Paul F. Lizzul MD PhD MBA and Vic A. Narurkar MD FAAD
Radiesse® (Bioform Medical, San Mateo, CA) is a synthetic calcium hydroxylapatite microsphere filler suspended in an aqueous
carrier gel. Radiesse currently has indications in the United States (U.S.) for the correction of signs of lipoatrophy in individuals with
human immunodeficiency virus (HIV) as well as for the correction of moderate-to-deep nasolabial folds. There are also numerous off
label reports in the literature of use in other facial aesthetic procedures. This review describes the composition of calcium hydroxylapatite,
its mechanism of action, durability and safety, pre- and post-procedure care, injection techniques, appropriate use, concomitant
anesthesia, as well as potential adverse events and complications.
Tiffani K. Hamilton MD and Cheryl M. Burgess MD
With demand for minimally invasive cosmetic procedures rising in patients of color, it is becoming increasingly important for clinical
dermatologists to be aware of specific needs of these patients. This article therefore reviews considerations for using cosmetic
procedures on skin of color, and reports the authors’ clinical experience with the use of injectable poly-L-lactic acid (PLLA, Sculptra®,
Dermik Laboratories, a business of sanofi-aventis U.S. LLC) in this patient population. The authors’ experience indicates that patients
with skin of color may require an increased interval between treatments; however, with proper attention to patient selection and
administration technique, injectable PLLA can be used effectively in this patient group. Controlled clinical studies that include more
patients of color are needed to fully assess the benefits and risks of cosmetic products, such as injectable PLLA, in these populations.
Kenneth Beer MD and Mary P. Lupo MD FAAD
The types and number of dermal fillers have evolved, allowing clinicians to select the most appropriate agent for each specific use.
Filler properties differ both between and among classes, so clinicians must have a thorough understanding of these properties and
the best techniques to use to provide the most satisfactory outcomes. This article reviews and highlights the key properties of different
types of fillers, technical aspects of their use, safety considerations and the importance of patient factors in treatment selection.
Making the right treatment choices must involve all of these issues to optimize aesthetic outcomes and patient satisfaction. The
authors illustrate how to make the best choices through a series of case examples using a variety of filler types. Although most fillers
can provide acceptable outcomes when used appropriately, the hyaluronic acids have become the most frequently used products
because of their physicochemical properties and clinical benefits.
Alessio Redaelli MD, Domenico Romano MD, Antonio Marcianò MD
Background: Platelet-rich plasma (PRP) has long been known as an effective treatment in various surgical and medical fields. Face
and neck revitalization with PRP is an application that is currently being explored. The aim of this paper is practical: to evaluate if there
are real outcomes, benefits and side effects of a standardized injection protocol in a continuous series, without control groups.
Materials and Methods: In a three-month study, a consecutive series of 23 patients were treated with one session of injections
with PRP every month from September 2008 to December 2008 (a total of three sessions). For blood management, a sterile Regen
Lab® Kit was used. Patients received 4 mL of PRP, activated with calcium chloride, at standard injection points into face and neck
skin. The study was documented with imaging before and after each session using a dermoscope, a digital camera, as well as a
comprehensive state-of-the-art imaging system and dedicated medical imaging software.
Results: The results were evaluated one month after the last session (January 2009) by a special spider improvement score, a photograph
score, a patient’s satisfaction score and a doctor’s satisfaction score. Finally, a definitive graduated score was calculated for
each patient. Overall, the results were satisfactory. No serious and persistent side effects were detected.
Conclusion: Face and neck revitalization with PRP is a promising easy-to-perform technique in face and neck rejuvenation and scar
attenuation. Further work needs to be carried out to investigate its exact mechanism of action.
Adrienne N. Choksi MD, Tasneem Poonawalla MD, Michael G. Wilkerson MD
Nano-sized particles represent a unique class of materials with novel physiochemical properties due to increased surface area. Many
sunscreens and cosmetics are now using nano-sized titanium dioxide and zinc oxide, which avoids the white, chalky appearance
of the older preparations. Although the U.S. Food and Drug Administration (FDA) has determined that nano-sized titanium dioxide
is not a new ingredient, but a specific grade of the original product, recent studies suggest that nanomaterials products may not
be equivalent to their respective bulk-form products, and the adverse effects of nanoparticles cannot be reliably predicted from the
properties of the material in bulk form.
Nanoparticles are incorporated into a variety of skin care products, and in the future may be useful as transdermal drug delivery
devices. Thus, understanding potential epidermal and dermal penetration, as well as possible toxicity, is important to the field of
dermatology. The authors present a review of the therapeutic applications and potential toxicity of nanoparticles relevant to the field
of dermatology thus far.
Benzoyl peroxide (BPO) is a commonly used and highly effective topical treatment for acne that is available in concentrations from
2.5–10%. The compound is not associated with bacterial resistance, and published acne treatment guidelines recommend BPO in conjunction
with the long-term use of both topical and systemic antibiotics. A number of combination products containing antibiotics, BPO
and/or retinoids are available and useful for tailoring treatment to the needs of each patient over the course of what is often a chronic
condition. Fixed combinations of BPO and antibiotics or retinoids address multiple pathogenetic factors by using agents with complementary,
but different modes of action. These agents are convenient to use and may improve adherence to therapy by simplifying the
regimen for the patient. However, BPO is associated with dose-dependent irritation and dryness. Therefore, formulations containing
lower concentrations of BPO (2.5%) minimize irritation, which may improve tolerability and maximize treatment outcomes.
Alan B. Fleischer Jr. MD and Mark Boguniewicz MD
Persistent pruritus, or itch, is one of the earliest symptoms of atopic dermatitis (AD). When pruritus is untreated, the incessant
scratching response by the patient can increase the inflammatory response, resulting in aggravation of disease symptoms and severity,
increasing flares and worsening patient quality of life. Therefore, it is essential that pruritus be treated effectively, rapidly and
safely for optimal management of AD. In this article, the authors review clinical trials using tacrolimus ointment, a topical calcineurin
inhibitor, to treat adult and pediatric patients with AD over a wide range of disease severity focusing on its efficacy in rapidly reducing
pruritus. Furthermore, the authors evaluate trials in which tacrolimus ointment was directly compared with topical corticosteroids, the
mainstay of AD treatment, and pimecrolimus cream, another topical calcineurin inhibitor, as well as long-term safety trials in which
patients applied tacrolimus ointment for extended periods.
Chronic idiopathic urticaria (CIU) is a serious disorder that can greatly compromise quality of life. While H1 antihistamines are the
accepted first-line treatment for CIU, older generations of these agents (e.g., hydroxyzine, diphenhydramine) are associated with
anticholinergic and CNS effects, such as drowsiness and sedation, that can pose risks to patients, especially when driving. Secondgeneration
agents available in the United States (U.S.) (e.g., cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine) has
greatly reduced these CNS effects, making them the current treatments of choice in CIU, but their potency and tolerability profiles
vary. Differences in duration of in vivo receptor occupancy may affect the potency of H1 antihistamines. Levocetirizine appears to
have greater in vivo H1 receptor occupancy compared with later generation H1 antihistamines, which may confer an advantageous
efficacy/safety profile. This has been confirmed in a recent head-to-head study showing that levocetirizine was more effective than
desloratadine in improving pruritus in CIU patients. Fexofenadine has been shown to have a low occupancy of H1 antihistamine
receptors in the brain, which reduces the likelihood of sedation. More studies are required to further assess receptor occupancy and
other factors that may differentiate the second-generation H1 antihistamines.
Oliver A. Perez MD, Martha H. Viera MD, Jitendra K. Patel MD, Sailesh Konda MD,Sadegh Amini MD, Ran Huo MD, Deborah Zell MD, Sujatha Tadicherla MD, Brian Berman MD PhD
Background: Onion extract gel (OE) and 0.5% hydrocortisone, silicone and vitamin E lotion (HSE) are two over-the-counter preparations
used to enhance the cosmesis of keloids and hypertrophic scars.
Objective: To determine the tolerability and efficacy of OE versus HSE versus placebo in subjects with keloids and hypertrophic scars.
Methods: Thirty subjects (≥18 years) with keloids or hypertrophic scars were randomly assigned to one of three study preparations
for 16 weeks. Scar volume was measured at baseline and weeks 4, 8, 12 and 16. Subjects and blinded investigators assessed scar
parameters (induration, erythema, pigmentation alteration, pain, itching, tenderness and cosmetic appearance) and patient satisfaction
at each visit using a visual analog scale (VAS). Data analysis included: mean percentage change (MPC) for subjects completing
the study (n=15); the mixed model test to determine differences between the groups over time; and the Kruskal-Wallis test for the
analysis of differences in subjects’ satisfaction within the three groups over 16 weeks for subjects who completed at least one
follow-up visit (n=21).
Results: All three preparations were well tolerated with the exception of a mild acneiform-like eruption in one OE patient. Significant
improvements were obtained with OE in volume, length, width and induration and with HSE in volume, length, induration, erythema
and pigmentation alteration. There was a trend showing that a higher percentage of subjects were satisfied with OE than with HSE
or placebo. The Mix Model Analysis (MMA) showed significant improvements with OE over placebo in investigator cosmetic assessment,
lesion induration, pigmentation and tenderness and with HSE over placebo in investigator cosmetic assessment, lesion induration,
pigmentation and erythema. Improvements in erythema and pigmentation were significantly greater in HSE than in OE.
br />Conclusion: Both OE and HSE were more effective than placebo in the management of hypertrophic scars and keloids.
Megan A. Kinney MHAM BS,a Brad A. Yentzer MD,a Alan B. Fleischer Jr. MD,a Steven R. Feldman MD PhDa,b,c
Background: Acne vulgaris has been treated with long-term courses of antibiotics since the 1960s. Antibiotic-resistance of Propionibacterium
acnes (P. acnes) was first documented in the late 1970s, and, over 20 years later, the problem of antibiotic resistance
Purpose: The aim of this study was to assess trends in prescribing antibiotics for acne from 1997−2006.
Methods: The authors examined the National Ambulatory Medical Care Survey (NAMCS) database and recorded medications at all
visits to the physician in which acne vulgaris (ICD-9-CM code 706.1) was the only diagnosis from 1997−2006.
Results: Declines in the use of erythromycin and isotretinoin (both P<0.001) for acne were noted for all physicians. Tetracyclines saw
significant increases in use by both dermatologists and non-dermatologists (P<0.01 and P=0.05, respectively). Prescribing of benzoyl
peroxide monotherapy was unchanged for non-dermatologists (P=0.22) and is on the decline for dermatologists (P<0.001). The use
of BPO + clindamycin combination topical treatments rose sharply for all physicians (P<0.001), resulting in greater use of both total
BPO and total clindamycin for acne over time (P<0.001). Topical retinoid use increased among dermatologists (P<0.05) but appeared
to be on the decline among non-dermatologists (P=0.067).
Conclusion: The development of antibiotic resistance is of concern. Greater awareness of retinoid use for maintenance therapy,
using topical benzoyl peroxide to prevent resistance, and limiting use of oral antibiotics to as short a time period as possible are measures
to contribute to better eco-responsible acne treatment.
Giuseppe Togni PhD and Federico Mailland MD
P-3051 is an innovative 8% ciclopirox nail lacquer, based on hydroxypropyl chitosan (HPCH) as a film-forming agent. The authors’
aim was to investigate P-3051’s in vitro antifungal activity, as well as its in vitro and in vivo nail permeation. The dilution susceptibility
tests performed for Trichophyton rubrum (T. rubrum) and Candida parapsilosis (C. parapsilosis) showed that the minimum inhibitory
concentrations (MICs) of P-3051, as percent of ciclopirox, was for both fungi ≤0.0015% (equivalent to a concentration of 15.6 mg/
ml). In the biological assay of in vitro nail permeation and fungal inhibition, the authors observed that P-3051 permeated well through
bovine hoof membranes and produced dose-dependent inhibitory effects on dermatophyte, yeast and mold strains. Moreover, the
inhibition effects were higher than those obtained by equal amounts of the ciclopirox reference nail lacquer. P-3051 and the reference
showed the same protective activity in experimental infections with strains of dermatophytes isolated from clinical samples. The
amount of ciclopirox remained in cut fingernails washed six hours after in vivo application of P-3051 ranged between 18 and 35% of
the applied dose. After in vitro application to cut human nails, 40–50% of the applied ciclopirox penetrated during the first six hours,
independent of nails being infected or uninfected, intact or filed. In both experiments, the concentration of ciclopirox is largely higher
(three to four orders of magnitude) than the MICs for nail pathogens.
Topical dapsone gel 5% is indicated for the treatment of acne vulgaris and has been marketed since late 2008. The topical formulation
retains the anti-inflammatory benefits of dapsone while minimizing the risk of toxicity associated with systemic exposure. This
review summarizes the pharmacokinetic and safety data of topical dapsone gel 5% in acne patients, including those with glucose-
6-phosphate dehydrogenase (G6PD) deficiency, and provides support for dapsone usage in sulfonamide-allergic patients. Overall,
topical dapsone gel has a favorable short- and long-term safety profile and has been shown to have no risk of hemolytic anemia,
including in G6PD deficient patients. Although there are some structural similarities between dapsone and sulfonamides, dapsone is
not a sulfonamide and cross-reaction with sulfonamides has not been demonstrated.
Fadwah Abdullah BPharm and Rashid M. Rashid MD PhD
The use of herbal medications in dermatologic disease has become common practice among consumers. In this paper, the authors
review and discuss the existing evidence-based botanical modalities in the peer-reviewed literature with a particular focus on various
presentations of alopecia. To maximize potential clinical application, this review has been limited human studies. The goal of the
study was to provide a thorough evaluation of the current understanding of the use of non-pharmaceutical botanical products in the
management of hair loss.
Steven P. Davison MD DDS, Joseph F. Sobanko MD, Mark W. Clemens MD
Background: Keloids occurring on the chest can be deforming with significant painful sequelae for patients. These lesions can pose
a therapeutic dilemma for the dermatologic surgeon as certain excision defects may be too large to close primarily and recurrences
tend to be high (40–100%). A collagen-glycosaminoglycan copolymer (Integra) has been found to be useful in the surgical treatment
of scar excisions as the bovine collagen and glycosaminoglycans provide a template for neocollagenesis. Additionally, this dermal
regeneration template concomitantly reduces tensile forces on the wound.
Methods: The authors’ group has followed five patients with chronic chest keloids refractory to myriad of interventions and treated
these patients with surgical excision followed by Integra placement into the wound bed on the chest. Split-thickness grafts were
applied shortly thereafter. Patients were followed at regular intervals and all patients received adjuvant therapy with single-dose radiation
and intralesional chemotherapy (triamcinolone and/or 5 fluorouracil).
Results: This treatment protocol has provided a cure rate of 100% over an average of 43 months follow-up. The symptoms often
accompanied by these chest keloids also appear to improve.
Conclusion: The authors believe that this study provides the groundwork for further investigation of Integra for surgical management
of keloids. A placebo-controlled study should be performed to adequately determine if this data holds true.
Emil Tanghetti MD, Sunil Dhawan MD, Lawrence Green MD, James Del Rosso DO, Zoe Draelos MD,James Leyden MD, Alan Shalita MD, Dee Anna Glaser MD, Pearl Grimes MD, Guy Webster MD PhD,Pamela Barnett BS, Nicolas Le Gall MSc
This 16-week study evaluated once-daily tazarotene 0.1% cream and adapalene 0.3% gel in patients with moderate-to-severe acne.
Patients treated with tazarotene 0.1% cream performed better in many acne efficacy measures (reduction in lesion counts, percentage
of patients achieving a 50 percent lesion count reduction, overall disease severity, investigator’s global assessment) than did
patients treated with adapalene 0.3% gel. Reduction in postinflammatory hyperpigmentation (PIH) was also significantly greater with
tazarotene 0.1% cream than with adapalene 0.3% gel (P≤0.018). Irritation was infrequent, generally mild and similar between treatment
groups. In conclusion, both tazarotene 0.1% cream and adapalene 0.3% gel were effective and well tolerated in patients with
at least moderate acne. Tazarotene 0.1% cream appeared to be more effective and nearly as well tolerated as adapalene 0.3% gel
in reducing acne lesions and was more effective than adapalene 0.3% gel in reducing PIH.
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