Lasers and skin of color

This is from Skin and Allergy News

Volume 38, Issue 4, Page 58 (April 2007)

[color:#FF6666]With Skin of Color, Use Lasers Carefully to Avoid Malpractice[/color]
ALICIA AULT (Associate Editor, Practice Trends)

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WASHINGTON — Special consideration should be taken when conducting cosmetic dermatologic procedures—especially with lasers—on skin of color, because the malpractice risk is higher, Dr. David J. Goldberg said at the annual meeting of the American Academy of Dermatology.

Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York, and adjunct professor at Fordham University School of Law, New York, said that thinking like a first-year law student and being aware of the inherent risks associated with using lasers in darker skin can minimize risk.

Lawsuits are brought for a variety of reasons, primarily because of negligence, but also because physicians are poor communicators or because patients may be seeking retribution for unsatisfactory results or just trying to get some money, said Dr. Goldberg.

For a lawsuit to be successful, though, it must be proved that a physician breached his or her duty, that the breach caused the problem, and that it is serious enough to warrant damages. These basic tort components are drilled into first-year students, he said.

With laser and intense pulsed light (IPL) procedures, ethnic skin is more susceptible to damage because melanocytes in the skin compete with the technologies, Dr. Goldberg said.

Often, insufficient protection against cold is employed when surgeons treat patients with darker skin types.

Side effects that could lead to claims include erythema, hypo- or hyperpigmentation, infections, and scarring. Warning patients with darker skin about these potential complications is essential. White patients may experience pigmentation issues, but the changes are generally not permanent and will not likely lead to a lawsuit, said Dr. Goldberg.

Those changes can be long-lasting or even permanent in skin of color. “If it’s permanent, it will be a successful lawsuit,” Dr. Goldberg said. He noted one of his cases from a decade ago, in which he had used an IPL device to remove tattoos on a young man’s skull. IPL devices were approved for that indication, but he said “they clearly don’t work at all.” He induced hypopigmentation, which was fairly long-lasting. The patient did not file a claim, but “today it would lead to a lawsuit.”

Complications don’t automatically lead to a claim or to a successful lawsuit. If a physician performed a procedure correctly, and there was no breach of duty but there was a complication, there would be no negligence, he said.

If there is a cold-induced injury and the patient hasn’t been warned, or was warned but the physician did something wrong, and the damage is permanent, there will be a lawsuit, Dr. Goldberg said.

Getting patient consent is crucial, but if a patient says he or she does not remember the warnings in the consent, a lawsuit could proceed.

Some suits might not ever come to fruition because of the slow pace of the U.S. legal system.

“Sometimes, by the time you get in front of the jury, the jury looks and says there is not much here any more,” he said, and noted that what had appeared permanent might have faded by trial time.

To reduce the risk of getting to that stage, physicians should handle disgruntled patients head on. “Keep them happy, talk to them, and think like a first-year law student. That’s going to solve 99% of your problems,” he said.

PII: S0037-6337(07)70292-9


© 2007 Elsevier Inc. All rights reserved.

See post above as well.

Volume 38, Issue 4, Page 1,34 (April 2007)

From Skin and Allergy News:

[color:#FF6666]Combo Therapy May Be Hydroquinone Alternative[/color]
GREG MUIRHEAD (Contributing Writer)

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MAUI, HAWAII — Combination therapy with mequinol 2% and tretinoin 0.01% solution was slightly more effective than hydroquinone 4% cream in reducing hyperpigmentation in African American patients with postinflammatory hyperpigmentation after 12 weeks, Dr. Susan Taylor said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

The results suggest that this off-label use of mequinol 2% and tretinoin 0.01% solution (Solagé) may be a viable alternative to hydroquinone, the skin-lightening ingredient that the Food and Drug Administration has proposed banning from over-the-counter cosmetic products, said Dr. Taylor of Columbia University, New York.

The study was an open-label, phase IV trial of treatment with Solagé versus hydroquinone 4% cream in the reduction of facial postinflammatory hyperpigmentation, said Dr. Taylor, an investigator for Barrier Therapeutics (which markets Solagé) who also is affiliated with many other companies.

Each treatment was assigned to one side of the face and applied consistently twice daily, at intervals greater than 8 hours, for 12 weeks. Results were assessed at weeks 4, 8, and 12 using a 7-point investigator and patient global assessment of improvement, with 0 indicating “completely clear” with no hyperpigmentation and 6 indicating hyperpigmentation that was worse than at baseline.

A total of 61 African American patients were enrolled, with 47 completing the 12-week study. Patients’ average age was 33.5 years. At the time of enrollment, facial pigmentation was mild in 31% of patients and moderate in 69%.

“A combination of mequinol 2% and tretinoin 0.01% showed an improvement more gradually than 4% generic hydroquinone,” Dr. Taylor pointed out, but “by 12 weeks the mequinol and tretinoin, in combination, in this particular study, performed very well—and at the very end of the trial outperformed hydroquinone.” (See box.)

The treatments were well tolerated. Eighteen patients were adversely affected by treatment, but no one discontinued the study because of an adverse effect (AE). Most skin-related AEs were mild or moderate, with severe AEs occurring in four patients (22%). Most AEs developed early in the trial, and all were resolved with appropriate treatment. Of the patients who were adversely affected by treatment, nine had multiple AEs: Three needed dosage adjustments; and two temporarily discontinued the study medication. The most frequent AEs were burning (14 Solagé patients vs. 2 hydroquinone patients), scabbing/peeling (7 Solagé patients vs. 0 hydroquinone patients), and dryness (4 Solagé patients vs. 1 hydroquinone patient).

Given these findings, Dr. Taylor said, “we have another safe and effective treatment for the treatment of facial postinflammatory hyperpigmentation secondary to acne.”

To put the study’s results in context, Dr. Taylor explained that postinflammatory hyperpigmentation (PIH) is typically a result of increased melanin production and presents as discrete, hyperpigmented macules that have hazy, feathered margins. It occurs primarily in women of color, including African Americans, Asians, and Hispanics. It occurs on sun-exposed areas of the skin, especially around the center of the face, she said.

Exacerbating factors may include pregnancy, estrogens, and oral contraceptives. PIH forms in an area that has previously experienced inflammation, cutaneous injury, a cosmetic or surgical procedure, or any of a variety of inflammatory dermatoses. “In my practice, I see it most often as a result of acne vulgaris,” Dr. Taylor noted.

She observed that patients with skin of color who have acne often “don’t present with acne. Their chief complaint is the hyperpigmentation.”

Given the association of acne and PIH, “it behooves us to spend some time to explain to our patients that we must treat the acne, as well as the postinflammatory hyperpigmentation,” she said, adding that “patients will take their prescriptions, but they won’t use the acne medicines.”

As preventive measures, patients need to use sunscreens and otherwise protect themselves from ultraviolet radiation, Dr. Taylor explained. Treatment is needed when the first signs of skin irritation/inflammation appear.

Current topical treatments for PIH include phenols, including hydroquinone and mequinol; the retinoids, including tretinoin; corticosteroids that can be used in combination with other treatments; azelaic acid; kojic acid; alpha-hydroxy acids; and combinations of these treatments.

Available procedures include salicylic acid and trichloracetic acid peels. Cryosurgery also can be helpful, as can dermabrasion and microdermabrasion. Lasers, especially fractional lasers, can help with dermal pigmentation. Even with all these therapeutic options, though, “dyschromias remain a therapeutic challenge,” Dr. Taylor said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.