Dr. Weiss presented a series of photographs of patients to this panel and asked each of the experts how they would approach treatment for each of the patients. The result was a lively and insightful discussion that explored the many ways that the patients' problems could be addressed. Meet the Panel A. Jay Burns, M.D., is Assistant Professor of Plastic Surgery, University of Texas Southwestern Medical School and Director of the Dallas Medical Skin Care Clinic. Henry H. L. Chan, M.D., F.R.C.P., is a dermatologist in private practice and Clinical Associate Professor, Dermatology Department, at the University of Hong Kong and Chinese University of Hong Kong. Jeffrey S. Dover, M.D., is a Director of SkinCare Physicians of Chestnut Hill in Chestnut Hill, MA. He’s also Associate Clinical Professor of Dermatology, Section of Dermatologic Surgery and Oncology, at Yale University School of Medicine. Roy G. Geronemus, M.D., is the Director of the Laser & Skin Surgery Center of New York in New York City. Elizabeth L. Tanzi, M.D., is the Co-Director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C. She’s also Clinical Instructor of Dermatology at Johns Hopkins University School of Medicine. Patient One: Addressing Spotted and Coarse Skin Dr. Weiss: This patient (see first set of photos on next page) wants to eliminate the spots and improve her skin texture. What are we going to do here? Dr. Dover: She is my favorite kind of patient: a woman who used to have blond or light hair who freckled in youth and now has scattered lentigines. If you improve the color and make it more homogenous, these patients look younger, their skin looks smoother and tighter — even if you don’t improve the texture. I would start with sunscreen, sun avoidance, and a retinoid, preferably Avage cream because I’ve found it to work quickly to treat dyspigmentation with a bit less irritation. We could also use Differin, Renova, or Retin A. I might try a Q-switched alexandrite ruby or Nd:YAG for two or three treatments, and get close to 95% improvement. Finally, I would use intense pulsed light (IPL) photorejuvenation to mop up all the dusty coloration left behind. You could also add a 5-aminolevulinic acid (ALA) (Levulan, Metvix) to the IPL to speed up the process. Patients have nice results with this. Dr. Burns: Another option would be the large-spot size, Gemini KTP laser, but the sunscreens and topical treatments are essential. Dr. Geronemus: There are several ways to handle this. One way would be to use a Q-switched laser, which would be a nice way to start a rapid response. The downside would be that there is minor scabbing or crusting for 3 to 5 days. I would then provide some rejuvenation using either the CoolTouch or SmoothBeam or one of the IPLs, with or without the ALA applied topically. However, I would opt for the Fraxel to get improvement of the overall dyschromia and a nice improvement of the overall texture and tone of the skin. Dr. Tanzi: Since the patient wanted overall improvement of dyspigmentation and also tone or texture and may have the beginnings of a few actinic keratoses (AKs), I would talk to her about starting a series of photodynamic therapy sessions using ALA incubated for an hour followed by an intense pulsed light treatment. I typically advise patients that two to three treatments are necessary for the best result, spaced about a month apart. This approach would yield a nice improvement of not only the lentigines but potentially the actinic keratoses. If she came back on her second or third treatment and we were still having difficulty with the AKs, then I would increase the incubation of the Levulan to 2 to 3 hours, provided she could handle the potential downtime. Typically, a day or so later patients are erythematous and may get a fine desquamation. Ultraviolet avoidance for 36 hours is mandatory. I would suggest a GentleWaves treatment or an LED treatment to keep the skin in good condition. Daily sunscreen and a retinoid will maximize the complete treatment. Dr. Weiss: A number of approaches will work with this patient. You could use the large-spot size Gemini. You could use IPL. You could do the Q-switched laser first and then clean up with the IPL later. This patient is ideal if you have any photorejuvenation device in the office. In the end, my patient didn’t think that there was much improvement. However, she did have remarkable improvement after treatment with the Starlux IPL system with the LuxG head, two treatments spaced 1 month apart. Patient Two: Avoiding A Surgical Facelift Dr. Weiss: Our next patient is a professional who is concerned about her appearance, but she does not want any downtime (see photos far right). Dr. Burns: While this patient would benefit from a surgical neck and facelift, it’s not unreasonable for a patient to want to avoid surgery and minimize downtime. In that case, Thermage would be the reasonable approach, as long as the patient was willing to accept the variability in results. I would also suggest submental liposuction, with a pressure garment, although there is a little downtime to that. If done well, you can direct the swelling and bruising down on to the neck, and she can wear a collared shirt in 2 to 3 days to work. Dr. Geronemus: She’s a surgical candidate, and I would document the fact that the discussion took place. Liposuction would be a good choice. There are newer techniques, such as using an Nd:YAG laser through a cannula for a laser liposuction, which removes a lot of the subcutaneous fat as well as creating a bit of tightening of the neck. There would be a small amount of swelling and perhaps a little eccymosis afterward. Short of all that, Thermage would be effective. Dr. Tanzi: I agree that she is a surgical candidate. But, if she does not want any downtime, then I would go with a radiofrequency treatment, probably multiple treatments, as long as she is aware of the potential inconsistency in the results. I might also use fillers near the melolabial fold to bolster and soften the lower part of the chin. Dr. Chan: The patient needs to inform us what she wants to be done. Thermage is wonderful to do a half face procedure for her, and it would be my treatment of choice. However, if she just wants more localized areas to improve, I would recommend treating her with the Titan. I can get about a 50% improvement with the Titan, not as good as Thermage but it is a lot more cost-effective. Dr. Dover: If you’re not going to do cold steel surgery, then Thermage is the way to go. While the results may not be as good as a facelift, Thermage can produce tightening of the forehead, lifting of the brow, helping the nasolabial, and the medial labial fold and the neck. She won’t have a spectacular result, but she’ll improve. Dr. Burns: This type of patient wants to know that she’s looked at every option and done everything she can do before having surgery. Often, these patients opt for the surgery after their non-surgical options have been exhausted. Dr. Weiss: Once again, the panel made the correct suggestions. We treated this patient with Thermage, doing about five passes on the treated areas with progressively lower energies. We used the 1.5-cm tip, starting with 62 (scale set by manufacturer) as the setting and then down to 61.5. We also pulled up on the skin in some areas and did three to four passes, but not serially. We went over the entire area and then went back to do it again after a rest interval to allow the erythema to dissipate between passes. We’re going to wait a full 6 months to observe results with this patient, and then we will consider using fillers. We also did not treat this patient’s forehead with Thermage, so we may end up using botulinum toxin type A (Botox). She does not need any other textural improvement. She’s happy with this result. Patient Three: Addressing Scarring Caused By Earlier Procedures Dr. Weiss: This patient has some scarring she wants to address, which may be the results of earlier treatments. She has a long history of treatments, switching doctors, and possibly disregarding treatment instructions and warnings about sun exposure. How do we deal with a patient like this? (See photos at right.) Dr. Dover: We’ve had great success treating red hypertrophic scars with a pulsed dye laser. Typically, I use a 7-mm spot, at 7 to 7.5 J/cm2, with a pulse of 1.5 ms using the Vbeam. Patients get purpura for up to about 7 days. I tell all my patients who are undergoing treatment for scars that they need a minimum of two treatments and that with more treatments, the scar will continue to improve and occasionally become nearly undetectable. However, if the patient is not willing to do at least two treatments, we won’t start. Dr. Burns: Knowing her history of dissatisfaction, I probably wouldn’t treat this patient. But if I treated her scar, I would use the shorter 450 ms domain with the V-Star laser. Because the results are not predictable in all cases, I would have a low-level injectable steroid available. But at 6 months, the patient will be on the normal curve of wound healing, and the scar will improve with time. Dr. Geronemus: I would use the pulsed dye laser with non-purpura doses to improve the texture of the scar and some of the erythema, but the patient must understand that it will take multiple treatments. I would also add injections of intralesional 5-fluorouracil with triamcinolone. It is more painful, but you don’t see the atrophy that you get with other steroids or the subsequent erythema and telangiectasia from triamcinolone or Kenalog. I would not use Kenalog for somebody with an erythematous scar. I would also have the patient massage the scar and perhaps use occlusive dressings. To address the inevitable hypopigmentation, I would use ReLume or the excimer laser. Dr. Tanzi: I would use a low-dose pulsed dye laser with short pulse durations, 1.5 ms or 0.45 ms, with a 10-mm spot size, starting around 4.5 or 5 J/cm2. I would use multiple treatments at 6-week intervals. Dr. Chan: My approach is to inject the scar to flatten it and then use a pulsed dye laser at a sub-purpuric dose. Purpuric doses do not improve results with scars and may make them worse. Dr. Weiss: For this patient, we started with two pulsed dye treatments and then IPL on the rest of her skin and over the scar after we had flattened it. There was some hypopigmentation, which is why we did the IPL after the pulsed dye. We used low doses, with a V-Star at 2 ms and fluence of 7 J/cm2. We did not use intralesional steroids. The patient is happy with this result. Patient Four: Treating Sebaceous Hyperplasia and Telangiectasia Dr. Weiss: This patient had a lot of sebaceous hyperplasia. He wanted to look better and was willing to do whatever was needed, but was trying to avoid significant downtime. (See photos on page 50 at bottom.) Dr. Chan: If the sebaceous hyperplasia is his main complaint, I would use a CO2 laser. We also have a 1540 nm laser that can be used either as a non-ablative rejuvenation or by removing the cooling we can constrain the sebaceous hyperplasia. I would also use a Vbeam laser to remove the telangiectasia. However, if the patient also wanted improvement in treating wrinkling, then I’d use Fraxel to treat his rhytids. Dr. Tanzi: If this patient could tolerate a weekend of downtime with possible swelling, then I would address his telangiectasia and the erythema with a pulsed dye laser in a non-purpuric mode using a pulse-stacking technique. For the sebaceous hyperplasia, I would add Levulan, with a 2- to 4-hour incubation time then aggressively treat the sebaceous hyperplasia. This patient is going to require about three to five treatments. Dr. Geronemus: I would first treat the vascular component with the Gemini 532 nm large-spot size or a smaller spot size 532 nm in conjunction with a pulsed dye laser at non-purpuric doses. Then I would switch to the Fraxel, which can have a benefit in these finer vascular lesions, particularly in poikiloderma. It would also clean up any residual redness from treating the vascular component. The sebaceous hyperplasia could be addressed with electro-surgery. Dr. Burns:You must also address the neck, and I would use the Fraxel on the neck in combination with IPL. Dr. Dover:You can do purpura-free treatments using a long-pulsed pulsed dye laser or the 532 nm Gemini laser to cautiously treat the face and the neck. We get exquisite results treating poikiloderma of the neck. If you don’t treat this patient’s neck, he might look worse because of the definition at the jaw line. Cautery works beautifully, if used judiciously, on small sebaceous hyperplasia, with repeat treatments once a month using a blunt tip at low energies. Dr. Weiss:This patient required a series of treatments and multiple modalities, starting with IPL (using the Quantum SR) plus Levulan with 1 hour of incubation. This improved the sebaceous hyperplasia and some surface texture. He was then treated with the Gemini and a series of Fraxel treatments. He’s been happy with the progress. Alternatively, the sebaceous hyperplasia could have been treated with an erbium with a 2-mm spot at ablative energies or the SmoothBeam with a 4-mm spot at 14 to 16 J/cm2. Patient Five: Tackling Resistant Acne and Scarring Dr. Weiss: This patient, who is in her thirties or early forties, wanted to address her acne, pigmentation irregularities and acne scarring. (See photos at right.) Dr. Dover: Women this age with resistant acne do well with light combination chemical therapies. SmoothBeam would do beautifully, and CoolTouch or Aramis will improve acne and texture. I would recommend a series of six treatments done once a month. Other options could include ALA with light alone. Topical and systemic therapies are still the treatments of choice for acne, so a hormonal regimen for a woman at this age is essential, with the anti-androgen, perhaps the systemic antibiotic and topical therapy. We usually combine them when we add in light. Dr. Geronemus: If isotretinoin (Accutane) and anti-androgens were not a possibility here, I would use the SmoothBeam, which would help both the acne and the acne scars. Dr. Tanzi: This patient may require spironolactone, depending on hormone levels. I might add a series of salicylic and lactic acid chemical peels in combination with mid-infrared laser treatments. That would help the acne and the post-inflammatory hyperpigmentation (PIH). Dr. Chan: A chemical peel can be effective for this patient. I do use photodynamic therapy (ALA and IPL) in combinations for Asian patients, with no increase in the risks of PIH. If anything, PIH seems to improve. I tell patients to expect about a 50% improvement. Dr. Weiss: My patient is on a topical retinoid. (She can only tolerate adapalene gel [Differin]). We also used the CoolTouch and one treatment of low-dose, long-pulsed pulsed dye laser. We’ve also used the SmoothBeam, and the patient has had about six treatments. l Final Thoughts Experience tells us that there are many different ways to approach the same problem. What we have seen with our panel is that while there may be therapies that all dermatologists agree on, there are also different ways to approach the same patient to achieve the desired results. The real message is that we should develop and refine standard approaches that we know will produce the best results for specific classes of patients, but we should also be open to new ideas and approaches.
How Would You Treat These Patients?
Dr. Weiss presented a series of photographs of patients to this panel and asked each of the experts how they would approach treatment for each of the patients. The result was a lively and insightful discussion that explored the many ways that the patients' problems could be addressed. Meet the Panel A. Jay Burns, M.D., is Assistant Professor of Plastic Surgery, University of Texas Southwestern Medical School and Director of the Dallas Medical Skin Care Clinic. Henry H. L. Chan, M.D., F.R.C.P., is a dermatologist in private practice and Clinical Associate Professor, Dermatology Department, at the University of Hong Kong and Chinese University of Hong Kong. Jeffrey S. Dover, M.D., is a Director of SkinCare Physicians of Chestnut Hill in Chestnut Hill, MA. He’s also Associate Clinical Professor of Dermatology, Section of Dermatologic Surgery and Oncology, at Yale University School of Medicine. Roy G. Geronemus, M.D., is the Director of the Laser & Skin Surgery Center of New York in New York City. Elizabeth L. Tanzi, M.D., is the Co-Director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C. She’s also Clinical Instructor of Dermatology at Johns Hopkins University School of Medicine. Patient One: Addressing Spotted and Coarse Skin Dr. Weiss: This patient (see first set of photos on next page) wants to eliminate the spots and improve her skin texture. What are we going to do here? Dr. Dover: She is my favorite kind of patient: a woman who used to have blond or light hair who freckled in youth and now has scattered lentigines. If you improve the color and make it more homogenous, these patients look younger, their skin looks smoother and tighter — even if you don’t improve the texture. I would start with sunscreen, sun avoidance, and a retinoid, preferably Avage cream because I’ve found it to work quickly to treat dyspigmentation with a bit less irritation. We could also use Differin, Renova, or Retin A. I might try a Q-switched alexandrite ruby or Nd:YAG for two or three treatments, and get close to 95% improvement. Finally, I would use intense pulsed light (IPL) photorejuvenation to mop up all the dusty coloration left behind. You could also add a 5-aminolevulinic acid (ALA) (Levulan, Metvix) to the IPL to speed up the process. Patients have nice results with this. Dr. Burns: Another option would be the large-spot size, Gemini KTP laser, but the sunscreens and topical treatments are essential. Dr. Geronemus: There are several ways to handle this. One way would be to use a Q-switched laser, which would be a nice way to start a rapid response. The downside would be that there is minor scabbing or crusting for 3 to 5 days. I would then provide some rejuvenation using either the CoolTouch or SmoothBeam or one of the IPLs, with or without the ALA applied topically. However, I would opt for the Fraxel to get improvement of the overall dyschromia and a nice improvement of the overall texture and tone of the skin. Dr. Tanzi: Since the patient wanted overall improvement of dyspigmentation and also tone or texture and may have the beginnings of a few actinic keratoses (AKs), I would talk to her about starting a series of photodynamic therapy sessions using ALA incubated for an hour followed by an intense pulsed light treatment. I typically advise patients that two to three treatments are necessary for the best result, spaced about a month apart. This approach would yield a nice improvement of not only the lentigines but potentially the actinic keratoses. If she came back on her second or third treatment and we were still having difficulty with the AKs, then I would increase the incubation of the Levulan to 2 to 3 hours, provided she could handle the potential downtime. Typically, a day or so later patients are erythematous and may get a fine desquamation. Ultraviolet avoidance for 36 hours is mandatory. I would suggest a GentleWaves treatment or an LED treatment to keep the skin in good condition. Daily sunscreen and a retinoid will maximize the complete treatment. Dr. Weiss: A number of approaches will work with this patient. You could use the large-spot size Gemini. You could use IPL. You could do the Q-switched laser first and then clean up with the IPL later. This patient is ideal if you have any photorejuvenation device in the office. In the end, my patient didn’t think that there was much improvement. However, she did have remarkable improvement after treatment with the Starlux IPL system with the LuxG head, two treatments spaced 1 month apart. Patient Two: Avoiding A Surgical Facelift Dr. Weiss: Our next patient is a professional who is concerned about her appearance, but she does not want any downtime (see photos far right). Dr. Burns: While this patient would benefit from a surgical neck and facelift, it’s not unreasonable for a patient to want to avoid surgery and minimize downtime. In that case, Thermage would be the reasonable approach, as long as the patient was willing to accept the variability in results. I would also suggest submental liposuction, with a pressure garment, although there is a little downtime to that. If done well, you can direct the swelling and bruising down on to the neck, and she can wear a collared shirt in 2 to 3 days to work. Dr. Geronemus: She’s a surgical candidate, and I would document the fact that the discussion took place. Liposuction would be a good choice. There are newer techniques, such as using an Nd:YAG laser through a cannula for a laser liposuction, which removes a lot of the subcutaneous fat as well as creating a bit of tightening of the neck. There would be a small amount of swelling and perhaps a little eccymosis afterward. Short of all that, Thermage would be effective. Dr. Tanzi: I agree that she is a surgical candidate. But, if she does not want any downtime, then I would go with a radiofrequency treatment, probably multiple treatments, as long as she is aware of the potential inconsistency in the results. I might also use fillers near the melolabial fold to bolster and soften the lower part of the chin. Dr. Chan: The patient needs to inform us what she wants to be done. Thermage is wonderful to do a half face procedure for her, and it would be my treatment of choice. However, if she just wants more localized areas to improve, I would recommend treating her with the Titan. I can get about a 50% improvement with the Titan, not as good as Thermage but it is a lot more cost-effective. Dr. Dover: If you’re not going to do cold steel surgery, then Thermage is the way to go. While the results may not be as good as a facelift, Thermage can produce tightening of the forehead, lifting of the brow, helping the nasolabial, and the medial labial fold and the neck. She won’t have a spectacular result, but she’ll improve. Dr. Burns: This type of patient wants to know that she’s looked at every option and done everything she can do before having surgery. Often, these patients opt for the surgery after their non-surgical options have been exhausted. Dr. Weiss: Once again, the panel made the correct suggestions. We treated this patient with Thermage, doing about five passes on the treated areas with progressively lower energies. We used the 1.5-cm tip, starting with 62 (scale set by manufacturer) as the setting and then down to 61.5. We also pulled up on the skin in some areas and did three to four passes, but not serially. We went over the entire area and then went back to do it again after a rest interval to allow the erythema to dissipate between passes. We’re going to wait a full 6 months to observe results with this patient, and then we will consider using fillers. We also did not treat this patient’s forehead with Thermage, so we may end up using botulinum toxin type A (Botox). She does not need any other textural improvement. She’s happy with this result. Patient Three: Addressing Scarring Caused By Earlier Procedures Dr. Weiss: This patient has some scarring she wants to address, which may be the results of earlier treatments. She has a long history of treatments, switching doctors, and possibly disregarding treatment instructions and warnings about sun exposure. How do we deal with a patient like this? (See photos at right.) Dr. Dover: We’ve had great success treating red hypertrophic scars with a pulsed dye laser. Typically, I use a 7-mm spot, at 7 to 7.5 J/cm2, with a pulse of 1.5 ms using the Vbeam. Patients get purpura for up to about 7 days. I tell all my patients who are undergoing treatment for scars that they need a minimum of two treatments and that with more treatments, the scar will continue to improve and occasionally become nearly undetectable. However, if the patient is not willing to do at least two treatments, we won’t start. Dr. Burns: Knowing her history of dissatisfaction, I probably wouldn’t treat this patient. But if I treated her scar, I would use the shorter 450 ms domain with the V-Star laser. Because the results are not predictable in all cases, I would have a low-level injectable steroid available. But at 6 months, the patient will be on the normal curve of wound healing, and the scar will improve with time. Dr. Geronemus: I would use the pulsed dye laser with non-purpura doses to improve the texture of the scar and some of the erythema, but the patient must understand that it will take multiple treatments. I would also add injections of intralesional 5-fluorouracil with triamcinolone. It is more painful, but you don’t see the atrophy that you get with other steroids or the subsequent erythema and telangiectasia from triamcinolone or Kenalog. I would not use Kenalog for somebody with an erythematous scar. I would also have the patient massage the scar and perhaps use occlusive dressings. To address the inevitable hypopigmentation, I would use ReLume or the excimer laser. Dr. Tanzi: I would use a low-dose pulsed dye laser with short pulse durations, 1.5 ms or 0.45 ms, with a 10-mm spot size, starting around 4.5 or 5 J/cm2. I would use multiple treatments at 6-week intervals. Dr. Chan: My approach is to inject the scar to flatten it and then use a pulsed dye laser at a sub-purpuric dose. Purpuric doses do not improve results with scars and may make them worse. Dr. Weiss: For this patient, we started with two pulsed dye treatments and then IPL on the rest of her skin and over the scar after we had flattened it. There was some hypopigmentation, which is why we did the IPL after the pulsed dye. We used low doses, with a V-Star at 2 ms and fluence of 7 J/cm2. We did not use intralesional steroids. The patient is happy with this result. Patient Four: Treating Sebaceous Hyperplasia and Telangiectasia Dr. Weiss: This patient had a lot of sebaceous hyperplasia. He wanted to look better and was willing to do whatever was needed, but was trying to avoid significant downtime. (See photos on page 50 at bottom.) Dr. Chan: If the sebaceous hyperplasia is his main complaint, I would use a CO2 laser. We also have a 1540 nm laser that can be used either as a non-ablative rejuvenation or by removing the cooling we can constrain the sebaceous hyperplasia. I would also use a Vbeam laser to remove the telangiectasia. However, if the patient also wanted improvement in treating wrinkling, then I’d use Fraxel to treat his rhytids. Dr. Tanzi: If this patient could tolerate a weekend of downtime with possible swelling, then I would address his telangiectasia and the erythema with a pulsed dye laser in a non-purpuric mode using a pulse-stacking technique. For the sebaceous hyperplasia, I would add Levulan, with a 2- to 4-hour incubation time then aggressively treat the sebaceous hyperplasia. This patient is going to require about three to five treatments. Dr. Geronemus: I would first treat the vascular component with the Gemini 532 nm large-spot size or a smaller spot size 532 nm in conjunction with a pulsed dye laser at non-purpuric doses. Then I would switch to the Fraxel, which can have a benefit in these finer vascular lesions, particularly in poikiloderma. It would also clean up any residual redness from treating the vascular component. The sebaceous hyperplasia could be addressed with electro-surgery. Dr. Burns:You must also address the neck, and I would use the Fraxel on the neck in combination with IPL. Dr. Dover:You can do purpura-free treatments using a long-pulsed pulsed dye laser or the 532 nm Gemini laser to cautiously treat the face and the neck. We get exquisite results treating poikiloderma of the neck. If you don’t treat this patient’s neck, he might look worse because of the definition at the jaw line. Cautery works beautifully, if used judiciously, on small sebaceous hyperplasia, with repeat treatments once a month using a blunt tip at low energies. Dr. Weiss:This patient required a series of treatments and multiple modalities, starting with IPL (using the Quantum SR) plus Levulan with 1 hour of incubation. This improved the sebaceous hyperplasia and some surface texture. He was then treated with the Gemini and a series of Fraxel treatments. He’s been happy with the progress. Alternatively, the sebaceous hyperplasia could have been treated with an erbium with a 2-mm spot at ablative energies or the SmoothBeam with a 4-mm spot at 14 to 16 J/cm2. Patient Five: Tackling Resistant Acne and Scarring Dr. Weiss: This patient, who is in her thirties or early forties, wanted to address her acne, pigmentation irregularities and acne scarring. (See photos at right.) Dr. Dover: Women this age with resistant acne do well with light combination chemical therapies. SmoothBeam would do beautifully, and CoolTouch or Aramis will improve acne and texture. I would recommend a series of six treatments done once a month. Other options could include ALA with light alone. Topical and systemic therapies are still the treatments of choice for acne, so a hormonal regimen for a woman at this age is essential, with the anti-androgen, perhaps the systemic antibiotic and topical therapy. We usually combine them when we add in light. Dr. Geronemus: If isotretinoin (Accutane) and anti-androgens were not a possibility here, I would use the SmoothBeam, which would help both the acne and the acne scars. Dr. Tanzi: This patient may require spironolactone, depending on hormone levels. I might add a series of salicylic and lactic acid chemical peels in combination with mid-infrared laser treatments. That would help the acne and the post-inflammatory hyperpigmentation (PIH). Dr. Chan: A chemical peel can be effective for this patient. I do use photodynamic therapy (ALA and IPL) in combinations for Asian patients, with no increase in the risks of PIH. If anything, PIH seems to improve. I tell patients to expect about a 50% improvement. Dr. Weiss: My patient is on a topical retinoid. (She can only tolerate adapalene gel [Differin]). We also used the CoolTouch and one treatment of low-dose, long-pulsed pulsed dye laser. We’ve also used the SmoothBeam, and the patient has had about six treatments. l Final Thoughts Experience tells us that there are many different ways to approach the same problem. What we have seen with our panel is that while there may be therapies that all dermatologists agree on, there are also different ways to approach the same patient to achieve the desired results. The real message is that we should develop and refine standard approaches that we know will produce the best results for specific classes of patients, but we should also be open to new ideas and approaches.
Dr. Weiss presented a series of photographs of patients to this panel and asked each of the experts how they would approach treatment for each of the patients. The result was a lively and insightful discussion that explored the many ways that the patients' problems could be addressed. Meet the Panel A. Jay Burns, M.D., is Assistant Professor of Plastic Surgery, University of Texas Southwestern Medical School and Director of the Dallas Medical Skin Care Clinic. Henry H. L. Chan, M.D., F.R.C.P., is a dermatologist in private practice and Clinical Associate Professor, Dermatology Department, at the University of Hong Kong and Chinese University of Hong Kong. Jeffrey S. Dover, M.D., is a Director of SkinCare Physicians of Chestnut Hill in Chestnut Hill, MA. He’s also Associate Clinical Professor of Dermatology, Section of Dermatologic Surgery and Oncology, at Yale University School of Medicine. Roy G. Geronemus, M.D., is the Director of the Laser & Skin Surgery Center of New York in New York City. Elizabeth L. Tanzi, M.D., is the Co-Director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C. She’s also Clinical Instructor of Dermatology at Johns Hopkins University School of Medicine. Patient One: Addressing Spotted and Coarse Skin Dr. Weiss: This patient (see first set of photos on next page) wants to eliminate the spots and improve her skin texture. What are we going to do here? Dr. Dover: She is my favorite kind of patient: a woman who used to have blond or light hair who freckled in youth and now has scattered lentigines. If you improve the color and make it more homogenous, these patients look younger, their skin looks smoother and tighter — even if you don’t improve the texture. I would start with sunscreen, sun avoidance, and a retinoid, preferably Avage cream because I’ve found it to work quickly to treat dyspigmentation with a bit less irritation. We could also use Differin, Renova, or Retin A. I might try a Q-switched alexandrite ruby or Nd:YAG for two or three treatments, and get close to 95% improvement. Finally, I would use intense pulsed light (IPL) photorejuvenation to mop up all the dusty coloration left behind. You could also add a 5-aminolevulinic acid (ALA) (Levulan, Metvix) to the IPL to speed up the process. Patients have nice results with this. Dr. Burns: Another option would be the large-spot size, Gemini KTP laser, but the sunscreens and topical treatments are essential. Dr. Geronemus: There are several ways to handle this. One way would be to use a Q-switched laser, which would be a nice way to start a rapid response. The downside would be that there is minor scabbing or crusting for 3 to 5 days. I would then provide some rejuvenation using either the CoolTouch or SmoothBeam or one of the IPLs, with or without the ALA applied topically. However, I would opt for the Fraxel to get improvement of the overall dyschromia and a nice improvement of the overall texture and tone of the skin. Dr. Tanzi: Since the patient wanted overall improvement of dyspigmentation and also tone or texture and may have the beginnings of a few actinic keratoses (AKs), I would talk to her about starting a series of photodynamic therapy sessions using ALA incubated for an hour followed by an intense pulsed light treatment. I typically advise patients that two to three treatments are necessary for the best result, spaced about a month apart. This approach would yield a nice improvement of not only the lentigines but potentially the actinic keratoses. If she came back on her second or third treatment and we were still having difficulty with the AKs, then I would increase the incubation of the Levulan to 2 to 3 hours, provided she could handle the potential downtime. Typically, a day or so later patients are erythematous and may get a fine desquamation. Ultraviolet avoidance for 36 hours is mandatory. I would suggest a GentleWaves treatment or an LED treatment to keep the skin in good condition. Daily sunscreen and a retinoid will maximize the complete treatment. Dr. Weiss: A number of approaches will work with this patient. You could use the large-spot size Gemini. You could use IPL. You could do the Q-switched laser first and then clean up with the IPL later. This patient is ideal if you have any photorejuvenation device in the office. In the end, my patient didn’t think that there was much improvement. However, she did have remarkable improvement after treatment with the Starlux IPL system with the LuxG head, two treatments spaced 1 month apart. Patient Two: Avoiding A Surgical Facelift Dr. Weiss: Our next patient is a professional who is concerned about her appearance, but she does not want any downtime (see photos far right). Dr. Burns: While this patient would benefit from a surgical neck and facelift, it’s not unreasonable for a patient to want to avoid surgery and minimize downtime. In that case, Thermage would be the reasonable approach, as long as the patient was willing to accept the variability in results. I would also suggest submental liposuction, with a pressure garment, although there is a little downtime to that. If done well, you can direct the swelling and bruising down on to the neck, and she can wear a collared shirt in 2 to 3 days to work. Dr. Geronemus: She’s a surgical candidate, and I would document the fact that the discussion took place. Liposuction would be a good choice. There are newer techniques, such as using an Nd:YAG laser through a cannula for a laser liposuction, which removes a lot of the subcutaneous fat as well as creating a bit of tightening of the neck. There would be a small amount of swelling and perhaps a little eccymosis afterward. Short of all that, Thermage would be effective. Dr. Tanzi: I agree that she is a surgical candidate. But, if she does not want any downtime, then I would go with a radiofrequency treatment, probably multiple treatments, as long as she is aware of the potential inconsistency in the results. I might also use fillers near the melolabial fold to bolster and soften the lower part of the chin. Dr. Chan: The patient needs to inform us what she wants to be done. Thermage is wonderful to do a half face procedure for her, and it would be my treatment of choice. However, if she just wants more localized areas to improve, I would recommend treating her with the Titan. I can get about a 50% improvement with the Titan, not as good as Thermage but it is a lot more cost-effective. Dr. Dover: If you’re not going to do cold steel surgery, then Thermage is the way to go. While the results may not be as good as a facelift, Thermage can produce tightening of the forehead, lifting of the brow, helping the nasolabial, and the medial labial fold and the neck. She won’t have a spectacular result, but she’ll improve. Dr. Burns: This type of patient wants to know that she’s looked at every option and done everything she can do before having surgery. Often, these patients opt for the surgery after their non-surgical options have been exhausted. Dr. Weiss: Once again, the panel made the correct suggestions. We treated this patient with Thermage, doing about five passes on the treated areas with progressively lower energies. We used the 1.5-cm tip, starting with 62 (scale set by manufacturer) as the setting and then down to 61.5. We also pulled up on the skin in some areas and did three to four passes, but not serially. We went over the entire area and then went back to do it again after a rest interval to allow the erythema to dissipate between passes. We’re going to wait a full 6 months to observe results with this patient, and then we will consider using fillers. We also did not treat this patient’s forehead with Thermage, so we may end up using botulinum toxin type A (Botox). She does not need any other textural improvement. She’s happy with this result. Patient Three: Addressing Scarring Caused By Earlier Procedures Dr. Weiss: This patient has some scarring she wants to address, which may be the results of earlier treatments. She has a long history of treatments, switching doctors, and possibly disregarding treatment instructions and warnings about sun exposure. How do we deal with a patient like this? (See photos at right.) Dr. Dover: We’ve had great success treating red hypertrophic scars with a pulsed dye laser. Typically, I use a 7-mm spot, at 7 to 7.5 J/cm2, with a pulse of 1.5 ms using the Vbeam. Patients get purpura for up to about 7 days. I tell all my patients who are undergoing treatment for scars that they need a minimum of two treatments and that with more treatments, the scar will continue to improve and occasionally become nearly undetectable. However, if the patient is not willing to do at least two treatments, we won’t start. Dr. Burns: Knowing her history of dissatisfaction, I probably wouldn’t treat this patient. But if I treated her scar, I would use the shorter 450 ms domain with the V-Star laser. Because the results are not predictable in all cases, I would have a low-level injectable steroid available. But at 6 months, the patient will be on the normal curve of wound healing, and the scar will improve with time. Dr. Geronemus: I would use the pulsed dye laser with non-purpura doses to improve the texture of the scar and some of the erythema, but the patient must understand that it will take multiple treatments. I would also add injections of intralesional 5-fluorouracil with triamcinolone. It is more painful, but you don’t see the atrophy that you get with other steroids or the subsequent erythema and telangiectasia from triamcinolone or Kenalog. I would not use Kenalog for somebody with an erythematous scar. I would also have the patient massage the scar and perhaps use occlusive dressings. To address the inevitable hypopigmentation, I would use ReLume or the excimer laser. Dr. Tanzi: I would use a low-dose pulsed dye laser with short pulse durations, 1.5 ms or 0.45 ms, with a 10-mm spot size, starting around 4.5 or 5 J/cm2. I would use multiple treatments at 6-week intervals. Dr. Chan: My approach is to inject the scar to flatten it and then use a pulsed dye laser at a sub-purpuric dose. Purpuric doses do not improve results with scars and may make them worse. Dr. Weiss: For this patient, we started with two pulsed dye treatments and then IPL on the rest of her skin and over the scar after we had flattened it. There was some hypopigmentation, which is why we did the IPL after the pulsed dye. We used low doses, with a V-Star at 2 ms and fluence of 7 J/cm2. We did not use intralesional steroids. The patient is happy with this result. Patient Four: Treating Sebaceous Hyperplasia and Telangiectasia Dr. Weiss: This patient had a lot of sebaceous hyperplasia. He wanted to look better and was willing to do whatever was needed, but was trying to avoid significant downtime. (See photos on page 50 at bottom.) Dr. Chan: If the sebaceous hyperplasia is his main complaint, I would use a CO2 laser. We also have a 1540 nm laser that can be used either as a non-ablative rejuvenation or by removing the cooling we can constrain the sebaceous hyperplasia. I would also use a Vbeam laser to remove the telangiectasia. However, if the patient also wanted improvement in treating wrinkling, then I’d use Fraxel to treat his rhytids. Dr. Tanzi: If this patient could tolerate a weekend of downtime with possible swelling, then I would address his telangiectasia and the erythema with a pulsed dye laser in a non-purpuric mode using a pulse-stacking technique. For the sebaceous hyperplasia, I would add Levulan, with a 2- to 4-hour incubation time then aggressively treat the sebaceous hyperplasia. This patient is going to require about three to five treatments. Dr. Geronemus: I would first treat the vascular component with the Gemini 532 nm large-spot size or a smaller spot size 532 nm in conjunction with a pulsed dye laser at non-purpuric doses. Then I would switch to the Fraxel, which can have a benefit in these finer vascular lesions, particularly in poikiloderma. It would also clean up any residual redness from treating the vascular component. The sebaceous hyperplasia could be addressed with electro-surgery. Dr. Burns:You must also address the neck, and I would use the Fraxel on the neck in combination with IPL. Dr. Dover:You can do purpura-free treatments using a long-pulsed pulsed dye laser or the 532 nm Gemini laser to cautiously treat the face and the neck. We get exquisite results treating poikiloderma of the neck. If you don’t treat this patient’s neck, he might look worse because of the definition at the jaw line. Cautery works beautifully, if used judiciously, on small sebaceous hyperplasia, with repeat treatments once a month using a blunt tip at low energies. Dr. Weiss:This patient required a series of treatments and multiple modalities, starting with IPL (using the Quantum SR) plus Levulan with 1 hour of incubation. This improved the sebaceous hyperplasia and some surface texture. He was then treated with the Gemini and a series of Fraxel treatments. He’s been happy with the progress. Alternatively, the sebaceous hyperplasia could have been treated with an erbium with a 2-mm spot at ablative energies or the SmoothBeam with a 4-mm spot at 14 to 16 J/cm2. Patient Five: Tackling Resistant Acne and Scarring Dr. Weiss: This patient, who is in her thirties or early forties, wanted to address her acne, pigmentation irregularities and acne scarring. (See photos at right.) Dr. Dover: Women this age with resistant acne do well with light combination chemical therapies. SmoothBeam would do beautifully, and CoolTouch or Aramis will improve acne and texture. I would recommend a series of six treatments done once a month. Other options could include ALA with light alone. Topical and systemic therapies are still the treatments of choice for acne, so a hormonal regimen for a woman at this age is essential, with the anti-androgen, perhaps the systemic antibiotic and topical therapy. We usually combine them when we add in light. Dr. Geronemus: If isotretinoin (Accutane) and anti-androgens were not a possibility here, I would use the SmoothBeam, which would help both the acne and the acne scars. Dr. Tanzi: This patient may require spironolactone, depending on hormone levels. I might add a series of salicylic and lactic acid chemical peels in combination with mid-infrared laser treatments. That would help the acne and the post-inflammatory hyperpigmentation (PIH). Dr. Chan: A chemical peel can be effective for this patient. I do use photodynamic therapy (ALA and IPL) in combinations for Asian patients, with no increase in the risks of PIH. If anything, PIH seems to improve. I tell patients to expect about a 50% improvement. Dr. Weiss: My patient is on a topical retinoid. (She can only tolerate adapalene gel [Differin]). We also used the CoolTouch and one treatment of low-dose, long-pulsed pulsed dye laser. We’ve also used the SmoothBeam, and the patient has had about six treatments. l Final Thoughts Experience tells us that there are many different ways to approach the same problem. What we have seen with our panel is that while there may be therapies that all dermatologists agree on, there are also different ways to approach the same patient to achieve the desired results. The real message is that we should develop and refine standard approaches that we know will produce the best results for specific classes of patients, but we should also be open to new ideas and approaches.
