Ebook Color atlas of cosmetic dermatology (2/E): Part 1

179 66 0
Ebook Color atlas of cosmetic dermatology (2/E): Part 1

Đang tải... (xem toàn văn)

Tài liệu hạn chế xem trước, để xem đầy đủ mời bạn chọn Tải xuống

Thông tin tài liệu

Part 1 book “Color atlas of cosmetic dermatology” has contents: Topical treatment options, soft tissue augmentation, chemical peels, ablative laser resurfacing, nonablative laser resurfacing, nonablative laser resurfacing, sebaceous hyperplasia, male pattern hair loss,… and other contents.

Color Atlas of • �osme -., c ��erma o o ZEINA TANNOUS SANDY TSAO I I MATHEW M AVRAM MARC R AVRAM _ Color Atlas of Cosmetic Dermatology This page intentionally left blank Color Atlas of Cosmetic Dermatology Second Edition Ze ina Tannous, M D Chief, Mohs/Dermatologi c Surgery, Boston VA Medical Center Massachusetts General Hospital, Dermatology Laser & Cosmetic Center Affiliate Faculty, Wellman Center for Photomedicine Faculty Director for Dermatopathology, Department of Dermatology, Harvard Medical School Assistant Professor in Dermatology, Harvard Medical School Boston, Massachusetts Mathew M Avram, M D, JD Director Massachusetts General Hospital, Dermatology Laser & Cosmetic Center Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School Affiliate Faculty, Wellman Center for Photomedicine Boston, Massachusetts Sandy Tsao, M D Director of Procedural Dermatology Harvard Medical School Massachusetts General Hospital, Dermatology Laser & Cosmetic Center Boston, Massachusetts Marc R Avram, M D Clinical Professor of Dermatology Weill Cornell Medical School Private Practice-905 Fifth Avenue New York, New York B Medical New York Mexico City Milan Chicago San Francisco New Delhi San J uan Lisbon Seoul London Madrid Singapore Sydney Toronto The McGrow·H/11 Companies Copyright© 2011 - by The McGraw-Hill Companies, Inc All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-163975-0 MinD : 0-07-163975-6 The material in this eBook also appears in the print version of this title: ISBN: MinD : 0-07-163503-3 978-0-07-163503-5, All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occun·ence of a trademarked name, we use names in an editorial faslllon only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs To contact a representative please e-mail us at bulksales@mcgraw-lllll.com Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they clisclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to adntinister to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc ("McGrawHill") and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, moclify, create derivative works based upon, transntit, distribute, clisseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill's prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prolllbited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED "AS IS." McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or en·or free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/ or its licensors be liable for any indirect, incidental, special, punitive, consequential or s.irnilar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise D E D I CATI O N I wou ld l i ke t o ded icate this book t o the memory of m y beloved father, who a l ways gave me h is u lti mate love a n d s u p port Zeina Tannous, MD I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morre l l a n d M a ria Avra m You have provided me u ncond itional love a n d end less s u p po rt s i n ce the day I was born I love yo u Mathew M Avram, MD, JD To my h us ba n d , Hensi n You a re my stre ngth a n d i n s p i ration You r l ove, wisd o m a n d encou ragement h e l p m e rea l ize a nyth i n g is poss i b l e You a re a wo n d e rfu l h us ba n d , father a n d best fri e n d I wi l l love y o u a lways To my sons, Se basti a n a n d H u nter You r u nconditional love, enthusiasm a n d sense o f adventure h e l p me remem ber what is truly i m porta nt Yo u brighten my days a n d fi l l my l ife with h a p p i n ess and love Sandy Tsao, MD T h i s book is ded icated to my wife R o b i n a n d my two sons Robert a n d J a c o b I tha n k t h e m f o r the love a n d s u p port t h a t they give me every day Marc R Avram, MD This page intentionally left blank CONTENTS ix Preface SECTION THREE: DISORDERS OF ECCRINE GLANDS Chapter 16: Hyperhidrosis 86 SECTION ONE: PHO TOAGING Chapter 1: Analysis of the Aging Face and Non-Facial Regions SECTION FOUR: DISORDERS OF HAIR FOLLICLES Chapter 17: Hirsutism Chapter 2: Topical Treatment Options 92 99 Chapter 18: Pseudofolliculitis Chapter 3: Soft Tissue Augmentation 14 Chapter 19: Male Pattern Hair Loss 103 Chapter 4: Botulinum Toxin 21 Chapter 20: Female Pattern Hair Loss 126 Chapter 5: Chemical Peels 29 Chapter 6: Nonablative Laser Resurfacing Chapter 7: Ablative Laser Resurfacing 39 43 Chapter 21: Low Level Light Therapy (LLLT) and Hair Loss 133 SECTION FIVE: DISORDERS OF PIGMENTATION Chapter 22: Cafe Au Lait Macule 136 Chapter 8: Nonablative Fractional Laser Resurfacing 52 Chapter 23: Ephelides Chapter 9: Ablative Fractional Laser Resurfacing Chapter 10: Tissue Tightening 57 Chapter 24: Lentigines 62 Chapter 25: Melasma Chapter 11: Dermatochalasis Chapter 26: Nevus of Ota Chapter 12: Poikiloderma of Civatte 64 67 139 144 149 154 Chapter 27: Postinflammatory hyperpigmentation 158 Chapter 28: Vitiligo SECTION TWO: DISORDERS OF SEBACEOUS 163 GLANDS Chapter 13: Acne Vulgaris 72 SECTION SIX: VASCULAR ALTERATIONS Chapter 14: Rosacea 76 Chapter 29: Angiokeratoma Chapter 15: Sebaceous Hyperplasia 81 Chapter 30: Cherry and Spider Angiomas vi i 168 170 Chapter 31: Granuloma Faciale Chapter 32: Infantile Hemangioma Chapter 33: Keratosis Pilaris Atrophicans Chapter 34: Port-wine Stains Chapter 35: Pyogenic Granuloma 177 183 188 192 Chapter 39: Warts Chapter 41: Becker's Nevus 203 206 Chapter 42: Epidermal Inclusion Cyst Chapter 43: Epidermal Nevus 248 252 256 Chapter 54: Lichen Planus Chapter 55: Morphea Chapter 56: Psoriasis 262 265 267 272 276 Chapter 59: HIV Lipodystrophy/Facial Lipoatrophy Chapter 60: Striae Distensae SECTION TEN: ADIPOSE TISSUE ALTERATIONS SECTION NINE: INFLAMMATORY DISORDERS Chapter 58: Cellulite 198 Chapter 53: Squamous Cell Carcinoma SECTION SEVEN: BENIGN GROWTHS Chapter 52: Basal Cell Carcinoma Chapter 57: Gynecomastia Chapter 40: Angiofibroma Chapter 38: Venous Lakes Chapter 51: Actinic Keratosis 181 Chapter 37: Lower Extremity Telangiectasias, Reticular and Varicose Veins SECTION EIGHT: CUTANEOUS CARCINOMAS Chapter 36: Facial Telangiectasias 174 212 216 219 222 280 285 SECTION ELEVEN: WOUND HEALING ALTERATIONS Chapter 44: Lipoma Chapter 61: Hypertrophic Scars, Keloids, and Acne Scars 226 290 298 Chapter 63: Tattoo Removal 300 Chapter 64: Torn Earlobe 308 Index 311 Chapter 45: Milium Chapter 47: Seborrheic Keratosis Chapter 48: Syringoma Chapter 49: Dermatosis Papulosa Nigra Chapter 50: Xanthelasma Chapter 46: Neurofibroma 229 231 234 SECTION TWELVE EXOGENOUS CUTANEOUS ALTERATIONS Chapter 62: Ear Piercing 238 241 243 viii PREFACE There has been a revol ution in the treatment of med ical a n d cos­ go these proced u res The decision as to when not to treat a patient m etic d isord ers of the s ki n I n la rge part, this is d u e to the ava i l ­ is perha ps the m ost i m porta nt i n this fie l d a b i l ity o f procedu res a n d tec h nologies t h a t prod uce clear, cosmet­ With t h i s i n m i n d , Color Atlas o f Cosmetic Dermatology, Second ic benefit with few side effects a n d l ittle downti m e With the advent Edition seeks to provide a succ i n ct yet broad overview of cosmetic of lasers and l ight sou rces over the past 20 yea rs, cosmetic thera py There a re a plethora i l l ustrations and gra phs to e l u c i date i m prove ment is a m atter of q u ic k , relatively pa i n less proced u res consu ltati o n , management, treatment and side effects of n u m e r­ N on-laser treatments such as soft tissue fi l l ers, botu l i n u m tox i n ous cos metic proced u res Its pra ctica l format is gea red to the busy i njections, sclerothera py, h a i r tra ns p l a n tation a n d others have a lso practitioner or tra i nee who seeks a q u ic k , comprehensive refer­ d matica l ly expa nded the scope of this field These procedu res ence fo r a pproa c h i n g the cosmetic patient It a lso e m p h asizes coincide with the busy l ifestyle of many patients who seek a n pitfa l l s of treatment in ord e r to ed ucate the reader as to potenti a l i m prove ment i n a p pea nce that does n ot interfere with t h e i r pro­ p r o b l e m s w i t h certa i n treatments It serves as a n i nva l ua ble fessiona l , soc i a l or perso n a l obl igati o n s resource to both the experienced a n d novice These proced u res, however, a re n ot without potentia l side effects o r co m p l icati o n s Physicians who perform these treatments Zeina Ta n nous, M D in the a bsence of tra i n i ng or ed u cation a re certa i n to encou nter M athew M Avra m , M D , J D poor resu lts , c o m p l ications and i rate patie nts Beca use patients Sandy Tsao, M D a re p u rs u i ng el ective treatments fo r cosmetic benefit, a ny worsen ­ M a rc R Avra m , M D i ng o f a p pea n c e wi l l u n d e rsta n d a bly a nger patients who u n d e r- ix 52 I Color Atlas of Cosmetic Dermatology glyco l i c a c id/hyd roq u i no n e c rea m has been shown to be effective • Seria l su perfic i a l c h e m i c a l peels s u ch as sa l icyl ic a c i d a n d glyco l i c acid pee ls a re the safest peels i n d a rker skin phototypes Caution is req u i red for d a rker skin phototypes to avo i d hyperpigmentati o n LAS ERS • Q-Sw i t c h e d Lasers a-switched laser treatment for melasma is not recom­ mended given its h igh i ncid ence of posti nflam matory hyperpigmentation Add itiona l ly, it is not d matica l ly effec­ tive except in some cases of su perficial melasm a A • A b l at i ve Laser I n cases refractory t o topica l crea ms and chem ica l peels, erbium :YAG laser prod uced sign ificant, tem porary i m prove­ ment in 10 patients in one study but was com p l i cated by su bseq uent posti nfla m mato ry hyperpigme ntation in a l l patie nts • N o n -A b l a t i ve Fract i o n a l R e s u rfac i n g N o n -A blative Fracti o n a l res u rfacing can be su ccessful for some cases of melasma , espec i a l ly epidermal types ( Fig ) • Long-term data a re lacking • Treatment is ge nera l ly performed at su perfic i a l d e pth • Treatment is genera l ly performed at h igher densities relative to treatments for rhytid es and acne sca rs I t is m ost successfu l i n patients with l ighter skin p h o­ totypes, suc h as s k i n types I a n d I I I m provement is less p red i cta b l e in sk i n type I l l , but is often a c h i eved S k i n ph ototypes IV a n d V often not respond favor­ a b ly to fra ctional resu rfa c i ng Postinflam mato ry hyper­ pigme ntation is a high risk • P re- a n d posttreatment use of hyd roq u i none a n d l onger i nterva ls between treatments may red uce postinflam­ matory hyperpigme ntation i n d a rker s k i n phototypes P I T FALLS TO AVO I D/ COM P L I CAT I O N S/MANAG E M ENTI O U TCO M E EXPECTAT I O N S • A l l forms o f melasma a re d iffic u lt a n d frustrating to treat Recu rrence is co m m o n • Derm a l melasma is pa rticula rly d iffic u lt • Patie nts should be a p prised of the reca lc itra nt nature of t h i s condition in some cases B Figure 25.3 (A) Young female with melasma (B) Characteristic darkening of melasma -day post intense pulsed light treatment Secti o n : D i so rd e rs of Pigmenta t i o n • Postpa rtu m state a n d d isconti n ua n ce of oral contra­ Phys i c a l Exam ce ptive p i l ls a re freq uently s uccessfu l thera pies • Some treatme nts worse n its a p pea n c e • Strict s u n avo i d a n ce is c r u cia l w i t h a su nscreen with • S u n exposed a rea-face more often t h a n arms • D i st r i b ut i on-cheeks, l ower face , med i a l face, in any com b i nation Wood 's Light to determ i n e e p i dermal vs • d e r m a l d i stri b u t i o n of pigment UVNUVB protection a nd/o r a physical block such as tita n i u m d ioxide o r z i n c oxi d e d u ri n g a n d after a ny treatment regi men I C l i n ical D ifferential Diagnosis approach to diagnosing • Post- i nf l a m matory hyperpigme ntat i o n melasma • M e d i cation i n d uced hyperpigme ntat ion B I B L I OG RAPHY Risk Factors F i n ke l U , D itre C M , H a m i lton TA, E l l is C N , Voorhees J J To pica l treti n o i n ( reti noic a c i d ) i m proves melasm a A veh i c l e-contro l l ed , c l i n i c a l tria l Br J Dermatol 993 ; 129: 5-42 G r i mes P E M a nagement of hyperpigme ntation i n d a rker • Pregnancy • Oral contracepti ves • I ncreased p igme ntat i o n w i t h s u n expos ure Figure 25.4 Clinical approach to diagnosing melasma rac i a l eth n i c grou ps Semin Cutan Med Surg 2009 ; 28( ) : 77-85 Lawre nce N, Cox S E , B rody HJ Treatment of melasma with J essner's sol ution versus glycol i c acid : A com pa rison of c l i n ic a l efficacy and eva l uation of the pred ictive a bi l ity of Wood 's l ight exa m i nati o n J Am Acad Dermatol 1997;36: 589-593 Lee H S , Won C H , Lee D H , et a l Treatment of melasma i n As i a n s k i n using a fractional , 550 n m laser: An open c l i n ical study Dermatol Surg 2009;35( ) : 1499 - 504 M a n a loto R M , Alser T M Erb i u m :YAG laser resu rfa c i n g MELASMA f o r refractory melas m a Dermatol Surg 1999 ; 25 : - Vig i l a nt sunscreen is cruc ial 123 S P F30 before , d u r i ng a n d after any therapy R o k h s a r C K , Fitzpatrick R E The treatment o f melasma I m provem e n t i s var i a b l e a n d rec u rrence i s common with fractional p h otothermo lysis: A p i lot study Dermatol Surg 2005;3 ( ) : 645- 650 To ro k HM, J ones T, Rich P, S m ith S, Tschen E Top i c a l Mechanical Lasers • H yd roq u i n o n e • Ret i n o i d s to n i de % : A safe a n d efficacious 2-month treat­ • S u perf i c i a l pee l s • A b l at i ve resorfa c i n g ment for melasma Cutis 2005 ; 5( } ; 57-62 • Koj i c a c i d • Q-switched • Aze l a i c a c i d lasers • Licorice extracts Hyd roq u i none % , treti n o i n % , fl uocinolone ace­ Vera l lo- Rowe l l V M , Ve lo V, G u pe K, Lo pez-V i l lafuerte L, G a rcia Lopez M Double- b l i n d com parison of azeleic acid and hyd roq u i none i n the treatment of melasma • M i crodermabras i o n • Fract i o n a l photothermolysis I + + Acta Derm Venereal 989 ; 143: 58-6 A com b i n at i o n of a topical s u c h as Victor FC, G e l ber J , Rao B Melasma : A revi ew J Cutan m i crodermabrasion for months is a n Med Surg 2004; 8(2) :97- 02 effect ive a n d safe com b i n at i o n t h erapy hyd roq u i n o n e , w i t h month ly pee l s a n d/or + • Laser/l ight sou rces s h o u l d be u sed o n l y after c o m b i nation of topicals a n d pee l s m i crodermabrasion fa i l • R i sk of post- i n f l a m matory hyperpigme ntat i o n from a n y l aser ( m ay persist for months) • Fract i o n a l photothermolysis has fewer s i d e effects a n d l ess down­ time t h a n a b l at i ve lasers • A b l at i ve resorfa c i n g o n l y for t h e m ost refractory cases in patie nts who can tolerate months of post i nf l a m m atory c h a n ges • Q-switched l asers a re ofte n not effect ive a n d often worsen m e l asma Figure 25.5 Melasma treatment protocol 53 54 I Color Atlas of Cosmetic Dermatology CHAPT E R Nevus of Ota N evus of Ota , a lso known as nevus fuscoceru leus oph ­ tha l momaxi l l a ris, represents a ben ign pa rtia l ly confl uent mac u l a r b rown- b l u e pigme ntation of the ski n and m ucous mem bra nes i n t h e d istri bution o f the fi rst a n d second b n c hes o f t h e trige m i n a l nerve It may b e u n i ­ late l o r bi latera l The i psi latera l scl era is freq ue ntly i nvolved E P I D E M I O LOGY Incidence: 0.4% to 0.8% of J a pa nese dermatology patients Age: b i modal d istri bution at birth a n d p u berty Race: m ore common in Asia ns a n d b l a c ks than wh ites Sex: m ore fema les t h a n ma les seek treatment for this cond ition ; u n known if there is a sex p red i lection Precipitating factors: spora d i c , not a n i n h e rited d isord er PATHOG E N E S I S Hyperpigme ntation a rises as a res u l t of dermal melan ocytes t h a t have n o t m igrated to the epid erm i s PATHOLOGY H eavily pigme nted , e l ongated , d e n d ritic melan ocytes a re located a mong the reti c u l a r dermal collage n Most typi­ c a l l y, these mela nocytes a re fo u n d i n the u p per one-t h i rd of the reticu l a r dermis but a re a lso seen in the pa p i l l a ry d e r m i s i n s o m e lesions A PHYS I CAL LES I O N S I t presents a s confl uent o r pa rtia l ly co nfl uent b rown- b l u e patches i n the d istri bution o f the fi rst a n d second b n c h es of the trige m i n a l n e rve G ray, black, and p u r p l e coloration may be p resent i n s o m e lesions as wel l I t can be u n i latera l o r bi latera l The magnitude of i nvolvement can va ry fro m loca l perioc u l a r i nvolvement to much of the side of the face A p p roxi mately two-th i rd s of patie nts fea­ t u re i psi latera l sclera l i nvolvement D I FFERENTIAL D I AG N OS I S Melasma, cafe a u I t m a c u l e , H o ri's macule b l u e nevus, bru ising, och ronosis, a rgyria , p h otod ermatoses, fixed d rug eru ption, a n d other m ed ication-related eru ptions should be considered i n the proper c l i n ical setting B Figure 26 (A) Nevus of Ota prior to treatment with Q-switched ruby laser (8) Significant clearance after serial treatments with Q-switched ruby laser Secti o n : D i so rd e rs o f Pigmenta t i o n I 55 LABO RATORY EXA M I NAT I O N B i o psy m a y b e i n d icated i f t h e d iagnosis i s i n q u estio n o r t o exc l u d e the re case o f melanoma a rising i n this lesion CO U RS E There i s a b i modal d istri bution fo r n evus o f Ota , b i rth a n d p u be rty It rema i n s relatively s i m i l a r i n a p pearance after i n itia l presentatio n KEY CO N S U LTAT I V E QU EST I O N S • O nset o f eru ption • Med ication h i story MANAG E M ENT There is no medical i n d ication t o treat nevus o f Ota Cosmetic a p pea n ce, however, is d istressi n g to patients W h i l e c ryothera py and topica l b l ea c h i n g treatments have been util ized , the treatment of c h oice is Q-switc hed laser treatment TOP I CAL T R EATM ENT M a k e u p can camouflage o r assist i n ca mo uflag i n g nevus of Ota To pica l med ications a re less effective than laser Figure 26.2 Nevus of Ota Periorbital blue-gray pigmentation with scleral involvement (Kay K, Jen R, Richard J, et at eds Color Atlas & Synopsis of Pediatric Dermatology McGraw-Hill, Inc ; 2002) T R EAT M E N T • N u merous stu d ies have s hown that nevus o f Ota i s a m e n a b l e t o su ccessfu l reso l ution with Q-switc hed laser thera pies i n c l u d i ng the Q-switched ru by ( 694 n m ) , the a l exa n d rite (755 n m ) , a n d the N d :YAG ( , 064 n m ) lasers ( Figs a n d 26 ) • • Test s pot ca n be performed prior t o treatment The Q-switc hed r u by laser has been shown to be effec­ NEVUS OF OTA tive at prod u c i n g % or greater c l ea nce at fl uences of to J/c m , 4-m m s pot size, a n d a 30-ns pu lse width at 3-to-4- month treatment i nterva ls - I n a study of 46 c h i l d ren a n d 107 a d u lts with nevus of Ota , treatments were more s uccessfu l i n c h i l d ren Topica l Mechanical Lasers Camouflage may be h e l pfu l for some patients M i croderma b rasi o n s h o u l d not b e performed • H igh risk of dysc h rom i a a n d/or scarr i ng • Q-switched l asers are the t reat ment of choice • A b l a t i ve-no • t h a n i n a d u lts • - The mean n u m be r of treatment sess ions to a c h ieve sign ifica nt cleari ng or better was for the younger • age gro u p and 5.9 fo r the older age gro u p - Ad d itional ly, com p l i cations we re lowe r i n t h e c h i l d ren t h a n ad u lts, that is, 4.8% as com pa red to 22.4% - One retros pective study exa m i ned 101 M u l t i p l e t reatments with Q-switched l asers are needed I m p rovement moderate to dramatic after m u lt i p l e treatments • Q-switched l aser treatment of lesions that arise in i nfancy may respond better to l aser t h erapy than l ater in l ife • If a Q-switched VAG l aser is u sed a com b i n a t i o n of 532 n m/ 064 n m m a y res u l t i n better c l i n i cal i m provement t h a n 064 n m a l o n e • pati ents yea r after treatment with Q-switc hed r u by laser a n d Figure 26.3 Treatment of nevus of Ota algorithm 56 I Color Atlas of Cosmetic Dermatology fo u n d that 8% d is played hypopigme ntation a n d % showed hyperpigmentatio n One patient w h o had com plete resol ution d eve loped rec u rrence • The Q-switched a lexa nd rite laser is a lso effective for the treatment of nevus of Ota Dermal white n i n g is the key c l i n ica l end point when treati ng nevus of Ota with Q-switc hed lasers - One gro u p reported the su ccessful treatm e nt o f nevus of Ota with fractional p h otothermo lysis N o n etheless, Q-switc hed laser is the treatment of choice • To p i c a l • Ca mouflage may be hel pf u l fo r some patients • M ec h a n i c a l • M i c roderma b rasion s h o u l d not be performed • H igh risk of dysc h ro m i a a n d/o r sca rring • Lasers • Q-switched lasers a re the treatment of choice • Ablative-no • M u lt i p l e treatme nts with Q-switc hed lasers a re need e d • I m provement moderate t o d matic after m u ltiple treat­ ments • Q-switched laser treatment of lesions that a rise i n i nfa ncy may respond better t o laser thera py t h a n later in l ife • If a Q-switc hed YAG laser is use d , a c o m b i nation of 532 n m/ , 064 nm may res u l t in better c l i n ical i m prove­ ment tha n , 064 nm a l o n e - One study treated patients at fl uen ces ngi ng between a n d J/c m at 8-week i n terva ls T h e mea n n u m ber o f treatments w a s a pproxi mately seve n Seve n patients ach ieved 75% or bette r l ight­ e n i ng, th ree patie nts a c h ieved between % a n d % i m prove ment, one a c h ieved between % a n d % i m p rovement, a n d a noth e r a c h i eved less tha n 25% i m provement - Two patie nts experienced tra nsient hyperpigme nta­ t i o n ; one ex perienced tra nsient hypopigme ntatio n • T h e Q-switc hed N d : YAG ( ,064 n m ) laser h a s a lso prove n to be effective - Sl ightly less effective than other Q-switc hed lasers - I t is safer for use in dark skin types - Less risk of hypopigme ntatio n Secti o n 5: D i so rd e rs of Pigmenta t i o n P I T FALLS TO AVO I D/O UTCO M E EXPECTAT I O N S/CO M P L I CAT I O N S/ MANAG E M ENT • Laser treatment for nevus o f Ota is freq uently successfu l • G iven t h e h igh proportio n o f patients with d a r k s k i n phototypes, there is the r i s k o f hypo- a n d hyperpigmen­ tatio n • The r i s k o f suc h a n a dverse reaction s h o u l d be d is­ • Add itiona l ly, a test site can be treated before perform­ • Q-switc hed l a s e r treatment can be associated w i t h tra n ­ cussed with the patient prior to thera py i n g fu l l treatment of a n y les i o n sient hyperpigme ntation • Recu rrence after treatment is i n freq uent B I B L I OG RAPHY C h a n H H , Le u n g R S , Ying SY, e t a l A retrospective a n a ly­ sis of compl ications in the treatment of n evus of Ota with the Q-switc hed a l exa n d rite and Q-switched N d : YAG lasers Dermato/ Surg 2000;26( 1 ): 000- 006 Chan H H , Ying SY, Ho WS, Kono T, King WW An i n vivo trial c o m pa ri ng the c l i n ic a l efficacy and c o m p l icati ons of Q-switc hed 755 nm a lexa nd rite a n d Q-switched 064 n m N d :YAG lasers i n t h e treatm e nt o f nevus o f Ota Dermatol Surg 2000;26( ) : 9-92 Ko no T , C h a n H H , Ercocen A R , e t a l Use o f Q-switc hed r u by laser in the treatment of nevus of Ota i n d i ffe rent age gro u ps Lasers Surg Med 2003;32(5) :39 -395 Ko no T, N oza ki M, Chan H H , M i ka s h i m a Y A retrospec­ tive study looking at the long-term com pl ications of Q-switc hed r u by laser in the treatment of nevus of Ota Lasers Surg Med 200 ;29(2) : 56 - Ko u ba DJ , F i n c h e r EF, M oy R L N e v u s o f Ota successfu l ly treated by fractio n a l p h otothermo lysis u s i ng a fra ction­ ated 1440- n m N d :YAG laser Arch Dermatol 2008; 144( ) : 56- 58 R a d m a n esh M Naevus o f Ota treatment w i t h c ryother­ a py J Dermatol Treat 200 ; (4) : 205-209 I 57 58 I Color Atlas of Cosmetic Dermatology CHAPT E R Posti nfl a m mato ry hype rpig m e ntatio n Posti nfla m matory hyperpigmentation ( P I H ) is a c o m m o n seq uela o f i nfla m matory dermatoses or i nj u ry t o the ski n It occ u rs most commonly in d a rker skin types Depend i n g on the etiology of the hyperpigmentation , p ig­ ment may be de posited in the dermis o r epidermis with i m porta nt i m p l ications for treati ng the pigment c h a nges It is a c o m m o n seq uela of laser treatment, pa rti c u l a rly i n d a rker s k i n p hototypes ( Fig 27 ) EPI D E M I O LOGY Incidence: com m o n , espec i a l ly in d a rker skin types Age: a l l ages Race: m ore common in d a rker s k i n types Figure 27 PI H seen after a series of treatments with nonablative Sex: none fractional resurfacing for a scar The PIH resolved on its own within weeks Precipitating factors: a ny i nfla m m atory d isorder o r i nj u ry to the ski n can p rod uce hyperpigmentatio n It may a lso res u lt from laser thera py, derma b rasi o n , c ryothera py, or c h e m i ca l peels I t p rese nts more exu bera ntly a n d with a greate r d u ration i n d a rker s k i n ph ototypes PATHOG E N ES I S U n known D E R M ATOPAT H O LOGY Basa l cel l layer pigme ntatio n and dermal mela n o p hages a re see n PHYS I CAL LES I O N S I n epidermal P I H , patients d isplay i n d isti nct ta n t o d a rk b rown m a c u l es at s ites of previous s k in i nfla m mation I n d e r m a l P I H , there i s m o re of a brown-gray h u e D I F F E R E N T I A L D I AG N OS I S M astocytosis, m a c u l a r a myloidosis, m i noc i n hyperpig­ mentatio n , exogenous oc h ronosis, melasma, and ery­ thema dysc h ro m i c u m persta n s LABORATORY EXAM I NAT I O N None A _ Figure 27.2 (A) Pseudo-ochronosis seen after years of hydroquinone treatment Secti o n : D i so rd e rs o f Pigmenta t i o n I 59 CO U RS E P I H d oes not worse n i n the a bsence o f further i ns u lt o r i nfla m mation a t the affected site P I H usually resolves ove r a period of a few months In the case of dermal hyperpigmentati o n , th ere may n ot be i m provement KEY CO N S U LTAT I V E QU EST I O N S • S u n expos u re, s u nscreen use • lime of onset • Recent rashes, i nj u ry, or treatment of s k i n • Med ication use MANAG E M ENT W h i l e there is no medical i n d ication to treat P I H , m a n y patients a re as bothered by P I H as t h ey a re by t h e Figure 27.2 (B) ( Continued) Significan t improvement after treatment with a-switched laser p rocesses that prod uced it i n itial ly F u rthermore, P I H c a n end u re fa r longer tha n the origi n a l e r u ptio n There a re m u ltiple treatments i n c l u d i ng to pica l , laser, a n d c h e m ical peels ( Ta ble ) I t is essentia l to fi rst dete r m i n e the cause of the hyperpigmentation C u l prits nge from hemosiderin to pigment to vasc u l a r Without d eterm i n i ng the etio l ogy correctly, treatment w i l l , at best, provide no i m provement, o r worsen the P I H Freq ue ntly, the safest a n d most effective treatment is ti m e Atte m pted treat­ ment of P I H , espec ia l ly in da rker s k in ph ototypes, c a n often worsen a n d prolong hyperpigmentatio n N o r m a l ly, e p i d e r m a l P I H w i l l resolve on its own ove r a period of months Thera peutic o ptions i n c l u d e topical reti noids, bleach­ i n g crea ms, chemical pee ls ( i nc l u d i ng glycol i c a c i d peels, TAB L E 27 • Post- i nflammatory Hyperpigmentation treatment Fractio n a l Thera peutic R eti n oid/ Peels/ o ptions hyd roq u i none m i c roderm a b rasion Q-switc hed laser Ablative lasers resu rfa c i ng Post-i nfla m m atory N eeds to be used 20-70% glycol i c acid No No No hyperpigmentation for weeks to peels, jessner peels, months for c o m b i nation j essner i m prove ment TCNpee ls and Sa l ic i lyc acid peels a n d/or m ic roderma brasion may h e l p i m prove m ore q u ickly Fa ce/u pper body R i s k of pa rad oxic a l l y i m proves more m a k i ng posti nfla m matory q u ickly t h a n lower c h a nges worse if too If of the body m u c h i nf la m mation is c reated 60 I Color Atlas of Cosmetic Dermatology J essner peels, c o m b i nation J essnerfTCA pee ls, a n d sa l i­ cyl i c a c i d pee l s ), a n d fractional laser treatment There is a risk of paradoxica l ly m a k i n g post- i nfla m matory c h a nges worse if too m uc h i nfla m mation is created S U N P ROTECT I O N S u n b l oc ks a n d s u n sc reens used d a i ly a re c r u c i a l t o pre­ vent worse n i ng, as is sun avoid a n c e Without their use, other thera pies w i l l n ot be effective If a patient d oes n ot avoid s u n expos u re , P I H wi l l worsen S u n avo i d a n ce i n c l udes avoid i ng pea k s u n h o u rs , wea r i n g a hat out d oors to protect the face from s u n exposu re a n d a n awa re ness t h a t UVA rays pen etrates through w i n d ows w h i l e d riving, w h i l e at work a n d wh i l e at home TOP I CAL T R EATM ENTS T here a re a h ost of topical treatments fo r P I H that pro­ d uce m i l d i m provement and may exped ite reso l ution • Hyd roq u i none form u lations, pa rticu larly with su nscreens - Hyd roq u i none ( %-4% ) c rea ms a re effective, fi rst­ l i n e treatment - Prolonged usage of hyd roq u i none can res u lt i n a A c h a cteristic s k i n d iscol oration known as pse udo­ och ronosis ( Fig ) - B lea c h i ng c rea ms a re contra i n d i cated i n pregnant a n d lactat i n g wo m e n • Reti noids - Solage ( % meq u i nol a n d % treti n o i n ) and Tri l u ma ( 0 % fluoc i nolone aceto n i d e , 4% hyd ro­ q u i none, a n d 0.05% treti n o i n ) provide an exfol iative benefit - Tri l u m a s h o u l d n ot be used i n defi n itely d ue to its cor­ ticosteroid content and risk for atrophy • Aze l a i c ac i d ( 20% ) c rea m a p pl ied twice d a i ly provides slow l ighte n i ng of pigmentati o n • Koj ic a c i d ( %-2 % ) c rea m - The exact conce ntratio n of koj i c a c i d needed for effective res u lts is u n known • If any of these to picals prod uces sign ifi ca nt i nfla m ma ­ tion or i rritati o n , it is i m porta nt t o d isconti n u e its use to avoid worse n i ng of P I H C H EM I CAL P E E LS Chem ica l peels a re an effective treatment option for the red uction of P I H • Over-the-cou nter a-hyd roxy a c i d peels a re a benefi c i a l adj u nct to phys i c i a n -strength c h e m i c a l pee ls The conti n u a l exfoliation ach ieved from cons iste nt use of the peels may res u l t i n m i l d l ighte n i ng B Figure 27.3 (A) Hyperpigmentation on left side of face before treatment (8) Improvement after a series of salicylic acid peels and topical applica­ tion of % hydroquinone (Courtesy of Pearl E Grimes, MDJ Secti o n 5: D i so rd e rs of Pigmenta t i o n • I 61 G lyco l i c a c i d pee ls (20%-70% ) a re a d m i n istered every to weeks utilizing i n c reasing strengths as tole rated - The treatment end poi nt is m i ld confl uent e rythe m a - Treated a reas m ust b e f u l l y ne utra l ized with sod i u m b i ca rbonate or wate r a t t h e com pletion o f t h e pee l - Lighte n i ng o f su perfi c i a l P I H m a y b e o bserved after fo u r to six peels - Strict photoprotection for m o nth is essential and m u st be stressed • J essner peels ( resorc i n o l , lactic acid , a n d sa l icyl ic a c i d ) a re a d m i n i stered every t o weeks - Treatment end point is a l ight white n i ng of the ski n - Strict photo protection for t o months i s advised - M u ltiple treatments a re reco m m e nded - Contra i n d icated i n p regnant a n d lactating women • Com bi nation J essner/10% tri c h loroacetic (TCA) peels A may a lso be em ployed in a s i m i l a r fas h i o n as the J essne r pee l The J ess ner peel res u l ts i n exfo l iation a l lowi ng for greater penetration of the TCA pee l - M u ltiple peels a re ge nera l ly needed - Contra i nd icated in p regnant a n d lactating wom e n - Deeper pee ls a re re ly e m ployed given t h e r i s k of P I H exacerbation with h ea l i ng • Caution m u st be used i n treating s k i n phototypes I l l to VI, pa rti c u l a rly with med i u m-depth pee l s Sa l i cyl ic a c i d peels a re safest for d a r k s k i n phototypes ( Fig ) LAS ERS Trad itiona l ly, laser treatment for P I H d oes n ot p rod uce re l i a b l e i m provement and is n ot fi rst- l i n e thera py In fa ct, laser thera py may exacerbate P I H In genera l , it is n ot reco m m e n d ed F racti o n a l phototh ermolysis ( F P ) ca n , however, provide i m prove ment of P I H ( Fig 27 4) T h i s is espec i a l l y true for patients with l ighter s k i n p h ototypes I n d a rker s k i n types, P I H often worsen s I t s h o u l d not be recom m e nd ed as a fi rst- l i n e thera py Rather, blea c h i ng c reams a n d c h e m i c a l p e e l s provide more consistent, reprod u c i ble resu lts Typical ly, F P treatments s h o u l d be d i rected toward s u perfic i a l s k i n d e pth a n d avoid higher treatment densi­ ties P I T FALLS TO AVO I D/CO M P L I CAT I O N S/ MANAG E M E NTIOUTCO M E EXPECTAT I O N S • I t is i m porta nt t o reassu re patie nts that P I H w i l l resolve on its own with t i m e , except if it is a dermal process • Laser treatment is u n re l i a b l e a n d may prod uce worsen­ i n g It is u s u a l l y not reco m m e n d ed B Figure 27.4 (A) Hyperpigmentation after a series of Q-switched laser tat­ too treatments (B) Improvement of PIH after two nonablative fractional resurfacing treatments utilizing superficial depth and lower treatment densities 62 • I Color Atlas of Cosmetic Dermatology It is i m porta nt to d isconti n u e a n y to pical m ed i cations that prod uce i nfla m mation or i rritation to avoid wo rsen­ i ng P I H • C h e m i c a l peels a re l i kely to only l i ghten a n d not f u l l y e l i m i nate the P I H C a u t i o n s h o u l d be ta ken i n d a r ker s k i n phototypes • I t is bette r and safe r to uti l ize seri a l s u perfi c i a l peels rather tha n a si ngle deeper peel to m i n i m ize the risk of PI H • P I H may not i m prove d espite seria l c h e m i c a l peel use P I H res u lt i n g from hemosiderin (ie, leg vei n treatme nts) w i l l not res pond to lasers, pee ls, a nd bleac h i ng c rea ms In fact, treatment w i l l l i kely worsen the P I H B I B L I OG RAPHY K i l mer S L Laser erad ication o f pigme nted lesions a n d tattoos Dermatol Clin 2002;20( ) :37-53 M is h i m a Y, Ohyama Y, S h i bata T, et a l I n h i b itory action of koj ic acid on m e l a n ogenesis and its therapeutic effect for va rious h u m a n hyperpigme ntation d isorders Skin Res 994;36( ) : 34- 50 N a kagawa M , Kawa i K Conta ct a l le rgy t o koj i c a c i d i n s k i n c a re prod ucts Contact Dermatitis 1995;3 ( ) :9- Ngujen Q H , B u i T P Azel a ic a c i d : Pha rmacoki netic a n d pha rmacodyn a m i c properties a n d its therapeutic role i n hyperpigmenta ry d isorders a n d a c n e lnt J Dermatol 1995;34( ) : 75-84 Secti o n : D i so rd e rs of Pigmenta t i o n CHAPT E R 28 Vitiligo Viti l igo is an acq u i red i d i o path ic cond ition that prod u ces sym metric d e pigm ented patc hes of the ski n It is pa rtic u ­ larly d istress i n g a n d c l i n i ca l ly a p pa rent i n patients with d a rker skin p h ototypes EPI D E M I O LOGY Incidence: a p p roxi mately 2% of the world popu lation Age: can present at a ny age but most commonly presents in the second to fou rt h decade Race: eq u a l Sex: eq ual Precipitating factors: i n h erita nce, tra u m a , i l l ness, emo­ tional states PATHOG EN ES I S U n k nown D E R M ATOPATHOLOGY There a re no melanocytes i n basa l cel l layer PHYS I CAL LES I ON S Patients d isplay wel l-demarcated , sym metric, depig­ mented , chal k-wh ite macules Common locations include el bows, knees, sacra l a rea , pen is, periora l a reas, a n d neck H a i r may also lose pigmentation ( Figs 28 and 28.2 ) D I F F E R E N T I AL D I AG N OS I S Chem ical leukoderma, postinfl a m matory hypopigme nta­ tion, nevus depigmentosus, nevus a nemicus, pityriasis a l ba , l u pus erythe matos us, leprosy, and genodermatoses LABO RATORY EXA M I NAT I O N Wood 's l a m p exa m i nation i s h e l pfu l i n m a k i n g the d iag­ nosis In cases of u ncerta i nty, b i o psy s h o u l d be per­ fo rmed of both lesiona l a n d n o n lesional s k i n in order to d eter m i n e if there is an a bsence of melan ocytes in the affected s ki n Check thyro i d-st i m u lating hormone (TS H ) fo r hypothyro i d i s m CO U RS E Viti l igo c a n p u rsue a va ria ble cou rse After a n i n itial pid p resentati o n , it te nds to sta bi l ize Typical ly, it is a c h ro n i c Figure 28 Vitiligo on the trunk and neck of a young patient I 63 64 I Color Atlas of Cosmetic Dermatology d isease with periods of pa rt i a l re pigmentation but not res­ ol ution It may i m p rove in the s u m merti m e I n some cases, depigmentation beco mes extensive KEY CO N S U LTAT I V E QU EST I O N S • Age o f patient • Time of onset • Fa m i ly h i story • Occu pation • Chemical exposu res MANAG E M ENT There a re m u ltiple treatment modal ities for viti ligo U n fo rtu nately, treatment is frustrating a n d often i n effec­ tive Patie nts u nd e rsta n d a bly a re d istressed by the a p pearance of viti l igo and desi re treatment In exte ns ive cases, it p rod u ces a stri ki ng a ppea nce, pa rti c u l a rly for patients with darker s k i n ph ototypes P R EV E N T I O N S u nscreens a n d s u n avoida nce protect viti l iginous s k in from b u rn i ng a n d a re a n i m porta nt com ponent of ther­ a py F u rther, ta n n i ng u naffected s k i n wi l l accentuate the contrast between normal a n d viti l iginous ski n , worse n i ng the cosmetic a ppea nce of the d i sease TOP I CAL T R EAT M E N T There a re a host o f topical treatments for viti l i go T h ey include • Corticosteroids - To pica l - l ntra lesi o n a l • • Ca l c i n e u r i n i n h i bitors: tac ro l i m us, pi mecrol i m us Monobenzylether of hyd roq u i none - Prod u ces permanent d e pigmentation - Twice d a i l y ove r 1-yea r period - Permanent d e p igmentation is prod uced in less t h a n 50% o f patie nts - Poor or no depigmentation in nearly h a lf of patients - Caution prior to p u rs u i n g this permanent treatment - Side effects i n c l u d e contact d ermatitis, e ryt h e m a , a n d pru ritus - He ightened risk of s u n burn after this perma nent treatment • Cam ouflaging m a ke u p and self-ta n n i ng agents to h i d e depigmented m a c u l es Figure 28.2 White forelock in the same patient Secti o n : D i so rd e rs of Pigmenta t i o n I 65 PH OTOTH E RAPY P h otothera py is a m a i nstay of viti l igo treatment • Psora len and u ltravio l et A ( P UVA) with topical o r o l 5-methoxypsora len or 8-methoxypsora len • N a rrow- ba n d UVB ORAL T H E RAPY Oral thera pies i n c l u d e • Ora l 5- or 8-methoxypsora len i n c o m b i nation w i t h gra d ­ u a l , l i m ited s u n exposu re • P u lse thera py with corticosteroi d s A S U RG I CAL TREATM ENTS Autologous s k i n grafti n g can be a h e l pf u l treatment for viti l igo reca lc itra nt to other thera p ies I t is not a fi rst- or seco n d - l i n e treatment S p l it-t h i c k n ess grafts, epidermal bl iste r grafts, c u ltu red melanocyte grafts, si ngle hair grafts, a nd noncu ltu red epidermal suspension grafts have a l l been exa m i n ed Pa i n after graft p roced u res is com m o n , pa rti c u l a rly at the rvest site ( Fig 28 ) • A majority o f patients e m p loying t h e epidermal suction graft tec h n i q u e sh owed i m prove ment • S p l it-thi c k ness grafting and derma brasion have a lso a c h i eved re pigmentation with i n an ave rage of months i n one stu dy of 22 patients • Si ngle h a i r grafts a re m ost effective i n loca l ized or seg­ mental viti l igo Success in genera l i zed viti l igo is poor • Both c u ltured p u re melanocyte suspension as wel l as c u ltured epidermal grafting after treatment with C0 laser have been shown to be successful in treating viti l igo - Resu lts were best i n loca l ized cases of viti l igo LAS ER T H E RAPY • Exc i m e r Laser An exci mer laser em its UVB nge l ight a t 308 n m , close to the wavelength of na rrow-ba nd UVB thera py that has been used to successfu lly treat viti l igo Begi n n i ng with a starting d ose of 00 mJ/cm , with i n c reasing d oses i n sta ndard photothera py increments , there was good i m provement i n reca lc itra nt viti l igo after 30 weeks o f treatments • Acra l lesions were m ost refractory to treatment • Few adverse effects • Best res u l ts a re p rod uced on the face > neck, extre m i ­ ties, tru n k , a n d gen ita l i a > hands, feet • M ore expensive tha n m a ny trad itiona l thera pies Co m bi nation treatment with tacro l i m u s % is more effective than treatment with exc i m e r laser a l o n e B Figure 28.3 (A) Depigmented patch of skin on right mandible (B) Significan t improvement after m ultiple -mm punch grafts (Courtesy of Pearl E Grimes, MD) 66 I Color Atlas of Cosmetic Dermatology P I T FALLS TO AVO I D/CO M PL I CAT I O N S/ MANAG E M E N T/O UTCO M E EXPECTAT I O N S • Viti l igo is a d i ffi c u lt d isease to treat • There a re m u ltiple fi rst- a n d secon d - l i n e therapies that should be e m p loyed before seeking s u rgica l o r laser treatments • I t is es pec i a l ly d iffi c u lt to p rod uce long-term sign ifica nt cosmetic i m provement i n extensive cases • Freq ue ntly, re pigmentation may be confi ned to perifol­ l i c u l a r a reas c reating a "spotty" a ppea n c e • Patients n eed to be e d u cated t h a t a n y thera py m a y not succeed • The exc i m e r laser is not widely ava i la b l e , ma king its use pa rtic u la rly d iffi c u lt B I B L I OG RAPHY Chen Y F, Ya ng PY, H u D N , Kuo FS, H u ng CS, H u ng C M Treatment o f viti l igo by tra nspla ntation o f c u l t u red p u re melanocyte suspensi o n : Ana lysis of 20 cases J Am Acad Dermato/ 2004; ( ) : 68-74 H a d i S M , Spencer J M , Lebwo h l M The use of the 308nm exc i m e r laser fo r the treatment of viti l igo Dermatol Surg 2004;30 ( ) :983-986 Koga M Epidermal grafting u s i ng the tops of s uction b l is­ te rs in the treatment of viti l igo Arch Dermatol 988; 24( 1 ) : 656- 658 Na GY, Seo SK, Choi SK Single hair grafting for the treat­ ment of viti l igo JAmAcad Dermatol 998;38(4): 580-584 Ozd e m i r M, Ceti n ka l e 0, Wolf R, et a l Com parison of two s u rgica l a p proa c hes for treati ng viti l igo: A pre l i m i n a ry study lnt J Dermatol 2002 ;4 ( ) : 135-138 Passeron T, Ostova ri N, Zakaria W, et al To pical tacrol i m us a n d the 308 n m exc i m e r laser: A synergistic c o m b i nation for the treatment of viti l igo Arch Dermatol 2004; 140(9 ) : 065- 069 Ta neja A, Tre h a n M , Taylor C R 308- n m exc i m e r laser for the treatment of loca l ized viti l igo tnt J Dermatol 2003 ;42(8) : 658-662 To riya ma K, Ka mei Y, Kazeto T, et a l Combi nation of s h o rt- p u l sed C02 laser resu rfa c i n g a n d c u l t u red epid er­ mal sheet a utografting in the treatm e nt of vitil igo: A prel i m i n a ry report Ann Plast Surg 2004 ; 53 ( ) : 78- 80 va n G e e l N , Ongenae K, De M i l M , Haeghen YV, Vervaet C, N aeyaert J M Dou ble-b l i n d placebo-controlled stu dy of a utologous tra nsplanted epidermal c e l l suspensions for re pigmenting viti ligo Arch Dermatol 203- 208 2004; 140( ) : .. .Color Atlas of Cosmetic Dermatology This page intentionally left blank Color Atlas of Cosmetic Dermatology Second Edition Ze ina Tannous, M D Chief,... pects Pigment Cell Res 2006; : 550-57 I 13 14 I Color Atlas of Cosmetic Dermatology CHAPT E R Soft Tissue Aug m e ntatio n M ECHAN I S M OF ACT I O N Use of a synthetic or biologica l prod uct... l ied a m i n i m u m of 30 m i n ­ utes prior t o s u n expos u re I 1 12 • I Color Atlas of Cosmetic Dermatology A p p roxi m ate ly 35 m l is the average a m o u nt of s u n ­ screen t h

Ngày đăng: 21/01/2020, 10:05

Từ khóa liên quan

Tài liệu cùng người dùng

  • Đang cập nhật ...

Tài liệu liên quan