Treatments for Common Birthmarks, Dysplastic Nevi and Congenital Nevi

A birthmark is a colored mark on or under the skin that’s present at birth or develops shortly after birth.Some birthmarks fade with time; others become more pronounced. Birthmarks may be caused by extra pigment in the skin or by blood vessels that do not grow normally. Most birthmarks are painless and harmless. In rare cases, they can cause complications or are associated with other conditions. All birthmarks should be checked by a doctor.

See  the slideshow here:   http://www.medicinenet.com/birthmarks_pictures_slideshow/article.htm

Former Soviet President Mikhail Gorbachev has a port wine stain.

Salmon Patches

Salmon patches are nests of blood vessels that appear as small, pink, flat marks on the skin. They occur in 1/3 of newborn babies. Salmon patches can appear on the back of the neck (“stork bite”), between the eyes (“angel’s kiss”), or on the forehead, nose, upper lip, or eyelids. Some fade as baby grows, but patches on the back of the neck usually don’t go away. Salmon patches require no treatment.

Port Wine Stains

A port wine stain begins as a flat, pinkish-red mark at birth and gradually becomes darker and reddish-purple with age. Most will get bigger and thicker, too. Port wine stains are caused by dilated blood capillaries. Those on the eyelid may increase the risk of glaucoma. Port wine stains may be a sign of other disorders, but usually not. Treatment includes laser therapy, skin grafts, and masking makeup.

Mongolian Spots

Mongolian spots are flat, smooth marks that are present from birth. Frequently found on the buttocks or lower back, they’re typically blue, but can also be bluish gray, bluish black, or brown. They may resemble a bruise. Mongolian spots are most common on darker-skinned babies. They usually fade by school age, but may never disappear entirely. No treatment is required.

Cafe-Au-Lait Spots

Cafe-au-lait spots are smooth and oval and range in color from light to medium brown, which is how they got their name, “coffee with milk” in French. They’re typically found on the torso, buttocks, and legs. Cafe-au-lait spots may get bigger and darker with age, but are generally not considered a problem. However, having several spots larger than a quarter is linked with neurofibromatosis and the rare McCune-Albright syndrome. Consult a doctor if your child has several spots.

Strawberry Hemangiomas

Hemangiomas are a collection of small, closely packed blood vessels. Strawberry hemangiomas occur on the surface of the skin, usually on the face, scalp, back, or chest. They may be red or purple; they can be flat or slightly raised, with sharp borders. Strawberry hemangiomas usually develop a few weeks after birth. They grow rapidly through the first year before subsiding around age 9. Some slight discoloration or puckering of the skin may remain at the site. No treatment is required, but when desired, medicines and laser therapy are effective.

Cavernous Hemangiomas

Present at birth, deeper cavernous hemangiomas are just under the skin and appear as a bluish spongy mass of tissue filled with blood. If they’re deep enough, the overlying skin may look normal. Cavernous hemangiomas typically appear on the head or neck. Most disappear by puberty. A combination of cavernous and strawberry hemangioma can occur.

Venous Malformation

Venous malformations are caused by abnormally formed, dilated veins. Although present at birth, they may not become apparent until later in childhood or adulthood. Venous malformations appear in 1% to 4% of babies. They are often found on the jaw, cheek, tongue, and lips. They may also appear on the limbs, trunk and internal organs, including the brain. They will continue to grow slowly, and they don’t shrink with time. Treatment — often sclerotherapy or surgery — may be necessary for pain or impaired function.

Pigmented Nevi (Moles)

Moles occur when cells in the skin grow in a cluster instead of being spread throughout the skin. They can appear anywhere on the body, alone or in groups. Moles are usually flesh-colored, brown, or black. Moles may darken with sun exposure and during pregnancy. They tend to lose color during adulthood and may disappear in old age. Most moles are not cause for alarm. However, moles may have a slightly increased risk of becoming skin cancer. Moles should be checked by a doctor if:

* They change size or shape
* They look diffrent from other moles
* They appear after age 20

Actress Eva Mendes sports a “beauty mark” on her check.

Congenital Nevi

Congenital nevi are moles that appear at birth. The skin texture may range from normal to raised, or nodular to irregular. Congenital
nevi can grow anywhere on the body and vary in size –from a small 1-inch mark to a giant birthmark covering half of the body or more. Small congenital nevi occur in 1% of newborns. Most moles are not dangerous. But congenital nevi, especially large ones, should always be evaluated by a doctor since they may have an increased risk of becoming skin cancer.

Dysplastic Nevi (Atypical Moles)

Atypical moles are generally larger (one-quarter inch across or more) than ordinary moles and have irregular and indistinct borders. They may resemble cancerous moles. They may have a mix of colors including pink, red, tan and brown.These moles tend to be hereditary. Atypical moles have an increased chance of developing into melanoma skin cancer. Have a doctor evaluate all moles that look unusual, grow larger, or change in any way.

Tips to Remove Skin Tags

I know skin tags are harmless, but how do I get rid of them?

A plague of skin tags

Q: My neck is slowly becoming populated with tiny brown tags of skin, mostly where I used to wear necklaces. They are not painful, but I would like to get rid of them. My GP was dismissive, saying that I should just leave them. Will they go, will more come, and how can I get rid of them?

A: They are skin tags. They aren’t serious, they aren’t cancerous and they won’t go away of their own accord. I don’t know if more will appear, but people who get them usually get quite a few. Another common place for skin tags is under the breasts and in the armpits. They become more common with age. There are several ways to remove them. A doctor will use either a scalpel, a pair of surgical scissors, or a freezing device that kills them. Another option is to tie them with thread. This cuts off their blood supply and they eventually die and drop off. Patients have told me that a simpler way of getting rid of them is to regularly rub them with a loofah or bath glove that is designed to clear away dead skin cells. If you do try this, let me know if it works.
Article from:    The Independent (London, England)  | Article date:  July 17, 2007 | Author:  Dr Fred Kavalier

Skin Tag Orgins and Removal Treatments

What are skin tags?

Skin tags are small, benign growths that are composed of a core of fibers and ducts, nerve cells, fat cells, and a covering or epidermis. Additional names for skin tags include acrochordon, cutaneous papilloma, cutaneous tag, fibroepithelial polyp, fibroma molluscum, fibroma pendulum, papilloma colli, soft fibroma, and Templeton skin tag. They are often seen raised from the skin on a stalk called a peduncle.

Who gets skin tags?
Both men and women tend to get skin tags as they age. Skin tags are also more common in pregnant women, obese people, and people with type 2 diabetes mellitus. About 46% of people develop skin tags at some point in their lives.

Where do skin tags appear?
Skin tags often form in areas where the skin creases, such as the neckline, the groin, the underside of the arms, the area beneath the breasts, and the eyelids. The most common location is the armpit. It is common for skin tags to appear in groups. They often become stuck on jewelry, are shaved in error, and are agitated by clothing. Women who shave their armpits should be careful not to shave or cut skin tags that are located there.

Are skin tags harmful?
Although skin tags are technically tumors, they are benign and normally harmless. They can, however, become damaged and become inflamed and sore. If shaved off or rubbed hard, they may bleed.

What causes skin tags?
Although we do not know the exact cause of skin tags, the following are thought to be associated with their appearance:

* Chaffing and irritation from the skin rubbing together
* Hormones secreted during pregnancy or in cases of acromegaly (gigantism)
* Insulin resistance caused by diabetes
* Human papilloma virus
* Illegal steroid use that interferes with the body and muscles, causing the collagen fibers in the skin to bond so that skin tags are formed

How are skin tags removed?
Since skin tags are generally harmless, they are usually removed for aesthetic or cosmetic reasons. Physicians usually remove skin tags using one of the following methods:

* Cauterizatio - the skin tag is burned off using electrolysis
* Cryosurgery - the skin tag is frozen off using liquid nitrogen
* Ligation - the blood supply to the skin tag is interrupted
* Excision - the skin tag is removed with a scalpel

Squamous Cell Carcinoma Treatments

Most squamous cell carcinomas may be treated by one of the following methods. More healthy tissue around the lesion is removed
than for basal cell carcinomas because of the potential of squamous cell carcinomas to spread. Nearby lymph nodes are also examined
carefully. The choice of treatment is influenced by:

* size, location, grade, and type of tumour
* whether the tumour is primary or is recurring
* person’s age and health
* people with organ transplants are at a high risk of aggressive squamous cell carcinoma, which is considered in their treatment plan
* availability of the treatment

Surgery (Wide Excision)

# used for:
- most small lesions that are less than 2 cm
- superficial or SCC that has not spread
- verrucous carcinomas (slow growing and less aggressive)
- tumours that have previously been treated with radiation therapy
- lesions on the eyelid, forehead, scalp, lip, penis, vulva and anus

Mohs Micrographic Surgery

* used for all types of squamous cell cancer
* commonly used for:
- areas that are at high risk of recurrence (eyelids, nose, ears, forehead, scalp), as well as areas that have - already recurred
- areas where it is important to keep function and appearance
- lesions that are larger than 2 cm, and lesions with poorly defined borders
- aggressive tumours, and invasive lesions that have spread to nerves, cartilage or bone
- tumours that have been left untreated for a long time
- lesions that had not been completely removed with prior surgery it involves a meticulous study of tissues removed by a  pathologist at the time of surgery

Radiation Therapy

* used after surgery for:
- elderly individuals
- ensuring cancer free margins
- treatment of involved lymph nodes
- squamous cell carcinoma that has recurred after surgery
- to relieve or control the symptoms of very large tumours
- for people who are unwilling or unable to undergo surgery
- tumours on the eyelid, cheek, earlobe and nose not used for verrucous carcinomas (slow growing and less aggressive)

Chemotherapy

* systemic chemotherapy is used for squamous cell cancer that has spread to other parts of the body
* drugs used most often in chemotherapy:
- cisplatin
- doxorubicin
- bleomycin

Curettage And Electrodesiccation (C & E)

used for
- small areas that are less than 2 cm
- lesions that haven’t spread
- squamous cell carcinoma with distinct margins in Actinic Keratosis should not be used for:

- larger lesions that are greater than 2 cm
- recurrent tumours
- aggressive squamous cell carcinoma
- lesions with poorly defined borders
- hairy areas like the underarms, scalp, and the pubic area
- areas where it is important to keep function and appearance uncommonly used

Wart Treatment by Type of Drug and Procedure

The new advance in treatment of genital warts has been imiquimod (Aldara). This encourages the patient’s autoimmune system to attack the wart. This is particularly helpful in the moist areas of the skin or mucosal surfaces.

Salicylic acid
Salicylic acid can be applied either in the form of plasters or as liquid on to the warts. This will break down the thickened skin on the surface. It is more effective if the area is covered. These are useful for warts on the hands, knees and feet. They do turn the skin white. They can be used in combination with paring of the warts. Treatment with these at nighttime and covering with duct tape can be effective although slow.

Podophyllin

Podophyllin has a long history of use. It is useful mostly in genital warts. It should be applied very carefully on the warts, trying to prevent spread on to normal skin. It should be washed off after a few hours. There is irritation usually for a few days. Repeat treatments are usually required. A more purified form of podophyllin called podophyllotoxin is available for patient use. It can be used once or twice daily for a few days in succession. This produces some irritation. It has the advantage of not being as irritating as podophyllin and can be applied by the patients themselves.

Vitamin Acid

Vitamin acid (Tretinoin) is a vitamin A preparation. It is used in the treatment of acne and photo damage. Vitamin A products tend to regulate the surface of the skin, generally trying to keep the epidermis behaving normally. It may also cause some inflammation. In some individuals it can help reduce or even eliminate warts.

Cantharone

Cantharone (cantharidin) is derived from an insect. It can be very helpful in children but the application is painful. Inflammation and
blistering usually occurs later in the day, after application. Multiple treatments may be required. There are two concentrations. The
stronger version combines Cantharone with podophyllin and salicylic acid. Very occasionally the blistering reaction can be quite severe
and associated with swelling and pain. It is often very effective even in resistant warts.

Cryotherapy

Cryotherapy is the use of liquid nitrogen. This can be applied either with a Q-Tip or it can be sprayed on to the skin. It causes destruction by freezing water inside the cells. This damages the cell causing death. It is painful to apply and there is blistering associated with this. Multiple treatments may be required. Thawing and freezing again makes this therapy more effective. It can be a problem in dark skin in that it can either increase or decrease pigmentation, which can be permanent. This treatment can be used in combination with other therapies.

Electrodesiccation

Electrodesiccation is the use of an electric needle to burn warts. It usually requires a local anesthetic. It does have a potential risk of scarring. Very large warts can sometimes be scraped off before they are cauterized.

CO2 Laser

The CO2 laser has been used for many years. It essentially vaporizes water in the skin and causes destruction. It leaves a hole in the skin which will heal. There is often scarring with this technique. Other lasers such as the pulse dye laser are easier to use. The yellow light is absorbed by blood in the vessels that feed the warts. This is a similar laser used in the treatment of red birthmarks. The pulse dye laser at a high power setting can be effective particularly if multiple pulses are used in succession.

Aldara

Aldara is an immune response modulator. It boosts the patient’s immune response to viruses. It can also encourage the production of a
lasting immune memory. It has been available in Canada since 1999. It works best in the genital area as penetration into the skin is easier. When it is used elsewhere it often has to be covered to help with penetration into the skin. It has been shown to work well particularly in women. It is applied three times weekly. There will be some inflammation associated with this. The results may be enhanced by combining this with liquid nitrogen. This drug has added a very significant tool in treating genital warts.

Understanding Basic Types of Moles

It is necessary to clarify that not all moles are the same. There are a few classifications. But the most important for you is to be able to
discern the common mole from the moles that are more risky to cause skin cancer.

Moles are overgrowths of the skin’s pigment cells called melanocytes. Usually the moles are round spots on the skin colored in medium to dark brown. The greater part of moles is flat with constant color and regular in shape. A number of moles are raised with lighter colors. The people often had mistaken the new moles with the freckles. Sporadically the moles may develop a white halo around them.

Common Mole

In fact the moles could come into view everywhere on the body. Their color is usually brown, because is caused by the pigment melanin. Usually the common mole appears at the first part of life, when the system is growing but it is not impossible some moles to appear after the age of 20. The sun is one of the direct factors that have a strong influence on the moles. The people who are often exposed at sun light tend to have more moles that the others.

The common moles could change during the adolescence and the pregnancy, because of the big hormonal changes in the system. There is no typical way of change of one common mole. Usually one mole exists about forty to fifty years. Usually at the beginning of its life cycle the mole is flat and thin something like a freckle. Sometimes the color of the new mole is brown to black or even pink.

According to the size and shape the moles become bigger and rise over the surrounding skin with the time. Usually this is attended with the lightening of their color. It is not unusual some moles to rise over the skin and to develop a small stalk. The older moles tend to have some hairs on it that makes it odious sometimes. Some moles do not ever change.

The question which excites a lot of people is: Is it possible the common mole to disappear by its own? In fact the answer is yes. Some moles at the end of their life cycle tend to loose their color and to fade away. The raised moles also could fall of if they are raised vastly over the skin and have a thin stalk, but remember you must not try to wrench it away yourself. Look for a professional medical pracictioner to remove your mole for you.

As you can see there is no typical course of mole development. Because of that it is very important to know well your moles and to keep the history of their growth. According to the risk of skin cancer the early mark of any changes in the mole could be the decisive factor for the success of the melanoma treatment.

In order to make the process of the moles observation easier and at the same time enough efficient and useful for your dermatologist, our organization develops a list of common descriptions and characteristics of the moles that will help you to check your moles regularly and correctly. Be sure that you know the common types of moles.

Types of Moles

Each person has at least a few skin moles. They usually come out by the time an individual is 20 and at the beginning looks like freckles. Of course there are a lot of people who were born with skin moles. Usually every 1 of 20 babies has one or more moles at its birth.  A skin mole’s shade and form don’t usually change. A mole typically lasts about forty or even fifty years before start to become lighter. Some skin moles fade away completely, and some never fade at all. Sometimes a number of moles extend stalks that raise them above the skin’s surface it is possible these moles to drop off.

A skin mole is a spot on the skin with darker color. Generally it is part of skin pigmentation and could appear anywhere at the body. Most often we are talking about benign moles that are just a couple colored cells of the skin. Sometimes the facial moles could be even charming. On the other hand, from time to time moles can cause a serious health risk and can become Cancerous moles.

There are several skin mole types depending on its placement on our body:

Facial moles – or all moles on the face. It could appear all over the face and the head.

Body moles – are the moles at the other parts of the body with no specific location.

Genital Moles – Very often a lot of people feel ashamed of its genital moles. It is not surprising that most often the mole can cause
more psychological than health problems to its owner.

Moles in Children – It is normal the kids to have some moles at their bodies and it is important their parents to know what to check and how to examine the moles of the children

Black Moles
This variant of a benign mole (the common mole) is also referred to as a mole of midlife. It typically is seen in darker-skinned persons

between the ages of sixteen and thirty years. Of course this rule has a lot of exceptions. Usually the black mole is little, up to 5 mm.

Bleeding Moles
In common cases the mole which is bleeding or ooze is a reason to go to dermatologist. But even in this case the bleeding could be caused by irritation of the mole on the underwear or just a cut during shaving.

Body Moles
Moles may come out from the birth of an individual or may appear later during the whole life. It may begin from maturity and could still
grow when the person become forty or fifty years old. There is no specific place where the moles tend to occur more often

Changing Moles
The changes in the mole have to be brought to the attention of your dermatologist. It is normal the mole to grow with us and to change through the years but any unusual change in the color, fast growth, bleeding or oozing, inching or pain could indicate that the mole is turning into a melanoma.

The average person seldom has only “beauty marks”. In fact, in our present society the moles are often seen as a hindrance for their owner. There are a lot of people who feel depressed by their moles, especially if we are talking about the facial moles. If such a mole has strong influence upon the overall appearance and the general condition of the person may be it will be better for him or her to remove it.

Common Bacterial Infections of the Skin

Our skin is host to a number of bacteria, most of which are beneficial. Including the friendly flora in our gut, more than 200 species of bacteria reside within the tissues exposed to the external environment. Skin infections result from these bacteria when the integrity of the skin breaks down or when the immune defense system is weak.

Skin infections can occur on the skin surface or deeper within the skin tissue. The most common bacteria that infect the skin are Staphylococcus aureus and Streptococcus pyogenes. Read more about bacterial infections on www.skincareguide.ca/conditions/bacterial_infections

TYPES OF BACTERIAL INFECTIONS:

Impetigo and Ecthyma

Impetigo begins with a redness of the skin and progresses to blisters that fill with fluid and itch, and then produce honey-colored crusts. Lesions usually form around the nose and face. Ecthyma is a deeper version of impetigo that usually forms on the legs. It causes large boils, crusts, and deep sores that leave scars.

Folliculitis

Folliculitis is an infection of the hair follicles. It produces pimplelike skin bumps and small blisters with pus. Folliculitis occurs on the face, upper trunk, arms, and buttocks. When the infection goes deeper, feels tender, and produces more pus, it is furunculosis. Carbuncles are furuncles that have fused.

Abscess

An abscess is a deep infection that appears like a closed blister or an open hole with pus. It is usually tender and becomes sore and painful as the infection progresses.

Erysipelas and Cellulitis

Erysipelas is a superficial infection that tends to occur in young children and the elderly. It is also seen in those who have chronic swelling of the limbs, are addicted to alcohol, have diabetes mellitus, or have experienced trauma. Erysipelas mostly occurs on the face or legs. A fever occurs abruptly, the cheeks become red, and the skin feels hot, tense, and swollen. Cellulitis is a deeper form of this infection.

TREATMENTS:

Bacterial skin infections are treated according to their severity. Your physician may incise and drain deeper infections and abscesses, and recommend that you apply warm compresses. Creams such as Fucidin® or Bactroban® are prescribed for mild stages of:

* impetigo
* ecthyma
* folliculitis
* abscess

If the infection is more extensive, oral antibiotics such as Cloxacillin or Cephalexin are used as well as those in the erythromycin family. Penicillin is often used to treat for strep.

Antibiotic resistance is an increasing problem so it is best to have early adequate proper treatment to minimize risk of exposure to antibiotics and lower the risk of transmission to others.

During treatment, remember to wash your hands daily with an antibacterial solution such as Trisan®, Tersaseptic® or Hibitane®, or use a product like Safe4Hours® (www.invisicare.com) which kills bacteria for four hours. Hand washing is the most important thing you can do to minimize the spread of infection.

If you suspect a bacterial skin infection, see your doctor before it becomes severe. Due to the increase of bacterial resistance to drugs in general, it is important to take the full course of your prescribed medicines.

Skin Tags and Seborrheic Keratoses

Nuisances You don’t have to put up with. As time goes on, we all acquire tiny bits of extra skin called skin tags. These can range in size from 1-10 mm, and are flesh colored or brown.

Skin tags can be found on any part of the body, but are most common on the eyelids and neck, and in the armpits and groin, and under the breasts.  While skin tags are benign they can be annoying if they become irritating or rub on sporting equipment, and skin tags can interfere with shaving and can detract from one’s appearance and self-image.

Fortunately, we don’t have to put up with skin tags. These little annoyances can be easily removed in an office visit with little or no discomfort. Skin tags can almost always be removed without needing stitches, and the treated areas usually have healed completely in a week or two.

The cost of removing skin tags is quite reasonable - ranging from about $80 for a few tiny ones to about $200 for a larger number scattered over several areas.

Seborrheic keratoses are firm flat or raised, sometimes scaly or crusty flesh-colored, brown or black “barnacles” which accumulate (usually on the face and trunk) as time goes on. Some people start to develop seborrheic keratoses in their thirties, and most people have at least a few by the time they are sixty. To look at pictures of different types of moles, click on www.SkinCancerGuide.ca .

Seborrheic keratoses are usually just a nuisance, but - like skin tags — they can rub on clothing and equipment, and their appearance can sometimes be so distressing that they interfere with choice of clothing, sports like swimming, and intimacy.  Because seborrheic keratoses grow above the skin (but not down into the skin) they can be easily scraped off, and the treated areas heal up nicely within a few weeks. Sometimes the healed area remains pink for a few months after the seborrheic keratosis is removed.

The cost of removing seborrheic keratoses is similar to that for removal of skin tags: about $80 for one or two, with the cost gradually increasing depending on the number and size of seborrheic keratoses to be removed.

The cost of removing skin tags and seborrheic keratoses is a tax-deductible medical expense, just like things like dental bills.  So, if you are annoyed by skin tags or seborrheic keratoses you can be confident that it is simple and inexpensive to rid yourself of these nuisances.

By Kevin C. Smith MD FACP FRCPC

Using Lasers and IPL for Pigmentary Lesions

Lasers and intense pulsed light sources are frequently used for the treatment of pigmented lesions, and the appropriate selection of devices for different lesions is vital to achieving satisfactory clinical outcomes. In dark-skinned patients, the risk of post-inflammatory hyperpigmentation is of particular importance. In general, long-pulse laser and intense pulsed light sources can be effective with a low risk of post-inflammatory hyperpigmentation (PIH) when used for the treatment of lentigines. However, for dermal pigmentation and tattoo, Q-switched lasers are effective, with a lower risk of complications. In the removal of melanocytic nevi, a combined approach with a long-pulse pigmented laser and a Q-switched laser is particularly applicable.
Key Words: pigmented lesions, hyperpigmentation, lasers, intense pulsed light sources

The cutaneous application of lasers and intense pulsed light sources for the treatment of pigmented lesions can be divided into the following categories:

• a)  Tattoos
• b)  Epidermal pigmentation such as lentigines and café au lait patches
• c)  Dermal pigmentation such as nevus of Ota, acquired bilateral nevus of Ota, and melanocytic nevi

Tattoos

The use of lasers has been effective in the removal of some,  but not all, tattoos. Q-switched lasers have been found to be safe and effective in the treatment of tattoos. The response to laser treatment can vary greatly due to the wide range of tattoo ink. Previous in vitro quantitative chemical analysis of tattoo pigments found that the most common elements were aluminium, titanium, and carbon. Titanium overrepresentation was identified as the main reason for a poor response to laser treatment. Picosecond lasers were found to be more effective in achieving a greater degree of clearing. To improve the clinical outcome, more recent developments have included the external application of magnets to improve the removal of magnetite skin tattoos after Q-switched laser treatment, and the use of intradermal focusing of the Q-switched laser. In terms of complications, tattoos can darken after laser treatment due to the reduction of ferric oxide to ferrous oxide. This can be rectified with repeated Q-switched laser treatment and the use of a resurfacing laser. Less common complications include the development of allergic dermatitis or even anaphylactic shock after the laser surgery. Such reactions are thought to occur due to the release of allergic pigment into the extracellular space after laser exposure.

Epidermal Lesions

Lentigines

Lasers have been used for the treatment of lentigines, and although this is often effective for light-skinned patients with limited complications, for dark-skinned patients with a higher epidermal melanin content it can be associated with complications such as hyperpigmentation. Two years ago, our group performed an in vivo study of 34 patients and compared a Q-switched 532nm Neodymium:Yttrium-Aluminum-Garnet (QS 532nm Nd:YAG) laser to a long-pulse 532nm Nd:YAG laser. We found that the long pulse 532nm Nd:YAG laser (2msec pulse duration, 6.5-8J/cm2 fluence, 2mm spot size, with slate gray appearance as the clinical end-point) can result in a lower risk of PIH when used in the treatment of lentigines in Asians. We created controversy when we suggested that the photomechanical effect of QS lasers might not be desirable when used in such treatment. Intense pulsed light sources (IPL), which emit a broad band of visible light from a non-coherent filtered flashlamp, produce only photothermal effects. Recent studies that investigated the use of IPL to remove lentigines in Asians confirmed their effectiveness. Interestingly, no case of PIH was observed in two independent studies.

These observations confirm our hypothesis that the photomechanical effect of Q-switched laser for the treatment of lentigines in Asians is not desirable. The main concern regarding the use of the long-pulse laser for the treatment of cutaneous pigmented lesions is the potential of thermal diffusion from the epidermis to the dermis, which increases the risk of scar formation. To prevent such an occurrence, the pulse duration should be shorter than the thermal relaxation time of the epidermis basal layer, which was estimated to be in the range of 1.6-2.8ms if the epidermal basal layer thickness was 20mm.

It is now our routine approach to test patients with a long pulse 532nm Nd:YAG laser (2ms pulse duration, 6.5J/cm2 fluence, 2mm spot size), and if they respond well, we offer them full treatment. Those who do not wish to have down time, or those who develop post-inflammatory hyperpigmentation after the test, are offered IPL treatment, which requires several more treatment sessions to achieve the desired clinical outcome.

Café au Lait Patch

The use of lasers in the treatment of the café au lait patch has yielded variable results, and although some early studies indicated complete removal without recurrence, such findings have not always been repeated. Previous studies showed that 510nm pulsed dye lasers and copper vapor lasers can be used successfully, with no recurrence, at least one year after treatment. These reports were confirmed by others. Grossman, et al. used a QS Ruby laser and a frequency double Q-switched Nd:YAG laser, and found that the degree of clearance varied across lesions. Moreover, the categorization of the patches into the two histological sub-types that they identified did not help to predict the extent of the clinical response. We looked at the use of normal-mode ruby laser (NMRL) and compared it to QS Ruby laser in the clearing of café au lait patches in 33 patients. Our preliminary data indicated that there was a lower risk of recurrence when the NMRL was used (42.4% of recurrence, as compared to 81.8% recrrence in those who were treated with QS Ruby laser) 3 months after a single treatment. By affecting the follicular melanocytes, the long-pulse laser may reduce the recurrence rate. Further histological study is necessary to confirm this hypothesis.

Dermal Lesions

Nevus of Ota

Q-switched Alexandrite (QS Alex), QS Ruby, and QS 1064nm Nd:YAG have been used for the treatment of nevus of Ota with excellent results and minimal risk of complications. The clinical efficacy of the QS Ruby was confirmed when Watanabe and Takahashi⁶ studied 114 nevus of Ota patients and found that a good-to-excellent degree of lightening was achieved after three or more treatment sessions. The side-effects were few, with transient hyperpigmentation after the first treatment being the most common. Studies comparing the use of QS Alex and QS Nd:YAG lasers found that most patients better tolerated the former. However, QS Nd:YAG laser appeared to be more effective than QS Alex in the lightening of nevus of Ota after three or more laser treatment sessions. In terms of complications, hypopigmentation was common, especially among those treated with QS Ruby. The original pigmentation could also recur in patients after complete laser-induced clearing, which is an important issue, especially for pediatric patients. The risk of such recurrence is estimated to be between 0.6% and 1.2%. However, the use of QS Ruby laser for the treatment of nevus of Ota in children can achieve an excellent result in fewer sessions and at a lower complication rate than later treatment.  Hence, the advantages and disadvantages of treating nevus of Ota early in childhood should be thoroughly discussed with the patient’s relatives.

Acquired Bilateral Nevus of Ota-like Macules (ABNOM) or Hori’s Macules

Acquired bilateral nevus of Ota-like macules (ABNOM), or Hori’s macules, are a pigmentary disorder that is clinically characterized by speckled or confluent brownish-blue or slate gray pigmentation over the face, and histologically characterized by diffuse upper dermal melanocytosis. Unlike nevus of Ota, the pigmentation occurs in a symmetrical bilateral fashion, has a late onset in adulthood, and does not involve the mucosa.

One hundred forty patients with ABNOM were treated with a Q-switched Ruby laser (7-10J/cm2 fluence at a repetition rate of 1Hz, 2-4mm spot size). Complete clearance was obtained in 131 patients, and hyperpigmentation was observed in 7%. Hypopigmentation persisted in 2.1% of the patients, and there was no recurrence after 6 months to 4.3 years of follow up (mean was 2.5 years). QS Nd:YAG laser was also used to treat ABNOM, and the rate of PIH was estimated to be between 50% and 73%.⁸ Our group showed that QS Alex laser is effective in the treatment of ABNOM. Post-operative pigmentary changes were frequent, and the use of topical bleaching agents was necessary to achieve a satisfactory result. The risk of transient hypopigmentation was high, and it affected up to 50% of the patients. More recently, a combination approach with a scanned carbon dioxide laser followed by a Q-switched Ruby laser has been found to be effective.

Melanocytic nevi are common, and often removed for cosmetic reasons. Various pigmented lasers have been used in their removal. A previous study using a QS Ruby laser found that an average clearance of 76% occurred after eight treatment sessions.10 However, recurrence can be a problem depending upon the depth of the nests of melanocytes. The use of a normal mode ruby laser (NMRL) for the treatment of melanocytic nevi is based upon the principle that with longer pulse durations, a greater degree of clearance is achieved when nests of cells are destroyed. A combined approach with a QS Ruby laser followed immediately, or 2 weeks later, with an NMRL has more recently been used with the intention of removing the superficial pigment first with the QS Ruby laser, thereby enhancing the penetration of the NMRL. A previous study found that although 52% of the nevi showed a visible reduction in pigment, no lesion had complete histological clearance. The short- and long-term histological findings of congenital nevi that have been treated with the NMRL indicated that subtle microscopic scars of up to 1mm in diameter are frequent. It has been proposed that such scars cover the underlying nevus cells, which leads to cosmetic improvement. Better cosmetic results were produced by first using an NMRL to remove the epidermis, immediately followed by multiple passes of a QS Ruby laser.¹¹ This approach effectively removes the epidermis, and in doing so enables a greater degree of penetration by the QS Ruby, of which multiple passes further enhance the clinical efficacy. A similar approach using a long-pulse pigmented laser immediately followed by multiple passes of a Q-switched pigmented laser can obtain similar results.

Conclusion

For epidermal pigmented lesions, long-pulse pigmented laser or IPL can be effective with a lower risk of post-inflammatory hyperpigmentation, especially when used on dark-skinned patients. Q-switched laser is necessary to remove dermal pigment and tattoo in order to avoid the risk of scarring. A combination approach can be used for the removal of melanocytic nevi.

H.H.L. Chan, MD, FRCP¹, and T. Kono, MD^2
1Division of Dermatology, Department of Medicine, the University of Hong Kong, China
²Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, Tokyo, Japan

Methyl Aminolevulinate Cream + Benzyl Alcohol

Update on Drugs and Drug News

Name/Company	Approval Dates and Comments
Benzyl Alcohol Lotion 5% Sciele Pharma	The US FDA approved this prescription medication in April 2009 for the treatment of head lice infestation for use in patients 6 months of age and older.
Red Light Technology Device + Methyl Aminolevulinate Cream Aktilite® CL 128 + Metvix® Photocure/ Galderma	Health Canada approved this LED-based narrow band red light technology device in combination with methyl aminolevulinate in April 2009 for the treatment of actinic keratosis and superficial basal cell carcinoma.

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Drug News

Bayer HealthCare Pharmaceuticals and Onyx Pharmaceuticals, Inc. announced in April 2009 that a Phase III trial evaluating sorafenib tablets (Nexavar®) in patients with unresectable Stage III or Stage IV melanoma was stopped early following a planned interim analysis by the independent Data Monitoring Committee (DMC). The trial was sponsored by the National Cancer Institute (NCI) and led by the Eastern Cooperative Oncology Group (ECOG) under a Clinical Trials Agreement between NCI and Bayer and Onyx. The DMC concluded that the study would not meet the primary endpoint of improved overall survival among patients receiving sorafenib in combination with the chemotherapeutic agents carboplatin and paclitaxel vs. patients receiving placebo plus the chemotherapeutic agents. The treatment effect was comparable in each arm. There were no unexpected serious side-effects, though the final analysis of the data will occur per protocol and statistical analysis plan. Bayer and Onyx will further review the findings of this analysis to determine what, if any, impact these data might have on other ongoing sorafenib melanoma trials. Data from this study are expected to be presented at an upcoming scientific meeting.

In a study presented at the 2009 Annual Meeting of the American Academy of Allergy, Asthma & Immunology*, researchers at Mount Sinai Hospital in New York studied 14 patients with persistent atopic dermatitis who received traditional Chinese medicine at Ming Qi Natural Health Center in Manhattan between August 2006 and May 2008. The treatments consisted of Erka Shizheng Herbal Tea, a bath additive, creams, and acupuncture. The study authors utilized 2 measures: the SCORAD index to gauge atopic dermatitis severity and the Dermatology Life Quality Index (DLQI) to calculate impairment to life quality. Baseline median scores for SCORAD and DLQI were 89 and 17, respectively. After a median 8 months of treatment, the median scores fell to 11 for SCORAD and 1 for DLQI. In all but 1 patient, SCORAD measures decreased between 60% to 90% after 3.3 months of treatment. More than 50% improvement in DLQI scores was documented in all but 1 patient after 2.4 months. Patients also reported a reduction in the use of steroids, antibiotics, and antihistamines within 3 months of being treated with traditional Chinese medicine. There were no abnormalities of liver and kidney function observed. While the researchers concluded that the use of traditional Chinese medicine is safe and effective for patients with persistent atopic dermatitis, especially those with a severe case and significant life quality impairment, it is still recommended to speak with a physician before taking any complementary or alternative medicines. * Wisniewski J, Nowak-Wegrzyn A, Steenburgh-Thanik H, et al. Efficacy and safety of traditional Chinese medicine for treatment of atopic dermatitis (AD). J Allergy Clin Immunol 123(Suppl 2):Abstract #131 (2009 Feb).

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