Aesthetic Dermatology

Sailesh Konda, MD, Aanand N. Geria, MD, and Rebat M. Halder, MD

Pigmentary abnormalities are among the most common reasons why patients with skin of color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of hyperpigmentation; however, concerns regarding adverse effects have prompted a search for alternative agents. Some promising topical treatments include soy, licorice, rucinol, mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light, fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s armamentarium for treating hyperpigmentation.

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

Sailesh Konda, MD, Aanand N. Geria, MD, and Rebat M. Halder, MD

Pigmentary abnormalities are among the most common reasons why patients with skin of color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of hyperpigmentation; however, concerns regarding adverse effects have prompted a search for alternative agents. Some promising topical treatments include soy, licorice, rucinol, mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light, fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s armamentarium for treating hyperpigmentation.

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

Sailesh Konda, MD, Aanand N. Geria, MD, and Rebat M. Halder, MD

Pigmentary abnormalities are among the most common reasons why patients with skin of color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of hyperpigmentation; however, concerns regarding adverse effects have prompted a search for alternative agents. Some promising topical treatments include soy, licorice, rucinol, mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light, fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s armamentarium for treating hyperpigmentation.

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

KISSIMMEE, FLA. – Treatment with a 2,940 Er:YAG ablative fractional laser led to a clinically significant reduction of third-degree burn scars in a prospective study of 11 patients.

Clinical and histologic findings from the laser study provide important clues as to the mechanism of action and appropriate treatment intervals, Dr. Jill S. Waibel reported at the meeting. Scars from fire or thermal injury are among the worst that are seen in clinical practice, and although fractional laser therapy is emerging as the preferred treatment for these injuries, a better understanding of the optimal laser wavelengths, clinical response patterns, scar tissue response, and histologic changes will improve outcomes.

Patients in this study underwent three ablative treatments at 4-week intervals, and – based on blinded evaluation by independent investigators – were found to have an overall modified Manchester score of 2.3 out of 3 points, indicating moderate to excellent improvement. The scores for dyschromia, hypertrophy reduction, vascularity, and scar texture improvement were 1.7, 1.9, 2.0, and 2.0, respectively, indicating mild to moderate improvement, said Dr. Waibel, a physician in private practice in Miami.

The patients, who had third-degree burn scars over an average of 80% of their body, were treated with one pass at depths ranging from 400 to 800 microns, depending on scar thickness and density.

Biopsies were performed at baseline and at 3 months after the final treatment. On biopsies taken at baseline, the scars were noted to have thickened, homogenized, dystrophic collagen structures; and on biopsies taken 3 months after the final treatment, a decrease in these dystrophic fibers was seen, she said.

Dr. Waibel hypothesized that scar improvement resulted from the complete replacement of ablated zones by newly synthesized collagen and that the collagen remodeling led to more normal-appearing skin.

She noted that the erbium laser is "very powerful" and caused a great deal of erythema in two patients, leading her to "turn the power down" over the course of the study. Although no worsening of scars was seen, the increased vascularity in the two patients suggested that intervals longer than 4 weeks between treatments – perhaps to between 2 and 3 months - may be warranted.

Although additional study is needed, the findings suggest that the 2,940 Er:YAG laser is effective for clinically improving burn scars through vaporization and by inducing an organized wound-healing response; this histologic healing response may lead to the improvement that is seen clinically, she concluded.

This study was funded by Sciton. Dr. Waibel said she had no other relevant financial disclosures.

KISSIMMEE, FLA. – Treatment with a 2,940 Er:YAG ablative fractional laser led to a clinically significant reduction of third-degree burn scars in a prospective study of 11 patients.

Clinical and histologic findings from the laser study provide important clues as to the mechanism of action and appropriate treatment intervals, Dr. Jill S. Waibel reported at the meeting. Scars from fire or thermal injury are among the worst that are seen in clinical practice, and although fractional laser therapy is emerging as the preferred treatment for these injuries, a better understanding of the optimal laser wavelengths, clinical response patterns, scar tissue response, and histologic changes will improve outcomes.

Patients in this study underwent three ablative treatments at 4-week intervals, and – based on blinded evaluation by independent investigators – were found to have an overall modified Manchester score of 2.3 out of 3 points, indicating moderate to excellent improvement. The scores for dyschromia, hypertrophy reduction, vascularity, and scar texture improvement were 1.7, 1.9, 2.0, and 2.0, respectively, indicating mild to moderate improvement, said Dr. Waibel, a physician in private practice in Miami.

The patients, who had third-degree burn scars over an average of 80% of their body, were treated with one pass at depths ranging from 400 to 800 microns, depending on scar thickness and density.

Biopsies were performed at baseline and at 3 months after the final treatment. On biopsies taken at baseline, the scars were noted to have thickened, homogenized, dystrophic collagen structures; and on biopsies taken 3 months after the final treatment, a decrease in these dystrophic fibers was seen, she said.

Dr. Waibel hypothesized that scar improvement resulted from the complete replacement of ablated zones by newly synthesized collagen and that the collagen remodeling led to more normal-appearing skin.

She noted that the erbium laser is "very powerful" and caused a great deal of erythema in two patients, leading her to "turn the power down" over the course of the study. Although no worsening of scars was seen, the increased vascularity in the two patients suggested that intervals longer than 4 weeks between treatments – perhaps to between 2 and 3 months - may be warranted.

Although additional study is needed, the findings suggest that the 2,940 Er:YAG laser is effective for clinically improving burn scars through vaporization and by inducing an organized wound-healing response; this histologic healing response may lead to the improvement that is seen clinically, she concluded.

This study was funded by Sciton. Dr. Waibel said she had no other relevant financial disclosures.

KISSIMMEE, FLA. – Treatment with a 2,940 Er:YAG ablative fractional laser led to a clinically significant reduction of third-degree burn scars in a prospective study of 11 patients.

Clinical and histologic findings from the laser study provide important clues as to the mechanism of action and appropriate treatment intervals, Dr. Jill S. Waibel reported at the meeting. Scars from fire or thermal injury are among the worst that are seen in clinical practice, and although fractional laser therapy is emerging as the preferred treatment for these injuries, a better understanding of the optimal laser wavelengths, clinical response patterns, scar tissue response, and histologic changes will improve outcomes.

Patients in this study underwent three ablative treatments at 4-week intervals, and – based on blinded evaluation by independent investigators – were found to have an overall modified Manchester score of 2.3 out of 3 points, indicating moderate to excellent improvement. The scores for dyschromia, hypertrophy reduction, vascularity, and scar texture improvement were 1.7, 1.9, 2.0, and 2.0, respectively, indicating mild to moderate improvement, said Dr. Waibel, a physician in private practice in Miami.

The patients, who had third-degree burn scars over an average of 80% of their body, were treated with one pass at depths ranging from 400 to 800 microns, depending on scar thickness and density.

Biopsies were performed at baseline and at 3 months after the final treatment. On biopsies taken at baseline, the scars were noted to have thickened, homogenized, dystrophic collagen structures; and on biopsies taken 3 months after the final treatment, a decrease in these dystrophic fibers was seen, she said.

Dr. Waibel hypothesized that scar improvement resulted from the complete replacement of ablated zones by newly synthesized collagen and that the collagen remodeling led to more normal-appearing skin.

She noted that the erbium laser is "very powerful" and caused a great deal of erythema in two patients, leading her to "turn the power down" over the course of the study. Although no worsening of scars was seen, the increased vascularity in the two patients suggested that intervals longer than 4 weeks between treatments – perhaps to between 2 and 3 months - may be warranted.

Although additional study is needed, the findings suggest that the 2,940 Er:YAG laser is effective for clinically improving burn scars through vaporization and by inducing an organized wound-healing response; this histologic healing response may lead to the improvement that is seen clinically, she concluded.

This study was funded by Sciton. Dr. Waibel said she had no other relevant financial disclosures.

KISSIMMEE, FLA. – Two new studies have found safe and effective means for improving the results of lower abdomen cryolipolysis.

In the first study, 20 patients underwent one lower abdomen cryolipolysis treatment for 60 minutes, followed by a second treatment 2 months later. A consistent and discernable decrease in the thickness of the fat layer was noted in an independent photo review 4 months following the initial treatment.

Blinded independent reviewers, including two plastic surgeons and one dermatologist, compared the follow-up photos with those taken at baseline, and correctly identified the posttreatment image 86% of the time, Dr. Flor Mayoral reported at the annual meeting of the American Society for Laser Medicine and Surgery.

"Massage appears to be a safe, effective way to further reduce the fat layer following a cryolipolysis procedure."

Patient satisfaction was also high, with 75% of study participants reporting a "somewhat to very visible" change in the treated region, said Dr. Mayoral, a dermatologist in private practice in Coral Gables, Fla.

"Patients didn’t have the advantage of looking at their own photographs to determine whether they looked better or not," she noted.

Study patients were treated using CoolSculpting, by Zeltiq Aesthetics, at a cooling intensity factor of 42. No adverse events were reported.

Additional treatment following initial cryolipolysis of the abdomen appeared to be safe and effective, Dr. Mayoral concluded.

In a separate single-center study, Dr. Gerald Boey, a dermatologist in private practice in Vancouver, B.C., found that performing manual massage to the abdominal area following cryolipolysis led to improved outcomes, compared with cryolipolysis without the manual massage.

Massage was performed on one randomly selected side of the abdomen immediately following treatment of the entire lower abdomen in 10 patients, and outcomes on each side were compared using photos taken at baseline and at the 2-month follow-up. Improvement occurred on both sides, but greater improvement was noted on the massaged side in all patients, and ultrasound measurement confirmed that the fat reduction on the massaged side was, on average, 68% greater than on the control side, Dr. Boey said.

In a separate set of seven patients, biopsies performed at baseline and at 3, 8, 13, 30, 60, and 120 days following massage demonstrated that massage was not associated with any evidence of necrosis or fibrosis.

As in Dr. Mayoral’s study, cryolipolysis in this study was performed using CoolSculpting at a cooling intensity factor of 42 for 60 minutes. Massage was performed for 1 minute using a vigorous kneading motion, followed by 1 minute using a circular motion with the pads of the fingers.

"Massage appears to be a safe, effective way to further reduce the fat layer following a cryolipolysis procedure," Dr. Boey said. As for why the massage helps, one possible explanation is that manipulation of the fat while it is in the crystalline state induced by cryolipolysis may cause an accelerated reperfusion injury.

Dr. Mayoral reported that her study was funded by Zeltiq Aesthetics. She had no other disclosures to report. Dr. Boey had no disclosures to report.

KISSIMMEE, FLA. – Two new studies have found safe and effective means for improving the results of lower abdomen cryolipolysis.

In the first study, 20 patients underwent one lower abdomen cryolipolysis treatment for 60 minutes, followed by a second treatment 2 months later. A consistent and discernable decrease in the thickness of the fat layer was noted in an independent photo review 4 months following the initial treatment.

Blinded independent reviewers, including two plastic surgeons and one dermatologist, compared the follow-up photos with those taken at baseline, and correctly identified the posttreatment image 86% of the time, Dr. Flor Mayoral reported at the annual meeting of the American Society for Laser Medicine and Surgery.

"Massage appears to be a safe, effective way to further reduce the fat layer following a cryolipolysis procedure."

Patient satisfaction was also high, with 75% of study participants reporting a "somewhat to very visible" change in the treated region, said Dr. Mayoral, a dermatologist in private practice in Coral Gables, Fla.

"Patients didn’t have the advantage of looking at their own photographs to determine whether they looked better or not," she noted.

Study patients were treated using CoolSculpting, by Zeltiq Aesthetics, at a cooling intensity factor of 42. No adverse events were reported.

Additional treatment following initial cryolipolysis of the abdomen appeared to be safe and effective, Dr. Mayoral concluded.

In a separate single-center study, Dr. Gerald Boey, a dermatologist in private practice in Vancouver, B.C., found that performing manual massage to the abdominal area following cryolipolysis led to improved outcomes, compared with cryolipolysis without the manual massage.

Massage was performed on one randomly selected side of the abdomen immediately following treatment of the entire lower abdomen in 10 patients, and outcomes on each side were compared using photos taken at baseline and at the 2-month follow-up. Improvement occurred on both sides, but greater improvement was noted on the massaged side in all patients, and ultrasound measurement confirmed that the fat reduction on the massaged side was, on average, 68% greater than on the control side, Dr. Boey said.

In a separate set of seven patients, biopsies performed at baseline and at 3, 8, 13, 30, 60, and 120 days following massage demonstrated that massage was not associated with any evidence of necrosis or fibrosis.

As in Dr. Mayoral’s study, cryolipolysis in this study was performed using CoolSculpting at a cooling intensity factor of 42 for 60 minutes. Massage was performed for 1 minute using a vigorous kneading motion, followed by 1 minute using a circular motion with the pads of the fingers.

"Massage appears to be a safe, effective way to further reduce the fat layer following a cryolipolysis procedure," Dr. Boey said. As for why the massage helps, one possible explanation is that manipulation of the fat while it is in the crystalline state induced by cryolipolysis may cause an accelerated reperfusion injury.

Dr. Mayoral reported that her study was funded by Zeltiq Aesthetics. She had no other disclosures to report. Dr. Boey had no disclosures to report.

KISSIMMEE, FLA. – Two new studies have found safe and effective means for improving the results of lower abdomen cryolipolysis.

In the first study, 20 patients underwent one lower abdomen cryolipolysis treatment for 60 minutes, followed by a second treatment 2 months later. A consistent and discernable decrease in the thickness of the fat layer was noted in an independent photo review 4 months following the initial treatment.

Blinded independent reviewers, including two plastic surgeons and one dermatologist, compared the follow-up photos with those taken at baseline, and correctly identified the posttreatment image 86% of the time, Dr. Flor Mayoral reported at the annual meeting of the American Society for Laser Medicine and Surgery.

"Massage appears to be a safe, effective way to further reduce the fat layer following a cryolipolysis procedure."

Patient satisfaction was also high, with 75% of study participants reporting a "somewhat to very visible" change in the treated region, said Dr. Mayoral, a dermatologist in private practice in Coral Gables, Fla.

"Patients didn’t have the advantage of looking at their own photographs to determine whether they looked better or not," she noted.

Study patients were treated using CoolSculpting, by Zeltiq Aesthetics, at a cooling intensity factor of 42. No adverse events were reported.

Additional treatment following initial cryolipolysis of the abdomen appeared to be safe and effective, Dr. Mayoral concluded.

In a separate single-center study, Dr. Gerald Boey, a dermatologist in private practice in Vancouver, B.C., found that performing manual massage to the abdominal area following cryolipolysis led to improved outcomes, compared with cryolipolysis without the manual massage.

Massage was performed on one randomly selected side of the abdomen immediately following treatment of the entire lower abdomen in 10 patients, and outcomes on each side were compared using photos taken at baseline and at the 2-month follow-up. Improvement occurred on both sides, but greater improvement was noted on the massaged side in all patients, and ultrasound measurement confirmed that the fat reduction on the massaged side was, on average, 68% greater than on the control side, Dr. Boey said.

In a separate set of seven patients, biopsies performed at baseline and at 3, 8, 13, 30, 60, and 120 days following massage demonstrated that massage was not associated with any evidence of necrosis or fibrosis.

As in Dr. Mayoral’s study, cryolipolysis in this study was performed using CoolSculpting at a cooling intensity factor of 42 for 60 minutes. Massage was performed for 1 minute using a vigorous kneading motion, followed by 1 minute using a circular motion with the pads of the fingers.

"Massage appears to be a safe, effective way to further reduce the fat layer following a cryolipolysis procedure," Dr. Boey said. As for why the massage helps, one possible explanation is that manipulation of the fat while it is in the crystalline state induced by cryolipolysis may cause an accelerated reperfusion injury.

Dr. Mayoral reported that her study was funded by Zeltiq Aesthetics. She had no other disclosures to report. Dr. Boey had no disclosures to report.

KISSIMMEE, FLA. – The nonablative 1540-nm fractional laser can be safely converted to a quasi-ablative device for treating facial actinic keratoses and photodamage, according to Dr. Moshe Lapidoth.

By slightly modifying technique, a 50%-75% improvement in actinic keratoses and photodamage was noted in 17 patients who underwent two to three treatments at 4-week intervals, Dr. Lapidoth reported at the annual meeting of the American Society for Laser Medicine and Surgery. The laser was used in noncontact mode hovering 5-10 mm above the skin rather than in contact mode.

The patients had actinic keratoses and photodamage requiring ablative treatment of the epidermis. Treatment was applied using a fluence of 75 J/cm², a 15-ms pulse duration, and a 10-mm spot size. Two blinded assessors and the participants evaluated clinical improvement at 3 months after the final treatment using a quartile grading scale (Lasers Med. Sci. 2012 April 27 [doi: 10.1007/s10103-012-1103-6])

A score of 0 was associated with no improvement; a score of 1 with 1%-25% improvement, a score of 2 with 26%-50% improvement, a score of 3 with 51%-75% improvement, and a score of 4 with 76%-100% improvement. The mean score for actinic keratoses was 3.4, and for skin appearance was 3.2, said Dr. Lapidoth, head of the laser department at Rabin Medical Center in Israel.

Side effects after each treatment included erythema, mild edema, erosion in two patients, and mild desquamation, but no scarring or postinflammatory pigmentary changes occurred, he said.

Although more current fractional laser devices are designed to be either ablative or nonablative, the 1540-nm fractional laser was designed to be nonablative.

"The question is, ‘Can you take a 1540-nm laser, which is totally nonablative, and turn it to be ablative or quasi-ablative?’ and the answer is, ‘yes,’ Dr. Lapidoth said.

This treatment approach can be used in conjunction with contact mode, he added, explaining that the nonablative contact mode can be used first to target the dermis for treatment of fine wrinkles and scars, followed by the ablative noncontact mode to treat actinic keratoses and resistant lentigines and other lesions.

Dr. Lapidoth reported having no disclosures.

KISSIMMEE, FLA. – The nonablative 1540-nm fractional laser can be safely converted to a quasi-ablative device for treating facial actinic keratoses and photodamage, according to Dr. Moshe Lapidoth.

By slightly modifying technique, a 50%-75% improvement in actinic keratoses and photodamage was noted in 17 patients who underwent two to three treatments at 4-week intervals, Dr. Lapidoth reported at the annual meeting of the American Society for Laser Medicine and Surgery. The laser was used in noncontact mode hovering 5-10 mm above the skin rather than in contact mode.

The patients had actinic keratoses and photodamage requiring ablative treatment of the epidermis. Treatment was applied using a fluence of 75 J/cm², a 15-ms pulse duration, and a 10-mm spot size. Two blinded assessors and the participants evaluated clinical improvement at 3 months after the final treatment using a quartile grading scale (Lasers Med. Sci. 2012 April 27 [doi: 10.1007/s10103-012-1103-6])

A score of 0 was associated with no improvement; a score of 1 with 1%-25% improvement, a score of 2 with 26%-50% improvement, a score of 3 with 51%-75% improvement, and a score of 4 with 76%-100% improvement. The mean score for actinic keratoses was 3.4, and for skin appearance was 3.2, said Dr. Lapidoth, head of the laser department at Rabin Medical Center in Israel.

Side effects after each treatment included erythema, mild edema, erosion in two patients, and mild desquamation, but no scarring or postinflammatory pigmentary changes occurred, he said.

Although more current fractional laser devices are designed to be either ablative or nonablative, the 1540-nm fractional laser was designed to be nonablative.

"The question is, ‘Can you take a 1540-nm laser, which is totally nonablative, and turn it to be ablative or quasi-ablative?’ and the answer is, ‘yes,’ Dr. Lapidoth said.

This treatment approach can be used in conjunction with contact mode, he added, explaining that the nonablative contact mode can be used first to target the dermis for treatment of fine wrinkles and scars, followed by the ablative noncontact mode to treat actinic keratoses and resistant lentigines and other lesions.

Dr. Lapidoth reported having no disclosures.

KISSIMMEE, FLA. – The nonablative 1540-nm fractional laser can be safely converted to a quasi-ablative device for treating facial actinic keratoses and photodamage, according to Dr. Moshe Lapidoth.

By slightly modifying technique, a 50%-75% improvement in actinic keratoses and photodamage was noted in 17 patients who underwent two to three treatments at 4-week intervals, Dr. Lapidoth reported at the annual meeting of the American Society for Laser Medicine and Surgery. The laser was used in noncontact mode hovering 5-10 mm above the skin rather than in contact mode.

The patients had actinic keratoses and photodamage requiring ablative treatment of the epidermis. Treatment was applied using a fluence of 75 J/cm², a 15-ms pulse duration, and a 10-mm spot size. Two blinded assessors and the participants evaluated clinical improvement at 3 months after the final treatment using a quartile grading scale (Lasers Med. Sci. 2012 April 27 [doi: 10.1007/s10103-012-1103-6])

A score of 0 was associated with no improvement; a score of 1 with 1%-25% improvement, a score of 2 with 26%-50% improvement, a score of 3 with 51%-75% improvement, and a score of 4 with 76%-100% improvement. The mean score for actinic keratoses was 3.4, and for skin appearance was 3.2, said Dr. Lapidoth, head of the laser department at Rabin Medical Center in Israel.

Side effects after each treatment included erythema, mild edema, erosion in two patients, and mild desquamation, but no scarring or postinflammatory pigmentary changes occurred, he said.

Although more current fractional laser devices are designed to be either ablative or nonablative, the 1540-nm fractional laser was designed to be nonablative.

"The question is, ‘Can you take a 1540-nm laser, which is totally nonablative, and turn it to be ablative or quasi-ablative?’ and the answer is, ‘yes,’ Dr. Lapidoth said.

This treatment approach can be used in conjunction with contact mode, he added, explaining that the nonablative contact mode can be used first to target the dermis for treatment of fine wrinkles and scars, followed by the ablative noncontact mode to treat actinic keratoses and resistant lentigines and other lesions.

Dr. Lapidoth reported having no disclosures.

KISSIMMEE, FLA. – Optimized intense pulsed light was found to safely enable effective clearance of port wine stains and capillary malformations in 16 patients.

The outcomes were so impressive in two patients, who achieved 80-100% improvement after only one treatment with this "new class of filtered IPL," that additional planned treatments were canceled, Dr. Maurice Adatto reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The 16 study patients from two centers had Fitzpatrick skin types II-IV and a mean age of 40 years (range, 11-71 years). All patients experienced improvement with one to four treatments, with 10 of the 16 patients achieving greater than 50% improvement, said Dr. Adatto, a dermatologist in private practice in Geneva, Switzerland.

The 10 females and 6 males had port wine stains of the face, neck, trunk, or extremities, with the exception of two patients who had capillary malformations.

Treatments were applied using Palomar’s MaxG IPL system with a spot size of 10 x 15 mm. Patients were treated using either one pass at a fluence of 50 J/cm² and a 10-ms pulse duration, or two passes, with the first pass at 34-36 J/cm² and a 10-ms pulse duration and the second at 20-28 J/cm² and a 5-ms pulse duration.

Outcomes were assessed on the basis of clinical images generated using Miravex’s Antera 3D system to evaluate hemoglobin clearance. Photos were taken between 48 and 96 hours after each treatment and also at 2 months after each treatment, Dr. Adatto said.

The only reported side effects were limited or slight transitory purpura for 3-5 days, and mild to moderate edema for 1-3 days.

Lasers are more often used to treat port wine stains, but the higher peak power and the short pulse widths available with the new optimized pulsed light technology appear to allow for safe and effective clearance, Dr. Adatto said. Further optimization of the parameters and safety profile of the optimized pulsed light device is possible, and another study of its use in pediatric patients is currently underway, he noted.

Dr. Adatto disclosed that the equipment from Palomar used in the study was purchased at a discount. He had no other disclosures to report.

KISSIMMEE, FLA. – Optimized intense pulsed light was found to safely enable effective clearance of port wine stains and capillary malformations in 16 patients.

The outcomes were so impressive in two patients, who achieved 80-100% improvement after only one treatment with this "new class of filtered IPL," that additional planned treatments were canceled, Dr. Maurice Adatto reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The 16 study patients from two centers had Fitzpatrick skin types II-IV and a mean age of 40 years (range, 11-71 years). All patients experienced improvement with one to four treatments, with 10 of the 16 patients achieving greater than 50% improvement, said Dr. Adatto, a dermatologist in private practice in Geneva, Switzerland.

The 10 females and 6 males had port wine stains of the face, neck, trunk, or extremities, with the exception of two patients who had capillary malformations.

Treatments were applied using Palomar’s MaxG IPL system with a spot size of 10 x 15 mm. Patients were treated using either one pass at a fluence of 50 J/cm² and a 10-ms pulse duration, or two passes, with the first pass at 34-36 J/cm² and a 10-ms pulse duration and the second at 20-28 J/cm² and a 5-ms pulse duration.

Outcomes were assessed on the basis of clinical images generated using Miravex’s Antera 3D system to evaluate hemoglobin clearance. Photos were taken between 48 and 96 hours after each treatment and also at 2 months after each treatment, Dr. Adatto said.

The only reported side effects were limited or slight transitory purpura for 3-5 days, and mild to moderate edema for 1-3 days.

Lasers are more often used to treat port wine stains, but the higher peak power and the short pulse widths available with the new optimized pulsed light technology appear to allow for safe and effective clearance, Dr. Adatto said. Further optimization of the parameters and safety profile of the optimized pulsed light device is possible, and another study of its use in pediatric patients is currently underway, he noted.

Dr. Adatto disclosed that the equipment from Palomar used in the study was purchased at a discount. He had no other disclosures to report.

KISSIMMEE, FLA. – Optimized intense pulsed light was found to safely enable effective clearance of port wine stains and capillary malformations in 16 patients.

The outcomes were so impressive in two patients, who achieved 80-100% improvement after only one treatment with this "new class of filtered IPL," that additional planned treatments were canceled, Dr. Maurice Adatto reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The 16 study patients from two centers had Fitzpatrick skin types II-IV and a mean age of 40 years (range, 11-71 years). All patients experienced improvement with one to four treatments, with 10 of the 16 patients achieving greater than 50% improvement, said Dr. Adatto, a dermatologist in private practice in Geneva, Switzerland.

The 10 females and 6 males had port wine stains of the face, neck, trunk, or extremities, with the exception of two patients who had capillary malformations.

Treatments were applied using Palomar’s MaxG IPL system with a spot size of 10 x 15 mm. Patients were treated using either one pass at a fluence of 50 J/cm² and a 10-ms pulse duration, or two passes, with the first pass at 34-36 J/cm² and a 10-ms pulse duration and the second at 20-28 J/cm² and a 5-ms pulse duration.

Outcomes were assessed on the basis of clinical images generated using Miravex’s Antera 3D system to evaluate hemoglobin clearance. Photos were taken between 48 and 96 hours after each treatment and also at 2 months after each treatment, Dr. Adatto said.

The only reported side effects were limited or slight transitory purpura for 3-5 days, and mild to moderate edema for 1-3 days.

Lasers are more often used to treat port wine stains, but the higher peak power and the short pulse widths available with the new optimized pulsed light technology appear to allow for safe and effective clearance, Dr. Adatto said. Further optimization of the parameters and safety profile of the optimized pulsed light device is possible, and another study of its use in pediatric patients is currently underway, he noted.

Dr. Adatto disclosed that the equipment from Palomar used in the study was purchased at a discount. He had no other disclosures to report.

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.

KISSIMMEE, FLA. – A microsecond 1,064-nm Nd:YAG laser was found to be effective for treating facial telangiectasias without the scarring and discomfort that can occur with millisecond pulse systems.

A prospective single-center study enrolled 20 patients aged 35-70 years with Fitzpatrick skin types I-III. After undergoing one treatment per month for 2 months with the 650-microsecond LightPod Neo 1,064-nm Nd:YAG laser (manufactured by Aerolase), the patients experienced significant, and even "dramatic," improvements in the appearance of facial telangiectasias on the nose and cheek, Dr. David J. Goldberg reported at the annual meeting of the American Society for Laser Medicine and Surgery.

"We saw significant improvements in the appearance of telangiectasia with minimal discomfort, presumably because of the microsecond pulse duration," said Dr. Goldberg, a dermatologist at Mount Sinai School of Medicine, New York.

The treatments were applied at a fluence of 199 J/cm², a pulse duration of 650 microseconds, and a 2-mm spot size. The multisetting device was set at treatment level 6. Evaluation of results was based on clinical assessment of digital photographs and both patient and investigator assessment of the reduction in the size and appearance of telangiectasias based on a 5-point scale.

"Most people know that facial telangiectasias can be treated with a variety of wavelengths, and the 532-nm laser has traditionally been effective for small vessels," Dr. Goldberg said.

However, longer wavelength lasers, such as the 1,064-nm Nd:YAG with a millisecond pulse duration (3-30 milliseconds), which have also been used to treat larger vessels, are associated with "well-documented scarring and greater discomfort," he noted.

These adverse effects were not seen with the use of the microsecond system, he said, adding: "I think this is really the most important part of the study because of the previous documentation of problems with Nd:YAG laser systems for the treatment of patients with telangiectasias."

The study was supported by a research grant from Aerolase. Dr. Goldberg had no other disclosures to report.

KISSIMMEE, FLA. – A microsecond 1,064-nm Nd:YAG laser was found to be effective for treating facial telangiectasias without the scarring and discomfort that can occur with millisecond pulse systems.

A prospective single-center study enrolled 20 patients aged 35-70 years with Fitzpatrick skin types I-III. After undergoing one treatment per month for 2 months with the 650-microsecond LightPod Neo 1,064-nm Nd:YAG laser (manufactured by Aerolase), the patients experienced significant, and even "dramatic," improvements in the appearance of facial telangiectasias on the nose and cheek, Dr. David J. Goldberg reported at the annual meeting of the American Society for Laser Medicine and Surgery.

"We saw significant improvements in the appearance of telangiectasia with minimal discomfort, presumably because of the microsecond pulse duration," said Dr. Goldberg, a dermatologist at Mount Sinai School of Medicine, New York.

The treatments were applied at a fluence of 199 J/cm², a pulse duration of 650 microseconds, and a 2-mm spot size. The multisetting device was set at treatment level 6. Evaluation of results was based on clinical assessment of digital photographs and both patient and investigator assessment of the reduction in the size and appearance of telangiectasias based on a 5-point scale.

"Most people know that facial telangiectasias can be treated with a variety of wavelengths, and the 532-nm laser has traditionally been effective for small vessels," Dr. Goldberg said.

However, longer wavelength lasers, such as the 1,064-nm Nd:YAG with a millisecond pulse duration (3-30 milliseconds), which have also been used to treat larger vessels, are associated with "well-documented scarring and greater discomfort," he noted.

These adverse effects were not seen with the use of the microsecond system, he said, adding: "I think this is really the most important part of the study because of the previous documentation of problems with Nd:YAG laser systems for the treatment of patients with telangiectasias."

The study was supported by a research grant from Aerolase. Dr. Goldberg had no other disclosures to report.

KISSIMMEE, FLA. – A microsecond 1,064-nm Nd:YAG laser was found to be effective for treating facial telangiectasias without the scarring and discomfort that can occur with millisecond pulse systems.

A prospective single-center study enrolled 20 patients aged 35-70 years with Fitzpatrick skin types I-III. After undergoing one treatment per month for 2 months with the 650-microsecond LightPod Neo 1,064-nm Nd:YAG laser (manufactured by Aerolase), the patients experienced significant, and even "dramatic," improvements in the appearance of facial telangiectasias on the nose and cheek, Dr. David J. Goldberg reported at the annual meeting of the American Society for Laser Medicine and Surgery.

"We saw significant improvements in the appearance of telangiectasia with minimal discomfort, presumably because of the microsecond pulse duration," said Dr. Goldberg, a dermatologist at Mount Sinai School of Medicine, New York.

The treatments were applied at a fluence of 199 J/cm², a pulse duration of 650 microseconds, and a 2-mm spot size. The multisetting device was set at treatment level 6. Evaluation of results was based on clinical assessment of digital photographs and both patient and investigator assessment of the reduction in the size and appearance of telangiectasias based on a 5-point scale.

"Most people know that facial telangiectasias can be treated with a variety of wavelengths, and the 532-nm laser has traditionally been effective for small vessels," Dr. Goldberg said.

However, longer wavelength lasers, such as the 1,064-nm Nd:YAG with a millisecond pulse duration (3-30 milliseconds), which have also been used to treat larger vessels, are associated with "well-documented scarring and greater discomfort," he noted.

These adverse effects were not seen with the use of the microsecond system, he said, adding: "I think this is really the most important part of the study because of the previous documentation of problems with Nd:YAG laser systems for the treatment of patients with telangiectasias."

The study was supported by a research grant from Aerolase. Dr. Goldberg had no other disclosures to report.

How many times a week do you get asked by your patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments.

Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

©Elsevier Inc.

1. Infraorbital fat pad protrusion. Also known as "eye bags."

• Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.

• If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

• For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.

• Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.

• Advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.

• Also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.

• Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin.

• Again, advise patients to avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.

• Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.

• Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.

• Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.

• The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.

• There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed.

• Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:

• For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, advise or help them pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best.

• Encourage patients to quit smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation.

• Advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

- Lily Talakoub, M.D.

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

How many times a week do you get asked by your patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments.

Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

©Elsevier Inc.

1. Infraorbital fat pad protrusion. Also known as "eye bags."

• Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.

• If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

• For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.

• Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.

• Advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.

• Also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.

• Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin.

• Again, advise patients to avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.

• Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.

• Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.

• Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.

• The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.

• There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed.

• Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:

• For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, advise or help them pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best.

• Encourage patients to quit smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation.

• Advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

- Lily Talakoub, M.D.

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

How many times a week do you get asked by your patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments.

Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

©Elsevier Inc.

1. Infraorbital fat pad protrusion. Also known as "eye bags."

• Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.

• If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

• For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.

• Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.

• Advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.

• Also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.

• Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin.

• Again, advise patients to avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.

• Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.

• Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.

• Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.

• The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.

• There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed.

• Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:

• For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, advise or help them pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best.

• Encourage patients to quit smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation.

• Advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

- Lily Talakoub, M.D.

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

KISSIMMEE, FLA. – Broadband light therapy virtually halted the signs of aging in women treated at least annually for 8 years, according to Dr. Patrick Bitter Jr.

"This really is the closest thing we have to a fountain of youth for delaying skin aging," Dr. Bitter said at the annual meeting of the American Society for Laser Medicine and Surgery.

Eleven women underwent treatment of the entire face with the Sciton BroadBand Light system at least once a year over an 8-year period. Blinded evaluators (490), including 51 dermatologists, indicated that the women aged no more than about 6 months during that time, said Dr. Bitter, a dermatologist in private practice in Los Gatos, Calif.

The mean age of the women at the start of treatment was 45 years, and the dermatologists who participated in the evaluations of "before" and "after" photographs rated their age as a mean of 45 years based on the "before" images. At an average of 8 years follow-up, the evaluators rated the age of the participants at a mean of 45 to 45.5 years, which was a mean of 9 years younger than the participants’ actual ages, he said.

Study participants included women in Dr. Bitter’s practice who received at least one treatment annually with good "before" photos who had not received any laser treatments or cosmetic surgery. Skin care regimens varied among the women.

The evaluators – only the dermatologists’ responses were included in the data Dr. Bitter presented – were blinded to any treatments the women underwent, and photos were taken in a way that ensured the evaluation was based entirely on skin appearance and not on other signs of aging (such as graying hair), he noted.

Broadband light technologies are known to be effective for reversing the signs of aging, such as wrinkles, redness, and brown spots, and data have shown that broadband light can improve the skin histologically. However, this is the first blinded evaluation of long-term results among those receiving regular treatments, Dr. Bitter said, noting that this study was prompted in part by a Swiss study published several years ago that speculated that such treatments might actually accelerate aging of the skin when used over time. His experience in 14 years of using broadband light treatments suggested otherwise, and these findings provide further evidence that long-term use reverses and prevents the signs of aging, he said.

New data from a corollary study to be presented at an upcoming meeting of the Society for Investigative Dermatology will provide additional evidence that light "does more than just make reds and browns go away," he said. "What is seems to do is make skin cells behave like younger skin cells."

Dr. Bitter noted that the difference between a patient’s really liking results and not seeing a difference is technique. "This is a great technology, buy you need to know how to use it," he said, explaining that it is important to know the optimal parameters based on skin type, to perform enough passes at each session, and to conduct enough sessions.

In an interview, Dr. Robert A. Weiss of the department of dermatology at Johns Hopkins University, Baltimore, agreed that the technique – and a thorough knowledge of the parameters, limitations, and application of the intense pulsed light that is used – is critical to success. "Continued sun protection is critical, as well," he said.

Like Dr. Bitter, Dr. Weiss has seen effective long-term results with IPL technology. In a study published in 2002, he and his colleagues reported on 80 randomly selected patients with skin types I-IV who were treated with filtered flashlamp IPL between 1996 and 1997. At 4-year follow-up after the first of a median of three treatments, 83% of patients had improved skin texture, 82% had improved telangiectasias, and 79% had improved pigmentation (Dermatol. Surg. 2002;28:1115-9). "The end result is clearer, brighter, younger, healthier-looking skin," he said.

Dr. Bitter owns the trademark for PhotoFacial intense pulsed light treatments. Dr. Weiss reported at the time his study was published that he was a consultant and preceptor for Lumenis, and that the devices used in the study were purchased at a discount.

KISSIMMEE, FLA. – Broadband light therapy virtually halted the signs of aging in women treated at least annually for 8 years, according to Dr. Patrick Bitter Jr.

"This really is the closest thing we have to a fountain of youth for delaying skin aging," Dr. Bitter said at the annual meeting of the American Society for Laser Medicine and Surgery.

Eleven women underwent treatment of the entire face with the Sciton BroadBand Light system at least once a year over an 8-year period. Blinded evaluators (490), including 51 dermatologists, indicated that the women aged no more than about 6 months during that time, said Dr. Bitter, a dermatologist in private practice in Los Gatos, Calif.

The mean age of the women at the start of treatment was 45 years, and the dermatologists who participated in the evaluations of "before" and "after" photographs rated their age as a mean of 45 years based on the "before" images. At an average of 8 years follow-up, the evaluators rated the age of the participants at a mean of 45 to 45.5 years, which was a mean of 9 years younger than the participants’ actual ages, he said.

Study participants included women in Dr. Bitter’s practice who received at least one treatment annually with good "before" photos who had not received any laser treatments or cosmetic surgery. Skin care regimens varied among the women.

The evaluators – only the dermatologists’ responses were included in the data Dr. Bitter presented – were blinded to any treatments the women underwent, and photos were taken in a way that ensured the evaluation was based entirely on skin appearance and not on other signs of aging (such as graying hair), he noted.

Broadband light technologies are known to be effective for reversing the signs of aging, such as wrinkles, redness, and brown spots, and data have shown that broadband light can improve the skin histologically. However, this is the first blinded evaluation of long-term results among those receiving regular treatments, Dr. Bitter said, noting that this study was prompted in part by a Swiss study published several years ago that speculated that such treatments might actually accelerate aging of the skin when used over time. His experience in 14 years of using broadband light treatments suggested otherwise, and these findings provide further evidence that long-term use reverses and prevents the signs of aging, he said.

New data from a corollary study to be presented at an upcoming meeting of the Society for Investigative Dermatology will provide additional evidence that light "does more than just make reds and browns go away," he said. "What is seems to do is make skin cells behave like younger skin cells."

Dr. Bitter noted that the difference between a patient’s really liking results and not seeing a difference is technique. "This is a great technology, buy you need to know how to use it," he said, explaining that it is important to know the optimal parameters based on skin type, to perform enough passes at each session, and to conduct enough sessions.

In an interview, Dr. Robert A. Weiss of the department of dermatology at Johns Hopkins University, Baltimore, agreed that the technique – and a thorough knowledge of the parameters, limitations, and application of the intense pulsed light that is used – is critical to success. "Continued sun protection is critical, as well," he said.

Like Dr. Bitter, Dr. Weiss has seen effective long-term results with IPL technology. In a study published in 2002, he and his colleagues reported on 80 randomly selected patients with skin types I-IV who were treated with filtered flashlamp IPL between 1996 and 1997. At 4-year follow-up after the first of a median of three treatments, 83% of patients had improved skin texture, 82% had improved telangiectasias, and 79% had improved pigmentation (Dermatol. Surg. 2002;28:1115-9). "The end result is clearer, brighter, younger, healthier-looking skin," he said.

Dr. Bitter owns the trademark for PhotoFacial intense pulsed light treatments. Dr. Weiss reported at the time his study was published that he was a consultant and preceptor for Lumenis, and that the devices used in the study were purchased at a discount.

KISSIMMEE, FLA. – Broadband light therapy virtually halted the signs of aging in women treated at least annually for 8 years, according to Dr. Patrick Bitter Jr.

"This really is the closest thing we have to a fountain of youth for delaying skin aging," Dr. Bitter said at the annual meeting of the American Society for Laser Medicine and Surgery.

Eleven women underwent treatment of the entire face with the Sciton BroadBand Light system at least once a year over an 8-year period. Blinded evaluators (490), including 51 dermatologists, indicated that the women aged no more than about 6 months during that time, said Dr. Bitter, a dermatologist in private practice in Los Gatos, Calif.

The mean age of the women at the start of treatment was 45 years, and the dermatologists who participated in the evaluations of "before" and "after" photographs rated their age as a mean of 45 years based on the "before" images. At an average of 8 years follow-up, the evaluators rated the age of the participants at a mean of 45 to 45.5 years, which was a mean of 9 years younger than the participants’ actual ages, he said.

Study participants included women in Dr. Bitter’s practice who received at least one treatment annually with good "before" photos who had not received any laser treatments or cosmetic surgery. Skin care regimens varied among the women.

The evaluators – only the dermatologists’ responses were included in the data Dr. Bitter presented – were blinded to any treatments the women underwent, and photos were taken in a way that ensured the evaluation was based entirely on skin appearance and not on other signs of aging (such as graying hair), he noted.

Broadband light technologies are known to be effective for reversing the signs of aging, such as wrinkles, redness, and brown spots, and data have shown that broadband light can improve the skin histologically. However, this is the first blinded evaluation of long-term results among those receiving regular treatments, Dr. Bitter said, noting that this study was prompted in part by a Swiss study published several years ago that speculated that such treatments might actually accelerate aging of the skin when used over time. His experience in 14 years of using broadband light treatments suggested otherwise, and these findings provide further evidence that long-term use reverses and prevents the signs of aging, he said.

New data from a corollary study to be presented at an upcoming meeting of the Society for Investigative Dermatology will provide additional evidence that light "does more than just make reds and browns go away," he said. "What is seems to do is make skin cells behave like younger skin cells."

Dr. Bitter noted that the difference between a patient’s really liking results and not seeing a difference is technique. "This is a great technology, buy you need to know how to use it," he said, explaining that it is important to know the optimal parameters based on skin type, to perform enough passes at each session, and to conduct enough sessions.

In an interview, Dr. Robert A. Weiss of the department of dermatology at Johns Hopkins University, Baltimore, agreed that the technique – and a thorough knowledge of the parameters, limitations, and application of the intense pulsed light that is used – is critical to success. "Continued sun protection is critical, as well," he said.

Like Dr. Bitter, Dr. Weiss has seen effective long-term results with IPL technology. In a study published in 2002, he and his colleagues reported on 80 randomly selected patients with skin types I-IV who were treated with filtered flashlamp IPL between 1996 and 1997. At 4-year follow-up after the first of a median of three treatments, 83% of patients had improved skin texture, 82% had improved telangiectasias, and 79% had improved pigmentation (Dermatol. Surg. 2002;28:1115-9). "The end result is clearer, brighter, younger, healthier-looking skin," he said.

Dr. Bitter owns the trademark for PhotoFacial intense pulsed light treatments. Dr. Weiss reported at the time his study was published that he was a consultant and preceptor for Lumenis, and that the devices used in the study were purchased at a discount.

Dr. Jill S. Waibel, a private practice physician in Miami, and her colleagues are studying the efficacy of ablative fractional lasers for treating burn scars.

A study of 11 patients treated with a 2,940 Er:YAG laser revealed that "through the induction of unique histologic ablation zones, fractional technology leads to an organized wound healing response leading to improved clinical appearance of scars," according to Dr. Waibel and colleagues.

In an interview with reporter Naseem S. Miller at the American Society for Laser Medicine and Surgery in Kissimmee, Fla., Dr. Waibel said that treating the scars and improving the patients' range of motion has been very rewarding.

Dr. Jill S. Waibel, a private practice physician in Miami, and her colleagues are studying the efficacy of ablative fractional lasers for treating burn scars.

A study of 11 patients treated with a 2,940 Er:YAG laser revealed that "through the induction of unique histologic ablation zones, fractional technology leads to an organized wound healing response leading to improved clinical appearance of scars," according to Dr. Waibel and colleagues.

In an interview with reporter Naseem S. Miller at the American Society for Laser Medicine and Surgery in Kissimmee, Fla., Dr. Waibel said that treating the scars and improving the patients' range of motion has been very rewarding.

Dr. Jill S. Waibel, a private practice physician in Miami, and her colleagues are studying the efficacy of ablative fractional lasers for treating burn scars.

A study of 11 patients treated with a 2,940 Er:YAG laser revealed that "through the induction of unique histologic ablation zones, fractional technology leads to an organized wound healing response leading to improved clinical appearance of scars," according to Dr. Waibel and colleagues.

In an interview with reporter Naseem S. Miller at the American Society for Laser Medicine and Surgery in Kissimmee, Fla., Dr. Waibel said that treating the scars and improving the patients' range of motion has been very rewarding.