COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE in VS .NET

Paint QR Code ISO/IEC18004 in VS .NET COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE

COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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SOLAR LENTIGOS
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Up to 90% of elderly patients have one or more solar lentigos58 As the name suggests, the sun is the culprit here, with both acute and chronic exposure linked to engendering these macular brown lesions usually 1 cm in diameter Solar lentigos are more common in men than
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FIGURE 13-7 Clinical photo of solar lentigos women, as opposed to ephelides (freckles), which are reportedly more common in women59 The face and backs of hands are the typical areas affected These lesions are seldom seen among patients younger than 50 years and, therefore, have also been called senile lentigos The sun, rather than age, is the causative factor, however These lesions do not occur on sun-protected skin, even in the elderly (Fig 13-7) Solar lentigos, ephelides, and lentigos simplex are difficult to distinguish from each other clinically Taken together, these types of lesions constitute a significant risk factor for melanoma and basal cell carcinoma60,61 vated risk of melanoma, the importance of preventing the onset of such lesions cannot be overstated
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Treatment
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Solar lentigos can be treated with various methods depending on convenience for the patient For example, some patients may want to treat with slower methods that require no down time; other patients want to have the lesions removed in as few office visits as possible and don t mind the down time All patients should be treated with a home regimen of sunscreen and a combination of topical retinoids, topical bleaching agents, and hydroxy acids For those patients who want faster and more visible results, TCA peels, lasers (eg, QSwitch Ruby, Alexandrite, and Nd:Yag), local dermabrasion, and cryotherapy can be used When treating a patient with cryotherapy, only a single freeze thaw is recommended, since an aggressive treatment may lead to scarring and hypopigmentation64 Chemical peeling agents
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Histopathology
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Solar lentigos exhibit elongated rete ridges that contain deeply pigmented basaloid cells intermingled with melanocytes Also, they have an elevated number of melanocytes, which have been shown to have an increased capacity for melanin production58 The melanin content of the epidermis in facial solar lentigos has been demonstrated to be 22 times higher than that in photodamaged skin62 Solar lentigos can be distinguished from freckles histologically because freckles do not have elongated rete ridges and have a normal or lower number of melanocytes (Fig 13-8) Prevention of solar lentigos is best achieved through use of sunscreens and sun avoidance A study in JAMA revealed that sunscreen usage helped reduce the occurrence of nevi in white children63 Because increased numbers of these nevi are associated with an ele-
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FIGURE 13-8 Hematoxylin and eosin (H&E) stain of a solar lentigo (Photo courtesy of George loannides, MD)
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such as TCA, glycolic acid, and combination peels have been used for many years for the treatment of solar lentigines65 67 Although effective, the pain and burning sensation that especially accompanies treatment of a large surface area may be a limiting factor Several studies have compared the efficacy of these various treatments An ingenious method developed by Hexsel utilizes a tiny dermabrasion instrument to remove the solar lentigos68 She treated 10 female patients who had solar lentigos on the backs of their hands with either localized dermabrasion or cryotherapy More than 50% of the patients treated with cryotherapy continued to display hypochromia in the treated areas 6 months after treatment, compared with 11% of the patients treated with dermabrasion The percentage of recurrence of solar lentigos was the same with both treatments (5555%) In a study comparing liquid nitrogen to 35% TCA in the treatment of solar lentigines of hands in 25 patients, cryotherapy was found to be superior with 71% of subjects showing 50% or more improvement compared to 47% improvement with TCA peel69 In this study, although most patients believed that TCA peel has the fastest healing time, liquid nitrogen was rated more efficacious Laser therapy has also been shown to be effective in treating solar lentigos One study examining the efficacy of the Qswitched ruby laser in the treatment of solar lentigos demonstrated a response rate of 70% after one or two treatments70 The Alexandrite 755 nm,71 Q-switched Nd:YAG 532 nm, long pulse Nd:YAG 532 nm,72 1550-nm diode-pumped erbium fiber laser (Fraxel),73 and IPL74 have all been used in the treatment of solar lentigos with success These methods will be further discussed in 24 Although lasers are very effective for these lesions, patients should be warned that treated areas will be red or have a scab for approximately 7 to 10 days depending on the type of laser used The most common side effect of laser treatment is PIPA A rare side effect worth mentioning is chrysiasis after treatment with Q-switched lasers in patients previously treated with oral or parenteral gold75 77 Therefore, it is recommended that all patients get screened for past gold treatment Topical creams and bleaching agents are good alternatives for patients who do not wish to undergo aggressive treatments Topical retinoids (ie, tretinoin, tazarotene, and adapalene) are effective options and can be used alone or in combination with other bleaching agents such
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