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Archives Volume 9 | Issue 1

Original Articles

Oxidative Damage, Skin Aging, Antioxidants and a Novel Antioxidant Rating System

Debbie M. Palmer DO and Jennifer Silverman Kitchin MD
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It is believed that oxidative stress is caused by an imbalance between the production of reactive oxygen and a biological system’s ability to neutralize the reactive intermediates. Oxidative damage occurs because of both intrinsic and extrinsic mechanisms. Together, intrinsic and extrinsic damage are the primary causes of skin aging. The skin uses a series of intrinsic antioxidants to protect itself from free radical damage. Naturally occurring extrinsic antioxidants have also been widely shown to offset and alleviate these changes. Unlike sunscreens, which have an SPF rating system to guide consumers in their purchases, there is no widely accepted method to choose antioxidant anti-aging products. ORAC (Oxygen Radical Absorbance Capacity) and ABEL-RAC (Analysis By Emitted Light-Relative Antioxidant Capacity), are both accepted worldwide as a standard measure of the antioxidant capacity of foods, and are rating systems that could be applied to all antioxidant skincare products. The standardization of antioxidant creams could revolutionize the cosmeceutical market and give physicians and consumers the ability to compare and choose effectively

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A Prospective Study of the Improvement in Periorbital Wrinkles and Eyebrow Elevation With a Novel Fractional CO2 Laser—The Fractional Eyelift

Dvora Ancona MD and Bruce E. Katz MD
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Background and Objective: The purpose of this study was to assess the efficacy and safety of a new fractional CO2 laser system for improving periorbital rhytids, tightening skin and elevating the eyebrow.
Materials and Methods: One hundred subjects with periocular wrinkles, tissue laxity, photoaged skin and moderate dermatochalasis of the face were prospectively treated one to four times in the periorbital area with a fractional CO2 laser device equipped with a scanning handpiece. Improvements in eyelid wrinkles, crow’s feet and skin laxity were evaluated photographically by two blinded, independent observers. Eyebrow elevation was measured by the investigators. Subjects also scored satisfaction and tolerability.
Results: Approximately half of subjects achieved or maintained 26–50% improvement at 12 months. Nearly 40% of subjects maintained 1–2 mm elevation of the brow at six and 12 months after treatment. Subject satisfaction was high and the procedure was well tolerated. Mild-to-moderate erythema and edema persisted for up to three to four days.
Conclusion: Treatment with a fractional CO2 laser device improves periorbital rhytids, tightens skin and elevates the eyebrow with minimal adverse effects.

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A Controlled Multi-Center Study Evaluating the Efficacy of Vivité Skin Care in the Treatment of Photoaging of the Face, Eye and Mouth

Mitchel P. Goldman MD and Michael H. Gold MD
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Purpose: To determine the efficacy of a skin care system developed with a partially neutralized glycolic compound and natural antioxidants when compared to Cetaphil moisturizing regimen for the treatment of photoaging of the face, eye and mouth.
Methods: A total of 36 patients between 35 and 65 years of age were randomized on a 3:1 ratio to use either Vivité Skin Care System or Cetaphil cleanser and moisturizer for 60 days. Facial skin was evaluated at baseline, day 30 and day 60. Subjects were required to fill out a self-evaluation of facial skin quality before, during, and after treatment. Investigators evaluated facial wrinkling using a common wrinkling scale as well as a visual evaluation of skin texture in a masked manner.
Results: A similar proportion of patients in each group had a 1-point improvement on the hyperpigmentation scale (42% of Vivité patients, 44% of Cetaphil patients). There were no statistically significant between-group differences in investigator rating of wrinkles. Subjectively, patients preferred Vivité to Cetaphil for noticeable improvement in fine lines or wrinkles (37.6–0%, respectively) at the first follow-up. By the final follow-up, more than half the patients in the Vivité group continued to notice an improvement in fine lines or wrinkles, compared with fewer than 25% in the Cetaphil group. More than twice the number of patients in the Vivité group noticed improvement in skin elasticity or tightness compared with those in the Cetaphil group.
Conclusion: Patients reported that the Vivité skin care system improved the appearance of wrinkling and improved skin texture associated with moderate photoaging of the face, eye and mouth areas. Vivité had a higher patient preference rating than a commonly used moisturizing regimen. There were no differences noted in the physician evaluations.

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Cost Effectiveness of Botulinum Toxins for the Treatment of Depression: Preliminary Observations

Kenneth Beer MD PA
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The standard of care for the treatment of depression involves pharmacologic therapy with selective serotonin reuptake inhibitors (SSRIs). Cognitive therapy is typically utilized in addition to a pharmacologic intervention. However, the benefits of the drugs used may be marginal compared with placebo yet the costs associated with their use continue to increase. One potential treatment for depression utilizes botulinum toxins. At the present time there is a small body of evidence supporting their use for depression, the potential efficacy and cost effectiveness of this treatment warrants further consideration including head to head clinical trials.

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Dapsone Gel 5% in Combination With Adapalene Gel 0.1%, Benzoyl Peroxide Gel 4% or Moisturizer for the Treatment of Acne Vulgaris: A 12-Week, Randomized, Double-Blind Study

Alan B. Fleischer Jr. MD, Alan Shalita MD, Lawrence F. Eichenfield MD, William Abramovits MD, Anne Lucky MD, Steven Garrett DDS, for the Dapsone Gel in Combination Treatment Study Group
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Purpose: To evaluate the safety and efficacy of dapsone gel 5% in the treatment of acne when used in combination with adapalene gel 0.1%, benzoyl peroxide gel 4% or moisturizer.
Methods: This was a twelve-week, randomized, double-blind study. Patients aged 12 years and older (n=301) applied dapsone gel twice daily and were randomly assigned (1:1:1) to one of three additional treatments, applied once daily.
Results: By week 12, dapsone gel combined with any of the three additional treatments reduced the mean number of inflammatory lesions. However, the authors did not detect a significant difference in the reduction of inflammatory lesions when dapsone was used in combination with adapalene gel or with benzoyl peroxide gel compared to the dapsone plus moisturizer combination group (P=0.052 for both versus moisturizer combination). Patients treated with dapsone gel combined with adapalene showed a significantly better response in reduction in non-inflammatory and total acne lesion count than those who received the moisturizer combination. Local adverse reactions in all three treatment groups were minimal and generally mild in severity.
Conclusion: Dapsone gel in combination with adapalene gel or benzoyl peroxide gel is safe and well tolerated for the treatment of acne vulgaris.

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The Evolving Role of Therapeutic Shampoos for Targeting Symptoms of Inflammatory Scalp Disorders

Leon Kircik MD
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Scalp lesions are common among patients with psoriasis, seborrheic dermatitis and a number of other inflammatory and fungal conditions. Topical corticosteroids are a mainstay of treatment for many scalp dermatoses and they significantly reduce erythema, scaling and pruritus. Conventional corticosteroid formulations such as cream and ointments are often difficult or time consuming for patients to apply and may produce undesirable cosmetic effects. Medicated shampoos provide a more convenient alternative for patients who require topical administration of corticosteroids for scalp conditions. Tar shampoos have long been used to treat psoriasis and are effective for the long-term maintenance of remission in patients who respond to therapy. Antifungal shampoos are effective for the treatment of seborrheic dermatitis and other mycotic conditions. A shampoo formulation containing fluocinolone acetonide, 0.01% is also approved for the treatment of seborrheic dermatitis. One superpotent corticosteroid shampoo (clobetasol propionate 0.05%; Clobex® Shampoo) is approved in the United States (U.S.) for once-daily treatment of psoriasis of the scalp. The results of a 2007 pilot study also demonstrated that clobetasol propionate shampoo improved the signs and symptoms of seborrheic dermatitis. These findings suggest that high-potency corticosteroid shampoos may provide an important option for topical corticosteroid therapy in dermatologic conditions affecting the scalp

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Efficacy of Hexapeptide-7 on Menopausal Skin

Timothy J. Falla PhD and Lijuan Zhang PhD
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Due to a reduction in estrogen levels peri- and post-menopausal skin exhibit a specific phenotype characterized by reduced thickness, reduced elasticity and increased dryness. Loss of these elements results in increased skin wrinkling and skin sagging. In addition, it is well documented that reduced estrogen levels also negatively impacts dermal wound healing. As a result we tested the hypothesis that molecules capable of stimulating and accelerating wound healing can supplement the skin’s diminished activities produced by reduced estrogen. Heptapeptide-7, a fragment of a well-characterized wound healing peptide (HB-107), was found to stimulate keratinocyte proliferation and migration and induce collagen synthesis. Microarray analysis of Heptapeptide-7-treated dermal keratinocytes revealed an up-regulation of cell division, growth factor and extracellular matrix genes. Validation of this approach was seen in a clinical study of 32 women (mean age 54) in which forehead wrinkles and skin texture were improved with the application of this peptide fragment.

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Case Reports

Atypical Presentation of Histoplasmosis in a Patient With Psoriasis and Psoriatic Arthritis on Infliximab Therapy

Qurat ul Ain Kamili MD and Alan Menter MD
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Infliximab is a chimeric monoclonal antibody to TNF-α which acts on both the soluble and transmembrane forms of TNF-α. It has been used successfully for the treatment of psoriasis and psoriatic arthritis, rheumatoid arthritis, Crohn’s disease and ankylosing spondylitis either as monotherapy or in combination with drugs such as methotrexate. To date, over 20,440 patients with moderate-to-severe psoriasis have been treated with infliximab worldwide. Opportunistic infections and reactivation of underlying latent infections are an area of concern with the use of infliximab particularly when used in conjunction with other immunosuppresants. The authors report a case of histoplasmosis presenting with signs of severe hypercalcemia and renal failure in a patient on infliximab for approximately three years in combination with low dosages of methotrexate and prednisone. This report stresses the importance of maintaining a high index of suspicion for unusual pathogens while managing patients receiving TNF-α inhibitors, particularly when used in combination with other immunosuppressants. In addition, the authors emphasize the role of a multi-disciplinary approach and appropriate coordination among caregivers.

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Hair Growth in Patients With Alopecia Areata Totalis After Treatment With Simvatatin and Ezetimibe

Asra Ali MD and John M. Martin IV MD
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Alopecia areata is an autoimmune disorder characterized by the sudden development of a circumscribed patch of nonscarring hair loss on the scalp or any hair-bearing surface. The presentation of this disorder can be hair loss in a single circumscribed patch, complete loss of hair on the scalp (alopecia totalis) or complete loss of hair on the entire body (alopecia universalis). The following cases involve two patients with treatment-refractory alopecias that benefited significantly after treatment with a combination of ezetimibe and simvastatin, in addition to the continuation of intra-lesional corticosteroid injections. In this report, the known immunomodulatory effects of statins in combination with ezetimibe are discussed along with the known histopathologic findings of autoimmune alopecia. Major histocompatibility complex class II (MHC-II) and intracellular adhesion molecule-1(ICAM-1) appear to be involved in both the immunomodulatory effects of statins and the pathophysiology of autoimmune alopecia.

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Fractional Photothermolysis Improves a Depressed Alar Scar Following Mohs Micrographic Surgery

Kimberly K. Schulz MD and Hobart W. Walling MD PhD
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Fractional photothermolysis (FPT; Fraxel SR laser) is a 1550 nm non-ablative erbium laser device with a variety of clinical applications. FPT has been used to treat photodamage, photoaging, melasma, actinic keratoses and acne scarring. We present the case of a 49-year-old woman with a depressed 0.7 x 0.5 cm alar scar resulting from Mohs micrographic surgery for basal cell carcinoma with secondary intention healing. She was treated with FPT initially eight weeks post-operatively. FPT was performed a total of five times at four-week intervals. At the completion of FPT, the scar was nearly imperceptible and has remained so eighteen months later. To the authors’ knowledge, treatment of facial scars resulting from Mohs micrographic surgery for cutaneous malignancy has not previously been reported.

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Recalcitrant Cicatricial Pemphigoid Treated With the Anti-TNF-Alpha Agent Etanercept

Maj. Jeremy Scott Kennedy DO, Col. (Ret) Richard L. Devillez MD, Maj. Jeffrey Scott Henning DO
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Cicatricial pemphigoid (mucous membrane pemphigoid) is a group of chronic disorders characterized by recurrent subepithelial blisters and scarring, predominantly of the mucous membranes.1,2 The authors report the case of a 63-year-old female with a 20-year history of cicatricial pemphigoid who had failed treatment with cytoxan, dapsone, systemic steroids and minocycline. She achieved complete clinical remission with the addition of etanercept 50 mg twice a week with azathioprine 150 mg daily. This patient has remained clear for two years with this combination and has tolerated a tapering of the azathioprine from the initial dose of 250 mg. Etanercept is a recombinant human dimeric fusion protein which acts as a competitive inhibitor of TNF-alpha by binding to both soluble and receptor-bound molecules of TNF-alpha.14 There have been a few reports of successful use of TNF-alpha inhibitors in cicatricial pemphigoid. This report will discuss the possible mechanism of action of the addition of TNF-alpha inhibitors as a steroidsparing agent in these patients.

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Oral Lichenoid Drug Reaction Associated With Antihypertensive and Hypoglycemic Drugs

Ruchadaporn Kaomongkolgit DDS MS PhD
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Oral lichen planus and oral lichenoid drug reactions have similar clinical and histologic findings. The onset of oral lichenoid drug reactions appears to correspond to the administration of medications, especially antihypertensive drugs, oral hypoglycemic drugs, antimalarial drugs, gold salts, penicillamine and others. The author reports the case of 58-year-old male patient with oral lichenoid drug reaction, hypertension and diabetes mellitus. The oral manifestation showed radiated white lines with erythematous and erosive areas. The patient experienced pain and a burning sensation when eating spicy food. A tissue biopsy was carried out and revealed the characteristics of lichen planus. The patient was treated with 0.1% fluocinolone acetonide in an orabase as well as the replacement of the oral hypoglycemic and antihypertensive agents. The lesions improved and the burning sensation disappeared in two weeks after treatment. No recurrence was observed in the follow-up after three months.

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Departments

News, Views & Reviews

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Pipeline Previews

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Clinical Trial Review

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Supplements

Expanding the Use of Neurotoxins in Facial Aesthetics: A Consensus Panel’s Assessment and Recommendations

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This supplement to the Journal of Drugs in Dermatology is jointly sponsored by the Annenberg Center for Health Sciences at Eisenhower and Signature Business Solution, LLC.This activity is supported by an independent educational grant from Medicis Pharmaceutical Corporation.

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Archives Volume 9 | Issue 1

Original Articles

Case Reports

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Supplements

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