyogenic granulomas, venous lakes, and poikiloderma of Civatte, as well as small leg telangiectasias. Quasi-continuous wave lasers such as the APTDL, copper vapor, krypton, and KTP lasers can be used to treat telangiectasias and other vascular lesions as well. Although they carry a higher risk of complications, they may prove more useful in treating larger caliber vessels. Although the PDL often produces superior clinical results than the quasi-continuous wave lasers, some patients may prefer these latter lasers because of the lack of post-operative purpura. Lastly, newer lasers, as well as noncoherent light sources, are being developed for the treatment of leg telangiectasias. Continuing advances in laser technology will enhance results, decrease side effects, improve equipment, and reduce costs, with great benefit to an increasing patient population

BACKGROUND: Chemical peels using alpha hydroxy acids have become one of the most frequently requested dermatologic procedures. The use of glycolic acid in superficial chemical peels is now well established. However, the role of glycolic acid in medium-depth chemical peels has yet to be elucidated. OBJECTIVE: We performed a clinical and histologic comparison of 70% glycolic acid versus Jessner's solution as part of a medium-depth chemical peel using 35% trichloroacetic acid (TCA). METHODS: Thirteen patients with actinic keratoses, solar lentigines and fine wrinkling were evaluated prospectively. Each patient was treated with 70% glycolic acid plus 35% TCA (GA-TCA) to the right face and Jessner's solution plus 35% TCA (JS-TCA) to the left face. Clinical and histologic changes were evaluated at 7, 30, and 60 days postoperatively. RESULTS: Clinically, the GA-TCA peel was effective in treating photodamaged skin. The GA-TCA peel was slightly more efficacious in removing actinic keratoses (clinical response score = 1.5) than the JS-TCA peel (clinical response score = 1.0). Histologically, the GA-TCA peel caused the formation of a slightly thicker Grenz zone (mean = 0.053 mm) 60 days postpeel than the JS-TCA peel (mean = 0.048 mm) (not statistically significant). The GA-TCA peel caused more neoelastogenesis than the JS-TCA peel, while the JS-TCA peel resulted in more papillary dermal fibrosis and neovascularization than the GA-TCA peel. CONCLUSION: The GA-TCA peel is a new medium-depth chemical peel that is effective in treating photodamaged skin

BACKGROUND: The Q-switched ruby laser (QSRL) is useful in the treatment of benign pigmented lesions and tattoos. Two spot sizes are available in the QSRL (5 and 6.5 mm). It has not been shown if one spot size is more efficacious in the treatment of benign pigmented lesions and tattoos. OBJECTIVE: The purpose of this study is to compare the clinical lightening and side effects observed with the 5.0- and 6.5-mm spot sizes of the QSRL in the treatment of benign pigmented lesions and tattoos. METHODS: Eleven patients with 12 benign pigmented lesions or tattoos were prospectively studied with the QSRL. Half of the lesion was treated with the 5.0-mm spot size while the other half was treated with the 6.5-mm spot size. Clinical lightening of the lesion was assessed using pretreatment and posttreatment photographs. RESULTS: No significant clinical difference in the lightening of lesions or in the side effect profile was observed with either spot size. CONCLUSIONS: The 5.0- and 6.5-mm spot sizes of the QSRL are equally efficacious in the removal of benign pigmented lesions and tattoos. It seems prudent to use the 6.5-mm spot size when treating large lesions to reduce treatment time, patient discomfort, and treatment cost