Methods.

2. Ries LG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 19752004, National Cancer Institute (November 2006 SEER data submission). http:
//seer.cancer.gov/csr/1975_2004/. Accessed January 4, 2008.
3. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin.
2008;58(2):71-96.
4. McPherson M, Elwood M, English DR, Baade PD, Youl PH, Aitken JF. Presentation and detection of invasive melanoma in a high-risk population. J Am
Acad Dermatol. 2006;54(5):783-792.
5. Carli P, De Giorgi V, Palli D, et al; Italian Multidisciplinary Group on Melanoma. Dermatologist detection and skin self- examination are associated with
thinner melanomas; results from a survey of Italian multidisciplinary group
on melanoma. Arch Dermatol. 2003;139(5):607-612.
6. Brady MS, Oliveria SA, Christos PJ, et al. Patterns of detection in patients with
cutaneous melanoma. Cancer. 2000;89(2):342-347.
7. Robinson JK, Turrisi R, Stapleton J. Efficacy of a partner assistance intervention designed to increase skin self-examination performance. Arch Dermatol.
2007;143(1):37-41.
8. Robinson JK, Turrisi R, Stapleton J. Examination of mediating variables in a
partner assistance intervention designed to increase performance of skin
self-examination. J Am Acad Dermatol. 2007;56(3):391-397.
9. Robinson JK, Stapleton J, Turrisi R. Relationship and partner moderator variables increase self-efficacy of performing skin self-examination. J Am Acad
Dermatol. 2008;58(5):755-762.
A Simple Solution to the Common Problem
of Ecchymosis
P
ostprocedural and traumatic ecchymosis is an
extremely common occurrence. Patients are
increasingly seeking minimally invasive procedures that potentially cause bruising. Oftentimes,
patients are anxious to minimize bruising so that others do not notice that they had cosmetic intervention.
Strategies to reduce ecchymosis are limited to agents
of only modest benefit (eg, arnica and bromelain).1,2
Pulsed-dye laser (PDL) therapy is known to be beneficial for the treatment of vascular conditions. The
objective of this study was to evaluate the effectiveness
and safety of a long-pulse PDL (595 nm) for the treatment of ecchymoses.
Methods. Ten adults with skin types ranging from I to
IV and at least 1 ecchymosis were enrolled in the study.
Ecchymosis resulted from cosmetic procedures or traumatic injury. Duration of ecchymoses ranged from 48
hours (n=6) to 72 hours (n=4). Subjects received a single
treatment with the 595-nm V-Beam PDA (Candela Corp,
Wayland, Massachusetts) with the following settings: spot
size, 10 mm; fluence, 7.5 J/cm2; and pulse duration, 6 milliseconds. The DCD (Dynamic Cooling Device; Candela Corp) was set at 30 milliseconds with a 20 millisecond delay. Each subject served as his or her own control:
subjects with 2 ecchymoses had 1 treated; those with a
single lesion had half treated. Photographs were taken
before treatment and at 24 hours, 48 hours, and 7 days
after treatment. Two blinded assessors graded bruise severity from 0 to 10 (0, no bruise; 10, worst bruising).
Results. Relative to the untreated ecchymosis, treated lesions resolved more rapidly (Figure). In all 10 subjects, accelerated resolution of the treated bruise was evident within 24 hours. Benefit was apparent 6 hours after
treatment in 1 patient. Twenty-four hours after treatment, the average improvement was 62% and 13% for
treated and untreated bruises, respectively. Forty-eight
hours after treatment, the average improvement was 76%
and 37% for treated and untreated lesions, respectively.
One week after treatment, treated and untreated bruises
had improved by 87% and 81%, respectively. Adverse effects were minimal, but 2 patients experienced minor transient crusting.
Comment. The precise mechanism by which laser treatment accelerates resolution of ecchymoses is unknown.
Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older
A
B
C
D
E
F
Figure. Two ecchymoses of equal duration on the inner aspect of the upper extremity. In each figure panel, the bruise labeled “A” on the patient’s arm is the
experimental bruise; the one labeled “B” on the patient’s arm is the control bruise and never received treatment. All further citations herein to alphabetic labels
refer to figure panel labels, not bruise labels. A, Before treatment with pulsed-dye laser (PDL); B, 6 hours after a single PDL treatment; C, 24 hours after treatment;
D, 48 hours after treatment; E, 96 hours after treatment; and F, 1 week after treatment.
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bruises correlates with macrophage degradation of hemoglobin to bilirubin. The PDL emits yellow light (595
nm) matching an absorption peak of oxyhemoglobin. Bilirubin has a broad absorption peak at 460 nm.3
We observed the most dramatic responses in bruises
with pronounced erythematous and/or violaceous components, suggesting that laser intervention is most effective if initiated when hemoglobin predominates. All of
the bruises in our study were between 48 and 72 hours
old. In a recently published study, DeFatta et al4 reported maximum efficacy of PDL treatment for ecchymoses resulting from facial cosmetic procedures when
the PDL therapy was performed between 5 and 10 days
postoperatively. Our greater success in treating younger
bruises may relate to different bruise causes. In our study,
bruises were the result of either minor trauma or nonsurgical cosmetic procedures. Relative to bruising due to
surgery, such bruising is typically more superficial and
associated with less tissue inflammation and edema, both
of which potentially impede laser energy absorption. Furthermore, we used higher fluences than DeFatta et al used
(7.5 J/cm2 vs 6 J/cm2).
In conclusion, this study demonstrates that the longpulsed PDL can safely be used to improve ecchymoses.
Further study will help to better define optimal laser parameters. This simple technique can help to alleviate the
common stigma associated with cosmetic intervention
by expediting healing.
Julie K. Karen, MD
Elizabeth K. Hale, MD
Roy G. Geronemus, MD
Accepted for Publication: July 23, 2009.
Author Affiliations: Laser & Skin Surgery Center of New
York and New York University School of Medicine, New
York.
Correspondence: Dr Karen, Laser & Skin Surgery Center of New York, 317 E 34th St, New York, NY 10016
([email protected]).
Author Contributions: All authors had full access to all
of the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis. Study concept and design: Karen, Hale, and Geronemus. Acquisition of data: Karen, Hale, and Geronemus.
Analysis and interpretation of data: Karen, Hale, and
Geronemus. Drafting of the manuscript: Karen and Hale.
Critical revision of the manuscript for important intellectual content: Hale and Geronemus. Administrative, technical, and material support: Karen, Hale, and Geronemus. Study supervision: Hale and Geronemus.
Financial Disclosure: Dr Hale serves as a consultant to
Schering-Plough, Johnson & Johnson, and SanofiAventis. Dr Geronemus serves as a consultant to Candela
Corp and serves on the medical advisory boards for Photomedex, Lumenis, Candela, Zeltiq, Skin Cancer Company, and Endymion; he is also an investigator for Solta
Medical, Candela, DUSA, DermTech, Syneron, Endymion, and Palomar and is a stockholder in Solta Medical.
Additional Contributions: Chris Hunzeker, MD, and
Elliot Weiss, MD, assisted as our blinded assessors.
1. Seeley BM, Denton AB, Ahn MS, Maas CS. Effect of homeopathic Arnica montana on bruising in face-lifts: results of a randomized, double-blind, placebocontrolled clinical trial. Arch Facial Plast Surg. 2006;8(1):54-59.
2. MacKay D, Miller AL. Nutritional support for wound healing. Altern Med Rev.
2003;8(4):359-377.
3. Merrick MF, Pardue HL. Evaluation of absorption and first- and second- derivative spectra for simultaneous quantification of bilirubin and hemoglobin.
Clin Chem. 1986;32(4):598-602.
4. DeFatta RJ, Krishna S, Williams EF III. Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg. 2009;11(2):
99-103.
VIGNETTES
Pretibial Lymphoplasmacytic Plaque
in Children
R
ecently, Gilliam et al 1 described 2 young
patients with a persistent, reddish-brown pretibial plaque. Based on the presence of numerous polyclonal plasma cells in the infiltration, the
authors proposed a diagnosis of isolated cutaneous
plasmacytosis.
Report of a Case. Herein, we describe an 11-year-old girl
with a 5-year history of a reddish-brown, uneven, irregular plaque, 4.0⫻ 2.5 cm in diameter, on the left anterior
tibia. The lesion resembled clinically the entity described by Gilliam et al1 (Figure 1). It had been stable
over the last 5 years, apart from a short-term, partial remission following intralesional steroid injections (performed before our observation).
Three biopsy specimens taken over a period of 8
months revealed different features. The first was characterized by small dermal granulomas admixed with lymphocytes and numerous plasma cells (Figure 2A). The
2 subsequent specimens showed features similar to those
reported by Gilliam et al1 and were characterized by dense
dermal lymphoid infiltrates admixed with numerous
plasma cells, without granulomas (Figure 2B). The epidermis showed focal parakeratosis in all 3 biopsy specimens. Immunohistochemical analysis of the plasma cells
revealed a polyclonal pattern of immunoglobulin light
chain expression.
A mycobacterial infection was excluded by Mantoux
test, QuantiFERON-TB Gold test (Cellestis Inc, Valencia, California), Fite stain, and polymerase chain reaction (PCR) for Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium intracellulare, mycobacteria
other than tuberculosis, and a fresh tissue culture. Results of investigations for Bartonella henselae (PCR); Toxoplasma gondii (PCR and serologic analysis); leishmania
(Giemsa stain and serologic analysis); Treponema pallidum (immunohistochemical and serologic analysis); Borrelia burgdorferi, Borrelia afzelii, and Borrelia garinii (serologic analysis); and fungi (culture, fresh tissue culture,
and periodic acid–Schiff stain) were all negative.
Comment. Primary cutaneous plasmacytosis typically presents with multiple, brownish-red macules and plaques
on the trunk, mainly in Asian adult patients. Histologically, it is characterized by dense perivascular infiltrates
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