Hair & Nails

Ethnic hair can become dry, brittle, and fractured when exposed to harsh solvents, heat, and repeat chemical treatments. To combat these issues, consider discussing the use of dry shampoo with your patients.

Dry shampoo is a powdered substance used to absorb oil in hair when traditional shampoo is not available, or for use with hair that dries out after repeat washings.

The ingredients in dry shampoo are called "absorbing agents," which soak up excess oil and dirt on the scalp. The most common absorbing agents are Oryza sativa starch, aluminum starch octenylsuccinate, zea mays starch, and silica.

There are two types of dry shampoo: those that come in a loose powder form and those that come in an aerosol form.

Powder dry shampoo can be applied directly to the scalp from the bottle and either brushed through or massaged in. Dry shampoo aerosol can be sprayed directly onto the scalp from a few inches away.

Recent advances in dry shampoos have instituted different coloring agents to help match the hair, as well as fragrances to mask any odor.

Many of these products can be found on www.dryshampoo.com.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

Ethnic hair can become dry, brittle, and fractured when exposed to harsh solvents, heat, and repeat chemical treatments. To combat these issues, consider discussing the use of dry shampoo with your patients.

Dry shampoo is a powdered substance used to absorb oil in hair when traditional shampoo is not available, or for use with hair that dries out after repeat washings.

The ingredients in dry shampoo are called "absorbing agents," which soak up excess oil and dirt on the scalp. The most common absorbing agents are Oryza sativa starch, aluminum starch octenylsuccinate, zea mays starch, and silica.

There are two types of dry shampoo: those that come in a loose powder form and those that come in an aerosol form.

Powder dry shampoo can be applied directly to the scalp from the bottle and either brushed through or massaged in. Dry shampoo aerosol can be sprayed directly onto the scalp from a few inches away.

Recent advances in dry shampoos have instituted different coloring agents to help match the hair, as well as fragrances to mask any odor.

Many of these products can be found on www.dryshampoo.com.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

Ethnic hair can become dry, brittle, and fractured when exposed to harsh solvents, heat, and repeat chemical treatments. To combat these issues, consider discussing the use of dry shampoo with your patients.

Dry shampoo is a powdered substance used to absorb oil in hair when traditional shampoo is not available, or for use with hair that dries out after repeat washings.

The ingredients in dry shampoo are called "absorbing agents," which soak up excess oil and dirt on the scalp. The most common absorbing agents are Oryza sativa starch, aluminum starch octenylsuccinate, zea mays starch, and silica.

There are two types of dry shampoo: those that come in a loose powder form and those that come in an aerosol form.

Powder dry shampoo can be applied directly to the scalp from the bottle and either brushed through or massaged in. Dry shampoo aerosol can be sprayed directly onto the scalp from a few inches away.

Recent advances in dry shampoos have instituted different coloring agents to help match the hair, as well as fragrances to mask any odor.

Many of these products can be found on www.dryshampoo.com.

- Lily Talakoub, M.D.

Do you have questions about treating patients with darker skin? If so, send them to [email protected].

DANA POINT, CALIF. – An at-home, consumer hot-wire hair removal device worked no better than did standard shaving, according to a recent study.

"Relative to shaving, treatment with the hot-wire device did not produce statistically significant differences in the percentage change from baseline in hair count, duration of hair removal effect, or color and/or thickness of regrowing hair," Dr. Brian S. Biesman said.

© Casarsa/iStockphoto.com

There have been no controlled published studies of the no!no! hair removal device (manufactured by Radiancy) in peer-reviewed literature, which led Dr. Biesman to conduct a small study comparing the device’s efficacy with that of standard shaving.

According to information on the no!no! website, the device uses Thermicon technology "to conduct a gentle pulse of heat to the hair," which "instantly removes hair and slows the rate of hair regrowth with no pain." In Dr. Biesman’s study, however, the effectiveness of the hot-wire device, used according to the manufacturer’s recommendations (four passes per session), was found to be equivalent to standard shaving for all study end points.

For instance, active hair follicles and hair regrowth were not affected by a series of treatments with the hair removal device, compared with shaving. Also, hair thickness and color did not change after treatment with the device, Dr. Biesman reported in a poster at the Summit in Aesthetic Medicine sponsored by Skin Disease Education Foundation (SDEF).

A total of 23 patients (7 men, 16 women) aged 18-55 years completed the study; 90% of participants were white. Two sites on one leg of each patient were shaved 4 days before baseline, and then were treated every 3-4 days with the hot-wire device on one site on the leg and by shaving the other site for 8 weeks. The treatment sites were two symmetric 3 × 3 cm areas of the leg that were 3 cm apart and contained at least 15 hairs. The corners of the sites were micro-tattooed with ink, which was visible under black light.

Photographs were taken to measure hair count at baseline, weekly during treatment (before and after), at 4 days following final treatment, and at each follow-up visit (4, 8, and 12 weeks after final treatment), and "blinded visual and digital assessments were made for hair thickness and color," noted Dr. Biesman, who has a private practice in Nashville, Tenn.

The mean baseline hair count of the hot-wire and shaving sites were 86 and 79, respectively, "which remained stable during the 8-week treatment phase. No hair count reduction was seen." At post-treatment follow up, hair counts increased to 95 (treatment site) and 84 (shaving site) at 4 days, 104 and 99 at 1 month, 106 and 100 at 2 months, and 109 and 105 at 3 months. Hair regrowth was noted immediately after ceasing treatment with the hot-wire device.

The mean percent change at 4 days post treatment was 19% with the hot-wire device, compared with 14% with shaving; 41% and 41% at 1 month post treatment; 31% and 28% at 2 months post treatment; and 32% and 37% at 3 months.

A study limitation was that hair removal was evaluated only on the lower leg to sites not randomly assigned.

The study was sponsored by Tria Beauty, for which Dr. Biesman has consulted and from which he has received research support. SDEF and this news organization are owned by Elsevier.

DANA POINT, CALIF. – An at-home, consumer hot-wire hair removal device worked no better than did standard shaving, according to a recent study.

"Relative to shaving, treatment with the hot-wire device did not produce statistically significant differences in the percentage change from baseline in hair count, duration of hair removal effect, or color and/or thickness of regrowing hair," Dr. Brian S. Biesman said.

© Casarsa/iStockphoto.com

There have been no controlled published studies of the no!no! hair removal device (manufactured by Radiancy) in peer-reviewed literature, which led Dr. Biesman to conduct a small study comparing the device’s efficacy with that of standard shaving.

According to information on the no!no! website, the device uses Thermicon technology "to conduct a gentle pulse of heat to the hair," which "instantly removes hair and slows the rate of hair regrowth with no pain." In Dr. Biesman’s study, however, the effectiveness of the hot-wire device, used according to the manufacturer’s recommendations (four passes per session), was found to be equivalent to standard shaving for all study end points.

For instance, active hair follicles and hair regrowth were not affected by a series of treatments with the hair removal device, compared with shaving. Also, hair thickness and color did not change after treatment with the device, Dr. Biesman reported in a poster at the Summit in Aesthetic Medicine sponsored by Skin Disease Education Foundation (SDEF).

A total of 23 patients (7 men, 16 women) aged 18-55 years completed the study; 90% of participants were white. Two sites on one leg of each patient were shaved 4 days before baseline, and then were treated every 3-4 days with the hot-wire device on one site on the leg and by shaving the other site for 8 weeks. The treatment sites were two symmetric 3 × 3 cm areas of the leg that were 3 cm apart and contained at least 15 hairs. The corners of the sites were micro-tattooed with ink, which was visible under black light.

Photographs were taken to measure hair count at baseline, weekly during treatment (before and after), at 4 days following final treatment, and at each follow-up visit (4, 8, and 12 weeks after final treatment), and "blinded visual and digital assessments were made for hair thickness and color," noted Dr. Biesman, who has a private practice in Nashville, Tenn.

The mean baseline hair count of the hot-wire and shaving sites were 86 and 79, respectively, "which remained stable during the 8-week treatment phase. No hair count reduction was seen." At post-treatment follow up, hair counts increased to 95 (treatment site) and 84 (shaving site) at 4 days, 104 and 99 at 1 month, 106 and 100 at 2 months, and 109 and 105 at 3 months. Hair regrowth was noted immediately after ceasing treatment with the hot-wire device.

The mean percent change at 4 days post treatment was 19% with the hot-wire device, compared with 14% with shaving; 41% and 41% at 1 month post treatment; 31% and 28% at 2 months post treatment; and 32% and 37% at 3 months.

A study limitation was that hair removal was evaluated only on the lower leg to sites not randomly assigned.

The study was sponsored by Tria Beauty, for which Dr. Biesman has consulted and from which he has received research support. SDEF and this news organization are owned by Elsevier.

DANA POINT, CALIF. – An at-home, consumer hot-wire hair removal device worked no better than did standard shaving, according to a recent study.

"Relative to shaving, treatment with the hot-wire device did not produce statistically significant differences in the percentage change from baseline in hair count, duration of hair removal effect, or color and/or thickness of regrowing hair," Dr. Brian S. Biesman said.

© Casarsa/iStockphoto.com

There have been no controlled published studies of the no!no! hair removal device (manufactured by Radiancy) in peer-reviewed literature, which led Dr. Biesman to conduct a small study comparing the device’s efficacy with that of standard shaving.

According to information on the no!no! website, the device uses Thermicon technology "to conduct a gentle pulse of heat to the hair," which "instantly removes hair and slows the rate of hair regrowth with no pain." In Dr. Biesman’s study, however, the effectiveness of the hot-wire device, used according to the manufacturer’s recommendations (four passes per session), was found to be equivalent to standard shaving for all study end points.

For instance, active hair follicles and hair regrowth were not affected by a series of treatments with the hair removal device, compared with shaving. Also, hair thickness and color did not change after treatment with the device, Dr. Biesman reported in a poster at the Summit in Aesthetic Medicine sponsored by Skin Disease Education Foundation (SDEF).

A total of 23 patients (7 men, 16 women) aged 18-55 years completed the study; 90% of participants were white. Two sites on one leg of each patient were shaved 4 days before baseline, and then were treated every 3-4 days with the hot-wire device on one site on the leg and by shaving the other site for 8 weeks. The treatment sites were two symmetric 3 × 3 cm areas of the leg that were 3 cm apart and contained at least 15 hairs. The corners of the sites were micro-tattooed with ink, which was visible under black light.

Photographs were taken to measure hair count at baseline, weekly during treatment (before and after), at 4 days following final treatment, and at each follow-up visit (4, 8, and 12 weeks after final treatment), and "blinded visual and digital assessments were made for hair thickness and color," noted Dr. Biesman, who has a private practice in Nashville, Tenn.

The mean baseline hair count of the hot-wire and shaving sites were 86 and 79, respectively, "which remained stable during the 8-week treatment phase. No hair count reduction was seen." At post-treatment follow up, hair counts increased to 95 (treatment site) and 84 (shaving site) at 4 days, 104 and 99 at 1 month, 106 and 100 at 2 months, and 109 and 105 at 3 months. Hair regrowth was noted immediately after ceasing treatment with the hot-wire device.

The mean percent change at 4 days post treatment was 19% with the hot-wire device, compared with 14% with shaving; 41% and 41% at 1 month post treatment; 31% and 28% at 2 months post treatment; and 32% and 37% at 3 months.

A study limitation was that hair removal was evaluated only on the lower leg to sites not randomly assigned.

The study was sponsored by Tria Beauty, for which Dr. Biesman has consulted and from which he has received research support. SDEF and this news organization are owned by Elsevier.

It was questionable whether in 1952, when Dr. Norman Orentreich performed the first hair transplant and Dr. George Mackee reported on his 50-year experience with phenol chemical peels, anyone envisioned how far the field of dermatologic surgery would advance, but there’s no question now: The specialty has come a long way.

"Dermatologic surgery has blossomed into a full and diverse specialty with many elements," Dr. C. William Hanke noted in the June issue of Seminars in Cutaneous Medicine and Surgery (2012;31:52-9). He highlighted key events that shaped the burgeoning specialty.

Historical Highlights

From the first report on phenol peels by Dr. Mackee (Br. J. Dermatol. 1952;64:456-9), to the coining of the term "tumescent local anesthesia" by Dr. Hanke and his colleagues in 1998 – and publication of a comprehensive text on the tumescent technique 2 years later by Dr. Jeffery A. Klein ("Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction," St. Louis, Mosby, 2000) – Dr. Hanke chronicled the specialty’s evolution.

For example, he noted that in 1961, Dr. Leon Goldman became the first physician to treat patients with lasers. "He is acknowledged as the father of lasers in medicine and surgery," Dr. Hanke, a dermatologist in private practice in Carmel, Indiana, wrote. He added that the pioneer's first medicinal use of a laser launched 3 decades of related leadership, practice, and research.

Among other events that stand out in the history of the specialty, according to Dr. Hanke, are the first reports on cryosurgery with liquid nitrogen in 1966 by Dr. Setrag Zacarian ("Cryosurgery of Skin Cancer and Cutaneous Disorders," Mosby, St. Louis, 1985), and on ambulatory phlebectomy by Dr. Robert Muller the same year (Phlebologie 1966;19:227-9).

And, in 1967, Dr. Frederic E. Mohs founded the American College of Chemosurgery, which is today known as the American College of Mohs Surgery. "Mohs surgery continues to be an important part of the dermatologic surgery curriculum," Dr. Hanke said.

Advancements in vein ablation took pace in 1982 when the first report on hypertonic saline injections for treating leg veins, by Bruce Chrisman, was published (Hawaii Med. J. 1982;41:406-8).

In 1986, Dr. Saul Asken published the "Manual of Liposuction Surgery and Autologous Fat Transplantation Under Local Anesthesia" (Terry and Associates, Irvine, Calif.), and the following year, Dr. Jeffery A. Klein published the first report on the tumescent technique for liposuction (Am. J. Cosm. Surg. 1987;4:263-7).

Dr. Alastair Carruthers and Dr. Jean Carruthers revolutionized the field in 1987 when they began using botulinum toxin for cosmetic purposes. "Their joint observation that botulinum toxin can affect the muscles of facial expression began a revolution in cosmetic dermatology," wrote Dr. Hanke.

He also highlighted the launch of numerous societies and publications that helped to advance the specialty, including the founding of the American Society for Dermatologic Surgery in 1970, the launch of the Journal of Dermatologic Surgery in 1975, and the founding of the American Society for Lasers in Medicine and Surgery in 1981. And the specialty has continued to evolve at a rapid pace since that time, he noted.

Work by Dr. R. Rox Anderson and Dr. John A. Parrish on selective photothermolysis, for example, launched research leading to the fractionated laser technology in use today; and ongoing work by the Carruthers on botulinum toxin launched a new era in noninvasive facial rejuvenation, he said.

"Facelift bypass" procedures have satisfied many patients without subjecting them to the expense or morbidity of extensive facial surgery, Dr. Hanke noted, adding that new filler materials can be placed in the subcutaneous or supraperiosteal planes of the face with good results and minimal complications.

"A newly approved hyaluronic acid from Germany will allow treatment of very superficial wrinkles without the risk of the 'Tyndall effect,' " he added.

Also in the last decade, dermatologic surgery-related educational initiatives have been advanced. In 2004, 1-year fellowship training programs were approved by the Accreditation Council for Graduate Medical Education for training in dermatologic surgery; and last year, there were 47 ACGME-accredited procedural dermatology fellowship training programs in place, he said.

"Dermatologic surgery is an important component of nearly all dermatology postgraduate courses," added Dr. Hanke.

The history of fractional laser technology and fillers were addressed in separate articles in the same issue of Seminars in Cutaneous Medicine and Surgery, underscoring the importance of the two recent developments.

Fillers

The next phase of development in injectable fillers has begun, according to Dr. Richard G. Glogau.

"The concept of augmentation has moved from simple lines, scars, and wrinkles to revolumizing the aging face," noted Dr. Glogau, a clinical professor of dermatology at the University of California, San Francisco. "While seeking extended duration of effect balanced against the safety profile of the injectable, our focus is now directed to extending the lifting or volumizing effect that one can achieve with these fillers."

The initial movement into 3-dimensional correction with injectable fillers began with the dramatic improvement seen in lip volume championed in the 1980s, and each of a litany of fillers that followed, including fat, collagen, silicone, hyaluronic acids, poly-l-lactic acids, calcium hydroxylapatite, and polymethylmethacrylate (Sem. Cut. Med. Surg. 2012;31:78-87).

New fillers, some which represent refinements of existing technologies, continue to undergo review. Aquamid a biocompatible, nonabsorbable, permanent injectable hydrogel implant is currently under review by the Food and Drug Administration and is approved for use in Europe.

It is also possible that fillers will move beyond the traditional concept of inert medical devices and into the realm of true biologics – "materials that will improve the texture, elasticity, radiance, and possibly color, of the skin itself," he added.

"Just as the last 40 years has seen the movement from 2 to 3 dimensions, the next 2 decades will see movement form the macro to the micro level, and fillers will become systems for active metabolic manipulation and protection of the aging skin," he concluded.

Fractionation

The development of fractional photothermolysis was "a milestone in the history of laser technology and cutaneous resurfacing," according to Dr. Nazanin Saedi, a dermatologist in private practice in Chestnut Hill, Mass., and her colleagues.

The technology, noted the study authors, builds on the knowledge gained from early CO₂ and Er:YAG laser treatment experiences, achieving greater optimization of parameters to induce the types of benefits seen with CO₂ resurfacing, but without the significant postoperative morbidity, complications, and discomfort associated with the earlier technologies.

Furthermore, the older therapies destroyed the barrier protection, which "significantly increased the risk of infection throughout the recovery period and required extensive home care. The risk of scarring, delayed-onset permanent hypopigmentation, and demarcation lines was significant even in the hands of an experienced operator," they wrote (Sem. Cut. Med. Surg. 2012;31:105-9).

In an en effort to overcome these problems, what followed was nonablative dermal remodeling (with less than impressive results), and ultimately, the "idea of fractionated laser technology," they continued.

First used in hair transplant surgery, the technology led to development of the 1,550-nm nonablative "Fraxel" laser (now called the Fraxel Re:Store by Solta Medical), which debuted in the literature in 2004. This and other fractional laser technologies are now used to treat photoaging, superficial and deep rhytids, scars (including in patients with darker skin types), and pigmentation.

Both nonablative and ablative fractional resurfacing have proved to be safer than have traditional ablative lasers, Dr. Saedi and her colleagues noted. However, complications can still occur, such as infections (with herpes simplex virus being the most common), acneiform eruptions, prolonged erythema, pigmentary alteration, and scarring (rare, but can also result from infection associated with treatment).

"Counterintuitively, nonablative or ablative fractionated devices at low energies and densities can be useful in the treatment of scarring, including hypertrophic scars" as previously mentioned, they noted.

"While [fractional lasers are] inherently safer due to the pixelated manner of the treatment, complications can be further prevented with attentive surgical technique and judicious use of prophylaxis," they wrote.

The future of fractional laser technology promises to hold exciting developments. For example, since ablative fractional resurfacing creates microscopic vertical holes in tissue, the delivery of topical drugs through these holes is possible. In animal models, the photosensitizer methylaminolevulinic acid has been delivered using this approach, and tests suggest that low density treatment would be sufficient for deep dermal drug delivery.

"Treatment of skin in a porcine model showed enhanced depth of photodynamic therapy following porphyrin application after pretreatment with fractional resurfacing. An in vitro study utilizing low fluence fractionated Erbium:YAG demonstrated upwards of a 125-fold increase in imiquimod delivery," they noted.

Trials in humans are underway to assess the feasibility and safety of enhanced drug delivery using this approach, and there is speculation that ultimately, it could be used for delivery of biologic peptides and vaccines.

Tattoo removal is another promising use for fractional lasers, with early studies demonstrating good results, noted Dr. Saedi and her colleagues, explaining that ablative fractional lasers, when used in conjunction with a Q-switched laser, appear to provide enhanced tattoo removal capabilities.

"With new devices and wavelengths, the applications of this technology continue to grow," they wrote, concluding that "the future remains bright for fractionated laser devices."

Likewise, the future of dermatologic surgery in general remains promising, Dr. Hanke said. "Many new procedures and advances lie ahead."

Neither Dr. Hanke nor Dr. Saedi had disclosures to report. Another author on the article by Dr. Saedi (Dr. Christopher Zachary) reported receiving an honorarium from Solta Medical.

It was questionable whether in 1952, when Dr. Norman Orentreich performed the first hair transplant and Dr. George Mackee reported on his 50-year experience with phenol chemical peels, anyone envisioned how far the field of dermatologic surgery would advance, but there’s no question now: The specialty has come a long way.

"Dermatologic surgery has blossomed into a full and diverse specialty with many elements," Dr. C. William Hanke noted in the June issue of Seminars in Cutaneous Medicine and Surgery (2012;31:52-9). He highlighted key events that shaped the burgeoning specialty.

Historical Highlights

From the first report on phenol peels by Dr. Mackee (Br. J. Dermatol. 1952;64:456-9), to the coining of the term "tumescent local anesthesia" by Dr. Hanke and his colleagues in 1998 – and publication of a comprehensive text on the tumescent technique 2 years later by Dr. Jeffery A. Klein ("Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction," St. Louis, Mosby, 2000) – Dr. Hanke chronicled the specialty’s evolution.

For example, he noted that in 1961, Dr. Leon Goldman became the first physician to treat patients with lasers. "He is acknowledged as the father of lasers in medicine and surgery," Dr. Hanke, a dermatologist in private practice in Carmel, Indiana, wrote. He added that the pioneer's first medicinal use of a laser launched 3 decades of related leadership, practice, and research.

Among other events that stand out in the history of the specialty, according to Dr. Hanke, are the first reports on cryosurgery with liquid nitrogen in 1966 by Dr. Setrag Zacarian ("Cryosurgery of Skin Cancer and Cutaneous Disorders," Mosby, St. Louis, 1985), and on ambulatory phlebectomy by Dr. Robert Muller the same year (Phlebologie 1966;19:227-9).

And, in 1967, Dr. Frederic E. Mohs founded the American College of Chemosurgery, which is today known as the American College of Mohs Surgery. "Mohs surgery continues to be an important part of the dermatologic surgery curriculum," Dr. Hanke said.

Advancements in vein ablation took pace in 1982 when the first report on hypertonic saline injections for treating leg veins, by Bruce Chrisman, was published (Hawaii Med. J. 1982;41:406-8).

In 1986, Dr. Saul Asken published the "Manual of Liposuction Surgery and Autologous Fat Transplantation Under Local Anesthesia" (Terry and Associates, Irvine, Calif.), and the following year, Dr. Jeffery A. Klein published the first report on the tumescent technique for liposuction (Am. J. Cosm. Surg. 1987;4:263-7).

Dr. Alastair Carruthers and Dr. Jean Carruthers revolutionized the field in 1987 when they began using botulinum toxin for cosmetic purposes. "Their joint observation that botulinum toxin can affect the muscles of facial expression began a revolution in cosmetic dermatology," wrote Dr. Hanke.

He also highlighted the launch of numerous societies and publications that helped to advance the specialty, including the founding of the American Society for Dermatologic Surgery in 1970, the launch of the Journal of Dermatologic Surgery in 1975, and the founding of the American Society for Lasers in Medicine and Surgery in 1981. And the specialty has continued to evolve at a rapid pace since that time, he noted.

Work by Dr. R. Rox Anderson and Dr. John A. Parrish on selective photothermolysis, for example, launched research leading to the fractionated laser technology in use today; and ongoing work by the Carruthers on botulinum toxin launched a new era in noninvasive facial rejuvenation, he said.

"Facelift bypass" procedures have satisfied many patients without subjecting them to the expense or morbidity of extensive facial surgery, Dr. Hanke noted, adding that new filler materials can be placed in the subcutaneous or supraperiosteal planes of the face with good results and minimal complications.

"A newly approved hyaluronic acid from Germany will allow treatment of very superficial wrinkles without the risk of the 'Tyndall effect,' " he added.

Also in the last decade, dermatologic surgery-related educational initiatives have been advanced. In 2004, 1-year fellowship training programs were approved by the Accreditation Council for Graduate Medical Education for training in dermatologic surgery; and last year, there were 47 ACGME-accredited procedural dermatology fellowship training programs in place, he said.

"Dermatologic surgery is an important component of nearly all dermatology postgraduate courses," added Dr. Hanke.

The history of fractional laser technology and fillers were addressed in separate articles in the same issue of Seminars in Cutaneous Medicine and Surgery, underscoring the importance of the two recent developments.

Fillers

The next phase of development in injectable fillers has begun, according to Dr. Richard G. Glogau.

"The concept of augmentation has moved from simple lines, scars, and wrinkles to revolumizing the aging face," noted Dr. Glogau, a clinical professor of dermatology at the University of California, San Francisco. "While seeking extended duration of effect balanced against the safety profile of the injectable, our focus is now directed to extending the lifting or volumizing effect that one can achieve with these fillers."

The initial movement into 3-dimensional correction with injectable fillers began with the dramatic improvement seen in lip volume championed in the 1980s, and each of a litany of fillers that followed, including fat, collagen, silicone, hyaluronic acids, poly-l-lactic acids, calcium hydroxylapatite, and polymethylmethacrylate (Sem. Cut. Med. Surg. 2012;31:78-87).

New fillers, some which represent refinements of existing technologies, continue to undergo review. Aquamid a biocompatible, nonabsorbable, permanent injectable hydrogel implant is currently under review by the Food and Drug Administration and is approved for use in Europe.

It is also possible that fillers will move beyond the traditional concept of inert medical devices and into the realm of true biologics – "materials that will improve the texture, elasticity, radiance, and possibly color, of the skin itself," he added.

"Just as the last 40 years has seen the movement from 2 to 3 dimensions, the next 2 decades will see movement form the macro to the micro level, and fillers will become systems for active metabolic manipulation and protection of the aging skin," he concluded.

Fractionation

The development of fractional photothermolysis was "a milestone in the history of laser technology and cutaneous resurfacing," according to Dr. Nazanin Saedi, a dermatologist in private practice in Chestnut Hill, Mass., and her colleagues.

The technology, noted the study authors, builds on the knowledge gained from early CO₂ and Er:YAG laser treatment experiences, achieving greater optimization of parameters to induce the types of benefits seen with CO₂ resurfacing, but without the significant postoperative morbidity, complications, and discomfort associated with the earlier technologies.

Furthermore, the older therapies destroyed the barrier protection, which "significantly increased the risk of infection throughout the recovery period and required extensive home care. The risk of scarring, delayed-onset permanent hypopigmentation, and demarcation lines was significant even in the hands of an experienced operator," they wrote (Sem. Cut. Med. Surg. 2012;31:105-9).

In an en effort to overcome these problems, what followed was nonablative dermal remodeling (with less than impressive results), and ultimately, the "idea of fractionated laser technology," they continued.

First used in hair transplant surgery, the technology led to development of the 1,550-nm nonablative "Fraxel" laser (now called the Fraxel Re:Store by Solta Medical), which debuted in the literature in 2004. This and other fractional laser technologies are now used to treat photoaging, superficial and deep rhytids, scars (including in patients with darker skin types), and pigmentation.

Both nonablative and ablative fractional resurfacing have proved to be safer than have traditional ablative lasers, Dr. Saedi and her colleagues noted. However, complications can still occur, such as infections (with herpes simplex virus being the most common), acneiform eruptions, prolonged erythema, pigmentary alteration, and scarring (rare, but can also result from infection associated with treatment).

"Counterintuitively, nonablative or ablative fractionated devices at low energies and densities can be useful in the treatment of scarring, including hypertrophic scars" as previously mentioned, they noted.

"While [fractional lasers are] inherently safer due to the pixelated manner of the treatment, complications can be further prevented with attentive surgical technique and judicious use of prophylaxis," they wrote.

The future of fractional laser technology promises to hold exciting developments. For example, since ablative fractional resurfacing creates microscopic vertical holes in tissue, the delivery of topical drugs through these holes is possible. In animal models, the photosensitizer methylaminolevulinic acid has been delivered using this approach, and tests suggest that low density treatment would be sufficient for deep dermal drug delivery.

"Treatment of skin in a porcine model showed enhanced depth of photodynamic therapy following porphyrin application after pretreatment with fractional resurfacing. An in vitro study utilizing low fluence fractionated Erbium:YAG demonstrated upwards of a 125-fold increase in imiquimod delivery," they noted.

Trials in humans are underway to assess the feasibility and safety of enhanced drug delivery using this approach, and there is speculation that ultimately, it could be used for delivery of biologic peptides and vaccines.

Tattoo removal is another promising use for fractional lasers, with early studies demonstrating good results, noted Dr. Saedi and her colleagues, explaining that ablative fractional lasers, when used in conjunction with a Q-switched laser, appear to provide enhanced tattoo removal capabilities.

"With new devices and wavelengths, the applications of this technology continue to grow," they wrote, concluding that "the future remains bright for fractionated laser devices."

Likewise, the future of dermatologic surgery in general remains promising, Dr. Hanke said. "Many new procedures and advances lie ahead."

Neither Dr. Hanke nor Dr. Saedi had disclosures to report. Another author on the article by Dr. Saedi (Dr. Christopher Zachary) reported receiving an honorarium from Solta Medical.

It was questionable whether in 1952, when Dr. Norman Orentreich performed the first hair transplant and Dr. George Mackee reported on his 50-year experience with phenol chemical peels, anyone envisioned how far the field of dermatologic surgery would advance, but there’s no question now: The specialty has come a long way.

"Dermatologic surgery has blossomed into a full and diverse specialty with many elements," Dr. C. William Hanke noted in the June issue of Seminars in Cutaneous Medicine and Surgery (2012;31:52-9). He highlighted key events that shaped the burgeoning specialty.

Historical Highlights

From the first report on phenol peels by Dr. Mackee (Br. J. Dermatol. 1952;64:456-9), to the coining of the term "tumescent local anesthesia" by Dr. Hanke and his colleagues in 1998 – and publication of a comprehensive text on the tumescent technique 2 years later by Dr. Jeffery A. Klein ("Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction," St. Louis, Mosby, 2000) – Dr. Hanke chronicled the specialty’s evolution.

For example, he noted that in 1961, Dr. Leon Goldman became the first physician to treat patients with lasers. "He is acknowledged as the father of lasers in medicine and surgery," Dr. Hanke, a dermatologist in private practice in Carmel, Indiana, wrote. He added that the pioneer's first medicinal use of a laser launched 3 decades of related leadership, practice, and research.

Among other events that stand out in the history of the specialty, according to Dr. Hanke, are the first reports on cryosurgery with liquid nitrogen in 1966 by Dr. Setrag Zacarian ("Cryosurgery of Skin Cancer and Cutaneous Disorders," Mosby, St. Louis, 1985), and on ambulatory phlebectomy by Dr. Robert Muller the same year (Phlebologie 1966;19:227-9).

And, in 1967, Dr. Frederic E. Mohs founded the American College of Chemosurgery, which is today known as the American College of Mohs Surgery. "Mohs surgery continues to be an important part of the dermatologic surgery curriculum," Dr. Hanke said.

Advancements in vein ablation took pace in 1982 when the first report on hypertonic saline injections for treating leg veins, by Bruce Chrisman, was published (Hawaii Med. J. 1982;41:406-8).

In 1986, Dr. Saul Asken published the "Manual of Liposuction Surgery and Autologous Fat Transplantation Under Local Anesthesia" (Terry and Associates, Irvine, Calif.), and the following year, Dr. Jeffery A. Klein published the first report on the tumescent technique for liposuction (Am. J. Cosm. Surg. 1987;4:263-7).

Dr. Alastair Carruthers and Dr. Jean Carruthers revolutionized the field in 1987 when they began using botulinum toxin for cosmetic purposes. "Their joint observation that botulinum toxin can affect the muscles of facial expression began a revolution in cosmetic dermatology," wrote Dr. Hanke.

He also highlighted the launch of numerous societies and publications that helped to advance the specialty, including the founding of the American Society for Dermatologic Surgery in 1970, the launch of the Journal of Dermatologic Surgery in 1975, and the founding of the American Society for Lasers in Medicine and Surgery in 1981. And the specialty has continued to evolve at a rapid pace since that time, he noted.

Work by Dr. R. Rox Anderson and Dr. John A. Parrish on selective photothermolysis, for example, launched research leading to the fractionated laser technology in use today; and ongoing work by the Carruthers on botulinum toxin launched a new era in noninvasive facial rejuvenation, he said.

"Facelift bypass" procedures have satisfied many patients without subjecting them to the expense or morbidity of extensive facial surgery, Dr. Hanke noted, adding that new filler materials can be placed in the subcutaneous or supraperiosteal planes of the face with good results and minimal complications.

"A newly approved hyaluronic acid from Germany will allow treatment of very superficial wrinkles without the risk of the 'Tyndall effect,' " he added.

Also in the last decade, dermatologic surgery-related educational initiatives have been advanced. In 2004, 1-year fellowship training programs were approved by the Accreditation Council for Graduate Medical Education for training in dermatologic surgery; and last year, there were 47 ACGME-accredited procedural dermatology fellowship training programs in place, he said.

"Dermatologic surgery is an important component of nearly all dermatology postgraduate courses," added Dr. Hanke.

The history of fractional laser technology and fillers were addressed in separate articles in the same issue of Seminars in Cutaneous Medicine and Surgery, underscoring the importance of the two recent developments.

Fillers

The next phase of development in injectable fillers has begun, according to Dr. Richard G. Glogau.

"The concept of augmentation has moved from simple lines, scars, and wrinkles to revolumizing the aging face," noted Dr. Glogau, a clinical professor of dermatology at the University of California, San Francisco. "While seeking extended duration of effect balanced against the safety profile of the injectable, our focus is now directed to extending the lifting or volumizing effect that one can achieve with these fillers."

The initial movement into 3-dimensional correction with injectable fillers began with the dramatic improvement seen in lip volume championed in the 1980s, and each of a litany of fillers that followed, including fat, collagen, silicone, hyaluronic acids, poly-l-lactic acids, calcium hydroxylapatite, and polymethylmethacrylate (Sem. Cut. Med. Surg. 2012;31:78-87).

New fillers, some which represent refinements of existing technologies, continue to undergo review. Aquamid a biocompatible, nonabsorbable, permanent injectable hydrogel implant is currently under review by the Food and Drug Administration and is approved for use in Europe.

It is also possible that fillers will move beyond the traditional concept of inert medical devices and into the realm of true biologics – "materials that will improve the texture, elasticity, radiance, and possibly color, of the skin itself," he added.

"Just as the last 40 years has seen the movement from 2 to 3 dimensions, the next 2 decades will see movement form the macro to the micro level, and fillers will become systems for active metabolic manipulation and protection of the aging skin," he concluded.

Fractionation

The development of fractional photothermolysis was "a milestone in the history of laser technology and cutaneous resurfacing," according to Dr. Nazanin Saedi, a dermatologist in private practice in Chestnut Hill, Mass., and her colleagues.

The technology, noted the study authors, builds on the knowledge gained from early CO₂ and Er:YAG laser treatment experiences, achieving greater optimization of parameters to induce the types of benefits seen with CO₂ resurfacing, but without the significant postoperative morbidity, complications, and discomfort associated with the earlier technologies.

Furthermore, the older therapies destroyed the barrier protection, which "significantly increased the risk of infection throughout the recovery period and required extensive home care. The risk of scarring, delayed-onset permanent hypopigmentation, and demarcation lines was significant even in the hands of an experienced operator," they wrote (Sem. Cut. Med. Surg. 2012;31:105-9).

In an en effort to overcome these problems, what followed was nonablative dermal remodeling (with less than impressive results), and ultimately, the "idea of fractionated laser technology," they continued.

First used in hair transplant surgery, the technology led to development of the 1,550-nm nonablative "Fraxel" laser (now called the Fraxel Re:Store by Solta Medical), which debuted in the literature in 2004. This and other fractional laser technologies are now used to treat photoaging, superficial and deep rhytids, scars (including in patients with darker skin types), and pigmentation.

Both nonablative and ablative fractional resurfacing have proved to be safer than have traditional ablative lasers, Dr. Saedi and her colleagues noted. However, complications can still occur, such as infections (with herpes simplex virus being the most common), acneiform eruptions, prolonged erythema, pigmentary alteration, and scarring (rare, but can also result from infection associated with treatment).

"Counterintuitively, nonablative or ablative fractionated devices at low energies and densities can be useful in the treatment of scarring, including hypertrophic scars" as previously mentioned, they noted.

"While [fractional lasers are] inherently safer due to the pixelated manner of the treatment, complications can be further prevented with attentive surgical technique and judicious use of prophylaxis," they wrote.

The future of fractional laser technology promises to hold exciting developments. For example, since ablative fractional resurfacing creates microscopic vertical holes in tissue, the delivery of topical drugs through these holes is possible. In animal models, the photosensitizer methylaminolevulinic acid has been delivered using this approach, and tests suggest that low density treatment would be sufficient for deep dermal drug delivery.

"Treatment of skin in a porcine model showed enhanced depth of photodynamic therapy following porphyrin application after pretreatment with fractional resurfacing. An in vitro study utilizing low fluence fractionated Erbium:YAG demonstrated upwards of a 125-fold increase in imiquimod delivery," they noted.

Trials in humans are underway to assess the feasibility and safety of enhanced drug delivery using this approach, and there is speculation that ultimately, it could be used for delivery of biologic peptides and vaccines.

Tattoo removal is another promising use for fractional lasers, with early studies demonstrating good results, noted Dr. Saedi and her colleagues, explaining that ablative fractional lasers, when used in conjunction with a Q-switched laser, appear to provide enhanced tattoo removal capabilities.

"With new devices and wavelengths, the applications of this technology continue to grow," they wrote, concluding that "the future remains bright for fractionated laser devices."

Likewise, the future of dermatologic surgery in general remains promising, Dr. Hanke said. "Many new procedures and advances lie ahead."

Neither Dr. Hanke nor Dr. Saedi had disclosures to report. Another author on the article by Dr. Saedi (Dr. Christopher Zachary) reported receiving an honorarium from Solta Medical.

Dermatologic surgery has come a long way since the 1950s. This look at some of the highlights – from phenol peels and hair transplants to tumescent liposuction and botulinum toxin injections – covers the subspecialty's evolution and influence.

Dermatologic surgery has come a long way since the 1950s. This look at some of the highlights – from phenol peels and hair transplants to tumescent liposuction and botulinum toxin injections – covers the subspecialty's evolution and influence.

Dermatologic surgery has come a long way since the 1950s. This look at some of the highlights – from phenol peels and hair transplants to tumescent liposuction and botulinum toxin injections – covers the subspecialty's evolution and influence.

KISSIMMEE, FLA. – A combined 800-nm diode laser and vacuum system for photoepilation resulted in high patient satisfaction and was safe and virtually painless for more than 2,000 treated patients.

Photoepilation is among the most popular aesthetic treatments worldwide, and is the second most popular aesthetic treatment in Latin America, where most patients have darker skin types that can be prone to greater risk of adverse outcomes, Dr. Rafael Nunes said at the annual meeting of the American Society for Laser Medicine and Surgery. On the basis of this study, however, the LightSheer Duet laser system appears to be a safe method for successful photoepilation even in darker-skinned patients.

Of the 2,158 study patients, 1,845 were women and 313 were men; they had a mean age of 36 years (range, 18-63 years) and skin types I-IV. Photoepilation was performed on various body and facial areas at one of four participating laser centers in Brazil over an 18-month period, with a mean of six treatments every 28-45 days. The investigators treated patients with a Lumenis 800-nm LightSheer Duet diode laser and vacuum-assist technology at a fluence of 6-12 J/cm², a spot size of 22 x 35 mm, a pulse width of 30-100 ms, and a single pass, said Dr. Nunes, a plastic surgeon in private practice in Rio de Janeiro.

At the 3- to 6-month follow-up, after completion of 4-10 treatment sessions, 92% of patients rated their outcomes as "good" or "great."

The system requires no pretreatment ice packs, creams, or anesthesia, and the vacuum system should be used only on the low setting to prevent injury – particularly in areas where there is skin laxity.

No permanent or severe adverse effects occurred in any of the patients. The only adverse effect was transient erythema in six patients (0.3%). Treatment tolerance was also impressive, with patients experiencing only a small sensation of heat at the treatment site, and "no discomfort whatsoever" following treatment, Dr. Nunes said.

Dr. Nunes is a speaker or consultant for Allergan, Alma Lasers, Q-MED (Galderma), Lumenis, MedixSysteme, Palomar, and Solta Medical.

KISSIMMEE, FLA. – A combined 800-nm diode laser and vacuum system for photoepilation resulted in high patient satisfaction and was safe and virtually painless for more than 2,000 treated patients.

Photoepilation is among the most popular aesthetic treatments worldwide, and is the second most popular aesthetic treatment in Latin America, where most patients have darker skin types that can be prone to greater risk of adverse outcomes, Dr. Rafael Nunes said at the annual meeting of the American Society for Laser Medicine and Surgery. On the basis of this study, however, the LightSheer Duet laser system appears to be a safe method for successful photoepilation even in darker-skinned patients.

Of the 2,158 study patients, 1,845 were women and 313 were men; they had a mean age of 36 years (range, 18-63 years) and skin types I-IV. Photoepilation was performed on various body and facial areas at one of four participating laser centers in Brazil over an 18-month period, with a mean of six treatments every 28-45 days. The investigators treated patients with a Lumenis 800-nm LightSheer Duet diode laser and vacuum-assist technology at a fluence of 6-12 J/cm², a spot size of 22 x 35 mm, a pulse width of 30-100 ms, and a single pass, said Dr. Nunes, a plastic surgeon in private practice in Rio de Janeiro.

At the 3- to 6-month follow-up, after completion of 4-10 treatment sessions, 92% of patients rated their outcomes as "good" or "great."

The system requires no pretreatment ice packs, creams, or anesthesia, and the vacuum system should be used only on the low setting to prevent injury – particularly in areas where there is skin laxity.

No permanent or severe adverse effects occurred in any of the patients. The only adverse effect was transient erythema in six patients (0.3%). Treatment tolerance was also impressive, with patients experiencing only a small sensation of heat at the treatment site, and "no discomfort whatsoever" following treatment, Dr. Nunes said.

Dr. Nunes is a speaker or consultant for Allergan, Alma Lasers, Q-MED (Galderma), Lumenis, MedixSysteme, Palomar, and Solta Medical.

KISSIMMEE, FLA. – A combined 800-nm diode laser and vacuum system for photoepilation resulted in high patient satisfaction and was safe and virtually painless for more than 2,000 treated patients.

Photoepilation is among the most popular aesthetic treatments worldwide, and is the second most popular aesthetic treatment in Latin America, where most patients have darker skin types that can be prone to greater risk of adverse outcomes, Dr. Rafael Nunes said at the annual meeting of the American Society for Laser Medicine and Surgery. On the basis of this study, however, the LightSheer Duet laser system appears to be a safe method for successful photoepilation even in darker-skinned patients.

Of the 2,158 study patients, 1,845 were women and 313 were men; they had a mean age of 36 years (range, 18-63 years) and skin types I-IV. Photoepilation was performed on various body and facial areas at one of four participating laser centers in Brazil over an 18-month period, with a mean of six treatments every 28-45 days. The investigators treated patients with a Lumenis 800-nm LightSheer Duet diode laser and vacuum-assist technology at a fluence of 6-12 J/cm², a spot size of 22 x 35 mm, a pulse width of 30-100 ms, and a single pass, said Dr. Nunes, a plastic surgeon in private practice in Rio de Janeiro.

At the 3- to 6-month follow-up, after completion of 4-10 treatment sessions, 92% of patients rated their outcomes as "good" or "great."

The system requires no pretreatment ice packs, creams, or anesthesia, and the vacuum system should be used only on the low setting to prevent injury – particularly in areas where there is skin laxity.

No permanent or severe adverse effects occurred in any of the patients. The only adverse effect was transient erythema in six patients (0.3%). Treatment tolerance was also impressive, with patients experiencing only a small sensation of heat at the treatment site, and "no discomfort whatsoever" following treatment, Dr. Nunes said.

Dr. Nunes is a speaker or consultant for Allergan, Alma Lasers, Q-MED (Galderma), Lumenis, MedixSysteme, Palomar, and Solta Medical.

WAIKOLOA, HAWAII  – The use of eflornithine cream may increase the effectiveness of laser hair removal for treating pseudofolliculitis barbae, according to Dr. Andrew F. Alexis.

Laser hair removal has proved to be a game changer in the treatment of pseudofolliculitis barbae, a common chronic, inflammatory dermatosis that’s often been a difficult therapeutic challenge, Dr. Alexis said at the seminar sponsored by Skin Disease Education Foundation (SDEF). And the use of adjunctive eflornithine cream makes laser therapy even more effective, based on a recent study, which is one of the few rigorous studies conducted in pseudofolliculitis barbae (PFB) patients, noted Dr. Alexis, director of the skin of color center at St. Luke’s–Roosevelt Hospital and a dermatologist at Columbia University, New York.

Photo: Dermatologic Clinics 2003;21;629-44

The double-blind placebo controlled study was carried out by U.S. military physicians. PFB, which is predominantly a disorder of black men, has at times been a source of racial tension in the military because the simplest treatment for PFB is to stop shaving and grow a beard, a form of individual expression at odds with regulations.

The study included 27 men with PFB. They received laser therapy once every 4 weeks for 16 weeks. In addition, they applied eflornithine cream to one side of their bearded neck region and placebo to the other side twice daily.

At 16 weeks, the laser plus eflornithine cream side produced a median 99.5% reduction in hair count and inflammatory papules. This was a significantly better result than the median 85% reduction on the laser plus placebo–treated side (J. Am. Acad. Dermatol. 2012 Jan. 8; in press).

The PFB study follows an earlier study by other investigators who demonstrated that eflornithine cream as an adjunct to laser hair removal for facial hirsutism in women was more effective than laser therapy alone (J. Am. Acad. Dermatol. 2007;57:54-9).

Dr. Alexis said performing laser hair removal safely in darker-skinned patients with PFB requires attention to several key principles: longer wavelengths, lower fluences, longer pulse durations, and plenty of epidermal cooling.

"The No. 1 thing is to use longer wavelengths, because the goal is deeper penetration to maximize the ratio of the temperature in the bulb of the follicle to the temperature in the epidermis," he explained.

The long-pulsed 1,064-nm Nd:YAG laser has the lowest rate of associated epidermal burns, hypopigmentation, and other adverse events in darker-skinned patients, as has been shown in a review of a wide assortment of lasers (J. Drugs Dermatol. 2007;6:40-6). It is clearly the safest laser option in patients with skin types IV-VI. The 810-nm diode laser is a reasonable alternative in skin types IV-V, Dr. Alexis said.

In treating patients for PFB with the 1,064-nm Nd:YAG laser, he said that he typically starts with a fluence of 20 J/cm² and a pulse duration of 20-30 milliseconds. After several sessions, as he makes inroads into the initially dense follicular distribution, he said that he might increase the fluence to a maximum of 50 J/cm² in the setting of skin type VI, and as high as 100 J/cm² in skin types IV or V.

Longer pulse durations allow for more efficient epidermal cooling. This minimizes heat injury to melanin-containing epidermal cells. For the 810-nm diode laser, Dr. Alexis said he uses pulse durations of 100 or 400 milliseconds.

Epidermal cooling can be accomplished in several ways. His preferred method is to utilize contact cooling via a sapphire tip or chilled copper plate attached to the laser; the cooling is done before delivering the laser pulse. Alternatively, the epidermal cooling can be done using cold gels, forced air, or spray cooling, although dyschromia can occur in darker skin types if the spray technique isn’t optimal. Another option is to apply an ice pack for 5-10 minutes post treatment.

Laser therapy is expensive, so Dr. Alexis said he likes to give his patients a range of therapeutic options. These include growing a beard, chemical depilation with barium sulfide or calcium thioglycolate every 2-4 days, modification of shaving practices, and salicylic acid chemical peels.

"It’s kind of a long conversation," he said.

Whatever form of therapy the patient decides upon, it’s important that the patient stops tweezing to remove ingrown hairs. This is a common practice that induces trauma and worsens postinflammatory hyperpigmentation.

Dr. Alexis reported that he serves as a consultant to Schick and is on the advisory board for Allergan. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII  – The use of eflornithine cream may increase the effectiveness of laser hair removal for treating pseudofolliculitis barbae, according to Dr. Andrew F. Alexis.

Laser hair removal has proved to be a game changer in the treatment of pseudofolliculitis barbae, a common chronic, inflammatory dermatosis that’s often been a difficult therapeutic challenge, Dr. Alexis said at the seminar sponsored by Skin Disease Education Foundation (SDEF). And the use of adjunctive eflornithine cream makes laser therapy even more effective, based on a recent study, which is one of the few rigorous studies conducted in pseudofolliculitis barbae (PFB) patients, noted Dr. Alexis, director of the skin of color center at St. Luke’s–Roosevelt Hospital and a dermatologist at Columbia University, New York.

Photo: Dermatologic Clinics 2003;21;629-44

The double-blind placebo controlled study was carried out by U.S. military physicians. PFB, which is predominantly a disorder of black men, has at times been a source of racial tension in the military because the simplest treatment for PFB is to stop shaving and grow a beard, a form of individual expression at odds with regulations.

The study included 27 men with PFB. They received laser therapy once every 4 weeks for 16 weeks. In addition, they applied eflornithine cream to one side of their bearded neck region and placebo to the other side twice daily.

At 16 weeks, the laser plus eflornithine cream side produced a median 99.5% reduction in hair count and inflammatory papules. This was a significantly better result than the median 85% reduction on the laser plus placebo–treated side (J. Am. Acad. Dermatol. 2012 Jan. 8; in press).

The PFB study follows an earlier study by other investigators who demonstrated that eflornithine cream as an adjunct to laser hair removal for facial hirsutism in women was more effective than laser therapy alone (J. Am. Acad. Dermatol. 2007;57:54-9).

Dr. Alexis said performing laser hair removal safely in darker-skinned patients with PFB requires attention to several key principles: longer wavelengths, lower fluences, longer pulse durations, and plenty of epidermal cooling.

"The No. 1 thing is to use longer wavelengths, because the goal is deeper penetration to maximize the ratio of the temperature in the bulb of the follicle to the temperature in the epidermis," he explained.

The long-pulsed 1,064-nm Nd:YAG laser has the lowest rate of associated epidermal burns, hypopigmentation, and other adverse events in darker-skinned patients, as has been shown in a review of a wide assortment of lasers (J. Drugs Dermatol. 2007;6:40-6). It is clearly the safest laser option in patients with skin types IV-VI. The 810-nm diode laser is a reasonable alternative in skin types IV-V, Dr. Alexis said.

In treating patients for PFB with the 1,064-nm Nd:YAG laser, he said that he typically starts with a fluence of 20 J/cm² and a pulse duration of 20-30 milliseconds. After several sessions, as he makes inroads into the initially dense follicular distribution, he said that he might increase the fluence to a maximum of 50 J/cm² in the setting of skin type VI, and as high as 100 J/cm² in skin types IV or V.

Longer pulse durations allow for more efficient epidermal cooling. This minimizes heat injury to melanin-containing epidermal cells. For the 810-nm diode laser, Dr. Alexis said he uses pulse durations of 100 or 400 milliseconds.

Epidermal cooling can be accomplished in several ways. His preferred method is to utilize contact cooling via a sapphire tip or chilled copper plate attached to the laser; the cooling is done before delivering the laser pulse. Alternatively, the epidermal cooling can be done using cold gels, forced air, or spray cooling, although dyschromia can occur in darker skin types if the spray technique isn’t optimal. Another option is to apply an ice pack for 5-10 minutes post treatment.

Laser therapy is expensive, so Dr. Alexis said he likes to give his patients a range of therapeutic options. These include growing a beard, chemical depilation with barium sulfide or calcium thioglycolate every 2-4 days, modification of shaving practices, and salicylic acid chemical peels.

"It’s kind of a long conversation," he said.

Whatever form of therapy the patient decides upon, it’s important that the patient stops tweezing to remove ingrown hairs. This is a common practice that induces trauma and worsens postinflammatory hyperpigmentation.

Dr. Alexis reported that he serves as a consultant to Schick and is on the advisory board for Allergan. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII  – The use of eflornithine cream may increase the effectiveness of laser hair removal for treating pseudofolliculitis barbae, according to Dr. Andrew F. Alexis.

Laser hair removal has proved to be a game changer in the treatment of pseudofolliculitis barbae, a common chronic, inflammatory dermatosis that’s often been a difficult therapeutic challenge, Dr. Alexis said at the seminar sponsored by Skin Disease Education Foundation (SDEF). And the use of adjunctive eflornithine cream makes laser therapy even more effective, based on a recent study, which is one of the few rigorous studies conducted in pseudofolliculitis barbae (PFB) patients, noted Dr. Alexis, director of the skin of color center at St. Luke’s–Roosevelt Hospital and a dermatologist at Columbia University, New York.

Photo: Dermatologic Clinics 2003;21;629-44

The double-blind placebo controlled study was carried out by U.S. military physicians. PFB, which is predominantly a disorder of black men, has at times been a source of racial tension in the military because the simplest treatment for PFB is to stop shaving and grow a beard, a form of individual expression at odds with regulations.

The study included 27 men with PFB. They received laser therapy once every 4 weeks for 16 weeks. In addition, they applied eflornithine cream to one side of their bearded neck region and placebo to the other side twice daily.

At 16 weeks, the laser plus eflornithine cream side produced a median 99.5% reduction in hair count and inflammatory papules. This was a significantly better result than the median 85% reduction on the laser plus placebo–treated side (J. Am. Acad. Dermatol. 2012 Jan. 8; in press).

The PFB study follows an earlier study by other investigators who demonstrated that eflornithine cream as an adjunct to laser hair removal for facial hirsutism in women was more effective than laser therapy alone (J. Am. Acad. Dermatol. 2007;57:54-9).

Dr. Alexis said performing laser hair removal safely in darker-skinned patients with PFB requires attention to several key principles: longer wavelengths, lower fluences, longer pulse durations, and plenty of epidermal cooling.

"The No. 1 thing is to use longer wavelengths, because the goal is deeper penetration to maximize the ratio of the temperature in the bulb of the follicle to the temperature in the epidermis," he explained.

The long-pulsed 1,064-nm Nd:YAG laser has the lowest rate of associated epidermal burns, hypopigmentation, and other adverse events in darker-skinned patients, as has been shown in a review of a wide assortment of lasers (J. Drugs Dermatol. 2007;6:40-6). It is clearly the safest laser option in patients with skin types IV-VI. The 810-nm diode laser is a reasonable alternative in skin types IV-V, Dr. Alexis said.

In treating patients for PFB with the 1,064-nm Nd:YAG laser, he said that he typically starts with a fluence of 20 J/cm² and a pulse duration of 20-30 milliseconds. After several sessions, as he makes inroads into the initially dense follicular distribution, he said that he might increase the fluence to a maximum of 50 J/cm² in the setting of skin type VI, and as high as 100 J/cm² in skin types IV or V.

Longer pulse durations allow for more efficient epidermal cooling. This minimizes heat injury to melanin-containing epidermal cells. For the 810-nm diode laser, Dr. Alexis said he uses pulse durations of 100 or 400 milliseconds.

Epidermal cooling can be accomplished in several ways. His preferred method is to utilize contact cooling via a sapphire tip or chilled copper plate attached to the laser; the cooling is done before delivering the laser pulse. Alternatively, the epidermal cooling can be done using cold gels, forced air, or spray cooling, although dyschromia can occur in darker skin types if the spray technique isn’t optimal. Another option is to apply an ice pack for 5-10 minutes post treatment.

Laser therapy is expensive, so Dr. Alexis said he likes to give his patients a range of therapeutic options. These include growing a beard, chemical depilation with barium sulfide or calcium thioglycolate every 2-4 days, modification of shaving practices, and salicylic acid chemical peels.

"It’s kind of a long conversation," he said.

Whatever form of therapy the patient decides upon, it’s important that the patient stops tweezing to remove ingrown hairs. This is a common practice that induces trauma and worsens postinflammatory hyperpigmentation.

Dr. Alexis reported that he serves as a consultant to Schick and is on the advisory board for Allergan. SDEF and this news organization are owned by Elsevier.

NEW YORK – To successfully treat alopecia in darker-skinned patients, it is important to first get to the root of a patient’s hair care regimen, according to Dr. Amy McMichael.

For the past 18 years, Dr. McMichael of Wake Forest University in Winston-Salem, N.C., has run a hair disorders clinic. She said she often finds herself at odds with patients who can’t understand why their hair won’t grow.

"Of course, we know it’s growing; it’s just breaking off. They’re having issues with damaged hair," she said at the Skin of Color Seminar Series. Patients "want me to find some underlying vitamin disorder or disease, or something [in their diet] that they can ‘cut out,’ " she said.

Photos courtesy Valerie Callender M.D.

Instead, the key is to specifically ask patients about their hair care regimen. She also uses a "60-second comb test" to assess fragility, whereby she instructs patients to brush their hair over a white pillow for 60 seconds and then count the broken and full-bulb hairs that are seen on the pillow.

More often than not, she said she finds that the number of full telogen hairs do not differ between white and darker-skinned people, but that broken hairs (versus bulb hairs) are found significantly more often in women of African descent.

This standardized approach may help convince women that, indeed, breakage – and not some underlying condition – is at the root of their problem, and that changes in behavior could have big effects.

Traction alopecia is a major issue in this population – even among patients who say they don’t pull their hair – and is likely because of the African American custom of getting tight braids starting at a young age. "They tell me their hair braids were so tight, they couldn’t chew the next day," she said. "That is not normal."

Additionally, many skin of color patients use powerful, lye-based chemical relaxers. The damage inflicted by these products, combined with braids, increases the risk for alopecia.

She pointed to a 2008 study of 574 African school girls and 604 African women that showed that females who both relaxed and braided their hair had a 3.5 times greater risk for traction alopecia, compared with patients who did neither (J. Am. Acad. Dermatol. 2008;59:432-8).

Central centrifugal scarring alopecia is also associated with particular cultural practices. For example, Dr. McMichael cited a 2009 study that looked at 101 black women with the condition and found that there was a strong association between scarring alopecia and patients who reported using sewn-in hair weaves and braided styles with hair extensions (J. Am. Acad. Dermatol. 2009;60:574-8).

A second 2011 study by Dr. McMichael and her colleagues confirmed this, but also found associations with chemical relaxers in 44 surveyed patients (Cosmet. Dermatol. 2011;24:331-7).

She recommends that patients discontinue tight braids, sewn-in weaves, relaxers, and heat treatments. "A lot of women still go under hooded hair dryers," she said. She also advocates serial trimming of the hair every 6-8 weeks, as well as gentle hair conditioning with positively charged silicones and dimethicone coating agents.

"These work very nicely in this population," she said. She also recommends using foams as a vehicle for treatments when available. For patients with more severe issues, however, she has administered intralesional corticosteroids, and followed with an off-label use of topical minoxidil.

Additionally, "a lot of women do well with surgical hair restoration," she said, despite initial patient concerns about it being prohibitively expensive. "It might be much less expensive [than patients think] because they have a small area to treat."

Finally, Dr. McMichael said she refers patients with cicatricial alopecia to the Cicatricial Alopecia Research Foundation.

Dr. McMichael stated that she has been an investigator for Abbott, Allergan, Intendis (now Bayer HealthCare), and Procter and Gamble. She also disclosed serving as a consultant for Allergan, Galderma, Guthy-Ranker, Johnson and Johnson, Procter and Gamble, and Stiefel.

NEW YORK – To successfully treat alopecia in darker-skinned patients, it is important to first get to the root of a patient’s hair care regimen, according to Dr. Amy McMichael.

For the past 18 years, Dr. McMichael of Wake Forest University in Winston-Salem, N.C., has run a hair disorders clinic. She said she often finds herself at odds with patients who can’t understand why their hair won’t grow.

"Of course, we know it’s growing; it’s just breaking off. They’re having issues with damaged hair," she said at the Skin of Color Seminar Series. Patients "want me to find some underlying vitamin disorder or disease, or something [in their diet] that they can ‘cut out,’ " she said.

Photos courtesy Valerie Callender M.D.

Instead, the key is to specifically ask patients about their hair care regimen. She also uses a "60-second comb test" to assess fragility, whereby she instructs patients to brush their hair over a white pillow for 60 seconds and then count the broken and full-bulb hairs that are seen on the pillow.

More often than not, she said she finds that the number of full telogen hairs do not differ between white and darker-skinned people, but that broken hairs (versus bulb hairs) are found significantly more often in women of African descent.

This standardized approach may help convince women that, indeed, breakage – and not some underlying condition – is at the root of their problem, and that changes in behavior could have big effects.

Traction alopecia is a major issue in this population – even among patients who say they don’t pull their hair – and is likely because of the African American custom of getting tight braids starting at a young age. "They tell me their hair braids were so tight, they couldn’t chew the next day," she said. "That is not normal."

Additionally, many skin of color patients use powerful, lye-based chemical relaxers. The damage inflicted by these products, combined with braids, increases the risk for alopecia.

She pointed to a 2008 study of 574 African school girls and 604 African women that showed that females who both relaxed and braided their hair had a 3.5 times greater risk for traction alopecia, compared with patients who did neither (J. Am. Acad. Dermatol. 2008;59:432-8).

Central centrifugal scarring alopecia is also associated with particular cultural practices. For example, Dr. McMichael cited a 2009 study that looked at 101 black women with the condition and found that there was a strong association between scarring alopecia and patients who reported using sewn-in hair weaves and braided styles with hair extensions (J. Am. Acad. Dermatol. 2009;60:574-8).

A second 2011 study by Dr. McMichael and her colleagues confirmed this, but also found associations with chemical relaxers in 44 surveyed patients (Cosmet. Dermatol. 2011;24:331-7).

She recommends that patients discontinue tight braids, sewn-in weaves, relaxers, and heat treatments. "A lot of women still go under hooded hair dryers," she said. She also advocates serial trimming of the hair every 6-8 weeks, as well as gentle hair conditioning with positively charged silicones and dimethicone coating agents.

"These work very nicely in this population," she said. She also recommends using foams as a vehicle for treatments when available. For patients with more severe issues, however, she has administered intralesional corticosteroids, and followed with an off-label use of topical minoxidil.

Additionally, "a lot of women do well with surgical hair restoration," she said, despite initial patient concerns about it being prohibitively expensive. "It might be much less expensive [than patients think] because they have a small area to treat."

Finally, Dr. McMichael said she refers patients with cicatricial alopecia to the Cicatricial Alopecia Research Foundation.

Dr. McMichael stated that she has been an investigator for Abbott, Allergan, Intendis (now Bayer HealthCare), and Procter and Gamble. She also disclosed serving as a consultant for Allergan, Galderma, Guthy-Ranker, Johnson and Johnson, Procter and Gamble, and Stiefel.

NEW YORK – To successfully treat alopecia in darker-skinned patients, it is important to first get to the root of a patient’s hair care regimen, according to Dr. Amy McMichael.

For the past 18 years, Dr. McMichael of Wake Forest University in Winston-Salem, N.C., has run a hair disorders clinic. She said she often finds herself at odds with patients who can’t understand why their hair won’t grow.

"Of course, we know it’s growing; it’s just breaking off. They’re having issues with damaged hair," she said at the Skin of Color Seminar Series. Patients "want me to find some underlying vitamin disorder or disease, or something [in their diet] that they can ‘cut out,’ " she said.

Photos courtesy Valerie Callender M.D.

Instead, the key is to specifically ask patients about their hair care regimen. She also uses a "60-second comb test" to assess fragility, whereby she instructs patients to brush their hair over a white pillow for 60 seconds and then count the broken and full-bulb hairs that are seen on the pillow.

More often than not, she said she finds that the number of full telogen hairs do not differ between white and darker-skinned people, but that broken hairs (versus bulb hairs) are found significantly more often in women of African descent.

This standardized approach may help convince women that, indeed, breakage – and not some underlying condition – is at the root of their problem, and that changes in behavior could have big effects.

Traction alopecia is a major issue in this population – even among patients who say they don’t pull their hair – and is likely because of the African American custom of getting tight braids starting at a young age. "They tell me their hair braids were so tight, they couldn’t chew the next day," she said. "That is not normal."

Additionally, many skin of color patients use powerful, lye-based chemical relaxers. The damage inflicted by these products, combined with braids, increases the risk for alopecia.

She pointed to a 2008 study of 574 African school girls and 604 African women that showed that females who both relaxed and braided their hair had a 3.5 times greater risk for traction alopecia, compared with patients who did neither (J. Am. Acad. Dermatol. 2008;59:432-8).

Central centrifugal scarring alopecia is also associated with particular cultural practices. For example, Dr. McMichael cited a 2009 study that looked at 101 black women with the condition and found that there was a strong association between scarring alopecia and patients who reported using sewn-in hair weaves and braided styles with hair extensions (J. Am. Acad. Dermatol. 2009;60:574-8).

A second 2011 study by Dr. McMichael and her colleagues confirmed this, but also found associations with chemical relaxers in 44 surveyed patients (Cosmet. Dermatol. 2011;24:331-7).

She recommends that patients discontinue tight braids, sewn-in weaves, relaxers, and heat treatments. "A lot of women still go under hooded hair dryers," she said. She also advocates serial trimming of the hair every 6-8 weeks, as well as gentle hair conditioning with positively charged silicones and dimethicone coating agents.

"These work very nicely in this population," she said. She also recommends using foams as a vehicle for treatments when available. For patients with more severe issues, however, she has administered intralesional corticosteroids, and followed with an off-label use of topical minoxidil.

Additionally, "a lot of women do well with surgical hair restoration," she said, despite initial patient concerns about it being prohibitively expensive. "It might be much less expensive [than patients think] because they have a small area to treat."

Finally, Dr. McMichael said she refers patients with cicatricial alopecia to the Cicatricial Alopecia Research Foundation.

Dr. McMichael stated that she has been an investigator for Abbott, Allergan, Intendis (now Bayer HealthCare), and Procter and Gamble. She also disclosed serving as a consultant for Allergan, Galderma, Guthy-Ranker, Johnson and Johnson, Procter and Gamble, and Stiefel.

SAN DIEGO – Although previous studies of 1,064-nm Nd:YAG lasers for the treatment of onychomycosis have reported significant mycological cure rates, results from a newer, ongoing study challenge such findings.

At the annual meeting of the American Academy of Dermatology, Dr. Boni E. Elewski reported findings from a trial in which she and her colleagues set out to answer two questions: Can fungal organisms be killed by heat at temperatures tolerable to patients? And, can a laser be directly fungicidal on a growing fungal colony or dilute suspension?

Dr. Elewski and her colleagues conducted a heat kill study of three fungi: Trichophyton rubrum, Epidermophyton floccosum, and Scytalidium.

For T. rubrum, they found that growth was halted after the nail was treated at 50° C for 15 minutes. For E. floccosum, they found that growth was halted after the nail was treated at 50° C for 10 minutes, and for Scytalidium, growth was halted after the nail was treated at 55° C for 5 minutes. "However, nail temperatures that reach 40-41° C cause enough pain for patients to pull away, and the maximum nail temperature patients could tolerate was 45° C," said Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

In part two of the study, the researchers used a 1,064-nm Nd:YAG laser to treat colonies and dilute solutions before growth occurred. They used various laser parameters, including spot sizes ranging from 3 to 5 mm, pulse durations that ranged from 100 to 300 milliseconds, fluences of 15 to 50 J/cm², and frequencies of 2 to 10 Hz. "We found that there was no effect on fungal growth at numerous settings, and the temperature of the agar plate reached about 40° C," Dr. Elewski said. "We decided to take this knowledge and move it into our clinical practice."

In an ongoing study that has enrolled 10 patients to date, she and her associates use a 1,064-nm Nd:YAG laser for a protocol that involves five treatments at settings of 16 J/cm², 0.3 microseconds, and 2 Hz. They use a 5-mm spot size with more than 300 pulses over the nail in a predetermined pattern. "You see some clearance," Dr. Elewski said of the results so far. "We have no mycological cures to date, but improvement as shown by other companies is noted. Some improvement may be seen, but in my opinion a durable response is needed to satisfy patients."

In a 2010 study from Yugoslavia, mycological cures were reported using a fluence of 35-40 J/cm², Dr. Elewski said, "but our patients could not tolerate anything above 16 J/cm², at least without a digital block. All I can assume is that patients in Yugoslavia are significantly heartier than patients in Alabama" (J. Laser and Health Academy 2010;1:1-8).

She concluded her remarks by noting that photodynamic therapy "may be an option for your patients who have failed other treatments or who could not tolerate another treatment. Laser treatment is still under investigation, but might be desirable for those who would be satisfied with an improvement."

Dr. Elewski disclosed that Cutera provided research funds for the study. She said that she had no financial conflicts of interest to disclose, and emphasized that she has never been a paid consultant to any laser device company.

SAN DIEGO – Although previous studies of 1,064-nm Nd:YAG lasers for the treatment of onychomycosis have reported significant mycological cure rates, results from a newer, ongoing study challenge such findings.

At the annual meeting of the American Academy of Dermatology, Dr. Boni E. Elewski reported findings from a trial in which she and her colleagues set out to answer two questions: Can fungal organisms be killed by heat at temperatures tolerable to patients? And, can a laser be directly fungicidal on a growing fungal colony or dilute suspension?

Dr. Elewski and her colleagues conducted a heat kill study of three fungi: Trichophyton rubrum, Epidermophyton floccosum, and Scytalidium.

For T. rubrum, they found that growth was halted after the nail was treated at 50° C for 15 minutes. For E. floccosum, they found that growth was halted after the nail was treated at 50° C for 10 minutes, and for Scytalidium, growth was halted after the nail was treated at 55° C for 5 minutes. "However, nail temperatures that reach 40-41° C cause enough pain for patients to pull away, and the maximum nail temperature patients could tolerate was 45° C," said Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

In part two of the study, the researchers used a 1,064-nm Nd:YAG laser to treat colonies and dilute solutions before growth occurred. They used various laser parameters, including spot sizes ranging from 3 to 5 mm, pulse durations that ranged from 100 to 300 milliseconds, fluences of 15 to 50 J/cm², and frequencies of 2 to 10 Hz. "We found that there was no effect on fungal growth at numerous settings, and the temperature of the agar plate reached about 40° C," Dr. Elewski said. "We decided to take this knowledge and move it into our clinical practice."

In an ongoing study that has enrolled 10 patients to date, she and her associates use a 1,064-nm Nd:YAG laser for a protocol that involves five treatments at settings of 16 J/cm², 0.3 microseconds, and 2 Hz. They use a 5-mm spot size with more than 300 pulses over the nail in a predetermined pattern. "You see some clearance," Dr. Elewski said of the results so far. "We have no mycological cures to date, but improvement as shown by other companies is noted. Some improvement may be seen, but in my opinion a durable response is needed to satisfy patients."

In a 2010 study from Yugoslavia, mycological cures were reported using a fluence of 35-40 J/cm², Dr. Elewski said, "but our patients could not tolerate anything above 16 J/cm², at least without a digital block. All I can assume is that patients in Yugoslavia are significantly heartier than patients in Alabama" (J. Laser and Health Academy 2010;1:1-8).

She concluded her remarks by noting that photodynamic therapy "may be an option for your patients who have failed other treatments or who could not tolerate another treatment. Laser treatment is still under investigation, but might be desirable for those who would be satisfied with an improvement."

Dr. Elewski disclosed that Cutera provided research funds for the study. She said that she had no financial conflicts of interest to disclose, and emphasized that she has never been a paid consultant to any laser device company.

SAN DIEGO – Although previous studies of 1,064-nm Nd:YAG lasers for the treatment of onychomycosis have reported significant mycological cure rates, results from a newer, ongoing study challenge such findings.

At the annual meeting of the American Academy of Dermatology, Dr. Boni E. Elewski reported findings from a trial in which she and her colleagues set out to answer two questions: Can fungal organisms be killed by heat at temperatures tolerable to patients? And, can a laser be directly fungicidal on a growing fungal colony or dilute suspension?

Dr. Elewski and her colleagues conducted a heat kill study of three fungi: Trichophyton rubrum, Epidermophyton floccosum, and Scytalidium.

For T. rubrum, they found that growth was halted after the nail was treated at 50° C for 15 minutes. For E. floccosum, they found that growth was halted after the nail was treated at 50° C for 10 minutes, and for Scytalidium, growth was halted after the nail was treated at 55° C for 5 minutes. "However, nail temperatures that reach 40-41° C cause enough pain for patients to pull away, and the maximum nail temperature patients could tolerate was 45° C," said Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

In part two of the study, the researchers used a 1,064-nm Nd:YAG laser to treat colonies and dilute solutions before growth occurred. They used various laser parameters, including spot sizes ranging from 3 to 5 mm, pulse durations that ranged from 100 to 300 milliseconds, fluences of 15 to 50 J/cm², and frequencies of 2 to 10 Hz. "We found that there was no effect on fungal growth at numerous settings, and the temperature of the agar plate reached about 40° C," Dr. Elewski said. "We decided to take this knowledge and move it into our clinical practice."

In an ongoing study that has enrolled 10 patients to date, she and her associates use a 1,064-nm Nd:YAG laser for a protocol that involves five treatments at settings of 16 J/cm², 0.3 microseconds, and 2 Hz. They use a 5-mm spot size with more than 300 pulses over the nail in a predetermined pattern. "You see some clearance," Dr. Elewski said of the results so far. "We have no mycological cures to date, but improvement as shown by other companies is noted. Some improvement may be seen, but in my opinion a durable response is needed to satisfy patients."

In a 2010 study from Yugoslavia, mycological cures were reported using a fluence of 35-40 J/cm², Dr. Elewski said, "but our patients could not tolerate anything above 16 J/cm², at least without a digital block. All I can assume is that patients in Yugoslavia are significantly heartier than patients in Alabama" (J. Laser and Health Academy 2010;1:1-8).

She concluded her remarks by noting that photodynamic therapy "may be an option for your patients who have failed other treatments or who could not tolerate another treatment. Laser treatment is still under investigation, but might be desirable for those who would be satisfied with an improvement."

Dr. Elewski disclosed that Cutera provided research funds for the study. She said that she had no financial conflicts of interest to disclose, and emphasized that she has never been a paid consultant to any laser device company.