Volume 10 | Issue 4
Ashley R. Mason MD and Melinda R. Mohr MDa|
Resident Rounds is a new section of the JDD dedicated to highlighting various dermatology departments with residency training programs. Resident Rounds will feature 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 Eastern Virginia Medical School Dermatology Residency Program. The editor of Resident Rounds is Omar A. Ibrahimi, MD, PhD. Dr. Ibrahimi is a recent graduate of the Harvard Combined Program in Dermatology and currently a fellow in Mohs, Laser and Cosmetic Surgery at the University of California Davis. If you are interested in highlighting your training program in a future issue, please contact Dr. Ibrahimi at firstname.lastname@example.org
Multi-Center Clinical Study and Review of Fractional Ablative CO2 Laser Resurfacing for the Treatment of Rhytides, Photoaging, Scars and Striae
Macrene Alexiades-Armenakas MD PhD FAAD,a Deborah Sarnoff MD, Robert Gotkin MD, Neil Sadick MD|
Laser skin resurfacing has shifted over the past two decades from standard ablative resurfacing to non-ablative resurfacing and most recently, to fractional laser resurfacing. In this most recent category, fractional non-ablative lasers were first introduced followed by fractional ablative lasers, which offer an improved balance between safety and efficacy. In the current article, a review of fractional ablative resurfacing is presented alongside the results from a multi-center clinical study employing the fractional carbon dioxide (CO2) laser (SmartXide DOT, DEKA) for the treatment of rhytides, photoaging, scars and striae distensae.
J Drugs Dermatol. 2011;10(4):352-362.
Clare E. Foss MD and Asmaa A. Chaudhry MD|No abstract details for the moment.
Adalimumab Plus Narrowband Ultraviolet B Light Phototherapy for the Treatment of Moderate to Severe Psoriasis
Jerry Bagel MDa,b|
Background: Combining systemic agents with phototherapy is becoming a standard of care for patients with moderate to severe psoriasis. The combination of adalimumab and phototherapy has not been previously explored.
Methods: In this 24-week single-arm open-label study, adults with moderate to severe psoriasis received adalimumab 40 mg every other week and narrowband (NB)-UVB phototherapy three times a week for 12 weeks and then were followed for 12 weeks without treatment. Response to therapy was determined using the Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA) affected and Physician’s Global Assessment (PGA) of psoriasis.
Results: Twenty patients were enrolled with mean baseline scores of 17.0 for PASI, 21.2 for BSA and 3.5 for PGA. Half (10/20) of the patients achieved PASI 75 response by week 4. At the end of treatment at week 12, 19 (95%) patients achieved PASI-75, 15 (75%) patients achieved PASI-90 and 11 (55%) patients achieved PASI-100. Seventeen (85%) patients were clear or almost clear (PGA score ≤1). Mean baseline PASI, BSA and PGA scores improved by 95 percent, 93 percent and 80 percent, respectively. Disease improvement was observed through the end of follow up period at week 24. No serious adverse events were noted.
Conclusion: Concurrent use of adalimumab and NB-UVB phototherapy was clinically effective and well tolerated in patients with moderate to severe psoriasis. This combination regimen represents a new treatment option for clinical practice and warrants further investigation in controlled clinical trials.
J Drugs Dermatol. 2011;10(4):366--371.
Prospective, Case-Based Assessment of Sequential Therapy With Topical Fluorouracil Cream 0.5% and ALA-PDT for the Treatment of Actinic Keratosis
George Martin, MD|
The sequential use of topical therapies and short-incubation photodynamic therapy for actinic keratosis (AK) has not been extensively studied. The author reports on treatment with sequential 5-fluorouracil (5-FU) cream 0.5% and 5-aminolevulinic acid-photodynamic therapy (ALA-PDT) in three older men with photodamaged skin and a history of AK. These findings suggest that this combination therapy, when compared with short-contact (1 hour) ALA-PDT alone, is more effective, minimizes the recurrence of areas of field cancerization and improves the appearance of the skin. The use of 5-FU cream 0.5% before and after photodynamic therapy is effective in revealing the presence of both clinical and subclinical AK lesions.
J Drugs Dermatol. 2011;10(4):372-378.
Treatment of Hidradenitis Suppurativa by Photodynamic Therapy With Aminolevulinic Acid: Preliminary Results
Eric S. Schweiger MD,a Christy C. Riddle MD,b Daniel J. Aires MDb|
Background: The current standard of care for hidradenitis suppurativa (HS) includes antibiotics (oral/topical), retinoids (oral/topical) and intralesional steroids and is unsatisfactory. Photodynamic therapy (PDT) with 20% 5-aminolevulinic acid (ALA) has been used "off label" to treat acne vulgaris and may hold promise as a therapy for HS. This open-label, non-blinded study investigated the efficacy and safety of ALA PDT for the treatment of HS using two blue light sources and intense pulsed light (IPL) for photoactivation.
Methods: Twelve subjects with active HS enrolled to undergo ALA PDT once weekly for four weeks with follow-up visits 4, 8, and 12 or more weeks later. Nine subjects completed the study through the week 8 follow-up visit. Lesions were counted at each treatment visit at week 4, week 8 and at the final week.
Results: Mean lesion counts were 11.25 at baseline, 6.5 at 4 weeks (50.8% reduction), and 7.5 at 8 weeks (29.9% reduction). Mean Global Severity Scores were 2.2 at baseline, 1.5 at 4 weeks, and 1.8 at 8 weeks. Mean DLQI scores were 17.3 at baseline, 13.1 at 4 weeks (27.2% improvement), 14.00 at 8 weeks (19.3% improvement) and 14.0 (19.3% improvement) at the final week (16-62 weeks). Three subjects (25%) had complete clearance and no active lesions 4 weeks after the final treatment. Treatments were more tolerable for subjects treated with blue light than with IPL.
Conclusion: ALA PDT may be a safe and effective treatment of hidradenitis suppurativa.
J Drugs Dermatol. 2011;10(4):381-386.
Eric F. Bernstein MD MSE,a Jay Bhawalkar PhD,b Joan Clifford MS,b James White,b James Hsia PhDb|
Background: Due to the hemoglobin-selective wavelength of the 595 nm pulsed-dye laser, it is a device of choice for treating cutaneous vascular lesions. However, it is less effective and removing dyschromia, which along with hypervascularity is a cardinal sign of cutaneous photodamage. A novel 607 nm dye laser was developed as a first step in creating a dual-wavelength pulsed-dye laser.
Study Design/Materials and Methods: Twenty-five subjects with dyschromia on the chest due to chronic photodamage were enrolled into an open-label study to explore the safety and efficacy of a 607 nm pulsed-dye laser, with 22 completing the study. Two treatments were administered to the chest, one month apart, with fluences ranging from 3-6 J/cm,2 using a 10 mm diameter spot and pulse duration of 1.5 msec. Cross-polarized digital photographs were taken before and two months following the final treatment and rated for improvement by physicians in a blinded fashion.
Results: Improvement was rated on a five-point scale with no subjects rated as poor (<25%) clearance, three subjects (13.6%) demonstrating fair (26-50%) improvement, seven subjects (31.8%) rated as good (51-75%) improvement, 12 (54.5%) were rated as excellent (76-95%) improvement, while none were rated as outstanding improvement (>95%).
Conclusion: This is the first study of the 607 nm pulsed-dye laser which showed it to be safe and effective for treating dyschromia of the chest due to chronic photodamage, and may in the future expand the ability of the pulsed-dye laser to treat photodamaged skin.
J Drugs Dermatol. 2011;10(4):388-394.
An Open-Label, Prospective Cohort Pilot Study to Evaluate the Efficacy and Safety of Etanercept in the Treatment of Moderate to Severe Plaque Psoriasis in Patients Who Have Not Had an Adequate Response to Adalimumab
Ronald Vender MD FRCPC|
Background: The past several years have seen the approval of five different biologic agents for the treatment of moderate to severe plaque psoriasis in the United States and Canada. Psoriasis has proven to be a difficult disease to treat and treatment failures, even with newer biologic therapies, are not uncommon. The vast majority of clinical data for these medications is derived from treatment of biologic-naïve patients, or patients who have not responded to, or lost response to, or not tolerated systemic therapy for psoriasis. There is currently little data available on therapeutic response of a second biologic therapy after loss of response, or no response, to the first biologic therapy initiated. It has become common clinical practice to switch medications that are structurally distinct but therapeutically similar in order to achieve an improved clinical outcome. Therapeutic interchange now is being applied to the biologic agents used to treat psoriasis.
Objectives: Using a proof of concept study, describe the response of etanercept after adalimumab has failed to produce a satisfactory response in moderate to severe plaque psoriasis.
Methods: A total of 10 biologically naïve patients with moderate to severe psoriasis who were initiated on adalimumab for at least 12 weeks but had a Physician’s Global Assessment (PGA) of mild or worse were transitioned to commercial etanercept 50 mg twice weekly (BIW) for 12 weeks followed by a dose reduction to 50 mg once weekly (OW) for an additional 12 weeks. Ethics approval was obtained and the study registered with ClinicalTrials.gov (NCT00833729). The primary outcome measured was the mean change in Physician’s Global Assessment (PGA) score (range 0-5) from baseline (when the first etanercept injection is given) to 12 weeks of etanercept therapy. The secondary outcomes measures included the mean change in Dermatology Quality of Life Index (DLQI), mean change in body surface area (BSA) covered in psoriasis, Subject’s Global Assessment of disease (SGA), proportion of patients achieving an improvement in PGA score from baseline to 12 weeks and again at 24 weeks and safety.
Results: Overall, there were significant favorable changes in all outcomes measured (PGA, SGA, BSA and DLQI) with respect to etanercept’s efficacy after an inadequate response to at least 12 weeks of adalimumab therapy. There were no significant safety issues noted especially during the transition period from adalimumab to etanercept. ClinicalTrials.gov identifier: NCT00833729.
J Drugs Dermatol. 2011;10(4):396-402.
The Efficacy of Vorinostat in Combination With Interferon Alpha and Extracorporeal Photopheresis in Late Stage Mycosis Fungoides and Sézary Syndrome
Hatice Sanli MD,a Bengu Nisa Akay MD,a Rana Anadolu MD,a Muhit Ozcan MD,b Secil Saral MD,a Aynur Akyol MDa|
Objective: Long-term survival for advanced stages of mycosis fungoides (MF) may be beneficially affected by the use of multimodality therapy. We aim to evaluate the activity of vorinostat in combination with interferon (IFN) alpha and extracorporeal photopheresis (ECP) with persistent, progressive advanced stage MF and Sezary syndrome (SS).
Patients and Methods: Three patients with stage IIB-IVA MF/SS were treated with vorinostat 400 mg/day/po. Vorinostat was added to ongoing ECP and IFN-alpha-2a therapies in all three patients.
Results: The patient with stage IIB MF achieved a complete response. The patient with SS showed a stable disease of less than 50 percent improvement in body surface area with reduction in the sizes of axillary and inguinal lymph nodes. A partial remission was maintained for 24 weeks in the patient with stage IVA MF, followed by rapid disease progression under treatment which led to cessation of vorinostat treatment due to study criteria as well as serious side effects.
Conclusion: Our experience in this case series is suggestive of the synergistic effect of vorinostat in combination with IFN and ECP and supports the efficacy of vorinostat in inducing prolonged responses in patients with progressive disease and/or stable disease in otherwise progressive and treatment refractory late stage MF/SS.
J Drugs Dermatol. 2011;10(4):403-408.
Jennifer Hayes BAa and John Koo MDb|
The potential relationship between systemic retinoids used in dermatology and affective disorders is controversial. Acitretin, which is widely used in the treatment of psoriasis is part of this controversy secondary to its chemical relation to isotretinoin, a drug which has been associated with a large number of anecdotal case reports of depression and suicidal ideation. Moreover, an FDA package insert precaution regarding acitretin's association with depression and suicide has elevated the level of concern for patient safety. The objective of this article is to review the evidence in the literature regarding acitretin's association with affective disorders. After 12 years of worldwide use only two cases involving acitretin have been reported in the literature. In addition, despite many anecdotal cases involving isotretinoin, there have been no clinical studies that have proven a causal relationship between isotretinoin and depression or suicidal ideation. For acitretin there have been no systematic clinical studies that examine such a relationship. Moreover, it is notable that the FDA precaution regarding depression and suicide on the package insert of acitretin predates the publication of the aforementioned two cases. This suggests that a relationship between acitretin and affective disorders is a class labeling rather than a scientifically proven association.
J Drugs Dermatol. 2011;10(4):409-412.
No abstract details for the moment.
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.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Adam Rees MD, Quyn Sherrod MD, Lorraine Young MD|Chemical burn is a rare complication of topical polyvinylpyrrolidone-iodine (PVP-I), commonly called povidone-iodine (trade name Betadine, Purdue, Stamford, NJ). This adverse reaction occurred on the buttocks of an eight-year-old male after undergoing a laparoscopic appendectomy involving antiseptic skin preparation using a 10% PVP-I solution. This case is consistent with previous reports in which a chemical burn develops when PVP-I does not adequately dry, pools beneath a dependent body part during surgery, or is placed under an occlusive device. Symptoms develop immediately to one day after surgery. The proposed mechanism is irritation from iodine coupled with maceration, pressure and friction. While patients typically heal without significant scarring, the burn subjects the patient to unnecessary pain, prolongs hospitalization and increases the risk for infection. Physicians should be aware of this complication and therefore take preventative measures. These include allowing PVP-I to completely dry, preventing dripping and pooling and avoiding occlusion.
J Drugs Dermatol. 2011;10(4):414-417.
Fatal Cutaneous Strongyloidiasis as a Side Effect of Pemphigus Foliaceus Treatment With Mycophenolate Mofetil
Magalys Vitiello MD,b Michael Shelling MD,a Ivan Camacho MD,a Clara Milikowski MD,a Francisco A. Kerdel BSc MBBSb|Strongyloidiasis is caused by the roundworm Strongyloides stercoralis (S. stercoralis). It is uncommon in the Unites States, and most cases are brought by travelers who have visited or lived in South America or Africa.1 Individuals with an intact immune system may experience mild gastrointestinal symptoms or none at all. In contrast, those with a compromised immune system may develop a rapidly fatal infection, commonly referred to as hyperinfection syndrome or disseminated Strongyloidiasis. We present a 66-year-old inmunocompromised male with Pemphigus Foliaceus who was admitted to the intensive care unit in critical condition and in whom a skin biopsy proved to be the main tool in the diagnosis of Strongyloidiasis.
J Drugs Dermatol. 2011;10(4):418-421.
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. We trust you will find this information beneficial to your practice and research.