Ethan T. Routt MD,a Shelbi C. Jim On MD,a Joshua A. Zeichner MD,a and Leon H. Kircik MDb,c,d
Approximately 20-25% of the population worldwide is affected by superficial cutaneous mycoses (SCM). SCM are cutaneous fungal infections with a wide array of systemic and topical treatment options. However, successful therapeutic outcomes are limited by patient non-adherence, medication side effects, potential drug interactions, antifungal resistance and disease recurrence. Advances in formulation technology have allowed for the development of more effective and safer therapies. In this article we will review several new and emerging pharmacotherapeutics for onychomycosis and tinea pedis.
J Drugs Dermatol. 2014;13(4):391-395.
Stephanie J. Kang DO,a Scott A. Davis MA,a Steven R. Feldman MD PhD,a,b,c and Amy J. McMichael MDa
BACKGROUND: Dyschromias are becoming a more common concern among patients, particularly among persons of color. There are a variety of treatments, including more novel agents for dyschromias. Evaluating common agents prescribed among various races may prompt efforts to enhance care for dyschromias in patients of color.
OBJECTIVE: To determine whether racial or ethnic groups are treated differently for dyschromia. The secondary objective is to discover the main treatments used and determine trends over time in demographics.
METHODS: We searched the 1993-2010 National Ambulatory Medical Care Survey (NAMCS) for visits associated with a diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09). The demographics and leading treatments were tabulated, and trends over time were assessed by linear regression.
RESULTS: There were about 24.7 million visits for dyschromia over the 18-year period. Among 5,531,000 patients with the sole diagnosis of dyschromia, there were 2,800 visits from females and 1,200 visits from males per 100,000 population. Females were more likely to receive prescription combination therapy for dyschromia than males by a ratio of 10 to 1. Leading treatments overall prescribed by dermatologists included hydroquinone, topical corticosteroids, and retinoids. Asians were 27% more likely to receive a combination therapy than non-Asians. African Americans and Hispanics were less likely to have a procedure performed for dyschromia.
LIMITATIONS: Data are based on a number of ambulatory care visits, which does not allow direct estimation of prevalence.
CONCLUSIONS: Dyschromia is a significant concern for many patients, and this is especially true among patients of color. Treatment for dyschromia is influenced by skin type, and thus ethnic or racial groups are treated differently. Studies have shown that combination therapy may offer better results than a single medication for hyperpigmentation disorders. Combination agents may be underutilized in African Americans and Hispanics for dyschromia.
J Drugs Dermatol. 2014;13(4):401-406.
Michael Lundin BS,a Simran Chawa BS,a Amit Sachdev MD,b Dhaval Bhanusali MD,c Kristina Seiffert-Sinha MD,d Animesh A. Sinha MD PhDd
Alopecia areata (AA) is a common, non-scarring, autoimmune hair-loss disorder with a complex genetic and environmental etiology. A higher incidence rate of AA in the female population is well described. It is unclear why females are more likely to be diagnosed with AA and what, if any, differences in disease phenotype exist between males and females. The identification of gender specific characteristics of disease may help clinical management and patient education in cases of AA. Accordingly, we recruited 481 North-American Caucasian AA patients (336 female, 145 male) to assess age of onset, autoimmune and atopic co-morbidity, nail involvement, family history of AA and autoimmune disease, and disease subtype. There was a female predominance (female to male ratio 2.3:1) in this AA study population. We found that male AA patients are more likely to be diagnosed in childhood (age <10 years, P= 0.067) and have a family history of AA (P= 0.004). On the other hand, female AA patients are more likely to be diagnosed in adolescence (age 10-20 years, P= 0.083), have co-morbid nail involvement (P= 0.0257), and have concomitant autoimmune disease (P= 0.014), particularly thyroid disease (P= 0.058). The clinical implications of disease heterogeneity between males and females remains to be determined.
J Drugs Dermatol. 2014;13(4):409-413.
Flor A. Mayoral MD,a Julie R. Kenner MD PhD,b and Zoe Diana Draelos MDc
The use of cosmeceuticals by patients is now commonplace. Without consultation and direction from an informed clinician, marketing pressures can lead consumers to make poor product choices that can result in wasted money and unsatisfactory outcomes. Skin professionals need a scientifically based, succinct tool to guide their patients toward best topical skincare practices. The Skin Health and Beauty PyramidTM is an educational framework and product guide created from extensive scientific literature and study review on ingredients, formulations and technologies affecting skin biology. This clinical tool can simplify product choices for physicians and clinicians in the process of professionally guiding patients toward the optimal use of topical products to achieve best outcomes for skin health and beauty.
J Drugs Dermatol. 2014;13(4):414-421.
Steven R. Feldman MD PhD
Topical treatment is a pillar of dermatologic practice. The delivery of drug by a topical vehicle is dependent on complex physical chemistry and on how well patients apply the product. The potency of topical agents is not solely dependent on the concentration of active drug in the vehicle. A corticosteroid molecule may have vastly different potency depending on what vehicle is used to deliver it. Similarly, a new gel vehicle is able to deliver considerably more active antifungal than an older vehicle technology and may represent a promising vehicle for other novel formulations. The use of new vehicles can provide more effective means for treating patients with skin disease.
J Drugs Dermatol. 2014;13(4):423-427.
Shereen N. Mahmood MD and Whitney P. Bowe MD
The prevalence of adult acne in the US appears to be increasing over the last few decades. But what’s behind the rise: is it nature or nurture? We are well aware that genetics can strongly influence a patient’s risk of developing acne. However, significant changes in germline genetic variants are unlikely to have occurred over the last 20 years. Consequently, we are forced to examine environmental variables, including diet. This review article presents the most updated evidence supporting a link between refined carbohydrates and acne. Based on the data summarized here, dermatologists should encourage their acne patients to minimize their intake of high glycemic index foods.
J Drugs Dermatol. 2014;13(4):428-435.
Nevien Samy PhDa and Maha Fadel PhDb
BACKGROUND: Blond and white hair removal by laser is a complicated task with weak satisfactory results due to the deficiency in laser-absorbing chromophore.
OBJECTIVE: To investigate if repetitive sessions of photodynamic therapy (PDT) using external application of liposomal Rose bengal (RB) photosensitizer followed by intense pulsed light (IPL) exposure enables removal of gray and white hair.
MATERIALS and METHODS: Rose bengal loaded in liposomes (LRB) was constructed, prepared in hydrogel, and was studied for some pharmaceutical properties. Penetration and selective hair follicle damage in mice skin were studied. Topical gel containing LRB was used for treating fifteen adult females who were complaining of facial white terminal hair. Unwanted facial hair was treated for three sessions at intervals of 4–6 weeks using intense pulsed light (IPL). At each session, the treatment area was pre-treated with topical LRB gel, while a control group of another 15 patients applied placebo gel before IPL treatment. Evaluations included hair regrowth, which was measured 4 weeks after each treatment session and at 6 months follow-up by counting the number of terminal hair compared with baseline pretreatment values. Treatment outcomes and complications if any were also reported.
RESULTS: Average hair regrowth in the LRB group was 56% after 3 treatment cycles. After six-months follow up, average terminal hair count compared with baseline pretreatment showed 40% reduction and no recorded side effects.
A significant difference (P<0.05) was seen compared with the control group; the clinical results were promising.
CONCLUSIONS: Photodynamic hair removal using rose bengal-encapsulated liposomal gel in combination with IPL treatment showed significant efficacy in the treatment of white hair compared with a control group.
J Drugs Dermatol. 2014;13(4):436-442.
Doris Hexsel MD,a,b Mariana Soirefmann MD MsC,a,b Juliana Dumêt Fernandes MD PhD,c and Carolina Siega BSca
BACKGROUND: Melasma has a negative impact on quality of life since it typically occurs on the face.
OBJECTIVES: To evaluate the erythema and pigmentation of melasma lesions and the surrounding areas in patients receiving triple combination (TC: hydroquinone, tretinoin, and fluocinolone acetonide) regimens.
METHODS: Patients first received an 8-week daily TC treatment and were then randomized to twice weekly or tapering regimen with TC. Melanin and erythema levels of lesions and surrounding areas were objectively measured using a narrowband reflectance spectrophotometer.
RESULTS: Progressive reduction in the mean melanin levels was observed in the treatment phase. Following both maintenance regimens, there was no difference between melanin levels in the melasma lesions. Adverse effects were rare in both phases of the study and there was borderline reduction in erythema with regimen II.
CONCLUSION: Both maintenance regimens were effective in maintaining results obtained during the initial treatment phase, and were safe and well-tolerated. Erythema was less intense with the tapering regimen.
J Drugs Dermatol. 2014;13(4):444-448.
David Caplin MD FACSa and Jordan Austin BSb
BACKGROUND: Primary Focal Axillary Hyperhidrosis (PHH) is a chronic disorder of excessive underarm sweat that causes significant impairment of an individual's daily activities. Multiple studies have established the psychosocial burden of PHH and its negative impact on quality of life. Current first-line therapies include the use of topical aluminum chloride with limited efficacy. Second line therapy includes the use of Botulinum toxin, which is effective, but duration is limited to 6-7 months. Objective: The purpose was to evaluate the long term efficacy and safety of the Nd:YAG 1440nm wavelength with a unique delivery fiber (SideLaze) and the Smartlipo TriPlex device (Cynosure Inc).
METHODS: Fifteen subjects were recruited to an approved Institutional Review Board study. Outcome measures were comprised of clinical and quantitative evaluation of functional impairment. This included HDSS scale, physician and subject evaluation, and digital photography of before and after starch iodine tests utilizing image processing and analysis software. Subjects received a single treatment and were evaluated at 1 week and at 3, 6, and 12 months post treatment. Responders were defined as those that scored an HDSS score of 1 or 2 post-treatment. Those that were non-responsive at 6 months received a second treatment.
RESULTS: All patients responded to treatment with 72% reporting a two-point HDSS score improvement and 28% reporting a 1-point improvement at 1-year follow-up. The average HDSS score improvement was 1.9/3.0. Three of the 15 patients at 6 months received a second treatment. The HDSS average score for all patients remained statistically stable at 1-year follow-up.
CONCLUSIONS: Treatment of axillary hyperhidrosis with the 1440nm Nd:YAG-pulsed laser combined with a targeted fiber and temperature-sensing device provides a safe and minimally invasive approach to the treatment of axillary hyperhidrosis with minimal side effects and long-term efficacy.
J Drugs Dermatol. 2014;13(4):449-456.
Alison Harvey PhD MS and Tu T. Huynh PhD
Acne vulgaris is a common skin disease in which abnormal desquamation, excess sebum production, proliferation of Propionibacterium acnes, and production of proinflammatory mediators all contribute to the pathogenesis of the disease. A review of the literature shows that our current understanding of acne pathogenesis continues to evolve. Recent data suggests that inflammatory mediators may play a more important role than previously realized; however, how these mediators work independently as well as together in acne lesion progression is not well understood. Several cell types and mediators involved in the pathology of acne are responsible for producing or exacerbating an inflammatory response. Here, we present an updated theoretical model of acne lesion progression that highlights the role inflammatory mediators may play throughout acne lesion development.
J Drugs Dermatol. 2014;13(4):459-463.
Topical tretinoin has been a standard treatment for acne vulgaris for more than 4 decades. While tretinoin has demonstrated proven efficacy in the treatment of acne lesions, it also is associated with the potential for skin irritation. Newer formulations have been designed to optimize both the drug concentration and the delivery vehicle with the aim to enable clinicians to provide increasingly effective acne treatment that minimizes irritation. These therapies include formulations with varying concentrations of tretinoin and vehicles that utilize a microsponge delivery system, hydrogels and micronized tretinoin, or propolymers. The purpose of this review is to evaluate different formulations and combinations of tretinoin in the treatment of acne vulgaris. While these advanced formulations were designed for controlled release of active ingredient, and have the potential to reduce cutaneous irritation relative to standard tretinoin cream and gel formulations, there is a need for comparative studies to evaluate the relative benefits of each of these advanced tretinoin formulations in optimizing acne treatment.
J Drugs Dermatol. 2014;13(4):466-470.
Periorbital hyperpigmentation (POH) is a common worldwide problem. It is challenging to treat, complex in pathogenesis, and lacking straightforward and repeatable therapeutic options. It may occur in the young and old, however the development of dark circles under the eyes in any age is of great aesthetic concern because it may depict the individual as sad, tired, stressed, and old. While “dark circles” are seen in all skin types, POH is often more commonly seen in skin of color patients worldwide.1 With a shifting US demographic characterized by growing number of aging patients as well as skin of color patients, we will encounter POH with greater frequency. As forecasted by the US Census, by 2030 1 in 5 Americans will be 65 plus years old and greater than 50% of the population will possess ethnic skin of color.2 The disparity in the medical community’s understanding of POH versus popular demand for treatment is best illustrated when you have only 65 cited articles to date indexed on PubMed line3 compared to the 150,000,000 results on Google search engine.4 Most importantly POH may be a final common pathway of dermatitis, allergy, systemic disorders, sleep disturbances, or nutritional deficiences that lends itself to medical, surgical, and cosmeceutical treatments. A complete medical history with ROS and physical examination is encouraged prior to treating the aesthetic component. Sun protection is a cornerstone of therapy. Safety issues are of utmost concern when embarking upon treatments such as chemical peeling, filler injection, and laser therapy as not to worsen the pigmentation. Without intervention, POH usually progresses over time so early intervention and management is encouraged. The objective of this study was to review the current body of knowledge on POH, provide the clinician with a guide to the evaluation and treatment of POH, and to present diverse clinical cases of POH that have responded to different therapies including non-ablative fractional photothermolysis in two skin of color patients.
J Drugs Dermatol. 2014;13(4):472-482.