510-nm pigmented lesion dye laser. Its characteristics and clinical uses

BACKGROUND: Benign pigmented lesions are of a cosmetic concern to many individuals. Numerous treatments exist, including several types of lasers. The Candela 510 nm pigmented lesion dye laser has recently been added to this armamentarium. It is designed specifically for the treatment of superficial pigmented lesions while significantly decreasing the risk of scarring and prolonged hypopigmentation. OBJECTIVES: To describe the characteristics of the Candela pigmented lesion dye laser and report on the therapeutic outcome of patients treated for actinic lentigines, café-au-lait macules, melasma and red tattoos by one of the authors (RCG). METHODS: The Candela 510 nm pigmented lesion dye laser was used to treat solar lentigines, café-au-lait macules, melasma and red tattoo. RESULTS: Excellent outcomes resulted on facial and hand lentigines (89% and 88% of patients had greater than 75% clearing, respectively), but often required more than one treatment. Lentigines located on the upper extremities and trunk improved less dramatically. Immediate greying occurred universally. Bruising was often noted. Treatment failures have been observed especially in treating lentigines located on the lower extremities. Café-au-lait macules responded inconsistently, with facial lesions giving the best results. Melasma responded poorly, often with hyperpigmentation. Three red tattoos cleared. Treatment failure may be related to inaccurate clinical assessment of pigment depth or regrowth of the lesion. Several cases are presented to demonstrate clinical and histologic effects of the laser. CONCLUSION: The Candela 510-nm pigmented lesion dye laser is an effective treatment for superficial pigmented lesions. Its associated morbidity is minimal.     

5. Update on lasers in dermatology

A range of lasers with acceptably low rates of side effects is now available. Improved laser therapy has been made possible by combining wavelengths that are selectively absorbed by the target and pulses short enough to prevent heat transfer to surrounding tissue. Carbon dioxide (CO2) lasers are useful for treating disorders of skin surface texture and topography (wrinkles, scars, sun damage, benign skin appendages and rhinophyma). Vascular lasers, such as the flashlamp-pumped dye laser, are particularly effective for treating port-wine stains, haemangiomas, telangiectasia, rosacea and spider naevi. Q-switched lasers, which allow ultrashort high intensity pulses, are effective for treating most tattoos and some benign pigmented lesions.     

Laser applications in dermatology

Over the past decades continuous wave laser systems have been used in dermatology for the photocoagulation and vaporization of vascular neoformations and malformations and to remove epithelial lesions. However, their mainly thermal effect can have negative impact on wound healing and scar formation due to thermal damage of adjacent tissue. More recent laser systems now permit more selective and more restrictive destruction of pathological tissue. They include pulsed and Q-switched lasers matched to the absorption characteristics of the target structures, which permit skin ablation and selective photothermolosysis of pigmented or vascular lesions. These technical innovations have expanded the therapeutic spectrum in dermatology and improved the quality of the results achieved. Nevertheless, these systems should be used only for carefully selected indications, in particular when corrective-aesthetic considerations are of importance. Furthermore, prior to treatment, it is mandatory for the dermatologist, to establish the proper diagnosis, especially in the case of pigmented lesions and skin changes of uncertain dignity.     

DNA-based HLA class II postmortem typing: evaluation of different techniques for prospective corneal allografting

BACKGROUND: Two new types of lasers, the pulsed dye laser and the Q-switched ruby laser, have shown good to excellent results in the treatment of vascular malformations and benign pigmented lesions of the skin. A new and very effective alternative to pulsed dye laser is the recently introduced Photoderm VL. This device is based on the use of a wide-band non-coherent intense pulsed light source which emits a continuous spectrum in the range of 515 nm to 1200 nm. PATIENTS AND METHODS: More than a 1000 patients with a variety of lesions of the skin were treated by these new laser systems and the Photoderm VL. The Q-switched ruby laser (wavelength 694 nm, pulse duration 25 ns) is suitable for the treatment of benign lentigines, café-au-lait macules, seborrhoic ceratosis, tattoos, and traumatic tattoos. The pulsed dye laser (585 nm, 0,3-0,45 ms) treats nevi flammei, capillary hemangiomas, telangiectasias, xanthelasma, hypertrophic scarring, and adenoma sebaceum. In addition we present the facilities of the new Photoderm VL (515 nm-1200 nm, 0,5-20 ms) for the treatment of nevi flammei, benign hemangiomatous malformations, telangiectasias, erythrosis interfollicularis colli, hypertrophic scarring, and hypertrichosis. RESULTS AND CONCLUSIONS: the Q-switched ruby laser, the pulsed dye laser, and the Photoderm VL show excellent results in the treatment of lesions of the skin, which otherwise would have been difficult to treat of untreatable. The efficiency of the laser types presented is based on the theory of selective photothermolysis. Scarring is almost never seen and hypo- or hyperpigmentation is in most cases transient.     

Bronchiolo-alveolar cell carcinoma with apparent response to chemotherapy to anti-tuberculosis

Pigmented vulvar lesions were observed in a child during a sexual abuse evaluation. Gross examination of the lesions appeared most consistent with bowenoid papulosis; however, biopsy confirmed the lesions to be pigmented apocrine hamartomas. To our knowledge, these rare and benign tumors have never been described as pigmented, but should be added to the differential diagnosis of pigmented vulvar lesions.     

Evaluation of medical internet resources: quality criteria

Nevus spilus is a pigmented skin lesion composed of a pigmented macule on which darker lesions appear at a later stage. There are an increasing number of reports of malignant melanoma occurring within these lesions, leading to greater concern regarding the malignant potential of these lesions. We describe the case of a fatal malignant melanoma arising in a congenital nevus spilus.     

Pigmented lesions in newborn infants

1058 newborn infants were examined. Forty-one (3-9%) had clinically discernible pigmented lesions compatible with melanocytic naevi. Biopsy was performed on thirty-four of the forty-one and of these; eleven, representing 1-01% of the infants, proved to be melanocytic naevi. No giant (garment) naevi were seen in this series. Two of the eleven naevi pathologically examined showed histological changes similar to those that have been reported in some giant naevi, but the remaining nine were not only different from criteria usually assigned to giant naevi, but they also differed from the usual adult naevi, in that most were predominantly junctional. None of the melanocytic naevi in this series showed any suggestion of malignant change. In newborn infants it is often impossible clinically to distinguish naevi from other types of pigmented lesions, as only eleven out of the thirty-four pigmented lesions were melanocytic naevi. Seven of the eleven melanocytic naevi were under 1-5 cm in diameter. No pigmented lesions were found on the palms, soles or genitalia.     

The recovery of visual performance in strabismus with eccentric fixation

Pigmented basal cell carcinoma (PBCC) is a tumour with distinct clinical features which occasionally may be difficult to differentiate from malignant melanoma (MM). The purpose of this study was to re-examine the epiluminescence microscopy (ELM) criteria for PBCC and to determine their statistical significance in the differential diagnosis of MM. Fifty histologically verified pigmented skin lesions (25 PBCCs and 25 MMs) were investigated using ELM for the presence of ELM criteria; their significance was determined by calculating the odds ratios. We found that individual ELM criteria have different weights of significance in the differential diagnosis of PBCC (leaf-like distribution of diffuse pigmentation, gradual thinning at the periphery and telangiectasia) and MM (pigment network, black and grey pigmentation, radial streaming, pseudopods, brown globules and black dots). Selected patterns of ELM criteria adjusted to the distinct types of pigmented skin lesions are characteristic features for preoperative diagnosis. The prevalence of distinct ELM criteria in PBCC and MM is of critical value in differentiating between the two types of lesions.     

Interobserver variability on the histopathologic diagnosis of cutaneous melanoma and other pigmented skin lesions

PURPOSE: To assess the interobserver agreement on the diagnosis and classification of cutaneous melanoma. MATERIALS AND METHODS: A set of 140 slides of cutaneous melanoma, including a small subset of benign pigmented skin lesions, were circulated to four experienced histopathologists. The kappa statistic for multiple ratings per subject was calculated using the method described by Fleiss. RESULTS: The kappa value on the diagnosis of cutaneous melanoma versus benign lesions was 0.61. There was some discordance on the diagnosis in 37 of 140 cases (26%). For the histopathologic classification of cutaneous melanoma, the highest kappa values were attained for Breslow thickness (kappa = 0.76) and presence of ulceration (kappa = 0.87). The agreement was generally poor for other histologic features, such as level of dermal invasion (kappa = 0.38), presence of regression (kappa = 0.27), and lymphocytic infiltration (kappa = 0.27). CONCLUSION: Our study suggests considerable disagreement among pathologists on the diagnosis of melanoma versus other pigmented lesions. Tumor thickness and presence of ulceration are the most reproducible histologic features of cutaneous melanoma.     

Retained intraocular foreign body simulating choroidal melanoma. A report of two cases

Many different lesions can be difficult to distinguish from malignant melanomas of the choroid. With the use of modern diagnostic facilities the misdiagnosis rate has been greatly reduced. In a recent report from the Collaborative Ocular Melanoma Study Group the incidence of misdiagnosis was only 0.48%. The presence of a retained intraocular foreign body presenting as a raised pigmented choroidal mass similar to a uveal melanoma is rare. We report two cases in which retained intraocular foreign bodies presented clinically as raised pigmented intraocular lesions. Retained intraocular foreign bodies should be considered in the differential diagnosis of ocular tumours, especially if there are any atypical features.     

Expression of hindlimb abnormalities under rearing temperature effects during the larval development of the salamander Pleurodeles waltl (urodele amphibian)

The Q-switched ruby laser (694 nm, 25-40 nsec) is an effective and safe therapeutic device for the treatment of tattoos and well-defined, benign, pigmented epidermal and dermal lesions. Because of its selective mode of action, dermal pigments of natural and artificial origin are destroyed photothermically and removed without scar. This method is exceptionally suited for the elimination of lay and professional tattoos, traumatic tattoos, and permanent makeup. Other frequent indications include benign pigmented lesions such as lentigines, freckles, café-au-lait spots, seborrheic keratosis, and Becker nevi. As a dermal pigmented lesion, the nevus of Ota is perfectly treatable. However, chloasma can no longer be considered an indication for ruby laser treatment due to unsatisfactory results. Melanocytic nevi and congenital nevi should be treated only in clinical studies. The effectiveness of the long-term epilation of dark hair with this laser device has to be verified in future investigations. Particularly attractive is the nonproblematic and straightforward removal of pigmented lesions in precarious anatomic regions like the lips, eyelids, and genitals (e.g., benign melanosis of the lips or of the penis, seborrheic keratosis of the lid angle).     

Subungual pigmented nevus: evaluation of DNA ploidy in six cases

The discrimination between subungual pigmented nevus and subungual melanoma in situ is still a clinical problem. We measured DNA ploidy in six cases of subungual melanotic lesions which exhibited the features of subungual pigmented nevus or lentigo simplex histologically. Five cases presented a diploid pattern with or without a slight increase of hyperdiploid cells. One case presented a polyploid pattern; it also exhibited histologically abnormal melanocytes with large nuclei and pigment-filled elongated dendrites. The DNA ploidy pattern and histologic features suggest that the lesion of this latter case contains abnormal melanocytes which probably have the potential to undergo a malignant transformation into a subungual melanoma. DNA ploidy analysis, therefore, is likely to provide information for evaluating the biologic behavior of subungual melanotic lesions.     

Hemangiomas and vascular malformations

The biological classification system provides a useful clinical distinction between proliferative and biologically stable vascular anomalies. Hemangiomas demonstrate the ability to proliferate, then involute, and the majority still are followed conservatively. Intervention usually is reserved for life- or vision-threatening lesions. Surgical reconstruction may be indicated for the 10% to 30% of hemangiomas that do not regress adequately. The use of lasers to treat early hemangiomas is controversial but may gain greater clinical application as favorable data accumulate. In the future, biological suppression with antiangiogenic agents may become the preferred mode of therapy. Vascular malformations represent developmental errors in embryogenesis. They are present at birth, do not proliferate, and do not regress spontaneously. Lasers, interventional radiology, and surgical therapy may offer significant palliation and possible cures. It is important that the physician understand the difference between these two groups to better provide appropriate prognostic and therapeutic advice to the parents of children with these anomalies.     

Lasers in urology

Ever since Mulvany first described use of Ruby laser for lithotripsy, urologists have been exploiting every possible application of this technology. Laser lithotripsy in the 1980s and now laser prostatectomy in the 1990s have dominated laser usage in urology. Applications of lasers for superficial lesions (e.g., condylomata acuminata and carcinoma of penis) have found an established role. Interests in laser welding, photodynamic therapy and fluorescence continues to grow and evolve. The laser industry at the same time is striving to provide more efficient lasers. High power lasers (Holmium:YAG, KTP:YAG) and laser machines combining double wavelengths (Nd:YAG and KTP, Ho: YAG and Nd:YAG) are commercially available. Diode lasers with their portability and reliability qualities can now provide high output powers in various wavelengths. Here, we have reviewed different lasers, laser tissue interaction and clinical laser applications relevent to urology.     

Genetic and environmental contributions to size, color, shape, and other characteristics of melanocytic naevi in a sample of adolescent twins

The presence of melanocytic naevi is the strongest known risk factor for malignant melanoma. We have developed a computer imaging system with which it is possible to make quantitative measures of the size, color, and shape of pigmented lesions. The objective of this study was to examine the genetic and environmental contributions to these characteristics of naevi as measured by computer image analysis in a sample of adolescent twins. We captured video images of the 5 most atypical pigmented skin lesions (i.e., the largest, darkest, or most irregularly shaped) on each individual from 322 Australian adolescent twin pairs. Features extracted by computer image analysis for each lesion included color, size, symmetry, elongation, boundary irregularity, and edge distinctness. We found major genetic influences on the color and size of lesions accounting for between 40 and 80% of total variance. There were significant components of shared environmental influence (22-45% of total variance) for the color variables, with sun exposure the most obvious explanation. Differences between individuals in naevus color and size are largely genetic in origin although there are significant environmental contributions to color as well.     

Use of the laser in the oral cavity

Literature on head and neck oncology continues to support the use of lasers in surgery of malignant and premalignant lesions of the oral cavity. This article explores the indications, techniques, results, and complications of laser use for surgery involving these lesions. Highlighted is the carbon dioxide laser, which is well suited for transoral resections of premalignant lesions and early carcinomas in the oral cavity. In this study the local control, the 5-year survival rates, and the postoperative function with the carbon dioxide laser are at least comparable with those obtained using other surgical methods. The neodymium:yttrium-aluminum-garnet laser, which has specific advantages in the treatment of large vascular malformations of the oral cavity because of its unique characteristics, is also discussed.     

Hemangioma-like lesions: diagnosis and management

The distinctive color that serves as the basis for the appearance of blue lesions arises from the accumulation of pigmented material, blood, or clear fluid in abnormal amounts within the oral tissues. Clinical appearance of these lesions varies and, despite their morphological similarity, their pathogenesis, etiology, and clinical behavior is different, as are their treatment and prognosis. Because of the clinical similarity between benign and malignant blue lesions (as illustrated by the patients described in this report), the need for precise histologic diagnosis prior to definitive treatment is emphasized.     

Indocyanine green fluorescence angiography of the choroid

Indocyanine green fluorescence (ICG) angiography of the choroid gives better visualization of the choroidal vessels than does fluorescein angiography. We found that the detachment of the pigment epithelium seems bigger on ICG than on fluorescein angiograms, and pigmented lesions are more clearly delineated.     

Accelerated healing of laser-injured rabbit retina by basic fibroblast growth factor

PURPOSE: To improve the outcome of injured retina, human recombinant basic fibroblast growth factor (bFGF) was examined for its ability to accelerate healing in laser-injured New Zealand Red rabbits. METHODS: A multi-line argon laser (454 to 514 nm) was used to produce lesions near subretinal hemorrhaging levels. Within 30 minutes after irradiation, eyes were intravitreally injected directly above the lesions with 10 microliters vehicle or 10 micrograms of bFGF in 10 microliters of vehicle. Lesions were evaluated by funduscopy and fluorescein angiography. After 4 days of treatment, animals were killed and eyes examined histologically. RESULTS: On subsequent days, bFGF-treated lesions were less opaque, smaller in diameter, and less leaky to fluorescein than lesions in the control eyes. Eyes treated with bFGF exhibited reduction in lesion diameter (P < or = 0.001) and in the lesion periphery, decreased loss of photoreceptors (P < or = 0.001), and greater numbers of pigmented epithelial cells, compared to controls. By bromodeoxyuridine incorporation, increased proliferation occurred in fibroblasts, retinal pigmented epithelial cells, and inner retinal glial cells. CONCLUSIONS: These results indicate that bFGF both accelerated ocular tissue repair and also prevented photoreceptor loss. The rescue of photoreceptors by bFGF may occur through direct action on the photoreceptors, or indirectly through effects on other cells in the retina.     

Melanoma arising from the mucosal surfaces of the head and neck

Oral mucosal malignant melanoma is a rare disease. We reviewed 30 years of data from a tumor registry and identified 65 patients who had head and neck melanomas. Two thirds (43) of the 65 patients were identified as male, with the mean age in the sixth decade. Of the 65 patients, only 6 had melanoma that arose from the oropharyngeal mucosa. Of the lesions involving the oral mucosa, each lesion manifested itself as a mass or was associated with symptoms of discomfort; only one third (2) of the lesions were pigmented. The clinician must carefully examine the head, neck, and oral cavity, and any pigmented lesion that is not recognized as a specific entity, such as amalgam tattoo, should be biopsied. The more common presentation of amelanotic malignant melanoma requires a high index of suspicion for masses identified in the mouth and requires biopsy for definitive diagnosis. The prognosis for oral mucosal malignant melanoma is poor.