Volume 10 | Issue 11
Perry Robins MD and James M. Spencer MD|No abstract details for the moment.
Eliot F. Battle Jr. MD|
Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction.
J Drugs Dermatol. 2011;10(11):1235-1239.
Treatment of Actinic Cheilitis by Photodynamic Therapy With 5-Aminolevulinic Acid and Blue Light Activation
Martin Zaiac MD and Annabelle Clement MMS PA-C|Actinic cheilitis (AC), a common disorder of the lower lip, should be treated early to prevent progression to invasive squamous cell carcinoma. This study evaluated the safety and efficacy of photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) activated by blue light for the treatment of AC. Fifteen patients with clinically evident or biopsy-proven AC received two treatments with ALA PDT with blue light activation. Treatments were spaced three to five weeks apart. Most patients achieved 65% to 75% clearance three to five weeks after the first treatment and all achieved more than 75% clearance one month after the second treatment. Three patients achieved complete clearance. Pain and burning during irradiation were absent or mild. All patients said they would repeat the procedure. ALA PDT with 417 nm blue light is a promising option for the treatment of AC of the lower lip.
J Drugs Dermatol. 2011;10(11):1240-1245.
Moetaz El-Domyati MD,a Tarek S. El-Ammawi MD,a Osama Moawad MD,b Walid Medhat MD,a, c Mỹ G. Mahoney PhD,c Jouni Uitto MD PhDc|
Background: The use of intense pulsed light (IPL) for facial rejuvenation had been the topic of many studies. However, few of them discussed quantitative changes in extracellular matrix proteins after IPL therapy.
Objective: To objectively quantify the histological changes in extracellular matrix proteins after IPL treatment for facial wrinkles.
Methods: Biopsy specimens were obtained from the periocular area of six volunteers of Fitzpatrick skin type III–IV and Glogau's class I–III wrinkles. They were subjected to three months of IPL treatment (six sessions at two-week intervals). Using histological and immunostaining analysis coupled with computerized morphometric analysis, quantitative evaluation of collagen types I, III and VII, newly synthesized collagen, total elastin and tropoelastin was performed for skin biopsies at baseline, end of treatment, and three months post-treatment.
Results: Clinical assessment of volunteers did not show clinically noticeable improvement in facial wrinkles after IPL treatment. Furthermore, quantitative evaluation of extracellular matrix proteins showed no statistically significant changes (P>0.05) in response to IPL treatment.
Conclusion: Although 50 percent of volunteers showed mild improvement in skin texture at the end of IPL treatment, none of them reported improvement in skin tightening or wrinkles. No statistically significant histological changes were observed three months post IPL treatment.
J Drugs Dermatol. 2011;10(11):1246-1252.
Comparison Between Sequentional Treatment With Diode and Alexandrite Lasers Versus Alexandrite Laser Alone in the Treatment of Hirsutism
Laser systems that are commonly used for the treatment of hirsutism include the ruby laser (694 nm), the diode laser (800 nm), the alexandrite laser (755 nm) and the Nd:YAG laser (1084 nm). The diode laser and alexandrite laser are considered effective in treatment of hirsutism in dark-skinned patients. The response of hairs to these laser systems is variable and not complete. In this study, we compared the efficacy of these two laser systems for permanent hair removal. This was a randomized, controlled clinical trial that was performed with women of the age range 15−45 years old. After obtaining informed consent, the samples were randomized into two groups using random allocation software. The first group was treated with alexandrite laser alone (four sessions, two months apart). The second group was treated sequentially with diode laser for the first two sessions and alexandrite laser for the next two sessions. Overall, 111 patients (57 patients in the alexandrite laser group and 54 patients in the sequential diode-alexandrite laser group) were evaluated. There was no significant difference regarding mean of hair reduction between the two groups during the courses of treatment. Except for the first session, there was no significant difference regarding percent of patient satisfaction between the two groups (P value >0.05). Comparison between the two groups showed no significant difference one month, three months and six months after the last treatment (P value >0.05). Regarding the results of our study, there is no significant difference between sequential treatment with diode and alexandrite lasers versus alexandrite laser alone in the treatment of hirsutism. We suggest that in further studies, the efficacy of sequential treatment with other laser systems is evaluated against single treatment methods.
J Drugs Dermatol. 2011;10(11):1255-1259.
A Pilot Study Using Reflectance Confocal Microscopy (RCM) in the Assessment of a Novel Formulation for the Treatment of Melasma
Katerina Tsilika,a Jean Luc Levy MD,c Hee Young Kang MD PhD,a Luc Duteil PhD,a Abdallah Khemis MD,a Rosalind Hughes MD,a Thierry Passeron MD PhD,a,b Jean Paul Ortonne MD,a Philippe Bahadoran MD PhDa,b|
Introduction:Melasma is a common pigmentary disorder caused by abnormal melanin deposits within the skin. Hydroquinone (HQ) is presently the most popular depigmenting agent, however the treatment of melasma remains unsatisfactory, resulting in a need to evaluate new depigmenting agents.
Objective: The objective of this study was to assess, using standard methods and a novel technique, in vivo Reflectance Confocal Microscopy (RCM), the efficacy and safety of a new non-HQ bleaching agent Dermamelan® (Mesoestetic, Barcelona, Spain) in the treatment of melasma.
Methods: Ten women with melasma were enrolled in an open-label trial lasting four months. Patients were of Fitzpatrick skin types II–IV. A non-HQ depigmenting agent (Dermamelan) was applied once-daily for three months. Melasma Area and Severity Indices (MASI) were measured. Standard and UV-light photographs were taken and in vivo RCM, which detects pigmentary changes at a cellular level, was done. Evaluations were performed before treatment, on the first, second and third month of treatment and one month after treatment. Upon cessation of the trial, patients completed a questionnaire regarding efficacy and tolerance.
Results: At baseline, RCM detected hyperpigmented keratinocytes in all patients, dendritic cells in 2/10 patients, and melanophages in 2/10 patients. Based on the MASI score, Dermamelan treatment improved melasma by 50 percent. This was confirmed by standard and UV-light photography. Maximum therapeutic effect was usually reached by one month of treatment and was maintained at one month following its completion. Interestingly Dermamelan treatment also induced a statistically significant decrease of pigmented epidermal keratinocytes as detected by RCM. Patients with melanophages on RCM at baseline had a poorer outcome, but not those with dendritic cells. Mild irritation was the only adverse event observed during treatment. The majority of patients were satisfied with the result.
Conclusion: This study suggests that Dermamelan produces significant rapid improvement of melasma at a clinical and cellular level and demonstrates the potential of RCM to monitor and possibly predict efficacy of a new depigmenting agent in the treatment of melasma.
J Drugs Dermatol. 2011;10(11):1260-1264.
Eric F. Bernstein MD|Background and Objectives: The purpose of this study is to quantify the safety and effectiveness of a multiplexed 1,440 and 1,320 nm fractionated laser for the treatment of chronic photodamage.
Study Design: A total of twenty subjects with chronic photodamage were enrolled in this study. Subjects received a maximum of four full-face treatments at an average fluence of 9.5 J/cm2 at 1,320 nm and 2 J/cm2 at 1,450 nm, delivered sequentially using forced-air cooling, at monthly intervals. Digital photographs were taken two months following the final treatment and compared to pre-treatment photographs by two blinded physician observers.
Results: Improvement in photodamage, overall appearance, wrinkles, hyper-pigmentation, enlarged pores, and sagging skin was rated by blinded physician evaluation of digital photographs as being in the 25-50 percent range. Subjective ratings averaged improved for all criteria that were evaluated, including wrinkles, enlarged pores, redness, sagging skin and hyper-pigmentation.
Conclusions: The multiplexed 1,320 nm and 1,440 nm fractionated laser improves cuta/neous photodamage as assessed by objective and subjective criteria.
J Drugs Dermatol. 2011;10(11):1266-1270.
Isaac Zilinsky MD,a Perry Robins MD,b Alon Liran MD,a Oren Weissman MD,a Eran Millet MD,a Nimrod Farber MD,a Josef Haik MD,a Eyal Winkler MDa|
Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skinsparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.
J Drugs Dermatol. 2011;10(11):1271-1274.
A number of injection techniques have been described for the placement of hyaluronic acid fillers. Such techniques include, but are not limited to, linear threading, depot, fanning, and layering. The tower technique for hyaluronic acid filler injection is a novel variation of the depot and layering techniques. With this technique, the hyaluronic acid is deposited via a perpendicular approach to the deep tissue plane with a gradual tapering of product deposition as the needle is withdrawn. A series of towers or struts are thus created. These towers serve as support structures for the overlying soft tissue, thereby restoring the face to a more youthful appearance. The anatomic areas most amenable to this technique include the lateral brow, the nasolabial folds, the marionette lines, the prejowl sulcus, and the mental region. A detailed description of the tower technique for facial volume restoration with hyaluronic acid fillers is provided. Further prospective studies are needed to compare the efficacy, safety, and longevity of this technique to other commonly used techniques for the injection of hyaluronic acid fillers.
J Drugs Dermatol. 2011;10(11):1277-1280.
A Randomized, Double-Blind, Vehicle-Controlled Efficacy and Safety Study of Naftifine 2% Cream in the Treatment of Tinea Pedis
Lawrence Charles Parish MD,a,b Jennifer L. Parish MD,a Hirak B. Routh MB BS,b Alan B. Fleischer Jr. MD,c Edward V. Avakian MA PhD,c Stefan Plaum MD,c Bhushan Hardas MD MBAc|
Objective: Naftifine HCl 2% cream (NAFT-2) is a topical allylamine antifungal agent under development in the United States. This randomized, double-blind, vehicle-controlled, phase 3 trial evaluated the efficacy and safety of two weeks of NAFT-2 treatment in subjects with tinea pedis. Naftifine 1% cream (NAFT-1) treatment for four weeks and vehicle were also evaluated as a positive control.
Methods: 709 subjects were randomly assigned 2:1:2:1 to one of four treatment groups: (i) NAFT-2 (n= 235), (ii) two-week vehicle (n=118), (iii) NAFT-1 (n=237), or (iv) four-week vehicle (n=119). Efficacy was evaluated at baseline, week 2, week 4, and week 6 and consisted of mycology determination (KOH and dermatophyte culture) and scoring of clinical symptom severity (erythema, scaling, and pruritus). Efficacy was only analyzed in 425 subjects with positive baseline dermatophyte culture. Safety was evaluated by adverse events (AE) and laboratory values in 707 subjects.
Results: At week 6, NAFT-2 subjects achieved 18 percent complete cure rate, 67 percent mycological cure rate, 57 percent treatment effectiveness, 22 percent clinical cure rate, and 78 percent clinical success rate compared to respective vehicle rates of seven percent (one-sided, P<0.01), 21 percent (P<0.001), 20 percent (P<0.001), 11 percent (P=0.04) and 49 percent (P<0.001). Week 6 efficacy responses in NAFT-1-treated subjects were significantly higher than vehicle subjects and almost identical to NAFT-2 subjects. Mycological cure and clinical response rates in both NAFT-2 and NAFT-1 increased from week 2 to week 6. Treatment-related AEs occurred in five percent of NAFT-2 subjects, seven percent of vehicle subjects, four percent of NAFT-1 subjects and eight percent of vehicle subjects. The most common AEs for all groups were application site pruritus and skin irritation.
Conclusion: Topical NAFT-2 for two weeks is safe and provides significantly superior antifungal treatment than vehicle in tinea pedis subjects. NAFT-2 produces equivalent efficacy responses to four weeks of NAFT-1 treatment. The fungicidal activity of naftifine continues to increase for at least one month after treatment is completed. (Clinical Trials Identification Numbe=NCT00750139).
J Drugs Dermatol. 2011;10(11):1282-1288.
Tina Bhutani MD and John Koo MD|With the recent data showing that psoriasis patients are at higher risk for systemic malignancies, there is a growing awareness for the need to minimize cancer risks in psoriasis patients. Retinoids as a class of medication have been widely studied as potential agents for cancer chemoprevention. Since they act by inducing cell differentiation and maturation, they may help reverse the pathogenesis of malignancies. Through an extensive literature review, this paper provides an update on the available data on retinoids and their systemic anti-cancer properties. Retinoids appear to be beneficial in the prevention of cutaneous T-cell lymphoma, acute promyelocytic leukemia, head and neck cancers, hepatocellular carcinoma, breast cancer and neuroblastoma. So far the data does not support anti-cancer efficacy of retinoids in the prevention of prostate or pancreatic cancer and may possibly have harmful effects in the pathogenesis of lung cancer in smokers.
J Drugs Dermatol. 2011;10(11):1292-1298.
Consuelo V. David BA,a Hong Nguyen BS,b Gary Goldenberg MDc|
The immunomodulatory characteristics and topical application of imiquimod (IQ), a toll-like receptor 7 agonist, have lead to extensive off-label therapeutic trials. Off-label use is not uncommon in dermatology. However, clinicians must make informed decisions to ensure safe and effective implementation when standardized protocols are lacking. We present the highest level of clinical evidence for each off-label application of IQ, summarize management steps, treatment regimens, and results. We hope consolidation of this information will facilitate implementation of informed and evidence-based clinical decisions. Forty-six off-label applications were reported. Treatments were generally applied in the same manner, tailored to induce an inflammatory response and reduced with the development of adverse reactions. The efficacy of imiquimod ranged from promising to suboptimal compared to standard treatments and protocols. Clinicians who choose to use IQ off-label should have a firm understanding of the extent an application has been studied and how to manage adverse events.
J Drugs Dermatol. 2011;10(11):1300-1306.
Hair Regrowth Following a Wnt- and Follistatin- Containing Treatment: Safety and Efficacy in a First-in-Man Phase 1 Clinical TrialResearch has shown the importance of follistatin, Wnt 7a, and wound healing growth factors on the stimulation of bulge cells and inter-follicular stem cells to induce hair growth. We have studied the effects of a bioengineered, non-recombinant, human cell-derived formulation, termed Hair Stimulating Complex (HSC), containing these factors to assess its hair growth activity in male pattern baldness. HSC showed in vitro Wnt activity and contained follistatin, KGF, and VEGF. The clinical study was a double-blind, placebo-controlled, randomized single site trial and was designed to evaluate safety of the HSC product and assess efficacy in stimulating hair growth. All 26 subjects tolerated the single, intradermal injection of HSC procedures well, and no signs of an adverse reaction were reported. Histopathological evaluation of the treatment site biopsies taken at 22 and 52 weeks post-treatment revealed no abnormal morphology, hamartomas, or other pathological responses. Trichoscan image analysis of HSC-treated sites at 12 and 52 weeks showed significant improvements in hair growth over the placebo. At the initial 12-week evaluation period, HSC-treated sites demonstrated an increase in hair shaft thickness (6.3%±2.5% vs. -0.63%±2.1%; P=0.046), thickness density (12.8%±4.5% vs. -0.2%±2.9%; P=0.028), and terminal hair density (20.6±4.9% vs. 4.4±4.9%; P=0.029). At one year, a statistically significant increase in total hair count (P=0.032) continued to be seen. These results demonstrate that a single intradermal administration of HSC improved hair growth in subjects with androgenetic alopecia and is a clinical substantiation of previous preclinical research with Wnts, follistatin, and other growth factors associated with wound healing and regeneration.
J Drugs Dermatol. 2011;10(11):1308-1312.
Eric F. Bernstein MD|
A number of drugs can cause cutaneous hyperpigmentation through a variety of mechanisms. The pigment is comprised of dermal deposits of the drug and its metabolites, often combined with melanin and hemosiderin. Minocycline and amiodarone are among the most common medications to cause skin-induced pigmentation. Affected individuals generally develop slate-gray pigmentation in affected sites. Treatment with various Q-switched lasers has been shown to be effective at removing drug-induced pigmentation. The author presents a man with amiodarone pigmentation of the face who responded to treatment with the Q-switched neodymium:yttrium-aluminum-garnet (Nd:YAG) laser.
J Drugs Dermatol. 2011;10(11):1316-1319.
Flor A. Mayoral MD and Janelle M. Vega|A 45-year-old man requested treatment with Thermage for skin tightening. He was treated with the new Thermage CPT system and received several facial burns due to failure of the dielectric membrane. It may be contraindicated to treat male patients with this system.
J Drugs Dermatol. 2011;10(11):1320-1321.
Matteo C. LoPiccolo MD,a Marsha L. Chaffins MD,a David J. Kouba MD PhDa,b|
Cutaneous lymphadenoma (CL) is a benign neoplasm commonly presenting on the head and neck of young and middle-aged adults. Complete surgical excision of CL is the treatment of choice and appears to be curative. As compared to local excision without margin control, Mohs micrographic surgery (MMS) may allow for more definitive tumor extirpation for large cases of CL and allow for greater tissue preservation at functionally and aesthetically sensitive sites. We present a case of cutaneous lymphadenoma presenting on the right cheek of a middle-aged male who was successfully treated with MMS.
J Drugs Dermatol. 2011;10(11):1324-1326.
The development of autoimmune disorders and an increase in autoimmune phenomena have been reported following vaccinations in a number of cases. Blistering skin disorders such as pemphigus vulgaris (PV) and bullous pemphigoid (BP) have also developed following various vaccinations.1,2 Here we describe a case of BP that developed in a 72-year-old male after receiving the zoster vaccine. We believe the association between zoster immunization and the acute onset of BP in our patient may not be coincidental. We further discuss proposed mechanisms leading to autoimmunity post vaccination.
J Drugs Dermatol. 2011;10(11):1328-1330.
Amanda Pickert BS, Michele Hughes MD, Michael Wells MD|
Sorafenib is a chemotherapeutic agent primarily used to treat metastatic renal cell carcinoma. It is a multikinase inhibitor that blocks cell proliferation and angiogenesis. Numerous cutaneous side effects have been reported in association with this medication, including acral erythema, inflammation of actinic keratoses, erythema multiforme, vasculitis, and keratoacanthomas. Up to 40 percent of patients on this medication develop dermatologic manifestations. We describe chloracne-like eruptions in two different patients with no exposure to aromatic hydrocarbons but who were recently started on sorafenib for treatment of metastatic renal carcinoma. The primary reason for discontinuation of sorafenib is secondary to its adverse side effect profile. Recognizing these effects early and administering appropriate treatment will likely increase medication compliance and minimize both dose reductions and discontinuation of the medication resulting in optimal treatment outcomes.
J Drugs Dermatol. 2011;10(11):1331-1334.
Resident Rounds Part I: Program Spotlight - The University of Louisville Dermatology Residency Training Program
William Adams MD and Sunita Crittenden MD|Resident Rounds is a section of the JDD dedicated to highlighting various dermatology departments with residency training programs. Resident Rounds includes three sections: (1) a program spotlight, highlighting pertinent information about the department and residency training program; (2) a section presenting study materials used by residents at the program; and (3) a section designed to highlight recent interesting cases seen at the institution. This issue of Resident Rounds features the University of Louisville Dermatology Residency Training Program. The editor of Resident Rounds is Omar A. Ibrahimi MD PhD. He is currently the Director of Cutaneous Laser and Cosmetic Surgery and a Mohs surgeon at the University of Connecticut. Dr. Ibrahimi is also a Visiting Scientist at the Wellman Center for Photomedicine at Massachusetts General Hospital/Harvard Medical School. If you are interested in highlighting your training program in a future issue, please contact Dr. Ibrahimi at OIbrahimi@jddonline.com
Jonathan R. Van Meter MD, Tami B. Cassis MD, Jeffrey P. Callen MD, Soon Bahrami MD|No abstract details for the moment.
Resident Rounds. Part III: Erosive and Desquamative Syphilis Associated With Mucositis in the Setting of Acquired Immune Deficiency Syndrome
James Quertermous MS, J. Michael Bernardi MD, Janine Malone MD, Jeffrey P. Callen MD|No abstract details for the moment.
Kendra Gail Bergstrom MD|Psoriasis continues to be one of the most common and frustrating conditions that dermatologists and their patients face on a daily basis. Novel developments in basic science bring us closer than ever to understanding the pathogenesis of psoriasis. At the same time, the advent of biologic immunomodulators has opened doors in terms of treatment options and a better understanding of the underlying etiology of psoriasis. Genes involved in the immune system, keratinocyte differentiation, and vascular hyperplasia have all been implicated in psoriasis.
Pipeline Previews brings to you information on the newest drugs and medical products as they become available to the dermatologic community. This department may include additional information from the manufacturers, plus reports from physicians who wish to share their clinical experience with these new products. In addition, we will inform our readers about the latest drugs receiving Food and Drug Administration (FDA) approval.
Clinical Trial Review is a JDD department designed to provide physicians with information on drugs and devices undergoing clinical testing. It is our goal to inform the reader of the status of select drug and device studies relevant to the practice of dermatology before this information is available through standard channels. To participate in or learn more about these and additional trials, visit www.clinicaltrials.gov.