Aesthetic Dermatology

Nazanin Saedi, MD, and Michael Kaminer, MD

With the rising demand for body contouring, noninvasive devices for fat reduction have become increasingly popular and have grown dramatically over the past decade. Highintensity focused ultrasound (HIFU) has been used for nearly half a century for the noninvasive treatment of tumors of various organs, but has only recently been evaluated as a method for the selective destruction of adipose tissue. HIFU works by ablating subcutaneous adipose tissue and causing molecular vibrations that increase the temperature of local tissue and induce rapid cell necrosis. Several studies reveal the safety and efficacy of HIFU for fat reduction in the abdomen and the flanks. These studies indicate consistent reduction in abdominal circumference >2 cm after a single treatment. The adverse events are limited to transient tenderness, bruising, and edema. Increased utility of HIFU for fat reduction will likely increase over time.

*For a PDF of the full article, click on the link to the left of this introduction.

Nazanin Saedi, MD, and Michael Kaminer, MD

With the rising demand for body contouring, noninvasive devices for fat reduction have become increasingly popular and have grown dramatically over the past decade. Highintensity focused ultrasound (HIFU) has been used for nearly half a century for the noninvasive treatment of tumors of various organs, but has only recently been evaluated as a method for the selective destruction of adipose tissue. HIFU works by ablating subcutaneous adipose tissue and causing molecular vibrations that increase the temperature of local tissue and induce rapid cell necrosis. Several studies reveal the safety and efficacy of HIFU for fat reduction in the abdomen and the flanks. These studies indicate consistent reduction in abdominal circumference >2 cm after a single treatment. The adverse events are limited to transient tenderness, bruising, and edema. Increased utility of HIFU for fat reduction will likely increase over time.

*For a PDF of the full article, click on the link to the left of this introduction.

Nazanin Saedi, MD, and Michael Kaminer, MD

With the rising demand for body contouring, noninvasive devices for fat reduction have become increasingly popular and have grown dramatically over the past decade. Highintensity focused ultrasound (HIFU) has been used for nearly half a century for the noninvasive treatment of tumors of various organs, but has only recently been evaluated as a method for the selective destruction of adipose tissue. HIFU works by ablating subcutaneous adipose tissue and causing molecular vibrations that increase the temperature of local tissue and induce rapid cell necrosis. Several studies reveal the safety and efficacy of HIFU for fat reduction in the abdomen and the flanks. These studies indicate consistent reduction in abdominal circumference >2 cm after a single treatment. The adverse events are limited to transient tenderness, bruising, and edema. Increased utility of HIFU for fat reduction will likely increase over time.

*For a PDF of the full article, click on the link to the left of this introduction.

H. Ray Jalian, MD, and Mathew M. Avram, MD, JD

Dermatologists have long used cold-based therapeutic approaches for a variety of applications. Based on the differences in chemical composition, it is possible to selectively target certain tissues rich with lipid, while sparing the surrounding tissue predominantly containing water. With historical observations of cold-induced panniculitis suggesting the feasibility of this strategy, cryolipolysis has emerged as a new methodology using controlled cooling to selectively target fat. Both preclinical and clinical studies have established the safety and efficacy of cryolipolysis for noninvasive body contouring. This review will focus on the evolution of cryolipolysis from initial case reports of cold-induced panniculitis, to preclinical and clinical studies, and the current clinical practice.

*For a PDF of the full article, click on the link to the left of this introduction.

H. Ray Jalian, MD, and Mathew M. Avram, MD, JD

Dermatologists have long used cold-based therapeutic approaches for a variety of applications. Based on the differences in chemical composition, it is possible to selectively target certain tissues rich with lipid, while sparing the surrounding tissue predominantly containing water. With historical observations of cold-induced panniculitis suggesting the feasibility of this strategy, cryolipolysis has emerged as a new methodology using controlled cooling to selectively target fat. Both preclinical and clinical studies have established the safety and efficacy of cryolipolysis for noninvasive body contouring. This review will focus on the evolution of cryolipolysis from initial case reports of cold-induced panniculitis, to preclinical and clinical studies, and the current clinical practice.

*For a PDF of the full article, click on the link to the left of this introduction.

H. Ray Jalian, MD, and Mathew M. Avram, MD, JD

Dermatologists have long used cold-based therapeutic approaches for a variety of applications. Based on the differences in chemical composition, it is possible to selectively target certain tissues rich with lipid, while sparing the surrounding tissue predominantly containing water. With historical observations of cold-induced panniculitis suggesting the feasibility of this strategy, cryolipolysis has emerged as a new methodology using controlled cooling to selectively target fat. Both preclinical and clinical studies have established the safety and efficacy of cryolipolysis for noninvasive body contouring. This review will focus on the evolution of cryolipolysis from initial case reports of cold-induced panniculitis, to preclinical and clinical studies, and the current clinical practice.

*For a PDF of the full article, click on the link to the left of this introduction.

Mark S. Nestor, MD, PhD, Jessica Newburger, DO, and Matthew B. Zarraga, DO

Noninvasive body contouring has become one of the fastest-growing areas of esthetic medicine. Many patients appear to prefer nonsurgical less-invasive procedures owing to the benefits of fewer side effects and shorter recovery times. Increasingly, 635-nm lowlevel laser therapy (LLLT) has been used in the treatment of a variety of medical conditions and has been shown to improve wound healing, reduce edema, and relieve acute pain. Within the past decade, LLLT has also emerged as a new modality for noninvasive body contouring. Research has shown that LLLT is effective in reducing overall body circumference measurements of specifically treated regions, including the hips, waist, thighs, and upper arms, with recent studies demonstrating the long-term effectiveness of results. The treatment is painless, and there appears to be no adverse events associated with LLLT. The mechanism of action of LLLT in body contouring is believed to stem from photoactivation of cytochrome c oxidase within hypertrophic adipocytes, which, in turn, affects intracellular secondary cascades, resulting in the formation of transitory pores within the adipocytes
membrane. The secondary cascades involved may include, but are not limited to, activation of cytosolic lipase and nitric oxide. Newly formed pores release intracellular lipids, which are further metabolized. Future studies need to fully outline the cellular and systemic effects of LLLT as well as determine optimal treatment protocols.

*For a PDF of the full article, click on the link to the left of this introduction.

Mark S. Nestor, MD, PhD, Jessica Newburger, DO, and Matthew B. Zarraga, DO

Noninvasive body contouring has become one of the fastest-growing areas of esthetic medicine. Many patients appear to prefer nonsurgical less-invasive procedures owing to the benefits of fewer side effects and shorter recovery times. Increasingly, 635-nm lowlevel laser therapy (LLLT) has been used in the treatment of a variety of medical conditions and has been shown to improve wound healing, reduce edema, and relieve acute pain. Within the past decade, LLLT has also emerged as a new modality for noninvasive body contouring. Research has shown that LLLT is effective in reducing overall body circumference measurements of specifically treated regions, including the hips, waist, thighs, and upper arms, with recent studies demonstrating the long-term effectiveness of results. The treatment is painless, and there appears to be no adverse events associated with LLLT. The mechanism of action of LLLT in body contouring is believed to stem from photoactivation of cytochrome c oxidase within hypertrophic adipocytes, which, in turn, affects intracellular secondary cascades, resulting in the formation of transitory pores within the adipocytes
membrane. The secondary cascades involved may include, but are not limited to, activation of cytosolic lipase and nitric oxide. Newly formed pores release intracellular lipids, which are further metabolized. Future studies need to fully outline the cellular and systemic effects of LLLT as well as determine optimal treatment protocols.

*For a PDF of the full article, click on the link to the left of this introduction.

Mark S. Nestor, MD, PhD, Jessica Newburger, DO, and Matthew B. Zarraga, DO

Noninvasive body contouring has become one of the fastest-growing areas of esthetic medicine. Many patients appear to prefer nonsurgical less-invasive procedures owing to the benefits of fewer side effects and shorter recovery times. Increasingly, 635-nm lowlevel laser therapy (LLLT) has been used in the treatment of a variety of medical conditions and has been shown to improve wound healing, reduce edema, and relieve acute pain. Within the past decade, LLLT has also emerged as a new modality for noninvasive body contouring. Research has shown that LLLT is effective in reducing overall body circumference measurements of specifically treated regions, including the hips, waist, thighs, and upper arms, with recent studies demonstrating the long-term effectiveness of results. The treatment is painless, and there appears to be no adverse events associated with LLLT. The mechanism of action of LLLT in body contouring is believed to stem from photoactivation of cytochrome c oxidase within hypertrophic adipocytes, which, in turn, affects intracellular secondary cascades, resulting in the formation of transitory pores within the adipocytes
membrane. The secondary cascades involved may include, but are not limited to, activation of cytosolic lipase and nitric oxide. Newly formed pores release intracellular lipids, which are further metabolized. Future studies need to fully outline the cellular and systemic effects of LLLT as well as determine optimal treatment protocols.

*For a PDF of the full article, click on the link to the left of this introduction.

Pinar Avci, MD, Asheesh Gupta, PhD, Magesh Sadasivam, MTech, Daniela Vecchio, PhD, Zeev Pam, MD, Nadav Pam, MD, and Michael R. Hamblin, PhD

Low-level laser (light) therapy (LLLT) is a fast-growing technology used to treat a multitude of conditions that require stimulation of healing, relief of pain and inflammation, and restoration of function. Although skin is naturally exposed to light more than any other organ, it still responds well to red and near-infrared wavelengths. The photons are absorbed by mitochondrial chromophores in skin cells. Consequently, electron transport, adenosine triphosphate nitric oxide release, blood flow, reactive oxygen species increase, and diverse signaling pathways are activated. Stem cells can be activated, allowing increased tissue repair and healing. In dermatology, LLLT has beneficial effects on wrinkles, acne scars, hypertrophic scars, and healing of burns. LLLT can reduce UV damage both as a treatment and as a prophylactic measure. In pigmentary disorders such as vitiligo, LLLT can increase pigmentation by stimulating melanocyte proliferation and reduce depigmentation by inhibiting autoimmunity. Inflammatory diseases such as psoriasis and acne can also be managed. The noninvasive nature and almost complete absence of side effects encourage further testing in dermatology.

*For a PDF of the full article, click on the link to the left of this introduction.

Pinar Avci, MD, Asheesh Gupta, PhD, Magesh Sadasivam, MTech, Daniela Vecchio, PhD, Zeev Pam, MD, Nadav Pam, MD, and Michael R. Hamblin, PhD

Low-level laser (light) therapy (LLLT) is a fast-growing technology used to treat a multitude of conditions that require stimulation of healing, relief of pain and inflammation, and restoration of function. Although skin is naturally exposed to light more than any other organ, it still responds well to red and near-infrared wavelengths. The photons are absorbed by mitochondrial chromophores in skin cells. Consequently, electron transport, adenosine triphosphate nitric oxide release, blood flow, reactive oxygen species increase, and diverse signaling pathways are activated. Stem cells can be activated, allowing increased tissue repair and healing. In dermatology, LLLT has beneficial effects on wrinkles, acne scars, hypertrophic scars, and healing of burns. LLLT can reduce UV damage both as a treatment and as a prophylactic measure. In pigmentary disorders such as vitiligo, LLLT can increase pigmentation by stimulating melanocyte proliferation and reduce depigmentation by inhibiting autoimmunity. Inflammatory diseases such as psoriasis and acne can also be managed. The noninvasive nature and almost complete absence of side effects encourage further testing in dermatology.

*For a PDF of the full article, click on the link to the left of this introduction.

Pinar Avci, MD, Asheesh Gupta, PhD, Magesh Sadasivam, MTech, Daniela Vecchio, PhD, Zeev Pam, MD, Nadav Pam, MD, and Michael R. Hamblin, PhD

Low-level laser (light) therapy (LLLT) is a fast-growing technology used to treat a multitude of conditions that require stimulation of healing, relief of pain and inflammation, and restoration of function. Although skin is naturally exposed to light more than any other organ, it still responds well to red and near-infrared wavelengths. The photons are absorbed by mitochondrial chromophores in skin cells. Consequently, electron transport, adenosine triphosphate nitric oxide release, blood flow, reactive oxygen species increase, and diverse signaling pathways are activated. Stem cells can be activated, allowing increased tissue repair and healing. In dermatology, LLLT has beneficial effects on wrinkles, acne scars, hypertrophic scars, and healing of burns. LLLT can reduce UV damage both as a treatment and as a prophylactic measure. In pigmentary disorders such as vitiligo, LLLT can increase pigmentation by stimulating melanocyte proliferation and reduce depigmentation by inhibiting autoimmunity. Inflammatory diseases such as psoriasis and acne can also be managed. The noninvasive nature and almost complete absence of side effects encourage further testing in dermatology.

*For a PDF of the full article, click on the link to the left of this introduction.

Rebecca Kleinerman, MD, Daniel B. Eisen, MD, Suzanne L. Kilmer, MD, and
Omar A. Ibrahimi, MD, PhD

The techniques of noninvasive facial rejuvenation are forever being redefined and improved. This article will review historical as well as present approaches to resurfacing, discussing the nonablative tools that can complement resurfacing procedures. Current thoughts on the pre- and postoperative care of resurfacing patients are also considered.

*For a PDF of the full article, click on the link to the left of this introduction.

Rebecca Kleinerman, MD, Daniel B. Eisen, MD, Suzanne L. Kilmer, MD, and
Omar A. Ibrahimi, MD, PhD

The techniques of noninvasive facial rejuvenation are forever being redefined and improved. This article will review historical as well as present approaches to resurfacing, discussing the nonablative tools that can complement resurfacing procedures. Current thoughts on the pre- and postoperative care of resurfacing patients are also considered.

*For a PDF of the full article, click on the link to the left of this introduction.

Rebecca Kleinerman, MD, Daniel B. Eisen, MD, Suzanne L. Kilmer, MD, and
Omar A. Ibrahimi, MD, PhD

The techniques of noninvasive facial rejuvenation are forever being redefined and improved. This article will review historical as well as present approaches to resurfacing, discussing the nonablative tools that can complement resurfacing procedures. Current thoughts on the pre- and postoperative care of resurfacing patients are also considered.

*For a PDF of the full article, click on the link to the left of this introduction.

Murad Alam, MD, MSCI

Noninvasive procedural dermatology has evolved rapidly during the past decade. An array of skin tightening, resurfacing, and fat-reducing energy devices can now be combined with filler and neurotoxin injectables to reduce the visible signs of aging with minimal downtime and risk. In the future, such advances will likely continue, although the pace of technological breakthroughs is difficult to predict. Complex feedback devices, nanotechnology, and cell-based therapies will eventually begin to fulfill the promise of scar removal, pigmentation correction, and replacement of aged skin with skin that is new and completely functional. Dermatologists are well equipped to retain their leadership in noninvasive esthetic medicine, and they will, to the extent that they continue to pioneer outstanding therapies that are effective, affordable, and safe.

*For a PDF of the full article, click on the link to the left of this introduction.

Murad Alam, MD, MSCI

Noninvasive procedural dermatology has evolved rapidly during the past decade. An array of skin tightening, resurfacing, and fat-reducing energy devices can now be combined with filler and neurotoxin injectables to reduce the visible signs of aging with minimal downtime and risk. In the future, such advances will likely continue, although the pace of technological breakthroughs is difficult to predict. Complex feedback devices, nanotechnology, and cell-based therapies will eventually begin to fulfill the promise of scar removal, pigmentation correction, and replacement of aged skin with skin that is new and completely functional. Dermatologists are well equipped to retain their leadership in noninvasive esthetic medicine, and they will, to the extent that they continue to pioneer outstanding therapies that are effective, affordable, and safe.

*For a PDF of the full article, click on the link to the left of this introduction.

Murad Alam, MD, MSCI

Noninvasive procedural dermatology has evolved rapidly during the past decade. An array of skin tightening, resurfacing, and fat-reducing energy devices can now be combined with filler and neurotoxin injectables to reduce the visible signs of aging with minimal downtime and risk. In the future, such advances will likely continue, although the pace of technological breakthroughs is difficult to predict. Complex feedback devices, nanotechnology, and cell-based therapies will eventually begin to fulfill the promise of scar removal, pigmentation correction, and replacement of aged skin with skin that is new and completely functional. Dermatologists are well equipped to retain their leadership in noninvasive esthetic medicine, and they will, to the extent that they continue to pioneer outstanding therapies that are effective, affordable, and safe.

*For a PDF of the full article, click on the link to the left of this introduction.

Patients and their families sued dermatologists in 21% of 174 lawsuits filed for injuries caused by cutaneous laser surgery from 1985 through 2011. Only plastic surgeons were more likely to be defendants, accounting for 26% of cases.

The incidence of lawsuits for cutaneous laser surgery injury generally is on the upswing, increasing from five or fewer cases per year in 1985-1999 to a peak of 22 cases in 2010, Dr. H. Ray Jalian and his associates reported.

The majority of the cases involved laser hair removal (36%) and rejuvenation procedures (25%). The rejuvenation procedures included conventional ablative resurfacing, nonablative resurfacing, intense pulsed light, and the use of both ablative and nonablative fractional lasers. Plaintiffs won an average of $380,700 each in 51% of the 120 cases that reached a decision or settlement. That’s more than the average $275,000 indemnity payment across all medical specialties in a 2011 report, but the two studies used different methodologies. Dr. Jalian and his associates analyzed cutaneous laser surgery cases in the national Westlaw Next database of public records that included some form of legal pleading (JAMA Dermatol. 2013;149:188-93). The previous data included all resolved claims (not only those with legal pleadings) in all specialties (N. Engl. J. Med. 2011;365:629-36).

The physicians being sued included at least 12 other kinds of specialists, suggesting that a significant number of physicians offer or supervise laser skin treatments outside the scope of their specialty, wrote Dr. Jalian, a clinical fellow at the Wellman Center for Photomedicine, Massachusetts General Hospital, Boston.

General surgeons, family physicians, ob.gyns., and otolaryngologists each accounted for 5% of cases. Others included ophthalmologists (3%), orthopedic surgeons (2%), and specialists in radiology, anesthesia, physical medicine and rehabilitation, preventative medicine, and vascular surgery (1% each). Physician extenders (including physician assistants, nurse practitioners, registered nurses, aestheticians, and technicians) were laser operators or supervisors in 20% of cases.

Notably, physicians were sued even when they weren’t operating the laser, but were responsible for supervising the operator. Nonphysician operators (including physician extenders, chiropractors, podiatrists, and others) comprised 38% of operators and 26% of defendants. Physicians comprised 58% of operators and 74% of defendants. The training status of 5% of operators was unknown. (Percentages were rounded.)

After hair removal and skin rejuvenation, the most often litigated cases involved treatment of vascular lesions and telangiectasia (8% of cases) or treatment of leg veins (another 8%). Seven percent of cases involved tattoo removal, 4% involved neoplasms, 3% stemmed from treatment of scars, 2% involved laser treatment of pigmentary disorders, 1% were the use of a laser to treat pigmented lesions, and 6% were other procedures.

The most common injuries were burns (47%), scars (39%), and hypo- or hyperpigmentation (24%). Two percent of cases involved eye injuries, and at least two patients died due to complications of anesthesia.

The researchers offered several tips for physicians to reduce the risk of a lawsuit from skin laser surgery, including ensuring proper staff training and supervising delegated tasks. Be careful to evaluate skin type and select the correct laser parameters, they said. For some patients, it may be wise to do a test spot before starting laser treatment, even though solid data are lacking to support this. Follow guidelines from professional medical associations, such as the guidelines from the American Society for Laser Medicine, on delegating laser-related tasks to nonphysicians, the researchers added.

In general, federal regulations do not specify who can operate a laser, which procedures must be supervised by physicians, or where to perform procedures. Several states, including New York and Texas, do not require a license to perform laser hair removal, the most common type of laser skin surgery, the investigators noted. The lawsuits were filed in 30 states, the District of Columbia, and federal court, with the most cases in California (27), New York (23) and Texas (23).

Dr. Jalian reported having no financial disclosures. One of his coinvestigators has been a consultant and advisor for Zeltiq Aesthetics and a consultant for Unilever.

[email protected]

On Twitter @sherryboschert

Patients and their families sued dermatologists in 21% of 174 lawsuits filed for injuries caused by cutaneous laser surgery from 1985 through 2011. Only plastic surgeons were more likely to be defendants, accounting for 26% of cases.

The incidence of lawsuits for cutaneous laser surgery injury generally is on the upswing, increasing from five or fewer cases per year in 1985-1999 to a peak of 22 cases in 2010, Dr. H. Ray Jalian and his associates reported.

The majority of the cases involved laser hair removal (36%) and rejuvenation procedures (25%). The rejuvenation procedures included conventional ablative resurfacing, nonablative resurfacing, intense pulsed light, and the use of both ablative and nonablative fractional lasers. Plaintiffs won an average of $380,700 each in 51% of the 120 cases that reached a decision or settlement. That’s more than the average $275,000 indemnity payment across all medical specialties in a 2011 report, but the two studies used different methodologies. Dr. Jalian and his associates analyzed cutaneous laser surgery cases in the national Westlaw Next database of public records that included some form of legal pleading (JAMA Dermatol. 2013;149:188-93). The previous data included all resolved claims (not only those with legal pleadings) in all specialties (N. Engl. J. Med. 2011;365:629-36).

The physicians being sued included at least 12 other kinds of specialists, suggesting that a significant number of physicians offer or supervise laser skin treatments outside the scope of their specialty, wrote Dr. Jalian, a clinical fellow at the Wellman Center for Photomedicine, Massachusetts General Hospital, Boston.

General surgeons, family physicians, ob.gyns., and otolaryngologists each accounted for 5% of cases. Others included ophthalmologists (3%), orthopedic surgeons (2%), and specialists in radiology, anesthesia, physical medicine and rehabilitation, preventative medicine, and vascular surgery (1% each). Physician extenders (including physician assistants, nurse practitioners, registered nurses, aestheticians, and technicians) were laser operators or supervisors in 20% of cases.

Notably, physicians were sued even when they weren’t operating the laser, but were responsible for supervising the operator. Nonphysician operators (including physician extenders, chiropractors, podiatrists, and others) comprised 38% of operators and 26% of defendants. Physicians comprised 58% of operators and 74% of defendants. The training status of 5% of operators was unknown. (Percentages were rounded.)

After hair removal and skin rejuvenation, the most often litigated cases involved treatment of vascular lesions and telangiectasia (8% of cases) or treatment of leg veins (another 8%). Seven percent of cases involved tattoo removal, 4% involved neoplasms, 3% stemmed from treatment of scars, 2% involved laser treatment of pigmentary disorders, 1% were the use of a laser to treat pigmented lesions, and 6% were other procedures.

The most common injuries were burns (47%), scars (39%), and hypo- or hyperpigmentation (24%). Two percent of cases involved eye injuries, and at least two patients died due to complications of anesthesia.

The researchers offered several tips for physicians to reduce the risk of a lawsuit from skin laser surgery, including ensuring proper staff training and supervising delegated tasks. Be careful to evaluate skin type and select the correct laser parameters, they said. For some patients, it may be wise to do a test spot before starting laser treatment, even though solid data are lacking to support this. Follow guidelines from professional medical associations, such as the guidelines from the American Society for Laser Medicine, on delegating laser-related tasks to nonphysicians, the researchers added.

In general, federal regulations do not specify who can operate a laser, which procedures must be supervised by physicians, or where to perform procedures. Several states, including New York and Texas, do not require a license to perform laser hair removal, the most common type of laser skin surgery, the investigators noted. The lawsuits were filed in 30 states, the District of Columbia, and federal court, with the most cases in California (27), New York (23) and Texas (23).

Dr. Jalian reported having no financial disclosures. One of his coinvestigators has been a consultant and advisor for Zeltiq Aesthetics and a consultant for Unilever.

[email protected]

On Twitter @sherryboschert

Patients and their families sued dermatologists in 21% of 174 lawsuits filed for injuries caused by cutaneous laser surgery from 1985 through 2011. Only plastic surgeons were more likely to be defendants, accounting for 26% of cases.

The incidence of lawsuits for cutaneous laser surgery injury generally is on the upswing, increasing from five or fewer cases per year in 1985-1999 to a peak of 22 cases in 2010, Dr. H. Ray Jalian and his associates reported.

The majority of the cases involved laser hair removal (36%) and rejuvenation procedures (25%). The rejuvenation procedures included conventional ablative resurfacing, nonablative resurfacing, intense pulsed light, and the use of both ablative and nonablative fractional lasers. Plaintiffs won an average of $380,700 each in 51% of the 120 cases that reached a decision or settlement. That’s more than the average $275,000 indemnity payment across all medical specialties in a 2011 report, but the two studies used different methodologies. Dr. Jalian and his associates analyzed cutaneous laser surgery cases in the national Westlaw Next database of public records that included some form of legal pleading (JAMA Dermatol. 2013;149:188-93). The previous data included all resolved claims (not only those with legal pleadings) in all specialties (N. Engl. J. Med. 2011;365:629-36).

The physicians being sued included at least 12 other kinds of specialists, suggesting that a significant number of physicians offer or supervise laser skin treatments outside the scope of their specialty, wrote Dr. Jalian, a clinical fellow at the Wellman Center for Photomedicine, Massachusetts General Hospital, Boston.

General surgeons, family physicians, ob.gyns., and otolaryngologists each accounted for 5% of cases. Others included ophthalmologists (3%), orthopedic surgeons (2%), and specialists in radiology, anesthesia, physical medicine and rehabilitation, preventative medicine, and vascular surgery (1% each). Physician extenders (including physician assistants, nurse practitioners, registered nurses, aestheticians, and technicians) were laser operators or supervisors in 20% of cases.

Notably, physicians were sued even when they weren’t operating the laser, but were responsible for supervising the operator. Nonphysician operators (including physician extenders, chiropractors, podiatrists, and others) comprised 38% of operators and 26% of defendants. Physicians comprised 58% of operators and 74% of defendants. The training status of 5% of operators was unknown. (Percentages were rounded.)

After hair removal and skin rejuvenation, the most often litigated cases involved treatment of vascular lesions and telangiectasia (8% of cases) or treatment of leg veins (another 8%). Seven percent of cases involved tattoo removal, 4% involved neoplasms, 3% stemmed from treatment of scars, 2% involved laser treatment of pigmentary disorders, 1% were the use of a laser to treat pigmented lesions, and 6% were other procedures.

The most common injuries were burns (47%), scars (39%), and hypo- or hyperpigmentation (24%). Two percent of cases involved eye injuries, and at least two patients died due to complications of anesthesia.

The researchers offered several tips for physicians to reduce the risk of a lawsuit from skin laser surgery, including ensuring proper staff training and supervising delegated tasks. Be careful to evaluate skin type and select the correct laser parameters, they said. For some patients, it may be wise to do a test spot before starting laser treatment, even though solid data are lacking to support this. Follow guidelines from professional medical associations, such as the guidelines from the American Society for Laser Medicine, on delegating laser-related tasks to nonphysicians, the researchers added.

In general, federal regulations do not specify who can operate a laser, which procedures must be supervised by physicians, or where to perform procedures. Several states, including New York and Texas, do not require a license to perform laser hair removal, the most common type of laser skin surgery, the investigators noted. The lawsuits were filed in 30 states, the District of Columbia, and federal court, with the most cases in California (27), New York (23) and Texas (23).

Dr. Jalian reported having no financial disclosures. One of his coinvestigators has been a consultant and advisor for Zeltiq Aesthetics and a consultant for Unilever.

[email protected]

On Twitter @sherryboschert

At the SDEF Hawaii Dermatology Seminar, Dr. Nazanin Saedi of Thomas Jefferson University in Philadelphia discusses the latest treatments for hyperhidrosis.

At the SDEF Hawaii Dermatology Seminar, Dr. Nazanin Saedi of Thomas Jefferson University in Philadelphia discusses the latest treatments for hyperhidrosis.

At the SDEF Hawaii Dermatology Seminar, Dr. Nazanin Saedi of Thomas Jefferson University in Philadelphia discusses the latest treatments for hyperhidrosis.

ORLANDO – In what might be the first success of its kind, dermatologists at the University of Texas report treating a case of neurotic excoriations with onabotulinumtoxinA.

A 36-year-old man presented with multiple excoriated, crusted erosions on his face and scalp and also complained of tension headaches and an inability to relax.

Images courtesy Dr. Jennifer Gordon

In an attempt to relieve his headaches, Dr. Jennifer Gordon and her colleagues injected his glabella and forehead with 56 units of onabotulinumtoxinA (Botox and Botox Cosmetic).

To their surprise, in 3 weeks he was not only relieved of his headaches, but also of his excoriations.

The patient has been free of symptoms for the past year and receives maintenance injections every 4-6 months, said Dr. Gordon, a second-year dermatology resident at the University of Texas, Austin.

Neurotic excoriations (NE), also known as psychogenic excoriation, dermatillomania, or skin picking syndrome, are the result of compulsive skin picking and scratching. The condition occurs in the absence of a physical pathology and is usually associated with psychological and medical conditions that cause psychological distress.

Some studies suggest that roughly 2% of the patients at dermatology clinics have NE, and there’s a 9% prevalence of NE in patients with pruritus (itching). Researchers believe, however, that the incidence and prevalence of the condition are underreported.

Current treatments for NE include antidepressants and cognitive-behavioral therapy.

Dr. Gordon, who presented a poster at the Orlando Dermatology Aesthetic and Clinical Conference, reported that her patient described "hairs" coming out of his skin, and that twisting his body caused the hairs to coil and pull. As a result, he would pick at these areas on his face and scalp. He also complained of frequent tension headaches.

His lab values were within normal limits, Dr. Gordon reported. He was first treated for folliculitis and was given wound care instructions. He was later started on citalopram, which eliminated complaints about the hairs, but the excoriations persisted. The patient already had been treated for delusions, "and we don’t hesitate to send [the patients] for psych treatment if they need it," said Dr. Gordon, who published the poster with Dr. Jason S. Reichenberg, a faculty member at the university.

The investigators said that they believed the onabotulinumtoxinA might have induced remission in the patient by eliminating tension headaches, which could have been a trigger for his picking. The treatment also might have helped his underlying depression.

Although some statistics show that as many as one-third of NE patients also have tension or migraine headaches and gynecologic symptoms related to menstruation, it is unclear whether this treatment would work on other patients with symptoms similar to this particular patient. It’s also not yet known whether the treatment would work on other sites of the body, or on patients who do not have tension headaches, Dr. Gordon said.

The key to treatment of NE, she said, "is finding the underlying trigger."

Dr. Gordon said that she had no disclosures.

[email protected]

On Twitter @naseemsmiller

ORLANDO – In what might be the first success of its kind, dermatologists at the University of Texas report treating a case of neurotic excoriations with onabotulinumtoxinA.

A 36-year-old man presented with multiple excoriated, crusted erosions on his face and scalp and also complained of tension headaches and an inability to relax.

Images courtesy Dr. Jennifer Gordon

In an attempt to relieve his headaches, Dr. Jennifer Gordon and her colleagues injected his glabella and forehead with 56 units of onabotulinumtoxinA (Botox and Botox Cosmetic).

To their surprise, in 3 weeks he was not only relieved of his headaches, but also of his excoriations.

The patient has been free of symptoms for the past year and receives maintenance injections every 4-6 months, said Dr. Gordon, a second-year dermatology resident at the University of Texas, Austin.

Neurotic excoriations (NE), also known as psychogenic excoriation, dermatillomania, or skin picking syndrome, are the result of compulsive skin picking and scratching. The condition occurs in the absence of a physical pathology and is usually associated with psychological and medical conditions that cause psychological distress.

Some studies suggest that roughly 2% of the patients at dermatology clinics have NE, and there’s a 9% prevalence of NE in patients with pruritus (itching). Researchers believe, however, that the incidence and prevalence of the condition are underreported.

Current treatments for NE include antidepressants and cognitive-behavioral therapy.

Dr. Gordon, who presented a poster at the Orlando Dermatology Aesthetic and Clinical Conference, reported that her patient described "hairs" coming out of his skin, and that twisting his body caused the hairs to coil and pull. As a result, he would pick at these areas on his face and scalp. He also complained of frequent tension headaches.

His lab values were within normal limits, Dr. Gordon reported. He was first treated for folliculitis and was given wound care instructions. He was later started on citalopram, which eliminated complaints about the hairs, but the excoriations persisted. The patient already had been treated for delusions, "and we don’t hesitate to send [the patients] for psych treatment if they need it," said Dr. Gordon, who published the poster with Dr. Jason S. Reichenberg, a faculty member at the university.

The investigators said that they believed the onabotulinumtoxinA might have induced remission in the patient by eliminating tension headaches, which could have been a trigger for his picking. The treatment also might have helped his underlying depression.

Although some statistics show that as many as one-third of NE patients also have tension or migraine headaches and gynecologic symptoms related to menstruation, it is unclear whether this treatment would work on other patients with symptoms similar to this particular patient. It’s also not yet known whether the treatment would work on other sites of the body, or on patients who do not have tension headaches, Dr. Gordon said.

The key to treatment of NE, she said, "is finding the underlying trigger."

Dr. Gordon said that she had no disclosures.

[email protected]

On Twitter @naseemsmiller

ORLANDO – In what might be the first success of its kind, dermatologists at the University of Texas report treating a case of neurotic excoriations with onabotulinumtoxinA.

A 36-year-old man presented with multiple excoriated, crusted erosions on his face and scalp and also complained of tension headaches and an inability to relax.

Images courtesy Dr. Jennifer Gordon

In an attempt to relieve his headaches, Dr. Jennifer Gordon and her colleagues injected his glabella and forehead with 56 units of onabotulinumtoxinA (Botox and Botox Cosmetic).

To their surprise, in 3 weeks he was not only relieved of his headaches, but also of his excoriations.

The patient has been free of symptoms for the past year and receives maintenance injections every 4-6 months, said Dr. Gordon, a second-year dermatology resident at the University of Texas, Austin.

Neurotic excoriations (NE), also known as psychogenic excoriation, dermatillomania, or skin picking syndrome, are the result of compulsive skin picking and scratching. The condition occurs in the absence of a physical pathology and is usually associated with psychological and medical conditions that cause psychological distress.

Some studies suggest that roughly 2% of the patients at dermatology clinics have NE, and there’s a 9% prevalence of NE in patients with pruritus (itching). Researchers believe, however, that the incidence and prevalence of the condition are underreported.

Current treatments for NE include antidepressants and cognitive-behavioral therapy.

Dr. Gordon, who presented a poster at the Orlando Dermatology Aesthetic and Clinical Conference, reported that her patient described "hairs" coming out of his skin, and that twisting his body caused the hairs to coil and pull. As a result, he would pick at these areas on his face and scalp. He also complained of frequent tension headaches.

His lab values were within normal limits, Dr. Gordon reported. He was first treated for folliculitis and was given wound care instructions. He was later started on citalopram, which eliminated complaints about the hairs, but the excoriations persisted. The patient already had been treated for delusions, "and we don’t hesitate to send [the patients] for psych treatment if they need it," said Dr. Gordon, who published the poster with Dr. Jason S. Reichenberg, a faculty member at the university.

The investigators said that they believed the onabotulinumtoxinA might have induced remission in the patient by eliminating tension headaches, which could have been a trigger for his picking. The treatment also might have helped his underlying depression.

Although some statistics show that as many as one-third of NE patients also have tension or migraine headaches and gynecologic symptoms related to menstruation, it is unclear whether this treatment would work on other patients with symptoms similar to this particular patient. It’s also not yet known whether the treatment would work on other sites of the body, or on patients who do not have tension headaches, Dr. Gordon said.

The key to treatment of NE, she said, "is finding the underlying trigger."

Dr. Gordon said that she had no disclosures.

[email protected]

On Twitter @naseemsmiller

The relationship between acne and diet has been an ongoing debate. There are no meta-analyses, randomized controlled clinical studies, or well-designed scientific trials that follow evidence-based guidelines to elucidate a cause-effect relationship. However, for decades anecdotal evidence has shown that acne and insulin resistance, such as that seen in patients with polycystic ovarian syndrome (PCOS), are highly linked. Now the literature points to the growing relationship between nutrition and the prevalence of acne, especially to glycemic index and the consumption of dairy.

Glycemic index is a ranking system based on the quality and quantity of consumed carbohydrates and its ability to raise blood sugar levels. Foods with high glycemic indices such as potatoes, bread, chips, and pasta, require more insulin to maintain blood glucose levels within the normal range. High-glycemic diets that are prevalent in the United States not only lead to insulin resistance, diabetes, obesity, and heart disease but also to acne.

Several studies have looked at the glycemic load, insulin sensitivity, and hormonal mediators correlating to acne (Am. J. Clin. Nutr. 2007; 86:107-15; J. Dermatol. Sci. 2008;50:41-52). Foods with a high-glycemic index may contribute to acne by elevating serum insulin concentrations (which can stimulate sebocyte proliferation and sebum production), suppress sex hormone-binding globulin (SHBG) concentrations, and raise androgen concentrations. On the contrary, low-glycemic-index foods increase SHBG and reduce androgen levels; this is of great importance because higher SHBG levels are associated with lower acne severity. Consumption of fat and carbohydrates increases sebum production and affects sebum composition, ultimately encouraging acne production (Br. J. Dermatol. 1967;79:119-21).

A new study by Anna Di Landro et al. published in the December 2012 found a link between acne and the consumption of milk, particularly in those drinking skim milk and more than three servings of milk per week (J. Am. Acad. Dermatol. 2012;67:1129-35).

Dr. Di Landro et al. also found that the consumption of fish had a protective effect on acne. This interesting finding points to the larger issue of acne developing in ethnic populations that immigrate to the United States. Population studies have shown that non-Western diets have a reduced incidence of acne. Western diets are deficient in long-chain omega-3 fatty acids. The ratio of omega-6 to omega-3 fatty acids in our Western diet is 10:1 to 20:1, vs. 3:1 to 2:1 in a non-Western diet. Omega-6 fatty acids in increased concentrations induce proinflammatory mediators and have been associated with the development of inflammatory acne. Western diets with high consumption of seafood have high levels of omega-3 fatty acids and have shown to decrease inflammatory mediators in the skin (Arch. Dermatol. 2003;139:941-2).

In my clinic, the ethnic populations that immigrate to the United States often develop acne to a greater extent than they had in their native countries. Although factors including stress, hormonal differences in foods, and pollution can be confounding factors, we must not ignore the Western diet that these populations adapt to is higher in refined sugars and carbohydrates and lower in vegetables and lean protein. Every acne patient in my clinic is asked to complete a nutritional questionnaire discussing the intake of fast food, carbohydrates, juice, sodas, and processed sugar. We have noticed that acne improves clinically and is more responsive to traditional acne medications when patients reduce their consumption of processed sugars and dairy and increase their intake of lean protein. Similarly, our PCOS patients who are treated with medications such as metformin, which improves the body’s ability to regulate blood glucose levels, have improvements in their acne. So, is acne a marker for early insulin resistance?

The underlying etiology of acne is multifactorial, although now we can appreciate diet as one of the causative factors. Although there is no direct correlation between obesity or insulin resistance and the prevalence of acne, a low glycemic index diet in combination with topical and systemic acne medications can be a powerful method of treating acne. Nutritional counseling is an adjunct educational service we should provide to our patients in addition to skin care advice and medical treatments for acne.

No single food directly causes acne, but a balanced diet can alter its severity. Encouraging our patients to eat a variety of fruits and vegetables, lean protein, and healthy fats can prevent the inflammation seen with acne and also can protect against cardiovascular disease, type II diabetes, and even obesity.

It is unfortunate that the medical education system in the United States has no formal nutrition education. Nearly every field of medicine including internal medicine, cardiology, endocrinology, allergy, pediatrics, obstetrics and gynecology, surgery, and not the least, dermatology, is influenced in some realm by nutrition. As the population diversifies, so will the importance of dietary guidance. We need to educate ourselves and our residents-in-training to better appreciate the symbiotic relationship between diet and skin health and to provide this guidance to our patients.

Dr. Talakoub is in private practice in McLean, Va.

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

The relationship between acne and diet has been an ongoing debate. There are no meta-analyses, randomized controlled clinical studies, or well-designed scientific trials that follow evidence-based guidelines to elucidate a cause-effect relationship. However, for decades anecdotal evidence has shown that acne and insulin resistance, such as that seen in patients with polycystic ovarian syndrome (PCOS), are highly linked. Now the literature points to the growing relationship between nutrition and the prevalence of acne, especially to glycemic index and the consumption of dairy.

Glycemic index is a ranking system based on the quality and quantity of consumed carbohydrates and its ability to raise blood sugar levels. Foods with high glycemic indices such as potatoes, bread, chips, and pasta, require more insulin to maintain blood glucose levels within the normal range. High-glycemic diets that are prevalent in the United States not only lead to insulin resistance, diabetes, obesity, and heart disease but also to acne.

Several studies have looked at the glycemic load, insulin sensitivity, and hormonal mediators correlating to acne (Am. J. Clin. Nutr. 2007; 86:107-15; J. Dermatol. Sci. 2008;50:41-52). Foods with a high-glycemic index may contribute to acne by elevating serum insulin concentrations (which can stimulate sebocyte proliferation and sebum production), suppress sex hormone-binding globulin (SHBG) concentrations, and raise androgen concentrations. On the contrary, low-glycemic-index foods increase SHBG and reduce androgen levels; this is of great importance because higher SHBG levels are associated with lower acne severity. Consumption of fat and carbohydrates increases sebum production and affects sebum composition, ultimately encouraging acne production (Br. J. Dermatol. 1967;79:119-21).

A new study by Anna Di Landro et al. published in the December 2012 found a link between acne and the consumption of milk, particularly in those drinking skim milk and more than three servings of milk per week (J. Am. Acad. Dermatol. 2012;67:1129-35).

Dr. Di Landro et al. also found that the consumption of fish had a protective effect on acne. This interesting finding points to the larger issue of acne developing in ethnic populations that immigrate to the United States. Population studies have shown that non-Western diets have a reduced incidence of acne. Western diets are deficient in long-chain omega-3 fatty acids. The ratio of omega-6 to omega-3 fatty acids in our Western diet is 10:1 to 20:1, vs. 3:1 to 2:1 in a non-Western diet. Omega-6 fatty acids in increased concentrations induce proinflammatory mediators and have been associated with the development of inflammatory acne. Western diets with high consumption of seafood have high levels of omega-3 fatty acids and have shown to decrease inflammatory mediators in the skin (Arch. Dermatol. 2003;139:941-2).

In my clinic, the ethnic populations that immigrate to the United States often develop acne to a greater extent than they had in their native countries. Although factors including stress, hormonal differences in foods, and pollution can be confounding factors, we must not ignore the Western diet that these populations adapt to is higher in refined sugars and carbohydrates and lower in vegetables and lean protein. Every acne patient in my clinic is asked to complete a nutritional questionnaire discussing the intake of fast food, carbohydrates, juice, sodas, and processed sugar. We have noticed that acne improves clinically and is more responsive to traditional acne medications when patients reduce their consumption of processed sugars and dairy and increase their intake of lean protein. Similarly, our PCOS patients who are treated with medications such as metformin, which improves the body’s ability to regulate blood glucose levels, have improvements in their acne. So, is acne a marker for early insulin resistance?

The underlying etiology of acne is multifactorial, although now we can appreciate diet as one of the causative factors. Although there is no direct correlation between obesity or insulin resistance and the prevalence of acne, a low glycemic index diet in combination with topical and systemic acne medications can be a powerful method of treating acne. Nutritional counseling is an adjunct educational service we should provide to our patients in addition to skin care advice and medical treatments for acne.

No single food directly causes acne, but a balanced diet can alter its severity. Encouraging our patients to eat a variety of fruits and vegetables, lean protein, and healthy fats can prevent the inflammation seen with acne and also can protect against cardiovascular disease, type II diabetes, and even obesity.

It is unfortunate that the medical education system in the United States has no formal nutrition education. Nearly every field of medicine including internal medicine, cardiology, endocrinology, allergy, pediatrics, obstetrics and gynecology, surgery, and not the least, dermatology, is influenced in some realm by nutrition. As the population diversifies, so will the importance of dietary guidance. We need to educate ourselves and our residents-in-training to better appreciate the symbiotic relationship between diet and skin health and to provide this guidance to our patients.

Dr. Talakoub is in private practice in McLean, Va.

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

The relationship between acne and diet has been an ongoing debate. There are no meta-analyses, randomized controlled clinical studies, or well-designed scientific trials that follow evidence-based guidelines to elucidate a cause-effect relationship. However, for decades anecdotal evidence has shown that acne and insulin resistance, such as that seen in patients with polycystic ovarian syndrome (PCOS), are highly linked. Now the literature points to the growing relationship between nutrition and the prevalence of acne, especially to glycemic index and the consumption of dairy.

Glycemic index is a ranking system based on the quality and quantity of consumed carbohydrates and its ability to raise blood sugar levels. Foods with high glycemic indices such as potatoes, bread, chips, and pasta, require more insulin to maintain blood glucose levels within the normal range. High-glycemic diets that are prevalent in the United States not only lead to insulin resistance, diabetes, obesity, and heart disease but also to acne.

Several studies have looked at the glycemic load, insulin sensitivity, and hormonal mediators correlating to acne (Am. J. Clin. Nutr. 2007; 86:107-15; J. Dermatol. Sci. 2008;50:41-52). Foods with a high-glycemic index may contribute to acne by elevating serum insulin concentrations (which can stimulate sebocyte proliferation and sebum production), suppress sex hormone-binding globulin (SHBG) concentrations, and raise androgen concentrations. On the contrary, low-glycemic-index foods increase SHBG and reduce androgen levels; this is of great importance because higher SHBG levels are associated with lower acne severity. Consumption of fat and carbohydrates increases sebum production and affects sebum composition, ultimately encouraging acne production (Br. J. Dermatol. 1967;79:119-21).

A new study by Anna Di Landro et al. published in the December 2012 found a link between acne and the consumption of milk, particularly in those drinking skim milk and more than three servings of milk per week (J. Am. Acad. Dermatol. 2012;67:1129-35).

Dr. Di Landro et al. also found that the consumption of fish had a protective effect on acne. This interesting finding points to the larger issue of acne developing in ethnic populations that immigrate to the United States. Population studies have shown that non-Western diets have a reduced incidence of acne. Western diets are deficient in long-chain omega-3 fatty acids. The ratio of omega-6 to omega-3 fatty acids in our Western diet is 10:1 to 20:1, vs. 3:1 to 2:1 in a non-Western diet. Omega-6 fatty acids in increased concentrations induce proinflammatory mediators and have been associated with the development of inflammatory acne. Western diets with high consumption of seafood have high levels of omega-3 fatty acids and have shown to decrease inflammatory mediators in the skin (Arch. Dermatol. 2003;139:941-2).

In my clinic, the ethnic populations that immigrate to the United States often develop acne to a greater extent than they had in their native countries. Although factors including stress, hormonal differences in foods, and pollution can be confounding factors, we must not ignore the Western diet that these populations adapt to is higher in refined sugars and carbohydrates and lower in vegetables and lean protein. Every acne patient in my clinic is asked to complete a nutritional questionnaire discussing the intake of fast food, carbohydrates, juice, sodas, and processed sugar. We have noticed that acne improves clinically and is more responsive to traditional acne medications when patients reduce their consumption of processed sugars and dairy and increase their intake of lean protein. Similarly, our PCOS patients who are treated with medications such as metformin, which improves the body’s ability to regulate blood glucose levels, have improvements in their acne. So, is acne a marker for early insulin resistance?

The underlying etiology of acne is multifactorial, although now we can appreciate diet as one of the causative factors. Although there is no direct correlation between obesity or insulin resistance and the prevalence of acne, a low glycemic index diet in combination with topical and systemic acne medications can be a powerful method of treating acne. Nutritional counseling is an adjunct educational service we should provide to our patients in addition to skin care advice and medical treatments for acne.

No single food directly causes acne, but a balanced diet can alter its severity. Encouraging our patients to eat a variety of fruits and vegetables, lean protein, and healthy fats can prevent the inflammation seen with acne and also can protect against cardiovascular disease, type II diabetes, and even obesity.

It is unfortunate that the medical education system in the United States has no formal nutrition education. Nearly every field of medicine including internal medicine, cardiology, endocrinology, allergy, pediatrics, obstetrics and gynecology, surgery, and not the least, dermatology, is influenced in some realm by nutrition. As the population diversifies, so will the importance of dietary guidance. We need to educate ourselves and our residents-in-training to better appreciate the symbiotic relationship between diet and skin health and to provide this guidance to our patients.

Dr. Talakoub is in private practice in McLean, Va.

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