Volume 8 | Issue 3
Macrene Alexiades-Armenakas|The US Food and Drug Administration (FDA) held a hearing on the safety of dermal fillers in November of 2008 which generated a great deal of media attention and, more importantly, got our attention. The adverse reporting data came from the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database and numbered 930 cases over the past 6 years, bringing the complication rate to an estimated 1 in 10 000. Some of the complications were severe, such as facial palsy or anaphylaxis; while others included scarring. Such rare but grave complications are generally considered acceptable risks for treatments of medical illnesses (eg, infections or carcinomas); but are these rare complications for elective cosmetic enhancement acceptable?
Assessment of the Mobile Delivery of InfraredLight (1100-1800 nm) for the Treatment of Facialand Neck Skin Laxity
Macrene Alexiades-Armenakas MD PhD|Background: Previous studies have shown that although infrared light and radiofrequency delivered by stationary application is safe and effective for the treatment of rhytides, a mobile delivery of radiofrequency energy can render the treatment as painless. In addition, few studies have defined and assessed efficacy of these infrared treatments in treating laxity by quantitative grading.
Objective: This prospective study assesses the safety, efficacy, and pain profile of the application of infrared light with a mobile delivery method for the treatment of facial and neck skin laxity as assessed by a tested, quantitative grading scale.
Methods: In this study, 22 female subjects (aged 40-75 years; Caucasian and Asian ancestry) with a clinically observable excess of laxity (minimum grade 2 out of 4) on the face received 1 to 3 treatments with incoherent infrared (1100-1800 nm) light at 2-week to 4-week intervals. Each light pulse was administered in a mobile continuous fashion within a localized area measuring approximately 1 handpiece tip-width laterally and vertically. A series of 4 to 5 pulses were administered across small grid areas, followed by 6 to 8 passes to each grid area, totaling approximately 300 to 450 pulses per treatment. Each mobile pulse was delivered at fluences of 45 to 46 J/cm2 to the face, 45 J/cm2 to the mandible, and 44 J/cm2 to the neck. Clinical results were evaluated employing a comprehensive 4-point grading scale from photographs at baseline, and the 1-month and 3-month follow-up visits after the final treatment. Pain ratings were evaluated by visual analog scale (VAS) gradings and patient questionnaire immediately following treatment.
Results: All subjects completed and responded to treatment. The mean treatment number was 2.1 (+/- 0.9) and the mean follow-up interval was 1.9 (+/- 1) months. The quantitative evaluations demonstrated: a mean baseline laxity grade of 2.9 +/- 0.5 and mean posttreatment laxity grade of 2.5 +/- 0.6; and a mean difference in prelaxity grades versus postlaxity grades of 0.4 +/- 0.3 (95% CI; 0.2540- 0.5415). The data demonstrated a statistically significant difference between before and after measurements (P<.0001) and a mean percent improvement in laxity grading scores of 14.1 +/- 11.3%. The treatment discomfort was rated as a mean of 0.7 (+/- 0.6) on a VAS grading scale (0 to 10). By patient questionnaire, sensation during the treatment was rated as painless by 100% of patients and rare (<5) transient moments of heat-related pain sensation were reported by 18% of patients. None of patients reported the procedure as painful or as sensing frequent (>5) or persistent heat-related pain sensation during the treatment. Other side effects included minimal erythema which resolved within 1 to 3 hours. No crusting, dyspigmentation, or scarring was observed.
Conclusion: This prospective clinical study with quantitative grading of laxity and VAS pain scores demonstrated that mobile delivery of infrared light appears to be safe, clinically effective, and painless in reducing facial and neck laxity. The mobile infrared light delivery allowed for delivery of approximately 30% higher fluence dosages and increased passes to each pulse area. The clinically observable and quantified decreases in skin laxity following treatment were statistically significant.
Jacob Dudelzak MD, Mussarrat Hussain MD,David J. Goldberg, MD JD|Background: Facial telangiectasias have been successfully treated with a variety of laser wavelengths. Shorter wavelengths (532 nm) are generally effective in the treatment of smaller vessels; longer wavelengths (1064 nm), although potentially more effective in the treatment of larger vessels, may be associated with a higher complication rate. The 980-nm wavelength has the potential benefits of a longer wavelength with the safety of shorter wavelengths.
Objective: The efficacy and safety of a new 980-nm diode laser in the treatment of facial telangiectasias was evaluated.
Materials and Methods: Twelve subjects, aged 44 to 67 years with Fitzpatrick skin types 1 to 3 and bilateral facial telangiectasias, underwent 1 to 3 monthly treatments with a 980-nm diode laser using fluences ranging from 22.2 to 146.9 J/cm2, pulse durations of 50-160 ms, spot sizes of 0.7 to 1 mm, and pulse frequencies of 3 to 10 Hz. Clinical evaluation included digital photography, as well as subject and investigator assessment of reduction in the size and appearance of telangiectasias on a 1 to 5 point scale. Adverse effects were also assessed.
Results: Significant improvement in the appearance of telangiectasias was seen after treatment. No complications were observed.
Conclusion: A new 980-nm diode laser effectively treats facial telangiectasias without any observed complications.
Management of Moderate to Severe PlaquePsoriasis (Part II)- Clinical Update on T-CellModulators and Investigational Agents
Jeffrey M. Sobell MD, Robert E. Kalb MD,Jeffrey M. Weinberg MD|This second part of a 2-part review on the use of biologics for treatment of patients with psoriasis is focused on currently approved therapies that work through modulation of T cells: alefacept, a leukocyte function - associated antigen 3-immunoglobulin G fusion molecule; and efalizumab, an anti-CD11 humanized antibody. Efficacy and safety data from pivotal clinical trials are summarized and new data are presented for these biological agents, and considerations for optimal therapeutic selection are discussed. Clinical data from investigational agents currently in development are also reviewed. One of these new agents is ustekinumab, a humanized antibody that targets interleukins 12 and 23 and inhibits the differentiation of Th17 cells, a recently identified subset of CD4+ T-helper cells.
Rungsima Wanitphakdeedecha MD MA MSc,Elizabeth L. Tanzi MD, Tina S. Alster MD|
Background: A wide variety of laser and light-based therapies have been utilized for acne vulgaris; however, current techniques have been limited by photosensitivity issues or inconsistent results.
Objective: To determine the clinical efficacy and side-effect profile of photopneumatic therapy for the treatment of facial acne vulgaris.
Methods: Twenty adults with mild to severe facial acne vulgaris received 4 successive treatments at 2-week intervals with a combined photopneumatic device (intense pulsed light [IPL]: fluences=3.6-4.2 J/cm2; negative pressure=3 psi). Clinical improvement was evaluated on a quartile grading scale using comparative digital photographs at baseline, and 1 month and 3 months after the final treatment. Acne lesion counts were obtained at baseline, prior to each treatment session, and at the end of the study.
Results: Modest reduction in acne lesion counts and global clinical improvement was seen in the majority of patients. Patients with severe acne experienced the most clinical improvement. Side effects were mild and limited to transient erythema and rare purpura. Most patients experienced acne worsening early in the treatment course.
Conclusion: Photopneumatic therapy is a safe and effective treatment for acne vulgaris. Patients with more severe acne respond best to treatment.
Erin E. Ducharme MD, Jeffrey M. Weinberg MD|Only recently available on the US market, levocetirizine has emerged as an effective new option in the treatment of chronic idiopathic urticaria (CIU). Levocetirizine is the active isomer of cetirizine and demonstrates twice the affinity for the H1 receptor compared with the parent compound. In the treatment of CIU, levocetirizine has consistently demonstrated high response rates, fast onset, and a favorable side effect profile.
E. Victor Ross MD, Michael Swann MD, Seaver Soon MD,Arash Izadpanah MD, David Barnette MD,Scott Davenport BA|
Background: Traditional full-face resurfacing has been limited to erbium-doped yttrium aluminium garnet (Er:YAG) and carbon dioxide (CO2) lasers. These devices offer wavelength-specific advantages and disadvantages.
Methods: Nine patients were enrolled in a pilot study of a resurfacing system using a 2790-nm erbium:yttrium-scandium-galliumgarnet (Er:YSGG) laser system. Two treatments were carried out 1 month apart over the entire face. Test spots were performed prior to the full-face sessions to determine the optimal fluence for 1-pass laser resurfacing. Biopsies were performed at the time of treatment and at the final follow-up visit one month after the second treatment. Clinical endpoints included changes in pigment dyschromias, wrinkles, and skin tone. All outcomes were graded by blinded observers.
Results: Eight patients completed the 2 treatments. Biopsies showed thermal damage extending as deep as 80 μm below the stratum corneum. Reepithelialization was complete within 4 days. No scarring, post inflammatory hyperpigmentation (PIH), or infections were observed.
Conclusion: A 2790-nm laser can be used for skin rejuvenation with a 4 day recovery window.
George Hruza MD, Amy Forman Taub MD, Susannah L.Collier MD, Stephen Robert Mulholland MD|
Introduction: Skin resurfacing has evolved rapidly over the past 15 years from ablative techniques to nonablative methods and most recently fractional ablative resurfacing. The purposes of this study were to analyze the degree of tissue ablation, coagulation, and heating; and to evaluate the clinical efficacy and safety of a fractional radiofrequency (RF) device, for the treatment of wrinkles with fractional skin ablation and coagulation.
Material and Methods: Individuals scheduled for abdominoplasty received fractional RF treatment to the abdomen area, using different tips at varying energy densities and coverage rates. Biopsies were performed ex vivo following abdominoplasty and tissue samples were routinely processed and stained, using hematoxylin and eosin). Another group of subjects received 3 facial treatments, scheduled at 3 to 4 week intervals. Clinical improvement and response to therapy were evaluated with standardized photography and clinical assessment by the subjects and investigators.
Results: Histological findings immediately posttreatment revealed demarcated zones of ablation/coagulation/necrosis and subnecrosis up to a depth of 450 μm. Higher energy levels generated deeper effects. We noticed a tunable balance between ablation and coagulation/necrosis. These effects were coverage mode and energy density dependent. Subjects undergoing facial treatment had minimal pain, no permanent side effects, or significant downtime. Investigators’ assessment for improvement in skin texture correlated with subjects’ evaluation and was greater than 40% for approximately 50% of subjects. Eighty percent of the subjects were satisfied with the results. Higher energy levels and lower coverage rates produced better aesthetic results along with less pain.
Conclusion: The clinical observations and histological findings suggest that fractionated ablative skin resurfacing using a fractional radiofrequency device resulted in a safe, tolerable and effective improvement in skin texture and reduction of wrinkles. The depth of tissue ablation, coagulation and necrosis and the relative proportions of these phenomena were found to be controllable and could be modulated to optimize treatment of variable dermatologic conditions.
Treatment of Recalcitrant Verruca Vulgariswith Candida Antigen in Patient With HumanImmunodeficiency Virus
Pamela Summers MD, Patricia Richards-Altmon MD,Rebat Halder MD|Verruca vulgaris is often difficult to treat in individuals with human immunodeficiency virus (HIV) infection. We present a case of an HIV positive 44 year-old male with a 3-year history of multiple recalcitrant verruca vulgaris involving his hands and face. He did not respond to cryotherapy, urea 40% cream, imiquimod 5% cream, paring, intralesional bleomycin, salicylic acid 6% gel, and electrodesiccation and curettage. The patient achieved complete clearance of all warts within 1 month following treatment of his hands with intralesional Candida antigen. This case reports a complete response of verruca vulgaris to intralesional Candida antigen in an immunocompromised patient.
Irene J. Vergilis-Kalner MD, David J. Mann MD, Justin Wasserman MD, Vesna Petronic-Rosic MD MSc,Maria M. Tsoukas MD PhD|Pityriasis rubra pilaris (PRP) is a rare skin condition which typically presents in adults as red-orange plaques with islands of sparing, perifollicular keratotic papules, waxy palmoplantar keratoderma, and erythema with fine, diffuse scale. Currently, there are no well-established treatment guidelines for this condition. This is party due to a lack of universally effective treatments for PRP, with some cases being resistant to multiple topical and systemic therapies. Systemic retinoids have been used with some success. Several phototherapy regimens have lead to variable results. The authors present a case of PRP, unresponsive to 6 month treatment of isotretinoin, that was subsequently treated with narrow-band ultraviolet B (NB-UVB) light therapy with complete resolution after four months of light treatment. The observed clinical benefit may encourage future phototesting and consideration of NB-UVB light therapy in recalcitrant PRP cases.
Evangelos Cholongitas MD, Chrysoula Pipili MD,Despina Ioannidou MD|Cetuximab, a new recombinant monoclonal antibody that inhibits the epidermal growth factor receptor (EGFR), is frequently associated with cutaneous reaction. A 85 year-old male with a diagnosis of adenocarcinoma of the right parotid gland referred to our department for persistent acneiform eruption on the face and trunk induced after cetuximab administration. Despite cetuximab discontinuation and administration of antibiotics as well as topical steroids, the skin lesions were persisted for several months. Interestingly, the pustules and the acneiform eruption showed significant improvement after a course of oral itraconazole. The latter was given when the microscopic examination of the pus obtained from the lesions revealed the presence of Malassezia folliculitis.
Robert Baran MD, Luc Thomas MD PhD|Yellow nail syndrome (YNS) is an uncommon disorder that is characterized by the slow nail growth, marked thickening, and yellow to yellow-green discoloration of the fingernails or toenails. Although the etiology of YNS is unknown, a diagnosis is indicated by the concurrent presentation of the nail changes, with lymphedema and respiratory manifestations. Although lymphedema and respiratory manifestations are sometimes manageable with regimens of medical and surgical treatments, YNS treatment options are limited and often unsuccessful. For the patient, YNS can also be cosmetically unacceptable and concealment with nail polish may not always be possible. However, it is now widely accepted that the azole class of antifungals can stimulate linear nail growth. In addition, vitamin E has also been reported in the treatment of YNS with positive results. Herein, the authors report on a promising combination treatment of oral fluconazole pulse therapy and oral alpha-tocopherol (vitamin E) in 13 patients with YNS with clinical successes observed in 2 individuals and clinical cures observed in 11 subjects.
Matthew R. Hanson MD, Christina L. Chung MD|Infection with methicillin-resistant Staphylococcus aureus (MRSA) is a growing presence in both the community and hospital settings. Initially, MRSA was a difficult to treat infection isolated to hospitalized patients. With the introduction of vancomycin and other newer antibiotics, successful treatment of nosocomial, or hospital-acquired MRSA (HA-MRSA) has become commonplace. More recently, MRSA has evolved independently in each community. These community-acquired MRSA (CA-MRSA) strains initially had more limited resistance profiles, but selective pressures have broadened the resistance in many areas. Given the evolution in resistance among MRSA isolates, choosing an appropriate antibiotic therapy is challenging. Here the authors present 3 cases of HA- and CA-MRSA from an inner-city, tertiary care center and review recent literature with regards to antibiotic selection and administration.
Rodrigo Roldán-Marín MD, Fernando de-la-BarredaBecerril MD|Lidocaine/prilocaine cream is a topical anesthetic commonly used in pediatric and dermatologic practice to obtain local anesthesia. Common side effects include: transient skin blanching, erythema, urticaria, allergic contact dermatitis, irritant contact dermatitis, and hyperpigmentation. The authors report a petechial and purpuric reaction after the application of lidocaine/prilocaine cream. This is a rare side effect, since to our knowledge only few case reports have been documented in literature.
Jill Waibel MD, Kenneth Beer MD|Burn scars are the result of wound healing following a partial-thickness or full-thickness thermal injury. Thermal injury can frequently result in extensive scarring, which may have profound psychologic impact on the victim, serving as a visible and palpable reminder of a traumatic event. Standard treatments for scars include the use of skin grafts, intralesional steroid injections, and pulsed-dye laser treatments. The authors have previously described successful treatment of a burn scar with nonablative fractional resurfacing.1 Ablative fractional lasers may offer burn patients advantages over nonablative techniques, including improved function and cosmetic outcomes. In addition, ablative fractional laser may require fewer treatments, and therefore, be a more cost-effective treatment option for patients. The authors report the use of fractional ablative laser for the treatment of a disfiguring scar that was more than 50 years old. To our knowledge, this is the first report of this technology for the treatment of a scar resulting from a third-degree burn in the literature. The demonstrated successful outcome in this case patient may indicate a progessive treatment option for many patients who have been disfigured by these types of thermal injuries.
Mark W. Trumbore PhD, Jay A. Goldstein MD, Ronald M.Gurge PhD|Acne rosacea is a chronic cutaneous disorder affecting as many as 14 million Americans. Papulopustular rosacea is the classic form of rosacea characterized by papules, pustules, and erythema. The skin barrier deficiency and vascular hyperactivity characteristic of papulopustular rosacea increase skin dryness and irritation, which can be further exacerbated by medications commonly used to treat rosacea. Sodium sulfacetamide 10%/sulfur 5% emollient foam (SSSE foam) is formulated for topical administration and is fragrance free and alcohol free. This nonrandomized, noncontrolled, open-label, prospective case series was designed to evaluate the efficacy and safety of a SSSE foam for the treatment of papulopustular rosacea in 8 patients. Patients experienced clinically significant improvements in the severity of rosacea with a favorable safety profile, and reported of an improved quality of life. The high patient satisfaction ratings for SSSE foam suggest that the product may improve long-term compliance rates, with the potential to yield more favorable clinical outcomes.
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Koen De Boulle MD, Sandra Swinberghe, Marie Engman, David Shoshani|This supplement to the Journal of Drugs in Dermatology was supported by an independent educational grant from Ortho Dermatologics.