Letter to the Editor: Actinic Keratoses and Dermabrasion

| September 3, 2009
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Dear Editor:
A recently published “comprehensive update” of therapies directed toward actinic keratoses (AKs)[1] does, in its final sentence, mention “dermabrasion has been demonstrated to provide long-term (5-year) clearance of AKs in a small, retrospective study.”[2]

Our literature is replete with successes of dermabrasion regarding AKs beginning in the 1950s,[3] evolving,[4] and continuing to date. While agreeing with Dzubow’s editorial commentary[5] on Coleman, Yarborough, and Mandy’s referenced article on dermabrasion and its superior value for prophylaxis and treatment of AKs, actual experiences to date (2009) continue to support dermabrasion’s superior position to all other present modalities.

This commentary correctly brought attention to the fact that for equal results, the varying approaches we use must “achieve the same endpoint.” Therefore, the same wounding depth with wheel, chemical, cryogen, or laser beam or light with or without topical chemical is expected to give equal results. The final result of any abrasive injury depends both on our ability to precisely control the depth of wounding and to control and facilitate the healing process resulting from that particular injury.

On individuals with diamond fraise dermabrasion performed on one side and a taped Baker’s phenol peel on the other side, dermabrasion has consistently proven superior for prophylaxis of AKs, carcinoma, and for cosmesis. Dermatologists with long-term experience have and do consistently consider dermabrasion a superior modality (i.e., J. Fulton, W. Coleman, J. Yarborough, S. Mandy, J. Burks, G. Farber, A. Benedetto, C. Griffith, C. Harmon, R. Luikart, E. Epstein, and countless others). Recurrences over the years are noted to selectively arise in peeled skin at the juncture of dermabrasion and phenol-treated epidermis. Carcinomas arising in dermabraded skin are not seen without similar and greater numbers occurring in the peeled skin.

Laserabrasion can be expected to give the same results when beams are delivered to the same depth. Many fine laser surgeons already see relatively early recurrence of wrinkling and AKs as compared to dermabrasion and phenol peels. This is almost certainly due to superficial (and therefore conservative) insults. Early recurrences will give rise to many unhappy patients, and deep insults will give rise to all the major complications seen with dermabrasion and deep peel techniques.[6] Ostertag et al[7] found significantly high recurrence rates of AKs and basal cell carcinomas after laser resurfacing, which they as well as James Fulton, MD, found unacceptable (when compared to our own long-term experiences with dermabrasion).[8,9] Indeed, a 10-year follow up of a scalp dermabrasion in Wales revealed no recurrences.[10]

We have not evolved very far with long-term collective experiences in some of the “newer approaches,” and per the editorial comment,[5] “traditional techniques” most certainly should not be invalidated or discarded. I have long urged dermabrasion for these problems, and the intervening decades have not blunted my enthusiasm. With the advent of surgical tumescent anesthesia, significant blood spatter is a thing of the past. The entire situation must constantly be re-evaluated, but the “gold standard” remains a properly performed diamond fraise or manual dermabrasion.

Prof. Lawrence M. Field, MD, FIACS
International Traveling Chair of Dermatologic Surgery (International Society of Dermatologic Surgery); University of California, San Francisco (Dermatologic Surgery), Emeritus 2006; Stanford University Medical School, Department of Dermatology, Emeritus 2006; Presidential Citation, International Society for Dermatologic Surgery, Amsterdam, Netherlands 1997; Outstanding Achievement Award, American Society for Dermatologic Surgery, Portland, Oregon 1998 and Presidential Award, Atlanta, Georgia 2005; International Society of Dermatologic Surgery—Outstanding Educator’s Award, Las Vegas, Nevada, 2008; Emeritus Fellow and Examiner, American Board of Cosmetic Surgery; Senior Consulting and Contributing Editor, Dermatologic Surgery

References
1.    Ibrahim S, Brown M. Actinic keratoses—A Comprehensive Update. J Clin Aesthetic Dermatol. 2009;2(7):43–48.
2.    Coleman W, Yaraborough J, Mandy S. Dermabrasion for prophylaxis and treatment of actinic keratoses. Dermatol Surg. 1996;22:17–21.
3.    Epstein E. Planing for precancerous skin. Arch Dermatol. 1958:77:676.
4.    Field L. Dermabrasion for prevention of premalignant and malignant lesions. Cutis. 1971;2:186–190.
5.    Dzubow LM. An abrasion by any other name . . . Dermatol Surg. 1996;22:12.
6.    Ostertag J, Quaedvlieg PJ, Neumann MH, Krekels GA. Recurrence rates and long-term follow-up after laser resurfacing as a treatment for widespread actinic keratoses on the face and scalp. Dermatol Surg. 2006;32(2):261–267.
7.    Bogdana K, Field L. Hemi-facial fine diamond dermabrasion vs. hemi-facial CO2 laser after 3 years—which side retains which wrinkles and where? Book of Astracts, ISDS XXII Annual Congress Congreso de la Sociedad Mexicana de Cirugia Dermatologica y Oncologica; 2001: Guadalajara, Jalisco, Mexico.
8.    Fulton J, Rahimi A, Helton P, et al. Disappointing results following resurfacing of facial skin with CO2 lasers for prophylaxis of keratoses and cancers. Dermatol Surg. 1999;25:729–732.
9.    Fulton J. Commentary supporting: Field L. The superiority of dermabrasion over laser abrasion in the prophylaxis of malignant and  premalignant disease. Dermatol Surg. 2007;33:258
10.    Field L, Motley R. Tumescent scalp dermabrasion—10-year follow-up with no recurrences! Book of Abstracts, ISDS XXVII Annual Congress; 2006: Istanbul, Turkey.

Authors’ reply:
One of the greatest aspects of being a dermatologist treating actinic keratoses (AKs) is the multiple treatment options that are available. Each patient needs to be individualized, and not infrequently different treatment modalities are utilized on the same patient over the many years of required treatment. Many practicing dermatologists firmly believe that cryosurgery is the “gold standard,” but published data show that many diverse treatments are highly effective for treating AKs, and combination therapy is becoming increasingly popular. Dr. Field reminds us of the importance of dermabrasion as an effective therapeutic tool for the treatment of AKs. Although not a primary choice for most dermatologists, nonetheless, the effectiveness of dermabrasion should not be forgotten.

Sherrif F. Ibrahim, MD, PhD, and Marc D. Brown, MD
University of Rochester School of Medicine and Dentistry, Department of Dermatology, Rochester, New York

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Category: 09-2009 (September 2009), Letters to the Editor

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