canadian dermatology association association

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canadian dermatology association association
C AN AD IAN
D E R MATO LO G Y
AS S O C I AT I O N
Bulletin
A S S O C I AT I O N C A N A D I E N N E D E D E R M AT O L O G I E
Volume 18, no. 2
issn 1494-0345
June 2011 Juin
EDITORIAL BOARD
CONSEIL DE RÉDACTION
editorial / Rédaction ..................................................................... C.W. lynde
3
Guest editorial / Rédaction invité ........................................... G.D. schachter
3
Clinical Outline of lasers – Cutaneous Vascular lesions ........... s. laughlin
4
Photodynamic therapy .................................................................... M. Gidon
7
laser safety .................................................................................. H. Bargman
8
laser in Pediatric Dermatology ................................................... C. McCuaig
9
non-invasive Body Contouring ..................................................... J.K. Rivers
10
laser Complications ......................................................................... A. Curtis
12
lasers – to Fractionate… or not to Fractionate...............................M. lupin
13
President’s Column / Rubrique du president ................................. i. landells
15
treasurer’s Report / Rapport du trésorier ........................................... D. Zloty
17
CDA Bulletin editor’s Meeting - edmonton ...................................... l.Vogel
17
secretary’s Report / Rapport de la sécretaire ............................... B. Barankin
18
news CDA Members / nouveau membres de l’ACD.......................................
18
executive Director’s Report / Rapport du directeur exécutif .. C. Courchesne
19
CDA 2011 Business Meetings – edmonton .....................................................
20
Brief History of Dermatology in edmonton ................................ G.J. lauzon
21
Canadian Dermatology Foundation news .................................... G.J. lauzon
23
Canadian society for Dermatologic surgery .............................M. sapijaszko
24
new McGill Program Director ....................................................... l. Moreau
25
société de dermatologie de Montréal 2010-2011......................... C. McCuaig
25
Alberta news.......................................................................................... C. Zip
26
Maritime news ............................................................................. M. Bourcier
26
Manitoba news ............................................................................... V. taraska
26
Ontario news .......................................................................... G.D. schachter
26
Clinical tips & Pearls of Wisdom ................................................B. Barankin
27
IAN LANDELLS, MD
1 Anderson Ave., st.John’s, nl A1B 3ei
tel: (709) 726-7546 Fax: (709) 726-7575
e-mail: [email protected]
Drive news ................................................................................... G.J. lauzon
27
CDA-RFs Co-Chair update .......................................................... M. Ramien
28
CATHERINE McCUAIG
Hôpital ste-Justine - Dermatologie
3175 Ch. Côte-ste-Catherine, Montréal, QC H3t 1C5
tel: (514) 345-4675 Fax: (514) 345-4822
e-mail: [email protected]
Dermatology Fellowship .................................................................... l. Vogel
28
National Editor / Rédacteur en chef
CHARLES W. LYNDE, MD
3 Ovida Blvd., Markham, On l3P 7n8
tel: (905) 472-1700 Fax: (905) 472-6343
e-mail: [email protected]
Executive Director / Directeure générale
CHANTAL COURCHESNE
425 – 1385 Bank street, Ottawa, On K1H 8n4
tel: (613) 738-1748 / 1-800-267-3376 Fax: (613) 738-4695
Fax: 1-866-267-2178
e-mail: [email protected]
General e-mail: [email protected]
www.dermatology.ca
Publisher / Éditeur
LOUIS VOGEL
5353 boul. thimens, st-laurent, QC H4R 2H4
tel: (514) 334-3835 ext: 121 Fax: (514) 334-7078
e-mail: [email protected]
www.canderm.com
Publication Coordinator / Coordonnatrice de publication
CHRISTINA GATTUSO
e-mail: [email protected]
Regional Editors / Rédacteurs régionaux
BENJAMIN BARANKIN, MD
4256 Bathhurst st., ste 400
toronto, On M3H 5Y8
tel: (416) 633-0001 Fax: (416) 633-0002
e-mail: [email protected]
MARC BOURCIER, MD
35 rue Providence,
Moncton nB e1C 8X3
tel: (506) 857-9015 Fax: (506) 862-4256
e-mail: [email protected]
LAURA FINLAYSON, MD
Dickson Bldg., Rm. 4193,
1276 south Park st.
Halifax, nova scotia B3H 2Y9
tel: (902) 470-8043 Fax: (902) 470-8137
e-mail: [email protected]
GILLIAN de GANNES, MD
888 West 8th Ave., ste 314, Vancouver, BC V5Z 3Y1
tel: (604) 731-5353 Fax: (604) 731-6166
email: [email protected]
PETER R. HULL, MD
103 Hospital Drive, saskatoon, sK s7n 0W8
tel: (306) 966-5157 Fax: (306) 966-5166
e-mail: [email protected]
ROBERT JACKSON, MD
82 Viscount Avenue, Ottawa, On K1Z 7M9
Cell: (613) 851-2197 Fax: (613) 729-8179
e-mail: [email protected]
SUNIL KALIA, MD
the skin Care Centre, 835 W. 10th Ave,
Vancouver, BC V5Z 4e8
tel: (604) 875-4747 Fax: (604) 873-9919
e-mail: [email protected]
KATHLEEN MOSES, MD
1752 Rhodes Crescent, Ottawa, On K1H 5t2
tel: (613) 733-5411 Fax: (613) 733-3755
e-mail: [email protected]
YVES POULIN, MD
2880 Chem. Quatre-Bourgeois, Québec QC G1V 4X7
tel: (418) 650-3555 Fax: (418) 650-1260
e-mail: [email protected]
G. DANIEL SCHACHTER, MD
208 Bloor street, W. suite 403, toronto, On M5s 3B4
tel: (416) 922-9620 Fax: (416) 922-4358
e-mail: [email protected]
VICTORIA TARASKA, MD
Winnipeg Clinic, 425 st. Mary Ave, Winnipeg, MB R3C 0n2
tel: (204) 957-1900 Fax: (204) 942-2044
e-mail: [email protected]
CATHERINE ZIP, MD
124-42nd Avenue sW, Calgary, AB t2s 3B3
tel: (403) 299-5800 Fax: (403) 299-5828
e-mail: [email protected]
2
Pharmaceutical Corporate Report ...................................................... l. Vogel 28
Position Available in B.C...................................................................................
28
university of Alberta Program update ......................................... V. Prajapati
29
university of Monreal Program update ........... J. Bertrand, s. Vadeboncoeur
29
university of Ottawa Program update ................................M. Mioduszewski 29
université de sherbrooke Program update ....................................... s. sivret 30
Office Moves and Practice starts ....................................................... l. Vogel
30
Birth Announcements/ naissances ..................................................... l. Vogel
30
Obituaries/ nécrologies ..................................................... R. lester, l. Vogel
31
Wine and Food Gems.......................................................................... l. Vogel
32
Rédaction
Editorial
Laser et lumière… Et la lumière fut !!
Lasers & Lights…
for whom the light shines!!
il fut un temps où les départements des universités
constituaient les seuls endroits où les dermatologues avaient accès au laser. De nos jours, ils s’en
servent à leur propre cabinet. la technologie du
laser et de la lumière a sans contredit révolutionné
le domaine de la dermatologie au cours des 30
dernières années. On a de plus en plus recours au
laser et à la lumière en dermatologie pour soigner
un grand nombre de problèmes de peau.
it used to be that only at academic university
departments did Dermatologists have access to
lasers, now most Dermatologists have access to
lasers within their own private practice. laser
and light technology has certainly revolutionized
the field of Dermatology for over the last 30
years. lasers and light are increasingly being
employed in dermatological practices to treat a
wide range of skin disorders.
CHARles W. lYnDe, MD notre rédacteur invité, le Dr Dan schachter, a été
Markham
l’un des pionniers de l’utilisation du laser en derOur guest editor Dr Dan schachter has been one
matologie depuis la fin des années 1970, avec les
of the pioneers of lasers in dermatological pracanciens lasers à argon. il a accepté d’emblée d’être le rédacteur
tice since the late 1970’s with the old Argon lasers. He readiinvité de ce numéro du Bulletin de l’Association canadienne de
ly agreed to be the guest editor for this issue of the Canadian
dermatologie et a réuni un groupe enthousiaste des grands
Dermatology Association Bulletin on lasers and light and has
noms du laser de la dermatologie canadienne. Ce groupe sélect
ensembled an enthusiastic group of “Who’s Who” in the laser
nous a fourni un ensemble d’excellents petits articles portant
world of Canadian Dermatology. this select group has providsur l’utilisation du laser et de la phototechnologie.
ed us with a collection of excellent short papers on the use of
laser and light-based technology.
il s’agit d'un volet de la dermatologie qui continue de croître
et d’évoluer. en notre qualité de dermatologues, nous devons
this is an area of Dermatology that continues to expand and
demeurer à l’avant-plan de cette technologie particulière et,
change. We as Dermatologists must be kept at the forefront of
comme toujours, demeurer les « experts de la peau ». J’espère
this particular technology and, as always be the “skin experts”.
que vous prendrez autant de plaisir que moi à lire ces
i hope you enjoy these papers as i have and i thank our guest
articles et je remercie nos « experts du laser » de nous les avoir
“laser specialists” for their articles.
fournis.
Guest Editorial
Rédaction invité
Laser and Light Sources
Laser et sources de lumière
We have come a long way since the first laser was
developed by Maimon and its early use by Dr
leon Goldman in the 1960’s. the early lasers
lacked specificity and risks of treatment often out
weighted the benefits.
since then we have seen the development of
vascular and pigment lasers based on the theory of
selective Photothermolysis. even though we have
many vascular lasers, the treatment of Portwine
stains remains a challenge. We can treat pigmented lesions and tattoos, acne, and fat. the technology is rapidly changing.
il a coulé beaucoup d’eau sous les ponts depuis
la mise au point du premier laser par Maimon et
ses premières utilisations par le Dr leon
Goldman dans les années 1960. les premiers
lasers manquaient de précision et les risques que
comportait le traitement l’emportaient souvent
sur ses avantages.
Depuis ce temps, nous avons vu l’avènement des
lasers vasculaires et pigmentaires, qui fonctionnent selon la théorie de la photothermolyse
sélective. Même si nous disposons de nombreux
lasers vasculaires, le traitement des angiomes demeure un défi.
nous pouvons traiter les lésions pigmentées et les tatouages,
l’acné et les graisses. la technologie évolue rapidement.
G. DAniel sCHACHteR,
MD, toronto
Attending the annual laser meeting AslMs in Dallas this
year we learned about technologies ranging from microwaves
used to treat Hyperhidrosis to improvements/upgrades in
intense Pulsed light (Broad Band) to new treatments for fat or
the aging face to laser treatment of fungal toenails.
this issue of the CDA Bulletin presents a number of short
reviews of laser and light technology targeting the general
À l’occasion du Congrès annuel de l’AslMs sur le laser, qui
avait lieu cette année à Dallas, nous nous sommes familiarisés
avec diverses technologies, par exemple les micro-ondes utilisées pour soigner l’hyperhidrose, les améliorations et mises à
niveau en matière de lumière intense pulsée (large bande), les
nouveaux traitements contre les graisses ou le vieillissement
continued on page 6
suite à la page 6
3
A Clinical Outline of Lasers Used to Treat Cutaneous Vascular Lesions
Historical Perspective
the theory of selective photothermolysis (sP) provided
the scientific basis for contemporary laser treatment of
vascular lesions 1, when a
preferentially absorbed wavelength is delivered to a target
chromophore in a pulse duration < it’s thermal relaxation
time (tRt). this achieves
irreversible
thermal injury of
sHARYn lAuGHlin, MD,
microvessels,
where photocouniversity of Ottawa
agulation of blood damages
the endothelium in contact by diffusion without damage to the
adjacent dermis (spatial confinement). A flashlamp pulsed dye
laser (PDl) that met the objectives of sP was shown to be
effective in the treatment of portwine stains (PWs) 2. it became
the cornerstone for the development of new vascular laser systems and is still the standard of care for the treatment of many
vascular lesions. i was introduced to this laser in 1987 during a
preceptorship with Dr O tan, one of the pioneers in clinical
PDl treatment 2, and i acquired a PDl in 1988.
Photobiology
the potential target chromophores in vascular lesions include
oxyhemoglobin (HbO2), de-oxyhemoglobin (Hb), and methemoglobin (Met-Hb). A target chromophore with a high photon
absorption coefficient for the preferred wavelength is selected
after considering the characteristics of the lesion to be treated.
Vessel diameter is then matched to pulse duration – smaller
vessels require shorter exposure times. longer wavelengths
penetrate more and combined with larger spotsizes (less dermal
scattering) can achieve deeper injury. Photocoagulation causes
secondary injury to the endothelial lining from thermal diffusion. the classical clinical endpoint for thermal injury was purpura at the effective fluence. With longer exposure times therapeutic injury can be achieved below, at purpura threshold, or
above. For larger vessels longer exposure times also achieve
irreversible injury through mechanisms other than photocoagulation. the theory of extended sPtl3 uses a pulse duration
longer than the tRt to achieve injury to the vessel wall and
perivascular collagen in the treatment of larger vessels (such
as leg veins), or larger structures (such as a hair follicles)
where the chromophore is not evenly distributed within the
target structure.
Other therapeutic approaches use the greater absorption of certain wavelengths by met-Hb compared to HbO2 at 1.8 X for
595-nm and 3-5 X for 1064 nm 4, 5. new systems deliver therapeutic energy levels in longer exposure times, and 1064-nm in
an extended pulse at a judicious fluence, can achieve irreversible injury of vessels in the deeper dermis and subcutaneous tissue. the conversion of HbO2 to Met-Hb occurs in 1030 milliseconds at optimal fluence and pulse duration 6 and new
dual wavelength platforms exploit this phenomenon. the ‘heat
sink’ effect uses the increased absorption of the 595-nm wavelength by a clot formed after a first laser pass at a fluence above
the purpura threshold. 4 tanghetti et al 7 showed that with fluences above purpura threshold, there is time-dependent
increased depth of injury with a second pass at 595-nm in normal skin. We used these reports as the basis of a new approach
in the treatment of portwine stains, where a second pass with
595-nm at a 20-30 minute interval produces renewed fading in
resistant lesions from deeper and extended injury beyond the
coagulation zone.8
Clinical Considerations
Presently available vascular technology in n. America includes
75 different systems from 22 different manufacturers. the principle of sP should guide the average clinician in selecting the
best approach to treat a specific vascular lesion, and the extended theory is carefully applied to larger vessels. Adhering to the
precepts of sP 1 and the judicious application of extended sP
determines the extent of injury beyond the target chromophore.
in the vascular model a small vessel requires the combination
of fluence, spotsize, and pulsewidth, for heating of blood within the lumen and diffusion only to the endothelium. For larger
vessels, a longer pulsewidth is required to achieve permanent
injury by wider thermal injury possibly through cavitation and
steam bubble formation or thermal denaturation of collagen in
the perivascular cuff.9 As the pulse duration increases the ratio
of stenosis/thrombosis increases with better closure of larger
vessels.10 the thermal injury must still be confined to the target to avoid injury from diffusion to the adjacent or intervening
dermis. Anderson, who founded the theory selective photothermolysis 1 points out that with each new application – one
constant remains – scarring only occurs when the dermis between the targets undergoes necrosis 11. epidermal cooling is an
essential requirement and lowers the risk of adverse effects.
With access to 5 vascular lasers and several iPl systems, the
selection of a treatment option is tailored to the individual
patient and the vascular morphology. the Ontario Ministry of
Health licensed my facility (laserderm) as an iHF in 1991.
each year over 1800 hours of vascular laser surgery are
performed on about 600 patients for insured benign vascular
lesions (mainly malformations and hemangiomas). Another
3000 uninsured treatments are performed on 1000 patients with
all the usual vascular lesions. My personal preferences are
based on this experience over 23 years and the evidenced based
consensus in the published literature.
Portwine stains
Mathematical models confirm that the optimal pulse duration
for the average capillary malformation with a range of vessel
sizes is 1-10 milliseconds.12
• the 585-nm at 0.45 milliseconds PDl is still ideally suited
to treating infantile PWs and small calibre telangiectasia.
• newer yellow light systems use the 595-nm wavelength over
longer exposure times up to 40 milliseconds and achieve
continued on page 5
4
continued from page 4
efficacy for larger micro-vessels in mature portwine stains and
for larger capillary telangiectasia. A very light pink PWs in a
child can be treated with 532-nm (green light).
• 25-50% PWs become resistant to treatment. there are several reasons for treatment resistance and incomplete clearance
with green and yellow light. One factor is the limited ability
of short wavelengths to affect ectatic vessels beyond a depth
>2 mm. Multiple passes or pulse-stacking techniques have
been used to improve the extent and rate of fading, but
increased adverse effects have limited this clinical approach.
• near infra-red wavelengths (755-nm and 1064-nm) are being
used more frequently to treat mature, thicker, or nodular purple stains. the 755 nm alexandrite laser can be useful for the
treatment of hypertrophic and treatment-resistant PWs in
adult and pediatric patients 13 and deeper PWs may be treated effectively with the 1064nm nd:YAG laser.14 these methods are best used in experienced hands. the risk of adverse
effects increase despite epidermal cooling, as longer exposure times and increased relative absorption change the paradigm for the mechanism of injury with a smaller therapeutic
margin of safety. the 755-nm wavelength has advantages
over a 1064-nm wavelength.12 the 755 nm absorption coefficient of de-oxyhemeglobin is > that of oxyhemeglobin and
an alexandrite laser likely damages veins more than arteries.
the 1064-nm nd:YAG wavelength is absorbed more by
HbO2 than Hb and damages arteries more than veins. Yang et
al.14 reported that at 1064-nm fluences just above minimal
purpura dose (MPD) can produce extensive deep dermal
necrosis and scarring. the MPD varied greatly among
patients and within a lesion, and since PWs are heterogeneous lesions the narrow range for therapeutic fluence
reduces both efficacy and safety. Formation of met-Hb within the longer exposure times > 10 milliseconds contributes to
greater absorption in blood that may produce uncontrollable
effects. the met-Hb phenomenon is less at 755-nm and still
less at 595-nm.
Hemangioma
the treatment of hemangiomas should be correlated to its natural biologic course and requires a different clinical approach
from a portwine stain.12 Hemangiomas are true tumours, not
malformations like portwine stains. they resemble the fetal
placenta and have cell mediated protection during their growth
phase from the host immune system. involution occurs when
this immune privilege disappears for unknown reasons, and
host cells and enzymes regulating cellular immunity induce
apoptosis within the hemangioma. laser treatment should trigger or assist immune mediated regression and should produce
focal injury in phase with the cellular biology. low fluences in
short pulses best achieves this response and liberates the cells
required for the immune process. it is a mistake to approach
treatment in the same way one treats a portwine stain. Pulsed
dye lasers were never designed to treat even a superficial
hemangioma containing clumps of tangled blood vessels.
these lesions are thicker than portwine stains and beyond the
effective depth for green or yellow light lasers. unlike portwine
stains where dilated small calibre vessels are dispersed within
intervening stroma, hemangiomas are tortuous masses of larger vessels with little or no connective tissue or stroma.
superficial lesions in the early growth stage can be cleared
completely by the flashlamp pulsed dye laser. Adverse effects
can occur, when lasers are used at the same levels as for treating portwine stains, particularly without cryogen cooling of the
epidermis. Our experience indicates that hemangiomas respond
better to yellow (595-nm) or near infra-red pulses (755-nm)at
low energy and short pulses. the PDl is very effective for an
ulcerated hemangioma. i avoid the use of the 1064-nm, which
can be risky even in experienced hands, given the delicate therapeutic balance. Propranolol may become the primary treatment for large complicated hemangiomas and lasers used only
in a supportive role. Aggressive laser therapy with any wavelength at higher fluences is imprudent and should be avoided.
Venous Lesions
Venous malformations can be carefully treated with the deeper
penetrating nd:YAG that reaches the deep components better
than 755-nm. interventional radiology with Bleomycin sclerotherapy is now considered as a primary approach and laser
therapy reserved for residual elements. Venous lakes respond
well to the 1064-nm nd:YAG in 1-3 treatments at 6-8 weeks
apart. the lower absorption in venous blood modulates the
effect of the deeply penetrating wavelength.
Telangiectasia
Fixed erythema and most telangiectasia require green or
yellow light lasers – normal mode 532-nm and 585 or 595-nm.
Although these small capillaries need only relatively short
pulses, purpura-free treatments with longer pulses can lessen
downtime. intense Pulse light (iPl) is a popular choice among
patients, as there is no swelling or bruising, but several treatments are required to achieve similar results as lasers. My personal preferences include:
• iPl for full-face, necks, chest, and hands – any body site, as
this lowers treatment costs and also removes freckles, actinic
dyschromia, lentigines. it is useful for maintenance therapy.
• 532-nm in normal mode for full-face or focal treatments have
erythema and swelling for 3 days but no bruising. it requires
fewer treatments than iPl – usually 2 or 3 – and is useful for
pediatric PWs, fixed erythema, and ulerythema oophryogenes.
• Pulsed dye 595-nm is better for severe cases and larger vessels, but is associated with purpura of smaller vessels for the
best efficacy – usually one treatment. longer pulse exposures
are purpura fee and useful for full-face treatments.
• large purple vessels e.g. on the nose are still best treated
with 595-nm for safety. Many clinicians are tempted to use
the 1064-nm nd:YAG but the Met-Hb effect complicates the
use of longer pulse durations required for a larger diameter
vessel. the greater absorption by HbO2 raises the spectre of
stenosing a feeder arterial vessel with scarring to a wider area
than the skin over the treated vessel. the 755-nm alexandrite
could be a safer choice, in theory, for a capillary with backflow venous contamination.
continued on page 6
5
continued from page 5
• Pyogenic granulomas respond poorly to vascular lasers and
are best removed with a CO2 laser. Avoid the temptation to
use the nd.YAG. Angiokeratomas are difficult to treat, but in
my opinion, the 755-nm alexandrite laser provides the best
option. the rare tufted angiomas does not respond to the PDl.
Summary
With the plethora of vascular laser systems available, the prudent physician learns to apply the principles outlined herein,
and selects a laser to treat a specific vascular abnormality by
matching emission parameters to the characteristics and morphology of the lesion.
6. Barton JK, Frangineas G, Pummer H, et al. Cooperative phenomena in twopulse, two-color laser photocoagulation of cutaneous blood vessels.
Photochem Photobiol 2001;73(6):642-650..
7. tanghetti e, et al. the effects of pulse dye laser double-pass treatment intervals on depth of vessel coagulation. lasers surg Med 2006; 38:16-21.
8. Rajaratnam R, laughlin sA, Dudley D. Pulsed dye laser double-pass treatment of patients with resistant capillary malformations. lasers Med sci.
2011 Apr 8. [epub ahead of print].
9. suthamjariya K, Farinelli WA, Koh W, Anderson RR. Mechanisms of
microvascular response to laser pulses. J invest Dermatol 2004;122:518-525.
10. Parlette eC, Groff WF, Kinshella MJ, et al. Optimal pulse durations for the
treatment of leg telangiectasias with a neodymium YAG laser. lasers surg
Med 2006;38:98-105.
References
11. Anderson RR. infant hemangiomas: A controversy worth solving. lasers
surg Med 2006;38:92-93.
1. Anderson RR, Parrish J. selective photothermolysis: precise microsurgery
by selective absorption of pulsed radiation. science 1983;220:524–527.
12. Van Gemert MJC, Welch AJ, Amin AP. is there an optimal laser treatment
for port wine stains. lasers surg
2. tan Ot, Carney JM, Margolis R, et al. Histologic responses of portwine
stains treated by argon, carbon dioxide and tunable dye lasers. Arch
Dermatol 1986;122:1016-1022.
13. Med 1986;6:76–83.
3. Altshuler GB, Anderson RR, Manstein D, et al. extended theory of
selective Photothermolysis. lasers surg Med 2001;29:416–432.
4. Barton JK, et al. Optical and magnetic resonance changes in photothermally
coagulating blood. Proceedings of sPie 2002;4609:10-19.
14. izikson l, nelson Js, Anderson RR. treatment of hypertrophic and resistant port wine stains with a 755 nm laser: a case series of 20 patients. lasers
in surg Med 2009;41:427–432.Y
15. Yang Mu, Yaroslavsky An, Farinelli WA, et al. long-pulsed neodymium:
yttrium-aluminum-garnet laser treatment for port-wine stains. J Am Acad
Dermatol 2005;52:480–490.
5. Kuenstner Jt, norris KH. spectrophotometry of human hemoglobin in the
near infrared region from 1000 to 2500 nm. near infrared spectrosc
1994;2:59-65.
Guest Editorial – Laser and Light Sources
Rédaction invité – Laser et sources de lumière
continued from page 3
suite de la page 3
dermatology audience. this is an exciting time for the technology savvy Dermatologist and more treatment options are
available for our patients. it is important for Dermatologists to
understand this field since other specialties, GP’s and estheticians are increasingly performing procedures and using technology on the skin. if this information piques your interest,
there are several experts in the laser field, across Canada.
du visage et le traitement au laser des mycoses des ongles
d’orteil.
6
Ce numéro du Bulletin de l’ACD vous présente quelques brefs
exposés au sujet du laser et de la technologie de la lumière à
l’intention des dermatologues en général. il s’agit d’une
époque exaltante pour les dermatologues spécialisés en technologie et un plus grand choix de traitements s’offre à nos
patients. les dermatologues doivent bien comprendre ce
domaine puisque, de plus en plus, d’autres spécialités, les
omnipraticiens et les esthéticiennes ont recours à la technologie pour effectuer des interventions sur la peau. si cette information pique votre curiosité, il existe plusieurs experts du laser
partout au Canada.
Photodynamic Therapy
Photodynamic therapy (PDt)
is a medical treatment used to
treat premalignant lesions
such as actinic keratoses and
Bowen’s disease, early-stage
cancers such as superficial
basal cell carcinomas, and
acne. the concept dates back
to 1913 when the German
physician Friedrich MeyerBetz performed the first studies on his own skin. PDt
requires 3 key components: a
MARtie GiDOn, MD,
photosensitizer that can be
toronto
excited by a specific wavelength of light, a light at a wavelength appropriate for the photosensitizer, and oxygen. internal organs may be treated with
intravenous photosensitizers and fibre optic catheters for the
light activation.
two photosensitizers are commonly used for skin, aminolevulinic acid HCl (AlA available as levulan® Kerastick®) and
methyl aminolevulinate HCl (MAl available as Metvix®). the
photosensitizer is applied to the affected area and kept on for 1
to 3 hours, depending on which chemical is used. Metabolically
active cells, such as precancerous, cancerous and sebaceous
cells, differentially take up the chemical. the AlA is converted by the cells to protoporphyrin iX, a photosensitizer. the
affected area is then exposed to a blue or red light for several
minutes to activate the photosensitizer. When the activated photosensitizer and an oxygen molecule are in contact, an energy
transfer takes place that creates an excited singlet state oxygen
radical which destroys the targeted cells. there is usually ery-
activated by the Blu-u® Blue light Photodynamic therapy
illuminator (DusA Pharmaceuticals), intense pulsed light or
pulsed dye laser. MAl (Galderma Canada) is applied as a
cream to similarly prepared skin, occluded for 3 hours to prevent light exposure, and then activated by the Aktilite Cl128
lamp or other red light source. some patients experience pain
during the light treatment and blowing cold air makes them
more comfortable. sunscreen is applied immediately after the
treatment but the patient is advised to avoid visible light as well
as ultraviolet light for the next 48 hours, to avoid excessive activation. After the treatment, patients may experience varying
degrees of discomfort or burning, which can be alleviated by
cold packs. Patients are warned about erythema, peeling and
possible crusting which may last 3 to 5 days. Actinic lesions
require 1 to 2 treatments, about 3 weeks apart. Acne patients
require a series of 5 treatments, 3 to 4 weeks apart. Both treatments provide an excellent cosmetic result.
Laser and Light-based Treatments for Acne
Acne can be a major concern for teens and many adults.
traditionally, we have treated acne with topical medications,
and/or systemic therapy, including antibiotics, hormonal
manipulation and isotretinoin. Alternative treatments with
lasers and light are becoming more attractive, especially with
patients wishing to avoid systemic medication. they can be
used as mono therapy, but are usually used together with topical medication, and oral antibiotics if needed. As the patient
improves, the systemic antibiotics can be discontinued.
P. acnes produces porphyrins, mainly coproporphyrin iii, in the
pilosebacous follicles and are potential targets for photodynamic therapy. On their own, visible blue light at a wavelength
of 405-420 nm and visible red light at 570-670 nm have been
shown to have anti-inflammatory
Comparison of ALA and MAL
effects on keratinocytes by decreasing the cytokine-induced production
Photosensitizer Indications and
Vehicle
Incubation Time Light Activation
Number of
Off-label use
Treatments
of il-1a and intracellular adhesion
molecule-1. Blue and red light also
AlA
AK’s
20%
1 hour
Blu-u 417 nm AK’s: 1-2
stimulate porphyrins to release sinAcne
hydroalcoholic no occlusion iPl, pulsed
Acne: 5
glet oxygen which destroys P. acnes.
solution
dye laser
this treatment can be helpful in mild
to moderate acne. there are no side
MAl
AK’s,
16% lipophilic
3 hours
Red light
AK’s,
effects, no downtime and bacterial
Bowen’s
cream
With occlusion 570-670 nm
Bowen’s,
resistance is unlikely. Blue or red
disease,
Aktilite
BCC’s: 1-2
light can be used once or twice a
superficial
634 nm
Acne: 3-5
week for 20 minutes for about 3
BCC’s, acne
months. Maintenance treatments can
thema and some peeling or crusting for 3 to 5 days. Basal cell
be done as needed. With the addition of a photosensitizing
carcinomas may require a second treatment 2 to 3 weeks later,
medication such as levulan® or Metvix® in moderate to
and acne usually requires a series of 5 treatments, 3 to 4 weeks
severe acne, more porphyrins are produced for a greater reducapart. it is mandatory to avoid bright light exposure for 48
tion in P. acnes, as well as shrinkage of the sebaceous glands,
hours after the treatment to avoid too intense a reaction.
decreased sebum production, and an increased turnover of epiAlA is applied to the skin after a vigorous acetone scrub to
dermal cells, thus unplugging the follicles. the skin is scrubbed
degrease the skin and remove any loose scales. the patient sits
well with acetone, the photosensitizing medication is applied,
in a darkened room for one hour and then the AlA is typically
left on the skin for 1 to 3 hours and then exposed to the light for
continued on page 8
7
Laser Safety
HOWAD BARGMAn, MD
toronto
the issue of laser safety is
often overlooked during the
mentoring and learning
process. At past AAD meetings that i have attended, in
spite of numerous laser presentations, there have been
times when none dealt with
the issue of laser safety. in all
the years that i have attended
the Women’s College laser
update, i only recall one 20
minute talk on laser safety.
About 5 years ago i realized
that our laser clinic at sunnybrook Health sciences Centre was
not as compliant with the standards that we should have been.
i undertook to educate myself and after taking a written exam,
qualified as a Certified Medical laser safety Officer (u.s.).
i performed laser safety audits of both hospital and private laser
settings and was surprised at the major deficiencies in these
clinics. Recently, at a south Beach seminar, there was a great
presentation, on screen, of various laser techniques, performed
live by luminaries. All the important laser innovations were
being displayed. this was all taking place in an auditorium
apart from the viewing audience. i noticed immediately that the
operators were wearing protective eye goggles, but their colleagues, and the patients who were waiting, were not, and they
were within feet of the working laser systems. if an accidental
eye injury had occurred, it would have been difficult to defend.
some of the many issues that laser safety addresses are: the
designation and educational requirements of the laser safety
officer where Class 111B and 1V lasers are used (every laser
clinic must have an lsO), credentialing of all staff, fire and
explosion hazards, door signs and locks, plume scavenging (i.e.
smoke evacuation)
Photodynamic Therapy
the Canadian safety standard (CsA) laser safety document, as
it stands now, is licensed from the American standard Ansi
Z163.3-2005. A new Ansi standard will be published by the
laser institute of America before the year end. the CsA is now
debating whether to establish a new ‘made-in-Canada’ laser
safety version which it last did in 1992. if they do, it will be
quite stringent in its recommendations for training and documentation, among many other issues. there are now a couple
of states in the u.s. that will not accept laser training from a
company that sells lasers and this requirement will likely be
copied here in Canada.
Plume scavenging (i.e., smoke evacuation) standards have been
published by the CsA and have become the world standard for
the last couple of years. You should know that any facility that
performs a procedure that produces a plume is obligated to
operate within the parameters set out by this standard. this
includes dermatology suites where cautery is performed.
i remember one day a rabbi asked me if i was observant, and
after i swallowed hard, i answered that i was. He looked at me
and said “Well, we can all do better”. this advice pertains to
protecting our patients, ourselves and our employees from the
potential hazards of lasers.
i encourage questions and can be reached at my e-mail address
[email protected]
continued from page 7
10 to 15 minutes. Five treatments, 3 weeks apart are recommended. the patient must avoid light exposure for 48 hours and
usually experiences erythema, peeling and some crusting, lasting about 3 to 5 days.
isolaz photopneumatic therapy is helpful in mild to moderate
acne. it involves a pore cleansing vacuum that empties debris
from the follicles and then pulses a broadband light. lasers at
1450 nm heat the sebaceous glands causing some destruction
and decreased sebum production, but since they do cause
discomfort, they are not often used for acne.
Once acne scarring has occurred, fairly aggressive treatment
is needed for improvement of the scars. Fractional laser treat-
8
and other strategies for protecting from laser generated airborne contaminants, laser maintenance logs, standard operating
protocols, proper goggles for the laser room, and for outside the
room (this seems to be very important for the Ministry of
Health in Ontario), storage of the laser key when the laser is not
in use, laser type and wavelength signs, warning signs and
labels (warning signs must be removed or turned around when
the laser is not in use), room designs and risks of specular
reflection hazards, development of protocols for laser incidents
and reports thereof, and infection control.
ments are much more popular than the old traditional surgical
dermabrasion or CO2 resurfacing since there is less recovery
time, more predictable results and much less chance of side
effects such as white scars and persistent erythema. Depending
on the patient’s skin type, non-ablative fractional resurfacing
with a few days’ downtime, or ablative fractional CO2 resurfacing with a week’s downtime can be used successfully. three
to 5 treatments, performed 1 to 3 months apart, usually result in
at least a 50% improvement of the scars and additional treatments can be done if desired.
The Laser in Pediatric Dermatology 2011
Pulsed Dye Laser: Cynosure 585 nm, 0.5-40 msec, 7 or 10 mm; cooling device
Vascular Malformations: Port Wine stain, capillarovenous : Angiokeratoma, verrucous hemangioma
Hemangioma: Residual, ulcerated
spider Angioma
Pyogenic Granuloma
Hypertrophic scars, striae
early Angiofibroma
erythematous lesions as seen in Connective tissue Disease, Keratosis Pilaris, Goltz syndrome
CAtHeRine MCCuAiG, MD
université de Montréal
Verrucae, Mollusca
We have had the pulsed dye laser at the CHuMe sainte Justine,
Montreal, Quebec since 1992, and it is an integral part of our
multispecialty vascular anomalies team.1 Port wine stains are
best treated beginning in the first year of life, and will require
at least 6 treatments in most cases, followed by annual followup with laser as needed. Most patients are significantly
improved after 3 sessions, but seldom clear completely.
Centrofacial and distal portion of the extremities respond less.
We offer general anesthesia primarily using propofol in an
operating room set up in our dermatology unit, and local anesthesia, with topical lidocaine under occlusion (with strict observance for dose/ weight), ibuprofen, codeine, and or midazolam.
Recent studies suggest the use of topical angiogenesis
inhibitors such as imiquimod and rapamycin may counteract
angiogenesis in the post PDl phase.1 A corrective make-up
session is offered at the hospital for certain recalcitrant cases.
Various combination therapies are being proposed for more
resistant PWs, including intense pulsed light, photodynamic
therapy, the 800 diode laser, 2 and most promising is the 755
alexandrite laser.3
treatment of hemangioma with PDl is limited to residual
telangiectasia, or actively ulcerating hemangioma with a clean
granulation base. Although studies suggest its utility in early
superficial hemangioma( it can leave hyper or hypopigmentation 4, 14% respectively) 4, simple observance or topical timolol are best in our experience, and no treatment prevents the
deeper component form appearing. the 1064nm nd-YAG laser
has been used primarily in europe for hemangioma and vascular malformations.
spider angioma usually clear after a single treatment, and only
small pyogenic granuloma <3 mm are amenable to 1–3 treatments with the PDl (Differential diagnosis spitz nevus and
amelanotic melanoma). Hypertrophic scars that are still erythematous respond well to 1–3 treatments. early bright red
angiofibroma in tuberous sclerosus respond well to PDl.
We treat warts primarily with cryotherapy, keratolytics, 5-fluorouracil , bleomycin, immunotherapy, and imiquimod, but the
PDl can be useful with total clearance varying from 48-75%
average,5,6 although the PDl is painful as high fluencies must
be used. studies have also demonstrated use of the PDl
in mollusca, however we prefer cantharone, curettage, and
imiquimod.
CO2 laser (ultrapulse, 10,600 nm)
epidermal nevi
Keloids
Angiofibroma in tuberous sclerosus
lymphangioma
Verrucae
the CO2 laser is used with general anesthetic for the treatment
of large epidermal nevi with remarkable success. Keloids are
excised, followed by CO2 laser at the base, intraoperative
triamcinolone acetonide injection of 20 mg/cc, with strict
follow-up including compression, intralesional corticosteroid,
and silicone dressings with minimal recurrence.7 in tuberous
sclerosus, angiofibroma with a fibrous component respond
well. non-resectable lymphangioma with a superficial component improve at least temporarily. the CO2 laser is rarely used
now for warts, due to significant post-operative pain, scarring,
and potential recurrence.
Q-switched Nd:YAG 532nm, Q-switched alexandrite755nm,
Q-switched ruby 694nm
nevus of Ota
Congenital melanocytic nevus
Mongolian spots
Pigmented lesions that can be treated by laser include nevus
of Ota, congenital melanocytic nevus, Mongolian spots.1
Q-switched nd:YAG, 532nm appears to be superior to
Q-switched ruby 694 nm, Q-switched Alexandrite 755 nm, but
all can be used and clear nevus of Ota very well. Congenital
melanocytic nevus may improve cosmetically, but tends to
repigment with time, and must be surveyed for possible
melanoma. surprisingly Mongolian spots have also been treated with these lasers, however given they spontaneously fade
with time, it would be rarely necessary. Café au lait spots have
been notoriously refractory to laser, as Becker’s nevus. the
continued on page 11
9
Non-invasive Body Contouring: What’s the skinny on fat in 2011?
JAsOn K RiVeRs, MD
Vancouver
north Americans boast the
dubious distinction of being
one of the most overweight
people in the world. indeed,
23% of adult Canadians are
considered obese based on
a body mass index (BMi) of
greater than 30, while a further 36% are considered overweight (BMi 25 -29.9). this
is a growing problem and represents a target market for
several companies that have
expanded into this arena.
the pursuit for non-invasive modalities to reduce body fat is
not a new ideology. indeed, in the 1960’s mechanized belt driven devices existed to help jiggle away body fat. similar devices
were on display at the annual meeting of the American society
of Dermatologic surgery in 2010.
in Canada there are several devices currently Health Protection
Branch approved for non-invasive body contouring. some
of the more recent of these include focused ultrasound
(ultrashape Contour 1), high intensity focused ultrasound,
HiFu (liposonix), cryolipolysis (Zeltiq) and most recently
low level laser at 635 nm (Zerona). Although there have been
scientific publications to support the use of each of these
devices, the current evidence is that clinical responses can be
quite variable. in this author’s opinion, these devices need to be
used in conjunction with diet and exercise to maximize the
improvement. Approximately 80-85% of patients will be satisfied with the treatment. Why some patients do not respond is
unclear at this time.
Patient selection is critical to optimize the results. those who
have a BMi of less than 25 would be considered ideal candidates if they have small pockets of residual subcutaneous fat
around the central abdominal region or flanks (saddlebags).
the subcutaneous fat should be loose and easily pinched
between the fingers. Mesenteric fat is not appropriate for treatment as the devices will not penetrate to this level.
One of the main problems in substantiating the benefits of these
devices lies in the fact that it is very difficult to accurately
measure changes in waist circumference ( a common end point
used in clinical trials). For example, significant differences can
be obtained on the same day depending on whether the patient
has voided or emptied their bowels prior to measurements, if
the measuring tape is not held at the exact location with the
same tension, and if the patient alters their standing posture.
Photographic documentation is difficult to duplicate between
sessions – even with a dedicated system. subtle changes in posture and distance from the camera can create an illusion of a
clinical response. Perhaps the best way to determine efficacy is
to have the patient retain a pair of pants that they can wear
before and after the treatment ( weeks to months later). it is
important that the article of clothing not be washed during this
time frame.
ultrashape incorporates a 0.2 MHz low intensity fixed depth
focused ultrasound delivered through a transducer to create
non-thermal disruption of subcutaneous fat. three treatments at
2 week intervals is the general recommendation. the reported
reduction in waist circumference ranges from a remarkable 6.0
cm to a more modest 3.5 cm as presented in more recent studies. However in one report, no response to treatment was seen
in 53 Asian patients. At present the parent company is totally
revamping their device so as to incorporate radiofrequency,
vacuum assist and a transducer that can focus the ultrasound at
different levels within the subcutaneous tissue.
the liposonix system utilizes a 2 MHz high intensity variable
depth and variable fluence focused ultrasound to produce thermal coagulation of the targeted subcutaneous adipose tissue, at
the predicted locations and depths without damage to surrounding tissue including the skin and fascia. At present one
treatment session is recommended, and on average, patients
can lose 2.0 cm off their waist circumference as measured 8 to
12 weeks post treatment.
Cryolipolysis is based on the principle of cold or “popsicle”
panniculitis. the Zeltiq treatment device requires no technicians to deliver the treatment but a dedicated room is needed
for the session, each of which requires 1 to 2 hours of time. the
target area is identified and suction applied between two chilling plates that lower the skin temperature to close to freezing.
like the other treatments mentioned thus far, clinical improvement occurs over two or three months. in clinical trials a 20%
sustained reduction in fat as measured by diagnostic ultrasound
and clinical improvement has been observed. Multiple treatments with the cryolipolysis device apparently can cause a
cumulative effect.
the most recent addition to this stable is photobiomodulation
by means of a low energy 635 nm diode laser by Zerona.
Patients expose their front and back treatment area to the laser
for 20 minutes per side. treatments occur every 48 hours for a
total of six treatments. Of note, patients need to abstain from
alcohol, exercise 30 minutes a day, and to drink 2 litres of water
daily. significant combined loss (as measured over several
body sites) has been reported in the astounding range of 17.5
cm. it has been speculated that the laser creates the formation
of transitory pores in the adipose cell membranes followed by
the collapse of these cells. Critics have suggested that the science behind this data may be flawed and further follow up
(beyond two weeks) is mandatory in order to confirm whether
or not this is a transient event perhaps related to the high
volume of water intake (which has an effect on leptin).
Although adverse events from these devices are uncommon,
they may happen. in Asian patients, it has been reported that
skin ulceration can develop over bony prominences after treatment with low frequency focused ultrasound. HiFu treatment
often causes pain during therapy, while temporary bruising,
continued on page 11
10
The Laser in Pediatric Dermatology 2011
continued from page 9
latter may lighten with the 1550nm wavelength erbium-doped
fiber laser (Fraxel).1
treatment of hypertrichosis with the laser is generally not recommended until after the age of 18 years, due to the likelihood
of recurrence.
308-nm excimer laser
Vitiligo
Alopecia Areata
Psoriasis
the 308-nm excimer laser can repigment at least 50% of depigmented patches, particularly of the face, neck and trunk.8
improvement can be achieved by adding topical calcineurin
inhibitors.9 Recently the eximer laser was also shown to be
effective in alopecia areata, used twice a week for a period
of 12 weeks inducing hair regrowth in 60% which was sustained in the majority.10 the 308-nm excimer laser had induced
significant improvement in psoriasis in 60% of patients after
an average of 17 sessions in a study that included some
children.11
in summary, the laser is a useful therapeutic tool in pediatric
dermatology, and we use it primarily in the treatment of vascular lesions, scars including keloids, epidermal nevi and resistant verrucae. nevus of Ota can be removed dramatically by a
Q-switched laser. the excimer laser holds promise for select
limited areas of vitiligo, alopecia areata, and psoriasis.
Non-invasive Body Contouring
References
1. Cordisco MR. An update on lasers in children. Curr Opin Pediatr.
2009;21(4):499-504.
2. Whang KK, Byun JY, Kim sH. A dual-wavelength approach with 585-nm
pulsed-dye laser and 800-nm diode laser for treatment-resistant port-wine
stains. Clin exp Dermatol. 2009 ;34(7):e436-7.
3. izikson l, nelson Js, Anderson RR. treatment of hypertrophic and resistant port wine stains with a 755 nm laser: a case series of 20 patients.
lasers surg Med. 2009;41(6):427-32.
4. Rizzo C. Outcomes of childhood hemangiomas treated with the pulsed-dye
laser with dynamic cooling: a retrospective chart analysis. Dermatol surg.
2009;35(12):1947-54
5. sethuraman G. Richards KA, Hiremagalore Rn, Wagner A. effectiveness
of pulsed dye laser in the treatment of recalcitrant warts in children.
Dermatol surg. 2010;36(1):58-65.
6. Park Hs, Choi Ws. Pulsed dye laser treatment for viral warts: a study of
120 patients. J Dermatol. 2008;35(8):491-8.
7. Cassuto DA. J Cosmet laser ther. 2010 Feb;12(1):32-7. treatment of
hypertrophic scars and keloids with an lBO laser (532 nm) and silicone
gel sheeting.
8. Cho s, et al. the 308-nm excimer laser: a promising device for the treatment of childhood vitiligo. Photodermatol Photoimmunol
Photomed.2011;27(1):24-9.
9. Patel n, O'Haver J, Hansen RC. Vitiligo therapy in children: a case for
considering excimer laser treatment. Clin Pediatr (Phila). 2010
sep;49(9):823-9.
10. Al-Mutairi n. 308-nm excimer laser for the treatment of alopecia areata
in children. Pediatr Dermatol. 2009 sep-Oct;26(5):547-50.
11. Hadi sM, Al-Quran H, de sá earp AP, Hadi As, lebwohl M. the use of
the 308-nm excimer laser for the treatment of psoriasis. Photomed laser
surg. 2010;28(5):693-5.
continued from page 10
edema, and prolonged tenderness (the latter measured in
weeks) can develop after this procedure. Cryolipolysis may
induce discomfort during treatment, followed by numbness,
bruising and soreness. severe pain developing during treatment
and lasting for several weeks thereafter has been reported. in at
least one case, cryolipolysis resulted in a significant panniculitis that required the administration of systemic steroids.
in summary, fat busting without cutting is the new frontier
and the foie gras of those seeking midriff reduction. However,
the science of non-invasive body contouring is still in its
infancy. therefore, both patients and physicians alike should
be aware of the limitations inherent with this evolving field
before embarking on the journey to find the perfect abdominal
six pack.
11
Laser Complications
there are many potential laser complications. eye injuries are particularly serious and, like needle stick
injuries, everyone knows they need
to be careful but accidents still happen. the correct goggles for each
laser need to be well marked, so that
students or less experienced employees don’t think they can carry goggles from room to room. Busy physicians who already wear glasses, and
Anne CuRtis, MD,
perhaps have a syris light on as well,
toronto
have been known to forget to put on
laser goggles. lasers which can be set to different wavelengths
require particular attention, if you might have to change goggles in the middle of a procedure. Family members in the room
need an explanation for why they mustn’t take off their goggles
during a procedure. Patient safety must be protected, particularly with longer wavelength lasers which penetrate more
deeply. the laser must be angled away from the eye as even eye
shields only protect the front of the eye. Avoid treating within
the orbital rim, especially with the longer wavelength lasers.
Reflecting surfaces in the room must be avoided, since goggles
are designed to protect from sidelong exposure to the laser
beam, not from a beam pointed straight at you.
laser burns occur when the fluence is too high for one of multiple reasons. tanned patients are more likely to burn.
sometimes a patient has been treated several times before, and
as the fluence is progressively increased, eventually the burn
threshold is crossed. Patients may have been more careful with
cooling initially, and then done less cooling with a later treatment because they had had no problem before. For lasers where
the pulse duration can be adjusted, remember that shortening
the pulse duration constitutes making the treatment more
aggressive.
Post-inflammatory hyperpigmentation is very unwelcome
when a procedure is being done for cosmetic improvement.
Darker skinned patients, and patients with melasma are particularly prone to this. With fractional lasers it is more often the
density (treatment level) rather than the fluence that causes
problems. With intense pulsed light, sometimes a melasma
patient is encouraged by the first couple of treatments when
they see improvement, then discouraged when they seem to
plateau. it is dangerous to increase the fluence too much at this
stage, as the resulting post-inflammatory hyperpigmentation
can leave the patient darker than they started, though the extra
pigment may resolve with time and with bleaching creams. sun
avoidance for 3 to 4 weeks after laser treatments is particularly
critical. Most patients aren’t sufficiently conscientious with
sunscreens to expect that they can carry on with a lot of outdoor
activity and rely on the sunscreen to protect them. if they don’t
want to avoid sun exposure their treatment can be scheduled at
a less sunny time of year.
12
Post-inflammatory hypopigmentation was particularly a
problem with resurfacing lasers, but also occurs after burns.
Fortunately the burn related ones often repigment eventually.
Patients with actinic bronzing treated with intense pulsed light
may get streaks of hypopigmentation, which are in fact areas
that have now returned to the base level of pigmentation (as
seen on the ventral forearm) but which don’t match the bronzed
skin. this is a patient selection issue- some patients are not
suitable for treatment. Vitiligo can be triggered by laser treatments, and of course can appear on its own in new areas
so you can’t be certain if the laser was really responsible.
Any prospective patient with vitiligo needs to clearly understand this.
laser hair removal is known to carry a risk of paradoxical stimulation of hair growth. this is more common in Mediterranean
and east indian skin types. Frequently the hair appears at the
margins of the treated areas, and it is thought that fluences too
low to destroy follicles are the ones that can stimulate them.
the treatment is more laser at higher fluence.
A less common but very difficult to manage complication of
Q switched laser treatments is the appearance of blue grey
marks in patients who have previously received systemic gold
treatments. it is wise to specifically ask all patients who will be
treated with a Q switched laser if they ever received gold in
their life. You can put it on the information sheet for patients
and the consent form, but the patient may skim over that. the
marks may lighten with more Q switched laser treatment, but
you tend to see a widening circle where you are clearing the
center but continuing to produce new blue discoloration at the
edges. A related and more common phenomenon is a colour
change in cosmetic tattoos from red, pink or flesh coloured to
black if the original tattoo pigment contained iron. Again, theoretically you may be able to clear the black with multiple
more Q switched laser treatments, but many physicians prefer
not to use laser if they will then have black to remove. A test
spot can be done to see if the tattoo changes colour, but the
patient needs to have the whole situation explained in advance
as the black dot may have to be removed surgically.
there is a possibility of reactivation of the herpes simplex virus
any time treatments are done around the mouth. Viral prophylaxis is often recommended, especially for resurfacing procedures, usually starting the day before the procedure and carrying on for at least a few days after, depending on the anticipated healing time. Bacterial and yeast infections are also possible
in healing wounds, and the physician wants to maintain a high
index of suspicion, and treat at the first sign of a problem.
Knowledge of laser complications, how to avoid them and how
to treat them, is part of doing laser treatments. in the “Buyer
Beware” world of lasers operated in non-medical facilities,
your expertise in this area is one of the things that makes
patients value treatments provided by a dermatologist.
Lasers – to Fractionate … or not to Fractionate
traditional ablative CO2 laser
facial resurfacing was the gold
standard for many years in
wrinkle eradication but led
to a high percentage of complications such as prolonged healing, erythema and delayed,
permanent whitening. in 2004,
two decades after the original
concept of selective photothermolysis was developed by Drs
Anderson and Parish, “fractional photothermolysis,” the
MARK luPin, MD,
concept of treating microscopVictoria
ic fractions of the skin was presented. the first fractionated laser developed on this premise
was the Fraxel laser. in Canada, the Fraxel laser was approved
in 2005. As the first physician with this laser in Canada and
with prior experience in traditional fully ablative CO2 laser
resurfacing, it has been interesting to understand and watch the
evolution of fractionated devices.
the fractionated concept refers to a pixelated effect of multiple
small ablative and/or coagulative zones (i.e. microthermal
zones – MtZs). the theory is that there should be more rapid
skin healing and hence enhanced safety and lesser downtime. A
simplistic notion of skin healing is to consider that re-epithelialization comes from two stem cell populations: epidermal
stem cells and adnexal stem cells. Of these populations, the
adnexal stem cells are most important and we know that
because we have not been able to perform complete ablative
resurfacing off of the face where there is greater inter-adnexal
distance.
The Promise of fractionated lasers was perhaps to supplant the
need for heavy CO2 resurfacing and to allow speedier recoveries and with ability to treat off of the face. While it is true that
assertive CO2 resurfacing is of a bygone era, fractionated lasers
so far have not been able to erase wrinkles to the same extent –
so in this respect, we perhaps miss our old CO2 lasers.
However, wrinkle eradication is no longer the mantra – wrinkle
softening is more reasonable – but this requires managing
patients’ expectations as newer systems are actually less effective at wrinkle management.
Horizontal vs Vertical: Fractionated lasers initially reoriented
treatments from a complete horizontal skin approach to vertical
columns – like aerating your lawn rather than stripping and
reseeding. traditional CO2 laser resurfacing created its effect
through a combination of ablation and coagulation to depths of
approx. 100 and 300 microns respectively. in contrast, the
Fraxel laser coagulates to depths of up to 1500 microns.
initially, it was thought that deeper might be better which would
favour the vertical approach. However, fractionated ablative
lasers such as sciton’s erbium Profractional and fractionated
CO2 lasers like Fraxel re:pair or Deep FX have generally been
less effective on wrinkle removal when compared to fully ablative lasers. Where deeper is better is in treatment of scars.
Ablative vs Non-ablative: the first fractionated lasers were
non-ablative such as the Fraxel laser and Palomar’s lux 1540.
these were shortly followed by fractionated ablative lasers in
part because it was found that the non-ablative lasers were not
very effective for rhytides. Although the move to fractionated
ablative lasers shortened overall healing time compared to traditional fully ablative resurfacing, the initial healing period paradoxically looked worse than traditional CO2 resurfacing
because of greater swelling and sanguineous crust as a result of
insufficient coagulation.
Direct vs Indirect Effects: As with superficial erbium peels,
where treating the epidermis alone causes indirect dermal
remodeling without heating (an indirect biologic vertical
effect), there is also an indirect horizontal effect with fractionated resurfacing, whereby a true side benefit is often noted in
the overall appearance of the skin when only treating a fraction.
Energy and Density: there is an ever increasing number of
systems marketed both for fractionated ablative and non-ablative treatments. it should be kept in mind that they are not
equal. there is a difference in the ratio of ablation and coagulation of the various CO2 lasers, differences in the spot sizes
and differences in how deep they are able to treat. For example,
the Deka smartXide DOt laser is an excellent laser but is primarily a superficial fractionated CO2 laser whereas the Fraxel
re:pair and ultrapulse Deep FX are able to treat more deeply.
Spot size: i define fractionated laser treatments with spot sizes
less than 250 microns as “microfractionated,” and those with
spot sizes greater than 250 microns as “macrofractionated,” as
the larger spot sizes are easily visible to the naked eye. some
systems have fixed spot sizes and some have variable spot
sizes. the range is 135-600 microns depending on the system.
the choice of spot size depends naturally on what you are treating. For flat epidermal lesions such as lentigines and actinic keratoses, larger spot sizes and superficial depths would be ideal.
To Roll or to Stamp: the two principal methods for application of fractionated laser light to the skin are to use a stamp type
device (where the laser beam is “split” into an array of smaller
beams or the light is scanned) or to employ a rolling applicator
where a linear scanner is employed (e.g. Fraxel). Where this
becomes especially relevant is with ablative systems using high
energy and high density settings; the room for error is low and
a rolling scanner system would theoretically be better as it
should provide more even coverage. An analogy is to consider
the effect of painting a wall – if you want it to look smooth and
even, would you use a sponge … or a roller?
Shallow vs Deep: As regards the face, consider that there is
variation in the natural thickness of the epidermis and dermis
according to the region. As a rough guide, the epidermal thickness for the eyelid is approx. 50 microns compared to the face
which is approx. 100 microns. the dermal thickness for the
eyelid is approx. 300 microns versus the remainder of the face
of about 600 microns. And the upper lip, where there is
often the greatest concentration of rhytides, appears to have the
greatest thickness and will tend to need more assertive
continued on page 14
13
continued on page 13
treatments. shallow depths can be achieved either with systems
with shallow wavelengths such as the 1927 thulium fibre laser
on the Fraxel DuAl or with use of lower energy settings.
separate full face treatment sessions is also a consideration.
Patients’ tolerances for downtime will often dictate the best
treatment path for each individual.
Is Deeper Better? the short answer, it seems, is generally
“no.” the exception, as i have noted, is when treating deep
scars. Histologically, rhytides are scars and can be both flexible
and non-flexible which relates to how we choose to treat.
So What?
let’s consider a few common conditions and as far as fractionated devices are concerned, what we would choose as the most
effective tool:
Conditions that have benefitted the most: While we have yet
to hit the homerun, fractionated lasers have helped enormously
in treatment of melasma and scars. they have opened up a new
world of non-facial treatments such as actinically damaged
areas of the neck, chest, arms and hands.
Limitations: As with any treatment, it is important to remember that fractionated lasers are but one tool and should not be
expected to “fix” everything. A common example, i find, is
with regard to lip treatments where restoring lost volume with
dermal fillers is often just as important if not more important
than laser resurfacing alone and where the two treatments go
hand in hand for best results.
Combination Treatments:
Following are common combination treatments that i have
found truly synergistic. they are from personal experience and
not meant as a recommendation or as a substitute for good
judgement:
Fractionated non-ablative + Q switched laser or cryotherapy lentigines
electrocautery or CO2 laser 0.2mm spot treatment +
Fractionated ablative - sebaceous hyperplasia
Fractionated non-ablative (face)+ Fractionated ablative (periorbital and perioral)
Fractionated ablative lite (low energy, low density) x 2 + dermal filler revolumization - acne scars
CO2 laser 0.2mm spot + Fractionated non-ablative - fixed deep
atrophic acne scars
Fractionated ablative + photodynamic therapy +/- cryotherapy
– actinic keratoses
Vascular laser or iPl phototherapy + Fractionated non-ablative
or ablative – traumatic or surgical scars
What not to combine?
neuromodulators such as Botox Cosmetic® work well in combination with most other cosmetic procedures but should not be
performed on the same day and in the same facial region as
fractionated lasers because of the possibility of spread of the
neuromodulator beyond its normal radius of diffusion. ideally,
neuromodulators should be performed a week or two prior to
laser treatments.
Back to the Future: the paradigm shift for laser resurfacing
of rhytides from complete ablation to fractionated non-ablative
to fractionated ablative treatments is now swinging back towards
either a series of fractionated ablative treatments, realizing that one
is not enough, or consideration for a fully ablative erbium rather
than CO2 laser treatment for better risk:benefit ratio. Mixing
and matching the technologies with combination fractionated
non-ablative and ablative for different facial regions or as
14
Condition
Type
Depth
Spot size
# of
treatments
Lentigines
nonablative
nonablative
nonablative
ablative
superficial
macro
3
superficial
macro
3
superficialdeep
superficialdeep
micro/
macro
micro/
macro
6-8
Actinic
keratosis
Acne scars
Rhytides/
Elastosis
3
In summary, fractionated lasers have revolutionized our ability to treat conditions like scars and melasma, and liberated us
to be able to treat non-facial conditions such as Poikiloderma
of Civatte. there has been great progress towards improved
safety and reduced downtime. More work needs to be done for
conditions like disseminated superficial actinic porokeratosis
and striae as well as optimizing treatments for melasma. there
is exciting work looking at enhanced topical drug delivery in
conjunction with fractionated laser resurfacing and the fractionated concept has spilled over into other technologies such
as radiofrequency devices and high intensity ultrasound.
Fractionated lasers are here to stay and have significantly added
to our treatment palette which ultimately benefits our patients.
References
Bernstein lJ, Kauvar An, Grossman MC, Geronemus RG. the shortand long-term side effects of carbon dioxide laser resurfacing. Dermatolog
surg 1997;23:519-525
Anderson R, Parish J. selective photothermolysis: Precise microsurgery
by selective absorption of pulsed radiation. science 1983;220:524
Manstein D, Herron Gs, sink RK, Anderson. Fractional photothermolysis:
A new concept for cutaneous remodeling using microscopic patterns of
thermal injury. lasers surg Med 2004;34(5):426-438
Allemann i, Kaufman J. Fractional photothermolysis-an update. lasers
Med sci 2010;25:137-144
laubach H, tannous Z, Anderson R, et al. skin responses to fractional
photothermolysis. lasers surg Med 2006;38:142-149
Kligman AM, Zheng P, lavker RM. the anatomy and pathogenesis of
wrinkles. Br J Dermatol 1985;113(1):37-42
Alexiades-Armenakas, Dover Js, Arndt KA. the spectrum of laser skin
resurfacing: nonablative, fractional, and ablative laser resurfacing.
JAAD 2008;58(5):719-737
tierney eP, Hanke CW, Watkins l. treatment of lower eyelid rhytids and
laxity with ablative carbon-dioxide laser resurfacing: Case series and
review of the literature. JAAD 2011;64(4):730-740
Orringer Js, Rittie l, Hamilton t et al. intraepidermal erbium:YAG laser
resurfacing: impact on the dermal matrix. JAAD 2011;64(1):119-128
Haedersdal M, sakamoto FH, Farinelli WA, Doukas AG, tam J,
Anderson R. Fractional CO2 laser-Assisted Drug Delivery.
lasers surg Med 2010;42(2):113-122
President’s Column
Rubrique du président
As our annual meeting in edmonton approaches
it astonishes me that my Presidency is nearing its
end and that a year has passed. it has been a busy
and eventful year for me, and it has been a great
honour to serve as your president.
À l’approche de notre Congrès annuel à edmonton,
je constate avec stupéfaction que ma présidence tire
à sa fin et qu’une année s'est écoulée. J'ai vécu une
année chargée et remplie d'événements, et ce fut
pour moi un grand honneur d'être votre président.
Our new executive Director, Chantal Courchesne,
has transitioned nicely into her position, and head
office is running smoothly. A large number of
projects are now under way as we continue
to promote Canadian Dermatology and
Dermatologists.
notre nouvelle directeure générale, Chantal
Courchesne, a très bien vécu son arrivée en poste et
les activités du siège social se déroulent rondement. un grand nombre de projets sont maintenant
en cours, alors que nous continuons de faire la promotion de la dermatologie et des dermatologues
canadiens.
iAn lAnDells, MD,
st. John’s
Our annual sun Awareness program launches
this year with sun Awareness Week from June 6th - 12th, and
it focuses on safe Fun in the sun. there is a kids safe Fun in
the sun poster competition, with Provincial and national winners to be selected in 3 categories: Ages 5 and under, 6-8, and
9-12. Please mention this to your paediatric patients and to
your own children or grandchildren. there are fantastic prizes
to be won. the poster contest entry sheet and all the details are
available on our website at www.dermatology.ca/safefuninthesun/index.html. the deadline for entries is June 13th.
there will once again be skin cancer screening events across
the country during sun Awareness Week, and we will also be
conducting a screening at Parliament Hill in the fall, once
Parliament is in session. this has been very successful in the
past. i encourage all members to participate in their local
screenings. every year we detect skin malignancies in the public participants, and help to raise public awareness. it helps the
public and Canadian Dermatology, so get out there!
in the fall we will be initiating a new Hair and nails Awareness
Program. this is to raise public awareness of disorders of the
hair and nails, their impact on those who suffer from them, as
well as the fact that dermatologists are the medical experts who
help to deal with them. there will be web-based content available on the CDA website free of charge, a hair and nail
brochure for CDA members to distribute to their patients, as
well as media materials including statistics and facts about the
incidence and prevalence of hair and nail disorders.
We are also looking forward to launching our skin Health
Program, which will provide direction to patients on the best
ways to care for their skin. this will once again be accessible
through our website which is growing by leaps and bounds.
Please always mention dermatology.ca as the preferred site for
your patients to begin their inevitable online searches. Disease
specific information is available for them there.
there are also patient handouts for a variety of conditions
always available for your use on our web site, or you
may order materials from head office by emailing: [email protected] Over time i hope you will all use
our website on a daily basis and keep a link on your desktop at
all times.
continued on page 16
notre programme annuel de Prudence au soleil commence
cette année avec la semaine nationale de prudence au soleil,
qui aura lieu du 6 au 12 juin et qui aura pour thème « s’amuser
au soleil en toute sécurité ». nous organisons un concours
d'affiches pour les enfants sur le même thème. nous choisirons
des gagnants provinciaux et nationaux dans trois groupes
d’âge : 5 ans et moins, 6 à 8 ans et 9 à 12 ans. n’oubliez pas de
parler de ce concours à vos patients pédiatriques et à vos propres enfants et petits-enfants. il y a de merveilleux prix à gagner. On peut se procurer le formulaire de participation ainsi que
les détails du concours sur notre site web, à l’adresse www.
dermatology.ca/french/programs/sap/ausoleilensecurite/index.
html. la date limite de réception des envois est le 13 juin.
nous organiserons de nouveau des séances de dépistage du
cancer de la peau partout au pays dans le cadre de la semaine
nationale de prudence au soleil. nous procéderons également à
un dépistage sur la Colline parlementaire à l’automne, lorsque
les travaux reprendront à la Chambre des communes. Cet
événement a connu beaucoup de succès dans le passé.
J’encourage tous les membres à participer au dépistage dans
leur région. Chaque année, nous détectons des cancers de la
peau chez les participants du public et nous contribuons à
sensibiliser les gens. Ce type d’événement aide la population et
la dermatologie au Canada, alors participez !
nous présenterons à l’automne un nouveau programme de
sensibilisation aux maladies des cheveux et des ongles. Ce programme vise à sensibiliser les gens aux troubles des cheveux et
des ongles et à leurs conséquences pour les personnes atteintes,
ainsi qu’au fait que les dermatologues sont les experts médicaux qui peuvent aider les gens à faire face à ces problèmes.
nous offrirons gratuitement du contenu sur le site web de
l’ACD, un dépliant sur les cheveux et les ongles que les membres de l’ACD pourront distribuer à leurs patients, ainsi que
de la documentation à l’intention des médias, notamment des
statistiques et des faits sur l’incidence et la prévalence des
troubles des cheveux et de la peau.
nous sommes de plus impatients de lancer notre programme de
santé de la peau, qui orientera les patients sur les meilleures
façons de prendre soin de leur peau. encore une fois,
l’information sera accessible sur notre site web, qui grandit à
suite à la page 16
15
continued from page 15
suite de la page 15
When i first became Vice-President i spoke in my position
statement of my goal to see our website as the preferred destination for our patients as well as to create a virtual network by
which Canadian dermatologists could share and access information. this will become reality in the very near future, and
you will see at our Annual Meeting in edmonton how this will
be another benefit of CDA membership.
vue d’œil. Mentionnez toujours à vos patients de privilégier
d’abord le site web dermatologue.ca pour leurs inévitables
recherches en ligne. ils y trouveront des renseignements particuliers aux maladies de la peau.
As my term ends, i would like to highlight the outstanding
work being conducted by the team at our head office. they
have been a joy to work with, and i would like to thank them
all for their enthusiastic and superlative productivity. i have
had the pleasure of working with two exceptional executive
Directors, Chantal Courchesne, and before her, Michelle
Albagli, and the team of Caroline Herzberg, Professional
education and Programs Officer, Maura Hope, Corporate
Affairs and Membership Officer, Jennifer scott, Communications and Programs Officer, lisa Rainville, Project and
Administrative Assistant, and Andrea Van de tillaart. Financial
Officer. i would like to offer them all my sincere thanks for a
job well done.
Finally, i would like to thank you all, our members, for making
the CDA a great Association of medical professionals, colleagues, and friends. it has truly been a privilege to serve as
your president, and i hope you all consider volunteering in
some capacity. there are many committees that could use
your skills, and the work involved is not demanding, but is
extremely gratifying.
thank you again, and i look forward to seeing you all in
edmonton.
Vous trouverez aussi sur notre site web de la documentation
destinée aux patients au sujet de différentes maladies. Vous
pouvez de plus commander du matériel auprès du siège social
en écrivant à l’adresse:[email protected]
Avec le temps, j’espère que vous vous servirez tous de notre
site web quotidiennement et que vous conservez son hyperlien
sur votre bureau en tout temps.
lorsque je suis devenu vice-président, j’ai parlé, dans ma
déclaration, de mon objectif de voir notre site web devenir le
lieu de prédilection de nos patients et créer un réseau virtuel
au moyen duquel les dermatologues canadiens pourraient
échanger de l’information et y accéder. Cet objectif se concrétisera dans un avenir très rapproché, et vous serez à même de
constater, au Congrès général d’edmonton, dans quelle mesure
il s’agira d’un autre avantage d’être membre de l’ACD.
en cette fin de mandat, je désire souligner le travail remarquable effectué par l’équipe de notre siège social. Ce fut pour
moi un plaisir de travailler avec les membres de cette équipe, et
je désire remercier chacune d’entre elles pour leur productivité
enthousiaste et hors du commun. J’ai eu le plaisir de travailler
avec deux directeures générales d’exception, Chantal Courchesne
et Michelle Albagli avant elle, ainsi qu'avec l’équipe de Caroline
Herzberg, agente de l’éducation professionnelle et des programmes, Maura Hope, agente des affaires corporatives et de
l’adhésion, Jennifer scott, agente de communications et projets, lisa Rainville, adjointe administrative et de projets, et
Andrea Van de tillaart, agente des finances. Je les remercie
chaleureusement de leur excellent travail.
enfin, je veux remercier chacun et chacune d’entre vous, nos
membres, de faire de l’ACD une prestigieuse association de
professionnels du monde médical, de collègues et d’amis. Ce
fut un réel privilège d’être votre président, et j’espère que vous
envisagez tous de vous porter volontaire d’une façon ou d’une
autre au sein de l’Association. De nombreux comités pourraient profiter de vos compétences. le travail qu’on vous
demande n’est pas exigeant, mais extrêmement gratifiant.
encore une fois, merci. J’ai bien hâte de vous voir tous à
edmonton.
16
Treasurer's Report
Rapport du trésorier
As i write this treasurer's report on March 31,
2011, the 2010 financial statements are currently going through the audit process, to be completed by the end of April.
Au moment où je rédige ce rapport du trésorier, le
31 mars 2011, la vérification des états financiers de
2010 est en cours et sera terminée d’ici la fin avril.
le budget de 2010 prévoyait un déficit, mais selon
the 2010 budget predicted a deficit position, but
les données actuelles, l’ACD affiche un excédent
current figures place the CDA at a budget surbudgétaire d’environ 39 000,00 $ pour l’exercice
plus of approximately $39,000.00 for the 2010
2010. les cotisations annuelles, les frais d’inscripfiscal year. Greater then expected revenue was
tion au Congrès annuel et aux symposiums, le
generated from annual dues, Annual Conference
JCMs ainsi que les contrats du Programme
symposia and registrations, the JCMs, and
d’évaluation de la protection solaire ont permis
DAViD ZlOtY, MD,
sPeP contracts. On the expenses side the CDA
d’enregistrer des revenus supérieurs aux préviVancouver
came in under budget for the AAD meeting,
sions. Quant aux dépenses, il n’y a pas eu de
and our Annual Conference. A Board approved change to
dépassement du budget pour la réunion de l’AAD et pour notre
the Resident Grant Program was also successful in reducing
Congrès annuel. un changement au Programme de subvention
CDA costs.
pour les résidents approuvé par le Conseil a également contribué à réduire les coûts pour l’ACD.
looking at revenue trends over the last 5 years within the
CDA, one observes a relatively stable revenue stream. However
selon une analyse des tendances des revenus de l’ACD au
over the same 5 year period expenses have been increasing,
cours des cinq dernières années, ses sources de revenus sont
except during the 2010 fiscal year. i feel the 2010 year is
relativement stables. Cependant, au cours de cette même
the exception to the general trend of rising CDA costs. the
période, les dépenses ont augmenté, sauf au cours de l’exerciBoard is thus constantly analyzing expenses to ensure the
ce 2010. À mon avis, l’exercice financier de 2010 est la seule
membership is receiving maximum value. the Board is also
exception à la tendance généralisée de la hausse des coûts de
hopeful that the skin Health Program will become a new
l’ACD. le Conseil analyse donc constamment les dépenses
source of revenue to support CDA activities. Overall the CDA
afin de s’assurer que les membres de l’ACD obtiennent la
balance sheet to the end of December 2010 shows a stable asset
pleine valeur de leur adhésion. le Conseil espère aussi que le
base of $1,866,473.00.
Programme de santé de la peau générera des revenus pour
soutenir les activités de l’ACD. Dans l’ensemble, les actifs de
Further details of the 2010 fiscal year will be presented during
l’Association au bilan à la fin de décembre 2010 atteignaient
the treasurer's report At the Annual General Meeting in
1 866 473,00 $.
edmonton.
nous communiquerons plus de détails sur l’exercice financier
de 2010 à la lecture du rapport du trésorier lors de l’assemblée
générale annuelle à edmonton.
CDA Bulletin Editor’s Meeting,
Edmonton 2011
lOuis VOGel, Publisher, Montreal
Please note the meeting has been rescheduled to the following time:
Date:
time:
Room:
Wednesday, June 22nd
7:00 to 8:00 PM
salon 5 of the shaw Convention Centre
We invite you to RsVP your attendance to [email protected]
17
Secretary’s Report
Rapport de la secrétaire
the CDA would like to welcome its newest
members, Drs Jeffrey sugarman & linda
Rochette, and Dr steven Glassman as Associate
member.
l’ACD souhaite la bienvenue à ses tout nouveaux
membres, les Drs Jeffrey sugarman et linda
Rochette, ainsi qu’au Dr steven Glassman à titre de
membre associé.
the CDA has 584 members in Canada, and 84
outside of Canada for a total of 668. there are
120 residents who are members, one of the
largest groups in many years, so the future of our
profession and CDA is very bright. On a provincial level, Quebec dermatologists are the least
likely to be CDA members, followed by Ontario
dermatologists so there is still work to be done.
l’ACD compte 584 membres au Canada et 84
membres à l’étranger, pour un total de 668 membres. On compte 120 membres résidents, soit l’un
des plus grands groupes de cette catégorie depuis
de nombreuses années. l’avenir de notre profession et de l’ACD s’annonce prometteur. À l’échelle
BenJAMin BARAnKin,
provinciale, les dermatologues du Québec sont les
MD, toronto
moins enclins à devenir membres de l’ACD, suivis
des dermatologues de l’Ontario. nous avons donc encore beauWe encourage the CDA membership to invite your colleagues
coup de travail à faire de ce côté.
who are not yet members to become members, as our strength
as a profession is based on our unity and numbers.
nous encourageons les membres de l’ACD à inviter leurs collègues à devenir membres s’ils ne le sont pas déjà, puisque
looking forward to seeing everyone at the annual conference
notre profession puise sa force dans son unité et le nombre de
coming up soon in edmonton. it should be another memorable
ses membres.
CDA annual meeting, a great place to visit, terrific talks, and
ofcourse spectacular social functions.
J’ai très hâte de voir chacun d'entre vous au Congrès annuel
d'edmonton, qui approche à grands pas. il devrait s’agir d'un
see you there!
autre Congrès annuel de l'ACD mémorable : un bel endroit à
visiter, des discussions stimulantes et, bien entendu, des fonctions sociales spectaculaires. Au plaisir de vous y rencontrer !
New CDA Members / Nouveaux membres de l’ACD
the following new members have been accepted by the Board of Directors
les nouveaux membres suivants ont été acceptés par le Conseil d’administration
18
Dr linda Rochette
Québec, QC
Dr Jeffrey sugarman
santa Rosa, CA
Dr steven Glassman
Ottawa, On
Executive Director’s Report
i was truly delighted to experience my first faceto-face meetings with members of the Canadian
Dermatology Association at the American
Academy of Dermatology Annual Meeting in
new Orleans in February. it was a great introduction to the profession, and such a pleasure to meet
every one who attended so early in my tenure as
your new executive director. From a personal perspective, it is great to be working with the medical profession again, and i look forward to meeting many more of our members at our Annual
Meeting in edmonton (June 22-26, 2011).
Rapport du directeure générale
J’ai été vraiment ravie de ma première rencontre
en personne avec les membres de l’Association
canadienne de dermatologie à l’occasion du
congrès annuel de l’American Academy of
Dermatology à la nouvelle-Orléans, en février.
Ce fut une excellente façon d’apprendre à connaître la profession et un réel plaisir de rencontrer
tous les participants si tôt après être devenue votre
nouvelle directeure générale. D’un point de vue
personnel, je suis très heureuse de travailler à
nouveau auprès de la profession médicale et j’ai
hâte de vous rencontrer en plus grands nombres
encore à l’occasion de notre Congrès annuel à
edmonton (du 22 au 26 juin 2011).
While in new Orleans, President elect, Denise CHAntAl COuRCHesne
Ottawa
Wexler toured me through the impressive trade
show, and the dazzling array of dermatological products, cosÀ la nouvelle-Orléans, notre présidente désignée Denise
metics, impressive tools and specialized equipment. i now
Wexler a orienté ma tournée de l’exposition commerciale
know that next year i will have to be more strategic about packimpressionnante avec son éventail étourdissant de produits
ing my suitcase for my return home! speaking of strategy, i
dermatologiques et cosmétiques, d’instruments fascinants et de
look forward eagerly to working with the Board, with and for
matériel spécialisé. Je sais maintenant que l’an prochain je dois
all of you on our future strategic direction.
faire ma valise plus stratégiquement afin de prévoir le retour à
la maison ! et parlant de stratégie, j’ai très hâte de travailler
We are planning many new projects including the launch of
avec le Conseil d’administration, avec et pour vous tous et
the skin Health program for the fall. We are exploring harmotoutes, à la mise au point de notre future orientation stratégique.
nizing the recognition logo for skin Health with the sun
Protection evaluation Program. And we hope to better reflect
nous avons beaucoup de nouveaux projets en marche, y
changing times by adapting our communications tools to social
compris le lancement du Programme de santé de la peau, prévu
media formats. We will be revising and energizing our web site
pour cet automne. nous explorons aussi la possibilité
too. Watch for the unveiling of something new at our AGM
d’harmoniser le logo d’homologation pour le Programme de
in edmonton!
santé de la peau avec celui du Programme d’évaluation de la
protection solaire. et nous espérons mieux suivre l’évolution
i want to express my sincere thanks to Michelle Albagli. she
des temps en adaptant nos outils de communication aux forwas very generous with her time and freely shared much
mats des médias sociaux. nous entreprendrons aussi de revoir
valuable information and many insights that have helped get
et de dynamiser notre site web. ne manquez pas les nouveautés
me started at CDA. she built a hard working, effective, very
qui seront dévoilées à notre Congrès annuel à edmonton !
supportive team that works exceptionally well.
Je tiens à offrir mes remerciements les plus sincères à Michelle
they have helped to energize me, and i am very excited about
Albagli. elle a été très généreuse de son temps et n’a pas hésité
the work underway in your national Office. i am pleased to
à partager avec moi une foule de renseignements précieux et
have all the supports in place to advance the opportunity you
beaucoup d’informations qui m’ont aidée à démarrer à l’ACD.
have entrusted me with to help you to grow and strengthen
elle a mis en place une équipe très travaillante, efficace et
dermatology in Canada and beyond our borders.
dévouée qui fonctionne particulièrement bien.
i welcome your comments and thoughts…
les membres de l’équipe ont contribué à « m’énergiser » et je
suis très enthousiaste à la perspective du travail en cours à votre
bureau national. Je suis heureuse d’avoir tous les éléments en
place pour accomplir la tâche et faire avancer les dossiers que
vous m’avez confiés, afin de vous aider à favoriser la croissance
et le renforcement de la dermatologie au Canada et au-delà
nos frontières.
Je serais heureuse de recevoir vos commentaires et réflexions…
19
CDA 2011 Business Meetings Schedule – Edmonton
as at April 16, 2011
20
A Brief History of Dermatology in Edmonton, Alberta
Gilles J. lAuZOn, MD, Canmore
the early history of Dermatology in edmonton is exciting and
vibrant. the area’s first dermatologist, Dr Harold Orr (18891952), was an intense and colourful man who represented
dermatology honourably as President of the Canadian
Dermatological Association (1939), of the Alberta Medical
Association (1946-47) and of the Canadian Medical
Association (1952) 1. in the Army Medical Corps during World
War 1, he devised a dry heat chamber affectionately known as
the Orr Hut to rid clothing of lice and mites - thus alleviating
the misery associated with infestations at the front. Around
1920, following specialty training in london, he arrived in
edmonton to practice as the city’s first formally trained dermatologist and was appointed Director, Division of Dermatology,
university of Alberta. His dry heat chamber was modified to a
“steam box”, the use of which was extended to the hyperthermic therapy of syphilis in the 1920’s 2, during which time he
founded the Venereal Diseases Control Agency of Alberta
and practiced syphilology with abundant zeal. in 1933, so
impressed was he of the importance of mycology to medicine
and dermatology that he founded the Mycology unit of the
Alberta Provincial laboratory of Public Health (still in existence today). He was thereafter much involved in mycology
research and described in particular the striking variety of clinical zoophilic infections by Trichophyton menta-grophytes in
Alberta farmers: acute vesicular lesions on glabrous skin,
chronic scaly and sometimes vesicular lesions on feet and pustular, boggy, nodular lesions of the beard with hair infection3 .
His mycological research also impacted the classification of the
dermatophyte genus Microsporum, as accepted today.
Dr Harold Orr
Dr Paul Rentiers
in 1946, Dr Orr was joined by Dr Paul Rentiers who took over
the position of Director, Division of Dermatology, in 1952, at
the time of Dr Orr’s death. Dr Rentiers was President of the
Canadian Dermatology Association in 1966. A tireless clinician, Dr Rentiers dedicated himself to patient care in edmonton
until his retirement in 1975. He died in 2006, having lived
much of his retirement in the interior of British Columbia.
in 1954, Dr Rentiers had been joined by Dr isidore Hardin, an
Albertan who had completed his dermatology training in the
usA. He practiced a relentless daily clinical routine in
edmonton until 1987. the Faculty of Medicine at the
university of Alberta bestows a yearly award, the “Dr isidore
and Rebecca Hardin Prize in Dermatology”, to a medical
student who has shown proficiency in dermatology. Dr Hardin
died in Calgary in 2007.
Drs Jack Brown and noel Jampolsky, initiated their edmonton
practices in the 1960's and greatly enhanced the dermatologic
services available to the growing city. in 1975, upon Dr
Rentiers’ retirement, Dr Brown took over the position of
Divisional Director which he held until 1987. today, Drs
Brown and Jampolsky are retired in edmonton and Vancouver,
respectively.
the period 1970 to early 1980’s was to be a period of active
recruitment of clinical dermatologists to edmonton with the
arrivals of Drs Orest talpash, James Kulak, Janice liao,
Donald Groot, Bryson Rogers, eric schloss and Alfons Krol.
today, Dr talpash divides his retirement between edmonton,
Vancouver and saskatoon. sadly, Dr Kulak suffered an untimely death in 2006. All others from this cohort are still actively
practicing clinical dermatology.
in 1987, Dr Kowichi Jimbow was recruited from Japan to hold
an academic full-time position as the Director, Division of
Dermatology, university of Alberta. this marked the beginning
of the final maturation of the division. in 1988, as a result of Dr
Jimbow's efforts, the first three residents were admitted to the
newly accredited dermatology training program at the
university of Alberta – Drs naji tawfik, tom salopek and
Gilles lauzon. Dr Jimbow also set up and directed a large, well
supported and very active basic research laboratory investigating melanoma and melanocyte biology where many obtained
advanced graduate degrees (Msc, PhD). During Dr Jimbow's
tenure, Drs Barry lycka and Andrew lin (full-time academic)
started their clinical practices in 1990 and 1994, respectively.
Dr Jimbow returned to Japan in 1997 to Chair the Department
of Dermatology and Plastic surgery at the university of
sapporo. He was later appointed Dean of the Faculty of
Medicine at this same university. Presently Dr Jimbow is
retired but remains active in melanocytic research as a
Professor emeritus, university of sapporo, Japan.
Following Dr Jimbow’s departure, Dr Alfie Krol was appointed Director of the Division of Dermatology (1997-2001),
followed by Dr Gilles lauzon (2001-2007) and Dr tom
salopek (2007-present). Residency Program Directors have
included (sequentially) Drs Kowichi Jimbow, Gilles lauzon,
Andrew lin, Gordon searles and Jaggi Rao (present Program
Director). the year 2007 saw the arrival of Dr Alain Brassard
as a full-time academic dermatologist at the university of
Alberta.
continued on page 22
21
continued from page 21
Dr Jimbow in 1987 for a training program in this growing and
modern city.
Divisional group photo 1989: Front row left to right - Drs A. Krol (sitting on
wall), J. Brown, K. Jimbow, e. schloss & O. talpash. Back row left to right:
Drs t. salopek, R. Prokopetz, G. lauzon, n. tawfik, a laboratory researcher
and Dr D. sawyer (dermatopathologist).
the future of dermatology in edmonton appears bright and
dynamic with many young and enthusiastic dermatologists providing a wide range of medical, surgical and cosmetic services.
there is also much pride here in the fact that edmonton
dermatologists and graduates of the local program have
contributed competently both nationally and internationally to
dermatology in the realms of clinical practice, education,
research, administration and wide-ranging committee work.
thoughts of our local history bring to mind the fact that we
must acknowledge the contributions of our predecessors if we
are to understand and appreciate where we are today, and also
to give us clearer ideas about how to contribute to our society
in the future. to our many pioneers and early mentors named
above, we express our gratitude for preparing such fertile
grounds for local dermatology and for our own careers. For
edmonton, it has been a great privilege to be a part of the
history of Canadian dermatology and local dermatologists look
forward to a productive future within our professional dermatology community!
References
1 Can Med Assoc J 68: 185 Obit 1953
2 Personal communication, Dr J. Brown
3 Dowding Ae Can Med Assoc J 68: 386-387, 1953
Divisional group photo of laboratory and clinical personnel, 1994. Dr Jimbow
sits centrally in front row with Drs Brown, talpash, Krol and lauzon to the
right. Front row from left are Drs lin, salopek and schloss. Dr searles is
second from right in back row.
to April 2011, 29 dermatologists have been clinically trained in
the university of Alberta program and practice clinical dermatology in Canada, the united states, ireland and saudi Arabia.
the addendum lists all those who have graduated from this
division, and highlights* those still practicing in edmonton.
there are presently 20 dermatologists practicing in edmonton
and area, 12 of whom are graduates of the local training
program – surely an endorsement of the need appreciated by
Wine & Food Gems
naji tawfik
stewart Adams
Gordon searles*
Mohamed shokravi
thomas nakatsui*
Marlene Dytoc*
Ken Alanen
Joe Coffey
John elliott*
Melody Cheung-lee*
Gilles lauzon
nick Walsh
Daniel Chang
Aziz Al-sadhan
loretta Fiorillo*
Jaggi Rao
Muba taher*
sheilagh Maguiness
Michael Kalisiak
Andrei Metelitsa
tom salopek*
Adrian Gili
simon lee
norman Wasel*
Paul lubitz
*Ben Barankin
Chris Keeling*
Jay Coffey
Jeremy Man*
* practice clinical dermatology in edmonton as of April 2011
continued from back page
roots to concentrate the fruit, colour and tannin.
the tasting was conducted by André Côté, a professional sommelier and the General Manager of the university Club of
Montreal. their chef Alain Monod prepared a menu with a
22
Addendum: cumulative list of clinical graduates of the
Division of Dermatology, university of Alberta, as of April
2011
touch of Australia, i.e. spices, nuts. each wine was tasted, first
alone, then immediately with a specific food course. the
Hickinbotham and sandown Cabs were served together, as well
as the Brookman and Hickinbotham shiraz.
Canadian Dermatology Foundation News
Gilles J. lAuZOn, MD, secretary
CDF Secretary’s Report
Board of Directors for 2010-2011
Directors are elected at the annual membership meeting for
terms of three years. the 2010-2011 Board membership consists of the following, as approved by the membership at the
AGM of July 3, 2010:
Dr neil H. shear
President
Dr Gilles J. lauzon
secretary
Dr Kenneth A. Kobayashi
treasurer
Dr Harvey lui
Chair, scientific Advisory Committee
Dr Robert Bissonnette
Dr laura Finlayson
Mr. Richard J. MacKay
Dr Zohair tomi
Dr Jan Dutz
Dr Catherine J. McCuaig
Dr Cheryl Rosen
Dr Jack toole
Dr ian landells
CDA President
eX OFFiCiO
Dr H. John Albers
Past President
Announcements
CDF Board meeting at CDA 2011 in Edmonton: this
meeting will take place on Wednesday June 22, 2011 at 4:306:00 PM
CDF AGM at CDA 2011 in Edmonton: this meeting will take
place on saturday June 25, 2011 immediately following the
CDA AGM, starting at about 4:15 PM.
Membership: the following members have upgraded their
membership since June 2010
Benefactor Life Membership: Dr s. Hofstader as recipient of
the 2010 Practitioner of the Year award (the CDF wishes to
express its gratitude to Abbott Canada for the sponsorship of
this membership upgrade)
Life Membership: Drs B. Barankin, V. Bertucci, J. Dutz,
i. ezers, R. Kuninetz and C. McCuaig.
A sincere thank you to all these members for their support.
scholarships for Dermatology training”. it is assumed that the
residents applying will be driven by curiosity and a strong
desire to learn or to take part in a learning experience.
Activities undertaken primarily to acquire financial gains or
skills to produce income do not qualify. endorsement of the
application by a senior faculty member of a Canadian university is required.
Dr Kerri Purdy (R5, Dalhousie) completed an elective (supported by the Kalz Bursary fund) with Dr Melanie Pratt
september 8 to October 5, 2010 to acquire knowledge and
experience in contact dermatitis and patch testing. Dr Purdy
stated “in my training centre we don't have access to patch
testing beyond the north American Contact Dermatitis Group
standard series, so it was certainly eye opening to have access
and exposure to Dr Pratt's immense collection of allergens.....
i learned about proper patch testing including application and
interpretation, how to obtain a relevant occupational contact
history and also the management of allergic contact dermatitis.... Dr Pratt is a teacher and a mentor that i was fortunate to
be able to work with for the month.”
The CDF wishes to acknowledge the generous $6000 donation by the CDA to the Dr Frederick Kalz Bursary Fund in
2010.
Dr Frederick Kalz Bursary Applications are invited. the
CDF Board accepts enquiries outlining the proposed training
activity and completed applications at any time by writing to
the secretary at the CDF address below. Application forms can
be downloaded from the website (www.cdf.ca), completed and
sent by mail to the CDF address below. Processing of an application can take up to six months.
Acknowledgements
the Board acknowledges the continuing support of CDF operations by stiefel, a GsK company.
REMEMBER…Membership renewals and donations can
now be processed on-line! simply log on to www.cdf.ca.
Payment is via PayPal and is easy, secure and reliable.
Furthermore, receipting is immediate! Try it out!!
Gilles J. Lauzon MD, Secretary
Canadian Dermatology Foundation
211 Lady Macdonald Drive
Canmore, AB T1W 1H2
(Nous regrettons de ne pas pouvoir inclure un texte en français)
Dr Frederick Kalz Bursaries
in 1991, the late Dr Zoltan Fekete initiated the Dr Frederick
Kalz Fund with a generous gift to the Canadian Dermatology
Foundation. numerous colleagues and friends of Dr Kalz
(1906-1993) have contributed to this fund.
the fund’s purpose is “to commemorate the name, life, work
and teaching of Dr Frederick Kalz through bursaries or
23
Canadian Society for Dermatologic Surgery
MARiusZ sAPiJAsZKO, MD, President
Regulatory Issues
the dermatologic surgery regulatory environment continues to
evolve and has a significant impact on the practice of surgical
and cosmetic dermatology. Although each province has its own
unique set of rules and regulations, the recently approved
Ontario College of Physicians and surgeons Out-of-Hospital
Premises (OHP) standards illustrate the national trend that
originally started in British Columbia and Alberta. these
standards are designed to regulate out-patient procedures and
surgery settings and can be accessed via the web on:
http://www.cpso.on.ca/uploadedFiles/policies/guidelines/office
/ohp_standards.pdf
All dermatologic surgeons practicing surgical or cosmetic dermatology are advised to become familiar with these regulations
as they will likely apply not only to Ontario physicians but all
physicians in the future.
group of speakers with an educational component that will
address current topics of interest to dermatologic surgeons. All
members are invited and encouraged to attend. Furthermore,
our Annual General Meeting will immediately follow the
surgery session of the CDA.
CSDS Website
Our web site is in the final stages of being deployed. We now
need, and will need in the future, assistance from our members
with respect to the content of the website.
Members are encouraged to complete their profile (emailed
earlier) as soon as possible so that members listings can be
updated on the Canadian society for Dermatologic surgery
web site. those who wish to obtain the profile form again,
pay their dues, or become a member can contact Mariusz
sapijaszko (CsDs President) at [email protected] or Jean
Francois tremblay at [email protected]
Educational Event
the main CsDs educational event will be held during the 2011
CDA meeting in edmonton on June 23. We have a diverse
Michele Albagli’s Retirement Party at AAD, 2011
Drs Jean Carruthers, David Mclean, Alastair Carruthers with Michele Albagli
24
McGill Dermatology Program Director’s Update
i was appointed Program
Director in July 2010. i was
very proud to take on this
challenge as i have been
myself a dermatology resident
at McGill. i graduated in
1999, spent 4 years in solo
practice before deciding to
return to McGill as an academic focus to my practice. i
then did one year of Contact
Dermatitis fellowship under
Dr Denis sasseville’s supervilinDA MOReAu, MD,
sion
in 2004-2005. After that,
Program Director
i embarked as a full time academic staff within the Dermatology Division. During this time,
i have participated in building up the Contact Dermatitis clinic
that had already been firmly established and reputed by
Dr sasseville. i also took on the challenge of continuing
and supervising the leg ulcer clinic about 3 years ago upon
the departure of its founders’, Drs Marie st-Jacques and Alain
Brassard.
this past year, we were faced with some important challenges
as the MuHC is undergoing planning for the transition and
future development of its new location, the Glen Center. Many
specialties had hopes of being in this new megahospital with
brand new facilities and a strong research backbone; however
the budget has been so significantly reduced that many services will not be present within its new walls. At this point, it still
remains uncertain as to where our dermatology facilities would
be located in the future.
We have a very strong commitment within the McGill dermatology program and are striving to have our vision and voice
heard. We have been firmly advocating for adequate space and
ancillary personnel for full support to our dedicated staff. We
have also been advocating better amenities for our residents.
Our vision for the MuHC and our program is the establishment
and consolidation of specialty clinics as well as the development of an important research arm. We currently have an active
focus on many specialty clinics. For example, our Contact
Dermatitis clinic, run by Dr Denis sasseville and myself, has
acquired a renowned reputation throughout Quebec and cases
from the entire province are being sent to us for specific patch
tests which relate mainly to occupational causes. From our
clinical data, we have been able to publish a multitude of articles related to the discovery of new emerging allergens. Our
residents and students are also involved in many of those
publications, thereby increasing their opportunities to actively
participate in the medical literature while in training.
Our other specialty clinics at the MuHC include the lupus
clinic, conjointly supervised by Dr elisabeth O’Brien and our
rheumatology colleagues, the Cutaneous Problems in Organ
transplant Patients clinic, run by Dr Mannish Khanna, the
Melanoma clinic, run by Dr Beatrice Wang and the leg ulcer
clinic, run by me. We also have a busy phototherapy service
under the supervision of Dr Raynald Molinari. At the Jewish
General Hospital, we also have a strong surgical service supervised by Dr Khanna who is specialized in Mohs micrographic
surgery and a lymphoma clinic, conjointly run by Dr Kevin
Pehr and the hematology team.
We are in the process of establishing an active research arm
within our Dermatology Division and have established strong
laboratory links to develop more significant projects under the
supervision of our Research Coordinator, Dr Denis sasseville.
As Program Director, i am very proud of our focus on quality
teaching and patient care. We strive to abide by a very important philosophy, that of respect, care and empathy for patients,
peers, and colleagues and thereby promote a respectable, safe
and caring teaching environment.
L'année 2010-2011 en perspective : société de dermatologie de Montréal
la réunion le 23 avril au royal victoria était annulée pour permettre
les dermatologistes d’assister à l’Atlantic Dermatology
29 avril 2011 Atlantic Derm Boston
5-8 mai 2011 ADQ estrimont
14 mai mélanome métastatique Québec Chateau Bonne entente
9 juin 2011 thomas Kupper, CtCl
CAtHeRine MCCuAiG, MD,
Montreal
Nous avons le plaisir d’annoncer l’arrivée de Mme Hélène Bourgeois, Adjointe administrative,
Association des dermatologistes du Québec et de la Société de Dermatologie de Montréal qui
remplace Mme Francine Labelle, après des années de service.
25
Alberta News
CAtHeRine ZiP, MD,
Calgary
Manitoba News
the
Alberta
society
of
Dermatologists held its ‘spring’
Meeting a bit early this year, in
association with the 5th Canadian
Melanoma Conference in Banff on
February 26. the weather was anything but spring-like, but the scientific program was outstanding.
Amongst the organizers of this
multidisciplinary meeting were
Drs Joel Claveau and thomas
salopek.
in edmonton, two new residents,
Dr Kyle Cunningham and Dr
timothy Pyra, will begin their dermatology residency in July.
Dr Parbeer Grewal will be joining the practice of Dr norman
Wasel this summer, and Dr Amro el sadaf will be opening his
own practice on the south side of the city. Drs Alain Brassard
and Christopher Keeling have begun a monthly cutaneous
lupus clinic.
in Calgary, we have three new dermatology residents beginning
their residency this summer: Drs Jori Hardin, ilya shoimer and
Kayi li. Dr neil shear graced our city in early April. He spoke
to the dermatology group on ‘stickiness’ and presented Grand
Rounds on the topic of Drug eruptions.
Maritime News
it seems that things have been
quiet in the Maritimes since
Christmas. Maybe we had too
much snow!
Dr Mélanie Pratt gave a lecture in
Halifax on March 29th 2011. it
was the third annual Dr J. Barrie
Ross lecture in Dermatology. she
discussed interesting cases from
the Ottawa contact dermatitis
clinic. Her presentation was well
MARC BOuRCieR, MD, attended and appreciated by the
participants.
Moncton
Hello from sunny Manitoba! We
have just survived another year of
flooding.
Our Dermatology group has finally been successful at creating a
billing code for Moh’s surgery
with Manitoba Health. After a long
letter writing campaign and many
meetings over the importance of
Moh’s surgery for Manitoban
patients, Dr tarek Afifi can finally
ViCtORiA tARAsKA, start performing Moh’s surgery on
his long patient list. thanks to Drs
MD, Winnipeg
Jack toole, lorne Hurst, shane
silver and terek Afifi for their effort to bring this important
service to our province’s patients. it will be nice for those in
need not to have to travel to another province to receive Moh’s,
the standard of care needed for certain skin cancers. Dr Afifi has
set up his Moh’s surgery at the Winnipeg Clinic and is plodding
through his long list. Although, we have a code unfortunately it
was not the amount we feel is appropriate. so we will continue
to lobby for changes. Also we have yet to hear about our other
fee code negotiations with Manitoba Health and hopefully we
will hear soon.
Our sun Awareness campaigns this year included a screening
performed at the Manitoba legislative building with provincial
staff, MlAs and ministers. the screening team consisted of
Drs Marni Wiseman, tarek Afifi, Beth Collin and Rochelle Van
de Velde. A sincere thanks to the dermatologists who were able
to donate their time to this worthy cause. there were many staff
screened, 11 MlAs and Ministers included the Honourable Bill
Blaikie, Jim Rondeau, Andrew swan, and Dave Chomiak. We
had great media exposure for this event with many interviews
which helps disseminate our important information on sun
awareness and skin reviews to detect skin cancer. Our next
event will be the teddy Bear Picnic with loads of children
learning about safe sun exposure.
Ontario News
• Very little news
• Fee negotiations are in progress
• up coming meetings include:
numerous international meetings were attended by many dermatologists in the Maritimes.
DAniel sCHACHteR,
MD, toronto
26
1. toPs Psoriasis Meeting #7Friday september 23rd
Guest speaker.. Bruce strober
2. Bob lester Post-Grad Meeting
Friday, november 18th Guest
speaker.. Dr. A. tosti
3. laser update Meeting Friday
October 21st
Guest speakers include..
Vic narurkar, Brian Biesman,
and Howard Bargman
Clinical Tips & Pearls of Wisdom
BenJAMin BARAnKin, MD, toronto
In the American publication Skin & Aging, I have a column
called “Clinical Tips” where we publish tips and pearls related to diagnosis, treatment, practice management, and all other
facets related to the art and science of dermatology. Skin &
Aging is kind enough to allow us to republish these tips and
pearls in the CDA Bulletin since the publication is not readily
available in Canada.
Each issue of CDA Bulletin going forward will publish three
such tips and pearls. Please submit your tips and pearls to keep
this an active forum for our mutual benefit; submissions can be
emailed to: [email protected]
relationship. Dacher Keltner, author of Born to Be Good: the
science of a Meaningful life (norton, 2009), maintains that
touching others is “our richest means of emotional expression.”
A warm touch triggers release of oxytocin, the hormone that
nurtures bonding and trust. Patients who receive a meaningful
touch from their doctor perceive that their visit lasted twice as
long as that reported by patients who receive no touch during
their visit. the implications of this are enormous for dermatologists, who touch nearly every patient they treat over the course
of a typical day in practice.
– Dr. Brian t. Maurer
Hiring Staff
Reducing Patient Discomfort
i always look to hire someone with good people skills, someone who smiles and interacts well. An employee who is or was
an aerobics instructor makes a great nurse.
i provide my patients a squeeze/stress ball during procedures
where i am inflicting some discomfort such as BOtOX, fillers,
electrodessication etc. My patients have repeatedly commented
that this does indeed reduce discomfort, as does the soothing
music playing in the background which allows their minds to
go elsewhere. if you don’t want to set up an expensive overhead
system, a small CD player in each room works great.
– Dr. Benjamin Barankin
i do think that the doctor sets the tone in the office. the doctor
has to treat his patients and employees well or the employees
will follow suit.
– Dr. Barry Ginsburg
The Therapeutic Value of Touch
in the office or clinic, an appropriate reassuring touch from the
clinician might serve to enhance the professional doctor-patient
DRIVE News
Gilles J. lAuZOn, MD, Canmore, Chair, DRiVe 2011
DRiVe 2011 took place in toronto on February 17-20, 2011.
twenty residents participated in the program: two from the
university of British Columbia, three from the university of
Alberta, five from the university of toronto, one from the
university of Ottawa, three from McGill university, three from
université de Montréal, one from université laval, one from
Dalhousie university and one candidate from the united states.
the program included practice written and OsCe-type oral
examinations and presentations by faculty based on a perceived
needs assessment completed by the participating residents.
Participating faculty included (west to east): Jaggi Rao,
Marlene Dytoc, Gordon searles, tom salopek, laurie Parsons,
Gilles lauzon, neil shear, Davindra singh, scott Walsh, Joel
DeKoven, Jean-Pierre DesGroseilliers, Judith Cameron,
elizabeth O'Brien, Benoit Côté and laura Finlayson. the program Chair wishes to express his gratitude to all participating
faculty and, in particular, to the DRiVe Committee comprised
of Drs searles, DeKoven and Finlayson and the President of the
Canadian Professors of Dermatology (CPD), Dr neil shear.
DRiVe is a program conducted under the authority of the CPD.
DRiVe 2012 will take place in February 2012. the location
will be announced in a future DRiVe news segment. the
Co-chairs of DRiVe 2012 will be Drs Judith Cameron and
Gilles lauzon.
the Chair wishes to express his sincere gratitude to AmgenPfizer for its unconditional sponsorship of DRiVe and for the
professional and attentive conduct of its representatives who
assisted with integrity in the administration and logistics of the
program. the program was deemed a success by residents and
faculty alike.
27
Update from the Co-Chairs 2010 – 2011
i am very happy to welcome
Geeta Yadav as the new RFs CoChair. Her term began in March
2011 and will run until March
2012. Having overlapping CoChair terms was one of the
changes we implemented this
year to promote continuity in the
CDA-RFs.
the next Canadian Residents
Reception will be Saturday
March 17, 2012 in San
Francisco. thank you to the
Vogels for your continued support of the RFs.
Personally, i would like to thank
all the resident representatives
from our Canadian programs
An exciting project that we've
who have made my Co-Chair
been working on is the Fellowjob so much easier this year.
ship Directory – the preliminary
Having a reliable and accessible
MiCHele RAMien, MD; GeetA YADAV, MD
version is now available on the
executive Committee and group
université d’Ottawa / university of Ottawa
CDA webpage under the Resident
of volunteers every time input or
CDA-RFs Co-Chairs
& Fellows society tab. Here you
help was requested has been an
can find information on Canadian
invaluable resource. Thank you
Fellowship opportunities available for those considering further
Christina Han, Vimal Prajapati, Megan isaac-Renton, nicole
training. this is a work in progress, and we will continue to add
Hawkins, erin Dahlke, Carrie lynde, Alexis Williams, Carly
information as it become available.
Kirshen, Janie Bertrand, sophie Vadeboncoeur, Mathieu
Powell, Barbara Miedzybrodzki, sophie sivret, Angélique
We are also looking forward to the upcoming CDA meeting in
Gagné, Anne-Marie Drolet, and Kerri Purdy.
edmonton. We hope to see all our resident members at the
RFS Reception on Friday, June 24th from 4:30 – 6:30 PM.
i highly encourage interested residents get get involved in the
the theme will be mentorship.
RFs or in any one of the numerous CDA committees that have
resident representation. You will be surprised at how rewarding
On behalf of the resident members of the CDA-RFs, we would
the experience is – i know i found it to be.
like to thank Drs neil shear and Gilles lauzon for all their hard
work and effort to organize the first Canadian course on the
My term as Co-Chair will end during the CDA in June 2011. i
Basics of skin science titled the BOSS program. We would
know i leave the RFs in capable hands – Geeta Yadav is expealso like to thank the sponsor, Abbott laboratories.
rienced and energetic and i have no doubt that she and the new
Co-Chair, who will start during the CDA, will continue to grow
Barry, louis and sylvia Vogel are enthusiastic supporters of the
and develop the resources available to and representation of
RFs and have always made the Resident Reception at the AAD
Canadian Dermatology residents.
their priority. Mr. Vogel has already confirmed that the date of
Dermatology Fellowship
Dermatologists!
Thinking of retiring or a sabbatical in
beautiful British Columbia?
BC dermatologist has three deluxe offices 2-4 days a week
available in each. Administration taken care of –
you just turn up and enjoy what you do!
West Vancouver, Victoria and nanaimo.
see drskinlaser.com for website
Contact: 250-729-2665 or [email protected] for details
28
lOuis VOGel, Publisher, Montréal
Dr Christina lam; graduate of université de Montréal will start
a Dermatology/Rheumetology Fellowship at Brigham and
Women’s Hospital in Boston, MA
Pharmaceutical Corporate
Report
lOuis VOGel, PuBlisHeR, Montreal
Sanofi-aventis, France’s largest pharmaceutical company has
gained control of Genzyme Corp, Boston, MA
University of Alberta Program Update
ViMAl PRAJAPAti, MD, edmonton
From the melting snow ridden depths of edmonton, the
Division of Dermatology and Cutaneous sciences at the
university of Alberta extends their greetings to all.
We are pleased to commemorate two award recipients in
our program:
Dr thomas salopek was presented with a Resident teaching
Award in recognition of excellence in resident teaching in the
field of dermatology. Despite his commitments as Division
Director, Dr salopek
always provides highquality teaching during
and after his clinics, and
even on weekends. For
instance, each year, he
administers an orientation to dermatologic surgery for our PGY3 residents and facilitates several mock oral examinations with our PGY5 residents, all after hours.
these are just a few
examples of his dedication to resident teaching.
Dr thomas salopek receives the Resident
Dr
salopek is an outteaching Award from Zaki taher (PGY4).
standing clinician, surgeon, and educator. We residents at the university of Alberta
consider ourselves very fortunate to learn from his expertise.
Dr eric schloss has earned our first ever lifetime Achievement
Award in recognition of outstanding career contributions to the
field of dermatology. Despite his busy community practice
as a dermatologist and
dermatopathologist,
Dr schloss is a regular
attendee at our academic
half-day to which he has
been bringing patients for
over 2 decades. the latter
is truly remarkable and
clearly demonstrates his
commitment to resident
teaching. Dr schloss has
a wealth of knowledge in
both dermatology and
dermatopathology, and all
current residents and previous graduates of our
Dr eric schloss receives the lifetime program have benefited
Achievement Award from Zaki taher (PGY4) from his expertise.
Congratulations Dr schloss!
the next few months will be busy for the residents and staff
here at the university of Alberta. Our residents in their final
year are studying diligently for the Royal College examination.
We wish them all the best. in addition, we are actively preparing for the upcoming CDA Conference, which will take place
from June 22 – 26, 2011. We hope you will join us in “the City
of Champions”.
Congratulations Dr salopek!
University of Montreal Program
Update
University of Ottawa Update
JAnie BeRtRAnD, MD, sOPHie VADeBOnCOeuR, MD,
Montreal
Greetings from Ottawa!
this semester, two new residents transferred from the
university of sherbrooke to our program. We are happy to welcome Drs Carolina lucena-Fernandez and sophie sivret. We
hope you’ll enjoy your new hometown and take advantage of
all that Montreal has to offer: festivals, art, restaurants and
entertaining!
Congratulations to Dr Christina lam who will be starting a fellowship in connective tissue diseases at Brigham and Women's
Hospital and to Dr Caridad Vera-suarez, who will be starting
her practice in Joliette, QC.
MARGARet MiODusZeWsKi, MD, Ottawa
the last few months have brought about exciting changes
to the lives of many of Ottawa’s dermatology residents.
Congratulations to Caroline Heughan who gave birth to a baby
boy, Alec. Recent graduate Dalia also gave birth to a baby boy,
Joshua. Alex Kuritzky is currently expecting her own bundle of
joy come July.
We wish Carly Kirshen and Brad Meulenkamp as well as Geeta
Yadav and Andrew Graham all the best in their upcoming
nuptials. Congrats to Renee Beach for winning Best Resident
project at the AAD’s skin of Color society symposium for her
work on “Changes in il1a in Afro-textured hair,” and Michele
Ramien for winning a Fischer award at the ACDs meeting.
looking forward to seeing everyone in edmonton!
29
Université de Sherbrooke Program Update
sOPHie siVRet, MD, sherbrooke
Voici quelques nouvelles de sherbrooke...
Here is some news from sherbrooke…
nous sommes heureux d’accueillir Alexandra Mereniuk et
Cynthia eid qui commenceront leur première année de résidence en juillet prochain. Félicitation à vous deux et bienvenue
à sherbrooke !
We are pleased to welcome Alexandra Mereniuk and Cynthia
eid who'll start their first year of residency next July.
Congratulations to you both, we’re thrilled to have you with us!
en janvier 2011, Carolina lucena
Fernandes, R3, a quitté sherbrooke
pour poursuivre sa résidence à
l'université de Montréal. Je ferai
de même en juillet. Merci à
l'université de Montréal de nous
accueillir !
this past January (2011), Carolina
lucena Fernandes, R3, left
sherbrooke to pursue her residency
in Montreal. i'll do the same in July.
i’d like to take this opportunity to
thank the university of Montreal for
welcoming us so generously in their
team!
Pour leur part, Alice Dahl et
Mylène sara Veilleux, toutes deux
R1, restent à sherbrooke pour
terminer leur tronc commun de
Médecine interne. Bonne chance
les filles !
Concerning Mylène sara Veilleux
and Alice Dahl, both first-year
residents, they are staying in
sherbrooke to complete their common core of internal medecine.
Good luck girls!
Alice Dahl, Carolina lucena Fernandes, sophie sivret,
Finalement, nous remercions sincèreFinally, we’d sincerely like to thank
Mylène sarah Veilleux.
ment nos chers patrons : Dr Bruno
our dear professors: Dr Bruno
Maynard, Dre Dominique Hanna et Dre Valérie Joncas. Merci
Maynard, Dr Dominique Hanna and Dr Valérie Joncas. thanks
de partager vos connaissances et votre passion avec nous. Vous
for sharing your knowledge and passion with us. You inspire
êtes inspirants !
us daily!
Au plaisir de vous croiser au Congrès Annuel de l'ACD
à edmonton !
looking forward to meet you all at the CDA Congress
in edmonton!
Office Moves and Practice Starts
Québec
lOuis VOGel, PuBlisHeR, Montréal
BC
Dr Chris sladden has started his practice at 1993 High schylea
Drive, Kamloops V2e 1s2
Ontario
Dr Daniel Chang has relocated his practice to 480 Chrysler Dr.,
unit 38, Brampton l6s 0C1
Dr Maria Perla lansang has started her practice at sunnybrook
Health science Centre – Dermatology M1-700, 2075 Bayview Ave
M4n 3M5
Dr Franklynne Vincent is presently practicing at st. Joseph’s
Health Centre – Dermatology, 30 the Queensway, toronto
M6R 1B5
Dr Carl Wyse is no longer at sunnybrook, and is practicing
at 3 Ovida Blvd., Markham l3P 7n8; in association with
Dr Charles lynde
Dr Jeanne Zeller has started her practice at st. Joseph’s Health
Centre – Dermatology, 30 the Queensway, toronto M6R 1B5
30
Dr Audrey lovett is presently practicing at the Montreal
Children’s Hospital – Dermatology, 2300 rue tupper, Montreal
H3H 1P3
Dr Hai Hoc nguyen a déménagé sa pratique au 383 boul du
séminaire nord, bureau 120, st-Jean-sur-Richelieu J3B 8C5
Dr simon nigen, a déménagé sa pratique au 55 rue de l’ Église,
bureau 47, Verdun H4G 3e7
Dr Osama Roshby has started his practice at the Jewish
General Hospital – Dermatology, 3755 Côte ste-Catherine Rd,
Montreal H3t 1e2
Birth Announcements /
Naissances
lOuis VOGel, PuBlisHeR, Montréal
Drs Benjamin Barankin and Kim Barankin, of toronto, were
thrilled to announce the birth of Olivia Goldi, born April 3; a
sister to Alexis.
Dr Dalia Mikhael saikaly, of Ottawa, and her husband Charles
saikaly celebrated the birth of their son Joshua.
Obituaries/ Nécrologies
Gordon Kerbel
ROBeRt lesteR, MD, toronto
On December 28, 2010,
Canadian dermatology lost an
esteemed colleague and for
many of us a good friend.
Gordon was born on February
8, 1936. He attended Bloor
Collegiate initially and later
Forest Hill collegiate. After
graduating from high school,
he entered university in science but never completed his
degree as he was accepted
1936-2010
into the university of toronto
medical school after two years in science. Gordon graduated
from medical school in 1959 and did his junior internship at the
toronto Western Hospital. subsequently, he spent two years at
Bellevue in new York. While there he had the opportunity to
train under a host of legends in dermatology including
Al Kopf and Rudy Baer. He then returned to toronto to complete his training at the toronto General Hospital as a resident
in the developing university of toronto dermatology training
program.
After graduation, he set up his office at Yonge and Davisville
and spent his entire career there. He felt it was a privilege to
be known and respected for being a general medical dermatologist and was devoted to the care of his patients. A little known
fact about Gordon is that he is credited to being the first dermatologist in Canada to recognize the cutaneous manifestations of AiDs.
Gordon also had a keen interest in academic dermatology and
spent many years seeing patients and teaching in the out patient
department at the toronto General Hospital as well as seeing
inpatient consultations. He loved to teach and was admired by
both students and residents.
Recognizing a gap in continuing medical education for dermatologists in Canada, he was the organizing founder of the Post
Graduate seminar in Dermatology over thirty years ago. this
meeting has become an important event on the calendar of
many Canadian and u.s. dermatologists since its inception
under Gordon’s leadership. He was also instrumental in initiating a Dermatology Journal Club.
Beyond his career in dermatology, he was active in the Medical
Alumni Association at the university of toronto, and was the
president of the Jewish Historical society of toronto.
unfortunately, as a result of complications of Juvenile Diabetes
his health declined over the latter years of his career, and he
retired ten years ago. He is survived by three loving sons,
steven, Howard and Jordan, who were always very close to
Gordon, as well as six grandchildren.
Gordon will be remembered for his wonderful dry sense of
humour and as a dependable colleague who contributed greatly to dermatology in toronto and nationally. He will be sorely
missed by all of us who had the privilege of being his friend or
working with him.
Britain Marchand Sanders
lOuis VOGel, Publisher, Montreal
Dr Britain sanders passed
away April 23, 2011. He was
married to Maxine for 60
years; father of Charles and
Kimberley and had four
grandchildren.
1925-2011
Britain grew up in exeter and
graduated in medicine from
the university of Western
Ontario in 1948. He did one
year internship and two years
internal medicine in london,
On, then spent two years in
general practice in Chatham.
He trained as a dermatologist at the toronto General and sick
Children’s Hospitals and Michigan state university Hospital
1953 – 1955 and was certified in Dermatology by RCPsC in
1955. He had a dedicated Dermatology practice for 44 years at
the Medical Arts Building in toronto until he retired in 2000.
He was Associate Professor of Dermatology at the university
of toronto and on staff at toronto General Hospital and sick
Children’s Hospital. He ran the VD Clinic at t.G.H, and was an
expert on Venereal Diseases.
Britain was very helpful to the Residents preparing for their
examinations. He had a high iQ, a sly sense of humor and was
well-liked by his patients and respected by his colleagues.
He was an avid reader of many different genres, a sports car
racing enthusiast and lover of jazz music and the clarinet.
31
Wine and Food Gems
lOuis VOGel, Montréal, Publisher
Remarkable Wine Tasting
several years ago, the Ontario liquor Board offered a package
of six Magnums of 2004 Clarendon Hills Wines from Mclaren
Vale, Australia.
i purchased and stored the wines on behalf of our Montreal
Branch of the international
Wine & Food society.
the producer / winemaker
Roman Bratasiuk, a biochemist and wine taster decided in the 1980’s to produce his
own wines. though he never
trained as a winemaker, he
was guided by his refined
palate and scientific knowledge. Mr. Bratasiuk’s objective was to bring out best and
unique qualities of each of his
vineyards. they hand-sourced
very old, special pre-phylloxera bush vines; made the wine
by hand, using only natural
processes, to express the unique
varietal of a vineyard by conveying its vintage and location.
We compared three varietals from the same producer (shiraz,
Grenache and Cabernet sauvignon) and also the difference in
vineyards for the same varietal (3 shiraz and 2 Cabernet
sauvignon).
the wines were decanted about 2 hours before tasting.
Romas Grenache 2004, McLaren Vale
A refined wine, from the steepest part of Blewitt springs site;
shows fruit, florals and minerals; with another 20 years of aging
potential. Vines were planted in 1925 – a flagship grenache.
Hickinbotham Cabernet Sauvignon 2004, McLaren Vale
A powerful old-world style cab.
lots of dark fruit and spices,
well-structured.
Sandown Cabernet
Sauvignon 2004, McLaren
Vale
A velvety texture, lighter red
colour, fresh, soft and ready.
Planted in1940 in sand, provided deep roots, and resilience to
climatic variations.
Brookman Syrah 2004,
McLaren Vale
earthy, tobacco, coffee layered
with blue fruit flavor. A soft
wine with aging potential.
Vines were planted in 1965 in
brown clay soils.
Hickinbotham Shiraz 2004, McLaren Vale
A masculine, harder-edged, powerful, mineral characteristics.
Piggot Range Shiraz 2004, McLaren Vale
Complex structure, needing more cellar aging. Planted in 1965
in rich red loamy top soil on pure rock; limits the vigor of the
continued on page 22
the Canadian Dermatology Association Bulletin is published three times yearly by the Canadian Dermatology Association as a forum for
Association news, information of interest to members and for members’ opinions. • statements and opinions expressed in the CDAB reflect
the opinions of the authors and not necessarily the CDA. the CDA does not assume responsibility or liability for damages arising from errors
or omissions, or from the use of information or advice contained in the CDAB articles or letters. Please notify the executive Director of any
change of address.
l’Association canadienne de dermatologie publie trois fois par année le Bulletin de l’Association canadienne de dermatologie en tant que
forum de nouvelles de l’Association, d’informations qui pourraient intéresser nos membres, ainsi que pour recueillir leurs opinions. • les textes
et les opinions publiés dans le BACD reflètent les points de vue de leurs auteurs et non pas nécessairement ceux de l’ACD. l’ACD ne peut
être tenue responsable des dommages qui pourraient résulter d’erreurs ou d’omissions reliées à l’utilisation de renseignements ou de conseils
inclus dans les articles ou lettres apparaissant dans le BACD. Prière d’aviser la Directeure générale pour tout changement d’adresse.
CHANTAL COURCHESNE
eXeCutiVe DiReCtOR / DiReCteuRe GÉnÉRAle
425 – 1385 Bank street, Ottawa, On K1H 8n4
tel: (613) 738-1748 / 1-800-267-3376 • Fax: (613) 738-4695
e-mail: [email protected] General e-mail: [email protected]
Published by / Publié par :
LOUIS VOGEL
Head – Dermatology liaison Programs
Chef – Programmes de liaison dermatologique
5353 boul. thimens, st. laurent, QC H4R 2H4
®2011 Canadian Dermatology Association • l’Association canadienne de dermatologie
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Imprimé sur papier recyclé

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