Aesthetik.lumenis.de

Supplement to November 2002
TO TREAT LEUKODERMAL SKIN CONDITIONS
SUCH AS STRETCH MARKS AND
HMP Communications Supported by an educational grant from Lumenis Inc.

TO TREAT LEUKODERMAL SKIN CONDITIONS
New research highlights successes in repigmenting mature stretch marks and hypopigmented scars.
Stretch marks, or striae distensae, occur very commonly and create significant cosmetic skin disfigurement. These marks affect a largeportion of the population. It's reported that approximately 90% of pregnant women, 70% of adolescent females and 40% of adolescent males have stretch marks.1 In men, striae typically occur as a result of a rapid growth spurt or weight gain at puberty, from endocrine disor- ders or as a consequence of participation in certain sports, espe- cially weightlifting. Excessive or chronic use of potent topi- cal or systemic corticosteroids also promotes the forma- tion of striae.2 Although frequently classified into two types, early (red) and mature (white or alba), striae represent linear dermal scars accompanied by epi- dermal atrophy. While the use of lasers or light treatments to diminish the appearance of striae has been reported by a number of sources, controlled clinical studies are rare. New evi- dence suggests that targeted light therapy may have a significant benefit. We believe that the hypopigmented component of stri- ae can be safely treated with targeted 290 nm to 400 nm ultraviolet (UV) light. The improvement may be enhanced in combi- nation with other therapeutic modalities that aid in collagen remodeling in order to achieve safe and effective improvement in the appearance of striae distensae.
In this article, we'll focus on the use of a novel target- ed incoherent UV light source, the ReLume™ The Lumenis ReLume Repigmentation Phototherapy System

Hypopigmented traumatic scar before (at left) and after eight ReLume treatments (at right).
Photos courtesy of Dr. Roy Geronemus & Dr. Macrene Alexiades-Armenakas Repigmentation Phototherapy System (Lumenis, agents has been aggressively sought for many years.
Inc., Santa Clara, CA), for treating mature striae and Topical tretinoin in a 0.1% concentration has been other hypopigmented non-linear dermal scars. First, shown to be effective for striae rubra or early, red, we'll review the etiology of striae and discuss other inflammatory stretch marks.6 However, it failed to sig- treatments that have been employed to diminish nificantly improve mature stretch marks (striae alba).7 their appearance.
Whether the improvement of striae rubra leads to adiminution in the final appearance of the striae remains unknown. Recent data suggests that the appli- The factors that lead to the development of striae cation of 20% glycolic acid (MD Forte, Allergan) with are poorly understood. Early changes include inflam- either 0.05% tretinoin emollient cream (Renova, mation and capillary dilation. It is believed Ortho Pharmaceuticals) or 10% that stress shattering of the collagen L-ascorbic acid (SkinCeuticals) on framework initiates an inflam- a daily basis may slightly improve matory response that ultimately the appearance of striae alba.8 In results in a thin and flattened general, topical treatments have epidermis with loss of the rete yielded disappointing results with ridges and loss of melanocytes.
only modest improvement reported Elastic stains show breakage and in mature striae.
retraction of the elasticfibers in the LASER/ INTENSE PULSED LIGHT (IPL™) TREATMENT OF STRIAE dermis.3, 4 Other dermal Many lasers including the CO2, changes include thin, densely packed Erbium:YAG, 1320 nm Nd:YAG and collagen bundles arranged in a parallel array hori- pulsed dye lasers have been used to treat zontal to the epidermis at the level of the papillary scars and stretch marks.9,10 Many have also dermis. Extracellular matrix alterations that mediate used Intense Pulsed Light (IPL) with fil- the clinical appearance of stretch marks remain poor- ters ranging from 550 nm to 590 nm, but ly understood. With time, striae assume their typical no controlled trials have been performed.
white atrophic appearance with the long axis aligned IPL induces some improvement of the ery- parallel to the lines of skin tension. According to thematous component of new striae; how- McDaniel, this development is very similar to that of ever, the effects on mature striae are uncer- surgical wound healing.5 tain and have not been thoroughly studied.
A REVIEW OF TOPICAL TREATMENTS FOR STRIAE Improvement in the appearance of striae by topical Handpiece for the ReLume system.
Pulsed dye laser therapy has been shown to improve all typesof striae, but red, early striae improve more dramatically while Robert A. Weiss, M.D. — Associate
white mature striae are less responsive. The optimal fluence Professor of Dermatology, Johns Hopkins was determined to be 3 J/cm2 using a 10-mm spot size. This University School of Medicine study also revealed that laser therapy of striae requirespatience with continual improvement observed 6 to 12 months Roy G. Geronemus, M.D. — Director of the
after treatment.11 Using similar pulsed dye laser treatment Laser & Skin Surgery Center of New York; methods, other investigators failed to note much clinical or Clinical Professor of Dermatology, New YorkUniversity Medical Center, New York, NY histological improvement of striae.12,13 The 1320 nm Nd:YAGdynamically cooled laser has been demonstrated to produce Macrene Alexiades-Armenakas, M.D.,
modest improvement (about 10% per treatment) in the tex- Ph.D. — Director of Research, Laser & Skin
ture of mature striae.14 Therefore, lasers and light sources have Surgery Center of New York not achieved consistent success nor has the mature hypopig-mented component of striae been specifically addressed. Jeffrey S. Dover, M.D., F.R.C.P.C. —
Associate Clinical Professor of Dermatology,
LIGHT-BASED TREATMENT OF HYPOPIGMENTED SCARS Section of Dermatologic Surgery andOncology, Yale University School of Medicine; We have had initial success treating hypopigmented scars Adjunct Professor of Medicine (Dermatology), using the ReLume Repigmentation Phototherapy System, Dartmouth Medical School; Director, which combines the benefits of safe and effective UV pho- SkinCare Physicians of Chestnut Hill, MA totherapy with the latest advances in targeted light technology. Pilot clinical investigations with approximately 50 patients Mitchel P. Goldman, M.D. — Clinical
from our centers combined have shown repigmentation in Professor of Dermatology/Medicine, approximately 80% of patients within a 2- to 3-month period, University of California, San Diego; Medical with a total number of treatments up to 14. Treatment flu- Director, Dermatology/Cosmetic Laser ences are initially administered at or slightly below the erythe- Associates of La Jolla mogenic threshold and the dose is increased as patients Neil S. Sadick, M.D. — Clinical Professor of
become more photo-tolerant. The induction and retention of Dermatology, Weill Medical College of Cornell pigmentation varies somewhat and may depend on several fac- tors including the individual's skin phototype, the body sitetreated and the type and age of the lesion. However, marked Christine C. Dierickx, M.D. — Visiting Research
improvement is commonly observed beyond 3 months post Scientist, Harvard University Medical School; treatment. These clinical trials are ongoing and the outcomes Consulting Staff, Department of Dermatology, reported here represent very early clinical results. University Hospital of Ghent, Belgium; Director of Scars treated with this light source have varied from surgical the Boom Laser Clinic, Belgium incisions to the hypopigmentation seen as a late side effect of Jean Carruthers, M.D., F.R.C.S.(C),
CO2 laser resurfacing. Excimer laser phototherapy and topical F.R.C.Ophth — Clinical Professor,
photochemotherapy have also been used to provide moder- Department of Ophthalmology, University of ately to highly effective repigmentation of laser resurfacing- British Columbia, Vancouver, Canada; induced leukoderma.15,16 Director, Carruthers Aesthetic Facial An example of traumatic surgical scar repigmentation is shown in the photos on the previous page. This patient's scaracquired robust pigmentation in eight ReLume treatments, Mark S. Nestor M.D., Ph.D. — Clinical
Associate Professor of Dermatology and
performed weekly to bi-weekly with a fluence of 260 mJ/cm2. Cutaneous Surgery, University of Miami Treatment times are short, and coverage of large areas can be School of Medicine; Director, The Center for achieved quickly using a delivery spot of adjustable size and Cosmetic Enhancement, Aventura, FL shape. A spacer on the handpiece allows the practitioner to visu-alize the treatment field to improve the accuracy of treatments.
Darrell S. Rigel, M.D. — Clinical Professor of
Dermatology, Department of Dermatology,
LIGHT-BASED TREATMENT New York University School of Medicine, New OF MATURE HYPOPIGMENTED STRIAE ALBA Striae assume their typical white sunken appearance in a process very similar to that of surgical wound heal-ing.5 Based on the successful clinical trials of repig-mentation of hypopigmented surgical scars, webelieve that there is much promise in utilization ofthe ReLume device for selective repigmentation ofmature striae alba. Initial clinical results haveshown that the improvement of mature striae ispossible with targeted UV phototherapy. Examplesare shown in photos at right.
It is also interesting to speculate regarding the reversal of the atrophic nature of striae. The cuta-neous responses to UV irradiation in human skinare well established. UVB irradiation results in epi-dermal hyperplasia and dramatic thickening of thestratum corneum.17,18 Furthermore, UV irradiationcan affect the arrangement of dermal matrix colla-gen and elastin proteins. This raises the possibilitythat targeted UV phototherapy administered withhighly controlled doses will be able to treat boththe depigmented and atrophic components ofmature striae alba simultaneously. Ongoing clini-cal trials with histological evaluation will answerthese questions. Striae are a very common cosmetic problem.
There is great potential to improve the appear-ance by repigmentation of mature striae alba and Stretch marks on the right hip of a female patient hypopigmented white scars of multiple etiologies.
before (top photo) and after (bottom) seven ReLume Multicenter trials on hundreds of patients should treatments. Total cumulative dose was 640 mJ/cm2.
be completed within the next year. The ReLume Photos courtesy of Dr. Roy Geronemus & Dr. Macrene Alexiades-Armenakas Repigmentation Phototherapy System appears to Dermatol Surg Oncol 1990; 16:267-70.
offer great promise. In preliminary clinical trials, 8. Ash K, Lord J, Zukowski M, McDaniel DH. Comparison of topicaltherapy for striae alba (20% glycolic acid/0.05% tretinoin versus 20% excellent results have been observed with response glycolic acid/10% L-ascorbic acid). Dermatol Surg 1998; 24:849-56.
rates as high as 80% in hypopigmented scars and 9. Alster TS, Lewis AB, Rosenbach A. Laser scar revision: comparisonof CO2 laser vaporization with and without simultaneous pulsed dye mature striae alba. These results may be further laser treatment. Dermatol Surg 1998; 24:1299-302.
enhanced in combination with other therapeutic 10. Lupton JR, Alster TS. Laser scar revision. Dermatol Clin 2002; 20:55-65.
11. McDaniel DH, Ash K, Zukowski M. Treatment of stretch marks with modalities that aid in collagen remodeling in the 585-nm flashlamp-pumped pulsed dye laser. Dermatol Surg 1996; order to achieve safe and effective improvement in 22:332-7.
12. Nehal KS, Lichtenstein DA, Kamino H, Levine VJ, Ashinoff R.
the appearance of mature striae distensae.
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13. Nouri K, Romagosa R, Chartier T, Bowes L, Spencer JM. Comparison of the 585 nm pulse dye laser and the short pulsed CO2 laser in the 1. Arnold HL, James WD, Odom RB. Abnormalities of dermal connec- treatment of striae distensae in skin types IV and VI. Dermatol Surg 1999; tive tissue. In: Odom RB, James WD, Berger TG, ed. Andrews' diseases of the skin: Clinical Dermatology. 9th edn. Philadelphia: W.B. Saunders Co., 14. Goldman MP, Rostan EF. Treatment of striae distensae with a 1320- 2000: 645-646.
nm dynamic cooling laser. J Eur Acad Dermatol Venereol 2000; 14(Suppl. 1):52.
2. Lebwohl M, Ali S. Treatment of psoriasis. Part 1. Topical therapy and 15. Friedman PM, Geronemus RG. Use of the 308-nm excimer laser for phototherapy. J Am Acad Dermatol 2001; 45:487-98.
postresurfacing leukoderma. Arch Dermatol 2001; 137:824-5.
3. Tsuji T, Sawabe M. Elastic fibers in striae distensae. J Cutan Pathol 16. Grimes PE, Bhawan J, Kim J, Chiu M, Lask G. Laser resurfacing- 1988; 15:215-22.
induced hypopigmentation: histologic alterations and repigmentation 4. Sheu HM, Yu HS, Chang CH. Mast cell degranulation and elastolysis with topical photochemotherapy. Dermatol Surg 2001; 27:515-20.
in the early stage of striae distensae. J Cutan Pathol 1991; 18:410-6.
17. Meischer G. Das problems des Lichtschutzes und der 5. McDaniel DH. Laser therapy of stretch marks. Dermatol Clin 2002; Lichtgewohnung. Strahlentherapie 1930; 35:403-43.
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18. Rosario R, Mark GJ, Parrish JA, Mihm MC, Jr. Histological changes 6. Kang S, Kim KJ, Griffiths CE, et al. Topical tretinoin (retinoic acid) produced in skin by equally erythemogenic doses of UV-A, UV-B, UV-C improves early stretch marks. Arch Dermatol 1996; 132:519-26.
and UV-A with psoralens. Br J Dermatol 1979; 101:299-308.
7. Elson ML. Treatment of striae distensae with topical tretinoin. J HMP COMMUNICATIONS 83 General Warren Blvd., Suite 100, Malvern, PA 19355 Phone: 800-237-7285 (610) 560-0500 Fax: 610-560-0501

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