J. Barton Sterling MD, C. William Hanke MD MPH FACP
Dioxin toxicity can lead to severe cutaneous and systemic disease. The poisoning of Ukrainian President Viktor Yushchenko
dramatically illustrates the damage dioxin can inflict. The hallmark of dioxin toxicity is chloracne and should alert the clinician
to this diagnosis, which can be confirmed by blood tests. Olestra, a non-absorbable, non-digestible fat substitute is a
promising new treatment to lower systemic dioxin levels.
Alan Shalita MD, B. Miller MD, A Menter MD, W. Abramovits MD, K. Loven MD, L. Kakita MD
A multicenter, double-blind, randomized, parallel-group trial compared tazarotene 0.1% cream with adapalene 0.1% cream,
once daily for 12 weeks, in 173 patients with facial acne vulgaris. Tazarotene was associated with a significantly greater incidence
of patients achieving 50% or greater global improvement (77% vs. 55%, P < .01), and a significantly greater reduction
in comedo count (median of 68% vs. 36%, P <.001, compared with adapalene. A significant between-group difference in baseline
inflammatory lesion count precluded a comparison of efficacy against inflammatory acne. The most common adverse
events were dryness, peeling/flaking, itching, redness/erythema, burning, and facial irritation with comparable incidences of
each between groups. Mean peeling and burning levels were milder with adapalene, though were trace or less in both groups
throughout. There were no significant between-group differences in the incidence of patients discontinuing due to lack of efficacy
or adverse events. Tazarotene cream offers significantly greater efficacy and comparable tolerability to adapalene cream.
Actinic keratoses (AKs) are traditionally treated with cryotherapy, curettage, and 5-fluorouracil (5-FU, Efudex®, ICN
Pharmaceuticals, Inc.), all of which are associated with adverse effects. Although photodynamic therapy (PDT) with topical
5-aminolevulinic acid (ALA) offers a treatment alternative, current protocols require 14 to 18 hours incubation with ALA and
patients experience pain during light treatment. Fifteen patients with multiple and diffuse facial AKs applied 5-FU nightly for
5 days and underwent PDT with ALA (Levulan® Kerastick®, Dusa Pharmaceuticals, Inc.) on the sixth day. ALA was applied
to their entire faces and remained in contact with the skin for 30 to 45 minutes under low-intensity visible light. After removing
ALA, faces received a single pass of 560- to 1200-nm intense pulsed light (VascuLight or Lumenis One, Lumenis). At 1
month and at 1 year post-treatment, 90% of treated AKs had resolved in all but one patient. Erythema resolved 7 to 10 days
after treatment. Patients with multiple diffuse AKs may benefit from the application of 5-FU for 5 days followed by ALA-PDT
with intense pulsed light activation.
This article will examine various clinical experiences with acne patients successfully treated with topical clindamycin 1% benzoyl
peroxide 5% gel (Duac®) alone and in combination with other acne treatments. Clindamycin 1% benzoyl peroxide 5%,
the only once-daily prescription topical aqueous gel combining a benzoyl peroxide and an antibiotic, has demonstrated excellent
tolerability and efficacy and is stable when used concomitantly with other therapies. A regimen of topical clindamycin 1%
benzoyl peroxide 5% gel, oral doxycycline hyclate (Doryx®), and adapalene gel (Differin®) seems especially advantageous from
a theoretical and practical perspective. Improvement is noted by means of photographic, physician, and/or patient assessments
at baseline and follow-up visits.
Rajesh Balkrishnan PhD, Julia C. Sansbury MD, Rahul A. Shenolikar MS, Alan B. Fleischer Jr. MD, Steven R. Feldman MD PhD
Objective: Fears of potentially costly use of topical retinoids for cosmetic treatment of photodamaged skin have resulted
in many managed care organizations placing prior authorization requirements on this class of medications. The purpose
of this investigation was to examine whether prescribing patterns of a nationally representative sample of US
physicians shed light on the incidence of use of topical retinoids for indications other than acne.
Methods: A retrospective, cross-sectional study of data from the National Ambulatory Medical Care Survey (1996-
2000) was used to examine the impact of physician specialty as well as patient diagnosis of acne on the probability of
retinoid prescription in weighted multivariate logistic regression models.
Results: Topical retinoids were prescribed in 0.4% (14.7 million out of 3.67 billion) physician visits for any diagnosis
in the 5-year period from 1996 to 2000, and in nearly 31% (12.0 million out of 38.7 million) of physician visits for a
diagnosis of acne. Topical retinoids were prescribed for acne in 77.1% of the cases. This finding held when individual
retinoids (tretinoin and adapalene) were examined separately. Clear age-related prescription trends are observed, with
a significant decrease in prescriptions beyond the teen years. In older patients, tretinoin prescribing did not decrease as
much as adapalene prescribing.
Conclusions: These data suggest that managed care organizations may want to examine their own data to determine the
optimum criteria for operation of prior authorization (PA) programs for retinoids. PA requirements for these medications
appear unnecessary in young patients, given the very small probability of non-acne related use. PA in older
patients might be targeted to those patients on topical retinoids (such as tretinoin) for which there is evidence of efficacy
in treatment of cosmetic photoaging.
Neil S. Sadick MD FACP FAACS, Macrene Alexiades-Armenakas MD PhD, Patrick Bitter Jr. MD, George Hruza MD, R. Stephen Mulholland MD
Background: The authors previously reported their experience achieving non-ablative skin enhancement with serial,
full-face, intense pulsed light treatments in a large series of patients. A new method for skin renewal electro-optical synergy
(ELOS), which combines intense pulsed optical energy and conducted bipolar radiofrequency (RF) energy into a
single pulse, has been recently introduced. Intense pulsed optical energy and bipolar RF energy have been used in dermatologic
surgery for many years; however, this study represents the therapeutic impact of the combined energies.
Objective: The authors report their experience using an ELOS system (Aurora SR, Syneron, Yokneam, Israel) on 108
consecutive patients treated with a series of full-face procedures.
Methods: Patients received 5 full-face treatments every 3 weeks. Each treatment consisted of 1 to 8 full-face and segmental
passes. The number of passes, specific wavelength of pulsed optical energy, and RF energy were determined by
the patient’s skin type, dyschromia, wrinkle pathology, and presence of a tan. A total of 540 treatments were performed
on 108 subjects. All patients had pre- and post-procedural photographs. Results were assessed by double-blinded physician
photographic evaluation and patient satisfaction scales.
Results: Overall skin improvement was rated at 75.3%. Overall average wrinkle improvement was 41.2%, with an
average Class 1 wrinkle improvement of 64.7%, Class 2 wrinkle improvement of 38.6%, and Class 3 wrinkle improvement
of 20.4%. Improvement in skin laxity was rated at 62.9%. Skin texture was reported to improve 74.1%.
Improvement in the appearance of pore size was rated at 65.1%. Average improvement in erythema and telangiectasia
was 68.4%. Average improvement in hyperpigmentation and dyschromia was 79.3%. Overall patient satisfaction was
92%. The overall minor complication rate, including blistering, crusting, and stripping was 8.3%, and the major complication
rate was less than 1%. One small, depressed nasal scar was observed in one patient.
Conclusions: This study demonstrates the safety and efficacy of a new technology using combined optical and conducted
bipolar RF energies for noninvasive skin rejuvenation. The results show improvement in wrinkle reduction and
amelioration of erythema, telangiectasia, and hyperpigmentation comparable to that reported for other intense pulsed
Shahrad M. Behnam BS, Shahdad E. Behnam MD, John Y. Koo MD
Cyclosporine is an immunosuppressive agent that has been shown to be effective in the treatment of psoriasis. However, its
serious side effects in transplant patients have hindered many dermatologists from exploiting its therapeutic capabilities. The
literature contains reports of lymphomas, internal malignancies, skin cancers, and serious infections in psoriasis patients on
cyclosporine therapy. However, no study has evaluated the relative risk of these side effects in relation to the general population,
nor monitored the patients for years after cyclosporine was discontinued. The recently published 5-year cohort study is
the most rigorous data to date on the long-term safety of cyclosporine and shows no increased risk of lymphoma or internal
malignancies. The study, however, illustrates increased risk of non-melanoma skin cancers, especially squamous cell carcinoma.
Review of the literature does not suggest any increased risk of opportunistic infections or tuberculosis reactivation. These
data suggest that cyclosporine in dermatologic dosage (3-5 mg/kg/d) is safe and dermatologists may consider using it.
Roberta Bibas MD, Neide Kalil Gaspar MD PhD, Marcia Ramos-e-Silva MD PhD
The authors review all aspects related to colchicine from its pharmacology to its usage in several skin diseases
Pediculosis is the result of infestation by one of two families of sucking lice. The Pediculidae include the agents of head and
body lice. Pubic lice belong to the family Pthiridae. Pediculus humanus capitis (the head louse) and Pediculus humanus humanus
(the body louse) look identical. The two differ by the slightly larger size of the average body louse, as well as where they reside
and deposit their eggs. Head lice live in the scalp hair and deposit their ova on hair shafts. Body lice live in the seams of clothing
and deposit their ova on fabric fibers, usually in the seams of the clothing. Although body lice are common vectors of disease,
head lice have not been proven to act as disease vectors. This having been said, the two are so closely related that it is
naïve to believe that head lice will never be shown to spread disease.
Isaac Zilinsky MD, Eran Bar-Meir MD, Ruth Zaslansky DSc, David Mendes MD, Eyal Winkler MD, Arie Orenstein MD
Local anesthetic agents are administered before many ambulatory cutaneous operations. The injection of the local anesthetic
agent is often the only painful aspect of the procedure. There are various factors that determine how painful the anesthetic
administration may be. These include the preparation used, the size of the needle and syringe used, injection technique, depth
of injection, attitude of the physician, and more. In this article, we present the different techniques we apply to achieve minimal
pain during the injection of local anesthetics.