Daniel Navi BS, John Koo MD
It is the experience of dermatologists worldwide that a significant proportion of their patient population has underlying
psychological components to their dermatologic complaints. Since these patients are often reluctant to see a mental health
professional, the effective management of the underlying psychopathology may require the use of psychotropic medications
by the dermatologists. This paper aims to update dermatologists on recent safety information on some of the most
commonly prescribed psychotropic medications in psychodermatology. In the process it will also address the implications of
these recent safety updates for prescribing clinicians.
Imatinib mesylate (Gleevec, also known as STI-571), is an approved oral treatment for patients with chronic myeloid
leukemia (CML). It blocks the activity of Abelson cytoplasmic tyrosine kinase (ABL), c-Kit and the platelet-derived growth
factor receptor (PDGFR). As an inhibitor of PDGFR, imatinib mesylate appears to have utility in the treatment of a variety
of dermatological diseases. Imatinib has been reported to be an effective treatment for FIP1L1-PDGFR?+ mast cell disease,
hypereosinophilic syndrome, and dermatofibrosarcoma protuberans. One report notes its effectiveness for treating HIV related
Kaposi’s sarcoma; imatinib has not been effective for the treatment of melanoma.
Joseph Bikowski MD, Radhakrishnan Pillai PhD, Braham Shroot PhD
Many topical corticosteroids currently on the market contain a halogen substitution at the C6, C9, or the side-chain C21 position
of the corticosteroid skeleton. These modifications have enhanced the efficacy of corticosteroids as compared to hydrocortisone
as topical anti-inflammatory agents, but have often increased side effects such as skin atrophy, adrenal suppression,
and telangiectasia. These side effects have been attributed to the presence of halogens in the corticosteroid molecule and
have raised concerns regarding the safety of all halogenated corticosteroids. In this review, we assert that it is the position
and nature of the halogen atom(s) in the corticosteroid molecule that determine potency/toxicity, rather than their mere
presence. A greater understanding of the role of halogenation in determining corticosteroid potency and side effects will
clarify why all halogenated steroids are not the same.
J. Jorizzo MD, J. Weiss MD, G. Vamvakias BS
Topical fluorouracil is currently approved for the treatment of actinic keratosis (AK) and is often used prior to or following
cryosurgery as interval therapy in patients with severe AK lesions. No randomized, controlled studies are available to confirm
anecdotal evidence suggesting pretreatment with fluorouracil is beneficial. This prospective, randomized, double-blind,
vehicle-controlled study evaluated the effect of pretreatment with 0.5% fluorouracil cream (FC; Carac®) or a vehicle cream
(VC) once daily for 7 days to the face plus scalp, ears, neck, and/or lips in patients with ?5 visible or palpable AKs on the
face prior to cryosurgery. Efficacy was determined by evaluating AK reduction and clearance (complete lack of AK lesions in
the treatment area) at 4 weeks follow-up. Statistically significant decreases from baseline number of AKs were observed on
all treatment areas in both groups. However, the mean number of facial AKs was significantly lower in the FC group at each
treatment cycle (p=.011). No serious adverse events were considered related to treatment.
Mark S. Nestor MD PhD (chair), Michael H. Gold MD (co-chair), Arielle N. B. Kauvar MD, Amy F. Taub MD, Roy G. Geronemus MD, Eva C. Ritvo MD, Dore J. Gilbert MD, Mitchel P. Goldman MD, Donald F. Richey MD
Photodynamic therapy (PDT) has significant promise in improving outcomes of patients with a variety of cutaneous conditions.
A group of experts met to review the principles, indications, and clinical benefits of PDT with 5-aminolevulinic
acid (ALA). They also reviewed PDT with methyl aminolevulinate. The experts established consensus statements for pretreatment,
posttreatment, ALA contact time, light sources, and numbers of sessions associated with ALA PDT for actinic
keratosis and superficial basal cell carcinoma, photorejuvenation and cosmetic enhancement, acne, sebaceous skin, rosacea,
and rhinophyma. They based consensus recommendations on their clinical experience and the medical literature. They also
suggested future applications of ALA PDT. Experts concluded that ALA PDT is a safe and effective modality for the treatment
of conditions commonly encountered in dermatology. Since downtime is minimal, the technique is suitable for
patients of all ages and lifestyles. Appropriate light sources are available in many dermatology offices. The expanding clinical
and financial benefits of PDT justify the purchase of an appropriate light source.
Stacy R. Smith MD, Vera B. Morhenn MD, Daniel J. Piacquadio MD
Actinic keratoses (AKs) are a common precancerous condition and are said to account for 14% of visits to dermatologists in
the US each year. Along with cryotherapy, topical treatments are a mainstay of therapy for these lesions. One of the potential
benefits of topical therapy is less pain and irritation as compared to cryotherapy. Additionally, topical therapies have a
perceived benefit of treating subclinical lesions along with clinically evident keratoses. We conducted a bilateral comparison
study of the efficacy and tolerability of diclofenac 3% gel used for 90 days and 5% fluorouracil cream used for 28 days in thirty
patients with AK of the face and scalp. The diclofenac gel and 5-fluorouracil cream each demonstrated substantial efficacy
in the number of lesions cleared and the proportion of patients with significant lesion clearing. In most patients, diclofenac
induced only mild signs of inflammation compared to 5-fluoruracil, despite a longer treatment period. A greater number of
patients expressed significant satisfaction with diclofenac gel compared to the 5-fluorouracil cream.
James Q. Del Rosso DO FAOCD, Emil Tanghetti MD
A major challenge encountered in clinical practice in patients with acne vulgaris is irritation related to topical medications
used for treatment. Advances in vehicle technology have improved formulations containing active ingredients known to
produce irritation in some patients, such as benzoyl peroxide (BP) and topical retinoids. Clinical studies, including combination
therapy studies have demonstrated that certain additives, such as silicates and specific humectants, reduce irritation
by maintaining barrier integrity. A patented gel formulation of BP 5%/clindamycin phosphate 1% (clindamycin) containing
dimethicone and glycerin has been studied both as a monotherapy and in combination with topical retinoid use. This
article evaluates specific vehicle additives included in this gel formulation and explains their role in reducing irritation.
Data from clinical trials utilizing this technology in acne management are also reviewed.
Brian Berman MD PhD, Adariana M. Villa MD, Claudia C. Ramirez MD
Actinic keratosis (AK) constitutes the initial lesion in a disease continuum that can progress to invasive squamous cell carcinoma
(SCC). In this article, we describe the mechanisms of action, tolerability, and efficacy of the most frequently used
chemopreventative, chemotherapeutic, destructive, and novel immunologic methods for the control and treatment of actinic