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Archives Volume 5 | Issue 10

Original Articles

Post-Herpetic Neuralgia: A Review of Advances in Treatment and Prevention

Lorraine Young MD
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Post-herpetic neuralgia (PHN) is primarily a disease of the elderly and often refractory to treatment. Randomized and controlled trials have yielded several significant advances in the treatment and prevention of this disease. Treatment advances include the lidocaine patch, opioid analgesics, nortriptyline, amitriptyline, and gabapentin. However, no treatment regimen fully eliminates the pain. Improvements in prevention include prompt recognition and treatment of high-risk herpes zoster (HZ) patients with antiviral and analgesic therapies. Even with these advances, PHN remains a debilitating and painful disease. Vaccines offer the greatest promise of relief. The childhood vaccine against varicella zoster virus offers long-lasting immunity, largely preventing HZ and PHN. But most adults have already had varicella and are at risk for HZ and PHN as they age. Therefore, a more potent vaccine against varicella has been developed for use in adults. This vaccine offers a new and significant advance in the prevention of HZ and its most noteworthy complication, PHN.

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Multivesicular Emulsion: A Novel, Controlled-Release Delivery System for Topical Dermatological Agents

Joseph Bikowski MD, Radhakrishnan Pillai PhD, Braham Shroot PhD
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Multivesicular emulsion systems are a new patented technology for topical delivery of pharmaceutical and over-the-counter actives. This novel technology involves the creation of a 2-phase, oil-in-water emulsion system that produces concentric multilamellar spheres of oil and water. Active ingredients can be released from their respective layers upon application to the skin. In addition to a controlled-release of active agents, the multivesicular emulsion base improves the biophysical properties of the skin by reducing transepidermal water loss and enhancing skin hydration. This technology has been applied to 6% salicylic acid formulations that in clinical experience show efficacy with high tolerance in several hyperkeratotic disorders. Subjects’ self-assessment was clearly indicative of the excellent cosmetic elegance of the multivesicular emulsion system.

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Cosmetic Injectable Devices: A Review of the Injection Techniques

D. Vleggaar MD, R. Forte MD
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An ever increasing number of devices and procedures designed to rejuvenate the aging face are available to dermatologists and plastic surgeons. These devices include products consisting of autologous materials, natural polymers, and synthetic compounds. The diversity of these materials is reflected by the wide variety of techniques used to administer them. Differences in terms of injection technique and the equipment used for each device are usually a consequence of the nature of the material. The depth at which a substance is deposited is also very important as device-related adverse events are often a result of improper placement. The techniques used to inject the commonly encountered soft tissue fillers and volume enhancers are compared here, with special reference to the degree with which injection technique causes device-related adverse events.

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Hyaluronic Acid Gel in Skin Rejuvenation

Jean Carruthers MD, Alastair Carruthers MD
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Hyaluronans have become the most popular agents used for soft tissue augmentation in the entire facial area. They are biodegradeable, nonpermanent and have a remarkable safety profile. Their natural biocompatibility means that no pretreatment skin test is necessary. The soft pliable enhancement of natural tissue turgor and contour makes them very acceptable in the lips and perioral and periocular regions. The more viscous agents are very helpful in the treatment of facial lipoatrophy particularly in the region of the cheeks and chin.

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The Subcutaneous Loop: A Single Suture Technique for Skin Closure after Superficial and Subcutaneous Surgery

Sody Abby Naimer MD, Amnon Biton MD, Morris Topaz MD
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Background: Removal of subcutaneous skin masses and certain deep skin injuries results in defects, which demand immediate closure. Although primary closure of these defects in 2 layers is an acceptable solution, this technique has a number of drawbacks, such as extended time consumption upon performance, demand for additional suture material and occasional tissue response or foreign body reaction to retained absorbable stitches leading to infection and its sequelae. Objective: We describe an approach intended to furnish a satisfactory solution to the needs of tissue closure in such cases. The significant innovation of this technique is the closure of both deep and superficial layers of skin in one single suture. Materials and Methods: Our suture combines the advantages of the classic mattress suture together with those of the buried subcutaneous suture. We performed the vertical mattress suture with 3/0 polypropylene or monofilament suture and added a subcutaneous loop to achieve sufficient approximation of deep tissue surfaces. This suture technique was applied in our first 50 cases. The defects were closed without adverse sequelae. No tissue infections were observed. Wound dehiscence occurred in one case after premature suture removal. The stitches were slightly more difficult to remove than regular sutures. Review of the resulting scars exhibited acceptable results similar to those of parallel closure techniques. Conclusions: This easily performed technique yields the benefits of reducing suture cost, annulling foreign body reaction, and resulting in both a functional and aesthetically pleasing outcome. The subcutaneous loop technique has become our standard closure of choice for wounds demanding cutanwous and subcutanwous repair.

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The Characteristics and Utility of Solid Phase Porous Microspheres: A Review

Stacy Smith MD, Vera Morhenn MD, Guy Webster MD
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Cutaneous Drug Reactions Associated with Newer Antiretroviral Agents

Ciro R. Martins MD
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Skin is the most commonly affected organ in patients with HIV, and the incidence of cutaneous adverse reactions in persons infected with HIV versus those who are not infected is significantly higher. Cutaneous drug reactions contribute to increased morbidity and are often the cause of treatment nonadherence. Undoubtedly, the widespread use of highly active antiretroviral therapy has had a positive effect on the natural course of the disease; however, advances in HIV therapy will continue to increase the potential for cutaneous eruptions, further complicating the evaluation of skin manifestations that are so common in this disease. Distinguishing between cutaneous drug reactions and other cutaneous diseases associated with HIV infection can be challenging. Nevertheless, it is important for clinicians to be knowledgeable about the clinical characteristics and presentations of these reactions and to determine whether drug discontinuation is indicated.

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Beneficial Effect of a Moisturizing Cream as Adjunctive Treatment to Oral Isotretinoin or Topical Tretinoin in the Management of Acne

Sabine Laquieze MD, Janusz Czernielewski MD, Marie-José Rueda MD
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Despite their beneficial effects on the treatment of acne vulgaris, topical and oral retinoids may cause severe local irritation (retinoid dermatitis) due to their mechanism of action, thereby jeopardizing patient adherence, and thus compromising treatment efficacy. Alleviating dryness and improving skin comfort by using a moisturizer concomitantly to retinoids could enhance efficacy. In the present study, 30 subjects receiving either oral isotretinoin for at least 2 months or topical tretinoin for at least one month applied a moisturizing cream (Cetaphil® Moisturizing Cream) twice daily for 15 days on one half of the face while the other side remained untreated. Clinical assessments, confirmed by biophysical measurements, showed that the moisturizer provided a significant improvement in skin dryness, roughness, and desquamation. Skin properties and skin discomfort were also greatly improved and subjects were very satisfied with the product. Retinoid-induced skin irritation can be relieved by the regular use of a gentle moisturizing cream as an adjunctive treatment.

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Case Reports

Nodular Vasculitis Responsive to Mycophenolate Mofetil

Josephine A. Taverna MD, Arash Radfar MD, Alice Pentland MD, George Poggioli MD, Marie-France Demierre MD FRCPC
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Mycophenolate mofetil is commonly used as a steroid-sparing agent effective in the management of erythema nodosum, idiopathic nodular panniculitis (Pfiefer-Weber-Christian disease), bullous pemphigoid, pemphigus vulgaris, and psoriasis. We report a case of nodular vasculitis responsive to mycophenolate mofetil. The clinical presentation, etiology, and management options for nodular vasculitis are discussed.

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Successful Treatment of Severe Refractory Atopic Dermatitis with Efalizumab

Arta Farshidi BS, Parrish Sadeghi MD
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Despite multiple therapeutic modalities, treatment of atopic dermatitis with its chronic, relapsing nature remains a challenge. Chronic use of standard therapies is associated with variable efficacy and potential side effects. Targeted therapeutic approaches using biologic agents may prove to be a novel alternative. We present a case of severe recalcitrant atopic dermatitis successfully treated with efalizumab.

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Treatment of Postoperative Soft Tissue Loss with Injectable Poly-L-lactic Acid

James P. Ralston MD, Jonathan E. Blume MD, Nathalie C. Zeitouni MD
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We present a case of a 40-year-old woman with a history of a wide local excision for a melanoma and subsequent postoperative soft tissue loss who was successfully treated with injectable poly-L-lactic acid (Sculptra®). After only one treatment with the filler agent, the treated area showed significant volume enhancement and improved cosmesis 10 months postinjection. We propose a possible role for injectable poly-L-lactic acid in improving the appearance of postoperative volume loss.

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Multiple Palmar Keratoacanthomas Treated with Acitretin

Gerald A. Rosenblum MD
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A 62-year-old female presented with multiple keratoacanthomas of the palmar aspects of the hands, wrists, and proximal fingers. Surgery or radiation therapy would have caused significant impairment. A 30-day course of 1 mg/kg per day of acitretin led to a complete resolution. Maintenance therapy with 25 mg per day of acitretin was needed to prevent recurrence. The medical treatment of keratoacanthomas is herein discussed as well.

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Treatment of Atypical Hidradenitis Suppurativa with the Tumor Necrosis Factor Receptor-Fc Fusion Protein Etanercept

Robert L Henderson Jr. MD
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We present a case where etanercept—a soluble tumor necrosis factor receptor-Fc fusion protein—was safe and effective in treating the painful skin lesions of a 24-year-old patient with hidradenitis suppurativa, resulting in an improvement in quality of life.

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Urticarial Vasculitis Secondary to Paroxetine

John Patrick Welsh MD, Carrie Ann Cusack MD, Christine Ko MD
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Background: Carbon dioxide laser resurfacing remains the gold standard for the treatment of photoaged skin. Today, however, fewer patients will tolerate the postoperative downtime associated with the use of this device. Fractional photothermolysis was designed to overcome the disadvantages associated with ablative resurfacing. Prototype fractional lasers (Fraxel®, Reliant Technologies Inc.) have required the use of blue tracking dye to give evenly spaced microtreatment zones, and treatments are associated with moderate levels of discomfort because of microtreatment zone depths reaching nearly 1000 ?m. Newer technologies have evolved that do not require tracking dye, and are less painful than older prototypes because microtreatments are associated with moderate levels of discomfort because of microtreatment zones are more superficial (100 to 300um) than that of the Fraxel laser. Newer devices offere advances in treating facial ryhtides and skin laxity through the use of 2 laser wavelengths (1320 nm/1440 nm)emitted sequentially through a specialized diffractive lens array that produces high-intensity microtreatment zones surrounded by low level heating.

Observations: One to 3 treatments with this combination fractional laser device were performed on 16 Caucasian females with static periocular rhytides or skin laxity affecting the nasolabial crease. There was a 3-week period between treatments. Improvement was noted in both areas after a small number of treatments.

Conclusion: The technology behind fractional lasers is rapidly evolving, and new devices offer significant advances over older prototypes. where id= 776;

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Features

PEARLS (NEW!)

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WASHINGTON WHISPERS

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PIPELINE PREVIEWS

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CLINICAL TRIAL REVIEW

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Archives Volume 5 | Issue 10

Original Articles

Case Reports

Features

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