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Color Atlas of
CosmeticDeraologySon ton
Zeina Tannous, MDChef Mohs/Dermatologc Surgery, Boston VA Medcal Center
Massachsetts Genera Hospta Dermatoogy Lase & Cosmetic CeterAffate Facuty Welan Center for Photomedce
Facuty Direcor or Deraopathology Depatet of Deatoogy, Harard Medca SchooAssstant Proesso n Deatoogy, Harard Medca Schoo
Bosto Massachsetts
Mathew M Avram, MD, DDecor
Massachsetts General Hospta Dermatoogy Lase & Cosmetic Ceteracty Diecor for Poceda Dermaology Traning Depatment o Deraology Haad Medical Schoo
Affate Facuty Welan Center for Photomedce
Bosto Massachsetts
Sandy Tsao, MDDrecor of Procedura Deatology
Haad Medca SchoolMassachsetts General Hospta Dermatoogy Lase & Cosmetic Ceter
Boston Massachsetts
Marc R Avram, MDClncal Professor of Dermatology
Well Cornell Medcal SchoolPrate Practce- Fift Aene
New York, New York
B Medical
New York Chicago San Francsco Lisbon London Madrid
Mexico City ilan ew Deh San Juan Seo Singapore Sydney Toronto
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he / opani-
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DEDCATON
I woul ke o e icae ts book o e eory o y belove ate
wo always gave e his uliate ove an suppot
Zeina Tannous M
I woul ke o eicae ts book to y woeu parents, Moe an
Maa Ava ou ave provie e u ncot io nal l ove a en esssuppor since te ay I was bo I love you
Mathew M vram M J
To y husba , ensi n ou ae y strengt an nsp raio our ove wiso aencourageent elp e eal ize anytn g s possib le ou are a woneu h usban
ae an bes e I wi l l ove you aways To y sons Sebastian a H uter ouncon it o a love, eusas an sense o aveue ep e emebe wa s uly
potan ou bigten my ays an i l y e wih ap pi ess an ove
Sandy Tsao M
Tis book is eicate o y we R obi n an y wo sons Robet an acob
I t a k te o te love an s up pot a t ey gve e evey ay
Marc vram M
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COTTS
Preface x
T HOOGINGChapte 1: Analysis of the Agig Face ad
Non-Fcial Regios . 2
Chapte 2: Topic reatmen Options. 7
Chapte 3: So Tissue Agmentatio . .. 4
Chapte 4: Botuium Toxi . . 2
Chapte 5: Chemic Pees . .. . . 29
Chapte 6: Nonabative Laser Resurfacig . 39
Chapte 7: Abltive aser Resurfacng . 43
Chapte 8: Nonabative Fractiona serResurfacig ....... .. 52
Chapte 9: Abltive Fractonal aseResuacig . . 57
Chapte 10: Tissue geng . 62
Chapte 11: Dematochaasis.... ... 64
Chapte 12: Poikilodema of Civae . 67
T TW DISORDERS O SEEOUSGLNDS
Chapte 13: Ace Vgaris ... . .. . 72
Chapte 14: Rosacea . 76
Chapte 15: Sebaceous Hypepasa..... 8
T T DSORDERS O ERINE GLNDS
Chapte 16 Hypehidrosis. ... . . 86
T DSORDERS O HIR OLLILES
Chapte 17: istism . 92
Chapte 18: Pseudofolicults .. . 99
Chapte 19: Mae Pattern Hair oss .. .. 03
Chapte 20: Female Patern Hir oss 26
Chapte 21: Low eve Light Tepy (L)and ar Loss . . 33
T DISORDES O IGMENION
Chapte 22: Caf Au ait Mcule .. ... 36
Chapte 23: Eedes . 39
Chapte 24: Lentigines . . . . . . 44
Chapte 25: Measma . .. 49
Chapte 26: Nevus of Oa . 54
Chapte 27: Postinmmtoryhyperpigmetation ..... .. 58
Chapte 28: Vitilgo... . . . . . 63
T X SUL LRIONS
Chapte 29: Angokeratoma 68
Chapte 30: Chery ad Spder Angomas ... 170
v
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Chapter 31: Granuloma Faciale . . .. 74
Chapter 32: Infantle emangioma . . . 77
Chapter 33: Keraosis Plars Atropicas . .8
Chapter 34: Po-wine Stains . 83
Chapter 35: Pyogenc Granoma 88
Chapter 36: Faca Telangectasas 92
Chapter 37: Lower Extremty Telangectasias,Reticuar and Varicose Vens 98
Chapter 38: Venos akes . .203
Chapter 39: Was . . . . . 206
T ENGN GROHS
Chapter 40: Angofbroma . .. . . .22
Chapter 41: Becker's Nevus . . .. 26
Chapter 42: Epderma Incusion Cyst 29
Chapter 43: Epderma Nevus 222
Chapter 44: Lipoma 226
Chapter 45: Mum . . . 229
Capter 46: Neurofibroma
.
23
Chapter 47: Seborreic Keratoss . . 234
Chapter 48: Syrngoma . . . . .238
Chapter 49: Dermatoss Papulosa Nigra . 24
Chapter 50: Xanthelasma . . . .243
vii
T UNEOUS RNOMS
Chapter 51: Actnc Keratoss . .248
Chapter 52: Basa Ce Carcnoma 5
Chapte 53: Sqamous Ce Carcinoma . . 256
INLMMOR DSORDERS
Chapter 54: chen lanus . 262
Chapte 55: Morphea 265
Chapte 56: Psoriass 67
T DIOSE ISSUE LERIONS
Chapte 57: Gynecomastia 272
Chapter 58: Ceute . .. .. . .. . 276
Chapte 59: HIV Lipodystrophy/FacaLipoatrophy 280
Chapte 60: Strae Distensae 285
T OUND HELING LERONS
Chapte 61: Hyperophc Scars, Keods,and Acne Scars 290
T TW EOGENOUSUNEOUS ERIONS
Chapte 62: Ear Percng 298
Chapte 63: Tattoo Remova. . 300
Chapter 64: Torn Earlobe . . 308
ndex 3
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PRFAC
Thee has bee a revoutio he treatmet of meical a cos
meic soes o he ski I large part this is ue to the availab ity of poceures a echnologes tha t pouce clear cosme
ic beef with ew si e eects an l ttle owtim e Wh the avetof lasers a ligh sources over the pas 20 years, cosmetc
impoveme is a matte o qick elat vey pailess proceres.
Noaser treatmets sch as soft isse f ers, botul ium toxiijectos, scl erotheapy, h ai transpa ntaio a oters have also
ramatcally expae he scope of is fiel hese poceuescoice wit the busy lifesye o may paiets who seek a
im poveme ap pearace tha oes ot erfere wth e r pro
fessioa, social o persoa obligatios
These proceres howeve, are ot without poteta sie
effects or compcatios Pysicias wo perform ese treatmets
i te absece of tag or eucatio are cea to ecoterpoo resus, complcatios a rate patets Because patiets
are prsug elecive teatmets for cosmetc benefit, ay worse
ig o appearace wi erstaaby age patiets who uer
ix
go these poceres. The ecsio as to whe not to reat a patiet
s pehaps he most mpoat tis ie With h s i m Color Atlas o f Cosmetic Dermatolo Second
Edition seeks to prov e a succ ct yet broa overview of cosmeic
therapy ere are a plethoa il usratios a graps to elcae
consutao, maagemet, treatmet a sie efects of nmer
ous cosmetic poce es. ts praccal oma is geare o the busypractiioer or raiee who seeks a quick comprehesive reer
ece for approachg te cosmetc patet t a so emphasizespialls of teatmet i orer o eucate the reae as to poteial
prob ems wt ceai treatmets t serves as a i va uabl e
resorce to both te experiece a ovice
Ze ia Taous M
Mathew M Avram MD, JSay Tsao M D
Mac R Avram, M
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ACKNOWEDGMENTS
We wol i ke o tak wo eople wo prove sgifcant e l n e
prodction o tis textbook Dr Rox Aderso a Dr Gary ask a i io we wol
i ke to ta k te office staff at te Massacses Geera Hosta Dermatoogy
Laser Cosmetic Cete a e oce sa of Dr Mac Avra for ther har work addedicato obtag hgqaity otograps
Fi al ly we wol i ke to tak te rofessiona l sta at McGraw l l forteir great elp a devoto i rocig his book Tak yo or psig s to
strve or te best possi ble Atlas
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tnnig Tis slcs s exacebated by a reexstng tea
tog defomty O bicl aris oc li m sce tosis can ceatea m ala r fl ness, efered to as a mal a cescent
Te midface ices te ceekboes tat form asmoot contnos convexty om te eyel to te l
Te meoabial od epesets a fa smoot jcto
between te owe ceek ad te ppe l p Te agngace ests n a ownwa migraion of e maar soft tis
se accetating skeeonzatio of te orbital imCetral ceek fat toss creates a fness ateral to te
melo abi a fod refered o as asolab ial fods
Te lowe face ossesses a weldefied madba bode an a weldefned cevicometal angle Wt aging
latysma! msce osis an ceek fat ptosis alog temanibe prodce jows" oveyig te awline So tsse
atopy anteior to te jows creates a rejow scs"
wi c acceates te skeletonized aearance Platysmatosis of te pe neck blnts te ceicomental agle
ceatig platysma bas o a tkey neck" defomity
Facial extral cages icle serficia an deeytes, gmentary dstbances, telangiectasia foma
ton oss of skin eastcity and actiic keratoses
PREOPERATVE EVALUATON
An inividalzed treatmen pan desiged to mnimize s
gica isk is essentia Te goal is a yotfl and naa postoeatve reslt A stae so d be fom lated for eac of
te tee facia zoes as wel as eac ndivdal nonfacia
egio as eac aaomic regio eqies a specific management wic infl eces te reman ig aatomic egios
A systematic evalao sod inclde te degree otexa cages, yd fomation pigmeay canges
loss o sbctaneos at, ca nges in acia m scate
cart i agos a nd bony srctes an eastic ty oss
Goga Phooag ig C lass i ca oW k l e S c a e
Te Gloga Potoagng Cassficao as been devsed
wc broady efnes te canges tat may be see at
differen ages wit c m ave s expose
ype 1-"no wnkes (Fg. 1 . 1 )
Early potoagng
Mild gmetary cage
No keatoses
Mn ma wr k es
Patiet age: wenties or t iies
Mi i ma o no make se
ype 2-"wrnkes n moton (Fg. 1 .2)
Early o moderate potoaging
Ear y sen e lent ig nes v sb le
Secion 1: Photoaging 3
igue A&B logau pe photoaging Fine lines barely visible
Minimal pigmenta changes noted
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4 Coor Atas of Cosmetc Deratolo
Keratoses alabl e bt ot visib e
Para l le l smi l e l i es begi g to apear
Patet age: late thties or otes
Us al y wears soe fo datio
Type 3-"wn kle s at est (Fg 1 3)
Advaced hotoagig
Obvos dyschro a telagiectasa
Visible eatoses
Wri les eve we ot movg
Patiet age: ies or older
Aways weas heavy fo atio
Type "onl y wnes (Fg 1 4)
Sevee photoagg
ellowgray A3 col o o s
P o s mal igacies Wri led togo o oal s i
Patet age: sxtes o seveies
Ca ot wea ma ep caes a cacks"
• Pgmetay Cages
A vtal asect o te atiet eva atio is te eterma
tio o f the aiets ski respose to eythemapodc g
doses o lavoet l g Ftzpatcks class icaio of
ski tyes ov des a stog i cat o of e otet a
for ost lamatory yer igmetat io ad hypopig
metat io a oet a l o yscomia o e de
ma l ad/o pa l la y ema l i jy (Tab e 1 .3)
TABE ipaticks Classifcaton of Skn ypes
Ski tye Colo Reactio to s
I Vey wh ite o frecled Always b sI I Wte sa ly brs
I l Wte to olive Sometimes bsI V Bow Rare y bs
Da bow Vey aely brs
V B lack Neve bs
A atiets teatet esose ca be deemedby assessig both te degree o hotodamage peset
ad te igmeay s tye A roceda isk
beefit ratio wil l d e eedg o te atets ii
v ida d gs (F gs 5 a 6) . I geea l , at iets
wth Fitzatr ic ski tyes I I I ca oleate moe ederma l ad derma l j w th m ima l r isk o res da l
dyschromia Pat iets wit F itzatr ick s i tyes IVV
ave a ig isk of residal dyschromia wit ceases ij ry tat may ec de the se o may treatmet
modal ies .
gue A&B /ogau pe photoaging yspigmentation and wrinkles
are evident
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Su bcaeos a Aophy
Agng reslts in a sgicat degee o oss or redistrb
t on o s bctaneos a especa l y o te oreead em
poral ossae perioral area cin and emaa aeas
Ts leads to a skeetonized aearance Restoration o
volme oss ests n te resapng o te ace or a
e onde appeaace
F a c i a l M s c a r e C h a g e s
Agng aso rests n msclar atroy contibng o
vom e loss As well dyamc yt es wc ae m sc
la n or igi n oten ceae an a g t ed or aged appearance Seectve cemca denevaton ovides maked
relaxation o tese lines.
Cha ges i Ca l age , Boy
Scues a Uer y gSuppo ive Sruces
Agng rests in saggig and loss o esil iency R ed apgrepostonng and dicios remova o skin and sot ts
se assist n te resorato o a yol appeaaceOce a systemc a proac as been ol owed te or
Secion 1 : Photoaging 5
Rs o aca re venaionrelax re l l ed rape and esr- acecan be applied soley or in combination to erestore a moe yot aearance
BBLOGRAPHY
Cng J En HC Angogenes is in sk n ag ng ad po
toaging J ermal 2007;3(9):593600
Davis RE Faceli ad anc l a acal cosmetic srge procedres Noi K eaoi S eds eiqe iermalgi Srge ondon Mosby 2003, p 33334
Fitzatick T Te validity and pactica o snreactive
ski n types I trog VI Ar ermal. 1998;12869871
Gloga R Aesteic ad anatomic analysis o te agng
s k in . Semi a Me Sr 199615(3) 134-138.
Montagna W Car s le K Kircne S piermal aermal ilgial Marer f Pamage ma
Faial Si. Selton C: RicardsonVcks 1988
Paes EC Teeen HJ Koop WA et al Peioral wrnkles:
Histologic deences between men and women AeeSrgJ. 2009;29(6):6772
Saw R B J r Kael EB Kolz PF et a Agng o te
mandib le and ts aestet ic iml ica ons Pla ReSr 201025(9) 332342
igue A&B logau pe 4 photoaging tensive wrinkle andpminent dyspigmentation
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6 Coor Atas of Cosmetc Deratolo
gure Female patient who avoided sun exposure throughout her lifeHer skin reects only minimal signs of photoaging
gure Female patient with a histo of extensive sun exposure in herlife Her skin reects extensive photodamage with dyspigmentation and
extensive wrinkle formation
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Secion 1 : Photoaging 7
CHAPTER 2 Topca reatment Optons
MECHANSM OF ACON
Suscree
The ulavioe (UV) aveleghs o lig associaed
cuaeous damage ae UVB (290320 m) a dUVA (32000 m ) igh.
UVB absorpio by DNA esuts a p53 uor sup
presso gene muaio resu ig pyrdne de
orma ion , ich is muageic ad ked to cua
eous carciogeess.
Acue UVB exposue resus n a suburn (Fg. 2).
Repea acue UVB exposues ove me ave been
assocaed i e omaion o basal ce cacnoa
and meaoa
Croic UVB exposure as bee ked o e deveope o aci c eraoses and squamo us cel caci om a.
UVA s uaeced by ndo gass, a itude, ie oday, or seaso ad ca poduce a a and dyspig
eaion out pecedi g eyem a
UVA lg peeraes deeply o he deis, poduc
ig many o e cl ical dings assocaed
phoo damage (Fig. 22)
UVA absopo by DNA resuls oration o oxy
ge ee radicas tought o conrbue o caco
geess. I causes mmunosuppresso ough hedepeo o angerans ce s ad reduced aige
presening cel acivty.
UVA exposure as bee lnked o he deveopmen omelaoa an ima modes .
Ceical suscee (Tabe 2 )absobs l gt n e
UV avelegth o g (UVB 29320 n) ad UVA
TABLE Chemcal Susceen Active IgedientsAvobezone
Cnoxae
Dioxybezone
omosaae
eyl anhran laeexoyl SX
exoyl XOcocyee
Ocy eoxycaate
Ocyl saicylaeOxybenzoe
Padate Paraam iobezoc ac id ( PABA)
Peyl bezimdazoe su lon ic ac d
Sul isobezoe
Troam ne sa icyate
Figue Patient with an acute sunbu There is marked swelling andredness present The upper back scar is the si te of a previous superficialspreading melanoma Courtesy of ichard Johnson M
Figue Patient with marked photodamage due to chronic sun exposureThe patient was an avid golfer and reported only occasional sunscreen use
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8 Coor Atas of Cosmetc Deratolo
32000 m) rasormg is l ig ino armless og
ave rad ao and re-emg as ea ene rgy.
Pysica screen (abe 2.2)scaers or relecs UV
rada ion . Ca a so absorb V l ig and re ease as
ea .
TABE . Physica Sunscreen Active IngredientsTiaiu m d ioxide
Zinc oxide
Sun proecve acorpmaly a suscreen oud provide proecion aga s e ul l specrum o V radaon .
e su proecve acor (S PF) s e oly ernaioa ly
sandardzed measure o a suscreens abily o ier UVradiao . I s e rao o e UV energy eeded o produce
a mimal erema dose (MED) o sunscreeproeced
sk o e UV eergy required o produce an MED o
un proeced sk . e America Academ y o Dermaoogy
currey recommeds e daiy use o suscreen
SP F 30 or greaer
Aioxidanseorecaly ork o reduce ad neura
ze ree radcals a damage DNA cyoskeeal srucures and celular proens. Tey also possess ai
nlammaory eecs and may pay a role i pigme
reduc ion .
n order o be bioogicaly eecive ese producs
mus be able o peerae ino e skin and remain
bologca ly acive og eoug o exe e desiredbeneis. A majoriy o e currenly availabe aoxi
dan p roducs are very usable i oxiaon makng em cemca l ly inac ive . Moecu lar orma ion
and packagng are key acors e sabizaon o
ese producs
Anioxdans may ork synergscaly o provde er
greaes benei.
Viamin Ce only anioxda o dae o aveproven beei or rikle mproveme due o s
ab l iy o icrease collage ormaio raer a isanioxdaive eecs.
Vamin demonsraed o iib V-nduced ey
ema ad edema i animals. as g coac
dermai s r isk.
Coezyme Qaural ly occurr g nur ien added
o many overe-couer producs. Currely ere
are o sudes available o documen s log-erm
beneis on sk agi ng.
debeon esyneic anal og o Coenzyme Q .
Re o ic ac dreoids are naural ly occurrg deriva
ves o -caroee ad labeed as vam A and is
derivaves ncluded are reinol realdeyde rey
esers ad renoc acid (Fg. 23) Is bees are bo
prevenave and reparave.
First Generation (onaromtics)
Retinol
CH20H
Tretinoin COOH
Iortinoin �OOH
Second GeneratonMonoAromtics)
Etretiate
Acitretin
OO
H
H
3
CO
-
Third Genertion oly-Aromtic)
Aroinoid
Adpalene
OOH
0
Tzrotene
Figure Chemical structures of retinoic acids The addition of aromatic
rings has made thirdgeneration retinoids more stable for more targetedtherapy with less potential side eects eproduced with permission,from Baumann L Cosmetic ermatolo Principles and Practice nd ed
New York McGrawHill 00
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UVB exposure resuls e upeglaio o sevea
colagedegadg ax ealopoenases, cldig colagese, geainase ad soeys ic
case colage degadao Reods ac o i n bi eind ucion o ese ea opoeiases
UVB exposure aso decreses collage poducion
Renods ok o i bit is l oss o pocolage syess
Treona isgeeaion enod ic as e
is avai abe opicl eioid I is a oselecvere o d , ac iva ig a e io c ac d paays is
no potosab le s ava ab le a gene ic o as
el l as n band oua ios suc as Reova adAva Cenly Reov s DA appoved or po
oagig Te io is a lso ava a b le i cob na io as
e no n 0. 025% c nd ayc or pa es seek
ig beeis or bo acne ad pooagig ad as
e no in 0.25% cobna io 4% ydo
qu oe ad 0.05% uoc ino lone aceo ide oypepigenao
Renotis podc ust be coveted o etade
yde and e o al seioic cid ii e ke
aocye ode o becoe acve us dspayingless aciviy a etio I is toug o be appox
aely 20% less poe a eioc acid s no as
eqey associaed i rriaion o erytea is
pi ai ly ond overecoe poducs a vai
os coceaions
Adapaenea idgeneaion eoid t seecive
aity o specic eoic acid ecepos, c
alos o oe ageed beei and educto opotea sde eecs I s oe ceically sabe
a eoi and does o beak don in e pes
ence o l ig C urely avaiab e as Dieri n a 0. %
and a 0.3% cocenta on I is cue ly DA
appoved or opica ace teapy
Tazaroeea ti dgeneaion einod seecive
aiy o speciic reinoc ecepos or oe a
geted beei Has bee associaed sgiicay
ge ir i o an oer reinods I s v lable n
0. % ad 005% ges ad in 0. % d 005%ceas s cu ely DA ap poved o opcal acne
eapy ad plaque psoiass
Skin l igening agestese poducs ac o ibi
one or mo e seps i e ela ni n bosytess paay
Te ai age is yrosase ic is e ae ingsep ean n poduc on (able 23 )
ydroqu ionepeo ic copoud ound aura y
i many plas, coee ea bear ad e
In b s covers on o yos ase o mea i
Deceases yrosi ase acviy by 90% .
ay i b i DA syes s
ay ibi RA syess
TABE Skn Lghteni ng Agents Tyrosinase ibtos
ydroquoneAoes
Arbun
Ascobic ac d
avoodsGe is c ac idyd roxycou arin s
Koji c acid
Licorice exac l bey exac
ea ocye ase i n ib io
Lecs
Nac iaide
Soybea/i exacs e aocye cyooxic agens
Azela c ac id
equ o loobenzone
Skn uove acceeao
Gyco c ac i d
Lacc acidL io le c ac id
Reno c ac d
Secion 1 : Photoaging 9
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1 0 Color Atlas of Cosmetic Deratoo
Can be cooxc o elanocyes poducing e
vesible ce damage i onobenzyl eer oydoqunoe
Cocern egarding cacnogenc poeiaurrenly
eaviy regulaed and/o baned i Eope Asaand sevea Aca cou nr ies
Availabe over-e-couer producs up o 2%and by pescpion n 3% o % coceaonsCan be copou nded u p o 0% cocenaion .
Cureny avai able n cobnao opica
reinod a cid a nd opcal seoid a nd i oe sk n
l igeni g agens
Reino ic ac i d
Acceleae epidera unover esu ing n increased keanocye seddg eading o pigen oss
ay nibi yrosnase ndcion
ay esu in keranocye pigme d sperson
ay neere i keanocye pgme n a se
Naural coseceucals
Kojc acdderived o vaious unga species
suc as Aspergillus and Penicilium Pra ly usedas a ood pesevaive and o pooe he edden
ing o unpe saberies Geneal y used n % o% concenaon. Noed o ave g sensi zing
poen ia
Licori ce exraceved ro e roo o Gcyrriza
g/abra linneva Is ain acve igredie is
gabidin I iibs yosnase acviy assocaed cooxiciy. as been so o be 6
oe eicacious a n ydoquinone
Azeac acdderived ro Pyospou ovale Isecansm o acion n o ul ly udersood I
orks bes o acive ea nocyes.
Aoesndeived ro aoe vea. I acs as a copei ive nibior on OPA oxidaio and nonco
pei ive nhibior o yosine We used n
cobnaion i arbun, as been demon
saed to inb UV-duced eanogeesis
Arbunerived om e bearbery I acs oin i bi ea nosoal yosiase acviy Avai la be as
a ono eae or n % concenao i oedepge ning agens.
Pape u bey-eived o e roos o a ona
enal ee Broussonetia papyrifera
Soyacs o nb keanocye elanosoepagocyosis us reducig ela ranser
Cosmeceuica l eec noed ol y res soy lk
Niaciadeacs o inbi eanocye ranser
Aso exbs ani naaory ad an-oxda
propees
Table Use of the ''teaspoon ule" for sunscreen a ppi caton can bebenefic a n educatng patients on the proper of amount of sunscreethat shoud be appied with each appl cation.
Use o ore an a a easpoo each on:
ead ad neck egion
Rig a
e ar
Use o ore an a easpoon eac o :
Aerio orso Poseor oso
Rig eg
e leg
(D fro Daos ZD. ocds i Costic Dtoo Cosctics.
Sds 2005.)
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Ascobc acidacts at vaos oxdatve steps
n ean in synthesis by ieractg wh coppe i onsat the yosnase active sie and educ ig d opa
q noe .
Glycoi c acidhas a ep dea d scohesive eect,esult ing in ncrease epideal tnover or
nceased shedng o pgented keatnocytesShoud be se in lowe cocentaons o avod
skn i at io
NDCAONS
Reduce e occence o actic keatoses and non
eanoa skn cancer
Redce te oaon o sk n agng
Rhytides
Ephe des
Lentigines easma
Postinlaatoy ypepigentaion
PREREAMEN EVALUAON
Eva uaon o peexistng al lergies to a y actve ingedent
Past poduct use and esponse
DEAL CANDDAE
Al patients benet ro e daiy appcao o a topi
cal s usceen, SPF 30 o geate
Patents wth reastic expectatons that topca edica
tions may povie peveatve benets an ae ess
ikey to edce oerate o deep hytides
LESS HAN DEAL CANDDAE
U ealist ic paient expectatons
Patents wth arkedy dry o sensitive skintopcal
teatents ay exacerbate condito
CONRANDCAONS
Preexisng a legy to actve ngredent
Use o topica l etino i sa cy ic ac i and skn ghte
ing agets n p egnant and lactang woen
APPLCAON ECHN QU ES
A sunsceen shold be appl ed a n u o 30 in
utes prio to sun expose
Secon 1 : Photoaging 1 1
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1 2 Color Atlas of Cosmetic Deratoo
Approxiaey 35 s e aveage ao o s
scee a soud be applied o e average-sizedadl eac appicaio Tis aslaes o a ea
spoo (approxiaey 6 o suscee o eac leg,
back ad ces ad a a easpoo (appoximaely
3 m ) ap p ed o e as ace a d eck o u l cover
age (abe 2) opical reioc acd producs sould be appled spa
gly o eae aeas 30 iues ae asig o
i i mize poeial o ir a io.
Beachg ceams should be app ied o ypepg
eed eae aeas oy eos ade o avod
vo ved ski
COM PLCA ON$
Coac al egic derai is
Coac iia derais
Ace la e
Ski peel g
Xeoss
yea
Phooaegic eaco
Phoooxic eaco
eoeca edcio viai D absopio i su
scee use
Hypepigeao ih beac g crea se
xogeous o cooss i bleac ig cea
Hypopigeaio beac g crea
Poeial cacogec r isk o ydoqu o e se
POSREAMEN CARE
Sic poopoecio sho ld be o oed dai y ic ld
g su avodace as uch as poss ib le , e use o a
daly sscee SPF 30 o geaer use o a debred a ad s proecve clog
PEARLS FOR REAM EN SU CCESS
i ze e u be o podcs app ied da i y o avode poeial or iiaio
Check he expaio daes o al poducs appl ied hs
s paicular key o suscees, as e acive iged
es ay o povde beei beyod e ecoeded
dae o use
opical eoic acd poducs soud be dscoied
2 eeks pro o acal pocedues suc as axig o
eezi g i ode o avod ski d esquaaio
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Beachig ages should be discoiued i edess o
iriaio deveops as hey ay ose exsig pgea io.
s useu o dscoue he use o a hydoquoe
cream every 3 o mohs o decrease he risk oexogeous o cooss a d o peve s de eecs
BBLOGRAPHY
Bruce S Coseceucals o he aeuao o exr sc
ad s ic dea agig. J Drugs Dermatol, 2008;
7(2 Supp) s17s22.
Cove R, Piel SR. opca l v iami C agg Clin
Dermaol 1996; :22723
Dreher F, aibach Poecve eecs o opical aoxdas i huas. Curr Pbl Dermatol 200029: 1 576.
Fiser G, Talar S, Li e a olecula mecasms
o phooagg i hua s i i v ivo ad he preve oby al l as rei oic acid . Phoochem Phoobiol. 999;69:
1557.
Gesler L, Aick Peg e a I porace o heor o opica viai E o peveio o phoocarcio
geesis. Nutr Cance 996;26:183191
Guevara L, Pada AG. elasa reaed ih ydoqu oe reio i an d a uoraed seod lnt J Dermatol
2001 ;30:212215
Kag S Vooees Pooagg erapy i opical
reoi: An evidecebased aalyss. J Am Acad
Dermatol 1998;39:S55S61
Ki ga A The grog i porace o opica reiod s
in cliica deaoogy: A reospecve ad prospecve
aalys is JAmAcad Dermatol. 998;39:S2S7
L W aylor , oiga , e a . Aer ica
Academy o erao ogy Cosesus C oerece o U VA
proeco o suscees, suay ad recommenda os . JAm Acad Dermatol 2000:505508.
Naylo , Boyd A, Smih D, e a . Hig su proecioacor suscrees i e s uppessio o acc eopas a
Arch Dermato/ 1 995 3 : 70 75 .
Ogde S, Sauel , Grihs SE. A evie o azaoee
in e eae o phoodaaged s i Clin lntervAging2008;3( ) :776 .
Picad , Carera e ad experea eaeso cloasa ad oe ypemeaoses. Dermatol Clin
2007;25:353362
Scheide The easpoo u le o appy ig sunscee.
Arch Dermatol. 2002; 38:838839.
Soao F Briga S, Pcardo , e a . Hypopigeig
ages: A updaed revie o boogcal, ceca adciical aspecs. Pigment Cell Res 2006;19:550571
Secon 1 : Photoaging 1 3
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1 4 Color Atlas of Cosmetic Deratoo
CHAPTER 3 Soft Tssue Augmentaton
M ECHANS M OF ACTON
Use o a syneic or bo ogcal produc or srgca resrc
ring or e repacee o voue loss and enance
e o dera subcaeous and uscla r deciences
ha resu ro rau a s rgca deecs poaroph ic co
d ons pooaging or croological agng.
DEAL FLLER (Table 31)
Bocopa b e
Non iuoge ic
Noncarcnogenic noneraogec
Nonresorbabe
Nongraory
nexpensive
as y obained and sored
asy o adiiser
Provdes reproduc ble coseically beecal res s
FDA approved o auoogos
Deosraes u ipu rpose se
No sde eecs
asy o reove n he even o a poor cosec oucoe
TABE . Commoy Used Fi l ig Agets
Name
Adaos i 5000 (DoCorn ng d l and l )
A oder (L e Cel Corp. Brancbu rg N ;Obaji edca C cago L)
Aqad (Conura Inernaional SoeboraDenar)
Are i l (Cander Phara nc Quebec
Canada edca nera iona V B redae Neerands)
Beoero So Beoero Basic (erzPara Franur Gerany)
BioAcad (Br ind is I a ly)
Capique (l naed Corp Sana
oca CA)
Cosoder™ Cosoplas™ (A ergan
I rv ie CA)
Cyera Lie Cell Corp. Brancburg NObaj i edica Ch icago IL
Co posiion FDA app rova Ski esig requ red
S icone No No
Acel lar processed u an es Nocadaveric dera al logra
Polyacrylaid e ge No No
Bovne collagen i poy( ey No es
ehacrylae) beads
Noaal ya ron ic ac d der ved No Noro baceria erenaon
Poy-acrya de No es
Non-an alsab l zed yaluroc es No
acid(NASA) derved ro pan
Recobian u an co lage es No
Acelu ar processed lyop izedhu a n cadaverc ssue
No
Longeviy
Perae
2 yr
Perae
Perane
6 o
Perane
6 o
6 o
6 o
(coninued)
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TABLE Commoy Used Fiig Agets ontinued
Name
Fasca (Fascia Biomaeia s, evey
Hi l s CA
Fa, subcuaneous
Hyaom® (Bioma ix nc . , Ridgeie ld , N ;! naed Cop Sana oica , CA
lso age ( l so agen c . , Hoson, TX
uvedem™ Ua, Ura XC Ulra Pls,
Ula P us XC (A Iegan, I nc . , ine, CA
Preve le Si k ( eo Copoaio, Sana
Barbara, CA
Radiesse (B ioom edica , San
aeo CA
Resyae Resyae, Peane
Per ae ™ (Qed AB, Sede;edc is Phoex, AZ
Sil ikone000 Adaos l5000 (Acon absI nc, For Woh, TX
Soorm (cGa edica Sana
Babaa, CA
Sculpa™ (Boec ndsy, SA,
Luxeboug Dek Beyn, PA
Zyderm®, Zyplas (AI egan, ine, CA
PREOPERATVE EVALUATON
Composi ion
H um a cadavei c pesevedpaicuae ascia aa
Aoogos
Hyal oc acid deri ved odom esic ol coxcom bs
Auoogous ibrobass
o-a ma sabi ized yauron ic
acd (NASHA deived ombacea ere naion. XC
omulaions ih 03% id ocane
onan i malder ived ya uoic
ac d ih 03% idocane
Syheic cac iu m hydroxyapae
oamasabil ized hyaluonic
acid (ASHA deived rom
bacea ermeao
ormua ons h 03% idocae
S l icoe
Goeex
yoph il zed poyLacic acd
Bovie co agen
deiy he appropae paen and eame egion
Sgiica pas medca soy, icudig isoy obeed ng o co ig d sordes; kelod omaio; exs
ing dug al egies; immunocomprosed sae
Cure medicaio use pas o curen isoeinoin se
Pas surgical inevenions, year, ad eamen
response
Cin cal evaluaion o deemie i e desed eame areas are aenab e o coecion ou ie base
l i e sucua iregular i es
Dscuss lie soeing vesus volue epaceme o
i ler seecion
Discuss medicaos o avod 10 days preopeavely
en medica ly sae, inc d ng aspr in , nonsero ida l
edicaos, vamn suppees, S os Wo
and oer erba ed icaons a ave a a nicoagulai ve eec
Secon 1 : Photoaging 5
FDA appova Sk esg equ ed Longevy
No 3 m o
N/A No 9 2 mo
es No 6 m o
es No 2 yr
es No 69 mo
es No 6 m o
es No 92 mo
es No 9 mo
No No Pemane
N/A No Peanen
es No 2 yr
es es 3 o
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1 6 Color Atlas of Cosmetic Deratoo
Dscuss te rss ad beeits o te treamet
A ergc reactio , localzed versus sysemc
Procedura ad posoperatve discomo
Posoperatve edema
Posoperave bruisg
Scar ormato ecio
Reacvaio o erpes sm plex vrus
compl ete augmetao
rregula r coou /texu re
deiy cora d icaos o reamet
Active ieco at t e treame ste
Nodisesibe r gd, or icepic scars
Extesve jol ormaio promi e olds a d urros
d eryig coecive t ssue disorder
m mu ologic d isease Pro alergc reacio o ller/reaed l er/postive
s es
se o sore oi ii te precedg 6 o 2 m os
Pregacy
reast ic expectaios
Out e the predicted oucome ad l imiatos to ereame
Duraio o correcio
Posopeatve recovey perod
ssue source
Expese
SK N TESTNG (WHEN APPLCABLE)
iial es doseto si ess recommeded
eced i ubercul i ma er o vola orearm
Fouree o bseratio per od or s test
Repea s es placed i oppose orearm
Toee observao period or secod test
Retest d osesig e test recomme ded
Fo e pates o ave received reame byaoer pysca or paies ho have o received
reame or more ha yea
Toee observaio period recommeded
Post ive i l er reacio
Sel ig, duraio ederess or eryema apersss or occurs 6 hours o loger aer test impa
tao
A postive si tes s a absolute coraidicao o
l l er use
Fgure Massager utilie uring filler placement to minimie treat
ment iscomfort
Fgure Clinical finings afer EMLA application to skin Expecteblanching lasts apprximately to hours afer application
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ANESHESA
eco o so ssue l ers may be paiu, especa ly
w reame o e ips. os paies require someorm o aesesia o mimize reame dscomor
"Takesesia, adodig, vibraoy assager ear
e reame sie are useu o pae disracio( F i g 3 . ) .
opca aesesa ca be ui l zed or smal reae
areas. Commoy used ages icude Beacaie
Eaced Ge (Caderm, Quebec, Caada), Beaca e
Pus (Caderm, Quebec Caada), X ad5 (Ferdae Labs, Ferda e , ) , ELA (AsraZeeca
Boso A), ad ice (F ig 32)
Ldocaie iegraed drecly io e i ler may e imi
ae e eed or aeae ors o a esesa .
Regioal erve bocks are eas ly admsered prior o
reame. e pae sould avoid exremey o or
cold beverages ad oods or 2 o 3 ours aer mealad/or raorba erve blocks o avoid m ucosa iu ry
due o iab iy o deec eperaure accuraely
Localzed umesce aesesia is ui zed or a
exracio w auoogous a raser
ilraive aesesia is o be avoded o obviae issued so o o e eame sie.
PROCEDURAL MED CAON S
Varex 500 mg BID x 5 o 7 days i aed 1 day prior
o e procedure or paies wi a sory o erpes
sm plex vrus or ear e reae sie
Keex 500 mg BID x 7 days iaed 1 day prior o e
procedure or paies udergog auoogous a ras
er or Goreex impaao
Dazepa 5 o 0 mg ca be oered o axious
paies 30 mues prior o e pocedure
LEVEL OF NJECON (Fig 33)
Superic ia ders e l es; verm io boder l p aug
eaio
Zyderm , I ; Cosmoderm , ; Resy lae F e ie;Hy aorm F e ie
id o deep dermis supericia o moderae rydes,
scars, ad deecs; ip augmeao
Capque; Cosmoderm I Cosmoplas; yaorm;
uvederm ra ; Prevel le S lk ; Resy ae; Zyderm I I ,
Zyplas
Deep dermis, subcuaeous a, ad musce: deeper,
more subsaa deecs ad rydes ( Fig. 3 )
Auologous a raser; GoeTex; ylaor Pus;uvederm ra Plus; Perae; Radesse; Scupra
Secon 1 : Photoaging 7
Figure ecommene filler injection epths Aapte from KeyvanN, usana LK, es Tech niques in ermatologic urge Unite
Kingom Mosby; 00
A
BFigure (A) Prominent nasolabial fols prior to augmentation withhyaluronic aci (B) ofening of fols aer c hyalunic place intotreatment sites
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1 8 Color Atlas of Cosmetic Deratoo
Comba io demal subcuaeous ad muscle :
deecs ih boh a supeicia l ad a deep compoeui ize bo a supeic a ad deep ixe o opma aug
mea io (F g 3 5)
NJECON ECHN QU E (Fig 36) Seal pucue: cosely spaced pucues ceaed
alog es o ds (F ig 37 )
Liea headig: daal o l e alog he egh
o e aca deec as a coi uous h read o maea(F g 3 8) .
Fai g: s m lar o ea headi g N eede d rec io is
couay caged hou ihdraig he eedle
p Useu o oa commissues uppe asoabia Aolds
Crosshacg: simia o l iea readg aeial s
jeced a ig ages o e rs ijecos Used o
sapg ac ia coous
DEGREE OF CORRECON
Depede o he l le used I geeal overcoecio
s o ecommeded The mos commo ecique
ero is udecoecio
u ipe eame sessios ae geealy equred o
volume epaceme ages c lud g s i l coe ad
poy-Lacic acid
DURAON OF CORRECON
Depede o e mae ia l m paed m paa io ech
que ad amou mpaed he ype o deec admeca cal sresses a e i mp aaio ses
ADVERSE REACONS
• Hypesens ve
Prooged eryema a d edema a ecio ses
Cysabscess omaologasig ca persis o
moe ha 2 o 3 yeas
Grau oma oma o
Aapyaxs
• Nonypesens i t ve
Bo m
Bru s g
ecoic lud es eacivao o epes sm plex vrus
ad bacea eco
BFigue (A) Facial lipoatrophy with "sunken cheek appearance priorto Cymetra treatment (B) Impvement of cheek volume afer Cymetratreatment, 0 cc total volume
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Necrossde o vasclar coprose a e ea
e se
Nod e oaon/bead g
Paa vs o osse o vascar coprose a e
reaen s e
Ulcerao
• e c h q e C o m p i c a i o s
rregl ar exede o u even placeen
Beadgue o oo sper c a p acee ( F g 3 9)
I p lan rejeconue o oo supeca placee
Necrossde o vascar eco or vasclar co
presso
PEARLS FOR TREATM ENT S UCCESS
W lers e aeced eaen ses sod be y
age ed o esre a eve cop lee ageaoUdercorreco w l lead o a nadequae agena
o and pae dssasacon W os epoay
lers s s oba ed a e s reae Per aelers reqe repea reaes or corecon cople
o
W eporay l lers paens s dersad a
e reamen respose s varable and ca as less
a or greae an e average expeced e Repea
reaen w be req red over e
Paen expecaos s be epered o nze
nreasc expecaos abo ller benes Paess be aware a e reaen edpo s a soe
g o e aeced a reas
Posopeave beadng s geneally resposve o local
zed assage over 5 o 7 days Perssen beadg can
be correced by njecg 2 g/ o r acoloeaceon de no e bead or by -b lade nc s oa l
exraco o e l ler aera
A ooug preoperave evaaon s necessary oensure a ere are o cora dcaos o l er se
especa y wen sg perae ers.
Coservave ageao o e gabe a rego scr ca o avod vasc a r necoss
BBLOGRAPHY
Beer K Solc N yalurocs or so sse agea
o: Paccal consderaos and eccal recoeda ons J Drgs Dermao. 20098(2) 086-09
Clak DP ake CW Swanso N. Dera plas:
Saey o p oducs jeced or so ssue a ge ao J
Am Aa Dermao 9892 :992998
Secon 1 : Photoaging 9
Figure Injection techniques A Linear threaing technique B eriapuncture technique Aapte from Keyvan N, usana L-K, esTech niques in ermatoogic urge Unite Kingom Mosby; 00
Figure eria puncture metho of injection
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20 Color Atlas of Cosmetic Deratoo
Cohe J desandg avoid ig and anagig der
a l le copl ca io Dermal Srg 2008;(3 Spp) :S92S93.
Coean S R Fac ia l recoour g ih i poscupure lPlas Sr 19972(2)37367
Glac AS, Coe L, Godberg H necio ecross o
he gabea: Proocol or preveio and reate aeruse o deral ers Dermal Srg 2006;32(2) :27628
oes DH Seiperaet ad perane iecabe
i lers . Dermal 200927()33
aarasso SL ecable collages: os b o ogo
ea eve o producs, dicaios ad eco echques Plas Recsrc Srg 200720(6 Supp ) :
7S26S
Sc u le rPeovic S I povig he aesheic aspec o soisse deecs o he ace us ng auoogous a ran sp an
aio. acal Plas Srg. 19973(2) 192
Fgure Lnear threang metho of njecton
Fgure Fller beang ue to too superfcal placement
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CHAPTER 4 Botunum Toxn
PHARMACOLOGY
Bou um oxn is poen poduced by the bceum
Clostrdum botulnum Seve seoypes exs, desigteds A, B, C , D, , F, d G c oe o em is pro
ese ih gt c i ed to evy c i by dis ul
de bondc s gecl ly ds inc Hoeve, botu um oxi
A (BTXA) B ( BTXB) , nd e te oly seoypes curret ly v i l b e o c i c l use (Tble 4. 1) .
TABE Botul um Toxi Preparatios
Type
Boox Cosmetic (AI Iegn c. , vieCA )ype A
Rex (edicis setics, Scosde,
AZ) Dyspor ( pse Lmited, Bekshie
U )ype A
Reox/Dyspor
yoboc (So ice eurosceces, S
rncisco CA)ype B
Xeomi ( ez Prmceu c ls ,
rut, Germny)ype A
euoox (edyox, Ic, Seou,Sout ore)ype A
Prosge (nzou Isitue o BiologcProducts, nzou, Ci)ype A
M ECHAN SM OF ACON
is oxi/bole
100 yopil zed pode
500 yop l ized
poder
Avege 12.5 m i
preservtiveee opreserved sle
2,500, 5000, d
0,000 /m queous
soluo
100 U v i
1 00 v il
50 U vl d 100 v
I b i io o cey lchol ine e lese t the eu romuscu
ju c ion resu lt g i muscu cc id p lys is Receptose bi dn g s med ited by e evy ch poion o he
ox, is specic or e ox seotype, d is evesbe.
Oce boud e ecepore u ooxi complex s intezed into te ee eml d e oxi g ch
cs s poese o ceve specic syptc poe
peptide bods equired or ceylchoie omio Therge o BTXA s the sypsomessocited poe o
25 kD SAP25. BXB d BX ceve e vesicessocied m emb ne prote synpobevi
Dosg equ ivlets
1 Boox Dyspo
1 Botox 2.5
No e estblsed o
cosmeic use
Repoted 1 Boox 1
Xeomi
Repoed 1 Boox 1 Neuoox
o e l esb sed
Secon 1 : Photoaging 2
D lu io
Avege 1 mL inpreserviveee opreserved sl e
My be used s s or d i l ue
ih s l e
o e l estb ised
o e l esb is ed
o ell esblis hed
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22 Color Atlas of Cosmetic Deratoo
DLU TON
BTX-A is soed in yophi zed vials can be recos
ued i preserved saline o presevaiveree salne.D lu ios vay accodg o physician peerece and
experence h BTX. A d u on ranges om m
(0 U/0 cc) o m L (25 /0 1 cc) . Dyspo di l ued o2.5 l aain a concenraio o 20 /0. cc. The
injeced voume mus be suiciey sal o provideaccurae oxin delvery hou an excessive voume
eec o delivey o oxn o suoudng musces ohe
han e argeed uscles. he voue mus be suicey age o permi accurae njecon no he ageed
usces .
CONTRANDCATONS
• Absolue
Udeyng neuouscula codi ion such as yashenia gravis o ayoroph c aera sclerosis
Pregnancy/breas-eedigpegnancy caegory C
Acve i necio in eaen area
U ea is ic paien expecaions
• Rea ive
Calciu chane blockes usemay poenae eec
Anogycosde anibioic usemay poeniae eec
Paens ho ae dependen o acia expresson o
her i ve hood (eg, acos)
Proen eyeid poss, heavy bro o ecopion
PREOPERATVE EVALUATON
Paen expecaons us be deined and ached
ih h e expeced eamen oucom es
Paen edca l hsoy
Pas eaen hi sory and ou come
C in ca l eva ua on
Deemie locaon and exen o nvovemen o he
reaen si e
Documen asymeies noed presence o posis/ld
axy/bo poence
• owe Eyel i "Sap Back es oAssess Lowe Laxy
The ddle o he oe id is grasped beeen he index
inger ad he hub ad pu ed oad and upad
The l id s hen eeased and al oed o snap" back
rocrsscl
s l sscl -=
:.
vo ispior is
siscl
I
vo\ sp o s scl
Zyg maticus
jo sc
Fgure Anatomical illustration of the upper an mifacial musculature
X
�
Fgure Approximate injection sites for the forehea to obtain a more
horiontal brow This patte is most frequen tly use to create a moremasculine bw
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agais he globe. A q uic k eu o s omal sae di
caes mi ma l la xiy. Boul u m oxi o i s ego caprovide beei . A slow eu o ski o is aura posi
o dicaes sg ca axy Bou ium ox shoud
o be used ese paies as i may acceuae he
l es pese
PROCEDURE
Pae cose obaied
Preoperave picues ake a es ad wi ageed
musce groups coraced
Prereame w opcal aesheic o ice or pai
reducio
Pae paced u prig
eame areas wiped wih a coo
jecos adm i iseed. Use o 1 m syiges wih a 30
o 32 gauge eede s requey ui zed. Use o su syriges w a iegraed 30gauge syrge ad a
ubess sysem may ep o educe ox volume loss
MU SCLE GROUPS
A hooug kowledge o he aca muscuaure ad
aca aaomy s equred o e poper use ad paceme o bou i um oxi ( F g . )
oehearoa i s M sc e( g s 4 . 2 a 4 . 3
Inseion: Origaes a oal boe gaea apoeuoca
ad ses o ibes o e poceus corrugao ad
orb cu la rs ocu
Function: Opposes depesso m uscles o e gabel a
compex a d brows o eevae e bow a d orehead
Lines noted Horizoal ies acoss he oeead
Injection technique: 2 o 3 uis (U) added a 15cmievas across e mdorehead a miimum o 2 m
above e up per bow
Dose injected: Average 12 o 20 U
Avoid:
xcess reame o s muscle uopposed depresso
ucio wl l esul i oss o upper acia expressio a" red" a ppearace a d r sk o brow poss.
eame o s musce e oals is su ppoig apoc upper eyeid o e pae as owse bows
ad/o excess upper eyelid s k
Ijec 1 m above he eyebrows o reduce e isk o
brow posis Paie mus be awae ha esdua ies
wl l be p rese ae he reame i ow orehead wr
kes are pese
Secon 1 : Photoaging 23
A
BFigure . () Forehea lnes pror to BTXA treatment (B) Forehea
lnes 1 month followng BTX-A treatment
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24 Color Atlas of Cosmetic Deratoo
jeco oo close o e med a obia r im ; oxi d iu
sio roug e obial sepum o e levao pa pebaesuper ior is ad ob icu a s uscles ay lead o d p opia
• G abe l a Comp exhe Corgaor
S u p e rc l , he P ro ce r s , M e a lO rb i c l a i s O c , a o na l i sM s c l e s ( g s 4 . 4 a 4 . 5
Inseion O gi aes a e asa pocess o e oa
boe ad exeds laeay ad upad o iset io em id de d o e eyebo
Function Opposes elevaor muscles o e roas o
bro adducio ad bo/ski doad ad edalovee
Lines noted ro ies; agy" o oied" appea
ace
Injection techniqu Femaes ave aced eyebos;maes ave ae o ozoa eyebos; ecque aloed o ac e bo sape; 3 o 0 U o e pro
ceus; o 6 U e ierio ad supeio bees o e
cougaos; 2 o 3 o e media obicu as ocul i
Dose injected 15 o 0 U (depede o usce mass)
Avoid
U deeame o i s egio
Too o o a ijeco esu ig i oxi diusio io
e orbial sepu ad obi resua id poss
Pa paio o e supeor boy obial im i ijeco m o moe above is adak eps o mize
is r isk
Coc ure reame o e oeead a eavy bo soed
• Per ob a l Reg oOrb i c a s Oc I ( F g s . 4 . 6 a 4 . 7
Insetion Ec rces e peoba ego a d ses o
e media a d laera ca a edos as e as o e
ibes o e oal, pocerus ad corugao supec l i musces
Function oceu closure o e eyes ad depresso oe bos ad eyelid s
Lines noted aeral caal es; cos ee"
Injection technique 3 o 5 are eced io ee
pois i a veica le 1 m rom e aeral caus; i asog sap es is oed 2 o U ca be placed 3 m
belo e mi d pupi l ay ie
Dose injected 22 o 38 U
X X
XX
X
�
.
X X
Fgure Appximate injection sites for the glabellar frwn lines() Female brow (B) Male brow
Fgure () Glabellar complex before BTX-A injection an (B) weeksfollowing BTX-A injection
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A
njeco o he iaoba ego i a delayed snp es
is noed; ecopo o he injeced d may deveop
Oveeame o is aea mpope eye cosue, bo
poss o lid posis may esue
An ecio ai med oo o a e loe peiobial
kes Weakeing o he evao abi supeiois musces
h a uppe l ip doop nd boma sm e may beobseved
• ppe Nasa l Roo (F ig 4.8
se cicles he peiobil egio and ises i no
he m edil and aea ca hal endos as e l s io ebes o he oal, poceus ad cougo supec l
musces
t sa k ing
es te Up pe ose a g hdes; bu y l es"Ijecio ecque: 2 o U s ijeced no ech ae
sa l l no he bel y o he u ppe asa i s as i aveseshe dosu m o he ose
Dse jete o 8 U
A Ijecon o e uppe asoacial goove may
esu i l ip poss
Use o bou um oxin he loe ce is mnimaly
beneca Ohe eame moda es ae l kely o be
moe benecal h ee poeia side eecs A sog
und esand g o he l oe ace d eck aomy s c iica o eco pcemen (Fig 9)
• N a s o l a b i a l o l ( F g s 4 1 0 a 4 .
I s key o eig e imied benei o BTXA hs
egion comped h he nceased isk o compicos Fll g ages may povide geae bee h
ee sde eecs
se Resul o ski lax gvaio poss and
subcueous a loss oveying e cuaneous atch
men e zygomacus mao nd mio evao ab isupe o is ad evao ab i supe o is a laeque as
musces
t Assocaed i mou ad p moveme
es te Pomien cease, media l cheek gummy
sho"
jet teqe o 2 U neced o he uppe
aspec o he nasoa bia od 2 o 3 m m l aea o is ise
o ih he nose
Dse jete 2 o U
A
Complee eaxon o hs ea; uppe lp poss ce
ig sd appeaace my occu
Secon 1 : Photoaging 25
N
�
� ·
t
, '
·
Figure Apprxmate njetn stes fr perrbtal lnes
A
BFigure 7 () Perrbtal lnes prr t treatmen t wth BTXA (B)
Perrbtal lnes 6 weeks fllwng BTXA treatment
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26 Color Atlas of Cosmetic Deratoo
Ueve paralyss a asymmeric smle or dspopor
oae l i p may be see
• P e o a l R e g i o O b i c u a s O sw i h C o i b u i g b e s o m
h e B u c c n a o , C a n i u s , a agu a is Musc les ; DepessoA ng u l i O s ; M e a s M u sc e( F g s . 4 . 1 2 a 4 . 3
sei Orbicuar s ois orgiaes from e max lay
a veoar border ruig c rcmere ia ly arod emou o e overy g cuaeous aacmes depres
sor agu i oris ( DAO ar ses om e mad b lar ob l q ue
l ie iser ig o e age o e mo I s co iuosw e playsma muscle; mealis muscle origiaes
from e madbular cisve fossa ad desceds o acaeos serio
i Oppos o ad proruso o e ps mou
age depresso lowe l p prorusio ad c dimpg
ies e Deep ad superficia rhydes, ppe ad
lowe l ip ; promie agula o ds sad appearace" ;
ch i w l g
jei eie 0 5 o 0 U eced 2 o 3 mm
above e vemi o border i or aeas each for e
upper ad lower p 1 o 2 ijeced a e ersecioo a l ie d raw from e asolaba l od ad a aea 1 m
above e awlie age 5 o 0 io e ferior midc h i
Dse ijee o 8 U or e u pper ad ower ps; 2 o U or e DAO; 5 o 0 or e meals musce
Ai
Overreame of is area; speec dfcules, a
asymmer ic smi e ia b i l y o c ose e mou d roo l ig
ad alered acia expressios may esue
Dee p eco s; i creased rsk o sde efecs
oo ig o a iecio or e DAO abliy o raisee corer o e mou may develop
• NeckPlaysma Musc e Comp lex( F g . 4 . 14
sei Oigaes o e fascia o e upper pecoalismaor ad deod musces ad proceeds upward ad
media ly al og e sdes o e e c Fi bers are seedio e ma di ble, subcuaeous issue of e ower face,
peroral musce, ad si
i Facial aimaio; lowe jaw depesso; ower
i p depresso
ies e ec wri l g; cera l bads
·
)
l
Figure 8 Approximae injection sites for upper nasal root es
sporss
r ar s sp or s
r ar s atr or us
-
= +
0 rb cu la is or is us:fDepesso
a o s s
psso abi i rors s
Figure 9 Ana tomical illustration of the musculature of the lower facean neck
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Injction tchniqu 2 o 5 njeced rom e supe io o
ineior poio o eac paysma! bad a o .5 minevas i e paies ee cleced o conac e
musce d ur g ec o
Dos injctd 20 o 00
Avoid Too deep a injeco neck eakness larygeal
musc e eakess or dysphagia may develop
POSTOPRATVE CONS DRATO NS
c e o cold c ompresses may be app i ed o reduce pos
s ib le bru is i g ad edema
Acive conacio o he reaed muscles or 20 o 30
seconds evey 30 miues or ours aer reamemay expedie oxi upake
Physca aciviy sould be imed or ours aer
reamen o avoid he eoeical possbi iy o uo
ard oxi d iusion
COMPLCATONS
asie pai
Eyeid poss
Eyebro poss
Bru is ing
Headache
ncomp ee or asymmeric chemica deervaio
Dpopia
Dry eyes
Ecropio
Asymmer ical smi e
Drooling
Deceased pucker
Dysphagia
Puncae keraiis
asklike expressionless ace
Anbody resisace
Flul ike sympoms
TREATMEN T BEN EFTS
Recovery rom BXA paralysis geerally begis a 3 o
4 mohs aer iecio. Paiens ho ouiely eceive
BTXA may noe e recovery ime o exend o o6 mos over ime. Side eecs icudig eyeld ad
eyebro poss ad bruising geneay resolve ihi 2 o3 eeks o ose Teame bees may be egeed
ih c ocom a coservave use o a i le or so issu e
augmenaio
Secon 1 : Photoaging 27
Figure Approximate injection sites for nasolabial folds
Figure Approximate injection sites for the perioral muscles
Figure 2 Approximate injection sites for the depressor anguli orismuscle
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28 Color Atlas of Cosmetic Deratoo
PEARLS FOR TREATM ENT SU CCESS
Paties ith o eual izig atibodies agaist
BooxA may respod o yoboc give he ack o sigi ca coss eacivy betee he o oxi s
Oy FDAappoved botu ium poducts should be ui
zed Ulcesed boul num oxin may esul i severe, eeaei g botulis m
he eve o an eyeid poss, use o (adrenegic
agos eyedops such as apraclondie hydochoide0.5% eyedops (lpdie, Alcon, For Woth, may
be used o povide empoay id elevaio
Paties shoud be nomed ha he maxmum beeto Boox ca tae up o ees to deveo p
Deep uros il oly pa a l y espod to boulium
reatme Combiaion therapy th a i e subsacemay pov ide the bes c l i ica edpoi
shoul d be emphas zed o paiets ha a sgle bou
u m reame i l no be compeely eecive i e im na ig a l reaed l nes ad r kles As e l , i t shou d
be expa ed tha some es idua l muscular moveme ishe des ied eatme ed poi
BBLOGRAPHY
Alam , Dover S Adt Pai associated ith i ec
tio o boulum A exooxi ecosiuted usig isotocsodiu m ch lori de h ad thout pesevave: A dou ble
b id , adomized coto ed t a Arch Dermatol
2002; 38:505
Alse T, upo Bou i u m toxi ype B o dyam ic
gabear hyes eracoy o bou um toxi ype A
Dermatol Sur 200329(5) 5658
Blizer A Binde WJ, Aviv e a The managemet o
hypeucioa aca l ies ith bou um oxin A collaboaive study o 20 injecto stes n 162 paes
Arch Otolangol Head Neck Surg 199723:389392.
Bad FS , Boe A Botu l i um oxi o the eatme oec ies ad ec bads Demao C 200;22: 1 59
66
Cauhers A Boge Caruers D e a A andom
ized, eval uaobl i nded ocente sudy o he saey adeect o voume o he duso ad ecacy o botul ium toxi ype A in he eatme o ateal obia
rhyes Dermatol Surg 200733:56757
Caruhers A Kiee K Caruhes Bou ium A exooxi use i cl iical demaoogy J Am Acad Dermatol
996;3:788797
Caruhers Carruhes A Botu l i num oxi A i th e mdand loer ace and ec Dermatol Clin 200225
58
Figure Approximate injection site for the mentalis muscle
Figure Approximate injection sites for the platysma muscle complex
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Crruhers Mrrso S; Botox Consensus Grou
Consensus recoed o on he use o bou l nuoxn ye A n c eshecs Plastic Reconstruct Surg
2004; 14 1 S-22S
Cheow S Tn E Mslnk SE e Bou is i4 d s ol l owng coseic necions wih n u n censed
hghly concened bolu preprion JAMA2006;29624762479
Hs TS ove S Arnd KA Eec o volue d co
cenron on he dusion o boul n exotoxn Arch
Dermatol. 20044035354
Leoun C Bou l in oxn A nd c i nes he vr
be cocentron Aesth Plast Surg. 200257384
Zibler MS ods B Koosk MS e Eec o bou
l nu oxn reemen on ser resucing ess A
rosecive rndozed b nded r Arch Facial Plast
Surg. 200 36569
CHAPTER 5 Chemca ees
MECHANSM OF ACON
Th e ppl ic ion o woudi ng gen o i nduce epiderlnd/o der s loghng
NDCAONS
Eder deecsehel des es
Eder nd derl deecsels ent g nes
pos-inlory hypergmenton cinic ker
oses s uperci l ryes cne vugrs
erl deecsdee rhyes cne scrig scrs
PREOPERAVE EVALUAON
Peeling gens e seeced bsed on he pes
lesyle deec deph skin chrcteistics nd deeclocion (Tbles 5 15 3 )
Ps edcl hsoy
Ps rdo hsoryecresed dex structresl ike y
Hsory o or hees splex vrusrecvon
y occur
Pregnncyees conr di ced wh he exceion
o gycoic c d
Hsory o keoid oronodere nd deedeh peels should be voided
Secon 1 : Photoaging 29
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30 Color Atlas of Cosmetic Deratoo
TABE C iical Ind ications and Pee Types
Ind c ion Peel type Peel deh/ree ed pon
Acne vu lgr sEphe des e ig ies
Su erici l when civeSuper ic i l or ediu
Loc zed eder eelng requred eso roveenTol eider peeling requ red or coee remov ; l gheing
wih superc l ic ion
Pos-l ory i nlonMels
Super ic i or ediuSuperic i l or ediu
ol ep ider l peei g equ ired; l ighei ng wh either srenghTol ei der peel ing requ red; l igheni g wih eihe srengh;
ncossten resonseLoclzed eider peeling requred; soenngSupeci rhytes
Mod ere hy es
ee rhyes
Acn c ke roses
epressed scrs
Supeic i l
Mediu o deeee
o ederl nd ppil ry der pee g required; soeningo eder l o recul r der peel requi red; soeni ng
Me d iu
Med iu or deep
o ederl o ppil del peeg requred; esion clerce
Leson edges rgeed; otl epider d ri derl
peeling requied esiol leing; vrible response
TABE 2 Wound ing Depth of Supeicia l, Medu mDepth ad DeepDepth Strength Peels
Superci peel Medi umdeph peel ee pee
ydroxy cdModi ied nns resorcino se
esser's
Gyco c c id d CAesser's nd TCA
Bker's Gordon pheno, uoccludedBker's Gordon pheno, occuded
Sl cy l c c d
Sol d crbon d ioxde s lush
renon 0%25 % TCA 35% vbe
TABE 3 Peeling Agent Characterstics
Peel ype
Glyco c c id
essner
CA (30 % or geter)
Phenol
Ps surgc hsory
Color end pon
Conue erhe
Ple wh te
Sol d whie
Gry wh ie
Sol d crbon d ioxide nd TCA50% TCA
Pyruvc cid
88% Full-sength phenol
Ap cion
2 cos
Cos re pp lied s gy nd
endpoin oniored or
34 n prior o repe
l ic ionSinge even pp ic on ;
oclzed icos or
gher whie res ybe consideed
Snge eve l icion ; cnbe conservvely reped
Pror cosec proceduresprior ce blephropsy, crbon doxide resurcing or derbrson
y ec eel oucoe Icresed ecropion r isk
presen
Medcon use
Prevous soreion use nd yer
Topic edicions such s reino nd -hydroxycids y oenie ee enerion
Coudn use
Hel ing ie
2 h
45 d i ld epde
desquto noed
104 d ; sevee
sunburn- ike pee ig
observed
104 d; suer c i
burn ernce
Se or
A sk i ypes
A sk in yes
I nd I ; cu ion
wh I nd IV
I n d I I
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Fizrck skn hooye
Skn ooyes I I I ens resond o l eel yes
Skin hooyes IV nd V iens lso resond o
ee yes, b u e r isk o osree dysigen
io is greer
A es se y be wrr ned or drker sk yes oeve eel oucoe
egree o cn c d ge nd ooging
A we le o dercion beween eeled ndun eeed skin y be roinen e resece o
odere o severe deroheloss
Woods l evluon
He l i n scer ni g igenion ye resen
Eider or g in es o co or ennceen
(F ig 5 )
er l o r cob i o e ider l nd der l no
lesionl color enhncee o g
xnion does no ccurely redc cl iic eelresonse
Eiderl igen y resond beer o eeling
ges cored wi der or cobinion gen deos ion
Medic clernce
A recen elecrocrdogr s necessry o serve s bsel ne or henol eels n he even o crdi ooxcy
Lver n con nd re un cion ess shol d be ev
ued o ensure deqe heoren uncon or
heno eels
DEAL CANDDAE
Skin ooye I or I
Aci i c dged skn
Sc rhdes ssocied wi sun exosure
LESS DEAL CANDDAE
ync rhyeschieved benes re eorry in
nure
Exensive grvionl ods nd rrowsikey o
reqi re surgcl nervenon n conjuncio wh ce i
cl ees
ee rhyes
Boxcr cne o r odere de roc scrr ig
CONRA ND CA ONS
Un reis ic ien execions
Pien uble o eor ecessry osoerve cre
Secon 1 : Photoaging 3
Figure Thirty-one-year-ol female with melasma Woo 's lamp accentuate her facial pigmentation
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32 Color Atlas of Cosmetic Deratoo
Ptients with iceck scrs or deep troic scrs
Ptients with dited rge ore sze
History o or isotretnoin use within yer pror to pro
cedure
History o keoid ortion
Ptient wit underlyng crdic rrhhis (or deeeels)
Coud n use (or dee peels)
Skin hototypes I l V (or deep ees)
MEDCATONS
Preoertve ntvir edictios re recoended
Vltrex 500 g B or Acyclovir 400 g n t ited
on te dy o rocedure nd contiued or 5 to 4 dys
s dinstered depending o ee deth
opicl retinoic cd d -ydroxy cid rodcts re
discontiued 48 hours rior to glyco ic cid eel nd week pror to deeper eel nd not reinit ted or
week ost tretent
WOUN D DEPH
eter ed by ut ip e ctors
Antoc considertions
Fcl sk ders ro noncil skn i the relt ive
nuber o i losebceos units er cosetic unit dthickness Proinet dex strctures re required
to proote reeiteztion ost tretent The nose nd oreed hve ore sebceos gnds
thn do te ceeks or teles
The ce hs ore sebceos glnds thn the onc i res inc l d ig the neck
More ctin i c ly d ged skin is t n ner with ewer
p osebceous u its present
Body loctio nd presence o ctiicl y dged
skin signi icntly ects te seection o the wonding
get he pee ing gent y be ore destructive n
res with ewer dnexl strctures nd thinner skin;
thereore ess ggressve peeling gent shoud be ut
ized in these res
Preeel ski dettngse o cetone to det the
tretent re reslts i deeer enetrtng pee
Wondig gent strengt ncresed strength wi l
resu t i deeper ski n peel ing
Aou t o gent li edeeer skn enetrtion with
ec eel yer lied
AFigue 2 () Epiermal melasma unresponsive to topical bleaching
creams
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PEE L YPES
Suerici eelsr or coee eiderl nury;
y exend ino he i ry ders (Fig 52A nd B)
Mediudeh eelsinury exends ino he lry
o uer eicu r ders (F ig 53A nd B)
ee eelsinuy exends no he d-reicurderis
PROCEDURE
Preoerve wrten consen obned
Preoerve icures ken
Pens keu reoved nd ce censed wh nnisec wsh (eg chorhexidine)
Scrb he reen re wih ceone on coon guze
or 2 o 3 nues
he eelng gen shou d be oured no gss cu h e eel ng gen s ied o he reen sie
A inbush o coon b y be used o ly glyco l ic c d
A sble br sh s recoended o essne ee or
incresed enerion
Coton-ed icos or coon guze y be
used o ly ichoocec cid (CA) eeling
gens
One or two sl coon-ed icors re used
or heno icion
A round oohick o wooden orion o brokencoton-ied ico y be sed o re
ind iv idu l hy des nd ce ck cne scrs
he nuber o icors used nd he ressure ied o he reen sie wih gen licon
wl ec souon delvery nd deh o eneron
(F igs 5 4 nd 5 .5 ) .
A n s req ired o he educe he ssoced en
dscoo
Prereen wih essner or glycoic cd ror o
CA eel ows or deeer eel enerion
Feher ng ino he h i r in e nd he w ine concels
he ossible ine o dercion Fehering shoudso be eored when he erio re s reed
one o reven l nes o dercion ( Fig 5 .6)
he eriorb issue shold be eed is wih TCAees, olowed by he nose cheeks eior re nd
orehed o bes en olernce he uer ndowe eyeld s y be reed Exension 2 o 3 ono
he eiol vei on s benecil or rhyes reduc
ion
A s ne syr inge should b e v i l b e n h e cse o nd
veren noducon o he eeling gen ino he eye
Secon 1 : Photoaging 33
Figue 2 (continue 8 Mil improvement note following two 50%glycolic aci peels
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34 Color Atlas of Cosmetic Deratoo
he icor shoud be wrng ou nd sei-dred o
reven driig The gss conine shold be hedwy o e en o void drec si l ing oo he
en
essner ee CA d heno eels re se
nelzig Gyco c cid ees s be neurl zed
wih we or bicrboe souion Cool wshco s ied o he reed res
Vselne is ied o he reen sie or esser
TCA nd henol ees Gycolc cd ees equre
g osr ize
ee eels hve inheren crdic ren d heic
oxc ies F ce cion req es nrveos ds sedion crdc oioring ulse oxieer nd
blood resse o ior ng
COM PLCA ON$
Greer deh o eel rovided hn execed ( Fig 5 7)
neconvr bcer ugl
eorry o ernen hyerigenon or deg
enon
Proonged eryhe
Scrngrohic hyerrohc keoid ecoon
de yed hel ng
Conc deriis
exrl ch ges
Acne
Mi l Crd ic rryhs (dee heno eel)
Lryngel ede (dee he o ee )
POSTOPERATVE CARE
A l gh osizer s l ied wce d l y or gycoic c d
eels
Vselne is ke on ound e cock wih wice d y
clensig so nd wer esser CA nd heno
eels
Sic hooroecion is sressed or ini o onh er gycolc cid eel d 2 o 3 onhs or
he re nder o eels
Pens re nsruced o l low nurl s lough g o he
reed ski n Te skin s no be n ly reoved
PEARLS FOR REAM ENT SU CCESS
Ceul en seleco nd eel seleco is neces
sry or een su ccess I s bes o un dere wh ess oen eelng gen i noncil res o ii
ize e r sk o sc or on
AFgure 3 () Pseuoochnosis The pigmenta changes persisteespite iscontinuation of the inc iting meication
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Pens s be wre o the exected recovery e
wh ech cheic eel nd he necessy osoerive wound ce hey wil need o eror o exede
heng. Alhough one dee ee y ovide he gre
es beet iesye or work consrins ke serl
suercl or ediu-deh ees beer ong-er
go h e rgn o sey is ch nrrower d he r sk o
cocions ch greer wh ncresed eel
seghs
Piens wh skn hooyes I l l nd IV hve greer
r isk o deveoing regnncyindced hyereso
e che cl ee Cos derio n o test site is w
rned or eddeth ees
Cheic l ee s wi l no lter oe s ze nd y in c
inc rese heir sze
BBLOGRAPHYBke Godon H L M osenko P e Longer hi so
logcl sudy o skin e cheic cil eeng. PlasRecsr Sr 197453522-525
Brody H Med deh chec eel ng o he skin : A
vro o suerc cheosurgery. A Dermal1988;3205-220
Gries PE. Mes Eiologc nd theretc cosider
ios. Arc Dermal 19973 453-1457
Gross . Cdc rhyhi duing henol ce ee ing.
Plas Recsr Sr 1984 73 590594
Klign AM Bke Gordo H. onger hisoogcollowu o henol ce eels. Plas Recsr Srg1985;75652659
Lndu M . Co b ion o cheic l ee ngs wth bol n oxi iec ons nd derl i l ers . J smeDermal 20065(2) 226
Mc Kee GM Kr L T he ree o os-cne scrswih heo Br J Dermal 195264(12) 456-459
Mrsso S G logu RG Che cl ce eels. Dermal
i 1 99 9 3 50
Monhei G he essner'sr ichloroceic cid eel.
Dermal li 19953(2) 277-283
Murd H Shbn AT Preo PS The se o gyco ccd s eeling gen. Dermal li 995; 13(2) 285-
307
Que SK Bergsro KG Hyergeion Od robe
new heres. Drgs Derma l 20098(9)879882
R ll P Kr A M. Cheicl ees or drke skn yes
acial Plas Srg li Nr Am 2 0 1 0 ; 1 8 ( ) 1 1 3 1
Szzchowicz EH Wigh WK. eyed he ing er ul l
ce chec ee s . acial Plas Srg 19896(1 ) 6-13
Secon 1 : Photoaging 35
Figure 3 (continue (B) Marke pigment lightening aer three Jessner5% TCA peels
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36 Color Atlas of Cosmetic Deratoo
Fgue Fine white color immeiately following a 0% salicylic aci
peel
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Secon 1 : Photoaging 37
Figue Pale white color immeiately following a Jessner peel
Figue oli white color immeiately following a Jessner5 % TCApeel
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38 Color Atlas of Cosmetic Deratoo
Figue 7 Patient with line of emarcation between the Jessner5 %TCA peel treate perioral area an untreate skin Patient appears
hypopigmente in the treatment site A subsequent meiumepth peelto the remainer of the face resulte in a more even facial appearance
Figue 8 Localie fsting following application of a 50% glycolic aci
peel The localie peel resulte in some mil esquamation for ays
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Secon 1 : Photoaging 39
CHAPTER 6 Nonabatve Lase Resufacng
NTRODUCTON
Thee re l le lser nd l ight sorce eens or
hooging These reens rnge n eiccy nd side
eecs. Tycly here is rde-o beween clinic
i oveen nd concon i ncrese n sd e eecs
nd downe ro work nd socl civi es Oher
chers hve ocsed on sc eens s nonb
ve rcon resrcng blive rcionl resrcingnd rdi ionl resrcng. Tis cher exines non
b ve lser resurcng nd n cl e se o
i di nrred lsers. Oher devices sch s i nense lsedlgh nonbve rcionl rescing sers nd vs
cr lses so chieve nonbtve benes nd re
ddessed n deil i n oer chers.
Phoogng encosses l he chnges odced byexosre o rviole (V) rd on incding elngiec
sis hytes oor skn exre nd one s wel s
skin xiy (see eohelioss cher) Nonbive
revenon es sn dged ski n by heing der l
co l gen wih he i o s i ng new col lgen grohI is lso eecve n he reen o cne scs
der coolng s rovided o ensure h her
heing s rgeing e deis nd no he eideris.The bes dvnge o nonb ve reens s h hey
reqi e l i le ny downe ro work nd soci cvies Ths s in conrs o blive nd rcon blive
retens. n ski led hnds side eecs re yiclly
i d nd eorry (F g 6 ) Oen ey rodce sbe or i d benes even er
t ile reens. nornely e redicb iy o
ioveen is ncerin Soe iens do no exeri
ence ny discenibe bene even er l le re
ens. In he s ew yers nonblive rconl lsershve rodced enhnced resls ro oer ors o
nonb live rescng wih l le reens Theselsers ve lso roven o be se in skled hnds W
the dven o nonbve rcionl sers rdi on
nonb live lser rescing hs declin ed n o r yn dd i on o nense lsed l igh sorces nd vsc r
lsers ere re n y nonb lve devices h l ize vsible ner-inrred nd idinrred wveenghs wh
eder skn coo ing These wvelenghs get he
wer h s b ndn in derl isse The skn coo ngroecs gins eide dge hese sers ro
d ce deeer derl enerion greer bsoron nd
der l hel inu ry th n vsculr lsers Fher here
is signicnly decresed risk o igenry chnges n
drker skn hooyes hese wveenghs. Whie hebes cndides or reen e those wih ild o od
ere sc rhyes e degree o iroveen erreten s diic o qny
Figue Vesicles appeare 1 ay afer treatment with a 1450nmioe laser with a Fipatrick skin type 1 patient These esicles com
pletely cleare without sequelae ays later
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40 Color Atlas of Cosmetic Deratoo
No bve sers
Su ble proveen o rhy es rcul r ly when copred o b ltve devices
Bes or pens wih ld o odere phood
ge skin xiy, nd ski n corseess Requres u iple reents o rovide d prove
en o ski n exure, one, nd rhyes Le o no osoperive dowie copred o rdi
o a bve devces
Pten c reur o work or soci civ ies the se
dy s he proced re
Cn re coseic uis eecivey whou lines odercio
NDCAONS
nd c ios
Mld rhydes
Phoodge i c udi ng skin exure d one
Acne scrs in cu din g boxcr ropi c ro l g scrs
Su be bee
Mld proveen in skn lxy
No eectve or dync or deeper rhyides
PREOPERAVE EVALUAON
Sk in ye (cn tre drker sk in ypes wih id rred
sers bu req res cton wih ski coo ng)
Sun exposure Hsory o keoids
sotreno in use in st 6 ohs
Ptens wih unresc expecions
A consulon is requred beore s reen ossess the pie s we l s rorey prepre he
ptien or he procedure The ten should be yeduced s o he r isks nd bees o he p rocedu re I
is ierve h expectos re se reis ic y n
ers o h e i ld degree o i roveen ht w l l oenbe see or rhes The en shoul d so be i ored
h he ben eis o rhyid reen ccrue 3 o 6 onhs
er ree
PROPHYLAXS/ANESHESA
M y n c ld e n y o he o l owing
Antvir proyxs
opicl nesheic
23% idocne% ercne
7% docine/7% ercne
utecc ixure o oc neshec (E MA)
A
BFigure 2 () Patient with EMLA uner occlusion prior to treatment ofacne scars (B) Treatment with 1450nm ioe laser with C cooling
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Becse soe o d-inrred lser reens cn be
nul soe or o neshesi s oen requi red . w lvry ccodng o he ggressveness o reen he
riculr ssceibi i es o he ien, nd e hys
c ns coo wih vros neshec regens .
Mi iae Lases
The 320-n NdAG ser (Coooc Inc Rosevi e CA eures erl eedbck syse h esres
eder eerre o oe recsely rge derco gen. Ths he lse sgeon cn conro heng
wih oe recson I s heorized h new colgen
siion is cused by inlory cyoknes er
Secon 1 : Photoaging 4
derl he ing. AThe 450-n d iode ser (Soohbe Cndel
Cor. Wynd MA so rges derl wer while
roecng he ederis wh cryogen sy device
( Fg 6. 2) The re s no e ere eedbck device. Wheher device ggressive coong cn odce eory
igen chnges.
LASER SAFETY
Eye oecon el eye gogges
A esonnel resen e e o reen s
wer sey glsses/gogges o void indverenconel dge.
ADVERS E S DE EFFECTS
Adverse side eecs r ess coon n blive ocedres bu do occur wh higher lences s wel s
indveren lse scking (ie, ir ng wice n id sc
cesson over he se e
Scrr ng
B e ( g . 6 2)
Posinlory hyergenion (sl y roovery ggressve skn cooing)
Posopeaive Cae (Fig 6 . 1
L e osrocede i n
Any erye s d nd resolves shoy er re
en
hee s no reqireen or ollow- vs er re
en .
No osoerive cre s reqired.
Pen shod be i nsrced o cl i erhe ersiss
or i ves ic les or b le develo (F ig . 6 )
B
Fgure 3 Pretreatment an immeiate posttreatmen t photos of nonbruising pulse ye laser treatments There is mil erythema aer treatments Many patients note an impvement in the texture an tone ofskin after a series of treatments
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42 Color Atlas of Cosmetic Deratoo
Posoerve eryhe resoves qicky Sric sn
voidnce s recoended
The o owing prcices l l s ign icny ncrese he
risk o scr
Aggressve reens i ncrese risk o scr
Poor ech iq e ie excessive overl ( se scking)
In s onb lve ser resrci g rocedres oer
he dvnge o qick se reens h roduce
ild iproveen o hoodged skin slly hey
cn be erored on he se dy s work nd socl
oblgions Noeheless, he reen hs s drwbcks sch s
Resuls re s y odes
ro o benei, i ny s no known
Bes resus oen reqire ore ile reens
Becse he iroveen s oen sbe nd nre
dcbe even er ile reens oher roce
dres sch s nonblve rcon resrcng hvein cresigy s lned he el o rd on no bl
ive rocedres
BBLOGRAPHY
nzi EL, Wl s CM Aser S reen o ci
ryides wi nonbive 450 diode ser A con
ro ed cl n ic nd hsologc sdy Dermal Srg.2003;29(2 ) 124-128
nzi E Alser TS Corison o 1450-n dode
lser d 320n dAG lser he ree orohic c l scrs A rosecve cl in icl d hsoogc
sdy Dermal Sr 200430(2 P ) 15257
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Secon 1 : Photoaging 43
CHAPTER 7 Ablatve ase Resacng
MECHANSM OF ACON
Uti zing the rinciples of selective hoothemosis
aba ve remova of skn n a recisel coo led fasho
with resu lant mi ima srrondig herma damage is
achieved Te deth of t issue eneraion is deenden
on se ective a bsotion of waer I mm ed ae ss ue eecsare deenden on he spot sze ad owe uized as wel
as e seed o reatme admnistrao The me oflasertissue neaction is the ci ical factor fo resdua
therma damage E iderma ob ierat io and(o art ia l
ab a on or coaguat ion o the uper dermis s the edpon Reeithe ia ization resus from te mgraion of
cel s that ar ise from srrounding fo l cu ar adnexae
Norma comact co lagen and elastic ibes repace the
amorhos easotic derma comonens and normalweoganized epithelia l cels repace the dsorganized
hotodamaged eiderms Collagen remodelg s noted
both ntraoperative via themal shr inkage and conrac
ton and ostoeratve wiin the remodeig phase of
wond hea ig
Cabon D ox e Lase(C02 Resuac ing)
Contin uos wave ( 0600 nm) sue-ulsed and
scanned C asers are ti zed or esfacig A rela
t ve b oodess surger wih educed swel l i ng is ac hievedvia the hoocoagu ative efec on blood vessels and lm
phatics The r isk o scarr ing unpredictable evel of themal da mage and d eaed hea ing of he coniuous wave
laser imt its c iica se he scanned and ulsed Clasers de iver igh peak uences in less an 00 0 seconds to achieve tssue vaoizaion of 20 o 30 m er
pass Approximatel 40 o 20 m of residual thermadamage is noted pe ass (F ig 7 )
E b u m : Y i u m A u m n u m G a e tLase (E :YAG)
A aser of wavelegth 2490 n m i s uti l zed or moresuerficia resufacng I is 6 moe selectvel
absorbed b waer t acheves tissue vaporizaion of to
5 m per ass It resuts n a naowe zone of esidualtherma damage (30 m ) A s a zone of thema dam
age o 50 m or greaer is equi red or photocoaguation
Er:YAG teament resuts in a s i ghtl bood surgica ied
The therma damage s a so isc ient to produce
immediate colagen coracto ongerm colagenremode ing is imited (F ig 72)
AFgue 7 () A 5-year-ol woman with extensive actinic amage
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Color Atlas of Cosmetic Deratoo
NDCAONS
Abative lasers have been uti ized as a cutting too ad
vaporz ing tool t o treat e dermal and supef ic ia l dermallesons.
Cung too kelods, ace keloidal s nuchae, cst
remova , basa l cac ioma bur and u cer debr dement hair taslatato beharopast othe nci
siona s urgeries where coto ed hemostasis s desired
or whee ei ephr ne is containd cated or a pace precl udes use of eectosuger
Vaporzng tool treatment of numerous condit ionsncluding static and dnamic rhtdes boxcar cratei
form ad hertrophc acne scars pox scars, warts,
entigines, adenoma sebaceum agokeratomas, o
genic granu oma, lmhangioma c rcumsc iptum,
Bowen's disease ethroasia of Queat, ora f o dpapi omatosis, actn ic chei t is , actn ic keratoses, ep
dermal nevi, sringomas ganuoma faciae, neurofi
bromas, xanthelasma, and tattoos.
Not idcated for the treatment of cepick ace scas
PREOPERAVE EVALUAON
Sgn ifcat ast med ca h sto nc udes a hi sto of her
pes lab ia l is unde ing auto mmue d isease o immune
deficenc underlig koebnerizng/infectious condit ions
including psoriasis, verucae, and mouscum histo of
keloid o hpertrohic scar fomation underig cadiac
or pu lmo nar condit ions that ma be exacebated b the
use of anesthetc medications exst ing drug al lergestobacco use a ctive ace vulgaris
Significat past surgica h sto icudes pro surgicatreatments to the treatment sites, surgica dates, and
patent esponse
The patient must be aware of the ength recoverperod that wi equire extesive hands-on patent cae
for otima treatment resuts. Re-epithe a izato equi res7 to 0 das with associated pai , edema, and e rthema
Postoperative erthema resolves ove a average period
of 3 to 5 months Strict su avodance must be foowed
for a mnmum of 1 ear postoeative to avod pigme
tar changes and photosensitvit Reaistic exectatons
are the most impotant determinants of treatment success. The patient must be aware that the treatment wi l
im ove but does not e im inate a l or eve most rhtides
or scars and that damc htides are l ke to recur
within a few months postoeratvel.Procedural r isks to emphasze icude temoar
and/o permanet hperpgmentato and degmentation, infecto (viral, bacterial , east) and scar (atrophc
hertrophic, kelodal) formation acne flare eczema
lastng 1 to 2 moths. Pedictable sde effects incudeprocedu ra a nd ostoperatve discomfot edem a, oozing,
BFgure (continue (B) A marke reuction in rhyties an yspigmentation is note months after fullface carbon ioxie resurfacing
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and crusing lasig o 2 weeks; ehema ski igh
ness, and prurius lasing u p o 3 o 4 monhs.
DEAL LASER CANDDATE
Fair sk n ye (Fparick phooyes I l l )
Laserame nabe lesions
Mi i ma associaed dysigmenaion o eck and ches
Abl e o olerae exended eiod o convalesce nce pos
oeraivey
Abe o o low and execue ecessary posoperave ski
cae regimen
Realisic eamen expecaions
LESS THAN DEAL LASER CANDDATE
Darker skn type (Fizpar ick phooyes I l IV and V;
rea wih cauion due o signi ican r sk o emporaryand/or permaen igmenary aeraions
Moderae associaed dysgmenaion o neck and
ches
Uabe o oow ad execue ecessay posoperaive
skin care regme
Pri o acial surgica procedures peomed
Promien acia pore paernaser reame may
exacerbae hei r a ppearance
ABSOLUTE CONTRA ND CATO NS Use o ora rein oin whi 1 year o surgey
Ski n hooypes V ad V
Acive cuaeous ineco
Preexsing ecropion
Poor pa ien coml ance
U reais ic aien expecaions
RELATVE CONRANDCATONS
Exensive undery ng dysigmenaion o ace andsurounding eck ad ches-risk o demarca ion i e/deece in skn color o reaed versus ureaed skin
Skin hooypes I l ad IV
U deryin g conecve issue
Uder y ing koeber z ing condi ion
Uder ly ing mm unoogic d isease
Previous ower lid and/or bepharolasty (o inraorbial
resuacng)
Secon 1 : Photoaging 45
AFigure 72 () A 45yearol woman with facial photoaging an mil acne
scarring
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46 Color Atlas of Cosmetic Deratoo
Pevious ab lative resuac g demab rasion crosurge
ace l ft or heno eel
Histor o faca radiation treatment
MEDCAONS
Antbacteal thea: to avoid imetign zation and
bacterial inection of e treatment sites rohacticantbiotcs are iitiaed 1 da reoerativel
Dicloxaci l i 500 mg PO BID o eex 500 mg PO
B I D for 1 0 to 14 das s escri bed.
n en ic i l in-a ergic id v dua ls , Cio oxac 500 mg
P O B I D x 0 to 1 das or azihomcin 500 mg
PO x da followed b 250 mg dal or 5 das isrecommended
Antvira thea: laser esurfacig ma trigger a heres
simex outbeak tha ca sead to the treatment sites
with a creased isk of sca ormation Prohlactic antivial medicatos are iit iated da
reoeative
Valaccov 500 mg PO BD fo 4 das or acclovir
400 mg PO TID for 1 das is recommended
oical tretioi n
Use of tret o in r ior to C aser esuacing has
bee show c ica l ad v ia b iochemica ana ls is onot ovde ehanced collagen fomao accee
ated re-eiheazatio o qucker resolution o ost
oeaive ehema
Use of th is med icat o s oiona
Use o this medication ostoerativel sould be
osoned unt l a l l associated erthema and iflam
mation have resolved.
Beachig creams no ubished controed tr a ls have
demostrated he benefis of eoeratve bleachigcreams o educe he isk of ostiammator her
igmentation. To ossib reduce this i sk aiets wih
skin hototes l and IV are escibed a bleaching
cream to be alied twice dai fo 6 to 7 weeks rio to
treatment. As we l s ic sun avoida nce s mand ato
ANESHESA
Colda ir coo ig (Z immer) ma be adequate for loca l
zed o sing eass C treatment o Er:YAG treatmet
oical aeshesia ma be adequate fo ocaized o
sig e-ass C treatment o Er:YAG treatmet.
Regiona erve bocks wi sulemea ifi trative
anesthesa are geneall ad mi istered fo mut i leass
C treatment.
BFgure 72 (continue (B) Impvement of photoaging weeks aer fullface erbium treatment
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Ste-dependet b locks c ude supraorb ita supra
trochlear ifaorbtal ad mental bocks.
L docaie ( %) wih 00,000 or 1 200000 epi
nephe, a tota of 05 to 0 m is admnsteed per
ste.
Suppemental infi ltrative anesthesia cosistig o a
equal mixtue of 1% idocae, 05% bupivaca eand :0 sodium b carboate is genera l requ ired,especa for the jaw e, upper ee ds, a nd tem ples.
Haluroidase (Wdase) 75 U or t issue dffusio
ma be add ed to the i nfi ra ve aesthesia.
Treatment is delaed 0 o 15 mnutes to a low for
com pete an esthetc effect
Coscious taveous sedato a nd geera anesthesiahave been empoed b traed phscas n cefied
aci t ies patiets uabe to toerae he nectios oror arge procedures.
SAFETY MEASURES
Ee p otecton
Oe or two drops of 005% topca proparacaie(Acaie) o 0.05% opcal tetacaie (Potocane)
are p aced to ea ch ee of he patiet fo owed b
the applcatio o opica erthromci oitment orophtha lmic u br cant (eg, acr i-Lube) ad nonefec
tive metal ic ocular sheds (eg Bro MedicalTucson AZ Ocu o-Past ik , Montrea l Caada) .
A person el m ust wear cear p astic safet glasses to
avod nadvertet conea damage. Operative field
A relectve surfaces ad wdows must be covered
to avod a dvertent treatmet of a efectve surface.
The reatmet room door mu st be abeed poper to
war others ot to eter d ui g lase treatme.
A f lammable materals and anesthetic gases mustbe kept awa rom the operative field
Wet drapes ad spoges are pla ced around the su
gica sie to prevent accidental rradaton of suroundg skn and to minmze poteta f re r isk.
A oflammable o ntmet (eg Surg lube; Y Je l l)mus be placed over te exposed haire ad eebrows to avod ha ir singeing Su rg ube should not be
used over the eelashes to avoid the rsk of cornealkeaits
A surgical tools utlized must possess a onrelective
or roughened back coatg to prevent aser beamdeflectio
A laser smoke evacuator that lters particles as small
as 0 2 m i d ameter and aser-grade surgicamasks must be used to reduce potentia spread of
ifectous partices n the lase pume.
Secon 1 : Photoaging 47
AFigure 7 3 () A female patient who was most bothere by her perioralrhyties but was also note to have moerate ermatoheliosis with
numerous lentigines an actinic amage of the remainer of her face
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48 Color Atlas of Cosmetic Deratoo
Use of Hbcens isoprop alcoo and acetoe is
prohbied due to heir ammabe naure. A makeuand hairsa are o be removed, as te are poen
t ia l ammabe
The ase shoud be ket n the stadb mode a a lt imes oher ta acive treament to avod acci dental
ir ng Oxgen should be avoided, bu if needed soud be
closel moitored and on used n conjuncion wth a
closed gas ssem ta incudes eier endoraceal
nubaion o larngeal mask arwa.
PROCEDURE
A thoroug eview of e risks and benefis is per
ormed
Patien wrtten cosen s obained
Reresentative preoperatve ictures are obtaned. Pretreamen preparation is perormed
he choce of aser and lase arameers varies
deeding on e c l n ica s ituation .
The C aser s preferabe or deeer lnes and
scarring rocesses and fo fasknned patiets
(F g . 7 )
The Er:YAG aser is beneficia or supeficia l ies anddspigmentaion and or darker skinned patiens
(F g . 7 2 )
Th e atient's postoperative co sderati ons al so afectthe choice o aser. Te C
aser wil have an
expected longer recover compared wih e ErYAG
aser.
n genera reatme o a cosmec uit or ful l ace is
bes to miimize e risk of textural mismatc beween
nontreaed and reated aeas. In an isolated teament,one mus trea te eire esion or ine to eir end
rathe han rema n withi n a cosmetic un t .
he vermi ion border can be treated conseativel o
min imize i ps ick b leed ing "
reament sould exed beod te aatomica unibeng reaed wh a featheing echnique (deceased
uence) em poed o blend i nto he ureated ski n For depressed scars, addit ional passes wi a sma ler
so size on te deect edge aow or moe significant
attenin g of he scar.
Scar conracion wi occur wih healing. o avoid
atrohic scar ormaion, admister reame o the
evel of ear nor mal adjacent skin ol.
Ablaive resufacin g of dnamc rtes provides onl
temorar benefi Consdeaion o combinaion ther
a with boul in um oxin or a i l l e subsance shou d beentertained to achieve maxm um benefit.
Figure 73 continue 8 ame patient immeiately afer perioralcarbon ioxie laser resurfacing an a Jessner5% trichloroacetic aci
peel to the remainer of her face
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Mima mechaca l tauma techque fewe Cpasses peformed wth etainment of the ast passeschar to expedte hea ng and mnmze scar r isk and
pgmentar changes. is techique s opimal fo
ouge patents with moe suefcial lesions ad for
darke sk in es.
Wit a teatment modat, te esence o ager collagen bundles head ent into the dee eticular der
ms ad wan of he possib l it of scar fomato
Treatment shoul d be di scontnued im mediate
Resufacig of nonacia htes s associaed with a
hgh isk fo textua and pigmeta changes due to
the eduction n adnexa stuctues ad poo vascularit
in compa rson to the face Te C aser shoud not be
utlized for the teatment of nofacial rhtes The
ErYAG laser should be ut ized with extreme cauon
Combinato theraies of cabo doxde esuacing
and chemica l eels botu in um toxin , or so t ssue aug
metation ma rovde the greatest benef (Fig 73)
POSTOPE RAT VE CARE
An ope wound techiq ue o closed tech q ue ma be
olowed
Postoeative discomort s characteized b modeate
bun i ng with i the f irst 24 hous T h is s mi n i mized wit
the use o an occlusve dessig. It can geea be
contoled with ce packs cod comesses and aceta
m nope n, as we as frequet woun d cae
Postoeative edema develops 24 to hous postopeativel and ca be controled with ice acks and head
eevaton Ora steoids ae emloed when markedsweling develops intaoperative or mmedatel post
oeatve.
Re-epite a zato occurs witin 3 o 10 das ad s
deedent on the lase utlized the numbe of laser
passes executed and the s urgica ca did ate Younge
patients patiets who undego EAG teatment and
ewer asses show faster ealg eaed heaig is
observed n older aents smokers and icreased
aser passes
opca atibiotics ad Aquaho Healg Ointmentshould be avoided due to the isk of aegc contact
dermatit s
Cose olowup is m andator o esue oe cae ad
hea ng of the teated s tes (F gs 7 4 and 75 )
Prophactic atibiotics and aivia medicatos ae
continued fo 10 to 14 das postoerative to avoid
infecton
Stic sun avodace s maianed for 1 ea postopea
tive to avod hotosenst iv it ad to m in m ize the r iskof postiam mato hperpigmentatio
Secon 1 : Photoaging 49
cFigure 73 (continue (C) ame patient 6 months following her treat
ment A marke reuction in both her rhyties an yspigmentation isappreciate
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50 Color Atlas of Cosmetic Deratoo
PEARLS FOR TREATM ENT SU CCESS
Preoeratve wound care instructons ae ciical o
treatment success. Te atient and sigicant othesmus be preaed or e extensive care tat will be
requed or exedient and sae eaing. Paients
shoud be shown posopeative pictues to preae
them for how he wi apea. Postoeaive supples
ncluding wound care sulies and desired camouageoundation should be obtaied ior to te teament
date Patients with ounger ch lden must repare
them fo te signiica changes that w l be noted d ung the eaig eiod A ostoeave assisance te
atent ma requie shoud be arranged prio to treatment ossbe
Patients equire equent postoperative evauation fo
the ist 14 das to ensure oer wound care is beingemoed edicted heaing s oted and no side
eects such as sca ormation o ifection occur.
Paties shoud be evaluated on ostoeative da 2,posoeative da 5 o 7 , an d postoeratve da 0 to
4 and antime e atient exresses a concer oneed o eva uati on
Patients exectatos must be tailored to the expected
benefits. Paients should be iformed tha e greaest
benefits wi ot be apeciaed fo 6 o 12 months
osoerative.
Stic hotoprotecion and su n otectio ae cr t ical n
reduci g te occurrence of ostifla mmaor eig
mentaion and suburn and shoud be fo lowed or aminimum of ea ate treatment.
eaed skin s sesiive o a majort of facal poducts
eumes, a d toica m edicatios or an average o 2weeks postteatment Bland roducts ncludng a sun
block, are ecommeded du ing is hea i ng ime.
Pesiste aeas of ethema soud raise concernregadig sca ormation o infecton A culture is rec
ommeded to rule out bacteria or east iection. Useof a otent oca corticosteoid and/or pused de
aser s cucal wit cose olow-u to esue resolution .
BBLOGRAPHY
Aster TS Cutaneous resurfacing wth C ande r b u mAG lasers: Preoeratve, intaoperative and ost
opeative consdeatons. Past Recostr Srg.999; 03:6 19-634
Anderson RR, Parr is JA Selectve hoothemolsis
Precise microsurger b seective absopion of used
rad a ion . Sciece 1983220:524527
Carruthers Carruthes A Zel ichowska A h e ower o
combined theapies Botox and ablat ve aser esufac
ing Am J Cosmet Srg 2000 7 293 1
Figure 7 Uner aressive woun care A substantia amount of crusting is observe Proper woun care was emonstrate in-oce an withrepeat written instructions reviewe
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David , Ruiz-Esaza J. Fast heang ate aser skn
resuac ng The m i i mal mechanca tauma echnique .
Dermaol Srg 99723:35936
Dove S uza G Andt K asers n ski n esuracin g.
Semi a Me Srg 19965:7788
Duke D Grevel nk M Care beoe and aer laser ski
resuacng A survey and review o the ieratue.Dermaol Srg 99824:20206
Fitzatr ck RS Go dma n M P Satur M oe WD. P used
cabo di oxde laser esurfaci ng o otoaged aca s kn .
Ar Dermaol. 199632:395402
Fitzatr ck RE Toe WD Goldma MP et al Pulsed
cabo dioxide laser t cl oroacetc ac d BackerGordonhenol and dermabras ion : A comaa ve c in ica l and
hisoogc study of cutaeous esuracig in a ocine
mode. Ar Dermaol 99632:46947
Nan CA Aste S. Comlicaions of carbon dioxde
lase r resuacing An evauaton o 500 atients. DermaolSrg. 19982435320
Oinger S ang S Johnson M et a Tetinoi teat
ment befoe carbondioxide aser esuacing: A cl in ica
and b iocemca l ana ys is . J Am Aa Dermaol.December 20045 (6) :940946
Rau l in C G rema . Sigeass carbon d oxide laser skiesuacing combied with coldair cooling: Eicacy and
atent satisaction of a rosectve sidebyside study.
Ar Dermaol. 200440( ) 333336
Ru iz-Esarza Barba Gomez M Gomez de a Torre O.
Wound cae aer laser skin esuaci ng. A com bi natio o
oen and closed methods usng a new olyeyenemask. Dermaol Srg 99824:798
Secon 1 : Photoaging 5
Figure 7 Postinammato hyperpigmentation 6 weeks after perioral
arbon ioxie resurfaing This pigmentation resolve with the use of4 % hyroquinone twie aily for mon ths
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52 Color Atlas of Cosmetic Deratoo
CHAPTER 8 onabatve Fractona aser Resurfacng
MECHANSM OF ACTON
Noablaive ractiona resuacing (NAR) is a nove co
ce o ski reuvenaion hat can arget boh edemal
and derma cod i ios NAFR roduces a u que hermal
damage aern consstig of mut ie colums o ther
mal coagulative damage, reerred to as micotermal
treatment zoes (MTZs) (g 8) NAFR characterist i
call sares the t issue surroun d g eac MZ thus al l ow
ing ast edemal reair due to microscoic sze o the
wounds and short migrato disance or the viabe ker
atioces resent a he MZ edermal margis O l a
fraction of he sk in of the s urface area is treated
DERMAOPATHOLOGYMTZ eveals homogenzed colu mns o derma matr x andthe omaion o microscoic edermal necroic debrs
(MEND) ( ig 82) MEND format o s hought to ree
se e rocess o elimnation o the hermall damaged
eidermis contaiig igmet b e raid migating
vable keranoctes at the MTZ ma rgins ME D ma aso
contan derma sucures such as the elastc bers
Vessels in t he MT Z regos can be thermal destroed i
a nonseective manner igher energies result i deeeand wder MTZs Hgher eerges resut i deee ad
wider MZs NAF R can be he u l in e reatmet o e
dermal igmetatio suc as melasma ad enignesdue to the rocess of MEND omaion AFR can also
be helful in imrovng rhtdes and scarng due to therocess of co agen remode i ng ad new colage orma
t ion , nduced b the derma herma damage
NDCATONS
NA R ca n be a n effectve treatment of eomoderate
rtides acne scars, surgca, taumatic and bur scars
melasma dscroma and dermatoel ios s (F g 83)
PREOPERATVE EVALUATON
Sgni ican ast medcal hso ic udes hstor o er
es aba s keod or heroic scar omaion, oa
retioin iake (date as course cometed), tocalretoid use, tobacco use, and known drug a lerges
nc l ud in g doca ie a eg
Sgni icant ast surgica hisor cudes rior surgcal
treatments to he treament stes he dates of te ro
cedures, the atie's resonse, and he associatedside eects
Laser
-
E p dr m i s
Subcutaous fat
Fract oa phootrmoyss
I I II I I II II II I I I I I
Fgure 8 chematic of microscopic treatment ones MTZ create by
fractional resurfacing laser note the characteristic sparing of the surrouning tissue between the treatment ones
Figure 82 H & E histolo of microthermal treatme nt one MTZ 1 ayafter fractional resurfacing treatment note the microscopic epiermalnecrotic ebris MEN overlying a column of homogenie ermis
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he atient shoud be aware o the folowing
Procedu a d iscomfot
Sunbun- l ke sensaton fo seveal hours ate theprocedure
Sunbun l ke ostoperative ertema that ma e
sst for 3 to 7 das (Fg 84
Postoeative edema geneal mld that usua
resoves witi n 2 to 3 das
Postoeative bronzng that is geneall noted on thethrd postoerative da ad often erssts fo 3 to
4 das
Postoeative suefcial peeing that s oten mdand s noted to stat on the thrd postoeratve da
an d to ersst o 3 to 4 das
Rea ist ic expectatons for the ocedu e: te atent
shoul d be aware that the treatment wil im ove fine
tomoderate wikes pigmetato and supecal
scars but does not elimate moderate-to-deertides A modest benet ma be oted or deepew ink es
Procedua risks athough these advese events are
uncommon and are much ess frequet tha thoseassocated wth ablatve resuacing the stil exst
The ncude temoa ostnfammator heig
mentat ion (F g 85) b l ster ng crust g m a(Fig. 8.6), acnefom erutio inoit hemorhage
(Fig. 87) hees simlex reactvation and aehetophc scaring. Ts s in addt ion to the re
dctabe side eects that nclude procedura discom
o ostoeative erthema bonzing and edema.hee is usual no associated oozig o crustig
unless ve hg eneges and/or hgh densit ies ae
ut l ized
he idea candidate is a fair-skin atet (Fitzatick
hototes Howeve AFR can be sae andefectve daker sk tes (Fitzatick hototes IV
and V) It s a so sae to use on nofaca aeas nclud
ing the neck tuk and extemit es rovded thatdeceased fuences ad de nsit ies are ut l ized
CONTRA ND CAT ONS Ora tretinon use within 6 months to ea of surge
Actve cutaeous infecto
U realist ic ati ent exectations
Pregnant o actating woma
MEDCAONS
Antbactea theap: oplactic antibiotics ae gen
ea l ot equi red
Secon 1 : Photoaging 53
A BFigure 8 3 Perirbital rhytides () fllwing ne fractinal resurfacing
treatment and (B) fllwing fur fractinal resurfacing treatments Anappreciable sftening is nted Curtesy f Fitzpatrick, M
Figure 8 Mild sunbu like ethema immediately fllwing Fraxel lasertreatment with 6 t mJ, 50 MTcm, eight passes This ethemamay persist fr t days
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Color Atlas of Cosmetic Deratoo
Antivira theap
ractional esuacng ma tigge reactvaton o hepes s m plex tat can sp read to he teatment sites.
Poplact c ant v a medcat ions are n i iated
da pior to he procedure Vaaccovir 500 mgPO BID or acc ov ir 400 mg PO TID o 7 das s
usua l recommended An a ternat ve s va acclov 2 PO B D for 1 da to be started he mon i ng o theprocedue
etino n: it s advised to dsconinue tretnoi n cream at
seveal das before NAFR to prevent skn rritation atthe eatment sites
ANESHESA
Cold-a r cool ng (Z mm er) s ver eective in decreasng
the pocedu ral d scomo.
opca anestesia (oi or ceam base) apied a east hou before he procedue s general adequate, ese
cia n combi naton wih colda coolng (Zm mer)
Regiona nerve blocks can be efecve to reduce the
discomfo o patents wi low ai n thresods ese
c ia l l when ut i z ing h ighe uences and densit es .
Inraobial and mental bocks can be helpul wen
treating perioal wrin kes but ae usual l not necessar.
PREOPERAVE PREPARAO N
Expa n th e r isks and benefts of the procedure .
Obtain the patient's witten consent
Wash the area to be teated wh soa and waer
Obtain preoperative pctures.
A a hick lae of topcal aneshetic in an oi l orcream base o the treament site
Wat at east 60 m in utes o acheve opm al anesthec
eect
Wipe off the topica anesthetc with a damp cloth
PROCEDU RAL PS
e laser arametes are chosen accordn g to the c l n ca taget.
Fo eiderma condt ions such as hotodamage,
entigines, melasma, and dschromia lower fuencesand hghe denst ies are usua l uti l zed
o deeer processes such as htes or acne scar
r ing: highe u ences ae uti ized
Lowe pecent coverage o skin surace area tha is,
owe densit es are ndicaed n darke skn tpes to
avoid posnam mato hperpigmentaton
Figure 8 Pstnflammat hyperpgmentatn fllwng fractnal
resurfacng treatment t the upper lp
Figure 8 Mla n the chn 1 day after NAF
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Caution s hou d be exeted wen teaing small er areas
suc as ue l nose ad teme order to avodb lk heang at can result in b serng and scaring
Aow adequate ime between asses for the heat to
dssae and the ski to cool down before the nextass
When reatng he uer a tenae the reatmebetween he rigt sde and e e side and staeac ass rom the same ont
hee to six treatmet sessons (deed ing on the ndi
cation or reatmet) ae administeed 3 to weeksaa Longer eriod beween reaments is advised in
darker-ski atents o avoid or decease the i cdeceof ostiam maor herigmentatio (P I H ) .
POSOPE RA VE CARE
Postoeaive discomfo is geerall mld and ta
sent The atent wi exerece a snburn sesationor severa hous
Patents ma a l makeu mmed ate afte the treat
ment
Patents are encoaged to use mld mostuzers or
sevea d as after the rocedure
Postoea ive edema is usua l min ima but ca becontoled with ice acks and head elevaton In rare
insances of marked swel ig oral redisoe can berescrbed for 3 to 7 das
Sun avodance s maintaned for a east to 6 weeks
afte the ocedure to minimize e risk o ostflammator hergmeato Suscreens wth a min
mu m S PF of 30 are ecommended
cal, atients can reun o wok on the irst ostoeave da
PEARLS FOR REAMEN SUCCESS
Patent seection is the ke Treatng rtes or scars
that are too dee w l rove disaoi nting o he aienand hsician The atient ms be awae of e need
or mul ie teaments to obtain the desred c ical
benefit
NAFR can resu in serious side effecs such as scar
r ing when used a ver high fl ences b nexeriencedhsicans or heath care workes Caton sould be
take to sta witin he recommended aametes ad
al ao ae over ang ecique to avoid
otea comlcaions
Patients m ust be aware that benefs ma be sh ort as
ing and ma equire maitenance teaments fo con
in ued c l in ica l beneft
Secon 1 : Photoaging 55
Figure 8 7 A patien t with rsacea wh develped pinpint hemrrhage1 day after Fraxel estre treatment Pinpint hemrrhage can ccur with
higher energies and usually reslves in few days with n sequelae
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56 Color Atlas of Cosmetic Deratoo
Eecve NAFR reamen in paes wi skn phoo
pes l l o V ca be achieved. An icreased incidenceof posinflammaor perpgmenaton is geneall
noed Patiens mus be aware o he possbi of P
wih each reamen. ecreasing he densi of tea
men reduces e isk o PI .
DEVCES
he mos common used NAR devces ha are ava ab le in he make are Faxe Resore (Soa Medica I c. ,
Haward, CA) ux 1 540 nm aser (Pa lomar Medica l
ecologies Burl ingon, MA), and Airm 1440 nmNd:YAG aser (Cnosue Wesford, MA (Tabe 81)
raxe Resore utlizes he scannng ecolog whereasLux 1540 nm and Affirm 1,440 nm asers uilze he
samping ecnoog and do no usua requie opcal
anesthesia or dsposabl e ips.
TABE 8 Noabate Fractoal asers
Compa Lase devce Laser
waveengh (nm)
lta al Fraxel Resoe 1 550
(Fraxel SR 1500)
a ma Lux 1,540 1540
Cue Airm 1440 Nd:YAG 1440
BBLOGRAPHY
Laubach , Tannous Z Andeson RR Ma nse i Sk in
responses o faciona phoohemolsis asers Sre 200638(2) 142-149
Manse , Herron GS, Sink R, anner , Anderson
R R . Fraciona phoohermosis A new cocep for cua
neous emodeli g usn g m croscopc paerns o hermal
inju asers Sr e 200434(5)426438
Narurkar VA Nonablaive ractonal aser esurfacg
Dermal li. 200927(4)473-478 v .
annous Z Fracoa esurfacing. li Dermal 2007
25(5):480486
Mode Tip
d ameer (mm)
Scanng 7
1 5
Stampg 10
1 5
Stampg 10
Max eerg/MTZ
or mcrobeam (mJ)
70
100
1 5
8 J/cm/pulse
ensi
devered (cm )
124000 (548%)
100
320
1000
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Secon 1 : Photoaging 57
CHAPTER 9 Ablatve Factiona ase Resuacng
NTRODUCTON
Treatments or photoagng range from nonablative aser
resuracng to ablative aser resuacng. Bo o these
technq es are descrbed in deta l in previous capters
Pt simpl te most eectve lasers carbon doxide
and erbim abative resuacng asers provde the mostdramatc bene for potoagng and other skin condi
t o ns but a so carr te h igest r i sk or adverse eects.The remain the god standard treatment for potodam
aged skin ramatic resuts however can be seen wt
one reatment Sde eects nclude rolonged erthema(for months) permanent hopgmentaton temporar
herpgmentaton inecion and scar. Addt ional downtime rom work and soca activit es s sgni ican
For this reason te popularit o ablative asers hasdecreased dramatcall over te past severa ears
among paients and hscans
B contrast nona batve asers with mu t ipl e treatmentsessions rovide a sae method or providing mld
improvemen o mildto-moderate poodamage wh tte risk o sde eects. Unfotnael e redictabi it o
improvemen is uncertain Some paients do not exeri
ence an discernibe beneit even ater mlt ple reatments. n te past 5 ears n ona blative ractio nal lasers
have produced enhanced resuls rom oer forms o
nonablative resuacng with mult le treaments hese
lasers ave aso proven to be safe n skied hands. Stil
ther ecac is l mted especal when compared oab a ve laser resuraci ng
More recent fractona abatve asers both carbondi oxide and erb u m variants have been develoed to pro
vde enanced resuts wth relative good saet. he
concept is to provde the more aggressve technolog oaba on but to conine potenta downtime and sde
eects b empong a ractional pattern o tissue dam
age whic encorages more rapd ealing t mes with
fewer sde eects. O n a racton of the skn is ab laed at
eac treatment as opposed o raditona abative resurfacng procedres Futher the deth of abaton s
deeer tan w tradit iona ablative resurfacng procedures
Advantages of raciona l a blative las ers are as fol ows
Better improvement o deeer rtdes tan nonaba
tive devces
Sign i cant beneit with one treatment
Can provde some imrovemen for skin axit pigmented lesions and vascula r dschroma as well
Signi cant reducton n posoperative downtime com
pared to tradtiona abative devces
Figure 9 Immediate endpint f pixilated damage patte with anerbium fractinal ablative device
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58 Color Atlas of Cosmetic Deratoo
Can reat cosmec unis effective wthou lines of
demarcao oen seen wth tradtiona ablative ocedu res tha is eroral/eriorbital areas
NDCATONS
Rhtes eseca modeaeosevee perioa and
eriorba rhtes
Photodamage, i c ud ing skin exure and toe
Acne scars in cl udi ng boxca arohic rol l ng scars
Sugica and burn scas
Mild mprovemen in skn axt
Not effecve or dna m c r hides
PREOPERATVE EVALUATON
Sk i n tpe ( II I I are best canddaes)
Su n exosure
Hstor o keoids
Ssemic necions
Prio lastc surger especal neck l g rocedures
an d face l fts
sotreno in use in ast 6 mohs
Patiens with uneastc expectaions
A consultaton s requed before ts treament o
assess te ate as wel as aroiate prepae the
patent for the procedure The atient should be u educated as o e isks and benefis of is procedure
he patie must be aware of the recover erod of 4 o
7 das (on average) he atent should be shown post
oeaive ictures to eare em for ow he wl
aear An posoeratve assistance e aient ma
requi e sou d be aranged pro to treatment i possib e
he paten shoud also be iformed that he benefits of
the treament accrue 3 o 6 months ae treatmen Apaten who is unabe o foow and execue necessar
posoeave skin care regmen should not be reated
PRO PHY LAX SIAN EST H ES lA
Ma nclude an of he fol owi ng
Antvira and anibiotic rohaxis
opical anestheic
23% idocane/7% tetacane
Ora pa n med icat o and anxo t c
Vcodin/acetaminohen/atvan/nothing
Nerve blocks/M Toradol
General a esthesia
Figure 92 Patient immediately after C ablative fractinal resurfacingtreatment Nte erythema, edema, and pinpint hemrrhage
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Because this rocedure is painfu some form o
anesthesa is requed. t wi l vary accordng to theaggressveness of treatment, he pacular suscetb i
t es of the atent, and e hysican s comfor wivarous aesthec regimens Regional neve bocks wth
sulemental nf ltrat ve anesthesa ae general y elpful
Site-deendent b ocks i c ude suraorb ta infraob ia l ,and mena b ocks . docaine (%) wh 1 00000 or
1 :200000 einehr ne, at a tota o 0.5 to 1 0 m ca be
injected at each sie
LASER SAFETY
Eye oecton: metal eye shelds
Oe or two drops of 0.05% toca roaracaine(Acaie) or 0.05% opcal tetacaine (Pontocane)
are aced no eac h eye of the aient, foll owed by
the applcation o toica erythromyci oinment or
ohtha lmic u br cant (eg, acr i-Lube) and nonefective meta ocular shieds
A ersonnel prese at e treatment must wearsafety gasses/gogges to avoid nadvertent corneal
damage
Due to the ai , b eeding, an d pai n med cations assoc
ated with thi s teatmet, t is m erave that the atient be
accoman ed by a frend, spouse or reative who can d riveo accompany the patet home aer the procedu re
• Posoperave Cae (Fg 9 . 1
nterestngly, l itt le ostrocedure pan (Fi g 9 2) Best exanaion: heat release through abated cannes
meratve to give oa a nd wrien wound care i nstructions to atent
Gauze soaks and emoents mmedatey ostoeratve
Room temerature steie water soaks for 20 minutes
every 3 to 4 hou s fol owed by Aqua ho rasel ne a pi
cation for 2 o 3 days
• ol owp a 48 o 72 hous( i g . 9 .3
Re-eie a zat o s usua l ly comlete
Eytema, edema and res dua io nt emorrhagc
crusting are exected.
M il a a re commo n ad oen cl ear whi n a few days
Assess for vesicles, bu a e, ustues.
Emoles twce daly for 3 o 7 days.
nstructos to ca f any concens or changes i woud
hea ng
Postoperatve erytema resolves over a erod of
weeks Strct sun avoidance mus be olowed or a
Secon 1 : Photoaging 59
Figure 93 Patient at -hour followup Note that hemorrhage is nolonger present, but edema and ethema persist
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60 Color Atlas of Cosmetic Deratoo
minimum of 3 months postoperativel to avoid pigmen
tar cha nges and photosensitivit
• Adverse Sie Eects
Delaed onset hpopigmentation
Scar ing
Postinflam mator hpepgmentation
Pesistet ehema
nfecton
he side effects for fractiona abative resuacing are
the same as those for tradtional ablatve resuracingprocedures abeit far less frequet or severe in ski led
hands As with onabative actiona resurfacing
postnflammator hperigmentation (PI) is more kelto occur wt higher treatment desit ies paicular in
darker skin phototpes (Fig 94) perophic scarrng o
the neck is a sg ficant and potential l permaent compication o fractonated C laser resuracing (Fg 95)
Caution s requred for these procedues
he fo owing practices al l s ignficant ncease the
risk of scar:
Aggessive treatments i ncrease isk of scar
Poor tech iqu e that i s excessive ovela
Postoperative wound nfection
Hi stor o face or eck i ing procedues
Treatment o nofacial ski especial the neck
• I n f e c i o ( F g . 9 6 The ke to teating i ection s to recogize i t at ts ncep
tion Infections are diagnosed cl n ical l Cultues can
confirm a d iagnosis Em p ic at ib iot ics and c lose c l i ica
followup are the kes to teatment Persstent areas of
erthema sho uld aise concen egardi ng scar formationor necton A cultue is recommended to rue out bacte
rial or east inecton Do not perform these procedures ifou cannot recognize ad treat bacterial , v ra funga
infectons
• N o a c a l S k i
Nofacia l sk in i s moe vu neab e to thermal eneg due
to underiv leged wound heaing caabil it ies here are
fewer plosebaceous units on te neck and more mited
cutaneous vasculature to suport woud hea ing hi s isespeca true where thee is a histo of pior lastic
suger Face/neck iftig pocedures place neck skinonto the face tus ou ma be treating neck sk on
the face I there is a histor of pior plastc surge it is
best to treat at lower sengsBecause of the isks of seious side eects it is
stog advsed that ractional abatve resurfacing
Fgure 9 Test spot treatments with a C abative fractiona resurfacingdevice in a young mae with tzpatrick skin type 5 The test spots are
not arranged in order of aressiveness The darker areas of PIH coincidewith increased treatment densi Increasing puse energies do itte to
worsen PIH
Fgure 9 Hypertphic scar aer treatment with a C
fractiona aba
tive device
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shoud o be erformed b a arorate traned
hscian exerenced n ostoperative woud care folowng resurfacn g rocedures
n sum , ablative ractiona resu rfacing rocedu res oferthe advaage of good esuts wth oe treatment as we
as offerng signficant mrovemen where nonabatve
ractona an d n onractiona devces do ot such as moderae and severe rhdes At he same ime it offers the
exib it o treating smaer aeas than tradit ional resuacg rocedures because it does ot tpcal eave
nes of demarcation Addit oa there is sgnifcant
reduced c n ica and socia downtme compaed to ul surface a baive rocedu res onetheess the teatment
has ts drawbacks such as
ghtenig is usua modest.
Durato of benefits s not known
Bes resu ts ofte requ re mo re tha oe treament.
Especa acne scars
Requ res 1 week awa rom work and socia actvit ies.
Seres onabatve reatments ma be more toerabe
and ractca or man patents.
Secon 1 : Photoaging 6
Figure 9 Localized miu te pustules, edema ad erythema represetiga localized pseudomoas ifectio i the settig of post-C fractioalablative resurfacig for a bu scar It cleared fully without sequelae aeroval atibiotic treatmet
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62 Color Atlas of Cosmetic Deratoo
CHAPTER 10 Tssue Tghtenng
hee have been a va e o f on invasive devices ha
prpor o l i ad ighen loose" necks jawines and
ees. These devices work b delivering monoola bi ola o ifrared energ o he deep dems and sbca
neous isse es i g in ighenig and l i ing of skin a d
creaion of new colagen. The chief obsace or hese
devices has bee nconsise clnica ress. Somepaens have had dramaic resus in comparison o a
dioal nvasive srge ad ohers have seen lile or o
imoveme Paes who ndersand he isks befoe
he procedue ae happ wih excellen esuls and o
d sapoied b lack o im proveme
MECHANSM OF ACTON
hee ae differen radiofeqenc (RF) echoog and
infraed devces ha del iver volu meric h ea o h e deep
derms and sbcuaeous issue which ighens exisingcollage and hel ps creae new collagen
CANDDATE SELECTON
As wih a procedres can didae selecio s vial o he
success of he rocedre . These devces wi n o rea epi
dema chages of agg such as lenigo eangiecasa
o rogh skn Candidaes shold have deep cuaneos
signs of aging such as saggng" ski in he neck aw oaound he ees. Some hscas have reored goodsuccess i reaing aeas o he ace incldig ppe
ams abdomen and breass. Al paies ms be awae
ha he amo n of c i ica i provemen s highl variabl eno predicab e before he poced e Paiens ha do no
ndersand his should no ndergo he procedre
THE PROCEDURE
When f irs noduced he ch ief compla i wi RF
devices was nolerabe ain. The pocedure was doe
wih a sigle pass a hig eerg seigs. Over he eashe rend has been oward moe passes wi lower flue
ces Ths has greal redced he pai assocaed wihhe ocedue Ml ipe passes lower uencies and dif
feren so sizes have esued in greae immediae s
sue ighening obseved in paiens ad a igher
perceage o paes wih im ovemen aer 6 mon hs.
• Peproceue Check is
Remove a l makep
Rem ove al l jewelr.
AFgure (A) Prior to treatment skin axity is observed in the jowregion
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No acemake or defbriator.
A l atents wt facal m ants soud ave te mateia l o the i m ant identifed before the ocedu e. f t s
un known do ot teat di ectly ove he i m an
Ay tick ayer o toical anestetic 30 mnutes
befoe rocedure
Deteme a roriate sot size ad fluence
Kee e h and ece eve wt te skn t hrougout the
rocedure
Afte the ocedure atients ca esume egua activi
t ies i mmed ately
Patents should communicate with ter hyscian n
case of ay qu estions o co ncerns.
movemet occus for u to 6 monts ater e o
cedue
SDE EFFECS
The amount of serous sde eecs has been educedover the years as treatment otocols ave been refned.
With ower f uences the i sk o sde eects has bee su bstatal y educed
Pote ia l S de Eecs
Atrohoderma whch may be emoay o emaent
Burn
Eosion/uce
Scar
Dyschroma
Nerve damage
Ocua damage
CL N CAL PEARLS
Al atents should be waed befoe ay rocedure
that the amount o cl n ca imovement vaes rom
erson to erson Imrovemet ca range rom da
matic to NO imrovement at a l Any atent wo does
not uderstand the otenta for no imovement
sould not ave the ocedue efomed
Wie teatig each atent cotinuously obseve te
ski a d ask the atient to in form the hysca n f tere sa at icul ar sot with ncreased a n o u nusual sym
toms f a atient comlains of unusua an o sym
toms sto te rocedure and reevaluate te settings
Ma ke sue a uni form am ount of enegy is deivered with
eac ulse. This is done by using e aoriate sosize and alying unfom gente but firm ressure to
the skin
Do not efom the rocedure on a atient wth actve
sunbun o tan
Secon 1 : Photoaging 63
BFigure (continue () ix months afer treatment appearance of thejowl and neck is impved slightl eproduced with permission, fromHirsch adick N, Cohen JL Aesthetic ejuvenation A egionalApproach New York McGrawHill, 00
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64 Color Atlas of Cosmetic Deratoo
CHAPTER 11 Dematochaass
Dermatocaasis is a condi ion characterized b pe
and/or lower eeid skn, muscle redndac and laxi
an d fat ad heniat on t s ma in attibua be to ch ronologica l aging and chron c su n exposure .
EPDEMOLOGY
dee ver commo n
Ae most frequent obseved n ndividals oder an
50 eas
Sex no predi ection
Rae mos common in fa irskinned nd iv dua ls (skin Aphotopes I ad I ) ess common in dakerskinned ndi-
vidu as (sk n p ootpes VV I )
repa ars crooogica l aging chron ic sun
exposure throd d isease
PAHOGENESS
Uer and/or lower eeld skin and msce hpertrohand proase fat ad descensio .
PHYSCA EXAMNAON
Ear ind ngs inc ude a do be l id crease wih on mod
es hooding. Severe findngs nclde rominen eeldhooding wi per ad atera l v sa l e ld obsrct ion .
Coexsting brow tosis ma furer comromise he
per era v s ion
Tests for ower id axit ep deemin e i a l dtghening
procedure is eeded
owe lid horizona axi is measred b he disrac
tion es that req ires ing he lower l id anteror l awafrom e globe A greaer tha 7mm id excusion ind
cates laxit
Orbic ar is ocul tone is meas red b e snap tes that
is erformed b ul ing the lower l id nferior If the l id
does ot spontaeous retun to the normal osit ionprio o the nex bl in k te tes is osit ive id icaing l ower
lid axit.
D FFERENA DAGNOSS
Bleharochalas is (recrren id iopath ic ee id n lammation wth reslan reaxato o the uer id skin); uper
eed hooding seconda to eebrow oss
BFigure () A 5yearold female conceed about her sunken eyesand forehead wrinkles (B) Impvement of the blepharloptoss sunkeneyes and forehead wrinkles months followin upper lid blepharop/astyand leavator aponeurotca advancement eproduced wth permssonfm Harue uzuk M Kyoto Japan
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DERMATOPATHOLOGY
Epdema acanthosis wth fattening o the derma
ederma uction derma colagen breakdown wthormation of amophous masses and ncrease in gl
cosamioglcans.
COURSE
Chronic rogressive course; visua ee elds ma beaected.
KEY CONS ULTATVE QU ESTON S
An assocated smptoms incuding visual obsruction
d r ees excessive ear ing
Uderng medical condit ons especial l ee disease
and hod condit os
Prio treatmet and response
MANAGEMENT
Prevento s ict sun avoda nce
Control un derg throd d sease
TREATMENT
opca thera dail sunscreen appicaton wth UVB/UVA coverage
Su gica thea
Coronal bowftupper face euvenato
Trchophtc bowltuper ace ejuveato
Bepharopastup er ad lower eeld reuvenation
( F i g 1 1 1 )
Laser thera p
Pacement of otectve ee sheds pro to aser
treatment if paamou nt
Conservave teatment s necessa to avoid ectropon omaion and/o sca omaton
Carbon d oxde aser esurfaci ng ErbumYAG laser.
ractonated abative carbon doxide aser esuac
ing
P TFALLS TO AVO D
A conservatve approach to surgical remova of this skin
is vta to peve a saed" appearance or ectropio
Secon 1 : Photoaging 65
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66 Color Atlas of Cosmetic Deratoo
Retenion of al or oions of an herniaed fat ads
hes miimize the skeeonzed aeaance oennoed to develo with age and loss of facal volme.
Drec v sua zaton of the infeor ob l q e muscle s v ta
to avod musce in r.
reamen wh ubica nts and tai g l d s ma hel e
ve keraoconctivtis.
BBLOGRAPHY
Anc ona D az BE . A rosectve sd of he m rovement n eriorbia wrinkes ad eebow elevaion wih a
novel fracional C lasere fracional eelif J Drugs
Dermatol 20109 ) 1 6-21
Carter S Se S Co P ower eeld C laser ejvena
ton: A andomzed rosecive cl in ca sud.
Ophthalmolo 2001108:437-441.
Codne MA Wolf Anzar A Prima transctaneous lower beharoast wh roine aeral canthalsuor A comeensive 10-ear eview Plast Reconst
Surg 2008121 :12411250
unzeker CM Wess E Geoems RG Fracionaed
C aser resufacing: Our exeriece wi more an
2000 reatmens. Aesthet Surg J 200929(4)317322.
orn BS kkawa DO Cohen SR. anscaeos loweeed blearolas wh orbiomaar ssenson:
Retrosecive review of 212 consectve cases Plast
Reconstr Sur 2010125(1 ) 315-323
Lee D aw V. Subbrow beharolast fo e eed
rejvenation n Asians. Aesthet Surg J . 2009;29(4):284288.
Lemke BN Sasor OG he anatom of ee id osis.
Arch Ophthalmol 1932100:981986.
Lev ne MR Manual of Oculoplastic Surgre
Ph ade h ia : Beoh eneman 2003.
Shor N, Enzer Y Consideraions in aesthetc eeidsuger J Dermatol Surg Onl 19921 10811095.
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Secon 1 : Photoaging J 6
CHAPTER 12 okodema of Cvatte
Pok i odema of Cvae ( POC) i s a cond ion ha s at ib
uabe o chonc sun exosue o the eck and he chest.
The sevei of fin d ngs is deenden on he d uaion andinensi of sun exosue cosuive skin coo
( Fiaick skin e) and e caaci o an.
EPDEMOLOGY
iee common
ge mos feque obseved in esons olde an
40 ea s
Se s gh female edomi nance
Rae mos common in fa i-skinned ind iv idua ls (skin
hotoes I and I ; ael seen in dake-skinned idvdua s (sk n ooes VV )
reiiig aor chon ic sun exosue nc ud ng
inenona su exosue since outh and occuaionaexosue auma; chonoogica agng
PAHOGENESS
Ulavio e B (V B) i s he mos damagng V ad a ion
wih high dose ulavoe A (VA) conbug to he
noed changes. n add i on vis ib e an d inaed ada os
have been shown o augmen he acio o UVB .
PHYSCAL EXAMNATON
Telangiecases md aoh eicuaed hegmena
on and hoigmenaon affecng he aea ad os
eo asec of he neck aeio ches and jawine
Submena l neck s saed Pe ifo l icu la sa ng noed
(F gs . 12 1 and 2 2)
DERMAOPAHOLOGY
Eidema acanhoss wi aenng o he dema
eidema junc io Focal ncease e idemal basacel meanoces; iegua basal cel eigmenaon
Dema collagen beakdown wih fomaion of amo
hous masses and ncease in gcosaminogcansTelangiecasa noed.
DFFERENA DAGNOSS
RothmudTomson sndome; ad ia io dema is ;
Knd e sndome; B oom's sdome; Aaxa
eangecasa.
Fgue 2 oikiloderma of Civatte etiulated pigmentation, ethema, and atrophy an be een ith harateriti paring of the ubmental area The erythematou omponent i more prminent in thipatient Courtey of ihard A Johnon, M
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68 Color Atlas of Cosmetic Deratoo
COURSE
Ch ronic rogressve course with contin ued sun exosure.
KEY CONSULATVE QUESONS
Past and curre su exosure histor Occuato
Hobb es/soing activities
Uder ng medca l condit ions
H/o radat o therap
Past treatments ad resonse
MANAGEMEN
Preveo : str ict sun avoda nce
REAMENT
oical thera: dail sunscree alcaion with
UVB/UVA coverage
Laser thera great caution must be foowed with an
aser treatment admiistered to mimze the r isk o
scar formato dsgmentation figer-rint ig" ortreatment skp areas ad textural ch anges The nec k is
aicu la r rone to scarr ig given fewer i osebaceous
un ts. A test ste s recomme nded . Mu l il e sessions are
geera required.
Laser fuences shoud be lowered b aproximatel25% to 30% of facia arameters to avoid adverse
eects.
Pulsed de aser-ow fluences utilzed (eg, Vbeam
595 m 04.0 ms J/cm 7 10-mm sot
DCD 30/20) Im roveme in telangiectasa a d atroh seen. im ted benet for dsigmentation .
ntese used igh (eg StarLux 230 ms
234 J/dm 10% ass overa)mrovement oal comonets ma be possible.
Versa Pu lse 532n m laserlow fuences ecessar
(F g . 12 .3) .
Fractionated noab lative ad a blative lasera l comonets ma be targeted Can be safe utilzed inaected bod areas hough conservative aser ara
meters are requi red to avoid oteta scar r ng.
P FALLS TO AVO D
A consevatve aproach mus be foowed wth an
treatment used or POC gven the sigificat risk o
uneven removal of the igmentation and erthema
resut ing in a footr int" l ike aearance (F g . 12.4)
Figure 2 2 Poikiloderma of Civattethe pigmented component is more
pminent in this patient
A
BFigure 2 3 () Poikiloderma of Civatte pretreatmen t (B) Poikiloderma ofCivatte following three VersaPulse 5nm laser treatments Markedreduction in ethematous component is observed
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This motted appearace can occur nomal drng the
corse of treatment he patient mst be aware of thispossibi l it Contined treatmet to the residal esions
genera ests i a resoltion o ths side efect
Patients ms be awae o he dicult n improving
ths co ndt io . M lt l e treaments are execed for ed
poin of gtenng Textual changes are ke to pesist
POC with a pri mar erthematos com poent tpical
responds bee tha POC with a prmari hepig
mented compone
BBLOGRAPHY
Batta i ndson C Cotter i A Fo ds S Treatmen
of po ik oderma o Civatte wih he oass um ita phosphate (P) laser . r J Drml. 1 9991 40(6 ) :
1 1 9 1 - 1 1 9 2
Geronems R Poiki odema of Civatte Ar Drml.1990; 26(4) 547-548
atoulis AC Stavrianeas G Panaoides G et a
Poki oderma of Cvatte: A histopathoogca and lrastcural std Drml. 2007214(2) : 17782
Langelad Teatmet of poiki loderma of Cvae with
the lsed de aser A series o seve cases J sr r. 1 9991 (2 ) : 1 2 7
Rusciani A Motta A Fo P Menichni G Treatment of
pok i oderma of Civae sn g intense plsed igh sorce7 eas o experece Drml Srg 200834(3):34-
3 9 Terne EP anke CW Treatmet of poikloderma of
Civate with abatve fractioa laser resrfacing
Prospective std ad eview of the iteatre J DrgsDrml. 20098(6):527534
Terne EP ouba DJ ake CW Revew o ractiona
photohermolsis Treatme ndications and efcac.Drml Srg 200935(10) : 1445-46
Secon 1 : Photoaging 6
Figure 2 "Footprinting o f th ntrior nk fr singl intnspulsd light PL sour trtmnt for Poikilodrm of Civtt his subsquntly rsolvd with ontinud IPL trtmnts
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TW
Disordes of Sebaceous G lands
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72 Color Atlas of Cosmetic Deratoo
CHAPER 13 Acn e Vuga rs
Acne vulgas is a chronic nammator disease of the
p losebaceous ni Acne esos favo the face neck
uppe back chest and pe ams M lt e c n ica l var ants exist and the inclde comedonal acne papopus
ta acne oduocstic acne acne congobata and
acne fu lmnans .
EP E M OLOGY
a ag predominant a dsode o adolescence affects 85% of ndivduas between 12 and
24 eas of age ma aec al age groups
Ra lower ncidence in Ar can-Amercas and Asians
S moe severe forms n maes
rg ars genetc redisposit o endocrine
dsordes sress mechaca factos ( ic ion resseoccus ion) conact wth acnegenc mate a ls (o i s ch o
nated hdrocarbons cosmetcs) and drugs (steods
l i th um adrogens hdanto n)
PAHOGENESS
Ma patens wth nodulocstic ace have a fistdegree
relative wih a hsto of sevee acne. The rma pahophsiolog voves aeed folcar keratzaion resutng
i o bstucto o sebaceous o lc es iceased seb m p ro
dction heroliferation of Poponibacterum acesand increased poduction of cemotacc factos whch
resut n iammato.
PHYSCAL EAMNAON
Comedones (cosed and open) ehemaous paulespstues nodules and csts Ma esove with esidual
herpigmeation o scaig.
D FFERENTAL DAGNOSS
Acne osacea steoid ace acne mecaica
Ptrospom o l l cu t is and baceia fo l l ic u t s .
LABORAORY DAA
• E n d o c n e S t d i e s
No rotne studies are needed If hstor and phscal
examnaion aise concens hen cosider odeig
sceen fo free and total testosteone de hdoea d rosterone and fo ic e st imulat ig homoe/ luteiz ing
Fgure An 1 -year-old male wth yst ane beng treated wth1450-nm dode laser
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hormone (S/LH) ratios to exclude polcstic ova sn
drome or other hormonal abnormalit ies esecal inwomen with moderatetosevere acne h rsutism rregu
la menses and weight gai iet may pa a role i n laresof acne. High gcemic diets ma exacerbate acne
uther stud ies are eeded
• Demaopahoogy
Patholog of ear lesion (comedone) reveals obstruction
of the fo c u a i nfundib u u m b con ied ce l s ead ng to
dilatatio ater esos reveal fol icua upture wth m
phoctes neutrophils, and macrohages Scarr ig ma
be see
COURSE
Ths dsease demostrates a chronic course and remts
sotaneousl in the earltomidthid decade i themaorit of atients owever, acne ma pesist much
longer i some patets.
MANAGEMEN
Ear treatmet of acne is essentia or the prevento of
dschromia or assocated scarr ing (see scar treatment
chater 6) Man ace patients beet from combinaton theraies. A thorough histor ad hsica examna
t on a re aam ount to ad mi nistering a maxi mal l eectiveplan h is should inc ude current cosmet ics and sun
screens skn te festle occupatio medications
past teatments ad esponse det mestrua and oal
contracetive h stor
• Topica Teae
Toical treatmet ma be requi red or the du ration of th scondit ion Topica ormuations shoud be aplied to the
lesons as wel as to the adjacent acneone cl n ica lnorma l sk in
Retnoids tretnoin adapaene tazarotene
Antbactera agents benzol peroxide cl indamcin,
erthromcin
Keratoltic agents sa icl c acd hdrox acd azelaic
ac id sod um su lfacetamide an d su fur
• Sysem c Teamet
Antbiot cs: tetraccline doxccline minoccline ae
most commonl used Alternatives ncude er
thromc n az ith romc in and amoxic l l n
Hormones: oral cotracetives or srooactone or
women with persstent acne on lower face chin andneck
Secton 2 : Disorders of Sebaceos Glands 73
A
BFigure 32 () Facial iammato ace ulgaris uresposie to multiple topical ad oral treatmet regimes (B) Marked improemet of ace
6 moths folloig fie 1 450m diode laser treatmets moothbeamadela orp , Waylad, MA, 6mm spot, 1 4 Jm 0 ms
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74 Color Atlas of Cosmetic Deratoo
sotretnoin or severe nodu ocsic ac e hat has fai led
other tocal and sstem c heraies
• Sug ca Teamet
Comedone exractio exresson of keratious con
tents of oen comedones b alng the comedoneexractor to the comedoes and aplig ressureA n ick ma be made to the over l ng skn with a
#11blade or 18gauge needle to ease n the extraction
The Schamberg na and Saalf ie d comedoneexressors are most common ui zed Comedone
exracto s contraidicated for inflamed comedonesor pustues due to increased scar rsk
ntralesional steroid injecon: tr iamcnooe acetoide
(23 mg/m is ineced no iflamed cstc lesionsusg a 30gauge neede Maxmum dose injected
shoud ot exceed 01 m er eso to avod atroh
Paties shoul d be warned tha atroh from an nammator cstic esion can occur wth or wthout an
ntraesona steroid injection
Chemca l ee s ser a l sa l c ic ac id ees g lcol ic ac id
eels (270%) and tr chloroacetc acid (TCA) ees
(1020) have been uti l zed o reduce he number ocomedones and improve postilammator erg Amentaon and ersisen erthema Pees ma be er
ormed ever 2 o 4 weeks wh ncreasig srengthsand tme apled as toeraed Mild irr ta ion ma be
observed Adunctive thera is geeral necessar
Microdermabraso: this s rimarl efective or come
donal ace t is usual eormed ever 2 to 3 weeks
Mulile treames are needed with varabe imrove
me
• Lgh Teame
Lasers lasers and light sources are no te firs-line
thera for acne but ca n be a n efective a ternaive oraduvant to med ca hera wen requi red
1450-nm diode aser (Smoothbeam laser Candea
Cor , Waland MA) treatme fluencies rom 8 to14 J/cm 6mm sot s ze and dnamic coo ing
device seting of 335 ms can resut m il d o dra
matc improvement of nfammator trunk and facalacne wi a sgnficant reducion in eson coun after
an average of three searaed b 4-to-6week nterva s (F igs 131 and 132) I t s imortat o de ver
nonoverlappng ulses to reduce the r isk of side
efects Toical l doca ne cream ap l ed ror to reatmet s needed to mimze the treatment-assocated
a n I is vita o al the cream over a im ted bodsurface to limt an rsk of idocae toxc
Lower luencies of 8 /cm with two ful-face asses
versus a single ful l-face ass at hgher fuecies(1 014 /cm) have been used to reduce a
BFigure () evere acne before treatment (B) Aer three treatmentsof photodynamic therapy with topical 5aminolevulinic acid and pulseddye laser mm spot 6 !m 6ms pulse duration Courtesy of MarkNesto M h
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Plsed dye laser (PD stdes examiing the e
cacy of PDL or inlammatory acne ave odcedconf ict ig data. Plsed dye laser aone or i combi
nat ion with long sed 1 ,064-nm YAG lase asbee effective n reducng nflammatoy acne PDL
can mrove ostace eyhema Flences of 55 to
7 /cm
, 7-mm spot s ze wth lse du rat ons of 3 o6 ms are most commoly emoyed. Severa treat
mets are n eeded to ach eve the greatest benefi.
Phototheray: mut e l ight sorces have been
reoted to sigicantly im prove acne wh m n ma side
eects These soces icde igh-intesy narowband b e l ght , h ig- intens ty mea ha ide la m h gh
enegy broadspecrm be l igt, as well as mixed
b e and red l ight
Photodynamc eay (PD): PDT ti l z ng the topica
administatio of 5amnolev in ic acid (AA evlan
Kerast ick DUSA Parmaceut ica s , Inc Wi mingon,
MA) activated by lght exosure is aother otetiayeective modality to teat acne (Fgs. 13.3 and 134).Sho contac AAPD ( 160min te drg ncu baon)
was capabe of i mrovng ace sgficaty n a variety
of cinica stdes Dierent gh soces have beent l zed icdng blue l ght (405420 nm), ed l ght
(635 nm), long-ulsed 595-m ulsed dye asers and
intense sed ight (4301200 nm) (Fg. 13.5).
BBLOGRAPHY
Secton 2 : Disorders of Sebaceos Gla nds 75
A BFgue 3 () Facial inammato acne prior to photodynamic therapy Marked redction of the inammato acne er three eion ofphotodynmic therapy Cortesy of Mrk Neto M, Ph
Bowe WP, osh SS, Sha ta AR. Det and acne. J Am AAc Derml 2 01 0 6 3(1 ) 1 2 4 1 41 .r edman PM, M, K imya Asad A , Go ldberg .
Treatment of iflammatory faca ace vulgaris wth the
1450nm diode laser A ot sdy. Derml Srg.200430(2 pt 1) :147151
Ham to F , Car J , Lyons C, Ca M, ayo A, Maeed A.
Laser an d other ght thera es for e treatment of acnevgaris: Systematic revew r J Derml. 2009160(6)
12731285.
Leheta M. Role of e 585nm p sed dye aser thetreatment of acne n c omarison wit othe toical tera
etic moda t es J me er er. 2 0091 1 (2 )
118-124
Po lock B, urner D, Str inger MR, et a l opca l amio e
v n c acdpotodynamic theapy for the reatme oface vlgaris: A stdy of c cal efficacy and mec an ism
of act io r J Derm/ 2004151(3) 616622.
Yeng CK, Shek SY, Y CS, Kono T, Chan H. reamentof inflammatoy facal acne wth 1450-nm dode ase n
tye V o V Asa skin sig an otimal combinato of
laser arametes. Derml Sr 200935(4)593-600.
BFgue 3 () Mild acne scarring and dyschromia prior to Er YG laerresrfacing (B) For months aer Er YG laser rerfacing tiliing a5mm spot at 1 J with for passes reslts in significant impvement
eprodced with permission, from over J, dt K Geronems ,et a Illstrated Ctaneos & Aesthetic aser rge McGrawi//Inc; 000
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76 Color Atlas of Cosmetic Deratoo
CHAPTER 14 Rosacea
Acne rosacea s a chronic vascular ad aceiorm disor
der of the l osebaceous u nit that aects redomin ant
the cetra face cudig he centa cheeks nose andchin e ees and the eelids can occasona be
involved Tical thee is an icreased reactvit of cai l ar es o eat leading to lushing and ut imate eang
iecasia Subtes of rosacea include (1) vascuarrosacea (erthematotelangiectac) (2) auloustula
rosacea (3) sebaceous herasia (maous rosacea)
inc ud ing rh noha (nasa sebaceous her as ia)
and ( 4) ocula r rosacea G rau omatous rosacea is a var
ant of rosacea
EP E M OLOGY
iee comon
Ae 30 to 50 ears eak ncdece between 40 and
50 ears
Sex femae red lecton male redomnance or hino
hma
Re: most common n far-sked indviduas (skn
hototes I and I ) rarel seen n darker-skn ned id
vdu as (sk n ototes VV I )
reiii rs excessive su exosue caenesic oods ot foods and beveages heat acoho seb
orrhea tocal coicosteoid use ad uderling
Parki nsons dsease
PAHOGENESS
Mutie actors are nvoved n the ahogeesis of
rosacea incuding vascuar heractivit emodex foll icuorum mites Helcobacter or i and hersest iv t
to Poonibacteium aces
PHYSCAL EXMNAON
Variable c n cal features can be reset deending on
the sevet an d th e subte o osacea Eal featuesincude ransent and ontransent flusing ertema
tous aules ad ustules No coedoes ae noed
Late features cude telagiectasas sebaceous er
as ia nasa th ckenig and en argeet (rh inohma)
and medema Ocula invovemen is equent seen
D FFERENAL DAGNOSS
Acne vulgaris seborrheic dermati s erioa demait s
sterod rosacea sstemc uus erthematosus ad
B uus mi l a is d issem natus fac e i
A
BFigure 14.1 A&B evere rhinophyma prior to electrosurery Courtesy ofuzanne Olbriht M
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DERMATOPATHOLOGY
Vascul ar ectasia as wel as perfo l i cu ar and perivascula r
lmphohistioctic infi trates are he most common fidings Demodex o ic uor um is usua l detected in the fol
c es Nocaseat ig epthe o id gau omas ae seen n
the granulomatous vaiat Sebaceos hperpasa and bross ae seen i rh nophma
COURSE
Ch ronic with fequent ecurrences Ma spontaneouslresolve afer seveal eas
MANAGEMEN
Preveion reducion o e imination of exacebas; suavodance
Topica Therapy
Metonidazole (0. 75%1 %) once o twce da 10%
sodium su lfacetamide with 5% su lfur oce da i , and
azela ic ac d once da i a lone o n combinat ion , a re he lp
l in suppress ing the papopustu lar componen of
rosacea
Sysemc Terapy
eracci ne 1 000 to 1 500 mg dai in d ivided doses
untl clea hen tape to a manteance dose of 250 to
500 mg da M ioccli e ad d oxccline , 50 to 00 mg twice da
Secton 2: Disorders of Sebaceos Glands J
c
with a tapeing to oce dai use '- "
Ora sotretnoin is reserved for sevee cases ot
respond ng o oral anti biotics and equ ires close fol lowup A lowdose regme ma be eective
Su g ic a Therapy
RhinophymaMut iple surgica modai ies have been used to coect
the hpertrophic changes of rhnophma t s impotant
to examne a photograph of the patiet pior to the onsetof the rh nophmaous chage n oder to help g ide thesugeon in he emodelng of the nose A egional neve
bock wth addit ional local anesthesa is suffic et in he
maorit of cases for periopeative pai managemeDirect nectio of anesthesia equires mul ipe ifi tra
tos ad s ess efective and far more painful
Electrosurger elecosecton (cuing) s ve efecive
in debuking and econtouring he hiophmatous
nose with the added advantage of a eativel bloodessfield t is sm la in ecac to C aser reatmen and
ess expensive ( g 14 1)
Figure (continue C, D,&E ebulking and recontouring of therhinophymatous nose in a relatively bloodless field utiliing large wire
loop electrosurger Impressive attening of the rhinophymatous noseafter electrosurge The wound is left to heal by seconda intentionourtesy of uanne Olbricht, M
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78 Color Atlas of Cosmetic Deratoo
he herrohed issue s removed wi cae o pre
serve he iosebaceous uns.
Overcorrecion wil l oduce scarr ng a d conacures.
Wound conracure wh hea l ng ma u e nasa
uward
Pemaen depgmeao ma resu from overvgor
ous reamen.
The E lman Surgiron can be used wih a large wireoo n blended waveform ul l recif ed" mode
wch rovdes cuing wh hemosass, a a ower
conro beween 4 and 5.
A vacuum evacuaor shoud be ui zed or e imina
ng l umes o smoke.
An remaning beedng ons can be coaguaed a Ahe end o he procedue b swiching o he coagua-
ion aia l recf ied" mode
The woun d s a owed o hea b secondar inenion.
The aes are n sruced o kee h e woun d m osb mu i e apl ica ios of ero eum e l da i un lre-ephei a l i zaion s com lee aroxmae 2 weeks
oso.
Excsion b e far-i nrared lasers (e , C or Er :YAG)olowed b vaoizaion s also ver eecve w h a r e-
aive bloodess surgical ield A scaned C aser s
he opima device gven he need o debul k arge hck
areas of skin . The u lsed C aser can also be used in
he con iuous wave mode o remove he bu k of her nohma and n he pu lsed mode o scu l and
resurface he reman der o he nose.
TeangectasasLaser and asham reames based on selecve ig
absoron b emogobin are usua ver eecive for
removing elangiecasas a d aria l l eecve n in h b
ing ush ing Paens m us be awae ha ove me he
are l kel o develo more eangecasias and back
ground erema
Lase eamen: mul e eecive oions are avail
ab e
Pulsed de asers (P) ae he reamen o coceor facia el angiecasias.
he radional P wih a shor u lse duraio of045 or 1 5 ms rovides he mos eecive ea
men or faca elangecasias. However, osrea
men purura occurs whic generall ass 10 o14 das
A var ab le-u se P (595 nm, Candela V-beam
Waad MA ) wh suered u se du ra ios ( ie
045 15 3 6 10, 20 30 40 ms) can ovde a
reduced urura reamen of acia elagiec
asias bu s somewha less efecive and usua
requires mul le reamens
cFgure ( B, C) Pminent facia ethema prior to treatment with
/PL
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Commol, subpurpurc luences of less tan
0 J/cm at pu lse durat o of 10 ms with a 7- mmsot size a re uti l zed
Better eicac of the varia blepu se PD L n treat
ing faca teangiectasias can be acheved b uti izing purpuric fluences o with a puse stackng
of subpururic uses (stacked 2 subpurpurcpulses at a 5Hz repett ion rate 75 J/cm ,
0ms puse duratio 0mm spot size CD of
30/20).
aca edema, ethema and discomfo can
occur after extensive treatment wt h the purp ura
ree variabepulse PD. owever these undesred effects are general better tolerated wen
compared to a pu ru rai du cng laser treatment
Intense pused l ght ( PL) can be igh eective in
treatig background erthema while P s wok bet
ter for id ividu al teangectasia I PL uencies of 30 to
40 J/cm with a 20 msec pulse duraton are usualleffectve (Staux ux G adpiece, Paoma MedcalTecoogies Bur ington, MA The treatment end
point s i mmed iate vessel cle arace or seectve ves
se darkenng. Mult e treatments ma be requredor the greatest treatment beneft.
The variabe puse wdth 064-nm d YAG aser
has roven to be eective i the treatmet of facateagectasias Shorter ulse widts with higher fu
ences migt be necessar for eective treatment ofsmaler vessels but have an ias risk of blister
and scar fomaton.
requecdoubed 532 nm d YAG aser asocalled potassiumttaphoshate (TP) lase pro
vdes effective absorption of hemoglobin with a puse
duratio of to 50 ms makng it ideal suited to treatsu eric a l vessels wtout pur pura formation acing
of i dvid ual vesses is a useful tech iq ue for atientswth a cou ntable n um ber of discrete vs ibl e vessels
lashamp (pulsed l ght) treatment P provdes
anoter eectve pururaree metod for reducigac ia l te angectas ias and ehema (F igs . 142 and
4 . 3 ) .
BBLOGRAPHY
Aferzo M M i l ma B. Exc is ion o r inophma wit h ighrequenc electrosurger. Dma Sg. 200228(8)
735-738
Aam M Dover JS, Arndt Treatment of facal telag
iectasia wth variabeulse higfluence pusedde
laser Comariso o efficac wit fluences mmedateabove and below the purpura threshod. Dma Sg.2003;29(7)681-684 Discusson 685.
Secton 2 : Disorders of Sebaceos Glands J
Figure 2 (contnue (0, E, F) eduction of the facia ethema afte
two teatments with PL taux Lux G handpiece
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80 Color Atlas of Cosmetic Deratoo
Besten EF igman A. Rosacea teament usig the
new-geeation h gh-energ 595 nm long useduato ulsedde ase. asrs Srg M. 2008;
40(4):233-239.
De Rosso Q Ani nammato dose doxcci e in thetreatment o osacea. J Drgs Drmal. 2009;8(7)
664668asm ZF Woo W andle M. Long-ulsed (6-ms) delaser treatmet o osacea-associaed teagiectasa
us ig subuu ic c l n ica theshold Drmal Srg.2004;30( 1) :37-40.
Mak K Saaco RM Voigt A Maeus Sano DS.
Objective and quanttaive imoveme o osacea
assocated ethema ae ntese ulsed ght treament.
Drmal Sr 2003;29(6):600-604 163-167.
Discusson 167.
Neu haus I M Za ne T Toe WD Comaatve eicac o
nonuuagenic ulsed de laser and intense ulsed
li ght or erthematotelang iectaic rosacea Drmal Srg2009;35(6)920928.
Sarradet DM Hussa n M Goldberg D Mi l isecond064-nm eodmium: YAG ase eatmen o acial
telagiectases. Drmal Srg. 200329 ( 1): 5658
hbouot DM Fescher AB Del Rosso Q Rich P.
Reated Aticles 7: A mult icener stud of tocal azelaic Aacid 15% ge i combnato wih ora doxcclne as ii-t ia l thea and azea c ac d 5% gel as matenance
monohea. J Drgs Drmal. 20098(7):639-648.
BFigure 3 () Prminent facial elangiectasias prir reatment with/PL (B) Psttreatmen erhema immeiately afer IPL treament
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Secton 2 : Disorders of Sebaceos Glands J 8
CHAPTER 15 Sebaceous Hyperpasa
Sebaceus erlasia aears as 1-t-3-mm ellw
um bil cated a ules with verig tea gectasias n he
ace mdde-aged ind v idua ls (F ig . 5.1) he reresen a bengn rieatin sebaceus glands The
less are smeimes misaken r basa cell carcin ma
EPDEMOLOGY
Icidece ve cmm
Age ms cmml mdd le age ad e der but can
aear i ung id v id ua ls as wel
Race mre cmmn in Caucasians
Sex equa
Precipitatig factors rga translatatn is a rare re
c ant
PAHOGENESS
Unknwn
PAHOLOGY
Increased numbers large maure sebaceus bues
are clustered arud a cetra duc n he uer dermisThe lbu es e c ser than nrmal t the e idermis
PHYSCAL LESONS
Thee are s inge r mut e -t-3-mm e w umb l i
cated aules with verlng elagiecasas tha t aear
n he ace he ehead, cheeks and nse are he
ms cmmn lcains It can rare resent n the
arela
D FFERENAL DAGNOSS
Ms cmm nl m saken r basa ce l carcin ma
LABORATORY EXAMNATON
Ne i s nd icated. B is i cns derig basa l ce l carc inma
COURSE
Ben ign but d regress r reslve wthu thera
KEY CONSULTATVE QUESTONS
An hsr he lesin bleedig
Figue Lage sebaceous hypeplasia on the foehead
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82 Color Atlas of Cosmetic Deratoo
MANAGEMEN
hee s no medic a ind icaon o teat sebaceous hper
pasia Si some idividas are signficant bothered bits apearance and eques emova paicuar n the
ccumstace of m iple lesions eatments icde
ora destcive lase and hotodnamic heaesEach has is side effecs and isk of ecuence
REAMENS
Al patients shold be inomed before an teatmentmoda it that impovement is vaabe and n the fte
new lesions ma a ise requi ig ol owp teatments
• Destct ve Modal t es
igh" crohera and el ectrosger ae qu ick nexpensve means of reang sebaceous hperp asia
• aser eapy
he 1 450-nm d iode ase has bee stud ied n
10 aients fo he eatme of sebaceous hperasi a
( gs 15 2 and 15 3)
Eac atient was eated 1 to 5 times
ue ces o 16 o 17 /cm were emoed wi cool-
ng d ratios of 40 to 50 ms
Ate wo to thee eatmes with he diode lase
84% of lesions deceased i size geater an 50%
and 70% decreased greaer than 75% Patient and
phscian satisacion was igh
Sde effects icuded one case of a aophc scar
and one case o hperpgmentation
Pulsed de ase (P (585 nm) has bee show to
m ove sebaceous easia
Successu reament as been shown with ee
stacked 5mm pu ses a e nces o 7 and 7 5 J/cm
Most esions respond ate one treatment wit flaenng s i k ng or esout on
Seven percent o esio ns ecued com p ee
Oe std showed cleaance in two paties teatedwith te P L at 585 nm 6 5 to 8 J/cm ad a ulse
width of 300 to 450 seconds wo to ree reatmenswere eformed
EbumYAG o C laser abaion ca aso mrove
sebaceos eplasia
Laseasssed hoodnamic era wi toica 20%
5amno levl i ic ac id and PDL ir rad a ion (595 m)
blue l gh o nese pulse l ght 1 to 4 treaments are
needed wih vaiabe improvement and fuue ec
ence acieved moe effective mpovemen of seba
ceous eplasia than PL aone
A
B
Fgure 2 () Patient with sebaeous hyperplasia on the right templeand forehead 8 Improvement 1 month aer treatment with 1,450nmdiode laser moothbeam, Candela Corp , ayland, MA utilizing a 6-mmspot with a uene of 14 Jm and a pulse duration of 5 ms
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Treatments were erormed at 1-to-6-week i nterval s
Both theraies showed greater im rovement than nothera at al l . There wee no l ongterm resuts
Sde efects wee imited to mild temorar edess
edema ad custng
PTFALLS O AVOD/OUTCOMEEXPECTATONS/COMPLCATONS/MANAGEMENT
Patients shoud be i normed that com ete resoution s
dicut and not alwas ermaent.
Destructive modaites such as cothea and elec
Secton 2 : Disorders of Sebaceos Glands J 83
trodesccation can roduce igmentar chages and Aeven sca rri ng i done too aggessivel. Recu rences arecommon
Local excson eaves a scar
Ora tera with isotretinoin s cear an aternativetreatment and s not as eicacious as other moda t ies
and carries with it the risk o signiicat side eectssuch as teratogenict d skn and mucous mem
branes high tr gcerdes and choesterol diuse
skeetal heostoss iver unction abnomalt ies
reduced ight vis o seudotumor cerebri leukoenia
oss ib e deress ion and su ic da deat o Toica tretnoin can oduce skin ir itat ion.
se thea must be used with caution esecal in
dark sk in hototes given th e risk o herigmentation
here can be scarr ing redness edema and crusting
as shown i Figue 153. Recurrence is not uncommon
BBLOGRAPHY
Aghassi D Gonzalez E Anderson RR Raadhaksha M
Gonzalez S. Eluc idating the u sed-de lase treatmet o
sebaceous herlasia i vivo with ea-tme conocascanning aser mcrosco. J Am Aa Drmaol. 2000
43(1 t 1) :49-53.
Alster TS anzi E Photodnamic thera with toicalaminolevulin ic acid ad ulsed de aser irradiation or
sebaceous herlasia. J Drs Drmaol 20032(5)
501-504Kim SK Do J E Kang HY ee ES Kim YC. Combinatio o
tocal 5aminoevulin c acidhotodnamic thera with
cabon doxide lase or sebaceous herasia J AmAa Drmaol 200756(3)523524.
Ri che DF Ami noevu i ic acid hotodam c thera orsebaceous gand herlasia. Drmaol li. 200725(1 ) :
59-65. Revew.
Schoermark MP Schmdt C Rauln C eatment osebaceous glad heasa with the used de ase.
asrs Sr . 199721 (4) 313-316 .
BFigure 3 () ebaceous hyperplasiabefore 8 Improvement one
month ar treatment with 1 450 nm diode lasr 14 5 Jm 5 mscoolin sinl pulse per lesion
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Disordes of Eccrine Glands
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86 Color Atlas of Cosmetic Deratoo
CHAPER 16 yperhdross
Herhdoss is e seceion o excessve amounts of
swea om the eccr ne sweat gland s a est an d a nor mal
room emeraure. oduces both hsca and socialdscomor he most common afected aeas are te
axi ae, alms and anar ee It can resen n a b lat
eral or smmetric fasion. Te most common cause of
her idros is is id i oath ic .
EPDEMOLOGY
d: no good eidem ologc studies o revalence.
A amolanar bih ax l lar ubert.
R: no racal ed ecion.
Sx equa .
r r d io atc, emoiona central nervoussstem inur/disease dug, surgcal injur are he mos
common causes. n most cases, there is a amil histo.
PAHOGENESS
Eccine glands are rimai l innevated b smathec
fibes tha are coinergc rathe an adrenegic in
neual resonse.
PHYSCAL F ND NGS
Palmolanar excessive sweat and sweat dolets roducin g a most aearance and c am m fee
Axi ar staning o shis in e underarm area
D FFERENAL DAGNOSS
Cl in ical a earance d oes not suggest othe dsoders.
LABORAORY EMNAON
Starch-odne or nnhdrn test are useful n defining
areas o sweat ng (F ig 16 1) .
DERMAOPAHOLOGY
No characterst c ndings. Bios las no role n management.
COURSE
Does not rem sonaneous ma m rove sl gtl with
age
Figure 16.1 An xml of th strhodn tst n th lft xll Not
th romnnt drk blublk dsolorton t sts of hyrhdss
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KEY CONS ULTATVE QU ESTON S
Medication histo
Past teatments and response
Assess for sstemi c a bnor ma i
Recent s urger
MANAGEMENT
The goa of the treament is to substan ia decrease
swea roduct on to mrove phsica and socia l d is
comfort not complee e im nat ion There are mu t p e
t eatments or herh d ros s (F ig 16 2) Bou num
toxn A s a ver effectve treament roviding emorar educt on in sweat ing Topca and ora l medica
tions are onl modestl effectve Surgical therainc ud ng posuct ion , s more effect ive than opica
therapComensator hehdross seconda to smahectom l m ts ts use at present except as a fina l theapeut ic
modalit
TOPCAL MEDCATONS
A um n um ch or de hexahdrate
Applicaton of 10% to 30% alumnum choride hexa
hdate souion n ethano with or without occusionto unshaven skin fo 6 o 8 hous nght for 3 to
4 das can be benefcal but s comcated b ocal
irritation Retreatment once o twice weekl fo maintenance is recommended Treated skn should be
washed the ol l owng mornin g
In he ax lae t s appl ed at n ght to unshaven sknand washed off in the moni ng
Frequenc of a cat ion d mn shes wth mprove
ment
ap water ion tohoress ca n be eective
The rocedue requires continua applcation for 15
to 20 mi nues 2 to 3 mes er week
B istering and burning ave been reoed as side
effects
Containdcaions nclude regnanc cardiac pace
makers, and metal imants
ORAL M ED CATONS
Oral anticholnergics ncludng bonaprine glcoprron ium bromide, propanthel ne and metantha l ine
bromde are of limited effcac The produce dose
relaed anicholnegic side effects
Section Disorders of Eccr ne G and s J 87
HYPERHROSIS
Atiperspant Firs tratmnt A u m u m c o i d (0%5%
Atiperspat
Boto
app d in vg t m s p wk
Effctv for may patits
Dyss and itat o a ma si d cts
Botoo Bot n m ox typ A ( Botox)
most commony sd Avag dos 5000 us p ax a
o Saf h g y ffctiv 3-9 mo hso Expnsv f not covd by suanc
ecatis
At ico ingcs; ighcdc o sd fcs
Sur
ecati
Suge
Consid i a o tapy a s
Edoscop c oacic sympacomy mostfcv o pama or faca hypid osis
H ighy ctv pocdu whn pomd by ask i d spca is
Fgue 2 Hyperhidrosis treatent diagra
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88 Color Atlas of Cosmetic Deratoo
SURGERY
Srgica ocedues icde the folowng
Endoscoc or classc smathecom is usua l
reserved as a fina teraeutc otion fo amar herhidrosis Srge rovides onglasng contro. Geeral
aneshesa is eqred. Side eects nclude bleedg,scar fomaion, infecion, eacto to anesesa, com
ensato herhidoss, gustaor sweaing, ne
mothorax, and oners sdrome.
Selecve gad remova s reserved fo ax a her
h idros is
Losucto for axi a herhdross volves subder
mal iosuct on . he l iosct o cau a s he d wh
the beve side u a the sbdemal eve for sctonigof hs rego .
BOTUL NU M TOX N ABotnum oxn A rovides emoar eectve treatmet
for hs condit on is a bacterial oxn tha decreasessweang b evesibl blockig acetcho ine eease
from cho nergic esnaic vesicles (Fg 16.3)
• Anesthes a
oica anesthetc cream and/or ce generall can ro
vide s cent an eshec eect.
Sil , neve blocks shold be considered or o la ntaand alm ar reatments o mi ni mize e associated ain .
Pa ntar sural an d osteior t ib ia erves
Palmar a r and median erves
• Teatmen
A starchiodne est erformed rior o treament ca
he deli eate the areas to be jected. Iodne is lacedon the aected aea, folowed b te acation of
constarch roducng a ominent dak beblack ds
coorato he stach-iodne aste shod be washedo rior to Botox ectios
Eecve Boox diuons var A Botox A (100 /vial)
d i lut ion of 2.0 U/0. 1 cc s eec ve .
nectos are erformed a 1 to 2 m ntervals intrader
mall throughot the aected area (Figs 164, 16.5
and 16. 6). wo n ts so l d be ieced e sie.
A otal dose anging from 50 to 100 U/axi a alm, or
sol e can be nected for a tota d ose of 100 to 200 forboth reatme ses A decreased dose can be sed for
oca zed herhidross.
em orar ha d an d fnge m sce weakness ma be a
coml ica ion of a mar bo inm toxin A n ec ios,
esecial l wh ic reasing dosages. Paients sod use
Nora ina o
Sympati nv Atyl o
Irvaon bokd by Boox
XSypai nv Atylo i
X
E inswagand
Fgure 3 Mechanism of action of Botox in hyperhidsis Blockingacetylcholine release fm cholinergic presynaptic vesicles
t
Figure Apppriate injection sites of botlinm toxin A fortreatment of () palmar hyperhidrosis and (B) axillary hyperhidrosis Eachinection sho ld be appximately 1 to m apart
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caution wen odig cus ad other obects su
oed b e tear m uscle w e the weakness is rese Ths weakess genea dssiaes within 3 to
4 weeks
Deceased sweating is obseed within to 2 weeks.
Benefits geneal are noted betwee 3 and 9 monts.
Side effecs ma incude ocal muscle weakness or almar njectios brusig antibod resistace and rare
an analacic reaction
Th e eicac of bou i nu m toxin nectios s ot aeced
b aser a r emova i the same area of reatmen
M e c a o s
Antco i nergics; igh inci dece of sde effects
PTFALLS TO AVOD Tem orar h ad and nger musc e weakness ma be a
comcaion o alma injecions of botu ium toxn Aeseca wth i ncreasng dosages
Botox inectos ae contraindicated in atients wt
under ing neuomuscular condi ions as wel as inregnat ad lactating atients
Deceased doses should be consdeed or aets onangiotensin-covertig ezme (ACE) inhibiors whc
can oteiate Botox eects
t is imora to counsel that te beefits of Boox aretemorar and requre reeat reatmes.
None o te teraes s uivesall effcacious. Te
atient must be awae that e treatment endoi is a
reduction in sweatng and not comlete e iminato
reament side effects ma be considerabe deending
on the treament cosen ad must be evewed atdet wih te atient ior to an treatment in t iat on
BBLOGRAPHY
Camaat i A aga a G Pe na L Gesuita R Of dai A.
Loca neura bock at te wrist or reatme of amar
heridrosis wit botu ium toxin Technical imrovements. J Am A ad Derma. 20045(3)345-348.
Glaser DA. Teatment of ax lar herhdross bchemoden ervation of sweat gands usng botul i um toxin
te A. J Drg Derma 20043(6) 627-63.
Goh C Aumium ch or ide hexahdrate versus a marheridrosis. J Derma. 99029:368-370.
Gregoriou S Rigooulos D Makrs M et al Effects of bo
ul ium toxina tera o almar hehidrosis in pantar sweat roducton Derma Sr 20036(4)
496-498.
Section Disorders of Eccr ne G and s J 89
Figure Injection sites marked on right axia of a mae prior to botuinum toxin A injection
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9 Color Atlas of Cosmetic Deratoo
Hamm H The lace o botl inm oxi te A in he
treament o foca hehidosis Br J Dermatol
2004; 15 6 5- 22
Heckma M, Ceba losBaman AO, Pewig G
Bot nm toxn A or axi ar herhdross (excessvesweang) N Eng/ J Med 2001344488-493
Herbst F Plas EG Fggo R Fr tsch A Endoscoc horacc smathecom or imar herhidross of thee mbs: A ci ical anasis and ong-tem esls n
480 oeratons Ann Sur 99422086-90
Lowe Camanat A, Bodokh I et a he use of ocalgcorroate i the eament o herhid rosis Clin p
Dermatol 99823204205
Pa A Kranz G Schind A Kranz GS A E Scha T
Dode ase hair emoval does ot nefere with bo
inm toxin A treament agans axi a hehdrosisLasers Surg Med 200423 21 1-2 14
Rena uer S, esse A Scha G oz e E Iontohores s
wh a tenaing c rrent and d ect current ose (A/C ontohoresis): A n ew aroach or treatment o herhi dro
s s Br J Dermatol 9931 29 166-169
Figure 166 The sites of hyperhidrosis
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FOURDisorde s of H ai Fo ic es
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92 Color Atlas of Cosmetic Deratoo
CHAPER 17 rsutsm
Hirsutism represents a mae paen overgroh o temi
nal and ve us has in women Far rom beng solel a
cosmetic concern hirsutism can be a important manfesato of an u nder n g endocrne dsorder ar s i ng rom
increased andogenic activit Oten it esults from anoverproduction of adrea and ovarian hormones and
ma accompan other s igns o v ir i izat o. I ts appearaceproduces socia anxiet distress ad ostacism in
afected patients I aso merts an appropriate medcal
worku. B corast hperrichosis eaues fine ars n
and ogensest ive as we as and rogeninsensit ive areas
Normal racia and ehnic varat ions ma cause conusionwith these disorders
EP E M O LOGYee: common .
Age usu al ostubeta b ut age o onset can var n the
setting o medicatio n tu mor or endocr ine ab noma it
Rae: racial and culua actors aect te perception ofwat constitutes abnormal hair grow Skin tpe aects
treatment opions as well .
Sex: emae .
reg ars: hirsuism s caused b a host ofendocr ine abnorma i ies Adrea causes inc lude
Cushig's dsease ectopic adrenococoropic hormone
(ACTH production pr mar androgeproducig eopasms and cogenita adrenal hperpasa Ovarian
causes can be relaed to pocstic ovarian sndome
and prima tumors among other causes Fina l med
ications such as oral coracetive i s anabo csterods and a ndogens ma cause hi rsutism
PHYSCAL EM NATON
hee s an overgrowth of ha in an drogensensit ive ha irfo l l ic les . Common s tes ic lude te beard aea o the
face chn eauricular ace l nea aba periareolar aea
and chest Depeding o he severit of the conditonother signs o vir i l izatio such as increased musce mass
dee voice mae paern hair loss and c itoral earge
ment ma be present
D FFERENTAL DAGNOSS
Wh le both h irsutism ad pertr ichosis eature ha ir over
groh tese coditos can be diferentiated b thelocation and q ua it o the hair growth Hi rsuism is car
acterized b termnal hair overgrowth in androgendepede nt areas wh ile hpertr ichosis featues ie hai rs
Fgure 7 pot se, mm versus 1 5 mm Larger spot ses penetratedeeper and aow qucker treatments
Fgure 7 2 Har trmmed pror to treatment
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in androgen-sensiive as well as androgen-insensiive
areas. Norma raca and ehnc varia ions ma caseconfusion wih hese dsorders
LABORATORY T ESTS
The aborao worku shold be gided b the atent'sclnica fndings as wel as b a detaied aent histo.Testing can el establi sh f there s an a drena o ovarian
souce of the hair groh Ovaian adrenal, and ititatumos should be red o n cases o rad onse b an
endocrnoogst and/or a gnecologist. Total testosterone
leves dehdroeiandrosterone slfate leves rinar reecortiso evels dexamehasone suression test rolacn
leves ACT simuation einzing ormoneoll ic lesmating homone (H/FS) ratio 17hdrox roges
terone eves, and evc urasound ma al resent mor
tant comonents of a thorogh endocrinoogic wok
COURSE
Course is deenden on th e et io og of th e h irsism
KEY CONS ULTATVE QU ESTON S
Menstrua hisorregar or i regar
Medication histo
Onse and rogession o smoms
Fami hstor of inflammator csic acne and hai oss
istor o endocr ne abno rma i ies
MANAGEMEN
The imar goa of the treament is to deermine he
ndeng case o hirstism and trea Aer determin
ing the case a nd en sr i ng aror ate medica therathe goal can tanst ion to reversng the abnorma air
groh. Tere are mt i le mea ns b whi ch temorarand ermanen hai r removal can be ach eved.
C o s l a o w E o c n o o gy
In cases of hstsm e first riorit is to ncover thesource o the aberant hai growth. Nmeros laboaor
investigations as dea led above ma be reqred.
Consultation and referal to an endocrinologs is srongrecommended as art of such a work.
No ase herap es
Thee ae several emorar means to concea ar overgrowth. Te ncde makeu beaches, and hdrogen
eroxide. Shavng also can emoari hde ha groh
Secion 4 Disorders of Hair Fol ic es J 93
Fgue 7 3 aser light firing
Fgue 7 Characteristic posttreatment perifolliclar ethema
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Color Atlas of Cosmetic Deratoo
ar emoval can be achieved with deiat on, epi a
t ion as er thera eectrolss, a d toical efornith ne.
Dep at onDeilat ion is the process of emovng pa of the hai
shaf. ts effects ae temoar. There ae chemca andmechanca l methods of de at io. Ch emic a de lator es ,
such as thogcoate salts ad sufides o akal metasdssove hair shafts. The can roduce ocazed tat ionat the site o treatment. Mechanical dep at on ca be
qte cude inc d ing shavng of ha r as we as ubbghai with a pum ice stone
p a onEp at on s the pocess of removig the entire hair shaftIt provides more ongevit than depiaton but is not er
manet I t ic udes waxing, p luckng, threadng, and
eectr cal devices that remove the har shaf Each ofthese otions s reat ve inexensve but can oduce
pain ad irr itat o as side effects. Puckng can reslt in
localized infection ngown has, ad even scarrng.Each of these treatments can be used n combation
with toical efornth ine o the ace of women
Topca efonthne anqa)oca efornth ine wice dail has been aproved b the
US Food and Drug Admnstraton (FDA) for tempoa
hai remova o the face of women. It should onl be
used on the ace and not on othe ats of the bod. Itdeceases the rate o hai growh b nhibit ng orthine
decarboxase. It shoud be sed n conjnction with
other hai remova methods such as shavng waxig, o
puckng Patients should use the medicatos fo
8 weeks to udge its eicac. I there is no imrovementafte 8 weeks, the medication shod be dscontinued. If
the medcation woks, t should be continued.
Dscontnuaton of teatment results a esumption ofhai groh. Sde effects ncde loca irr tat o t should
not be used dring pregnac.
• E eco lys s
Remova ca be ermanent
Eectross uses d rect eect ca c rent to destro thedemal a i l l a of the ha i r o l l ic l e . A f ne needle placed
direct into the ha r fo l l c e de ives the e lectr ica lcrrent to the fo c le 's base without roducing scarr ng . he ste of treatment s shaved severa d as pior
to therap and toca aesthetc cream can be sed
1 hou o to the rocedure to redce pa n Side
efects ncde scar ho/hpegmentation and
nfect ion . t s most appror iate or sma areas of
treatment
Need for mu lt e treatments fo i mited teatment zone.
Greate r sk of side eects, anfu l.
Not actc a for a ge areas of the bod
Fgure 7 Bizarre growth of back hair on a male due to poor technique
Fgure 7 tensive dyschromia seconda to inappropriate uence andpulse duration
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Lase a i emova
Lasers are the treatment of choice fo permanent reduc
ton of uwanted, pigmented termna ha fol ic es aserha removal s qu ick, re lat ive nonpaifu , especa
compared to eectrolsis uhemore, t can cove a far
moe extensive area of afected ski n with less pa n n less(e, imprope spacng and ovelap) t ime An average of
ve to seven treatmets are eeded or geate than 50%reduct ion
Mechan sm of actonLasers are based on the selectve phototermoss he
lght s absobed b te pgment in ha fol l c les
Theefore, f hair fol ic es ave no pgment ( e, blond or
Secion 4 Disorders of Hair Fol ic es J 95
gra air), asers do not wok asers work best o tcker Aha o l ic es
.
at ent Consu tat ion
Ha r co o r
Skin tpall skn tpes can beneft fom aser hair
remova
Past medical hstor
Medications
Past teatmen ts
Emphasize the need for fve to seven teatments on an
average to rem ove t e majoit o unwanted ha ir
mpovement is vaable
Low risk of no mprovemet or increased hair (espe
ca l n emaes of Mediterranean hertage)
Rsk o hpe- o hpopgmentat on that ma ast
months rarel pemanent
Scarrng s are
Lkeiood of at east some pain te amout of pan
assocated wth the procedure is a reflection of t e caliber and densit of hair i th e treated region
dea l cand idate has dak course ha ir and ight ski
phototpe
Average candidatefine/lght brown hair
Poo candi dateblond/gra h ai r shou d not be teated
wth a 80-nm dode aser wth curent lasersAddt ioa patents with unealst c expectations or
medic a contra in dcations should not be treated
a ent Cons lta on io oTeatment
Su n avoidance s crucia If a patiet is taned , the procedure shoud be postponed unti l te tan completel
fades If the pocedue is pefomed on taned skn,
th e isk of dschromia s marked ncreased
BFgue 7 7 () Appearance of skin prior to laser hair remoal (B) Hair onlateral cheeks
Fgue 7 8 Appropriate clinical endpoint of perifollicular ethema in
this 4-year-old female with type VI skin and polycystic oarian syndrometreated with the long-pulsed 1 064-nm NdYAG laser
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96 Color Atlas of Cosmetic Deratoo
Shave ai por to ar v ing in the oice Alerativey
the ha ir can be im med the ofice wth a mou stacetrimme hs w l l focus e majoity o eegy to the
pigmented a i fo l ic es the skin .
A toica a esthetc ceam ca n be apl ed 1 h ou r por
to eapy to decrease te ai d uri ng the procedu e. It
s i mpotant to advse te pate to ap ply topical a esthetic ove a m ited suface of the ski n to avoid a ny isk
of lidocane toxici.
Hai waxng shoud ot be efomed 2 to 3 weeks
beoe teament.
f thee s a hstoy of ecurent hees smplex vrus
prohyaxis sould be provided befoe ase haemova o face
Pregacy there ae no cea studes demonstrating
safety o sk t is mpota to educate pegnatpatents desir ing hai emoval as to his uncetainty
Mos hysca s wil not eat pates wh le prega f
treatment s usued is ecommeded to tea only mied aeas du rng thid meser ater medca c ear
ance fom a obsetrician.
• Js Pr io o Treame
Witten conse
Photogahy
m ha
• aser Ha i r Remova Tech qe
( F g s 1 7 . - 7 8 (Table 1 7 Key coc es fo otima l esu ls are as fo lows
o skn types I to I l l use eatvey gh eergy wth a
shoter u se du ratio o otima l esuls.
TABE 7 • Laser Hai Removal Techque
Lase tye Safest ski n type Waveleg (n m Pulse d uation Enegy (/cm Comments
Ruby I I
Aexandrite I I I
Dode V
NdYAG IV
Intese pulsed I IV
I gtnoc oheen
igh
694
755
8 1 0
1064
5501200
120 ms
Sk tyes I I 3 ms
skn types I and IV1020 ms
3100 ms
1040 /cm
Ski types I I I
2025 /cm
sk tye V 1 20 J/cm
300 /cm
is lase used fo
ha removal s lower to use
3 ms ad 1020 ms
use d urao emostateequa eicacy
Loge u lse du rato otreatment of sk n tyes Vand V
Sk tyes I I 1020 ms Skn tyes I I 350 Saest devce foskin tyes IVVI 21 ms /cm sk tyes emovng a i in sk
1 . 53 . 5 ms
I l lVI 2535 /cm tyes IVV
2550 /cm Mos variable esuls
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LASR SAFTY
Hazard: ocula
DangesCoea, tina o lean amag
Dmg cu rfrom d t o f l ct d bas .paie n t jewery, ches
Q-h la armo hazadu caa b
�
corea
ens
Hazard: fire
DangersA ar a poially f
Mos como y sih C02
aa a ufom d i c xpou rfl bam
Enhance SafeyBale eye exam
Le ol p ty 0 hd bq u l t ga tha h ck s)
I spc ols fo s il dama degradain f e filer d ia
a k at apppat fowvlngh u
Rmov boiz cov r ny cVa i a m, i e. irm a l l i aa ca
Rmov pa jwl wahs
han ce Safeyem e o v ay in le m . miro tlliaba a
A h r a t i uy
vapo p to trt f ttmtape ame wh we z o toe l
Remve l l f lmb l tm i. d zw l,
a xps ha w waba jlly
cas F02 o % wh at aaha tb
Hazard l lar Dangrs ha ne SafeyIa a val U makDNA uh P mb h pum Sk vaaof CO
ue ptce apa a d ah Q·hd la
Hazar DangesEvn w w ffan aue h/ t
Hazar:
DaesApa a
hane Safeyy al l c a ope la
Ch fo te pll oe p i
nhn e SfetyAlw mmtly pt on tndbme h ea pat e t
u pp la
u a ms a las ety
Fgure 7 9 Laser safet It is important to emphasize that lasers present special safety conces for physicians s ta and patientsAmong the risks are ocular inju fire electrocution and dissemination of infectious disease No lasers should be operated in theabsence of a detailed knowledge of laser safety issues between the physician and the staf Educating staff members is an essentialcomponen t of safe laser practices Periodic laser safety training is required by many hospitals and remains good practice for privatephysician offices as well () Patient and all personnel are wearing protective eye wear Note gauze is moist to reduce the risk of fire
8 moke evacuato (C) afety sign placed outside appropriate laser room to ensure proper warning of laser use
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98 Color Atlas of Cosmetic Deratoo
Skin tpes V o V mus use longer pulse and longer
waveength such as a 1064-m YAG
f ucera as to treatment parameers perform tes
sies with varia be fluencies ad p ulse du raions
A l machies u ize coo ig of epidermal ski v ia croge coact cooling or ge
Optmal coog sett gs must be ut ized to lower he
rsk of dschromi a
Use larger spo szes for deeper penerao ad more
rapid treatmet of arger areas
Safet gogges for patient and medca team
Use the argest spo size possib le for target regio
Overlap laser pulses 10% over the etire treatment
region
• Poseamen src ios o Pa en
Expect red ess for u p t o several ho urs afer treamen t
f red ness or pai perssts for more tha 12 h ours cal the oice I there are an cutaneous changes i the
ski n he da afer the p rocedure or beod the paiet
mus be old to cotact the treaing psici a
Once redess fades patiet ma conue to wear
makeup
Avod s u or 48 hou rs o ta ig
Hair removal is o entrel mmedate Some har w l l
al ou 1 to 3 d as aer treatmet
Do ot worr if some h air persss aer reatme
Cal the oice f dscooration develops i the reaed sites
Cal the oce wi qu estos or concerns
PTFALLS TO AVOD/COMPLCATONS/MANAGEM ENT (Figs 1 75-176
There is o effecive mechansm or aser removal of
g or blod hair
Excessive fluecies or icorrec pulse durato maproduce epidermal damage ad dschroma These
effects are tpicall temporar but ca be permanet f
there s a doub regardg laser parameters performa est sie
Skin tpes IV o VI require loger pulse duratos adower fue cies
Coic de tattoos ad letges ma experece l ght
en ng Patets shoud be formed of ths possibi l t
Awas keep contact cooing agast the skn to avod
burng
Overlap ( 10% ) i the treated zone Do not leave gaps"that can create biza rre hai r growth paterns as ha ir
regrows
(� "
Y JLens
Wae- Sign or ymtomlenh nm Laer Ee njr of n
Cornea len Retna
<0 ys
0 0 Exc1mr ys : ys : ys0 nm)
000 Agon es Fash of te nm) emt wavlnh
: solowed by
KTP atmag o a m n ) complmntay color
Pusd y s
la 0 nm
N VAG es Damage om a -switchd0 nm) NdVAG ar may not
dettd as rena Ruby e lacks pa ibrs nm)
swiched lases haveAlexandrte yes hghes ential to nm) cau bindne
Do : y Ma uce a poping nm) sound, hn sualdsoientation
0 N VAG e00 0 m )
Nd VAG
0 m
D1od : s
0 m
E AG yes Burg pa at the ite of00 0 nm exsu on the cornea o
scea
CO
ys000 nm
Fgure 7 Lasers and eye inurieshttp eyesafet4ursafety cmlasereyesafety htm
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For dYAG lasers patients ma experence pain even
afte opical anesesia.
BBLOGRAPHY
Azziz R. Te evauat ion and maagement of h rsu ism.
Obstet Gynecol. 2003101 (5 pt 1 ) 995-1007.
Battle EF, Hobbs M. aserassised hair remova fordarker sk in pes. Dermatol Ther 2004 17 (2) 177183
Bouzari Tabataba H, Abbasi Z, Fiooz A Dowai Y.
aser air removal Comparison of ongpulsed d:YAG
longpused aexandrie, and longpulsed diode asers.
Dermatol Surg 200430(4 pt 1)498502
Godberg DJ. ase ar remova Dermatol Clin.
2002;20(3) 561-567.
Tanzi E Aster TS ongpused 1 064m d YAG laser
asssted har removal in al l skn pes. Dermatol Surg
2004;30(1 ) 1317 .
CHAPTER 18 Pseudofo cu ts
Pseudofol icu it is s a common, chronc inflammaor dis
order at presens wi infammator papules ad pustules n he beard distr bution of maes, paicula those
with darker skin photopes ad gl coied ar
oetheless, pseudofo l cu it is ca preset n a skinthat s reguar shaved and in al l ski phototpes. n
females it is most commonl seen in the axi lar adpubic areas teds to pesent n a more mld form i
l gher sk n photopes.
EPDEMOLOGY
Incidence over 50% of African American males
Age begis wi savig or puckng
Race more common in beard dis ibuion of males wth
darke skin phototpes
Sex male > females
Precipiting factors shavng in an region of the bod
PATHOGENESS
Ths d isoder s induced b savig. Shav ng shapes
cu red a r Sharpened igh cu rled a rs pierce io theskin adjacen o the hair fo ic le and nvade ino he der
mis producing an nfammaor reacion. I can also fol
low ar puckig, especal n femaes wi hsutsm.
Secion 4 Disorders of Hair Fol ic es J
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Color Atlas of Cosmetic Dermatology
DERMAOPATHOLOGY
Hair enetration esuls in edema invagiation with
associated microabscess, mxed inlammato nfiltrate
and foreign bod ga reacion at the i o the ivading
hai . emal fi brosis ma be observed
PHYSCAL LESON S
Mos common, it esents wth fo l icua aples us
tes and ostinflammato hpergmentato in the
bead aea and anteolateal neck o maes and undearms ad bikin i areas o emales. Paues can develop
into csts. Sca ormation ma be obseed. The ue
ctaneous ip i s tical sared
D FFERENAL DAGNOS S
Acne vu lgar s fo i cu l t is
LABORAORY EXAMNAON
Noe .
COURSE
Begns with shaving or lucking and cont iues nt i
cessaion or modficatio in he ar emoval echnique.
MANAGEMENT
h e goal o t e treatmet i s to pevent th e omaion o
the paules usules scar ing and ostilammaor
herpigmeation associated wth this dsorder There
are mt ipe treatment optos available to accomish
this goal. Cessation o shavng o luckng s e most
successu teatment but t is m racica and nd esirable
for man patiens. aser era is hghl eective withhgh patient satsaction.
TREAMEN
• Shav i g Cessa io
he mos sim le iexpensive a nd eective eatme fopseudofol cul it is is the cessaton o shaving. Man
pat ents wi l f ind h is ot on ndesiab le or i mpactca l
• M o f a o o f S h a v g e i q e
A oper shaving techn iq ue ma event or sgifcatl
decease the r sk o sedoo i cul i is A mong these prac
tices are ift ing no uckng igrow hairs, thorough
BFgure 8 () A youg male with type VI ski phototype ad pseudofolliculitis barbae prior to treatmet (B) ame patiet moths later aerseveral treatmets with logpulsed 1, 064m Nd YAG laser Courtesy ofE Victor oss M
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wetting the area ror to ain g shavig cream usig a
sha razor, shavig in te drection of the har growth,and avoid ig shaving more than one d irect ion i the
same area The Bu m Fighter Razor revents the shavedha from being cut too shot Addt ional l, cuig te a ir
twice dai l wit ha cl ers revents hai rs fom ercig
into the sk
Topica Treaet
Toical ati biotics ae effectve n treating the i flam ma
to and occasona metgiizato associated with thiscodt io Toical tretoin, benzol eroxide, ad g
colic acids can be helful adjucts
Laser Ha r Remova (F gs . 1 8 . a d 8 . 2
Laser hai r removal s a sae, h igh effective teatmentmodat for short ad og-term mrovement
Skin tes to I l
The long-u sed a exadr ite lase (755 m), d odelaser (810 m), itese u se ght (590100 m)
and ong-used NdYAG (1064 m) aser have theaorate waveengts to seective target the
chromohore mela n found i the ha ir bu l b
Mut ile treatments (average of 10) ever 4 to 8weeks achieve a aveage of 50% to 75% ema ent
reduction of fol l cular aules/ustules
Ski n tes V to VI
The long-u lsed 1 ,064-m d YAG aser s te treatmet of choice n sk hototes IV to V It s safe
and effectve Log ulse durations are ecessaror edermal rotectio Pulse duratos o 30 to
100 ms ae generall recommended Otma uences
range from 20 to 40 /cm Treatment s erfomed
wth nooverlang uses uti l zing cooig to the
eide rms va crogen, contact cool g, or ge
ewer generation diode asers wth loger ulse
du ratios u to 400 ms ca also be uti zed wth cau
tio in d arke sk tes
Tc a l, 5 to 10 treatmets saced ever 4 to 8 weeks
ae eeded fo 50% to 75% ermanent reducto n
P TFALLS O AVO D/OUTCOM EEXPECTATONS/COMPLCATONS/MANAGEMENT
Taed atets soud ot be treated wth aser hair
remova Once the ta/nfammatio subsdes har
remova ca begin
Do ot u ck or wax h a ir r or to or dur ig te course of
aser ha ir emoval
Secon 4 Disorders of Har Fol c es 0
igure 8 2 Pseudofolliculitislaser therapy pigmented versusunpigmented hair follicle
Fgue 8 3 Etiolo of pseudofolliculitis
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102 Color Atlas of Cosmetic Dermatology
Patients with unigmented hair (blond gray red) wi
not beefit from aser hair removal and shoud not betreated
here is te risk of transient and ongterm yeig
mentation ad hyoigmetatio Transient erythemascabbi ng an d r sk of scar formation also exist
A maority o atients wi see 75% mprovement. Asmal m no ity w l l see l itt e or no im ovemet.
Futue maintenance treatments may be eeded
A smal m iority of patiets w l l exerience a paradox
ca ncrease in hair growh part cuar ly emales o
Mediterranea descent.
reatment may not benet reexistig yeigmenta
ton and will not imrove scars
t is imortant to inorm atiets tat side eects are
often delayed in ski hototypes IV to V ad may ot
be observed for 1 to 2 weeks after treatment. Test spot
s advsed for these patiets (Figs 183 an d 184 ).
BBLOGRAPHY
Battle EF Jr Hobbs M aserassisted hair removal fo
darker sk in tyes. Demal Te 200417(2) 177183
Br idgema-Shah S . Th e medca l and surgica theay of
pseudofol cul it is barbae Demal e 2004; 17(2 ) :158163
Haedersdal M Wulf HC Evidencebased review of hair
remova usng asers and l ght sources. J AadDemal Veeel 200620(1) 920
Kontoes P Vlacos S, Konstantnos M Anastasia L, Myrt
S. Ha ir nd ucto aer laserasssted a r remova a nd ts
treatment. J Am Aad Demal. 200654(1) 6467
Ross EV, Cooke M imko AL Oversteet KA, Graham
BS Banete J Teatment of seudofo i cul t is barbae nskin tyes V V ad VI with a og-pused neodymum
Yttr um alumnum garnet aser. J Am Aad Demal2002;47(2):888-893
A
BFigure 8 () Test sot teatment unde chin and on chee is advisedfo dae sin hototyes befoe teating seudofolliculitis (B) Twowees ae test sot teatment, some hai emoval is achieved with noigmenta changes
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Secon 4 Disorders of Har Fol c es 03
CHAPTER 19 Mae aern ar oss
Mal e paen h air oss classcall p eses wth bempora
ha l oss that progesses o the loss of ha r on t he vetex,
rontal and empoal scalp Paieta and occpita asare usua uafeced It is a onscarrng or of alope
ca ha occurs i geneical susceptbe males. The
gradua ioa oss of har does chage he naural
frame ha r p rovdes around o u face T he gradual loss ofha resu ng n an ivoutar chage n appeaance
creaes varng degree of emotona and pschologicastess Man me seek eamen for mae paern hair
loss because of unhappness wth its cosmetic appear
ance and association with agg
EPDEMOLOGY
iee 30% o maes oder than 30 ears more than
ha of ma es ode than 50 ears
Age begs ate pubert
eipiaig faos pogenetic erited pedisposit on
No diagnosic tests exis to deermne the eoog and
natual progession
PAHOGENESS
The pecise pahophsolog remans uknown Ths
process s beleved to resut fom bo a pogenec
inheied suscepibi l as wel as androgenc simuaion.The mos mporant androge n this process is dih
drotestoserone.Thee s a dinuion in the sze o aeced ermnal
fol l c es tha egress to become ve us fo l ic les tha even
tua l disappear Thee is a inc rease n teloge h ai rs anda decrease in anage hars
PHYSCAL EM NAON ANDNAURAL PROGRESSON
Tpcall, onal ad tempoal hair oss/hnning s pre
sen fist. This begins in pube and progesses overdecades The ate and exte of hair oss vaes from ndi
v dua o nd iv dua Some progress to complee ba dness
in earl 20s ad others gradu all th n over decades.
DFFERENAL DAGNOSS
I n males the paen o hair oss s chaacterst c sugges
ing no ohe dagnoses.
Fgue 9 Nowood cassification of the natua pogession of maepatte hai loss
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1 04 Color Atlas of Cosmetic Dermatology
TABE 9 • Minoxidi and inasteridhe Only Two DA-Approved Medications for Male Pattern air oss
Mecha nsm o action
Ke to su ccess
S de eects
Cl in ical on set of action
Dose
Can dd ate seectio
Noood I IV
Norwood IVV I I
nasterde
5 reductase te n hi bior bock g the coversio oftestosterone to dhdrotesosteroe
Em hasze mai neance over regrowh of hai r and com l ance
or at least moths to see benefi
2% o men experece sexua dsunction Reversb e wth n
das i dscotn ued
o al l ergic reacios, b ood mo itor ng or drug iteractiosPre menoa use of fema es shoud ever hande or take
medcaio Wome ma have some benef
moths
1 mg qd wh or wthout ood
H ghl effective
Somewha effecive
ABORATORY EXAMNATON
I n ma les o l aborator worku i s tpica requi red
M ED CAL THERAPY
• Key Consu tat ve Qes os
Age of onset
Rate of hair oss Past medcal hstor
Medcatons used to date ad success of era
Patent exectato of an medical or surgica therap
• DA-Appoved Medca eapy(a e 9 .
M inoxid l a d inasteride are the ol two medications for
mae patter hair loss aproved b e US Food DrugAdmi n istrat io (FDA)
HA R TRANSP LANTATO N
• D e n t o
Minox id l
Uknown
Emhasze maintenace over regrowth of
ha r and coml iance mohs osee beef
Drness and pruritus of the scalp Rarea ergic reaction
moths
wo to fou r drops o ne to wo tm es da
to froal a nd veex o sca p
H gh effectve
Somewhat effectve
Al pates sou d exec conssel atura ap earigtranspanted har Based o the heor of door domi
nance, ha r o l ic es ma ta he ir geetc dest wer
ever the grow o our scal ar trasplated from theposterior sca wil l grow or as ong as i was genetcal l
progra m med to grow For the vas majorit of me transpa ed hai r wi grow or decades
Figure 92 Unnatural "pluy hairline using 10 to 5 hair grashould never happen in twentyfirst century
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a ir naura l gows in 1 to 4 hair o icu lar bu nd les
Contemporar hai ransplantation uti l izes a large umber o 1 to 4 ha ir fo l l cu ar groupings The resu lt s cons is
tentl atural apearng transpanted hair for men and
women
THE CONSULT
Key Ques ios
How og have ou noticed hai loss?
Rate of hai r oss?
Whic h m edicaions wethe presciption or alernative
have been tied a d for how long?
Expectations?
y s c a E x a m a o
Norwood stage (Fig 191)
Dono densit
Cal i ber o ha ir fo l ic les
Idea l cadi date: h g donor dens it ick ca l i ber ha r
o l ic le rea l s ic exectat ion ( F igs 9.3 a nd 194)
Poo candidate poo dono densi, beow average
hai r ca iber u neals ic exectations
Key o ts o mphas ize Beoe Ha i Tas laat ion
Net peceived densit rom a a transat = the
nu mber of har fol l ic les tanspl aed{gong hai r loss
Fine hair fol c es wi create thn natual coveage and
th ck cal iber o l ic les w l ceate more peceived densit
Ongoig hai r oss wil aec e cosmetc appeaance oa ranslant
Visble donor sca or scas i har is shaved or cose
croped in posero scalp
Limted donor su pp
Ke to success hscian and patient have simiar
expectaions o what te rocedue wil l and wi notachieve over the so (13 ears) and ong term
( 1020 ears).
M e d c a o a d Ta n s p a at o
Medicat io to maia n exist ing ha ir w l maximize the
denst from a transpla nt bu med ications should alwas
remai eective Hair ine design and distr bution o ecii
ent stes should alwas assume ongoing hair oss
Secon 4 Disorders of Har Fol c es 05
Fgue 9 3 ealitic expectation uing 1 to 4 hair graf Before
Noood V
Fgue 9 ealitic expectation uing 1 to 4 hair graf er 1 1 001 to 4 hair gra
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106 Color Atlas of Cosmetic Dermatology
SURGCAL PROCEDURE
• Peopera ive src os
No seci c b ood tests
Medca l cearance aroriate
Photograhs
nformed wren consent sent to the aient for review
at least 1 week befoe the rocedure
• Day o Procedre
Wrtten consent with ostoerative isructons reviewed
ntroduce h ar rasla nt team
Review rocedure and goals with atient
• D o o r eg i o O y L m i t i g ac o r
H a Ta s p a a i o ( F g s 1 9 . 5a d 1 9 . 1 0
Anesthesa n dono egon
% docaine wth 1 200000 einehr i e
30 o 60 cc sa ine
Sa i ne i n door region rov ides
anesthesa
hemostass
less transecton of hair fol l c es
less ikey to transect the occi ital arteies
Dono havestng technques (ab es 1 9.2and 193)
E l it ica str ha rvesting: >95 % of atents
Fol cu lar uit extrac ion <5% of atents ( F ig 19. 1 )
Ell ptca stp harvestng
Use sk hooks to retract when removing donor e l l se
to mn mize transact on of ha i ol l ic es (F ig 19 12)
TABE 9 2 • Advantages an d Dsadvantages ofFocular Unt Extracton (FUE)
Advaage
No near donor scar
Oen mn mal y v is ib e
scarr ng n t im med
donor region; advantageor atens with sho
hastyeCan be used for aties
with extensive scarring
n osterior sca frommu lt il e revious sugeres
Disadvantage
More t me consumng
More FU E sessons to
equa l d esity from
e ise
Greate transectio of
ha ir fo ic es with
otentia decreasedye ld
Fgure 9 Trim donor region with moustache trimmer, and tape hair upso donor suture will not be visible in the postoperative period
Fgure 9 Patient in prone position
Fgure 9 7 onor strip shou ld not be more than 1 m wide trips>1 m have an increased risk of creating a hypertrphic scar
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Secon 4 Disorders of Har Fol c es 07
TABLE 93 • Door Harvestig Techq ues E l iptic al Sti p Harvestig Vesus Fol ic u ar t Extracto
Mi n im a ansect io of dono ha i
N um ber of 1 gras sae harvested pe r poced e
Tme to havest dono ha
Vs ib e dono scar wth h a egt >1 mVis ib e dono scar wth h a egt <05 m
Oveal l percentage o cases used
U derm in ing donor egon rare necessa
Do be l ae of st res ael necessar
Sutes o sapes to cose in sige lae
Sutes o sapes ot i 7 to 10 das
Keys to success door haestg of elpse
Dono st width <1 m
Ae l idocaine add saline to dono region to povdehemostasis a nesthesia a nd redce tasecion o ha r
o l ic les
Ski n h ooks to retract t sse whil e removing el l se
Do ot sh
• F o c u a i t e x t a c t o n
Den t ion remova of fo l i cu a goupi ngs fom the poste
r ior sca l p us ng 1m m p nches
Excelet teament oto fo patients ver shotdono hair at do want a vis be dono sca and fo
patents wth seveel depeted donor regios from mulpe previous hair tansplants
• Gat ceat on
All grafts shoud mimc the naua 1 to 4 fo iclar bu
d les that naua l l occ on the sca p .
Keys to success i c eatig to ha gafts
Good egonomics and nsuments Pep bades and
#10 blades are often sed to seaate fo i cul ar goup
ings from te dono e ipse Magnfication ca aid theprocess n separatig fo icla grouigs from the
dono e l i pse
Do not allow gafs to d The must alwas be n
ch i l ed sa ine
Well -tai ned staff of hree to four su gical assistas
Sta tanng
Enthusiasm/nterest n pocedue
Patience 6 to 12 months or an assista o earn to
creae 200 to 300 gas per hour
E l ipse Fo icar un extracton
Yes o
1 , 5002000 200500
1520 min 12
o oYes Likel no
>95% <5%
Fgue 9 8 losig door regio ith stples
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1 08 Color Atlas of Cosmetic Dermatology
• A n e s t h e s a n R e c p i e n R e g i o n
Fie d b lock an d oca if i t at ion wth 1% idoca ie wth
1 200000 eiehr ine and 0.25% Marca ine with1 200000 eiehr ine .
Suaorb ita l and suatoch ear b o ck is ot iona
Suef ic a inf i l t rat ion i d emi s no t subcutaneous t ssue wll ceate good hemostasis
• a i n e e s i g n
Den t ion a ha ir l ne is an ir regu ar i l def ned rans it ionzoe from skin to inceasing denst of termnal ig
mented hai fol ic es
Awas cosde the fota temoral and osterior
ha l ines
he fonta and ostero hai l ines shoud be iregular
and n the same la i . Th is means genera l avo d ng
translantig the vertex aicua n ougeratents. he reason is te ever-exandng bading sotn e veex.
When designing a fonta temoal hai l ne a was
assume rogression of hai loss o owood stage V
Fronta hai r l ne at east 9 m above glabe la
Be co nservative
• Rec p ient S te Ceat o ( ig 9 . 8
Commol used needes to ceae eciet sites are
#19 or #20 gauge eedle Magicato to reduce tansaction of existig ig-
mented temia l ha i
SP 88 to 90 gauge need le
0.5- to 1 .0-mm cag eed e
Key ponts
Dstr ibute reciie nt sites rand oml a d c osel ogetherand i a d istribut io that w l l aea atura l if a l l ha ir is
ost i the fronta two-thds of the sca
Avod trau ma to existng h ai r fol l c les
Magifcato n recii ent sites
Follow the natural 15 to 30degee angle of hair fol l
c les i n th e frontal twothirds of the scal
Excel lent emostas is us ig 1 : 100000 eineh ie
10 to 30 s tes/cm deed ing on the am oun of existing
ha and area (cm ) to dsribute grafts
• Grat lacement ( g . 1 9 . 9
wo o three surgica assistas lace the gras ntoreciient sites using mi crovascular forces
Figure 9 9 A cwide door scar fro 1 5cwide ellipse
Fgure 9 Follicular uit extractio usig 1 - sites
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Keys to success
Hande gafts in perol l cuar t issueneve cus hairo l ic les
Keep all grafts n ch led sanenever alow a grat to
desccate
Staff tran ing
Excel ent hemostas is us ig 1 100000 epner e
Patence
osoperave e o
Ovenight d ress ng to p rotect gras
Ora sterods 40 mg qd for 3 to 4 days to educe ontaledema.
yleno #3 oe tabet q 4 to 6 hours fo 1 day PR
Thee shoul d b e no d iscomort morin g after surge
Sh ower n m on ng after surgey. Avod tra um a to trans
panted zone
Peiol cu ar emorrhagi c crusting rema ns 5 to 8 days
The vast maorty o patents eturn to work 2 to
3 days ater the procedure
Norma actvties immediatey o heavy exercse for
5 to 7 days.
opca a tibiotic to dono wound for 7 to 1 0 days
Sutu es o stapes em oved 7 to 0 days aer sugery.
Co o os H a ras a S i e
Eecs Fontal ed ema astin g 3 to 4 days postoperatvely
Pruri tus n dono r and/or reci pient zone
asitory o ic u t s
eloge eluv um n patets wit dffuse th n ni g
Rae Se Eecs
Hyetropic scarr ng donor region in el ipses less
than 1 m
Pesistet numbess or discomo in door or recipi
ent zone
Cystic nodules
Poo qua ity growth of transpa nted hai r
necto
ossurgca Pe io aeSuues/Saples Reove
Resume fu spos 1 week ate surge
Dye ha i 2 weeks ater surgery
Secon 4 Disorders of Har Fol c es 09
Fgue 9 kin hooks to aid in removal of donor ellipse
Fgue 9 2 onor ellipse with natural follicular bundles
Figue 93 Magnification helps visualize 1 to 4 hair bundles and minimize transection when separating with surgical prep blades
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1 1 0 Color Atlas of Cosmetic Dermatology
TABE 9 • Teatment Options fo Corective H ai Trans plan t Surge
reatment o on Advaage
Adding 13 ha i graftsbetwee existig large
1025 hai ugs"
Excso o gafts
Laser ai r emoval
Combat o
Damatcall sote h air i e and ad d fuer dest to
exstg ugs"
Pate requestig " woud rathe ust be ba d" Stausquo ante
Novasve
Reduce ugg" grafts
Maort of ates ulize a combatio of he above
or otimal esults
n i ia l fo lowu 8 o 2 monts aer s urger
Ful cosmec resul 9 o 5 moths after s urge
• Correc ve H a Tansp la n S gery
(a e 9 . 4
For the majort of me n corecive ha ir translan t surgeris cosmeticall ad emotonal man daor o elective
ConsutKe queso: wa is our ce conce ad goal for
ossibl e correctve suger?
BBLOGRAPHY
Avram MR Poar zed ghtemitt ig dode magifcatio
for otima recet ste ceaio during har trasat
Dermatol Surg 2005319 1 1 1 2 4 1 1 2 7 iscusson
1 1 27
Este S h e teament of female atter a r oss and
other alicatios of surgica ar estoaton i women
Facial Plast Surg Clin North Am 2004 12 2 241 -247
Harr is JA. Fo icu l ar u t translatat o: ssect g ad
a ng techniques Facial Plast Surg C!n Noh Am
2004; 12 2 225232
Dsadvatage
Donor rego ma be deeted
Patet not schologcal abe to gothroug an oer har tas la rocedure
Poteta v is b e e ematous scaror weeks to months
Permae scar and/o dschromi a
4080% moveme aterfve to
seve does ot work o band a
As above
Leavitt M PerezMeza D Rao NA et al Eecs of finas
terde 1 mg) o ha aslat Dermatol Surg
2005;3110 1268-276 Discussio 1276
Figure 9 1 to 4 a ir gra
Lmmer B El it ical doo sereoscocall assistedmi cograg as a a roach to uhe ref ement a r
translantaon J Dermatol Surg Onl 1994;2012
789793
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Secon 4 Disorders of Har Fol c es 1
Fgue 9 1 to 4 hai gas in chilled saline
Fgue 9 Natual iegula fontal hailine
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1 1 2 Color Atlas of Cosmetic Dermatology
Figure 9 7 Magnification with polaized light to ceate ecipient sites
Fgure 9 8 Placing 1 to 4 hai gas with micovascula foceps
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Secon 4 Disorders of Har Fol c es 3
Figue 99 Preoperatve Norwood Ill
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1 1 4 Color Atlas of Cosmetic Dermatology
Fgure 9 2 Aer ,400 1 to 4 hair grafs
Fgure 9 2 Preoperative Norwood Ill to IV
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Secon 4 Disorders of Har Fol c es 5
Fgue 9 2 2 After 00 1 to 4 hair grafts
Fgue 9 23 Preoperative Norwood IV to V
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1 1 6 Color Atlas of Cosmetic Dermatology
Figure 9 2 Aer ,00 1 to 4 hair gras
Figure 9 2 Preoperative Norwood IV to V
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Secon 4 Disorders of Har Fol c es 1
Figue 9 2 Afer 1 , 000 1 o 4 hair grafs
Figue 9 2 7 raigh "pluy fronal hairline
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Secon 4 Disorders of Har Fol c es 1
Figue 9 3 Preoperative Norwood IV to V
igure 9 3 2 Aer an additional 00 hair gras second surge
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120 Color Atlas of Cosmetic Dermatology
Figure 9 33 traight "plu hairline
Figure 9 3 Ater 500 1 to hair gras
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Secon 4 Disorders of Har Fol c es 2
Illustration . Obsolete 4-mm "pluy gras
S fd
E d o o
I l lustration . lliptical door strip fm posterior scalp
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122 Color Atlas of Cosmetic Dermatology
Ilustation . to hair follicular groupings ithin donor strip
Ilustation . Versus to hair pluy graf Natural to follicular groupings
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Secon 4 Disorders of Har Fol c es 23
Il lustration . traight artificial "plug hairl ine using 1 to hairgras
I l lustration ecipient sites created at 1 5 to 45degree angles not degrees
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124 Color Atlas of Cosmetic Dermatology
A
8
I lustatio Corrective hair transplant adding 1 to hair grasbetween and in front of "p/uy gras
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Secon 4 Disorders of Har Fol c es 25
Illustration Adding 1 to hair gras between large "plug grasto improve cosmetic appearance
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126 Color Atlas of Cosmetic Dermatology
CHAPTER 20 Femae atten a oss
emae aern hair loss resents with a duse thnnng
of the mi dsca wth a characteris ic ma ntenace of he
frontal har n e It ma also resent wih the tca biemoral hair recesson seen n male atten har loss
Paretal and occiial hars are usua unafectedemae aern hair oss is ar icuar robematc for
women for whom har oss roduces greater soca andself-esteem diicuies than for men wth male attern
ha i r oss ( igs 201 and 20.2) .
EP E M OLOGY
ee: nea 30% of femaes older tha 30 ears
ge begis n secod ad in thrd decade
Rae: none reored n femaes
reg ar olgenetc i nheited redisosion
is resen I is o one ae's fau
PAHOGENESS
hee is a d m nuton in the sze of affeced tem a fol l
c es that regess o become vel us fo icles tha eventua
dsaear Thee is an ncease i teogen hairs ad adecease anage ars Hormones la a roe bu the
exact athosioog is unceain
COURSE
Begns in entes a nd rogresses over decades T he rae
and extent of har oss vares
KEY CONSULAVE QUESONS
Durat on of ha i oss
Mestrual hstor
Medcaton histor
N utrt on d eing weight oss
Hai r carebleach ng bra d ing
aml histor of hair loss
Hstor of majo unexected emotioal or hsica
stress
Medca l histor hat is throid d isease ron defcenc
PHYSCAL EXAMNAON
Noscarr ig aoecano erhema scale, atroh n
sk in with femae attern a ir loss
Figure 2 reoperatve Lu dwg l l
Fgure 2 2 Ater 0 0 1 t o 4 har grafs
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D FFERENAL DAGNOSS OF FEMALEPAERN HAR LOSS
eloge eluvi um
Poo hai s ngchem icas excessive dig
ro defcienc hrod disease chroic medcal dis-
ease polcsc o ohe endocie im balace Medicaionreaed hair loss
Poor nr io n weigh loss
choi l omania
Dffuse aloecia areaaare
KEY QUESONS O DSNG US HDFFERENAL DAGNOSS
How o g has ou h ai oss persised?
Changes n die o weigh oss over pas 6 o 12 mohs?
An new prescriio ove-he-couner (OC medica
ions o sup peme s?
An major srge o nusua emoional sess?
An change n hai r care? Chemica s o ha r?
KEY PONTS
Paiens ma have a combnaion of eologes
f here is an quesionng afer hisor and phsicalexamnaion scalp bios is ndicaed
hrod ncion ess iron sudies ainclear anibod (AA apid pasma eagi (R PR
Refera o gecologis and/o endocinoogs apro
priae on hsor and/o exam naion
MEDCAL HERAPY
Toical minoxidi l (2% and 5% soluion) ae he ol medcaions for emale aern hai r oss aoved b he U S
Food and Drg Admin sa ion (FDA) (Table 201) The
mechan ism of acion is u known s sae for log-erm
al ica ion
TLE 2 • Mnoxd
Mechanism of ac ionOnse of acion
Sid e eecsUse wih reganc
or beasfeed ng
5% versus 2%
Unknown6 monhs
Dness prurius greas har o
5% slighl more eecive bmoe geas slgh
nc eased isk o hisusm
Secon 4 Disorders of Har Fol c es 27
Figure 2 3 Preoperative temporal scarchief complaint "I cannot wear
my hair back
Figure 2 After 65 0 1 to hair grafts
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1 28 Color Atlas of Cosmetic Dermatology
Minoxidil 5% foam s oly aoved for men but ofte
is used by women. The reason s d ue to minoxid l in sma lerceage of women inducng unwanted igmeted
termia ars he medcaton-induced irsutsm is
reversib e if the medcatio is discotnu ed
Many women who do get mi noxid i l- nd uced h i sut ism
a so get exce ent gowth of har o their scal and ot tocontinue e medcation and use ases to remove the
unwanted hai on e face.The foam ceaes much ess irr iat o on the scal
making i t much eas ier to be coml i ant han h e so lut ion .
KEYS TO SUCCESS
Com iance: must use fo 6 o 8 monh s o roduce the
desired eec
Emhasize mainteace over regrowth of air Mioxid
stos ha r oss i e ma oity of atients and grows back
igmeed teminal ha i n a m nority o atients.
NONFDA APPROVED MEDCATONS
Fnasterde a tye I 5 reductase inhbitor is contrandicated i women of ch ldbearng age. Sudes
demostrate some effcacy n osmenoausa
emales
Ora androgen eceto antagonss such as sronoac
tone ad cyoterone acetate are other a tenatves with mied roof of effcacy n both remenoausa and
osmenoausa femaes. They are contrandicated in
regnat atets given he isk of roducng sexuadefects n a mae etus They shoud theefore be dis
cotnued months or to a an ned regnancy
SURGCAL
• C o s a o
Chef comla nt : see hough fronta ha ir l ine l mited
sty ng oions fear of wdy days.
• Key Qest ion s How og has a r oss ersisted on?
Medca l worku to date
Medcaton used to reat ar loss ad fo how long
Patient's c hief cosmetc concern
Patient's goal or hair taslatato
PHYSCAL EAMNATON
Dono densty
Fgure 2 Preoperative Ludwig I to II
Fgure 2 After 600 1 t o hair grafs
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Ca iber o har oss
Exent o hai r oss
KEY PONTS
Emhasize unedictabe donor densit The ransaned hai wi grow for as long as it was genecal
rogammed o gow
Increased rsk o ostsurgical teloge effluvium.
Ongoig hair oss wi afect eceived densit of hai
transant.
SU RG CAL APPROACH :FEMALE VERSUS MALE HA RTRANSPLANTAON (Table 202)
Secon 4 Disorders of Har Fol c es 29
Ha r transa ntation fo men and women uti l ze the samedono ha rvesing techn qu es, gat creatio instumes,
an esthesa and re- and ostsuger couse.igure 27 Preoperative Ludwig I to II
FEMALE SURGCAL PLANNNG
Transant rontal onehrd o sca ol hs wil l
addess che comai nt ad reduce the isk of teoge
ef luv um
Chief coma see though" frona ha l ne
Sable fotal temora ad osteror ha l nes
Difuse th i nn ingno bad sots
Rs k of telogen euvu m
Uredctabe long-erm growth of har from the
donor regon
TABLE 22 • Surgical Approach: emale Versus Ma e Hair Tansplantaton
Donor densiHar l ne des ign
Ca i ber of ha rMedicatio use with har
transantaion
Exectations
Ma le
Moe red cab eU nstabe a d recedin g ronta tem ora and osterior
ha ir l ineNeed o desgn ha r trans ant or longtem natural
cosmetic aeaance (> 10 ears)
Var iab e between n d iv dua s
If exist ig hair emans medication w l add dest
b mi i ng urher hair ossMedcatio awas rema ins eectve
Need to desgn ha ir trans ant assu mi ng ogoing
hair loss and recedg har nesKe to su ccess
Femae
Less redicabe ong term
Stabl e ha r l nes Mao cosmetic advantage
over me fo sugical anng
Variabe between ndviduasA l women shou d use mi nox id l to he m a na i
exstig hai r a d decrease r isk of ostsugerteogen euvi um
Densit = n um ber of ha ir fo l c es tanslaed
ongoing ha i lossKe to success
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1 30 Color Atlas of Cosmetic Dermatology
• Peopera ive src os
�-uman cho ion c gonadoro n (B-CG) in aro i-
ate atent
Consent
Photos
Medcal ceaance aroriate
Ok o de a r u u nti l da beore ocedu e
Procedure
ntroduce staff
Revew surgcal la n
Revew ossurgca care anesthesa nstumets
donor harvesting graft creato grafts acemen are
the same as or me
• Posopera ive src os
Ovenght d ress ng to rotec grafs as e hea
Resume regular acivies Lght exercise 2 to 3 das
aer surge Ful exercise when stales/sutuesremoved 7 to 0 das ostoerative.
f an dscomfort or an ake Tenol #3 wth ood q 4
to 6 hours Fif ercent o aties take no ain med
caion ad e other 50% take oe o two tablets I a
atent as an discomfo or an after te da ofsuger te should contact their hsicia n
Prednsone 4 0 mg q d for 3 o 4 das to eve frontal
edema I a aient cannot or w l not take redn isoe
ce oehead for 0 minues ever 30 mnutes ove edressing fo the first aftenoon/evening of suger o
reduce bu no e mate edema Edema begns
24 ours after suger eaks 72 hours ostsurger
and disaeas 5 to 6 das ostsurger Rare eorbital ecchmoses
The morn ng afte surge the dessng s removed A l
atents are encou raged to showe o he educe ostsuger emorhagc crustig Paients should OT
ick o ru b scabs; ths ma erma nen damage translaned ha r
Afte showe bow dr with wam not ot air on ow
ower A ocal antbiot c o Aquahor to door egion
twice da l for 7 das
Resume mi noxidi 48 o 72 ho us ost surge.
• Posoperat ive Per od
Continu e m noxd i o ne to two tmes da l
Teogen effuv um ma beg n 2 to 3 weeks afte surgerand continu e for 2 o 3 months
Figure 2 8 Aer 50 1 to hair gras
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Secon 4 Disorders of Har Fol c es 33
CHAPTER 2 ow evel ght Therapy (T) and Har oss
Low leve ig aser herap (LT) has been sed o tea
a vaie of medcal disordes fom cers o msc
loskelea disordes In 2007 a low eve g device wasapoved b he .S. Food ad rg Adminsraion
(FDA) o rea mae aern ha i loss (F ig . 2 . ; a i rmaxBoca Raon, F or ida) . The lase comb s a handhed
device ha was aproved as a devce whch has a differ
ent sandad fo FA approval ha a medicaon The
device is sold over the cone witho psica e
scp on or phscan mooring hee ae varios oter
manfacres of ligh era devices ha ae sold o
phsicians offces a ae o handhed such as heSne ics device (F gs 2 2 and 2 .3; Sne cs
I nenaiona Las Vegas NV).
MECHAN S M OF ACONUN KNOWN
Canddae seectional skin pes. All ha colos.
Mos effective a eaer sages of hai oss. FA
apoved for male aen hair loss. Ma phscasbeieve i ma ave a roe i eaing femae paen hai
oss
APPROPRAE USE
he manfacuer ecommends s low combig he
device throgo e affeced aeas of a more han
0 m n es hee imes week (F ig . 21 4)
hee ae no pb shed sdes com aig d ifeen e
qenc and me o se of he devce
PEARLS OF W SDOM
A l paies wh ha i loss shold be evalaed b a der
maologs o esablsh a diagnoss before consderng
an m edica heap.
Mioxid l or men and women ad fiasterde for men
remai the medica l reamen of choice fo mae ad
emale paen a oss.
LT appears o be safe b longem independen
sdes confimi ng effcac over pacebo ave not bee
done
Cooaended sudies have demonsaed some
efcac i he reatme of mae aen hai loss.
LLT sold be consdered ae cear medcal fa re
wh mioxid l and/o naseride
Figue 2 Had hed LL LT device hairmax asecomb Boca ato,orida
Figure 2 2 Oice based LL LT device uetics, as Vegas, Nevada
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1 34 Color Atlas of Cosmetic Dermatology
BBLOGRAPHY
Avram MR, eoard RT r, Epstei ES W l iams ,
Bau ma A T e cu rret role o laser/ g sources i thetreatmet of male ad emae paer hair loss J Cosmet
Laser Ther 20079 1 2728 Review
Avram MR , Rogers N E H a r trasatatio or me JCosmet Laser Ther 2008 1 03 1 54-1 60 Review
Avram MR, Rogers NE he use of lowleve light for hair
growth Part J Cosmet Laser Ther 2009; 1 1 2 1 10-
1 1 7
Hodso S Curret ad future treds i ome laser
devces Semin Cutan Med Surg 2008274292300
Leavitt M Carles G eyma E, Mchaes HarMax
LaserComb aser pototherapy device the treatmet o
mae adrogeetc alopeca A radomzed doubleb d sam devcecotro l led , mu lt cetre tr a Clin Drug
lnvesti 2009295283-292
Fgure 2 3 Patient undergoing LLLT treatment for male patte hair lossin a physician office
Fgure 2 Patient performing home LLL T treatment
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FIVEDisordes of Pgmentation
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1 36 Color Atlas of Cosmetic Dermatology
CHAPER 22 Caf Au at Macue
Caf au a macules (CAMs) are beign we demar
cated ight brown macues that tcall resent in earl
chidhood. Te igmentation s tical unform. Lesionsma be mu ile or isolated. he grow i roportion o
the growth o the ch d . Te are resent n as an as20% o e popu aion a nd rarel can be assocated wih
a host of genodermatoses
EP E M O LOGY
idee: 10% to 20% of the oulatio
Age brth and ear childhood
Rae ore comon n African Aercas than Caucasians
Sex none
Preipiaig ar: ost coonl hese are begn
iso ated ind gs i heah ch ldren . Mu t i e CAMs canbe associated with genodermatoses such as neuro
fibromatosis tuberous sceross Bloo sdroe
McCuneAlbrgh sdrome RussellS lver sdroe
Waso sndroe and Westerof sndrome
PATHOGENESS
Unkown.
PATHOLOGY
A
I ncreased melan n n basal keratoces. Cl n cal darker Blesons contan more elaoctes tha lger ones.
PHYSCAL LESONS
Lesos are wel dearcaed uniform pgmeted mac
ues that var n color fro hues of an o lg brown o
brown The ca prese anwere on the bod butsare mucous embranes. Ther s ze can range ro a
ew mil meters to over 20 m.
D FFERENTAL DAGNOSS
Posinlammato hergmeato Becker's nevus
measma entigies eedes beroque deratit s and
congenta evus
LABORATORY EMNATON
Bio s is o in dcated. Add it ional laborator workup abe aroriate n the event of suspcion of an u nderi ng
sstemic dsorder
cFigure 22 () Caf au lai macule o le cheek of a 1 earold femaleprior o reame (B) Ehema ad ligheig of caf au a i macule
aer oe reame wih 64m Qswiched rub laer (C) igificaclearig aer four reames wih Qswiched rub laser
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COURSE
Te grow n roort ion to the growt of t e c h i d O n ce
a c d has u gown, CAMs do not change n s izeor co or There is no increased r isk o mal igant tras
omat ion
KEY CONS ULTATVE QU ESTON S
me of onset
Fai ure to meet mi estones
Photosensitivit
nte lectua l im aiment
Hi sto o ult i e ractues
Cental nevous sstem d isoders or tumo rs
Poo gowth
Scoiosis Ohthamologc imaiment
MANAGEMEN
CAMs d o not equ ire treatment un less th ei a eaace
is dsguig o distessing to the atient or aentsMu t il e lesions ma suggest an und erling sstem c dis
orde f tee is an indicaton o underling sstemic
ab nomal t ies in th e setting o mu t ile CA Ms referal toaoiate ediatr ic secia ists is indicated ase the
a s oten emloed as a treatment CAMs tend to be
moe diicut to teat than other benign igmentedlesons sc as eeides and entigines Te equre
mu t il e teatments and com lete reso ut o can be callenging Recuence is common Cotea ad surgi
ca excision ae atenatives to ase thera but ca the
risk of gmenta alteratios, oor cosmesis ain ad
scaring
L SER TREATM EN ( Fgs 221-22 3)
Prior to treatment a test site shoud be erfomed toassess or ecac and eigmentato CAMs
resond variab l to mu t ile modal it ies o laser thea
Q-swtced lasers inclding te feqenc-doubled
Q-switched NdYAG (532 m) Q-swtced ub
(694 nm) , and te Q-switched aexand te (755 nm ) ae
emloed fo selective igment emova
It is imoant to note tat treatment wit Q
switced lases s not cookbook Energ sengs var
from lase to ase Te also var beore and aer
maitenance hus treatment should be based onachievig eidermal whitenng ater teatment
Wtout eiderma witenng the teatment is
u n I i ke to be effective
Secion 5 Disorders of Pigenaton 37
A
BFigue 222 (A) Caf au ait macule adjoining right lateral commissure oflips (B) Near clearance aer three treatments with a 55nm Qswitcheda/exandrite laser
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1 38 Color Atlas of Cosmetic Dermatology
Howeve, it s impotant to note hat ovel aggessive
treatments produce igmenta changes such as hpoand herigmenation
n one sud Q-switched rub and fequenc
doubled Qswitched d:YAG treatments, each at6 J/cm oduced vara be responses ncl ud ng
Sgnican ightenng which was most fequentlobserved
Cearance with ecurrence
Darken g
Q-switched asers have a dec reased r s k o textu ralchange versus oher laser heraies, but sti l carr he
risk o hperpgmetato
Resuls ae variabe wth approximate 50% of Aesions showing a esose
Whie u resolution ca be obtained wh he
Qswitched asers thee are frequent ecurrences
Frustaing recurreces ma occur 6 months o1 ear after treatment Sometimes ightening aher
than u l resoluti on s the best obaina be result Al ofthese asers oduce equivaent resus in the teat
ment of CALMs
TOPCAL TREATM ENT
CALMs ae not resosive to opcal beachi ng creams
P TFALLS TO AVO D/OUTCOM EEXPECTATONS/COMPLCATONS/MANAGEMENT
Uotunatel, despie their superfcia l nature, CALMs
can be d icult to treat completel
he ke cl in ica f inding is ederma whitenng after
Qswtched laser treatmen
Lghteni g, rather than ul l c eaace s oten the best
resut even after mutple treatments
here s a h gh ri sk of recurece of CALMs u to 1 ear
after reatme
Studies in dicate a isk or he- and hopigmeationassociated wth the Q-switched ases especa in
darker s kn phototpes
eatng a bove the theaeutic threshod ma resul i n
prologed hea ing and increased r sk o igmenta
changes
Patents wth da rker skn tpes should be reated cautous a nd conservatvel gve n the low er heraeuic
threshod
Lase treatmet of tanned atents shoud be avoded
Figue 223 (A) Tretment of cf u it mcule on the chin of youngmn with 5nm frequencydoubled Qwitched Nd YAG ler(B) Completion of tretment of cf u it mcule with the ppropriteclinicl endpoint of tiue whitening nd ethem
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BBLOGRAPHY
Aoa MB Ardt KA. Teatment o a cafeaua t macue
with the erbum:YAG laser. J Am Aad Drmal.2001;45(4):566568.
Grossman MC, Aderso RR Farnell W Flotte TJ
Grevelink JM. Treatment of ca au la it macues withlasers A c iicoathoogic correlation Ar Drma/1995; 131 14161420.
Kim JS Km MJ C o SB. reatment of segmental ca aulait macules using 1064nm Qswtced d:YAG aser
with ow ulse eneg. /i Drmal 200934(7) :222223.
Lev J ordon S PizAnseme M. reatment o id
vdua cafe au a it macules with te Qswitced dYAG:A c in coatoogic correat ion. a asr r. 1999
1(4) 217223.
CHAPTER 23 Ephedes
Eheldes moe common known as freckes, are
benign, sma , welldemarcated brown macules oundon the suexosed skn of bond, l gt bown and ed
haed ndivduas Te resent earl ch dhood anddecease n olde age. e can be dst ingushed rom
lentignes in that te daken in tmes of igh sun exo
sue and ade durng eiods of l i mited sun exosure.
EPDEMOLOGY
id ver common acu ar l in fa irskinned
atents
Ag ea chil dood
Ra more common n Caucasians but also see in
AsansSx equa
Priiig ars nd v dua s wt gt ha ir and com
exion suc as b londs an d redheads
PAHOGENESS
The brown igmetation associated wt eedes
results rom inceased roducton of meain i suexosed areas of te ski n.
Secion 5 Disorders of Pigenaton 39
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140 Color Atlas of Cosmetic Dermatology
PAHOLOGY
Keratnoces disla an nc rease in mela n n esecial l in
the basal lae but ere s n o substanta increase in tenumber of melanoces in eheides
PHYSCAL LESON SEhedes are welldemarcated light bown to dark brown
macules of several m l l imeters dameter that resent nsun-exosed areas of the skin .
D FFERENAL DAGNOS S
he dierenta diagnosis includes other benign lesons Asuc as ent ig ines and u nciona l nev .
ABORAORY EXAMNATON
None
COURSE
he resent n eal ch ldood. The darken in erods
of hgh sun exosure and l gten durng eriods of mited sun exosure
KEY CONSULTAVE QUESONS
Sun exosure
MANAGEMEN
hee is no medcal nd icaton to reat ehel des The
cosmetc aearance however ma disease some
indviduals Sun avodance and sunscreens otect
aganst darken ng of ehel des B leacing ceams suchas hdroqunone and toica renoids can roduce l ight
ening. Crotera and laser treatment ae aso effectve.
Recu rrence is fequent art icua r wth sun exosure.
TREAMENS
• Topi ca l Teamentoca bleachng creams ma rovde some ightening
Mu t i e fomuat ons are ava i lab e d ier ing n te ir roduct contens an d strengths
Hdroqu none ( 2%) c reams have trad t iona l l been
emoed
Twce dail aication of he cream o the eheldes
over 3 months is general necessar to achieve sg
nfcant if no comete imrovement.
Side effecs incude rr itat ion uritus eelng and
d rness of the reated a reas
B
cFigure 23 () A yearold male fm outhe Califoia with exten
sive ephelides (B) ame patient with posttreatment whitening immediately afer frequencydoubled switched Nd YAG 5 nm laser
therapy C) ignificant improvement weeks aer single treatment with
frequency-doubled -switched Nd YAG 5 nm laser utilizing a uenceof 1 5 Jcm and a 0 mm spot size
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If erthema and irritaton occur exercise caution to
avod hyperpgmentation especial ly darke sknphototypes
Patents m ust dscontnue the teatmet f any l ght
eni ng of nonlesonal skn s observed
Beacing creams are contraindicated in pegant
and lactatng women
Prooged treatment may produce sk di scoloation
known as pseudoochonosis
Ret no ids
Retods have been added n products such as Solage(2% mequnol ad % tretnoin) and Tri luma
(001 % fluocnoone acetonde 4% ydroqunoe an d
005 % tretnoi n) to provide an exfoiative benefit
Appicato of ri luma must be mited in duraton
due to the possibilty of side eects with repeated
cocosteroid usage such as ski atrophy and acne
Azeac acd (20% ) cream s u npred ctab y eective forephel des ad ent gines
Koc acid 2 5% ) cream
C e i c a l e e l s
Chemica pees can be he lpfu l n reducig the appear
ance o ephel des Superf c a depth pees medum
depth pees an d deeper pees are a l eective A ca reful
evalu aton of skn type owever s essenta l p rior to treatment As the depth of the pee increases the cance fo
impovemet along with advese sde efects ncreases
Ove-thecounter -ydoxy acid pees are a beneficaladju ct to physicanstrength chem ica pees he con
tinual exfo iat on achieved from cosistent use of thepees w l resu lt n m ld ighten ng
Gycoi c acd pees (370%) a re ad m nsteed every 2
to 3 weeks utilzing increasng strengths as toleatedLightenng o epheldes may be observed ae fou to
six pees Strict photopotecton is stressed Saicycac id peels (2030 % ) are also efectve hey can be
used saey n al l sk in types
Jessner peels (resoc ino l act ic ac d and sa l cy ic ac d)
are ad mi isteed eve 6 to 8 weeks
Strict ph oto protecton for 2 to 3 months s advsed
Mu t iple treatmets are recommen ded
Conta id cated i n pregant and lactatng women
Combinato Jessne/0% tr choroacetc (TCA) pees
may aso be empoyed i a sm ar fashon as the
Jesser pee
The Jesser pee esults in exolat o a lowing for
greater peetrato of the TCA pee
Mut iple peels are geera ly eeded Cotraindicated
in pegnant and actatng women
Secion 5 Disorders of Pigenaton 4
A
BFgue 23 2 () A 40-year-old Japanese female wih ephelides and lenig
ines prior o 64-nm Q-swiched ruby laser reamen 8 Immediaeissue whiening and eryhema aer reamen
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142 Color Atlas of Cosmetic Dermatology
Caution to avod pigmear chages eseca n
darker sk in tpes
A est sie can be consi dered
• Cyoheapy
Crotherap ca produce l ightei ng o reck ig Has a r sk o hpo- or hperpgmetation at and ar ond
treated stes especial i darker skin phototes andtaned patents
Recurrece is common
• aser heapy (F gs 2 3 . 1 a d 2 3 . 2
Laser and ight sorce therap can be eective i treatigehe des
ntese lsed l ght requencdoubled Qswiched
Nd:YAG (532 nm) Qswitched aexandrite (755 nm)
Qswtched rub (694 nm) Qswitched Nd:YAG(1064 nm) pused de (595 nm) ractona resac
ng and TP asers (532 m) are all efective
Wih Qswitched lasers:
Perorm a est so o d arker skn es
Treatment ed pont or Qswtched asers is mmed ate t ssue whteng For the Qswitched Nd:YAG
(1 064 nm) sma l p n pont b leedig ma be seen
A 7-to- 10-da hea ng t m e ca be exected or crustn g to resolve wth Qswtched lasers
O e std used h e requecdoub ed d: YAG
(532 nm) to treat eheldes i 20 patients with tpe V
sk Eight percent o atents showed better than
50% improvemet Recurrece was commo
Hopigmentaton teura changes ad herigmenta
tion a resoved with 2 to 6 moths aer i a treatmet
a other stud 197 Asian s were treated with the
Qswiched aexadrte (755 nm) a 70 J/cm wth a
pulse width o 100 ns a 8week itervals Clncal o Aow p aer an average o 1 5 treatment sessios showeda 76% decrease in the n um ber o ehel des No scarring
textural chages or pgmetar changes were oted
he Qswched rb (694 nm) ad aexandrite lasers
(755 m ) are aso eective
I the cinca edoit o mmediate whitening is
achieved the ephelides shoud clear wh one treatmet
Qswitched asers are m ost efecive or da rker le so s
Fracional resuacg (Fraxel aser Relat techoo-
gies San Diego CA) s aso eective (ig 233 )
Treatmet s genera l perormed at supec ial dephs
com pared to treatments o rhdes ad ace sca rs
gh treatment den sites a re most efective
Mld-o-moderae erthema resemblg a sunburn
reaction s observed Postprocedure swelng s also
common
BFigure 23 3 () Young male with ephelides on his left cheek at baseline(B) Improement of ephelides afer seeral nonablatie fractional resurfacing treatments
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The erhema resoves i 3 to 5 das and c an be cov
ered wi makeu wiin a da of he treamen.
Log-erm daa are cu rren lackig .
I ntese pu se l ight is aso eecive
The c i ica l endpoint is darkeng of he lent g ies
Caution shoud be emoed when treatig atienswih da rker skn tpes o avod hperigmentation hat
ma erss for months.
Recurrence of recklng afte treatment owever is
common .
Suscree and su avodace are mandaor adjunctsto lase r thera.
PFALLS O AVOD/COMPLCAONS/MANAGEMEN
Laser reatme of ehelides is reque successul
but often ansien.
Paients sould be infomed ha recurrece is highl
i ke especial l wh sun exosue.
Dail stric hotooecio wih a sunscreen whUVVB rotecon and/or a phsical bock such as
itanium dioxide o inc oxde ae sessed as we assun avodace.
If bleachig creams oduce ehema cauion is
advised as erhema ca produce irr iat io and her
pgmentation.
Paients should be couseled regardng e ossibi iof postinlammator gmentaion changes aer reat
ment ase remova of ehelides ma also roduce aunattractive so hoigmenaon esecal in
darke s k n phototpes.
BBLOGRAPHY
Jag Chung EC Choi J Sung KJ Moon KC KoJ K. Successful removal of freckes n Asian skin wih a Q
swced alexadrie laser. Dermatol Surg 200026(3) :
231234
M ish ma Y Ohama Y Sh baa T et a . In h bior acion of
koic acd o melanogenesis and its theraeutic eec forvarious huma hperpigmentation disoders Skn Res
1994;36(2) : 1341 50
Nakagawa M Kawai K Contac a lerg o ko c acid n
skn care roducs Contact Dermatts 1 995 ;31 (1 ) : 9 1 3
Ngujen Q Bu i TP Aela ic ac d Phamacokiet ic adphamacodamic propeies ad is heraeuic role n
herpigmear disoders and ace. lnt J Dermatol
1995;34(2) :7584
Rashid T ussa in I Ha ider M H aroon TS aser therap
of freckles and lentignes with quasiconiuous frequenc-doubled NdYAG (532 m) lase i Fiatr ick
skin tpe IV A 24-month fo owu J Cosmet Laser Ther
2002;4(34):8185
Secion 5 Disorders of Pigenaton 43
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1 Color Atlas of Cosmetic Dermatology
CHAPTER 24 entgnes
ere are two major tyes o lentgines entgo simex
and solar lenigos. Tey are bengn lesions. Alough
both are c l in ca l ly dent ca l , they aea n ent re lydieent cl in ca settings Lentigo smlex yica y irst
resent in ch i dood as mult e wel ldemarcated,
brown or black macules that can aear on any at o
the skin or mucous membranes They are c l in ica yind ist ngusabl e rom unc iona l nev There is no asso
cation with sun exosure n his ye o lengo Incontrast, so la lent igos, more common y known as l iver
sots," are we ldeined brown macules that aear on
sunexosed skin o adu lts hey increase in n um ber
wth age They most oen aear on te dorsa hands
shou ders and ace o l ight ly igmented and reda i redatients
EP EM O LOGY
ee very common acu a ly in a ir-skinned
atents
Ae bmoda d sr ibut ion n ch i dood and in sun
damaged skin o adu ls
Re more common n Caucasians
Sex equal
re os sun exosure s closey related to
solar enigines Mult i e entgines are associated wth aew genodermatoses ncluding EOPARD syndrome,
LAMB syndome, and PeuzJeghers synd rome
PATHOGENESS
Unknown
PATHOLOGY
hee s a u norm el ongation o the ree ridges o te ei dermis a long with nc reased mean in in melanocytes and
basal keratinoctes n addt ion, thee ae an ncreasednumber o melanoctes in te basa cel layer
Mea nohages are resent n the ai l l ary dermi s
PHYSCAL LESON S
Welldeined brown macules Lentigo smex maculestend to be evenly distr ibuted and sm all measu ing only a
ew mi imeters Solar lent gos have a redi lection or the
sun-exosed areas o the dorsal hands and ace Tey
can be larger than lentgo sim lex
A
BFigure 2 () Lento on le cheek of a female (B) nficantmprovement aer one tretment wth a 5-nm Q-switched Nd YAGlaser at a fluence of 1 0 Jm and a mm spot sie
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146 Color Atlas of Cosmetic Dermatology
uocioone acetoide) ca be used as wel . However
bleac i ng creams a re often ot com letel eective.
oical tein on can roduce ighteni ng but not usua
c learance of es os I t ma a lso i combinat ion wit
sun avoidance and sunscreen use evet te devel
omet of lentignes.
Retreament is often necessar.
f an of these toca medicaons roduce signficantnfammation or r itat ion i is imortant to discontnue
the r use to avoid ostnfa mmato herigmetatio
I n a ddit ion seudoocronosis ma occu wit cont iuous ogtem use of ocal droqu io ne.
Beachig creams are reat ivel corandicated n
regnat a d actating wome
CRYOHERAPY
is is a chea swi and effective means for reating
entigines.
A ication o crotera can be accoml ised wt a
smal cottoi a cator or with a crotera gun .
t is oen ess effecive than oetime treatmet with a
Q-switched laser.
Tere is a signficant isk o hoigmentation with
crohera f it s aled excessve or on a taed
atent.
CH EM CAL PEELS
Su eicial deh eels mediu m det eels and deeereels are al eectve for etgies. A caeu evaluaton of
sk te owever is essentia to avod gm entar com li
cations. A s the de h of he eel n creases te ca ce oimrovemet along wh adverse side eects creases
LASER A ND LGH SOURCE REAMEN
Multie dieen teraies are eective for treating entig
ines In genera darker lentigines fare best wth Qswitched
lasers Were tere are numerous fainte lentignesintense u sed l ight sources and to a esser extent oab
lative fraction a resuacg lasers are ve eective ntese ulsed l gt frequencdoubed Qswiched
Nd :YAG lase (532 nm ) ( F ig . 24. ) Qswitced a exan
drte laser (755 nm) (Fig 242) Qswtced rub laser
(694 m) Qswtced Nd:YAG laser (064 nm) ulsedde laser wt gmeted lesio widow (595 nm) and
ractiona resurfacing lases ae al effective.
Wi Qswitced lases:
Peom a test so on da rker skn es.
Treatment end ont fo Qswitched asers is im med
ate t ssue wteng For the Qswitced Nd:YAG
( 1064 nm) sma l n oint b leedig ma be seen
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A 7-to- 0-da heal ing t me can be exected fo crust
in g to resolve ae Q-switched aser treatment
Legs resond more sowl tha the face ad hands
Caution should be take wh le treatig ower legs asthe often heigment Herigmentation ma
ersist for months
he frequecdoubled Qswitched dYAG (532 nm)
aser has been shown to imrove lentigines safel andeectve
In one stud 37 atents were treated once with afluence o 2 to 5 J/cm a 20mm sot size ad a
0ns ulse width
Highe fuences ovded best results with 60% of
atients showig 75% or better ceaaces
Minor transient hoigmentation hergmenta
tion and erthema wee noted i a few atients
Has been shown to oduce beer clearng than
35% TCA eel
Has bee shown to teat letigines more eective
tha n cotera
he Qswitched ru b (694 nm ) l aser s a so ver eective
In one treatment substantial clearing occurred atflueces of 45 a d/or 75 J/cm and a ulse width of
40 ns
I the c l i ica l endont of mmediate whiten g s
ach ieved the etigo should c lear wth oe treatmet
actiona resurfacig can also be eective
reatment is general erformed at suerfciade ths and owe energes coma red to treatmets o
rhtes and acne scars
H igh teatment den sites a re most effective Tic al
requies mu t ie teatments
Mild-to-modeate erthema resembig a sunbun
reaction is obseved Postrocedue sweing is aso
common
he erthema esoves in 3 to 5 das ad ca be
covered with makeu withn a da of the treatment
Longterm d ata are crrent lacki g
ntese u se l ight is aso eective Sevent-four ercet cearance o letiges in 18
atients with oe treatment
The c i ica l edoint is darkeng of the lent g ies
PFALLS O AVOD/COMPLCAONS/
MANAGEMENOUCOMEEXPECAONS
Qswtched laser and lght source treatmet fo lentig
ines s frequentl successu onablative fractionalresufac ng s the least efectve of th s grou
Secion 5 Disorders of Pigenaton 47
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148 Color Atlas of Cosmetic Dermatology
Patients shoud be counseled regarding te ossib l it
of postiammator gmentation changes ae teatment especial on the ower egs.
Recurence ater teatment s not unco mmon .
Bo s an leso that demostrates an cl n ical ata
ro to treatig with laser or cotheap. Lase thera
of a ma ignant esio such as a etigo maligna ormelanoma ma mask its c in ca aearance and thus
cause a dela in diagnosis.
Avoid usig Q-switched asers in patients with an
pri or histo of go d intake. Ch rsiasis resetig asb uegra c ircu lar macues o te ski can occur aer
Q-switched aser treatment of soar letigines in thesepat ients (F ig 24.2) .
BBLOGRAPHY
Bjerr ing P Crist iansen K. I ntense u sed l gt souce or
treatment of sma meanoctic nevi ad solar entigines.J Cuan Lase The 20002 77-8 .
Ga eckas KJ Ross EV U ebelh oer N S . A used de lase
with a 10mm beam dameter and a igmented esionwindow fo pururafree photoejuvenato. Demaol
Sug 200834(3)308-33.
Gest DE Ph l l i ps TJ. Deveopment o chsiasis aer Q
swtced rub aser teatment of solar lentigines Am
Acad Demaol 200655(Sup 2 S 59-S60.
K me SL. Laser eradcaton o gmented lesions and
tattoos. Demaol Clin 200220() 37-53.
Ki m er SL Wheeand RG Gold berg D Anderson RR .reatment of epdema igmented lesos with te re
quencdoubled Qswtched d:YAG lase. A contoed
sigle-imact dose-esponse mult icenter t ia . Ach
Demaol 1 994 30(1 2 ) 5 5 5 9 .
L Y Yang KC. Compa rson o th e eque ncdoub ed Qswtced d:YAG aser and 35% tr ichoroacetc acid fo
the treatmet of face lentgines Demaol Sug
999;25(3):202204.
Sadighha A Saatee S Muaghegh-Zahed G Eficac
and adverse eects of Q-switched rub lase on solar
lentignes: A rospective stud of 9 atients with
tzpatr ck skn te I I l l and IV Demaol Sug2008;34(1 ) : 14651468
Stern RS Dover S evin JA Arndt K aser theapversus crotera o lentgies A comarative tal. JAmAcad Demaol 199430(6)985-987
alor CR Andeson RR Treatment o beng pigmented
eiderma esions b Qswtced rub aser n J
Demaol 199332(2) 908-92.
odd M M Ra is TM Gerwels W ata TR . A compaison
of 3 lasers and iquid itroge in the teatment o sola
lentignes: A andomized cotrol led comaative t ia l .
Ach Demaol 200036(7)84846.
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CHAPTER 25 Measma
Melasma s an acqu i red brown macu a r hpep gmen
tat on usua l of te face. t is far mo re common i n
femaes than i males . I t usua pesents b i latera and smmetr ica l l on the face but extensor foearms
ma aso be ivolved. There ae be eved to be threeh sto log c var iats of me asma ep derma l dema and
mixed derma l and ep iderma l . Ep iderma me asmaresponds best to theap All forms have a hgh ate of
recurence makng th is a frustra ing cond t io to teat .Sun exposure peganc and ora contracept ive p l s
are al l assocated with its presentaton ad ecurence
( F g . 2 5 . 1 ) .
EPDEMOLOGY
i common
g oug femaes
Ra Centra l and South Amer ican Mdd le Easten
Inda East Asan females ae most fequentl affected
S fema es > ma es (9 : 1 )
Priiaig ars pregnac ora contraceptve pi l ls
sun exposue homone eplacement therap
PAHOGENESS
Unknown.
DERMAOPAHOLOGY
In epderma measma tere is increased melanin depo
s ion in the epiderms part icular l in the basa andsupabasal aes n der mal melasma tere ae per vas
cu ar me aincoa n ng macophages the superfc ia
and mi ddermi s M ixed-tpe meas ma exhb ts feaues ofeach of the above fid ngs.
PHYSCAL LESONS
Patents present wih we-demarcated l ight brown todak b rown smme ic m acu la hperp gmetat ion . n
app roxmate two-th ids of pat ients i t appeas on
the centra face inc lud ing he foreead nose upper
cutaneous p and ch in . t presents less fequent on
te malar aeas ad jawl ine . More rare i t appeas onte dorsa l forearms. Dermal measma has moe of a
b lue-ga hue. Mixed-tpe melasma has a brown-gra
cooat ion .
Secion 5 Disorders of Pigenaton 49
Fgue 2 Fmal ith tnsiv mlasma rcalcitrant t multipltpical rgimns fr svral yars
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1 50 Color Atlas of Cosmetic Dermatology
D FFERENAL DAGNOSS
Posifa mmaor erpigmenaio, exogenous ochrono
sis, drug-duced/oo-erigmeaion, nevus of Oaerema dschromicum ersans
LABORAORY EMNAON
Wood's lam p exam iatio accenuaes e i creased ep i
dermal pgmenation n measma bu does o igh g
its dermal comoen
COURSE
he igmenaon reses over a perod of weeks
occurs mos common i summer me, wit igesrogen saes du ri ng regnanc, ad pri or to me
strua ion t ma fade co mplee mons aer de l iver
or afer d iscont inuat ion of ora l conracept ive i l ls ma reaear in subsequen regancies and/or sun
exosure
KEY CONSULAVE QUESONS
Medication istor
Pregnanc
Su n exosure
m e of ose
Previous reamens
MANAGEMEN
ere is no medica i nd caton o reat measma
Neverteless, man aiens undersandabl are disressed b is apearace ad desire reamen Te goal
of te reame is o igen or remove he pgmenationreaig melasma can be qu te frustraing P rio r o in t ia
ing erap, s essental for e scian o exan
measma and is treament i detai to the paien Wieere are ma treaments for measma, i shoud be
sressed ha man are ofen onl arial effecve
Recu rrences are ver commo nI is also imoa o deermine whic form of
measma s being reated ta s eidermal versus
mixed-e versus derma melasma (Fg 252). Tere
are mul e opca and laser thera ies ava i lab e( Fig 25 3) . Treamen is frusratig an d oen neffecve
ere is a gh rate of recurrece Derma ad mxedte meas ma are leas responsi ve o era I n a l
measma atiens, sr ic sun avoidance is crucia w a
sunscreen wi VV roecion ad/or a scalb ock such as ian iu m d oxide or z inc oxde dur ig and
aer an reamen regmen
AFigure 2 2 () A female patient ith therapyresistant melasmaCourtesy of Hoard Conn
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OPCAL REAMEN (abe 251)
Thee are a host o topica teatments fo melas ma
Numerous formulations contaiing bleachg agets
suc as 4% hdroquione are eective treatments to
lighten o resove pigmentatio he are most effective
if used over a perod of weeks to a few months f theskin becomes signficantl irr itated from treatment d is
continue its use to avoid postinflammator hperpg
metation Proonged usage o hdoqu non e can result
in a chaacterstc skn dscoloratio kow as seudo
ochoosis
Ret no ids such as topca 0.1% tret ino n apl ed oce
dail for 40 weeks has been shown to be eectve but
ess effective tha hdroqui noe
Combation thera of 0.05% tretinon 4% hdro
quinone, ad 0.01% fuocinoloe acetode that is
Triuma produces favorabe clnical results for melasma
and postif ammato hperpgmentation wt d ecreasedirrtation Treatmet duration s limited b side eectsof prolonged topical steoid use ncudig skin atroph
and acne
Azeac acid has also been show to produce m prove
met
CH EM CAL PEELS
Chemical peels are often efective fo melasma
n one stud there was no diference resuts whe
comparng Jessner's sout on versus 70% glcoc acidpees ate performing three peels 1 mot apart oneac si de of the face
Secion 5 Disorders of Pigenaton 5
B Gcoc acd peels performed ever 3 weeks comb
nat ion wit da i sunscreen and a combinat on
Fgure 22 (B) (Continue Marked resolution in the melasma ater fourtreatm ent sessions with Fraxel laser Courtesy of Howard Conn
TABLE 2 • Teatent of Pgented Lesions on the ace
Retnoid/hdoquinone Gcoi c acd peels Qswtced laser Abative resuacng Fractona resuracg
Melasma Variabe imovement Mut ip le ght pee s i o Yes; but carefu Yes i skn
cojunction with patent seecto tes ;suscree and and ong postaser caut ion ski
tocal retinod/ recover tpe Vhdoquinone
Postinammato Yes; weeks to mont hs Vaiabe impovemet o No No
herpgmentatio to see c l in ica lmrovemet
Letigo Min ima/moderate Mima/modeate Yes; one to two Yes; M d/modeate
mrovemet after change with tree teatments are ostinflammator
month s of use to fou peels hgh s uccessful ertema che
obstacle
Nevus o f Ota Noe None Yes; mult e No No
treatments resultn improvement
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1 52 Color Atlas of Cosmetic Dermatology
gco c ac d/hdroqu none cream has bee show to
be effective.
Seral suercia l chemica pees such as salclc acid
ad gcoic acid ees are the safest pees n daker
skn ototpesCauto is requred or darker skn phototes to avoid
herpigmetatio
LASERS
• QSwitce ases
swtced aser treatmet fo measma s ot recom
mended give its high incidence o ostinfammato
herigmentation Additona l it s ot dramatca l eectve except in some cases of superical measma.
• Aat ive Lase
I cases refractor to topca ceams ad chemical eelserbum:YAG ase produced signcat temoar improve
met i 0 atets i oe stud but was com l icated bsubsequet ostinfammator hperigmentation n a l
0 atets.
• NoA a ve ract ioa l esurfac g
NoAbatve ractional resurfacig can be successful or
some cases of measma esecal epdemal tpes
(F ig . 25.2) .
Log-term data are lacking.
reatment is genea eormed at suerficia l deth
relatve to treatmets or rhtes ad acne sca rs.
reatment s geera erformed at hgher d enst es
It is most successful n atients with ighter skin ho
totpes such as skin tpes a d I I mp rovement s essredctabe in sk tpe l l but s oe ach eved.
Ski hototpes IV ad V ofte do ot respond avor
ab to fractional resurfaci ng. Postinla mmator hper
pigmentation is a high r sk.
Pre a d ostteatment use of hdroqu i noe and ogenteas betwee treatmets ma reduce ostiflam
mator hpegmentaton n da rker sk hototes.
PTFALLS TO AVOD/COMPLCATONS/MANAGEMENTIOUTCOME EXPECTATONS
Al orms of melasma are diicut and frustratng to
treat. Recurrence s commo
Dermal melasma is pat icu ar d icu t .
Patents shoud be apprised of te recacitrat nature o
this codit o some cases.
A
BFigure 23 () Young female with melasma (B) Characteristic darkeningof melasma 1 -day post intense pulsed light treatmen t
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Postpartum state and discontinuace of ora contra
cetve pi s a re reque ntl successul terapi es
Some treatments worsen ts apearance
Strict sun avodance is crucial wit a sunscree wt
UVUVB protecto and/or a pscal bock such ast itaum d ioxide or z inc oxide dur ig and aer an
treatment regimen
BBLOGRAPHY
inke Ditre CM amiton TA, E is CN Voorees JTocal tretinoin (retioc acid) improves measma A
veic econtro led , c l ica tr ia l J m 1993 129
41 5 42 1
Gr imes P E Management of per gmentat on in darker
racia etnic grous Smi Md Sg 2009;28(2) 77-85
Lawrence N, Cox SE Brod HJ Treatmet of melasmawith Jessners solutio versus gco c acd : A com parisonof c n ica eicac and evaluation o the predictive abi l it
of Woods l ight examnatio J Am Ad m.1997;36:589-593
Lee S Won C , ee D , et al reatment o melasma i
Asa skn us g a ract iona l 1 550 nm aser : An open
ciical stud m S 200935(10) :14991504
Manaoto RM Aser M Erb um:YAG laser resurfac ing
for refractor melasma m Sg 1999;25121-
123
Rokhsar CK, Ftzatrck RE Te treatmet o melasma
with ractiona potothermosis: A lot stud mSg. 200531 (12) 16451650
Torok M, oes T Ric P, Smth S, Tscen E
Hdroquione 4% tret no 005%, f luoc no lone acetonde 001%: A safe and efficacious 12month treat
ment for measma i. 200575(1} 5762
Veral o-Rowel VM Verao V Graue K Loez-V l auerteL, Garc ia opez M Double-b l ind comar son of azele ic
acd ad droqunone in te treatment of melasmaA m 198914358-61
Victor C, Gelber J, Rao B Measma: A revew J Md Sg. 20048(2) :97102
Cl ca apoac todagnosg
easma
Secion 5 Disorders of Pigenaton 53
Pyscal Exa Sun exposed areaface moe often tha ars Distrbt onceeks, lowe face, meda facein any combat on
Wood's Light to deteme epiea vs.dera d s bu o of p gment
erenta iagnosis Post nf amatory hypepgetaon
Medcao indce hyperpgmentatio
Rsk Factos Pregnancy Oa contracepves
Iceased pigmentation wth sun exposre
Fgue 2 Cinicl ppch t dignsing msm
ELASA
Vgant sunsce s ccal
SPF30 before du ing an d afte any teapyImpoveen s va abe and ecurence is comon
opica echanical Hydroquinoe Microerabraso Re nods
Supef c ia pees Koj ic acd Azea c acd
Lico rce exacs
I
+ +A combnato of a topca such as
hydouone wth onthy pees ad/ormcoemabrason fo 6 monts s aneffecte and safe com bn ation th erapy
Lasers Fraconapototheroyss
Aba e resofac g Q-swtched
ases
+
Lase/ g souces shoud be used ony afte combnation of topcasand peesmcodemabrason fa
Ri sk of post- inf am matoy hypepigmentation fom an y ase(may persst fo monts) Fracona potohermoysis as fewer sde effects and ess down
time than aba ive ases Abae resofacg ony for the mos efactoy cases in patents
who can toeate onhs of post infammato canges
Q-swched asers are often not effecive and ofen worsen measa
Fgue 2 Msm ttmnt ptcl
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1 54 Color Atlas of Cosmetic Dermatology
CHAPTER 26 Nevus of Ota
Nevus of Ota aso known as nevus uscoceruleus o
thamomaxi ar s represents a bengn ata coflent
macuar brow-blue gmentat on of the skn andmucous membraes in the d istr but ion of the irs ad
second brances of the tr igemin a nee. I ma be un ilatera or bi aeral. e isiateral scera is fequentl
involved
EPDEMOLOGY
cic 0.4% t o 08% of Jaanese dematoo paients
g bmodal dst ibuon at b and bert
Rc: moe common in Asans and blacks tha whites
Sx moe females than maes seek treament o thiscondit ion u nknown if ere is a sex redi lection
rciiig cors: soradc not an ierted dsorde
PAHOGENESS
Hperigmentaton arises as a resut of dermal
mean oces tha have ot m grated to the epid emis .
PAHOLOGY
Heav igmented eongated dendrtic meanoctes arelocated among the reticla dema collage. Mos tp
call these mela noctes are ound n te u er onethrd
of he recular derms but are aso see in the pa la
dermis i n some es ions.
PHYSCAL LESON S
I t p resens as couen or paa l conlue b rown-blu epatches in the dsr ibuton of the rst and second
branches o the tr gemina nerve. Gra back and urpecoloratio ma be resent in some lesons as well It can
be nilatera or b latera . The magntude of ivovementcan var from local eriocua r i nvolvement o much of hesd e of the face Ap roximate twoth ds of atie nts ea
tre ipsi latea sceral ivolvement.
D FFERENTAL DAGNOSS
Measma caf au I ai t macule Hor i s macue b l ue nevus
brusng ochroosis agra oodemaoses fixed
drug erupto and oter medcaion-reated erutonsshoud be consdered in the roer c i n cal setting
A
Bigure () Nvus of Ota rior to tratmnt with Q-switchd rublsr 8 ignificnt claranc ar srial trtmnts with Q-switchdrub lasr
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LABORAORY EXAMNAON
Bios ma be id caed i f th e d iagosis is i n qu es ion or
to exc lude te are case of meanoma ar is ing n th sleso.
COURSE
Thee s a bmo da d isti buion for nevus of Ota b ith an dube. It remains eatve similar aearance afte
in it a resetato
KEY CONS ULAVE QU ESON S
Onse of erutio
Medication histo
MANAGEMENThee is no medcal idcaion to trea nevus o Ota.Cosmetc a earance howeve s dstessg to aents
Wh le cohea and toica beachi g reatmes havebeen uized the teatment of choice is Qswched ase
treatment
OPCAL REAM EN
Mak eup can cam ouflage or asss in cam oulagng nevus
of Ota To ca med icatio ns are less effecive tha ase.
REAMEN
N ume rous sudes have sow that evus of Ota i s
ameabe to successfu esoluion with Q-swtced
aser teraes icudig the Q-switched ub
(694 nm) the aexandrte (755 nm) and te Nd:YAG( 1 064 m) lases (F gs . 26.2 ad 26.3) .
est sot can be perormed pro o teatmen t
he Qswched ub lase has b een sh own to be effec
tive a poducin g 75 % o geate cearance at luences
of 5 to 7 J/cm 4mm sot size and a 30s pulse
wdth a 3to4mot treament inteals In a stud of 46 c l dren ad 107 adu lts wi evus
of Ota treatments were moe successu in cidren
than n adu ts
The mean nu mber of treament sessions to ach eve
sgnficant cearing or better was 35 fo the ouger
age goup and 5.9 for the oder age group
Addit onal complications were lower n e childen
than ad ults that s 48% as compaed to 22.4%.
Oe erospectve stud examined 101 patens1 ea ater teament wit Q-swtched ru b aser ad
Secion 5 Disorders of Pigenaton 55
Figure Nevs of Ota Periorital legray pigmentation ith scleralinvolvement Kay K Jen ichard J, et a eds Color Atlas & ynopsis ofPediatric ermatolo McGraHill, Inc; 00
Topca Caoagea e e o soe aies
NEVUS OF OTA
echancal iodeaasoso o e eoed g is o soaa/or sag
Lasers Qswied asesae e eae ooie Alaeo
li le reaes wi Qswie ases ae eeded I oee oerae o draa aer e eaes Qswie ase reae o esios a aise ia aresod eer o laser ea a lae i l ie a Qswie A ase is se a oaio o 532 /106 a resl ee al ioee a 1 06 aloe
Figure Treatment of nevs of Ota algorithm
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1 56 Color Atlas of Cosmetic Dermatology
ound ha 168% dsplayed hypopgmenaon ad
5.9% showed hyperpigmeaio One paen whohad com pee resouio developed recurrence
he Qswched a lexand ie laser s a so efecve or he
reamen o nevus o Oa Dermal when g is hekey c in ca endpon when reaing nevus o Oa wih
Qswched lasers Oe group reored he successu reamen o
nevus o Oa wih racional phoohemoysis
oeheess Qswched aser s he reame ochoice
• To ica
Camoulage may be he ul or some paens.
• M e c h a n c a
Mi crodemabrason shoul d no be perormed
H igh r isk o dyschromi a ad/or scaing
• asers
Q-swiched asers are he reamen o choice
Ablaiveno
Muipe reamens wh Q-swched lases are needed
m povemen moderae o dramaic aer m u iple ea
mens.
Qswiched aser reamen o lesons ha arise nnancy may respond bee o lase heray han aer
n le
a Q-swched YAG aser is used a combinaion o
532 nm/1,064 nm may resu n beer cncal impove
men han 1 064 nm alone
Oe sudy reaed 13 paes a luences ragng
beween 6 and 8 /cm a 8week inevas he
mea number o reamens was approximaey
seven Seven paiens acheved 75% or beer igh
enng hree paiens acheved beween 51% and75% impoveme one achieved bewee 25% and
50% improvemen and anoher achieved less han25% mprovemen.
wo paens experenced ransien hyperpigmena
ion one experienced rasien hypopigmenaion
he Q-swched NdYAG (1 064 nm) laser has a lso
proven o be eecve
S ighy ess eecve han ohe r Qswched lasers.
I is saer o use n dark sk ypes
Less risk o hypopigmenaion.
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PFALLS O AVOD/OUCOMEEXPECAONS/COMPLCAONS/MANAGEMEN
Lase treatment for nevus o Ota is requently su ccessfu
Given te igh proportion o patents wit dark ski
phototypes, there is the isk of hypo an d hyperpigmentat io.
he r isk of such an advese eact o shou d be d scussed with the patient prior to therapy.
Additionay, a test site can be teated befoe peform
ing u l treatment of any eso.
Qswtced ase r treatment can be associated with tran
sient hypepgmentation.
Recurence ater treatment s ifequent.
BBLOGRAPHY
Cha n H eung RS, Ying SY et al . A retospective aa y
sis of complcations in the treatment of nevus of Ota wth
the Qswitched aexandite ad Qswtched d:YAGlasers erm Surg 200026( 1 1 ) 10001006.
Chan H H Y ng SY, Ho WS, Kono T King An i v ivotr ia l comparing te cl in ical efficacy and compcatos of
Q-switched 755 nm alexandte and Q-swtched 1064 nm
Nd :YAG lases i n t e treatment of evus of Ota. erml
Surg 200026( 10 ) 91 9-922.
Kono Cha n H , Ercocen AR , et a l . Use of Q-swtced
ru by laser n the teatment of nevus of Ota i n di ferent age
groups. Lsers Surg Med 200332(5) 391395.Kono ozaki M, Cha H Mkashima Y. A retrospec
tve study ooking at the ong-tem compications of
Qswitched uby aser in the treatment of nevus of Ota.
Lsers Surg Med 2001 29(2) 156159.
Kou ba D Fin che EF, M oy RL e vus o Ota successful y
treated by fractional potothemoyss using a fraction
ated 1440nm d:YAG aser Arch erml 2008
144(2) : 156158.
Radmanesh M aevus o Ota treatment with cryothe
apy. J erml Tre 200112(4)205-209.
Secion 5 Disorders of Pigenaton 57
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1 58 Color Atlas of Cosmetic Dermatology
CHAPTER 27 ost nf a m ma tory hyperpg me ntaton
Posinlam mator hergmenaion (P I ) is a commo n
sequea o i nflammato dermatoses or inju r to the ski.
It occrs mos common n darker sk tpes.Deendng on the etolog of the hergmenaon, pig
ment ma be deposed n the dermis or epdermis wthimorant micatons for teatng the gmen changes.
It s a common seqel a of ase eatmen art ic ar i ndarker sk n hototpes ( ig 27 . ) .
EPDEMOLOGY
ee: comm on, esecia l n da rke skn tpes
e a l ages
Rae: moe common in da rker skin tpesSex: none
rea ars an inlammato disorder or injuto the skin ca rodce hperigmentatio. It ma aso
result rom lase thera, demabrasion, crothera or
chemcal pees It resents more exberatl and with agreaer duraon in daker skn photoes
PAHOGENESS
Unknown.
DERMAOPAHOLOGY
Basa cel laer pigmentaton and dermal meanophages
are seen.
PHYSCAL LESON S
In epidermal P H, at ents d ispa nd ist ic an o dakbrown macles a sies of prevos skin inflammaon In
derma l P here s more o a browngra he
D FFERENAL DAGNOSS
Masoctosis, macular amoidosis, minoci herg
mentaion, exogenos ochronosis, melasma and er
thema dschromicm pesans
LABORAORY EMNAON
None .
Figure 27 PIH seen aer a seres o treatments wth nonablatveractonal resurfacn or a scar The PIH resolved on ts own wthn
weeks
A_
_
Figure 27 2 () Pseudo-ochronoss seen aer years o hydrqunone
treatment
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COURSE
P I H does not wosen i n he absence o uther n sult o
infla mmation at he aected sie. PI H usuall resovesover a eiod of a few mohs. In he case o demal
herpigmeaton thee ma not be im ovemet
KEY CONS ULTATVE QU ESTON S
Su n exosue susceen use
me of onset
Recet rashes injur or treatment of skin
Medication use
MANAGEMEN
Secion 5 Disorders of Pigenaton 59
Whle tere s o medica ndication to treat P manatents ae as botheed b PI as the ae b the
rocesses that produced i i it ia l Furtermoe PIH ca
endue ar longe than he original eruption here are
mu t ip le teatmens nc ud i ng to ica l lase ad chemica leels (able 271) It is essenia o rst determne he
cause of the heigmentaton Culits ange romhemosidei n o igment to vascul ar Wihout detemi ing
the etioog correct reatmen wll at best rovide no
imoveme or worsen the PH Frequent the safestand most eecive teament is time Attemted teat
ment of P esecia n daker skin hotoes caoen wose and olong hergmetato ormall
ederma PIH wi l resolve on its own over a eriod omonths
Figure 272 (B) (Continue ignificant improvement aer treatment with
switched laser
Theaeutc otions include toical retioids bleac
ing ceams chemica l pee s ( i nc ud ing glcol c ac id eels
TLE 27 • Post-fammatory Hypepigmetatio teatmet
Theaeutic Retinoid/ Peels/otons hdoqui none mic rodemabrasion
Pos-iflammator
herigmenatio
eeds to be used
for weeks to
months fomovemet
ace/ue bod
moves more
qui ck than owe
ha If of he bod
2070% glcoc acid
ees jessner ees
combinaton esserTCees and Saic c
acid ees and/omicrodermabason
ma hel imrove
moe qu ck Risk o aadoxica l l
mak ng ostnam maor
changes wr if oo
much inf ammat on
is ceated
Qswitched lase Ablat ve ases
o o
Fractiona
resufacing
o
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1 60 Color Atlas of Cosmetic Dermatology
essne peels, combinatio JessneTCA pees and sali
cl c ac d peels) a nd factiona lase teatmet Tee sa isk o paadoxcall making posnammato changes
rs f oo much inam mation s ceated
SUNPROTECTON
S n bocks and sunsceens used dai l ae cucal to pe
vent wosenng as s sun avoidance Wot thei se,
ohe eapies wll not be eectve f a patent does notavod sn expose P IH w l l wosen Sun avodance
incudes avodng peak sn hos weaing a at otdoos to potect the face om sn expose and an
awaeness at UVA as peetaes though wdows
wi e d iv ng, wh e at wok ad wi le at home
TOPCAL TREAMENTS
hee ae a ost of topcal eatments o PIH tha pod ce ml d mpovement and ma expedite eso ion
Hdoq inone omlaios paticla l wh su nsceens
Hdoqunone (2%4%) ceams ae effective fist
i ne teatment
Poonged usage o hdoqone can eslt in a Achaacteist ic skn dscooaion known as psedo
ochonosis (F ig 272 )
Bleacing ceams ae contaidicated in pegnant
and lactat ng wome
Ret io ids
Solage (2% meqno l ad 0.01% te ino in) andT ma (001% f loc no lone aceton ide 4% do
qinone and 005% tetinon) povide an exfoliat ive
benefit
T ma s hol d not be used i ndefinitel due o its co
ticoseod conet and sk fo atoph
Azeac acd (20%) ceam app ed twce dai povides
slow l ghtening of pigmentation
Koj c ac id ( 1 %2 . 5% ) ceam
The exac concenaion of kojc acid eeded foefective eslts is nknow
f an o hese topicals poduces sgnficant inflamma
ton o i itat ion, it s i mpoant o di scotin e ts use to
avoid wosening of PI H
CH EM CAL PEELS
Chemca peels ae an effective eatment opton fo theedct ion o P I H
Ovethecounte dox acd peels ae a beneficial
adunct to phsicanstenh chemcal peels econtna exfo ia ion achieved fom cosistet se o
the peels ma esu lt n m l d l ighten g
BFigure 27 3 () Hyperpigmentation on le side of face before treatment
8 Impvement aer a series of salicylic acid peels and topical application of 4% hydroquinone Courtesy of Pearl E Grimes, M
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Gco ic ac id ees (20%70 % ) are adminisered ever
2 to 3 weeks ui zg icreasng sreghs as olerated
The reatme edpoint is m d con en eema .
Treaed aeas ms be u l neua zed wih sodium
bcabonae o waer at h e comeo o f the ee l .
Ligheni g o suefc a l P ma be o bserved ateror o six peels.
Srict photooection o 1 monh s essetal and
ms be stressed.
essner eels (resocnol, acic acd and salc ic acd)
are ad mi i seed ever 6 o 8 weeks.
Treament edon s a l igh whiten ng o the skin .
Strict photoproecon for 2 o 3 monhs s advsed.
Mu ile eatmes are recommended .
Conta id caed i n regant and lacang women.
Combnao Jessne/0% r choroacec (TCA) ees
ma also be emoed i a sim a fashion as heesser pee . The Jessne eel esuts in exoa oalowing for geae peneaion o he CA ee.
Mu ile eels are genea l needed.
Conaid caed i regant and lacang women.
Deee eels ae ael emploed gven the sk ofP exacebaion wh healing
Caution must be used n reaig skin hototpes I oVI pa icu la with medi m-deth ees Sa l ic c ac d
pees are safes or dark skin photoes (Fig. 27.3).
LASERSTraditiona, aser reament fo PI does no roduce
relab e mpovemen and s no firs l i e hera. n aclaser thea ma exacerbae PI. n geeral i is not
recommendedFraciona l hoothemolsis (FP) can however ovde
im oveme of P ( F ig 274) . h s is esecia l l re o
atens wh gter skin hotoes. I da rke skin es,PI oe worsens. I shoud no be recommended as a
rs l ne hera Rahe beac hing creams and chemi caeels rovide more consse eoduc ble esus
Ticall FP reatmes shoud be directed owad
suerficia skn deh ad avod hgher eatme densi es .
PFALLS O AVOD/COMPLCAONS/MANAGEMENOUCOMEEXPECAONS
I t is im orant o reassure aiens ha P H w l resove
on is own wh tm e excet f it is a de ma ocess
Lase treatme is u eliab e and ma produce worse
ing. I is usua l l no recommended
Secion 5 Disorders of Pigenaton 6
A
BFgure 27 () Hyperpigmentation aer a series of Qswitched laser tattoo treatments (B) Impvement of PIH after two nonablative fractionalresurfacing treatments utilizing superficial depth and lower treatment
densities
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1 62 Color Atlas of Cosmetic Dermatology
t is important o disconinue an topca medications
that poduce nfammation o ta on to avoid worse
ng P IH
Chemical peels ae l ike to onl l ghte and not ful l
e l iminate the PIH Caut io should be ake n dake
skin pototpes
t is beer and safer o ut l ize seria supecial peelsathe than a si nge deepe pee o mi n mize the isk ofP I H .
PH ma ot improve despite serial cemca pee use
P I H result ng fom hemosidein ( ie, leg vei eatments)wi not respond to asers, peels and beach ing creams
In fact, teatment wi i kel worse the PI H .
BBLOGRAPHY
Kime SL Lase eradicaton of pgmented lesions and
tattoos Drmal. li. 200220() 37-53
Mis i ma Y Ohama Y, Sh baa T et a l n h i b ior acion ofkojic acd o melanogenesis and its herapeutic effect fo
vaious huma hperpigmentation disoders Ski Rs.994;36(2) 134-150.
Nakagawa M Kawai K Contact a lerg to koj ic acid n
sk in care poducs a Drmaiis. 1 995 3 ( ) 9 3 .
Ngujen QH, Bu i P. Azela ic ac d : Phamacokinet c ad
phamacodamic propertes ad its erapeuic role n
hperpigmea disodes and ace l J Drmal.995;34(2) 75-84.
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CHAPTER 28 Vtgo
Vt igo is a acquired idiopathic condt ion that produces
smmetic deigmented patches of the skn It s art icu
la dstressng and cl ica apparet i patets wthdarker skin phototpes
EPDEMOLOGY
i ap roxmatel 2% o the world popu lation
Ag: can reset at an age but most commonl presents
in the secod to ourth de cade
Ra: equal
Sx equa
riiig ars nher itance trauma i ess, emo
to a states
PAHOGENESS
Unkown
DERMAOPAHOLOGY
Thee are no melaoces n basal ce ae
PHYSCAL LESONS
Patents dispa weldemarcated smmetic, depigmented, chakwite macues Common locatios icudeelbows, kees, sacra area penis, peroa areas and neck
Hai r ma also ose pigmentaton ( Figs. 28. 1 and 282).
DFFERENAL DAGNOSS
Chemical eukoderma ostnflammato hopgmentaton, nevus deigmetosus, evus aemicus, ptr iasis
alba, upus erhematosus, lepros, and geodermatoses
LABORAORY EXMNAON
Wood's amp exam iat io s he pfu i making the d iag
nosis In cases of uceaint, bios should be eormed o both esional and onesioa skin in oder to
determine i there s an absence of meanoctes i the
aected skn Check trod-stmuatng ormone (S)or hothrodism
COURSE
Vit igo can p ursue a variabl e course After an i t ia ra id
presentation , it tends to sta bi ize Tpica , it is a ch ronic
Secion 5 Disorders of Pigenaton 63
Fgure 28 Vitiig n th trunk and nck f a yung patint
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1 64 Color Atlas of Cosmetic Dermatology
dsease with eriods of artial regmentaton but ot res
outon . It ma im rove in the sum mei me. In somecases degmetation becomes extensive
KEY CONSULATVE QUESONS
Age of ati ent
me of oset
aml histor
Occuato
Chemcal exosures
MANAGEMEN
hee are mult ile treatment modalt ies or vit i igo
Unortuate treatment is frustratng and ofte nefec
tive Patients understandabl are dstressed b the
aearance of vtil igo ad desie treatment extensvecases t roduces a str ki g aearance aticu ar oatents wit darker skn hototes.
PREVENON
Sunscreens and sun avodance rotect vit l iginous skinfrom burn ng and are an imortant comoent o ter
a Furter tannng unafected skin wil accentuate thecontrast between norma l ad vt i ig nous sk worseing
the cosmetc a earance o the disease.
OPCAL REATME N
hee are a h ost of toi cal treatmets fo vti i go. he
inc lude
Cotcosterods
oica
ntra les iona l
Calc ineur i n ib itors tacro l mus imecro l mus
Moobenzlether of hdroqu noe
Produces ermanet deigmetation
wce dal over 1-ear eriod
Permanent degmetato is roduced n ess than
50% of atients
Poor or no deigmetaton n eal haf of atents
Caution or to u rsuig ths erma net treatment
Side efects nclude contact demattis erthema
and rur itus
eighteed sk of sunbur ate ts ermanent
treatment
Camouagng makeu and self-tanning agents to hde
deigmented macues
Figure 28 2 White forelock in the same patient
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PHOTOTHERAPY
Photothera is a ma insta of vii l i go eatmen
Psoraen and utravioet A (PVA) with toical or oral
5methoxsoalen or 8meoxsoraen
Narrow-band UVB
ORAL TH ERAPY
Oral thera es ic l ude
Ora 5 o 8methoxsoa en n combinat on wth grad
ual l mited sun exosue
Pu lse era with co costeods
SU RG CAL TREATM ENTS
Autologous skin gang can be a eu teatme for
vi i go recalctant o othe theaies It s not a first orsecond-l ie teatment Si-hickness gafs, eidemal
blister gas cutued melanocte grats single hairgrats and noncutured eidermal susesio gas
have a been examned Pai aer grat rocedues s
comm on aicu ar l at e ha rvest site (g 28 3)
A majoi of ates em oing the ede ma sucto
grat techni que showed m ovemet
Sit-ckess gaig and dermabasio have aso
achieved eigmenation within an average o 6 months
in one stud of 22 atients
Single a gras ae mos efectve in localized o seg
menta vit l igo Success n genera zed vt i go is oor Both cultured ure meanoce susenson as wel as
cuued eidermal gaig ae treatmet with C asehave bee sown to be successful in teating vitiigo
Resu s were best in l oca ized cases of viti igo
LASER THERAPY
Excie Lase
An excime laser em is UVB rage igt at 308 nm cl ose tothe wavelegt of aowband UVB tea that has been
used to successful teat vtil igo Begin ni ng wih a staingdose o 100 m/cm wt increasing doses in sandadhotothera in cements hee was good m rovement n
recalc itrant viti igo ater 30 weeks of teatmets
Acal lesons were most efracto to treament
ew a dvese eects
Bes esuts are roduced on the ace > neck extem
t ies tunk a nd genita i a > hands eet
Moe exensive than ma tradt iona theraies
Combnat ion treament with aco l imus 01% s more
eectve tha treament wi excim er ase alon e
Secion 5 Disorders of Pigenaton 65
A
BFigure (A) epigmented patch of sin on right mandible
(B) ignificant improvement aer multiple 1 -mm punch gras Courtesyof Pearl E Grimes, M
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1 66 Color Atlas of Cosmetic Dermatology
PFALLS O AVOD/COMPLCAONS/MANAGEMEN/OUCOMEEXPECAONS
Viti go is a difficut dsease to treat
here ae mu lt ip le f irst and secod l n e theraies tat
shoud be emloed befoe seeking surgical or lasertreatments
t is esecal dfficut to roduce ongterm signficant
cosmetic improvement in extesve cases
Fequentl, eigmentaton ma be cofied to erio
cul ar areas creating a spott" appeaace.
Patients need to be educated that a therap ma not
succeed
he excim er ase s not wdel avai ab e, m aki g its use
paicu lar d ifficu lt
BBLOGRAPHY
Chen Y, Yag PY, u D, Kuo FS, ung CS, Hug CM
reatment of vt i l igo b transantation of cutured puremeanocte susenso Analsis o 120 cases J Am
Aad Dermao 200451(1) 6874
Hadi SM, Spence M ebwohl M. The use of the 308-
nm excimer ase or the treatment o vitil igo Dermaol
Surg 200430(7)983-986.
Koga M Epide rma grating us ig te tops o suctio b is
ters in the treatmet o vitil igo Arh Dermaol
1988; 1 24(1 1 ) : 1 656-1658.
Na GY Seo SK, Choi SK Sigle hair graing for the treatment of viti igo JAmAad Dermaol 1998;38(4):580584
Ozdemi r M, Cetnkae , Wolf R et a . Comparson of twosugical aroaches or treatng vit i igo: A e iminar
stud ln J Dermaol 200241(3) 135-138.
Passeon , Ostovar N Zakaia W, et al opicatacro mus and te 308 nm excimer laser A snegistic
comb ination or the treatment o vit i l igo Arh Dermaol
2004; 140(9) : 1065-1 069
aneja A, reha M , alo CR. 308nm excim er aser fo
the treatment of localized vt l igo n J Dermaol
2003;42(8)658-662.
oriama K, Kamei Y, Kazeto T, et al Combinato of
short-ulsed C aser resurfacing and cutured epiderma sheet autogating in the treatment o vit l igo: A
preiminar reort Ann Plas Surg 200453(2) 178-180.
va Geel , Ongeae K, e Ml M, Haegen YV, Vervaet
C, aeaert M oubleb l d aceboconto led stud of
autologous transpanted epidemal cel suspensions or
repgmentng vit igo. Arh Dermaol 2004;140(10):
12031208.
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S IX
Vascu lar A l terat i ons
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1 68 Color Atlas of Cosmetic Dermatology
CHAPER 29 Angokeatoma
Angokeratomas are teagectasias wt keratotic ele
mets. Te esent dierent c in ca scearios inc lud
ing (a) so ita or mult i le agiokeratomas occrr ingredomi nantl o owe extemit es; ( b) a ngiokeratoma o
ordce aectng the scrotum ad the vuva (c) angio keratoma o Mibe l l i a autosomal domiant d isorde
afectg dorsum o ands ad eet ebows ad knees(d) angiokeatoma cororis dsum associated wth
abs disease an liked ecessive dsorder caracterzed b gaactosidaseA decienc and afecting
the ower abdomen bttocks ad genia ia; ad (e)
angiokeraoma crcumsctum sua groued o one
exremit.
EPDEMOLOGY
Ae: solitar or mut ile angiokeratomas usal aect
oug aduls angiokeratomas o ordce aect mddle
aged ad edel individas. Agokeratoma o Mibe iand angiokeratoma circmscritm are sal diag
nosed i cildhood.
Sex angiokeratoma o Mibel and angokeratoma cir
cmscrtum exhbit emale redominance. Otherwse
there is n o sex redsosit ion
PHYSCAL EXAMNATONRed to v io aceous wel l- c ircm scr ibed herkeratot icau es and aques
DFFERENTAL DAGNOSES
Soliar esos can be mistaken or melanoma acqed
hemagoma mhagioma seborrhe c keratos s and
wars.
LABORATORY DATA
• Dematopathoogy
Maked di ated inwaed bood vesses i te ai ar
derms associated wit an overlig acanthotic herker
atotic eidemis.
COURSE MANAGEMENT
Maagemet o agiokeratomas emans a ca ege.Ma m oda it ies have bee reoed in the iteraure with
variabe success. Treatment modai ies icde
A
BFgure 29 () Aniokeratomas on the abdomen of a youn patient(B) Aniokeratoma imaed thuh an epiluminescence micscopeermLite
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Lasers angiokeraomas have occasiona been treaed
successfu wih asers
The p used de aser ( P) is an eective device for
the mprovement of the vascuar component of
angiokeraomas but frequentl some keraosis
remais The targe chromophore is hemogobin
P has proven successful at 595 m 5to7mmspo 9 to 1 1 J/cm, C 30/20 Covering the angiok
eratoma with a glass s ide that is, diascop, is hel p
u The endpoin is es iona p urpura eal i ng occursin more than 10 o 14 das Muipe reaments ma
be requ red (F ig 293 )
Resurfacn g lasers such as C and ErYAG lasers canbe utilzed fo lesiona vaporzation Paiens general
require local infilration wi 1% idocaine with or without epine pr ne prior to treatmet The Utra Puse C (umenis, Santa Cara, CA is empoed usng a 3mm
colimated hadpiece wi an eerg o 300 to 500 mJ
wh ooverlapping pulses The varous scanned C lasers such as the Sharplan FeaherTouch areempoed using the 125mm handpiece, 3-mm scan
size a 14 to 40 W he treatment endpoint is abation
to achieve esional flattenng and opaesceceTreamen sites shoud be ceansed with sa i ne soaked
gauze betwee aser passes Postoperative care
requires wice dail washing wit soap and waer and
app icaon of a a ntibiot c ointment eal ing occurs nmore than 2 o 6 weeks As with a abative proce-
dures scarrig ma be observed
Oer asers that have been used in the past wthvarabe success i ncud e potassiu mtitanp hospate
laser argon laser ad coppe vapor laser og
pulsed NdYAG (1064 nm) aser as been shown obe eective in improving angokeratomas due o is
selectivit ad is deeper peneraion ito the skin
Section 6: Vascula r A lerat ions 6
Fgure 29 2 Angiokeratoma on the le thigh resistant to multiple treatments with pulsed dye laser
Successu reatmen wih a dual-waveength laser Asstem (595 and 1064 nm) has been recent
repoed (Cnerg with Mutplex™ CnosueWestford MA SA)
Other surgical reatmets incude excision eectro
cauter elecrofulg uratio n or crosurger
P TFALLS O AVO D Patients shoud be advised that the PL reatme wil l
cause obvious brui s ng or u p to 14 das
Keratotic features ma pesis after treatmen
mp rovement s oen eusive
BBLOGRAPHY
Gorse SJ J ames W, M urson MS S uccessfu treament ofangiokeraoma wih poassium titanl phospate aser rJ Dermal 2004150(3)620-622
BFgure 293 (A) iopsyproven angiokeratoma on the thigh of a youngchild (B) ome resolution aer one treatment with pulsed dye laser at awavelength of 55 nm with a 1 0mm spot, pulse duration of 1 5 ms, a
uence of 5 cm and C 00
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170 Color Atlas of Cosmetic Dermatology
Lais Emtestam M arcusso JA A ngiokeaomas n
abs disease and odces dsease: Successful teatmet wth coe vaou ase Aca Derm Venerel
993; 73(2) 133-135.
Occe la C B le id l D Ramin i P Sch iaa L Rami i EArgo ase teatmet of cutaeous mul i e agioker
atomas. Dermaol Surg 1 9952 (2 ) 70 72 Odemir M Basal I Eg B Odemi S. eament oangiokeaoma of Fodce with log-use eodmium
doed iu m al um iu m gaet ase. Dermaol Surg
2009;35() 92-97
Pirman G Rau l in C arsa i S. Angiokeratoma o the
lowe extremi ies Successul treatment with a dualwaveegt laser ssem (595 ad 064 nm). Eur Acad
Dermaol Venerel 200923(2) 86-87.
Sommer S Merchat WJ SheehaDae R Sevee edomiant aca l va iant of angiokeatoma of Mibe l i
Resose to long-use NdYAG (064 nm) aser teat
ment . JAmAcad Dermaol 20045(5)764-766
CHAPTER 30 Cherry and Spder Angomas
Che agiomas a so kow as rub sots seni e
hemagiomas acqued cai la hemangioma ad
Cambe de Moga sots are ve commo benign vascula esions that edomant afect te tuk. Side
agiomas aso know as nevus aaneus side teangiectasa arteia sider ad vascuar side eeset local
ied teagectasias adaig rom ceta feedig
ateroes. The ae commo vascula esions hat edom ina tl aect the face u er runk arms and ha nds.
EP EM O LOGY
Incidence ve commo
Age che agiomasmid d eaged ad ederl eole;s ider agomasa l ages
Sex moe commo in females
Precipiaing facors che agomas ca erut duing
regac o with heatc disease Side agiomas ae
stog associated wth eganc ntake of oal cota
cetive ls and heatocelu ar disease
PAHOGENESS
Ukown fo both. Associaion wth egac ora con
taceive use and live dsease suggest a omonallmediated angiogenic mechaism .
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PHYSCAL EM NATON
Cherr agoma presents as a 1-o-3-mm bright ed o
voaceous smooth dome-shaed apule Spderangioma d isplas a network of d lated ca l lar es radiai ng
rom a central vesse Bo ma bleed when taumaized
PAHOLOGY
Cherr angomas show oss of rete ridges as wel as congested and ectatic cap l ar ies and postca l a venules i
the ap la demis Sider angiomas revea a centalascendg arerole at banches and commucates
with m ult i e d lated ca la ies
D FFERENTAL DAGNOSES
Cherr agiomas can be mstaken fo agokeratoma,
gomeru o d hemangioma pogenic granuoma andnodular melanoma S ider angiomas can be m sake for
geera zed essetial telagiectasas and heredta hemorrhagic ea ngiectasia
COURSE
Cherr and spide angomas ais ng duig pregnancma egress pospaum Spider angomas aris ng in
ch dhood ma aso esolve spoaneous Otherwise
both esions ted to pesst
MANAGEMEN
Althoug medica l ns ign f cant cerr and spider
angiomas ae fequen teaed for cosmeic purposes
Mutple effecive surgica teatment otions exstDependig on the rocedure selected he cost to he
patent ma va sgical Cer and spider
angiomas a pesen durng egnanc shoud no be
treated unt severa mohs afte delve as the ma
resolve o th ei own
Electrosurger
Eectrodessicao wth coagulaion (monoolar set
t ing 12 W followed b gele cueage wth endpoin of lesional atteing and hemosass) has bee n
the rad ioa reatme moda it for hese lesi ons
I is eecive and easil accessib e
The potenial for sca ormation m ust be considered
Laser surger: d fferent lases ave been used success
fu i treament o cerr and spde agom as
Pulsed de aser (PL) is the treamen of choice A
so size should be seected that matches diameter
of the angioma Wh sider angomas the centra
Section 6: Vascul ar Alerations 7
A
BFigure 3 () pide angioma, ight nose (B) Full esolution of spideangioma ae a single pulsed dye lase teatment to cental vessel and
suounding skin
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172 Color Atlas of Cosmetic Dermatology
eedng vesse as wel as he surroundg vesses
sho uld be reaed I is bes o com press he esion
wh a mcoscoe s ide o banch al l but he cenral
eedng vessel. A purpuric laser pulse shoud be
deiveed he microscoe sl de shoud be removed
o aow fo coong of he aea. Subseque, a pu
puric laser pulse can be emploed o arget heeagecasias adiatig from he eedig vessel The
purp uc eamen end poin represens coaguaonof he argeed vessels (gs. 301 ad 30.2)
The poassum-ianlhosae (KTP) 532 m laser
produces a avorabe resonse Spo size shoudmach he leson diamee. he vessels shoud be
raced ou complee or mos effectve reamen
Treame endpoi s lesional cleaace or supeicia whienng Erhema can be expeced osrea
men lasng 24 o 48 hous
Carbo d oxide lase (UraPu se 3mm col l imaed
handece 30000 mJ/puse, nonoverlappgpulses Sharpan eaherTouch 125-mm andpece140 W, 3mm scan size, nonoverlaping puses)
has been empoed as secondl ine hera wih
success. Treame edpon s esoa atenng.Poena sca fomaion mus be consdeed
Lgh hera
nese pused l igh ( P) has aso been emploedwih some success. As coagulaion s eeded or
esional esoluion, hghe fluences ma be equredo reamen ecac
Sugica excson
Excsion should be eseved fo lesons ha are ressan o oher reamens A posopeaive sca s
expeced which ma be less cosmeica peasig
han he angioma .
PTFALLS TO AVOD
Paties eed o be counseed as o the kelhood o
obvious pu rpu ra fol l owing eamen wh P DL tha ma
perss o 1 0 o 14 das, espec ial l off he ace esios
are ess ikel o be comeel eaed a subpurpuric
uences
Smple elecrocaue ma be us as effecve as PD
a a educed cos o he paie
Com essng he esion wh a glass sl ide du ring PD o
KP eamen is he lpfu l o mi i mize s s ze and a l ow
ng for greaer laser eetrao. This reduces he oa
eneg needed fo coagulaio and increases he reamen success ae.
M u p e reamens ma be requ ied , i a ic u a for
age spde angomas.
A
BFgue 3 2 () Cher angiomas on the trunk in a middle-aged female(B) The appropriate endpoint is purpura obtained after pulsed dye lasertreatment wavelength of 55 nm, -mm spot 1 5-ms pulse duration,uence of 1 Jm C 00
AFgue 33 () Cher angioma, chest
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BBLOGRAPHY
Daw G G uta G Com arson of otassium ttanl hos
hate vascuar aser and frecator in e treament ovascular siders ad cherr angiomas. l pDermaol 200328(6)581-583.
Fodor , Ramo Y, Fodor A, Carmi , Pe ed IJ , U mannY. A sdebside rosecve stud o tense ulsed ght
and dYAG aser reatment or vascuar esions. Alas Sr 200656(2}164-170.
Section 6: Vascula r A lerat ions 73
B
c
Figure 33 (Continue (B) Pulsed dye laser treatment to cher angioma
utilizng diascop (C) Purpura immedately post pulsed dye laser treatment (D) Complete resolution of cher angioma aer one pulsed dyelaser treatment
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174 Color Atlas of Cosmetic Dermatology
CHAPTER 3 G a nuoma Faca e
Graloma facae (GF) was first described by Wigey i
1945 wo labeled the d isease eos inop l c gra o ma "
Pin ks reamed th s d isorder gran loma fac a le n 1952.GF s a id iopat c croic ctaeos d isorder that s
a ly ivolves e face pac lar y the ose. ca presetwith a sige leso or mt iple esos
EPDEMOLOGY
idee: ncommo
Ae: 30 to 50 years
Rae: prmar ly see in Cacasas
Se males > femaes
PATHOGENESS
U kown bt may be mediated by im m ne compledeposit o
PHYSCAL EM NATON
Sige idraed acal browisred apule or paqe.Some lesions may have telagiectasa tple es ons may
be preset Etrafacia stes rarely observed. esios may
vay i size from milimeters o cetmeters (Fig. 311)
D FFERENAL DAGNOSES
Ctaneos ps erytematoss sarcodoss ymomapseudoympoma ctaneos Tce lymoma fed
d rg erupto rosacea
DERMATOPATHOLOGY
Dense oymoros iflammatoy cel fltrate i te
er words of te derms. e ifltrate s comosedof nmeros eosophis erophils ymocyes ad
istiocyes. A promient grenz zone s caraceriscalypreset ekocyocastc vascl s is frequety observed
COURSE
Te lesions of GF are usaly croic ad only occasoaly resolve sontaeosly
Fgre 3 Granuloma faciale on the scalp
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MANAGEMEN
Dicl to reat wi any modaiy Any successul teat
ment often leaves scar ing
• Topica Teaet
Corticoserods topica ntralesional
acro l mus o ntme (0 1 %)
• Systec Teaet
Dasone
Ant malar a ls
Coc c e
Cofazimine
Gold n ect ions
SU RGCAL REATMENT
Cryosrgey: mt iple eports indcatig successl
c earance Resuts are n predictab le ( F g 3 2)
Sgica ecison
Dermabasio
Electrosurgery
• igh Teae
opca psorae and ltravioe A (PUVA) radatonteray
Laser e ray d ierent ase rs ave been sed in e
treatment o GF wit romsing rests eter as an
ab laive terapy wt carbo doide aser or as a seec
tive teray tagetng te prominet vasclature i GF
esions sing te Qswitced argon laser pulsed dye
dode laser and otassm ttany pospate (KP)532nm laser (F ig 31 3)
P FALLS TO AVO D
GF s oen recalcitan to eray Patents sold beconseled tat successful teatment is often elusive
BBLOGRAPHY
Am m rati C rza G reament of grau oma aciae
wit te 585nm pulsed dye laser Dema.1999; 35 (8) 903-905
Apelbeg D Dker D Maser MR Las H Spence
Denea D Granoma aciae reamen wit eargo ase Dema. 1983119(7) 573-576
Section 6: Vascula r A lerat ions 75
A
BFgure 3 2 () utipe esions of ganuoma faciae on the face (8) Nosignificant impvement detected ae one teatment with cotheapy ona 4month foowup visit
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176 Color Atlas of Cosmetic Dermatology
Catrat V Rorer TE Grauoma facale successfuly
treated wt longused tunable dye aser DermalSrg. 200228(6)527529.
Eson Teament of grauloma facae wt te
pused dye laser is 200065(2)97-98
Ka ed A oes Zerma R et a l Grau loma fac ia le
algia. 200799(5)306-308.
ail lard Grogard C Toedano C a V acet Vai la Grauloma facae: Eicacy of cryosurgery
2 cases Ann Dermal Venerel 200027)77-79.
omson N Ser ing JC Sa lvay I . Grau loma fac a etreated successfully wit opical tacro mus li Dermal. 200934(3)424425
Weead RG Asley R Smit A E is WeeandN Carbo d ioide aser treatmet o granu loma fac a le
J Dermal Srg Onl 19840(9) 730-733. A
BFigure 33 (A) Indurated brwnishred laque on the le cheek of amiddleaged female with granuloma facia/e (B) Twoyear followu showing resolution of granuloma faciale after multile ulsed dye laser treat
ments
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Section 6: Vascul ar Aleration s 77
CHAPTER 32 Inante emangoma
Infani le emangoma ( aso kow as srawbery
cail ay or cavernos hemangioma is a benign
endoeia rolieraon ha epreses e mos common mor in inacy. I can be classfied no serfic a l
hemagioma (S 55% o cases) dee hemangioma(D 30% o cases) ad mixed se c a l and dee
hemagioma ( M 15% o cases) . hey occur m os commony on ead ad neck areas .
EPDEMOLOGY
i % o 3% are rese at brh 0% o 12%
are rese by yea o age
Ag majoriy (80%) become aaren bewee 2 and
5 weeks o age 2 0% a re noed a birhSx emaes ae aected wo o fo mes more hanmales
ripiig faors remaure nans are more com
mon ly aeced
PHYSCA EXAMNATON
The aearance deends on th e deh of he heman
goma ad he ase o evoion S eses as brgh
redcolored aqe D resens as a so derma or sub
caeos nodule wi a bishrle coo M shows
eares o boh S and D Mu ile ruca hemangomas may be observed Involtng hemagiomas
demosrae a flatte sface with a grayishre heha begins cenra ly and exads oward. he heman
gomas migh become uceaed and emorhagc
Residu a fay issue arohy eangectasia scar omaon and hyerohy may be observed
D FFERENA DAGNOSES
Congenal hemangomas can be confsed wi a vascu
la mafomaion sch as owne san a bh.emangiomas are geneay prese aer br vesus
vasclar malormaions whch ae geeray preset abrh.
LABORATORY TESTS
• Demaopahoogy
Po iferaons o m endohea l ce s ha may exendrom he serfca l dems o he dee sbcaneous
ssue deendi ng on he hemangioma su bye
A
BFgure 32 () Le upper eyelid hemangioma in its early gwth phase
a lesion that may threaten the ch ild vision (B) Marked lightening andattening of the hemangioma aer multiple pulsed dye laser treatments
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ig-opt cardac fa lre); (b) large acial emagiomas
a sally vote wit permaent dsfgring; (c) cerated emagomas; ad (d) emangomas e daper
area at are very i kely to ce rate causi g severe pai
edic a treament
Serods ncluding opica sterod applcaion (class 1
corcoseroid applied twce da y wit montorigevery 2 weeks) iralesional seroids (r iamciooneaceoide 10 mgm administered monly) ad oral
seroids (52 mg/kg/d o prednsoe) are e mainsay of treatment Patents m ust be mon tored cosey
especay wit oral serod se give te rsk o sys
emc comp ications c di ng grow reardato andgcose alterations ocaized sde effecs incde
aropy ad yeas ifeco
Oer treamet opt ons nc de topica mq imod
Section 6: Vascula r A lerat ions
(appl ied da ly) inteeron (3 mi l l on uits/m /d ASC) and v icris ine ( 005 mg/kg/d if less ta 0 kg
IV) especia y in steroid-resstant As iterfero-is associaed wi spastic diplega patiens ms be
moniored cosey
Propranool a a dose of 2 mg/kg/d as bee recently
reported o be very effecive n reating severe I s eve
in seroidresistat Is Tis treatmen s proposed torepace ora or nraveos sterods ta are associated
w signfica side eecs owever paiens on propraoo sold be cosey motored or bradycarda
ypoension a d ypogycemia especal y a e onse
of e treatment
Laser treatme
Plsed dye laser (PD treamen iduces signficanly aser regresson of te Fences ower
tan tose o PWS are effective ad are assocatedw ower r sk of laserindced scarr ig (Fgs 321
322 a d 323) P D L as bee sed eens ivey ine reame of I in tree c l in ica scenar os :
1 Uceraed emagomas respond eecively o
PD PD markedly decreases te associated
pai ad idces rapd ealg o e lcerato(75% witn 2 weeks) (Fg 324) Residal scar
ormation from te ceratio is epeced
2 Ss ca respond well o PDL f stared eier
before or eary n te proleraive paseiple reames every 4 to 6 weeks are
reqired in te proliferative pase e ony
ecepon s a rapi dy prol iferang faca e ma goma PD treamet may idce lceration of
tese varans so treatmen sould be avodedI wit deeper compones (M D respond
less effecvely to PD becase o te lmtaion
of penetraton o PDL o 12 mm n te ski n
3 PD can e p rea e res idua l erema and
telagiectasas on te srface of ivoluted
emagiomas
BFigure {A) egmental hemangioma involving the hand of a 1 yearold girl {B) Complete resolution of the hemangioma afer four treatmentswith 55nm pulsed dye laser at low fluences
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1 80 Color Atlas of Cosmetic Dermatology
Log-plsed Nd:YAG asers ae sef or potocoag
atio o DHs bt ave a ger cdece of scarrg
Oter tervetios icde srgica debkg ad
embolizaio. Te risks ad beets of eac srgcal
approach sold cosidered carely before iteetio sice te scar rom spotaeos regresso s sualy
beter ta te sgica scar Embolizatio is tiized nhemagiomas associated wt gotpt cardiac fail re
PTFALLS TO AVOD
Use of ecessve P fle ces withou ski cool g ca
ca se scar
Paes are desadaby aous abot ter ci ld's
emagioma. A fl l d iscsson o te atral course of
emagiomas is madatory prior o start ig herapy
Te opio of foregog treamet ad cl ica ly mo
tor g a patiet sold be revewed careflly pr or to
sta g reatme
Pares sod aso ave a realist ic dea of te mta
tons o erapy arge emagomas respod less sccesslly to ora srgcal ad lase terapy
Complicated emagiomas at may iterfere wi te
c ld's healt sod be referred to a appropiaepediatrc specialis Parets mst be awae ta teat
met wil provide a im provemet bt may ot eslt
l reso lt o of t e emagoma.
Paes need to be edcated o prope wod care
especial ly or lcerated emagiomas order omprove te chids quality o lfe.
ibrofaty cages ae oe a seqea of esolved
hemagiomas Sc chages ca be mproved
sig catly wt noabave ad ablat ve actona
resracig
BBLOGRAPHY
Batta K, Goodyear HM Moss C Wi l ams HC i e
Waers R Radomised cotrol led sudy o eary psed
dye laser reatme o co mp icaed ci ld ood aema gomas Results of a 1year aalysis. ae 2002
360(9332):521527.
Lat-abrze C Dmas de Ia Roqe E Hubche
Boraevi am bo B Ta·eb A. Proprao o for sevee
emangomas o iacy N g J Med 20083582649
2651
L YC McCa E Rowe NA Mar PA W lcsek GA
Mati Sccess reatmet of ifati le aemagomas o te orb it wi propraolo l . li peimepalmol 201038(6)54-559.
Moe i G a O Yo J Westo WL Treatmet ofcerated emagomas facy. A edia Ado/esMed 1994148(0) 04-05.
A
B
cFigure 32 () Ulceated hemangioma, isolated nodula type, extemelypainful and hemohaging, teated twice with pulsed dye lase 6 m,mm spot sie, 50 nm (B) At months ' followup significant healingof the ulceation ae a single teatment with pulsed dye lase (C) Foumonths ate initial pulsed dye lase teatment and months afte
second pulsed dye lase teatment, thee is complete healing of theulceation
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Section 6: Vascul ar Aleration s 8
CHAPTER 33 Keatoss ars Atrophcans
Keratoss p lar i s atrop icas ( KPA) s a grop of n erted
disorders wit tree sbtypes cludg (a) keratoss
p lar is aropcas facie (KPA) (b) atropoderma vermiclatm (AV) ad (c) keratos s o ic ar s spnlosa
decavas (KSD) KPA and AV preset many on teace wit KSD oen appearig on te eyebrow ad AV
mos commoy see o te ceeks sparig e eyebrows ad scap KSD can aect te ace scap ad
trk Iner tace patte can be atosoma domiant( KPAF AV) recessve (AV) or i ked ( KSD)
EPDEMOLOGY
id very are KPA is te most commo sbtype
Ag KPA and K SD ifacy AV c i doodSx males a re more severely aected in KSD
PAHOGENESS
Aborma fol l clar keratization of te pper secio of
te air fo l c le tat may ater eslt i aropic fol l clar
scarr ig
PHYSCAL EXAMNAON
o iclar pgging wt eyema early stages( gre 331) Atropic fo icu ar scar ormat ion wtassociated aopecia i aer stages
D FFERENAL DAGNOSS
Keratoss pi ar s keratosis p ar is rbra seborreic der
mati s (KPAF) atopic dermatt is (KFSD) oter etiologesof scarr g aopecia (KFSD) ace scar ng (AV) Rombo
syndrome (AV) and K D sydrome (KFSD)
DERMAOPAHOLOGYDilated fo l ic les wit fo l car yperkeratosis ad iam
mat ion i e ar ly sages o ic a r bros is ad atropy n
later stages
COURSE
Te corse s cron ic wit o spotaeos resolt on
Wit t me te erytemaous fo l l ic ar yperkeratot c
papu les voute into depressed atrop c fo ic l ar scarswit a lopeca
Fgue 33 Kratosis pilaris fin sandpaprlik follicular papuls onth arm of a young man
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1 82 Color Atlas of Cosmetic Dermatology
MANAGEMEN
Thee s no cometely effective teatment for KPA
t ie treatmet otions have bee t ied wth oly varab le success Patiets shold be conseled that theay
may ot be effective
Topical theapy may at best prodce modest beefit Lactc acd ad ydoy acid lot ions (0% 2% )
aled twce da ly may mrove the texra rog
ess oweve tey may rodce rtation
Ret ino ds (tazarotene ret inA) ap ed n ight y may
mpove texta rougness Tey may podce r i
tat io
Cortcosteoids a l ied sa gly ma y show mp ove
ment Rsk of facal atrohy l m its the se A Systemi c te ray
Oter otions that ave rovded vaable sccess
nc ude ora et io ids ad da psone
They are most hel for te inflammatoy stage of
KPA bt ovde minima movemet in te ol icu
a yekeratoss
They eqre caref motoring o potential side
eects
Lase theay
Plsed dye aser (595 m 7-mm sot 710 /cmDCD 40/20 pse datio o 53 ms) ca be
eective in th e teatmet o te assocated erythem a
of KPAF bt wi l not sigicaty im rove te textarogness o KPA ( ig 332A, )
Lase-assisted ai remova wit og-lsed noQ-swtched by ase may be a effective treatmentn patents wit KFSD
P FALLS O AVO D
Patet exectatos ae genealy very high hey mustbe conseed as to te conc natre o te codt ion
ad mimal esose to ava able therapes
BBLOGRAPHY
ade HP yers R Clca idngs cutaneous patology and response to te ay n 2 atets wt keatoss
p la is atroicans Ar Dra. 1994 30(4) :469
475
Chi CT erge TG Prce V Zacary C Recalcitrant
scag ol cul ar d isodes treated by ase-asssted hai remova: A prelmnary eor Dra Srg. 999;
25( ) :34-37
Clak S i s C aiga SW Treatmet o keatossp la is atophicas wit te sed tnable dye ase Ja asr r. 20002(3) 5-56
BFgure 33 2 () Kratosis piaris atphicans Patint is otionaly both
rd by prsistn t rythma (8) Markd ightning of thma yarsfoowing thr pusd dy lasr tratnts
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Kane , Haas E Emme S Scn P Ztt
Successfl treatment of severe keratoss p i ars r bra wta 595- pulsed dye aser Dermaol Surg 200935
15921595
arqel ing AL Gi l am AE Prendiv le et a Keratos spi lar is rubra A common bt ud errecognized codt ion
Arch Dermaol 2006142 12 16 1 1- 161 6
Ricard G, Hart W. Keratos is o l icu ar s spnlosadecavans erapy wt sotretnoi and etretinate in te
inflammatory stage. Haur 1993448 529-534
CHAPTER 34 Pot-wne Stans
Powie stans (PWS) are owfow capi lary maforma
tons. Tey represet te most common type of vascu ar
malformatios. Any area of te body can b e affected
However te ead and neck areas are most commoyaffected
EPDEMOLOGY
Incidence 3 per 1000 newborns
Age present at brt n te majorty of patets rarely
appear i n adolescence or ad ltood
Sex no se pred ectionRace ess common As ians and Afr ca Amer cans
Associaed syndmes PWS can be a manfestaton ofseveral syndromes icudig SturgeWeber syndrome
K ippe lrenanay syndrome, Protes syndrome andpakomatosis pig mentovasc lars
PHYSCAL EXAMNATON
PWS presents at birt as l gt pk, welldemarcated
macuar esios and patces sualy n a segmental ds
tr ibto. Tey can transform wit age into ypertropc
dark red ad/or purprc paqes wt noduar ity. PWS
involves te face most commony aong te tr igemina
nerve distr bton: optalmic branc 1 (upper eyel d
and foreead) ma l la branc 2 (upper l p ceeklower eye id) and m andi bu ar branc 3
D FFERENTAL DAGNOSS
PWS ebts caracterist ic cl n cal features and s sel
dom misdiagosed It can be confsed wt te macuar
stage o emangioma at b .
Section 6: Vascul ar Aleration s 83
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1 84 Color Atlas of Cosmetic Dermatology
DERMAOPATHOLOGY
t ip e d i ated t n-wal ed vesses n te ap l lary and
ret car dermis
ANCLLARY ESS
Te parents sod be conseed regardng te ossi
bi l ty o StrgeWeber syndome (SWS) n lesions
ocated n a facia Vl or V2 dematoma distr btionSWS is caracterized by te presence o facial PWS
wit si latera oclar and eptomeingea aomalesTen to fifeen percent of patients wit PWS n te Vldistr btion wi ave SWS Patents wit b atea PWS
ave even a ige risk of SWS An optamoogiceaminaton to le out gacoma ad cataract oma
ton wit contined ollowup s ecessay fo tesepatents A ead compted tomograpy (CT) o mag Aet c resonace magng (RI) sold be obta ned to
rue ot bran invovement tat cold aect mentadeveopment and eslt n se izres
PWS oveying te spie can be associated wit s nalanomay sc as spina dysrap sm or tetered spa
cod Neuroogc evaato and approriate imagg
stdies are recomme nded
Large etremity PWS sod raise te consdeaton of
KippeTrenaay syndrome caracterzed by capilaveos ma lormations or cap laymaticvenos mal
ormato ns w t ytrop y of te affected eremty eg
gi and legt sod be meased ad foowed overtime
COURSE
PWS grows propooaly wit te patet and gada y
tickens and darkes in colo rom pnk to dark ed to
dee ppe Eleven percent may deveop noda ty and24% may develop pyogenc granomas PWS may be
associated wit ypertopy of n deryg soft t sse a d
bone part iclar ly i SturgeWeber syndome andKippeTenaay syndrome
KEY CONSULTAVE QUESTONS
Onset of esion
Assocated cl iical fndgs
s te c d meetng deveopm eta m iestones?
Has te cd ad an eye eamiatio?
Has te c d ad a ead R I o CT?
Past teatments ad response
eedng
ebs
Growt of PWS
B
cFgure 3 (A) PW on the right inner thigh of an infant gir(B) ignificant lightening of the PW aer a single P treatment(C) Complete resolution of the PW aer P treatments
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MANAGEMEN
PWS demostrates progressve vascar d latato ad
yperopy wt age s makg treatmet drigeary ifacy essetal fo a better respose Treame
ca be staed as ear y as 2 week s of age. Treatmet p ro
vdes a edctio i te um ber of vessels ad does otcom petey remove te etire lesio . ereore t e PWS
may eib t some dakeg ad ickeig ove t imedespite nteveo Genera aestesa migt be
eeded for rea g lage PWS in c i ldren .
Laser treatmet (gs 34.134.5) .
Plsed dye aser (P) remais te gold stadard for
te treamet of PWS. Effectve P parametes icde
waveegts o 585 to 600 m fle nces of 6 to 1 5 /cm,
Section 6: Vascul ar Aleration s 85
pse dratios of 0.45 or 1.5 ms wt coge spay Acooli g ( CSC) our to tweve laser sessios wit 4to8week itevals are usaly eqired i order to acieve
sgifca t bla ci g o te PWS. Lowe fleces are ii-
taly utlized for PWS of te face ad i darker ski
types. e se o s cocomitatly dig PL teat-
met sgificay decreases te pai associated wi eprocedure ad e cidece of bl serg s protects
te epiderms ad a ows for delivery of iger fleces
result g more eective bacig of e PWS. P
treatmet s fo lowed by temporay p rp ra tat usa ly
resolves n 7 to 14 days. Complete lgteig of PWS wtP treatmet is acieved i ess ta 20% of PWS.
Resistace to PL teatmet s more feqetly
encotered deeper ad yperropic PWS. elplmaeuvers to potetiate e efficacy o P incde
i ceasg t e flue ces wt ad equate cryoge cool g toprotec te epidermis ad creasig te waveegt p
to 600 m to arget deepe vessels. A pilo stdy demon
staed tat PWS ta are treated wt topcal imiimonce daiy fo 1 mot afer PL eposre maiest
speror bacig respose over t ime as compared toP aloe . Aoter report i vestgated te com bined se
of P ad a topica agiogeesis bor raamyisg te vvo odet widow camber model. ere
was o reformatio a nd reperfsio o blood vessels aer
treatment wt PL folowed by topcal rapamycn for14 days cotras o P alo ne Wt ereme cauio
to avod scarr g ad dyspigmetao t s possbe otreat PL-resstat PWS ad deeper or ypeopc
ad l P WS sccess y wi l oger wavelegt lasers tat
a low deeper peetatio io te ski suc as og-psed aleadrie (755 m) laser ong-pulsed NdYAG
( 1 064 m) aser ad dua l 595-m P ad 1 064-mNd YAG ase coped wit adeqate coo i g Use o te
NdYAG aser can be reacerous as tere is a arrow
terapeutc rage Ri sk of scar ca be sgifcat.
Lgt treatmet i tese p sed l igt ( I P) may be effec
tive reatmet of PWS incdig PL-resisat PWS.
A gree-yeow wavebad ad lowest ava lable pse
BFigure (A) tensive ort-wine stain on the right face and foreheadof an infant male (8) ignificant resolution aer m ultile treatmentswith ulsed dye laser
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1 86 Color Atlas of Cosmetic Dermatology
drato shold be sed wi skin cooling A recet
randomized c l i ica tr a compar ng PL and IPL s deby side reveaed a better efcacy ad hgher paet
preferece afer PL treatmet Potodyamc herapy
may aso prove to be a alterative eficacios reat
ment or PWS
Other treatment modaties for PWS that can be efectve icl de tattooing and cosmetic make p
PTFALLS TO AVOD
Patients sold be coseled that PWS dsplay a vari
abe respose o treatmet More extesive and thcker
esons respod ess well wen com pared to sperfic a l
esons acia PWS respods best PW S treamet effi- Acacy decreases as oe d esceds from face to fee wth
the ower etremiies dispayg he eas treatment
beefit
Mt ipe treatmet sessions may be reqired ruisings a necessary sde efect o obta n eicac ous t erapy
Laser treatment may prodce footprntig" or oy par
t a mprovemet
reamets sould be ceased when the paient is sais
ed with ghteng or we no ther benefit has
been noted tha is afer two sbseqent treatmets
BBLOGRAPHY
Alster S anzi E Combied 595-m and 064-nm
laser irradiatio of recactrant and ypertropic portwine sa ns ch i ldre ad adts Deral Srg.2009;35(5) 813815.
Chang CJ s iao YC Mi m M C r N elso JS P i ot stdyexam n i g the combi ned se o plsed dye laser ad op-
ical lmqimod verss laser alone for treatmet o po
wine stai brhmarks asers Srg Me. 200840(9)
60560.
Chapas AM Eickhors K Geroems RG Efcacy of
eary treatment of facal po wne stas i newbors A
revew o 49 cases asers Srg Me 200739(7) 563568.
Ch C Ca o WS Yeg CK Ne lso SProspective sudy of p sed dye aser i conj ction withcryogen spray coolg for treatment o pot wne stas in
Chese patients Deral Srg 2003;29(9) 90995.
Discsso 95.
arscho A ogsverd-o K Zachariae C Haedersdal
M P sed dye aser vs iense pulsed l igt for port-wine
stais: A randomized sidebysde tr ia l wt bl indedrespose evalatio r Deral. 200960(2) 359
BFigure 33 () tensive portwine stain on the right neck of a young
feale (B) Marked resolution of the port-ine stain aer ultiple treat-ents with pulsed dye laser
�. Figure 3 () Portine stain on the lower ucosal and cutaneous lip
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Ho WS, Yng SY Can PC, Ca HH. Treament of port
wine stans wt ntense psed g A prospective sudy.
Derma Srg. .
Hkesoven , Koser P, de oge CA eek F, van
Geert van der Horst C Redarkenig o port-winestans years after lseddyea ser treame N g J
e.L Kono T Goff WF Can H, Kazawa Y, ozak Com parison sdy o a ong-p lse p sed dye aser and a
longpse psed aleadrte laser n te reatmet oport wine sains. J sme ser Ter. .
Png TL , Ob e DA a W, enamin E im C r Neso S Can te wond heang response o uman
sk in e mod aed aer laser treament and t e eecs oeposre eended? I mp icaons on e combi ned use o
te psed dye laser and a opcal agogenesis nhibior
or teament o po wne stain tmarks asers Srg
e. Se m , Ke ly K e son S, Wendelscaer-Crabb G
Kennedy WR, Zeckson D. Cooca microscoy sdy
of nerves and bood vesses n reated and treaed
portwne sains Prelmna obseatos. Derma Srg.
Yang , Yarosavsky A Farie i et al Longpsed
neodymim Yttr iuma mnumgane laser treamentor portwne stains J Am Aca Derma. .
Section 6: Vascular Alerations 87
BFigue 3 (Continue (B) igniicant ightening o powine stain aer
three treatments with a combination o pused dye aser to the cutaneous ipand vermiion and ongpuse 1 064nm Nd YAG aser to the innermucosa/ ip and vermiion
Figure 3 Hypopigmentation, which can be permanent, aer aressive treatment o a PWS in an AricanAmerican patient
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1 88 Color Atlas of Cosmetic Dermatology
CHAPTER 3 5 yogenc Granuoma
Pyogenic gra loma ( PG) can be regaded a s a begn
vasc a tmo r or as a eact ve vascula pocess ar is g
at stes of pevos trama or r itat on. PG is aso kowas ob a r cap i l la y hemang oma gan oma te lag
iectat cum and gra lom a grav dam when present ing
on te gingiva of pregnant wome. t commonly occrs
in areas of trau ma inc ld ing the ace and iges
EPDEMOLOGY
iee: common
Ae: most common ch i de and yong ad ts
Preiii ars m o tama p regnancy lase treat
met o otwne stai ns sotretn on
PAHOGENESS
Reactve neovascuarizatio sggested by commo asso
cato wit peexistig trama or i itat on and mted
growth caacty.
PHYSCAL EXAMNAON
Red to voaceos domesaped f able pale o
node 0.5 to 15 m i sze wth smoot sace tatfreqent ly u lceates (F igs . 35 352 ad 35.3 )
DFFERENAL DAGNOSES
Nodua amelaot c melanoma g loms tmo eman
goma sqamos ce l carc inoma (SCC) (F ig 354)nodar basa cel cacinoma wart bac lary angiomato
ss aposi's sarcoma and metastatc cacer
DERMAOPAHOLOGY
Wellci cumscibed exophytc lo bl a prol eato of cap
i l ar es wit flatteed and sometmes eroded oveyigepidermis with per iphea l epiderma co l larettes ."
COURSE
PG sualy grows rapdy over te cose o weeks or
monts ad the stab l zes It b eeds freqety wit
mi nor tra ma and ca persist nd efntely i not treated.
Fgre 3 Classic hemorrhaic pyoenic ran uloma
Fige 3 2 Pyoenic ranu loma on the palm of a prenant womanleein frequently
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MANAGEMEN
Laser treatmet
Pulsed dye aser (58600 m 04 5 s 70 m
5 /cm, C 20/20 wt or wtou diascopy) isa safe ad efecive device for te treatmen of small
esos ad for pedatrc patens Sera reatets aresally requred Treatme s wel tolerated wtot
anestesia A recet repor sggested save ecson
oowed by immediate pulse dye laser (PL for largeresos P as been a lso repoted to be effective i
ggva PG NdYAG laser ca also eectve
Carbo doide s efectve esioal faeing s e
c i ca l edpont tra es ioa l l idoca ne % is eces
sary pror o reatme Postoperave care requrestwce da ly cleasig wit soap ad water and appli
catio o atbi oic ointmet over a 2 to 6 weeks ealig t ime Scar ormaton s l kely A ow recurrece
rate is noted
Surgica reame: all reatmes may res i scar for
ma io
Save ecison fo owed by eectrodessicato of te
base is te procedre most commony empoyedRecrrence s commo ( igs 35 5 ad 356)
El ipt ical ecso ca be performed wt low recur
rence bt wil leave a scar
Lgatio of te base
Cryosrge
Aterave reame optos n c ude
lmiqumod 5% cream as bee recety repoted tobe efective i edatric patets ad i paties wt
recrret PG
lntralesoal injecto of absote etao
Scleroterapy wt mooeaolam e ol eate
Topica a tretoi (9 retno c cid ) gel a drug at
is sed for te treatment of Kaos 's sarc oma
P FALLS O AVO D
Paets sould be aware at recrrece s commo
ater reatme
Paets sold be iformed tat al l reamets may
resu scarr g
Amelaoc meanoma as well as SCC ad oter sk ca
cers ca mimic PG A bopsy soud be performed forany sspic ous esos i te app roprae cln ical seig
BBLOGRAPHY
Borggon R, Paqet P P rardracimot C,Pirard GE reamet of pyogeic graulomas wt e
NdYAG laser J Draolog ra. 20067(4)247249
Section 6: Vascul ar Aleration s 89
Figure 3 3 Pyogenic granuloa overlying a deral nevus
Figure 3 Pyogenic granuloa iicking a squaous cell carcinoaon the le lower ucosa/ lip of a patient with ultiple non elanoaskin cancers
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1 90 Color Atlas of Cosmetic Dermatology
al a iscer G Zagare a S Pyogenc gran oma n
c i dren: Treatment wt to ica imiqmod Asralas Jrmaol 200748(4)27220
Kand S, Sama VK Sccessf treament of mlt i
e gingiva yogenc granomas wi lsed-dye aser
ia J rmaol rl / 200874(3)275277
aloney Scmdt vic Al ite ino n ge l totreat yogenc granoma J Am Aca rmaol. 200247(6):969-970
atsmoto Nakanis i Se ke T Ko zm Y Mi hara K
Kbo Y Treatment o yogenc granloma wt a sclerosing aget rmaol Sr 20027(6) 521523
Ra in C Greve ammes S Te combined continoswave( sed ca rbon d oide laser for treatmet o yo
genic gran oma Arc rmaol. 2002;138() :3337
Sd AR Tan ST Pyogenc granloma comcatingsed-dye aser teray for cerry angoma J las
Rcosr As Sr 201063(8)364368
A
BFgu 3 (A) having a hemorrhagic and ainful yogenic granulomaon the lantar foot with # 1 5 blade he secimen was sent for histological
confirmation (B) Electdessication of the residual yogenic granuloma
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Section 6: Vascul ar Aleration s 9
A
BFigue 3 (A) Biopsyprven pyogenic granuloma on the right chin of ayoung female (8) have excision of pyogenic granuloma with ermaBlade Personna edical, Verona, VA
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1 92 Color Atlas of Cosmetic Dermatology
CHAPTER 36 Faca Te a ngectasas
acia telangiectasias are d lated vesses appearing
sperf c a y n te derms most ly o te a lae as i
Teangectasias are aso common scars and variosskin les ions
EP E M OLOGY
iee: very commo
Ae most common n adts ad elderly peope
Sex re no se or race predsposit ion
Precipiat ng factors cronic actinic damage rosacea,
and topcal steroid se are te most commo precipitat
ing factors Oter ess common etooges ic d e ered
tary emorragic telengiectasa, Cockayne syndrome, Aataia telegiecasa, loom's syndrome, Rotmnd
Tomson sydrome scleroderma, CREST syndrome,l ps, and rad aton dermat tis
PHYSCAL EXAMNATON
Tea ngiectasas consis of fin e, t i ny erytematos l i ear
vessels typca l ly 02 o 2 mm in d iameter cors ing
a ong te sace of te skin , wic b anc eas i ly ponpressre
DERMAOPATHOLOGY
Dilated, ti-wa ed vessels in e pper dermis
COURSE
acia telangiectasias are sua y cronic n atre wit
no sponaneos resoluion
MANAGEMENT
acia telangiectasas are reqenly treated for cosmetic
pr poses. t ipl e eective treament optons eist
Laser treatmet: mlt pe eective options are availabe Patients ms be aware tat over t ime tey are
kely to deveop more tela ngiectasas
Plsed dye asers (PD are te treament o coceor facia telangectasias ( igs 36 136 . 5) .
Te radtioal PD wit a sort plse dration o
0.45 or .5 ms provides te mos eecive treametor facial eangiecasias owever posttreatmet
pr pra occ rs wc generaly asts 7 o 4 days
B
cFigure 3 () Middleged mle wih muliple fil elngiesis(B) Purpur observed immediely er pu lsed dye lser remen(C) ignifin reduion in elngiesis er singlepulsed dyelser remen
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Newer geeratio 595-nm PD (ie V-beam or
V-beam Pefecta asers Candea Corp, Wayad,A w va iab e p lse d a ions (045 5, 3, 6
0, 20, 30, 40 ms can provde a redced prpratreatmen of facal telangiectasas wen onger
pse duraions are ti zed, bt is somewa ess
effecve ad sa y requ ires m l pl e reamens Commoly, spurpurc feces o ess tan 0
/cm at pse dra on of 0 ms w a 7-mm
spo size ae ti l zed
Beer eicacy of e variable pse PD n tea
ing faca teangecasias can be aceved by ti
iz ing p urp rc fluences or y pse stack ng wisbpurpuric plses (stacked 2 sbppric
Section 6: Vascula r A lerat ions 93
plses at a 5Hz repett on rae, 75 /cm, A0ms pse dratio 0mm spot size DCD of
30/20 or by peormng mlt pe passes dring
te same sessio
Large cke inear vesses ca be treaed wte ewest generaon 595-m ong-PL (V-beamPefecta Candea Corp, Wayland A sng a
3 x 0 mm eiptical spot size 40ms pse dra
t ion , 5 to 7 /cm, and DCD 30 to 40/20 Teendpoi is transient blis darkening of te
vessel followed by vessel blancig (Figs 364
and 365 is treatment may res in m ld
prpra in arond 23% of paiens
Facia edema, eryema, and dscomot ca occurae exensive teament wi e p rp ra-ree vari
able-pse PDL oweve, tese ndesed eects
are generally better tolerated wen compared o aprpra-ndcng laser teamet
Te varable pse wd ,064nm Nd:YAG laser as
proven o be eecive in e reament of acalteagectasias Sorer pulse wids wit iger fl
ences mig be necessary for eective reament ofsmale vesses bt ave an increased sk o bster
and scar formatio Te seqenal delivery of 595-
and ,064-nm wavelengt as been repoed to bemore effectve a a sg le waveeng treament
Freqecydoubed 532nm NdYAG laser asocalled potassimtanyl-pospate (KP aser pro
vdes effective absorption of emoglobin wit a psedratio of 1 to 50 ms makng i idealy sied to treas perfic a l vesses wiot pr pra fomaion acn g
of id vda l vesses is a sefl eci qe for paientswt a counabl e n m ber of discree, vis i ble vessels
Flas amp ( i nense plsed g [ IP L eatmen
IPL povides aoe effective, purpura-free meod
or redcg acial eangiecasias and erytema
( Fig 36 6 For examp le, f leces of 30 o 40 /cm
w 20-ms pse dratio ae effective wi e StarlxLx G adpece (Paomar edical Tecnologies
B
cFgure 3 2 () Telangiectasias prior to pulsed dye laser treatment Thesetting was 1 0-mm spot 55 nm J!m 6-ms pulse duration
(B) Immediately posttreatment (C) Ten days afer pulsed dye lasertreatment
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1 94 Color Atlas of Cosmetic Dermatology
Blgo, A T tratmt dpoit is immdia
vss caac or sctiv vssl dark g ltip tams may b rqrd for t grast tatm
bit
Otr tratmt optios icd ctrosrgy,
cryohrapy, ad lrato of scrosg agts Ts
ar ss slctiv of ss fctv, a d mor i ky orst scarr g tha lasr or P L tratm
PTFALLS TO AVOD
Tatmt ypcaly is wl oad
Obvios postatmt ppa or 7 to 4 days wit
prprc sgs is pctd
Prpra ca b avoidd by i z g oprpric st
tgs a t ps o dcrasd ficacy
Facia dm a rytma, a d d scomort ca occr ar
tsiv tatmt wit t p r p afr vaiabl p lsP
Ta gctasias wi l cr ov yars
Catio i dakr ski typs
BBLOGRAPHY
Brst EF, igma A Rosaca tamt sig tw-gatio, hig-rgy, 595 m, log pls-dra
to pusd-dy asr asers Srg Me. 200840(4)233-
239.
A
rgs GF, Hdd Hadrsda ogpsd
Bdy lasr vrsus ts psd ligt or potodamagd
ski A radomizd spli-fac tr ia l wt bl idd rsposvaatio asers Srg Me. 200840(5)293-299.
Karsai S Roos S, Ral C Tratmt o facia lagic
tasia sig a dalwavlgt asr sysm (595 ad
064 m): A adomzd coro d r ia wit b l idd
rspos vaato Dermal Srg 200834(5) 702708.
Rohrr TE, Catrath V Iygar V. Dos ps sackig
impov t rss o tatmt with variablplspsddy asrs? Dermal Sr 200430(2 pt ) 63
67. Discsso 676
Ross EV, U bor N S Doma kvtz Y Us of a ov
ps dy lasr for apid sig-pass prpa- trat-
mt o tlagictass Dermal Srg. 2007 33( 2 )466469.
Sarradt D Hussa Goldbrg D l iscod
064nm odymimYAG lasr tatmt of facal
tagictass Dermal Srg. 200329( ) 5658.
cFigue (A) Female with centfacial telangiectasias an erythemaprior to pulse ye laser therap (B) Pulse ye laser treatme nt at awavelength of 55 nm, 1 -ms pulse uration Jm, -mm spot size
(C) Apppriate clinical enpoint of ethema an slight eema at sites oftreatment No purpura was prouce
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Section 6: Vascul ar Aleration s 95
A
B
cFigure Telangiectasias prior to long pulseduration pulsed dye lasertreatment The settings were 40ms pulse duration, mm spot, 55 nm,1!m (B) Note the transient vasoconstriction with almost completedisappearance of the telangiectasias immediately posttreatment(C) light decrease in diameter of the telangiectasias 1 month aer onetreatment
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1 96 Color Atlas of Cosmetic Dermatology
A
BFigue (A) Large caliber nasal telangiectasias on the nose prior tolong-pulse duration pulsed dye laser treatment (B) ecrease in the diameter of the telangiectasias aer six treatments ith PL using long pulse
duration of 40 ms mm spot sie, and uences up to 1 1 5 Jm
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Section 6: Vascul ar Aleration s
cFigure (Continued) {) Marked resolution of the telangiectasias aeran additional four PL treatments utilizing short pulse duration of 1 5ms, mm spot size and 1 Jm
Fgue 3 Intense pulsed treatment with tarlux Palomar Inc ,
urlington MA of facial telangiectasias he handpiece is in full contactwith the skin
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1 98 Color Atlas of Cosmetic Dermatology
CHAPTER 3 7 ower Extremty Teangectasas, Retcuar andVarcose Vens
Lower eemy eagecasias recula and varicose
veins deveop as a resu l of venos sysem mpai rmen
EPDEMOLOGY
Iiee: very common ad he icdece icreases
wh age Reicar vens can occr i p o 0% of chil
dren 10 o 1 2 years od Te i ncd ence of varicose veins
in e seve decade is 72% n women ad 43% i men
Age more common i n adu s and e der ly
Sex more common in wome
reiiig ars: amil a l predispos io regnancy
sac graviaional ressures, dyamc msclar forceshormonal i lences
PAHOPHYSOLOGY
Veos paology develops when venos reurn sim ared for ay easo
I ca develop rom venous obscion (hromboc or
nonomboic) o r from venos valvu a in compeence
PHYSCAL EXAMNATON
Lower eremiy elagiecasias are red o violaceos nco lor and p to 2 m m in d iameer R e cu lar ve ins arebe o buegreen color and up o 4 mm in diameter
Varicose ves are blue o ble-green n coor wt ad ameer greaer an 3 o 4 mm
LABORATORY DATA
• Dematopathoogy
Dilaed vascuar cannes in e dermis
• Vasc l a Stu esDopper lrasond and/or duple scannig are idcaedin e fol owing c in cal scearios
Asympomac varicosy greaer an 4 mm in diameer
Sympomaic ves
Reicua perforang and/or varicose veis
Sg ns of venous isffc ency or sasis c anges
Prior sory of deep ven r ombosis or hrombop eb s
Prio hisory of scleroeray wih recurences o badocome
A
BFigure 37 () clertherapy of spider veins The needle is bent at a45degree angle and the vessel is canalized (B) Immediate vesselblanch ing seen aer injecting the sclerosant agent
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MANAGEMEN
Sce otheapy (F gs 3 7 3 7 3 )
Sc erotherapy i s the reatme of c oice for ower egtelagiectasas ad retcu ar veins It sould be repeated
at 6 to 8 week ntervas Paiets may reqre two to s
scleroterapy sessions o acheve the geatest teatmetbeeft
Scl eosng agentsAn ideal sclerosg agen causes complete loca edotela desruction of he vesse wall wit secondary fboss
and men oblterato wit no systemc toicity
Sce rosi g agets are cassfied nto tree go ps depedig on te r mecasm of act o of id c ig endothel ia l
ijry These cde hypeosmotc agets, deegents,and cemical rr itants (Tables 37 ad 372) The most
com mo y used scerosant agets n the U ied States ae
hypertoic sa ine (S) ad sodim tetradecy sfate
(STS) Bot S ad STS are FDA approved and have owest c idence of a ergeic ity Sod m morhuate and pol
docaol a re also FDA ap proved
Scleotheapy technique fo teangectasas andetcu la ei ns
Fil l the sclerosant aget nto 3 cm disposable syri ges
wth d isposabe 30gage half i c eedles
Swab te ste to be teated with a coo to beer vis al
ize te vesses
Trea larger vessels first
Bed the neede at a 30degree angle to 45degree
ag e
Stetc te sk in overying the vessels be g reated
Isert the eedle sowly i the vesse wa Yo may se
the air bo s echni que by jectig ess ta 05 cm ofa in te vessel or the pctrefi l echnque re yig o
the feel assocated wth vessel wa peforato wheinectig Te em pty vei teci q e performed by ee
vaig the eg and gely kneadg the ven prior to
inectio a lows for thombus reductio and eed forsma le sc leosant vo mes Whe treat g et ic ar ad
varicose ves, asprate a smal am o of blood to con
f irm itravascular loca ion
ject the sclerosat very sowly to ensre sucet
contact of the scerosa wi e vessel e dothelia l wa l
ad to prevet disento ad rpure ec less tan
0 5 c m per i jeco at 3cm i ervals
Appy smal c irclar bad aids taped cotton balls orro ls a the injecto sites for com presson
Foam sc leotheapyA reatmet mod ifcato can be made o arger vesselsby vigorosly foam ng a a r-scerosat soto j st pr or
to injecton to ndce a soltion at displaces bood ad
remas fo an etended t m e te arget vessel witot
Section 6: Vascula r A lerat ions 99
A
B
igure 372 (A) pider veins, prir t treatment with sclertherap(B) arked reslutin f the spider veins aer sclertherapy treatment
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200 Color Atlas of Cosmetic Dermatology
being fl sed Teoretical ly, ower scerosant concentra
tions can be sed with a ower cidence o pigmentatioad mattg (Tables 372 ad 373) Te oamig deter
gent o eiter sotradecol or polidocanol is prepared by
ming e deergen wt ar (sa y 1:4 m ratio of
deterget o ar) i a b ack and fort moton us ing a tree
way sop ock t l a foamed emsion s creaed Thefoam sclerosant s injected in a manner similar to tat
wth oer sceroerapy tech q es
Postopeatve cae
Compresso ncreases te ecacy of sceroterapyand decreases te ncidence of yperpigmetation AElastc co m pression stocki gs ( 1560 mm g) arehigy recommeded immediaely folowing sceroter
apy and p to 2 to 3 weeks aer te procedre, espe-
cia ly posreatmet o arger ca iber vessels Fasio
hose ( 8 m m Hg) ad C ass I ose (2030 mm g)
are the mos commoy sed gradaed compresso
hose sed possclerotherapy o telagectasas andret cu lar veins
Encorage wak ng to avoid tromb oembo c d seases
Avod sn eposure to minimze posttreatmet yper
pigmentation
Comp licatons (Tabe 37 .3) B Postscleroterapy hyperpgmentatio (PSH): Te ici
dece of PS can be p to 30% dependig o te
tec q e sed t e sze of the treaed vesses, the type
of sclerosing agent and e sotion concentrationPosscerotherapy compressio decreases e inc
dece of PS . PS s cased by perivascular deposit on of emosider i rater than me a ad fol lows the
Figure 37.3 (A) Lowe leg telangiectasias a t asel ine (B) Maked esolution of the telangiectasias 1 m onth afte one scleotheapy teatment Note the development of slight telangiectatic matting supeio to the
teated aea
TLE 3 7. 1 • Scerosing Agents
Sclerosat class
Hype rosmotc agets
Detergens
Chemcal irr itants
Sc erosant types
Hypeonc sa ie ( 130%)Hypeonc sa ie (10%) detrose (25%) (Sclerode)
Sodi m tetradecy sfate (Soradeco, Trom boinject)
Pold ocano (Aethoysclero Aetosce rol, S ceroven)
Sodim morrae (Scleromate)
Ethanolamie oeatePoly iod de od ide (Var ig loban , Var g lob n Sc erod e)
Gycer i ( 72%) wi 8% chromum potass m a um ( Chrome)
TLE 37.2 • Recommended Scerosant Concentration
Sclerosant/recommededconcetratio eagectasas Ret icu ar ve s Varicose veins
Hypertonic sane 7234% 234% Not commoy sed
Sodi m tetradecy s fae 0 5% 035% 025% foam 053% 0 51% oam
ecaism
Dehydrato
S rface tenson ca nge
Corrosves
Dose mtation
60 m of 830%
sotion0 m of 3% so t on
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LE 3 7.3 • Compications o Sclerotherapy
Scerosa Aergeniciy Cram ng
Hyeonc sa l ie
Sodi um eradecyl s lfae + Anahyais
(rare < 001 %)
+
corse of e eaed site he igmenaon usaly
resoves 6 o 2 mons. I ca improve w the se
of inense u lsed ig ( P
Telangecta c maing (M ) The nc idence of M ca
be o 6% t cosiss of a nework of blsh ke fine
(<0.2 mm elangecaic vessels surroudng a revi
osy reaed area occrrng wihin days o monts
after scleroerapy They usaly resove wihin 3 o
2 monhs Pedisosg facors incde pregnacy
obesity hormoa eray and family story o elang
iecasas ca mrove w psed dye aser or PWays to avoid hs com p icao ncl ude
Lower njecon pressre
Lower sclerosa volume ( to 10 m er ijecion
se)
Lower scerosan concerato
L im ing b lachg ( o 2 m)
Skin ecrosis and ceraio: Necrosis ca occr sec
ondary o eravasaion of te sclerosing age no the
isse regardless of he eciqe used or e sce
rosa ype o miimize etravasaion the sgeon
soul d so he injecon wen econteri g Even sg resstance o necio
Beb formaon
Increased ai reorted by e patien
eravasaion is recogzed immediatey e srgeon
ca i njec ormal sal ne at e sie or aply 2% itrogycerin ase
Oer comp ca os nc lude pa i and cramig (com
mo) a l ergic react ons (rare) sef c a l hrombohleb is (u o %) and thromboembo ic reac ios
(very rare)
Lase a tese Pu se L ghtThea ies ( gs 3 7 . 4 a d 37 .5
Lasers ad IP L soces ca occasioally be sccessf i
th e reatment of lower eremiy telag ectasas a d reclar ves eseca ly wen coped wh longer plse
draio and cooling devices ey are considered sec
od -i ne reamen after sceroerapy Waveegs in erange of 500 o 100 nm are mos effecive wi sorer
wavelengs eg plsed dye ase (Pl otassm ianyl
osate (KTP) beig used for red sercial bood
Pa
A
+
+
yerpgmeato
+
+
Section 6: Vascul ar Aleration s 201
Teagiectatic mang
+
+
Skn necrosis
+
+
Fgure 37.4 (A) Marked erythema immediately aer pulsed dye lasertreatment to lower extremity spider veins
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202 Color Atlas of Cosmetic Dermatology
vessels ad longer wavelengts (eg 755-m Aeadrte
laser wi arod 60 ms pse drao 1064 NdYAGlaser) or buis deepe bood vessels ndcatons or
laser/I PL reames inc d e e fol lowig
Needle p obic paties
Vesses ressant o sc eroerapy
Vesses located beow e ankle
M
Propesty or PS or T M
• Abulaoy Ph lebecoy,Endovascu la echn ques , Sug ica lL ga io/S pp ng
M l pe treatmet optios eist for varicose vens ic d
ing am bulaor p lebecomy e ndovascular laser abaio
endovasca r radiofreqency ob ierato as wel as sgi
cal l gato and spping procedres. Amblato plebectomy ca be sed or arge varicoses. Edoveosocclso can be acieved wt radioreqency (RF or
laser sorces. Eter a laser fiber or a RF caeer is
in seted no te sapen os vei a or st beow te kneeLaser systems clde 810nm dode 940-m diode
980m diode and 1320nm dYAG asers esedevices spare te eed or genera aesesia ad
etended recovery t me associated wi vei strip pi g and
igation ere is ittle dowme wi patets esmignorm a acivites o te same day of te poced re
BBLOGRAPHY
Barre M A e B Ockeford A Goldma P.
icrofoam rasoud-gded sceroteapy o varicoseveis i 100 legs Demal Sr 200430(1) 6-12
Coerdge Smi P Scleoerapy and foam scleroterapy
for varicose ves lel 200924(6)260269.
Kae B Leg K. Eficacy of sceroteapy varicose
veisprospectve binded pacebocontoled sdy.Demal S 200430(5)723-728.
Ker P Ra meet AA Wtscet R ayoz D Comp resson
ae sceroterapy for telangiectasas ad reclar leg
veins A randomzed controled stdy Vas Srg2007;45(6) 1 212-121 6
Morrison Neuard D Foam sceoterapy Cardacand cerebral motorig lel 200924(6)252259
Ross EV Meea K Gi lbe S Doma kevitz Y. Opma l
pse duraons for te reatmen of eg eangecasiasw a aleadrite aser. ases Sr Med 200941(2)
104-109.
BFigure 37.4 (Continue (B) Mld educton n spder vens aer a snlepulsed dye laser teatment
Figure 375 ostnflammato changes afer laser le ven treatment
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CHAPTER 38 Venos akes
Veos la kes are begn vasc ar l esons a res rom
di laed ven les ey commo y aec e ps face and
ears
EPDEMOLOGY
iee common
Age mos commo ly observed i e el derly
reiiaig ars may be relaed o su eposre
PHYSCAL EM NATON
Ves ake rese as dark b ue o v o aceous e e
vaed so ad easiy compressible ale r le
D FFERENTAL DAGNOSES
Pyogenc graloma meaoma laial melai male aial es emagioma
DERMATOPATHOLOGY
Di aed h i-wa led vees n e superf c a dermis rombosis may be observed
EP LUM N ESCENCE M CROSCOPY
Ep mescence microscopy (EL) reveas eryema
os globes w o pigmeary etwork s elpful dierenia ig s vascar esion rom a melaocyic
leso
COURSE
ey sa ly perss for years and c a bleed aer ra ma
MANAGEMEN
Veos lakes are freqeny reaed or cosmec pur
poses ip e reame opions eis
Lgh reamen
Lasers (gs 38 38 3)
P sed dye aser (8 9 m 04 . ms 0
mm spo 70 J/cm DCD 3040/20 w ad
wiho diascopy) lse ye laser ies i
sise eei r es akes.
Section 6: Vascu la r Alerations 203
A
Bigure 3.1 (A) Venous like on the lower li of an elerly man(B) Marke resolution of the venous ake aer multile treatment sessions with the ulse ye laser
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204 Color Atlas of Cosmetic Dermatology
Diode laser (80010 nm 30 ms 3050 /cm)
can aso be a ve eecve teatment t is elpto a low 3 secods of compresso of e es ion wit
te c l p pror to te laser pse. A pysicakickback" s ofe el by te ase surgeon a te
t me o te pu sa ion Te c l ca edpont is
immediate prpra .Long-plsed NdYAG aser and intense psed ig
(IP ave aso been repoed to be eectve.
Scleroterapy I one stdy ntralesional i njectios wit% poidocao ave been sow to be effective i
clearng two veos lakes after two sessons o sce
roteapy sa was noted to occu r i one pate
Eectrosurge srgcal ecision cryoterapy are oter
alteate eatmen opons owever tese modalites
can rest in a scar
PTFALLS
Ote req i res severa reatmes w aser
Al teapetic mod alit ies may prodce a sca.
BBLOGRAPHY
Beko PS Long-psed dYAG aser teatment ofvenos akes Repot o a series of 34 cases DeaolSg. 200632(9) 151-54
ay Borek C Treamet of a venos ake agioma wintense plsed igt. ae 199835(9096) 2
K o W Yang C Veous l ake o t e i p reated wi a
sclerosig agent Report o wo cases Deaol Sg.2003;29(4)425-428
Wal l T Grass i A Avram . Cleaance o ml ip e
venos lakes wit an 800-nm dode aser A ovelappoac Deaol Sg. 200733( ) 00-03
A
BFgue 32 (A) Venous lake on the uppe lip (B) Five-onth follow-up
deonstating coplete esolution of the venous lake ae a single teatent with an 00-n diode lase 0-s pulse duation at enegy settings of 45 J! one pulse and 50 J! one pulse
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Section 6: Vascul ar Aleration s 205
�_
o o o p
opo p l d
Fgure 3.3 Clinical efficacy of pulsed dye laser for a venous lake withcompression of the vessels during treatment versus no compression
Dioe
n '
P Isd dye asr • •
n m) :
Las pnetaon uls dy vs d oe
Figure 3.4 Pulsed dye laser does not penetrate deep enoughCompression is needed iode laser penetrates deeper and therefore ismore eective than PL
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206 Color Atlas of Cosmetic Dermatology
CHAPTER 39 Warts
Vral warts are cased by h ma pa p lo mavrses (H PV)
Varios types o H PV- dced warts eist ic udi g com
mo warts (70% of a wars), palmopatar warts paewarts, ad geta warts
EPDEMOLOGY
ee commo
Ae ch l dre ad adu lts
re r sk trama, immosuppress io
(IV ad rasplat pates), geetc predisposit io
(ep demodysplasa verrcfom is)
PAHOGENESS
H PVs are oeveoped do be-straded DN A vrses Athat prodce ectio a d d co of yperprolieratio
we the v ir s eters pro iferat ig basa l epe ia ce s
Avoidace o host imme sel lace occrs Eactmecasms o ifecto, latecy ad reacivato of
HPV are ukow
PHYSCAL EXAMNAON
Wars peset as sgle or ml ipe hyperkeratoic eo
phytic sk-colored paples odes or paqes eyca have ger-lke proectios (filiform warts) o ca beflat-topped (p la e warts) la ck p ctate dots represet
ig thrombosed caplaries are observed reqetly ey
mos commo y preset o figers, do rsal ads platarsraces ad pressre areas
DFFERENAL DAGNOSES
Hypertropic actic keraoss, seborreic keaosis,sqamos ce l l carc ioma verrcos carc oma ad
acal amelaotic melaoma Platar wats ca aso be
mistake fo cos or ca l ses
DERMAOPAHOLOGY
he epd erms feaures yperkeratosis, aca tosis pap l
lomatoss, wth tiers of parakeratoss, valeys o yper
gralosis ad ko ocytosis Te dermis eatres di latedcapil ary loops ad emorrage
BFgure 39.1 (A) Verruca vulars on the le thumb mmedately
posttreatment wth pulsed dye lase 50-nm wavelenth, -mm spotsze, 1 0 J!m, wth pulse stackn (B) Fve-month follow-up wth complete resoluton of the wart afer snle pulsed dye laser treatment
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208 Color Atlas of Cosmetic Dermatology
Plsed dye aser (P D ( F igs . 39 394)
PDL s te mos commonly e mpl oyed aser for was.t may idce a terapetc response by vascula
absorption of lase l igt podcng terma ecross
of wart tisse as wel as by ndcon of a ostmmne respose. Cl i ica improveme is va iab e .
PDL is generaly t ized aer a ure of first l ineterapes.
PDL potoco
Protective laser masks gloves and gowns as we
as us e of a sm oke evacaor are recomme ded oavod rasmisson of e wart virs.
Te yperkeatotic poon of te wart sold be
pared pri or to treatmet eedi g is to be avoided a s
ts w l m m ize laser g absorpton b y te wa.
Hig ences (58595 nm 0451.5 ms plsedrat on 15 J/cm) are ypicay reqred or
eectve teatment. ltple pulses are mos effec
tve bt sold be performed wt cauon.Diascopy wt pses sod be consdered. Teat
to 2 mm of suroudig ealy ski
Trea nt i es oa pur pura s appaent .
Repettive treamets spaced 3 weeks apart ae
general y opima Loger iervas between treament sessios may fac itate wa egrow ad
soer inervals ma y prevent compete ea i g.
Cabo dode ase (C)
C aser treatmet is geerally eseved fo recacitrant wdespead panf or ypekeratotc warts
Advatages ig sccess rate usay after one owo sessios o bleedi g
Dsadva ages: known azard o PV in aser
pme isks of dyscromia ecurrece and nection prologed ea ng t me of weeks to mons
resida scarr g tat ca be pa nfl r isk of perma
en na dystropy w per ngu a eatmen
C proocol
Protective aser masks goves and gows as we as
se of a smoke evacaor are recommeded to avoidtransmssion of e wart vs.
Admiister ntraesiona nfi ltraive anestesia or a digita l b lock ( % idoca ne wit o wtot 1 : 100000 epep ine )
Vaporize te wart and a 2 to 5mm margn u l te sr
ace s carred (Utaplse CW defocsed 1520 W
Sarpa sperpu sed mode 12 mm spot 515 W)
Remove e car by rbbng a saline-soaked gauze
pad. A low e area o d.
Revaporze e wart as above wit ca removal
between passes unt tssue separatio occrs and ormal t isse is obseed.
cFgure 39 .2 Continue () ecurrence of the wart after sx PL
treatments
A
BFigure 39.3 (A) Plantar verruca wth characterstc thrombosed capllares(8) Parng of wart wth # 1 blade pror to pulsed dye therapy
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Nonase surgica moda t ies
Cryoerapy with l iqd ntrogen s te most commolyemployed surgica teatment moda ty empoyed
Treatmet beeft s depedent on ce cystalndcedcell death as well as e dcto of a host imme
respose
Treamet may be deliveed via a cryosrgca unit(ml l Cryogenc Sysems E igton CT or via a
cottonipped applcator, dipsck or forceps
A sngl e or do be 5 to 15 seconds freezethaw cycemay be delvered depending o te teatment ste
ad les ion ickess T cker les ons ad paarlesions reqire moe aggessve treament t ipe
treatmet sessions are geeally req ed
Treamet may dce empoa o permanent
yperpigmenation ad ypopigmentaion b isteing
ad scar fomao
Electrodesscation and creage and sgica ecson
ave also been em poyed wi varia be espose
P TFALLS O AVO D
Be ve aware of te dept of destructio wt Claser As you go below te papllary dermis te rsk oscarig ad dyschromia ncreases
Patets mst be aware that scar fomation s lkey ad
may be pa n Pa ifu l scarr ig is most common opressrebeaig areas
Rec ences mos req enly occ at the won d edge
Treating a ma rgi of norma ski mi n mzes this r sk Cryoterapy ca p rodce pgmen cha nges and scar
I mp roveme s varable wi an y teamet moda ity
Wars can rec ate any treatmen
BBLOGRAPHY
Park S Coi WS Plsed dye aser treatmet fo val
wars A stdy of 120 patients Dermaol. 200835(8)
491-498.
Scel laas U Gerber W ammes S Ockene ls
P sed dye aser teatmet s eective i te reamen orecactan vral was Dermaol Srg 2008;34(1) 67-72.
Sero Somek E S ccessfl treament of recalctrat
wars pediatr ic patients with carbo dioide laser r eiar Srg 200313(4)219223.
Sethaman G Richads K i remagalore R N Wagner
A Effectiveess of psed dye ase in e reatmen ofreca lc itan was i ch i dren Dermaol Sr 2010
36(1 ) 5865.
Sme S O'Keefe E Beomycin i te treatment ofrecacitan wa rts Am Aa Dermaol 1983991 .
Section 6: Vascula r A lerat ions 209
igure 39.4 Mechanism of action of pulsed dye laser treatmen of
verruca (A) The verruca is characerized by a rich vascular suppl(B) The pulsed dye laser selectively targes the vascular component of theverruca (C) The laser light is selectively absorbed by the blood leading
o coagulation of he vessels (0) and resolution of the wart
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SEENBenign Gowhs
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2 1 2 Color Atlas of Cosmetic Dermatology
CHAPER 40 Angofboma
Agofbroma s a descipve erm or a goup of lesos
with differet c ical presetatios but wt the same
hsopatoogy Tese esios cude fbrous papulefac a agiof broma pea ly pei e papue adeoma
sebaceum peiugual f boma ad Koees tumor.
Ths capter w l l focus o faca agiofibroma. Geeral y
a agiofiboma presets as a to 5 mm sk-colored toerytematous dome-saped papu le o the face Whe t
preses as mut iple aca lesos it ca be associatedwh tubeous sceosis or mu ipe edocre eopasa
type (E )
EPDEMOLOGY
commoAg major ity i ear ly to m d c h d hood
Ra oe
Sx equa
rg ars tuberous scleoss E
PAHOGENESS
Ukow.
PHYS CAL EXAM NATO N (Fig 40 1)rm skicolored to eythematous papules (5 mm) o
the ose c i ad cheeks wc may be aaged
b atea ly Id v idua s wi uberous sc eros s ca a lso
ave perugual fromas fibous paques ad asleaf
macules .
D FFERENAL DAGNOSS
Itradermal meaocytic evi appedagea tumors
basa ce l carc oma ace vu lgar is
DERMAOPAHOLOGY
A symmetic wellc rcumscr bed papul e wt a orma to
s ight y aroph c epidemis Te pap l lary ad et icu ar
derm s eaures a prol feaio of vayig degrees of or
ma bood vesses wii a fibrotic stoma. Te collage
fibes are arraged perpedi cua r y to the epdermi s adcocetr ica y aroud te vessels ad a r o l c es .
Ste late-saped m ult i uc eated fibroba sts may be see .
Fgure 40.1 Patent th numerous faca angofbmas He s noted to
have assocated tuberus sceross
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LABORAORY EXAMNAON
I e seig of m lt ip le ac a a d/or e iga agof i
bromas uberos sceross ad MEN 1 mst be ivestigated is s best perormed by reerra to pediatrc
secal ists
COURSE
Mt ip le fac a ago bomas ty ica l ly prese c i dood ad may be associaed wit tberous scleoss
(F g 40.2) . Iso aed es ios remai caged. Fteragiofibomas may develop i adltood.
KEY CONS ULAVE QU ESON S
Ose a d ocatio o lesos
ami y story of sm a esos
ami y story of cacer
Associated cea ervos system di sorders
MANAGEMEN
Tee s o med ca i d icaio to treat agobomas.
Teir cosmetic appeaace owever may be strkigad udersadably coceig o some d iv ida l s .
Teatmet
Mt ple treatmet modalit ies ae ava able. Recrrecerate s ig wit te majoty o e treatmet optos.
Secion 7 Benign Growhs 1 3
A
Treatmet opos may be combed for te bes trea- met otcome
Srgica
Save ecisouie leso prior to apyg ocalaestesia as e leso may blac after e aes
tesa is ected
Pc o e l l t ca ec s ioimited to isoated fewlesios Resd a scar epected
Eectodessicatio ad cretagemay eave resida
sca
Laser s rgerybest or m ult e lesios
P lsed dye laserredces e eytematos como
et of e esio oly Possible esioal fatteigwt se o 5amioevli ic acid be igt otody
amic terapy folowed by psed dye laser teatmet
Carbo diode ase (Fig 40.3)otios wavemode most effective og-tem imovemet as
bee see Adverse eactios icdig tempoaryad/o ermaet dyspigmeatio esecial y i
tzpatr ick ski ototypes l l a d V as wel as scar
ormatio esioa recurece s epected over me
cFgue 40.2 (A) Fibrous paques on the forehead in an adut patient with
tuberous scerosis (B) Fibrous paques on the scap (C) Ash eaf macueon the eg of the same patient
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2 1 4 Color Atlas of Cosmetic Dermatology
KTP aserstacked p lses wio coolig has bee
tized wi some sccess Requires wo o fivesessos for lesioa latteig Dyspgmeaio ad
scar ormaio are possible esioal recrrece is
epeced
Dermabrasiosimilar ocome o couos wave
carbo d oide l aser reamet
PTFALLS TO AVOD
og here are may reame modalies for hem roveme of agofibromas he e doin s geera y
esioal faeg ad o cearace Seg realis cepecaios ri or o reame s key
Paies ms be aware of he ike i hood of esio al recr
rece over m e Wh deryi g berous sclerosis ewesios are key o occur
Ablaive erapies carry a r isk of scarr g ad dyspig
meaio se of coservave parameers are para
mou t o avoid oeti al s de effecs
BBLOGRAPHY
Becor RC uilgo SC Seed PT Caoje E arkey
AC a row R Treame of ang ofbroma s wt a sca
g carbo d ode laser a c copatoogic sdy wi
log-erm olow-up J m a Dermao. 2001 ;45(5) 731735
Boeda P Sacezira es E Azaa Arrazola
oreo R Ledo A C argo ad lsed dye laserreame o agofibromas J Dermao Srg 1994;20(12) 808812
Papadavid E, arkey A Belaey G Walker NP Carbod ode ad plsed dye aser reame of agiofibromas
i 29 paies wt berous sceross r J Dermao2002; 147(2) 337342
oe WD Kageyama N o" KTP-aser reame of
ac a l a giomaa ases Srg Me. 2001 29(1 ) 78-81
Weberger C Ed rizi B Hook KP Lee P K Treame ofagoibromas of beros sceross wi 5amoeviic
acid ble l ig poodyamic erapy fol owed by imme
d ae used dye laser Dermao Sr 2035(11) 1849-
A
1 8 51 BFigure 403 (A) Mutipe angiofibrmas on a 1 6yearo mae with tuberous scerosis (B) Improvement mon ths aer singe treatment with aser
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Secion 7 Benign Growhs 2 5
cFgue 40 .3 Continue () Partial recurrence of angiofibmas noted months aer C laser treatment
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2 1 6 Color Atlas of Cosmetic Dermatology
CHAPER 4 1 Becker's Nevs
Beckers evus i s a sar py dem arcated ta o brow
patc o s igty raised verrucos la qe tat mos com
moly appears o te solder ces or upper back. Ittyca ly presets i atera y ad is reqely associated
wth oveyig hypercosis It s a beig amaroma.
EPDEMOLOGY
cidece: 05 % o maes
Ae tees to trt es rarely cogetal am ia cases
reported
Rce: all races
Sex: males > ema es (6 1 )
reciii crsoe
PAHOGENESS
Uclear etioogy. Posulated to ave a locaized crease
i adroge receptors ad egteed sesitvity toadroges
PAHOLOGY
hee is pap l lomatosis yperkeratosis acatosis ad
basal layer yepigmetaio. ere s a icrease i
te meai cotet o keratiocytes wt l e or ochage the mber o melaocytes. A smoo muscleam artoma is reqely preset i the derms.
PHYSCAL LESON S
hey occr most oe o te pper trk as a wel
demarcated latera ta o dark brow patc wt a
bock ike coguaio ragg rom a ew to >5 m.Hypertr cosis sua y deveops ater e yperpigmeta
t io ( gs . 4 ad 4 .2) Aceorm les ios stricty i m
ited to areas o yperpgm etato have bee reported
D FFERENAL DAGNOS S
Cogeita evs ca au a it mace epderma evs
peiorm eroibroma
LABORATORY EXAMNATON
Pysica eamiat io shoud be erormed to r e otassociated ypolasia o te silatera arm breas ae
oa o is aeral arm sorte g as well as pectus cara
tm o r toracc scolioss.
Figure 4 1 . 1 Becker's nevus A slihly rised lihn plque wihshrply defined nd hihly irreulr border nd hyperrichosis on heches of 5yerold mle Wolff K, Johnson A, uurmond
Fizpricks Color Als & ynopsis of Clinicl ermolo 5h ed NewYork McGrw-Hill; 005
Figure 412 Becker's nevus Lre bwn plque h becomes noiceble pubery wih incresed pimen followed by hir wh Wolff K,
Johnson A, uurmond Fizpricks Color Als & ynopsis of Cliniclermolo 5h ed New York McGrwHill; 005
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COURSE
I t most commol y presets at p bey as a un latera ta
patc Ove t e, it may develo to a plaque and dsay a darker brow e ar gro, wic becomes
darker ad coaser over tie, follows getary
ca nges ey ted o en a rge sowly for a few years, tenremai stab e ove t me e co lor ay fade wit t ime;
owever, te a gro saly persists
KEY CONS ULTATVE QU ESTON S
Oset of lesio?
Is te esio stable?
Is te pgm ent te ai r gro or bot cosmetcally trou
blig?
MANAGEMENee is o edica ndicatio to treat eckers evs
e cosmetc apearace, owever, may di slease soe
id v da smost ofe females wo ote its yertricoss reatment otos are mt iple, bt not always
effectve incdng camofage makeup eectrolyss,waig, laser teapy and sgical ecision Srgical
ecso is imactcal for arge esions Laser terapies
ca be ta loed for ar remova or get resoto
(F g 4 3 )
Lase Teame A test site s recommended before iit at g any aser
teray to assess fo eicacy ad side efects
Pgmet Qswtced rby (694 n), Qswtced
Nd:YAG (532 m o 1064 ), ad Qswtcedaeandrite (755 nm) asers ave bee repoed effec
tive i treatng te p igme tary com oent of a ecker'snevus (F ig 41 4)
I geera, esponse is oor l pe treatments ae
saly reqired for gteg
hee is a ig ae of egmeaton is s lkely
d e to dee ar fo l ic le el anoces
actoaed aser treatmet: the ,550nm waveegt
fractioated aser as been sown to safey ad efec
tivey redce te pgmetary componet t le treat
ets spaced 4 weeks apa rt were e m oyed
Har remova : log-sed a leadr te ad d ode
(800 m ) lasers ca oduce air redcto bt areess eective wt longterm pigmet igening
Abative teray Erbim YAG lase (2,940 m) has
bee demostrated to be more efectve ta logplsed NdYAG laser (,064 n) i sde by side com
pariso treatment of ecker's evs ot lasers
Secion 7 Benign Growhs 2 7
Figure 4 1 3 Incomplete improvement of eckers ne vus on upper buttockafer three treatments with Q-switched ruby laser Associated pigmentachanges noted
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2 1 8 Color Atlas of Cosmetic Dermatology
produce ethema whch clears witn 15 days The
og-term c in ical ad istoogcal clearance has beenoted
t is important to ote tat tee s a hg risk o te
tre change and/o scar formatio associated witabative terapy
ntese pulsed ight as demonstrated med sccessn improving pigmetato and air oss
PTFALLS TO AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS
Treatment o t e pigmentary component of th e nevus s
often ineffectve and recrrences are commo
Lase ar remova can impove overlyng ypertricosis
and s general y permanent n natre
Postinfla mmatory ypo ad yperpigmentation occrreqently, terefore a conseatve aser approac s
vital to miimize any associated pgmentary cange
Patents wit dak skin pototypes (types IV and V)
sod be treated cautosy ad at lower fluences, as
ther treshold espose occrs at ower enegies Aconservative laser approach s best to avod postinlam
matory yperpigmentaton and/o ypopigmentaton
Lase treatment sod be mited to notanned d vd
a s to avoid tem porary or permane nt dyspgmentation
Srgica ecison is depedent on the sze and ocaton
of a lesi on ad s generaly im ited to very smal lesions
BBLOGRAPHY
Cho E, m JW Se SH So SW, Ahn HH ye YC
Treatment o eckers Nev wit a Longpuse Aeandrite
laser Drmal Sr 200935(7) 105-08
Gla c AS, Goldberg , Da i T n ish ge H Fr iedman
P Fractioa Resrfacng A new therapeutc moda tyor ecker's nevs Ar Drmal 2007143(2) 488
490
opera D, oeetner U andthaer . Qality
swtced rby laser treatmet o solar letgnes adBeckers nevs A stopathologica and immnosto
chem cal study Drmal 199794(4)338343
Na CA Alster TS Treatment of a eckers nevs sng
a 694-m ong-psed rby lase Drmal Srg998;24(9) : 1032-1034
Treles A, Alones , orenoArias GA, Velez
eckers nevs A comparative study between erbm
YAG ad Q-switched neodymimYAG c l n ica l andstopatologica f ndigs r J Drmal 200552
(2) 308-33
BECKER'S NEVUS
Therapy d irected towa geao xessie a w e esio
Pigment reducti
Lasers Qswied R d A adAlexad re asers os eee arae roee Rs ee ge edoeaig oo ose esl Alaie lasers ae iger iso sde ees
Surgcal
Seal exso sold ol esed i esios o ed si e
Ha educton
Lasers og sed d A (06)s e eas i e l areoal lase o ase osaao agesogsed r alexadiead dode asers ae oe el o ase ogeao a ees es
erae air redo s a eee sae oio o roi g a eers es A og sed d A ase solde sed ase redio o e geed ooe is less eeiead a rode wose osei aearae A roee wi ases ad ge edio a eeoar w e reree
Figure 41.4 Bckr's nvus tratmnt diagram
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CHAPTER 42 Epd e m a ncuson Cys
Te epderma nclusion cyst (EC), a lso kow as seba
ceous cyst and epidermoid cyst, s te most common
cyst o te skin t rages siz e from a ew mi l m eters toa ew cetimeters and orignates rom the oicuar
inf ndi bu m ts contets are a ceesy, malodorous mitre o degraded pd and kerati t oen rptures, wit
assocated pa and n lammaton.
EPDEMOLOGY
ciece very commo
Age adlts
Rce none
Sex eqa
Preciiig cr deveop spontaneosly or as a reslt
of t rauma A
PAHOGENESS
Arise from epiderma ce l s i n te dermis ese ce l s may
be m planted as a res t o trama o r ar ise rom foll cul ar
infndibuar cels . Tese ce s may pro ierate as a resuto p losebaceous occson. lt pe esions ave assoc
ated wit Gardner sydrome ad basa cel nevus syn
drome .
PAHOLOGY
B
Secion 7 Benign Growhs 1
Wit the dermis or subctaneos at, tere s a wel
demarcated cyst contaiing amated kerati debrs
Te cyst wal is l ined by stratf ied squamos epitelium
eatri ng a gra ua r ce layer I ru ptured cysts tere is a
oreign body gran l omatous reacto wit m lt nuc eatedgat ce l ls Figue 42.1 (A) lliptical exciio arud epidermal icluio cyt
puctum (8) Cyt ac beig "delivered from exciio ite
PHYSCAL LESONS
A EIC s a dome-saped smoot f irm, we l-c rcmscr bed mob le node frequet y protrud g above te
ski s urace wt a centra l pore (F ig 42 ) Tey range
in sze from a few m meters to a few centimeters. Teytypca y preset on hair-bearig skin, sc as te upper
truk eck, earobes and face After rptre, these
cysts develop a strong ammatory reactio as a resuto te spi age o cyst contents ito te dermis. n ths
settng, te cysts become red, named tender, and
enl arged Per i les oa l ibros s may develop wth c ron c
in lammat io
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220 Color Atlas of Cosmetic Dermatology
D FFERENAL DAGNOSS
Piars cyst dermod cyst bracal cle cyst odar
f ibroma ad derma tmors may cause cofus o wtEICs. O tese lesios oly EICs featre cetra pores
LABORAORY EMNAON
I t e evet of ceaty of d agoss a b iopsy ca be
peormed to rue ot eopasm
COURSE
E Cs may crease i sze over t me especial ly wit pys
ical maipato Tese lesos freqety become
if lamed res t ig d iscomfo. Frak pr lece may
ar ise requ r ig c is io ad dra iage
KEY CONS ULAVE QU ESON S
s the es o recurret ly f lamed ad pa f l?
s the eso symptomatic?
s the eso creasig i size?
Has te eso bee amed beore?
Has te eso bee draied or ecised te past?
Wold te patet prefer a surgcal scar rater takeep g te cyst?
MANAGEMENTere s o medca d icatio to treat EI Cs tey are otsymptomatic. Te cosmetc appearace however may
dsplease some idvidals tese staces srgical
ecso s te treamet o coice. Rptred EICs caprodce recrret dscomfo ad repeated ifecios for
some pates. For tese esos srgcal removal s beeca l Cyst recu rrece s i ges or cysts tat ave bee
iflam ed wit th e developmet of assocated i brosis.
REAMEN
Patet edcao s paramot to avoid cys eargemet Dscotiatio of cyst ma p atio redces te
rsk of cyst e la rgeme t ad cyst ru pture
Srgica ecso is te treatmet of coce for cys
remova
For oflamed ECs
Te cyst margs sold be papaed ad delieated
pror o aestesia
The srgica cisio l ie sold trasect te epider
mal pore as possbe
A B
Fgure 422 (A) emoval of cyst with punc h biops (B) dissection of cystfrom surunding skin (C,) extrusion of cyst sac
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Typica y a small el t ical-shaped eciso or a small
p nc h bo psy is erformed over he cyst arond thecentra ore (Figs. 42 ad 422)
The cyst sac s the deti ed a d care y dissected
to kee the sac intact
Sac removal may reqire lateal compresson to
etrude the cys A porto o the cyst contes maybe removed to assist i n sac rem oval
It s m poant to note tha shor o l remova o he
etire sac wall thee is a ke ihood o recurece.
Consider irr gato of the wond with sale if cystccontents are oted n e wond
The patient mst be aware of the potea dead
space that may reslt rom cys remova eaig in
these nstaces may resl n an ndetato of the
aected ski
For if lamed E ICs
I the event of a nflamed ifected or ewly rtred cyst srgica remova shold be postoednt the nfection and inf ammati on have resolved
Iflamed EICs are more diclt to ecise as hey
become more irm y aderet to the surround g derma I st rct res
Dranage of contes is impoant pror to treatig
larger iflamed cysts
ltralesonal cocosterods warm comresses and
at ib iot cs ( in he evet o iect on) can a d n
decreasg ammation
When the inlammaton has sbsded sgcal eci
son ca n proceed
Consider a corse of postecisiona ora atboics
wen cysts are inlamed or have dranage
PFALLS O AVOD/COMPLCAONS/MANAGEMEN/OUCOMEEXPECAONS
t i s mortant to d scss wi the pat ient tha whi e sugca ecson o a EIC is a rote srgica rocede
the scar let om the s rgery may be mo re cosmetica y
dsurbig ha he EIC itsef. Patents m ust be aware tat cyst recu rrece may occ r
Chroicaly iflamed ECs should be ecsed o avod
her ammation/inecton
BBLOGRAPHY
eh rabi D eoha rd M rodel RT Remova of kerati
nos and p lar cysts with the pch icis o techiqe
Analysis o sgcal otcomes erml Srg 2002;28673677
Secion 7 Benign Growhs 221
A
BFgue 423 (A) Epiderml inclusion cyst prior to punch biopsy(B) Epiderml inclusion cyst immeditely following removl An intctcyst sc decreses the risk of cyst recurrence
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222 Color Atlas of Cosmetic Dermatology
Rao K Tran . Ecsion of pdrmoid cysts with a
min ima nar ic s on rmal li J 2006; 2 ( ) : 2
Smoo EC. Rmoval of larg clsion cysts wt mnmal
incsio scars la Rr Srg 2007 9(4) 395
Wad CL Hay C ood A. T ut l ty of submtt ing
pidrmod cysts or sologic amation. l Jrmal 20003934-35
CHAPTER 43 Epdema I Nevus
Epdrma vs (EN) s a big amartomatos
groh. It prsns as a grop of vrrcos c osygropd skncolord to brown paps oftn a nar
arrangmnt fo l owing L ins of lasck ( g 43 ) It dvlops primari y c ldood. Tr ar svra vari
atios o E ncding localizd vs ns latris sys
tmazd E E syndrom ad flammatoryvrrcos pdrma vs ( I LVE ) ( g . 432) .
EP E M OLOGY
i: 0 % of b rts
Ag majorty i t frst yar of f fw dvlop i
pby
Ra: o
Sx ma prdomnanc i VE
riiig ar: sa ly sporadic fam l ia l cass
rportd
PAHOGENESS
EN s cratd by ovrprodcto of kratnocyts rom
pr pont mbryonc pidrmal basal kratnocyts.Gtc mosa csm s toght to b rsposib or most
pidrma v .
PAHOLOGY
Pap l omatos is acanosis pidrmal yprplas a and
yprkratosis along wt longatd r ridgs ar prsn n som sions pidrmolic yprkratoss ad
var ab parakratos is may b prsnt . f th is f id n g smad n t sng o mt ip l pidrmal v gnt c
consl g s od b ord n ordr to d cat pats
as to t risk of pi drm olytc yprkraoss n ofspr ng .
Nopasms sch as kratoacantoma basa cll carci
noma ad sqamo s c l carc ioma may rarly dvlopin association wth pidrmal nv
Figre 4 3. 1 Youg ma with pirmal vus limit to his ck ap
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PHYSCAL LESONS
Commonly presen as a s gle near les on a log
n aera l or b laera l l inear p aqes may be prese os conss o m pe, wel-defied closey groped
liear, yelow pnk or brow verrcos paples o ay
body sie . E N oen fol l ows e Lnes o lasc ko o erunk ad raves ongid na ly o e erem ies Sze
can vay from a ew mil l meers o ml ple cenimeesay cke and become more vercos over me,
especal l y in leura egios Eyema s a comm o ea
re o VEN
D FFERENAL DAGNOSS
Nevs sebaceos, seborreic keraoss verca vlgar s cen sr as melaocy c evs ce pans
psoiasis
LABORATORY EXAMNATON
A bopsy may be indcaed o dis ingis rom nevs
sebaceos or ce s iaus Raely basa ce ad sqa
mos ce cac noma may ar se in E N
COURSE
An EN geea y peses a b i or c i dhood as mac
les in i a y wc icken over me Egy percen of
ENs appear w he frs year o ife A pbey, hey
end o enlage, darken, and become more vercosILVEN may be prr ic i naure
KEY CONS ULTATVE QU ESON S
Age of o se
CNS a bnormal i es
Skeea deecs
Prr is
Famiy sory
MANAGEMEN
I pa iens w mul p le ENs a orogh eamina onor sysemic aboma es s indicaed Tere s no
medca ind ca on o rea E Te cosme c appear
ance, owever may be boersome o e afeced indiv da l or parens of c dre wi d s gr g grows
Tere are m p le reame moda ies for EN inc l d n gsrgery demabrason, opica erapy, ad aser e
apy ( F ig 433) . Pa ens should be conseled a rea
me ress are varabe Te pyscan needs ocons der weer reame wi l l prodce a sper ior
Secion 7 Benign Growhs 223
Fgue 432 An extensive epidema nevus on the eft face and e ea
EPIDERMA NEVUS
ow eiolog rare Rae aes ae a assoaed sdroe wi CNSoa sloselea ages eaed eew o sses ad eaaio ediars wiaroae dagos ess sold e eored o e o Nsdoe
I
Lasers
I
eame of an epea nevus Cose ioee s araewi al l eaes
echaicalI
l sed aro doxdeaser eae o oew odeae o exee roee deedg ode o lesio
eaaso aa e lasesroide ee oo
esos a ara eoer ie R s o dsroa o sarg
Sugcal exciso ied arae sa ol lowig exisi o
Fgue 433 pidema nevus teatment diagam
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224 Color Atlas of Cosmetic Dermatology
ocome o noinervetio The mos aggressive forms
o theray laser abla on and sugcal ecsio carry ag r isk o sca ormaion and/or dyspigmenaon
(F g 43.4) .
TOPCAL TREATMENTSe following oical eraes provde l imted sccess
for esoa improvemet and may bes ui l ized fosympomaic rele of prurs: g-otency cocos
ero ids ret ino i atra 5f lororac i l odophy l
ca lc iotrio a d 5% 5 ororac i
SURGERY
ltickness srgical ecso of E is craive
Posoerave scar is epected
Cosmess is var able
Possib i l y of hyperoc o keod al scarr ig
S gica otcome s best for smale esions
Ecsio n may be d ffic t for yog ch i dre o toerate
Save bosy ad cretage may be too sefcialrecrences kely
CRYOTHRAPY/ELECTROCAUTRYIDERMABRASON
Cryoterapy eectrocaery and demabasio have m
ited efficacy a hg rae o rec rrence a nd ig isk of a
permanen ig mentary alteraion a d scaring.
LASR TRATE NT
Laser he ray can b e effecve n reag EN A tes se s
recommeded rio to reament
C aser (F ig 435)
Laser ablaton ca rovde good cono of te de of reatmen
Treament deh is imied to te api ary dermis in
orde o avod sca formaon
EbimYAG aser
acionated ablatve aser
os efective or more s eric a esos
Treamet depth is l m ied to he pa i l a derms
Wit abave aser treatme here is a narrow margbetween sccessfu treatmet ad a rml sde effecs
sc as scaig and emaent dyspgmetato
Rec rences ae com mon aer laser reament
Qswiced asers
AFigure 43.4 (A) Young patient with epidermal nevus syndrome Note theetensive nature of these lesions even afer several surgical procedures
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T Q-swcd alandrt (755 nm and frqncy
dobd Qswtcd NdYAG 532-nm asrs may bctv or m rovmt of tn ENs
P TFALLS O AVO D
t is i mpoant to norm patins ta tratmnt mayonly b artia ly sccssl and may rc
Lasr tratmnt o t pdrmis a lon w l l rslt n
inc omp t rmoval
Lasr ratm byond t pai ary drms may rsltin sca omation and/or dyspgmato
r is a lways t sk ta tratm wil odc aninior rst o no ni ntvntio
Advrs sid cts as dscribd abov must b
paind n dtail o patins or rastc ctationsrgadg tratmnt otcom
BBLOGRAPHY
Boyc S Astr TS C lasr tramnt of idrma
nvi Longrm sccss Dral Srg 200228(7) 6 6 4
Kim Cang W Scwaydr oca rtnoin ad
5- oouracil n t tatmnt of l nar vrcos pdmal vs A Acad Dral. 200043(1 t ) 29-
132
L BJ Manc in A Rncci Pa l r AS Ba S F l ltic knss srgca cision for ratm of inflam ma
to l inar vrrcous pidrmal nvs A la Srg.20047(3) 285292
itsasi Y Katagr Y Kondo S ratmnt of in am
matory nar vrrucos pidrmal avs wt to ca lv tami 3 r Dral. 997 36 (1 ) 34 35
orno Aras GA Frrado J Intns lsd ligt fo
mlanocytc sons Dral Srg. 227(4)397-4
Panagiotooos A Casai V kolao V al
Assssmnt of cryosrgry for t tratmnt o f vrrcos
drma navi Aca Dr rl. 200989(3)292294
Park wang ES Km SN t a ErYAG asr tratmnt of vrcos idrmal nvi Dral Srg. 2004
30(3) 37838
Toyozawa S Yamam oto Y Kami na ka C K isoka A Yon
N Fr kawa F Sccssf tramnt wit tr c ooactc
acd i ng fo nfamm atory l nar vrrcos drma
nvus Dral 201037(4)384386
Zvlnov A Grwad M Ha lvy S opca ca c ot o l
or ratmn of nfamm atory l nar vrrcos idrma
nvus Arc Dral 199733(5) 567568
Secion 7 Benign Growhs 225
Bigure 434 (Continued) (B) and aer greater than 0 subsequent surgicalprcedures including aps and skin gras Curtesy f ichard ennett,
Muba Taher, and Mathw Avra
AbveC02 lser
ecoe
ems
igue 435 ffect f ablative C laer n reving an epideral n vus
With the deral cpnent reaining, there is a risk f recurrence
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226 Color Atlas of Cosmetic Dermatology
CHAPER 44 poma
L poma s a beg tumor of maue at I t presets as a
sof subcutaeous les-coored tumo tat eey moves
agast ovelyg sk. ost ofte t presets as a solitary es o o te uk, eck, ad proma eremit ies
(F ig . 441) . Ifreqet ly , id v idua s may preset wmut pe pomas, rarey as a pa of a iherted sy
drome
EPDEMOLOY
ee: very commo
Ae ca prese at ay age but most commoly te
fo decade
Rae: oe
Sex eqa
re ar most frequetly, tere is o precipi
tatig factor ul ipe l pomas ca be associated wsydromes suc as Dercums disease, famil ia l mut iple
ipomatoss adelugs disease Garders sydome,Ba ayaZoaa a d roteus sydrome
PATHOENESS
Ukow
PATHOOY
Well-circumscribed, obuaed tmo o ufom, matureadipocytes i e subctaeos fat, ofe wit a ti sr
roudg bous capsle ad eccetric uc e i
PHYSCAL ESON S
A lipoma presets as a sof reely moble escolored
ova o oud s bcutaeous odul e wit a orma l ovely
ig epidermis Its size ca va greaty from millmeters tomay cetimeters. is oede uess presetig as
pa o Dercums dsease, as a agiol ipoma or i impgig o a eve.
D FFERENTAL DANOS S
Epderma c lus o cyst , p i a cyst , iberoma agi
o ipoma, ad oer faty tumos icludg posarcomamus be cosidered I te lesio s greate tha 10 m o
fied, maigacy sold be cosdered
Fgure . 1 A mddleaed female th to lipomas on her arms
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LABORATORY EXAMNATON
I omal c icumstaces o workp s d cated the
evet o rapd or etesve growth, however biopsy maybe dicated maigacy is sspected Cauto s di
cated e evet o ecsig a l ipoma located i the mi d
l e sacrococcygea egio t may epreset spiadysraphism. th s c cumstace, cosder rad io ogca
a d e rosurgica evalato Do ot peorm a bi opsy
COURS
They ed t o grow sowly to a cetai sze a d d o ot vo
lte without teveto
KEY CONS ULTATVE QU STON S
Nu mbe ad locat io o pomas
Fami y hstory of sm a esios
Hi story o keods/hypetroph ic scarr g
Assocated pai
Recet lesioa growth
MANAGEMENT
Thee is o medca idcatio o teat l ipomas uess
they produce pa or costco o movemet or
demostrate accelerated growt ay patiets ow
ever reques reatme for cosmesis Surgica removal,
va ecisio or l iposucto is te maistay o erapy. Ithe esio is located i th e mid i e sacrococcygeal egio
cos der spia dysraphi sm.
TREATMENT
Su rgica ecsio best for smal l pomas (F igs 442 a d
3)
Depedg o the size o he l poma a sma e l pt cal
ecsio s perormed over te tmor. Oce thelipoma s encoutered is disseced fom its su
rodg t ssue.
Aer remova, a layered close with subctaeossutures is geerally required to repair the cavty pro
d ced by the procedue
Recrrece s com mo due to te d iicty of d ist igish g tmor rom orma l su bctaeos at .
S rgica ecso is preerred o sma ller ipomas a dis less epesive tha iposuctio
Lposuctio best or age ipomas
A smal cisio is created wthi te ceter o he
lipoma ae egoa aesthesia ad iposctio of
the l ipoma s perormed
Secion 7 Benign Growhs 227
A
BFgure 2 (A) Lipoma on posterior neck prior to surgical excision(8) cision of lipoma
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228 Color Atlas of Cosmetic Dermatology
The entre tmor is ot necessarily removed Raer
portons o te lpoma are removed ntil the affectedarea es s with e srrondig skin
Postprocedre brosis can esre a persisten at
tened cotor of the remai n ng i poma tisse
The advantage of posction over ecso s tat it
prodces a sma ler scar
It is more epensive tan stadard ecsion
Low concentraton deoycoate injectons have been
sown o be eecive for te treatment of lpomas in a
limied study hese injectios obviate the need forsrgery and tus scarr ng oneeess frter stdy is
recommended before ts aternaive treament can berecommended
P TFALS TO AVO D/CO PL CATO NS/ cANAGEENT/OUTCOEEPECTATONS
e pysc an sod inform te patient that a l srgica lnterentos prod ce some d egree of scarr i ng
Scarrng may bother patents more tan te l poma
tself
Addtionaly removal o large ipomas frequenty reslts
n a postoperative skn depression
Recrrence is comm on especia l ly wi i posct on
BBLOGRAPHY
Harrigton AC Admot Cesser RS nf lrat ng l ipomas
of the pper eremt ies J Dmal Sg On 990;
6834836.
Rotnda AR Abon G Kolodey S ipomas reatedwth subctaneos deoychoate iecions Dmal
Sg 53(6)73-78.
Salasce S McCollog M Angeoni V Grabsk W
rontalisassociaed lipoma o te foreead J m a
Dmal. 198920462468
Sancez R Golomb A Moy A Potozkin R Gia ipoma: case report ad revew of te l iteratre J m
a Dmal 199328266268
ran AP Garden et a l ac ia l and sca lp pomas:
case reports ad stdy of prevalence J Dmal SgOn 1 9 8 5 9 .
Fgure 2 (Continue (C) ubcutanus sutu f clsu (D) Gsspath spcimn f lipma
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CHAPTER 45 Mum
ia are beign supericia l wieye ow kerainaceos
cyss tha ypcal y prese on e eyelids, oreead and
ace bu may prese aywhere (Fg. 45 . 1) . hey occr aa l ages ad a re very comm on
EPDEOLOGY
i: very commo
Ag: ay age; mos commo i newborns ad a du lts
Ra: oe
Sx eqa
Priiig ar: These are most reqely sporadic
lesons bu ey ca be assocaed w sbepderma
bl isering diseases sc as porphyria cuaea arda epidermolyss bulosa acqisia varcella zoser virus, bl
los pempgoid , and bl os ce planus . hey areaso associaed wi ski trama sc as abrasos
brns dermaologc srgery abat ve ad onabave
ractiona resrfacg resrfacg and radiaiotherapy Tey may also occr folowig reame wh
opcal 5-fluororac l , opcal coicoserods, and mcro
dermabras ion
PAHOGENESS
ia are believed o be retenio cysts derived rom velIs a r fo l l c les . i a secodary o tra ma or bu l los d s
eases arse rom ecopc air olicles
PAHOLOGY
They represen smal epdermod cyss ad eatre char
acers c srai ed sqamous epihelium wi laminatedkerai debris A gra ua r ayer is present i e cys wal
PHYSCAL LESONS
i a presen as 1 o 4 m m su pericia wieyelow cysstha mos commonly appear on the eyelids cheeks and
oreead.
D ERENTAL DAGNOSS
her c i ica l a ppearace is cha racer is ic .
LABORAORY EXANAON
Noe .
Secion 7 Benign Growhs 229
Fgure 4 5 . 1 mall milia on face of a yearold female
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230 Color Atlas of Cosmetic Dermatology
COURSE
They ca p rese a a y age ad do o resove wiot
itevetio
KEY CONS ULATVE QU ESON S
Is there a y h i story of b se g o rama?
MANAGEMENT
Tee s o medica d icato to treat m l a T e cosmetic
ap peaace owever may dspease some d ividua s
TREATMENT
c s io a d epess io: treatmet of choice ( F ig 452 )
Local a estesia ma y be req ed cisio wi a #1 bade ad emova of kerata-
ceous deb ris with pressre from comedo e etracormcrovasclar foceps or cotto swab tps
The procedure is fast simpe, ad eecive
Topical medcatios
Topica retoi ca be eective for mt iple mi a
Ohe reatmes
Eectr ica fgratio
Ablative or ractoa abative lases ca be effecivebt ae fa moe epesve wit a ger rae of side
efects ad recovery tme
EPECTATONS
Treatmet o m ia is straightfoard I cis o ad epresso s as s mpe, ad sccessl It emas the tea
met o choce I cases o ml pe mi ia opicalteto is a good coce part icar ly f e esios ae
smal (Fig 451) aser pays o paccal roe i te
teatmet of m ia
BBLOGRAPHYara DE Poabba i S, F ce EF oy R ract oa
photoermolysis or te treatmet of adlt colo d m li m rc ermao. 2007143(5) 572-574
DmovsekOp Ved i se of Er:YAG laser or
beig ski d sordes asers Sr e. 9 9 7 2 ( )
39
A
B
cFgure 452 (A) Lancet piercin a milium on the left ower anterior neck
of a patient (B) Comedone extractor extrudin keratinaceous debris from
miium (C) Postprocedure resolution of milium aer comedone extraction
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CHAPTER 46 Neurofbroma
Neuroibromas (NFs) are benig, soft pnk eromes
encyma tmos at ca be soitary or m iple
(Fg 461) Soltary tmors are not assocated with systemic findigs. l iple NFs are assocated with nerof
bromatoss pes I ad I bo e roctaneos disorderswit impotan sysemc maifestatios incding malg
naces Peiform NFs are see i paients wt neurobromatoss type I .
EPDOLOGY
iee common
Age youg ad lts
Rae oe
Sex eqa
Peiiig fas mltpe NFs are seen n assocatio
with ne rofbromatoss I and I I Tere are no precip tatingactors for sol iary N Fs
PAHOGENSS
Te paogenesis of so tary lesions s k nown ut ip le
germline ad somac mutatos ave been deiied orpatets wi neroi bromaoss ypes I a nd I I
PAHOLOGY
NF s caracerzed by a we circ mscribed, nencapsulated dema ad subct icu ar co l lect io of sma l nerve
bes and oosely arraged sp d e ce l s possessng wavy
ncle n a eosnopi c matr ast cels are commoy
seen itoses are abset
PHYSCAL LESONS
Ns present as skin co lored to p nk to brown soft or
rbbey papules or nodles (F g . 462) Te ab i i ty toeasily vagate he esio w pressue known as
buttoo ing" s a caracter ist ic pys ca l d igTey rage in size from a ew m meters to a ew ce
timeters Pleiform s are caracterzed by large
bag ike masses tat may ave associated yperpg
metat ion .
D ERENTAL DAGNOSS
Derma evi cogeial evi dermatofibromas; eromas ad f bomas
Secion 7 Benign Growhs 231
Figue 46.1 Multiple nonacial neurofibromas
Fgue 46.2 Multiple neurofibromas on the le face
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232 Color Atlas of Cosmetic Dermatology
LABORATORY EXAMNATON
A soltary NF does not merit a workp iopsy may be di
cated o a c nca ly atypca N F. ltip e N s mert reerrato neroogc ophtalmoogc genetcs ad ortopedic
special ists to assess or nerofibromatosis or I C ompete
sk and eye eaminaton o the patet and mmediaterelatives is idicated as wel . Ski eamation shod
assess for al a ry reckl ing caf a a it mac ues peormN Fs jveie antogra lomas an d sc odu es
COURS
hey tend to grow indoenty and pan lessly Peform N F
reqire contnos motoring or potenta magnantchange.
KEY CONSULTAVE QUESTONS
Nu mber o es ios
amly history
Cetal nevos system (CN S a bnorma it es
Scoiosis
Eye abnorma lt ies
one deects
Loss of earig
MANAGEMNT
hee is o medica indcation to treat NFs ness tey
prodce pa or are cosmetcally dis iguring or arechanging i growt any patients owever equest
treatment or mprovement of cosmetc appearace
TREATMEN (Fig. 46.3)
Sgica ecson
Whie tere are many metods or emovng Ns
sgcal ecson is te most common ad ecent
meas o remova Recurrence is key if the NF is
not completely ecised Elptical ecsion is an eectve nepensve treat
ment and is part ic lay appropriate or maagement
o a ew nmber o lesios As wit any srgery, an
epected scar w l l reslt ( Fg 46.4)
Laser a blatio
Not irst-line therapy
Carbon d ioide (C ) laser resacig can be ti-
ized for acial lesions C laser treatment of nona
cia esions is genera ly ot recommended gve r isk
of ypertopi c scar/kelod omatio
EUROFBRMA
C ial exa
So siooed ed/o ale/odle Sol ia leso oe oo a lle
So a esio (os oo) Sgial sae o exisoeae o oie No ole o ases
Figure 46.3 Neurofibroma diagram
I l i le les os e oassoaed eooaoss Sgial sae o exis oeae o oie ases seode ea
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A cttig teciqe ca be t l ized to ecise
tmos C treatmet a focsed cotouswave beam 15 to 30 W s erformed aog the
maked margi Re ic ise a log te margi t tedesred det s obtaied Tisse demiig ad
emorage cotol ca be obtaied t iz g the
same laser arameters wit te adiece eldaway fom the wod to defocus the beam Wo d
cos re is eformed i a stad ard fashio
A vaozatio tecque may be t l ized to atte
ad emove tmors C treatmet wt a defo
csed beam ad 3 to 6 W s eformed to the eveof adjacet oma ski It may be ecessary to
maa y etact age resdua dema tmor oce
visa ized Char sold be debded betweeasses wit a wet gaze a d d ied l ly pri o to co
tig teatmet
Several teatmet sessios may be reqed for
atets wit meros N FsPostiflammatoy yegmetato atophicscarrg yeroic scarr ig, ad complete
remova ave bee reoted as sde effects A test
site shold be cosidered i aicua patietswith Fitzatick ski ototyes I V I
Erb m ytr im a lmim garet laser esfac ig
ca be ut l ized for facial esios
Srface vaozatio to flate tumors hs teat
met modaity s ess effectve ta the C aser i
esoa emoval However, this ase may be morea oiate o atets wt daker Ftzpatr ck s ki
hototyes to mmze ostammato gmetay cages
Itestita photocoagulatio ca be perormed for
the teatmet o bkie lesios cldg oacalesos
PTFALLS O AVOD/COMPLCATONS/MANAGEMENOTCOMEEPECTATONS
e ysic ia sod iform t e patet tat ay sg
cal or aser itevetio rodces some degee o scarr ig
Removal of NFs via laser ablatio may podce
postfammatoy hyperpgmetato ad/o scag
Recrrece s commo
C aser ics oa treatmet ca ead to deceasedtes le wod stregt d ig te woud eali g phase
we comaed to stadard srgica ecso de toaser thema damage at the wod magi. Stres
sould be le o a addtioa week to assist
wod eal g
Secion 7 Benign Growhs 233
BFigure 464 (A) olita neurofibrma preop (8) olitary neurofibrma
following simple excision This is the treatment of choice for solita neurofibromas It is also a good option for removal of limited neurofibromas
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234 Color Atlas of Cosmetic Dermatology
C lasr vaporzation tratmnt should b l imitd to
acia NFs gvn an ncrasd risk of scar fomationwith us o nonfacia s its
BBLOGRAPHY
Co RP Wddowson D Moor JC Outcom orbumyttr ium alumnum garnt asr sracig tramnts ases Me Si. 200823(4)427-433.
Ewaki Samy A Ebasouny MS Non-csion trat
mnt o mul p ctanos nrofibromas by asr p otocoaguaton ases Me Si. 200823(3)30316
Mono JC atort C Lant r L S lr Rvuz
Wolknstin Carbo doid lasr fo rmoval of mt
p cutaous nrofibromas J Dema/. 2001
44( 5) 096098
Nv l H Symour-Dmpsy K Sops J t al rol
of srg c dn wi nuofibromatoss J eiaS. 20036(1) 2529
CHAPTER 47 Seborrhec Keratoss
Sboric kratosis (SK) ar t mos common bignctanos tumors and in adts SK ar warty kratotic
ski growt that irst prsnt aftr th fourt dcad T masr rom a fw mllmtrs to ctimrs Th coor
rangs rom pnk to ta to dark brown sions can b
sol tay or mut p l ( g 47) Ovr t m pat intsdvop aywh from a fw to undrds o SKs any
patts rqst rmova of SKs part icar y whn m lt ip or la rg bcaus of tir un sigty apparac
EPDEMOLOGY
iee: vry common
Ae usuay in oth dcad and bcom mor numr
os in m ddl ag and byondRae: mo common i Caucasias
Sex: qa
eiii as amily story wt iky atosomadomi nat inr itanc
PATHOGENESS
Unknow
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PATHOLOGY
Cassca ly, S Ks are wel -crcumscrbed ep dermal growts
tha rse above te srface of te srroudg skn. Aleatre yperkeratoss, pap omatoss, and acaoss.
Te epderms coans basaod cells that sow squa
mous dereao Squam os eddes may be preset
PHYSCA LESONS
Tee are many clcal varats o SKs. ey rage sze rom a few m l meers to a few cetm eters ad mos
comm oly occr o te face, eck, a nd tru k. Tey typ
caly frst preset as weldemacaed ta or lgt brown
macues Wt t me ey r se to become plaques and
deveop a warty ad sucko appearace. or cystsbecome appare wt te l esos Tey can occr ay
were o arbeang sk ad ae ot see o te palms
and soles
D ERENTA DAGNOSS
Letges, verruca, acrochodos, codyoma acuma
tm, acrokeratoss verrcforms dermaoss paposa
ga Bowes dsease evs epdermal evs ego
mal gna meanoma, ad sqamos ce l cac oma The
ccal appearace ad presence of orn cysts SKs
makes e dagoss stragorward
LABORATORY EXAMNATON
Noe; sk n b opsy f sspect ma gacy.
COURS
Tey presen t e forh decade a d persst for years.
Ove tme, hey become larger, more pgmented ad eatre a more verrcos appearace. Tey typcaly
become more m erous wth age Infreqently tey caregress spoa eous ly
KEY CONS ULTATVE QU ESTON S
Fam y hstory of sk cacer
Hstory o b leedng
m e of onset
Was there a rapd ose of merous SKs?
MANAGEMENT
Tee s no medca dcato to treat SKs, less tey
are rr tated St l l , e cosmetc appeaace boters may
patets There are ml ple modalt es fo treatg SKs
Secion 7 Benign Growhs 235
igure 47.1 Multiple seborrheic keratoses on back of elderly male
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236 Color Atlas of Cosmetic Dermatology
including cryoterapy, electodesccato, ceage
swtced and ablative laser terapy ost ote te tradt io na metods of treatg S s are most appropiate I
there s a rapid oset of wdespread esons, perform a
revew of systems and cosder a f l pyscal eamna
t ion to r e ot ay uder ly ing medica l cond ion or carc
noma (Sign of eser Telet).
TRADT ONA TRATM NTS
Emphasze r sk of incompete remova and recurece
with any reatmen modalty
Cryoerapy
Lght cryoerapy is a quck epesve ad efec
tive metod of reating Ss Ris k hypo or ypepg
mentato ad low rsk o scarig
f the lesio does no resove retreatment s neces
sary i 3 o 4 weeks
C rrettage ad ig ht catey
Eectrodesccaton of Ss is anoer q c k an d effec
tive meod o treatment Slg dscomfot assoc
ated wh oca anestesa
Creng the leso ate electrodesccao ca
ensre emoval
Lgt, qck eectodesccation of e base may alsoenhace eficacy and prevent ecrrence
Posprocedre wond cae is eeded with emo ent
or 7 to 0 days
Save eciso
Shave ecso n ca efectivey remove Ss
ASR TRATMNTS
Laser s ot a fst l n e treatment for Ss Rather, it sould
be cosdered a alerative treament and oly sed n
the correct c n ca l sett ng
ea n n targeng asers for tin S s
Qswtced by (694 nm) ad Qswtced aean
dr te (755 nm), and te longpsed 532 nm lasers
can eectvely treat thn S s (Fg. 47 2)
Somemes neective especial ly as thickness
nceases repeat treatmets may be reqred
Rsk of hypopgmentato
Epensve compared o tradit iona terap es, but maybe more toleab e o a patient wit m t i pe l esions
Ablaive lases
C and erbi m :YAG asers can abate Ss
Repgmentato of Ss occrs nfreqetly ae
treatment
Epensive compa red o tradt iona terapes
Figure 472 Posttreatment whitening of seborrheic keratoses atertreatment with a 55-nm Q-switched alexandrite laser with a uence of
10 J!m and a mm spot size The procedure was performed aferfractional resurfacing, which explains the blue dye remnants apparenton his face
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PTFALLS O AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS
SKs ca be treated wi a mber of d eret ad
eectve modalities
Te pysca so ld edcae te paet tat ay terapy as possbe adverse eects suc as pigmetarychages scarr ig ad recrece
Tradi o al terapies sc as gt cyotheapy o curet
tage ae simpe qck ad effectve (Fg 473)
Laser terapy is a alterative treatmet at a higerepese
BBLOGRAPHY
Brodsky J aageme of beg sk lesos commoy afecg e face: actc keratoss seborrec
keraoss ad rosacea Curr Opin Otolaryngo/ Head Neck
Surg 2009(4) 35320.
Cbeso GR 532m dode laser treatmet of sebo
rec keratoses wit coor eacemet pblised
oe aead o pi aary 29, 2008 Dermatol Surg
2008;34(4):525-528 discssio 528.
Kilmer SL Laser eradicato of pigmeted esios ad
tattoos Dermatol Clin. 200220)37-53
erabi D Bodell RT se of e aeadrte laser for
treatmet of seborrec keratoses Dermatol Surg
2002;28(5):437-439
Secion 7 Benign Growhs 237
cFgue 47.3 (A) Curettage of seborrheic keratosis (B) Immediatel aercurettage of seborrheic keratosis (C) Postinammato erthema 1 monthafer curettage of seborrheic keratosis
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238 Color Atlas of Cosmetic Dermatology
CHAPER 48 Syrngoma
Syrigomas are common beign adea neoplasms of
eccrie duct dervaion at preset mos freqety
in females o the ace especa y arod e eyes( Fig 48 ). ey may aso be seen on te cest u m b i
cs a lae and v va .
EPDEMOLOGY
cidece: commo
Ae saly present at pubey
Rce: oe
Sex ema e > ma le
Preciii crs: more common i Dows sydrome
PAHOGENESS
Unkown.
PAHOLOGY
hese beign symmetric wel-crcumscrbed dermaltmors are composed of mt ple smal ducts wt two
layers of cubodal eptelm ote wit a ta l" gvg atadpole" or comma- ike appearace in e pper der
mis Tese ducts are sometimes di ated a d are l ned by
a eos inop l ic ct c le ere s a srrodig denseibros eos iop i l c stroma
PHYSCAL ESON S
Ski coored to yel ow to 3mm rm pap es ey aresee most reqely arond the eyes especal y the
lower eyeld. Typica y tey are mut ple ad symmetric
hey can a so be seen on te ces mbi l cs ai ae
Figure 41 nfraorbital syrinomas bein treated with low settin electrocaute on a youn female The treatment was not eective
ad geital ia (Fig. 482). Acral esions are seen n erp At ive syrngomas.
D FFERENTAL AGNOSS
il a sebaceos yperpas a basa l ce l l carc ioma tr i
choepithe oma f i brous pap le
LBORATORY EXAMNATON
Biopsy may be d cated i basa ce carc noma s ss
pected. No oter laboraories are ind cated
BFgue 42 (A) Infraorbital syrinoms in a youn female (8) Followuppicture at 1 week afer ablative fractional C laser resurfacin showinimprvement of the syrinomas This improvement is attributed mostly to
the postprocedure edema No sinificant improvement was noted at alater follow up
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COURSE
Tey prese a pbey and do o resolve wot ite
ve ion
KEY CONS ULTATVE QU ESTON S
Time o f onse
MANAGEMENT
Tee is o medica ndicato to treat syrgomas. ay
patens owever reqes reament for cosmecapearace Syrngomas are eraeuica y callengig.
Altog ere are ml ple reame modalt ies avail
abe one is comeely sccessl compee orperm aen emoval of syringom as Oen te s de efects
of reamen wi boter atets more tha te syrigo
mas emselves Ideally e treament of syrgomassoud rodce destrcton of e tmo wi mnmal
scarr ing an d o ec rence Tere are no effecive opicalmedca ios .
TREATMENT
Srgica ecison bes reserved for solay lesos
Scar wi l be prodced
Electrocaery can be sccessfl
Locazed aesesia w % l docaine w or wit
ot epiepr i ne may be emoyed Low-energy seng elecrocaery eformed at to
2 W w e electrode aced i e center of e
syringoma.
C i cal endon s lesioal faeng.
Lg seings are advsed to avoid pigmenta
cages o scarr i g.
Getle curetage s recommeded o esre at
eectve removal o e syrgoma as bee
obta ned.
Carbo d ode (C ) lase s an effectve meas of
imoving ese lesons. The goal is to flae raer
a remove e lesons
Lmed to patients wt skin ootypes I I I .
Ind v ida l les os or m p le syr ingomas w te
same cosmec nit may be reated
C treatmen in a deocused mode 3 to 6 W 3mm
spo 01 o 02 secods may be eml oyed
tiple passes are peormed wt remova of resdal car bewee asses w saliesoaked gaze
pads. Leso s are treated to e evel of adjace no
ma l s k n
Secion 7 Benign Growhs 239
Fgue 4.3 Multiple syringomas on th e chest of a female
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240 Color Atlas of Cosmetic Dermatology
Lesonal recurence s common Postinfammatory
hyergmenatio a nd scarrg may occr
Oher eames nclde cryosrgey and dermaba
sio hee s l itt le data wit whc o judge their efi
cacy ad sideeect prole
PTFALS TO AVOD/COPLCATONS/ANAGEENT/OUTCOEEPECTATONS
Atough tere ae mlt pe reamen modal ies tey
are oten ressant o therapy Recrrece s common(F gs 483 and 484)
Ca io sou d be eerc sed wi ea c o the a bove
sted modal ies
Patens must aso be ormed ta e sde eecs of
reame may be moe cosmetca ly udesabe a
he syrngomas hemseves ese side efecs incldescarrng yerigmenaion recurence ad ery
thema
We teatng syrigomas care shoud be take to ot
overreat e esios I is not ecessary to completey
e l imiate e es ios as some dermal bros is sepected wi ealng with esidual lesons becoming
ess aaren over m e
Great care so d be given to the treatmet of aetswih skn ootyes V and higher o avoid tempora
and permanen ig mentary canges
BBLOGRAPHY
Akta H Takasu E Wasmi Y Sgaya N Nakazawa Y
atsaga K Syingoma of he face reated with frac
tiona photoermolysis J sme ase e 2009 (4) 2 6 -2 9 .
Frazier CC Camach o AP Cockere l C The treamet o
eruive syrgomas n a Afrcan Amercan atent wita combinaio of r icoroacetic acid ad C laser
desructon Demal S 20027(5) 489492.
Kag WH Km NS Km Y S im WC A new reatmeor syrgoma Comnation of carbo dode aser and
tr icloroacetic acd Demal Sg 99824( 2) 370
374
Karam P eedetto AV Syrigomas ew aoach o an
o d tecn iqe l J Demal 99635(3)29-220
Sajbe FP Ross E e se of e 0 mm adpece in
hg eergy ulsed C aser destructo of facal
adneal tmos Demal S 99925() 444
Wang Roeigk H Jr reame of mut p le fac a
syrigomas wh he carbo doide (C) ase DemalSg 99925(2) 3639
Topica o eeeopial ea
SYNGOMA
l o ea t a oda Cial ioee is aae
Mechaical oal aesesiai ig eleo
desiaio
asers Aaielsed C eos eeie oda i
os ase eea o 1 ees Ap eol i et oeeaed aea o oaea g
ig eee aeL a oda i
1 36 os
Fgure 44 iagam of syingoma teatment
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Secion 7 Benign Growhs 241
CHAPTER 49 Dermaoss apuosa Nga
Dermaoss papulosa ngra (DPNs are very common
benign brown way papules a appear n Afrca
Americas and oher patens wi dark skn pooypesDPNs usualy afect e ceeks neck and pper cest
(g. 49 ) DPN s are a type of seborrheic keratosis anypatiens request removal of DPNs paclary wen mul
t p e or large de to ther unsigtly appearance.
EPDEOLOGY
iee very commo i Afrca Americans ad Asians
Ae: second decade to mi dd e age
Rae: more common in Africa Americans ad Asans
Sex emales > maes (2:
reiii a srongy assocated wth famly sory
PAHOGENESS
Unknown
PAHOLOGY
DPNs feature yperkeraosis papi lomatosis and aca
thosis as see in seborrhec keraoses o squamos
eddies are prese
PHYSCA LESONS
Tey presen n a symmerc fashio as sma l browsmoot sess e papues on te face neck ad upper
trun k of Afr can Amercans ad Asians Tey range rom to 5 mm n dameter and are ofen pednculated.
D FFERENTA DAGNOSS
Seborrec keraoss entigo verrca acrocordon
melanocyic evus angiofibroma and adnexa tumors
are al l in te dierential dagnoss
LABORAORY EANAON
Noe .
COURSE
Tey present drig teeage years. Over time ey
become larger and more nmerous peakg in middle
age T hey do no regress spontaneo sly.
Figure 4 9 1 ermatosis papulos igra o the forehead of a AfricaAmerica female
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242 Color Atlas of Cosmetic Dermatology
KEY CONSULTATVE QUESTONS
ami h isor of DPNs
MANAGEMENT
hee is no medcal ndicaton to teat DPNs uless theare ir r ated St l l , he cosmeic appeaance bothes manpatents atclar when numeous hee are ml ipe
moda it es or treag DPN s in cl d ng crothera elec
trodesscatio, gadle scissor emoval, cuettage and
ablaive lase hea Primar considerato before teatment sou d be e eectve removal of e DP Ns wihout
prodcig pigmenar change
TREATMENS
Shave or grade scissor ecision ca efectvel emove
D P Ns Local ifi traton wth oca aesthesia o owed b gra
de scissor emoval s safe, fas and as the owesrisk o postnflamm ao dschom a
Cohera
Lght croera is a qick, inepensive sl ightlpa nfu , ad eectve method of eatig D PN s
Cation cotheap can oduce hpopigmentation
b destoing melanoctes pergmenation cana lso occ
Lght electrodesccaon and crettage
Lght eecodesiccation of DPNs s another quickan d eective method o treatment hee s a r sk of
posnammato dscroma
Wth ight electrodesiccato the lesion w l tn whe
On l ght eectrodesccaio should be emploed todecease the rsk of gmena ca nges
LASER TREATMENTS
ea n n argeng asers for thin DPN s
Qswitched ub (694 nm) ad Qswtced aean
drte (755 nm) can someimes eecvel eat thiner DPNs
Sot size shoul d b e ess han the size o e leson
Repea reatments ma be requied
Risk o hoigmenation and hpergmenaion
should be e ained ca refull to pate
Epensive compa red o tadit i ona theap es
Ablaive lases
C, factioal ablative and erbimYAG asers can
abae these ederma esons
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Epensive comp ared o radi onal terapies
Rsk o ypopigmenaion and yperpigmenaionsould be epla ned careflly o e paien.
PTFALLS O AVODCOMPLCATONS
MANAGEMENOUTCOMEEXPECTATONS
An y erapy a s possibl e advese eecs sc a s p gmenary canges scarr ing and recurrence Grade
scissor removal as e lowes r isk of dyscromi a
DPNs can be reaed wi a mbe of deren ad
eecve modaliies
radi io nal herapies sc as scissor ecson cu retage
or l ig cryoherapy are sim pe qu ck and eecve
Laser herapy is more epensive ad carres a ger
poena for yper or ypopi gmenaio es spo may
be app ropiae
BBLOGRAPHY
Kilme SL Laser eradicao o pigmened esons and
aoos. Dermatol Cln. 20022013753
Schweiger ES Kwasnak L Aires Treamen of dermaosis paplosa ngra wt a 10 nm NdYAG lase:
Report of wo cases J Cosmet Laser Ther 2008 10 2
120122
CHAPTER 50 Xanteasma
anteasmas also reerred o as anhelasma palpe
brarm are pane aomas occrr ng on he eyelds
EPDEMOLOGY
Incidence reavely common
Age mddeaged adls
Precipiting factors hyperl ipidema presen n 50% of
paens w aneasmas fam ly sory of yperl iped
ima and anesma Yonger adls who presen waneasma are more i key o have l i pid a bnoma i es
PATHOGENESS
Abnorma ies of apol poproein E phen oypes or oer
l poproe ins
Secion 7 Benign Growhs 243
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2 Color Atlas of Cosmetic Dermatology
PHYSCA EM NATON
ateasm as comm oy present as m l ipl e soft symmet
rca oval yelowis papes and plaqes o e eyelds
D FFERENTA AGNOSESSyrgomas, sebaceos neoplasms m l ia ecrobotcatoganuoma
DERMAOPATHOOGY
Coectios of foam cel s n te superficia de rms .
COURSE
ey are geerally permaent wt tedecy to i crease
in m ber ad coa esce wt ime
MANAGEMENT
anteasmas ofte recr aer treatment wit any
modality
• S u g i c a E x c s o
S rgica ecsio s te treatment of coice for ateas
mas Te esion s lited ad e ecised usg a bade
or a Grade scissor Te defect s eter et o eal bysecond tenio or stred sig s k or eti lon stes
(Fig 50) Tis pocedre sa ly reslts n a very cos
metically accepabl e otcome
• Loca ze Tssue Destruct io
C or erb m aser vapor iza io tr ic oroacet ic ac id
eectrosurgery or cryoteapy
PTALS TO AVOD
Atog 50% o paiets wi anelasmas areormolpemc it is crca o scree ew pates w
aeasmas for e presece of yperl pidema Tis
s part icuar y mportant i yoger paiets wo pre
se wt atelasma sice tey are moe kely to
ave assocated l ipd abormat ies
Patents mst be made aware at complee removal of
te antelasmas does ot prevet fte develome
of ew lesos
Etreme cation sold be eerted wen operating on
te eyeli ds i ord e to avoid eye nry
A
BFigure 50.1 Xanthelasma on the le upper medial eyelid in a middleaged woman (B) The resulting defect is su tured using ethilon suturesThis pcedure produced a very good cosmetic result
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BBLOGRAPHY
Eedy J Treae o xaneasa by excsion w sec
ondary ieno eang Clin p Dermatol 1 996 2 :273275
Gosh YK, Pradan E Auwa ia HS Exc is ion o xahe
lasaacap shave a sre lnt J Dermatol2009;48(2) : 81 183
Hawk . Cryohera py ay be eecve for eye d xahe
lasa Clin p Dermatol 200025:35
anio G Papale A e Bel a F e a se o
erb YAG aser n he reaen o pa pebra xanhelas
as Ophthalmic Surg Lasers 20032: 2933
Naas TR arques JC co e i A Cunha s wai
aas C Fi lho JV reaen o eyeid xanelasa
wih 70% r cloroacec acd Ophtha Past Reconstr
Surg 200925(4)280283
llann Y HarSai Y Pele I J . The use o C laser or
he reae o xaeasa papebraru Ann PlastSurg 19933:504507
Secion 7 Benign Growhs 245
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EIGHTCutaneous Carcinoas
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248 Color Atlas of Cosmetic Dermatology
CHAPER 51 Actnc Keatoss
Acnc keraosis (AK) presen as snge or ul iple is
cree scay esions oun os requenly in habiually
sun-exposed sk o au ls
EPDEMOLOGY
A os cooly noed n idle age occasona y
occurs n paens nder 30 years
Sx ore coon in ales
Icidece very coo i n Ausra l ia 1 1 000 persons
Ra skin phooypes I I rarely seen n s kn phooypes
I VVI
Occuptio ouoor workers (eg arer rancher salor)
and ouoor spors (go enn s sai l ng) A
PAHOGENESS
Proonged an repeaed su exposre i n suscepible per
sons resuls n culaive kerainocye daage he
princple su daage is secondary o uravo e B (UVB)(290320 n igh
PHYSCAL EXAMNAON
AKs presen as sngle or u iple ski n-colored, eryhea
ous or brown scaly paches There is a predilecion orsun-exposed areas ncuing he ace ears neck ore
ars an orsa hands. AKs ay becoe hickeneoring a cuaeous horn. ore eas ly palpaed han
seen. They are genera ly asypoac bu ay be ender or pru r i c Ac n c cei l is deveops on he ver l i on
borer as dise scalng or ryness. Assocae elang
iecasia solar easosis an lenignes are requeyobserve
DERMAOPAHOLOGY
Epdera pro ieraon wih il-ooerae bas ar kerainocye pleoorphs parakeraoss an yskeraoc
kerainocyes Cyologcaly aypical keranocyes areusua y conne o he epider al basa ayer.
D FFERENTA DAGNOSS
Eczeaous derai is
Exra a a ry Pages
Squaous ce carc inoa
Basal cel carcnoa
B
cFigure 51.1 (A) Numerus facal actc keratoss pre-Adara treatmet(B) pected erythema ad crust dur Aldara treatmet (C) Facalactc keratoss post-Adara treatmet appled twce weekly for 4 weeksCourtesy of Rchard Johso, M
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COURSE
AKs can self-resove b geeral y are perssen in
nare e progress on o sk n cancer w preexis ngAKs is know bu s esiae a less a 1% o ini
val esios Bopsy warane for pgene As
(speic a l p igene ac n ic keraos is) or olarkeraoss
KEY CONS ULTATVE QU STON S
ra o of les on(s)
Lesoa rae of grow
Prio reae for esions an response
Persoal an faily isory of pror skn cancers
Hi sory o pri or rai aion reae o he area
Crre eica isory
eicaion se Evience o iuosppresson
Preisposng syn roes
MANAGEMEN
Assessen o e ber s ze ocaon freqency oeveopen an any elyng uosppresse
sae sol be obae A b opsy so be obaine o
any leson ha s sspicos or skn caces
Consiera ion ay en be gven o reaen of in iv i
a o l pe lesions propylacc erapy a eeriaon o e nee for c iical fol lowp
TREATMENT
Preveo
Appl ica io o a y sunscree wi VVB pro
ecion
Topica reioi appie ngly
opca
Oce a ly (Carac) or wice aily (Efex) applcaion
of 5-fl oro acil for 3 o 4 weeks
Twice weekly or every ir ay applcaion ofi iq u no (Aara 3 S Pa ) or 4 weeks
(F ig 52 )
cofenac (Solaraze) 3% soi opica ge wceaily for 2 o 3 ons
lgeol ebae applie o 2 sbseqe ays or
wice 1 week apar
Genle cryosrgey w a single freezeaw cyce
B iser oraon possibe Repea reaen ay be
reqire Rsk of eporary yperpigenaon an
Secion 8 Caneos Carcinomas 249
A
BFigue 512 (A) Actinic cheil itis, lower lip Patient complained of frequent peeling that was poorly responsive to cosurge and efudex(8) eduction in actinic damage following carbon dioxide resurfacingPatient repoed complete resolution of peeling
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wl perss urng he uraon of reae an for o
2 weeks posreae A opica coicoseroi ay
be prescribe posreaen copleion o assis in he
resouion of hese fin ngs
BBLOGAPHYAlbers , Rager-oore J, Einspahr J e al Safey aefficacy o ose-inesve o ra via in A in subjecs wih
sunaage skin Clin Cancer Res. 20040(6)875880
Ercson B, Sanberg C, Senqus B, e al
Phooyna ic herapy of acin c eraosis a varyng fluence raes: Assessen of phoobeachi ng pa n a pri
ay c n cal oucoe. Br Dermatol. 20045 (6) :204-22
Haley G erry S, oore RA l iqu o for ac inc er
aosis Sysec revew an eaaalysis nvest
Dermatol 200626(6) : 25-255
Jarvis B, Figgi P opcal 3% icofenac n 25%
hyaluroic aci ge: A revew of s use in paens whacc keraosis Am Clin Dermatol. 2003;4(3)203-
2 3
Jorzo J, Weiss J Furs K, VaePo C Efec of a
-wee reae wih 05% opical uorouraci on
occurrence of acinc eraoss afaer cryosurgey: A ranoze, ve ic le-coro l le c l n ica l r a Arch Dermatol.
2004; 40(7) :8 3-86
Rofarus S, aheson R, avs S, e a opica eyainolevulinae pooynac herapy using re ! l gh
eing oe l gh for ul ple aciic keraoss: A ra
oze suy Dermatol Surg. 200935(4)586592.
S l ler G, Gebauer K, Welburn P, Kasaas J Ogbourne
S PEP5 (ngeo ebuae) ge, a nove age or
he reaen of acinc eraoss: Resus of a raoize, oublebin, vehicecorol le u icenre phase
lla suy Australas Dermatol. 200950() :622
hai KE, Fergi P Freean , e a A prospecive suyof he use of cryosurgery or e reae of aci ic er
aosis lnt Dermatol. 200443(9)687692
Secion 8 Caneos Carcinomas 251
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252 Color Atlas of Cosmetic Dermatology
CHAPER 52 Basa Ce Ca cn om a
Basa ce l carc inoa ( BCC) s a s low-growng al gna
skin or a preses i d s inc hisoogica subypes
inc lud ing odlar sperf c a croodar n ra ngand opeafor Nodar BCC is e os coon
ype occr ig predonany o e ead and neck
regons.
EP M OLOGY
dee: e os coon skn cancer in Caucasans
wih approxaey 800000 cases/year dagnosed in e
ned Saes
Age os coon n paes over 40 years
Rae: os coon in Cacasans
Sex higer inc idence i a es
reag ars: cron c rav o le ad a ion and
fa r ski are he os s ign if ican ped sposing facors Oher acors inc lde on z ing rad a on arseic expo
sre iuosuppress ion PVA ad gene c pred s
pos i on
PATHOGENESS
e os coon a ered gene in BCC s e or sppressor gee w a resuan alered
Hedgeog signaling pahway eadng o reglaed ce pro l ifera io and a lered ce l l d ifferenia io ua ons n
e 5 uo suppressor gene ae a lso freqen ly
observed ead ng o ce l l u a r i o ra y ad res isance
o apoposis.
PHYSCAL EXAMNATON
Pn eryeaos pea ly ras lcen paple nodu e
or paqe wi a ro led border and overlyng eangec
as ias (F ig 52 ) S perf ic ia B CC presens as a p i k or
eryeaous scaly paq e. e ceer ay becoe
ceraed and covered by a crus a s roden cer"opheaor BCC exhibis a scal ke appearance wh
i l dened borders. Tey os coonly pesen in po
odsr ibed aeas.
DFFRNTAL DAGNOSS
eral eanocyic nevi sebaceos yperpasia sqa
os ce l carc noa (S CC)
Figure 52.1 Large B o th e fae Note th e haraterst rolled borders, overlyg telagetasas, ad the etral ulerato
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LABORATORY DATA
Demaopahoogy
Lobes ess, or cords of eoplasic basaloid cels w
perpera pa isadg, ce ig ad cos sroa.
COURSE
Loca y i vasve ad sow growig over ohs a d eve
years easass is a exceedgly rare occrrece
KEY CONS ULTATVE QU ESTON S
Excessve s exposre a d oer predis posg acors
pr or h isory of BCC or SCC persoal a d a iy i so o
ski cacer osppresso.
MANAGEMENT
Tere are pe eods for reag BCC reae
selecio shold be based upo e age heal, ad
prefereces o e paie aer a ful l dscsso of rea
e opios r isks ad bees Gve e loca ly
desrucive aure of BCC, isologica cofiraio ocopee reoval s opa Surgca excso ad so
logcal eval uao rea i he reae of choce i os
cases Tors ixed o deryg boe especia ly hescap er radioogca workp prior o srgca excsio
or os icrograpc srger opcal herapes require
cose fo ow-p or ay evdece of reae fai lre orrecrrece Paie edcao regardg e bees ofs avoidac e suscree use ad regul ar seexa a
os a re i poa preveve easres
F i rs e Therap es
Excsoa surgey: geerally w 4 argis s e
reae of choce for o sperfcia l BCC ha do oee e crier ia of os crograp c s rgery
os crograpic surgery s e reae of coce
or grs aaoica ocaios (ie, ask" area of
e ace) ocaos where issue coservao is c ruca l
or f coal or coseic reasos recrre ors l
defied c ical args soogcally aggressive sbypes ors i iosuppressed paes, ors
arger ha 2 , ir rad iaed ski ad per iera l ivaso o bopsy (Figs 52 2524) Mos crograpic
srgery as he ges cre rae o ay reae of
BCC
Elecrodesscaio ad cureage
Cyoerapy
Secion 8 Caneos Carcinomas 253
A
BFgue 522 (A) on the nose with very ill-defined clinical margins(B) Large defect aer Mohs micrgraphic surge Mohs m icgraphicsurge is the ideal treatment for this type of skin cancer providing thehighest cure rate among all other treatment modalities
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254 Color Atlas of Cosmetic Dermatology
Radaion heapy is aohe reaen opio espe
cia ly we surgery s o feasible o conraid caed Ican also be used as an aduvan erapy we per
neu ra l i vas o s ide ied
• Aerae heap es
opical iiquod applied ive ies a wee or a oal
d urao o 6 wees. is F A ap proved for reaen osuperficia l BCC Recurece raes are sigificanly
higer an su gcal excsio
opical 5uorouraci is priaily reserved o reaeof su pecal BCC Howeve ecurrence aes are igh .
Phoodyac erapy produces a poocecal
reacon a requires e presence o a poosensizng agen ssue oxygen ad gh wi phooacvaing
waveeng e os coon opica phoosens izers 5anolevuliic acid (5ALA) 5AA is a precurso
of e i n insic iracell u a r e ebiosynec pawaywich resuls i e producio of a phooacive por
pyri prooporphyn . Te eyl dervave o 5 AALA eyl aoevuliic acd (MAL) s aso very
coony used ad deosaes a beer seecviy
or aliga cells . Te l g souces are usua y n evisbe ig rage ad ey incude ase (coeren)
g sources (eg pulsed dye lases) or oncohere
g sources (ed blue l g). Red g povides edeepes peerao of hese lg based reae
odali es P can provde 76% o 97% clearaceraes or supeficia l BCC. is paicuar y useul i
paens wo are poor surgca canddaes or ose who
have u iple BCCs ha requre u iple sugeries
Close cl in ca o owup afer reaen is required fo
any evdence of recurrece or icopee reoval
alesio al ineferon is arey perored
Cabo dioxide laseay be eecve for superfcial
BCC a d paiens w u p le sa ow uos such as
n basal cell nevus sydroe
PTFALLS TO AVOD
nfecion bleedg pan n erve daage poor cose
sis fol lowig su gcal epair yperopic or aopicscarr ig, and recurrece are al l coon pfa ls of
BCC surgcal eapy ad shoud be u ly discussed
wi e paie por o reae
Nonsurgca erapies ay provide beer cosess bu
sgnficanly iger raes o recurrece uerore
osugica nervenos do no provide e opporu
y o isoogical confirao of coplee reoval.
They are bes or paens wo have uerous BCCs
ad i ose wo are poor surgca c anddaes.
Fgure 52.3 (A) urgical defect aer Mohs micrgraphic surge of BCCon the right forehead (B) epair of the defect with an A to T advancement ap Notice that the horizontal incision line is hidden within theeyebw hairs for a better cosmetic outcome
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BBLOGRAPHY
A i S K Lesar A cNe l A e a An op en p o sy o
a bulaory phooynaic herapy si ng a wearable ow
irraiance orgaic l gei ing iode ig sorce i hereaen o noeaoa ski cancer J Dem.
2009. ler F awe RS oseley F eg C Radoize coparison of ohs crographic surgery
and surgca exciso for sa odar basa ce carcnoa isse-sparing oucoe Dem S 2009
Rowe E Carrol RJ ay C Jr og er recrrence
raes n previously ureae (prary) basa cel carci
noa Ipcaions for pae fo low-up J Dem Sg. 199;535-32
Terney E Barker A Ahdo Han ke CW oy RKoba J Phooynaic erapy for e reaen of
caeos neoplasa nflaaory disorers ad pho
oagig Dem Sg. 2009;35(5)72574Wolf J Zie i JA Srgcal argis or basal cel carc
noa A em 197;2334034.
Secion 8 Caneos Carcinomas 255
A
B
cFigure 52.4 (A) Nodua basa ce cacinoma on the e peauicuaaea (B) Ceaance of bas ce cacinoma ae Mohs suge
(C) Pimay cosue of the Mohs defect with dogea epai
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256 Color Atlas of Cosmetic Dermatology
CHAPER 53 Sqamous Ce Carcnoma
Sqaos ce carc ioa (SCC) os cooy or ig
aes o keraiocyes i s-daaged sk eie de
ovo o ro a preexsg acc keraosis or s s i(aso kow as Bowe's disease) predoiay aec
ig e ead eck ad ars. I ca aso aise i os-exposed sk os cooly ro croic eg
cers ad br scars.
EPDEMOLOY
Iee: s e secod os coo ski cacer
Cacasas ad e os coo ski cacer darkly
pgeed ski Appoxiaey 50000 cases/year aredagosed e ied Saes
Age: os co o i paes ove 55 yearsRae: ai y afecs Cacasia s
Sex iger ic idece i a es
reag ar: croic ravoe adiaio ad far
ski are e os sig ica predsposig acos. Oefacors c de iosuppress io ua pap loa
vs ecio iozig rada o arseic exposre
geec dsoders (epderodysplasia verucifoisa b i is xerodea pgeos epdeoys is b
losa) PVA expose sokig ad croc if laa io ( cers b scars d isco id ps)
PATHOENESS
e os coo a eed gee i SCC s e o
sppressor gee esl ig keaiocye ioa iza io ad ureglaed cell po feraio.
PHYSCAL EM NATON
Hyperkeraoic skicoored o eeaos papep aque o odu e (F igs . 53 ad 532) I ca be cer
aed friabe or exopyc os cooly preses
wi s-daaged ski .
DFERENTAL DANOSES
Keraoacaoa (Fig 533), ypeopc acic ke
aoss basa ce l cacioa (BCC) iflaed seboec
keaoss
Fgure 5 3 1 Inase squamou cell carcnoma on the rght nec
Figure 532 ecurrent squamous cell carcnoma on the chest o f an
elderly woman
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LABORATORY DATA
Demaopahoogy
Proliferaon of aypical keranocyes wi variabe derena on o he epders and varably sized ness and
is lands invadng he deris Foc i of era n za ion are
noed n well-dferenaed varias Perneral ivolveen ay be observed
COURSE
SCC eds o be ore aggressive an BCC wih a
repored 2% o 3% icdence of easass cocaneos S CC as a ger rae of easasis as
g as % ore aggressve ors of SCC are observedin unosppressed paens or s a arses win
prevosly irradiaed ses scars brns and areas of
inflaaion Tere s a ger easac poenial for
s arising on he ear and e ip
KEY CONS ULTATVE QU ESTON S
Evalae for pas hisory o bl isering snbrns and
chronc su exposure eerie if oher pred sposing
acors are presen sc as personal and faily isory of
skin cancer and inosppression especal y organransplanaon
MANAGEMENT
Preveave easres sc as sn avodance and da ysnscree se are cri cal or longer prevenion
Treaen selecion sould be based pon he age
ealh ad preferences of e paien afer a fl discsson of reae opions rss and benefs Gven he
easaic poenial o s sologcal coniraion ofcopee reova is aways advised Surgical excsion
and sologica evaluaio rean e reaen of
choice i os cases Tuors fixed o nderlying boneespecia ly e scalp eri radologcal workp prior o
srgca excision or os icrograpic srgery Prior oreaen lyp node palpaion is appropriae or arge
s s n nosppressed paiens and hig-rskSCCs opica erapes reqre cose fol ow-p or anyevidence of reaen fai re or recrrence
F i rs-L e Therap es
Excsio na su rgery: 4- argins are general ly reco
ended
os crograpc surgery s e reaen of coce
or g-r s aaoica ocaions (ie, as" area of
e face) ocaons where issue coservaion is cr ca l
Secion 8 Caneos Carcinomas 257
Figure 53.3 Giant keratoacanthoma on the chest Many authors regardkeratoacanthomas as variants of elldifferentiated squamous cellcarcinoma
AFigure 534 (A) efect on the ear aer Mohs excision of a squamous cellcarcinoma
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258 Color Atlas of Cosmetic Dermatology
or unciona or cosec reasons recurren uo rs i
dened cln ical argins h sologica y aggressive subypes uors n unosuppressed paiens uors
arger ha 2 ir rad ae skin ad per ieura nvasion o biopsy ( Figs. 53.4 an 53 .5 ) Cu re aes o SCC
depe on sze hisoogica grae perneural nvasio
and iuosuppression. arger esons less dierenaed varas wih perieural involvee and esions
n unocoprosed paiens eonsrae ower
cure raes
Eecrodessicaion and cureage (usually no reco
ene due o ac o hisologic conirao oreova)
Cryoherapy (usually no recoened ue o lack o
hisoogica coniraon o reova)
Rad oherapy (ap propriae or poor surgca can di aes)
• Aeae heap es opical 5uorouraci s e o SCC in siu
opica l q u i o is l ed o SCC in s iu
nalesion al inereron
Phoodynac erapy (P) using opical or sysecphoosensizers wh lasers or oncoeren red g
are os eecive or SCC n siu C leara nce aes range
ro 72% o 94%. PT can ac as an aernave reaen or large esos especially or hose paens who
are poor surgca c andid aes can serve as an a erna ve reae paiens wi u ip le SCCs For ese
paens PT an close c n cal ol ow-up ay obviae
he eed or uipe surgeries PT s aso eecive ordecreasig he nu ber o acn c eraosis us acing
as a prevenave o uure s evelope
Carbo d oxe laser is h ighy eecive or acini c chei l i s can a so be used o rea SCC s u
PTFALLS TO AVOD
Inecion beeng nerve daage pan yperropc
scarr ing poor cosess o lowng surgca repair and
recurrence are a co on pa s o SCC reaen a
sou d be u ly d scusse wi he pa en pr io r o reaen. Nonsurgcal erapies ay provie beer cose
ss bu sgniicany igher raes o recurrence.uherore nonsurgical inervenons do no provide
he op porun y or h soogica coraion o cop lee
reova . Th is s parcul ar y crucial gve he poenial oeasaic sprea wh SCC Tus sanard or Mohs
i crograp hic su rgical excsion wih hisoogica conir aion o clear argns s al ways e reaen o choce or
BFgure 534 (Continue {8) The Mohs defect is repaired ith a
fullthickness skin gra
s AFgure 53.5 {A) urgical defect aer Mohs micrgraphic surge of an on the lef cheek
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BBLOGRAPHY
Covadonga M arnez-Gonzez M , de Pozo J, Paradela S
ernnez-Jorge B ernnez-ores R, Fonseca EBowen's disease reaed by carbon doxide aser A seres
of 44 pai ens J Drmalg ra 20089(5)293299
Moon CA McKenna KE Rodes LE. Bri s Associaionof eraologss Terapy Gudelines an Audi
Subcoiee ad e Br is Pooeraoogy Group.
Gudeies o opca pooynaic erapy: pa rJ Drmal 200859(6)245246
Preson S Sern RS. Non elan oa cancers of e ski n g/ J M. 992327649662
Rowe E, C arrol RJ ay CL Jr. P rognosic facors fo
local recurence easasis, and srviva aes in squaous ce l l cac oa o e skn , ear, an i p . p ica os
or reae oay seecion J Am Aa Drmal.992;26:976990
Secion 8 Caneos Carcinomas 259
B
cFgure 53.5 (Continue (B) The Mhs defect is repaired with a traspsiti flap (C) Ater suture remval 1 week later
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IEInfammaoy Disoders
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262 Color Atlas of Cosmetic Dermatology
CHAPER 54 chen anus
Lche paus (LP) s a coo aaoy dsease
ivolvg e sk ad cous ebraes a y c i i ca l
varas exs ha clde aropc lcerave b lousauar ear iverse hyperrophic l chen paopilar s
acc P ad LP pigeoss
EPDEMOLOGY
Abo 05%
g: 30 o 60 years
Ra: All races are aeced eqally os varas
Sx Higer cdece i eales
rg ars: os cooly id iopah ic edica
os ay dce a LP- ike erupo
PATHOGENESS
Pri ai ly a he per ce ed aed reaco
PHYSCAL XMNATON
os cooly piay lesios consis o uiple vioa
ceos poygoa la-opped grouped papules ad
plaques ha are sal y pur ic heir surace s shiy or
aspare ad ay exhbi sal gaywhe pcae or
reicar ie whie ies kow as Wckha's srae Telesios avor he oroparyx exal wrss dorsa hads
edial hghs s s r k a d geal a . Posaaoyhyperpigeaion is coon. Aciic LP ad LP pge
osus ca prese w easa-ike hyperpigeed
paches o he oreead ad he ace ( Figs. 54. 54. 3)
D ERENTAL DAGNOS S
Psoriass che splex l icheoid gra-verss-hos ds
ease chroc caeos ups eryheaoss l cheod
drug erup io elasa
BORATORY DATA
Gve he assocao wih hepa is B ad C hepai s
serologes ca be vesigaed
• Dematopathoogy
Pahology reveals l icheoid ieace dera is hypek
eraosis ypegrauosis saw-oo acahoss associaed wih col o id o r civae bodes
Figure 54.1 Actnc LP on the forehed temples, nd lterl cheekmmckng melsma
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COURSE
Sponaeous reission of cuaeous P occurs wihin
year of onse in he aory of paens Ora LP pesiss
or any years Sq ao s ce c arcinoa ay arse fo
hese lesions predoanly fro e oral varian
(F g 544)
MANAGEMEN
• Topica Teamet
Coricoserods opica nralesional
l u ooduaors such as acro l i us
Cycosporne reeion ohwas for ora P
• Sysem c Teamet
Coricoserods Re ino ids : isore io in and ac ire in Ac re in is he
only sysec eaen ha has been evaaed in a
doubleb nd p laceboconro l led sudy
Griseolvn eronidazoe aniaar ia s eorex
ae cycosporne a d ycopeoae ofe l
• Ligh Teame
Narrow Band VB
PVA
308 VB excie aser for oral P
C aser for oral LP: vaiabe resuls wih ncreased
risks of sde eecs
Exracorporea phooporesis
BBLOGRAPHY
aak A asoudi A Boudaya S Bouassda S
arekch S Turki Ch ldood ac in ic ichen planus
(6 cases) [p b shed on ne ahead of pr in Januar 8,2008 Ar ediar. 2 008 5(2 ) : 4
Laurberg G Geige J orh , e al reaen of
l cen paus wih aciren A doubleblid placeboconroled sudy n 65 paens Am Aad Derma99;24(3) :434437
Trehan Tayor C R Low-dose excie r 308 laser for
he reae of ora cen panus Ar Derma2004; 40(4) :4 5420
van de He PS Egges M van der Wal JE Roodeburg
J C laser evaporaon o ora ichen paus raaxila Srg. 200837(7)630633
Secon Inf lammaory Dsorders 263
Fgure 54.2 Generaized lichen planus in a patient ith skin type 1 VV
invoving the trunk and buttocks ith postinammato hyperpigmentation
Figue 54.3 Hypertphic lichen panus on the legs of 4 years durationresistant to topica and intraesiona steroid therap The patientimproved markedly aer 1 month treatmen t ith acetretin
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264 Color Atlas of Cosmetic Dermatology
A
BFigure 54.4 (A) Ora/ lichen planus at baseline (B) Two month followupafter 1 treatmen ts with excimer laser admin istered weekly Courtesy of
Charles Taylor, M
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CHAPTER 55 Morphea
orphea s ocalzed sclerodera cofied o he sk.
os cooly affecs e ru k bu also occ rs o he
ace ad exrei es. Te for c ica varias cludepaqueype orpea geera ized orpea iear or
pea (e coup de sabre) ad pascleroic orpea ofch dre (orpea proda) .
EPDOLOGY
iee rare
Age os cooly occurs he secod o ff
decade. iear scerodera ad orpea profuda are
Secon Inf lammaory Dsorders 265
ore coo i c i dre ARae slgly ore coo i Caucasias
Sex eaes o re a ales (23 : )
reiiig aors orrelia ca r gger orpea i
soe cases predoay i Europe
PAHOGENESS
Overproduc io of co l lage (ypes , I l l ) ad gly
cosaioglycas by sk fibroblass ad vascuar daage Probable Tcel edaed peoeo.
PHYSCAL EXNATONI defed p k o v io laceos iduraed 2 o 5c
paques a rasor o soo scleroic vorycolored
plaques wih a g voaceous border ad a siy sur
ace Posflaaory yperpgeao is prevae
(Fg 55). iear orpea preses wi a ear eryeaous iflaaory sreak a ay progress o for a
scar ike bad volv ig uder y g fasc a scle adedos.
DERENTAL DAGNOSES
Acrodera is croica arophcas eosiophil ic asci s ce scerosus e aropcus scleredea sce
royxedea a d ep rogec syseic fibrosis
LABORATORY DATA
Seroogy
Ceck for Borrel a aibodes.
Bigure 551 (A) Early morphea on the let leg presenting as an ethematous plaque (B) ame patient with late stage morphea on the right legpresenting as linear depressed yellowish to white hard plaques with ethematous margins
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266 Color Atlas of Cosmetic Dermatology
• Dematopathoogy
Homogezaion and hickeng o erma colage bu
des apped and arophic eccine gads perivasclarmonocear inf lrate o lyhocyes ad asma cells
wih norma or aroic over ly ig edermis ner ly ing
subcaneos fat may aso be nvoved wit scleross iadvanced cases
COURSE
Course is vaiabe. Many paies remit soaneously
bt oers have a rogessve course.
MANAGEMENT
reatmen or this conit ion can be rusaing ue o re
qen reatme fai re Paens shoud be couseled
that era y ay ot be eectve
opical treament
Cocoseroids
Calcpot ee
Systemic reatme
Coicoseroids penciane vitan ethotrexate
Lght reate
ravolet A ooheapy
Plsed ye lase (585 n 5 J/cm twice monly)
repoted to be efective n s ngle cas e report
Subcs on : subcis o wit a okor 18G needle mayhep o eevate the bound-down skin It s most efecve for l ear orpea and facia hearohy
Subcsio is pefored under loca ini trat ve aneste
sa to he afeced ste wit % l idocaie wih
:00000 epinephr e . Te Nokor neede s inro
duced at a 45degee age into te skin i l zing a
sweeping moio o eease any eheed areas.
Mu ipe enrance sites soud be eomed or opi
a benefit r pressre is aplied to te treatment
stes or emosasis
Sof tissue agmetaion: varous fi es ave bee
emloyed wh varabe success to augmen e scerotc sies. Tey are most commoly l ized fo l inearophea an d acia hemi atropy Tepoar i l le rs cu
rently recomm ende give e unp red cable course o
ophea. Atologous at asfer can povde significant augmentation of e afected sies (g 55.2)
Repeat iections genea y equred En bloc atoogous derma a gat repoe o be efecive in one
case repo
A
BFigure 55.2 (A) Morhea wth sgnfcant edermal dermal and subcutaneous atrhy 8 Elevaton of the atrhc laque of morhea aer asngle autologous fat transfe The assocated telangectasas were subsequently treated wth the ulsed dye laser wth substantal mrovement
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P TFALL TO AVO D
Paens ms be awae o he nredcable nae o mo
hea, hereore he nredcabe nae o e eame
BBLOGRAPHY
Esen , Alser S se o 585 nm sed dye lase ohe eamen o morhea Dermal Sr 2002;28(7)
6566
Laiee JC Aasi S Cook B Moao A Sccessl cor
recion o deessed scars o he oehead seconday o
ama and morhea en co de sabe by e boc aologos dema a gra Dermal Sr 200026(8)793-
797
Nisic SP Saaceno R, Sciani C, Cosazo A,
Chmeni S een alcaios o monochromac
excme l gh in skn diseases Pme aser Sr
2009;27(4)647654
CHAPTER 56 Psoass
Psoiass s a commo choc n ammaoy dsease ohe skin They are symmeic in ds ibo and ao
ebows, knees, sca, reroaica sk and ner iginos aeas May cl in ical arians exis and incdeaqe sorass sa soasis, gae soiass,
inerse soass, and eyrodemic sorass, wh he
aqe aria being e mos common ye (gs 56
and 562) Na i ls and mcos membanes can be
aeced Psorasis is associaed wh soriac arhis ina eas 5% o aens
EPDEOLOGY
cece Abo 1 5% o 2% o he word 's olaio
Age can occ a any age Two eas o onse, he second and sixh decades Onse s ear ie in women
U ncomm ony aecs chi ld re
Race owe ncidence in Aican Ameicans, aie
Amer icans, and Asas
Sex eqa
Precg acrs baceal necions, esecaly seococca ineco (gae sorasis) ama (Koebner he
nomenon), sess genec edisosion, and medicaionse (mos commonly ihim bea blockes aimaaals)
Ra id coicoseroid aers may in dce sar soriasis
Secon Inf lammaory Dsorders 267
igure 56.1 Claic poriatic plaque on the knee
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268 Color Atlas of Cosmetic Dermatology
PATHOGENESS
Poygenc dsease wih a 4% isk fo a ch ld o develop
psoiass boh he paens ae aeced he piaypahophysoogy nvoves hypepofeaion and abno
a difeeniaon of epidea keainoces as we as
abnoal ce l u la im un e espose
PHYSCAL EXAMNATON
Paque vaian wih welldeacaed pn o eea
ous papules ad paques wih ovelyig si veywiescae Pinpoin bleeding obseved wih scae eoval
(Ausptz sign) Guae vaian wih ea dopshaped
lesons Eheaos genealized pusues ae seen whpsula psoass
DFFERENTAL AGNOSES
inea copois sebohec deai is eczemaos de
ai is ycosis fugodes paapsoass chen smpexchonics piy ass uba pi a is Ree's dsease
Bowen's disease
ABORATORY DATA
• Serology
Ansepolysi O(ASO) ie fo guae psoasis
• Dematopathoogy
Regua psoiasifo epdea hypepasa wih absen
ganu la ce l l laye ad h ni ng above the deal pap lae Ohe chaaceis ic feaues incude colecos of
neuopi s in epde mis as well as ouous blood vessels
in e pap lay des
COURSE
h s dsease deonsaes a chon c couse wi u ip le
exacebaions and essons wich can be seasonal o
eaed o sess
MANAGEMENT
hee ae mul pe heapeuic opions fo eamen o
psoiasis Coosng an appopiae heapy depends onhe age eah ad pefeences of he paten It a so
depe ds o he exent of he psoias s Te coss of he
apy vay damacal ly as wel Aenaive theapies aeos appop iae efacory cases Assessng he side
efec pofle of eamens is anohe cucal componen
Figure 56.2 Psoriatic plaques koebnerizing vitiligo patches
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o theray Combiatio terapes are geeraly most
eectve to decrease ilammato a reuce scae roduct io
opca reatmet
Coicosterods toica a itraesioal
Calcipotiee
Tazarotee
Coa tar
Athra l i
Sal cy ic ac
Systemc Treatmet
Metorexate
Retods redomaety acitret
Cycosore
Bioogcs suc as aleacept etaercept eauzimab,
ad i x mab
Laser ad igt Treatmets
sorae wt ltravoet A (PVA
ltrav io et B (V) 3nm arowbaVB (B
V
308-m VB excimer laser
A ateative or treatmet o mdtomoerate
soriasis where more covetoa t eraies havefailed It s eseciay hepfu fo localze eractory
aque soriass
Studes ave emostrate that tis ocalize VBtreatmet provides muc lower cumulative doses o
VB to uce clearace o soriat c laques compare to BVB te rapy
The exci mer laser migt also produce oge rems
sio eriods wth m i im izato o VB exosure tohealthy surrouig sk
Excme aser has proved to be eective a sae i
treatig reracto scal psoriass
rawbacks of excme aser sorasis teatmet
clude l mted ava labi ty treatmet exese a
extes ive treatmet tme eee e sessio
hotoyami c therapy has bee sh ow to m rove so
riasis i mult le stues The maor side efectsic luded pa ad burig sesat io assocated witT
ulsed ye aser (0455 ms 7mm sot 79 J/cm
C 30/20) has bee empoyed to target the vas
cularity associated wit soiatic esos with ote
beeit I a ecet study L roved to be eective
t e treatmet o a l soras s ( ig 563)
a recet study AG lase (064 m) ai le to
im ove local ized paq ue type soriass
Secon Inf lammaory Dsorders 269
T
Fgue 563 Improemen t in treated psoriatic plaque months after
pulsed dye laser treatme nt 55 nm, 1 0mm spot size, 5 Jm, no cooling, 0 45ms pulse duration, as compared to the con trol siteeproduced, with permission, from rian Zelickson, M
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270 Color Atlas of Cosmetic Dermatology
PTFALS
Patiens sou d be couseed at psoiasis is a cronc
condi ion wi lares ad reissions Laser terapysuc as te excie aser s a aeaive treaent
ha sould ony be considered aer a paen has ailed
u lt ipl e oher reaen regimens
Patiens shoud be awae a any treate adiis
ered i ay esu in spread o e psoasis (Koeber
penom enon) Tey sould a so be aware ha surgicalreatens peormed or any reason ay also resu in
s ii a spread .
BBLOGRAPHY
ernndez-Guar no M Haro A Snchez-Ronco M
Garca-Moraes , Jan P Pused dye ase vs poody
naic erapy in te treate o reracoy nail psoria
sis A coparave pilo study J Eur Acad DermalVenerel 200923(8)89895
Gattu S Rash id RM Wu JJ 308-n exce lase n
psoiasis vugaris scalp psoiasis and paloplantar pso
r ias is J EurAcad Dermal Venerel 200923() 36-4.
Noborio R Kuokawa M Kobayasi Moia AEvauat ion o e c l in ica and im uno iso ogica eicacy
o the 585 pulsed dye laser in he treaent o psoras is J Eur Acad Dermal Venel 200923(4)420
424
Ss T Kepennng MM va Erp PE va de KerkoPC Gerr sen MJ A paceboconro led randoized
sudy o e cl n ica eeciveness iunoisocheicalchanges ad prooporpyrin I accuulaion in acton
aed 5ainoaevuln ic acdphoodynaic herapy n
patens wi psoriasis Br J Dermal 200655(2) 429436
aylor CR Racee A. A 308-n exce laser or thetreaent o scalp psorasis. Lasers Surg Med
200434(2) 136-140.
Van ingen RG de Jong EM van Ep PE va M eeerenWS van De Kerkho PC Seyger MM Nd AG laser
(064 ) a s to ipove loca zed plaque type psoa
s is A c l in ica ad unosocheica l p i lo sudy
[pu bl ished o n i ne ahead o pr i Ocober 27 2008] EurJ Derma l 2008 8(6) 67 -676
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TEN
Ad pose T ssue A l terations
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274 Color Atlas of Cosmetic Dermatology
• Sugey
I n e even o edc a reaen a l ue s gcal era
is e nex oon I is reserved or aens w reacor gnecoasia a has ailed edca era he
reaens deen d o he exen o gnecoasa A ew
oons are descrbed beow
Sugca excsion incldng sadard el ical excision
as we as subcuaeous maseco
Conveniona and lrasoundasssed ioscion a
s ocalzed eova o gland ua r issue and/or excess
a Tis is arcal successul in ear sage and ied gnecomasa
Losucon is eormed hrough small cis ons n
e ax la and sernu o n ze scar r ing
Losucon is less eecive n ongsandi g and s ubsaial gecomasia
n rosae cace aiens earier erveion s
ore ecacous
Resdu a eraeolar a a be noed osl osucon
a ca be imroved w loca ized dissecon o a
v ia a sma l er areo ar nc s o
Posrocedue skin laxi a be noed
Cobnaion o surgica excisio and uescen l o
sucion is nvoves l iosuco, oen excson adskin reducon o ax osuco as also been
comb ned wi s bcuaneous aseco
Sugica excisio wih lasic surgical rea , ar ic
a r i n he eve o breas issue saggi g Excessive a,
gla du ar issue, and loose skn ae excsed va el l icalexc is on nc lud ng e i e ad areola e
ni le/areoa co ex is e aced e aroriaeanaoic os ion as a u l ck ness skn gra ae e
excess ga nd la sse s eoved
Psuedognecoasia ca be reaed wih liosuconMale breas a ends o be elaive ibrous ad s
ore dcul o rea uher care us be aken oavoid nur o e ecoralis scle n rue gnecos
asa excess glan du ar issue enders e rocedure
even ore calenging
We adi oa iosucio and umescen osucion
have domnaed losucon reaen o gnecoasiaand seudognecoasa laseassised iosucon s
a ecen add io o s e d Tee is no evidece o
sow a laserassised iosucon is sueor o eiero ese os o i osucio n
P TFALLS TO AVO D/CO PL CAT ON S/ANAGEENT/OUTCOEEXPECTATONS
s oan o recognze ha gnecoasa a s ml
e eooges beore aeing o rea i
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n mos cases wacu waing s e bes heap.
n cases o an unde rlig ssemc ca use eerra o e
ap opae specia is s man daed
n cases o drugnduced gnecomasia dsconua
ion o e medcaion is e bes managemen.
n case s o eraco o me dica ma ageme hee areseveral surgcal opions Compicaions rom ese o
cedures incude a poor cosmeic esu osoperavescarrng incomplee eova posprocede skin laxi
peane numbness n e aea and eaoma o
a on
BBLOGRAPHY
Asan G Tuncal i D Ter ogl A B ngu l F . Per iaeo la
ransareoarpeeal incision o e sugca reaeno gnecomasia Ann Plast Surg 200554(2) 30-34.
Bebo SA Cason Gnecoasia Is eaures andwen and ow o ea i. Clee Clin Med 2004;(6) 5 5
Gabra O Morabio A B iac A Bowe
Gnaecomasa n e adolescen A sugica reevancond ion Eur Pediatr Sur 20044() 36
Gaseon C Sagael o M Gasperon P. Technca eine
mens in e srgical reamen o gnecomasia. Ann
Plast Sur 200044(4)455-458
lwuagwu OC Cave A ll sle D Drew P . U lrasound
guded mn mal invas ive beas suger (UMIBS) Asuperor ecnique or gecomasia Ann Past Surg
2004;52(2) 31 33Rohr c R a R Kenke M Adams WP r .
Class icaion and managemen o gecomasia
Den ng e roe o ulrasound asssed l i posucon Plast
Reconstr Sur 2003 (2 ) 909923.
Gra R Auersva d A Damaso RC Rippel R de Arajo
LR Bigae i H Franck CL lasound-asssed l posucon: A anass o 348 cases Aesthetic Plast Surg
2003;2( 2) 461 53
Zeckson BD Dessel TD Discssion o aseassisedloscon. Lasers Surg Med 20094(0)0993.
Secion 1 : Adipose Tssue Aleaons 275
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KEY CONS ULTATVE QU ESTON S
I maes qu re as o a poss b l i o edocr ie abo
malies Ts is a ve ae assocao of celle males .
MANAGEMEN
Tere is o medca dicaio o ea ce l l ie S l l ma
paies reques herap Crrel here ae meosprpored erapies oe of whc ave prove o be
ver eecive. Ieresigl despie e ack o scecevde ce of im poveme ma paies repo sbecve
im proveme a d sasfacio wi erap
TREATMENTS
• Det
Weig has ol a mi o associaio wih cell u l ie
s commo femaes ad rae i obese maes
ee s o daa o sow a de ad exercse are
eecve eames
• Topca Treaets
Amoph l ie e o ids lac c ac id xa es adma oers have a bee sed w i le evidece o
ecac
Some ceam s ma podce moe ham a bene
fac oe sd dicaed 25% of ceue creamsexam ed coaed kow coac al erges
• I tervet oa I Treatets
Lposucton
ee are a few pbised epors o mproveme
owever pical i does o improve celuie
some cases acceaes he appearace o cel
i e
Prio o perform g a l posco procedure i s se
o orm paies ha er ce u e w l l o esolveThi s wil proec agai s pospoced re disappoi me
Endemooge
demologe is a FA cleaed devce o mprove he
appearace o ce e
Ski is keaded b a had eld machi e
i s rol led over aeced a reas of he bod a are cov
ered b a o s
prpos o mprove bood ad lmp ac fow as we l
as sk a rchiecre
Secion 1 : Adipose Tssue Aleaons 277
Figure 5.2 Velamooth laser treatment of thigh of young female
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278 Color Atlas of Cosmetic Dermatology
wce weekly teatmes of 10 o 45 mintes eac ae
ecommended
hee is a ie evde nce to sp po s efficacy
Subcis on
Req es oca aestesa
Usin g a scapel o special 16gauge neede he fa septae are c n e deep su bctaeos fa
Sde effecs icde pa bsing sca and puckeig
Lie data to sp po tempoa y eicacy
MesotherapyPospha idy co ne in ec ions ot a ecommended
herapy
neco of combinatons of igedents decty nosbcaneos fat
Phosphatidyco i ne and deoxycholae peparaios ae
mos commony used
eoxychoate s the acve gredie
No publised data o show efficacy
aser
VeaSmooh system (Syneon nc Rchmond Hi l l Oario Canada) combes neanfrared ight a a
waveength o 700 o ,000 m coninos-wave ado
freqecy ad mechanca scion (Fg 58)
Twce weekl y reatmes for a ota o f eght to ten ses
sions have been ecommended
Thee ae o long-em daa o spo is effcacy ipaiens
e TrAcive asedeolo (Cynose I nc Chel msod
Massacses) com bi nes six neanfared d iode asers a
a waveengh of 810 m locaized coolg and mecha
cal massage
Three weekly eamens for weeks and then
bweeky teatments fo 5 weeks ae sggested
Thee ae no long-em daa o spo is ecacy i
paiens
Oter FA cleaed devices iclde a nipoa adiofe
qency device (Alma Accent A ma c Buffalo G oveIll ) ad a dal waveegt laser sysem (SmootShapes
Eleme Medca Inc Merimack New Hampse)
PTFALS TO AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS
Paes so ld be i nfomed tha hee ae o ly eec
tive eames for cell ie t is also mpoan to ds n
gish teaments fo body conog and fat emovafom hose of cellie Mos of he posive esls reaing
to cellu l ie treamen ae aecdota o repoted n sma
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280 Color Atlas of Cosmetic Dermatology
CHAPER 59 V Lpodystrophy/Faca poatrophy
HI liodsro descibes a coselaio o chages i
subcaeous ad visceral a dis ibuio aies o
areovira heap dscio o l poaro"(wic descrbes local a loss) liodsro reers o
bo he accu u lao o a as well as he oss o a ioer areas I HI l iosroh he idigs icde sb
cuaeous a loss i e alar ad bccal a ads eaca l i oaoph as we as o e exremi es I a lso ea
res a accuulao o he dorsocevcal a ad( g 59 ) e balo hum p breass ad raabdoia l
cav s caraceis ic apearace s sigica i h a i
reduces aie coliace wi airerovira eraad derives aies o HI saus ivac paricularl i
comu es were I raes are ig s disoder isaso associaed w a hos o meaboic disorders wi
logerm iac o eah cdig ergcea Aherl deia ad eriglcerdema reaesvar accord g o e c ica digs
EPDEMOLOGY
cdece: 25% o 83% o aes reaed wi a rero
vias deed g o crier a used
e A ages b u older age is redcve o seve
Race: Noe
Sex Eqa severe d igs more reque i eales
PRECPTATNG FACTORS
Arerovra eraies are e recpiag acor. I aso
preses requel i HI aies ave o I er
a Tica aies are o combaio eraies.
PATHOGENESS
Pahogeess reais u kow I i s a u iacoria l dis
orde ha vaies accordg o e ed caios ake .
DERMATOPATHOLOGY
Coee o ear coee loss o a Jxaosiio o
he deris ad ascia ma be see Adioces ae
aked redced ber ad s ize
PHYSCAL ESONS
a accu mu laio a d a loss are disp laed
a accmuao
Figure 59.1 (A) "uffalo hump n dorsocervcal back of HI V-nfectedmale (8) ubstantal reducton n se of buffalo h ump after lposuctonpcedure
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Dorsocervcal at pad, ie, ualo hp
Beasts
Intra-abdonal cavi e Crx bell
a l oss
Mal ar ad bcca fat pads
Exeites and buocks
D ERENTA DAGNOSS
er ipodstrophes facial l poatroph fro agng IVwastg sdroe C si ngs disease, al uit o sates
anoexa nevosa etabolic sndoe cacexa sec
onda to cancer aasoption sndoes, otoxico
ss, and ut pe setic poatosis
LABORATORY EAMNATON
Bio ps s not sefl e c n cal n di gs ae sfc e toake a dagoss. Laorato wokup shod clde
assesset of bood gcose l pids ad tr gcedes f
Csig's s cl in ica sspected aoator exaaio
soud be pefored
COURSE
IV lipodstop does o spotaneous egress i eabsence of treate o edcato cage
KEY CONS ULTATVE QU ESTON S
Medcatio se
Cop iance
HIV staus
Du aton of podstopr
Associated peglceia pe ipdea, ad pe
tr iglceideia
PREVENTON
ce a patie as ee teaed for t e IV vus, thee so pevetion o IV l i podstop
MANAGEMENT
Cosetc poveent can e essetia to prootg a
patets aderece to ter V ed icato regi e ere
ae severa eans wich te cosetc appeaace of
IV l pdstop can be proved ese inc de edca
tio changes fil ler sstances and liposuction Diet adexercise can e hepfl boh or cosesis ad etabolc
Secion 1: Adipose Tssue Aleaons 281
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282 Color Atlas of Cosmetic Dermatology
deangemes. eaing te meaboc deagemens s
bes efeed o ysicians sklled in eag hyelidemia yeiglycedema and nsuin essance.
TREATMENTS
hee ae sevea eamens a can imove hecosmetc aeaance of hese dsodes. They can bedvided ino wo secions eament o l ioaohy and
eamen o a accum ulato n. Add i ional ly ca nges i n
medica os ca n b e usued. h s s bes entused o a
hysician who secializes in he cae o aies with HIV.
• O r a M e i c a i o s
A chages to a a netoval egime n ae bes handed
by hysicians who seca ze HIV eame hese
changes ca move he aeaance of HIV odyso
hy edicao chages icude scontn uance o f aneova heay
Obvous sks of disconinung medcaions fo a l ife
heateng less
Change HIV medicaions
Oe HIV medicaions oduce he same cod io
Some aeovas have a owe incdence of
iodysohy
• Teame of Fac a l i poaopy
Temporary fi ers PolyLacic ac d Scul a s A c eaed o he ea
men of HV faca l l oaohy
Syeic bodegadabe oyme
he mateial used n Vicyl suues
Sevea eamens ae equied deedng on sevey of ioaohy
Benefs ae o seen u weeks ae eac teament
8 o 24 moth d uao of f l e maeal
No need fo al legy esing
Calcium ydoxylaaie Radiesee s A cleaed ohe eame of HIV aca l oaohy
m mediae coecon
uaion u o 8 mons
No need fo all egy tesing
Permanen fi ers
S l icoe
No A cleaed
A highy uf ied 000cS s icon o has been exam
n ed in 7 7 aens
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284 Color Atlas of Cosmetic Dermatology
acial plastc sugcal proceures ca be eectie, but
reqi e ao i ase srge wt ts aedat r sk s oobity Tee s also iceased ow t e, pai, a
te r isk o geera l aesesia
BBLOGRAPHYBox Po ly act ic ac i pas A ew s e or l ipoatrophic aces?AIDS 2003 7 7 ) 2533-2535
Carrutes A, Carutes J Eaatio o ectabe ca
cum yoxyapatie o te reate o acia l l i poaropy assocate wi a iuodececy us
Dermaol Sur 200834 ) 486-499
Carrutes A ebesk , Carthes oster B
Radiograpic a copute toograpc stuies o ca
cum ydoxyapatite o eate o associatedaca poatopy ad coectio o asoabal olds
Dermaol Sur 200834Supp S78-S4
Conol ly , Maders E R d le S Shot cou icat o:Sctio-assse lpectoy o lipoystropy AIDS Res
Hum Rerviruses 2004208)8385
Haiga C Yawe S, Toas A, aers , Sax PE,Gispoo S etaboc eecs o osig itazoe i
ipoysopy A raoze, corol le tr a Ann Ine
Med 2004786-794
oes , Cates A, Oere c e a g ly p
ie 000 st s l ico o i l or treatet o ha i m u
odeicecy irusassocate aca l ipoatropy: A ope
p ot t ia l Dermaol Sur 2004300)279286
Koutkia P Caaa B, Beu J To iai , Kissko Grispoo S Growt omoe-eleasg oror
iected e wit l ipoystophy: A raomized cotro ed t ia l JAMA 20042922) 2028
Ley RM Redbo KP, ake CW Treatet o
lipoatopy ad l poaropy o agig wit poly--Iacc
aci a prospectie 3year ollowup stdy J Am Acad
Dermaol 2008596)923-933
Pileo P bbad , g J, arago J se o ulta
soogapyassiste iposuctio or te teaet o
ua muoeiciecy irus-associate elagemeto te dorsocecal at pad Clin Infec Dis 200337:
374377eggaa , Bauer ac ia eaceet ad teEuropea expeiece wit Sclpra polyLIacc aci)
J Drugs Dermaol 200435)542547
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Secion 1 : Adipose Tssue Aleaons 285
CHAPTER 60 Stiae Dstensae
Strae istesae moe commol kow as setch
maks" ae atoic ear bas o ski tha apear
ae cea recptating actos sch as pregacsteo use a amatc canges n weight o muscle
mass (g 60 1) A esetaton the eatre a pu le op k coo (st ae uba) at aes to a aer whie (st iae
a ba) over t ime. The ae most commo a ut women.
EPDEOLOGY
iee common
Age pube pregac
Rae moe commo in Caucasias
Sex emales > males (associate wth ubet a preganc)
reiiig ar toica a ora seroi use ACushgs snrome reganc breasteeig ubegeetic colage eecs a ramatic canges i
weght height o m usce mass
PAHOGENESS
Thee are changes in the extracellu la ermal matrix
inc ing ibr i i e last an co l agen res lt g rom
rooge sretchng o the ski
PAHOLOGY
Thee ae sca-ke eatures cal ee s a atrohic
ee rmis wit h arow coage bu les aage aa e
to the skin surace. e ete riges are eace earlst ae there is a supeca eep a n ntest ia l lm ho
ctc pervasclar i i trate a occasoa eosioh ls The i n lae aes i oe es os.
PHYSCAL LESONS
u t ip le smmetric near ban-l ike laq ues o atohcskin that esent mos commo the oute thighsbreasts an bttocks o wome a log the l i es o cleav
age The resent wi a pik/ure hue (str iae rubra)an become aler wit e wkl g ove t ime (str ae
aba) Str iae are largest a mos abuat i patets
with Cshigs sease. In regac stiae ae mostabuat o he abomen. weght ites the ae
mos romie o he souers. Topica cotcoseroiuse most common oces st ae o the ace geni
tal i a lexual aeas a bo os
BFigue 601 (A) triae alba at baeline (B) triae alba at 1 1 month
follow-up aer four treatment with a 1 450-nm diode laermoothbeam Candela Corp ayland M at energy etting of 1 to
1 4 J! uing a 6mm pot ize with a pule duration of 0 m
Treatment wa performed at interval of to month
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286 Color Atlas of Cosmetic Dermatology
D ERENTAL DAGNOSS
Lnear oca el astoss
LABORATORY EMNATON
he characers c cl in ica appeaance o str ae negatesany need or sk biopsy. Addtona aboatoy workup torle o Cshngs dsease s ndicate in te appropriae
cin ical sett ng
COURS
Str ae begn as pink o purple atop c es ions at
becoe pae and less obvos over t ime
KEY CONS ULTAVE QU ESTON S
rat on
Skin pootype
Pregnancy
Assess or sypos o Cs ng's d isease
Use o cortcosteods
H stoy o wegt c ange
H stoy o weg litin g
MANAGEMNT
hee is no edca n icaton o treat stiae St l l a nyind vid als are signiicany botered by ter appeaance
and request treatment hee ae nerous optios to
treat stiae. notun aey non e o e teatents is copetey sccess n ac ost teaents provde o
es o o beneit hs pro to eatmen patientsexpectaions need o be epeed Cobnaton eat
ent volving laser an topcal regimens sc as
tretnon s oten a hepl method o eatme Moereceny nonablative and ablaive actiona eatents
have eerged. Founatey te appearance, paticlaythe color o striae poves wit e Patets w skn
photoypes espond bette than those wit types
IVVI to laser the apy est stes p ro to therapy a re ec
oeded hee is soe data to show tat eates
impove siae ove noninteentio he ist prioity s toesabsh whete stra rbra o stra alba are being
treated as ter teaens er signiicanty
TRATM EN (Fig 60 2)
Sria bra te psed dye ase (585 n ) wit a 7 o 10m spot size and 2 to 4 /c uece as been sown
to ipove the eea o striae bt s associated wit
A
BFigure 60.2 (A) White striae axilla Pminent atrph textural changesand depigmentation are obsered (B) White striae axilla following threefractional resurfacing laser treatments Mild improement of the atphyand textural changes are noted Mild postinammato hyperpigmenta
tion is observed which resoled wees after the last laser treatment
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e risk of ypepgmeo i dke sk ooypes
A clcl edpoin of deep eye or ig pu soil In or exeriece owe flences re more sc
cess n ge fuences g 63)
lsed dye lse emens do i le if nyg oim ove e exue n d ropy of sie
I ovee cn be see even n cses of poo in i i l esponse 6 o s fe een
Sdies ecommed gns reing skin pooyes
VVI
Some d css doub on e eeciveness of ulseddye lse
Si lb onblve rcionl esufcng s been
sown o povide some benefi for sie be Sudessow ge o efficcy w ese emes
Secion 1: Adipose Tssue Aleaons 287
Tee is ie d o sgges wee dee d ep g Acoverge remens e moe effecive n ower de
lower coverge emens In o experience mospens see odes benei fom emen A mioriysees more sgnficn ress
Soulsed erbim:AG nd C sers c be mod
esly efecve b e o onger comoy used de osuc side eecs s proonged dicl eling d
pgmenry lero ey re no ecomended
e excmer se 38 m) s been exmied for
emen of srie b d scrs n 3 dls
Temens begn e Mnim Eyem oseE s 5 /cm o eced res nd wee
peormed biweeky fo weeks An povee n
co lo io by v su sec on 67%) nd coor ieic nyss 1%) ws noed nd coreled
sogy w e numbe of eens efomed Te
pgmen corecon owever euned cose o bsene
fer 6o fol owup o bl iseing o pigmery
dsbnces wee noed
TOPCA TREATM ENT
Erly s ie
Treno in %) ce cn mrove e p perce
of s e cully erly s ie wile decresing
ei eg d wid Mre srie
Treo n 5% ) d 2% glycoli c cid cn im povesie
Gyco c c id 2%) d % Lscob ic c id cn
im ove s e
MCRODERMABRASON
Micodebson cn poduce sml mpovemen
e six o e emens Mcodebson cn so
BFgure 60.3 (A) Numerous striae rubra and alba on the abdomen of ayoung woman (8) Immediate endpoint of purpura following low energshort pulse duration treatment with a pulsed dye laser
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ELEVEN
Wound Healing Alteraions
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290 Color Atlas of Cosmetic Dermatology
CHAPER 61 ypertropc Scars, Keods, and Acne Scars
NTROUCTON
Hyperophic scas ad keoids a re boh ch aracerzed by
excess fibros isse a a sie of ry in he skn
Hyperrophic scas are cofied o h e oiginal ou d
se hereas eoids by coas exed beyod he
o ig ia l oud s e (Tab e 6 ) Boh ae coon ad
reqenly disurb paes greay bo as a usighly
sca as ell as a emi der of prevous ra a o r srgeAce scars resu fo he loss o udelyig coage
ad easic sse fro deral in amao assocaed
ih ace par icuar y cysc ace. Ace scars ae aso
very co o a d a sou ce o dsress o he pae boh
fo heir obvios appearace on he ace as e as are nde o pevos ace
HYPERTROPH C SCARS AN KELO DS:PHYSCAL EAMNATO
Hypertrophic scas prese as hick nea plaques
a he sie of rauma. Iiay hey ay be eheaos
b oe becoe sk-coloed i me. Keods arefir bos paq es ha exed ousde he se of i ury
h cla-ie poecions.
Figure 6 1 1 ermal injection of hypertrophic scar that resulted from a
shave biopsy
ERENTAL DAGOSS
Dermaofibroma scar sacod deaoibrosarcoma po
beas graoa.
LABORATORY EXAMNATON
Noe I hoever a eoid is uresposive o l ipeherapies ski biopsy o rue o deaobosarcoa
poberas is dicaed
TLE 611 • yperophc Scars Vesus Keloids
Den io
Corse
Pecipiang facors
Ic dece
Keo id
Excess fibro s isse foaio i a ou d a
exeds beyod e orign al ou d seDoes o spoa eousy regess
ay arise ees or os ae ry
aiy hsor surge raa br ace earobepiercig; mos como in sin types IVV I
b ay arise i al l sn ypes ad al agesCoo aes = feales
Sern os coon ocao
Hyperophic scar
Excess fibros issue foraio i a ond ha
eais ih n e or ig ia ond s eOfe spoaeos regresso ohs ae he ury
sa ly ar ise hi eeks o iur
amiy hso srgery rauma burn ace; ayarse ay pae a al l ages
Coo aes = feales
Sern os coon locaion
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MANAGEMEN
Thee are multple erapies at are eective or
decreasig the usightly appeaace o keloids ahypertrophic scars oe s com petely satsacory a
oe ca be esigated as a treatmet o choice
Pates sho uld be eucate as to the reracory ature okeoids ad hypetrophic scars ad hat mult pe reat
mets over moths are typcaly requred or eicacyKeoids ted to be more resstat to therapy tha yper
trophc scars.
These treatmet opt ios i c lu de i tra les oa l tr amci
o loe acetode a les ioa 5 luorourac (5),
s l icoe shee ig, imiqu imod rad at o, e l ipt ca exc s o rac oa l resurfac ig, a pu lsed ye laser (PD
(595 m) These treatmets povde deret beeitsSome reduce eryhema, others ae lesios, ad some
perorm both te uctios ost ofte itraesoa
steois are a good ii ia heapy that ca be combie
wih or ol lowed by oer herapies Treatmets cabe broadly dvie io ase ad oase therapies
(Tab e 6 2)
TABLE 6 1 . 2 • Nonaser Treatent Options
Dose Iteva o time
ltralesoa 50 mgm Every 26 weeks
tr amco loe (sie depedet)aceoe
( g 6 )I tra lesoa 50 mg/m 3 times weekly
5-luorouraci or the i rst2 weeks
the every
25 weeksS l icoe sheet ig 2 hours per
day o
2 weeks
lmqu imod d uces umor ight yecosis actor app icatio or
a pha a 8 weeks
iteeo apha start g he
ad gamma day o su rgery
Excisio surgical
Section 1 1 Wond Hea ing A lteat ions 291
Fgure 61.2 ild purpura aer pulsed dye laser treatment of keloidal
acne on back of a teenager lntralesional kena log was also used to
pduce e ventual clin ical improvement after a series of treatmen ts
yperophic sca Keoids Commes
or mos scas, Variabe success most Eectve, sae
moderate to dramatic successul with iexpesive ca reim proveme ealy iterveto to avoi atrophy
Ca be eecive Variable success o cea adva tage
secod-l ie erapy over t iamciooeaceode
Vaiabe impovemet Variable mprovemet Sae
o studed Study sowed o o logterm
recureces u p to studies or
6 moths r isk ecurrec e rates
hyper pgmetato scar Further
study eede tocoirm these resus
osy usuccessul, Very hgh recurrece Immedate
ot recommede rate without ad u ct grat icatio b ut
without aduvat therapy All patiets icreased risk o
therapy must be aware ecurrecerecuret keod may
be wose tha oigal
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292 Color Atlas of Cosmetic Dermatology
ASER
PD (595 mas eerged as a imprtat adjuva fr
treatmet keds ad pertrpc scars (Fig. 612).Give is selecive targeig sperficial bd vessels
PD ca draaica l mprve e eema asscated
wih hperrpc scars ad keids (Table 613)Ieresg wer lece treatmes a sh plse
d rats ted be mre sccessf ta hi ger uecetreatmets t as als bee sw elp t fatte ess
as wel l
Abative ad abave racial resrfacig resrfacig has bee sw prvde mderae impvemet
fr ace srgica perrphic ad bur scas I s sti ukw weter ghdesi reames are mre
efecve a wdesi treamets. pcal scar Aredeg w ablatve ractia resacig
reqires sx t eig reames t aceve abut 50%
beeit (Fg. 63). Sgi ca prveme is see wi
e t w treatmets wi ablative fractial resuracigC laser reatme ese lesis wile reped
successu i sme te literare s t recededde t a gh rate f recrrece traesial ctics
terids are a elpul aduva t laser terap t hep flate lesis ad reduce puitus.
STUDES
Oe stud exa ied te efec f a fasa p p m ped
PD a 585 m r a f las amp PD at 50 m 5 paies wih red perpic scars. Afer a aver
age ear tw reates 77% iprveme wased Afer tree reaes 7 te 5 paies ad
cplee reslti
Ater sd sig the 585 PD reaed e al
f media stert pepic scas/keds 6
paets ad e te er sde teaed. Paties
receved w reaes ever 6 t 8 weeks ad were
examied aer 6 ts. B ided bservers ad ph
gap eveaed sgifca prvemet" i redess scar egt sk surface textue ad prurit s i
asertreaed scar areas ater 6 ts.
TABE 61.3 • Pulsed Dye aser for HyperophicScars/Keloids
Mecasm f aci
xpectati
PD setigs
Average be
reatmes
kw
Iprves erea
ckess ad pl iab i l i b p t 3090%
37 /cm 7 r 0-mm
sp 045 r 5ms
plse durai
46 bu ma requre arme
BFigure 61.3 (A) Pre and (B) postappearance of a traumatic scar aer aseries of fractional resurfacing treatments There is some m ild residualPIH that faded within to weeks
AFigure 61.4 (A) Ethematous deep acne scars
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CLN CAL EPE ENCE
Avoi elecive srgery in paens w a hsoy of
kelos/hyperop c scarr ig .
Cose beginn ng erapy a e m e o srgery or atsure remova
Kelois are more iffc o ea a more pre cab e in eir response an yperopc scars.
Hyperopic scars ofe improve wi no reamen n
6 monhs.P an fracional resrfacing asers ae efecive i
impovng hyperopc scars
racional resfacng can improve e exre aappearance of sgical an burn scas
ACNE SCARS
Acne scarrg is a common seqea o severe namma
ory or cysc acne t can presen i a m or cosmecaly sfigring form. e bes pevenon of acne
scarrng is aggressive reamen o acne vlgars a heme of presenaio, icing, wen appoprae
isoreion. Acne scars ave seveal vare es icig
arophic, icepck ro l ing a boxcar scars reamensvary accoi g o he ype o scar b en g reae I n ac, a
combnaon o reames s oen merie ha is PLor sca eryhema a subseqe n onabl aive fracoal
resracing for acne scars (ig 61) hey also vay ierms of urao of ecacy an expense P rior o srg
Section 1 1 Wond Hea ing A lteat ions 293
ca o r ablaive terapy s im poran o el ic ay recen B
isory o Accae se wihin e previos 6 mos aswe as a sory o yperopic o keloial scarr ng o
avoi poor wo hea ng an scarr ing afe erapy
• y s c a e s o s
Arophi c scars are epresse from te ski n s race a
resu rom local oss o ssue rom nam matioinralesiona l serois s kin s rgey wegh oss or rap
groh (able 61.)
ce-pick scars are narrow eep verica cyl inica
epessons a e s ie of he inn b l m. Gven e ir
ep hey are more resisa o laser therapy. Pucexcsions fo lowe by onablaive fracional resrac
ing can be e lpf l ( ig 61 .5) .
Roll ing scars are shallow epessions a are bes
appeciae wh a change i srface ightng hey can
vay sze a ofen coaesce wh negborng ro l ingscars ey are wer an cepick scars eir
epesse appearance reecs an neying brosis of
e er ms an sbcuaneos a.
Boxcar scars ae wier han ce-pick scars but less
eep hey ave a wel lefine c ircul ar or oval sha pe
cFigue 614 (Continue () Impvement in acne scar ehema afer aseries of pulsed dye laser treatments (C) Further improvement with acne
scars with subsequent nonablative fractional resurfacing
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294 Color Atlas of Cosmetic Dermatology
TABE 61.4 • Teatment Options fo Atophic Scas
h ea y Tye o te ray Cou rse
oca
Laser
l lers
l lers
l lers
l lers
Tetino 0.05% nigtly
450 dode: 2 3 /c
6m sot size 3040scryoge coo g s ay, t ee to
fou treatets oer otstreats actie ace as wel
ractioal resrac g ie o six
treatets deeer d et o
treatet s ore effecteuce ar g er o owe desity
o reate is oe efectie
raulsed ulse carbo doxdeaser
Resty lae ( ya lu ron ic ac d)
Auoogous fat
Boine co agen: Zyde I ,Zyder I Zylast
u a co lage
Sl gt roeent aer
612 onts
030 % proement
Noa blatie: od erate
i oee afer e o sx
treatesAblatie: oderate oeent
ae wo treatents
40% i oee oreeectie ta noablatie
laser
Draatic roeent
8 oths
Draatic roeent andoger durao a other
f lers
Good eoay ioementfor 23 oths
Good e oay i roement
for 23 oths
Coes
S i ght roeme as mootheay. Mosteecte as a adjuct wh oer odalites
If i it a l itao a ly eey oer ight ut
better toleratedMd imroeent
Sae in all skin yes
R sk o trasiory hyergetatio ostlase
ethea weeks to ohs m ay case acne
fareSide eecs nclude temoray ehea
edema crst g ad i ld a i
Soe ay deeo brozig ad ld ak ig
at 7 days
gher incdence o yerigmetaio idarke s k n ototyes
Low rsk for loger aderse side eects
excet tat sca g ay occr with a batie
fractioal deices
oe dowtie a d side eects tha oa batie lase
Posaser etea asti g weeks o onthsr isk o hyerigetatio iecto sca, a d
peraet yogetaoBest or sha low wid e scars such as boxcar scas
Antii rals or atents wi h stor o HSVTeoray
Lowrisk ale graloa do not oercorec
scars
Loger du raon
No r isk of a legy gra lo aMore dicut o aster eecte technique
Req u res test ste fo all ergy
g er r sk o a legy (ie 3%)
Tecique: oercorrec scars
Easier pocedue o inexereced acttioes
than othe fi l ersAderse efecs: s hoe d uratio
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TABLE 61.4 • Teatent Otions fo Atophc Scas (ontinue
Th ea y Tye of he ray Cou rse
ecaica / codermabras io, g yco ic ad i d im rovemechemica sa cy ic ac d ees ( F ig 6 4)
TCA eels demabraso
Surgca Subcis io ( i c s o to demis with d moveme
mecaca tauma ducig
ibross)
Surgca Puch excis io ig 61 6) uchgraftig uc h a utogafig,
Good improvemet
puch elevatio
Key Po ts Teat g Ac e Scars
Emhasize improvemet rathe tha complete esou
t io as a oba i ab e resu lt . scuss al l treatmet otios A l otios have adva
tages ad disadvaages
ay patiets wil beefit fom a combato of ther
ay
Obtai comlete medical h story ad medcato use,
that s Accutae withi 6 moths of ay surgica/ab ative treatmet.
ake sure ace s beig or as bee reated o preve
future scars.
BBLOGRAPHY
Aster TS Wl l ams CM Treatmet o kelod sterotomy
scars wh 585 m flashlamumed ulsed-dye laser.
ace. 1995345(8959): 98200.
Avram M Tope W Yu Szacowicz E Nelso S
Hyetrohc scar g o f he eck ollowg a blaive fac
toa carbo dioxde laser resufacg ae Sg Me.2009;4 1(3) 85188
Berma B auma . Pi o sudy o the efect o ostoeraive imquimod 5% cream o he recurrece rate of
excised kelods J m ca Demal. 2002;47(supl
4) S209S2 Berma B, Vial l A. miqumod 5% cream for keod ma
agemet Demal Sg. 200329(0) 05005 .
Section 1 1 Wond Hea ing A lteat ions 295
Commes
crodermabaso/gycoic ac id peels are safesal cy ic acd ees safe sk types IVVI
derma braso shou d ot be erformed
excet extremely exerieced ad sSafe
Tme cosumig. u ie teatmes. Bette
or ce-ick scars
Chua SH Ag P oo S, Go CL. Noablative 450 mdiode aser treatmet of faca atrohic ac e scars
tye IV Asia sk Demal Sg. 2004;(10) 28729 .
Fgue 61.5 (A) Ice pck scas po to punch excsons (8) Impvement
of ce pck scas 1 week ae sutue emoval Futhe mpovement wasacheve wth nonabatve factonal esufacng
itzpatrck RE. reamet o flamed hyperrohc scarsus ig ta es oa 5- F . Demal Sg. 999;25(3) :
224232.
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296 Color Atlas of Cosmetic Dermatology
Gla c AS Raha Z Goldberg Fr eda PM.
Fractona resracing for he eaet o hypopigeted scars A piot sdy Dermal Srg. 200733(3)
289294
Haedersdal M Morea KE Beyer DM ya PAsbjor B. Fractioal onablave 1540 aser resr
facig or eral br scars A radozed corol ledr ia aer Srg e 20094(3) 8995
acob Cl Dover S Kainer M S. Acne scarr ng A c ass
icaion syse and revew of reae optos. J AmAa Derma/ 200 45( ) 098
iwa A Me o AP Toreza A Osorio . Fracioal pho
toherolyss or he reae o ypertrophc scars:
Cliical eperece o eig cases Dermal Srg. 2009
35(5) 773777
ouri K ieez GP ar isonBaesra C Egart GW585 n pused dye aser n reaen o srgica scars
saring o sre reoval day Dermal Srg. 2003
29( ) 65-73
Waibel Beer K. Fracioal laser resrfaci g for era
brns J Drg Dermal 20087( ) 596
Fgr 61.6 Patient aer numerus punch excisions utures areremoved 5 to days afer the pcedure
TLE 61 5 • I-Pkxa Sar
Pn ch arvesig ad suure orpnch harvest and ipla f
hickness ga
Abatve C/Erb i:AG
Fl lers e Restylane co lageetc (see Tabe 6 4)
Noablaive lase
e 1 450- d ode 23 /cm (oe pass)
owe fecies (wo passes)
lt pe onhl y eates
Advaage
ow cost poetial draaic provemen;
best for a rrow dee p scars such as
ice-pck scars or deep bocar scars pn c
ecson can be o owed b y abla ve oroablaive fracioal resracg reaes
Poea 460% ongter iprovee;bes or shal ow bocar scars
Quick s ign if can proveet
ow rsk
asts onthsow r sk o seious side effecs
o downeTreas ay active ace
Disdvanage
U predcabe r sk of ak ing cosetcappearace worse t e cons ng
Postlaser eryea weeks o ons; risk
of ypepigeaion inecon scar and
peraen ypopg eaon
Anivi rals for paens wi h sor of HSV
No peranent i proveet
Need o repea a least wce an na ly
Iprovee 1030%
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TWELEExogenos Ctaneos Ateaons
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298 Color Atlas of Cosmetic Dermatology
CHAPER 62 Ea r Pie r ng
Ear pierc ng is perormed o fac l iae an id ivd a 's
desre to wear earrings. By avng e procedre per
ormed in a medical aci y by a pyscan e paien sreassred a te procedre s beig perormed in a
sae conrol led enviromen
KEY CONSULTATVE QUESTONS
Conact al ergens o meas
H sor o keoids or yperropic scar ng
esred se of pecing
PHYSCAL EAMNATON
Assess e ckness of earobes
MANAGEMENT
ere are wo commo meods for ea piecng I can
be peormed wit a needle by ad or wi e elp o
an auomaic ear-piercig gn (Fig. 62.) Before per
forming eter procedure i is mpoan o make ceraina e correc locaio or piercng as been seeced
Symm er wi e conralaera ear s essenia o a good
cosmetc a ppearance. Te paent sou d revew e sies
usi g a m irror prior o treamen.
TREATMENT
Seri ize a l nstruments
Seri ize ad a neseze bo ear lobu les
dent te exac sies o be pierced wit a makng pe
on e anteror and posteror porions of e ear lobue.
Conirm proper pacemen wit paiet beore proceeding
Usin g slow pressure advance a - o 8-gage needle
rog e poseror lobe no te anteror lob le
an aomaic ear-piecng g is sed e gn isadvanced rom e anerior l obu e oward e poserior
ob e
Use a sei zed earring wi a sainess steel pos
A nckefree pos of te earng s advanced w te
neede and e p s p lled back rog e ear
e cla sp is p t on e poseror pos
Leave te earrng in place for approximaely 1 days
ni l re-epelia l zaion of e rack
Cean e sie w ydogen peroxide and opcalan bo c onmen wice daily
Fgr 62.1 Ear-piercing gun being used on earlobe of a young female
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PTFALLS O AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEEXPECTATONS
i earo be ma y pl i epecal y i eavier ear ing
Pace eaig on e ame level oizoaly o aue
ymme A good c ean tei e ecni que c an avoi potpocedu re
inecon
i m poa o e ic any ioy of yperropc ca
o kelod in ee paen (Fig 62.2) a pecing
old o be pefomed o ee paie
Any toy of nickel or ote mea alege oud be
e c e pro o ay procee a e
ucate paient a o ound cae an e nee o
conac you in te even of inecon
n e event of conac ematii o allergy topica
teoid ae e m a nay of reamen
BBLOGRAPHY
Akn ak GP. E ar p ierc ing ad ugca epa r o e
ealobe. n : ak GP Moy R ed. Principles and
echniques of Cuaneous Surger Ne ork McGa
H i l c ; 1 996 .
Secon 1 2 Exogenous Cuaneous Aeaons 299
Fg 62.2 Keloi on posterior earlobe secona to e ar piercingCourtesy of Tomi Pan/fino M
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300 Color Atlas of Cosmetic Dermatology
CHAPTER 63 Tatoo Removal
ens of mi ions of Ameicans have attoos. Ove tmeany ecie that they want the tatoo to be removed
Qality-swtched (Q-switched) lases are eective nremoving ost atoo igments saey ( Fgs 63. 13.3 )he aoriate ase wavelegth s etere by the
tattoo nks absorpion spectru t is be eve that lase
puses in te nanosecon range taget tattoo gents
and beak them into smaler patic les hereby acil tat ing
reova of the igment tanseermaly o via
acophages a local scavenger ces I ore to reat
muticooed tattoos severa Qswitche ase wavelenghs must be em oye
KEY CONS ULTAVE QU ESTON S
Was the attoo place by an amateu o a oessiona
tattoo aist?
Was the tattoo lace o te urose of raaion te
ay?
s the tattoo the esu t o tam a o ny?
What colos are containe wthn te taoo? (abe 63.1)
Prevos teamen ts
Use of soetnoi with 6 months
H sto o keois/hyperohc scars
Duraton of tatoo
Skin hootype
Hstoy o HSV a ste o teatment
A
B Hstoy of aergc or ganomatos reaction to tattoo
igment Fgr 63.1 (A) Tattoo o le earlobe rior to theray (8) esolutio aer
six treatmets ith 1,064m Qsitched NdYG laser
TLE 631 • Lasr Thrapy b Ta lr
aoo ge nt ight sectum
Red Geen
ellow Geen
Geen Red/near infrae
Lgh b ue Re/near rared
Dark b le Re/near rare
B lack
Most eecve ase s
requency-dobled Q-swiche NAG(532 nm)
requency-dobled Q-swche NAG
(532 nm)Q-swiched by (694 nm)
Qswitche aexante (755 n)Q-swtche uby (694 nm)
Q-switche aexante (755 n)
swtche uby (694 nm) l igt skntyes ony
Qswitche alexante (755 n) ightskin tyes oly
Qswitche N AG ( 1 064 nm ): a l
skin tyes
Comen
ay cause gment alteaion i n aker sknLeast pai nfu l of Q-swtched lases
No vey eecve
ay cause hyoigmentation i da ker skin
ay cause yoigmenaion i daker skin
Qswitched d:AG (0 nm) sae inal sk n yes ess g en oss
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s the tattoo ace over or coveig aother attoo?
History of go ingesto
Does te taoo contai rst-coore or wte pget?
MANAGEMENTI t s i poa to ask te at iet wo pace t e taoo.
Professoa tattoo pgets are eser a lace
deeer n the eis tha ost aateur tattoos Ts
rees es e attoos m ore refacory to treaent aic
lar ly those ta are icoore a cotain etal ic
igets. It is iorant to ior the atet pror to
treatent at colete resouto s ot always fease.
It s a so iotat o counsel at ut ile eates
over to 2 years ay e requre or axal iproveet. Tere s o fxe aswer as to te er of trea
ets for tattoo emoval .
PRETREATMENT ASSESSMENT
Patients wt a ker s types are ore ey to sue
pgentary cages
Proessoa tattoos reqre ore reatets tan aa
te r attoos
Ol er attoos reso ore favora y an ew tattoos
Back a ark e taoos reso ore effectvely
ta ye ow taoos
Assess for snta f ate is ta e eay reate
untl ta resoves Mlicoore attoos are oe clt to sccessy
cear tha siglecoor tattoos D uri g treatent soe
Secon 1 2 Exogenous Cuaneous Aeaons 301
A
patiets ay e frustrate at the oniorm imrove en t of ese tattoos
Assess for scaring wt e taoo I resent show
te patiet a oc ent ri or to treang
N UM BER OF TREATME NTS
Professoa tattoos reque aout 6 o 20 treatents
prior to reova o inrequely ore tha 20 reatets are eede for ax ma i rovee
Aateur attoos coain less ense get aces
an usual y req ire aout four to sx teatets
Ra iaio tattoos an d tram atc tattoos are o re su er
fic ia a ess ense an professioa tatoos equ r in g
only a few reates or resolutio (g 634)
n geeral raaton tattoos ca e eove i oe to
tree treatents Soees ey reqire at ioaltreatents
Lower uec es a arger sot sizes can e as eective
as sa er spot szes an nc rease feces
cgr 63.2 (A) Tattoo on arm wit underlying portwine stain (B) Notete seletive removal of te tattoo wile te portwine stain persists
(C) Tattoo learane
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302 Color Atlas of Cosmetic Dermatology
est spot may be appropriate i darke sk pototypes
f concerng
est sos are clearly ndicated fo cosmetic taoos
rustcolored tattoos a d w ie taoos
TATTOO TREATMENT Photograph o tattoo prior o teatmet
opical aestesia or 1% docaine i te orm of ocal
njectio or erve bock w l make te teament more
comfortable for e patiet
reat the affeced areas wit te apopriae -swtced
aser alowg fo up o a 10% overlap (abe 632)
e c l ica e dpot is m mediate t issue wteing or
the 1 064m swtced Nd AG i ad dit o to ssue
witeng there may be a small amount of ppot
b leeding at te s ite of reatme ( F igs. 635 a d 63.6)
issue spater" ( e, edermal/demal dsrpo adbleedg) may p roduce scarr ig. If this occurs decrease
te fluence
f te aoo is mutcoored teat te red pgmet first
Erytema and fammato from oter treated sitesmay obscue vsazao of red taoo pigme
Appy tocal hydrated eroatum ad a noaderent
d ressig ater co mpetig te treamet
Couse su scee a d su avodace o te teament
area
POSTTREATM EN T CAR E
Su avoidace sscrees
ela dressng ad hydrated petrolatum otme wit
paper tape
f tattoo is ocaed i belt l ine a rea or above akles cau
to patets from wearg tight bets or boots that may
prod ce frco aga ist e treated area
Retrn or eatmet 6 to 8 weeks
A
B
Fgr 63.3 (A) Le shoulder tattoo with inferior scar resulting from priortreatment with dermabrasion (B) Improvement aer six treatments with
1 064nm Qswitched Nd YAG laser While improvement is not completethe cosmetic result is far superior to that o f dermabrasion
TLE 6 3.2 • Lasr Thrapy b Qa y-Sw Lasrs
Laser
Frequecy dobed switced dAG (532 m)
-swtched ruby (694 m)-switched aexadrte (755 nm)
-swtched NdAG (1064 m)
I t ia settgs
. 55 0 J 4. 00 mm spot size
3 00 J 6.5 mm spot size5 06 5 J 2 .00 mm spo size
3.0120 J 2.00 mm spot size
Eecive agais these attoo inks
Red orage, yel ow
Gree b lue b lack
Gree b le b ack
Ble back (saes i dak sk ypes)
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ADVERS E EECTS/PRECAUTO NS
Pgmentay aterato
Blistering (especia ly, Qswtched alexadite and rby)
(F ig 63.7 )
Scarr ng (F g 638)
n a patet with an allergic reaction to tattoo k n thepast ( Fg 639) , thee s the possibi ty o a rec rrenceseconday to the elease o tattoo nk folowng laser
therapy A ergic recations sho uld be taken System calergic reactions ca occr wth Qswtched ases
(un ke destrctive modalit eserabasio etc)
Rstcooed and white tattoos should be teated cae
ly as wel as ed and fleshcooed cosmetc tattoos
or exam ple, i er Sometimes whte n k is xed with
othe p gments (F ig 63 0)
The tattoo may darken as a esult o oxidation of iron
or t tan u m oxide pgment withi the tattoo
A test site can be efored 4 to 8 weeks pio totreatment fo possibe darken g
This darkenig can sometimes be treated wth lases
or may reqie excsion
They espod s lowly to lase theapy
Peom a test spot pi or to treati g atie nts wth istory
of gold salt ngestion Chysiasis, afested as darkbe pigmetaton can esult fo treatment with Q
switched ases
Rarely, patets wl expeence a trasient immune
resonse folowng a ase tattoo treatment Suc
resonses incude flu ike symtoms and enagedlymph nodes
PTFALLS TO AVOD/COMPLCATONS/MANAGEMENT/OUTCOMEPECTATONS
Response to tattoo treatment is dependent upo thedeth of pgmet, the color o pigment and the size o
pgment part ces It ca vay damatcal y o one to
tattoo to anoter
Efectve teatent for a rofessional tattoo may reqe
p to a 20 or more treatment sessons ove a period of 1
to 2 years Fheroe compete reova s oe not
feas b e
A successf treatment often eaves some resdua tat
too igent hs can be impoved wth noabatve
ractiona resfacng
Physic ians shod couse pat ients that s gn f icant ighteni ng may be the best feasbl e c n cal result
aoo treatent can produce ye- ad hypogmen
tatio in any patiet especa y those wth daker skntypes
Secon 1 2 Exogenous Cuaneous Aeaons 303
Fg 63.4 Taumatic tatt n knee f a female that has pesisted
0 eas afe childhd biccle fall switched 1 064nm Nd YAG
cleaed the tatt in thee teatments
Fg 63.5 ssue whitening afte teatment with the 5-nm fequenc
dubled switched Nd YAG and 64-nm -switched ub lase ssuewhitening is the apppiate endpint when teating tatts with switched lases Pinpint bleeding esulted fm injectin f lidcainewith epinephine pi t teatment
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304 Color Atlas of Cosmetic Dermatology
emen o oos in res of hi growh (ie eye
brows) my poduce empo hi remov
he eqencydoubled Qswched :AG Qswiched
uby nd Qswched lexndie lses e moe key o
cuse durbe pigmenry chnges hn he Q-swched
AG ( ,064 nm)
Mos eqely pigmen eion is emoy.Hypergmenon yc y esolves oe qu ic kly
Lowe leces nd diionl me beween emens
shou d be employed i n ke ski n h ooyes
BBLOGRAPHY
Alse T. Q-swiched exnd e se (7 55 n ) reeo pofessionl d eu oos J m Dmol. 199533:6973
eguson E Augus P Evl ion of he d/AG lse
or remen of meu nd poessio oos JDmol. 199635(4) 58659
zpck RE Goldm MP oo eovl using he
exn die ser Dmol. 199430: 5085 4
Gevel nk M Mu ls MW H R Go m n M Pzpck RE Greve in k JM . Lse reen of oos n
dkly igmened ens Eccy nd side eecs.
J m Dmol. 199634:653656
lzikso L, Avr MM Anderson RR nsien
i mm uno recivty er ser oo emovl Re o o wo
cses Sg . 200840(4)23232
Ki me SL Anerson RR . C l in ic l se of he Q-swiche
rby nd he Qswche d AG ( 1064 m nd 532 n m)lsers or een of oos. J Dmol Sg Ol.993; 9(4) :330338
Levne V Geoneus RG. oo emov wih he Qswced uby ser nd he Q-swiched d AG lse A
com pve sudy. i. 199555:29296
Fgr 63.6 Pp immeitely fte tetment of n eyebow tttoowith Qswitche N YG lse
Fgr 63.7 listeing e tttoo tetment Thi ection is commonn slly esolves completely within week with tine topicl skince
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Secon 1 2 Exogenous Cuaneous Aeaons 305
Fg 63. carring aer treatmen t ith a Qsitched rub laserCourtes of Teresa oriano, M
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306 Color Atlas of Cosmetic Dermatology
A
BFgr 639 (A) Allergic hypersensitivity reaction to tattoo see elevatedportions of tattoo (B) To avoid systemic allergic reaction with traditional
Qswitched laser treatment of the en tire tattoo focal treatment with anablative fractional erbium laser was performed Note focal impvementafter several treatments
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Secon 1 2 Exogenous Cuaneous Aeaons 307
A
BFg 63.10 (A) Tattoo prior to tst spot tratmnt (B) Tst spot tratmnt of tattoo with a 64-nm Q-switchd ruby lasr producs discoloration Tattoo ink combind blu and whit inks
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308 Color Atlas of Cosmetic Dermatology
CHAPER 64 Torn Ea obe
o ealobe ad eaged peced ealobe caals ae a
commo cosequece o weaig heavy eaigs o a
pooged peiod o me ( g 1 ) as wel as ohe acos suc as auma eavy ea gs i eco ow place
me o pecig pessue ecosis, ec I occus moseas y i i ea obues oopig o easily o ealobes
may also be secoday o a cogea deec o auma
KEY CONS ULTATVE QU ESTON S
Pecipiaig eve o ealobe ea
H so o keoids o hypeopc sca g
oes paie desie o wea eaigs agai ae he
epa?
MANAGEMNT
hee ae umeous sugcal mehods o epai com
peey ad paia ly o eaobes ee echiquesae sued o dee eas Paal eas ae moe easiy
eaed ad ca be coeced via sde-o-side closue as
we as puc excsio ad epa
TR EATM EN TS (Fgs 64 1-643)
Compee eas ae moe dicul o ea ha paialeas Thee ae u meous diee ec q ues ha cabe successul Mos commoy e Z-pasy epai o
ielocig s epa poduce he bes esul
Sei e pepaaio ad echique
Local a eshesia shou d be i eced io he epa sie
he epid emis o he opposi g edges o he ea woud
shou d be excsed
Sca pe
Scissos
euped 60 epidema suues appoximae ad
ever e woud edges o e aeo ad poseioobe
Be ceai o appoximae he wod edges o e
eo im o e ea caeu y o avod dso io omsa igme
The woud edges sou d be ude m i ma es io
o su bcuaeous suues ae used
Z-pasy epai ( ig 2) o i e loc ig s epai o
he im wi poduce issue appoxmao whie pe
veig he di mp ig o he eio m o e eaobe
A
BFgr 64. 1 (A) Female with large tear defect of earlobe at the site ofheavy earring (B) To earlobe reconstructed by prima repair
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aes shold be counsee o efrai fom wearig
eangs for 3 monhs fol owing he reai r
P TFALLS O AVO D/COM PL CAT ON S/MANAGEMENOUTCOM
EPECTATONS Mec os aeon o a roxma g he woud edges
ad he infero rm of e ea ae esseial for a sasfacory resu ocig o he iferio rm of e earlobe
can occr easi y s ignficay comromisg aeshecaearace
Cauio n a paen wih a hisoy of keods or yer
rohic scars
aie sh o l o wear ear ngs for 2 o 3 m ohs aersugery
Wond sreg is less an e oigna sreng o he
obe Avoid wearg eavy earrigs o reve recrece
BBLOGRAPHY
on B A sm le ech niq e for redcio of he ea
lobe Plast Reconstr S 198066630632
Secon 1 2 Exogenous Cuaneous Aeaons 309
b
gr 64.2 epai of complete ealobe tea utilizing a Z-plas to pevent dimpling of the infeio aspect of ealobe
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31 0 Color Atlas of Cosmetic Dermatology
Fgr 64.3 One stage preauricular ap to repair earlobe deformities
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I N D E X
ote: this n e te letes " n " enote figes n tbes espectively.
1 50nm ioe ser 8 8f 83f
5olevl nic c (5ALA) 75 5
5foroci, 07 4 9
130m :YAG se 41150nm ioe lser 4 7
AAbtve rcton lser resrfcing 39, 57
vntges o 57ictions, 58
ser sfey 59
vese sie eects 60 60
foloup, 59-60, 59
nfection, 60, 61nonfcil skin 601posoperive cre 57f, 58f 59
preopetve evlution 58
pohylis/neshesi 58-59
Abtve se escing, 151, 15
bsolte cotctions, 5
estes 67for Becker's nevs 18
for ee nevs 4
e lser cnite, 5
ictions,
ess t iel ser cnte, 45
echnis of co 3cbo ioie lse 3 3f, 4f
EYAG 3 5feictos 6
for i i, 30
posoertve cre 9 50 51
peopetve evlution 5pocere 89 9f
etve conr inicios 56
sfety meses 47-8
for seboec ketosis 36
tetmet pes, 50AC i bitos See Angioesicovetng ezye (ACE) iibitors
Acetminope 58
Acetoe 48
Acne scrs 90, 93
pysc lesos 93-95
tetet 95Acne vgis 7 76 00
vs. giofibro,
course, 73
ifeeni ignoss 7
eeioogy 7
botory tetoptoogy 73
enocrie stues 773
geent, 73
igh retmen, 7f 73f 7-75 75f
sgic tretmet 74
sysemc reten, 73-7topicl tretent, 73
3
ptogeesis, 7
pyscl eminto 7
Acqire cpil ry emgio, 170-73
Ac elnotc elno 06Actnic ceil tis 8
Actnic kertosis (AK) 48
consttve qestios 9
corse, 9
etopthology 48
ifeenil ignoss 8eeiology 8
mgement, 9
ptogeesis 8
pyscl eminto, 8
pitls, 50-51tetet 49-50
Actnc kertoses
vs s 06
Acycovi 3 6 5
Apene 9 73
Atos 5000 1t, 15t
Aeom sebcem Affi 1, 40 n :YAG ser 56 56t
Ageelte tetl chges t
Agg
Agg fce n nonci egos nyss o
toic consi etios 3, t
preopetve evltion 3ctige bony stctures, s potive strctres
cnges 5fci musctre cnges, 5
Glog Potoging Cssficton f 3, 3f, 5f
pigeny cnges , 6f
sbcteos ft tohy 5AK See Actin ic kertoss
AA See 5iolevul inic c
Acne See Topc prorcine
Acon 8
Acon bs 5A lergn 1t 15t 1
Alergic ectons
to scleotey, 0
Aloerm, 1t
Aoe ver 0
Aoesin 9t 10hyoy ci 3
otos, 18
for posinfl tory yperpigmetton 160
pees 1
Ai cloe hehyrte 87
Abloy plebectomy 0Aeicn Acemy of Demtology 8
Aoic l in 73
Ayorophc ltel scleosis
Aestesi, 88
for btve fcton l lser resrfcng
5859for btve ser resufcg 46-7
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3 1 2 I nd ex
or angioiroa 23
or l oma reatmen 227
or neuroiroma 236
or nonalaie fational lase esuaing 54or nonalaie laser resuang 40
dinared lases 40 41
or sot tssue augentation 6f 7
or wa reoal 207t 208
Angioroma 212215
onsultat e q uestions 2 3ourse 2 3 2 13
dermatoathoog 212
difeenia agnoss 2 2
eiemioog 212
aoator data 23
anagement 21 3214 21 4f 2 5fathogeness 2 12
hsia exaination 21 2 2 2
ita s 214
Angiokeraoa 168
vs angiomas 71
ourse anagement 681 69 69dermatoathoog 68
dieenia agnoses 168
eiemioog 68
hsia exaination 68
itas o aoid 69
Angiol ipoa 226Angiomas er and sder 170
ourse 171
difeenia agnoses 171
eiemioog 70
anageent 1772athogeness 170
atholog 171
phsia exaination 71
ita s o aoid 72
Angioesinoneting ene ACE)
nhios 89Antha in 224
Antiaeial agens 73
Antiaeial thera 46 53
Antiiotis 73
Antialarias 75
Antioxidants 8Antierspirant 89
Antira edatons 49
Anti ra tera 46 54
Aaodne hdrohlode 28
Aquamd 14t
Aquao H ea g Ointent 49Arutin 9t 0
Aefl l 4t
Aeria spide 17073
Asor aid 9t 1
Ash ea maue 2 12 2 13
Aspergilus, 10AstraZeea 7
Ataxatelangietasa 67
Atan 58
Atoph sas 294295
Atohodera emiuau AV) 8
Aa 9Aoenone 7t
Aela aid 9t 0 73 77 14 51 160
Aithon 46 73
BB l uus mi ar s dsseminatus aei 76
BHCG. See �um an hoi oni gonaooin
BannaanZonana snroe 226
Basa e l arnoa CC) 8 252254
ederma neus and 222 223
onsultatie questons 253
ourse 253dematoatholog 252
dierenial d iagnoses 252
edemoog 252
aoator data 253
aagement 253254 253 254 255f
pathogenesis 252phsal exaination 252 252
pitals 254
Bearer 10
Bekers neus 22 1 8
onsultatie questons 2 17
ourse 217
dierenial d iagnosis 21 6
edemoog 21 6
aoator examinaton 26aagement 2 1728 2 7
pathogenesis 216
patholog 26
phsal exai nation 2 6 2 6
pital s 218
Beotero Basi 14t
Beotero So 4t
Bengn growths
angioroma 21225
Bekers neus 22 1 8
ederma lusion st 2922
eerma neus 222225
Beno eroxide 73
�uman hoioi gonaooin BHCG)
Betaaine nha ned Ge 7Betaaine lus 17
BoAaid 14t
Boo edal 1 5t
Bomatix n. 15t
Bosies
ederma nlusion sts 220
eerma neus and 223
ioma 227
neurofroma 232
seorhe keraoss 235
Bioeh Indust 5
Bashk ies o 222
Beahing reas 46
Beaohalasis 64
Booms sndrome 67 136Bonane 87
Botox 89 See also Botu in um oxin A
Botox Coseti 2
Botu i u oxin
opliations 27
ontra in daons
asoute 22
elatie 22
di lut ion 22
ehanism o aon 21
usle grous 22f 23
forehea 22 2324 23
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glabella copex 4 4f
nasolabia fold 6, 27f
neck 627, 28
peioa egion, 6, 7 28fpeioba egion, 5, 5f
ue nasal oo 5 6f
phaacolog, 2 1, 1!
posoeae consideaons, 7
peopeae ealuaion, 2
owe eeld s nap back es 3peaaions, 2
pocedue, 3
eaen benefis 7
eaen peas, 28
Bou n u oxin A BXA, 1 87 88, 88f
aneshesa, 88anipespian 89
Boox 89
pehidoss ecanis of acon in, 88f
necion ses of, 88f, 89f
edicaons 89
sge, 89eaen 8889 88f, 89f
Boul inu oxn BX 1
Bou nu oxin BX), 1
Bndis 4
Boussoneta papyfea, 10
Bcc nao, 6, 7f, 8
cCa au la acues CAMs) 136
vs Beckes neus, 6
consulae qesons 37
couse, 137
diffeenial diagnoss, 136
edeoog, 36
aboao exainaon 136ase eaen, 137138
anageen, 137
vs. neuofboas 23
pahogeness, 136
paholog, 136
phsca lesions 136pifa s, 138
opical eaen 138
Cacpool , 4
Capbel de Mogan sos 170173
Candea Cop . , 4
Cande, 17Cande haa nc. , 14
Cannus, 6, 27f, 8f
Canaone 07
Capl a 177
Capque, 14
Cabon dioxide C) ase, 43, 43f 49 57, 17 39Cabon dioxide ase esfacing
fo angoiboa, 13 115f
fo angioas 17
fo basa ce cacnoa, 254
fo epdea nes, 4fo neuofiboa 3
fo sebohec keaosis 36
fo squaous cel cacinoa 58
fo enous akes, 08
fo was 07 08
Caenos heangoa 77180
Cele, 779 76f
consulae quesions, 77
couse, 276
edeiolog, 76aboao exainaon, 76
anageen, 77
phscal lesions, 76
pial s, 779
eaens, 27778, 77f
Cenofacal eangi ecasas 194fCheica peels 30, 74, 141
colcaions 34, 38f
conaindcaions, 33
deal canddae, 31
ess idea canddae, 3edcaions 3
pee pes 33
posoeaie cae 34
pocedue 3334 36f, 37f
eaen peals, 3435
wound deph 3Cheica sunsceen 78 7
Che angioas, 1773 17f
Cnoxae, 7
Cpofoxacn, 46
Cl indacin, 73
Cofazine, 75Clostdum botulnum 21
C ase abaon 8
C esufacing. See Cabon doxde C) ase
Coenze 10 8
Cocic ne, 1 75
Colagen, in angofboa, 1Coagenase 9
Comedone exacion, 74
Comon was 0609
Complee eas 308
Compession sockngs, 00
Congenial adenal hpeplasia 9Congenial heangoas, 177
Congenial neus, 1 6
Conua Inenaional, 14
Cooouc nc, 41
Coece a ansplan suge 1 10 10
Cougao suecil 4 4fCoicoseods 164 175
fo epdea nei, 4
fo epdea ncusi on css, 1
fo ia, 29
Cosode 4
Cosoplas, 14Cosshaching, 18
Cogen spa coong CSC), 185
Cosuge, 175
Cohea
fo deaoss pauosa n ga 4
fo epe des 14fo epdea neus, 24
fo lenignes, 146
fo sebaceous peplasia 83
fo seboheic keaosis 36
fo squaous cel cacinoa 58
fo enous lakes, 04fo wa emoa, 09
fo seboeic keaosis 36, 37, 37f
ndx 1
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3 1 4 I nd ex
Ceage
or edeal nes, 224
or wat reoal, 209
Cshngs dsease, 92, 285
Cng too, Cera ie Cel Co, 4
Cnose, 56, 56
Croerone aetae, 28
Css
D
eidera inlsion sts, 21922
orn, 235ia, 229230
ilar sts, 220
DAO. See Deresso angl i ois
Dasone, 75Deedeh srength eels, 30t, 33
Dee eangoa D), 77
Dee en hrombosis, 198
Deodex ol ilor, 77
De lat on, 94
Deresso angli oris DAO), 26, 27, 28Des disease, 226
Deabrasion, 75
or edeal nes, 224
or angioibroa, 24
Dea easa, 19
Deatohalasis, onsltate qestions, 65
orse, 65
deratoatoog, 65
dieenia dagnoss, 6
eidemioog, anageent, 65athogeness, 6
hsia exaination, 64
itas, 666
teatent, 65
Deatosis alosa ngra DNs),
24, 2onsltate qestions, 242
orse, 2
dieenia dagnoss, 21
eidemioog, 2
aboator examinaton, 241
aser teaents, 24223anageent, 22
athogeness, 21
atholog, 241
hsia esions, 241
ita s, 243
Deik, 5Destie oda ities,
o sebaeos heasia
Diazea, 17
Diloxai l n, 46
Diode ase teatents
or Bekes nes, 218or enos akes, 20
Dioxbenzone, 7t
DowCorning, 4t
Doxne, 73, 77
Ds See Deratosis a losa n igra
Dsroia
o war emoal , 207, 208, 209
Dsort, 2t
EEa iering, 298
ons ltatie qestons, 298anageent, 298, 298hsal exaination, 298
itals, 299, 299
teatent, 298
Eto a denooiotro horone rodtion, 92
Eletoate, 239or edea nes, 224
Eletodesiaton, or angioibroas, 213
or sebohe keatoses, 236
Eletolss, 9, 2 17Eletoseion, 77
Eletosge, 76, 77, 77, 82, 175
or enos lakes, 204
El l t al exsion, 23, 29, 227, 2132
Ell tal sti aestng, 06
vs. ol ilar nit extaion F UE), 07, 107tEl la n Sgitron, 78
Embol ization, 180
Endeologie
or ee, 277278
Endone stdies, o ane lgaris, 7273
Endonolog, onsltation wt, 93Endoso/assi satheto, 88
Eosinohl i granloa, 174
Eedes, 139
onsltatie qestons, 40
orse, 140
dierenial diagnosis, 40edeolog, 39
aboator exainaton, 140
anageent, 140
athogenesis, 139
atholog, 140
hsal lesons, 140vs soar lentigo, 145
teatents
heial eels, 4142
rotea, 42
aser thea, 1213
ital s o aoid/o iatons/anageent, 43toial treatent, 4041
Edera aanhosis, 65, 67
Edera nlson ss C), 219221
onsltatie qestons, 220
orse, 220
dierenial diagnosis, 220edeioog, 219
aboator data, 220
anageent, 220
athogeness, 219
atholog, 29
hsal exai nation, 21 9, 2 9itals, 22
teatent, 22022 , 2 19, 220
Edera elasa, 32, 149
Edera nes E), 222
vs. Bekers nes, 26
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consultatie qestons, 3
corse, 3
difeenial diagnoss, 3
ed emoogy, aboatory data, 3
pathogeess,
pathology,
physica exaination, 3
pitas, 5
vs. seborhec keaosis, 3, 35teatent, 45
Ederis
and epdera cl sion cysts, 19
n l ipoa, 6
Ederod cyst, 9
El i escence croscoy E LM ), 03Enehrne, 59
Er:YAG. See Eb m :Ytr uAlm n Garnet Lase
Erbm abate resufacing lasers, 57
Erbm:YrumAminu Garnet EYAG) laser
and a blatie ase resurfacng, 43, 45, 48, 49
ad epidera neus, 4and seborrhec keratoss, 36
Eyhematoteagectatc rosacea See Vasca rosacea
Eryhomycn, 73
Etecc m xture of loca an esthetc M LA), 7, 40
Excime aser, 65, 87
Excison sgcal , 53, 57, 9 , 9Eye nj r ies
and ases, 98
FFacial ageelated conto changes,
Facial musclate changes, 5Facial eangecasias, 19, 19f
corse, 9
dematopathoogy, 9edemoogy, 9
anagement, 1994physca exai nation, 9
pitfa s o aoid, 94
prior to ong p sedurato p sed dye laser
treatent, 95
prior to sed dye ase teatent, 93
Fang, 18Fascia Bioaeals, 15t
Fascian, 5
Fat accumulaion
teatent of, 83
FDAapoed med caions, for mae patern ha r loss, 04, 04t
Feale pater ha oss, 16, 16f See also Male pattern ha oss
chef coplaint, 31consult , 133
consultatie qestons, 6
corse, 6
dieenial diagnoss, 17
edemioogy, 6femae har tansantation, 31
to corect altered tepoal ha i ine, fom li ng procedre, 3 1
femae surgica plan ing, 19
posoperae stuctions, 30
posoeraie eriod, 13031
preopeate n sructions, 30vs. ale pattern hai oss, 19, 9t, 3
edca theray, 178
nonFDA aproed medicatons, 8
pathogenesis, 6
physcal exa naton, 16, 819suger, 8
Feae sugica panning, 19
posoeraie instuctons, 130
posoeraie eriod, 3031
preopeate nsructions, 130
Fendae abs, 7Fibrous paples, 1
Fl om was, 06
Fl lers
pemanent, 883
temporary, 8
Finasede, 104, 104, 8, 33Ftzatrick ski phooype, 3
Ftzatricks cassifcatio, of skin types, 4t
Flashlap, 78f, 79, 79f, 80
teatent, 93
Flaonoids, 9t
Foam scleotheapy, 9900Fo l ic lar infundb u, 9
Fol icla r nit extraction F E, 06, 07, 108
vs ell ptcal sti aestng, 07t
Fol icul is, 00
Foeead, f, 34, 4f
a, 930Fractona phototemolysis F)
Fractiona esrfacing, 5, 5, 53f
Fraxel Restoe, 56, 56!
Freckes See Eheides
Frotas muscle, , 34, 3
Frontas muscles, 4, 4fFUE See Fol icular nit extracton
GGelatinase, 9
Genita was, 009Gentsic acid, 9t
Glabellar comex, 4, 4f
G lab id n , 0
Gloga hotoaging Ca ssifcato, f, 3, 3f, 4, 5
Glycolc acid, 9, 3
Glycoic acid peel, 3, 33, 74, 60and eph ides, 41
and melasa, 5 , 5t
Glycoyroi um bomide, 87
G/ycyhza g/aba linneva, 10
Gold inectons, 75
Grafts, skin, 5
Granuoma faciale, 174, 74, 76course, 174
dematopat hol og, 17 4
differenial diagnoses, 74
edemiology, 174
g reatmen, 175anagement, 175
ut pe esons of, 175f
pathogenesis, 174
physcal exainaton, 174
pitfals o aoid, 175
sysemc reatmen, 75toca teatment, 175
ndx 3 5
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3 1 6 I nd ex
Grauloma gaidarum 119
Grauloma elagiectaicu 18891
Graulomatos rosacea 76
Gnecomasa 272275 272fconsultate qesions 273
corse 273
diffeenia agnoss 272
eiemioog 272
aoator exam nat on 272273
aagement 273pathogeness 272
phsca lesios 272
pifas/comlications/oucoe exectaons 274275
teatet 273274
HHar loss. See Female pate ha oss; Mae paten hai loss
Har emoa 217
Ha r ranspantaon 04105
Har ne desig 108
Haaoa 216 222
Heagioma segmenal 180fHeangioma lceated 79f
Heangioas 177
Heoma 226
H c lens Hrsism 92
consultate qesions 93corse 93
diffeenia agos s 9293
ei e io og 92
aoator tess 93
aageent 93
elecoss 94eocroog cons uaon wi 93
jus por o reamen 96
aser ha eoal technqe 95 9698non lase heap ies 9394
patient consaon 9596
posteaet instrucons to aient 98phsica exaination 92
pifas 94f 9899
H IV ipodsroh/faca l i poatoph 280284
consultate qesions 281
corse 28
dematopatoog 280diffeenia agnoss 281
eiemioog 280
aoator examnaton 281
aagement 281282
pathogeness 280
phsica l esios 28028pifas 283284
precitatg facors 280
preetion 281
teatets 282283
Hoosaae 7tHomones 73
H man pap i loaius V) 206209
Haurodase 47
Hdroquinone 9 9 13 140 146 151! 160
Hdrox aci 73
Hdroxcomarins 9tHaform® 15tHerhosis 86
oul um oxin A 88 88f
aesthesa 88
atiperspirant 89
otox 89edcaos 89
sger 89
teaet 8889 f 89f
consultatie qesons 87
corse 86
dematopaholog 86differenial diagnosis 86
eemoog 86
aoaor examinaon 86 86f
aagement 87 87f
oal edcaons 87
pathogenesis 86phscal findings 86
pitfals 8990
sger 88
topical medicatons 87
Hehosis
ses of 90fteaent dagram 87f
Hepgetaton
ad cohera 209
ad ostsclerothera 200
Hpesensite reacions of so tssue a gentaon 18
Hetoc saine 199 200 201tHetichosis 216 217
Herophic scas 290
clinica expeence 293
differenial diagnosis 290
vs keoids 290!aoator exam inat on 290
aser 29f 292 292f
aagement 291
phscal exainaion 290
pu
se de aser 292
suies 292Hpogmenao 67 187f
ad cothera 209 236
ad ase teaets 218
Iceick/Boxcar Scar
lcoin 58deeoe 8
l imod 179 207 291 29
lnamed Cop 4
lnamed Cop. 15t
Infai e hemangoma I) 177 177f 178f
acia tests 78coplications 78
corse 178
dematopatholog 177
differenial iagnoses 177
eemoog 77
aoaor tess 77aagement 17880
phscal exai naion 1 77
pitfal s o aoid 180
Intese puse ligh asers
for pseudofol i cul t is 01
for Beckers neus 218for cher an spder agiomas 172
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for potwine sta ns, 85
for posscerotherapy hyerpigmenation, 201-202, 20f, 202f
for veous akes, 204
Inteeon, 179
Interockng Ls repir, 308lntaesona 5foroacil (5FU), 291, 29t
lntaesona seroi inecton, 74
lntaesona tr iacinoone aceonides, 291, 29t
lopine, 28
I L See ntense pse ght
Ipsen Limite, 21tlsolagen, 15t
Isopopyl acohol, 8
lsotreino, 0, 58, 7, 77
JJessner, 30t, 35f
Jessner peels, 141 , 60
Jveder, 5
KKeex, 17, 46
Keos
dieeia iagnoss, 290
vs hyperropic scas, 29t
vs. keoids, 290t
boatory exa iat on, 290aser, 29, 292, 292
ngeent, 291
physc exaination, 290
pse dye aser, 292t
sues, 292
Ketnocyes, 40, 222Keatoyc gens, 73
Keatoses
seborrhec, 223Keatoss fo icla s sn losa decalvans ( KFSD), 81
Keatoss pi lais aropcans (KPA), 181, 18f, 182f
course, 18deatopatoogy, 181
difeeil iagnoss, 181
eeoogy, 81
ngeet, 182
pathogeess, 181
physc exaination, 181pitfa s o voi, 182
Keatoss plais ropcans face (KPAF), 181
Ketoses
ctic, 206
seborrhec, 206, 23-237
Kiner syome, 67Koees to, 212
Kojic acid, 9t, 10, 141
KT laser. See Potassumtanylphosphate lase
LLMX an 5, 7
Lacc acid, 82
acc aci, 9t
AB syndroe, 14
Lanzou stiute o Biologica roducs, 21tase ha r emova
n sus, 95
n pseuofo ic it is, 100, 10, 10
technq ue, 9&98
Lase l ght frig , 93f
Lase safety, 97f
nonbtve laser resucg,
for ab tve facol lser resacng, 59
vese si e effects, 60, 60
followp, 59-60, 59f
nfection, 60, 6
nonfca skin, 60
posoperive care, 57f, 58f, 59Lase therpy
for demtochaasis, 65
for ganuoma aciale, 75
for Poikiodema of Civtte, 68, 68f
for sebaceous yperplasi, 8283, 82f, 83f
Laseasssted photoyamic terapy, 82
Lases, 74
Lecitins, 9
Lentgnes, 1
checa peels, 46
consuttve questions, 4146course, 45
cryoteapy, 16
differeil iagnoss, 145
epeiology, 4
aboatory exiaton, 145
aser an ght soce treatmet, 146147mngement, 45
pathogenesis, 1
pathoogy, 14
physcl lesions, 14
ndx 3 7
pitfal s o void/cop icatios/mnageent/oucome expections,
147-48
vs seborhec keraosis, 235
topica medicatons, 15-146
Lentgo sex, 4LEOPARD syndroe, 1
Licen pans (L), 262-264
corse, 263, 264f
dematopathology, 262
differenil agnoss, 262
epeiology, 262
aboratory data, 262mngement, 263
pathogenesis, 262
physcl examiaton, 262, 262f, 263f
Licen striaus, 223
Licorce extract, 9t, 10
Liocaine, 47, 59, 107
for war remova, 208
Life Cell Corp., 1tLigt teament, of ace vulgaris, 72f, 73f, 74-75, 75f
Light cyotheapy, 82
Liear foca elastosis
Lier headig, 1 8
Lioleic c, 9
Lipecomy, 283
Lipoma, 22&228
consutatve qestions, 227
course, 227
diffeeil ignoss, 226epe iology, 226
aboatory data, 227
pathoogy, 226
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3 1 8 I nd ex
hysi exintion 226 226 227 228
its, 228
tetet 227-228 227 228
Liosom 226
Liosuion 88or elul e 277
or gyneost, 274
or IV podystrophy/il i orohy 283
or l o 227
Liver sots See Sor lentigos
LLL See Low leve ight lse theryLobu i ly emngo 8819
Longpused exdrite ser 0
Longpused Nd:YAG lse 10
Low leve gt ser hery (T 33 133 134
enis o io 33ers o wisdom 33
use o 33
Lowe exreity tengetasis 9-202
Lowe eye sn k tes 2223
Lowe e 3
Lowe lid oizon xity 64L See Lihe nus
Lux 540 n lse 56 56t
MMules 216 223Melugs disese 226
Mle ttern hir oss 03 See also Femle
ten h ir oss
onslt 05
diereni gnoss 103
epieioogy 03vs ee ttern hir loss 29 129t 13
ir trnspnio, 04105
bortory exnton 104
ei terpy, 04 104tntu ogressio, 103
togeness 103hysi exintion 03 103 105
surg roedue
oretive hi r trnspl n surgery 10, 10t
dy o roedure 06
dono hvesting enques 106 06 106t 107t
dono egion nesthes in 06ol iulr unit extio ( F E) 107 07t
grt eton 07
grt lemet 1 081 09 1 13
ir l ne design, 08
os i tns t side eets 1 09
osopeive perod 109
ossugi eiod te sutures/stlesreoved, 109-10
eoetve in srutions 06
e side eets 109
reient regon nesthesi in 08
reient site eton 1 08 1 2MuneAbrig sydroe 36
MGhn edil , 5t
MED See M ni eryte dose
Mel oiulis oul i , 24 24
Meis 15t
Meiis Estets 2tMeumdet eel 30t 33 34 35
Meyox In 2t
Me ln in
ostserohery hyperigmenton, 200
seorrei kertosis, 236
Mel noyte ytotoxi gens 9t
Melnoyte tnser hio, 9
Melno
vs. seborrhe kerosis 235
venous kes d 203
ws d 206
Meloges 1
Melsm, 149 49
tve ser 152
hemil eels 5152
onslttive questions 50
ourse, 150detothology 49
dieenil igosis 150
epeology 49
ton resurng 52 153
botory exminton 150
geent, 150 50 151 152
thogenesis, 149
hysl lesios 149
itl s 52-53
swhe lse 52
toil tretment, 5 5
M E N D See Mirosoi eperl neot ebis
Mets se 26 27 28
Metor orporion 5t
Mequino 9t
Merz hr 4 2t
Mesohery
or eue 278
Mehnhel u omide 87
Mehy molevu ini id (MA) 254
Mehy ntrite 7
Meronzole 77
Mexory SX 7tMexory X 7t
Miroerrsion 74 229 287
Mirosoi eper nerot ebs ( ME D) 52
Mirother retment zoes (MZs), 52
Mide 3
Midnrred sers 40 41
Mid trohy 67
Mi , 229-230
onsulttive questons 230
ourse, 230
epe iology 229
togeness, 229
thology 229
ysl exintio 229 229 230
itls 230tetet 230 230
Mii erythe dose (ED) 8
Mioylne 73 77
Minoxidi l 04 04 27 28 127t , 13 33
Mixed derm els 49
Mixed supel nd dee hegio () 177Mohs rogh surgey 254 257258
Mooenzone 9t
Morhe 265267
ourse, 266
detothology 266
dierenil dignosis 265
epdeology 265
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aboatory data 265-266
aageent 266 266
pathogeess 265
physca exaination 265 265fpita 267
MTZs See M croheal eatent zoes
Mubery extac 9t
Muscle grops 23
forehea 23-24
glabella copex 24 24nasoabia od 25-26 27f
neck 26-27 28
peioal egion 26 27 28f
peioa egion 2-25 25f
upe asal root 25 26
Myastheia gavis 22Myobloc 2t
NNAFR See Noalatve factoa aser resuacg
Nasa sebaceous hypepasa See Rhophyma
Nasoabia fol 25-26 27Nd:YAG ase 99 193
for sebohec keatosis 236
Neck 26-27 28
Neofroas ( F) 231-234
consltative qestos 232
course 232difeenial iagnoss 231
eeoogy 231
aboatory data 232
aageent 232
pathogeess 231
pathology 231physca exaination 231 23f
pitas 22322
teatet 232233 232Neofroatosis 36
Neoox 2
Nevus aaneus 170-73Nevus Becker's 216-218
Nevus edea 222-225 235
Nevus uscoceules ophthaomaxl lais 154
Nevu s of Ota 154
consltatve qestos 55
course 155difeenial agnoss 154
eeoogy 5
aboatory exaiaton 155
aageent 55
pathogeess 154
pathology 154physca lesos 15
pitas 157
topical teatent 155
teatet 5156
Nevus seaceos 223
Nacade 9t 10oaative factona aser resuacg ( AF R)
aesthesa 54
contandcaos 53
deatopathoogy 52 52f
devices 56 56t
d catios 52echanis o acio 52 52
ecatios 53-54
posoeraive care 55
preopeatve evaluation 52-53 53f 54f
preopeatve preparato 54
proceural ips 54-55teatet peals 55-56
Nonalatve factioal lasers 57
Nonalatve factoal esracig 39 60
Nona latve aser resacng 39 39
avese side eects 41
posoeraive care 2ndicatos 40
aser saey 4
preopeatve evaluation 40
prohyaxis/aneshesia 40
dfaed ses 4 41Nonfacal sk n 60
ndx 3 9
NonFDA aprove edications or feae patten hai oss 128
Non hypesesitive eactions of soft tsse augentato 1819
Nonlaser theapy 93
depiat on 94
topca elohe 94Noood cassficato 103
0Octocrylene 7t
Octy ethoxycamae 7t
Octy sa cyate 7
Ocla r rosacea 76Oral edicatons
n hyerhidrosis 87
Oral heapy 65
Orbclars oci 225 25f
Orbcuar s oci tone Orbcars os 26 27f 28fOxybezoe 7t
p3 to supresso gene 252
ABA. See aaai obezoc acid
adiae 7t
aoplantar arts 206209
aoa Medcal echnooges 56 56t 79ape ubery 10
apules
n angiofioas 212
n epidea evs 223
n arts 206
apulopstuar osacea 76aaamnobenzoic acid (ABA) 7t
aial ears 308atet consultato 95
pror to teatet 95-96
DL See ulse dye aserDT. See hotodya c theray
eary e le papues 212
eel tyes 33
ad c ca d icatons 30t
eelng aget characteistcs 30t
enic i l 10eifoll cu la eryhea chaacestc postteatet 93
eioa deatis 76
eioba egio 2-25 25f 26 27f 28f
eioba hytes 55f
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320 I nd ex
Peigal fibroas, 212
Pelane, 15t
Pelane 15
Pet-eghers syndome, PAE syndrome, 78
Pheno, 30
Phenyl benzm dazole sonic acid, 7
Photodynaic theray ( PDT), 75
Photodynaic theray, 25, 258, 269
Phototeapy, 75, 165Phyatos rosacea. ee Sebaceos hyerplasia
Physica sceen, 8, 8
Pigenay cages, n face, , 6f
P . ee Postinfaatory hyerpigenation; Pregnancyindced
yperesion
Piar cysts, 220, 26Pimecro ms, 16
Pityrospom ovae, 10
Pla e was, 20 209
Platar was, 06
Plaes
n angofbroma, 212n Becke's evs, 2 6
n seborrheic keatoss, 235
Playsa scle co ex, 2627, 28f
POC. ee Poki odera of Civatte
Podoy in, 22
Podoyotox, 207Poklodea of Cvatte (POC), 67
consltatve estions, 68
corse, 68
deratopatoogy, 67
diffeenia agnos s, 67eieioogy, 67
manageent, 68
pathogeness, 67
physica examination, 67, 67f, 68f
pitfas, 68-69, 69
prereaten, 68fteatmet, 68, 68f
Poidocanol, 199, 200, 00
PoyIacc ac, 18
Pontocane ee Toca tetacae
Porwne sains (PWS), 83, 18f, 185f, 186f
aclary tests, 83corse, 183
deatopatoogy, 183
diffeenia agnoss, 183
eieioogy, 83
maagement, 183
physica examination, 83pitfa s o avoid , 83
Post ha i tans at si de efects, 109
Postnfaatoy erythea
ad crettage, 237f
Postnfaatoy hyerpigenation ( PI H) , 158, 158f
cheical peels, 166consltatve estions, 159
corse, 159
deratopatoogy, 158
diffeenia agnoss, 158
eieioogy, 58
aboatory exanaton, 58asers, 161
teatmet, 218, 233
maageent, 159
pathogenesis, 158
physcal lesos, 158
pitfal s o avoid/cop icatons/manageent/ocome
expectaios, 61
snotecio, 159topical treatent, 160
Postsceroeapy hyperigenatio (P SH) , 200
Potasstaylphoshate lase, 79, 93
Prenisone, 130, 79
Pregnancy
ad telangecasias, 98, 201Pregnancydced hyeension ( PI ) , 60
Prevel le si k, 5t
Prmary andogenprodcng neoplass, 92
Procers, , 2f
Proanthelne, 87Proyacic antbotcs, 9, 53
Proranolo, 179
Prosgne, 2!
Prostate cace
proylaxis in, 273
Proes synd ome, 226Psedofol icts, 99
corse, 100
deatopatology, 00
diffeenial diagnosis, 00
ed eiology, 99
aboatory exainaton, 100maageent, 100
pathogenesis, 99
physcal lesos, 100
pitfal s, 101-02, 101, 102f
teatment
aser ha emoval, 101 , 0shavng cessato, 100
shavng technie, odifcaio o, 1001
topical teatent, 10
Psedofoll icits, and erology, 01
Psedogyecoasia, 272
Psedoochronoss, 3, 159fPsoralen and tavioet A (PVA), 65, 75
Psorass, 267270, 67f, 268f
corse, 268
diffeenial d iagnosis, 268
edeiology, 67
aboatory data, 268maageent, 268-269, 269f
pathogenesis, 268
physcal examination, 268
pitfals, 270
Psedogyecoasia, 27Psed carbon doxide laser, 250
Psed dye aser (PL)
for acne vlgas, 75
for angiofibroma, 213
for a ngiokeratoas , 169
for cery a spider agioas, 17 1for facia telagiectasa, 203, 203f, 205f
for facia telagiectasas, 192
for hypetroic scars/keloid s, 292t
for nfantile hemagioas, 79
for keatoss ais atroicans, 182
for orhea, 266for Po kiode ma of Civatte, 68
for powine stans, 85
for psorias, 69
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for pyogec ganloa 89
for rosacea 78
for seacious yperpasa 82
for strae distensae 287for telagiectasias 201
for venous aes, 203 205f
for wars 206f 208, 208f 209f
for wars 208
Pnch excsion 213
Pura 204 208PVA See Psora len and ultravioet A
Pyogenc gan loa ( PG) 88, 88f 89f
Q
iosyproven 9f
corse 88
deatopathoogy 188
diffeenial iagnoses 88eeioogy 88
aser teatent, 89
aageent 89
pathogeness 88
physca exaination 88
pitfas o avoid 89sgica treatmet 189
vs venos aes 03
Med AB 5tswche lasers 52
R
alexandite
for Becers nevs 27 28f
for caf a Ia it acles 37 138
for deatosis palosa n igra 242for epdera nevs 25
for nevs of Oa 55 56
for seorrheic eatosis 236
argon
and ganu loa facae 175
d:YAGfor Becers nevs 27 28f
for caf a Ia it acles 37 138
and eph ides 4
and ent gines 146
for nevs of Oa 55
for tattoo eoval 300 302uy
for Becers nevs 7 28f
for deatoss palosa nigra 42
for epil des 42
for etigies, 46 47
for nevs of Oa 55for seorrheic eatosis 23 6
for taoo eoval 300 302t
Radiato deatis 67
Radia ton terapy 25RadiesseTM, 15t
Radiofeqecy (RF) echology 62
Radi oteapy 258
Reepithel ial izat on 9
Rex in
Renova 9Restylane 15
RestylaneL 5
Rete rdges
n epidera evs 222
Reticar veins 98-202
Reticated ypepigentaio 67
RetinA 82Retinadehyde 8 9
Retioc acid 8-9 9 0 2
cheica structues of f
Retinods 73 41 5 51! 60 182
Retino 8
Retinyl esters 8R F technoogy See Radi ofeqecy ( RF ) echoogy
Rhophya 76, 76f 77-78
Rhes 58
Rosacea 76
course 77deatopathology 77
differeial diagnoss 76
epdeiology 76
aageent, 77
sgca terapy 7779
sysec herapy 77topica teapy 77
pathogeesis, 76
physcal exainaton 76
Rothud-oson syndome 67
Ry sot, 70-73 See also Chery angioas
Rssel-Silver synoe 36
sSaicylic aci 73 207
Sa ie
ad warts 207 208ad teangecasias, 20
Scarig
fo angiofioa treaten 24
fo surgical ncision 22 228
fo wa eoval 207 208 209
SCC See Squamos ce carcinoa
ndx 321
Sceroteapy 199-20 98f 99f 200f 200t 20t 204
Scoioss 232
Sculpa 15t
Seaceos cyst 2 9
Seaceos hyperplasa 76 77 8 8f
consutatve qestios 8course, 81
differeial diagnoss 8
epeiology 8
for seoeic keatosis 236f
aoratory exai naton 8
aageent, 82pathogeesis, 81
pathoogy 8
physcal lesios 8
pitfal s 83
teatets, 82
descive oda ies 82aser terapy 82-83 82f 83f
Seorhec eratitis 76
Seorh ec eraosis 23237 See also Deatosis paplosa gra
consutatve qestions 235
course 235
differeial dagnoss 235epde iol ogy 234
vs edera nevs 223 235
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322 I nd ex
anageen 235-236
pahology 235
physica exainaion 235
pifas 237eaen 236
s. was 206
Segena eangioa 8
Senie eangoas 170-173
Seia puncue 8
Seia saicyic acid peels 74Sharpan FeaherToch 169
Shave biopsies and excisons
for angiofiboas 21 3
for epdeal nevs 224
for l poa 227 227f
for neuofiboas 236for seboheic keaosis 236
Shaving cessaon 100
Shaving echnque odifcaion of 10010
Shoplsed eb 287
Sil cone 18
Sil cone sheeing 29 29S l kone1000 5
Skin gafs 225f
Skin l ghenng agens 9-1
Skin esng 16
Skn unove acceeaon 9
Skin ypesand eckes nevus 218
Soohbea 41
SA25 21
Sodiu ohuae 199
Sodiu slfacetaide 73 77Sodiu eadecy su fae 99 200 20
Sof issue agenaion
avese eacions
hypesensive 8
nonhypesensive 18-9
echniq ue copicaions 9aneshesa 16f 7
degree of coecion 18
duaion of coecon 18
dea fl e 4 14-15
necion echnque 18 18f 19f
evel of injecion 1718 17f 18fechans of acion 4
peopeave evauaion 15-16
pocedral edicaons 17
skin esng 6
eaen peas 19
Soffo 15Sola lenigo s epheid 145
Sola lenigos 44
Soa edical Inc 56 56
Soice euosciences 2
Soadecho 200
Soy 10Soybean/k exacs 9
SF See Su n poecive facor
Spe angoas 170-73 17
Spe elangecasa 170-73
Spnal dysaphs 227
Sponolacone 73 28Saous cell carcnoa (SCC) 256-258
conslave quesions 257
course 257
deaopahology 257
diffeenial diagnosis 256 257f
epe iology 256
s. epea nevus 223aboaoy daa 257
anageen 257-258 258f 259f
pahogenesis 256
physcal exainaion 256 256f
pifals 258
s. sebohec keaoss 235s. was 206 207
Sachod ine es
Saux Lux G handpiece 79
Seoi rosacea 76
Sockings eas c copesson 200
Sawbery 77180Sech aks. See Sae di sensae
Sa aba 287
Sia ruba 286-287 287f
Siae disensae 285 285f
conslaive quesons 286
course 286diffeenial iagnosis 286
epdeiology 285
aboaory exa ina on 286
anageen 286
icroerabasion 287
pahogenesis 285pahology 285
physcal lesons 285
pifal s 288
opical eaen 287
eaen 286-287Soeysn 9
Sge-Webe syndroe (SWS) 184
Subcision 278
Sbcaneos fa n ipoa 226
Subcaneous fa 5
Sbcaneos fa arophy 5Sfu 73
Sisobenzone 7
Sn exposue
and sceoheapy 200
and venos akes 203
Sn poecive facor (SPF) 8Snscreen 7-8 7f 7
Speficial heangoa (S) 177 179
Speficial peel 30 32f 33 33f
Sgery
n hypehidoss 88
Sgca excsion 175Sgca pocede for hai anspanaon
coecive ha ans pan sugey 10 1 10
day of pocedue 06
dono avesing echnques 106 06f 106 107
dono egion a neshesa in 06
fol icula n i exacon (F E) 107 07gaf ceaion 07
gaf paceen 108-109 13f
a in e desgn 108
pos ha i anspa n side effecs 109
posopeaive period 109
possugca peiod afe sues/stapleseoved 09- 10
peopeave nscions 06
ae sde effecs 109
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ecipen regio aeshesia in 08
ecipen se ceaio 08 2f
Sgca hera py
of ace vu gars 7
for angioibroma 23for Becker's nevs 27
for Deraochaasis 6f 65
for epdea nclsio cyss 220
for epdea nevs 22
for ipoa 227 227f 228f
for neuofibroa 232-233 232fof osacea 76f 77-79 79f 80f
for veous akes 20
for wa emova 207-209
Syigoma 238 238f
conslave quesons 239course 239
diffeeial iagnoss 238
epe ioogy 238
aboaory exa ia on 238
maageen 239
pahogeess 238pahology 238
physca lesios 238 238f
pifas 239f 240 20f
eaen 239-20
Sysec l ps erytheaoss 76
Sysec heapy
T
of ace vugars 73-7
of osacea 77
Tacrols 6
Tacrols oe 75
Takeshesa 7
Tap wae ionophoresis 87
Taoo reoval 300 300f
averse eecs/pecaos 303 30 305 306 307fconslave quesons 300-30
aser heapy 300
maageen 30
pifas 303-304
posteamen ca e 302
pereaen assesse 30aoo reame 302 302 303f 30f
eamen 30-302 303f
Tazaoene 9 73 82
TCA pees See Trichl ooacec acid peels
Teangecases 67
Telangiecasas 7879 78f 79f 80fower exremty 98-202
epeioogy 98
aboaory daa 9 8
maageen 99202 98f 99f 200f
pahophysoogy 98
physical exami naion 98Teangecaic mattg rM 20
Telogen efuvi 29 30-3
Teracycine 73 77
Tombophlebi s 98
Thyroidsi a g homone (TS) 63
Tsse ghening 62canddae seecio 62
cl in ca pears 63
mechanis of acon 62
procere 62
checklis 62-63
side eecs 63
Topica 5foroacil 25Topica eflornihine 9
Topica m ui od 25
Topica mecaions i hypehdrosis 87
Topica proparacane 7 59
Topica eioic acd 32
Topica eacae 47 59Topica herapy
of ace vu lgaris 73
for demaochaasis 65
for Poikioema of Civate 68
of pseudofol cul i s 0
of osacea 77Topica reame opi ons
app caion echq ues - 2
compica ons 2
conandcaios
deal can dae
nd icaos ess ha dea can ae
mechani s of aco 7-
poseamen cae 2
prereaen evaao
eame pearls 2-3
Topica reio 6 6Tor ea obe 308
key consaive quesions 308
maageen 308
ndx 323
pifal s o avoid/cop icaios/manageent/oucome expecaios 309
eames 308-309 308f 309f 30fTraoa PDL 78
Tradoa resuacig 39
Treno 9 6 54 73
ad epidermal evs 22
ad l i u 230
TriAcive Laserdeoogy 278Triamcoone aceoe 79
Triaguais mscles 26 27 28f
Trichloaceic acd (TCA) peels 30 7
for war remova 207
Tri ma 6
Trolame sacylae 7TS See Tyroidsilaing horone
Tuberos scerosis 36
Tuberos scerosis 23 23f
Tuors 220
Tyleno 09
Tyosinase 9Tyosinase i h biors 9
uUlceaed hemagioa 79fUla 5
Ula Plus 5
Ua Plus XC 5
Ua XC 5
Ulaso 98Ulaviole A (UA) 67
Ulaviole B (UB) 67
Upper and idfacia usculaue aaoca i srao
of 22f
Up per face 2-3