Medesthetics

NOV-DEC 2016

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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medestheticsmagazine.com | NOVEMBER/DECEMBER 2016 41 BACKGROUND: NICHOLAS VEASEY © GETTY IMAGES; LEFT: LISA SPINDLER PHOTOGRAPHY INC. © GETTY IMAGES Ideally, candidates for this procedure will have Fitzpatrick skin types I-III. Patients with darker IV and V skin types can be treated, but require less aggressive settings because be treated, but require less aggressive settings because they are at much higher risk of pigmentary alteration, says Rachel Nazarian, MD, FAAD, of Schweiger Dermatology Rachel Nazarian, MD, FAAD, of Schweiger Dermatology Group in New York City and assistant clinical professor at Mount Sinai Hospital. Contraindications You should not perform fractional ablative laser treat- You should not perform fractional ablative laser treat- ments on patients with a history of keloid formation, facial radiation or infectious conditions, including a con- current presence of molluscum contagiosum, verrucae or herpes labialis. "These patients are contraindicated due to risk of dissemination to treatment sites and wors ening of their condition, which increases the risk of scarring," says Dr. Nazarian. You must also exclude patients with very thin skin and those with underlying medical conditions that impede wound healing, such as connective tissue disorders or diabetes, says Vic Narurkar, MD, FAAD, director and diabetes, says Vic Narurkar, MD, FAAD, director and founder of Bay Area Laser Institute in San Francisco. Isotretinoin (Accutane) therapy, which also impedes wound healing, has been associated with hypertrophic wound healing, has been associated with hypertrophic scarring and keloid formation following laser resurfac ing, scarring and keloid formation following laser resurfac ing, says Macrene Alexiades, MD, PhD, FAAD, associate clinical says Macrene Alexiades, MD, PhD, FAAD, associate clinical professor at Yale University in New Haven, Connecticut. Other patients at high risk of adverse events include: • Those with prior scars or hypopigmentation, which may become worse with ablative resurfacing; may become worse with ablative resurfacing; • Those who are pregnant or breastfeeding, because • Those who are pregnant or breastfeeding, because post-infl ammatory hyperpigmentation (PIH) is com- post-infl ammatory hyperpigmentation (PIH) is com- mon under these circumstances; • Those who have had silicone injections, which can cause adverse outcomes following this procedure; • Those with active infections, which could worsen following resurfacing; following resurfacing; • Those with koebnerize (such as psoriasis or vitiligo), as traumatized and injured skin may induce fl aring of the disease; • Smokers, who have impaired wound healing second- ary to decreased oxygen concentration in the skin. ary to decreased oxygen concentration in the skin. Pretreatment Considerations Pre-existing skin conditions, such as active acne, must ng Pre-existing skin conditions, such as active acne, must skin conditions, such as active acne, must be controlled prior to beginning treatment, says Dr. lled prior to beginning treatment, says Dr. Alexiades. If a patient has melasma, which may be exac- If a patient has melasma, which may be exac- erbated by laser treatment, she prescribes a bleaching y erbated by laser treatment, she prescribes a bleaching laser treatment, she prescribes a bleaching cream such as Tri-Luma (Galderma). She also prescribes ch cream such as Tri-Luma (Galderma). She also prescribes as Tri-Luma (Galderma). She also prescribes antiviral drug famciclovir 250mg twice a day starting the rug antiviral drug famciclovir 250mg twice a day starting the famciclovir 250mg twice a day starting the day before treatment and continuing for fi ve days after- e day before treatment and continuing for fi ve days after- treatment and continuing for fi ve days after- ward. If a patient has a history of facial staph or strep patient has a history of facial staph or strep infections, Dr. Alexiades prescribes oral antibacterial Dr. Alexiades prescribes oral antibacterial antibiotic dicloxacillin 250mg-500mg four times a day for dicloxacillin antibiotic dicloxacillin 250mg-500mg four times a day for 250mg-500mg four times a day for fi ve days starting one day prior to treatment. starting fi ve days starting one day prior to treatment. one day prior to treatment. To reduce the risk of PIH in all patients, Girish "Gilly" uce To reduce the risk of PIH in all patients, Girish "Gilly" the risk of PIH in all patients, Girish "Gilly" Munavalli, MD, MHS, FACMS, medical director of Der- MD, MHS, FACMS, medical director of Der- matology, Laser & Vein Specialists of the Carolinas in Laser & Vein Specialists of the Carolinas in Charlotte, North Carolina, counsels sun avoidance for , Charlotte, North Carolina, counsels sun avoidance for North Carolina, counsels sun avoidance for four to six weeks prior to the procedure. He also rec- x four to six weeks prior to the procedure. He also rec- weeks prior to the procedure. He also rec- ommends a regimen consisting of antibiotics, antivirals s ommends a regimen consisting of antibiotics, antivirals a regimen consisting of antibiotics, antivirals and antifungals delivered immediately prior to, during ngals and antifungals delivered immediately prior to, during delivered immediately prior to, during and after the procedure. He typically prescribes Doryx and after the procedure. He typically prescribes Doryx the and after the procedure. He typically prescribes Doryx procedure. He typically prescribes Doryx (doxycycline, Mayne Pharma), Sitavig (acyclovir, Cipher) ne, Mayne Pharma), Sitavig (acyclovir, Cipher) and Difl ucan (fl uconazole, Pfi zer). "Although there is can and Difl ucan (fl uconazole, Pfi zer). "Although there is (fl uconazole, Pfi zer). "Although there is no solid proof of pretreatment with hydroquinone to roof of pretreatment with hydroquinone to prevent rebound hyperpigmentation, I oftentimes advise ebound prevent rebound hyperpigmentation, I oftentimes advise hyperpigmentation, I oftentimes advise it," he adds, noting that he typically starts patients on ds, it," he adds, noting that he typically starts patients on noting that he typically starts patients on retinoid and growth factor creams two months before a nd retinoid and growth factor creams two months before a growth factor creams two months before a procedure in order to rev up the skin for healing as well. e procedure in order to rev up the skin for healing as well. in order to rev up the skin for healing as well. Dr. Nazarian prescribes prophylactic antibiotics to zarian Dr. Nazarian prescribes prophylactic antibiotics to prescribes prophylactic antibiotics to prevent postoperative impetiginization and bacterial in- ostoperative prevent postoperative impetiginization and bacterial in- impetiginization and bacterial in- fection of the treated area as follows: Beginning one day the treated area as follows: Beginning one day before the procedure, she recommends taking either e before the procedure, she recommends taking either procedure, she recommends taking either Kefl ex (cephalexin, Pragma Pharmaceuticals) 500mg or phalexin, Pragma Pharmaceuticals) 500mg or cefdinir 300mg by mouth twice daily for 10 days. 00mg cefdinir 300mg by mouth twice daily for 10 days. by mouth twice daily for 10 days. All patients at the Bay Area Laser Institute are pre- ents All patients at the Bay Area Laser Institute are pre- at the Bay Area Laser Institute are pre- treated with antiviral prophylaxis to prevent a herpes ith antiviral prophylaxis to prevent a herpes simplex virus (HSV) fl are-up. For patients without a rus (HSV) fl are-up. For patients without a history of HSV, Dr. Narurkar prescribes a prophylactic HSV, Dr. Narurkar prescribes a prophylactic dose of Valtrex (valacyclovir, GlaxoSmithKline) 2g taken altrex dose of Valtrex (valacyclovir, GlaxoSmithKline) 2g taken (valacyclovir, GlaxoSmithKline) 2g taken once in the morning and once in the evening the day he once in the morning and once in the evening the day morning and once in the evening the day before laser resurfacing. For patients with a history of er resurfacing. For patients with a history of recurrent HSV, he also prescribes Valtrex 500mg twice HSV, he also prescribes Valtrex 500mg twice daily for one week after treatment. one daily for one week after treatment. week after treatment. "I am always on the lookout for any signs of charring, which include yellowish-brown debris."

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