"1927-nm Fractional resurfacing of facial actinic keratoses: A promising new therapeutic option"Weiss, Elliot T; Brauer, Jeremy A; Anolik, Robert; Reddy, Kavitha K; Karen, Julie K; Hale, Elizabeth K; Brightman, Lori A; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND: Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. OBJECTIVE: We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. METHODS: This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. RESULTS: At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. LIMITATIONS: This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. CONCLUSION: The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option..
"Investigation into optimal treatment intervals of facial port-wine stains using the pulsed dye laser"Anolik, R; Newlove, T; Weiss, ET; Brightman, L; Hale, EK; Karen, JK; Bernstein, L; GERONEMUS, RG
BACKGROUND: Port-wine stains (PWS) affect 0.3% to 0.5% of newborns and pulsed dye laser (PDL) remains the treatment of choice. Optimal treatment intervals have not been established. OBJECTIVE: We sought to validate the optimal treatment intervals for the management of facial PWS with PDL. METHODS: In all, 24 infants with facial PWS who received at least 5 treatments with the PDL at 2-, 3-, and 4-week intervals at a private laser and skin surgery center from 2009 to 2010 were identified by a retrospective chart review. Safety and efficacy were compared by blinded investigators. RESULTS: Side effects were equivalent in all interval groups and included only expected short-term erythema, edema, purpura, and mild postinflammatory hyperpigmentation. No patient developed hypopigmentation, scarring, or infection. All interval groups showed 50% to 100% clearance of their PWS after 5 treatments. Complete or near-complete clearance was seen in 6 of 8 (75%) and 7 of 8 (87.5%) patients in the 2- and 3-week interval groups, respectively, as compared with 3 of 8 (37.5%) patients in the 4-week interval group. LIMITATIONS: This was a retrospective chart review from a single institution. Long-term side effects and recurrence rates were not assessed. CONCLUSION: We conclude that PDL treatments at 2-, 3-, and 4-week intervals are effective for the management of facial PWS in infants with minimal short-term side effects. Shorter treatment intervals may allow for relatively more rapid and more effective treatment..
"Successful and rapid treatment of blue and green tattoo pigment with a novel picosecond laser"Brauer, Jeremy A; Reddy, Kavitha K; Anolik, Robert; Weiss, Elliot T; Karen, Julie K; Hale, Elizabeth K; Brightman, Lori A; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND While the understanding and technology of laser tattoo removal has advanced much over the last 5 decades, treatments and results remain far from perfect. With currently available devices, treatment courses are often painful and prolonged with mixed results. We describe the successful and rapid treatment of 12 tattoos containing blue and/or green pigment with a novel, picosecond, 755-nm alexandrite laser. OBSERVATIONS All previously untreated multicolored tattoos as well as tattoos recalcitrant to treatment demonstrated at least 75% clearance of blue and green pigment after 1 or 2 treatments with a novel, picosecond, 755-nm alexandrite laser. More than two-thirds of these tattoos approached closer to 100% clearance. CONCLUSIONS While additional future studies are needed, we believe that this new technology is more effective in targeting blue and green pigment, resulting in expedited clearance with less collateral injury to surrounding tissue..
"Ablative Fractional Resurfacing for Involuted Hemangioma Residuum"Brightman, Lori A; Brauer, Jeremy A; Terushkin, Vitaly; Hunzeker, Christopher; Reddy, Kavitha K; Weiss, Elliot T; Karen, Julie K; Hale, Elizabeth K; Anolik, Robert; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas..
"Calcium Hydroxylapatite Nodule Resolution After Fractional Carbon Dioxide Laser Therapy"Reddy, KK; Brauer, JA; Anolik, R; Bernstein, L; Brightman, LA; Hale, E; Karen, J; Weiss, E; GERONEMUS, RG
BACKGROUND: Injection of calcium hydroxylapatite filler may result in nodule formation owing to superficial placement of the filler. Calcium hydroxylapatite nodules are difficult to reverse. Previously reported therapeutic options are limited and include intralesional triamcinolone, massage, needling, and excision, each with inconsistent results or potential for scarring. Observation We have observed complete resolution of calcium hydroxylapatite nodules after a single treatment with fractional carbon dioxide laser. CONCLUSIONS: A single session of fractional carbon dioxide laser treatment may resolve selected cases of calcium hydroxylapatite nodules. The mechanism of action may involve conversion of the product into tricalcium phosphates which dissolve readily. This novel therapeutic technique may enhance treatment options for a difficult clinical problem..
"Glomuvenous Malformations (Familial generalized multiple glomangiomas)" [Case Report]Brauer, Jeremy A; Anolik, Robert; Tzu, Julia; Meehan, Shane; Lieber, Colette D; GERONEMUS, ROY G
A 15-year-old boy with a diagnosis of generalized multiple glomangiomas was referred for evaluation and treatment of enlarging and increasingly painful lesions on his right ankle. The patient underwent a series of two treatments with long-pulsed KTP 1064 nm laser that resulted in substantial improvement in appearance and decreased pain. Generalized glomuvenous malformations, or multiple glomangiomas, are the less common presentation of proliferation of glomus cells and may have extracutaneous involvement. Whereas surgical management is often employed and definitive for solitary lesions, interventions such as laser therapy, may be beneficial for improvement of functional impairment and cosmesis as was observed in our patient..
"Reduction of thickened flap using fractional carbon dioxide laser"Brightman, Lori A; Brauer, Jeremy A; Anolik, Robert; Weiss, Elliot T; Karen, Julie; Chapas, Anne; Hale, Elizabeth; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND AND OBJECTIVE: The paramedian forehead flap is an excellent choice when repairing a large nasal defect. However, even when carefully thinned, the flap may develop a bulky appearance, an ill-fitting contour, or trap door deformity. When on the face, these suboptimal results can be quite distressing. Surgical and non-surgical options for improvement exist. Surgical options include additional debulking and reorientation of the flap. Non-surgical options include intralesional corticosteroids or 5-flourouracil, dermabrasion, and ablative and non-ablative laser resurfacing. Each option has limited benefit as well potential side effects. STUDY DESIGN/MATERIALS AND METHODS: Case report. RESULTS: In this report, we present dramatic improvement of a thickened paramedian forehead flap using the Fraxel Re:pair, a fractional carbon dioxide (CO(2) ) laser (Solta Medical, Inc. Hayward, CA). CONCLUSION: To our knowledge, this is the first case in the literature demonstrating successful reduction of a bulky flap using a fractional ablative laser..
"Do lasers or topicals really work for nonmelanoma skin cancers?"Brightman, Lori; Warycha, Melanie; Anolik, Robert; GERONEMUS, ROY
Novel strategies are urgently needed to address the millions of nonmelanoma skin cancers treated in the United States annually. The need is greatest for those patients who are poor surgical candidates or those prone to numerous nonmelanoma skin cancers and therefore at risk for marked disfigurement. Traditional treatment strategies include electrosurgery with curettage, radiation therapy, cryotherapy, excision, and Mohs micrographic surgery. Alternatives to traditional treatment, including topical medications and light or laser therapies, are becoming popular; however, there are various degrees of efficacy among these alternative tactics. These alternatives include topical retinoids, peels, 5-fluorouracil, imiquimod, photodynamic therapy, and lasers. The purpose of this paper is to review the available data regarding these alternative strategies and permit the reader to have a sense of which therapies are reasonable options for care.
"Herpes zoster in the distribution of the trigeminal nerve after nonablative fractional photothermolysis of the face: report of 3 cases" [Case Report]Firoz, Bahar F; Katz, Tracy M; Goldberg, Leonard H; GERONEMUS, ROY G; Polder, Kristel D; Friedman, Paul M
"Treatment of Nevus of Ota in Fitzpatrick skin type VI with the 1064-nm QS Nd:YAG laser" [Case Report]Landau, Jennifer M; Vergilis-Kalner, Irene; Goldberg, Leonard H; GERONEMUS, ROY G; Friedman, Paul M
BACKGROUND: Nevus of Ota is a pigmented lesion that usually presents at birth. Due to a greater risk for complications, physicians have not always utilized laser therapy to treat these nevi in patients with darker skin types. OBJECTIVE: To evaluate the safety and efficacy of the 1,064-nm Q-switched neodymium-doped yttrium aluminium garnet (QS Nd:YAG) laser for the treatment of Nevus of Ota in two patients with Fitzpatrick skin type (FST) VI. RESULTS: After 4-13 treatment sessions with the 1,064-nm Q-switched Nd:YAG laser with a 4 mm spot size and fluence of 4-4.2 J/cm(2), two patients with FST VI noted substantial improvement in the appearance of the nevi. CONCLUSION: At conservative treatment settings, these two case reports have shown that the 1,064-nm QS Nd:YAG laser can be utilized to safely and effectively treat Nevus of Ota in individuals with FST IV-VI..
"Letter regarding early laser treatment of periorbital infantile hemangiomas may work, but is it really the best treatment option?" [Letter]GERONEMUS, ROY G; Hunzeker, Christopher M
"Treatment of superficial infantile hemangiomas of the eyelid using the 595-nm pulsed dye laser"Hunzeker, Christopher M; GERONEMUS, ROY G
BACKGROUND: Despite the proven effectiveness of the 595-nm pulsed dye laser (PDL) in treating superficial infantile hemangiomas, many physicians are reluctant to treat such lesions involving the eyelid. OBJECTIVE To examine the safety and efficacy of the 595-nm PDL for the treatment of superficial infantile hemangiomas of the eyelid. MATERIALS & METHODS: Records were reviewed for patients with superficial infantile hemangiomas of the eyelid treated with 595-nm PDL. Pre- and post-treatment photographs were compared. Reviewers rated the degree of improvement of the hemangioma as excellent (76-100%), good (51-75%), moderate (26-50%), or poor (0-25%) and indicated whether the hemangioma was 100% clear. Side effects of scarring, atrophy, hyperpigmentation, and hypopigmentation were assessed. RESULTS: Twenty-two patients met the study criteria. Eight (36.4%) demonstrated complete clearance of their hemangioma, 17 (77.3%) received an improvement rating of excellent, and five (22.7%) received a rating of good. No scarring, atrophy, or hypopigmentation was noted. Two patients (9.1%) were noted to have hyperpigmentation in the treated area. CONCLUSION: Early treatment with the 595-nm PDL can safely and effectively diminish proliferative growth and hasten resolution of superficial infantile hemangiomas of the eyelid..
"Led photomodulation I: Effects of pulsed and continuous wave modes on procollagen products of human skin fibroblasts" [Meeting Abstract]McDaniel D.H.; Mazur C.; Wilson S.; GERONEMUS R.G.; Weiss R.A.; Weiss M.
Background: The effect of exposure to various pulsed and continuous wave Treatments on human dermal fibroblasts in vitro was studied using ELISA assay procollagen I production as the endpoint measurement. The study was designed to evaluate the complex interactions that occur between the light source and the cell. Study: Human dermal fibroblasts in culture were exposed to a 590/870 nm LED array fixed at 3.8 mW/cm<sup>2</sup>. In the pulsed mode, a matrix of exposure parameters was tested including: msec exposure 'on' times of 1 (single pulse), 10, 100, 250, 500, 1000; msec 'of f times of 10,100, 250, 500, 1000; and total pulse numbers of 1, 10, 100, 250, 500, 1000. In continuous wave mode, a range of fourteen exposure times from 0.5 to 106 msec were tested. Four days after exposure, supernatants from the exposed fibroblasts were collected and assayed. Results: Measuring percent change from control, the parameters tested produced a wide range of responses from 0% change to greater than 90% increase in procollagen I. Pulse duty cycles (msec 'on') of 100 and 250, and msec 'of f of 10 and 100, and number of 100 pulses produced the most procollagen, as did 100 msec and 10,000 msec in continuous wave mode. Conclusion: These experiments show that procollagen production by human dermal fibroblasts in vitro can be modulated using pulsed and continuous wave modes. Responses to pulsed modes reveal a more complex pattern of cellular response to light than continuous wave mode.
"Led photomodulation II: Effect of energy fluence on procollagen products of human skin fibroblasts" [Meeting Abstract]McDaniel D.H.; Mazur C.; Wilson S.; GERONEMUS R.G.; Weiss R.A.; Weiss M.
Background: Delivery of pulsed or continuous wave 590/870 nm LED light modulates the production of procollagen I by human dermal fibroblasts in vitro. In pulsed mode, the number of pulses and exposure or on time of the LED pulsed mode the duty cycle determines the energy fluence delivered to the target. In continuous wave mode, the cumulative exposure time determines the energy fluence delivered to the target. Study: Human dermal fibroblasts in culture were exposed to a 590/870 nm LED array with an energy density of 3.8 mW/cm<sup>2</sup>.In the pulsed mode, a matrix of exposure parameters were tested including: msec 'on times of 1 (single pulse), 10, 100, 250, 500, 1000; msec with 'of f times of 10, 100, 250, 500, 1000; and total number of pulses of 1, 10, 100, 250, 500, 1000. In continuous wave mode, a range of fourteen exposure times from 0.5 to 10<sup>6</sup> msec were tested. Four days after exposure, supernatants from the exposed fibroblasts were assayed by ELISA for procollagen I production. Results: For pulsed parameters, procollagen production was highest for energy fluence of 0.01-0.24 J/cm<sup>2</sup> with a peak around 0.1 J/cm<sup>2</sup> for parameters of 250/100/100 (msec on/msec/of f/# pulses). Continuous wave highest peaks were at 100 msec and 10,000 msec (0.0004 and 0.04 J/cm<sup>2</sup> respectively. Conclusion: 0.1 J/cm<sup>2</sup> using a pulsed 590/870 nm LED parameters of 250 msec 'on' 100 msec 'of f 100 pulses was selected as most effective for procollagen I production.
"Led photomodulation III: Effect of wavelengths and ratio of wavelengths on gene expressions in human skin fibroblasts" [Meeting Abstract]McDaniel D.H.; Mazur C.; Wilson S.; GERONEMUS R.G.; Weiss R.A.; Weiss M.
Background: A variety of parameters with LED photomodulation can alter cellular response in vitro. The effects of one visible and one infrared wavelength were evaluated to determine the optimal ratio to produce a net increase in dermal collagen by altering the ratio of total energy output of each wavelength. The ratio between the two wavelengths (595 nm and 870 nm) was shifted in 25% increments. Study: Human dermal fibroblasts in culture were exposed to a 595/870 nm LED array with total combined energy density fixed at 4.0 mW/cm<sup>2</sup>. The ratio of 595/870 nm parameters were: 100%/ 0%; 75%/25%; 50%/50%; 25%/75%; and 0%/100%. These ratios were tested using pulsed duty cycle of exposure (250 msec 'on' time/100 msec 'of f time/100 pulses) and examined using commercially available extra cellular matrix and adhesion molecule RT PCR Arrays (SI Biosciences) for gene expression 24 hours post exposure. Results: There were different expression prof iles noticed for each of the ratios studied. Overall, there was an average (in an 80 gene array) of 6% directional expression difference. The greatest increase in Collagen I and decrease in Collagenase (MMP-1) was observed with 75%/25% ratio of 595/870 nm. The addition of increasing ratios of IR wavelengths causes an alteration in the gene expression prof ile. Even when the genes followed the same directional change, the ratios of the wavelengths caused variation in magnitude of expression. Conclusion: Varying the ratios of specific wavelength intensity in multiwavelength light therapy can alter the resulting gene expression patterns.
"Led photomodulation: Effects of different wavelengths and delivery modes on selected human cell types in vitro" [Meeting Abstract]McDaniel D.H.; Mazur C.; Wilson S.; GERONEMUS R.G.; Weiss R.A.; Weiss M.
Background: LED photomodulation effects on human dermal fibroblasts have been well documented. The effects of various wavelengths of light, on other cell types were evaluated using human dermal papillae, adipose, and retinal pigment epithelial cells. Study: Human dermal papillae (DP), adipocytes, and retinal pigment epithelial (RPE) cells were grown to near confluence in vitro and exposed to selected LED wavelengths in the visible and near IR light range. For DP cells the endpoint measurements were MTT assay, VEGF ELISA and hair growth-related gene expression using RT-PCR. Adipocyte endpoint measurements were leptin ELISA, total glycerol assay, and cytotoxicity measured by adenylate kinase. RPE cells were exposed to 425 nm or UVA1 light to cause cellular damage, post-treated with LED arrays, and stained with fluorescent Annexin V for apoptosis/ necrosis levels; VEGF and IL6 gene expression RT-PCR. Results: A variety of responses were seen in all studies. DP cells demonstrated increased clinically relevant responses in the 623-660 nm range, particularly at 660 nm using selected pulsed or continuous wave modes. Adipocytes demonstrated altered glycerol and leptin levels at 625 nm and 880 nm using pulsed mode. RPE cells showed a 30% decrease in staining and a downregulation of VEGF expression using 590/870 nm pulsed mode. Apotosis and necrosis of RPE cells was decreased from 92% untreated to 62-5% with various wavelengths. Conclusion: LED photomodulation demonstrated the ability to alter the expression of genes of known significance. Further investigation and optimization of parameters is warranted.
"Varying ratios of wavelengths in dual wavelength LED photomodulation alters gene expression profiles in human skin fibroblasts"McDaniel, D H; Weiss, R A; Geronemus, R G; Mazur, C; Wilson, S; Weiss, M A
BACKGROUND AND OBJECTIVE: LED photomodulation has been shown to profoundly influence cellular behavior. A variety of parameters with LED photomodulation can alter cellular response in vitro. The effects of one visible and one infrared wavelength were evaluated to determine the optimal ratio to produce a net increase in dermal collagen by altering the ratio of total energy output of each wavelength. The ratio between the two wavelengths (590 and 870 nm) was shifted in 25% increments. STUDY DESIGN/MATERIALS AND METHODS: Human skin fibroblasts in culture were exposed to a 590/870 nm LED array with total combined energy density fixed at 4.0 mW/cm.. The ratio of 590/870 nm tested parameters were: 100/0%, 75/25%, 50/50%, 25/75%, and 0/100%. These ratios were delivered using pulsed duty cycle of exposure (250 milliseconds 'on' time/100 milliseconds 'off' time/100 pulses) for a total energy fluence of 0.1 J/cm.. Gene expression was examined using commercially available extra cellular matrix and adhesion molecule RT PCR Arrays (SA Biosciences, Frederick, MD) at 24 hours post-exposure. RESULTS: Different expression profiles were noticed for each of the ratios studied. Overall, there was an average (in an 80 gene array) of 6% expression difference in up or downregulation between the arrays. The greatest increase in collagen I and decrease in collagenase (MMP-1) was observed with 75/25% ratio of 590/870 nm. The addition of increasing proportions of IR wavelengths causes alteration in gene expression profile. The ratios of the wavelengths caused variation in magnitude of expression. CONCLUSIONS: Cell metabolism and gene expression can be altered by simultaneous exposure to multiple wavelengths of low energy light. Varying the ratios of specific wavelength intensity in both visible and near infrared light therapy can strongly influence resulting fibroblast gene expression patterns.
"Choosing an alternate light source with a corresponding dose in photodynamic therapy (it's not rocket science, but it is quantum physics!): Determining the PpIX activiation effect" [Meeting Abstract]Sayre R.M.; Pariser D.; Goldberg D.J.; GERONEMUS R.; Gottschalk R.W.; Dowdy J.C.
Aim: Photodynamic therapy (PDT), a procedure approved in the US for the treatment of actinic keratoses and being investigated for treatment of other skin diseases, involves three components: a photosensitizer, light, and tissue oxygen. A photosensitizer is a chemical compound that can be excited by light at a specific wavelength. In PDT, a photosensitizer or the metabolic precursor to one is administered to the patient. Upon light exposure, the photosensitizer will become excited and energy is transferred from the excited photosensitizer to molecular oxygen in the treated tissue. The reactive oxygen species interact with nearby biomolecules resulting in cell death via apoptosis or necrosis. Methods: A study was conducted to evaluate the spectral output of several potential clinical light sources for PDT and other indications based upon the photosensitizer, protoporphyrin IX, absorption spectrum. The light sources examined included Clearlight(r), Clearlight(r) 100X, OmniLux BlueTM, Omnilux RedTM, Blu-U(r), and Aktilite(r). The spectral irradiance of these clinical sources used for PDT was measured by spectroradiometric techniques to determine specifically how well their emission overlapped with the absorption spectrum of protoporphyrin IX. Results: The results indicated that all sources examined have the potential to be useful in PDT with varying irradiances, ranging from 73 mW/cm<sup>2</sup> (Aktilite(r)) to 5 mW/cm<sup>2</sup> (Clearlight(r)). Thus the results of this study provided confirmation that there are various available light sources which could be effective when used in PDT. Conclusion: Dosage/fluence relationships from the various light sources are presented.
"Successful treatment of atrophic postoperative and traumatic scarring with carbon dioxide ablative fractional resurfacing: quantitative volumetric scar improvement"Weiss, Elliot T; Chapas, Anne; Brightman, Lori; Hunzeker, Christopher; Hale, Elizabeth K; Karen, Julie K; Bernstein, Leonard; GERONEMUS, ROY G
OBJECTIVE: To assess the safety and efficacy of ablative fractional resurfacing (AFR) for nonacne atrophic scarring. DESIGN: In this before-and-after trial, each scar received 3 AFR treatments and 6 months of follow-up. SETTING: Private academic practice. PATIENTS: Fifteen women with Fitzpatrick skin types I to IV, aged 21 to 66 years, presented with 22 nonacne atrophic scars between June 1 and November 30, 2007. Three patients (3 scars) were excluded from the study after receiving 1 AFR treatment and not returning for follow-up visits. The remaining 12 patients (19 scars) completed all 3 treatments and 6 months of follow-up. INTERVENTIONS: Each scar received 3 AFR treatments at 1- to 4-month intervals. MAIN OUTCOME MEASURES: Erythema, edema, petechiae, scarring, crusting, and dyschromia were graded after treatment and through 6 months of follow-up. Skin texture, pigmentation, atrophy, and overall appearance were evaluated after treatment and through 6 months of follow-up by the patient and a nonblinded investigator. A 3-dimensional optical profiling system generated high-resolution topographic representations of atrophic scars for objective measurement of changes in scar volume and depth. RESULTS: Adverse effects of treatment were mild to moderate, and no scarring or delayed-onset hypopigmentation was observed. At the 6-month follow-up visit, patient and investigator scores demonstrated improvements in skin texture for all scars (patient range, 1-4 [mean, 2.79]; investigator range, 2-4 [mean, 2.95]), pigmentation for all scars (patient range, 1-4 [mean, 2.32]; investigator range, 1-4 [mean, 2.21]), atrophy for all scars (patient range, 1-4 [mean, 2.26]; investigator range, 2-4 [mean, 2.95]), and overall scar appearance for all scars (patient range, 2-4 [mean, 2.89]; investigator range, 2-4 [mean, 3.05]). Image analysis revealed a 38.0% mean reduction of volume and 35.6% mean reduction of maximum scar depth. CONCLUSION: The AFR treatments represent a safe, effective treatment modality for improving atrophic scarring due to surgery or trauma..
"New technique using combined pulsed dye laser and fractional resurfacing for treating facial angiofibromas in tuberous sclerosis" [Case Report]Weiss, Elliot T; GERONEMUS, ROY G
BACKGROUND AND OBJECTIVE: Tuberous sclerosis (TS) is a well-described genetic disorder that is classically associated with up to hundreds of facial angiofibromas. Due to the progressive nature of the skin lesions and the early clinical presentation, a safe and effective technique for treating these disfiguring skin lesions is needed. STUDY DESIGN/PATIENTS AND METHODS: We report a combinatorial technique for treating the angiofibromas of TS. We present a case series of three TS patients treated with this technique combining pinpoint electrosurgery, pulsed-dye laser treatment, and ablative fractional resurfacing (AFR). RESULTS: In all presented cases, improvement in the number and appearance of facial angiofibromas and erythema is noted. No scarring or adverse events were reported. CONCLUSION: The technique of electrosurgery, pulsed-dye laser treatment, and AFR represents a new and safe therapeutic option for treating facial angiofibromas associated with TS..
"Radiofrequency devices for body shaping: a review and study of 12 patients"Anolik, Robert; Chapas, Anne M; Brightman, Lori A; GERONEMUS, ROY G
Radiofrequency (RF) devices such as ThermaCool TC (Solta Medical Inc., Hayward, CA) offer a nonablative and noninvasive treatment option for unwanted skin concerns of the head, neck, and body. Relatively fewer studies address RF treatment on the body when compared with the head and neck. The purpose of this report is to investigate the use of the ThermaCool TC system with the novel Thermage Multiplex Tip for the enhancement of body shape. Additionally, this report will review the literature of RF technology with a concentration on body shaping. Twelve subjects underwent ThermaCool TC treatments using the Thermage Multiplex Tip. Waist circumference, standardized photographs, skin laxity score, global aesthetic improvement score, and patient satisfaction surveys were assessed at baseline and several follow-up visits after treatment. Average waist circumference and skin laxity scores decreased after ThermaCool TC treatment, using the Thermage Multiplex Tip at follow-up visits held at 1, 2, 4, and 6 months after treatment. Global aesthetic improvement score and patient satisfaction surveys reflected these objective clinical improvements. RF devices, such as the ThermaCool TC offer a nonablative and noninvasive treatment option for unwanted skin findings of the head, neck, and body.
"Ablative and fractional ablative lasers"Brightman, Lori A; Brauer, Jeremy A; Anolik, Robert; Weiss, Elliot; Karen, Julie; Chapas, Anne; Hale, Elizabeth; Bernstein, Leonard; GERONEMUS, ROY G
The field of nonsurgical laser resurfacing for aesthetic enhancement continues to improve with new research and technological advances. Since its beginnings in the 1980s, the laser-resurfacing industry has produced a multitude of devices employing ablative, nonablative, and fractional ablative technologies. The three approaches largely differ in their method of thermal damage, weighing degrees of efficacy, downtime, and side effect profiles against each other. Nonablative technologies generate some interest, although only for those patient populations seeking mild improvements. Fractional technologies, however, have gained dramatic ground on fully ablative resurfacing. Fractional laser resurfacing, while exhibiting results that fall just short of the ideal outcomes of fully ablative treatments, is an increasingly attractive alternative because of its far more favorable side effect profile, reduced recovery time, and significant clinical outcome..
"Improvement in arm and post-partum abdominal and flank subcutaneous fat deposits and skin laxity using a bipolar radiofrequency, infrared, vacuum and mechanical massage device"Brightman, Lori; Weiss, Elliot; Chapas, Anne M; Karen, Julie; Hale, Elizabeth; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND AND OBJECTIVES: Skin laxity of the body is a growing cosmetic concern. Laxity can result from chronological or photoaging and changes in body dimensions during pregnancy or weight loss. The end result is loose, sagging skin, and localized fat deposits. Liposuction and abdominoplasty or brachioplasty are established approaches to these issues. Patient desire for alternatives to surgical correction has spawned the development of non-invasive body contouring devices. The combination of infrared light (IR), bipolar radiofrequency (RF), vacuum and mechanical massage (Velashape, Syneron Medical Ltd, Israel) has demonstrated efficacy in improving skin appearance and circumference of the thighs [Goldberg et al., Derm Surg 2008; 34:204-209; Fisher et al., Derm Surg 2005; 31:1237-1241; Arnoczky and Aksan, J Am Acad Orthop Surg 2000; 8:305-313; Alster and Tanzi, J Cosmetic Laser Therapy 2005; 7:81-85; Wanitphakdeedecha and Manuskiatti, J Cosmet Dermatol 2006; 5:284-288; Nootheti et al., Lasers Surg Med 2006; 38: 908-912], but only anecdotal evidence has supported its use on other anatomic locations. This study was designed to evaluate the efficacy and safety of Velashape on additional body sites and more rigorously examine the technology's impact on upper arm as well as abdominal and flank circumference. STUDY DESIGN AND METHODS: Subjects were 28-70 years old, skin types I-V. Nineteen subjects underwent 5 weekly treatments of the upper arms, and 10 subjects underwent 4 weekly treatments of the abdomen and flanks. Treatments were performed using Velashape. Circumference measurements, photographs, and subject weights were performed prior to treatment and at 1- and 3-month follow-ups. Subjects were asked to record their treatment satisfaction level. RESULTS: Change in arm circumference, at the 5th treatment was statistically significant with a mean loss of 0.625 cm. At 1- and 3-month follow-ups, mean loss was 0.71 and 0.597 cm respectively. Reduction of abdominal circumference at 3rd treatment was statistically significant with a 1.25 cm mean loss. At 1- and 3-month follow-ups, average loss was 1.43 and 1.82 cm respectively. CONCLUSIONS: This study demonstrates with statistical significance, sustainable reduction in circumference and improvement in appearance of arms and abdomen following treatment with Velashape..
"Fractionated CO2 laser resurfacing: our experience with more than 2000 treatments"Hunzeker, Christopher M; Weiss, Elliot T; GERONEMUS, ROY G
Fractionated carbon dioxide (CO(2)) laser resurfacing combines the concept of fractional photothermolysis with an ablative 10,600-nm wavelength. This technology allows for the effective treatment of rhytides, photodamage, and scars, with shorter recovery periods and a significantly reduced side effect profile as compared to traditional CO(2) laser resurfacing. In this article, the authors review the concept of fractional photothermolysis, the expanding array of indications for use of fractionated CO(2) lasers, and their preferred treatment technique..
"Port wine stain progression: a potential consequence of delayed and inadequate treatment?"Minkis, Kira; GERONEMUS, ROY G; Hale, Elizabeth K
BACKGROUND AND OBJECTIVES: Port wine stains are congenital low-flow vascular malformations of the skin. Unlike hemangiomas, PWS do not involute with time, but rather if left untreated can hypertrophy and develop nodularity. Laser therapy of PWS particularly with pulsed-dye lasers, is a safe, well-established treatment that is successful in the majority of patients, especially for younger patients. Patients that fail to receive treatment early in life may subsequent develop lesions more likely to progress. STUDY DESIGN/PATIENTS AND METHODS: A case report and review of the literature are presented. We report a 43 year-old man born with a port-wine stain on the right side of his face that extended in the V2 distribution on his face. He had undergone several sessions with a pulsed-dye laser, the sequential dual-wavelength (595 nm and 1064 nm) laser and a CO2 resurfacing laser from the age of 26 but failed to follow through with a sufficient number of treatments to prevent hypertrophy. RESULTS: Due to an insufficient number and interval of treatments (with only 7 treatments over 16 years starting at age 26) with the various lasers, the patient's port wine stain continued to progress in color and development of nodularity. CONCLUSIONS: Patients born with port wine stains should have early laser treatment to achieve optimal results. Delay in treatment, as in this patient until age 26, may result in hard to treat PWS that can continue to progress in nodularity. This case illustrates the hypertrophy and nodularity that can occur due to progression of a PWS with failure to follow through with sufficient number of laser treatments.
"Outcomes of childhood hemangiomas treated with the pulsed-dye laser with dynamic cooling: a retrospective chart analysis"Rizzo, Carina; Brightman, Lori; Chapas, Anne M; Hale, Elizabeth K; Cantatore-Francis, Julie L; Bernstein, Leonard J; GERONEMUS, ROY G
BACKGROUND: Laser treatment of childhood hemangiomas remains controversial. Previous studies have used outdated technology, resulting in a potential overrepresentation of adverse outcomes. OBJECTIVE: To evaluate outcomes of hemangiomas treated with the most current laser technology. METHODS: A retrospective chart analysis of 90 patients with a median age of 3.0 months and a total of 105 hemangiomas were enrolled over a 2.5-year period. All were treated with the 595-nm long-pulse pulsed-dye laser (LP-PDL) with dynamic epidermal cooling at 2- to 8-week intervals depending on the stage of growth. Exclusion criteria were previous laser, surgical, or corticosteroid treatment. Three reviewers assessed outcomes. RESULTS: Near-complete or complete clearance in color were achieved for 85 (81%) and in thickness for 67 (64%) hemangiomas. There was no scarring or atrophy. Ulceration occurred in one case and resolved during treatment. Hyperpigmentation and hypopigmentation occurred in 4% and 14% of hemangiomas, respectively. CONCLUSION: Early treatment of childhood hemangiomas with the 595-nm LP-PDL with dynamic cooling may reduce the proliferative phase and result in excellent rates of clearing and few adverse events..
"Anemia treatment with Q2W darbepoetin alfa in patients with chronic kidney disease naive to erythropoiesis-stimulating agents"Silver, M R; GERONEMUS, R; Krause, M; Chen, C Y; Kewalramani, R; Stehman-Breen, C
GRANTS:M01 RR000080/RR/NCRR NIH HHS/United States;M01 RR000080-45/RR/NCRR NIH HHS/United States
OBJECTIVE: To evaluate the efficacy and safety of darbepoetin alfa dosed every-other-week (Q2W) to treat anemia in subjects with chronic kidney disease (CKD), not receiving dialysis, who were naive to erythropoiesis-stimulating agent (ESA) therapy. RESEARCH DESIGN AND METHODS: This was an open-label, multicenter, single-arm study enrolling ESA-naive CKD subjects with baseline hemoglobin (Hb) < 11.0 g/dL. Q2W darbepoetin alfa treatment was initiated at a dose of 0.75 microg/kg and titrated to achieve and maintain Hb levels at 11.0-13.0 g/dL. Treatment was administered from week 1 to week 19. MAIN OUTCOME MEASURES: The primary endpoint was the proportion of subjects who achieved Hb > or = 11 g/dL at any study visit, except in week 1. Hb levels, darbepoetin alfa dose, and safety were also assessed. RESULTS: Of the 128 subjects who received at least one dose of darbepoetin alfa and of the subjects who completed the study, 118 (92%) and 112 (97%), respectively, achieved a Hb > or = 11 g/dL in a median time of 5 weeks. Median darbepoetin alfa dose at week 1 and at the time of achieving a Hb > or = 11 g/dL were 60 and 80 microg, respectively. Darbepoetin alfa was well-tolerated, and short-term adverse events were consistent with those expected in CKD subjects. CONCLUSIONS: This study demonstrates that de novo Q2W darbepoetin alfa was effective in correcting and maintaining Hb levels in ESA-naive subjects with CKD who were not receiving dialysis. Study limitations, including lack of a control arm for the study and multiple race information for subjects, must be considered in interpreting the results. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT00112008..
"What lies beneath? A lesson for the clinician. Intraoperative frozen section appearance of persistent basal cell carcinoma after apparent cure with imiquimod 5% cream"Sukal, Sean A; Mahlberg, Matthew J; Brightman, Lori; Daniel, David R; Mintzis, Medwin M; GERONEMUS, ROY G
"Three-dimensional surface imaging for clinical trials: improved precision and reproducibility in circumference measurements of thighs and abdomens"Weiss, Elliot T; Barzilai, Ori; Brightman, Lori; Chapas, Anne; Hale, Elizabeth; Karen, Julie; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND AND OBJECTIVES: Numerous body contouring and laser-assisted liposuction devices have recently obtained or are seeking FDA clearance, and assessment of efficacy of these devices is largely based upon qualitative comparisons of before and after photographs and measurable changes in patient circumference. The current standard for measuring body circumference in clinical trials involves the use of a standard measuring tape. These manual measurements introduce human error and may incorrectly support or refute a device or procedure's efficacy. A promising alternative to manual measurements is three-dimensional (3D) photography. This technology allows circumference measurements to be performed on 3D digital models. Our objective is to compare the precision and reproducibility of manual versus 3D photographic measurement of body circumference. STUDY DESIGN/MATERIALS AND METHODS: Thirty subjects completed this IRB approved study. Each subject's thighs and abdomen were measured twice by each of two blinded investigators and twice by the 3D system. RESULTS: For right and left thigh circumference, the variance of the replication errors [measurement 1-measurement 2] for the human investigators was 20.5% larger than the variance for the 3D photography system. For abdominal circumference, the variance for the human investigators was 231.3% larger than the variance for the 3D system. CONCLUSIONS: 3D photography is a valuable tool that enables investigators to reliably detect minute changes in body shape; consequently, 3D photography reduces the number of subjects needed to sufficiently power a clinical study. For studies involving abdominal circumference, utilizing 3D photography reduces the number of subjects needed by 1/2 to 2/3..
"Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing"Chapas, Anne M; Brightman, Lori; Sukal, Sean; Hale, Elizabeth; Daniel, David; Bernstein, Leonard J; GERONEMUS, ROY G
BACKGROUND: Acneiform scarring after severe episodes of acne is a common cosmetic concern, treatable by a variety of modalities with varying degrees of success. Ablative CO(2) laser resurfacing, while effective, is associated with an undesirable side effects profile, lengthy recovery period, and risk of infection as well as potential pigmentary alterations. Newer modalities using the principles of fractional photothermolysis (FP) create patterns of tiny microscopic wounds surrounded by undamaged tissue beneath the skin with an erbium-doped 1,550 nm laser. These devices produce more modest results in many cases than traditional carbon dioxide (CO(2)) lasers but with fewer side effects and shorter recovery periods. A novel ablative 30 W CO(2) laser device uses a technique called ablative fractional resurfacing (AFR), combines CO(2) ablation with a FP system. METHODS: Thirteen subjects (skin types I-IV, aged 28-58 years) with moderate to severe acne scars underwent two or three treatments with the AFR device at 1-2 months intervals. Post-treatment erythema and edema as well as improvements in texture, atrophy, and overall satisfaction with appearance were graded on a quartile scale by subjects and investigators after each treatment and 1 and 3 months after the final treatment. Petechiae, oozing and crusting, dyschromia, and scarring were graded as present or absent 3 days, 1 week, 1 month, and 3 months following each treatment. A three-dimensional optical profiling system (Primos imaging) was used to generate a high resolution topographic representation of the acneiform scar in order to measure the depths of 10 scars from each cheek prior to the first treatment and 3 months after the last treatment. RESULTS: Post-treatment side effects were mild to moderate and transient, resolving rapidly within the study period. No delayed onset hypo-pigmentation or permanent scarring was observed. Quartile grading scores correlating to at least 26-50% improvements in texture, atrophy, and overall improvement were noted in all patients. Primos topographic analysis showed that all patients had quantifiable objective improvement in the depths of acneiform scars that ranged from 43% to 79.9% with a mean level of improvement of 66.8%. CONCLUSION: Successfully combining ablative technology with FP, AFR treatments constitute a safe and effective treatment modality for acneiform scarring.
"Topical methyl-aminolevulinate photodynamic therapy using red light-emitting diode light for treatment of multiple actinic keratoses: A randomized, double-blind, placebo-controlled study"Pariser, David; Loss, Robert; Jarratt, Michael; Abramovits, William; Spencer, James; GERONEMUS, ROY; Bailin, Philip; Bruce, Suzanne
BACKGROUND: The use of light-emitting diode light offers practical advantages in photodynamic therapy (PDT) with topical methyl-aminolevulinate (MAL) for management of actinic keratoses (AK). OBJECTIVE: We sought to evaluate the efficacy of MAL PDT using red light-emitting diode light. METHODS: We conducted a multicenter, double-blind, randomized study. A total of 49 patients with 363 AK lesions had 16.8% MAL cream applied under occlusion for 3 hours, and 47 patients with 360 AK lesions had vehicle cream similarly applied. The lesions were then illuminated (630 nm, light dose 37 J/cm2) with repeated treatment 1 week later. Complete lesion and patient (all lesions showing complete response) response rates were evaluated 3 months after last treatment. RESULTS: MAL PDT was superior (P<.0001) to vehicle PDT with respect to lesion complete response (86.2% vs 52.2%, odds ratio 6.9 [95% confidence interval 4.7-10.3]) and patient complete response (59.2% vs 14.9%, odds ratio 13.2 [95% confidence interval 4.1-43.1]). LIMITATIONS: The study population may not be representative of all patients with AK. CONCLUSION: MAL PDT using red light-emitting diode light is an appropriate treatment alternative for multiple AK lesions..
"The safety and efficacy of fractional photothermolysis for the correction of striae distensae"Stotland, Mira; Chapas, Anne M; Brightman, Lori; Sukal, Sean; Hale, Elizabeth; Karen, Julie; Bernstein, Leonard; GERONEMUS, ROY G
BACKGROUND: Improving the appearance of striae distensae, particularly striae alba, has remained a challenge due to the limited availability of effective and low-risk treatment options. Fractional photothermolysis, a novel concept in skin rejuvenation, has been reported to be effective in the treatment of facial rhytides, acne scars, and surgical scars, but its use in the treatment of striae has not been well studied. OBJECTIVE: To determine the safety and efficacy of fractional photothermolysis treatment on striae alba and striae rubra. METHODS: Twenty female patients with striae rubra or striae alba on their abdomen, thighs, or buttocks were enrolled in the study. Lesions were randomized to receive treatment, with site-matched normal control areas. Patients received a total of 6 treatments using a 1550-nm, erbium-doped fiber laser with 2 to 3 weeks of elapsed time between treatments. Clinical response to treatment was assessed at each visit, and at 1-month, 2-month, and 3-month follow-up intervals by the patient and investigator. A comparison evaluation of 8 patients examining photographs of striae at baseline and at the 3-month follow-up evaluation which was assessed by 4 independent dermatologists using the quartile grading scale. RESULTS: The independent evaluators' assessments of improvement from photographs of 8 randomly selected patients showed an overall improvement of 26% to 50% in 63% (5/8) of patients. A less than 25% improvement in dyschromia was noted in 50% (4/8) of patients. An improvement in texture of 26% to 50% was observed in 50% (4/8) of patients. The clinical responses were independent of age, gender, and skin phototype. The treatments were tolerated well by all patients with a majority of patients experiencing transient posttreatment erythema and edema. CONCLUSION: Fractional photothermolysis can be effectively and safely used in the treatment of striae rubra and striae alba.
"Eyelid tightening and improved eyelid aperture through nonablative fractional resurfacing"Sukal, Sean A; Chapas, Anne M; Bernstein, Leonard J; Hale, Elizabeth K; Kim, Karen H; GERONEMUS, ROY G
BACKGROUND AND OBJECTIVE: The effects of fractional resurfacing on eyelid tightening and aperture are unknown. Our purpose was to retrospectively examine the potential for eyelid tightening and eye-aperture opening in patients treated with nonablative fractional resurfacing for facial photorejuvenation. STUDY DESIGN/MATERIALS AND METHODS: Fractional laser treatments using a 1,550-nm erbium-doped fiber laser system on the upper and lower eyelids were given at a pulse energy of 17 to 20 mJ at 125 micro-thermal zones (MTZ)/cm(2) to a final density of 500 to 750 MTZ/cm(2). Each patient had 3 to 7 treatments. Standard pre- and post-treatment photographs were taken at each visit. Physicians who graded 31 preselected patient photographs using a 4-point scale evaluated eyelid tightening. Increase in eyelid aperture was also evaluated. RESULTS: All patients had some degree of eyelid tightening; 19% achieved 1% to 25% tightening, 26% achieved 25% to 50%, 26% achieved 50% to 75%, and 29% achieved 75% to 100%. Increase in eyelid aperture was seen in 55.9% of patients. Postoperative wounding, hypopigmentation, hyperpigmentation, persistent erythema, and scarring were not observed. All patients experienced mild or no edema for a few days after treatment. CONCLUSION: Fractional resurfacing tightens and increases eyelid aperture without wounding, downtime, or long-term complications.
"Fractional photothermolysis"Sukal, Sean A; GERONEMUS, ROY G
"Thermage: the nonablative radiofrequency for rejuvenation"Sukal, Sean A; GERONEMUS, ROY G
Thermage is a noninvasive nonablative device that uses monopolar radiofrequency energy to bulk heat underlying skin while protecting the epidermis to produce skin tightening. It is used for the treatment of rhytids on the face including the periorbital region and lower face, and more recently, for off-face applications. Studies have shown that it can impart mild tightening of periorbital mid, and lower facial laxity. Other radiofrequency devices have also shown objective improvements in cellulite of the buttocks and thigh regions. Thermage is an efficacious and safe nonsurgical alternative for treating mild skin laxity.
"Efficacy of early treatment of facial port wine stains in newborns: a review of 49 cases"Chapas, Anne M; Eickhorst, Kimberly; GERONEMUS, ROY G
BACKGROUND: Port wine stains (PWS) affect 0.3-0.5% of both sexes of newborns, usually occurring on the face. OBJECTIVE: To document safety and effectiveness of cryogen spray cooled, pulsed-dye laser at higher fluences than previously used to lighten facial PWS in infants < or =6 months, and establish that frequent treatment early in life yields better clearance than if delayed until later in life. MATERIALS AND METHODS: Forty-nine infants who had been treated with pulsed-dye laser treatments for facial PWS at < or =6 months were identified by case review of photographs, age, sex, PWS severity score prior to laser treatment, number of treatments, and improvement following laser therapy. RESULTS: Patients averaged 9.3 (range 2-16) treatments at 4-6 week intervals at 7.75-9.5 J/cm(2). Average surface area treated was 24.0% with 88.6% average clearance after 1 year. Average clearance was 90.7% for lesions covering <20% surface area and 85.6% for lesions > or =20%. Location (V1, V2, V3, eye, and/or scalp), treated surface area, treatment number, and fluence predicted clearance. Average clearance for sole involvement of V1 was highest (at 93.8%), followed by V2 (at 91.1%), V3 (at 84.3%), V1/V2 (at 83.7%), V1/V2/V3 (at 81.0%), periocular (at 88.6%), and scalp (at 89.9%). All patients tolerated the higher treatment fluences without atrophy or scarring. DISCUSSION/CONCLUSIONS: Frequent, high energy pulsed-dye laser treatments are safe and highly effective in improving facial PWS in infants < or =6 months of age. Patients with PWS should be referred for pulsed-dye laser treatment during early infancy.