Volume 11 | Issue 7
Neil Sadick MD|No abstract details for the moment.
Joseph Alcalay MD, President, ISDS C. William Hanke MD, Executive Director, ISDS Gerhard Sattler MD, Executive Director, ISDS|No abstract details for the moment.
Lawrence F. Eichenfield MD|No abstract details for the moment.
Colloidal oatmeal has been used for decades to soothe and ameliorate atopic dermatitis and other pruritic and/or xerotic dermatoses. In-vitro and/or in-vivo studies have confirmed the anti-inflammatory, barrier repair, and moisturizing properties of this compound. A broad set of studies has been conducted in recent years to assess the effects of colloidal oatmeal as adjunct treatment in the management of atopic dermatitis (AD). This paper will review these studies. In these investigations, patients in all age groups (3 months to 60 years) with mild to moderate atopic dermatitis were included and allowed to continue their prescribed topical medications. These studies found that the daily use of moisturizers and/or cleansers containing colloidal oatmeal significantly improved many clinical outcomes of atopic dermatitis from baseline: investigator's assessment (IGA), eczema area and severity index (EASI), itch, dryness, and quality of life indices. Safety results showed that the formulations were well tolerated in babies, children, and adults with AD.
J Drugs Dermatol. 2012;11(7):804-807.
Aim: Despite a mostly self-limiting course, infantile hemangiomas can cause severe functional and/or cosmetic problems. The aim of this study was to determine the efficiency of propranolol treatment on infantile hemangiomas.
Methods: Sixty-seven infantile hemangioma patients were included in propranolol protocol in two institutions from 2009 to 2011. Participants included 36 boys and 31 girls. An associate protocol with radiology and pediatric cardiology was constructed for appropriate patient selection. Patients received a dose of 2 mg/kg/day, and all were admitted for the first 24 hours of therapy.
Results: Sixty-seven patients were included in the study. Mean age at the initiation of therapy was 7 months (1 to 24 months), and eleven patients were older than 12 months of age when propranolol was started. All patients showed improvement with varying responses. No side effects were detected during the treatment.
Conclusion: Previously defined treatments for hemangiomas were efficient, yet had a limited usage because of side effects. Propranolol, with a high efficacy (not as total involution but stabilization and regression) and feasibility deserves to be the first line therapy for infantile hemangiomas even after the proliferation phase.
J Drugs Dermatol. 2012;11(7):808-811.
Multiples of certain cutaneous lesions should alert the clinician to a wider differential diagnosis and possible systemic associations although the individual skin lesion is often benign in nature and banal in appearance.
This article focuses on such findings in selected multiple cutaneous lesions that may be classified according to the primary cutaneous feature as vascular, pigmentary, nevoid hamartomas, and tumors/neoplastic conditions. The clinical presentation of each entity and its significance, appropriate diagnostic evaluation, therapeutic and prognostic considerations and pertinent differential diagnoses will be reviewed.
J Drugs Dermatol. 2012;11(7):812-817.
Moderate to Severe Acne in Adolescents With Skin of Color: Benefits of a Fixed Combination Clindamycin Phosphate 1.2% and Benzoyl Peroxide 2.5% Aqueous Gel
Objective: Acne is common in adolescents and especially difficult to manage in people with color. A fixed combination of clindamycin phosphate and benzoyl peroxide (BPO) (clindamycin phosphate 1.2%/BPO 2.5% gel) was evaluated to determine its utility in treating moderate to severe acne in adolescents with skin of color.
Methods: Three hundred thirty-seven adolescent acne subjects (aged 12 to <18 years) with skin of color were evaluated from 2 multicenter, double-blind studies. Subjects were randomized to receive clindamycin phosphate 1.2%/BPO 2.5% gel or vehicle, once daily for 12 weeks. Efficacy and tolerability were evaluated. Data were compared with an adolescent (A) and skin of color (B) cohort from the same pivotal study enrolling 2,813 subjects.
Results: Superior mean percent reductions in inflammatory, noninflammatory, and total lesion counts were observed in subjects receiving clindamycin phosphate 1.2%/BPO 2.5% gel compared to vehicle. At week 12, clindamycin phosphate 1.2%/BPO 2.5% gel showed similar lesion reduction compared to groups A and B (P<0.001). Treatment success with clindamycin phosphate 1.2%/BPO 2.5% gel, assessed by investigator and subject, was superior to vehicle and comparable to that seen in groups A and B (P<0.001). Clindamycin phosphate 1.2%/ BPO 2.5% gel was associated with a low incidence of treatment-related AEs and a favorable cutaneous tolerability profile.
Conclusions: Clindamycin phosphate 1.2%/BPO 2.5% gel has been shown to be effective, safe, and well tolerated in moderate to severe acne in adolescents with skin of color.
J Drugs Dermatol. 2012;11(7):818-824.
Infantile hemangiomas are benign vascular neoplasms of childhood that often have implications on development, cosmesis, and comfort. Traditional therapy has involved either observation or corticosteroids, depending on location and size. Recent studies have reported the successful use of beta-adrenergic antagonists in treating infantile hemangiomas. This succinct review discusses the properties and current applications of beta-adrenergic antagonists as well as the established treatments for infantile hemangioma.
J Drugs Dermatol. 2012;11(7):826-829.
The Effect of Benzoyl Peroxide 9.8% Emollient Foam on Reduction of Propionibacterium acnes on the Back Using a Short Contact Therapy Approach
Benzoyl peroxide (BP) exerts its therapeutic effect for acne vulgaris through reduction of Propionibacterium acnes. A 1.0 to 2.0 log reduction in P acnes has been demonstrated primarily on the face with use of “leave-on” BP formulations, but also with some BP cleansers. In addition to use for facial acne vulgaris, cleanser formulations of BP are commonly used for truncal acne vulgaris due to ease of use on a large body-surface area and to avoid bleaching of fabric. To date, evaluation of P acnes reduction on the trunk has not been well studied with BP formulations, especially with the use of recognized and standardized methods to accurately determine P acnes colony counts. A previous study demonstrated that a BP 8% cleanser did not reduce counts of P acnes on the back when subjects were instructed to apply the cleanser in the shower, allow it to dry for 20 seconds on the skin, and then rinse off the cleanser. Evaluation of specified time intervals between application on the back and rinsing with BP formulations would help to better define the necessary skin contact time associated with high reductions of P acnes (>90%), recognizing also the potential roles of BP concentration and vehicle. This 2 week study using quantitative bacteriologic cultures evaluates the effectiveness of BP 9.8% emollient foam in reducing P acnes levels on the back with 2 minutes of skin contact time and compares results with a BP 5.3% “leave-on” emollient foam formulation. Short contact therapy utilizing a 2 minute skin contact time with BP 9.8% emollient foam used once daily over a 2 week duration was highly effective in reducing the quantity of P acnes organisms on the back and provided comparable colony count reduction to “leave on” therapy using BP 5.3% emollient foam.
J Drugs Dermatol. 2012;11(7):830-833.
Modulation of Cytokine and Nitric Oxide Production by Keratinocytes, Epithelial Cells, and Mononuclear Phagocytes in a Co-Culture Model of Inflammatory AcneIntroduction: Ultraviolet B (UVB, 290 nm to 320 nm) has been reported to modulate the cytokine-mediated inflammatory process in various inflammatory skin conditions, including production of TNF-α, IL-1α, IL-6, IL-8, and IL-10. We constructed an in vitro model system involving co-culture of different cell types to study the effect of UVB on the inflammatory process using nitric oxide (NO) and tumor necrosis factor (TNF)-α as markers of inflammation.
Objective: This study was conducted to quantitatively assess the products secreted by human epithelial keratinocytes in the presence and absence of macrophages/monocytes.
Methods: Cells were exposed to UVB radiation (50 mJ to 200 mJ per cm2) or treated with bacterial lipopolysaccharide (LPS) as stimulator of inflammatory response. Nitric oxide (NO) was measured by modified Griess assay and TNF-α was measured by quantitative ELISA. For the co-culture system, SC monocytes were seeded in a 24-well Transwell tissue culture plate whereas irradiated keratinocytes were seeded in the individual baskets subsequently placed on top of the monocyte cultures, and samples of culture supernatants were collected at 1 to 6 days.
Results: When primary human epidermal keratinocytes (NHEK) were irradiated with UVB, a dose-dependent stimulation of TNF-α production was observed (33% to 200% increase). TNF-α production was not changed significantly in SC monocytes/NHEK co-culture. In contrast, when macrophages were irradiated with UVB, significant inhibition of NO production (40% suppression, P<0.001) was seen.
Conclusion: This improved model of cutaneous inflammation could use multiple cells to study their interactions and to offer convenience, reproducibility, and a closer approximation of in vivo conditions.
J Drugs Dermatol. 2012;11(7):834-836.
Neal D. Bhatia MDa and James Q. Del Rosso DO FAOCDb|
The pathophysiology of papulopustular rosacea (PPR) is primarily characterized by inflammation associated with several factors such as abnormal innate immune response, neurovascular dysregulation, stratum corneum barrier dysfunction, and depletion of antioxidant reserve, with no definitive evidence supporting an underlying microbial etiology. Several molecular inflammatory pathways have now been identified that enable the development of therapeutic agents that target the signs and symptoms of disease by modifying specific pathophysiological mechanisms. Available evidence demonstrates that topical and oral agents commonly used to treat PPR appear to modify some of these pathophysiological mechanisms and may prove to be complimentary when used in combination potentially leading to better therapeutic outcomes.
During the past two decades, six clinical studies have been published on the benefits of combining oral and topical therapies for PPR. Four studies suggest that doxycycline, including anti-inflammatory dose doxycycline (doxycycline 40 mg modified-release capsule once daily) can be combined with topical metronidazole or azelaic acid in patients with PPR to achieve more rapid control of a flare. At present, subantimicrobial dosing of a tetracycline agent that also maintains anti-inflammatory activity has only been established with doxycycline. Although antibiotic doses of tetracycline agents (such as doxycycline, minocycline, and tetracycline) are known to be effective for PPR, the use of subantimicrobial dosing of doxycycline avoids the risk of antibiotic resistance.
J Drugs Dermatol. 2012;11(7):838-844.
Despite advances in diagnostics and therapeutics, infectious diseases continue to be a major cause of morbidity and mortality, surpassing cardiovascular diseases and cancer. Accurate identification of causative pathogens is critical to prevent the spread of infectious diseases and to deliver appropriate and timely therapy. Various limitations ranging from cost to lengthy yield times of current diagnostic modalities highlight the need for new approaches. Nanotechnology represents an innovative direction offering many advantages for pathogen detection and identification. Through surface modifications, nanoparticles can be tailored to bind microbial surface markers, nucleic acids, and toxins. Combining these nanoparticles with both standard and developing detection technologies has led to the development of faster, more sensitive, and more economical diagnostic assays. This review will focus on the diagnostic advances that utilize fluorescent, metallic, and magnetic nanomaterials, highlighting their potential applications in the diagnosis of infectious dermatological conditions.
J Drugs Dermatol. 2012;11(7):846-851.
Dhaval Bhanusali MD, Marcelyn Coley MD, Jonathan I. Silverberg MD MPH PhD, Andrew Alexis MD MPH and Nanette B. Silverberg MD|Background: Tinea capitis periodically undergoes demographic shifts in causative dermatophyte and therapeutic response to oral anti-fungal therapy.
Objective: To determine prevalent fungal species and response to standard antifungal therapy in inner-city children of color.
Methods: An IRB-approved chart review of demographic, clinical, diagnostic, and therapeutic data was conducted for children and young adults (0 to 18 years of age) who had scalp fungal culture performed for scalp hyperkeratosis and/or alopecia over a 2.5 year time-period. Supplemental parental phone interview was performed for missing data points.
Results: A total of 84 patients with final diagnosis of tinea capitis were identified—52% male, 60.6% African-American, 28.2% Hispanic, and 9.9% Caucasian. Complete resolution at 4 weeks was uncommon in all demographic groups (Hispanic: 11.7%, African-American: 41.3%). The Hispanic group and the youngest patients (aged less than 4 years) were less likely to respond to initial therapy, but the results were not significant. Of the 80 tinea capitis patients initially treated with griseofulvin, 41 out of 54 children (76%) had complete response to micronized suspension +/- crushed tablet (33% required shift to tablets from suspension) and 20 out of 26 (76.9%) cleared on crushed tablets alone. Of the 19 griseofulvin failures, 5 cleared on fluconazole suspension, 7 on terbinafine sprinkles, 3 on itraconazole therapy, and 4 were lost to follow-up. Of the 47 patients who could be evaluated long-term after a single course of oral griseofulvin at 6 weeks or greater, 38 had documented long-term mycological cure (80.8%) and 42 had long-term clinical cure (89%). Trichophyton tonsurans (n=40) was the most prevalent causative species identified on culture, followed by Alternaria species (n=10) and Microsporum canis (n=1).
Limitations: Retrospective chart review: patient population has a high rate of usage of over-the-counter antifungal creams and shampoos, affecting culture results.
Conclusions: Tinea capitis is still the most common cause of Trichophyton tonsurans in New York City. Response rates to griseofulvin are similar to rates seen in the 1970s, but require higher dosing and conversion to crushed tablets in partial responders. Usage of crushed ultramicronized griseofulvin, terbinafine sprinkles, itraconazole, and fluconazole are alternative regimens for those children whose tinea capitis does not clear on griseofulvin suspension.
J Drugs Dermatol. 2012;11(7):852-856.
Efficacy and Tolerability of Retapamulin 1% Ointment for the Treatment of Infected Atopic Dermatitis: A Pilot StudyBackground: Patients with atopic dermatitis (AD) are known to have a predisposition to colonization or infection by microbial organisms, including both Staphylococcus aureus and herpes simplex virus (HSV). S aureus infection leads to exacerbation of eczema and may induce flares in atopic skin by mediating inflammation. Retapamulin 1% ointment is a unique topical antibiotic formulation that may be a suitable option for the treatment of clinically infected AD.
Study Design: A single-center, open-label pilot study was conducted to investigate the efficacy and safety of retapamulin 1% (Altabax, Stiefel/ GlaxoSmithKline) ointment for the treatment of secondarily infected atopic dermatitis in subjects aged 9 months to 98 years old (n=29).
Results: Twice-daily application of retapamulin 1% produced a mean 8.1-point reduction from baseline in the mean Skin Infection Rating Scale score. The majority of subjects achieved clinical cure with topical retapamulin therapy. Retapamulin 1% ointment was effective against S aureus isolates, including methicillin-resistant Staphylococcus aureus (MRSA). Treatment was well tolerated.
Conclusion: Retapamulin 1% is effective for the treatment of atopic dermatitis infected with S aureus, and demonstrates efficacy against both methicillin-susceptible and methicillin-resistant strains. Given its efficacy and good tolerability in this pilot study, retapamulin 1% ointment should be further evaluated as a treatment for infected atopic dermatitis. It may provide convenience and efficacy with a low risk for development of bacterial resistance.
J Drugs Dermatol. 2012;11(7):858-860.
Combined Antibiotic/Corticosteroid Cream in the Empirical Treatment of Moderate to Severe Eczema: Friend or Foe?
Background: Eczema is a common atopic disease associated with pruritus, sleep disturbance, and impaired quality of life. Staphylococcus aureus colonization/infection is important in its pathophysiology.
Aim: To evaluate the prevalence of S aureus colonization/infection and the efficacy and acceptability of a combined antibiotic/corticosteroid cream in the empirical treatment of eczema.
Methods: Consecutive patients with moderate to severe eczema were recruited. Swab and cultures from the right antecubital fossa and the worst eczematous area, disease severity (SCORAD) and quality of life (Children's Dermatology Life Quality Index, CDLQI), skin hydration (SH), and transepidermal water loss (TEWL) were obtained prior to and following a two week twice-daily course of treatment with a fucidin/corticosteroid cream. General acceptability of treatment (GAT) was documented at completion.
Results: Thirty-five patients (63% males; mean age 13.5, standard deviation 3.6 years; with 21 moderate and 14 severe disease) were recruited. At start, S aureus was isolated from the right antecubital fossa and the worst affected areas in 66% and 71% of these patients, respectively. At completion, S aureus was isolated in 23% and 40% at the antecubital fossae and worst affected areas (P=0.001 and P=0.003, respectively). No methicillin-resistant S aureus was isolated in this series, but the percentage of fucidin-resistant S aureus increased from 8% to 58% (P<0.001). Disease severity and quality of life were significantly improved (pre-Objective SCORAD and post-Objective SCORAD were 38.4±13.7 and 29.7±14.2, P<0.001; pre-CDLQI and post-CDLQI were 9.4±5.2 and 7.1±4.8, P<0.001). At the right antecubital fossa, skin hydration improved from 30.8±14.2 to 36.7±15.2 (P=0.015); and TEWL from 10.7±2.3 to 9.4±2.2 (P<0.001). Eighty percent of patients found the treatment good or very good, and only one (3%) patient found it unacceptable.
Conclusions: The most prevalent organism in moderate to severe eczema was S aureus. Usage of the combined fucidin/corticosteroid cream is convenient and associated with a reduction in disease severity, improvement in quality of life, SH, and TEWL, but caution has to be taken with emergence of fucidin-resistant S aureus.
J Drugs Dermatol. 2012;11(7):861-864.
Reconstruction of Full-Thickness Defects With Bovine-Derived Collagen/Elastin Matrix: A Series of Challenging Cases and the First Reported Post-Burn Facial ReconstructionReconstruction of full-thickness defects may benefit from integration of dermal substitutes, which serve as a foundation for split-thickness skin grafts, thus enhancing short and long-term results. We present a series of 7 patients who were treated between 2010 and 2012 for complicated full-thickness defects by the second-generation collagen/elastin matrix Matriderm® covered by a split-thickness skin graft. The defects resulted from malignancy resection, trauma, and post-burn scar reconstruction. Overall graft take was excellent and no complications were noted regarding the dermal substitute. Graft quality was close to normal skin in terms of elasticity, pliability, texture, and color. Good contour and cushioning of defects in weight bearing areas was also achieved. Matriderm was found to be a useful adjunct to full-thickness defect reconstruction, especially in difficult areas where the desired result is a scar of the highest quality possible.
J Drugs Dermatol. 2012;11(7):866-868.
Effective Topical Combination Therapy for Treatment of Lichen Striatus in Children: A Case Series and ReviewLichen striatus (LS) is an uncommon linear dermatosis that is primarily seen in children from 4 months to 15 years of age. While some of these eruptions are asymptomatic, others can be quite pruritic. In darker-skinned individuals, post-inflammatory hypopigmentation can be significant and may provide a cause for concern for the patients and/or their parents. In our case series of 4 patients, we observed rapid resolution of LS by combining a topical retinoid with a topical steroid. To our knowledge, this is the first report of successful treatment with this kind of combination therapy in the English literature. The patients not only achieved satisfying cosmesis, but also complete resolution of their pruritus. The most common side effect of topical tazarotene is localized irritation at treatment sites, but the patients in this particular series tolerated the treatment well.
J Drugs Dermatol. 2012;11(7):872-875.
Syringomas are common benign eccrine ductal adnexial tumors, commonly found in periorbital area. Periorbital syringomas are aesthetically disturbing difficult to treat. Many treatment modalities are described in the literature, including topical and surgical methods, with potential problems such as postinflammatory hyper- and hypopigmentation, low efficacy, or scar formation. We present 5 patients with syringoma treated with the combination of radiofrequency ablation and carbon dioxide (CO2) lasers. Using low-energy parameters on the CO2 laser, and low energy on the radiofrequency, we could complement both treatments maximizing the destruction of the tumors and minimizing the adverse effects in only two sessions. This is a relatively easy, safe, and less painful treatment, with good cosmetic results on periorbital syringomas.
J Drugs Dermatol. 2012;11(7):879-880.
Michael S. Digby MD and Nicole M. Owens MD FAAD|
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 San Antonio Uniformed Services Health Education Consortium. 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.
Emily B. Wong MD and Todd T. Kobayashi MD FAAD|No abstract details for the moment.
Thomas Beachkofsky MD and W. Chad Cragun MD FAAD|No abstract details for the moment.
Jason Chouake and Adam Friedman|No abstract details for the moment.
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.