Lasers in Surgery and Medicine 46:73–74 (2014)
Introduction Introduction to Clinical Section Mathew M. Avram, MD, JD MGH Dermatology Laser & Cosmetic Center, Massachusetts General Hospital, Boston, Massachusetts It is our distinct pleasure to serve as Guest Editors for this Special Issue in Dermatology and Plastic Surgery of Lasers in Surgery and Medicine. Dr. Jalian and I have selected papers that highlight new advances in our field, provide evidence-based support for optimization of current treatment protocols, and shed light onto controversial, emerging treatment modalities in energy-based device medicine. This issue would not be possible without the contributions of those clinicians and scientists who chose LSM to display their innovative work. It’s a testament to Dr. Stuart Nelson and the high quality of LSM for continually publishing high-impact work with significant clinical implications. We would also like to acknowledge the tireless work of Beth Mallen, who was integral to the organization of this special issue. The clinical section of this issue contains several, high quality, evidence-based publications. Two of these publications involve the use of cryolipolysis and radiofrequency for body contouring. Cryolipolysis is the noninvasive removal of fat with controlled cooling. Many studies have demonstrated clinical efficacy, but none have offered objective, quantifiable evidence for volumetric fat reduction. In this issue, Garibyan et al. provide the first quantitative report of fat reduction after cryolipolysis treatment of the flanks. Eleven subjects underwent a single treatment cycle of a love handle. The contralateral side served as a control. Three-dimensional photographs were compared before and 2 months post-treatment for volumetric analysis in the treatment and control sites. A mean difference of nearly 40 cc was noted when comparing the treated to the untreated side. This was corroborated by other clinical measures such as caliper measurements and blinded investigator evaluations. With numerous noninvasive fat devices inundating the market, objective measurements of fat reduction is imperative to be able to independently verify efficacy while minimizing investigator error and bias. This study utilizing 3D photography introduces a convenient, user-friendly tool for volumetric reduction and should be used in future studies on noninvasive fat reduction. Non-invasive fat reduction with radiofrequency based devices has recently also gained popularity. Boisnic et al. report findings treating abdominal adiposity using a novel suction based, radiofrequency heating device. Twenty-four subjects underwent once weekly treatment of the abdomen for six weeks. Investigators report statistically significant reduction in abdominal circumference and abdominal tissue thickness 3 months following the final treatment. Biopsy specimens ß 2014 Wiley Periodicals, Inc.
demonstrate distorted adipocyte architecture as well as increased collagen synthesis. This study demonstrates the clinical efficacy of this RF device for body contouring with minimal side effects. Bernstein et al. investigated the use of a 532 nm KTP laser with contact cooling for the treatment of leg veins in a single center, prospective, uncontrolled study. Twentyseven subjects underwent two treatments, performed twelve weeks apart. Improvement was assessed by two blinded, independent physicians before and 12 weeks following the second treatment using a 5-point scale. In addition to a median improvement of 2.5 on the 5 point scale, 75% percent of subjects reported significant (75– 100%) improvement. Adverse effects were limited to hyperpigmentation in 2% of the sites and the procedure was well-tolerated by all subjects. The 532 nm KTP laser was found to be safe and effective and could be an adjunctive treatment to sclerotherapy for smaller, resistant vessels. Both ablative and non-ablative fractional resurfacing have proven clinical efficacy for the treatment of atrophic acne scars. While a series of treatment is often required, the ideal interval between these treatments has never been delineated. Bjorn et al. conducted a split face study investigating the efficacy of ablative fractional carbon dioxide laser on the atrophic acne scarring. Subjects underwent two treatments at either 1- or 3-month intervals. Investigators reported no significant difference at either 1 month or 6 months post-operative treatment between to the treatment sides. The authors conclude that fractional CO2 resurfacing improves atrophic scars and the treatment interval of 1-month versus 3-month does not influence outcome. Skin pigmentation, whether constitutive (inherent to skin phototype) or facultative (UV induced, or tanned) is thought to interfere with pigment selective treatments, such as hair removal, often increasing the risk of adverse events. No clinical study has sought to systematically investigate the role of natural versus UV-induced skin pigmentation on the incidence of adverse effects related to low fluence intense pulsed light (IPL) treatments. Correspondence to: Mathew M. Avram, MD, JD, MGH Dermatology Laser & Cosmetic Center, Massachusetts General Hospital, Boston, MA.
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22237
74
AVRAM
Thaysen-Petersen and colleagues report that the incidence of adverse events were related to increasing IPL fluence and did not appear to differ significantly based on the origin (natural versus UV induced) of pigmentation. Viral warts are one of the most common skin complaints for pediatricians and dermatologists. While numerous treatment modalities exist, a subset of lesions are recalcitrant to conventional treatments. The pulsed dye laser (PDL) has historical utility in the treatment of warts by selectively targeting the vasculature of the wart and causing tissue necrosis. Many clinicians combine various treatment regimens in order to boost treatment response. Dobson et al. report the combination of PDL and intralesional bleomycin. In a retrospective case series with mean follow-up of 24 months, 60% of subjects had complete response and 15% had partial response. Repeat treatment and injectable anesthesia, which allowed for more aggressive treatment, were associated with higher rates of clinical clearance. While not a first line treatment, this combination approach offers a novel, alternative treatment approach for recalcitrant warts.
Despite numerous topical therapies, topical treatments for the very common condition of onychomycosis are limited in efficacy. While oral therapies are more effective, they are limited by side effects such as liver toxicity; recurrence is an issue as well. Clearly, there is a need for alternative treatments that are both effective and safe. Ortiz et al. review the emerging field of laser and energybased treatments for the treatment of onychomycosis. Currently, laser and light source based treatments are shrouded in controversy as to their efficacy. Clear data and well-designed studies are wanting. This article provides a much-needed review and critical analysis of the current literature in an effort to clarify where we currently stand with regard to these treatments. We hope you found these studies provocative and a meaningful addition to your clinical practice. The findings of many of these studies have direct impact on patient care and can provide meaningful improvement to our clinical practices. It is fortunate to have a special forum to be able to highlight creative, innovative studies such as those contained in this issue.
Introduction Introduction to Clinical Section Mathew M. Avram, MD, JD MGH Dermatology Laser & Cosmetic Center, Massachusetts General Hospital, Boston, Massachusetts It is our distinct pleasure to serve as Guest Editors for this Special Issue in Dermatology and Plastic Surgery of Lasers in Surgery and Medicine. Dr. Jalian and I have selected papers that highlight new advances in our field, provide evidence-based support for optimization of current treatment protocols, and shed light onto controversial, emerging treatment modalities in energy-based device medicine. This issue would not be possible without the contributions of those clinicians and scientists who chose LSM to display their innovative work. It’s a testament to Dr. Stuart Nelson and the high quality of LSM for continually publishing high-impact work with significant clinical implications. We would also like to acknowledge the tireless work of Beth Mallen, who was integral to the organization of this special issue. The clinical section of this issue contains several, high quality, evidence-based publications. Two of these publications involve the use of cryolipolysis and radiofrequency for body contouring. Cryolipolysis is the noninvasive removal of fat with controlled cooling. Many studies have demonstrated clinical efficacy, but none have offered objective, quantifiable evidence for volumetric fat reduction. In this issue, Garibyan et al. provide the first quantitative report of fat reduction after cryolipolysis treatment of the flanks. Eleven subjects underwent a single treatment cycle of a love handle. The contralateral side served as a control. Three-dimensional photographs were compared before and 2 months post-treatment for volumetric analysis in the treatment and control sites. A mean difference of nearly 40 cc was noted when comparing the treated to the untreated side. This was corroborated by other clinical measures such as caliper measurements and blinded investigator evaluations. With numerous noninvasive fat devices inundating the market, objective measurements of fat reduction is imperative to be able to independently verify efficacy while minimizing investigator error and bias. This study utilizing 3D photography introduces a convenient, user-friendly tool for volumetric reduction and should be used in future studies on noninvasive fat reduction. Non-invasive fat reduction with radiofrequency based devices has recently also gained popularity. Boisnic et al. report findings treating abdominal adiposity using a novel suction based, radiofrequency heating device. Twenty-four subjects underwent once weekly treatment of the abdomen for six weeks. Investigators report statistically significant reduction in abdominal circumference and abdominal tissue thickness 3 months following the final treatment. Biopsy specimens ß 2014 Wiley Periodicals, Inc.
demonstrate distorted adipocyte architecture as well as increased collagen synthesis. This study demonstrates the clinical efficacy of this RF device for body contouring with minimal side effects. Bernstein et al. investigated the use of a 532 nm KTP laser with contact cooling for the treatment of leg veins in a single center, prospective, uncontrolled study. Twentyseven subjects underwent two treatments, performed twelve weeks apart. Improvement was assessed by two blinded, independent physicians before and 12 weeks following the second treatment using a 5-point scale. In addition to a median improvement of 2.5 on the 5 point scale, 75% percent of subjects reported significant (75– 100%) improvement. Adverse effects were limited to hyperpigmentation in 2% of the sites and the procedure was well-tolerated by all subjects. The 532 nm KTP laser was found to be safe and effective and could be an adjunctive treatment to sclerotherapy for smaller, resistant vessels. Both ablative and non-ablative fractional resurfacing have proven clinical efficacy for the treatment of atrophic acne scars. While a series of treatment is often required, the ideal interval between these treatments has never been delineated. Bjorn et al. conducted a split face study investigating the efficacy of ablative fractional carbon dioxide laser on the atrophic acne scarring. Subjects underwent two treatments at either 1- or 3-month intervals. Investigators reported no significant difference at either 1 month or 6 months post-operative treatment between to the treatment sides. The authors conclude that fractional CO2 resurfacing improves atrophic scars and the treatment interval of 1-month versus 3-month does not influence outcome. Skin pigmentation, whether constitutive (inherent to skin phototype) or facultative (UV induced, or tanned) is thought to interfere with pigment selective treatments, such as hair removal, often increasing the risk of adverse events. No clinical study has sought to systematically investigate the role of natural versus UV-induced skin pigmentation on the incidence of adverse effects related to low fluence intense pulsed light (IPL) treatments. Correspondence to: Mathew M. Avram, MD, JD, MGH Dermatology Laser & Cosmetic Center, Massachusetts General Hospital, Boston, MA.
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22237
74
AVRAM
Thaysen-Petersen and colleagues report that the incidence of adverse events were related to increasing IPL fluence and did not appear to differ significantly based on the origin (natural versus UV induced) of pigmentation. Viral warts are one of the most common skin complaints for pediatricians and dermatologists. While numerous treatment modalities exist, a subset of lesions are recalcitrant to conventional treatments. The pulsed dye laser (PDL) has historical utility in the treatment of warts by selectively targeting the vasculature of the wart and causing tissue necrosis. Many clinicians combine various treatment regimens in order to boost treatment response. Dobson et al. report the combination of PDL and intralesional bleomycin. In a retrospective case series with mean follow-up of 24 months, 60% of subjects had complete response and 15% had partial response. Repeat treatment and injectable anesthesia, which allowed for more aggressive treatment, were associated with higher rates of clinical clearance. While not a first line treatment, this combination approach offers a novel, alternative treatment approach for recalcitrant warts.
Despite numerous topical therapies, topical treatments for the very common condition of onychomycosis are limited in efficacy. While oral therapies are more effective, they are limited by side effects such as liver toxicity; recurrence is an issue as well. Clearly, there is a need for alternative treatments that are both effective and safe. Ortiz et al. review the emerging field of laser and energybased treatments for the treatment of onychomycosis. Currently, laser and light source based treatments are shrouded in controversy as to their efficacy. Clear data and well-designed studies are wanting. This article provides a much-needed review and critical analysis of the current literature in an effort to clarify where we currently stand with regard to these treatments. We hope you found these studies provocative and a meaningful addition to your clinical practice. The findings of many of these studies have direct impact on patient care and can provide meaningful improvement to our clinical practices. It is fortunate to have a special forum to be able to highlight creative, innovative studies such as those contained in this issue.
