Melasma is an acquired disorder of hyperpigmentation affecting millions of individuals worldwide. It is mostly observed in the facial area of darker-complexioned individuals (skin types IV-VI) exposed to intense ultraviolet (UV) radiation 1 and shorter wavelengths of visible light (VL). 2 At least 90% of those affected are women. 1 Melasma is characterized by symmetrically oriented hyperpigmented macules and patches, with varying presentations including blotchy, irregular, arcuate, and polycyclic. 3 One way of dividing the disorder into different subtypes is based on the distribution pattern: centrofacial (the most common), malar, and mandibular. Another division is

Purpose Rosacea is a common, chronic facial skin disease that affects the quality of life. Treatment of facial erythema with intradermal botulinum toxin injection has previously been reported. The primary objective of the study was the safety and efficacy of thermal decomposition of the stratum corneum using a novel non‐laser thermomechanical system (Tixel, Novoxel, Israel) to increase skin permeability for Botulinum toxin in the treatment of facial flushing of rosacea. Methods A retrospective review of16 patients aged 23–45 years with Fitzpatrick Skin Types II to IV and facial erythematotelangiectatic rosacea treated by Tixel followed by topical application of 100 U of abobotulinumtoxin. A standardized high‐definition digital camera photographed the patients at baseline and 1, 3, and 6 months after the last treatment. Objective and subjective assessments of the patients were done via Mexameter, the Clinicians Erythema Assessment (CEA), and Patients self‐assessment (PSA) scores and the dermatology life quality index (DLQI) validated instrument. Results The average Maxameter, CEA, and PSA scores at 1, 3, and 6 months were significantly improved compared with baseline (all had a P‐value <0.001). DLQI scores significantly improved with an average score of 18.6 at baseline at 6 months after treatment (P < 0.001). Self‐rated patient satisfaction was high. There were no motor function side‐effects or drooping. Conclusion Thermal breakage of the stratum corneum using the device to increase skin permeability for botulinum toxin type A in the treatment of facial flushing of rosacea seems both effective and safe. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

Background and Objectives: Thermo-mechanical fractional injury (TMFI) therapy (Tixel®; Novoxel®, Netanya, Israel) is an innovative technology. Along with its drug delivery enhancement features, it is widely used for facial skin rejuvenation. Our study explores the beneficial effect of the Tixel® on the different features of facial skin rejuvenation along with patients′ satisfaction rate, aiming to suggest practical recommendations for an optimal aesthetic result. Study Design/Materials and Methods: A retrospective chart review of 24 patients (20 women, 4 men, average age 56 years old) with skin types II-V who received 2 or 3 Tixel® treatments, 3-5 weeks apart in two medical centers (12 from Israel, 12 from the United Kingdom). Four experienced dermatologists compared standardized clinical photographs taken before each treatment and 3 months after the final treatment based on seven parameters that were set by 10 physicians and rated the difference on a scale of −1 to 4. Furthermore, epidemiology, treatment data, satisfaction, and safety were reviewed. Results: Out of the seven parameters that were compared (blood vessels and erythema, skin complexion, periorbital wrinkles, pigmentation and toning, pore size, vitality, wrinkles, and laxity), all features demonstrated an overall improvement, with the greatest improvement demonstrated in skin complexion (2.1± 0.49) and periorbital wrinkling (2.09 ± 0.65) followed by vitality (1.7 ± 0.49). Side effects were transient, including erythema and hyperpigmentation, and the average downtime was 1.7 days. Conclusion: TMFI is a safe and effective method for improving facial skin quality. Addressing patient′s expectations while maximizing the benefits of this novel technology will provide superior aesthetical results.

Café-au-lait macules (CALMs) present as benign hyperpigmented, well-circumscribed spots on the skin for which many patients seek treatment for aesthetic reasons. The objective of this study is to report our experience in treating CALMs using a picosecond 532-nm neodymium-doped yttrium aluminium garnet (PS 532 nm) laser. This is a retrospective case series of 16 patients with CALMs who were treated by a PS 532-nm laser (1-4 treatments, 4-8 weeks apart). Response as seen on clinical photographs was assessed by two independent dermatologists and graded on a scale of 0 (exacerbation) to 5 (95-100% improvement). Patient satisfaction and tolerance were documented at final visit. The results of 15 patients demonstrated significant improvement (average 3.43), and their satisfaction and tolerance levels were high. One patient had no response whatsoever to treatment. The PS 532-nm laser is a promising novel modality for the treatment of CALMs.

Background: Non-ablative fractional laser is an effective modality for the treatment of periorbital wrinkling, one of the earliest signs of skin aging. Thermomechanical fractional injury (TMFI) therapy (Tixel ® , Novoxel ® , Israel) is an innovative technology that is now being used for facial skin rejuvenation. Our study compares the clinical results, side effects, and downtime profile between TMFI treatment and non-ablative fractional 1565 nm laser (ResurFX ® , Lumenis, Israel). METHODS: This was a prospective study of 68 patients (64 women, 4 men) with skin types I-VI in two medical centers (34 from Israel, 34 from the USA) that were randomized to receive either TMFI or NAFL treatment for periorbital wrinkling. Patients received 3-5 treatments, 3-5 weeks apart. Six months after the last treatment, the change in Fitzpatrick Wrinkling Classification System (FWCS) was calculated by three non-involved physicians and compared to pretreatment results. Side effects and downtime profiles were assessed in each group (including VAS pain assessment, time required to refrain from work and social activity, and time required for the resolution of redness, edema, and crusts.) RESULTS: A moderate improvement in periorbital wrinkling was demonstrated in both groups, with an average improvement of 1.6 ± 0.6 in FWCS in the TMFI group and an average improvement of 1.7 ± 0.8 in the NAFL group (p < 0.001). Postprocedural VAS score was 5.86 ± 2.3 in the NAFL group and 4.01 ± 2.6 in the Tixel ® group. Approximately 80% of subjects returned to both work and social activities two days postprocedure. Crusts were reported by 52% of patients in the TMFI group, compared to 16% of patients in the NAFL group more than 48 hours postprocedure (p < 0.05). There were no statistically significant differences in the other parameters between the two groups. CONCLUSION: TMFI is an effective and safe modality for the treatment of periorbital wrinkling, with comparable results to the 1565 nm NAFL.

Background: Pediatric hypertrophic burn scars are challenging to treat due to their widespread nature and pain associated with the treatment. Intralesional triamcinolone acetonide (TAC) injection with or without 5-fluorouracil (5FU) is considered first-line treatment for severe hypertrophic scars. The pain associated with the procedure, the uneven topography, and epidermal atrophy, all limit the application of this treatment modality. Aims: We sought to evaluate the clinical effectiveness and safety profile of a novel thermomechanical system (Tixel, Novoxel) for transdermal delivery of a topical solution containing TAC and 5-FU in the treatment of hypertrophic scars. Patients/Methods: A retrospective study of pediatric hypertrophic burn scars treated between 2015 and 2017 was performed. Epidemiologic, treatment data, effectiveness score, and safety were reviewed. Results: Four children (one male and three females, ages 3-10 years old) with hypertrophic burn scars treated with the Tixel device were evaluated. Mean scar VSS was reduced from 8.4 ± 0.8-5.2 ± 0.5 (P-value-.001) after eight treatments. The mean improvement of toughness, thickness, color, and general aesthetic impression was 3.1 ± 0.43 → 2.2 ± 0.31, 3.4 ± 0.5 → 1.9 ± 0.63, 2.7 ± 0.21 → 2.4 ± 0.25, and 3.23 ± 0.44 → 1.6 ± 0.64, respectively. Mean treatment pain VAS score was 1.74 ± 0.9. Patient's parents rated their satisfaction level as "moderate-high." No topical or systemic complications were observed. Conclusion: Thermomechanical decomposition of the stratum corneum, in combination with topical application of TAC and 5-FU, is a safe, relatively painless, and efficient modality for the treatment of pediatric hypertrophic burn scars.

BACKGROUND Microneedling fractional radiofrequency (FRF) and chemical peels are widely used for skin rejuvenation. OBJECTIVE The authors aimed at evaluating the efficacy and safety of FRF and trichloroacetic acid 20% (TCA20%) peel in different combinations for determining the optimal treatment protocol. METHODS In this prospective clinical comparison of 4 protocols (FRF alone, TCA20% alone, TCA20% before FRF [TCA→FRF], and TCA20% following FRF [FRF→TCA]), the patients underwent 3.8 ± 1.2 successive treatments of one protocol at 4- to 6-week intervals. The patients and 2 dermatologists evaluated improvement of pigmentation and dyschromia, erythema and blood vessels, laxity and wrinkling, and skin imperfections using a global aesthetic improvement scale (GAIS) and a 1 to 5 scoring system. The patients rated their satisfaction and reported adverse effects and reduced activity. Skin impedance and histological changes following the different protocols were also evaluated on 3 additional volunteers. RESULTS Sixty-seven patients (age range 22–80 years) were studied. TCA→FRF caused skin impedance to decrease, yielding a more superficial and less-efficient penetration of FRF energy. FRF→TCA produced more significant improvement in overall facial skin appearance (GAIS) and most evaluated skin parameters. Adverse effects and satisfaction rates were similar for all approaches. CONCLUSION FRF→TCA had the best synergistic effect on skin rejuvenation compared with FRF or TCA20% alone and TCA→FRF.

Introduction Keloids are challenging to treat due to their inadequate response to treatment and high recurrence rate. Intralesional triamcinolone acetonide (TAC) injection with or without 5-fluorouracil (5FU) is considered the first-line treatment for keloids. Three significant disadvantages of intralesional injections are the pain associated with the procedure, the uneven topography, and epidermal atrophy. Fractionated ablative carbon dioxide (CO 2 ) laser-assisted drug delivery (LADD) of the topical solution can help facilitate transdermal drug delivery and shows promise in scar remodeling. This study examined the use of a thermomechanical device (Tixel, Novoxel) to facilitate the transdermal delivery of TAC and 5-FU in the treatment of keloid scars. Methods Seven patients each received eight topical thermal ablations, with one ablation performed every 2–3 weeks. TAC and 5FU were applied after each ablation. Outcomes were evaluated using the Vancouver Scar Scale (VSS), and pain was assessed using the Visual Analog Scale (VAS). Results Mean keloid VSS reduced from 8.6 ± 1.2 to 5 ± 2.7 after the eight treatments. Mean treatment pain VAS score was 2.4 ± 0.7. Patients rated their satisfaction level as moderate–high. No severe adverse reactions were noted. Conclusion Thermomechanical drug delivery of TAC and 5-FU is safe and effective. This is a promising option for the treatment of keloid scars, particularly in the pediatric population.