Ali Mohammad Saafan PhD and Manal Mohamed Salah MD
Objective: To evaluate the efficacy of application of dual long-pulsed dye/Nd:YAG lasers in the management of skin and mucous
membrane infantile hemangiomas.
Background: Management of hemangiomas may be a challenge. Different laser systems have been reported to be of significant
help for such cases with variable results.
Patients and Methods: In this study, the authors present a unique sequential laser system, which delivers pulsed dye laser (PDL)
595 nm followed by Nd:YAG 1064 nm, which they have found to be superior and more effective than other reported techniques.
Twenty-five cases of infantile hemangiomas in the skin and mucous membrane in the head and neck region were selected to be
enrolled in this study. Assessment for progress was achieved clinically.
Results: The authors achieved excellent results in eighteen patients (72%) out of the 25 treated patients, with no recurrence after sixmonth
follow-up. Laser application from skin and mucous membrane sides (sandwich technique) decreased number of sessions.
Conclusion: The sequential application of 595 nm PDL followed by 1064 nm Nd:YAG laser can be considered a superior method
for management of infantile hemangiomas, especially in the head and neck region, due to its excellent cosmetic results with fewer
Mario A. Trelles MD PhD, Mariano Velez MD, Michael H. Gold MD
Background: Melasma is a difficult entity to treat. Topical creams or chemical peels offer some success, and the newer fractional
lasers have also been proposed to be useful. This three-armed study compares topical creams, CO2 ablative fractional resurfacing
and the combination of both modalities.
Patients and Methods: Thirty females with melasma, mean age of 38 years, skin types II–IV, were allocated to three groups: group
A received treatment with Kligman’s formula maintenance topical cream program; group B, CO2 fractional resurfacing using high
power, fixed pulse width and low frequency; and group C, both laser and maintenance topical cream treatment. Subjective patient
and clinician assessments based on melasma area severity index (MASI) scores were made at baseline, one, two, six and 12
months, and the satisfaction index (SI) and overall efficacy calculated.
Results: All patients completed the study. The SI and overall efficacy in groups A, B and C were 100% at one month in all groups but
progressively decreased in further assessments except for group C in which better scores were maintained throughout. MASI scores
for group C were statistically significantly improved compared to A and B at six and 12 months (P<0.001 for both).
Conclusion: The fractional CO2 laser and topical cream regimen produced good, well-maintained results in melasma treatment compared
with the monotherapy groups.
Brad A. Yentzer MD, Fabian T. Camacho MS, Trudye Young MD, Julie M. Fountain CCRC,Adele R. Clark PA-C, Steven R. Feldman MD PhD
Background: Patients with atopic dermatitis (AD) may have poor adherence for several reasons, including fear of side effects or
dislike of messy topical therapies.
Purpose: To assess adherence to and efficacy of a multifaceted program for atopic dermatitis using a lightweight, easy-to-apply
medication and more frequent return visits.
Methods: Forty-one subjects with mild-to-moderate atopic dermatitis were instructed to use desonide hydrogel 0.05% twice daily.
Disease severity was measured at baseline and weeks 1, 2 and 4. Subjects also received a follow-up phone call on day 3. Adherence
was assessed using electronic monitors. At the end of the study, subjects sampled and rated the vehicle attributes of six different
topical corticosteroid formulations.
Results: Mean adherence to twice-daily application slowly declined over time, from 81% on day 1 to 50% by day 27. An improvement
in pruritus was observed as early as day 3, and by week 4, mean pruritus and EASI scores improved from baseline by 60% and
61%, respectively. Mean SGA scores also improved to marked improvement/almost clear by week 4. In vehicle attribute surveys,
the hydrogel was consistently rated higher than the other vehicles in all categories.
Conclusion: Subjects responded very well to treatment, and adherence to desonide hydrogel 0.05% was much better than previously
reported with ointments. The early efficacy, favorable attributes of the hydrogel vehicle and judicious follow up likely increased
adherence to topical therapy. The use of ointments or more potent topical steroids as a first choice may be counterproductive in the
treatment of atopic dermatitis.
Eunkyue Park PhD, William R. Levis MD, Nigel Greig PhD, Euisun Jung DVM,Georgia Schuller-Levis PhD
Thalidomide is anti-inflammatory under some conditions, yet has been reported to up-regulate Th1 (T helper 1) immunity measured
by increased IL-2 (Interleukin-2) and gamma interferon. The authors have assessed the effect of thalidomide and analogues, di- and
tri-thiothalidomide, on a lipopolysaccharide (LPS) activated macrophage cell line (RAW 246.7 cells). The authors’ findings showed
that nitric oxide (NO) was significantly inhibited by thalidomide (15%) and its analogues (di-thiothalidomide; 15%, tri-thiothalidomide;
32%). The proinflammatory molecules TNF-α (tumor necrosis factor-alpha) and IL-6 were not significantly inhibited. Pretreatment
with thalidomide and analogues before activation was not different from simultaneous treatment. Inhibition of inducible nitric oxide
synthase (iNOS) may prove to be an important target for the anti-inflammatory and anti-cancer effects of thalidomide and related
immunomodulatory drugs (IMiDs).
Atopic dermatitis (AD) is a chronic inflammatory skin condition affecting a predominantly pediatric population and characterized by a
cycle of flare and remission. Pruritus associated with AD results in substantial quality of life, societal, financial and emotional burdens
for patients and their caregivers. Daily management of AD is usually based on application of an emollient and a topical corticosteroid,
topical immunomodulator and/or oral antihistamine for the management of flares. A new nonsteroidal lamellar matrix cream has
been introduced for use in a variety of dermatologic conditions including AD. Its ingredients mimic stratum corneum components
which may help repair and restore skin barrier function and decrease transepidermal water loss. This article reviews the role of topical
therapy in AD management, and evaluates the usefulness of the lamellar matrix cream in reducing time to flare, limiting the use of
agents with greater side-effect profiles and lowering the overall cost of treatment.
Jill S. Wallace MD-Cand and John C. Hall MD
Acute cutaneous necrosis is defined as a sudden onset of gangrenous skin changes in the skin, associated with significant morbidity
and mortality. The following diseases are included in this discussion: coumadin necrosis, heparin necrosis, brown recluse spider bite,
necrotizing fasciitis, vasculitis, pyoderma gangrenosum, calciphylaxis, clotting abnormalities and embolic phenomena. The importance
of early diagnosis, early distinction and early drug therapy or drug withdrawal must match the diagnosis for maximal preservation
of the skin and underlying tissue.
Sae-Ryoon Chun BS and Rashid M. Rashid MD PhD
Incontinentia pigmenti (IP) is an X-linked dominant disorder that is seen in females. Although the medical literature has focused
strongly on the skin manifestations of IP, there is lack of comprehensive reviews focused on delayed nail lesions of IP. The authors
thus tabulated reported nail changes in IP with a focus on diagnosis and management of this delayed nail presentations. This review
emphasizes several observations with strong clinical relevance to management of IP. In particular, nail lesions may be additional clue
to vague or late-presenting cases of IP. Nail lesions are most common on the first three digits of the hands, can affect multiple digits
on multiple limbs, present from three to 45 years of age, and present on average over 20 years after skin lesions present. Clinically,
nail lesions can be subtle and often are indicators of underlying tumor. Finally, nail lesions are delayed and destructive in nature, despite
the clinically resolved cutaneous lesions, and require continual vigilance by pediatricians and dermatologist.
J. Mark Jackson MD, Joseph F. Fowler Jr. MD, Jeffrey P. Callen MD, Douglas J. Lorenz MA MSPH
Background: Chronic dermatitis that is refractory to topical therapy poses a difficult treatment problem. Many patients are corticosteroid
dependent. Mycophenolate mofetil (MMF) is a systemic B- and T-cell inhibitor that has some effect on delayed-type hypersensitivity.
Design, Setting, Interventions: In this open-label study conducted in a university-affiliated private practice setting, 16 patients with
chronic and refractory eczema of three months duration or longer were enrolled consecutively into one of three cohorts based on
dosage of MMF: five at 1 g /d, six at 1.5 g/d and five at 2.0 g/d. Patients in each cohort were allowed to increase dosage to a maximum
of 3 g/d during the study. The authors evaluated the improvement of eczema and the presence of side effects over a 34-week
period. Trends in patient and investigator global assessments were analyzed with the fitting of models using generalized estimating
Main Outcome Measures: To determine the efficacy and safety of mycophenolate mofetil (MMF) in the treatment of chronic and
Results: Twelve of 16 patients improved by patient global assessment and 14 of 16 patients improved by investigator global assessment
during the study. Three patients cleared completely and six patients were almost clear. MMF was well-tolerated. One
patient experienced a serious adverse event (pancreatic cancer), early in the study, while on therapy. This patient had dermatitis that
improved, but pruritus that was out of proportion to exam and a further workup to evaluate newly elevated liver functions after study
initiation revealed the pancreatic cancer.
Conclusion: Mycophenolate mofetil is an effective and well-tolerated treatment for some patients with chronic dermatitis.
The perioral region undergoes significant changes during aging that can contribute to a static, “sad” or “displeased” expression. The
most notable alterations usually involve ptosis of the oral commissures and the appearance of marionette lines and vertical rhytides.
Revolumization of facial structures in this region with hyaluronic acid dermal fillers can significantly reduce signs of aging. The choice
of injection technique depends on factors such as the specific perioral area, extent of correction and facial anatomy. This guide to
injection techniques in the perioral region provides practical approaches to revolumization of this region, along with tips for obtaining
optimal results and patient satisfaction.
Charu Taneja MPH, Richard J. Antaya MD, Ariel Berger MPH, Thomas S. Marshall PharmD,Raafat Seifeldin PhD, Gerry Oster PhD
Background: Tacrolimus 0.1% and pimecrolimus 1.0% are used for short-term and noncontinuous treatment of atopic dermatitis (AD)
in patients unresponsive to conventional therapies.
Objective: To assess the cost-effectiveness of tacrolimus versus pimecrolimus in adults with AD.
Methods: Using a Markov cohort model, the authors projected clinical and economic outcomes over six weeks in adults receiving
tacrolimus versus pimecrolimus. Cost-effectiveness was assessed in terms of the ratio of the expected cost of AD-related care to the
expected number of days with resolved AD.
Results: Patients receiving tacrolimus had an estimated 4.9 fewer days with active AD over six weeks (30.0 versus 34.9 for pimecrolimus).
Expected costs (per patient) of AD-related care also were lower for tacrolimus patients ($501.27 versus $546.14, respectively).
Limitation: While pimecrolimus is indicated for use solely in patients with mild-to-moderate AD, the trial on which this study was
based included some patients with severe AD.
Conclusion: In adults with AD, tacrolimus 0.1% may yield better clinical outcomes and lower costs of care than pimecrolimus 1.0%.
William Eng MD and Robert Norman DO
Increasing antibiotic resistance has prompted a search for new compounds with anti-microbial activity. In the authors’ previous study,
oregano extract was identified as one of the most potent anti-microbial compounds. The disk diffusion method was employed to
assess the degree of inhibition against various microorganisms, and the bacteriostatic or bactericidal mechanism of action. Disk diffusion
studies showed that oregano was found to be bacteriostatic for Staphylococcus aureus (S. aureus) and methicillin-resistant S.
aureus, (MRSA) but bacteriocidal for seven other microorganisms. Psuedomonas aeruginosa could not be inhibited by oregano. An
ointment consisting of 1–10% oregano could inhibit most organisms except for Proteus mirabilis and Proteus vulgaris, which required
20% and Pseudomonas which could not be inhibited even at the highest concentration of 80%. Oregano extracts can be formulated
into an ointment that shows broad antimicrobial activity. Additional testing to assess tissue toxicity and other adverse reactions would
be needed prior to human testing.
José Manuel Fernández-Vozmediano PhD and José Carlos Armario-Hita MD
For patients with basal cell carcinoma (BCC) in whom surgical intervention is not optimal, local treatment with interferon alfa-2b is
an alternative. In this study, patients with BCC of the nasal pyramid were treated with intralesional interferon alfa-2b (five million
international units three times per week) for four to eight weeks. Cutaneous biopsies were performed before and after treatment
for histologic examination. Twelve patients, primarily with the infiltrative histologic form (80%), were treated. Complete clinical and
histologic regression was confirmed in all cases, and the aesthetic results were excellent. After four years’ follow-up, no tumor persistence
was observed in any patient. The most frequent adverse events were transient, mild-to-moderate flu-like symptoms in 95%
of patients and asymptomatic leukopenia or neutropenia in 25%. These results suggest that intralesional interferon alfa-2b is a safe
and effective nonsurgical alternative approach to treat BCC of the nasal pyramid.
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