Effect of dual-optical pulses with temporal energy distribution on laser ablation performance in in vivo zebrafish model

A Q-switched laser system has been used in a single-pulse mode for skin melasma treatments because of instant heat deposition in the target. Despite the efficient ablation of the melanophores in the skin, the single, high-fluence pulse often causes undesirable damage to the surrounding tissue, leading to high recurrence rates. This study aims to investigate the feasibility of dual-optical pulses with a temporal energy distribution on the melasma treatment in in vivo zebrafish models in comparison to that of the single optical pulse. Based on the optical detection, the dual-optical pulses had a temporal energy distribution ratio of 4:1 and an interval of 61 μs between the two consecutive pulses. According to the histological analysis, the dual pulses removed melanophores and induced a few apoptotic nuclei with minimal recurrence. This study demonstrated that the feasibility of dual-optical pulses (energy ratio = 4:1) could enhance the laser ablation performance in vivo.

A retrospective study of 1064-nm Q-switched Nd:YAG laser therapy for acquired bilateral nevus of Ota-like macules

BACKGROUND

The therapeutic efficacy of laser treatments for acquired bilateral nevus of Ota-like macules (ABNOM) varies among studies, and few studies have evaluated the factors affecting therapeutic effects.

AIMS

To evaluate the efficacy and safety of 1064-nm Q-switched Nd:YAG laser (QSNYL) therapy for ABNOM and to identify the factors influencing the outcome.

METHODS

A total of 110 patients with ABNOM were retrospectively evaluated and received two-to-nine treatment sessions. The effects of different factors on the therapeutic effect were analyzed on the basis of the number of treatments, age at first treatment, skin type, lesion color, affected area, number of lesion sites, and presence of concomitant melasma.

RESULTS

The curative effect was positively correlated with the treatment time and negatively correlated with the increasing age at first treatment (p < 0.05). The curative effect was better in patients with skin type III than those with type IV ( p < 0.05) and in patients with a lesion area of less than 10 cm2 than those with a larger affected area (p < 0.05). Additionally, the treatment effect was poorer in patients with concomitant melasma (p < 0.05). The treatment effect was not significantly correlated with the lesion color or number of affected sites (p > 0.05). Eleven patients (10%) developed postinflammatory hyperpigmentation (PIH).

CONCLUSIONS

Early and repeated QSNYL therapy achieved satisfactory results for ABNOM. The risk of PIH after laser treatment is highest among patients with older age, darker lesion color, and darker skin color. For patients with ABNOM with concurrent melasma, low-energy laser therapy is recommended to reduce the risk of melasma aggravation.

A Randomized, Controlled, Split-Face Study of the Efficacy of a Picosecond Laser in the Treatment of Melasma

Introduction: Melasma is a common disorder where patients develop hyperpigmented macules and patches on the face and is thought to be the result of sun exposure and hormonal contributions, although the pathogenesis is not completely understood. Lasers have been used for melasma treatment with varying degrees of success. Objectives: The objective of this study was to examine the safety and efficacy of a novel picosecond laser for the treatment of melasma. Materials and Methods: Ten subjects received nine weekly laser treatments with a picosecond laser to a randomized half of their face. A lightening cream was applied to the entire face to serve as a control. The primary outcome measure was clinical efficacy measured by a patient-reported outcome survey, the Melasma Quality of Life (MELASQOL) questionnaire, and physician assessment with the Global Aesthetic Improvement Scale (GAIS). The secondary outcome measure was safety, which was assessed by monitoring for adverse events. Photos were taken before every treatment and at a 1-week follow-up. Results: Ninety percent of subjects rated their melasma as at least slightly better, and 90% percent of subjects would recommend this laser treatment to others with melasma. MELASQoL questionnaire scores improved by an average of 5.7 points after laser treatment. Assessments by two board-certified dermatologists using the GAIS revealed an overall improvement in 80% of patients on the laser treatment side versus 20% on the control side. Side effects, including erythema and discomfort, were minimal and transient post-treatment. Conclusions: This study suggests that picosecond laser treatments are a safe and efficacious way to treat melasma. J Drugs Dermatol. 2019;18(11):1104-1107.

Factors affecting response, number of laser sessions and complications in nevus of Ota treated by Q-switched alexandrite laser: a retrospective study

BACKGROUND

The aim of this study was to study and analyze the factors influencing the treatment response to Q-switched alexandrite laser in patients with nevus of Ota and the factors influencing the number of laser sessions.

METHODS

Forty-eight patients treated with Q-switched alexandrite between 2009 and 2013 for nevus of Ota were enrolled in this retrospective, single-center study. The subjects (13 male, 35 female) were divided into three groups according to the number of treatment sessions. Patients were then called back to the hospital for a follow-up interview and examination. Single and multiple variate analyses of various factors were performed.

RESULTS

The 48 patients were predominantly female (35 female, 13 male, F:M ratio = 2.7:1), mean age 17.2±10.41. Twenty-five (52.1%) had lesion on the right side of the face, 22 (45.8%) on the left side, and one (2.1%) on both sides. The predominant color was brown (41.7%), followed by cyan (39.6%) and lividity (18.8%). Satisfactory result was observed in all patients, after 3 to 11 treatment sessions (mean 5.37±2); 19 of these (39.6%) needed three to four sessions (short treatment sessions), 22 (45.8%) needed five to seven sessions (intermediate treatment sessions), and 7 (14.6%) needed nine to eleven sessions (long treatment sessions). The clinical response and treatment sessions of the young-age group were significantly better than the adult group. Those with higher Tanino's classification needed more treatment sessions. Dark-colored lesions, which reflect deep melanosis of the lesion, needed more sessions than lighter-colored lesions. As for skin color, better response was obtained in light-skinned patients than in dark-skinned ones. Two patients showed transient hypopigmentation that lasted for less than six months, and recurrence has been seen in one child with dark-colored lesion.

CONCLUSIONS

Q-switched alexandrite laser is an ideal minimally-invasive method for treating nevus of Ota. Fewer treatment sessions are needed for children and younger patients, whereas brown lesion, lower Tanino's classification and light skin patients.

A hyperpigmented perianal nodule

Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Ultraviolet light is an important risk factor for the pathogenesis of BCCs; the vast majority are found in sun-exposed areas. BCCs occurring in the perianal or genital regions are seldom seen. Less than 1% of all BCCs occur at these sites. Etiologic factors other than solar exposure must be taken into account for such cases. We report a rare case of BCC that was initially detected during a routine colonoscopy.

Achieving better esthetics by gingival de-pigmentation: report of three cases with a review of the literature

A smile expresses a feeling of joy and success and also reveals self-confidence and kindness in an individual. A holistic smile is dictated not only by the shape, position and color of the teeth but also by the health of the gingival tissues. Gingival appearance is an important component of an attractive smile. Melonin, carotene and hemoglobin are the most common natural pigments contributing to the normal color of gingiva. Although physiologic and ethnic melanin pigmentation is not a medical problem, complaints about "black gums" are common. For de-pigmentation of gingiva, different treatment modalities have been reported such as bur abrasion, scraping with scalpel, partial thickness flap, gingivectomy, cryotherapy, electrosurgery, lasers, free gingival autografting, sub-epithelial connective tissue graft and combination techniques. In the present case reports, scalpel surgery and electrosurgery were performed for gingival de-pigmentation, which are simple and effective. The esthetic results were pleasing and healing was uneventful. Patients were satisfied with the outcome at three month follow-up as evidenced from their feedback.

Cystic benign melanosis of the conjunctiva

PURPOSE

To report the clinical and histologic features of cystic benign melanosis.

METHODS

This case series reports on the clinical and histopathologic features of 3 patients with enlarging, cystic, brown, pigmented, conjunctival lesions.

RESULTS

Slit-lamp examination showed cystic melanotic lesions of bulbar conjunctiva. Histopathologic examination of the biopsy specimens showed epithelial lined cysts in the substantia propria, goblet cells, and secondary pigmentation of basilar keratinocytes.

CONCLUSIONS

Cystic benign melanosis, a unique conjunctival lesion, should be differentiated from cystic nevus and primary acquired melanosis.

Esthetic depigmentation of anterior gingiva. A case series

Gingival melanin pigmentation occurs in people of all races. Although clinical melanin pigmentation does not present a medical problem, demand for cosmetic therapy is commonly made by fair-skinned people with gingival melanin pigmentation. This problem is aggravated in patients with a "gummy smile" or excessive gingival display while smiling. Esthetic periodontal plastic surgery is especially successful in individuals with compromised esthetics. Three cases are reported here where gingival depigmentation was done using three different techniques: electrosurgery; scalpel surgery; and surgical abrasion. The clinical results of the three methods have been compared.

Management of oral melanin pigmentation

Melanin is an endogenous pigment responsible for human tissue coloration of the skin, mucosa, hair, eyes and parts of the brain. In the skin, its function is protection from the harmful effects of UV radiation. Its purpose in oral tissues has not yet been determined. Oral pigmentation could be an esthetic issue for some patients, particularly when it is located on the anterior labial gingiva in individuals with a high smile line. This article presents and describes several different approaches for the management of oral melanin pigmentation.

Laser treatment of pigmented lesions for Asians

The term Asian refers to East Asians of the Pacific Rim who share not only a common heritage and skin type but also the same set of clinical skin problems. Pigmentation of the skin is often considered the number one esthetic skin concern in Asians. Asians idealize unblemished complexion of facial skin and are less tolerant to facial dyschromia than White. The problems of ephelides (freckles), nevi of Ota, and melasma are common and difficult to treat. This article reviews laser treatment of pigmented lesions in Asians.

[A case of premalignant melanosis of the vagina recurring urethral orifice and intrapelvic retroperitoneum with malignant transformation]

A 67-year-old female who had undergone hysterectomy and colpectomy due to vaginal premalignant melanosis presented with sacralgia after 2-year discontinuation of follow-up. Mucosal pigmentation was observed around the external urethral orifice, strongly implying recurrence of premalignant melanosis. Magnetic resonance imaging for abdominal screening revealed a cystic mass adjacent to the urinary bladder with heterogeneous internal signal measuring 5 cm in diameter, but no definitive diagnosis could be made. She underwent urethrectomy and cystostomy, with simultaneous extirpation of the intrapelvic cystic tumor. The mucosal pigmentation included atypical melanocytes, and histologically the intrapelvic cystic tumor containing melanin-rich fluid demonstrated existence of malignant melanocytes. She received adjuvant DAV-Feron immunochemotherapy using dacarbazine, nimustine, vincristine and interferon-beta. She has been followed up for 14 months without any evidence of local recurrence or metastasis.

Iridociliary melanoma associated with ocular melanocytosis in a 6-year-old boy

A previously healthy 6-year-old boy presented to the ophthalmologist and was found to have congenital ocular melanocytosis associated with uveal melanoma. He was treated with enucleation of the affected eye and has shown no evidence of tumor recurrence or metastasis through over 20 years of postenucleation follow-up. Ocular melanocytosis can be associated with uveal melanoma even in young children.

Primary Acquired Melanosis of the Conjunctiva: Risks for Progression to Melanoma in 311 Eyes

PURPOSE

To evaluate the clinical features and risks for transformation of conjunctival primary acquired melanosis (PAM) into melanoma.

DESIGN

Noncomparative case series.

PARTICIPANTS

Three hundred eleven eyes with conjunctival PAM without melanoma at initial examination from a single-center tertiary referral center.

METHODS

Retrospective chart review with evaluation of the clinical features of PAM at initial presentation and follow-up. Times to PAM enlargement, recurrence, and transformation into melanoma were assessed using Kaplan-Meier estimates. Risk factors for these outcomes were analyzed using Cox proportional hazards regressions.

MAIN OUTCOME MEASURES

Primary acquired melanosis enlargement, recurrence, and transformation into melanoma.

RESULTS

Mean patient age at diagnosis of PAM was 56 years (range, 15-90), 62% were female, and 96% were Caucasian. The conjunctival quadrant(s) affected by PAM were temporal (57%), inferior (45%), nasal (42%), and superior (37%). The anatomic location(s) of PAM included bulbar conjunctiva (91%), limbal conjunctiva (55%), cornea (23%), forniceal conjunctiva (13%), palpebral conjunctiva (12%), and caruncle (11%). Primary acquired melanosis extended for a mean of 3 clock hours (range, 1-12). Initial management included observation (n = 194 eyes [62%]), biopsy combined with cryotherapy (n = 107 eyes [34%]), and topical chemotherapy and/or cryotherapy without biopsy (n = 10 [4%]). Of PAM that was observed, Kaplan-Meier estimates at 10 years revealed PAM enlargement in 35% and transformation into melanoma in 12%. Of those that underwent incisional or excisional biopsy, 10-year estimates of PAM recurrence and transformation into melanoma were 58% and 11%, respectively. Progression to melanoma occurred in 0% of cases of PAM without atypia, 0% of cases of PAM with mild atypia, and 13% of cases of PAM with severe atypia. Of the 9 patients with PAM who developed melanoma, none have developed systemic metastasis. Multivariable analysis revealed that the most significant factor for both PAM recurrence and progression to melanoma was extent of PAM in clock hours.

CONCLUSION

Primary acquired melanosis without atypia or with mild atypia shows 0% progression to melanoma, whereas PAM with severe atypia shows progression to melanoma in 13%. The greater the extent of PAM in clock hours, the greater the risk for transformation to melanoma.

Fractionated delivery systems for difficult to treat clinical applications: acne scarring, melasma, atrophic scarring, striae distensae, and deep rhytides

Fractional resurfacing or laser therapy (FLT) represents a technology that seeks to address the limitations of both ablative resurfacing and nonablative treatments. Many companies now offer versions of fractionated erbium or carbon dioxide lasers. The purpose of this paper is to examine FLT for difficult to treat applications such as melasma, acne scarring, atrophic scarring, striae distensae, and deep rhytides. Fractional laser therapy is a truly novel approach to many conditions, especially those with dermal pathology. Although published peer review data is limited, the ability to effectively and safely treat these conditions in all skin types appears to have been significantly enhanced with this new modality. We are early in our scientific explorations of what is possible with FLT.

A non-invasive pigmented nodule arising within primary acquired melanosis--an unusual phenomenon

We report a case of a raised pigmented nodule that arose within conjunctival primary acquired melanosis (PAM). This nodule showed no histological features of invasive disease.

Treatment of Gingival Hyperpigmentation by Erbium-Doped:Yttrium, Aluminum, and Garnet Laser for Esthetic Purposes

BACKGROUND

The normal color of gingiva is pink. Gingival hyperpigmentation is mostly caused by the physiologic deposition of melanin by melanocytes. In "gummy smile" patients, melanin gingival hyperpigmentation causes an esthetic problem and may cause physiologic disturbances. Methods to remove gingival hyperpigmentation vary, but it seems that the most reliable and satisfactory procedure is laser ablation.

METHODS

Six white patients (five females and one male), who complain of having dark-brown to black gingival hyperpigmentation were included in the study. Three of them were smokers. Laser ablation was performed by an erbium-doped:yttrium, aluminum, and garnet (Er:YAG) laser (settings: 250 mJ, 15 Hz, with water and air and using the defocused mode) without using topical or local anesthesia. Each patient required about 20 to 25 minutes for completion of the procedure. After 4 days, another laser ablation (with the same previous settings) was performed to ensure good results. Patients were evaluated a month after completion of treatment and on a semiannual basis. The follow-up period ranged between 6 and 18 months.

RESULTS

In all patients, no discomfort, pain, or bleeding complications were found intraoperatively or 4 days postoperatively. Ablated wounds healed almost completely within 4 days. No recurrence of gingival hyperpigmentation was found during the follow-up periods. Achieved results were satisfactory for patients and the operator.

CONCLUSIONS

Taking into account the advantages of using lasers, it seems to be that the depigmentation of melanin hyperpigmented gingiva by the Er:YAG laser is a reliable and satisfactory procedure. Esthetic results were satisfactory for patients and the operator, and no repigmentation was found during the follow-up period.

Approaches to Document the Efficacy and Safety of Microdermabrasion Procedure

BACKGROUND

Microdermabrasion is a popular cosmetic procedure for skin rejuvenation, which is achieved by mechanical abrasion of the skin at a superficial level.

OBJECTIVE

The objective was to study the efficacy of microdermabrasion in photoaging and to investigate the compatibility of a cleanser and a lotion with microdermabrasion.

METHODS

Sixteen women underwent microdermabrasion to the face once a week for a total of six treatments. Subjects were also given a personal skin care regimen (cleanser and lotion). Colorimetry values as well as investigator and patients ratings for safety and efficacy were analyzed at various time points and compared to baseline.

RESULTS

There were no significant changes in safety and tolerance variables throughout the study. Clinical efficacy variables (fine wrinkles, dullness, pigmentation, and large pores) significantly improved by the third treatment, with further improvement by the end of the study (six treatments). Subjects perceived improvement in facial photoaging variables. Colorimetry showed increased brightness and decreased yellowness of target skin sites on the face throughout the study.

CONCLUSION

Multiple microdermabrasions were effective in significantly improving various facial photoaging variables. The personal skin care regimen used was well tolerated by the subjects.

Microdermabrasion: Reappraisal and brief review of literature

BACKGROUND

Microdermabrasion (MDA) is a recently introduced noninvasive, nonsurgical, office-based esthetic procedure for revitalizing and rejuvenating the skin. It is a closed-loop vacuum-assisted abrasive procedure, which uses the physical action of inert crystals to exfoliate the skin.

OBJECTIVE

The aim was to evaluate the procedure of MDA in postacne scarring, melasma, and facial rejuvenation, and review the relevant literature.

METHODS

Ten patients each of postacne scarring, melasma, and facial rejuvenation were treated by a series of weekly MDA sittings alone or in conjunction with a topical retinoid. The results were assessed by patient questionnaire and an objective assessment by two independent observers. The literature was reviewed to find indications and efficacy of MDA.

RESULTS

All the patients of postacne scarring, melasma, and facial rejuvenation reported a mild but definite improvement, which increased when MDA was performed in conjunction with a topical retinoid. Most of the literature based on subjective and patient-dependent assessment parameters points toward a marginal improvement in the skin appearance following repeated procedures.

CONCLUSION

Reappraisal of this potentially useful procedure points toward a need for well-designed clinical trials and studies with a long follow-up based on objective assessment parameters.

Clinical and instrumental evaluation of skin improvement after treatment with a new 50% pyruvic acid peel

BACKGROUND

Pyruvic acid is an alpha-keto acid that presents keratolytic, antimicrobial, and sebostatic properties as well as the ability to stimulate new collagen production and elastic fibers formation. Because of its low pKa and its small dimension, it penetrates rapidly and deeply through the skin, so far as to be considered a potent chemical peel agent. It has proven its efficacy for the treatment of many dermatological conditions such as acne, superficial scarring, photodamage, and pigmentary disorders. Pyruvic acid application usually induces intense burning, and the postpeeling period is characterized by erythema, desquamation, and, sometimes, crusting.

OBJECTIVE

The aim of the study is to assess the efficacy and tolerability of 50% pyruvic acid in a new non-erythematogenic formulation (pyruvic acid 50%, dimethyl isosorbide, propylene glycol, ethyl alcohol, dimethyl sulfone, ethyl lactate, water) for the treatment of photodamage, superficial scarring, and melasma.

MATERIALS AND METHODS

Twenty subjects affected by photodamage, superficial scarring, and melasma, but otherwise healthy, entered the study. Four peeling sessions were performed once every 2 weeks. The patients were evaluated clinically and by means of several noninvasive methods in order to monitor the following parameters: hydration, color (erythema and pigmentation), elasticity, skin smoothness, skin roughness, scaliness, and wrinkles.

RESULTS

The patients did not report any discomfort either during the peeling session or during the postpeeling period, without any impact on their social life. We did not observe any case of persistent erythema as well as any case of postinflammatory hyperpigmentation. Instrumental evaluations showed a significant reduction in the degree of pigmentation in patients with melasma, a significant increase in skin elasticity, and an improvement of the degree of wrinkling in all the patients.

CONCLUSION

This innovative formulation of 50% pyruvic acid peel has been shown to be safe and effective to treat photodamage, melasma, and superficial scarring, allowing the patients to carry out regularly their working life as well as their social life. Furthermore, the results have been evaluated by means of noninvasive devices, which have permitted one to quantify the improvements.

[Melanosis of the urinary bladder--a case report with 10 years of follow-up and review of literature]

INTRODUCTION

Extradermal melanotic lesions are found predominantly in the oral cavity, colon or conjunctiva, and by far less frequently in other organs. We report for the first time a case of solitary melanosis of the urinary bladder with a follow-up of more than 10 years.

CASE REPORT

A 48-year old man presented with symptoms of frequency, urge incontinence, obstructive voiding symptoms and nocturia. On urethrocystoscopy under general anaesthesia, melanosis of the bladder with visibly reduced bladder capacity was diagnosed and confirmed on biopsy. The patient was treated for his micturation problems with alpha-blockers, intravesical electrostimulation and GAG-substitution therapy, without success. The chronic progression of bladder symptoms and shrinkage eventually led to cystoprostatectomy and bladder replacement by an orthotopic ileal neobladder, 10 years after primary diagnosis.

CONCLUSION

The very low number of reported cases accounts for the lack of management guidelines for this disease. Symptomatic treatment as well as repeated cystoscopic monitoring are logical therapeutic recommendations. Since the development of malignant disease can only be ruled out microscopically, repeated biopsies or prophylactic cystectomy need to be considered.

Laser treatment of atypical oral pigmentation. A case report

A 46-year-old female Caucasian patient presented with severe black pigmentation of the maxillary attached gingiva. The discoloration extended from tooth #2 to tooth #15 and was noted only on the buccal aspect of the arch. The patient reported that her gingival tissues appeared normal until age 22, at which time her first child was born. Cosmetic considerations prompted by this child's impending marriage caused the patient to seek treatment. It was important to determine the cause of the pigmentation so that we would be reasonably assured that it would not recur. A CO2 laser was used to remove the pigmented tissue in such a manner that the postoperative period was both painless and rapid.

[Management of corneo-conjunctival malignant melanoma with "no touch technique" surgical excision and corneoscleral lamellar keratoplasty]

OBJECTIVE

To study the management of "no touch technique" surgical excision and corneoscleral lamellar keratoplasty in the treatment of corneo-conjunctival malignant melanoma.

METHODS

Surgical excision for corneo-conjunctival malignant melanoma in six cases, from October 1989 to January 2004 in Zhongshan Ophthalmic Center, were performed. The entire tumors were removed in one piece without touching the tumor (no touch technique). The incision was outlined 4-6 mm outside the pigmented conjunctival mass, and 2 mm outside the corneal component. Dissecting deep enough without any tumor cell left to yield a tumor-free bed. After surgical incision, the host eyeball defect was covered with partial or total corneoscleral lamellar graft from fresh donor, and the conjunctiva defect was covered with or without amniotic membrane transplantation. All the patients were followed up to 6 months.

RESULTS

The tumors in the remaining conjunctival margins were completely removed by local dissection combined with cryotherapy in the six cases. Three cases were treated with partial corneoscleral lamellar keratoplasty, two cases with total corneoscleral lamellar keratoplasty and one case with total corneoscleral lamellar keratoplasty plus amniotic membrane transplantation. All cases were subsequently treated with 0.01% thiotepa eyedrops and supplemental dacarbazine chemotherapy. At the average 43.5 months follow-up time (14.6 years to 6 months), no evidences of local recurrence of malignant melanoma or distant metastasis were observed.

CONCLUSION

The clinical study suggests that using surgical excision of "no touch technique" to remove tumor in whole piece with corneoscleral lamellar keratoplasty is effective in the treatment of corneo-conjunctival malignant melanoma.

[Conjunctival primary acquired melanosis]

BACKGROUND

Pigmented lesions of the conjunctiva may represent primary acquired melanosis. If histological examination reveals atypical melanocytes in the epithelial layer of the conjunctiva, there is a close to 50% risk of transformation to a conjunctival malignant melanoma. A combination of surgical excision and cryotherapy is the most widely recommended treatment for conjunctival primary acquired melanosis with atypia. Recently, topical chemotherapy with mitomycin-C eye drops has been established as a therapeutic option.

MATERIAL AND METHODS

Based on two case reports and a review of the literature, clinical aspects and the use of topical chemotherapy are presented.

RESULTS AND INTERPRETATION

Pigmented conjunctival lesions arising in adults may represent primary acquired melanosis with atypia. In patients with large or multiple pigmentations, extensive surgery with cryotherapy is necessary. In such circumstances, topical chemotherapy with mitomycin-C eye drops is a good alternative and may lead to complete regression, as in our two patients.

Anterior esthetic gingival depigmentation and crown lengthening: report of a case

Excessive gingival display space and gingival hyperpigmentation are major concerns for a large number of patients visiting the dentist. Melanin hyperpigmentation usually does not present a medical problem, but patients usually complain of dark gums as unaesthetic. This problem is aggravated in patients with a "gummy smile" or excessive gingival display while smiling. Esthetic periodontal plastic surgery is especially rewarding in such individuals with compromised esthetics. A case is reported here on the cosmetic correction of "black gums" and "gummy smile." Periodontal plastic surgery combining gingival depigmentation and esthetic crown lengthening was performed in a single appointment using scalpel surgical technique. The outline of steps involved in the surgical procedure is demonstrated and a brief review of the various gingival depigmentation techniques is depicted here.

Lactic acid as a new therapeutic peeling agent in melasma

BACKGROUND

Melasma is a common disfiguring skin problem. Multiple modalities have been used in the treatment of melasma, such as bleaching agents and chemical peels. Many chemicals have been used in the skin peeling for melasma, such as Jessner's solution and glycolic acid. Lactic acid is an alpha-hydroxy acid that has not been used before in chemical peeling of melasma.

OBJECTIVE

The purpose of the present work is to evaluate the efficacy and safety of lactic acid in chemical peeling of melasma.

METHODS

This study was conducted at the outpatient Department of Dermatology and Venereology, Baghdad Teaching Hospital, in the period between April 2001 and August 2002. Twenty patients with melasma were included in this study; 18 (90%) were female and 2 (10%) were male, with an age range from 24 to 38 years and a mean of 29 +/- 4.264 SD. Full clinical examination was done of all patients, including Wood's light. The severity of melasma was assessed by the Melasma Area Severity Index (MASI). Pure lactic acid, full strength (92%; pH 3.5), was used as a new peeling agent. The chemical peeling sessions were done every 3 weeks until the desired response was achieved, but not more than six sessions. Follow-up was carried out for 6 months after the last session. All patients had skin type IV; morphologic forms of melasma were a mask-like shape in seven patients (35%), a butterfly shape in nine patients (45%), and a horseshoe shape in 4 patients (20%).

RESULTS

Eight patients defaulted from the study after the first session for unknown reasons. Twelve patients completed the study. Eleven patients were female (91.7%), and one patient was male (8.3%). Their ages ranged from 24 to 38 years, with a mean of 29.25 +/- 4.9 SD. Wood's light examination showed increased contrast in all patients (epidermal melasma). The number of sessions ranged from two to six. All 12 patients showed marked improvement, as calculated by the MASI score before and after treatment, and the response was highly statistically significant. No side effect was recorded in all treated patients.

CONCLUSION

Lactic acid was found to be a new effective and safe peeling agent in the treatment of melasma.

Congenital melanotic macules and Sebaceous Choristoma arising on the tongue of a newborn: epidermal choristoma?

Oral hyperpigmentation is a common event in older individuals, however, is exceptional in neonates (congenital melanotic macules). Conversely, 70-80% of people have sebaceous glands in the oral mucosa, with the tongue representing an ectopic location and termed sebaceous choristoma by some authors. We report a case that fulfills both conditions in a tongue lesion. A 1-month-old boy presented with a pigmented macula on his tongue noted at birth. An excisional biopsy was performed showing a lesion lined by an epidermal-like epithelium with basal pigmentation, under which, sebaceous glands, abortive hair follicles and ductal structures mimicking apocrine glands were found. Seven cases of congenital melanotic macules of the tongue have been reported, however, none of them showed sebaceous glands under the lesion. Furthermore, there has not been a reported case of sebaceous choristoma of the tongue present at birth. We present a case that shares clinical and histological features of both conditions and propose the name 'epidermal choristoma'.

[Neurocutaneous melanosis and congenital gigantic pigmented nevi in the light of current knowledge]

The aim of this work is to approach the subject of neurocutaneous melanosis and to point out the necessity and precise neurological diagnosis in each case of gigantic pigmented nevi. It is necessary to remember about early planning of skin changes removal which is the cause of lowering risk of malignant melanoma.

[Anatomo-clinical confrontation. Vulvar melanosis]

Vulvar melanosis is a benign disorder that may suggest a malignant melanoma. We report the case of a woman in whom partial vulvectomy was performed to eradicate the melanotic macule. The lesion corresponds to increased accumulation of melanin inside keratinocytes in the absence of any melanocytic neoplasm.

Gingival melanin pigmentation and its treatment with the CO2 laser

OBJECTIVE

There are only a few reports in the literature evaluating the effects of the carbon dioxide (CO2) laser on gingival melanin pigmentation (GMP). This study was performed to evaluate the effects of the CO2 laser at superpulse mode, applied for gingival depigmentation.

STUDY DESIGN

GMP at the anterior maxillary and mandibular gingiva of 10 patients was treated using the superpulsed CO2 laser (10 watts, 0.8 mm spot size, 20 Hz, 10 milliseconds). Pigmented areas were measured on pre- and postoperative standard digital images by the aid of an image- analyzing software. Statistical analysis of the data was performed by Mann Whitney U test.

RESULTS

Ablation of the hyperpigmented gingiva was accomplished with minimal carbonization and almost no bleeding. Postoperative healing was uneventful with no significant postoperative pain. Two cases of partial repigmentation were observed during 24-month follow-up. Statistical analysis of the data revealed a significant difference between pre- and postoperative measurements of pigmented area.

CONCLUSION

Application of the superpulse mode of CO2 laser appears to be an effective and safe method for the elimination of GMP.

Neurocutaneous melanosis

BACKGROUND

Neurocutaneous melanosis (NCM) is a rare phakomatosis characterized by a focal or diffuse proliferation of melanin-producing cells in both the skin and the leptomeninges. This syndrome is believed to result from an error in the morphogenesis of embryonal neuroectoderm.

FEATURES

Two-thirds of patients with NCM have giant congenital melanocytic nevi, and the remaining third have numerous lesions but no giant lesions. Most patients present neurological manifestations early in life, which can be secondary to intracranial hemorrhages, to impairment of cerebrospinal fluid circulation, and to malignant transformation of the melanocytes.

PROGNOSIS

The prognosis of patients with symptomatic neurocutaneous melanosis is extremely poor, even in the absence of malignancy. Chemotherapy has been ineffective in the few patients in whom it has been tried.

Treatment of phacomatosis pigmentovascularis: a combined multiple laser approach

BACKGROUND

Phacomatosis pigmentovascularis (PPV) consists of a capillary malformation with a variety of melanocytic lesions, which involve various regions of the body and are difficult to treat with conventional therapeutic tools.

OBJECTIVE

We described two cases with PPV (type IIa and IIb) that were successfully treated with different lasers.

METHODS

The areas involved by both melanocytic lesions and port-wine stains were treated using the Q-switched ruby laser, the Q-switched Alexandrite laser, and the flashlamp pumped pulsed-dye laser.

RESULTS

Removal of a good portion of cutaneous and vascular lesions using combined multiple laser approach was achieved after 6 sessions in the first case under general anesthesia and after 31 sessions under local anesthesia in the second case.

CONCLUSION

PPV type II can be treated successfully by laser treatment. We prefer to start combined multiple laser treatment of PPV in childhood period under general anesthesia because it will reduce the number of treatment, improve the patient's quality of life, and increase the cost-effectiveness of the treatment.

Peritoneal melanosis combined with serous cystadenoma of the ovary: a case report and literature review

Benign peritoneal melanosis is extremely rare and traditionally occurs in association with ovarian dermoid cysts, but rarely with peritoneal cyst, enteric duplication cyst or gastric triplication. The pathogenesis of peritoneal melanosis, in particular, the origin of the pigment-producing cells is unclear. We describe a case of peritoneal melanosis that was associated with ovarian serous cystadenoma in a young woman. Ovarian serous cystadenoma has not been previously described as a combined lesion of peritoneal melanosis. Based on the extremely rare incidence of this lesion and heterogeneous combined lesions, the possibility of an incidentally found, coexisting lesion couldn't be excluded. Here, we suggest that peritoneal mesothelial cells pinched off during the developmental period might be a source of pigment-producing cells.

Amniotic membrane transplantation for reconstruction after excision of large ocular surface neoplasias

AIM

To evaluate the clinical outcome of patients in whom ocular surface reconstruction was performed using amniotic membrane transplantation (AMT) after the excision of large (>20 mm square) ocular surface neoplasias (OSN).

METHODS

A non-comparative interventional case series. In 16 eyes of 16 patients, excision of large OSN including conjunctival intraepithelial neoplasia (CIN), primary acquired melanosis, and malignant melanoma was followed by adjunctive cryotherapy and suturing of a single layer of amniotic membrane (AM) with the basement membrane side facing up to the healthy bordering tissue. Epithelial healing, complications, and tumour recurrences were analysed.

RESULTS

During a mean follow up of 23.7 (SD 11, range 11-43) months, ocular surface healing was rapid and complete in all cases. One complication of pyogenic granuloma was noted. Tumour recurrence occurred in one out of 10 CIN cases (10%), no recurrences were observed in the patients with melanotic lesions.

CONCLUSIONS

AMT in lieu of conjunctival or mucosal autograft is an effective substrate for reconstructing the ocular surface following excision of large OSN. AMT is effective in managing large OSN by avoiding the complications that may be associated with conventional removal, specifically in cases where the limbal architecture is destroyed by surgical resection or adjuvant therapies.

Surgical treatment of melanin-pigmented gingiva; an esthetic approach

The aim of this clinical article is to review the methods of depigmentation of melanin pigmentation of gingiva and explain scalpel surgical technique for depigmentation of gingiva.

Latanoprost-induced iris heterochromia and open-angle glaucoma: a clinicopathologic report

PURPOSE

To report the histopathologic and immunohistochemical findings from the iridectomy specimen of a patient with acquired unilateral iris heterochromia due to latanoprost.

PATIENT AND METHODS

A 45-year-old woman with open-angle glaucoma and unilateral iris heterochromia was evaluated for uncontrolled intraocular pressure increase. Subsequently, the patient underwent trabeculectomy with mitomycin C and an iridectomy specimen was obtained for analysis.

RESULTS

The histopathologic analysis of the iridectomy specimen did not reveal any nuclear atypia, nuclear crowding, or mitotic figures. Immunohistochemical studies showed that the iris melanocytes were negative for HMB45 and S-100, and weakly positive for Melan A.

CONCLUSION

Latanoprost-associated iris color change may exhibit a diffuse, uniform, dark velvet-brown appearance, thereby simulating diffuse iris melanoma. Histopathologic and immunohistochemical analysis confirmed the benign characteristics of the affected iris melanocytes.

Cerebral mass due to neurocutaneous melanosis: eight years later

Neurocutaneous melanosis (NCM) is associated most commonly with giant congenital melanocytic nevi (CMN), in particular those on the scalp or in a posterior axial location that are accompanied by satellite congenital nevi. It also can occur in patients with multiple medium-sized CMN. In general, the prognosis of those with symptomatic NCM is poor, even in the absence of malignancy, while the prognosis of those with asymptomatic NCM detected via screening varies and is more difficult to predict. Herein we report an asymptomatic patient with a giant CMN and multiple satellite nevi who had a screening magnetic resonance imaging (MRI) study at age 5 months that showed a rounded area of increased signal in the right temporal lobe on T1-weighted images, suggestive of parenchymal melanosis. This melanotic mass was resected at age 10 months, and histologic examination of the surgical specimen showed prominent perivascular collections of benign, pigment-containing melanocytes within cerebral tissue. The patient remains healthy 8 years later. His excellent long-term outcome and other reports of NCM with localized central nervous system (CNS) involvement apparent on MRI may have implications for management, including early imaging of patients with high-risk CMN and potential surgical intervention for NCM.

Amniotic membrane transplantation in the management of conjunctival malignant melanoma and primary acquired melanosis with atypia

AIM

To evaluate the efficacy of amniotic membrane transplantation (AMT) for the management of conjunctival malignant melanoma and primary acquired melanosis (PAM) with atypia.

METHODS

Four consecutive patients with histologically proved invasive, primary conjunctival malignant melanoma were treated with wide surgical excision and AMT. Amniotic membrane grafts were harvested and processed under sterile conditions according to a standard protocol. The grafts were sutured to the margins of the surface defect. In one case, AMT was combined with a corneoscleral graft.

RESULTS

A satisfactory result and rapid postoperative recovery with few, transient side effects was noted in three patients with limbal/epibulbar melanomas. In another patient with an extensive lesion, involving the epibulbar, forniceal, and palpebral conjunctiva, AMT following wide excision was complicated by symblepharon formation and restricted ocular motility. Monitoring of local recurrence was facilitated by the transparency of the thin graft in all cases. The postoperative follow up time varied between several months and 3 years. In one case, local recurrence of PAM was observed and treated using topical mitomycin.

CONCLUSIONS

AMT is a useful technique for the reconstruction of both small and large surface defects that result from the surgical excision of conjunctival malignant melanoma and PAM. This method facilitates wide conjunctivectomy, although its role in repairing larger defects involving the fornix or palpebral conjunctiva still needs to be established. The transparency of amniotic membrane allows for monitoring of tumour recurrence, which is-together with superior cosmesis-an advantage over thicker (for example, buccal) mucous membrane grafts.