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Archives Volume 8 | Issue 1

Original Articles

Anatomic Considerations for Soft Tissue Augmentation of the Face

Joel L. Cohen MD, Mariah R. Brown MD
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Histologic and Clinical Response to Varying Density Settings With a Fractionally Scanned Carbon Dioxide Laser

Raminder Saluja MD, Jane Khoury MD, Susan P. Detwiler MD, Mitchel P. Goldman MD
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Objective: An evaluation of the histological and clinical response to varying density settings (-10%, 0, and 10% overlap) with a frac- tionally scanned CO2 laser.
Study design: Clinical and histological study evaluating abdominoplasty excised tissue for depth of penetration and width of tissue ablated with varying density and energy settings utilizing a scanned microsecond pulsed CO2 laser. These parameters were corre- lated clinically with patients treated with similar density settings.
Participants: Fifteen patients were enrolled with 5 patients in each group: group 1 (density 1 settings), group 2 (density 2 settings) and group 3 (density 3 settings).
Main outcome: Histological differences of width and depth of tissue ablated with varying density settings and correlation with pho- todamage improvement clinically.
Methods: Six samples of excised abdominoplasty tissue were treated with increased energy and density settings and were evalu- ated histologically. Clinically, 15 patients with photodamage to the face were randomized to receive a fractional CO2 laser treatment with density levels ranging from 1 to 3.
Results: Microarrays of tissue injury were visualized with multiple areas of superﬁ cial to full-thickness epidermal thermal damage. As energy increased (90W to 100W), the width of basophilic coagulation of the subepidermal collagen increased. Increased density paralleled increased depth of penetration of subepidermal coagulation. Patient assessment of discomfort, erythema, edema, and satisfaction with the procedure was proportional to increasing densities.
Conclusion: A fractional CO2 laser produces photorejuvenation, erythema, edema and discomfort in proportion with the depth and extent of epidermal and subepidermal thermal damage.

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Linear Closure for Nasal Defects After Mohs Micrographic Surgery

Adam J. Mamelak MD FRCPC, Steven Q. Wang MD, Leonard H. Goldberg MD FRCP
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Background: Skin cancers on the nose are very common. Excision of these tumors results in surgical defects that can pose a chal- lenge to repair.
Objective: To present the authors’ experience of using linear closures (LC) to repair surgical defects on the nose in patients who underwent Mohs micrographic surgery (MMS).
Methods: A retrospective analysis was conducted of 4765 patients with skin malignancies on the nose that were treated with MMS between July 1997 and January 2006. The following variables were examined: type of repair, age, and sex of the patients, postopera- tive size of the defect, type of malignancy, location of the defect, and ﬁ nal length of the closure. Short-term and long-term complica- tions were evaluated and discussed. In a second study arm, a limited prospective cosmetic outcome assessment of patients with nasal defects repaired by LC compared to ﬂ aps and grafts was also conducted.
Results: There were 2053 patients (1020 men and 1033 women) who underwent LC of nasal defects after MMS. The average post- operative defect size was 1.7 X 0.9 cm, with an average closure length of 2.7 cm (range: 0.6 cm to 8.5 cm). The 2 major malignancies treated were basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) . Short-term complications were minimal. Nasal asym- metry and/or raising of the nasal alae were occasionally seen, which improved over time. The cosmetic outcomes of the LC group were rated higher than the ﬂ ap/graft group for lesions on the nose, although this was not statistically signiﬁ cant.
Conclusions: A vertical or slightly vertical linear closure for nasal defects after Mohs micrographic surgery is a robust and reliable method to deliver excellent cosmetic and functional results. Linear closure should be considered for small and mid-sized cutaneous nasal defects whenever possible.

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Topical Sulindac Combined With Hydrogen Peroxide in the Treatment of Actinic Keratoses

Lionel Resnick MD, Harold Rabinovitz MD, David Binninger PhD, Maria Marchetti PhD, Herbert Weissbach PhD
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Background: Actinic keratoses (AKs) are a precancerous condition of the skin that have the potential to become squamous cell cancer (SCC). Sulindac is a Food and Drug Administration (FDA)-approved nonsteroidal anti-inﬂ ammatory drug (NSAID) that has been shown to have clinically signiﬁ cant anticancer effects. Malignant cells may have a different response to oxidative stress than normal cells.
Objective: To establish a role of increased reactive oxygen species (ROS) in the mechanism of cancer killing by sulindac in the presence of an oxidizing agent. To assess the tolerability and efﬁ cacy of the combination of gels containing sulindac and hydrogen peroxide in the treatment of patients with AKs.
Methods: Cell culture studies were performed using a skin SCC cell line and normal human epidermal keratinocytes. After treat- ment with sulindac and an oxidizing agent, cell viability, and intracellular ROS levels were measured. An open-label clinical trial was performed using sulindac and hydrogen peroxide gels daily for 3 weeks on AKs involving the upper extremities.
Results: In SCC cells, a combination of sulindac and an oxidizing agent lead to 400 to 500% increases in intracellular ROS, which resulted in signiﬁ cant cell death. In sharp contrast, normal keratinocytes did not show increases in ROS levels and were not killed. A clinical trial using the combination of sulindac and hydrogen peroxide therapy in 5 patients with AKs revealed that 60% of the treated AKs responded and 50% showed no residual AK on histopathology specimens after skin biopsy.
Limitations: The small number of patients and the lack of a placebo group.
Conclusion: Increased levels of ROS appear to be important in the selective killing of cancer cells in the presence of sulindac and oxidizing agents. Further studies are necessary to deﬁ ne the role of the combination of sulindac and oxidizing agent therapy in pa- tients with AKs and skin cancer.

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Methylene Blue Mediated Photodynamic Therapy for Resistant Plaque Psoriasis

Manal Salah MD, Nevien Sami PhD, Maha Fadel PhD
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Topical treatment of resistant psoriatic plaque stage lesions may be difﬁ cult and the systemic therapies seem inappropriate. There- fore, a topical 0.1% methylene blue (MB) hydrogel was prepared and evaluated for percent drug content, drug uniformity, pH, rheo- logical and organoleptic characters such as feel tackiness, grittiness sensation, and transparency in addition to release kinetics study in vitro. The efﬁ ciency of the photodynamic therapy (PDT) of MB photo-activated using 565 mW Light emitting diode (LED) 670 nm was evaluated in patients with resistant plaque psoriasis. The gel was evaluated in single blinded study. The patients were subjected to repeated sessions of irradiation, skin biopsies from each patient in the beginning and at the end of the sessions were taken for histopathological studies. Results showed the hydrogel was transparent nongritty and the drug uniformly dispersed with pH=7.2 and viscosity value= 25.04 Pa. The drug content was found to be 99.4 ± 0.15 %. Drug release was following zero order kinetics with rate constant K= 0.348 ± 0.01 and T 1\2 = 0.95±0.5 hours. Sixteen patients experienced complete clearance of their treated lesions. Skin appeared normal in color, texture, and pliability with no complications indicating the lack of skin sensitivity. Histopathological examina- tions showed nearly normal epidermis at the end of all sessions. The authors concluded that the prepared hydrogel was safe, stable, and very effective. The results are encouraging to accept MB as a photosensitizer for PDT and as a safe and effective method for treatment of selected cases of resistant localized psoriasis.

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Treatment of Actinic Keratoses With Sequential Use of Photodynamic Therapy and Imiquimod 5% Cream

Michael Shaffelburg MD FRCPC
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Background: Field-directed therapies for actinic keratosis include photodynamic therapy and imiquimod.
Objectives: The author designed a randomized, vehicle-controlled, split-face study to explore the safety and efﬁ cacy of photody- namic therapy followed by imiquimod.
Methods: The entire face of adults with ≥10 facial actinic keratoses were treated with photodynamic therapy with aminolevulinic acid 20% at baseline and at month 1. At month 2, imiquimod 5% cream was applied to one-half of the face and vehicle to the other half, 2-times-per-week for 16 weeks. Lesion counts were performed at baseline and months 1, 2, 3, 4, 6, and 12; and local skin reactions assessments at months 2, 3, 4, and 6.
Results: Of 25 participants enrolled, 24 completed the study. Baseline median lesions were 23.5 and 21.5 for the imiquimod- and vehicle-treated sides, respectively. At month 12, median lesion reductions was 89.9% versus 74.5% (P=.0023), respectively. No subject discontinued for an adverse event. Severe local skin reactions occurring in the most participants were erythema (17%) and ﬂ aking/scaling/dryness (13%).
Conclusions: Photodynamic therapy followed by imiquimod was well tolerated and improved reduction of actinic keratoses.

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Comparing Clobetasol Propionate 0.05% Spray to Calcipotriene 0.005% Betamethasone Dipropionate 0.064% Ointment for the Treatment of Moderate to Severe Plaque Psoriasis

Alan Menter MD, William Abramovits MD, Luz E. Colón MS, Lori A. Johnson PhD, Ronald W. Gottschalk MD
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Topical corticosteroids are widely used in the treatment of psoriasis. This study was conducted to compare the efﬁ cacy and safety of clobetasol propionate (CP) 0.005% spray to calcipotriene 0.005%-betamethasome diproprionate 0.064% (C-BD) ointment in patients with moderate to severe plaque psoriasis. Assessments were made at baseline, week 2, week 4 (end of treatment) and week 8 (4 weeks posttreatment). An assessment for Overall Disease Severity (ODS) found that 75% of CP spray-treated patients achieved a rating of clear or almost clear after 4 weeks of treatment compared to 45% of C-BD ointment-treated patients (P=.003). Adverse events were reported by less than one-third of patients from each treatment group (31% for CP spray and 33% for C-BD ointment).

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Case Reports

Photodistributed Erythema Multiforme: Palitaxel-related Photosensitive Conditions in Patients With Cancer

Philip R. Cohen MD
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Paclitaxel (Taxol®) is an intravenously administered antineoplastic agent derived from the yew tree, Taxus brevifolia, whose mecha- nism of action involves inhibition of mitosis. Some of the mucocutaneous reactions to the drug that have been observed include alopecia, mucositis, hypersensitivity reactions (with erythema and urticaria), nail changes, changes occurring at intravenous sites, and radiation recall dermatitis. Less commonly, acral erythema, erythema multiforme, pustular dermatitis, and scleroderma-like changes have been described. A female patient who was receiving adjuvant weekly paclitaxel for the treatment of intraductal breast carcinoma developed photodistributed erythema multiforme and onycholysis after sun exposure to the affected areas. Including this woman, paclitaxel-associated photosensitve conditions have only been reported in 9 female oncology patients: onycholysis (5), erythema multiforme and onycholysis (2), photo-recall phenomenon (1), and subacute cutaneous lupus erythematosus (1). The patients were either receiving treatment for breast carcinoma (8) or lung cancer (1). The skin lesions developed on sun-exposed areas, usually after the patient had received several weekly doses of paclitaxel, and resolved following discontinuation of the drug. Several of the patients were subsequently able to receive additional cycles of paclitaxel without recurrence of their drug-associated photosensitive conditions by concurrently using photoprotection to prevent additional sun exposure to the previously affected sites during treatment.

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Ablative Fractionated Erbium: YAG Laser for the Treatment of Ice Pick Alar Scars Due to Neodymium: YAG Laser Burns

Joel L. Cohen MD, Michael J. Babcock MD
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The authors present a case of ice pick scars forming in the nasal alar grooves of a patient who was treated with a 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser for facial telangiectasias. Treatment options for these types of scars are re- viewed and speciﬁ cally we report the success of an ablative fractionated 2940-nm erbium:yttrium-aluminum-garnet (Er:YAG) laser.

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Permanent Hyperpigmentation Following Laser Hair Removal Using the Dynamic Cooling Device

Dawn Davidson RN, Daniel Ritacca MD, Mitchel P. Goldman MD
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Treatment for Multiple Periorbital Eccrine Hidrocystomas: Botulinum Toxin A

Heather Woolery-Lloyd MD, Vidya Rajpara MD, Rajiv I. Nijhawan BS
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Hidrocystomas are relatively common cystic lesions that can display either apocrine or eccrine differentiation. While numerous treat- ment modalities exist for solitary hidrocystomas including simple excision, electrodesiccation, and CO 2 laser, treatment of multiple hidrocystomas can be challenging. A 38-year-old, black female with a 23-year history of multiple periorbital cystic nodules presented to the clinic with the complaint of lesions that were increasing in size and number. Prior treatment included excision resulting in scar- ring without signiﬁ cant clinical improvement. Initially, incision and drainage was performed with ﬂ attening of the cysts; however, the cystic nodules reﬁ lled to baseline by 6 weeks. Subsequently, intralesional botulinum toxin type A was offered as an alternate therapy in conjunction with incision and drainage. The patient reported sustained ﬂ attening of the lesions at both 1-month and 4-month follow-up appointments. Intralesional botulinum toxin A offers a novel treatment for patients with multiple hidrocystomas that have failed other therapies.

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Treatment of Inverse Psoriasis With Efalizumab

Dornechia George MD, Ted Rosen MD
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Various topical and systemic treatments have shown efﬁ cacy in plaque and palmoplantar psoriasis; however, studies regarding efﬁ - cacy in inverse psoriasis are few. The authors present a case of a patient with severe inverse psoriasis who was successfully treated with efalizumab, resulting in complete and sustained remission during prolonged maintenance therapy.

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Features

News, Views, and Reviews

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Clinical Pearl

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Clinical Trial Review

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Pipeline Previews

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2008 Case Report Contest Winners: Featured Abstracts

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Archives Volume 8 | Issue 1

Original Articles

Case Reports

Features

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