1Dermatology BulletinVolume 20 No: 2 2009
␣
A Bulletin to Promote Education and Research in Dermatology
DERMATOLOGY BULLET...
2 Volume 20 No: 2 2009 Dermatology Bulletin2 Volume 20 No: 2 2009 Dermatology Bulletin
3Dermatology BulletinVolume 20 No: 2 2009
Light Therapies For Acne
Dr Chua Sze Hon*
Introduction
M
edical therapy remains ...
4 Volume 20 No: 2 2009 Dermatology Bulletin
Light Therapies For Acne
Lee, et al (2007) investigated the efficacy of combine...
5Dermatology BulletinVolume 20 No: 2 2009
Light Therapies For Acne
4. Bernstein EF. Double-pass, low-fluence laser treatmen...
6 Volume 20 No: 2 2009 Dermatology Bulletin
Unwanted Hair Removal – An Update
Dr Priya Sen
Background
H
air removal has be...
7Dermatology BulletinVolume 20 No: 2 2009
Fig 1. Facial hair reduction with the long-pulsed Nd:YAG laser
Before Treatment ...
8 Volume 20 No: 2 2009 Dermatology Bulletin
Laser Parameters
1. Pulse width – Published studies have shown that
longer pul...
9Dermatology BulletinVolume 20 No: 2 2009
A Retrospective Review Of Mohs Micrographic Surgery Performed
At The National Sk...
10 Volume 20 No: 2 2009 Dermatology Bulletin
The processed slides is presented back to the dermatologist/
mohs surgeon for...
11Dermatology BulletinVolume 20 No: 2 2009
Clinical Outcomes In Patients With Incomplete Mohs Excisions
For Periocular Non...
12 Volume 20 No: 2 2009 Dermatology Bulletin
transferred so that anatomical orientation was maintained.
The tissue layer w...
13Dermatology BulletinVolume 20 No: 2 2009
sebaceous gland carcinoma in the remaining patient.
Six patients, (two BCC, fou...
14 Volume 20 No: 2 2009 Dermatology Bulletin
Periocular non melanoma skin cancer
occurred in one of the six patients manag...
15Dermatology BulletinVolume 20 No: 2 2009
Fractional Ablative Skin Resurfacing With A Novel Carbon Dioxide
Laser System I...
16 Volume 20 No: 2 2009 Dermatology Bulletin
areas and the surrounding skin. Only one treatment session
was performed.
Pos...
17Dermatology BulletinVolume 20 No: 2 2009
Fractional CO2
laser treatment of atrophic acne scars
Table 1 Patient subjectiv...
18 Volume 20 No: 2 2009 Dermatology Bulletin
Adverse effects were short lived and self-limiting. Erythema
is the most comm...
19Dermatology BulletinVolume 20 No: 2 2009
fractional CO2
resurfacing, which is a less aggressive form
of laser resurfacin...
20 Volume 20 No: 2 2009 Dermatology Bulletin
Body Dysmorphic Disease In Patients Attending
An Aesthetic Dermatology Clinic...
21Dermatology BulletinVolume 20 No: 2 2009
24 patients were recruited for the study. Their cosmetic
problems included faci...
22 Volume 20 No: 2 2009 Dermatology Bulletin
Body dysmorphic disease – a prevalence study
Our preliminary study suggests a...
23Dermatology BulletinVolume 20 No: 2 2009
Side Effects And Complications Of Fractional Carbon Dioxide Laser
Photothermoly...
24 Volume 20 No: 2 2009 Dermatology Bulletin
Table 1.
IV V VI
Number of treatments 187 10 4
Number of patients, n, (percen...
25Dermatology BulletinVolume 20 No: 2 2009
has shown that fractional photothermolysis is a safe
treatment modality in dark...
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DERMATOLOGY BULLETIN

  1. 1. 1Dermatology BulletinVolume 20 No: 2 2009 ␣ A Bulletin to Promote Education and Research in Dermatology DERMATOLOGY BULLETIN Institute Of Dermatology, Singapore Procedural Dermatology MICA (P) NO. 102/09/2009 VOLUME 20 NO: 2 2009 Invited Article 3 Light Therapies For Acne. Dr Chua Sze Hon 6 Unwanted Hair Removal – An Update. Dr Priya Sen Original Articles 9 A Retrospective Review of Mohs Micrographic Surgery Performed At The National Skin Centre, Singapore Dr Tan Wee Ping, Dr Heng Yee Kiat. Dr Melvin Ee Hock Leong 11 Clinical Outcomes In Patients With Incomplete Mohs Excisions For Periocular Non Melanoma Skin Cancer. Dr Melvin Ee Hock Leong, Dr Nabeel Malik, Dr Raman Malhotra, Dr Richard Collin, Dr Naresh Joshi, Dr Jane Olver, Dr Richard Barlow 15 Fractional Ablative Skin Resurfacing With A Novel Carbon Dioxide Laser System In The Treatment Of Atrophic Acne Scars In Asian Skin. Dr Melvin Ee Hock Leong, Dr Chua Sze Hon, Dr Tan Sze-Chin, Dr Priya Sen, Clin Prof Goh Chee Leok 20 Body Dysmorphic Disease In Patients Attending An Aesthetic Dermatology Clinic At The National Skin Centre – A Preliminary Prevalence Study. Clin Prof Goh Chee Leok, Dr Chua Sze Hon, Dr Priya Sen, Dr Melvin Ee Hock Leong 23 Side Effects And Complications Of Fractional Carbon Dioxide Laser Photothermolysis: Experience With 201 Treatments. Dr Tan Wee Ping, Dr Melvin Ee Hock Leong, Dr Priya Sen, Clin Prof Goh Chee Leok, Dr Chua Sze Hon Case Reports 26 A Case Of Microcystic Adnexal Carcinoma Treated With Mohs Micrographic Surgery. Dr Raymond Kwah Yung Chien, Dr Tan Suat Hoon, Dr Ong Beng Hock, Dr Melvin Ee Hock Leong 29 Management Of Extramammary Paget’s Disease With Moh’s Micrographic Surgery. Dr Raymond Kwah Yung Chien, Dr Tan Suat Hoon, Dr Wong Siew Ngoh, Dr Ong Beng Hock, Dr Melvin Ee Hock Leong 32 Gorlin Syndrome-related Basal Cell Carcinoma Treated With Mohs Micrographic Surgery. Dr Lee Ee Ching, Dr Melvin Ee Hock Leong, Dr Tan Suat Hoon Surgical Reconstruction 35 Burow’s Graft In The Reconstruction Of Nasal Side Wall. Dr Tan Wee Ping, Dr Melvin Ee Hock Leong 37 Nasal Reconstruction With A Local Flap. Dr Raymond Kwah Yung Chien, Dr Melvin Ee Hock Leong 40 Island Pedicle Flap For The Repair Of Defect Of The Upper Lateral Cutaneous Lip. Dr Tan Mei Ling, Dr Melvin Ee Hock Leong 42 Pivotal Advancement Flap In The Reconstruction Of A Medial Cheek And Nasojugal Defect. Dr Tan Wee Ping, Dr Melvin Ee Hock Leong Joint Teaching Seminar 44 Report On An In-House Joint Teaching Seminar On Oral Cavity Symposium. Dr Hazel Oon Hwee Boon STI Update 46 Update On Diagnostic Testing In Sexually Transmitted Infections. Dr Priya Sen Pharmacy Page 49 Hyaluronic Acid In Dermatology. Ms Elizabeth Tian
  2. 2. 2 Volume 20 No: 2 2009 Dermatology Bulletin2 Volume 20 No: 2 2009 Dermatology Bulletin
  3. 3. 3Dermatology BulletinVolume 20 No: 2 2009 Light Therapies For Acne Dr Chua Sze Hon* Introduction M edical therapy remains the 1st line treatment of acne vulgaris. However, while effective, growing concerns over antibiotic resistance with the use of topical and systemic antibiotics, and potential serious adverse effects with the use of systemic isotretinoin have led physicians to explore alternative acne therapies. Of these, lasers and other light sources, including photodynamic therapy (PDT), have been shown to be safe and effective and may play an increasing role in the future management of inflammatory acne. Lasers and light sources that have been developed to treat inflammatory acne act primarily in two ways: 1. Destroy the sebaceous gland, and 2. Kill Propionibacterium acnes (P. acnes) via the photo-activation of endogenous porphyrins. 1. Lasers Lasers are able to clear inflammatory acne vulgaris by targeting and destroying sebaceous glands. Most studies have been done using the near-infrared 1450nm diode laser. Near-infrared lasers target water, which is the dominant chromophore in the sebaceous glands. Paithankar, et al (2002) used the 1450nm diode laser with a cryogen spray in 27 patients. Inflammatory truncal acne was targeted. Results after 4 treatments spaced 3 weeks apart showed a 98% reduction in inflammatory acne lesions.1 Friedman, et al (2004) performed an open trail with 19 patients with facial inflammatory acne using the 1450nm diode laser and found progressive clinical improvements with multiple treatments. Lesion counts decreased 37% after one treatment, 58% after two treatments, and 83% after three treatments.2 Jih, et al (2006) treated 20 patients in a split-face study with 3 sessions of the 1450nm diode laser at 3-4 week intervals. High fluences were used (14 or 16 J/cm2 ). Clinical improvements were observed after the 1st treatment and after 3 treatments; there was reduction in mean acne lesion counts of 75.1% (14 J/cm2 ) and 70.6% (16 J/cm2 ). Significant long-term remission up to 12 months was reported.3 Treatment with high fluences (14-16J/cm2 ) of the 1450nm diode laser often results in significant pain experienced by the patient. In the attempt to reduce the pain during treatment, Bernstein, et al (2009) used 2 passes employing low fluences (averaging 7.8 J/cm) and a larger 12mm spot for treatment. The authors found significant clinical improvements in 8/11 patients and subjective reduction in skin oiliness. Acne counts were 67% lower after the 4th treatment.4 The effectiveness of using low-energy, double- pass treatment protocol was also verified by Noborio, et al (2009). The authors treated 30 Japanese patients in an open study and found significant clinical improvements in the 27 patients who completed the study.5 Chi, et al (2009) treated 26 patients (skin phototypes IV–V) with 3 passes of the 1450nm diode laser using a low fluence of 8 J/cm2 with dynamic cooling of 25ms to minimize PIH. After 4 treatment sessions, in the group with moderate acne, a mean reduction of 40% in inflammatory acne was reported 6 months after the last treatment.6 2. Phototherapy The basis of phototherapy of acne centres on the production of porphyrins (especially coproporphyrin III) by P. acnes. The mechanism of action involves the photo- excitation of the P. acnes porphyrins after exposure to the appropriate light source and the subsequent formation of singlet oxygen within the microorganism itself which results in destruction of the bacteria. The major absorption peak for these porphyrins is in the blue range of the visible light spectrum around 405-420nm (Soret band). A second absorption peak occurs in the red range of the visible light spectrum at around 620-660nm. These major absorption peaks have led to the development of light devices utilizing either blue or red light for the treatment of inflammatory acne. Blue light Several trials involving blue light have been reported in the literature. Papageorgiou, et al (2000) compared a daily mixed blue and red light phototherapy system (415nm and 660nm) with either blue light or white light applied 15 minutes daily for 12 weeks. The combination of blue and red light reduced inflammatory acne vulgaris lesions by 76% vs. 58% in the blue light only group. Both were superior to white light (25%).7 Tzung, et al (2004) attempted to determine the profile of a good candidate for blue light acne phototherapy. The authors performed a split-face study on 31 Asian patients with inflammatory facial acne. Clinical improvements after blue light irradiation were verified; success in treatment was not dependent on gender, scar type, pore size or pretreatment facial follicular porphyrin fluorescence intensity. They found that nodulocystic lesions tended to worsen despite treatment and suggested that patients without nodulocystic lesions were better candidates for blue light irradiation.8 INVITED ARTICLE 1 * Senior Consultant Dermatologist, National Skin Centre
  4. 4. 4 Volume 20 No: 2 2009 Dermatology Bulletin Light Therapies For Acne Lee, et al (2007) investigated the efficacy of combined blue and red light-emitting diode (LED) phototherapy for acne vulgaris. The authors conducted an open trial involving 24 patients with a LED device emitting alternating blue (415 nm) and red (633 nm) light. Improvements in both inflammatory as well as non-inflammatory acne lesions were reported with greater improvements seen in the inflammatory lesions (77.93% c/w 34.28%). Secondary benefits included brightened skin tone and improved skin texture in 14/24 patients.9 Noborio, et al (2007) treated 10 Japanese patients with inflammatory acne with targeted blue light phototherapy using the MultiClear. Of the 10 patients, eight had a significantly reduced acne severity score without any side effects, while 2 patients discontinued the study because of unsatisfactory results.10 Red light While less favoured as a light source for mono-phototherapy of inflammatory acne due to poorer absorption by P. acnes porphyrins, red light has nevertheless also been shown to be effective in the treatment of inflammatory acne. Na, et al (2007) treated 28 patients with a portable red light-emitting device for 15 minutes twice a day for 8 weeks. In this split-face trial, randomized trial, statistical improvements were noted on the treated side compared to the untreated control side at week 8.11 Zane, et al (2008) demonstrated a significant improvement of acne lesions and a significant decrease of skin sebum excretion and TEWL of the face in patients (n=15) treated with broad-band red (600-750 nm) light twice weekly for 4 weeks.12 3. PDT Photodynamic therapy (PDT) is a non-invasive therapy that utilizes light treatments along with an application of a photosensitizing agent such as 5-aminolevulinic acid (ALA) or methyl aminolaevulinate (MAL). The photosensitizing agent accumulates in the pilosebaceous unit after being applied topically and incubated for a period of time (75min –180 min).13 This is followed by the administration of light treatment to induce the photodynamic reaction. PDT in the treatment of inflammatory acne works via several mechanisms including killing of P. acnes following photo-excitation of endogenous porphyrins as well as by destruction of sebaceous glands. Hongcharu, et al (2000) conducted a randomized controlled trial of ALA-PDT for inflammatory acne. 22 subjects with acne on the back were treated with ALA (3 hour incubation) followed by irradiation with a 550nm-700nm broad band light source. Significant clinical clearance was evident after 4 weekly ALA-light treatments that lasted for at least 20 weeks. Reduction of sebaceous gland size on histology and reduction of sebum excretion were demonstrated 20 weeks after PDT. Side effects included skin peeling and post-inflammatory hyperpigmentation.14 Pollock, et al (2004) conducted another randomized intraindividual controlled study of ALA-PDT (3 h, 635nm) on 10 patients. Patients were treated weekly for 3 weeks. Significant reduction of inflammatory acne lesion counts were found at the ALA-PDT site but not at the control sites. The authors however did not find any reduction of sebum excretion unlike Hongcharu, et al and postulated that photodynamic killing of the P. acnes may be an alternative mechanism of action.15 Hörfelt, et al (2006) conducted blinded, prospective, randomized, placebo-controlled multicentre study involving 30 patients with moderate to severe acne. This was a split- face study, with a 3-hour drug incubation (using MAL) followed by illumination with red light. A second treatment was given 2 weeks later. At the end of the clinical trial, 12 weeks after the last treatment, there was a statistical reduction in acne lesions of 54% vs. 20% in the control group. As expected, MAL-PDT treated side was associated with more pain than the control side.16 ALA-PDT using IPL as the light source has also been reported to be effective in the treatment of inflammatory acne. Santos, et al (2005) explored the effectiveness of ALA-PDT in moderate-to-severe inflammatory acne vulgaris lesions utilizing ALA-PDT and IPL. In this split-face study, 13 patients were treated with the IPL device alone on 1 side of the face and with ALA augmentation on the other (3 hour drug incubation). The procedure was done twice at 2-week intervals. Improvement was more marked in the ALA-treated side of the face starting 4 weeks after treatment. The improvement persisted till 8-week post- treatment. On the other hand, the facial half treated with intense pulsed light only showed a return to baseline of their facial acne.17 In another split-face clinical trial, Rojanamatin, et al (2006) confirmed the results described by Santos, et al. They evaluated 14 patients in a split-face study with an IPL (3 treatment sessions at 3-4 week intervals) and found that the ALA-IPL combination was superior to treatment with the IPL alone. Lesion counts decreased 87.7% on the ALA pretreated side at 12 weeks as compared to 66.8% on the non-pretreated side.18 Conclusion Lasers and other light devices are increasingly being shown to be effective in treating inflammatory acne lesions and their mechanism of actions progressively illuminated. Refinement in the treatment protocols such as using lower laser fluences (for the 1450nm diode laser), combining blue and red light (for phototherapy), using lower drug concentrations and shorter drug incubation periods (for PDT) are translating to less patient discomfort and fewer side effects while maintaining treatment efficacy. The possibility of inducing long-term remission after treatment is exciting. These light modalities are likely to play a significant role in the future management of inflammatory acne. References 1. Paithankar DY, Ross EV, Saleh BA, Blair MA, Graham BS. Acne treatment with a 1,450 nm wavelength laser and cryogen spray cooling. Lasers Surg Med 2002;3:106-14 2. FriedmanPM,JihMH,Kimyai-AsadiA,GoldbergLH.Treatment of inflammatory facial acne vulgaris with the 1450-nm diode laser: a pilot study. Dermatol Surg 2004;30:147-51 3. Jih MH, Friedman PM, Goldberg LH, Robles M, Glaich AS, Kimyai-Asadi A. The 1450-nm diode laser for facial inflammatory acne vulgaris: dose-response and 12-month follow-up study. J Am Acad Dermatol 2006;55:80-7
  5. 5. 5Dermatology BulletinVolume 20 No: 2 2009 Light Therapies For Acne 4. Bernstein EF. Double-pass, low-fluence laser treatment using a large spot-size 1,450 nm laser improves acne. Lasers Surg Med 2009;41:116-21 5. Noborio R, Nishida E, Morita A. Clinical effect of low-energy double-pass 1450 nm laser treatment for acne in Asians. Photodermatol Photoimmunol Photomed 2009;25:3-7 6. Yeung CK, Shek SY, Yu CS, Kono T, Chan HH. Treatment of inflammatory facial acne with 1,450-nm diode laser in Type IV to V Asian skin using an optimal combination of laser parameters. Dermatol Surg 2009;35:593–600 7. Papageorgiou P, Katsambas A, Chu A. Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. Br J Dermatol 2000;142:973-8 8. Tzung TY, Wu KH, Huang ML. Blue light phototherapy in the treatment of acne. Photodermatol Photoimmunol Photomed 2004;20:266-9 9. Lee SY, You CE, Park MY. Blue and red light combination LED phototherapy for acne vulgaris in patients with skin phototype IV. Lasers Surg Med 2007;39:180-8 10. Noborio R, Nishida E, Kurokawa M, Morita A. A new targeted blue light phototherapy for the treatment of acne. Photodermatol Photoimmunol Photomed.. 2007;23:32-4 11. Na JI, Suh DH. Red light phototherapy alone is effective for acne vulgaris: randomized, single-blinded clinical trial. Dermatol Surg 2007;33:1228-33 12. Zane C, Capezzera R, Pedretti A, Facchinetti E, Calzavara-Pinton P. Non-invasive diagnostic evaluation of phototherapeutic effects of red light phototherapy of acne vulgaris. Photodermatol Photoimmunol Photomed 2008;24:244-8 13. Sakamoto FH, Tannous Z, Doukas AG, Farinelli WA, Smith NA, Zurakowski D, Anderson RR. Porphyrin distribution after topical aminolevulinic acid in a novel porcine model of sebaceous skin. Lasers Surg Med 2009;41:154-60 14. Hongcharu W, Taylor CR, Chang Y, Aghassi D, Suthamjariya K, Anderson RR. Topical ALA-photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol 2000;115:183-92 15. Pollock B, Turner D, Stringer MR, Bojar RA, Goulden V, Stables GI, Cunliffe WJ. Topical aminolaevulinic acid- photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br J Dermatol 2004;151:616-22 16. Hörfelt C, Funk J, Frohm-Nilsson M, Wiegleb Edström D, Wennberg AM. Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study. Br J Dermatol 2006;155:608-13 17. SantosMA,BeloVG,SantosG.Effectivenessofphotodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study. Dermatol Surg 2005;31:910-5 18. Rojanamatin J, Choawawanich P. Treatment of inflammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study. Dermatol Surg 2006;32:991-6
  6. 6. 6 Volume 20 No: 2 2009 Dermatology Bulletin Unwanted Hair Removal – An Update Dr Priya Sen Background H air removal has been practised for centuries in almost all human cultures. Many cultures have an aesthetic ideal amount of hair for both males and females and any individual whose amount or distribution of hair exceeds this may seek treatment for this. Hair is commonly removed for social reasons related to acceptance in society. The methods used vary according to the region involved as well as accessibility to modern technology such as hair removal light devices and lasers. The removal of unwanted hair has become an increasingly sought after cosmetic procedure by patients attending the National Skin Centre (NSC). In 2007 and 2008, the number of laser hair removal procedures performed at NSC was 642 and 674 respectively. Common Reasons for Seeking Hair Removal • Beauty enhancement • Temporary methods such as shaving and waxing bothersome • Hirsutism related to genetics, hormonal imbalance or side-effects of drugs • Sexual enhancement and hygiene • Sportsmen to reduce resistance against air or water • Medical indications such as folliculitis, shaving eczema, acne Temporary Methods of Hair Removal Depilation This involves removal of hair only to the level of skin. The hairs grow back within hours to days. This includes manual or electric devices used for shaving or trimming as well as depilatory creams or shaving powders which chemically dissolve hair. Epilation This involves removal of the entire hair including the root. The hairs grow back within days to weeks. Methods include plucking with tweezers, waxing where a hot or cold layer is applied to the skin and then removed with porous strips, sugaring which is similar to waxing but with a sticky paste and threading where a twisted cotton thread catches hairs as it is rolled across the skin. Epilators are mechanical devices which rapidly grasp hairs and then pull them out. Permanent Methods of Hair Reduction These methods target areas regulating hair growth. The FDA does not allow for the marketing of technologies and services that state permanent hair removal. The 1998 FDA definition states that “Permanent hair reduction is the long term, stable reduction in the number of hairs regrowing after a treatment regime”. Permanent Methods of Hair Reduction 1. Electrolysis 2. Lasers 3. Intense Pulsed Light (IPL) 4. Enzymes that inhibit the development of new hair cells e.g. eflornithine hydrochloride (13.9%) or Vaniqa 1. Electrolysis Electrolysis is a way of removing individual hairs from the face or body. These devices destroy the growth center of the hair using chemical or heat energy. A very fine probe is inserted into the hair follicle at the surface of the skin. The hair is then removed harmlessly with forceps. 2. Laser Hair Removal Hair removal lasers use the principle of selective photothermolysis to remove hair. Melanin pigment is the primary chromophore. There are two types of melanin in hair: eumelanin (which gives hair brown or black color) and pheomelanin (which gives hair blonde or red color). Because of the selective absorption of photons of laser light, only black or brown hair can be removed. By selectively targeting melanin in the hair follicle, the heat generated during the treatment only damages the hair follicle allowing for protection of the surrounding skin structures. Current lasers have epidermal cooling systems incorporated to allow for use of higher fluences whilst reducing pain and side- effects especially in darker skin types. There are a multitude of hair removal lasers in the market of varying wavelengths and are defined by the lasing medium used to create the wavelength (measured in nanometers (nm). At NSC, the long pulsed Nd:YAG (1064nm) is used as it is safe for all skin types especially those with darker skin. Types of Hair Removal Lasers • Long pulsed Ruby (694nm) not safe in non-white skin Epilaser, EpiTouch Silk Laser, Rubystar, Chromos • Long pulsed Alexandrite (735nm) most effective but safest on light skin Apogee, PhotoGenica, EpiTouch 5100, GentleLase • Long pulsed Diode (810nm) light to medium type skin Lightsheer, LaserLite • Long pulsed Nd:YAG (1064nm) safe for all skin types esp dark skin Coolglide, Lyra, GentleYAG, Sciton, Xeo INVITED ARTICLE 2 * Consultant Dermatologist, National Skin Centre
  7. 7. 7Dermatology BulletinVolume 20 No: 2 2009 Fig 1. Facial hair reduction with the long-pulsed Nd:YAG laser Before Treatment After 4 laser treatments + daily use of Vaniqa® Fig 2. Facial hair reduction with the long-pulsed Nd:YAG laser Before Treatment After 5 Treatments Fig 3. Axillary hair reduction with the long-pulsed Nd:YAG laser Before Treatment After 2 Treatments Update on hair removal
  8. 8. 8 Volume 20 No: 2 2009 Dermatology Bulletin Laser Parameters 1. Pulse width – Published studies have shown that longer pulse widths are safer in darker skin 2. Spot size – larger spot sizes enable more hairs to be removed at the same time 3. Fluence (J/cm2 ) – the higher the fluence the higher the chance of permanent hair reduction 4. Repetition rate – shooting more than 1 pulse with a specific delay between pulses can cause a slight improvement in the heating of a particular area Number of laser treatments required This is dependent on a multitude of factors including skin type, thickness of hair, colour of hair, stage of hair cycle, area being treated and sex of the patient. Lasers work best in the anagen phase of hair growth when melanin is most abundant. Treatments should be spaced at least 4 weeks apart to allow a sufficient interval for shedding of the treated hairs. Treatment Area Average no. of sessions required Axillae 4-6 sessions Lower legs 5-7 sessions Face 5-7 sessions Bikini line/brazilian 4-6 sessions Arms 5-7 sessions It is important to exclude underlying hormonal imbalances when treating female patients with male pattern hirsutism. In females with hirsutism check blood for DHEA,17-OHprogesterone, free or total testosterone 3. IPL This is a flashlamp that emits non-coherent light at a spectrum of wavelengths 500-1200nm. The intense light travels through the tissue of the skin until it strikes the hair shafts or the bulb (root) of the hair. The bulb is usually where the highest concentration of melanin is located, as opposed to the rest of the hair shaft. The light is converted to heat energy. The bulb and most of the hair shaft are instantly vaporized. The intense heat radiated by the hair also destroys the hair-producing papilla or the entire hair follicle. The number of sessions required when using IPL is similar if not slightly increased when compared to using lasers. It works better than lasers for skin types I-II when the hairs are brown and not black; however is not as safe as the long pulsed Nd:YAG in darker skin types. Neither IPL nor lasers work on white or very fine vellus hair and patients have to be told this before any treatment is commenced. The ideal candidate for lasers or IPL is an individual with fair skin and thick dark hair which is in the anagen phase of hair growth. 4. Eflornithine hydrochloride (13.9%) cream (Vaniqa® ) This has been FDA approved for reducing the growth of unwanted facial hair in women. It inhibits hair growth by irreversible blockage of ornithine decarboxylase resulting in a decrease in polyamines which are critical binding blocks for rapidly dividing tissues such as hair. Clinical studies have shown that Vaniqa® improves the effectiveness of laser hair removal when used in combination and can reduce the number of laser sessions required to achieve clearance of hair. It takes up to 8 weeks to see the effects. In clinical trials, some women reported mild and temporary skin irritations such as redness, stinging, burning, tingling, acne or rash. Discussion In our Asian context, it is important to understand the skin types and technologies available for safe and effective reduction in hair growth. Patients must be counseled on the risks and precautions to be taken. The long pulsed Nd:YAG laser is a safe and effective choice in achieving permanent hair reduction in Asian skin. Update on hair removal
  9. 9. 9Dermatology BulletinVolume 20 No: 2 2009 A Retrospective Review Of Mohs Micrographic Surgery Performed At The National Skin Centre Dr Tan Wee Ping*, Dr Heng Yee Kiat**, Dr Melvin Ee Hock Leong*** *Associate Consultant Dermatologist **Registrar ***Consultant Dermatologist, National Skin Centre ORIGINAL ARTICLE 1 Introduction M ohs micrographic surgery (MMS) has been practised for more than 70 years and is considered the treatment of choice for certain non melanoma skin cancers with high risk characteristics. The technique involves a series of excisions of thin layers of tissue1,2 . Each layer is subdivided, colour-coded with ink, carefully mapped corresponding to its anatomic orientation, then prepared with frozen sections for histologic review. Tissue sections on microscope slides, corresponding to each of the mapped subdivisions of the tumour, are examined under the microscope by the Mohs surgeon. The histologic sections are cut in a special horizontal fashion so that they completely reveal the peripheral margins of the surgical specimen, both deep and lateral. When a microscopic section contains tumour cells, it means that the tumour has extended to the peripheral margin of the surgical specimen in that subdivision. The Mohs surgeon examines the slides and notes all areas of tumour on the tissue map. The next surgical stage involves taking a thin layer of tissue only from areas that correspond to the mapped positive margins. In this fashion, consecutive layers are taken as the clinically silent extensions of tumour are traced out and resected. MMS using horizontal frozen sections has achieved wide acceptanceastheoptimaltreatmentforbasalcellcarcinomas (BCC) and squamous cell carcinomas (SCC) which fulfill certain characteristics. Incompletely excised or recurrent tumours, tumours on the face, genitalia or extremities where tissue conservation is crucial are best treated by MMS. Certain morphological or histological features of tumours e.g. morpheaform, infiltrating, micronodular BCC or moderately or poorly differentiated SCC, associated with a higher probability of recurrence should ideally be treated with MMS. BCC and SCC larger than 6mm in areas like ears, lip, nose, temples and periorbital skin are best treated by MMS. Similarly, those larger than 10mm over the cheek, forehead and scalp should be referred for MMS. MMS using frozen sections has also been described in the treatment of other tumours, including extramammary Paget’s disease, microcystic adnexal carcinoma and primary cutaneous neuroendocrine tumours. The Mohs micrographic surgical service commenced at the National Skin Centre, Singapore in November 2007. In this report, we describe our experience with 120 patients in whom MMS was performed. Methods We reviewed the medical records of 120 patients treated at the National Skin Centre, Singapore with MMS between 1 January 2008 and 31 December 2008. The following information was extracted from each patient’s records: age, gender, race, tumour type and location, history of previous treatment, pre-operative tumour size, size of postoperative surgical defect, number of stages required to complete the procedure, type of surgical repair and number of recurrences. Mohs Procedure All patients are screened pre-operatively for the suitability of MMS. Standard informed consent is obtained pre- operatively. After these arrangements, the patient is prepped and draped under a clean environment. Local anaesthesia is achieved with 1% lignocaine and 1:100000 epinephrine mixed with sodium bicarbonate. The margins of the neoplasm are assessed clinically and marked with skin marker. The lesion is first debulked by curettage whenever possible and tumour margins delineated. A 1mm margin is scored around the surgical defect before it is excised with a scalpel using a 45º inward bevel. The depth of excision is based on the clinical extent of the neoplasm. Following removal, strict orientation and mapping of the specimen is performed and it is immediately transported to the histopathology laboratory. Haemostasis is achieved using electrofulgaration and a pressure dressing is applied. Abstract Introduction: The Mohs micrographic surgical service commenced at the National Skin Centre, Singapore in November 2007. In this report, we describe our experience with 120 patients in whom MMS was performed. Methods: A retrospective case records review of patients treated at the National Skin Centre with MMS between 1 January 2008 and 31 December 2008 was conducted. Results: A total of 129 tumours in 120 patients were removed by MMS during this period. The most common tumour was basal cell carcinoma, accounting for 85.3%, followed by squamous cell carcinoma (11.6%). The indications for MMS included recurrent or persistent tumours after previous excisions, site and/or size of tumours and aggressive histological subtypes of tumours. Complications of surgery occurred in only seven of the 129 tumours treated (5.4%). Conclusion: MMS is a safe and reliable method of treatment for a variety of skin tumours. Superior cure rates are achieved compared to other skin cancer treatment modalities because it uses the most complete and accurate method for microscopically checking all of the surgical margins of the resected tissue, whilst keeping resection of surrounding normal tissue to a minimum.
  10. 10. 10 Volume 20 No: 2 2009 Dermatology Bulletin The processed slides is presented back to the dermatologist/ mohs surgeon for assessment and if any margins are positive for tumour, the patient is prepped and draped in a clean fashion and local anaesthesia in the area of residual tumour is achieved. A further 1mm margin of normal-appearing skin is excised to encompass the areas noted to be positive for neoplasm on the previous stage or a deeper section is procured.Thisprocessofhistologicalwoundexaminationand further excision continues till all the margins are histologically free of tumour. The patient will then return for wound closure by the same dermatologist/mohs surgeon. Results A total of 129 tumours in 120 patients were removed by MMS during this period. Nine patients had more than one tumour; eight of these patients had two BCC and one patient had one each of BCC and SCC. The most common tumour was BCC, accounting for 85.3%, and the most common BCC histologic subtype was the nodular subtype. SCC accounted for the majority of the rest (11.6%), and the remaining were two cases each of sebaceous carcinoma and extramammary Paget’s disease. Most were performed over the head and neck, with only one over the chest (morpheaform BCC) and two over the genitalia (extramammary Paget’s disease). Nineteen MMS were performed on incompletely excised tumours; seventeen tumours had one previous excision and two had two previous excisions. 117 were standard MMS, with use of horizontal frozen sections. Three required the use of paraffin-embedded sections (two cases of sebaceous carcinoma and one extramammary Paget’s disease). The mean number of surgical stages necessary to clear margins was 1.78. Four or more stages were required in nine cases of BCC (two infiltrative and seven nodular) and one case of moderately- differentiated SCC. Most of the surgical defects were closed by the Mohs surgeon. The wounds were closed directly in 46.5% of the cases. A variety of flaps, including different types of advancement, transposition and rotation flaps were required in 23 cases (17.8%). Full thickness skin grafts were necessary in ten (7.8%). Nine of these were for defects over the nose and one over the forehead. The wounds were left to heal by secondary intention in six cases (4.7%) involving the concavities of the ala nasi and ears. Nine MMS performed over the periorbital region required assistance from oculoplastic surgeons for closure. Three large defects over the scalp, cheek and forehead were referred to plastic surgeons for repair. Complications of surgery occurred in seven patients. Two patients had mild wound dehiscence over the scalp. Two patients had partial tip necrosis of their flaps and one patient had partial graft necrosis. All recovered well with secondary intention healing of their wounds. One patient developed hypertrophy of the flap and the last patient developed keloids after surgery over the chest requiring intralesional triamcinolone injections. All patients were followed up for a minimum of three to six months and none had recurrence at this duration of follow-up. Discussion Our study has shown that MMS can be used effectively to treat a variety of neoplasms locally. It is a microscopically controlled method of tumour excision, allowing maximal tissue conservation while minimizing recurrence rates. In our series, 21 tumours treated with MMS were BCC or SCC of histological subtypes associated with higher risk of recurrence and 19 tumours were recurrent or persistent tumours. 51 were performed over sites where tissue conservation was important such as periorbital region, ears, nose, lip and temples. The modification of MMS with paraffin-embedded sections has also allowed it to be used successfully to treat some other types of skin tumours like sebaceous carcinoma and dermatofibrosarcoma protuberans. In our series, paraffin-embedded sections were used in the treatment of sebaceous carcinoma and extramammary Paget’s disease. Other types of skin tumours that may be treated with this modification of MMS include microcystic adnexal carcinoma, dermatofibrosarcoma protuberans and Merkel cell carcinoma3 . Because of the more accurate determination of tumour- free margins in MMS, superior cure rates of BCC and SCC result after MMS when compared to other treatment modalities4,5 . Five-year recurrence rates for primary BCC following MMS and conventional surgical excision with predetermined margins are 1% and 10% respectively. For recurrent BCC, superior cure rates are also seen following MMS, with recurrence rates of 5.6% compared to 17.4% following conventional surgical excision. For SCC, five- year recurrence rates for primary SCC of the skin and lip following MMS and conventional surgical excision are 3.1% and 10.9% respectively. In our cohort of patients, none recurred after a follow-up of at least 3-6 months. This contrasts sharply with the clearance rates of 84.9% and 84.1% previously reported for conventional BCC and SCC excision from our centre6,7 . Inconclusion,MMSisasafeandreliablemethodoftreatment for a variety of skin tumours. It may be performed with frozen section method or paraffin-embedded method. Superior cure rates are achieved compared to other skin cancer treatment modalities because it uses the most complete and accurate method for microscopically checking all of the surgical margins of the resected tissue, whilst keeping resection of surrounding normal tissue to a minimum. References: 1. Buker JL, Amonette RA. Micrographic surgery. Clin Dermatol 1992;10:309-15. 2. Telfer NR. Mohs Micrographic surgery for nonmelanoma skin cancer. Clin Dermatol 1995;13:593-600. 3. Barlow RJ, Ramnarain N, Smith N, et al. Excision of selected skin tumours using Moh’s micrographic surgery with horizontal paraffin-embedded sections. Br J Dermatol 1996;135:911-17. 4. Rowe DE. Comparison of treatment modalities for basal cell carcinoma. Clin Dermatol 1995;13: 617-20. 5. Geisse JK. Comparison of treatment modalities for squamous cell carcinoma. Clin Dermatol 1995; 13:621-6. 6. Goh BK, Ang P, Wu YJ, Goh CL. Characteristics of basal cell carcinoma amongst Asians in Singapore and comparison between completely and incompletely excised tumours. Int J Dermatol 2006; 45: 561-4. 7. Ang P, Tan AW, Goh CL. Comparison of completely versus incompletely excised cutaneous squamous cell carcinomas. Ann Acad Med Singapore 2004; 33: 68-70. Mohs micrographic surgery at NSC
  11. 11. 11Dermatology BulletinVolume 20 No: 2 2009 Clinical Outcomes In Patients With Incomplete Mohs Excisions For Periocular Non Melanoma Skin Cancer Dr Melvin Ee Hock Leong*, Dr Nabeel Malik**, Dr Raman Malhotra**, Dr Richard Collin***, Dr Naresh Joshi****, Dr Jane Olver*****, Dr Richard Barlow****** *Consultant Dermatologist, National Skin Centre, Singapore **Queen Victoria Hospital NHS Foundation Trust, United Kingdom ***Moorfields Eye Hospital NHS Foundation Trust, United Kingdom ****Chelsea and Westminster Hospital NHS Foundation Trust, United Kingdom *****Western Eye Hospital, Imperial College Healthcare NHS Trust, United Kingdom ******St John’s Institute of Dermatology, St. Thomas’ Hospital, United Kingdom ORIGINAL ARTICLE 2 Introduction U p to 10% of skin cancers occur in periocular tissue, namely the upper lid and eyebrow, the lower lid to the orbital rim, the lateral and medial canthi1 . At these sites, both complete tumour removal and preservation of surrounding unaffected skin are particularly important for functional and cosmetic reasons. Mohs micrographic surgery is associated with cure rates of approximately 95-100% for primary periocular skin tumours and 92% for “recurrent”/persistent lesions, respectively2,3 . When performing periocular Mohs micrographic excisions under local anaesthetic, it may be difficult or impossible to dissect a further horizontal layer when tumour extends onto the bulbar conjunctiva or deep retro-orbital fat or when it is adherent to the episclera or bone. Under these circumstances, tumour can be assumed to persist on or in these tissues. We report a series of 12 such patients. In addition to unanticipated incomplete Mohs excisions, micrographic surgery is sometimes undertaken with the limited objective of obtaining tumour-free cutaneous margins in the context of known extension of tumour onto orbital tissue or bone. In both groups, subsequent management may consist of further attempted clearance of tumour under general anaesthetic, possibly with exenteration, or may be limited to reconstruction and observation. Materials and Methods We reviewed the notes of all patients (treated at St John’s Institute of Dermatology between January 1999 and December 2007) in whom attempted Mohs excisions had been suspended despite positive margins involving bone, the globe, or retro-orbital fat. All were referred by oculoplastic units, where they were managed post- operatively. Mohs micrographic surgery was performed with dissection of horizontal layers, 1-2 mm in thickness. After infiltration with 2% lidocaine containing epinephrine, curettage or excision was used to debulk the tumour and to define its clinical margins. The first layer was then cut, notched and Abstract We reviewed the case notes of 12 patients with periocular non-melanoma skin cancer in whom attempted Mohs excisions had been incomplete. Subsequent management was conservative in six patients and surgical in six. Approximately 1000 periocular Mohs procedures were performed between January 1999 and December 2007. We were unable to obtain tumour free margins in 12 of these patients because of involvement by tumour of the globe, deep retro-orbital fat or bone. Six patients had basal cell carcinomas (BCC), five squamous cell carcinomas (SCC) and one a sebaceous gland carcinoma (SGC) with Pagetoid spread onto the bulbar conjunctiva. Five (two BCC, three SCC) of the six patients with primary tumours were subsequently managed conservatively. The sixth patient had a large SCC and was subjected to local orbital clearance (local orbitectomy). All of the remaining six patients had had previous surgery or radiotherapy. Five (four BCC, one SCC) were treated with local orbitectomy. The twelfth patient had a sebaceous gland carcinoma (SGC) and was managed with exenteration. Only one patient (with a BCC treated with radiotherapy before persistent disease was recognised and referred for Mohs surgery) has manifested continued persistent tumour in the form of an orbital mass one year after orbitectomy. This was treated with exenteration.
  12. 12. 12 Volume 20 No: 2 2009 Dermatology Bulletin transferred so that anatomical orientation was maintained. The tissue layer was divided into sections, colour coded and mapped. Frozen sections were prepared in 11 patients, stained with haematoxylin and eosin and examined by the Mohs surgeon. In one patient with a sebaceous carcinoma, paraffin-embedded sections were used in order to track Pagetoid spread in the conjunctiva. We recorded age, sex, diagnosis, treatment history, tumour site, final wound size, number of Mohs layers and area of histological persistence. We also reviewed subsequent surgical management, if any, including post operative imaging and long term follow up for persistence. Results Over 4,000 Mohs procedures were performed between 1999-2007, of which approximately a quarter included periocular tumours. Of these, we identified 12 patients (8 female), mean age 70 (range 51-88) years in whom tumour was known to persist at the conclusion of Mohs surgery. The mean duration from onset was 1.95 (range 0.5-5) years (Table 1) and the mean follow-up period was 3.7 (range 0.5–7) years. Basal cell carcinomas (BCC) were present in six patients, squamous cell carcinomas (SCC) in five and a primary Table 1: Biographical and surgical data Patient Age (years) Time from onset (years) Treatment history Site Wound size (mm) Mohs layers Area of Persistence A (8) 89 1.5 Primary BCC Medial canthus 12x12 4 Retro orbital fat B (9) – 1 Primary BCC Medial canthus 12x6 3 Bulbar conjunctiva C (6) 67 0.5 Primary SCC Medial canthus 13x10 3 Bulbar conjunctiva, retro-orbital fat D (7) 89 1 Primary SCC Lower Lid 18x11 3 Retro-orbital fat E (10) 67 2 Primary SCC Upper Lid 10x5 2 Bulbar conjunctiva, nasal bone F (11) 73 1 Primary SCC Lateral canthus 21x40 15 Bulbar conjunctiva G (1) 84 2 BCC post radiotherapy Medial canthus 15x8 5 Episclera H (4) 56 5 BCC post radiotherapy Medial canthus 20x16 2 Bulbar conjunctiva, retro-orbital fat I (2) 74 1.5 BCC post surgery Lower Lid 12x4 3 Bulbar conjunctiva J (12) 74 1.5 Recurrent BCC Lateral canthus 9x32 7 Bulbar conjunctiva K (5) 86 2 SCC post radiotherapy Upper Lid 16x4 2 Bulbar conjunctiva, retro-orbital fat L (3) 62 3 Sebaceous ca, post surgery Upper Lid 15x7 2 Slow Bulbar conjunctiva Table 2: Subsequent clinical course Patient Post-Mohs intervention Post Op Imaging Follow up (years) Subsequent course A Nil Nil 5 Clinically clear B Nil Nil 1.5 Clinically clear C Nil 2 yearly MRI 9 Clinically clear D Nil Nil 2 (died, unrelated causes) Clinically clear E Nil Nil 7 Clinically clear F Local orbitectomy + IMRT Yearly 1 Clinically clear G Local orbitectomy Nil 1 Eyelid mass. Subsequent exenteration H Local orbitectomy Yearly MRI 5 Clinically clear I Local orbitectomy Nil 1 Clinically clear J Local orbitectomy Yearly 1 Clinically clear K Local orbitectomy Nil 2 (died, unrelated causes) Clinically clear L Exenteration Nil 3 Clinically clear IMRT=Immune-modulated radiotherapy Periocular non melanoma skin cancer
  13. 13. 13Dermatology BulletinVolume 20 No: 2 2009 sebaceous gland carcinoma in the remaining patient. Six patients, (two BCC, four SCC) had not been treated previously. The remaining patients (four BCC, one SCC, one sebaceous carcinoma) had lesions which had persisted despite previous surgery or radiotherapy. The medial canthus was the site most commonly affected (5), followed by the upper eyelid (3), lower eyelid (2) and lateral canthus (2). All tumours required at least two Mohs levels (range 2-15). Of the six patients with primary tumours (patients A-F), five (four BCC, one SCC) were subsequently managed conservatively (Table 2). This decision was largely a consequence of these patients declining further surgery. None of this group has manifested persistent tumour. The sixth patient (patient F) had a large SCC and was subjected to local orbital clearance, or orbitectomy (globe-sparing excision of orbital tissue in the involved orbital quadrant). This patient was also subjected to further adjunctive immune-modulated radiotherapy. All of the remaining six patients (patients G-L) had had previous surgery or radiotherapy. Five of these (four BCC, one SCC) were subsequently managed with orbitectomy. The remaining patient (patient L) had a sebaceous gland carcinoma and was treated with exenteration because of Pagetoid extension beyond the fornix superiorly and onto the bulbar conjunctiva. This patient has been followed for three years without clinical or radiographic evidence of persistent or metastatic disease. Of all 12 patients, only one has developed persistent tumour (Patient G). This patient had previously had radiotherapy for a medial canthal BCC and was subjected to orbitectomy following incomplete Mohs surgery. The patient developed a frozen orbit post-operatively. One year later, she developed an orbital recurrence which was treated with exenteration. There has been no clinical evidence to date (4 years) of persistent disease. Discussion Mohs micrographic surgery (MMS) is widely recognized as the optimal surgical procedure for removing non-melanoma skin cancer involving the eyelid. Malhotra et al2 reported five-year recurrence rates of 0% and 7.8% for primary and persistent periocular BCC, respectively. Similarly, the Australian database for periocular SCC managed by MMS reported a recurrence rate of 3.64%, which is lower than other treatment modalities.3 Our study describes the clinical features and treatment outcomes in 12 patients in whom Mohs surgery had been attempted for periocular non-melanoma skin cancer and was incomplete. These represent a small fraction of the more than 1,000 periocular Mohs procedures performed in our Unit between 1999-2007. Some patients had primary and others had persistent tumours. The medial canthus was the commonest anatomical site. In contrast to previous reports4 , there was no correlation between the number of Mohs levels and the likelihood of incomplete excision. Although it was not the aim of our study to identify patients with a likely outcome of incomplete Mohs surgery, our experience was similar to that of Madhani et al5 . Factors predictive of incomplete excisions included previous surgery or radiotherapy, a periocular (and especially medial canthal) site, infiltrative BCC and poorly differentiated or large (> 1cm) SCC. In our study, one patient had tumour extending into episcleral tissue, nine patients had tumour extending into conjunctiva, three had tumour involving the conjunctiva and retro orbital fat and two patients had tumour involving the retro orbital fat alone. (Table1). Of these, the only patient (patient G) who developed persistent disease had a treatment history of radiotherapy for a medial canthal BCC. There was no evidence of any bony involvement pre-operatively on computerised tomography (CT) nor any soft tissue involvement on magnetic resonance imaging (MRI). Mohs surgery was incomplete because tumour was adherent to the episclera. The patient was submitted for orbitectomy but subsequently developed an orbital mass and required exenteration. The subsequent management of patients with incompletely excised non-melanoma skin cancer is sometimes influenced by the consideration that tumour persistence is not inevitable. In reports of patients reviewed after incomplete excision of unselected non-melanoma skin cancer 8-12 , subsequent recurrence rates varied from 35% to 67%. Furthermore, studies of incompletely excised BCCs on the eyelids have shown that up to 65% do not persist clinically13-15 . In another study16 of 1392 unselected BCC, 7% were reported as incompletely excised. Of the 75% that were re-excised, residual tumour was reported histologically (again with vertical sections) in 54%. In the same study, 13% of peri-ocular lesions were reported as incompletely excised whereas, in contrast, only 25% of re-excisions showed residual tumour. Some authors will therefore argue for a conservative approach to the management of patients with incompletely excised periocular tumours, particularly when the alternative would be exenteration of the eye. Whatever their views on BCC, most practitioners seem to proceed to re-excision of incompletely excised SCC. In this group, data is limited for histological examination of re-excised tissue. In a retrospective study of 676 SCCs, 17.6% of the cases were incompletely excised. The majority were re-excised and histological examination revealed residual SCC in 28.6% of these specimens. We have been able to find only one other study18 of the significance of positive margins after attempted Mohs excisions in patients with periocular tumours. All six patients were subjected to further surgery, which involved exenteration in two. Five patients remained clinically tumour-free at four months, while the sixth had tumour persisting despite exenteration and further excisions. In summary, incomplete Mohs excisions are unusual but may be more common around the eye. In our patients, this outcome was more likely in the elderly and after radiotherapy, in patients with medial canthal tumours, infiltrative BCC or poorly-differentiated SCC. All six patients who were managed conservatively were done so largely owing to their reluctance about further surgery. Tumour persistence has not be noted in this group though has Periocular non melanoma skin cancer
  14. 14. 14 Volume 20 No: 2 2009 Dermatology Bulletin Periocular non melanoma skin cancer occurred in one of the six patients managed with further surgery. This is the only patient in whom Mohs surgery was abandoned because of infiltration by tumour of the episclera. In view of the functional and other implications of orbitectomy or exenteration, these data may give cause for cautious optimism in conservative or relatively conservative management of patients with incomplete Mohs excisions of periocular tumours . References: 1. Kleinstein RN, Lehman HF. Incidence and prevalence of eye cancer. Am J OptomPhysiol Optics 1977;54:49 –51 2. MalhotraR,HuilgolSC,HuynhNT,SelvaD.TheAustralianMohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up. Ophthalmology.2004 ;111:631-6 3. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database: periocular squamous cell carcinoma. Ophthalmology 2004;111:617– 623 4. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs Database, Part I Periocular Basal Cell Carcinoma Experience over 7 Years. Ophthalmology 2004:624-630 5. Madani S, Huilgol SC, Carruthers A. Unplanned incomplete Mohs micrographic surgery.Am Acad Dermatol. 2000 May;42(5 Pt 1):814-9 6. Bovill ES, Cullen KW, Barrett W, Banwell PE. Clinical and histological findings in re-excision of incompletely excised cutaneous squamous cell carcinoma. JPlastReconstrAesthet Surg. 2008 Jan 19. [Epub ahead of print] 7. Hamada S, Kersey T, Thaller VT. Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome. Br J Ophthalmol 2005;89:992–994 8. Shanoff LB, Spira M, Hardy SB. Basal cell carcinoma: a statistical approach to rational management. OphthalmolPlastReconstrSurg 1967;39:619 – 624.30 9. DeSilva SP, Dellon AL. Recurrence rate of positive margin basal cell carcinoma results of a five-year prospective study. J SurgOncol 1985; 28: 72 ± 4 10. Sarma DP, Griffing CC, Weilbaecher TG. Observations on the inadequately excised basal cell carcinomas. J SurgOncol 1984;25:79 – 80 11. Richmond JD, Davie RM. The significance of incomplete excision in patients with basal cell carcinoma. Br J PlastSurg 1987; 40: 63 ± 7 12. Hauben DJ, Zirkin H, Mahler D, et al. The biologic behavior of basal cell carcinoma: analysis of recurrence in excised basal cell carcinoma: part II. PlastReconstrSurg 1982;69: 110 –116 13. Dellon AL, DeSilva S, Connolly M, Ross A. Prediction of recurrence in incompletely excised basal cell carcinoma. PlastReconstrSurg 1985; 75: 860 -71 14. Liu FF, Maki R, Warde P, Payne D, Fitzpatrick P. A management approach to incompletely excised basal cell carcinomas of skin. Int J RadiatOncolBiol Phys 1991; 20: 423 - 8 15. Gooding CA, White G, Yatsuhashi M. Significance of marginal extension in excised basal cell carcinoma. N Engl J Med 1965; 273:923 - 4 16. Griffiths RW.Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision.Br J Plast Surg. 1999 Jan;52:24-8 17. Berlin J, Katz KH, Helm KF, Maloney ME. The significance of tumor persistence after incomplete excision of basal cell carcinoma. J Am Acad Dermatol. 2002 Apr;46(4):549-553 18. Boynton JR, Rounds MF, Quatela VC, Brown MD. The significance of positive margins (known and unknown) at the conclusion of Mohs surgery in the orbital region. OphthalPlastReconstr Surg.1996 ;12:51-7 19. Sussman LA, Liggins DF. Incompletely excised basal cell carcinoma: a management dilemma? Aust N Z J Surg 1996;66:276–8
  15. 15. 15Dermatology BulletinVolume 20 No: 2 2009 Fractional Ablative Skin Resurfacing With A Novel Carbon Dioxide Laser System In The Treatment Of Atrophic Acne Scars In Asian Skin Dr Melvin Ee Hock Leong*, Dr Chua Sze Hon**, Dr Tan Sze-Chin***, Dr Priya Sen*, Clin Prof Goh Chee Leok** * Consultant Dermatologist ** Senior Consultant Dermatologist ***Medical Officer, National Skin Centre ORIGINAL ARTICLE 3 Introduction A blative carbon dioxide (CO2) resurfacing has always been regarded as the gold standard for skin resurfacing. Clinical improvements of 30% to 75% can be achieved for patients with atrophic acne scars.1-2 However, it is coupled by a long downtime and carries with it a risk of prolonged erythema and dyspigmentation, making it less attractive as a treatment option among patients. As a result, the concept of fractional resurfacing was recently introduced. Although the results are in general not as dramatic as with carbon dioxide lasering, they purport to be remarkable, measurable, and consistent. In particular, the lack of downtime and the decreased risk for complications make them a more attractive alternative to carbon dioxide laser resurfacing. Recently, 2 studies have successfully demonstrated the use of ablative fractional CO2 on human skin 3-4 . There is at present little published data on the clinical effectiveness of such fractional ablative lasers in the treatment of atrophic acne scars and the safety of their use in patients with darker skin types. The aim of this preliminary study was to determine the clinical effectiveness and safety of a novel fractional ablative carbon dioxide laser in the treatment of facial atrophic acne scars in darker skin Asian patients. Secondary benefits such as reduction in seborrhea, reduction in pore size, and improvement in skin texture were also evaluated. Methodology This is a prospective noncomparative open study. 17 consecutive patients with moderate to severe facial atrophic acne scars and no active acne vulgaris were recruited for the study from December 2007 to February 2008. The study protocol also conformed to the guidelines of the 1975 Declaration of Helsinki. All patients were counseled and informed consent was obtained before commencement of the study. Inclusion criteria were age greater than 18 years of age (minimal age of consent in Singapore), facial acne scars of the atrophic type, and no active inflammatory acne over the past 6 months. Patients with the following exclusion criteria were not included: patients with active acne, patients on systemic isotretinoin therapy over the past 12 months, pregnant women, patients with hypertrophic or keloidal acne scars, and patients who were on other forms of acne scar treatment, for example, other forms of resurfacing techniques over the past 6 months. Treatment protocol Patients were treated with a new carbon dioxide laser (SLIM Evolution, Lasering, Modena, Italy) with a fractional modality (MiXto SX) coupled to a high-speed scanner. The MiXto SX™ is a microspot fractional carbon dioxide laser coupled with a computerized pattern generator. It can perform fractional resurfacing with a spot size of 300 microns, at depths ranging from 20-500 microns and treating 20-100% of the scanned areas. Pretreatment anesthetic cream (EMLA, AstraZeneca) was applied 2 hours before the laser treatment to minimize patient discomfort during the procedure. The following treatment variables were used: Index 6-8 (pulse duration: 2.5-3.5ms); power 8-14 watts; fluence, 28 to 69 J/cm2 . The acne scars were treated with 1– 3 overlapping passes over the affected Abstract Aims: This preliminary study aims to document the clinical effectiveness and the safety of its use in patients with darker skin types in the treatment of facial atrophic acne scars in Type IV-V Asian skin. Methods: This is a prospective non-comparative open study. Seventeen patients with moderate to severe facial atrophic acne scars were recruited. Only one laser treatment session was performed. Clinical evaluations of skin texture, side effects and photography were conducted before the procedure, immediately after and at 30 days after treatment. Both patients and two blinded non-treating dermatologists subjectively assessed the degree of improvement. Patient satisfaction surveys were also obtained. Results: Even at 1 month, subjective grading by the patients and blinded dermatologists confirmed that 5.88% vs. 35.3% no change (0%), 76.5% vs. 47% mild improvement (<25% improvement), 5.88% vs. 17.65% moderate improvement (25-49% improvement) and 11.8% vs. 0% marked improvement (50-74%) respectively. There were also documented improvement in reduction in pore size, skin texture and skin tightening over treated areas in 29%, 35% and 6% of the patients respectively. Patient satisfaction survey results mirrored the observed improvement. Common side effects included moderate pain during the treatment, transient erythema lasting up to 7 days and exacerbation of acne vulgaris in 1 case, which was promptly resolved with oral antibiotics. There was 1 (6%) case of pigmentary disturbance but no herpes activation or increased scarring. Conclusions: Fractional ablative carbon dioxide laser resurfacing is a modestly effective modality in improving facial atrophic scars after one treatment. The procedure is associated with minimal downtime and is safe for use in darker skin Types IV and V.
  16. 16. 16 Volume 20 No: 2 2009 Dermatology Bulletin areas and the surrounding skin. Only one treatment session was performed. Post-operatively, the lasered areas were cleansed with normal saline 4 hourly and emollient (white soft paraffin) applied 3-4 times a day till the process of scabbing passed. The patients were instructed to keep away from the sun and to avoid the use of cosmetics for 2 weeks. They restarted their use of sunscreen after the scabbing has cleared. Assessment of response The patients were evaluated at baseline and 1 month postoperatively. Photographs were obtained from the front and side of both cheeks at every visit. The same photographer took these with the same camera settings and ambient lighting. Patients were asked to grade their treatment response subjectively.Thepatientsgradedthedegreeofimprovement at 1 month. The degree of improvement was graded into 5 levels of response, no change (0%), mild improvement (<25% improvement), moderate improvement (25-49% improvement), marked improvement (50-74%) and almost to complete clearance (75-100%). In addition, 2 independent blinded dermatologists (Sen & Chan) who were not involved in patient treatment were also asked to grade the improvement using photographs (baseline and 1 month post treatment). The lower determination of the 2 was used as the final result. Complications including erythema, increased scarring, acne exacerbation,hyperpigmentationandhypopigmentationwere also recorded and graded (nil, mild, moderate and severe) by the primary investigators and blinded dermatologists. Secondary response variables such as effects on seborrhea, skin texture, pore size, and skin tightening over the treated areas as reported by patients was also recorded. These variables were assessed by direct questioning of the patients 1 month after the treatment in the form of a structured questionnaire in which patients were asked to rate each variable as being worse, no change, or improved compared with the same variable before treatment. Painintensitywasalsoassessedusingavisualanaloguescale with a grading of 0 to 10. (Table 1) In addition, satisfaction scores were derived using a 10-point scale. (Table 2) Fractional CO2 laser treatment of atrophic acne scars Figure 1: (A, B, C). Baseline Photographs. Figure (D, E, F) Moderate improvement 1 month after 1 treatment. A B C D E F
  17. 17. 17Dermatology BulletinVolume 20 No: 2 2009 Fractional CO2 laser treatment of atrophic acne scars Table 1 Patient subjective satisfaction grading system Score 1-2 3-4 5-6 7-10 Patient’s satisfaction Disappointed A little satisfied Quite satisfied Very satisfied Table 2 Patient subjective pain scoring system Score Characteristic of Pain 0 No pain 1-2 Mild pain, annoying 3-4 Nagging pain, uncomfortable, annoying 5-6 Miserable, distressing 7-8 Intense, dreadful, horrible 9-10 Worst pain possible, unbearable Results The clinical data of 17 patients who completed just one treatment were analyzed. All patients were of Fitzpatrick skin types IV and V. The mean age was 36 years (range, 18–64 years). The male-to-female ratio was 4.5:1. All the patients completed the treatment and were assessed at 1-month post treatment. Subjective patient assessment Subjectively, almost every patient (16/17) felt that they had at least mild improvement. The majority (13/17) felt they had mild (<25%) improvement while 1 felt there was moderate (25-49%) improvement and 2 indicated marked (50-74%) improvement. 1 patient felt there was no improvement. Patients assessment of secondary response after 1 month are as follows: improvement was reported in 70% of cases for seborrhea, 35% in skin texture, 29% in pore size, and 6% in skin tightening over the treated area. The majority of patients derived some satisfaction from the treatment. 59% of patient reported that they were a little satisfied with the treatment results, 12% quite satisfied, 12% very satisfied and 17% of patients were not satisfied. All patients tolerated the laser procedure. The mean pain score was 5.5 (range 0-9). The pain score varied with the number of passes as well as the energy and laser pulse duration per pass. With conservative treatment parameters (Index 8, 8W, 1 pass) all patients (2) did not feel any pain. With more aggressive treatment parameters (Index 6, 12- 14W, 2-3 passes), all described pain scores of at least 5. Figure 2: (A, B, C). Baseline Photographs. Figure (D, E, F) Moderate improvement 1 month after 1 treatment.
  18. 18. 18 Volume 20 No: 2 2009 Dermatology Bulletin Adverse effects were short lived and self-limiting. Erythema is the most common (82%) side effect followed by oedema (65%), pinpoint bleeding (24%), hyperpigmentation (24%) and crusting (4%). While erythema lasted a mean of 4.8 days (range: 3-7 days), oedema was evident for 2.8 days (range 1-7 days). Crust formation lasted for 7 days and only developed in 1 case. Pinpoint bleeding developed in 24% of cases and resolved within 48 hours. 12% of cases felt they developed hyperpigmentation 2 weeks after the procedure, which had resolved at the 1-month review. Subjective blinded dermatologist assessment 2-blinded dermatologists rated 18% of patients (3 out of 17) to have achieved moderate improvement (25-49% improvement) while another 47% (8 out of 17) had mild improvement (<25% improvement). They noted 35% (6 of 17) had no discernible improvement. Clinical improvement was most discernible in patients who had more aggressive treatment protocols (Index 6, 12- 14W, 2-3 passes). All cases with moderate improvement were treated with the more aggressive protocol (Figure 1 and 2). Of the cases that managed to achieve some mild improvement, one third of the cases underwent more conservative treatment protocols (Index 8, 8W, 1 pass) while the rest were treated with more aggressive protocols. Adverse effects were minimal. At 1-month post treatment, only 1 cases developed hyperpigmentation, which resolved promptly in 2 months with sun block. No acne exacerbation, erythema, hypopigmentation, edema, pin point bleeding, blistering or increased scarring were noted in any of the cases at 1 month. Discussion Acne scars can be a psychologically debilitating condition for many patients. The promise with various laser systems in the past purported to improve acne scarring with minimal downtime and yet yield good results had not been fulfilled. These tended to give variable results and can be rather difficult to satisfy the patients’ expectations. Full ablative carbon dioxide resurfacing techniques has long been the gold standard with regards to achieving scar improvement, but is coupled with a long downtime as well as increased morbidity. Even then, it can only give a modest improvement of 40-60%. This is more predictable and shows more consistent results with less inter patient variability. As such it can be quite bewildering for the practicing laser surgeon how non- ablative laser treatment modalities can yield results superior to traditional carbon dioxide resurfacing. Fractional carbon dioxide laser has been introduced recently with much hype in the hope of providing acne scar improvement with just 1 treatment and yet with the unique healing properties of being fractional, it is able to reduce the downtime to just 3–7 days depending on the intensity of treatment. In this study, we assessed a new carbon dioxide laser (SLIM Evolution, Lasering, Modena, Italy) with a fractional modality (MiXto SX) coupled to a high-speed scanner. With a microspot (300 microns) fractional modality and a novel- scanning algorithm that keeps the longest possible interval Fractional CO2 laser treatment of atrophic acne scars between two adjacent spots in order to minimize the heat accumulation around the treated areas, it is believed that both pain and probabilities of adverse events can be reduced significantly. The patients selected had moderate to severe acne scarring as determined by the global acne scarring classfication 5 .The scars were atrophic and were obvious at social distances of 50cm or greater and were not covered easily by makeup or the normal shadow of shaved beard hair in males. Clinically these were rolling, ‘‘box car,’’ mild to moderate hypertrophic or papular scars The present study has shown that even after a short follow up of 1 month, both patients and blinded physicians can observe discernible benefits. As one would expect, patient subjective assessment of improvement surpassed that of blinded dermatologist. In our study, with the exception of 1 patient, the rest felt they had a degree of improvement with up to a fifth felt they achieved at least 25% improvement. Interestingly, blinded investigators had a congruent result rating almost a fifth achieving at least 25% improvement but about a third having no improvement whatsoever while the rest achieving up to 25% improvement. We believe that after 1 month, post procedural oedema has abated and an element of fibrosis in skin effected to show initial effects of the laser. As expected, more improvement is consistently demonstrated if more aggressive protocols were utilized. This includes a variety of different parameters including increasing the pulse duration (dwell time of the laser), power and the number of passes. These increments were limited to patient tolerability of the procedure. It is currently difficult to postulate the optimum treatment parameters and more studies are required to ascertain this. We (Ee & Chua) employed multiple (up to 3) passes on patients who can tolerate the procedure well. One may argue that this might not be a “true” fractional approach and although we agree that multiple passes may approach the realms of full ablative resurfacing, the down time of the patient does not mimic so. It can be postulated that the use of the fractional photothermolysis concept coupled with ablative and microthermal zones in both the epidermis and dermis can effect a better treatment outcome as well as decreasing downtime. The results here are consistent and expected when compared to previous modalities used for resurfacing acne scars. Non-ablative lasers in the infrared range which initially promised improvement with minimal downtime can be somewhat unpredictable. A previous study by Chua et al6 using a non ablative diode laser to treat Asian patients with acne scars only managed at 17.3% and 5% improvement when graded by patients and blinded investigators respectively after 6 treatments. A further study by Tay et al7 with a Erbium:Yag resurfacing laser a showed mild to moderate improvement (up to 50% improvement) in all treated patients after 2 treatment sessions. The use of another non ablative Erbium glass1540nm laser device (Fraxel, Reliant) at our centre has also only produced results with less optimism (communications). On the other hand, Goh et al reported traditional ablative resurfacing can improve acne scarring by 25-75% in Asian patients only after 1 treatment2 . It is therefore not surprising that
  19. 19. 19Dermatology BulletinVolume 20 No: 2 2009 fractional CO2 resurfacing, which is a less aggressive form of laser resurfacing will elicit a lesser degree of fibrosis and as such a more modest degree of improvement. Our study also demonstrated subjective improvements in seborrhea, pore size, skin tightening and skin texture as reported by patients although these improvements were not validated by objective measurements. As such, we hesitate to recommend this treatment for these complaints until objective and sustainable results can be demonstrated by further studies. Pain experienced during treatment is also significant despite 2-hour pretreatment of anesthetic cream (EMLA, AstraZeneca) application. This was fleeting and settled promptly after the procedure with the application of a saline-soaked facial mask. All patients experienced side effects of erythema, edema, and desquamation. Epidermal sloughing was evident by day 2 of treatment. While treating with more conservative protocols had limited erythema and swelling confined to 4 days, more aggressive protocols with multiple passes can result in erythema, swelling and desquamation lasting up to a week. No infections and increased scarring were encountered and reepithelialization with normalization of external skin architecture occurred within a week. 1 case developed an element of post inflammatory hyperpigmentation, which spontaneously settled after 2 month with just the use of a sunscreen. Not surprisingly, a more aggressive regime had been employed for this patient. As with the other less aggressive resurfacing modalities, we expect better results with successive treatments. We are in the process of recruiting a larger cohort with longer- term data and various treatment protocols to investigate the outcome of multiple treatments. Conclusions Fractional carbon dioxide resurfacing is moderately effective in treating atrophic acne scars. The results are discernibly evident even at 1-month post procedure and can be applied safely on facial areas in type 4 photo types. Post treatment adverse events are minimal and tolerable. With more studies and better optimization of parameters, this system may offer clinical results closer to those seen in traditional carbon dioxide resurfacing but without the adverse effects. References 1. Walia S, Alster TS. Prolonged clinical and histologic effects from CO2 laser resurfacing of atrophic acne scars. Dermatol Surg 1999; 25:926–30 2. Goh CL, Khoo L. Laser skin resurfacing treatment outcome of facial scars and wrinkles in Asians with skin type III/ IV with the Unipulse CO2 laser system. Singapore Med J 2002;43:28–32 3. Hantash BM, Bedi VP, Kapadia B, Rahman Z, Jiang K, Tanner H, Chan KF, Zachary CB. In Vivo Histological Evaluation of a Novel Ablative Fractional Resurfacing Device. Lasers in Surgery and Medicine 2007; 39:96 – 107 4. Hantash BM, Bedi VP, Chan KF, Zachary CB. Ex Vivo Histological Characterization of a Novel Ablative Fractional Resurfacing Device. Lasers in Surgery and Medicine 2007; 39:87 – 95 5. Goodman GJ, Baron JA. Postacne Scarring: A Qualitative Global Scarring Grading System. Dermatol Surg 2006;32:1458–1466 6. Chua SH, Ang P, Khoo LS, Goh CL. Nonablative infrared skin tightening in Type IV to V Asian skin: a prospective clinical study. Dermatol Surg 2007;33:146-51 7. Tay YK, Kwok C. Minimally ablative erbium:YAG laser resurfacing of facial atrophic acne scars in Asian skin: a pilot study. Dermatol Surg.2008 ;34:681-5 Fractional CO2 laser treatment of atrophic acne scars
  20. 20. 20 Volume 20 No: 2 2009 Dermatology Bulletin Body Dysmorphic Disease In Patients Attending An Aesthetic Dermatology Clinic At The National Skin Centre – A Preliminary Prevalence Study Clin Prof Goh Chee Leok*, Dr Chua Sze Hon*, Dr Priya Sen**, Dr Melvin Ee Hock Leong** * Senior Consultant Dermatologist ** Consultant Dermatologist, National Skin Centre ORIGINAL ARTICLE 4 Introduction B ody dysmorphic disorder (BDD) is a psychiatric condition that is characterised by a distressing and impairing preoccupation with a non-existent or minimal defect in appearance.1,2 This condition has been described by other authors as dysmorphic syndrome, dermatologic hypochondriasis and dermatologic non- disease. BDD is regarded by some as a variant of monosymptomatic hypochondriasis. Patients with BDD are distressed by their perceived physical defect and may withdraw from family, work and social activities. In the extreme form, BDD may be associated with severe depression and may even lead to suicide. Patients with BDD may present to their dermatologist complaining repeatedly of their skin “defects” despite assurance that no significant abnormalities are present after a thorough clinical examination. Doctor-hopping and low satisfaction with treatment outcomes is typical. Patients with BDD are often dissatisfied with the surgical or laser treatments they have received and often adopt a demanding and unreasonable approach towards the attending doctor. In the clinics, BDD may go unrecognised and hence may be inappropriately managed. Recognition of BDD is crucial not only to avoid performing unnecessary aesthetic procedures, but also to initiate the appropriate psychiatric management to treat the underlying psychiatric disease. The prevalence of BDD in Singapore is unknown. BDD is likely to present more commonly to the dermatologic surgeon and aesthetic dermatologist who deal frequently with patients with cosmetic concerns. In previously reported studies, the prevalence of BDD is estimated to be between 0.7 and 2.4% of the population in Western countries3,4 and has been shown to reach 7-15% in patients undergoing aesthetic procedures.5-7 A validated questionnaire system reported recently appears to be a quick and simple tool that can be used to identify BDD. This questionnaire is based on the standard definition of BDD which consists of the following 3 criteria: (1) the patient is preoccupied with an imagined defect in appearance; if a slight physical anomaly is present the concern is markedly excessive; (2) the concern causes clinically significant distress or impairment in functioning and (3) the appearance preoccupation is not better accounted for by another mental disorder. The questionnaire was validated by a study in the United States. The questionnaire previously revealed a 15% prevalence of patients with BDD in a cosmetic setting in the United States. It was reported to have a sensitivity of 100% and a specificity of 92.3%. It had a positive predictive value of 70% and a negative predictive value of 100%.4 By correlating the answers with the psychiatric diagnosis of BDD, this brief questionnaire had been shown to be able to detect and calculate the prevalence of BDD in patients undergoing cosmetic dermatological procedures.5 Methodology This preliminary study on the prevalence of BDD among patients attending the NSC aesthetic dermatology clinic used such a questionnaire. The study was conducted at the Centre’s aesthetic dermatology clinic in patients over the age of 21 undergoing aesthetic procedures (Aesthetic Group) and compared the results with patients attending the general dermatology outpatient clinic (Control Group). Aesthetic procedure was defined as a procedure designed primarily to enhance the appearance without a primary medical dermatological condition. The study period was carried out between August 2008 and January 2009. The study protocol conformed to the hospital’s ethical guidelines and was approved by the Domain-Specific Review Board (DSRB) of the National Healthcare Group (NHG). All patients gave informed consent. Abstract Aims: Body dysmorphic disorder (BDD) is a psychiatric condition characterised by a distressing and impairing preoccupation with a non-existent or minimal defect in appearance. A validated patient questionnaire appears to be a quick and simple method for identifying BDD. This study aims to determine the prevalence of BDD among patients attending the NSC aesthetic dermatology clinic with the use of such a questionnaire. Methodology: The study group consisted of 24 patients attending the Centre’s aesthetic dermatology clinic. The control group consisted of 198 patients attending the general dermatology outpatient clinic with medical dermatological problems. Patients completed a questionnaire form which assisted in the identification of those with features of BDD. Results: 8/24 (33%) of patients in the Aesthetic Group had features suggestive of BDD. In contrast, only 8/198 (4%) of patients in the control group had features suggestive of BDD. Conclusions: A high proportion of patients attending the aesthetic dermatology clinic may have BDD compared to those attending the general dermatology outpatient clinic. Screening for BDD should perhaps be performed prior to the performance of aesthetic procedures for this group of patients.
  21. 21. 21Dermatology BulletinVolume 20 No: 2 2009 24 patients were recruited for the study. Their cosmetic problems included facial pigmentation such as melasma, lentigenes, nevus of Ota as well as acne scars and unwanted hair. The Control Group consisted of 198 consecutive patients with medical dermatology problems seen at general dermatology outpatient clinic; their dermatological problems included viral warts, eczema and urticaria. Patients filled up a questionnaire.8 In the questionnaire, patients were asked a screening question: “Are you very concerned about the appearance of some part of your body, which you consider especially unattractive?”. A “no” answer excluded BDD. If the answer to the screening question was “yes”, they were then asked 2 following questions: (a) Has your defect often caused you a lot of distress, torment or pain? How much? (b) Has your defect caused you impairment in social, occupational, or other important areas of functioning? How much? The patient was considered to have BDD if he/she answered “yes” to either question (a) and (b) with moderate distress or impairment in functioning. Data was collated and the prevalence of BDD between patients attending the aesthetic dermatology clinic and those attending the general outpatient dermatology clinic was determined. Cross tabulation analysis was used to compare the case and control groups. The Chi square test was used for statistical analysis. Results 24 patients were recruited from the aesthetic dermatology clinic and 198 controls from the general dermatology outpatient clinic. The mean age of Aesthetic Group was 40 (19-60) years compared to 37(19-76) years of the Control Group (statistically not significant, p=0.07). There was a preponderance of female patients in the Aesthetic Group compared to the Control Group (75% vs. 27%) (Table 1). The ethnic distribution (Chinese, Malays and Indians) was similar in both groups. 54% (13/24) in the Aesthetic Group answered “yes” when asked the BDD screening question compared to only 7% (14/198) in the Control Group (p<0.05). For these groups of patients, their answers to the follow-up questions (a) and (b) were as follows (Table 2): (a) Question (a): 5 patients or 21% (5/24) in the Aesthetic Group answered that their condition caused moderate to severe distress (BDD defining threshold) compared to 7 patients or 3.5% (7/198) in the Control Group (p < 0.001). (b) Question (b): 4 patients or 17% (4/24) in the Aesthetic Group answered that their condition caused moderate to severe impairment (BDD defining threshold) compared to 2 patients or 1% (2/198) in the Control Group (p<0.05). Of the above, there was 1 overlap patient in the Aesthetic Group; hence 33% (8/24) in the Aesthetic Group had features suggestive of BDD. In the Control Group, there was also 1 overlap patient; hence 4% (8/198) had features suggestive of BDD. Table 1. Demographic characteristics of patients from the Aesthetic Group vs.Control Group. Aesthetic Group (n=24) Control group (n=198) Sex • Female 18 (75%) 53 (26.8%) • Male 6 (24.2%) 145 (73.2%) Race • Chinese 20 (83.2%) 170 (85.9%) • Malay 2 (8.4%) 17 (8.6%) • Indian 1 (4.2%) 11 (5.6%) • Other 1 (4.2%) 0 (0%) Table 2 Answers to questions (1), (a) and (b) from patients from Aesthetic Group vs. those from the Control Group Aesthetic Group (n=24) Control Group (n=198) Answer to question (1) No 11 184 Yes 13 14 Answers to question (a) 13 14 a1. “No” 1 4 a2. Mild and not too disturbing 7 3 a3. Moderate and disturbing, but still manageable 4 4 a4. Severe and very disturbing 1 3 a5. Extreme and disabling 0 0 Answers to question (b) 13 14 b1. No limitation 5 11 b2. Mild interference, but overall performance not impaired 4 1 b3. Moderate definite interference, but still manageable 3 2 b4. Severe, causes substantial impairment 1 0 b5. Extreme, incapacitating 0 0 Question (1) = Are you very concerned about the appearance of some part of your body, which you consider especially unattractive? Question (a) = Has your defect often caused you a lot of distress, torment or pain? How much? Question (b) = Has your defect caused you impairment in social, occupational, or other important areas of functioning? How much? Based on the diagnostic criteria for BDD suggested by Dufresne5 , it would appear that 33% of patients attending the aesthetic dermatology clinic (Aesthetic Group) have features suggestive of BDD. This prevalence is significantly higher than those attending the general dermatology outpatient clinic (Control Group) in which only 4% had similar features. Discussion Prevelance of BDD in the general population range from 0.7% to 2.2% indicating that it is not a rare disorder.3,4 Body dysmorphic disease – a prevalence study
  22. 22. 22 Volume 20 No: 2 2009 Dermatology Bulletin Body dysmorphic disease – a prevalence study Our preliminary study suggests a fairly high proportion of patients attending the aesthetic dermatology clinic may have BDD (33%) compared to those attending the general dermatology outpatient clinic (4%). Other studies have reported the prevalence of BDD in cosmetic surgery practices to be around 6-15%.5,6 Thus, it is not uncommon for dermatologists to encounter such patients in their practice. Treating patients with BDD can be frustrating and challenging until the underlying problem is identified. Patients with BDD often have consulted numerous doctors for their perceived defects and are often not satisfied with the treatments they have received. They may demand for inappropriate and at times overly aggressive treatment for their perceived defects. Reassuring patients with BDD that there is nothing seriously wrong with them and that no treatment is necessary is often ineffective. Refusing treatment often drives such patients to seek treatment from another doctor and doctor-hopping is a common phenomenon. Even if minor defects are present and corrected, the patient will often shift the focus on a new perceived defect, requesting for additional procedures to be performed. Satisfaction after treatment is often poor, and patients may end up feeling depressed and suicidal8 angry; abusing the doctor and seeking litigation. The pathogenesis of BDD is complex and likely stems from an imbalance in neural processing in the hemispheric, limbic system and frontal-subcortical circuits.9 This condition is best viewed as psychiatric in nature and hence treated as such. Treatments reported to be beneficial include the use of serotonin reuptake inhibitors (e.g. fluvoxamine, fluoxetine, citalopram, sertraline or paroxetine) and cognitive behavioural therapy. 10,11 As the percentage of BDD appears much higher in patients attending an aesthetic dermatology clinic due to referral bias, it may be appropriate that screening for BDD be performed for this group of patients prior to the performance of aesthetic procedures. This screening can be quickly carried out using a simple patient questionnaire. Identification of patients who may have BDD from the screening process will help avoid the trap of performing procedures in this group of patients who are likely not to be satisfied with the treatment outcome. It will also allow the doctor to decide on the most appropriate management such as a referral to the psychiatrist. References 1. Allen A, Hollander E. Body Dysmorphic Disorder; Allen et al. Psychiatr Cln N Am 2000;23(3):617-28 2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th ed. Washington, DC: Am Psychiatr Assn,1994 3. Koran LM, Abujaoude E, Large MD, Serpe RT, The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr 2008;13:316-22 4. Vinkers DJ, van Rood YR, van der Wee NJ. Prevalence and comorbidity of body dysmorphic disorder in psychiatric outpatients. Tijdschr Psychiatr 2008;50:559-65 5. Dufresne R, Phillips K. Vittorio C et al., A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27:457- 62 6. Nachshoni T, Kotler M, Legal and medical aspects of body dysmorphic disorder. Med Law. 2007;26:721-35 7. Phillips KA, Dufresne R. Body dysmorphic disorder: a guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-43 8. Phillips KA, Suicidality in Body Dysmorphic Disorder. Prim psychiatry 2007;14(12):58-66 9. Feusner JD, Yaryura-Tobias J, Saxena S. The pathophysiology of body dysmorphic disorder. Body Image 2008;5:3-12, Epub 2008 Mar 7 10. Buhlmann U, Reese HE, Renaud S, Wilhelm S, Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy. Body Image 2008;5:39-49. Epub 2008 Mar 4 11. Phillips KA. Pharmacological treatment of body dysmorphic disorder: a review of empirical data and a proposed treatment algorithm. Psychia Clin N Am 2000;7:59-82
  23. 23. 23Dermatology BulletinVolume 20 No: 2 2009 Side Effects And Complications Of Fractional Carbon Dioxide Laser Photothermolysis: Experience With 201 Treatments Dr Tan Wee Ping*, Dr Melvin Ee Hock Leong**, Dr Priya Sen**, Clin Prof Chee Leok***, Dr Chua Sze Hon*** *Associate Consultant Dermatologist **Consultant Dermatologist *** Senior Consultant Dermatologist, National Skin Centre ORIGINAL ARTICLE 5 Introduction T he carbon dioxide laser is commonly used in facial resurfacing, exerting its effects through the vaporization of intracellular and extracellular water molecules, causing thermal damage to the surrounding tissues. This insult prompts fibroblasts to increase collagen production, resulting in desirable effects of wrinkle and photodamage reduction. However, the prolonged recovery time and complication risk of full ablative laser resurfacing has prompted the advancement of laser technology, with the development most recently of ablative fractional photothermolysis. Fractional resurfacing thermally ablates microscopic columns of epidermal and dermal tissue in a regularly spaced array comprising a fraction of the skin surface1 . It can be achieved through fractionate 10600nm CO2 , 1410nm erbium-doped fibre or 2940nm erbium:YAG lasers. This intermediate approach purports to increase the efficacy as compared to non-ablative resurfacing and at the same time decreases post treatment downtime and potential complications as compared to full ablative resurfacing. Side effects may still occur following fractional laser resurfacing, particularly the problem of dyspigmentation2 . Post-inflammatory hyperpigmentation is the most common adverse event, and has been said to be more frequently observed in individuals of skin types III-VI, in sunny regions. However, prior studies on fractional photothermolysis in patients predominantly of this skin types are lacking. Hence the aim of this study was to determine the side effects and complications associated with fractional photothermolysis in a cohort of patients with darker skin types. Methods A retrospective case records review was conducted at the National Skin Centre, Singapore. National Skin Centre is a tertiary dermatology centre that serves the Singapore population of 3.86 million, comprising an ethnic mix of 77.7% Chinese, 14.1% Malays, 7.1% Indians and 1.1% others3 . Medical records and laser charts of patients who underwent fractional 10600nm CO2 laser (Mixto Sx™) during the period of November 2007 to September 2008 were reviewed. The treatment protocol for all patients involved the application of topical lidocaine and prilocaine (EMLA® ) 1.5 hours prior to the procedure with occlusion. Treatment was then delivered to the areas with the 10600nm carbon dioxide laser device equipped with a 300μm hand piece. Forced air cooling (Zimmer MedizinSystems, Irvine, CA) may be used to alleviate discomfort during the procedure. All treatments were then followed by forced air cooling together with wet cotton mask applied over the entire face. Treatment may subsequently be repeated at six to eight weekly intervals. Patients were instructed to use a mild cleanser post treatment. They were also instructed to use a moisturizer (La Roche Posay Cicaplast cream) several times a day for the first post operative week. All patients received follow- up one month after each treatment session. The data collected included the patients’ age, gender, skin phototype, preoperative diagnosis, the number of treatment sessions delivered and laser parameters. Complications were evaluated by review of the medical records, as well as from doctor-administered questionnaires which were completed by the patients at each subsequent visit. Abstract Introduction: Fractional photothermolysis has proven efficacy in the management of rhytides, photodamaged skin as well as acne scarring. However, the evaluation of its potential complications in darker skin type patients is lacking. The aim of this study was to determine the side effects and complications associated with fractional photothermolysis in a cohort of patients with darker skin types. Methods: A retrospective case records review was conducted for patients who underwent fractional 10600nm CO2 laser (Mixto Sx™) during the period of November 2007 to September 2008. Complications were evaluated by review of the medical records, as well as from doctor-administered questionnaires. Results: 201 treatments in 83 patients were included in the data analysis. Adverse events occurred in 21 treatments. The most common adverse event was hyperpigmentation followed by acneiform eruption. No significant association was found between the likelihood of developing complications and index level (p= 0.417), fluence of energy delivered (p= 0.118) or number of passes (p= 0.592). Conclusion: Fractional photothermolysis with a 10600nm CO2 laser is a safe treatment modality in skin phototype four patients. The incidence of complications was low at 10%, and the risk of hyperpigmentation was 4.5%. Due to its known clinical efficacy and low complication profile, fractional photothermolysis may be considered as a treatment option for cutaneous resurfacing even in patients with darker skin types.
  24. 24. 24 Volume 20 No: 2 2009 Dermatology Bulletin Table 1. IV V VI Number of treatments 187 10 4 Number of patients, n, (percentage of males) 77 (51.9) 4 (50.0) 2 (50.0) Age (Mean, range) 34.9 (17-64) 39.5 (31-56) 27 (26-28) Diagnosis (n = number of patients) Acne scars Wrinkles Melasma Photoaged skin Others 65 4 1 1 6 4 2 Treatment Index, mean (range) Fluence (J/cm2), mean (range) Number of passes, n (%) 1 2 3 4 6.4 (3-11) 12.8 (6-18) 27 151 7 2 6.7 (6-8) 13.5 (8-16) 0 10 0 0 6 (6) 13 (10-16) 0 4 0 0 Mean duration of erythema, days (range) 5.7 (2-30) 5.8 (3-10) 4.5 (4-5) Mean duration of oedema, days (range) 2.3 (0-8) 4.75 (1-10) 2.5 (2-3) Presence of pinpoint bleeding, n (%) 12 (15.6) 1 (25) 0 (0) Complications Pain Prolonged erythema > 30days Swelling Hyperpigmentation Blisters/ Erosions Acneiform eruption Others 2 1 1 6 0 7 1 0 0 0 3 0 0 0 0 0 0 0 0 0 0 SPSS version 17.0 was used to analyze the data. Generalized estimating equations (GEE) model was utilized to evaluate the association between developing complications and index level, fluence of energy delivered and number of pass. Results A total of 260 treatment sessions in 139 patients were performed during the study period. Of these, 201 treatments in 83 patients were included in the data analysis; 52 patients were excluded due to loss to follow-up after the first visit and one patient who declined participation in all types of studies. Three Caucasian patients were also excluded. One hundred and nine treatments (54.2%) were performed on males and 92 on females of skin phototypes IV to VI. All treatments were performed on the face with the majority for treatment of acne scars (Table 1). Other indications included wrinkles, photodamaged skin, syringomas and post-traumatic scarring. Some patients had more than one indication for treatment, e.g. acne scars and wrinkles. The mean index and energy delivered were 6.5 and 12.1 J/cm2 respectively. For patients with skin phototype four, the mean index and fluence were 6.4 and 12.8 J/cm2 respectively. Most of patients had two passes during each treatment (80.2%). Side effects and complications occurred in 21 treatments (Table 1). No serious adverse events e.g. scarring or permanent hypopigmentation occurred. The mean duration of erythema following treatment was 5.31 days. The majority of patients experienced erythema of less than 14 days with only one patient with prolonged erythema of 30 days duration (This patient had three passes at index 6, 16 J/cm2 ). The most common adverse event was hyperpigmentation (Figure 1) followed by acneiform eruption (Figure 2). There was no significant association between the likelihood of developing complications and index level (p= 0.417), fluence of energy delivered (p= 0.118) or number of passes (p= 0.592). Acneiform eruption occurred following seven treatments. Five patients required treatment with oral doxycyline and topical clindamycin gel, as for management of a flare of acne vulgaris, and one patient with a one week course of oral augmentin. In five of these patients, laser treatment was continued according to schedule, whilst one patient had treatment deferred by three weeks. Discussion Though ablative carbon dioxide laser resurfacing has proven high efficacy, it is also associated with a prolonged post-treatment downtime and significant risks especially pigmentary complications in darker skin types4 . Our study Complications of fractional photothermolysis
  25. 25. 25Dermatology BulletinVolume 20 No: 2 2009 has shown that fractional photothermolysis is a safe treatment modality in darker skin types, with relatively low risks of side effects and complications. Despite the high levels of energy delivered, the overall complication rate in our cohort of patients was low at 10%. Though hyperpigmentation was the most common adverse event, the incidence rate was low at 4.5%. There are some limitations to our analysis. Our cohort comprised mainly of Chinese patients with skin phototype Complications of fractional photothermolysis four, with relatively small numbers of skin types five and six. The incidence of complications in these darker skin types may not be truly representative. Also, as this was a retrospective review, some missing data could not be accounted for. A study by Tan et al had also shown similarly low risk of post inflammatory hyperpigmentation in skin phototypes four and five patients treated with fractional carbon dioxide laser5 . In their small prospective study involving seven subjects, none developed complications, including post inflammatory hyperpigmentation, following a single treatment with a non sequential fractional carbon dioxide laser using an energy level of 60mJ and density setting of one, translating to ablation of 60% of facial skin surface (Ultrapulse® Encore™; Lumenis Inc, Santa Clara, CA). Other studies have often cited a much higher incidence of post inflammatory hyperpigmentation in darker skin types with non-ablative fractional resurfacing. Graber et al reported that the incidence of post-inflammatory hyperpigmentation in skin phototypes four and five following fractional photothermolysis with a 1550nm erbium-doped laser (Fraxel, Reliant Technologies Inc) was 11.6% and 33% respectively6 . Similarly Chan et al reported higher rates of post-inflammatory hyperpigmentation following treatment in a cohort of Chinese patients following non-ablative fractional resurfacing7. This suggests that the risk of post- inflammatory hyperpigmentation in darker skin types may be lower with fractional carbon dioxide laser compared to non-ablative fractional resurfacing. Previous small prospective studies have documented similar low risks of adverse events with fractional carbon dioxide laser. Rahman et al treated the forearm skin of twenty-four healthy volunteers with fractional carbon dioxide laser (Reliant technologies Inc, Mountain View, CA) at settings of 5-40mJ/MTZ and 400MTZ/cm2 . No serious adverse events were reported, and the incidence of erythema and oedema one month post-treatment were 33% and 10% respectively. A relatively high rate of post-inflammatory hyperpigmentation was observed in six subjects of skin types II and III (20%), albeit mild. No association between skin type and post inflammatory hyperpigmentation was observed. Regardless of the intrinsic skin type, patients with suntans should avoid treatment until their tans fade to reduce the likelihood of laser-induced melanocytic stimulation with subsequent postoperative hyperpigmentation. Treatment options to hasten the recovery of hyperpigmentation include the use of broad spectrum sunscreens and topical bleaching agents including hydroquinone, kojic acid and retinoids. Conclusion Fractional photothermolysis with a 10600nm CO2 laser was a safe treatment modality in skin phototype four patients. The incidence of complications was low at 10%. The most common adverse event was hyperpigmentation at 4.5%. Due to its known clinical efficacy and low complication profile, fractional photothermolysis should be considered as a treatment option for cutaneous resurfacing even in patients with darker skin types. Continue on page 28 Figure 1. Post inflammatory hyperpigmentation post fractional ablative laser resurfacing Figure 2. Acneiform eruption following fractional carbon dioxide laser resurfacing.

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