Aesthetic Dermatology

Anew patient-oriented Web site,"Explore Your Skin," is designed to provide general educational materials for patients about how skin diseases occur and how cosmetic procedures are performed. The interactive site is available in both English and Spanish. The Web site does not contain promotional messages. For more information, visit www.exploreyourskin.com

Anew patient-oriented Web site,"Explore Your Skin," is designed to provide general educational materials for patients about how skin diseases occur and how cosmetic procedures are performed. The interactive site is available in both English and Spanish. The Web site does not contain promotional messages. For more information, visit www.exploreyourskin.com

Anew patient-oriented Web site,"Explore Your Skin," is designed to provide general educational materials for patients about how skin diseases occur and how cosmetic procedures are performed. The interactive site is available in both English and Spanish. The Web site does not contain promotional messages. For more information, visit www.exploreyourskin.com

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

AUSTIN, TEX. — A new microfoam in trials in the United States holds promise for sclerotherapy, said Dr. Girish Munavalli, who also discussed other techniques currently available for addressing varicose veins.

It is important to address these veins, as they are indicative of venous insufficiency and saphenous reflux, Dr. Munavalli of Charlotte, N.C., said at the annual meeting of the American College of Mohs Surgery.

Some 60% of the U.S. population has varicose veins, and the frequency increases with age. Approximately 6 million workdays are lost annually because of complications from varicose veins, which can include venous leg ulcers, he said. Current treatment options include surgery (ligation and stripping); endovenous heat ablation; sclerotherapy; and a newer device, called ClosureFAST (VNUS Medical Technologies), which ablates the veins with a radiofrequency catheter. He said that he tends not to use lasers for sclerotherapy.

Dr. Munavalli is currently investigating the new microfoam, which is being used in Europe. It "is a really interesting technique. Hopefully, we'll get [Food and Drug Administration] approval soon," he said.

The product is contained in a can that holds air, but with less nitrogen than room air. When the sclerosant is pumped through the can, it creates much smaller bubbles, which increases the surface area of contact. The microfoam is thicker, compared with a sclerosant that's mixed with room air, said Dr. Munavalli. It still should be administered with ultrasound guidance.

In addition to being an investigator for the microfoam, Dr. Munavalli disclosed that he is on the speakers bureau and is a consultant for DUSA Pharmaceuticals.

AUSTIN, TEX. — A new microfoam in trials in the United States holds promise for sclerotherapy, said Dr. Girish Munavalli, who also discussed other techniques currently available for addressing varicose veins.

It is important to address these veins, as they are indicative of venous insufficiency and saphenous reflux, Dr. Munavalli of Charlotte, N.C., said at the annual meeting of the American College of Mohs Surgery.

Some 60% of the U.S. population has varicose veins, and the frequency increases with age. Approximately 6 million workdays are lost annually because of complications from varicose veins, which can include venous leg ulcers, he said. Current treatment options include surgery (ligation and stripping); endovenous heat ablation; sclerotherapy; and a newer device, called ClosureFAST (VNUS Medical Technologies), which ablates the veins with a radiofrequency catheter. He said that he tends not to use lasers for sclerotherapy.

Dr. Munavalli is currently investigating the new microfoam, which is being used in Europe. It "is a really interesting technique. Hopefully, we'll get [Food and Drug Administration] approval soon," he said.

The product is contained in a can that holds air, but with less nitrogen than room air. When the sclerosant is pumped through the can, it creates much smaller bubbles, which increases the surface area of contact. The microfoam is thicker, compared with a sclerosant that's mixed with room air, said Dr. Munavalli. It still should be administered with ultrasound guidance.

In addition to being an investigator for the microfoam, Dr. Munavalli disclosed that he is on the speakers bureau and is a consultant for DUSA Pharmaceuticals.

AUSTIN, TEX. — A new microfoam in trials in the United States holds promise for sclerotherapy, said Dr. Girish Munavalli, who also discussed other techniques currently available for addressing varicose veins.

It is important to address these veins, as they are indicative of venous insufficiency and saphenous reflux, Dr. Munavalli of Charlotte, N.C., said at the annual meeting of the American College of Mohs Surgery.

Some 60% of the U.S. population has varicose veins, and the frequency increases with age. Approximately 6 million workdays are lost annually because of complications from varicose veins, which can include venous leg ulcers, he said. Current treatment options include surgery (ligation and stripping); endovenous heat ablation; sclerotherapy; and a newer device, called ClosureFAST (VNUS Medical Technologies), which ablates the veins with a radiofrequency catheter. He said that he tends not to use lasers for sclerotherapy.

Dr. Munavalli is currently investigating the new microfoam, which is being used in Europe. It "is a really interesting technique. Hopefully, we'll get [Food and Drug Administration] approval soon," he said.

The product is contained in a can that holds air, but with less nitrogen than room air. When the sclerosant is pumped through the can, it creates much smaller bubbles, which increases the surface area of contact. The microfoam is thicker, compared with a sclerosant that's mixed with room air, said Dr. Munavalli. It still should be administered with ultrasound guidance.

In addition to being an investigator for the microfoam, Dr. Munavalli disclosed that he is on the speakers bureau and is a consultant for DUSA Pharmaceuticals.

SANTA MONICA, CALIF. — The ideal device for treating pigmentation disorders would reduce wrinkles, pigment, and redness in one pass with a low amount of pain and give patients a fast, easy recovery, according to Dr. E. Victor Ross.

"There's no device that does all those things, but the devices that actually selectively target blood and melanin are possibly the closest thing to it," Dr. Ross said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Ross of the Scripps Clinic in San Diego discussed the pros and cons of using intense pulsed light (IPL) devices, pulsed dye lasers (PDL), and potassium-titanyl-phosphate (KTP) lasers for treating pigmentation disorders.

Both pigmentation and vascular disorders can be treated in one pass using IPL therapy and KTP lasers, he said. The PDL was the first "boutique laser" to treat vascular lesions, he noted. Next came the KTP laser to treat isolated vessels. When IPL treatment entered the scene, it displaced the other devices because of its versatility, but all three approaches have a role in treating blood and pigment lesions. "My favorite on a daily basis is the KTP laser," he acknowledged.

PDL treatment is fast, and if a patient doesn't mind the resulting purpura, the PDL is probably the best device for improvement of redness in a single treatment, said Dr. Ross.

The PDL remains the standard for treating port wine stains. Nevertheless, it is not possible to reduce both red and brown facial lesions with this laser, and it cannot, in one pass, treat both blood and pigment lesions.

KTP lasers can treat both small and large spots. The spot-size reduction allows for safer treatment of darker-skinned (skin types IV and V) patients with telangiectasias. In addition, the device has a good vascular-to-pigment damage ratio. When a 1- to 5-mm spot size is used, vessel reduction can be seen in real time.

"It is nice to see a blood vessel disappear as you see it, which you can't do with the IPL," said Dr. Ross. "It's just fun to do." The handpiece is also light and easy to use.

KTP therapy has higher costs, however, and tends to cause more pain than IPL treatment. After KTP treatment, edema can be severe, and overtreatment can cause pitting.

IPL therapy is raising the bar for treating pigmentation. Filtration is better with an IPL device, lamp pumping is smoother, cooling has been added to the device, and the radio frequency has been improved. Most importantly, it is safe, he said.

One of IPL's drawbacks is that the divergence of the beam means the handpiece must be held close to the skin, which may compress vessels. Also, the nonlaser properties of IPL make it difficult to focus on small spots, so it can be challenging to use on discrete lesions. Finally, with large spot treatment capability comes the potential for big side effects, Dr. Ross noted.

He disclosed being a consultant for, and receiving research grants from, Palomar. Dr. Ross also has received research support from Cutera Inc., Lumenis, Candela Corp., Ulthera Inc., and Sciton Inc.

SDEF and this news organization are both owned by Elsevier.

My favorite laser on a daily basis for treating pigmentation disorders is the KTP. DR. ROSS

SANTA MONICA, CALIF. — The ideal device for treating pigmentation disorders would reduce wrinkles, pigment, and redness in one pass with a low amount of pain and give patients a fast, easy recovery, according to Dr. E. Victor Ross.

"There's no device that does all those things, but the devices that actually selectively target blood and melanin are possibly the closest thing to it," Dr. Ross said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Ross of the Scripps Clinic in San Diego discussed the pros and cons of using intense pulsed light (IPL) devices, pulsed dye lasers (PDL), and potassium-titanyl-phosphate (KTP) lasers for treating pigmentation disorders.

Both pigmentation and vascular disorders can be treated in one pass using IPL therapy and KTP lasers, he said. The PDL was the first "boutique laser" to treat vascular lesions, he noted. Next came the KTP laser to treat isolated vessels. When IPL treatment entered the scene, it displaced the other devices because of its versatility, but all three approaches have a role in treating blood and pigment lesions. "My favorite on a daily basis is the KTP laser," he acknowledged.

PDL treatment is fast, and if a patient doesn't mind the resulting purpura, the PDL is probably the best device for improvement of redness in a single treatment, said Dr. Ross.

The PDL remains the standard for treating port wine stains. Nevertheless, it is not possible to reduce both red and brown facial lesions with this laser, and it cannot, in one pass, treat both blood and pigment lesions.

KTP lasers can treat both small and large spots. The spot-size reduction allows for safer treatment of darker-skinned (skin types IV and V) patients with telangiectasias. In addition, the device has a good vascular-to-pigment damage ratio. When a 1- to 5-mm spot size is used, vessel reduction can be seen in real time.

"It is nice to see a blood vessel disappear as you see it, which you can't do with the IPL," said Dr. Ross. "It's just fun to do." The handpiece is also light and easy to use.

KTP therapy has higher costs, however, and tends to cause more pain than IPL treatment. After KTP treatment, edema can be severe, and overtreatment can cause pitting.

IPL therapy is raising the bar for treating pigmentation. Filtration is better with an IPL device, lamp pumping is smoother, cooling has been added to the device, and the radio frequency has been improved. Most importantly, it is safe, he said.

One of IPL's drawbacks is that the divergence of the beam means the handpiece must be held close to the skin, which may compress vessels. Also, the nonlaser properties of IPL make it difficult to focus on small spots, so it can be challenging to use on discrete lesions. Finally, with large spot treatment capability comes the potential for big side effects, Dr. Ross noted.

He disclosed being a consultant for, and receiving research grants from, Palomar. Dr. Ross also has received research support from Cutera Inc., Lumenis, Candela Corp., Ulthera Inc., and Sciton Inc.

SDEF and this news organization are both owned by Elsevier.

My favorite laser on a daily basis for treating pigmentation disorders is the KTP. DR. ROSS

SANTA MONICA, CALIF. — The ideal device for treating pigmentation disorders would reduce wrinkles, pigment, and redness in one pass with a low amount of pain and give patients a fast, easy recovery, according to Dr. E. Victor Ross.

"There's no device that does all those things, but the devices that actually selectively target blood and melanin are possibly the closest thing to it," Dr. Ross said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Ross of the Scripps Clinic in San Diego discussed the pros and cons of using intense pulsed light (IPL) devices, pulsed dye lasers (PDL), and potassium-titanyl-phosphate (KTP) lasers for treating pigmentation disorders.

Both pigmentation and vascular disorders can be treated in one pass using IPL therapy and KTP lasers, he said. The PDL was the first "boutique laser" to treat vascular lesions, he noted. Next came the KTP laser to treat isolated vessels. When IPL treatment entered the scene, it displaced the other devices because of its versatility, but all three approaches have a role in treating blood and pigment lesions. "My favorite on a daily basis is the KTP laser," he acknowledged.

PDL treatment is fast, and if a patient doesn't mind the resulting purpura, the PDL is probably the best device for improvement of redness in a single treatment, said Dr. Ross.

The PDL remains the standard for treating port wine stains. Nevertheless, it is not possible to reduce both red and brown facial lesions with this laser, and it cannot, in one pass, treat both blood and pigment lesions.

KTP lasers can treat both small and large spots. The spot-size reduction allows for safer treatment of darker-skinned (skin types IV and V) patients with telangiectasias. In addition, the device has a good vascular-to-pigment damage ratio. When a 1- to 5-mm spot size is used, vessel reduction can be seen in real time.

"It is nice to see a blood vessel disappear as you see it, which you can't do with the IPL," said Dr. Ross. "It's just fun to do." The handpiece is also light and easy to use.

KTP therapy has higher costs, however, and tends to cause more pain than IPL treatment. After KTP treatment, edema can be severe, and overtreatment can cause pitting.

IPL therapy is raising the bar for treating pigmentation. Filtration is better with an IPL device, lamp pumping is smoother, cooling has been added to the device, and the radio frequency has been improved. Most importantly, it is safe, he said.

One of IPL's drawbacks is that the divergence of the beam means the handpiece must be held close to the skin, which may compress vessels. Also, the nonlaser properties of IPL make it difficult to focus on small spots, so it can be challenging to use on discrete lesions. Finally, with large spot treatment capability comes the potential for big side effects, Dr. Ross noted.

He disclosed being a consultant for, and receiving research grants from, Palomar. Dr. Ross also has received research support from Cutera Inc., Lumenis, Candela Corp., Ulthera Inc., and Sciton Inc.

SDEF and this news organization are both owned by Elsevier.

My favorite laser on a daily basis for treating pigmentation disorders is the KTP. DR. ROSS

SANTA MONICA, CALIF. — The key to treating pigmentary disorders is making an accurate diagnosis using a Wood's lamp and classifying the patient's condition, according to Dr. Anand Ganesan.

"One of the things that is easy to learn but is easily forgotten is how to really prepare your patients when they first walk in the door, and for you to assess how well they are going to respond to the treatments that you are offering," said Dr. Ganesan, who is a professor of dermatology at the University of California, Irvine.

Dr. Ganesan discussed the etiology, diagnosis, and treatment of pigmentary disorders, as well as the triaging of patients with these conditions, at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Melasma

About 75% of melasma patients are female, and the condition is common in darker-skinned patients, he said. The exact cause of melasma is unknown, but triggers may include sun exposure, family history, phenytoin exposure, oral contraceptives, pregnancy, and increased estrogen.

The Wood's lamp is used to determine the classification of melasma: epidermal, dermal, or mixed. "If you can categorize your patients, you can actually predict very nicely how well they are going to respond to your treatment," he said.

In white and Hispanic patients, melasma appears as a reflected darker image. In patients with skin types V or VI the color will appear a little reddish, but a change can be seen over the pigmented area.

Melasma that has an epidermal component will respond well to almost any treatment. Dermal melasma tends to respond better to laser therapies. Darker-skinned patients will respond best to hydroquinone, while lighter skin responds best to peels and lasers.

Patients with melasma need to use a broad-spectrum sunscreen (UVA and UVB coverage with an SPF of 30 or more) every day, regardless of sun exposure, because fluorescent lighting emits some UVA rays, said Dr. Ganesan.

Birth control pills, cosmetic products, and phototoxic drugs should be discontinued if they appear to help cause the melasma.

Combining topical products is more effective than using tretinoin, hydroquinone, or steroids alone, he said, adding that it is important to balance an agent's potential for irritation with its strength because increased inflammation will result in poor clinical outcomes.

For patients who cannot tolerate hydroquinone, there are some less effective alternatives: kojic acid, which can be more irritating than hydroquinone; azelaic acid; mequinol, which has been shown to have some depigmenting activity and is less effective than hydroquinone; arbutin, which is a botanically related compound that can cause depigmentation; and licorice extract, available in Ayurvedic and other commercial preparations.

Chemical peels are not effective as single agents for treating melasma but may be slightly synergistic when used with hydroquinone. Peels are operator dependent, said Dr. Ganesan, so if the clinician has extensive clinical experience with them they may be a treatment option.

Studies suggest that the Q-switched Nd:YAG and ruby lasers, used in conjunction with hydroquinone, may be effective in treating dermal or mixed melasma. Positive results also have been seen with Fraxel lasers.

Vitiligo

The underlying factor thought to cause vitiligo is melanocyte susceptibility to destruction.

As with melasma, the diagnosis should be made with a Wood's lamp, which can distinguish vitiligo from other hypopigmenting conditions. Biopsy, along with Fontana-Masson staining, can be helpful to determine if melanocytes are present, Dr. Ganesan said.

There are two types of vitiligo: segmental (unresponsive to light therapy) and generalized (responsive to light therapy). Treatment options include photo therapy, lasers, surgery, and topical solutions. Given the safety and tolerability of narrow-band UVB, it is favored over treatment with PUVA.

A 380-nm excimer laser can be used to treat small surface areas, such as those on the face, but is less effective on the hands. An excimer laser should be used aggressively with dose escalation for best treatment results, Dr. Ganesan said. Because aggressive dosing regimens can lead to increased burning, it is best for treating localized areas and for patients who seek rapid improvement.

Although the excimer laser should be avoided when treating underarms, the device works well on the eyelids, he continued. It produces less response on the hands and feet but is an option if narrow-band UVB has failed.

Surgical options for treating vitiligo include punch grafting and suction blister grafting. Punch grafting has been found very effective for treating nonactive segmental lesions. A side effect of punch grafting is cobblestoning, which can diminish over time.

Dr. Ganesan disclosed having no conflicts related to his presentation.

SDEF and this news organization are both owned by Elsevier.

'If you can categorize your patients, you can actually predict very nicely how well they are going to respond.' DR. GANESAN

Possible melasma triggers include sun exposure, phenytoin exposure, and oral contraceptives. Courtesy Dr. Wendy E. Roberts

SANTA MONICA, CALIF. — The key to treating pigmentary disorders is making an accurate diagnosis using a Wood's lamp and classifying the patient's condition, according to Dr. Anand Ganesan.

"One of the things that is easy to learn but is easily forgotten is how to really prepare your patients when they first walk in the door, and for you to assess how well they are going to respond to the treatments that you are offering," said Dr. Ganesan, who is a professor of dermatology at the University of California, Irvine.

Dr. Ganesan discussed the etiology, diagnosis, and treatment of pigmentary disorders, as well as the triaging of patients with these conditions, at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Melasma

About 75% of melasma patients are female, and the condition is common in darker-skinned patients, he said. The exact cause of melasma is unknown, but triggers may include sun exposure, family history, phenytoin exposure, oral contraceptives, pregnancy, and increased estrogen.

The Wood's lamp is used to determine the classification of melasma: epidermal, dermal, or mixed. "If you can categorize your patients, you can actually predict very nicely how well they are going to respond to your treatment," he said.

In white and Hispanic patients, melasma appears as a reflected darker image. In patients with skin types V or VI the color will appear a little reddish, but a change can be seen over the pigmented area.

Melasma that has an epidermal component will respond well to almost any treatment. Dermal melasma tends to respond better to laser therapies. Darker-skinned patients will respond best to hydroquinone, while lighter skin responds best to peels and lasers.

Patients with melasma need to use a broad-spectrum sunscreen (UVA and UVB coverage with an SPF of 30 or more) every day, regardless of sun exposure, because fluorescent lighting emits some UVA rays, said Dr. Ganesan.

Birth control pills, cosmetic products, and phototoxic drugs should be discontinued if they appear to help cause the melasma.

Combining topical products is more effective than using tretinoin, hydroquinone, or steroids alone, he said, adding that it is important to balance an agent's potential for irritation with its strength because increased inflammation will result in poor clinical outcomes.

For patients who cannot tolerate hydroquinone, there are some less effective alternatives: kojic acid, which can be more irritating than hydroquinone; azelaic acid; mequinol, which has been shown to have some depigmenting activity and is less effective than hydroquinone; arbutin, which is a botanically related compound that can cause depigmentation; and licorice extract, available in Ayurvedic and other commercial preparations.

Chemical peels are not effective as single agents for treating melasma but may be slightly synergistic when used with hydroquinone. Peels are operator dependent, said Dr. Ganesan, so if the clinician has extensive clinical experience with them they may be a treatment option.

Studies suggest that the Q-switched Nd:YAG and ruby lasers, used in conjunction with hydroquinone, may be effective in treating dermal or mixed melasma. Positive results also have been seen with Fraxel lasers.

Vitiligo

The underlying factor thought to cause vitiligo is melanocyte susceptibility to destruction.

As with melasma, the diagnosis should be made with a Wood's lamp, which can distinguish vitiligo from other hypopigmenting conditions. Biopsy, along with Fontana-Masson staining, can be helpful to determine if melanocytes are present, Dr. Ganesan said.

There are two types of vitiligo: segmental (unresponsive to light therapy) and generalized (responsive to light therapy). Treatment options include photo therapy, lasers, surgery, and topical solutions. Given the safety and tolerability of narrow-band UVB, it is favored over treatment with PUVA.

A 380-nm excimer laser can be used to treat small surface areas, such as those on the face, but is less effective on the hands. An excimer laser should be used aggressively with dose escalation for best treatment results, Dr. Ganesan said. Because aggressive dosing regimens can lead to increased burning, it is best for treating localized areas and for patients who seek rapid improvement.

Although the excimer laser should be avoided when treating underarms, the device works well on the eyelids, he continued. It produces less response on the hands and feet but is an option if narrow-band UVB has failed.

Surgical options for treating vitiligo include punch grafting and suction blister grafting. Punch grafting has been found very effective for treating nonactive segmental lesions. A side effect of punch grafting is cobblestoning, which can diminish over time.

Dr. Ganesan disclosed having no conflicts related to his presentation.

SDEF and this news organization are both owned by Elsevier.

'If you can categorize your patients, you can actually predict very nicely how well they are going to respond.' DR. GANESAN

Possible melasma triggers include sun exposure, phenytoin exposure, and oral contraceptives. Courtesy Dr. Wendy E. Roberts

SANTA MONICA, CALIF. — The key to treating pigmentary disorders is making an accurate diagnosis using a Wood's lamp and classifying the patient's condition, according to Dr. Anand Ganesan.

"One of the things that is easy to learn but is easily forgotten is how to really prepare your patients when they first walk in the door, and for you to assess how well they are going to respond to the treatments that you are offering," said Dr. Ganesan, who is a professor of dermatology at the University of California, Irvine.

Dr. Ganesan discussed the etiology, diagnosis, and treatment of pigmentary disorders, as well as the triaging of patients with these conditions, at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Melasma

About 75% of melasma patients are female, and the condition is common in darker-skinned patients, he said. The exact cause of melasma is unknown, but triggers may include sun exposure, family history, phenytoin exposure, oral contraceptives, pregnancy, and increased estrogen.

The Wood's lamp is used to determine the classification of melasma: epidermal, dermal, or mixed. "If you can categorize your patients, you can actually predict very nicely how well they are going to respond to your treatment," he said.

In white and Hispanic patients, melasma appears as a reflected darker image. In patients with skin types V or VI the color will appear a little reddish, but a change can be seen over the pigmented area.

Melasma that has an epidermal component will respond well to almost any treatment. Dermal melasma tends to respond better to laser therapies. Darker-skinned patients will respond best to hydroquinone, while lighter skin responds best to peels and lasers.

Patients with melasma need to use a broad-spectrum sunscreen (UVA and UVB coverage with an SPF of 30 or more) every day, regardless of sun exposure, because fluorescent lighting emits some UVA rays, said Dr. Ganesan.

Birth control pills, cosmetic products, and phototoxic drugs should be discontinued if they appear to help cause the melasma.

Combining topical products is more effective than using tretinoin, hydroquinone, or steroids alone, he said, adding that it is important to balance an agent's potential for irritation with its strength because increased inflammation will result in poor clinical outcomes.

For patients who cannot tolerate hydroquinone, there are some less effective alternatives: kojic acid, which can be more irritating than hydroquinone; azelaic acid; mequinol, which has been shown to have some depigmenting activity and is less effective than hydroquinone; arbutin, which is a botanically related compound that can cause depigmentation; and licorice extract, available in Ayurvedic and other commercial preparations.

Chemical peels are not effective as single agents for treating melasma but may be slightly synergistic when used with hydroquinone. Peels are operator dependent, said Dr. Ganesan, so if the clinician has extensive clinical experience with them they may be a treatment option.

Studies suggest that the Q-switched Nd:YAG and ruby lasers, used in conjunction with hydroquinone, may be effective in treating dermal or mixed melasma. Positive results also have been seen with Fraxel lasers.

Vitiligo

The underlying factor thought to cause vitiligo is melanocyte susceptibility to destruction.

As with melasma, the diagnosis should be made with a Wood's lamp, which can distinguish vitiligo from other hypopigmenting conditions. Biopsy, along with Fontana-Masson staining, can be helpful to determine if melanocytes are present, Dr. Ganesan said.

There are two types of vitiligo: segmental (unresponsive to light therapy) and generalized (responsive to light therapy). Treatment options include photo therapy, lasers, surgery, and topical solutions. Given the safety and tolerability of narrow-band UVB, it is favored over treatment with PUVA.

A 380-nm excimer laser can be used to treat small surface areas, such as those on the face, but is less effective on the hands. An excimer laser should be used aggressively with dose escalation for best treatment results, Dr. Ganesan said. Because aggressive dosing regimens can lead to increased burning, it is best for treating localized areas and for patients who seek rapid improvement.

Although the excimer laser should be avoided when treating underarms, the device works well on the eyelids, he continued. It produces less response on the hands and feet but is an option if narrow-band UVB has failed.

Surgical options for treating vitiligo include punch grafting and suction blister grafting. Punch grafting has been found very effective for treating nonactive segmental lesions. A side effect of punch grafting is cobblestoning, which can diminish over time.

Dr. Ganesan disclosed having no conflicts related to his presentation.

SDEF and this news organization are both owned by Elsevier.

'If you can categorize your patients, you can actually predict very nicely how well they are going to respond.' DR. GANESAN

Possible melasma triggers include sun exposure, phenytoin exposure, and oral contraceptives. Courtesy Dr. Wendy E. Roberts

While advances in technology have made lasers more effective as a treatment for spider veins, sclerotherapy remains the standard for treatment, according to Dr. Margaret W. Mann.

While there have been significant advances in laser technology that make them an option for some spider veins, most telangiectases respond best to the more traditional treatment, said Dr. Mann, codirector of the dermatologic surgery and laser center at the University of California, Irvine.

"The majority of the time, I tend to reserve lasers for treating spider veins under a few circumstances," Dr. Mann said in an interview. They are best used for superficial vessels with a diameter of 1 mm or less, especially isolated telangiectases or those around the ankles. Patients with telangiectatic matting may also be candidates for laser treatment. Lasers might also be considered for a patient with needle phobia, or someone who has had a poor response to prior sclerotherapy, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Outside of those circumstances, I tend to use sclerotherapy, which provides more reproducible results with less discomfort and fewer complications."

Different laser types have specific applications when treating spider veins. The potassium-titanyl-phosphate (KTP) and pulsed dye lasers are usually reserved for small vessels with a diameter of up to 1.5 mm. Melanin tends to absorb the energy from these lasers, which can result in hyperpigmentation.

"The majority of the time, I use the 1064-nm Nd:YAG, because it has a lower risk of pigmentary changes and because the advances in cooling devices associated with the Nd:YAG make overheating less likely," Dr. Mann said.

In contrast to telangiectases on the face, which are best treated with lasers, spider veins on the legs do not uniformly respond to lasers. The homogenous nature of facial telangiectases, both in diameter and depth, makes them easier targets than leg veins. "Telangiectases in the legs are a more heterogenous group; they tend to be different sizes and different depths, so it is harder to uniformly target them than it is the facial vessels."

She recommended an ultrasound evaluation for patients who may have more complicated vessel disease, including those with vessels larger than 5 mm in diameter, palpable varicosities, or classic corona phlebectasia—a clustering of spider veins along the medial malleolus.

Patients who have not responded to multiple sessions with sclerotherapy or lasers should undergo an ultrasound evaluation. "These are all indications of larger vessel disease, such as greater saphenous vein insufficiency." If the ultrasound confirms these findings, treatment with endovenous ablation or microphlebectomy should precede any further sclerotherapy or laser treatments.

Endovenous ablation can be performed in the office with tumescent anesthesia, she said. It requires only a small incision in which a laser fiber is threaded under ultrasound guidance within the vein. The laser is activated and withdrawn, which gently heats the lining of the vein and seals it shut.

Ambulatory microphlebectomy is also a safe, effective option for isolated varicosities. The procedure involves making multiple tiny incisions (1–3 mm) through which the varicose veins are removed. A compression dressing is necessary for 24 hours after the procedure, after which the patient can resume normal activity while wearing compression hose for 3 weeks.

Dr. Mann reported no financial conflicts regarding her presentation.

SDEF and this news organization are owned by Elsevier.

Sclerotherapy 'provides more reproducible results withless discomfort and fewer complications.' DR. MANN

While advances in technology have made lasers more effective as a treatment for spider veins, sclerotherapy remains the standard for treatment, according to Dr. Margaret W. Mann.

While there have been significant advances in laser technology that make them an option for some spider veins, most telangiectases respond best to the more traditional treatment, said Dr. Mann, codirector of the dermatologic surgery and laser center at the University of California, Irvine.

"The majority of the time, I tend to reserve lasers for treating spider veins under a few circumstances," Dr. Mann said in an interview. They are best used for superficial vessels with a diameter of 1 mm or less, especially isolated telangiectases or those around the ankles. Patients with telangiectatic matting may also be candidates for laser treatment. Lasers might also be considered for a patient with needle phobia, or someone who has had a poor response to prior sclerotherapy, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Outside of those circumstances, I tend to use sclerotherapy, which provides more reproducible results with less discomfort and fewer complications."

Different laser types have specific applications when treating spider veins. The potassium-titanyl-phosphate (KTP) and pulsed dye lasers are usually reserved for small vessels with a diameter of up to 1.5 mm. Melanin tends to absorb the energy from these lasers, which can result in hyperpigmentation.

"The majority of the time, I use the 1064-nm Nd:YAG, because it has a lower risk of pigmentary changes and because the advances in cooling devices associated with the Nd:YAG make overheating less likely," Dr. Mann said.

In contrast to telangiectases on the face, which are best treated with lasers, spider veins on the legs do not uniformly respond to lasers. The homogenous nature of facial telangiectases, both in diameter and depth, makes them easier targets than leg veins. "Telangiectases in the legs are a more heterogenous group; they tend to be different sizes and different depths, so it is harder to uniformly target them than it is the facial vessels."

She recommended an ultrasound evaluation for patients who may have more complicated vessel disease, including those with vessels larger than 5 mm in diameter, palpable varicosities, or classic corona phlebectasia—a clustering of spider veins along the medial malleolus.

Patients who have not responded to multiple sessions with sclerotherapy or lasers should undergo an ultrasound evaluation. "These are all indications of larger vessel disease, such as greater saphenous vein insufficiency." If the ultrasound confirms these findings, treatment with endovenous ablation or microphlebectomy should precede any further sclerotherapy or laser treatments.

Endovenous ablation can be performed in the office with tumescent anesthesia, she said. It requires only a small incision in which a laser fiber is threaded under ultrasound guidance within the vein. The laser is activated and withdrawn, which gently heats the lining of the vein and seals it shut.

Ambulatory microphlebectomy is also a safe, effective option for isolated varicosities. The procedure involves making multiple tiny incisions (1–3 mm) through which the varicose veins are removed. A compression dressing is necessary for 24 hours after the procedure, after which the patient can resume normal activity while wearing compression hose for 3 weeks.

Dr. Mann reported no financial conflicts regarding her presentation.

SDEF and this news organization are owned by Elsevier.

Sclerotherapy 'provides more reproducible results withless discomfort and fewer complications.' DR. MANN

While advances in technology have made lasers more effective as a treatment for spider veins, sclerotherapy remains the standard for treatment, according to Dr. Margaret W. Mann.

While there have been significant advances in laser technology that make them an option for some spider veins, most telangiectases respond best to the more traditional treatment, said Dr. Mann, codirector of the dermatologic surgery and laser center at the University of California, Irvine.

"The majority of the time, I tend to reserve lasers for treating spider veins under a few circumstances," Dr. Mann said in an interview. They are best used for superficial vessels with a diameter of 1 mm or less, especially isolated telangiectases or those around the ankles. Patients with telangiectatic matting may also be candidates for laser treatment. Lasers might also be considered for a patient with needle phobia, or someone who has had a poor response to prior sclerotherapy, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Outside of those circumstances, I tend to use sclerotherapy, which provides more reproducible results with less discomfort and fewer complications."

Different laser types have specific applications when treating spider veins. The potassium-titanyl-phosphate (KTP) and pulsed dye lasers are usually reserved for small vessels with a diameter of up to 1.5 mm. Melanin tends to absorb the energy from these lasers, which can result in hyperpigmentation.

"The majority of the time, I use the 1064-nm Nd:YAG, because it has a lower risk of pigmentary changes and because the advances in cooling devices associated with the Nd:YAG make overheating less likely," Dr. Mann said.

In contrast to telangiectases on the face, which are best treated with lasers, spider veins on the legs do not uniformly respond to lasers. The homogenous nature of facial telangiectases, both in diameter and depth, makes them easier targets than leg veins. "Telangiectases in the legs are a more heterogenous group; they tend to be different sizes and different depths, so it is harder to uniformly target them than it is the facial vessels."

She recommended an ultrasound evaluation for patients who may have more complicated vessel disease, including those with vessels larger than 5 mm in diameter, palpable varicosities, or classic corona phlebectasia—a clustering of spider veins along the medial malleolus.

Patients who have not responded to multiple sessions with sclerotherapy or lasers should undergo an ultrasound evaluation. "These are all indications of larger vessel disease, such as greater saphenous vein insufficiency." If the ultrasound confirms these findings, treatment with endovenous ablation or microphlebectomy should precede any further sclerotherapy or laser treatments.

Endovenous ablation can be performed in the office with tumescent anesthesia, she said. It requires only a small incision in which a laser fiber is threaded under ultrasound guidance within the vein. The laser is activated and withdrawn, which gently heats the lining of the vein and seals it shut.

Ambulatory microphlebectomy is also a safe, effective option for isolated varicosities. The procedure involves making multiple tiny incisions (1–3 mm) through which the varicose veins are removed. A compression dressing is necessary for 24 hours after the procedure, after which the patient can resume normal activity while wearing compression hose for 3 weeks.

Dr. Mann reported no financial conflicts regarding her presentation.

SDEF and this news organization are owned by Elsevier.

Sclerotherapy 'provides more reproducible results withless discomfort and fewer complications.' DR. MANN

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

MIAMI BEACH — Less pain on injection, less postprocedure swelling, and greater convenience are among the advantages of hyaluronic acid and lidocaine combination products, according to two studies and a live patient demonstration at the South Beach Symposium.

Prevelle (Mentor Corp.) and Dermal Gel Extra (Genzyme Corp.) come premixed with lidocaine, thus saving preparation time for physicians who might otherwise mix in their own anesthetic. Prevelle is approved for correction of moderate-to-severe facial wrinkles and folds via injection into the mid- to deep dermis. Dermal Gel Extra (DGE) is under FDA review.

Prevelle and DGE are fully hydrated, unlike existing hyaluronic acid fillers that absorb water and increase in volume after injection. "Prevelle is like Captique with lidocaine, versus Restylane [Medicis Pharmaceutical Corp.] and Juvéderm [Allergan Inc.], which are underhydrated," said Dr. Stephen H. Mandy of the department of dermatology at the University of Miami. His disclosures include Allergan, Bioform Medical Inc., Galderma Laboratories LP, OrthoNeutrogena, Procter & Gamble, Sanofi-Aventis, and Stiefel Laboratories Inc.

Dr. Mandy and his associates assessed 45 patients in a randomized, controlled, patient-blinded comparison between Captique and Prevelle. Although participants reported pain with both fillers, there was no swelling and very little erythema. "Pain at injection was lower with Prevelle, greater than 50% less, and improves over 45 minutes."

Dr. Mandy also participated in a multicenter safety and efficacy study. The split-face comparison between DGE and Restylane included 140 patients at six U.S. centers. Although he was unable to share data, he said, "I can tell you there is less volume and less pain with [DGE], with volume filling as great as Restylane at 9 months." He added that it takes much less volume to get maximum effect, "so we should fill very conservatively."

DGE is a "very robust" filler material, Dr. Mandy said. "You can feel the difference as you inject it."

"The nice thing about the Prevelle product is the price point," said Dr. Susan H. Weinkle, a dermatologist in private practice in Bradenton, Fla. Her disclosures include Allergan, Bioform, DermAvance Pharmaceuticals Inc., Medicis, Procter & Gamble, and Stiefel.

"This is a great product for a first-time patient, [one who may be] needle-phobic or concerned about pain," said Dr. Gary D. Monheit of the department of dermatology and ophthalmology at the University of Alabama at Birmingham. Dr. Monheit's disclosures include Allergan, Dermik Laboratories, Genzyme, Medicis, Mentor Corp., Merz Pharma, and Stiefel.

Dr. Monheit injected the first patient volunteer at the meeting, a woman with asymmetrical lips and a history of lip correction. "She could benefit from a lift to the malar crease," he noted.

Use a fanning technique for volume effect on the mid-face, Dr. Monheit said. Start with injections along the nasolabial fold. "Then I like to advance to the modiolus to see the commissures go up."

As lidocaine takes effect, subsequent injections become easier, Dr. Monheit said. Prevelle "requires very little manipulation afterward—it has an even flow."

"It is important to stop [during the procedure], get a frontal look, and make sure you get same volume on both sides," Dr. Monheit said. Remember this filler is not hydrophilic, "so what you see at the end is what you will get."

Patient follow-up is important, Dr. Weinkle said. Ask patients to come back in 2 weeks to check the results, including symmetry. "Don't charge them if you use another small amount. It's all about patient retention." n

MIAMI BEACH — Less pain on injection, less postprocedure swelling, and greater convenience are among the advantages of hyaluronic acid and lidocaine combination products, according to two studies and a live patient demonstration at the South Beach Symposium.

Prevelle (Mentor Corp.) and Dermal Gel Extra (Genzyme Corp.) come premixed with lidocaine, thus saving preparation time for physicians who might otherwise mix in their own anesthetic. Prevelle is approved for correction of moderate-to-severe facial wrinkles and folds via injection into the mid- to deep dermis. Dermal Gel Extra (DGE) is under FDA review.

Prevelle and DGE are fully hydrated, unlike existing hyaluronic acid fillers that absorb water and increase in volume after injection. "Prevelle is like Captique with lidocaine, versus Restylane [Medicis Pharmaceutical Corp.] and Juvéderm [Allergan Inc.], which are underhydrated," said Dr. Stephen H. Mandy of the department of dermatology at the University of Miami. His disclosures include Allergan, Bioform Medical Inc., Galderma Laboratories LP, OrthoNeutrogena, Procter & Gamble, Sanofi-Aventis, and Stiefel Laboratories Inc.

Dr. Mandy and his associates assessed 45 patients in a randomized, controlled, patient-blinded comparison between Captique and Prevelle. Although participants reported pain with both fillers, there was no swelling and very little erythema. "Pain at injection was lower with Prevelle, greater than 50% less, and improves over 45 minutes."

Dr. Mandy also participated in a multicenter safety and efficacy study. The split-face comparison between DGE and Restylane included 140 patients at six U.S. centers. Although he was unable to share data, he said, "I can tell you there is less volume and less pain with [DGE], with volume filling as great as Restylane at 9 months." He added that it takes much less volume to get maximum effect, "so we should fill very conservatively."

DGE is a "very robust" filler material, Dr. Mandy said. "You can feel the difference as you inject it."

"The nice thing about the Prevelle product is the price point," said Dr. Susan H. Weinkle, a dermatologist in private practice in Bradenton, Fla. Her disclosures include Allergan, Bioform, DermAvance Pharmaceuticals Inc., Medicis, Procter & Gamble, and Stiefel.

"This is a great product for a first-time patient, [one who may be] needle-phobic or concerned about pain," said Dr. Gary D. Monheit of the department of dermatology and ophthalmology at the University of Alabama at Birmingham. Dr. Monheit's disclosures include Allergan, Dermik Laboratories, Genzyme, Medicis, Mentor Corp., Merz Pharma, and Stiefel.

Dr. Monheit injected the first patient volunteer at the meeting, a woman with asymmetrical lips and a history of lip correction. "She could benefit from a lift to the malar crease," he noted.

Use a fanning technique for volume effect on the mid-face, Dr. Monheit said. Start with injections along the nasolabial fold. "Then I like to advance to the modiolus to see the commissures go up."

As lidocaine takes effect, subsequent injections become easier, Dr. Monheit said. Prevelle "requires very little manipulation afterward—it has an even flow."

"It is important to stop [during the procedure], get a frontal look, and make sure you get same volume on both sides," Dr. Monheit said. Remember this filler is not hydrophilic, "so what you see at the end is what you will get."

Patient follow-up is important, Dr. Weinkle said. Ask patients to come back in 2 weeks to check the results, including symmetry. "Don't charge them if you use another small amount. It's all about patient retention." n

MIAMI BEACH — Less pain on injection, less postprocedure swelling, and greater convenience are among the advantages of hyaluronic acid and lidocaine combination products, according to two studies and a live patient demonstration at the South Beach Symposium.

Prevelle (Mentor Corp.) and Dermal Gel Extra (Genzyme Corp.) come premixed with lidocaine, thus saving preparation time for physicians who might otherwise mix in their own anesthetic. Prevelle is approved for correction of moderate-to-severe facial wrinkles and folds via injection into the mid- to deep dermis. Dermal Gel Extra (DGE) is under FDA review.

Prevelle and DGE are fully hydrated, unlike existing hyaluronic acid fillers that absorb water and increase in volume after injection. "Prevelle is like Captique with lidocaine, versus Restylane [Medicis Pharmaceutical Corp.] and Juvéderm [Allergan Inc.], which are underhydrated," said Dr. Stephen H. Mandy of the department of dermatology at the University of Miami. His disclosures include Allergan, Bioform Medical Inc., Galderma Laboratories LP, OrthoNeutrogena, Procter & Gamble, Sanofi-Aventis, and Stiefel Laboratories Inc.

Dr. Mandy and his associates assessed 45 patients in a randomized, controlled, patient-blinded comparison between Captique and Prevelle. Although participants reported pain with both fillers, there was no swelling and very little erythema. "Pain at injection was lower with Prevelle, greater than 50% less, and improves over 45 minutes."

Dr. Mandy also participated in a multicenter safety and efficacy study. The split-face comparison between DGE and Restylane included 140 patients at six U.S. centers. Although he was unable to share data, he said, "I can tell you there is less volume and less pain with [DGE], with volume filling as great as Restylane at 9 months." He added that it takes much less volume to get maximum effect, "so we should fill very conservatively."

DGE is a "very robust" filler material, Dr. Mandy said. "You can feel the difference as you inject it."

"The nice thing about the Prevelle product is the price point," said Dr. Susan H. Weinkle, a dermatologist in private practice in Bradenton, Fla. Her disclosures include Allergan, Bioform, DermAvance Pharmaceuticals Inc., Medicis, Procter & Gamble, and Stiefel.

"This is a great product for a first-time patient, [one who may be] needle-phobic or concerned about pain," said Dr. Gary D. Monheit of the department of dermatology and ophthalmology at the University of Alabama at Birmingham. Dr. Monheit's disclosures include Allergan, Dermik Laboratories, Genzyme, Medicis, Mentor Corp., Merz Pharma, and Stiefel.

Dr. Monheit injected the first patient volunteer at the meeting, a woman with asymmetrical lips and a history of lip correction. "She could benefit from a lift to the malar crease," he noted.

Use a fanning technique for volume effect on the mid-face, Dr. Monheit said. Start with injections along the nasolabial fold. "Then I like to advance to the modiolus to see the commissures go up."

As lidocaine takes effect, subsequent injections become easier, Dr. Monheit said. Prevelle "requires very little manipulation afterward—it has an even flow."

"It is important to stop [during the procedure], get a frontal look, and make sure you get same volume on both sides," Dr. Monheit said. Remember this filler is not hydrophilic, "so what you see at the end is what you will get."

Patient follow-up is important, Dr. Weinkle said. Ask patients to come back in 2 weeks to check the results, including symmetry. "Don't charge them if you use another small amount. It's all about patient retention." n