Search Results for "Photodynamic Therapy"
Amy Forman Taub MDa,b and Ann Cameron Schieber PA-Ca
The prolonged incubation time of Photodynamic Therapy (PDT) as well as the need for two treatments to achieve high efficacy have motivated physicians to experiment with treatment parameters and PDT enhancements in order to maximize results and practicality.
This review explores recent published strategies including occlusion, temperature elevation, pretreatment with topical 5-FU, and microneedle or laser-assisted reduction of the stratum corneum barrier. All of these innovations improve efficacy, reduce the need for multiple treatments or both, although there are concomitant increases in post-procedure side effects.
J Drugs Dermatol. 2015;14(11):1329-1334.
Tina S. Alster MD, Sharleen St. Surin-Lord MD
Photodynamic therapy (PDT) has been used in the treatment of a variety of benign and malignant cutaneous conditions.
More recently, it has been used to enhance the results of skin rejuvenation procedures. The purpose of this article
is to review the current practical applications of PDT in a cosmetic practice.
The use of photodynamic therapy (PDT) in the US has shown record growth in 2007 with more clinicians utilizing PDT
for more clinical entities than ever before. Research endeavors utilizing PDT in published clinical manuscripts have been
slow in 2007 and yet the use continues to rise significantly. This manuscript will highlight the state of PDT in the US
as 2007 comes to a close and focus on the future of PDT as we move toward 2008.
The sequential use of topical therapies and short-incubation photodynamic therapy for actinic keratosis (AK) has not been extensively
studied. The author reports on treatment with sequential 5-fluorouracil (5-FU) cream 0.5% and 5-aminolevulinic acid-photodynamic
therapy (ALA-PDT) in three older men with photodamaged skin and a history of AK. These findings suggest that this combination
therapy, when compared with short-contact (1 hour) ALA-PDT alone, is more effective, minimizes the recurrence of areas of field
cancerization and improves the appearance of the skin. The use of 5-FU cream 0.5% before and after photodynamic therapy is effective
in revealing the presence of both clinical and subclinical AK lesions.
J Drugs Dermatol. 2011;10(4):372-378.
Shaundre Terrell BS, Daniel Aires MD, Eric S. Schweiger MD
Background: Studies indicate photodynamic therapy is an effective treatment of infl ammatory acne lesions on patients with Fitzpatrick
skin types 1–3. There is a lack of evidence in the literature regarding the use of photodynamic therapy to treat acne vulgaris in
African American patients. This article reports the fi rst case of blue light photodynamic therapy to treat moderate infl ammatory facial
acne on an African American patient with type 5 skin.
Observations: This article describes a 26-year-old African American woman with moderate infl ammatory facial acne vulgaris. On
examination, she had over 15 infl ammatory papules on her face and post-infl ammatory hyperpigmentation. The patient had a history
of treatment failure with the following therapies: topical benzoyl peroxide, topical antibiotics, topical retinoids and oral antibiotics. At
presentation, the patient was using a combination topical benzoyl peroxide/clindamycin product in the morning and tazoratene gel in
the evening without success. The patient was treated with 20% aminolevulinic acid/blue-light photodynamic therapy spaced monthly
for a total of four treatments, a once-daily application of hydroquinone 4% cream and her existing topical regimen. The patient reported
signifi cant improvement of infl ammatory acne lesions and post-infl ammatory hyperpigmentation following two treatments
with photodynamic therapy and was virtually clear of all acne lesions after the third treatment.
Conclusion: Photodynamic therapy is an emerging remedy for patients with acne vulgaris resistant to standard treatment, particularly
in patients with skin of color who are more sensitive to post-infl ammatory hyperpigmentation. In this African-American patient,
20% aminolevulinic acid/blue-light photodynamic therapy was effective in treating facial acne vulgaris.
Elena Maydan MD, Pavan K. Nootheti MD, Mitchel P. Goldman MD
Since its FDA approval in 1999, photodynamic therapy (PDT) with topical 5-aminolevulinic acid has become an increasingly
popular modality for the treatment of actinic keratosis (AKs). It is hoped that in addition to improving clinical signs
and symptoms of AKs, PDT might prevent the development of skin cancer. We present a case of a patient developing a keratoacanthoma
immediately following PDT for AKs.
Michael Shaffelburg MD FRCPC
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.
Gabriel Serrano MD, Matilde Lorente MD, Madga Reyes MD, Fernando Millan MD, Adrian Lloret MD, Joaquin Melendez, Maria Navarro, Miguel Navarro MD
Topical aminolevulinic acid (ALA) photodynamic therapy (PDT) is currently being used for the treatment of actinic keratosis of the
face and scalp. This study reports the results obtained after three to four treatments with ALA-PDT in patients with acne (n=12),
photoaging (n=8) and vitiligo (n=6). ALA was applied on large areas (e.g., full face) and at very low strengths (1-2%). Side effects
were minimal and self-limited.
No abstract details for the moment.
Margit L.W. Juhasz MD,a,b Melissa K. Levin MD,a and Ellen S. Marmur MDa,c
“Fractionated photodynamic therapy (PDT)” is a new term being used by dermatologists to describe advances in PDT technology including fractionated light or the adjuvant use of fractional lasers. Although dermatologists have used PDT since the early 1990s for the treatment of photodamage and precancerous lesions, newer developments in technology have allowed for the treatment of non-melanoma skin cancers (NMSCs), in ammatory disorders, and even uses in the eld of anti-aging. Recent developments in fractionated light therapy have allowed for PDT with dark intervals and two-fold illumination schemes to increase cellular damage and apoptosis. Combining PDT with fractional laser technology has allowed for enhanced dermal penetration of topical photosensitizers including 5-aminolevulinic acid (ALA) and methyl aminolevulinate (MAL), as well as increased ef cacy of treatment. These advances in PDT technology will allow for increased convenience, decreased treatment time, only one application of topical photosensitizer, and decreased cost to the patient and dermatologist.
J Drugs Dermatol. 2016;15(11):1324-1328.
Mary M. Moore MD,a Cindy Reyna FNP-BC,b Richard H. Hope MDb
Photodynamic therapy (PDT) has been considered a safe and efficacious treatment for actinic keratoses (AKs) of the scalp and face. The procedure involves exposing a patient to a blue light source 1-4 hours after application of photosensitizing aminolevulinic acid (ALA) at a dose of 10 J/cm2 for up to 1000 seconds.1,2 We suggest that amount of exposure time and area of exposure should be stratified according to baseline photodamage .
J Drugs Dermatol. 2011;10(9):1057-1058.
Photodynamic therapy with short-contact 5-aminolevulinic acid (Levulan® Kerastick®, Dusa Pharmaceuticals, Inc.)
and activation by intense pulsed light in an initial treatment and blue light in 3 subsequent treatments has resulted in
significant improvement in severity of acne, reduction in the number of lesions, improvement in skin texture, and
smoothing of scar edges in an Asian patient with severe (class 4) facial cystic acne and scarring.
No abstract details for the moment.
Yik Weng Yew MD MPH,a Yi Chun Lai MD MPH,b Yen Loo Lim MD,a Wei-Sheng Chong MD,a and Colin Theng MDa
BACKGROUND: Photodynamic therapy (PDT) using topical application of aminolevulinic acid (ALA) is an effective treatment for acne vulgaris. However, there is no clear consensus on the treatment regime in Asians.
AIM: To determine the efficacy, safety and tolerability of 5% ALA PDT in the treatment of truncal acne in Asians.
METHODS: Patients with truncal acne were treated with 5%-ALA under occlusion for 3 hours. All were subsequently treated with a red light source at wavelength 630 nm and an irradiance of 38mW/cm2 giving a total dose of 37 J/cm2. The numbers of acne lesions were recorded at baseline and regular intervals after treatment together with any adverse effects.
RESULTS: Fifteen patients were recruited. Overall, there was a 64.2% reduction in the inflammatory lesions count and a 24.3% reduction in the non-inflammatory lesions count at the end of the 12 weeks follow-up. Both mean lesions counts were significantly lower than baseline at all follow-up time points with paired t tests (all P values <0.05). Pain was well tolerated among our patients.
CONCLUSION: A single treatment session of 5%-ALA PDT was effective for the treatment of truncal acne with little side effects and acceptable in our Asian patients.
J Drugs Dermatol. 2016;15(6):727-732.
aPeter K. Lee MD PhD and bAndrew Kloser PhD
There is some debate regarding the rate of progression of actinic keratosis (AK) into squamous cell carcinoma (SCC).1-4 However, it is clear that treatment for AK lesions is warranted. Results from numerous studies with aminolevulinic acid (ALA) and methyl aminolevulinate (MAL) photodynamic therapy (PDT) for the treatment of AKs, SCC, and Bowen's disease show high rates of clearance for these lesions. MAL/PDT provides similar efficacy to ALA/PDT with the benefits of shorter incubation times according to the approved FDA labeling, greater selectivity, reduced pain during and immediately following therapy, and fewer systemic side effects. Cosmetic outcomes are better with PDT than with cryosurgery or excisional surgery. A number of case reports show efficacy with ALA/PDT and MAL/PDT for acne, photorejuvenation, and other off-label indications. Side effects with PDT tend to be mild to moderate and transient in nature. Overall, ALA/PDT and MAL/PDT are effective for a variety of skin diseases and conditions. MAL/PDT provides some advantages over ALA/PDT.
J Drugs Dermatol. 2013;12(8):925-930.
Mark S. Nestor MD PhD (chair), Michael H. Gold MD (co-chair), Arielle N. B. Kauvar MD, Amy F. Taub MD, Roy G. Geronemus MD, Eva C. Ritvo MD, Dore J. Gilbert MD, Mitchel P. Goldman MD, Donald F. Richey MD
Photodynamic therapy (PDT) has significant promise in improving outcomes of patients with a variety of cutaneous conditions.
A group of experts met to review the principles, indications, and clinical benefits of PDT with 5-aminolevulinic
acid (ALA). They also reviewed PDT with methyl aminolevulinate. The experts established consensus statements for pretreatment,
posttreatment, ALA contact time, light sources, and numbers of sessions associated with ALA PDT for actinic
keratosis and superficial basal cell carcinoma, photorejuvenation and cosmetic enhancement, acne, sebaceous skin, rosacea,
and rhinophyma. They based consensus recommendations on their clinical experience and the medical literature. They also
suggested future applications of ALA PDT. Experts concluded that ALA PDT is a safe and effective modality for the treatment
of conditions commonly encountered in dermatology. Since downtime is minimal, the technique is suitable for
patients of all ages and lifestyles. Appropriate light sources are available in many dermatology offices. The expanding clinical
and financial benefits of PDT justify the purchase of an appropriate light source.
Molluscum contagiosum, a viral disease of the skin, manifests as a smooth-surfaced, firm, and spherical papule with umbilication of
the vertex. It commonly presents as multiple lesions, which may be extensive in immunocompromised patients, and may mimic cutaneous
tumors in HIV co-infected patients. Infection usually persists for 6 months to 5 years before resolving naturally. Among
immune-impaired persons with HIV, infection is generally more persistent. To date, single and combination therapies for such
patients have been unsatisfactory. Recent observations from a dermatology practice in which 6 patients with HIV and molluscum
contagiosum were treated with 5-aminolevulinic acid (Levulan® Kerastick®) in conjunction with photodynamic therapy suggest clinical
benefits; i.e., substantial reduction in lesional count and severity. Additional research is mandated.
Tina S. Alster, MD and Elizabeth L. Tanzi, MD
Successful and long-standing eradication of sebaceous hyperplasia has remained difficult due to the propensity
of these lesions to be extensive. Current treatments include excision, electrodesiccation, laser vaporization,
and oral isotretinoin, each often associated with unacceptable side effects or lesional recurrence. The purpose
of this study was to evaluate the safety and effectiveness of laser-assisted photodynamic therapy using topical
5-aminolevulinic acid (5-ALA) and 595 nm pulsed dye laser (PDL) irradiation for the treatment of sebaceous
Ten patients with sebaceous hyperplasia received 1 or 2 treatments at 6 week intervals with topical 20% 5-ALA
followed 1 hour later by 595 nm PDL irradiation. Matched lesions served as controls and were either treated
with PDL alone or were left untreated. Patients were evaluated at regular intervals for 3 months.
Results demonstrated that combination topical 5-ALA and PDL treatment effected better clinical results than
PDL treatment alone. No changes were observed in untreated control lesions. Side effects were mild and limited
to transient erythema, edema, and focal crusting.
It is the conclusion of the authors that laser-assisted photodynamic therapy with topical 5-ALA and PDL irradiation
can achieve safe and effective improvement of sebaceous hyperplasia. Further study is warranted to
determine the longevity of the clinical results observed.
Aimee Krausz BA and Adam J. Friedman MD
No abstract details for the moment.
Eric S. Schweiger MD, Laura Kwasniak BS, Viseslov Tonkovic-Capin MD
Nevoid basal cell carcinoma syndrome (NBCCS) is a genetic disorder characterized by multiple basal cell carcinomas (BCCs) in addition
to skeletal abnormalities and other neoplasms. Difficulty lies in treating the large number of BCCs that develop in these patients.
The authors report a case of a patient with NBCCS treated successfully with photodynamic therapy (PDT) using 20% 5-aminolevulinc
acid and blue light. The authors also review the literature and summarize past case reports and series using PDT to treat patient with
NBCCS. Based on their experience and the reports of others, the authors assert that PDT should become the first-line therapy in the
treatment of multiple BCCs in patients with NBCCS.
Michael H. Gold MD, Julie Biron
Background and Objectives: Photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) is becoming a more
popular dermatologic procedure. Newer protocols have virtually eliminated any associated untoward effects. Phototoxicity,
although rare, can still occur and requires aggressive post-therapy care. Recently, a new biorestorative skin care cream, containing
human growth factors and cytokines, was used to treat 2 severe cases of PDT-associated phototoxicity.
Materials and Methods: This paper describes 2 case reports of severe phototoxicity following ALA-PDT treatments. The
novel skin care cream was utilized in both cases phototoxicity.
Results: Complete resolution of the phototoxic reaction was seen, leaving both patients with normal skin texture and tone.
Conclusions: This novel skin care cream may prove useful in wound healing following treatment with lasers and light
sources or dermatologic surgery.
Methyl aminolevulinate photodynamic therapy (MAL-PDT) is utilized in several countries for the treatment of basal cell carcinoma,
but allergic sensitization has been reported by the manufacturer. To the best of our knowledge, we report the first case of urticaria
following MAL-PDT in a patient with nevoid basal cell carcinoma syndrome. Prophylactic use of antihistamines may allow continued
use of MAL-PDT in this setting.
J Drugs Dermatol. 2012;11(11):1364-1365.
Kelley Pagliai Redbord MD, C. William Hanke MD
Background: Topical photodynamic therapy (PDT) involves the use of a photosensitizing topical medication that is activated
by a light source in the presence of oxygen leading to cellular destruction and subsequent photorejuvenation. In
1999, the US FDA approved PDT for the treatment of nonhyperkeratotic actinic keratoses (AKs) on the face and scalp.
Observations: The study population comprised 85 patients treated with short-contact, topical aminolevulinic acid (ALA)-
PDT for a total of 247 treatments. Ninety percent of patients with a variety of dermatologic disorders had significant improvement
or total clearance. Ninety-eight percent of patients had no complications. Only 2 patients in our series had
a significant complication.
Conclusions: Short-contact, topical ALA-PDT is a safe and effective treatment for a variety of dermatologic disorders
including photoaging and AKs.
Irene J. Vergilis-Kalner MDa and Joel L. Cohen MDb
Jennifer Rivard MD, David Ozog MD
Background and Objectives: Photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) is becoming a more
popular dermatologic procedure. Newer protocols have virtually eliminated any associated untoward effects. Phototoxicity,
although rare, can still occur and requires aggressive post-therapy care. Recently, a new biorestorative skin care cream, containing
human growth factors and cytokines, was used to treat 2 severe cases of PDT-associated phototoxicity.
Materials and Methods: This paper describes 2 case reports of severe phototoxicity following ALA-PDT treatments. The
novel skin care cream was utilized in both cases phototoxicity.
Results: Complete resolution of the phototoxic reaction was seen, leaving both patients with normal skin texture and tone.
Conclusions: This novel skin care cream may prove useful in wound healing following treatment with lasers and light
sources or dermatologic surgery.
Mohammad Farhadi MD, Seyed Kamran Kamrava MD, Ashkan Heshmatzade Behzadi MD, Parviz Rafiezadeh MD, Alimohamad Asghari MD, Farhad Rezvan MD, Shayan Maleki MS
Objectives: A number of investigations have already been carried out to assess the effect of photodynamic therapy (PDT) on primary
basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) lesions, but lack of investigations on recurrent lesions or lesions with
treatment failure, prompted the authors to carry out this study. The aim of the present study was to evaluate the efficacy of photodynamic
therapy on recurrent BCC and SCC lesions on head and neck skin.
Patients and Methods: A total of 30 patients, including 16 men and 14 women, were selected from patients with recurrent SCC
and BCC who referred to Iran university ENT research center Rasool-e-Akram Hospital, Tehran-Iran, met the criteria and entered the
study. This is a longitudinal study of 30 patients with 43 histologically verified head and neck skin tumors, candidate for photodynamic
Results: To cite the results obtained in this study, it is worth mention that five cases expressed disagreement with this treatment
modality after the first session of illumination; the treatment was stopped because of pain or burning. In a three-month evaluation,
complete treatment response rates were obtained in 72% of patients (18 cases); in SCC cases it was 71.4% (10 cases) and in BCC
it was 72.7% (eight cases). The final result of complete response rate in three years of follow up, demonstrated that 16 (64%) patients
out of 25 were disease-free from recurrent BCC and SCC (Table 1). In BCC cases the final three-year response rate was seven
(63.6%) and in SCC cases it was nine (64.2%). Hence, there was no statistical difference between SCC and BCC cases to treatment
Discussion: The obtained data from the current study is supportive of the recommended treatment method of PDT as an effective,
tolerable and less invasive treatment in patients with recurrent BCC and SCC carcinomas, particularly when cosmetic effects are an
important consideration. However, more research is needed to establish this.
No abstract details for the moment.
Robert Bissonnette MD, Catherine Maari MD, Simon Nigen MD, Nathalie Provost MD, Chantal Bolduc MD
Background: Photodynamic therapy (PDT) with methylaminolevulinate (MAL) under occlusion is effective for the treatment of acne
vulgaris but is associated with significant phototoxic side effects.
Objective: To evaluate the safety and efficacy of topical MAL with or without occlusion followed by red light exposure in patients
with facial acne vulgaris.
Patients/Methods: Forty-four patients with facial acne vulgaris were randomized to receive four MAL applications (80 mg/g) at twoweek
intervals with occlusion on either the right or left side followed 90 minutes later by either 25 or 37 J/cm2 of red light.
Results: At 18 weeks after the first MAL-PDT treatment, the percentage of inflammatory lesions was reduced by a median of 31.7,
59.4, 58.1 and 55.8 percent for patients randomized to 25 J/cm2 without occlusion, 25 J/cm2 with occlusion, 37 J/cm2 without occlusion
and 37 J/cm2 with occlusion respectively. MAL-PDT was, in general, well tolerated and only two patients discontinued their
participation due to adverse events.
Conclusion: PDT with MAL at 80 mg/g without occlusion reduces the number of inflammatory lesions in patients with facial
Martin Zaiac MD and Annabelle Clement MMS PA-C
Actinic cheilitis (AC), a common disorder of the lower lip, should be treated early to prevent progression to invasive squamous cell carcinoma. This study evaluated the safety and efficacy of photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) activated by blue light for the treatment of AC. Fifteen patients with clinically evident or biopsy-proven AC received two treatments with ALA PDT with blue light activation. Treatments were spaced three to five weeks apart. Most patients achieved 65% to 75% clearance three to five weeks after the first treatment and all achieved more than 75% clearance one month after the second treatment. Three patients achieved complete clearance. Pain and burning during irradiation were absent or mild. All patients said they would repeat the procedure. ALA PDT with 417 nm blue light is a promising option for the treatment of AC of the lower lip.
J Drugs Dermatol. 2011;10(11):1240-1245.
Michael H. Gold, MD; Molly M. Boring, RN, MSN, FNP-C; Tancy Bridges, RN, MSN, FNP-C and Vriginia L. Bradshaw, RN, MSN, GNP-C
Photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) has been shown to be safe and effective for a variety of skin
concerns. The case report described is the first successfully documented use of ALA/PDT in the therapy of recalcitrant molluscum
contagiosum in HIV-positive individuals.
Ricardo Ruiz-Rodriguez MD PhD, Laura Lopez MD, Daniel Candelas MD, Javier Pedraz MD
Background: Photodynamic therapy has been proved to be effective in skin rejuvenation.
Objective: To evaluate clinical efficacy and side effects of photodynamic therapy using topical 5-methyl aminolevulinate
and red light for photorejuvenation.
Methods: A randomized, prospective, split-face comparison study of 10 white, adult patients with moderate photodamage,
Fitzpatrick skin types 2 or 3, and no occurrence of actinic keratosis was performed. Three treatments using topical
methyl aminolevulinate cream, applied for 1 hour on one half of the face and 3 hours on the other half before illumination
with red light. A blinded investigator prior to treatment and 2 months after the third treatment evaluated each side
of the subject’s faces.
Results: A moderate improvement in fine lines, tactile roughness, and skin tightness was observed in most of the patients,
mostly on the 3-hour time side. There were no changes in mottled pigmentation or telangiectasias. Side effects were observed
in all subjects (erythema, edema, scaling) mainly in the 3-hour incubation time side.
Limitations: The small number of patients and the lack of placebo group.
Conclusion: Methyl aminolevulinic-photodynamic therapy with red light can improve fine lines, tactile roughness and
skin tightness in patients with moderate photoaging and no occurrence of actinic keratosis.
Irene J. Vergilis-Kalner MD and Joel Cohen MD
No abstract details for the moment.
Actinic keratoses (AKs) are traditionally treated with cryotherapy, curettage, and 5-fluorouracil (5-FU, Efudex®, ICN
Pharmaceuticals, Inc.), all of which are associated with adverse effects. Although photodynamic therapy (PDT) with topical
5-aminolevulinic acid (ALA) offers a treatment alternative, current protocols require 14 to 18 hours incubation with ALA and
patients experience pain during light treatment. Fifteen patients with multiple and diffuse facial AKs applied 5-FU nightly for
5 days and underwent PDT with ALA (Levulan® Kerastick®, Dusa Pharmaceuticals, Inc.) on the sixth day. ALA was applied
to their entire faces and remained in contact with the skin for 30 to 45 minutes under low-intensity visible light. After removing
ALA, faces received a single pass of 560- to 1200-nm intense pulsed light (VascuLight or Lumenis One, Lumenis). At 1
month and at 1 year post-treatment, 90% of treated AKs had resolved in all but one patient. Erythema resolved 7 to 10 days
after treatment. Patients with multiple diffuse AKs may benefit from the application of 5-FU for 5 days followed by ALA-PDT
with intense pulsed light activation.
Michael H. Gold MD, Julie Biron BS
The use of photodynamic therapy (PDT) with 20% 5-aminolevulinic acid (ALA) for the treatment of acne vulgaris has
been explored. This study evaluates the safety and efficacy of a new Advanced Fluorescence Technology (AFT) pulsed
light source (420-950 nm) for photoactivation in ALA PDT for the treatment of moderate to severe inflammatory facial
acne vulgaris. Nineteen subjects received 4 ALA PDT treatments with the AFT pulsed light source. Treatments were
spaced 2 weeks apart. ALA was incubated for 15 to 30 minutes. At the end of the fourth treatment, the total reductions
in inflammatory and noninflammatory lesion counts were 54.5%and 37.5%, respectively.Median Global Severity Scores
suggest a trend toward reduction after several treatments. Investigator and subject assessments show moderate to marked
improvement in most patients. The new AFT pulsed light source with ALA PDT appears to be a safe and effective modality for the treatment of moderate to severe inflammatory acne vulgaris.
Maha Fadel PhD, Manal Salah MD, Nevien Samy PhD, Mona Soliman MD
Background: Photodynamic therapy (PDT) has been proposed as a treatment option for acne vulgaris. The authors have proposed in
this work a liposomal delivery for methylene blue (MB) for selective acne treatment.
Objectives: To evaluate the efficacy and tolerability of liposomes loaded methylene blue (LMB) based photodynamic therapy in patients
with mild-to-moderate acne vulgaris in a randomized, controlled and investigator blinded study.
Materials and methods: Liposomes loaded methylene blue (LMB) was prepared and studied for different pharmaceutical properties
and formulated in hydrogel (MB 0.1%). Permeability and selective sebaceous gland targeting in mice skin was studied. Gel containing
LMB was used for treating 13 patients complaining of mild-moderate acne vulgaris once a week for two weeks. Efficacy evaluation
included changes in lesions counts, clinical assessments of clinical improvement by patients and evaluating dermatologists. Pain and
local adverse effects were also evaluated.
Results: The mechanism of the drug released from liposomes (both in pH=5.5 and in pH=7.2) was following zero order kinetics
with significant increase in the drug released in pH=5.5. Drug released from free methylene blue (FMB) gel was significantly higher
(P≤0.05) with Higuichi’s diffusion model than LMB gel, which followed zero order kinetics. Free MB gel showed superficial destruction
in the mice hair shaft while LMB showed complete destruction of pilosebaceous unit. After only two sessions, there was a
83.3% reduction in the number of inflammatory acne lesions and a 63.6% reduction in the number of non-inflammatory acne lesions.
At 12 weeks, 90% of patients had a moderate-to-marked improvement of their acne in the treated areas. Most patients had no pain;
also no serious adverse side effects were recorded. All the patients had no edema. Slight transient hyperpigmentation was seen only
in three patients.
Conclusion: Liposomal MB hydrogel selectively delivered MB to sebaceous gland and was effective in photodynamic treatment of
mild-to-moderate acne vulgaris.
Emil A. Tanghetti MD, Carolyn Hamann MBA, and Margo Tanghetti BS
INTRODUCTION: Topical Fluorouracil 5% cream (5-FU) and 20% aminolevulinic acid (ALA)/ photodynamic therapy (PDT) are both FDA approved
for the treatment of Actinic Keratosis (AK). We have studied the use of these 2 agents alone and in a sequential manner. We have also used a 5-FU re-challenge 3 months after treatment to highlight the efficacy of these treatments.
METHODS: This was an investigator-blinded randomized study in which 30 patients were randomized 1:1:1 into the following groups: Group 1 patients pretreated for 6-7 days with 5-FU, ALA applied with incubation of 2 hours, ALA removed with wet gauze, illuminated treated areas with 10 J/cm2 with Blu-U device; Group 2 patients treated with 5-FU BID for 6-7 days and no ALA/PDT; Group 3 patients received no pretreatment, ALA applied with incubation of 2 hours, ALA removed with wet gauze, illuminated treated areas with 10 J.cm2 with Blu-U device. Patients were seen at screening/baseline, treatment for ALA/PDT, 24 hours post treatment, 1 week post treatment
and 3 months post treatment. All subjects were then given a re-challenge course of 5-FU for 6 days and reassessed.
RESULTS: AK counts in all groups were dramatically decreased and similar at 1 and 3 months post treatment. The re-challenge brought a significant difference with many subclinical lesions in the area of activity in the ALA and 5-FU alone groups.
CONCLUSIONS: All three arms appeared equal in treating visible AKs. These data strongly suggests a synergistic role of 5-FU with ALA/PDT over ALA/PDT or 5-FU alone in treating the subclinical lesions demonstrated on a 5-FU re-challenge. Treatment of these subclinical lesions should result in a longer remission. The data also suggests that a 5-FU re-challenge could be a clinical tool to judge the efficacy of treatment for AK if these subclinical lesions are proven to be an AK precursor.
J Drugs Dermatol. 2015;14(11):1241-1244.
Melanie D. Palm MD MBA and Mitchel P. Goldman MD
Background and Objective: Methyl aminolevulinate (MAL) is a recently FDA-approved molecule for photodynamic therapy (PDT) in
the treatment of nonhyperkeratotic actinic keratoses (AK). In the U.S., aminolevulinic acid (ALA) has been used in an off-label manner
with photodynamic therapy for the treatment of chronic photodamage. The published use of MAL-PDT for photorejuvenation is
more limited. MAL-PDT is usually conducted with a red light source, ALA-PDT with a blue light source. The purpose of this study is
to compare the use of red versus blue light sources in the treatment of photodamage using MAL-PDT, measuring safety and efficacy
outcomes following treatment.
Study Design/Material and Methods: Eighteen adult patients with moderate-to-severe photodamage of the head or upper trunk
were enrolled in a prospective, single center trial of MAL-PDT for photorejuvenation. Intrapatient randomization determined split-area
treatment with a blue or red light source. The majority of patients were also treated with pulsed dye laser (PDL) and/or intense pulsed
light (IPL) for photoactivation. Digitial photography documented the treatment area at each visit (days 0, 2, 7 and 30). Patient and
physician scoring of photodamage occurred at baseline and final visits. Side effects following MAL-PDT were evaluated.
Results: No statistically significant differences in signs of photodamage following MAL-PDT were observed between blue versus
red light treated sides. The greatest improvement in photodamage measures following 1 MAL-PDT were pigmentation, AK and
erythema. Side effects were mild in nature and did not differ between treatment sides, and all but mild erythema resolved by day 7.
Conclusion: Blue and red light have similar efficacy as the light source for MAL-PDT when combined with other light sources. Side
effects following MAL-PDT with red versus blue light were similar and mild in severity. MAL-PDT is an effective treatment modality
for chronic photodamage, in particular AK and pigmentation.
(J Drugs Dermatol. 2011;1053-60.)
Christopher M. Wolfe PA-C, Armand B. Cognetta Jr. MD
Background: Actinic keratoses (AKs) are a common premalignant tumor of the skin. Several treatment modalities exist
for broad-area therapy. Photodynamic therapy (PDT) is one such treatment modality. Disruption of squamous epithelium
locally compromises the normal physical barrier of the skin, potentially allowing bacteria penetration into the dermis. This
may occur subsequent to PDT, resulting in cellulitis and its sequelae. Undiagnosed and untreated this can prolong recovery
times and increase patient discomfort.
Objective:We report 4 cases of cellulitis that developed after treatment of AKs with PDT. These cases developed 1 to 4
days after PDT.
Methods: Standard short-contact 2-hour incubation is performed on patients receiving treatment on the face or scalp. Patients
are contacted by telephone on day 1 and day 3 postprocedure. Patients are asked to call immediately if they experience
no resolution of discomfort or an abrupt increase in pain in the days following treatment. Those patients reporting
an increase in pain and discomfort on either of these days are asked to come to the office for examination. A culture and
sensitivity is performed on those presenting with cellulitis clinically and empiric antibiotic therapy is initiated. Antibiotic
therapy is adjusted, if necessary, based on the culture and sensitivity report.
Results: All cases of cellulitis presented with an increase in pain and burning as the primary symptom between day 1 and 4
following PDT. The appearance of impetiginized areas or pustules was clearly evident in 2 out of the 4 patients. A culture
and sensitivity confirmed the growth of staphylococcus aureus in all 4 patients.
Conclusion: Cellulitis should be considered as a possible complication in patients reporting an abrupt increase in pain or
those who do not experience a gradual resolution of pain and discomfort following PDT.
Ricardo Ruiz-Rodriguez MD PhD, Laura López-Rodriguez MD
As demand for less invasive, highly effective cosmetic procedures grows, dermatologists must continue to explore and
develop new treatment options. Nonablative skin resurfacing techniques offer an effective and noninvasive treatment for
photorejuvenation. Several studies have shown improvement of photodamaged skin and increased collagen production after
nonablative treatments using vascular lasers, mid-infrared lasers, intense pulsed light, radiofrequency devices, fractional
resurfacing, and plasma skin rejuvenation. Among the novel methods for maximizing the efficacy of nonablative treatment
is the concurrent use of a photosensitizing agent. The light sources currently most used for photodynamic rejuvenation are
intense pulsed light and pulsed dye laser. We present some preliminary results on rejuvenation using Metvix and red light.
We are still far from a thorough understanding of the molecular mechanism of rejuvenation with this technique, although a
nonspecific immune response could be involved. Understanding the laser-tissue interactions associated with photodynamic
therapy is crucial in selecting patients that will most likely benefit.
C. Cantisani MD,a G. Paolino MD,a U. Bottoni MD,b and S. Calvieri MDa
BACKGROUND: non-melanoma skin cancer (NMSC) is the most common malignancy, whose public health significance is often unrecognized.
Its incidence continues to grow at an alarming rate, becoming an occupational disease. Available treatments alternative to surgery include: photodynamic therapy, electrochemiotherapy, cryotherapy, ablative lasers, 5–fluorouracil, imiquimod, ingenol mebutate,
and diclofenac. Each of these options has its advantages and disadvantages. Photodynamic therapy (PDT), using topically applied photosensitizer precursors such as methylaminolaevulinate (MAL), is a useful nonsurgical treatment, well accepted by patients, but the main limitation is pain. Recently, in order to overcome this limit, visible light irradiation photherapy was considered.
AIM: we report our experience comparing conventional PDT (406 patients) with daylight-mediated PDT (D-PDT) 240 patients with multiple
actinic keratoses (AK), afferent to our photodynamic outpatients clinic from September 2013 to June 2014.
MATERIALS AND METHODS: to establish predictors for the clinical response to conventional PDT and daylight PDT (DPDT), a retrospective study on 646 patients was performed. The following parameters have been evaluated: sex, age, anatomic site of the primary tumor and local skin reactions. We used the Spearmen’s coefficient between the clinical response and the predictors analyzed; while Odds Ratio (OR) was performed to evaluate general clinical response and local skin reaction between PDT and D-PDT patients. Subsequently, we performed a sub-analysis, focusing to the anatomical sites, and we subdivided anatomical sites in face and scalp, nose, trunk, and extremities.
RESULTS: a total of 406 patients treated with PDT and 240 patients treated with D-PDT, were enrolled in the current report. The median age was 71 years in PDT and 73 years in D-PDT. The mean clinical response in PDT was of 74.4% and 95% in D-PDT. Performing OR between PDT and D-PDT, according to the clinical response, we found a better behavior in patients treated with D-PDT (P < 0.03); the same significance was maintained according to the presence or absence of local skin reaction (P < 0.0002). Using no parametric Spearman’s
Coefficient test among predictive factors and the therapeutical response we found that D-PDT showed a better clinical response in patients with AK size ≥0.6 mm (P < 0.03), while this evidence was not present in PDT. The nose remained in both PDT and DPDT the main anatomical site with a better clinical response to the treatment.
CONCLUSION: Since efficacy of D-PDT is comparable or superior to conventional type, but is simpler and better appreciated by patients, in our opinion it may be used routinely to treat sun exposed multiple AKs especially in sun damaged skin also for aesthetic purposes.
J Drugs Dermatol. 2015;14(11):1349-1353.
Eric S. Schweiger MD,a Christy C. Riddle MD,b Daniel J. Aires MDb
Background: The current standard of care for hidradenitis suppurativa (HS) includes antibiotics (oral/topical), retinoids (oral/topical)
and intralesional steroids and is unsatisfactory. Photodynamic therapy (PDT) with 20% 5-aminolevulinic acid (ALA) has been used
"off label" to treat acne vulgaris and may hold promise as a therapy for HS. This open-label, non-blinded study investigated the efficacy
and safety of ALA PDT for the treatment of HS using two blue light sources and intense pulsed light (IPL) for photoactivation.
Methods: Twelve subjects with active HS enrolled to undergo ALA PDT once weekly for four weeks with follow-up visits 4, 8, and 12
or more weeks later. Nine subjects completed the study through the week 8 follow-up visit. Lesions were counted at each treatment
visit at week 4, week 8 and at the final week.
Results: Mean lesion counts were 11.25 at baseline, 6.5 at 4 weeks (50.8% reduction), and 7.5 at 8 weeks (29.9% reduction). Mean
Global Severity Scores were 2.2 at baseline, 1.5 at 4 weeks, and 1.8 at 8 weeks. Mean DLQI scores were 17.3 at baseline, 13.1 at
4 weeks (27.2% improvement), 14.00 at 8 weeks (19.3% improvement) and 14.0 (19.3% improvement) at the final week (16-62
weeks). Three subjects (25%) had complete clearance and no active lesions 4 weeks after the final treatment. Treatments were more
tolerable for subjects treated with blue light than with IPL.
Conclusion: ALA PDT may be a safe and effective treatment of hidradenitis suppurativa.
J Drugs Dermatol. 2011;10(4):381-386.
David E. Orbuch BS,c Lauren Penn MD MS,b Bradley S. Bloom MD,a,b Jeremy A. Brauer MD,a,b Daniel B. Shin MS PhD,d Joshua Greenbaum,a Leonard J. Bernstein MD,a,e Elliot T.Weiss MD,a,e Robert T. Anolik MD,a,b and Roy G. Geronemus MD1,2
BACKGROUND: Photodynamic therapy (PDT) is an FDA approved treatment for actinic keratoses (AK’s) although multiple off-label indi- cations are reported. Despite frequent use for AK’s, no clear consensus exists regarding protocols for overall treatment parameters.
METHODS: Retrospective chart review of 1,491 subjects who underwent PDT between 2007 and 2011 at a high volume laser surgery center. Demographic information, clinical history, treatment data, and subsequent diagnosis of skin cancers were recorded. An ex- ploratory subgroup analysis was performed for patients treated for AK and/or squamous cell carcinoma (SCC) that developed SCC or remained SCC-free one year after treatment.
RESULTS: The most common indications for PDT were actinic keratoses (n=1404, 94.9%) then NMSC (n=45, 3.0%) The most common treatment site was the head and neck (n=1274, 86.1%). Blue light activation (405-420nm) was used more frequently than red light and visible light. (73.8% vs. 22.8% vs. 6.8%). The most commonly used photosensitizer was aminolevulinic acid (ALA) (98.6%, n=1456). Topical application (97.7% n=1437) of photosensitizer was used more frequently than intralesional administration (2.0%, n=29). 580 patients met subgroup analysis criteria. 66 developed SCC at treatment site (11%). Factors associated with developing SCC were older age, SCC history, Fitzpatrick skin-type 1, and sixty-minute or less incubation times (P less than 0.05 for all factors). The SCC subgroup had a unique distribution of treatment sites (P less than.001). No statistically significant differences were observed for gender or wavelength.
CONCLUSION: There are differences in protocols based on indication and location of lesion. Blue light is preferable for superFIcial lesions and red light for deeper lesions. Intralesional delivery is used more commonly for NMSC. Extremities require longer incubation times. PDT may be more effective with younger patients and longer than sixty-minute incubation times. PDT chemoprevention is independent of light source used.
J Drugs Dermatol. 2016;15(11):1420-1426.
Christy C. Riddle MD, Shaundre N. Terrell BS, Molly B. Menser DO, Daniel J. Aires MD,Eric S. Schweiger MD
Background: Photodynamic therapy (PDT) is increasing in dermatology. Antibiotic resistance and the challenges of isotretinoin
therapy have led to investigation of PDT in the treatment of acne vulgaris.
Objective: To review the results of clinical trials and case series with respect to light source, topical photosensitizing agent, adverse
events, efficacy and skin type.
Methods: A non-critical review is presented of a PubMed search for studies examining PDT in the treatment of acne vulgaris.
Results: The authors found 21 clinical trials and case series of various designs. Eight studies employed a split-face design comparing
photosensitizer to placebo, no treatment or another photosensitizer. Two trials used three test spots and one control spot per patient.
Three studies utilized control subjects receiving no photosensitizer with or without light therapy. All 21 studies reported a reduction in
inflammatory lesions and/or a significant improvement in acne. The light sources utilized included blue light, pulsed-dye laser (PDL),
intense pulsed light (IPL) and red light. Studies comparing the use of PDT to light therapy alone demonstrated greater improvement
in treatment groups pretreated with a photosensitizer.
Conclusion: All studies reported reduction in inflammatory lesions or significant improvement in acne. Several studies confirm a
light source combined with photosensitizer is superior to light alone. Adverse reactions including photosensitivity, pustular eruptions,
and crusting varied among photosensitizers and light sources. PDT appears to be a useful therapeutic option for acne patients who
are recalcitrant to standard treatments and poor candidates for systemic retinoids. Further studies are still needed before a consensus
protocol can be established. Additional investigations are needed to establish optimal incubation time, activating light source and
frequency of treatment.
Ricardo Ruiz-Rodriguez MD PhD, Laura López MD, Daniel Candelas MD, Brian Zelickson MD
Background and Objectives: Conventional ablative resurfacing is the gold standard for removing signs of cutaneous
photodamage. Despite the excellent results one can achieve with this technique, it is accompanied with significant downtime
and risks. Fractional resurfacing and photodynamic therapy (PDT) with aminolevulinic acid (ALA) have been used
to improve the signs of photodamage with less downtime. However, independently they do not yield results as good as
ablative resurfacing. This pilot study will examine the potential for synergistic effects of combining fractional resurfacing
Materials and Methods: Four women with Fitzpatrick skin types II or III, mild to moderate rhytides and no actinic keratosis
in the perioral area were treated. The perioral area was treated with 2 sessions of fractional resurfacing with the Fraxel
SR (formerly Fraxel SR750, Reliant Technologies Inc, Palo Alto, CA) 3 weeks apart. Immediately after each fractional
treatment we applied methyl 5-aminolevulinate (MAL or Metvix) on one half of the perioral area and 3 hours later we
illuminated that area with a red light (Aktilite lamp, PhotoCure ASA, Oslo, Norway) in a dose of 37 J/cm2. Prior to treatment
and at 4 and 12 weeks after the final treatment, a blinded investigator evaluated each side of the perioral area and
rated the improvement from baseline as excellent, good, fair, or poor improvement of superficial wrinkles by comparing
the results with pretreatment photographs. Patients also completed an evaluation form assessing their satisfaction with the
treatment on each side of the perioral area while comparing the results with pretreatment photographs.
Results: The study showed increased improvement in superficial wrinkles in 3 out of 4 patients on the combined treatment
side. In one patient, the investigator found no significant difference when comparing both sides. All the patients noted greater
improvement in the combined fractional and PDT-treated side compared to the side only treated with fractional surfacing.
Conclusion: This pilot study shows a potential for enhanced clinical results when using combined fractional resurfacing and ALA-PDT compared to fractional resurfacing alone.
Brian Berman MD PhD, Mark S. Nestor MD PhD, Jessica Newburger DO,
Huynhee Park DO, and Nicole Swenson DO
OBJECTIVE: This randomized, 3-group study compared the efficacy and tolerability of 3 treatment modalities for facial actinic keratoses.
METHODS: Twenty-four healthy adult male and female subjects who had 4 to 8 clinically visible and discrete actinic keratoses on the face in a contiguous 25cm2 treatment area. Subjects were randomized into one of three treatment groups: 2 treatments with 5-aminolevulinic acid (ALA) and photodynamic therapy (PDT), 1 ALA-PDT treatment and 1 course of ingenol mebutate (ingenol mebutate) 0.015% gel daily for 3 consecutive days, or 1 course of ingenol mebutate gel alone. Actinic keratoses in the treatment field were counted at the baseline visit, and at the completion of the study (day 57 or day 71). At the site of application, local site reactions were graded at each visit.
RESULTS: Subjects in the two ALA-PDT treatment group had a 97.5% mean reduction (P<0.00001) from the number of baseline actinic keratosis; ALA-PDT plus ingenol mebutate gel group had an 86.7% mean reduction (P<0.00001); while subjects in the ingenol mebutate gel alone group had a 91.7% mean reduction from the number of baseline actinic keratoses. The peak composite LSR score was 4.625 for the ALA-PDT group, 10.375 for the ALA-PDT followed by ingenol mebutate gel group, and 12.625 for the ingenol mebutate gel alone group (P=0.0004 and 0.001, respectively).
CONCLUSION: ALA-PDT, ingenol mebutate gel, and a combination of the two treatment modalities are successful topical therapies for the reduction of actinic keratoses on the face. The group of subjects receiving 2 consecutive treatments with ALA-PDT, compared to treatment with ingenol mebutate gel alone or sequentially after one course of ALA-PDT had a significantly lower mean composite LSR score and a non-significant trend for greater efficacy.
J Drugs Dermatol. 2014;13(11):1353-1356.
Manal Salah MD, Nevien Sami PhD, Maha Fadel PhD
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.
Nevien Samy PhDa and Maha Fadel PhDb
BACKGROUND: Blond and white hair removal by laser is a complicated task with weak satisfactory results due to the deficiency in laser-absorbing chromophore.
OBJECTIVE: To investigate if repetitive sessions of photodynamic therapy (PDT) using external application of liposomal Rose bengal (RB) photosensitizer followed by intense pulsed light (IPL) exposure enables removal of gray and white hair.
MATERIALS and METHODS: Rose bengal loaded in liposomes (LRB) was constructed, prepared in hydrogel, and was studied for some pharmaceutical properties. Penetration and selective hair follicle damage in mice skin were studied. Topical gel containing LRB was used for treating fifteen adult females who were complaining of facial white terminal hair. Unwanted facial hair was treated for three sessions at intervals of 4–6 weeks using intense pulsed light (IPL). At each session, the treatment area was pre-treated with topical LRB gel, while a control group of another 15 patients applied placebo gel before IPL treatment. Evaluations included hair regrowth, which was measured 4 weeks after each treatment session and at 6 months follow-up by counting the number of terminal hair compared with baseline pretreatment values. Treatment outcomes and complications if any were also reported.
RESULTS: Average hair regrowth in the LRB group was 56% after 3 treatment cycles. After six-months follow up, average terminal hair count compared with baseline pretreatment showed 40% reduction and no recorded side effects.
A significant difference (P<0.05) was seen compared with the control group; the clinical results were promising.
CONCLUSIONS: Photodynamic hair removal using rose bengal-encapsulated liposomal gel in combination with IPL treatment showed significant efficacy in the treatment of white hair compared with a control group.
J Drugs Dermatol. 2014;13(4):436-442.
Mitchel P. Goldman, MD and Sarah M. Boyce, MD
This article describes a single-center trial involving twenty-two patients with acne vulgaris. Blu-U light was
used in all patients, while half were pre-treated with aminolevulinic acid. Preliminary results show promise for
this treatment in mild to moderate inflammatory acne vulgaris.
Barbara D. Garcia MD, Mitchel P. Goldman MD, Michael H. Gold MD
Photodynamic therapy (PDT) and intense pulsed light therapy (IPL) are commonly used in the setting of photorejuvenation.
Patient expectations for minimal to no downtime associated with these procedures has become an increasingly
important issue. In an attempt to define a topical skin care regimen that would reduce procedure-related symptoms and
possibly enhance therapeutic efficacy, 4 separate topical products were examined. Avène Thermal Spring Water (Laboratoires
Dermatologiques Avène, Les Cauquillous, France), NIA 24™ (Niadyne, Inc, Research Triangle Park, NC),
MimyX™ cream (Stiefel Laboratories, Coral Gables, FL), and Biafine® (OrthoNeutrogena, Los Angeles, CA) were studied
individually in the setting of either PDT or IPL treatments. The results of these studies indicate that a pre- and/or
postprocedure topical skin care regimen can be beneficial in reducing postprocedure symptoms.
Stuart J. Anderson MBBS FRACGP FACCO FARGP,a Howard K. Steinman MD,b Jason D. Mazzurco DO MS,c and Anthony J. Dixon PhD MBBSd
OBJECTIVE: To determine whether field photodynamic therapy (PDT) of actinic keratoses (AKs) using a novel preparation of 5-aminolevulonic acid (ALA) would result in fewer subsequent invasive skin cancers developing on the face.
DESIGN: A prospective multi-center randomized controlled trial. The protocol was approved by the Bond University Human Research Ethics Committee in accord with the TGA’s Clinical Trial Notification Scheme. The trial was registered (12609000025235) on the Australian New Zealand Clinical Trials Registry.
SETTING: Six centers in four states in Australia.
PROTOCOL: Two treatments of ALA PDT, 2 weeks apart for each patient. Controls were observed. Patients were followed up with biopsies of any suspicious lesions every 6 months for 2 years.
MAIN OUTCOME MEASURE(S): Development of new skin cancers.
RESULTS: The trial was suspended after 3 months and closed after 6 months after ethics committee approval was withdrawn on the basis of a breakdown in trial governance. Over the following 2 years, some investigators noted and formally reported the continued occurrence of serious adverse events in excess of those described with other approved cutaneous PDT treatments. USA dermatologists with experience managing AKs with FDA approved ALA products subsequently confirmed prolonged and severe adverse events in 6 of the former trial intervention patients.
DISCUSSION AND CONCLUSIONS: Adverse effects experienced by patients using the investigational ALA PDT appeared more severe than those experienced when an FDA-approved ALA product is used. We believe the former should be further evaluated for safety. It is of concern that this ALA product and lamp could be promoted and used widely in Australia following these reports of significant adverse events and continued lack of TGA approval.
J Drugs Dermatol. 2014;13(1):62-66.
Cindy Berthelot MD, Allison Rivera MD, Madeleine Duvic MD
Mycosis fungoides (MF) is a rare neoplasm of epidermotropic CD4+ lymphocytes and represents a majority of all cutaneous
T cell lymphomas. Early stage MF is limited to cutaneous patches and plaques that can be treated with topical modalities
with high response rates. More aggressive systemic treatment of early disease does not alter survival or cure the disease
and could accelerate progression by causing immunosuppression. Topical corticosteroids, mechlorethamine, and carmustine
have been the mainstays of early treatment of MF for more than 30 years. More recently, topical formulations of
retinoids, novel rexinoids, methotrexate, immunomodulators, and photodynamic compounds have been investigated for
their potential roles in treating early MF. The future of topical treatments for MF is promising both as primary and adjunctive
Emily Stamell Ruiz MD,a Joel L. Cohen MD,b,c
and Adam Friedman MDd
Although the therapeutic gold standard for basal cell carcinomas
(BCCs) is surgical excision, imiquimod, fluorouracil
cream, and photodynamic therapy are frequently used. All 3
modalities have been shown to be efficacious for the treatment
of superficial BCCs as well as other nonmelanoma
skin cancers; however, recent reports have emerged implicating
these agents in causing more aggressive recurrent
subtypes of BCCs. Here we review this literature as well as
offer an alternative explanation for these tumors.
Background: Actinic keratoses (AKs) are in situ epidermal tumors that may progress to invasive squamous cell carcinomas (SCCs). Aminolevulinic acid with photodynamic therapy (ALA PDT) is a field treatment for AK.
Objective: To evaluate the time to development of new non-melanoma skin cancers (NMSC) within one year of ALA-PDT treatment in immunocompetent patients with AK and a history of skin cancer.
Methods and Materials: One hundred forty anatomic sites in 114 patients were treated with topical ALA for a 1 to 3 hour incubation period followed by photodynamic therapy (PDT) with a blue light. All new NMSCs within the treatment areas were recorded over a 1-year observational period.
Results: Eighty-three anatomic sites (59%) did not develop new skin cancers within 1 year. Additionally, 92%, 78%, and 64% of anatomic sites were free of new skin cancers at 3, 6, and 9 months after treatment was initiated. Although approximately 41% of patients treated on both the scalp and face developed new skin cancers within 1 year of treatment, the average time to develop skin cancer was longer for the face (7.09 months) than for the scalp (5.34 months).
Conclusion: In patients with a history of NMSC and multiple AKs, ALA PDT may be a valuable option for the prevention and delay of new NMSCs.
J Drugs Dermatol. 2012;11(5):593-597.
Background/Objective: Actinic keratoses (AKs) on the upper extremities are difficult to treat. This study compares the efficacy and tolerability of photodynamic therapy (PDT) using 20% 5-aminolevulinic acid solution (ALA) and blue light versus ALA vehicle and blue light for the treatment of AKs of the dorsal hand and forearm.
Methods: Subjects were treated twice at an eight-week interval by ALA with blue light on one hand and forearm and with ALA vehicle and blue light on the contralateral hand and forearm. ALA incubation time was two hours under occlusion. Efficacy and tolerability were compared.
Results: The mean lesion count reductions (58.4±22.2% and 24.8±20.6% four weeks after the second treatment for the ALA and vehicle-treated sides, respectively) differed significantly (P=0.0004). Eleven of 15 subjects (73%) in the ALA-treated side achieved at least 50 percent reduction in lesion count compared to only two subjects (13%) in the vehicle-treated side four weeks after the second treatment. The difference was significant (P=0.0143). Photodamage grade reduction was also significant (P=0.0309) after the second treatment. Subject
satisfaction was moderate to very satisfied (86.7%) on the ALA-treated side. Transient adverse events were significantly greater on the ALA-treated side for erythema (P=0.0011), edema (P=0.0199) and stinging and burning (P=0.0016) 48 hours after the first treatment.
Conclusions: Two sessions of PDT using ALA with blue light is a moderately effective, well-tolerated treatment of actinic keratoses of the dorsal hand and forearm.
J Drugs Dermatol. 2011;10(9):1049-1056.
Macrene R Alexiades-Armenakas MD PhD, Roy G Geronemus MD
Actinic cheilitis (AC) is a common precancerous condition for which a safe, effective, rapid, and cosmetically favorable treatment is
needed. The objective of this study was to assess the safety and efficacy of the long-pulsed pulsed dye laser (LP PDL) (595 nm) with
photodynamic therapy (PDT) for the treatment of AC. This study was designed to be a prospective, proof-of concept pilot study to
assess safety and efficacy of LP PDL in conjunction with topical 20% 5-aminolevulinic acid solution PDT for the treatment of AC.
Control patients received LP PDL alone. The setting was an outpatient clinical research center. A volunteer sample of 21 patients
with biopsy-proven AC was enrolled (age range, 42-86 years; skin types I-III). All patients were refractory to prior therapies.
Patients with a history of herpes labialis were pre-treated with famcyclovir. Nineteen patients received one-to-three treatments of
topical 20% 5-aminolevulinic acid for 2-3 hours, followed by LP PDL (595 nm) at monthly intervals. Two control patients received
one treatment with LP PDL alone. Patients in the ALA-LP PDL group were followed at 1, 2, 3, 6, 9, and 12 months. Clearance of
AC was assessed by clinical evaluation. Control patients were followed to the one month interval.
We observed none-to-mild pain; slight-to-moderate erythema; no crusting, purpura, or scarring; treatment time of less than one
minute; and complete resolution of post-operative erythema by day three. Complete clearance was achieved in 13/19 (68%) of patients
following a mean of 1.8 treatments (7/13 (37%) after one, 2/13 (11%) after two, and 1/13 (21%) after three treatments). Patients were followed
for a mean of 4.1 (range 1-12) months. Among the remaining cases, partial clearing was achieved in two patients, recurrence during
the follow-up interval was observed in one patient, and failure to follow-up occurred in three patients. Post-operative impetiginization
occurred in three patients with erosive AC, which resolved with dicloxacillin therapy. Among the control patients, no clearing
Treatment of AC using LP PDL (595 nm) at nonpurpuric parameters following topical application of 5-aminolevulinic acid at short
incubation times is safe and effective. It may offer the advantages of rapid incubation, treatment, and recovery times, minimal discomfort,
excellent cosmetic outcome, and good efficacy rates. Patients with erosive AC should receive antibacterial prophylaxis.
Multiple treatments may be required for complete clearing.
Kavitha K. Reddy MD, C. William Hanke MD MPH, Emily P. Tierney MD,
Background: Methyl aminolevulinic acid photodynamic therapy (MAL-PDT) has antitumor activity and may promote wound healing.
Superficial and nodular basal cell carcinomas (BCCs) have been successfully treated with MAL-PDT in prior reports. In vitro and animal
studies have shown more rapid re-epithelialization and decreased myofibroblast response after treatment thus suggesting that PDT
may play a possible role in promotion of wound healing.
Objectives: To describe a novel case of a large multifocal BCC treated with postoperative PDT that showed results of tumor clearance
and rapid re-epithelialization and to review the relevant literature.
Case Report: A patient presented for Mohs micrographic surgery (MMS) after recent biopsy revealed recurrent BCC. Mohs
micrographic surgery was performed, where after six stages were taken, approximately 50% of the peripheral margins of the
tumor remained positive for superficial BCC. Given the large size of the wound defect (12.5 cm x 9 cm) and superficial nature of
the persistent tumor, the authors opted to treat the patient with adjuvant MAL-PDT in lieu of pursuing additional stages with MMS.
The patient returned the following day for adjuvant therapy with MAL-PDT. Two consecutive treatments one week apart were given
as an adjunctive treatment course for persistent BCC. At follow-up four weeks after the PDT treatment, the defect had fully reepithelialized.
In the authors’ clinical practice, an untreated wound of this size typically heals in 10–12 weeks. The patient has been
seen in six months of follow-up to date. Review of the literature relevant to use of MAL-PDT in treatment of basal cell carcinoma and
literature describing effects of PDT on wound healing was performed.
Conclusion: MAL-PDT may be an effective adjuvant tool against large multifocal BCCs for which surgery has not resulted in clearance.
Treatment with PDT resulted in rapid re-epithelialization of the surgical wound in this case. This observation is supported by
prior in vitro studies and in vivo animal experiments demonstrating more rapid re-epithelialization of wounds and decreased scarring response after PDT.
Nina Botto MD and Gary Rogers MD
This review discusses nontraditional modalities available for the treatment of basal cell carcinoma along with the existing evidence to support their respective uses in varying clinical situations. By definition, these modalities are nonsurgical, and in many cases, are not approved by the US Food and Drug Administration as treatments for basal cell carcinoma, including topical chemotherapies, photodynamic therapy, oral therapies, and complementary therapies. Nonetheless, as the population of patients with skin cancer increases at epidemic proportions, many of these modalities are, and will become, increasingly relevant in the dermatologist’s armamentarium.
J Drugs Dermatol. 2013;12(5):525-533.
George J. Schmieder DO,a Eugene Y. Huang MD PhD,b and Michael Jarratt MDc
Background: Photodynamic therapy (PDT) with aminolevulinic acid (ALA) has been shown to be safe and effective in the treatment of
actinic keratoses (AKs) of the face and scalp. A recent small study has suggested that ALA-PDT can be effective for AKs of the dorsal
hands/forearms. However, studies designed to provide sufficient statistical power to test this hypothesis are lacking in the literature.
Objectives: To determine and compare the safety and ef!cacy of blue light ALA-PDT vs blue light placebo vehicle (VEH) in the treatment
of AKs of the upper extremities and to evaluate the effect of occlusion after application of ALA vs VEH.
Methods: ALA or VEH was applied to both dorsal hands/forearms for the 3-hour incubation period before blue light treatment (10 J/
cm2). One extremity of each subject was covered with occlusive dressing during the incubation period. Treatment was repeated at
week 8 if any AK lesions remained.
Results: The median AK lesion clearance rate at week 12 was 88.7% for extremities treated with occluded ALA (ALA+OCC), 70.0%
for extremities treated with nonoccluded ALA, 16.7% for extremities treated with occluded VEH (VEH+OCC), and 5.6% for extremities
treated with nonoccluded VEH (P<.0001). ALA+OCC resulted in a significantly higher clearance rate compared with the nonoccluded
extremity at weeks 8 (P=.0006) and 12 (P=.0029). Thirty-four percent (12/35) of extremities treated with ALA+OCC had complete clearance
of lesions at week 12 compared with 0% (0/35) of extremities treated with VEH+OCC (P=.0002). The safety pro!le in this study
is consistent with previously reported side effects of the therapy.
Conclusion: Blue light ALA-PDT following a 3-hour incubation appears efficacious for AK clearance of the upper extremities. Incubation
using an occlusive dressing significantly increases the efficacy of the procedure and also increases the incidence and severity of some
acute inflammatory side effects of PDT.
J Drugs Dermatol. 2012;11(12):1483-1489.
Jenna O’Neill MD, Sari Fien MD, Nathalie C. Zeitouni MDC M FRCPC
Cutaneous pseudolymphoma (CPL) is a benign skin condition that may cause cosmetic disfigurement, severe itch and, albeit rarely,
transformation to malignant lymphoma. The usual treatment modalities for CPL have been associated with adverse effects including
skin atrophy and scarring. This article reports the case of a patient with CPL on the cheek, which was treated with 5-aminolevulinic
acid photodynamic therapy (ALA-PDT). Clinically significant improvement in lesion size and symptoms was noted, with few side effects.
Controlled trials and long-term monitoring are warranted to further explore this treatment modality for CPL.
Karin Caekelbergh MSc, Arjen F. Nikkels MD PhD, Bernard Leroy MD, Evelien Verhaeghe MD, Mark Lamotte MD, Vincent Rives PharmD
Background: Basal cell carcinoma (BCC) is the most common form of skin cancer worldwide. Different treatment options exist. The
efficacy of photodynamic therapy with methyl aminolevulinate (MAL-PDT) has been established in several randomized controlled trials
(RCTs). Real life data can differ greatly from data derived from randomized controlled trials (RCTs).
Objectives: To describe the results of a Belgian observational study concerning superficial BCC (sBCC) vis-à-vis clinical and health
economic outcomes in order to evaluate the real-life practice of MAL-PDT.
Methods: This study was a prospective, single-arm, open study conducted at eight dermatological institutions during six months after
the first MAL-PDT treatment. Eligible patients had to present with lesions, suitable for MAL-PDT according to Belgian reimbursement
criteria. Resource use was collected during the study period. Clinical Response (CR) and Cosmetic Outcome (CO), as well as cost of
care were evaluated. A subset analysis of patients with sBCC only was conducted.
Results: Ninety patients were identified for the analysis (mean age 65 years; 61% female). The mean number of lesions per patient
was 1.6, mostly located on the face, the back and the chest. For the entire period, the mean number of visits to a dermatologist was
4 per patient including two MAL-PDT sessions. The average, cumulative amount of MAL used per treatment was 1,256 mg. Two
patients experienced adverse events at the application site, none of them serious; all resolved completely. The CR rate was 89% at
the end of the study. The CO was “excellent” or “good” in 96% of the patients. Total cost of care was €289 ($414 U.S.) per patient.
Cost per lesion was €195 ($280 U.S.).
Conclusion: The results from the real-life practice study confirm the efficacy found in prior, prospective randomized trials. About four
visits and less than one tube of MAL are needed for the full treatment of sBCC in one patient.
Background/Objective: Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) has been shown to be useful in both spot and field treatments of actinic keratoses (AK). This study evaluates the safety and efficacy of pretreatment of AK lesions on the dorsal hands and forearms with tazarotene gel (0.1%) twice a day for one week before broad-area ALA PDT.
Methods: Ten subjects aged 75.4 ± 11.6 years (mean ± SD) with at least four AK lesions on their dorsal forearm or hand were randomized so that one dorsal hand or forearm was pretreated with tazarotene gel (0.1%) twice daily for one week before ALA PDT with blue light. The other hand or forearm (control) was not pretreated. After seven days, ALA was applied to both sides and incubated 60 minutes before irradiation with blue light. ALA was applied first only to the AK lesions and then to the entire treatment area (defined as the extensor surface of the hand or forearm between the elbow and the base of the fingers) before 60-minute incubation. The ALA area on the control side was occluded during the 60-minute incubation. Efficacy and adverse effects were evaluated within 48 hours and eight weeks later.
Results: For both the pretreated and control group, lesion counts of the target areas decreased significantly from baseline to eight weeks after ALA PDT. Reduction percentages of the target area, however, did not differ significantly between the two groups. When reduction percentages of the entire treatment area for both groups were compared the difference between the two groups was of borderline significance (P=0.0547). When the entire treatment area was analyzed, lesion counts of the tazarotene group differed significantly from baseline at eight weeks (P=0.0002), but this was not the case with the control group (P=0.0365). Adverse events were limited to those expected after ALA PDT. Erythema was significantly more severe (P=0.0029) in the pretreated arm five minutes after ALA PDT.
Conclusion: Pretreatment of AK lesions on the dorsal hand and forearm with tazarotene gel (0.1%) may enhance the therapeutic effect of ALA PDT without serious side effects.
J Drugs Dermatol. 2011;10(10):1124-1132.
Daniëlle I. Kuijpers MD, Monique R. Thissen PhD, Carleine A. Thissen MD, Martino H. Neumann MD PhD
We report a case of a 34-year-old woman who received cefuroxime, a second-generation cephalosporin, as treatment for
mastitis. She subsequently developed a serum sickness-like reaction (SSLR) with a generalized pruritic rash, joint pains,
and fever. She improved upon treatment with systemic steroids. SSLR is well-described to cefaclor, a second-generation
cephalosporin. However, there is a paucity of reports of SSLR to other cephalosporins such as this case.
Alexiades-Armenakas MD PhD
Background: Acne patients who fail to respond to conventional treatments have been treated with isotretinoin, an effective
treatment coming under strict regulation due to the risk of significant side effects. Photodynamic therapy (PDT) may be a
viable alternative treatment for recalcitrant acne of various types and levels of severity.
Objective: To determine the safety and efficacy of combination PDT with topical 5-aminolevulinic acid (ALA) and activation
by long-pulsed, pulsed dye laser (LP PDL, 595 nm) energy with topical therapy in patients with mild to severe acne.
Methods: A prospective, controlled pilot, proof-of-principle study of 19 consecutive patients (aged 16-47 years, Fitzpatrick
skin types I-VI) with mild to severe cystic, inflammatory, or comedonal acne of the face was conducted. All patients had
failed conventional therapy, including oral antibiotics, topical treatments, hormonal therapy, laser procedures (without
ALA), and/or oral isotretinoin. Fifteen patients were treated with ALA PDT and 4 patients served as controls; all were
continued on topical medications. Patients undergoing PDT were initially randomized to receive either blue light or laser
energy. Because recrudescence occurred in 1 patient while undergoing multiple treatments with ALA and blue light, all
subsequent patients were treated with ALA and laser energy. The total number of patients treated with LP PDL-mediated
ALA PDT was 14. ALA was applied for a short 45-minute incubation followed by 1 minimally overlapping pass with the LP
PDL (595 nm, 7.0-7.5 J/cm2 fluence, 10-ms pulse duration, 10-mm spot size, and dynamic cooling spray of 30 ms with a 30-
ms delay). Patients treated with conventional therapy (oral antibiotics, oral contraceptives, and topical medications) or laser
energy without ALA PDT served as control groups. Patients were followed monthly for up to 13 months.
Results: Complete clearance was achieved in 100% (14 out of 14) patients in the LP PDL PDT-treated group. A mean of
2.9 treatments (range 1-6; 2.0-3.7, 95% CI; n=14) was required to achieve complete clearance for a mean follow-up time of
6.4 months (range 1-13; 3.8-8.9 95% CI; n=14). The patient mean percent lesional clearance rate per treatment was 77%
(64%-90%, 95% CI; n=14). Improvement in acne lesions became apparent within 1 to 2 weeks after the first treatment.
Clearance in the LP PDL PDT group was superior to control groups. In the LP PDL-only control group (n=2), the patient
mean percent lesional clearance rate per treatment was 32% without complete clearance after 3 to 4 treatments. In the oral
antibiotics, oral contraceptives, and topicals control group (n=2), the clearance rate per treatment was 20%, the mean clearance
rate per month was 4%, and complete clearance was not achieved after 6 to 10 months. In the LP PDL-mediated PDT
group, treatments were well-tolerated with minimal erythema lasting 1 to 2 days. No cases of crusting, blistering, purpura,
scarring, or dyspigmentation occurred. A reduction in the erythema in erythematous acne scars was observed.
Conclusion: For teenage to adult patients with recalcitrant comedonal, inflammatory, or cystic acne of various degrees
of severity, ALA PDT with activation by LP PDL appears to be a safe and effective treatment with minimal side effects.
LP PDL-mediated PDT may serve as an important alternative to isotretinoin. Cosmetically well-accepted, LP PDL PDT
combined with topical therapy is the first PDT modality to achieve complete clearance with long-term follow-up as
compared to controls.
Tina S. Alster MD, Elizabeth L. Tanzi MD, Esperanza C. Welsh, MD
Background: Photorejuvenation of facial skin has been reported after intense pulsed light (IPL) therapy alone and in conjunction
with topical 5-aminolevulinic acid (5-ALA), but no comparative studies between these regimens have been performed.
Objective: To evaluate the safety and effectiveness of combination topical 5-ALA and IPL compared to IPL treatment alone.
Methods: Ten patients with mild to moderate photodamage were randomly assigned treatment with 5-ALA + IPL on one facial
half and IPL alone on the contralateral side. Two treatments were delivered at 4-week intervals. Clinical improvement scores
were determined by masked evaluations of digital photographs obtained at baseline, prior to each treatment session, and at 1, 3,
and 6 months after the final treatment.
Results: Higher clinical improvement scores were noted on the combination 5-ALA + IPL treated areas. Mild edema, erythema,
and desquamation were observed on the facial halves where 5-ALA was applied. No scarring or unwanted pigmentary alteration
Conclusions: Photodynamic therapy with combination topical 5-ALA + IPL is safe and more effective for facial rejuvenation
than IPL treatment alone.
Actinic keratosis (AK) is common and lesions may progress to squamous cell carcinoma. The choice of therapy depends
mainly on 2 factors: the efficacy of therapeutic options and the number of lesions present. Cryotherapy alone is suitable
for treating a few lesions, whereas topical medications, photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA),
or either in combination with cryotherapy are appropriate for treating multiple (>15) lesions. When combinations are
necessary, the total cost to treat multiple AKs to 100% clearance becomes important. This report provides a simple pharmacoeconomic
analysis of 4 FDA-cleared therapies (imiquimod, diclofenac, 5-fluorouacil [5-FU], and ALA PDT) for AK
given in combination with cryotherapy. This analysis assumes standard costs of procedures and office visits (based on April
2007 reimbursement data) and 2 treatment courses (medications: imiquimod, diclofenac, 5-FU) or sessions (ALA PDT)
of each modality followed by cryotherapy to 100% clearance. The total cost of each combination is $725.17 for ALA PDT,
$845.07 for diclofenac, $942.13 for 5-FU, and $1,473.39 for imiquimod. When phase III trial efficacies of the 4 modalities
are considered, the actual cost of using imiquimod or diclofenac increases because additional treatments may be required.
Among these 4 FDA-cleared therapies for multiple AK lesions, ALA PDT is the least expensive treatment and
imiquimod is the most expensive treatment under the stated assumptions.
Zheng Qian, MD; Nathalie C. Zitoun, MD; Sherry Shieh, MD Thomas Helm, MD and Allan R. Oseroff, MD
Extramammary Paget’s Disease (EMPD) is an uncommon neoplasm found in the genital, anorectal, or axillary area.
Surgical excision is considered the standard treatment, although possible loss of tissue function and disease recurrence are
seen. Other treatment modalities such as radiotherapy, topical chemotherapy, and photodynamic therapy are associated with
varying degrees of effectiveness, but the search for an effective, safe treatment with minimal side effects proves to be challenging.
We report a case where complete clinical and histological resolution of non-invasive EMPD of the penis was
achieved with minimal adverse effects after six weeks of imiquimod (Aldara) application. As an immune system modifier
that stimulates cytokine and interferon production, imiquimod may be a useful alternative or adjuvant in the
treatment of EMPD.
James M. Spencer MD MSa,b and Scott A. Freeman PAb
INTRODUCTION: Photodynamic Therapy (PDT) with topical Levulan is an approved and efficacious method for treating actinic keratoses. This therapy depends on the ability of the Levulan (delta amino levulinic acid) to penetrate the stratum corneum and enter the cells of the epidermis. Microneedling is an increasing popular cosmetic therapy in which an array of tiny needles is used to make holes in the epidermis and presumably induce a wound healing cascade that leads to cosmetic improvement of the skin. We were interested to know if prior microneedling would enhance the penetration of topical Levulan and thus enhance the PDT treatment, and if a cosmetic improvement beyond the PDT alone would be seen when it is used in conjunction with microneedling.
METHODS: 20 patients each with at least 4 non hyperkeratotic AKs on each side of their face were enrolled. All patients were randomized to receive multiple passes with a microneedling device to ½ of their face, left or right, followed by application of Levulan to the entire face. The Levulan was allowed to incubate 1 hour followed by exposure to blue light (Blu U) for 1000 seconds.
RESULTS: 19 patients completed the study with 4-month follow up. The mean percentage reduction in AKs was 89.3% on the microneedling side versus 69.5% on the PDT alone side, a significant difference. A physician’s global cosmetic assessment was performed based on Canfield Visia photographs: 15 of the 19 patients had a noticeable improved cosmetic appearance on one side of the face versus the other, and in 13 of these patients the improved side was the microneedled side.
DISCUSSION: Prior microneedling significantly enhances the effect of Levulan PDT. It also seems to provide a cosmetic benefit above and beyond the PDT alone. It was safe and well tolerated in this study.
J Drugs Dermatol. 2016;15(9):1072-1074.
Actinic keratoses (AKs) are cutaneous areas of atypical squamous transformation that are considered to be an early step in the continuum of transformation from normal skin to invasive and metastatic cutaneous squamous cell carcinoma (SCC). Enhanced understanding of the pathophysiologic changes leading from AK to malignancy, combined with an increasing global prevalence of AK, has led to a new focus on the importance of combining local tretments that remove individual lesions with topical or procedural field therapies that treat the entire actinically damaged field — also known as field cancerization — which is important because it is impossible to predict which AK lesions will progress to SCC. Currently available topical field therapies include 5-fluorouracil cream (5%, 1%, 0.5%), imiquimod cream (5% and 3.75%), diclofenac sodium gel 3% with 2.5% hyaluronic gel, and ingenol mebutate gel (0.05% and 0.015%). Photodynamic therapy is a procedural field therapy. Important considerations when developing a comprehensive treatment plan include patient risk factors; the number and location of AK lesions; strategies for minimizing sun exposure; and the mechanism of action, clearance rate, adverse effect profile, and application of local and topical therapies.
J Drugs Dermatol 2012;11(12):1462-1467.
Gary Goldenberg MDa and Omid Hamid MDb
Basal cell carcinoma (BCC) is the most common cancer in the world. It is typically slow growing and usually effectively managed
with surgery. However, BCCs in some patients are unsuitable for surgery or the patient may prefer a nonsurgical treatment. Radiotherapy
is a nonsurgical option for the primary treatment of either low- or high-risk BCCs. It is associated with high cure rates, albeit
somewhat lower than those observed with Mohs micrographic surgery for high-risk BCCs. Not all patients with BCCs are suitable
for radiotherapy. Superficial therapies for BCC include topical imiquimod or 5- fluorouracil and photodynamic therapy (PDT). These
therapies are generally associated with somewhat lower clearance rates and/or higher recurrence rates than surgery or radiotherapy,
although they may be suitable in patients with low-risk BCCs when surgery or radiotherapy are impractical or less appropriate. An
appealing feature of PDT is excellent cosmesis, but PDT is not currently approved by the Food and Drug Administration (FDA), and
regimens are not well standardized. Vismodegib is a first-in-class hedgehog pathway inhibitor and recent addition to the armamentarium
for the treatment of advanced BCC.
J Drugs Dermatol. 2013;12(12):1371-1378.
George M. Martin MDa and Eggert Stockfleth MD PhDb
Background: Diclofenac sodium 3% gel (Solaraze®) gained US approval for the treatment of actinic keratosis (AK) more than 10 years ago. Since the publication of the pivotal phase 3 studies, numerous clinical studies have assessed use of this therapy in a variety of body areas, special populations, and novel combinations.
Objective: To provide a comprehensive update on clinical data and research on the use of diclofenac sodium 3% gel in AK.
Results: Accumulating evidence from preclinical research supports that the proposed mechanism of diclofenac sodium 3% gel may include cyclo-oxgenase 2 (COX-2) inhibition, inhibition of angiogenesis, and induction of apoptosis. A literature review identified 17 publications (beyond the 2 pivotal studies) on the use of diclofenac sodium 3% gel for AK. A phase 4 open-label study reported that 58 percent of patients achieved complete clearance of target lesions at the 30-day post-treatment assessment; among patients who were evaluable at 1-year post-treatment, sustained long-term clearance of AK lesions was observed. Active comparator studies demonstrated comparable efficacy of diclofenac sodium 3% gel with 5-fluorouracil 5% and imiquimod 5%. Publications on the efficacy of diclofenac sodium 3% gel for AK of the lip report complete clearance rates comparable to those reported for other body areas. Diclofenac sodium 3% gel has also demonstrated efficacy for clearing AK lesions in immunosuppressed populations. Sequential use of diclofenac sodium 3% gel with cryosurgery or photodynamic therapy has been investigated and may emerge as a useful approach for some patients.
Conclusions: Diclofenac sodium 3% gel has a unique proposed mechanism of action in AK that may involve COX-2 inhibition, inhibition of angiogenesis, and induction of apoptosis. In the past decade, numerous clinical studies have demonstrated this topical therapy to be effective and well tolerated for the treatment of AK.
J Drugs Dermatol.2012;11(5):600-608.
Stacy Smith, MD; Dan Piacquadio, MD; Vera Morhenn, MD; Deborah Atkin, MD and Richard Fitzpatrick, ND
The efficacy of photodynamic therapy (PDT) using broad area treatment with 5-aminolevulinic acid (ALA) has not been compared
to topical 5-fluorouracil (5-FU) in the treatment of actinic keratoses (AK).
The purpose of this study was to compare the efficacy and tolerability of PDT using short incubation time, broad area treatment
with ALA plus activation with either blue light or laser light to topical 5-FU in the treatment of AK of the face and scalp.
Thirty-six subjects with AK of either the face or scalp were randomized to receive either application of ALA for 1 hour followed by
activation with blue light or pulsed dye laser or topical 5-FU. Efficacy was evaluated by grading AK lesions and photoaging signs.
Tolerability was assessed by scoring crusting /erosions, erythema and stinging /burning.
Treatment with PDT using ALA plus blue light was as effective as topical 5-FU in clearing AK. PDT using ALA plus laser light was
the least effective treatment. All treatments made improvements in the signs of photoaging. Both PDT treatments were better tolerated
In conclusion, broad area PDT treatment with ALA plus activation with blue light appears to be as effective as 5–FU in the treatment
of AK. ALA plus laser light is somewhat less effective than the above therapies. Efficacy could likely be improved with further
study of laser parameters and incubation tim
Erin Lessner MD,a Samantha Fisher MD,b Katherina Kobraei MD,b Michael Osleber MD,b Rebecca Lessner BS,c Lauren Elliott MD,d and Stanton Wesson MDb
PURPOSE: To access the efficacy of spironolactone and topical retinoids in the treatment of female cyclical acne.
METHODS: A retrospective chart review on 41 female patients age 19-57 years old with cyclical acne was performed. Patients were examined
over the course of 2 to 102 months while taking 50 to 200mg of spironolactone and topical tretinoin 0.025% or adapalene 0.1%
cream. All were diagnosed with acne rated mild to severe, prior to treatment, and were started on an initial dose of 50mg po daily. If
significant improvement was not seen within the first 3-6 months, the dose was either held or increased in 25mg increments every 3
months. Patients on oral and topical antibiotics, as well as patients on photodynamic therapy were excluded from the study. The response
to treatment was rated on a 0-4 scale with 0 being no response and 4 corresponding to clear skin.
RESULTS: One patient (2.4%) had no response to treatment. This patient was only on 50mg po daily for only 2 months. Only 5 (12.2%)
patients had minimal response to treatment and 9 (22.0%), 12 (29.3%), and 14 (34.1%) had a good, excellent, or clear response respectively.
The study showed 26 (63.4%) women on treatment with spironolactone and topical retinoids had an excellent or clear outcome,
and 35 (85.4%) were considered to have a good, excellent, or clear response.
CONCLUSION: The addition of spironolactone to topical retinoid treatment suggests a superior response to retinoids alone in clearance
of female adult cyclical acne.
J Drugs Dermatol. 2014;13(2):126-129.
Emily P. Tierney MD and C. William Hanke MD MPH
Background: A number of treatment modalities are currently in existence for non-melanoma skin cancer, including microscopically
controlled surgical excision (e.g., Mohs micrographic surgery [MMS]), traditional surgical excision, radiation therapy, electrodessication
and curettage, cryosurgery, photodynamic therapy and topical chemotherapeutic agents. MMS has the significant advantage
of the lower recurrence rates of all treatment modalities, where five-year cure rates for MMS for primary BCCs are 1% relative to
surgical excision (10.1%), electrodessication and curettage (7.7%), radiation therapy (8.7%) and cryotherapy (7.5%). Previous studies
have also indicated, across specialties, that dermatologists have the highest rates for complete removal of non melanoma skin
cancer (NMSC) which are significantly greater than those for otolaryngologists (P>0.02) and plastic surgeons (P<0.0008).
Objective: To evaluate and compare the results of recent studies comparing the cost effectiveness of MMS to other treatment modalities
performed by dermatologists and other physicians performing treatment of NMSC (otolaryngologic (ENT) surgeons, plastic
surgeons, general surgeons).
Results: MMS is equivalent in cost to excision with permanent sections, 12% less costly than office based excision with frozen
sections and 27% less costly than excision with frozen sections in an ambulatory surgical center (ASC). The most significant difference
between MMS and surgical excision was the facility fee of excision with frozen sections in an ASC, (differential of $443–$555).
With surgical excision, 32–39% of cases require a second procedure for clear margins. Additionally, with subsequent procedures for
surgical excision cases, there is likely a greater volume of tissue removed and ramifications on functional preservation and cosmesis,
which are difficult to quantify.
Conclusion: Analysis of the existing literature on MMS relative to surgical excision confirms the value of MMS in both obtaining the
highest initial cure rates and lowest recurrence rates. This analysis confirms that MMS is a cost effective treatment, which is lower
in cost than surgical excision, which often includes an ASC facility fee and a subsequent re-excision procedure. Cost effectiveness
analysis demonstrating the outcomes based efficiency of MMS are critical in the current health care climate with heightened sensitivity
to financial pressures and declining reimbursement rates which may challenge our ability to provide patients with the optimal
treatment for NMSC.
Stanley C. Gilbert MD
Oral valacyclovir’s efficacy and tolerability as suppressive therapy versus episodic therapy were compared for recurrent
herpes labialis (RHL). Subjects with a history of at least 3 RHL episodes in the past year were randomized to receive 6
months of oral valacyclovir episodic therapy at the first sign of prodrome (two 2-g doses separated by 12 hours) and 6
months of oral valacyclovir suppressive therapy (1 g once daily) for 6 months in open-label, crossover fashion. The
mean±SE number of recurrences per 120 days of follow-up (primary endpoint) was lower with suppressive therapy
(0.30±0.41) than episodic therapy (0.71±0.79) (P<.005). The probability of remaining recurrence free over 6 months
was significantly higher with suppressive therapy than episodic therapy. The median time to first recurrence was 81 days
with episodic therapy and was not calculable (>180 days) for suppressive therapy (P=0.021). Data for secondary efficacy
endpoints (pain severity score, mean duration of recurrences, maximal total lesion area) showed approximately a 30%
to 50% reduction in mean values with suppressive therapy compared with episodic therapy, but results were statistically
significantly different between the regimens for pain severity only. The percentage of subjects with at least one adverse
event over 6 months of treatment that was considered to be drug related was 3% with suppressive therapy and 6% with
episodic therapy. Suppressive therapy with oral valacyclovir was more effective than episodic therapy with oral valacyclovir
in reducing the frequency of recurrences of herpes labialis and prolonging the time to first recurrence and was also
William D. Tutrone MD, Kim Green MS, Jeffrey M. Weinberg MD, Selin Caglar MD, Dick Clarke
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of skin and subcutaneous tissue. The current accepted theory
is that PG is an immunologic-based phenomenon. Several therapies have been used to control this disease, including
corticosteroids, antibiotics, immunotherapy, dapsone, and hyperbaric oxygen therapy. This article will review the application
of hyperbaric oxygen (HBO) therapy in patients with PG. Information for this manuscript was derived from multiple
searches of MEDLINE and the National Baromedical Service literature collection. HBO therapy has been shown to
effectively treat PG ulcers and reduce pain associated with PG in several case studies. Evidence from the studies cited
herein help to establish a foundation for further research to investigate the role of HBO therapy as an adjuvant therapy
in the treatment of PG.
Pulse therapy has been used for many years, but rarely in a clinical setting. This article describes a clinical study designed to determine the efficacy of pulse therapy with 5-FU for patients with multiple actinic keratoses. The results indicated that pulse therapy was indeed effective in eradicating most of the actinic keratoses while causing less discomfort or disfigurement than the FDA recommended dose, especially for patients with less severe and milder forms of actinic keratoses.
A. Kasche MD, S. Luderschmidt MD, J. Ring MD, R. Hein MD
Background: Plaque psoriasis affects about 2% of the US population. A new and unique spray formulation of clobetasol propionate
(CP) 0.05% was developed to provide advantages over the currently available treatment formulations.
Objectives: To evaluate the efficacy and safety of CP 0.05% spray compared to its vehicle in the treatment of moderate to
severe plaque psoriasis.
Methods: A 4-week, single-center, randomized, double-blind, vehicle-controlled, intra-individual study in subjects with
plaque psoriasis. Each of 2 target lesions per subject were randomized to receive either CP 0.05% spray or its vehicle twice
daily over 4 weeks. Efficacy parameters included overall target plaque severity score, scaling, erythema, and plaque elevation
at all visits. Adverse events were reported throughout the study.
Results: A total of 27 subjects were enrolled in the study. At all visits there was a significant intra-individual treatment effect
for the overall target plaque severity (P<.001) in favor of CP spray. Throughout the study, results for scaling, erythema, and
plaque elevation were significantly (P<.001) in favor of CP spray. After 4 weeks of treatment, all intra-individual response
measures, with the exception of erythema, showed an average difference in severity scores of more than 4 points (based on
a 9-point scale) between the lesions treated with CP 0.05% spray and the lesions treated with vehicle. No serious adverse
event occurred during the course of the study. One local adverse event at the application site (5%) was considered probably
related to study medication.
Conclusion: CP 0.05% spray was effective and safe in reducing overall plaque severity, scaling, erythema, and plaque elevation from the first week of treatment continuing throughtout the trial.
Nevien A. Sami PhD, Abeer T. Attia PhD, Ashraf M. Badawi
Background: Achieving an effective management of acne vulgaris with minimal complications remains a difficult challenge
for physicians. Moreover, the rise in antibiotic-resistant strains reduce the future usefulness of current mainstay therapies,
and accordingly, the need for alternative therapies is mandatory. Phototherapy has been shown to be an effective
treatment for acne, and there has been a renewed interest in photodynamic therapy as a treatment modality for this condition.
Objectives: To evaluate the effectiveness of pulsed dye laser (PDL), intense pulsed light (IPL) and light-emitting diode
(LED) phototherapy for the treatment of moderate to severe acne vulgaris.
Methods: Forty-five patients with moderate to severe acne were randomly divided into 3 equal groups. Group 1 was treated
with a PDL, group 2 was treated with IPL, and group 3 was treated with a blue-red combination LED. Treatment was continued
until a ≥90% clearance of patient lesions was achieved. Clinical assessments were conducted before starting treatment,
at 1 month as a midpoint evaluation, and after the final treatment session.
Results: Patients treated with the PDL reached a ≥90% clearance of their inflammatory lesions after a mean of 4.1±1.39
sessions, while patients treated with IPL required a mean of 6±2.05 sessions. Patients treated with the LED required a
mean of 10±3.34 sessions. At the mid-point evaluation, the percent reduction in acne lesions treated with the PDL was
90% or more, in cases of IPL and the LED, the percent reductions were 41.7% and 35.3%, respectively. Laser and light
phototherapy sessions were well tolerated with minimal adverse events experienced as being mild and usually self-limiting.
Conclusions: The encouraging results of the present study contributes evidence of phototherapy as useful therapeutic option
for treatment of moderate to severe acne, and validates further studies to evaluate treatments with a larger number
of patients and for a longer period of follow-up.
Douglas Winstanley DO, Travis Blalock MD, Nancy Houghton BS, and E. Victor Ross MD
Background: Sebaceous hyperplasia is a common benign proliferation of sebaceous glands. Multiple treatment methods have been
applied in the past, including electrodessication, ablative and visible light lasers, applications of acids, and photodynamic therapy.
Often, however, only the superficial component of the lesion is treated, leading to rapid recurrence. It has been shown that human
fat has absorption peaks at 1,210 nm and 1,720 nm. We report the first use of a novel 1,720-nm laser in the treatment of sebaceous
hyperplasia in human subjects.
Methods: Four patients with sebaceous hyperplasia underwent a test spot treatment followed by 2 full treatment sessions using
the 1,720-nm laser. Photos were taken before treatment, at each treatment session, and 3 months following the last treatment.
Pretreatment photographs and 3-month follow-up photographs were compared to assess efficacy.
Results: Four weeks after the final treatment, 3 dermatologists blinded to the date of the photographs and uninvolved with the study
evaluated the photos and scored them based on a global assessment comprised of: 1) lesion diameter, 2) lesion height, and 3) lesion
color. Many of the lesions resolved almost completely after a single treatment, and no additional treatment was required. Overall,
there was a reduction in the color, diameter, and height of the lesions. Crusts were noted by all patients and resolved within 10 days.
Conclusion: The use of this novel device that exploits the intrinsic selectivity of 1,720 nm achieved nearly complete clearance of
sebaceous hyperplasia lesions without depressions or scarring. Complete heating of the sebaceous gland and sparing of the surrounding
skin offered by this device resulted in clinically apparent improvement with a minimum of adverse effects.
J Drugs Dermatol. 2012;11(11):1323-1326.
Navjeet K. Sidhu-Malik, MD and Andrew L. Kaplan, MD
Interferon/ribavirin combination therapy is the treatment of choice for chronic hepatitis C virus (HCV) infection.
Cutaneous reactions to interferon therapy, both local and distant from the injection site, are not uncommon.
Eczematous and lichenoid reactions are most commonly reported. Interferon therapy has also been
associated with the occurrence or worsening of a number of dermatologic disorders. We report the case of a
54-year-old man undergoing treatment with interferon/ribavirin combination therapy for hepatitis C who developed
a multiple fixed drug eruption associated with interferon injections. To our knowledge, this is the first
known reported case of a multiple fixed drug reaction triggered by interferon.
Patients with melanoma considered at high risk for recurrence or regional metastases often have to choose between adjuvant
interferon therapy or enrolling in a clinical trial. High-dose interleukin-2 therapy has had limited success in producing
durable responses in stage IV melanoma; this success has been offset by marked toxicity. High-dose interferon alpha
therapy has consistently shown disease-free survival benefit in clinical trials but has marked toxicity. The overall survival
benefit has been inconsistent and controversial. Treatment with granulocyte macrophage colony-stimulating factor has
shown promise in early studies. Various cytokines have had some success in treating advanced stage melanoma but with
marked toxicity. Cytokine therapy that is well-tolerated and consistently provides an overall survival benefit for highrisk
melanoma patients has not been achieved. Cytokines will continue to have a role in therapy for advanced-stage
melanoma, most likely in combination with other immunomodulatory therapy. The challenge is finding the right doses,
frequency, combinations, and duration of treatment.
Sara L. Jensen, MD and RonaBeth Holmes, MD
Rosacea fulminans is characterized by the sudden onset of large, coalescing nodules and draining sinuses on
the face. A few reports have linked medications to this condition, but none have described the onset of rosacea
fulminans with pegylated interferon or ribavirin therapy. We report a patient who presented with rosacea fulminans
after initiation of therapy for Hepatitis C.
CPT Naomi Creel MC USA, Victoria Werth MD
We describe a patient who developed rhabdomyolysis 6 weeks after starting combination therapy with hydroxychloroquine and
quinacrine for the treatment of chronic cutaneous lupus erythematosus (CCLE). Myopathy due to 4-aminoquinolone antimalarials
has been well documented. It is plausible that quinacrine may induce muscle injury in a manner similar to other antimalarials
but, to our knowledge, rhabdomyolysis associated with antimalarial therapy has not been reported.
Elaine Shnitkind MD, Yaping E PhD, Susan Geen, Alan R. Shalita MD, Wei-Li Lee PhD
Background: Narrow-band blue light (420 nm) has demonstrated safety and efficacy in the treatment of acne vulgaris. It
works by exhibiting a phototoxic effect on the heme metabolism of Propionibacterium acnes. Previous studies using blue light
showed more improvement in inflammatory lesions than in comedones, as well as some improvement on the untreated side.
Cytokines have demonstrated a critical role in the development of inflammation. The expression of pro-inflammatory
cytokines such as IL-1? have been shown to result in the expression of vascular and dermal adhesion molecules, the chemoattraction
of inflammatory cells, and the stimulation of other inflammatory mediators. In addition, UVB radiation serves as a
potent modulator of cell-mediated immune responses.
Purpose: This study investigated the effect of narrow-band blue light on the inflammatory process in the presence and
absence of cytokines and UVB using IL-1? and ICAM-1 as markers for inflammation.
Methods: Two immortalized keratinocyte cell lines were compared: HaCaT, produced by spontaneous immortalization of a
genetically altered cell line, and hTERT, obtained by stable transfection of primary cell culture with human telomerase
reverse transcriptase. Cells were treated with INF-? and TNF-? and exposed to UVB (312 nm at 50 mJ/cm2) and/or blue light
(420 nm at 54 mJ/cm2 and 134 mJ/cm2). The expression of IL-1? and ICAM-1 was measured by quantitative ELISA.
Results: The results showed that blue light and low-dose UVB treatment of HaCaT and hTERT cells resulted in inhibition
of cytokine-induced production of IL-1?. The level of IL-1? decreased by 82% in HaCaT and by 75% in hTERT cells when
exposed to blue light. It decreased by 95% in HaCaT and by 91% in hTERT cells when blue light was used in combination
with UVB. ICAM-1 expression was similarly reduced in HaCaT, but not in hTERT cells.
Conclusions: This study showed that narrow-band blue light has anti-inflammatory effects on keratinocytes by decreasing
the cytokine-induced production of IL-1? and ICAM-1. In addition, blue light demonstrated synergistic effects with lowdose
UVB light. These results expand the properties of narrow-band blue light in modulating the inflammatory process and
will facilitate testing of its phototherapeutic applications in different inflammatory skin conditions.
Galina Shistik MD, Amy V. Prakash MD, Neil A. Fenske MD, L. Frank Glass MD
We report a case of an 83-year-old female with locally metastatic melanoma treated with imiquimod and tazarotene. The
patient originally presented to our dermatology clinic with local metastases of malignant melanoma after having undergone
multiple surgical procedures and adjuvant radiation therapy for disease recurrence. At this juncture, she refused further
surgical management but was interested in topical therapy. A 4-week course of topical imiquimod therapy was initiated.
As no clinical response was noted at the end of the treatment period, tazarotene cream was introduced. The patient experienced
complete clinical clearance of the treated area after a 6-week course of combination imiquimod and tazarotene
therapy. The rationale for using both medications will be discussed.
This article will examine oral therapies utilized in the treatment of rosacea. Important topics include recognizing which types
of rosacea can benefit from oral therapy and concerns regarding the emergence of bacterial resistance.
Although intramuscular triamcinolone acetonide has been available as a dermatologic therapy for many years, it is used sparingly or
not at all by many dermatologists because of concern about its safety, as well as a lack of understanding of its specific therapeutic
benefits. This case report discusses the efficacy and safety of intramuscular triamcinolone acetonide, along with description of the
specific technique employed by the author, as well as the clinical indications and side effects seen by the author in his practice over
time. The report describes the positive results attained in the treatment of many chronic, recalcitrant dermatologic conditions that
cannot be adequately controlled by topical therapy alone. Because of its strong safety profile and unique therapeutic efficacy, intramuscular
triamcinolone should be considered as a primary therapy for many chronic, steroid responsive, dermatologic conditions
requiring a systemic approach.
Gillian M. Heinecke BS, Adam J. Luber BA, Jacob O. Levitt MD, and Mark G. Lebwohl MD
BACKGROUND: Patients with moderate to severe psoriasis may not respond adequately to single systemic agent and may require combination systemic therapy.
OBJECTIVE: To evaluate the prevalence, indications, and response to combination systemic therapy with ustekinumab for psoriasis in a tertiary referral center.
METHODS: This retrospective study comprised 102 psoriasis patients treated with ustekinumab at a single tertiary care center. Data was collected pertaining to history of psoriasis, past and current therapies including use of concomitant psoriasis agents, response to therapy, and side effects while on ustekinumab.
RESULTS: Twenty-two of 102 (22%) patients were identified as receiving combination systemic treatment involving ustekinumab and at least one additional agent. The most common indication for combination therapy was psoriatic arthritis (35%), followed by bridging therapy (26%), inadequate psoriasis control (13%), prevention of non-melanoma skin cancers (17%), and control of palmoplantar disease (9%). Methotrexate was the additional agent in 12 patients, cyclosporine in 7 patients, acitretin in 5 patients, and 1 patient received a second biologic agent, first etanercept and then adalimumab. Overall, the reduction in body surface area (BSA) was 80% for patients on combination therapy. For those patients on combination therapy for psoriatic arthritis, 75% had resolution or stabilization of their symptoms. Only one patient, receiving cyclosporine, discontinued combination therapy due to adverse side effects.
CONCLUSION: Combination systemic therapy with ustekinumab can be effective and well tolerated for patients who cannot be adequately treated with ustekinumab alone.
J Drugs Dermatol. 2013;12(10):1098-1102.
Shannon Famenini BSa and Jashin J. Wu MDb
Psoriasis is an immune-mediated cutaneous disease affecting 2% of the worldwide population. While topical therapy, phototherapy, oral systemic therapy, and biologic agents have been used, the treatment of psoriasis still remains a challenge. Ustekinumab is a biologic therapy that provides a novel avenue for management by blocking interleukin-12/23. The purpose of this article is to review the mechanism of action of ustekinumab and its efficacy in psoriatic patients. The use of ustekinumab in other immune-mediated diseases is also discussed. It is our goal to provide dermatologists with the knowledge to enable them to incorporate ustekinumab into their practice.
J Drugs Dermatol. 2013;12(3):317-320.
Nephrogenic systemic fibrosis (NSF) is a recently described systemic fibrosing disorder that develops in the setting of renal insufficiency. Exposure to gadolinium has been implicated in its development. While the primary manifestations are cutaneous, systemic fibrosis can also occur. Several anecdotal reports of successful treatment have been reported, but there is no consistently efficacious therapy. We report the improvement or stabilization of cutaneous disease in three patients with NSF using alefacept therapy.
J Drugs Dermatol. 2011;10(8):922-924.
Katherine B. Madden BA, Agyrios Stampas MD, Seth B. Forman MD
A case of pressure ulcer in a 25-year-old male patient with the neurodegenerative disorder giant axonal neuropathy (GAN) was safely
and effectively treated with an eight-week regimen of oxandrolone and nutritional supplementation. An initial dose of 5 mg twice daily
was begun for the first two weeks of therapy, followed by six weeks of treatment with 10 mg twice daily. This therapy was supported
with protein supplementation and adequate caloric intake. The patient’s liver function tests were monitored weekly and remained
within the normal range. His pressure ulcer was completely resolved at the conclusion of the eight weeks of therapy.
Amy L. Gosnell BS, Susan T. Nedorost MD
Background: Lower leg edema is a common side effect of amlodipine therapy, but is often unrecognized as a contributor to stasis
Objective: To determine whether amlodipine therapy is more common among patients with stasis dermatitis than age-matched
Methods: In this retrospective chart review study, the medication lists of all subjects with stasis dermatitis from a single practice
site over the past 2 years were compared to alphabetically consecutive charts of patients with basal cell carcinoma to determine the
relative usage of amlodipine.
Results: Patients with stasis dermatitis (n = 43) are more likely to take amlodipine than are basal cell carcinoma patients (n = 117) of
similar age (19% vs. 5%, P < .02), even when controlled for the use of any antihypertensive medications (25% vs. 10%, P = .05).
Conclusion: Amlodipine therapy is associated with stasis dermatitis and discontinuing amlodipine should be considered when stasis
dermatitis is diagnosed.
Navid Ezra BS, Natalie B. Goltche BS, Shahrad Hakimian BS, Arash Afari MD
CTLA4-blocking antibodies induce tumor regression in a subset of patients with metastatic melanoma by optimizing T-cell activity
to fight the malignant cells. In addition to therapeutic benefits, CTLA4 therapy may induce immune-related adverse events (irAE).
Studies on CTLA4 knockout and other CTLA4 deficient mice have resulted in splenomegaly, lymphoproliferation and fatal multi-organ
destruction. The authors present a case of a 68-year-old patient who has developed splenomegaly following CTLA4 therapy. CTLA4
therapy’s risks and benefits should be weighed carefully in the treatment of malignant melanoma. Larger prospective multi-center
trials are needed to gauge the efficacy and complication rate of CTLA4 therapy. The authors propose that patients should get shortterm
surveillance imaging (CT or PET/CT) to exclude the multiple abdominopelvic complications and quickly terminate therapy if
clinically warranted. It is also necessary for clinicians to carefully monitor for the number of possible complications associated with
Jonathan S. Weiss, MD and Joel S. Savin, MD
The agents most commonly used in combination for the management of acne include topical retinoids and antibiotics. Topical
retinoids normalize desquamation of the follicular epithelium, whereas antibiotics inhibit the growth of P. acnes and the production
of free fatty acids. This therapeutic combination decreases comedogenesis, bacterial growth, and inflammation, thus targeting three
of the four pathogenic factors associated with acne. Efficacy and tolerance are maximized with combination therapy, and the degree
of skin irritation is minimized. Furthermore, adjunctive therapy with topical retinoids and antibiotics tends to produce results more
quickly than single-agent therapy.
This article will examine the individual agents used in combination for acne management, and discuss the mechanisms by which they
achieve efficacy. The rationale of utilizing topical retinoids with antibiotics will be highlighted, particularly in relation to improved tolerance
and reduced irritation.
Diane M. Thiboutot MD, Harald P. Gollnick MD
Acne vulgaris is an exceptionally common, chronic, and recurring disease. It involves multiple etiological factors including
follicular hyperkeratinization, increased sebum production, Propionibacterium acnes proliferation, and inflammation.
Presently, oral isotretinoin is the only single agent that is effective against all 4 major pathophysiologic features. However,
this drug is also responsible for several serious side effects, including teratogenicity. Therefore, it should be used in only the
most severe cases and alternative treatment approaches for inflammatory acne, such as initial combination therapy, should
be considered first. Combination therapy in inflammatory acne simultaneously targets multiple pathogenic factors. Current
guidelines recommend early initiation of combination therapy with a topical retinoid and antimicrobials for mild to
moderate inflammatory acne and topical retinoids with oral antibiotics (with or without the use of benzoyl peroxide) for
moderate to severe cases of acne, followed by maintenance therapy with topical retinoids. This review evaluates the
rationale and clinical evidence for the use of adapalene in combination therapy for inflammatory acne.
Holly Bartell, Brian L. Ransdell MD, Asra Ali MD
We describe the incidental clearance of preexisting tinea versicolor skin infection with the treatment of oral isotretinoin
therapy for acne vulgaris.
Peter Rullan MD and Jenny Murase MD
Atopic dermatitis (AD) is a chronic inflammatory disease that is mediated by cytokines. In patients with AD, the use of tumor necrosis
factor (TNF) antagonists has had unpredictable results. Clinically significant improvements in skin symptoms of AD were observed in
two patients with severe, chronic disease who were treated with the soluble TNF receptor etanercept. These observations suggest
that etanercept therapy may be beneficial in patients with AD, particularly chronic variants with lichenification. Studies to identify
features of AD that may predict responsiveness to etanercept therapy in these patients are warranted.
Paul S. Yamauchi MD PhD, Nicole Mau BS
2008 JDD Case Report Contest Winners
Hidradenitis suppurativa (HS), a chronic, inﬂammatory, relapsing disease of the apocrine glands in the skin, commonly occurs in
women aged 20 to 40 years. Patients typically present with discomfort and/or itching associated with papules or nodules that may
recur and lead to abscess formation and sinus tracts. Recent reports have demonstrated that adalimumab, a tumor necrosis factor
(TNF) antagonist, may be effective in the treatment of patients with HS who have failed conventional therapy. The authors describe
3 patients who experienced the resolution of skin lesions associated with HS after treatment with adalimumab. The patients found
this treatment to be convenient, as they could administer the therapy at home, and 1 patient was able to avoid surgical intervention
through use of TNF-antagonist therapy. Adalimumab may resolve symptoms of HS when conventional therapy fails. More studies
are necessary to investigate the efﬁcacy and safety of adalimumab for the treatment of HS.
Danielle Levine MD, Stephen A. Switlyk MD, Alice Gottlieb MD PhD
Anti-tumor necrosis factor-α (TNF-α) immunotherapy is revolutionizing the treatment of immune disease, particularly Crohn’s disease,
rheumatoid arthritis, psoriatic arthritis and psoriasis. The role of anti-TNF-α agents in the management of cutaneous lupus erythematosus
(LE), however, is not as clear. While experimental reports have suggested a potential benefit of anti-TNF-α therapy in severe
cutaneous LE, newer reports have identified these medications as instigators or exacerbators of the disease. In this review, the
authors present a case of a patient whose persistent discoid LE (DLE) was exacerbated by a trial of adalimumab, one of the currently
available TNF-α-blocking agents. The authors review 128 cases in the literature in which anti-TNF-α therapy was implicated in cutaneous
LE pathogenesis, with emphasis on DLE, and consider a number of mechanisms whereby this arguably paradoxical effect may
occur. The authors then propose possible approaches to the management of anti-TNF-α therapy-induced cutaneous LE.
Brooke Walls DO,a Laura Jordan MS4,b Lisa Diaz DO PGY1,b and Richard Miller DO FAOCDc
The field of cutaneous oncology is exploding with innovative treatment options, specifically in the field of targeted therapy. These advances
offer new hope to select patients with high risk skin cancers. In part two of our series on targeted therapy for skin cancer, we
focus our attention on squamous cell carcinoma. We begin with the epidermal growth factor receptor inhibitors and branch out into
newer areas of active research.
J Drugs Dermatol. 2014;13(8):955-958.
Jing Huang BS, Shawn Cowper MD, Jeremy Moss MD PhD, and Michael Girardi MD
Little is known about the safety and effectiveness of excimer laser therapy when used in conjunction with other therapies in the treatment of mycosis fungoides (MF) lesions. We describe the use of adjunctive excimer laser therapy in combination with psoralen plus ultraviolet A (PUVA) and oral bexarotene for the treatment of recalcitrant and sanctuary plaques in a patient with MF. In our patient, this regimen successfully induced clinical and histologic resolution in MF plaques with minimal side effects limited to mild, short-lived tenderness and, rarely, local erythema. Our experience suggests that adjunctive excimer laser therapy with PUVA and oral bexarotene has the potential to be a safe, well-tolerated, and effective focal treatment regimen for cutaneous MF lesions.
J Drugs Dermatol. 2013;12(4):487-489.
Brooke Walls DO,a Laura Jordan MS4,b Lisa Diaz DO PGY1,b and Richard Miller DO FAOCDc
The field of cutaneous oncology is exploding with innovative treatment options, specifically in the field of targeted therapy. These advances
offer new hope to select patients with high risk skin cancers. Here we provide a two part series reviewing targeted therapy for
non-melanoma skin cancer. We begin our discussion with basal cell carcinoma, moving beyond the first-in-class hedgehog inhibitors
and highlighting promising clinical trials.
J Drugs Dermatol. 2014;13(8):947-952.
D. K. Damle MD DNB, P. M. Mahajan MD, S. N. Pradhan MD, V. A. Belgaumkar MD, A. P. Gosavi MD, S. N. Tolat MD, N. R. Gokhale MD, C. B. Mhaske MD
Background: Mycetoma has a worldwide geographical distribution which is extremely uneven; however, it is a common disease in
India and responsible for causing signiﬁ cant morbidity. Treatment of this condition is often a challenge for the treating dermatologist.
The authors report a promising therapy for patients of actinomycotic mycetoma.
Methods: This assessment series included 18 patients with a conﬁ rmed diagnosis of actinomycetoma, and who had shown a poor
response to previous treatments. Patient received a combination therapy of the Welsh regimen (amikacin along with cotrimoxazole)
to which rifampicin was added as a third drug. Clinical evaluation included radiology and laboratory investigations.
Results: Sixteen patients out of 18 completed the combination therapy, which lead to remission. Two patients were lost to follow-up.
Of the 16 patients in remission, no recurrence was observed during a follow-up period of up to 18 months.
Tatyana A. Petukhova MD MS, a,b Danielle M. Tartar MD PhD,a,b Karen Mayo MSN FNP-BC OCN,b Maxwell A. Fung MD,a Joseph Tuscano MD,a,b and Jared Jagdeo MD MSa.b
Erythema nodosum (EN) is a panniculitis frequently encountered secondary to medical therapy. We present a case of a 66-year-old gentleman with JAK2-positive myelofibrosis who developed transient EN-like lesions on his trunk and upper and lower extremities approximately three weeks after starting lenalidomide therapy. The subcutaneous nodules improved with intralesional triamcinolone and topical clobetasol without discontinuation of lenalidomide.
J Drugs Dermatol. 2016;15(8):1024-1025.
Abbas Zamanian MD, Mehdi Farshchian MD
Background: Immunosuppressive therapy is believed to be one of the most important risk factors in the development of
skin cancer in renal transplant recipients.
Objective: Our purpose was to determine the types of neoplastic skin lesions encountered in Iranian renal transplant recipients
and their associations with immunosuppressive regimens.
Methods: The entire bodies of renal transplant recipients attending an outpatient transplantation department were
Results: Neoplastic skin lesions were diagnosed in 13.1% of the renal transplant recipients. Actinic keratoses, squamous
cell carcinomas, and basal cell carcinomas were the most common neoplastic skin lesions observed. Transplant recipients
exposed to immunosuppressive therapy for more than 5 years have a significantly higher risk of developing skin cancers
than recipients with less than 5 years of immunosuppressive therapy.
Conclusions: Our study confirmed the relatively high prevalence of neoplastic skin lesions among renal transplant recipients in the Iranian population
Gerald A. Rosenblum MD
A 62-year-old female presented with multiple keratoacanthomas of the palmar aspects of the hands, wrists, and proximal fingers.
Surgery or radiation therapy would have caused significant impairment. A 30-day course of 1 mg/kg per day of acitretin
led to a complete resolution. Maintenance therapy with 25 mg per day of acitretin was needed to prevent recurrence. The
medical treatment of keratoacanthomas is herein discussed as well.
Acne therapy should be based on pathogenesis. Current mainstays of therapy include topical retinoids, antibiotics, and benzoyl peroxide. Newer research has shown that inflammation may precede comedo formation. Gene array analysis of acne lesions has elucidated newer inflammatory mediators that may become future targets for therapeutic development.
J Drugs Dermatol. 2013;12(suppl 6):s70-s72.
Jashin J. Wu MD,a Kwun-Yee T. Poon MS,b and Judith D. Bebchuk ScDb
OBJECTIVE: We sought to assess whether the type of TNF inhibitor therapy (soluble receptor versus monoclonal antibody) has an effect on MI risk; and determine whether length of TNF inhibitor therapy has an effect on MI risk.
DESIGN: Retrospective cohort study
SETTING: Between January 1, 2004 and November 30, 2010
PARTICIPANTS: At least 3 ICD9 codes for psoriasis (696.1) or psoriatic arthritis (696.0) (without antecedent MI).
MAIN OUTCOME MEASURE: Incident MI
RESULTS: In the 3 subgroups of TNF inhibitors, 976 received etanercept; 217 received monoclonal antibody; and 480 received etanercept or monoclonal antibody, in addition, 5075 received topical therapy and 2097 received oral therapy. In the Cox proportional hazards analysis, etanercept (HR, 0.53; 95% CI, 0.31-0.92) was associated with a significant reduction of MI risk, compared to topical agents and, monoclonal antibody only (HR, 0.25; 95% CI, 0.06-1.03), and etanercept or monoclonal antibody (HR, 0.53; 95% CI, 0.27-1.06) were associated with a non-significant reduction of MI risk compared to topical agents. Using year 1 as reference, those who received TNF inhibitor therapy at year 2 (HR, 1.15; 95% CI, 0.30-4.44), at year 3 (HR, 1.89; 95% CI, 0.64-5.58), and at year 4 and above (HR, 1.16; 95% CI, 0.46-2.94) had a non-significant increase of MI risk.
CONCLUSIONS: Treatment with etanercept, compared to treatment with topical agents, was associated with a significant decreased risk of MI in psoriasis patients. Treatment with monoclonal antibody and etanercept or monoclonal antibody, compared to treatment with topical agents, was associated with a non-significant decreased risk of MI risk in psoriasis patients. There were no statistically significant changes in risk of MI associated with length of TNF inhibitor treatment.
J Drugs Dermatol. 2013;12(8):899-903.
Khalifa E. Sharquie MD PhD,a Raad M. A. Helmi BDS PhD,b Adil A. Noiami MD DDV FICMS,c Raafa K. Al-Hayani MD DDV,d and Mohand A. A. Kadhom BDS MSce
OBJECTIVES: To evaluate the long-term remission efficacy and safety of isotretinoin in the treatment of Behcet's disease (BD).
PATIENTS and METHODS: This single-blind, controlled therapeutic study was conducted in the Department of Dermatology and Venereology at Baghdad Teaching Hospital from February 2011 to January 2012. Thirty patients with BD were included in this work. Each patient received isotretinoin 20 mg orally once daily for 3 months. They were assessed at week 2 and then monthly depending on the Clinical Manifestation Index (CMI) and to record any side effects. At week 12, isotretinoin was stopped and patients were given placebo therapy in a form of glucose capsules for another 3 months.
RESULTS: Thirty patients were treated, 14 (46.6%) males and 16 (53.3%) females, with a male to female ratio of 1:1. Their ages ranged from 16 to 64 years (mean +/- standard deviation [SD], 38.4 +/- 10.9 years). During the first 3 months of therapy, the pathergy test, oral pathergy test, and C-reactive protein were significantly minimized. The CMI before isotretinoin therapy ranged between 2 and 8 (mean +/- SD, 4.933 +/- 1.91). After therapy, within the first 14 days, the mean CMI started to decline to a lower level, and it continued to decline significantly until week 12. It then started to increase through week 4 of placebo therapy, but remained statistically significant until the second month of placebo therapy. Isotretinoin therapy also had a statistically significant effect in reducing oral ulcers and skin manifestations.
CONCLUSION: Isotretinoin is an effective therapeutic and prophylactic drug in the management of BD.
J Drugs Dermatol. 2013;12(4):e68-e73.
James M. Spencer MD MS, Carole Hazan MD, Sherry Hsiung MD, Perry Robins MD
Actinic keratoses (AKs) represent the second most common reason to visit a dermatologist in the United States and
their therapy has become a major portion of most dermatologists’ practice. An ever-increasing array of therapeutic
options exist for the therapy of actinic keratoses, offering physicians and patients a greater number of choices than ever
before. Patient expectations and needs seem to be changing at the same time, thus effecting therapeutic decisionmaking.
While destructive therapies with resultant wounds, time for wound healing, and possible hypopigmentation or
scarring were acceptable in the past, many patients from the baby-boom generation are now developing AKs and have
little tolerance for any time for wound healing or any cosmetic changes. This paper will raise some fundamental questions
regarding AKs and their management.
Lindsey Warino BS, James Libecco MD
Cancer is a major cause of death in immunosuppressed transplant patients. Therefore, sirolimus is frequently used in these
patients for its immunosuppressive and antineoplastic properties. However, a variety of cutaneous side effects have resulted
from sirolimus therapy. Consequently, dermatologists must be aware of such adverse events and understand the risks and
benefits of discontinuing therapy.
James Q. Del Rosso DO FAOCD
Anti-infl ammatory dose doxycycline (ADD), which is the administration of doxycycline 40 mg extended-release capsule once daily, is
the only oral therapy approved by the United States Food and Drug Administration (FDA) for treatment of rosacea. ADD once daily
has been shown to exhibit anti-infl ammatory activity while not demonstrating evidence of antibiotic effects, including with chronic
administration. This article summarizes the clinical studies to date on the use of ADD once daily in papulopustular rosacea, including
both monotherapy and combination therapy studies. The combination therapy approach of ADD once daily and metronidazole gel 1%
once daily has been shown to exhibit a more rapid onset of therapeutic effect than topical therapy alone. ADD once daily has been
demonstrated to be effective in adult subjects with moderate to severe rosacea, and exhibits a favorable safety profi le coupled with
absence of antibiotic selection pressure. Additionally, a much lower incidence of gastrointestinal side effects has been noted with
ADD once daily as compared to doxycycline 100 mg once daily.
Isotretinoin therapy for the treatment of severe nodulocystic acne has been used for the last twenty-three years. Its use has been
associated with many restrictions to the patient, with some of these based on mythology rather than on scientific evidence. The purpose
of the article is to discuss the myths associated with acne treatment with isotretinoin. This article expresses the sole opinion
Topical imiquimod has opened an entirely new area of dermatology that previously did not exist: medical therapy for
skin cancers. While surgery will continue to play a vital role in treating more aggressive tumors and in patients who
may not be imiquimod candidates, the availability of a viable medical therapy that can be used independently or in
combination with other modalities will considerably enhance our ability to treat skin cancer successfully.
Jennifer Soung MD, Justine Cohen BA, Robert Phelps MD, Steven R. Cohen MD MPH
Although disfiguring hyperpigmentation is a well-defined complication of minocycline therapy, modalities to reverse the
phenomenon are unpredictable. We report a case of minocycline-induced, blue-black pigmentation in a 23-year-old Hispanic
man, which resolved after treatment with oral isotretinoin for acne vulgaris.
Three conditions, erythema dyschromicum perstans (EDP), granulomatous periorificial dermatitis (GPD), and Kawasaki
disease (KD) are seen more frequently in children of color. EDP and GPD are benign and self-limited dermatoses; therapy
can shorten the course of the diseases. KD, a systemic vasculitis, can have life threatening cardiac consequences and
timely therapy is essential. In all 3 conditions, clinicians should proceed with prompt and appropriate evaluation, diagnosis,
and intervention when indicated. A case representing each condition is presented, followed by a discussion.
Arash Kimyai-Asadi, MD; Kathy Gohar, MD; Pil Kang, BS; Adil Usman, MD; Robert Zenenberg, DO and Ming H. Jih, MD, PHD
Mixed cryoglobulinemia is a systemic vasculitis associated with hepatitis C infection. We present a case of mixed cryoglobulinemia induced by interferon-a therapy for hepatitis C infection and review previous cases in which cryoglobulinemic symptom exacerbations were caused by interferon-a.
Monica B. Schadlow, MD; Grant J. Anhalt, MD and Animesh A. Sinha, Md, PhD
Paraneoplastic pemphigus (PNP) is a rare autoimmune mucocutaneous blistering disease that is commonly
associated with underlying B-cell neoplasms. There is no standard therapy for PNP. Potent immunosuppression
has been the only potentially effective treatment in the setting of malignancy because there is no correlation
between tumor burden and activity of disease. Two recent case reports have noted the resolution of
lesions of PNP after treatment of the underlying CD20+ B-cell lymphomas with rituximab. Rituximab is an
anti-CD20 antibody that has had some success in treating proliferative B-cell disorders. We report a case of
PNP in the setting of B-cell lymphoma that did not respond to this novel therapy, and discuss rituximab’s putative
mechanism of action along with the clinical settings in which this novel therapy may prove useful in the
treatment of PNP.
Trenton Custis MDa,b and Daniel B. Eisen MDa
BACKGROUND: Ablative fractional laser (AFL) therapy for scars is an area of increasing interest. While the enthusiasm for these treatments
is high, a systematic review of their use on surgical scars has not been done.
OBJECTIVE: To identify randomized trials that study the efficacy of ablative fractionated laser therapy for treatment of surgical scars.
METHODS AND MATERIALS: EMBASE, Web of Science, and Pubmed databases were searched for randomized trials with 10 or more surgical wounds. No restrictions were placed on the language of the publications.
RESULTS: Three randomized trials were identified that met the criteria for the review. One study found superior efficacy of ablative fractionated
laser treatment of surgical scars compared to pulsed dye laser while the others found equivalent efficacy when compared to dermabrasion or pulsed dye laser. One study found a superior safety profile for ablative fractionated laser treatment over dermabrasion. No studies compared fractionated laser therapy to sham therapy or observation.
CONCLUSIONS: AFL compares well with the scar amelioration techniques of dermabrasion and pulsed dye laser. Additional studies are needed to further contrast AFL to these and other modalities as well as to observation alone.
J Drugs Dermatol. 2015;14(11):1200-1204.
Syed O. Ali CPT MC USA, Richmond D. McCarty LT USAF MSC, Brian M. Davis Col USAF MC
Cutaneous hypersensitivity vasculitis is often idiopathic, but may be the result of therapeutic drugs. It is important to
be aware of previously unreported drugs that may be associated with this complication. We report a case of cutaneous
hypersensitivity vasculitis due to famciclovir therapy. To our knowledge, this is the first report of this interaction in the
medical literature in English.
Hendrik Uyttendaele, Md, PhD; Joseph Obadiah, MD and Marc Grossman, MD
Intravenous immunoglobulin (IVIG) therapy has been used to treat a variety of immune mediated disorders.
Cutaneous reactions to IVIG are rare and have only been anecdotally described. We describe three cases with
dyshidrotic-like biopsy proven spongiotic dermatitis after administration of IVIG. These three cases may highlight
an uncommon and rarely reported side effect of IVIG.
John R. Griffin MD and Mark D.P. Davis MD
Frequent causes of morbidity secondary to herpes zoster include acute pain, secondary infection, and postherpetic neuralgia. A
less documented complication is pruritus, which can be either acute or postinfectious when it persists more than 3 months after
the rash has healed. We discuss a case of severe, acute neuropathic pruritus and pain secondary to active herpes zoster that
was unresponsive to standard medical therapy, including oral antihistamines, topical lidocaine, oral gabapentin, and local wound
care. Modest control of the pruritus and pain was achieved with continued multimodal therapy and the addition of topical 2%
amitriptyline/0.5% ketamine gel.
J Drugs Dermatol. 2015;14(2):115-118.
Joshua A. Zeichner MD, Madelaine Haddican MD, Rita V. Linkner MD, and Vicky Wong BS
Combination therapy using medications with complementary mechanisms of action is the standard of care in treating acne. We report results of a clinical trial evaluating the use of a fixed-dose tretinoin 0.025%/clindamycin phosphate 1.2% (T/CP) gel in combination with a benzoyl peroxide 6% foaming cloth compared with T/CP alone for facial acne. At week 12, the combination therapy group showed a trend toward greater efficacy compared with T/CP alone. There was a high success rate observed in the study, which may be attributable to the large percentage of adult female acne patients enrolled. Cutaneous adverse events were not statistically different in using combination therapy compared with T/CP alone.
J Drugs Dermatol. 2013;12(3):277-282.
Background: Isotretinoin is a widely prescribed drug for the treatment of severe acne. Several adverse cardiac effects due to isotretinoin
have been previously reported. However, no data exist on the effects of isotretinoin therapy on QT intervals.
Objective: To investigate the effects of isotretinoin therapy on QT intervals and QT dispersion, and also to see if it is related to serum
lipids, homocysteine and lipoprotein (a) or not.
Methods: Forty-five patients with severe acne (mean age 21±6 years, range 14-38 years; 26 female) were included in the study.
Twelve-lead surface electrocardiograms (ECGs) were acquired at three stages: before therapy and at the ends of the first and sixth
months of 0.8 mg/kg/day of isotretinoin therapy. Serum levels of triglycerides, total cholesterol, low density lipoprotein cholesterol,
high density lipoprotein cholesterol, very low density lipoprotein cholesterol, homocysteine and lipoprotein (a) were also measured at
the day of ECG recordings. Minimum and maximum QT intervals were measured and QT dispersion was calculated.
Results: Mean heart rates were similar throughout the isotretinoin therapy. Serum levels of lipids, homocysteine and lipoprotein (a)
all increased significantly at the end of the first month and remained significantly elevated at the end of sixth month (P<0.05 for both
stages). QT intervals and QT dispersion did not differ significantly throughout the six months of isotretinoin therapy (P>0.05).
Conclusions: In patients with severe acne, six months of 0.8 mg/kg/day of isotretinoin therapy neither prolongs QT interval, nor
increases QT dispersion. This effect is not related to blood lipids, homocysteine or lipoprotein (a) levels. Our findings indicate that
from the point of polymorphic ventricular tachycardia risk, 0.8 mg/kg/day of isotretinoin therapy is a safe choice in acne treatment.
J Drugs Dermatol. 2011;10(7):710-714.
Colton Nielson BS,b Ryan Fischer MD,a Garth Fraga MD,a and Daniel Aires MDa
Monoclonal antibody therapy is a new innovation in cancer therapy. Binding of monoclonal antibodies to tumor cells facilitates their destruction by the immune system. Tumor cells with mutated target antigens may escape detection by monoclonal antibodies and exhibit a selective growth advantage. This phenomenon was first recognized in CD20-negative B-cell lymphomas in patients previously treated with the anti-CD20 monoclonal antibody rituximab. We report a cutaneous recurrence of systemic ALCL with an anomalous CD30-negative immunophenotype. The patient had been previously treated with the anti-CD30 monoclonal antibody brentuximab. To our knowledge, we present the first reported case of a cutaneous recurrence of systemic ALCL with an anomalous CD30-negative immunophenotype following chronic brentuximab therapy.
J Drugs Dermatol. 2016;15(7):894-895.
Philip R. Letada MD, Erin Hitchcock DO, Samuel L. Steele MD, Douglas Winstanley DO
Improvement in psoriasis after treatment of reactivated latent tuberculosis following initiation of TNF-α inhibitor therapy has yet to be described in the literature. The authors present a case of transient, yet significant, improvement in chronic plaque psoriasis after antibiotic therapy for reactivated TB.
J Drugs Dermatol. 2012;11(1):119-120.
Zennure Takci MD,a Gulcin Guler Simsek MD,b Hayriye Karabulut MD,c
Yunus Buran MD,c and Ayse Serap Karadag MDd
BACKGROUND: Currently, there are no studies investigating the topical or systemic effects of retinoids on human nasal mucosa. We aimed to investigate the effect of systemic isotretinoin therapy on mucociliary transport and nasal surface mucosa using the saccharine test (ST) and nasal cytology techniques.
METHODS: A total of 30 patients with severe or moderate acne were enrolled in this study. The median prescribed dose of isotretinoin was 0.75 mg per kg per day. Clinical and biochemical examinations were carried out periodically. The ST and nasal cytology were performed before treatment and during the third month of therapy.
RESULTS: Of the 30 patients who initially agreed to participate in the research, 21 completed the study (18 female and 3 male, mean ± standard deviation (SD) aged 20.9 ± 4.7 years, range 15-32 years). There was a significant difference between the mucociliary clearance time for subjects in the pre- and post-treatment periods (173.8 ± 89.2 seconds vs 245.2 ± 191.6 seconds, respectively; P=.009). Cytological examination revealed that the squamous cell ratio was significantly lower and the reactive changes of the respiratory epithelium were significantly higher 3 months after isotretinoin therapy than before therapy (P=.010, P=.002, respectively). There were mild signs of inflammation according to the number of neutrophilic leukocytes (8.3% vs 26.6%, P=.06) after 3 months of isotretinoin therapy.
CONCLUSION: Systemic isotretinoin alters the mucociliary transport, decreases the squamous cell ratio, increases the reactive changes in the respiratory epithelium significantly, and increases neutrophils in the nasal surface mucosa in the third month of treatment.
J Drugs Dermatol. 2013;12(8):e124-e128.
Marco Ardigò MD, Georgiana Clare Marulli MD, Carlo Cota MD, Antonio Mastroianni MD, Enzo Berardesca MD
A 74-year-old man presented with relapsing systemic anaplastic large cell lymphoma (ALCL) with cutaneous involvement
who had a third recurrence of cutaneous lesions associated with inguinal lymphonodes enlargement. Due to severe
worsening of general conditions, treatment with low dose bexarotene associated with interferon-? was initiated. Four
months later, skin nodules disappeared with reduction of lymphonodes size. Two months after stopping therapy, lymphonodal
relapse of the lymphoma was seen; however, cutaneous lesions were still in complete remission.
Association of low dose bexarotene with interferon-? seems to represent a possible alternative therapy for relapsing systemic
ALCL presenting as prevalent cutaneous involvement in patients with severe worsening of general conditions. In
our case, this protocol was unable to maintain a longer disease free survival in comparison with the 2 previous polychemotherapy
cycles. Further extended studies are required in order to define the possible rule of this combination therapy in relapsing sYstematic ALCL.
Acne therapies that are able to show efficacious treatment of acne lesions as well as to address the issues of oiliness and shine control
may be particularly appropriate for the treatment of patients with acne vulgaris that is accompanied by oily skin and facial shine. The
microsphere delivery system (MDS), a novel delivery technology for topical therapy, can be customized to optimize product attributes,
including oil absorption. Clinical trials have clearly established the efficacy and tolerability of such MDS formulations in the treatment of
acne. In addition, studies have shown that the use of products formulated with an MDS provides a more significant reduction in facial
shine than non-MDS acne therapy, as well as a reduction in facial sebum accumulation relative to control. Future clinical research should
aim to further delineate the effect of individual topical acne treatment formulations on oiliness and shine.
J Drugs Dermatol. 2013;12(11):1268-1270.
Robert J. Clemons, MD; Annette Clemons-Miller, PhD; Sandra Marchese Johnson, MD; Susan K. Williamson, MA, CPC and Thomas D. Horn, MD
To compare the cost of several common modalities used to treat non-genital warts in immunocompetent patients, we identified studies
published in English using standard search strategies and evaluated the literature for the following common non-genital wart
therapies: cryotherapy with liquid nitrogen, carbon dioxide and pulsed-dye laser therapy, topical squaric acid, intralesional
bleomycin, intralesional interferon alpha injections, and intralesional immunotherapy with Candida antigens. Standard treatment
algorithms, compiled by dermatologists experienced in the treatment of patients with moderate wart burdens, were utilized
for cost-comparison analyses.
Based on the cost analysis model, the least expensive treatment option for non-genital warts were carbon dioxide laser therapy
($157) and Candida antigen injections ($190). The other treatment modalities examined ranged from $495 (bleomycin) to $1227 (interferon
alpha). Although treatment with the carbon dioxide laser therapy is the least expensive, pain and post-procedure complications
limit the use of this modality.
Kimberly R. Edwards, MD; Christen M. Moward, MD and Wiiliam B. Tyler, MD
We report the case of a patient with persistent and worsening injection site reactions associated with subcutaneous
etanercept therapy. Injection site reactions are well documented to occur early in therapy; however they
typically decrease in frequency over time. This patient developed early injection site reactions that have persisted
and worsened into his tenth month of treatment with etanercept.
Fiona Larsen MBChB FRACP, Alan Menter MD, Clay J. Cockerell MD, Barry N. Wilcox MD
Verrucous linear segmental psoriasis (VLSP) is invariably recalcitrant to treatment. It is a distinct variant of psoriasis that frequently is
considered a form of a verrucous linear, epidermal nevus.1 The hypertrophic nature of the plaques makes treatment particularly chal-
lenging. The authors present a case of verrucous linear psoriasis of the right leg that responded to radiation therapy.
Saleem A Umar MD, Pradip Bhattacharjee MD, Robert T Brodell MD
Hailey-Hailey disease, or familial benign chronic pemphigus, is a chronic disease without a known cure. Current therapeutic strategies
attempt to suppress Hailey-Hailey outbreaks and allow the patient to live comfortably with this condition. We have found that
applying topical tacrolimus 0.1% ointment (Protopic®) twice a day to affected areas is an excellent way to control Hailey-Hailey disease.
In addition to effectively controlling Hailey-Hailey outbreaks, tacrolimus is a relatively safe and noninvasive mode of treatment, without
significant side effects. We recommend intermittent therapy with clobetasol propionate 0.05% foam (Olux Foam®) for patients
who break through suppressive therapy with tacrolimus a few times per year. In patients with frequent outbreaks of Hailey-Hailey
disease despite suppressive therapy with tacrolimus, we recommend alternating the tacrolimus with clobetasol propionate 0.05% foam
every 6 weeks.
Adriana M Villa and MD, Brian Berman MD PhD
Therapeutic interventions to augment tumor antigenicity or increase the host’s immune response against cancer cells include recombinant
cytokines, immune modulators, vaccination with tumor antigens, T cell-based immunotherapy, and gene therapy. We describe
the current role of the immunomodulators (up-regulators of the immune response) in the therapy of skin cancer (non melanoma skin
cancer, melanoma, lymphoma, Kaposi sarcoma, and extramammary Paget’s disease).
Background: Use of coal tar with narrowband (NB) ultraviolet B (UVB) light (the Goeckerman regimen) is an effective treatment for
plaque psoriasis that has become impractical in outpatient care mainly due to the inconvenience and aesthetic concerns of coal tar.
Objective: This study evaluated the safety, efficacy, and convenience of adding a novel LCD (coal tar) solution to standard NB-UVB
phototherapy in adults with chronic plaque psoriasis.
Methods: Patients applied LCD solution to half-body twice daily at home and received outpatient full-body NB-UVB light therapy
3 times a week for up to 12 weeks. A blinded investigator graded psoriasis severity of body halves and bilateral target lesions and
monitored adverse reactions. Patients rated their psoriasis symptoms and LCD solution aesthetics.
Results: NB-UVB + LCD therapy reduced the median time to clearance or minimal disease in at least 50% of the population by 3 weeks
(4 weeks with NB-UVB + LCD versus 7 weeks with NB-UVB alone). A statistically superior clinical response was observed by the end of
week 4 with NB-UVB + LCD versus NB-UVB alone (P < 0.05) for: PGA, target lesions, ESI scores, and patient-reported symptoms.
Conclusion: Incorporating an at-home regimen with a novel LCD solution into outpatient NB-UVB light therapy is safe, convenient,
effective, and can improve psoriasis more quickly than NB-UVB light therapy alone.
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.
Travis Vandergriff MD, Krystal Nakamura MD, Whitney A. High MD
Generalized eruptive keratoacanthomas of Grzybowski is a rare condition of unknown etiology. The disease is characterized by the
abrupt onset of many small crateriform papules on the skin and mucous membranes. The authors report of a man with multiple eruptive
keratoacanthomas of Grzybowski who responded favorably to oral isotretinoin therapy. After 2 years of follow-up, a complete
regression of all lesions was observed, and this rapid clearance under isotretinoin therapy is intriguing with regard to the possible
etiology of the condition.
Guy F. Webster MD PhD
Topical fixed-combination products and topical retinoid monotherapy are established first-line treatments for mild-to-moderate acne vulgaris, yet adequate comparative data are lacking. The following evidence-based review addresses the question: "In patients with mild-to-moderate acne, are topical fixed-combination products or topical retinoids a more efficacious choice in reducing noninflammatory, inflammatory and total lesions after 12 weeks of treatment?" To identify relevant studies, a PubMed search was performed using "acne" and search terms for adapalene, tretinoin, tazarotene, benzoyl peroxide, clindamycin, or erythromycin. Forty-two studies from January 1991 to November 2009 were included. The studies were evaluated using the Strength of Recommendation Taxonomy, and all but seven received the highest level of evidence grade. To evaluate efficacy, a side-by-side comparison was made using reduction in acne lesion counts at week 12 for study groups treated with fixed-combination therapy or retinoid monotherapy. Twenty-nine studies containing relevant efficacy data for fixed-combination therapy and retinoid monotherapy are summarized here. Nine studies compared fixed-combination therapy with retinoid monotherapy; in eight of these studies, fixed-combination therapy was significantly more efficacious in reducing acne lesion counts. This evidence-based review analyzes clinical evidence to date for these therapies to provide guidance in determining appropriate treatment for patients with mild-to-moderate acne.
J Drugs Dermatol. 2011;10(6):636-644.
Ethan C. Levin MD,a Maya Debbaneh BA,b John Koo MD,a and Wilson Liao MDa
BACKGROUND: The efficacy of biologic therapy in treating plaque-type psoriasis is well documented. However, there is less data for use in other psoriasis subtypes, such as erythrodermic and generalized pustular psoriasis.
OBJECTIVE: We sought to review the safety and efficacy of biologic medications in the treatment of these severe subtypes of psoriasis and to identify strategies to help clinicians optimally manage these patients.
METHODS: We searched Pubmed for English language literature that assessed the use of biologic medication to treat erythrodermic or generalized pustular psoriasis.
RESULTS: The primary literature included cases reports, cases series, and open-label, uncontrolled trials. There were no head-to-head studies or other controlled trials. In both erythrodermic and generalized pustular psoriasis, infliximab was used to treat over half of the reported cases. Other biologic medications that were successfully used included etanercept, ustekinumab, adalimumab, and anakinra. Most cases reported improvement with biologic therapy. Serious adverse events were reported in 10-12% of the patients.
CONCLUSION: Although the evidence is limited, biologic therapy appears to be effective in treating erythrodermic and generalized pustular psoriasis. In order to assess the comparative efficacy and safety of the biologic medications, larger controlled studies are needed.
J Drugs Dermatol. 2014;13(3):342-354.
John Y. M. Koo MD, Jerry Bagel MD, Marianne T. Sweetser MD PhD, Barry S. Ticho MD PhD
Combination therapy for moderate to severe psoriasis is often used to enhance efficacy and minimize treatment-related side
effects; however, data are limited on combination therapy with the newer biologic agents. The current study examined
patients who received alefacept in combination with ultraviolet B phototherapy as part of an international, open-label study
evaluating up to 3 courses of alefacept in combination with other psoriasis therapies. Physician Global Assessment (PGA)
scores improved by 2 or more categories in 76% of patients and by 1 or more categories in 88% of patients in course A.
Corresponding response rates were 100% and 55% in course B, and 85% and 77% in course C. At week 14, a PGA of “almost
clear” or “clear” was achieved by 13%, 14%, and 8% of patients in courses A, B, and C, respectively. There was no evidence
of a cumulative effect on T cells after multiple courses of therapy. The combination of alefacept and ultraviolet B was well
tolerated and provided improvement in psoriasis.
Brooke E. Rothstein BA,a,b Brianna McQuade PharmD,a Jacqueline E. Greb BA,a,b Ari M. Goldminz MD,a
and Alice B. Gottlieb MD PhDa,b
We report a 67-year-old Caucasian man with a long-term history of recalcitrant plaque psoriasis and psoriatic arthritis who was initiated on a treatment regimen of apremilast and secukinumab after failing multiple topical, photo, and systemic therapies. This combination provided significant skin improvement with minimal drug side effects.
J Drugs Dermatol. 2016;15(5):648-649.
Veronica Russo MD MPH and Ali Alikhan MD
BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, painful, inflammatory disorder of hair follicles and manifests with several cutaneous findings, including double comedones, papules, cysts, nodules, draining abscesses, and sinus tracts. It is associated with tremendous morbidity and decreased quality of life. Treatment of HS is challenging. Recently, there have been mixed reports regarding the efficacy of anakinra, an interleukin 1 receptor antagonist, in the management of HS.
CASE: A 55-year-old African American male with a several year history of severe HS, recalcitrant to multiple prior treatments, was treated with a 12 week course of anakinra 100 mg subcutaneously daily. After 3 months of therapy, minimal change was observed, and the patient strongly preferred to cease therapy due to lack of improvement and pain associated with daily injections.
CONCLUSION: Our case of severe HS proved refractory to anakinra. Tolerance of this therapy may be a limiting factor for some patients due to necessity for daily injections.
J Drugs Dermatol. 2016;15(6):772-774.
Richard G. Langley MD, Kenneth B. Gordon MD
Background: The efficacy of biologic agents to treat psoriasis has been established in well-designed clinical trials. The
primary endpoint is usually a 75% reduction from the baseline Psoriasis Area and Severity Index, stressing acute control
of symptoms. Another important endpoint is remission, or duration of response off therapy, which reduces exposure
to immunosuppressive agents and potentially lowers costs.
Methods:We searched the literature for randomized controlled clinical trials of remission with biologic agents.
Results and Conclusions: Among approved biologic agents, alefacept produced the longest posttreatment clinical benefits
in responders (7 to 8.6 months after a 12-week course), followed by infliximab (4.7 months after a 6-week, 3-dose
induction period), etanercept (2.8 to 3.5 months after 12 weeks of therapy), and efalizumab (2.8 months after 24 weeks
of therapy). Long-term response to infliximab in some patients may be limited by neutralizing antibodies. Additional data
on adalimumab are needed.
Emily M. Berger BA, Hassan I. Galadari MD, Alice B. Gottlieb MD PhD
Hailey-Hailey disease is an autosomal dominant skin condition characterized by waxing and waning painful and pruritic
vesicles and plaques affecting the intertriginous areas. Its pathogenesis involves inherited abnormalities in a cutaneous calcium
pump. Most patients are managed conservatively with topical corticosteroids as well as topical and oral anti-infective
agents. Scarce reports in the literature describe the use of oral retinoid therapy to manage refractory cases. We present
a case of Hailey-Hailey disease in a 64-year-old man who was refractory to conservative management but improved dramatically
over 6 months of oral therapy with 25 mg of acitretin daily. The mechanism by which such therapy improves
disease manifestations is unknown. A potential mechanism is based on the influence of retinoids on epidermal differentiation
and may involve cutaneous calcium homeostasis. Hailey-Hailey disease is discussed and the use of oral retinoid treatment
for Hailey-Hailey disease is reviewed.
Antifungal therapy has recently enjoyed a resurgence of interest due to the introduction of a number of new formulations of topical drugs and novel molecules. This has led to a plethora of new publications on management of cutaneous fungal disease. This paper summarizes the various clinical trial factors which may affect the published data regarding how well antifungal drugs work. Understanding these parameters allows the healthcare provider to choose more rationally between available agents based upon an assessment of the evidence.
J Drugs Dermatol. 2015;14(suppl 10):s48-s54.
Tina Bhutani MD, Kristine B. Zitelli MD, John Koo MD
Psoriasis is a chronic disease that exists in two phases: (1) the acute, flaring phase when psoriasis is highly inflamed, erythematous and pruritic and (2) the chronic, indolent phase after the acute manifestations are brought under control. Ideal therapies for psoriasis must focus on both of these phases. Therefore, a rapid and effective agent must be utilized to treat the acute phase, followed by safe long-term therapy for maintenance. This article proposes a new, effective sequential topical therapy for psoriasis using ongoing treatment with clobetasol (Clobex®) spray for one month followed by calcitriol (Vectical®) ointment for the next month. This strategy provides a highly effective, reliable and safe treatment option with minimal local and systemic adverse risks.
J Drugs Dermatol. 2011;10(8):831-834.
Ajith C. MD, Somesh Gupta MD DNB, Amrinder Jit Kanwar MD MNAMS
Background: Immunotherapy with sqauric acid dibutyl ester (SADBE) is a well-accepted therapy for alopecia areata.
Objective: To study efficacy, safety, and factors influencing the outcome in the treatment of alopecia areata.
Method: During a 4-year period, 70 patients of alopecia areata, unresponsive to conventional therapies, were treated with
SADBE for a period of 4 months and thereafter depending on the response with initial therapy. The percent scalp hair loss
was calculated using “Severity of Alopecia Tool” (SALT) score before and after the therapy.
Results: Out of 70 patients, 6 were lost to follow-up and 4 could not develop sensitization; therefore, data of 60 patients
was available for analysis. The overall success rate was 43%. In patients with <50% scalp involvement; the success rate was
better (68%) than in those with >50% involvement (29%). The response was better in patients with late onset and shorter
duration of disease. Family history of alopecia areata or other autoimmune diseases, personal or family history of atopy,
presence of auto antibodies in serum, and presence of nail changes were associated with poorer prognosis. Out of 26 patients
who responded, relapse occurred in 21 (81%) patients.
Conclusion: In conclusion, SADBE is an effective and well-tolerated mode of therapy in Indian patients of AA, although
the long-term results of SADBE were not encouraging.
Teresa M. Weber PhD,a Michael J. Babcock MD,b James H. Herndon Jr. MD,c Alexander W. Filbry PhD,d Ulrich Scherdin PhD,d and Frank Rippke MDd
Two over-the-counter products have been clinically tested for efficacy and tolerability in the treatment of atopic dermatitis. Study 1 evaluated a daily maintenance Body Cream (Eucerin Eczema Relief Body Crème) applied twice daily for 14 days, followed by treatment withdrawal for 5 days (regression period) in subjects with a history of atopic dermatitis. Study 2 evaluated an acute treatment (Eucerin Eczema Relief Instant Therapy [Instant Therapy]) for active atopic dermatitis lesions administered for 14 days.
Skin barrier function, hydration, tolerability, and relief of symptoms were assessed at baseline, day 7, and day 14. Study 2 also measured itch relief and treatment impact on work, social activities, and sleep.
Body Cream significantly improved skin hydration and barrier function (P<.001) at 14 days, with improvements persisting through the 5-day regression phase. Itching was significantly improved in 93.8% of subjects (P<.001).
Instant Therapy treatment of atopic dermatitis lesions significantly improved skin hydration and barrier function, as well as symptoms of erythema, pruritus, excoriation, and lichenification, with rapid improvement of itch reported within minutes of the first treatment application. Instant Therapy significantly reduced itch intensity and frequency, and demonstrated beneficial improvements in subjects’ quality of life. Body Cream and Instant Therapy were both safe and well tolerated.
J Drugs Dermatol. 2014;13(5):589-595.
William D. Tutrone MD, Kimberly M. Green MS, Tom Norris MD, Jeffrey M. Weinberg MD, Dick Clarke
Envenomation from the brown recluse (Loxosceles recluse) spider commonly proceed on one of three clinical pathways.
The majority of bites (90%) result in nothing more than a local reaction. They are essentially self-limiting, require little
if any attention, and resolve spontaneously. A great majority of the remaining bites will produce necrotic ulcerations
of various sizes and dimensions, with systemic sequela ranging from fever to hemolysis and kidney failure. Finally,
and in the most rare cases, the patient will succumb a fatal systemic reaction. Current therapeutic options for these
wounds remain controversial and include the following: local care, corticosteroids, dapsone, and hyperbaric oxygen
(HBO) therapy. This article will review the application of HBO therapy for patients who are envenomated by brown
recluse spiders. Information for this manuscript was derived from multiple MEDLINE searches as well as searches of the
National Baromedical Service’s hyperbaric specialty literature collection.
Psoriasis is a chronic inflammatory skin disease that is characterized by thickened red plaques covered with silvery scales. Excimer laser therapy is a cutting-edge advancement in UVB phototherapy. In contrast to traditional phototherapy, the 308 nm excimer laser only targets psoriasis plaques, while it spares uninvolved skin. It allows for treatment with a supra-erythmogenic dose of UVB irradiation. Targeted UVB therapy is a possible treatment especially for many who have failed topical treatments, systemic therapy, and traditional phototherapy. For safe and effective psoriasis treatment, a combination of therapies may be used, including a combination of laser treatment with topical medications. We present two cases demonstrating effective treatment with excimer laser in conjunction with clobetasol spray and calcitriol ointment for 12 weeks. Long-term near-clearance of psoriasis was sustained after 6 months and one-year follow up periods without further therapy.
J Drugs Dermatol. 2012;11(8):994-996.
Jennifer C. Sri BS, Charlotte L. Tsai MD, April Deng MD, Anthony A. Gaspari MD
Tumor necrosis factor alpha (TNF-?) inhibitors, such as infliximab, decrease the body’s inflammatory response and thus
the body’s reaction to infection. Given the immune-mediated processes in psoriasis and psoriatic arthritis, patients with
these disorders may benefit from infliximab therapy but may also suffer from an increased risk of infection. We present the
first case of osteomyelitis in a patient receiving infliximab therapy for severe psoriasis and psoriatic arthritis. Infliximab
and its serious adverse effects are discussed, and other cases of osteomyelitis with infliximab use are also reviewed.
No abstract details for the moment.
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.
Nawaf Al-Mutairi MD FRCPC, Y. Manchanda MD DNB, Osama Nour-Eldin MSc, Amani Sultan MB BCH
A total of 160 patients (59 male and 101 female) ages varying from 13 to 28 years (mean age 20 years) with moderate
to severe acne were treated with isotretinoin in the doses ranging from 0.5 mg/kg/day to 1 mg/kg/day. The drug
was given for a period ranging from 6 to 28 weeks. The patients were followed up regularly for a period of 12 months
after stoppage of isotretinoin for any evidence of relapse. In the event of a recurrence greater than mild acne after
8 weeks of stoppage of isotretinoin therapy, the patients were given another course of the drug. Patients were considered
to be non-relapsing if they had no evidence of recurrence after 12 months of follow-up. Twenty seven
patients were excluded from the study. Of the remaining 133 patients (51 male and 82 female) only 117 patients
(36 male and 81 female) could follow up for at least 12 months after stopping therapy. Of the 133 patients, a total
of 127 patients (95.5%) achieved complete or partial clearance. Forty two percent (total 49 patients: 20 male and
29 female) experienced relapse after stopping therapy. Of these, 21 (42.85%) were given a second course of the drug.
None of the patients developed a rise in lipids levels significant enough to warrant stoppage of the drug.
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.
A.F. Nikkels MD PhD, P. Gillard MD, G.E. Pierard MD PhD
Introduction: Pityriasis lichenoides (PL) exhibits a protean clinical presentation, particularly in its overlapping form (OPL) combin-
ing aspects of the acute and chronic types. Some patients are drug multiresistant and pose a therapeutic dilemma. The anti-tumor
necrosis factor (TNF)-α agent etanercept, was recently introduced as an alternative treatment for psoriasis, rheumatoid arthritis, and
Case Report: A 65-year-old woman suffered from an overlapping form of pityriasis lichenoides (OPL) for 5 years. Several initial acute
episodes were controlled by successive courses of oral antibiotics, topical corticosteroids, and/or psoralen ultraviolet light-A (PUVA)
therapy. The disease progressively evolved to a more chronic form. Topical immune response modifiers and corticosteroids, as well
as PUVA, ultraviolet light-B (UVB), methotrexate, dapsone, and cyclosporine were introduced, but all proved ineffective. Due to the
therapy multiresistance, 2 weekly injections of etanercept were administered. After 2 months, a marked improvement was observed
in regards to the patient’s pruritus and inflammation. No treatment-related adverse effects were observed. Therapy was continued
for 4 months without any new lesion development. However, 1 month after stopping treatment new OPL lesions recurred.
Conclusion: At the time of publication, this is the first report of the effectiveness of etanercept in OPL. This drug might be consid-
ered as a therapeutic alternative for treatment multiresistant OPL.
Sean D. Doherty MD, Sylvia Hsu MD
Introduction: Thalidomide is approved by the Food and Drug Administration (FDA) for erythema nodosum leprosum, but has been
used in many other dermatological conditions that are refractory to standard therapy.
Methods: The medical records of 48 patients treated with thalidomide at Baylor College of Medicine (Houston, TX) were retrospectively
reviewed to determine the conditions treated with thalidomide, dosing, effi cacy, treatment duration, side effects, adverse
events, and reason for discontinuing therapy.
Results: Forty-eight patients (men=18, women=30) with a mean age of 49.6 years (range: 20-79) were included in this study.
Patients were treated for prurigo nodularis, discoid lupus erythematosus, tumid lupus erythematosus, subacute cutaneous lupus
erythematosus, systemic lupus erythematosus, lichen planus, lichen planopilaris, cutaneous sarcoidosis, and prurigo nodularis. All
conditions were refractory to standard therapy. Patients were treated for a mean of 7.5 months (range: 3 days to 70 months). In most
of the disorders, a majority of patients experienced clinical improvement. The most common reason for discontinuation of therapy
was side effects, the most frequent being peripheral neuropathy.
Limitations: This study was limited by being retrospective in nature.
Conclusion: Thalidomide effectively treats some dermatologic conditions that are refractory to standard medications. There are
inconveniences associated with obtaining the medication and it is expensive. Physicians must be vigilant for possible side effects,
especially peripheral neuropathy.
Catherine Warner BS, Young Kwak BA, Mary H.B. Glover MD, and Loretta S. Davis MD
The most common subepidermal blistering disorder, bullous pemphigoid (BP) typically occurs in the elderly without any obvious inciting event.1 Anti-basement membrane zone antibodies are typically detected on direct and indirect immunofluorescence studies.2 A flu-like prodromal phase with a non-specific urticarial dermatitis may herald the development of the more characteristic tense bullae.3 Obtaining a thorough medication history is important as a number of pharmacological agents have been reported to trigger this same phenomenon. We report a case of generalized BP induced by hydrochlorothiazide therapy in a 32-year-old male.
J Drugs Dermatol. 2014;13(3):360-362.
Mona Sadeghpour MD, Kristen LoSicco MD, Laura K. Ferris MD PhD
No abstract details for the moment.
James Q. Del Rosso DO FAOCD, Joseph Bikowski MD
Metronidazole was the first topical agent approved by the US Food and Drug Administration for the treatment of
rosacea. Several controlled studies have confirmed the efficacy and safety of topical metronidazole 0.75% gel, lotion
and cream and 1% cream for rosacea. At present, little data exists regarding the use of combination topical therapy in
rosacea management, although anecdotal evidence and preliminary studies suggest at least some additive benefit when
topical metronidazole is used in combination with sulfacetamide 10%/sulfur 5%. In this paper, the results of observational
experience evaluating topical metronidazole 0.75% gel used in combination with other topical rosacea therapies
and/or subantimicrobial dose doxycycline are reported.
Hatice Sanli MD, Bengu Nisa Akay MD, Muhit Ozcan MD
There are several reports of patients who developed extracutaneous lymphoma after they started bexarotene treatment. The authors
report a case in which the initiation of bexarotene therapy for Sézary syndrome was temporally associated with the development
of Hodgkin’s lymphoma despite improvement in cutaneous signs and symptoms. It is possible that bexarotene may contribute to
the development of extracutaneous lymphoma. Although bexarotene therapy may relieve symptoms and signs of cutaneous T-cell
lymphoma, careful examination of the lymph nodes during treatment is recommended.
2LT Adam Perry MSC USAF, CPT Joshua D. Sparling MC USA, LCDR Mark Pennington MC USN
A causal relationship is thought to exist between several medications and the development of bullous pemphigoid.
Commonly implicated medications include furosemide, penicillins, and ibuprofen. The following is a case report of an
elderly man who developed generalized bullous pemphigoid for the first time after beginning therapy with an oral betablocker.
A literature search revealed only 2 other reports of beta-blocker associated bullous pemphigoid. As both bullous
pemphigoid and beta-blockers are common in elderly patients, dermatologists may want to consider beta-blockers
as potential etiological agents in the development of bullous pemphigoid.
Jennie T. Clarke MD, Harper Price MD, Shari Clarke MD, Rosalyn George MD, Jeffrey J. Miller MD
Alopecia, hypertrichosis, and hirsutism may be caused by a variety of medications. Drug-induced alterations in the texture
or structure of the hair shaft, however, are much less common. We report a female patient who presented with acquired
generalized kinking of the hair 6 months after the initiation of acitretin therapy for psoriasis. The hair change has
persisted despite reductions in the dose of acitretin. To our knowledge, this is the first report of hair kinking induced by
acitretin. It has been proposed that retinoid therapy may affect keratinization of the inner root sheath to cause this structural
hair shaft change.
Stephanie Bayers BSBA,a Daniel L. Kapp MD FACS,b
Kenneth R. Beer MD FAAD,b and Benjamin Slavinc
Historically, basal cell carcinomas (BCCs) that are neither surgically resectable nor candidates for radiation therapy have had few treatment options. The hedgehog pathway inhibitor, vismodegib, represents a new opportunity for the treatment of such patients. Vismodegib has approval from the United States Food and Drug Administration for treatment of metastatic BCC, locally advanced BCC recurring after surgery, and BCC that is not treatable via surgery or radiation. We present the case of a patient with a BCC infiltrating the spinal column that was neither possible to fully remove surgically nor a candidate for primary treatment with radiation. Treatment with vismodegib followed by adjuvant radiation therapy resulted in complete disease clearance. Vismodegib represents a promising treatment option for patients with surgically non-resectable BCCs that are not candidates for radiation therapy. Mechanism of action, benefits, and adverse events of vismodegib are reviewed, along with a brief discussion on newer options in the hedgehog inhibitor class.
J Drugs Dermatol. 2013;12(suppl 10):s147-s150.
Tracy M. Campbell MD, Clarence W. Brown Jr MD
The epidermal growth factor receptor (EGFR) inhibitor class of agents have been reported to cause multiple cutaneous adverse
events. These drug eruptions are thought by some to indicate a good prognosis. The authors report of a case of a psoriasiform scalp
eruption simultaneously occurring with an acneiform or follicular rash in a single patient. To present knowledge, this is the ﬁrst report
of a psoriasiform eruption triggered by erlotinib. In addition, this case report demonstrates 2 completely distinct cutaneous morpholo-
gies occurring simultaneously with erlotinib therapy in a single patient.
Kamruz Darabi MD, Rohit Jaiswal, Sarah Hostetler MD, Mark Bechtel MD, Matthew Zirwas MD
2008 JDD Case Report Contest Winner
Treatment of patients with moderate-severe psoriasis and/or psoriatic arthritis includes systemic biologic, antimetabolite, and im-
munosuppressive therapy. However, adverse events such as serious infectious complications must be considered before start-
ing therapy and throughout treatment. The authors describe the case of a male on combination etanercept and methotrexate for
psoriasis and psoriatic arthritis for years who developed a spontaneous epidural abscess with resulting quadriplegia. In addition, a
review of the literature was performed looking at the risk of serious infectious complications with antitumor necrosis factor (anti-TNF)
monotherapy or combination therapy with methotrexate fro the treatment of psoriasis and rheumatoid arthritis. Serious infectious
risk does not appear to be increased with etanercept or other anti-TNF agents either alone or in combination with methotrexate.
Nevertheless, clinicians are cautioned to carefully weigh the risks and beneﬁts of treating with anti-TNF agents in patients who are
prone to infection.
S. Ronger, MD; A.M .Villard, MD; F. Meunier-Mure, MD; B. Balme, MD and L. Thoma., MD
Background: Lichen sclerosus remains an elusive disease with an uncertain relationship to morphea and scleroderma.
The disorder has been difficult to treat, with no consistent and reproducible efficacious therapy.
Recently, a beneficial effect of treatment with oral calcitriol (1-25 dihydroxyvitamin D3) in patients
with scleroderma or morphea was described. This fact could be ascribed to the immunomodulatory
effects of calcitriol observed in vitro and to inhibition of fibroblastic growth. Because of the success of
calcitriol in localized scleroderma, we attempted this therapy in a patient with LS.
Observation: One patient with cutaneous generalized LS resistant to different therapeutics was treated with calcitriol
in an oral daily dose of 0.5 mcg. After 6 months of treatment, the skin extensibility increased, and the
lesions improved. The improvement persisted after discontinuation of therapy during a follow-up period
of one year. The only side effect was hypercalciuria, which resolved with dose reduction.
Conclusion: Calcitriol has shown a beneficial effect in scleroderma and morphea during open studies. A case is
reported of a patient with LS who had a dramatic response to calcitriol. Double blind, placebo-con
trolled trials are needed to assess the therapeutic value of calcitriol in patients with LS.
Whitney Bowe MD and Mary-Margaret Kober MD
Acne vulgaris is a multi-factorial disease affecting a significant
proportion of the population. A patient-centered approach is
most effective for the treatment of acne, focusing both on life
style interventions as well as pharmacologic therapy. Lifestyle
modifications include dietary counseling, as a link between
dietary choices and acne continues to grow. Pharmacologic
regimens must account for the severity of disease, emergence
of resistant bacterial strains and ease of patient compliance.
Combination topical therapy is often required for patients with
mixed inflammatory and comedonal acne, while oral medications
are frequently needed for severe cases or those involving
large surface areas such as the chest or back. With or without
a photosensitizer, light based treatments present an alternative
or adjuvant to traditional pharmacologic therapy. Novel formulations
of existing medications in addition to original compounds
continue in development, expanding therapeutic possibilities
for the future. With the emergence of antibiotic resistance,
we are forced to prescribe antibiotics more responsibly, while
exploring alternatives to this longstanding standard of care.
This article discusses current and emerging therapies for the
treatment of acne.
Macrene Alexiades MD PhDa,b
No abstract details for the moment.
Skin is the most commonly affected organ in patients with HIV, and the incidence of cutaneous adverse reactions in persons
infected with HIV versus those who are not infected is significantly higher. Cutaneous drug reactions contribute to increased
morbidity and are often the cause of treatment nonadherence. Undoubtedly, the widespread use of highly active antiretroviral
therapy has had a positive effect on the natural course of the disease; however, advances in HIV therapy will continue to
increase the potential for cutaneous eruptions, further complicating the evaluation of skin manifestations that are so common
in this disease. Distinguishing between cutaneous drug reactions and other cutaneous diseases associated with HIV
infection can be challenging. Nevertheless, it is important for clinicians to be knowledgeable about the clinical characteristics
and presentations of these reactions and to determine whether drug discontinuation is indicated.
No abstract details for the moment.
Anthony A. Gaspari MD, Stephen K. Tyring MD PhD, andTheodore Rosen MD
The therapeutic potential of imiquimod, a toll-like receptor (TLR)-7 agonist, was recognized in the clinical setting more than a decade
ago. Beginning with an approved indication for the treatment of external genital warts in 1997, imiquimod 5% topical cream (Aldara®)
has received further approval for treating actinic keratosis and superficial basal cell carcinoma. Currently, imiquimod 5% topical cream
is the most widely studied and characterized TLR agonist available in the clinical milieu. With new formulations and adjunctive regimens
being studied, this paper briefly reviews the mechanisms of action, approved indications, exploratory indications and the role
of combination therapy, add-on molecules, and new formulations to overcome treatment limitations.
Severe childhood atopic dermatitis refers to the presence of recurrent, widespread, eczematous dermatitis that significantly interferes with the daily activities and/or the quality of life of the affected child and family. The vast majority of children with severe, long-standing atopic dermatitis can be managed with the appropriate use of topical treatments, including long-term maintenance therapy and adjunctive treatments. In the recalcitrant patient, second line therapies such as narrowband ultraviolet light therapy and systemic immunosuppressants such as cyclosporine, azathioprine, mycophenolate moefetil, and methotrexate have been shown to be safe and effective in children with severe atopic dermatitis and can lead to sustained clinical improvement. To date, biologic therapy has not been uniformly effective in childhood atopic dermatitis. Management of severe childhood atopic dermatitis, including topical and adjunctive treatments and second-line therapies including systemic immunosuppressants will be reviewed here.
J Drugs Dermatol. 2012;11(10):1158-1165.
Sergio Di Nuzzo MD, Martina Zanni MD, Giuseppe De Panfilis MD
Psoriasis may be frequently associated with psychiatric diseases. We present a 44-year-old man undergoing cyclosporine
therapy for treatment of generalized plaque psoriasis which exacerbated his symptoms of paranoid schizophrenia, and disappeared
a few days after discontinuation of cyclosporine. Replacement therapy with etanercept achieved clinical remission
of psoriasis without any psychiatric side effects. Systemic medications, such as cyclosporine and etanercept, induce
modifications of the cytokine network. This is pathogenetically significant in both psoriasis and psychiatric disorders. This
case report suggests that dermatologists need to become more familiar with the risk-benefit of drug-induced cytokines dysregulation
in psoriatic patients with comorbid psychiatric disorders.
James Q. Del Rosso DO
Dermatological research continues to move toward the goal of developing an effective psoriasis treatment that would rapidly
clear lesions and provide long-term freedom from visible signs and symptoms. Currently, topical corticosteroids remain a
pivotal treatment due to their effective anti-inflammatory properties; however, potential adverse effects associated with
chronic application limit long-term continuous therapy. Vitamin D analogues provide another mechanism of action, reducing
lesions through effects on both keratinocytes and on the cytokine environment. A topical combination of corticosteroid
and vitamin D derivative appears to provide a balanced approach to psoriasis treatment. The development of clobetasol
propionate foam 0.05% (clobetasol propionate foam/Olux) offers a convenient topical corticosteroid that can be used
concomitantly, that is, immediately followed by application of calcipotriene ointment 0.005% (Dovonex). This regimen has
been shown to offer an increased short-term efficacy compared with either agent alone. Continued application of
calcipotriene ointment on weekdays supplemented by long-term clobetasol propionate foam pulse therapy on weekends
appears to provide an enhanced maintenance of remission compared with calcipotriene monotherapy.
Shannon Famenini BSa and Jashin J. Wu MDb
TNF-alpha inhibitors are used to treat numerous inflammatory conditions including rheumatoid arthritis and inflammatory bowel disease. Recent reports have illustrated the paradoxical development of psoriasis with TNF-alpha inhibitor therapy. We present here a review of 142 cases of new-onset psoriasis with infliximab, adalimumab, and etanercept therapy. This review illustrates the diverse conditions responsible for TNF-alpha-inhibitor induced psoriasis, the variable time prior to psoriasis development, and the most predominant forms of psoriasis. An analysis of the various therapeutic regimens applied may help provide guidelines for patient management.
J Drugs Dermatol. 2013;12(8):939-943.
Nicholas Golda MD, Shahrad M. Benham MD, John Koo MD
Recently, the biologics have emerged as a new class of drugs for systemic therapy of psoriasis with efalizumab (Raptiva®)
being one of the most recently FDA-approved agents. We report a case of a 34-year-old Caucasian male who experienced
psoriasis rebound during a 7-week lapse in treatment with subcutaneous efalizumab 0.8 mg/kg/week, which he had been using
for 4 weeks up to that point. The patient then restarted efalizumab, but his psoriasis continued to worsen causing him to be
admitted for Goeckerman day care. He rebounded again 4 weeks following his ultimate discontinuation of efaluzimab despite
intensive therapy with the Goeckerman regimen. This case is reported to highlight the recent findings that psoriasis
rebound, defined as psoriasis area and severity index (PASI) of 125% or greater or morphology change, has been associated
with both the use and the discontinuation of efalizumab.
Evelyn J. Cheung MD, Jaroslaw J. Jedrych MD, and Joseph C. English III MD
Until 2011, the standard-of-care therapy for patients with hepatitis C consisted of interferon and ribavirin. The recent advent of new targeted therapies against this virus has provided more options of treatment for infected patients. Sofosbuvir, a nucleotide inhibitor of hepatitis C virus (HCV) RNA polymerase, was recently approved by the US Food and Drug Administration in 2013. Various Phase 3 trials with sofosbuvir combination therapy have reported an incidence of rash between 7% and 18%. We here describe a case of sofosbuvir-induced erythrodermic pityriasis rubra pilaris-like drug eruption.
J Drugs Dermatol. 2015;14(10):1161-1162.
Sara K. Story MD,a Andrej A. Petrov MD,b and Larisa J. Geskin MD FAADa
Monoclonal antibodies (mAb) have become the standard of care for numerous diseases.
However, side effects including infusion and hypersensitivity reactions experienced by patients
continue to be a limiting factor in their use. In the therapy of cancer, treatment choices are
frequently limited and minimizing side effects of a life-saving or life-prolonging therapy becomes
of the utmost importance. We report the successful use of a rapid desensitization protocol in a
patient with NHL, treated with a novel antibody-drug conjugate, chimeric monoclonal antibody linked
to the antimitotic agent monomethyl auristatin E (MMAE) Brentuximab vedotin, who had previously
developed a hypersensitivity reaction.
J Drugs Dermatol. 2014;13(6):749-751.
E. Ladoyanni MD, R. Nambi MD
Interferon-alpha can exacerbate existing psoriasis and induce de novo psoriasis and psoriatic arthritits. The exact underlying mechanism
is not very well understood. It is not a contraindication to treat patients with pre-existing psoriasis with interferon-alpha.
In these patients interferon-alpha should be used with care and only if the potential benefits justify the potential risk.
Control of psoriasis prior to initiation of interferon-alpha and simultaneous antipsoriatic therapy while on interferon-alpha are
essential. We would like to report a 61-year-old male patient with stable psoriasis for over 20 years, who experienced exacerbation
of his psoriasis after receiving interferon-alpha for chronic myeloid leukemia. The association between the interferon-alpha therapy
and the exacerbation of his psoriasis was only recognized on rechallenge at the stage he was referred to our department.
Androgenetic alopecia is the progressive miniaturization of the scalp’s terminal follicles in aging men. Over 40% of Caucasian men develop
hair loss by the age of 40. Despite its prevalence, there are only two FDA approved medications to treat the condition. Recognizing
the unmet need, new medical, procedural, and surgical treatments are being adopted to combat progressive hair loss. This review examines emerging hair loss treatments including medical therapies that the target prostaglandins, low level light therapy, platelet rich plasma injections, and robotic hair transplantation.
J Drugs Dermatol. 2015;14(9):1036-1040.
Jeffrey M. Weinberg MDa and Evelyn K. Koestenblatt MS MTa
The treatment of cutaneous fungal infections has been shown to be directly affected by the extent of patients' adherence to therapy regimens that are often cumbersome and last for several weeks. One useful alternative approach is once-daily dosing of topical antifungal
agents rather than the traditional twice-daily regimen, an example of what has been called a “forgiving” regimen, designed to promote patient adherence. Sertaconazole, an imidazole antifungal agent, is known to be safe and effective when used twice daily in the treatment of tinea pedis. This report discusses a small (n=32) clinical trial designed to determine whether sertaconazole nitrate 2% cream, used once daily, is as effective as the traditional regimen. Results demonstrated that sertaconazole is as effective when used once daily for four weeks. Patients showed rapid improvement in pruritus as early as week 2, and at six weeks' follow up, all patients were free of erythema while 93.8 percent were free of pruritus; no relapses had occurred. These encouraging findings suggest that sertaconazole nitrate may be useful in a once-daily regimen and also may result in better patient adherence to therapy.
J Drugs Dermatol. 2011;10(10):1135-1140.
Acne is a very common skin disease; frequently seen in adolescents and often persisting or occurring into adulthood. Topical therapy is very effective in mild to moderate disease, and is used as maintenance therapy. Fixed combination products have been studied in moderately severe disease. Combinations of benzoyl peroxide and either clindamycin or adapalene appear very effective. When utilizing a topical retinoid alone or in combination, it is essential to incorporate an appropriate skin care regimen to minimize local irritation. In the absence of direct comparative clinical trials, this review provides timely guidance for clinicians on the use of these agents, and their benefits in special populations.
J Drugs Dermatol. 2015;14(6):567-572.
Ashley Delacerda MD, Jason S. Reichenberg MD, and Michelle Magid MD
Department of Dermatology, University of Texas Southwestern, Austin, TX
Delusions of parasitosis (DOP) is a somatic subtype of delusional disorder, also known as monosymptomatic hypochondriacal psychosis.
The management of DOP has been discussed extensively in the medical literature. Patients with suspected DOP have a broad differential
diagnosis, including skin-based or systemic medical conditions and several kinds of psychiatric disease. However, there are many patients
who have been labeled with DOP but do not meet the diagnostic criteria or who present with additional somatic complaints. These cases
are a unique therapeutic challenge for dermatologists and psychiatrists alike and have not been thoroughly studied or reported. We present
a patient referred for DOP who benefited substantially with antidepressant therapy.
J Drugs Dermatol. 2012;11(12):1506-1507.
Emily M. Berger BA, Hassan I. Galadari MD, Alice B. Gottlieb MD PhD
Bell’s palsy is an acute facial paralysis of unknown etiology. Infections including syphilis have been implicated as causes
for peripheral facial paresis. The Jarisch-Herxheimer reaction is an acute worsening of skin manifestations and systemic
symptoms occurring after administration of antimicrobial therapy for spirochetal infections. Although rare, neurological
signs can present as part of the Jarisch-Herxheimer reaction. The authors report a case of Bell’s palsy experienced by a
patient shortly after treatment with penicillin for secondary syphilis and propose that this acute unilateral peripheral facial
paralysis was a Jarisch-Herxheimer reaction in response to therapy.
BACKGROUND: Acne vulgaris is a common, chronic skin disease that requires long-term therapy. Oral antibiotics are a mainstay of treatment, but extended use is associated with the development of bacterial resistance. Topical therapies are often combined with oral antibiotics to achieve an initial improvement, after which the oral agents may be discontinued and the topical therapy used as maintenance.
OBJECTIVE: To assess the safety and efficacy of combination therapy with dapsone 5% gel with oral doxycycline hyclate 100mg, followed by monotherapy with dapsone 5% gel in improving and maintaining response in patients with moderate to severe acne.
METHODS: In this open-label study, all patients applied dapsone 5% gel twice daily along with doxycycline hyclate 100mg once daily for 12 weeks. Subjects who achieved a qualifying improvement at week 12 continued to the second phase of the study in which they applied only dapsone 5% gel twice daily for maintenance therapy of 12 more weeks. Subjects were evaluated for safety and efficacy at weeks 4, 8, 12, 16, 20, and 24.
RESULTS: All subjects (n=30) in the initial phase qualified to enter the maintenance phase. 82% of participants maintained their treatment response (Investigator’s Global Assessment score) at week 24. The regimen was safe and well tolerated.
CONCLUSIONS: The combination oral doxycycline hyclate 100 mg with topical dapsone 5% gel twice daily is an effective and well-tolerated regimen to treat moderate to severe acne vulgaris. After discontinuation of doxycycline, topical dapsone 5% gel is effective at maintaining a therapeutic response. These data suggest that topical dapsone 5% gel can be used effectively for long-term acne maintenance treatment without the risk of developing antibiotic resistance.
J Drugs Dermatol. 2016;15(2):191-195.
Sapna Modi BA, Mandy Harting MD, Theodore Rosen MD
No abstract details for the moment.
Jamie Rosen BA, Angelo Landriscina BA, and Adam J. Friedman MD
No abstract details for the moment.
Jayashri V. Ghate MD and Carrie D. Alspaugh MD FAAD
Palmoplantar pustular psoriasis (PPP) is an uncommon form of chronic psoriasis. Characterized by sterile, intra-epidermal pustules located
on the palms and soles, it is highly resistant to treatment. A patient presented with palmar inflammation and throbbing joint pain
in his hands, as well as erythematous, pustular, and micaceous scaling skin on his right foot, legs, elbows and hands. Approximately
4% of his body surface area was involved, and he was diagnosed with PPP after skin biopsy. After conventional therapy failed, the
patient underwent treatment with adalimumab and the majority of his symptoms resolved after 16 weeks of therapy. Adalimumab
may be effective for the treatment of PPP. Adalimumab, a fully human, immunoglobulin G1 monoclonal antibody that binds to tumor
necrosis factor, has been approved for the treatment of moderate-to-severe psoriasis, in the U.S., Europe and elsewhere.
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
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.
Hatice Sanli MD, Sebnem Ataman MD, Bengü Nisa Akay MD, Ahmet Yιlmaz MD, Derya Yιldιzlar MD, Erbak Gürgey MD
Immunosuppressive therapies, in particular cyclosporine, are known to induce the development of lymphoproliferative
malignancies. In general, the lymphomas that occur in the setting of impaired immune function are B cell non-Hodgkin’s
lymphomas, often large cell lymphomas. Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphomas,
which can require persistent antigen and superantigen stimulation by way of chronic immunosuppression and HIV. Tumor
necrosis factor antagonists, which are novel immunomodulatory agents, might produce significant adverse effects, including
an increased risk of malignancy. Currently available data do not show whether these agents were the proximate cause of
the reported lymphomas. We present a 32-year-old male with ankylosing spondylitis treated with infliximab who developed
MF during the second year of therapy.
Andrea L. Zaenglein MD,a Ava Shamban MD,b Guy Webster MD PhD,c James Del Rosso DO FAOCD,d Jeffrey S. Dover MD FRCPC,e Leonard Swinyer MD,f Linda Stein MD,g Xiaoming Lin MS RN,h Zoe Draelos MD,i Michael Gold MD,j and Diane Thiboutot MDa
BACKGROUND: Moderate to severe acne vulgaris is often treated with a combination of an oral antibiotic, topical antibiotic/retinoid, and benzoyl
peroxide (BP), but data are limited on the efficacy of this and other combination regimens that incorporate both oral and topical therapies.
METHODS: Patients were required to be aged 12–30 years with moderate to severe acne (grades 3–4 acne on the Investigator's Global
Assessment [IGA]) and deemed potential candidates for treatment with isotretinoin. Enrolled patients were given triple-combination
therapy, defined in this study as oral minocycline HCl extended release 1 mg/kg QD, 6% BP foaming cloths used QD, and clindamycin
phosphate 1.2%/tretinoin 0.025% gel applied QD, and were evaluated at baseline and weeks 2, 4, 8, and 12.
RESULTS: A total of 97 patients were enrolled in the study. At week 12, 89% of patients had at least a one-grade improvement from
baseline IGA and 96% had at least a one-grade improvement from baseline Global Aesthetic Improvement Scale score. Mean±SD in-
flammatory, non-inflammatory, and total lesion counts decreased from baseline by 61.8%±38.3%, 48.8%±34.5%, and 56.5%±29.9%,
respectively. The percentage of patients evaluated as candidates for isotretinoin by independent photographic review was 77% (69/90)
at baseline and only 16% (14/90) at week 12. Treatment-related adverse events (AEs) occurred in eight of 97 (8%) patients. Triplecombination
therapy was not associated with any serious AEs or AEs leading to discontinuation.
CONCLUSION: Triple-combination therapy was well tolerated and substantially reduced facial acne lesion counts, with 84% of patients
judged to no longer be candidates for isotretinoin therapy by study end. These data support the clinical observation that a triple-combination
regimen incorporating oral minocycline (dosed by patient weight), BP foaming cloths 6% QD, and clindamycin phosphate 1.2%/
tretinoin 0.025% gel QD can substantially improve moderate to severe acne vulgaris.
J Drugs Dermatol. 2013;12(6):619-625.
Adolfo C. Fernandez-Obregon MD
Although the precise pathogenesis is not known, vitiligo appears to be an autoimmune disease involving T cell-mediated
melanocyte destruction. Efalizumab, a recombinant, humanized monoclonal antibody, targets T cells, the key mediators
of the immunopathogenesis of psoriasis. Although a concomitant presentation of vitiligo with psoriasis is uncommon, several
cases have been reported previously in the literature. A case of a patient with vitiligo and psoriasis who was treated
with efalizumab to alleviate the symptoms of psoriasis is described. Over the course of the diseases, the patient had been
treated unsuccessfully with numerous therapies. The patient initiated efalizumab with a 0.7 mg/kg conditioning dose and
then continued on 1 mg/kg weekly. After 2 months of efalizumab therapy, the psoriasis symptoms were reduced, and the
vitiligo had visibly improved in some areas. The patient has remained on efalizumab therapy with no evidence of an exacerbation
of vitiligo. The management of acute flares is also discussed. This case is illustrative of a patient with psoriasis
and vitiligo who was treated successfully with efalizumab.
Aditya K. Gupta MD PhD FRCPC,a Boni E. Elewski MD,b Ted Rosen MD,c Bryan Caldwell DPM,dd David M Pariser MD,e Leon H. Kircik MD,f Neal Bhatia MD,g and Antonella Tosti MDh
Recurrence (relapse or re-infection) in onychomycosis is common, occurring in 10% to 53% of patients. However, data on prevalence is limited as few clinical studies follow patients beyond 12 months. It has been suggested that recurrence after continuous terbinafine treatment may be less common than with intermittent or continuous itraconazole therapy, probably due to the fungicidal activity of terbinafine, although these differences tended not to be significant. Relapse rates also increase with time, peaking at month 36. Although
a number of factors have been suggested to play a role in recurrence, only the co-existence of diabetes has been shown to have a significant impact. Data with topical therapy is sparse; a small study showed amorolfine prophylaxis may delay recurrence. High concentrations of efinaconazole have been reported in the nail two weeks’ post-treatment suggesting twice monthly prophylaxis with topical treatments may be a realistic option, and may be an important consideration in diabetic patients with onychomycosis. Data suggest that prophylaxis may need to be continued for up to three years for optimal effect. Treating tinea pedis and any immediate family members is also critical. Other preventative strategies include avoiding communal areas where infection can spread (such as swimming pools), and decontaminating footwear.
J Drugs Dermatol. 2016;15(3):279-282.
Fractional resurfacing or laser therapy (FLT) represents a technology that seeks to address the limitations of both ablative
resurfacing and nonablative treatments. Many companies now offer versions of fractionated erbium or carbon dioxide
lasers. The purpose of this paper is to examine FLT for difficult to treat applications such as melasma, acne scarring,
atrophic scarring, striae distensae, and deep rhytides. Fractional laser therapy is a truly novel approach to many conditions,
especially those with dermal pathology. Although published peer review data is limited, the ability to effectively
and safely treat these conditions in all skin types appears to have been significantly enhanced with this new modality.
We are early in our scientific explorations of what is possible with FLT.
James M. Swinehart MD
Problem: Surgical therapy of moderate or severe acne scars in African-Americans, Hispanics, and other individuals with
darkly pigmented skin.
Challenges: Dyspigmentation in more darkly complected individuals following surgical or resurfacing operations creates an
additional risk in an already difficult series of procedures. Other challenges include the lack of response of deep acne scars
to lasers in general, the unpredictability of various techniques, and the long learning curve involved with dermabrasion.
Methods: Case reports are presented in which chemical peeling, punch grafting, punch elevation, subcision, dermal grafting,
and wire brush and diamond fraise dermabrasion were employed in one Hispanic and one African-American patient.
Results: A satisfactory outcome was attained in each patient.
Nawaf Al-Mutairi MD FRCP, Arun Joshi MD, Amr Zaki MD, Ashok Kumar Sharma MD DNB, Osama Nour-Eldin MSc
A 54-year-old male presented with a sudden generalized eruption of itchy violaceous papules, annular plaques, superficial vesicles,
and erosions involving his trunk, limbs, oral cavity, and genitalia. The biopsy showed features of lichen planus (LP). Direct and
indirect immunofluorescence (IF) was negative. Systemic treatment with oral corticosteroids in the form of 10 tablets of
betamethasone 0.5 mg in a single dose was given after breakfast on 2 consecutive days every week. Complete arrest of progression,
control of itching, and flattening of lesions was achieved within 3 weeks allowing tapering of the dose of corticosteroid by 0.5 mg
every 2 weeks over next 10 weeks. No side effects of corticosteroid therapy were noted and the patient is in remission.
Summer D. Moon BS a and James M. Spencer MD MS b
A 93-year-old woman presented with biopsy-proven invasive melanoma of 2.75 mm depth, arising from a melanoma in situ. Standard treatment of this depth would be an extensive and mutilating excision, which presented a therapeutic dilemma. Imiquimod has the ability to clear melanoma in situ, but its effect on invasive melanoma is unknown. After a thorough discussion with the patient, we decided to attempt to treat the melanoma in situ with topical imiquimod and then excise the smaller invasive component. Following 5 weeks of topical imiquimod therapy, the area where the nodular melanoma had previously been was excised. Histological examination of the excisional specimen revealed no residual melanoma detected. In this case, it appears that 5 weeks of topical imiquimod therapy completely cleared an invasive melanoma of 2.75 mm depth, as well as clearing the component of melanoma in situ. The patient was followed for 14 months with no evidence of recurrence.
J Drugs Dermatol. 2013;12(1):107-108.
Isabel Hernandez Garcia MD
The author presents the case of a 27-year-old man who suffered 2 episodes of erythroderma while on therapy with efalizumab for
psoriasis. The ﬁ rst episode, occurred 2 weeks after the ﬁ rst dose, was well controlled without discontinuing the drug. A second eryth-
rodermic ﬂ are was observed after 4 weeks following efalizumab reintroduction. In this case, oral methotrexate was administered as
monotherapy during 4 months, and then was tapered off and efalizumab again reintroduced for continuous treatment for a period
14 months with excellent results. This second episode of erythroderma was clinically accompanied by a marked hyperkeratosis,
blepharitis, and nasal infection due to Staphylococcus aureus. Lymphocytosis and leukocyturia with negative urine culture were
also reported in both episodes. As a result, it was concluded that the erythroderma was an adverse reaction to efalizumab that could
be solved without treatment discontinuation. The author considered this patient as a good responder to continuous treatment with
James Q. Del Rosso DO FAOCD
Oral isotretinoin is a non-aromatic oral retinoid that is highly effective for the treatment of severe inflammatory acne vulgaris that is
refractory and/or prone to scarring, and has also been used successfully to treat several other disorders in selected cases. Since its
introduction into the United States marketplace in 1982, it has been well recognized that cutaneous side effects characterized by
xerotic and desquamative changes are very common, and appear to be related to epidermal dyscohesion, and to some extent the
sebosuppressive effects of the drug. Additionally, increased susceptibility to staphylococcal colonization has also been observed.
The epidermal barrier impairments that have been associated with oral isotretinoin are reviewed in this article along with clinical
implications. Strategies to mitigate the altered effects of epidermal barrier functions are reviewed including the importance of topical
barrier repair therapy.
J Drugs Dermatol. 2013;12(6):626-631.
Background: Tumor necrosis factor inhibitors are valuable tools for dermatologists. As their use increases, rare adverse events are more likely to be encountered.
Objective: We describe one patient who developed sarcoidosis while being treated for psoriasis with etanercept. We sought to review to previously reported cases and further characterize the nature of this reaction.
Methods: A literature search was performed with the key words "sarcoidosis, sarcoid, etanercept, infliximab, adalimumab, granulomatous, and drug reaction." All relevant cases in the English language were included and evaluated for demographic data, duration of therapy prior to developing sarcoid, duration of sarcoid signs/symptoms, treatments used and time to resolution after discontinuation of the drug.
Results: Including the present case, there are 34 cases of sarcoidosis developing during anti-tumor necrosis factor therapy. All previously reported cases were patients with a primarily rheumatologic diagnosis. In all but one case, discontinuation of the drug resulted in complete resolution of symptoms. The lung and surrounding lymph nodes were the areas most commonly affected. The average amount of time between initiation of therapy and onset of symptoms was 22 months. The average time to resolution of symptoms after discontinuation of the drug was 5.2 months.
Limitations: This is a retrospective case review.
Conclusions: These data indicated that sarcoid is a possible adverse effect of tumor necrosis factor inhibitor therapy that should be noted by dermatologists using these drugs. While it has been reported in the rheumatology literature, it may be under-recognized by dermatologists.
J Drugs Dermatol. 2012;11(5):609-612.
Rebecca G. Pomerantz, Elinor Mody MD, M. Elaine Husni MD MPH, and Abrar A. Qureshi MD MPH
Psoriatic arthritis (PsA) is a chronic inflammatory joint disease associated with psoriasis. Arthritis mutilans is a rare clinical form of PsA
in which osteolysis and destructive changes in the joints lead to irreversible deformity and loss of function. This paper describes three
patients with psoriatic arthritis mutilans who were followed for up to two years and received treatment with etanercept, a TNF-alpha
targeting agent that is used to treat PsA and psoriasis. Although these patients experienced significant joint and skin improvement
with etanercept therapy, they retained lasting deformities from years of progressive disease. In order to prevent permanent joint
damage, early recognition and treatment of PsA are critical. This highlights an important role for dermatologists in identifying early
joint symptoms that may be suggestive of PsA in patients with psoriasis.
Sophie Seité PhD,a Florence Benech PharmD,b Sandrine Berdah PhD,b Muriel Bayer PharmD,b Sophie Veyrat PharmD,b Evelyne Segot PharmD PhD,b Marcela Sakalikova Mgr,c Lucia Gibejova Mgr,c Hana Zelenkova MD PhDc
OBJECTIVE: The objective of these studies was to investigate whether a skincare product containing Ambophenol, Neurosensine, and La Roche-Posay thermal spring water formulated in a highly protective packaging can have an impact in the management of rosacea-prone skin subjects.
METHODS: Several studies were performed to evaluate the efficacy of this product in the management of rosacea prone skin, as either monotherapy or adjunctive therapy or to maintain the efficacy of a Metronidazole treatment. The first study was performed on 37 women aged 18-45 with added stage 2 erythro-couperosis, who applied test formula as monotherapy twice a day for 4 weeks. During a second study, a dermatological evaluation was performed on patients with stage I or II rosacea, a questionnaire containing information about patient characteristics, tolerance, clinical signs, symptoms and skin reactivity to “trigger factors” was completed by dermatologists at baseline and 2 months after treatment with the test formula as either monotherapy or adjunctive therapy. Finally, in a third study, 65 patients finishing a Metronidazole treatment applied once daily and the tested formula twice daily were divided into 2 groups using the test formula or vehicle control, twice a day for 8 weeks for the evaluation of efficacy as adjunctive therapy.
RESULTS: We noted that the test formula, as an adjunctive therapy, helped prolong the efficacy of a Metronidazole treatment. In monotherapy, there was a significant efficacy of the test formula associated with an excellent tolerance. A significant improvement of all the clinical signs and symptoms of rosacea and a reduction of the skin reactivity to "trigger factors" were shown.
CONCLUSIONS: These studies highlight the interest value and impact of a skincare product containing Ambophenol, Neurosensine, and La Roche-Posay thermal spring water formulated in a highly protective packaging in monotherapy or in combination with or after a therapeutic treatment in the management of patients suffering from rosacea.
J Drugs Dermatol. 2013;12(8):920-924.
Lauren A. Smith MD, Shane A. Meehan MD, and David E. Cohen MD MPH
Rosacea fulminans, previously known as pyoderma faciale,
is a rare disease occurring almost exclusively in young women
characterized by the sudden eruption of coalescing papules and pustules,
and large cystic nodules limited to the face. Patients generally respond
well to standard therapy consisting of systemic isotretinoin in combination
with topical and systemic corticosteroids. Lesions usually resolve with
minimal scarring with appropriate management. We describe an elderly male
patient with extrafacial rosacea fulminans successfully treated with daily
subantimicrobial (40mg) dose doxycycline (SDD). To our knowledge, this is
the first report of rosacea fulminans with extrafacial lesions in an elderly male.
We suggest that SDD may be a safe and effective alternative, particularly for those unable to tolerate standard therapy.
J Drugs Dermatol. 2014;13(6):763-765.
Aditya K. Gupta MD PhD FRCP(C), Elizabeth A. Cooper HBSc BESc, Jenna E. Bowen MSc
Despite its long history in clinical use, reported efficacy rates of griseofulvin remain highly variable. A meta-analysis of
clinical trials of griseofulvin use in tinea capitis was performed to determine mean griseofulvin efficacy. A review of the
literature identified 7 studies. When all 7 studies were pooled, the overall mean effective cure (negative KOH and culture)
of griseofulvin at 4 to 6 weeks posttreatment was 73.4%±7% (7 studies, n=438 patients). Higher efficacy rates appeared
to be reported with the use of higher dosages of griseofulvin (>18 mg/kg/d). When broken down by species, the
mean efficacy for Trichophyton and Microsporum were 67.6%±9% (5 studies, n=396) and 88.1%±5% (2 studies, n=42
patients), respectively. Based on these studies, griseofulvin efficacy has remained consistently high over the past decade.
Both genera showed good efficacy with griseofulvin therapy given from 6 to 8 weeks. Griseofulvin remains an effective
therapy for tinea capitis.
Joanna L. Chan, AB; Linda Davis-Reed, MD and Alexa Boer Kimball, MD, MPH
Atopic dermatitis has been characterized as an autoimmune or auto-allergic phenomenon in which environmental allergens resembling
human proteins activate auto-reactive T-cells to release pro-inflammatory cytokines of the T-helper 2 (Th2) cytokine profile
(IL-4, IL-5, IL-10, and IL-13)1-3. Infliximab is a chimeric IgG1 monoclonal antibody that blocks the effects of the inflammatory
cytokine tumor necrosis factor (TNF)-?. Infliximab has been shown to benefit greatly patients suffering from diseases associated with
a Th1 profile (IL-1, TNF-?, and IFN-?), such as psoriasis, Crohn’s disease and rheumatoid arthritis4-8. Some researchers have suggested
that disrupting the Th1-Th2 balance by downregulating Th1 cytokines may result in manifestations of Th2 disease. Consistent
with this hypothesis, we present the cases of three patients who exhibited vivid manifestations of atopic dermatitis after the inception
of infliximab induction therapy.
Given the multifactorial and complex contributors to acne development, combination therapy is standard of care. By addressing multiple pathogenic factors, combination therapy provides a quicker and more efficacious treatment outcome than monotherapy. Topical retinoids normalize follicular keratinocyte differentiation and are anti-inflammatory. Their use is limited by the potential for cutaneous irritation. Antimicrobials reduce Propionibacterium acnes colonization on the skin and reduce the bacteria's proinflammatory effects. Topical antibiotics and benzoyl peroxide (BPO) are commonly employed in fixed-dose combination products or two separate medications. BPO has the added benefit of being comedolytic and can minimize the risk for bacterial antibiotic resistance. Like topical retinoids, BPO may cause skin irritation, burning, erythema, and peeling. Managing cutaneous side effects when using multiple products that cause irritation can be a challenge. Careful product selection, dose titration, and patient-directed regimens can help to optimize outcomes. This review presents the latest data on two topical acne products that have demonstrated excellent efficacy and tolerability profiles. In addition, their in vitro profiles suggest the potential for combination use, affording greater dosing flexibility.
J Drugs Dermatol. 2012;11(3):313-317.
Nikki Vyas BS,a Nishit S. Patel MD, band George F. Cohen MDb
Pemphigus vulgaris (PV) is a life-threatening autoimmune bullous disorder. Although systemic corticosteroids are the standard treatment for PV, efficient transition to a steroid-sparing immunosuppressant is critical. There is significant debate in the literature as to what the optimal, first-line steroid-sparing agent should be in patients with PV. Mycophenolate mofetil (MMF), in particular, is a promising agent that should be strongly considered as a first-line steroid-sparing agent. The authors review treatment options for PV and describe a severe case treated successfully with prednisone and MMF as a first-line steroid-sparing agent. The patient's clinical improvement was rapid, and all PV lesions completely resolved. The dosage of prednisone was safely tapered using MMF, and the patient did not experience any flares or significant side effects during the course of treatment. Therapy for PV with systemic corticosteroids and MMF therapy was effective and well tolerated.
J Drugs Dermatol. 2013;12(2):210-216.
Heather Ciliberto MD,a Arta Farshidi MD,b David Berk MD,b and Susan Bayliss MDa
BACKGROUND: Current treatment options for keratosis pilaris (KP) are limited and are often found to be unsatisfactory to patients.
OBJECTIVE: Pilot study to determine if photopneumatic therapy (PPx) can improve the erythema and skin texture in KP.
METHODS: Ten patients with KP were treated with one session of PPx on the upper arm and then evaluated one month later for treatment efficacy.
RESULTS: Average investigator-assessed improvement was 27% in erythema and 56% in skin texture roughness. Average patient self-reported improvement was 52% in erythema and 53% in skin texture. The mean satisfaction score was 6.3 on a scale of 1 to 10 (median 7.5) and 8 out of 10 participants reported they would choose to receive PPx for their KP again in the future.
LIMITATIONS: Small number of patients, short follow-up period, and lack of blinding of the examiner and the patients making recall bias possible.
CONCLUSIONS: One treatment of PPx improved both the erythema and redness associated with KP over at least a one month period.
J Drugs Dermatol. 2013;12(7):804-806.
Aim: Despite a mostly self-limiting course, infantile hemangiomas can cause severe functional and/or cosmetic problems. The aim of this
study was to determine the efficiency of propranolol treatment on infantile hemangiomas.
Methods: Sixty-seven infantile hemangioma patients were included in propranolol protocol in two institutions from 2009 to 2011. Participants
included 36 boys and 31 girls. An associate protocol with radiology and pediatric cardiology was constructed for appropriate patient
selection. Patients received a dose of 2 mg/kg/day, and all were admitted for the first 24 hours of therapy.
Results: Sixty-seven patients were included in the study. Mean age at the initiation of therapy was 7 months (1 to 24 months), and eleven
patients were older than 12 months of age when propranolol was started. All patients showed improvement with varying responses. No
side effects were detected during the treatment.
Conclusion: Previously defined treatments for hemangiomas were efficient, yet had a limited usage because of side effects. Propranolol,
with a high efficacy (not as total involution but stabilization and regression) and feasibility deserves to be the first line therapy for infantile
hemangiomas even after the proliferation phase.
J Drugs Dermatol. 2012;11(7):808-811.
Vineet Mishra MDa, Ralph C. Daniel MDb, Craig A. Elmets MDa, Anna Levin MDc, and Boni E. Elewski MDa
No abstract details for the moment.
Richard W. McClain BS, Brad A. Yentzer MD, Steven R. Feldman MD PhD
Background: Topical corticosteroids are often considered to have greater safety and poorer efficacy than oral corticosteroids in
treating psoriasis and atopic dermatitis. There are limited data for assessing relative efficacy of topical and systemic corticosteroids,
however. The concentration of corticosteroid in skin, adjusted for the relative potency of the active compound, may be a predictor of
clinical efficacy and can be estimated for both topical and oral administration.
Purpose: To analyze the assumption that oral corticosteroid therapy should be more potent than topical therapy by comparing relative
corticosteroid concentrations in the skin expected with topical versus systemic administration.
Methods: The estimated skin concentration of prednisone following oral dosing was calculated based on data showing 70–100%
bioavailability and an even tissue distribution. Data on the concentration of corticosteroids found in skin after topical application were
obtained from the literature. The relative potencies of corticosteroid molecules were then used to compare skin concentrations of
corticosteroid following topical versus oral treatment.
Results: Data derived from the existing literature demonstrated that hydrocortisone 2.5% ointment, triamcinolone 0.1% ointment,
and clobetasol 0.05% foam achieved effective skin concentrations greater than the effective concentration achieved by oral prednisone.
Betamethasone 0.1% cream achieved effective concentrations in skin within the range created by oral prednisone.
Limitations: This analysis was limited by the paucity of data regarding cutaneous concentrations of corticosteroids after topical application,
and by the differing experimental designs utilized in the available studies.
Conclusion: Most topical corticosteroids have the potential to achieve greater effective drug levels in the superficial layers of skin
than those achieved with standard doses of oral prednisone. The apparently greater efficacy of oral corticosteroid therapy may be
attributable, in part, to poor patient compliance with topical therapy. Systemic alterations in immune function following oral, but not
topical, corticosteroid use may also play a role.
Aditya K. Gupta MD PhD FAAD FRCP(C), Michael Uro DPM, Elizabeth A. Cooper BESc HBSc
Methods to treat onychomycosis are varied, using therapies that can be categorized as topical, oral or device-related. Since their
development, oral therapies have represented the gold standard for treatment over other methods. However, efficacy with oral therapies
remains limited, and safety may be an issue, leaving many patients requiring alternative treatments. With research advances,
topical therapies as alternatives for onychomycosis are being investigated with greater interest as new technologies are overcoming
previous limitations of topical treatments, such as lack of nail penetration. New device-related topical therapy methods are particularly
noteworthy, as they may allow for shorter, more convenient treatments for patients, reducing issues with topical compliance, and, in
cases of non-drug light-based therapies, they will avoid potential for drug reactions. Research in these fields is preliminary, and the
impact these methods may have on the future of onychomycosis remains to be seen.
Antonio Rusciani MD, Angela Motta MD, Luigi Rusciani MD, Carmine Alfano MD
Melasma is a common disorder of hyperpigmentation involving sun exposed face and neck areas. Three clinical patterns
of melasma are recognized: the centrofacial, the malar, and the mandibular ones. Several factors have been implicated
in the pathogenesis of this disorder including pregnancy, oral contraceptive therapy, sun exposure, genetic factors,
cosmetics, and race.1 This condition is most frequently observed in women and affects all racial groups; however,
it is commonly found in darker-complexioned individuals (skin types IV through VI) and in Asian women who live
and work under strong sunlight exposure for long periods. Melasma is very difficult to treat and often resistant to therapy.
Treatment of melasma includes various hypopigmenting agents, chemical peeling, and laser surgery with unsatisfactory
results. We report 3 cases of facial melasma successfully treated with a Q-switched Alexandrite laser.
Adam J. Mamelak MD, Adrianna Jackson MD, Rabia Nizamani BS, Ofer Arnon MD,Nanette J. Liegeois MD PhD, Richard J. Redett MD, Patrick J. Byrne MD
Background: Over the ages, the use of leeches in medicine has evolved from haphazard bloodletting to a well-understood physiologic
process with defined, rational applications.
Objective: The authors describe the current role of leech therapy in cutaneous surgery and medicine.
Methods: Case series and review of the literature.
Results: Leech saliva contains anticoagulative, anti-aggregative and vasodilatory components. Combined with the annelid’s mechanical
ability to extract blood, leeches can contribute to patients’ health with minimal risks.
Conclusion: Leeches should be considered as novel therapies for disorders of coagulation and venous congestion. Implementation
of leech treatment should be tempered with the potential adverse effects, including Aeromonas infection and a drop in hematocrit
that might require a blood transfusion.
Anthony J. Chiaravalloti MDa and Bruce E. Strober MD PhDb,c
For nearly 5 decades, methotrexate has been the backbone of moderate-to-severe psoriasis treatment. The benefits of methotrexate
therapy include reliable efficacy, low cost, relative ease of administration, and its usefulness as part of combination therapy regimens,
making it a drug of choice for treating psoriasis. While methotrexate can be administered orally, intravenously, or intramuscularly, the
self-administered subcutaneous use of the drug is the most advantageous route. Subcutaneous methotrexate is associated with fewer
adverse events and higher absorption rates, accompanied by bioavailability that is both linear and predictable throughout the range of
possible doses. In addition, the subcutaneous route, when compared with oral administration, facilitates improved efficacy by
promoting higher intracellular levels of long-chain methotrexate polyglutamates. Taken together, these features allow patients the
highest probability of a successful therapeutic experience. Subcutaneous methotrexate should be considered a viable option for the
appropriate patient with moderate-to-severe psoriasis.
J Drugs Dermatol. 2014;13(8):929-931.
Background: Etanercept has been used to treat chronic plaque psoriasis. Previously reported data demonstrated that some patients experienced secondary failure and frequently rotational-switch therapy is used. The re-treatment with etanercept as part of the rotational therapy could be considered as another safe and efficient therapeutic approach.
Objective: To evaluate the efficacy of the re-treatment with etanercept in patients with a history of etanercept use with good response and secondary loss of efficacy.
Methods: This is an open label prospective study involving 20 patients with moderate to severe plaque psoriasis, who had been initially treated with etanercept and were re-treated after a variable interval with 50 mg BIW for 12 weeks.
Results: At week 12 of etanercept re-treatment, 13 of 20 patients (65%) achieved a PGA score of 2 or less and 40% (8 of 20), achieved a PGA score of 0 to 1. Etanercept was well tolerated and no serious adverse events were reported.
Limitations: Our study involved a small number of patients. Failure of etanercept was establish by patient's history. However we were able to correlate such failure from our medical records in 17 patients.
Conclusions: Re-treatment with etanercept, after secondary loss of efficacy should be considered in patients with psoriasis if satisfactory therapy cannot be achieved with other therapeutic regimens.
J Drugs Dermatol. 2012;11(8):950-954.
Emi Dika MD, Alessia Barisani MD, Sabina Vaccari MD, Pier Alessandro Fanti MD, Alma Ismaili MD, and Annalisa Patrizi MD PhD
No abstract details for the moment.
Soheil Simzar BS, Adam M. Rotunda MD, Noah Craft MD PhD
Induction therapy with all-trans-retinoic acid (ATRA), an oral vitamin A derivative, has been shown to improve the short and
long-term outcome of patients with acute promyelocytic leukemia (APML). Common side effects include headache, fever, dry
skin, and bone pain, and approximately 25% of treated patients experience ATRA syndrome, which includes fever, dyspnea,
weight gain, pulmonary infiltrates, and pleural or pericardial effusions. Scrotal ulcerations due to ATRA are rare with 16 previously
documented cases, most of whom were Asian. We report a Caucasian male with APML who developed scrotal ulceration
during ATRA induction therapy and review the previously reported cases. Physicians and patients should be aware of this disturbing, but self-limited, determatologic complication AFTRA.
Background: While randomized, controlled trials have generated information about the safety and efficacy of imiquimod 5% cream in
the treatment of actinic keratosis, still very little is known about the challenges and pitfalls of this therapy in the daily clinical routine.
Objective: To mirror the full picture of the actinic keratosis imiquimod routine therapy, ie, patient profile, in-therapy decisions,
tolerability, and satisfaction.
Methods: The present observational, multicenter study included 463 patients from the offices of 93 non-hospital based Austrian
dermatologists. Inclusion was solely based on the treatment decision of the dermatologist and the patient's will to participate.
There were no specific interventions except suggested time points of visits with pre-defined documentation forms.
Results: The typical actinic keratosis patient was a male, aged 74 years, with a disease history of 5.7±5.3 years, who presented
with 8.4±8.0 multiple pre-treated lesions at the face. More than 95% of the patients developed therapeutic skin responses (dominated by erythema and crusting), which led to a significant reduction of lesions from baseline to the end of the therapy. Notably,
one-third of those patients prone to a second therapeutic course were submitted to another form of treatment. Post-imiquimod
therapy comprised of antibiotic creams, topical steroids, and numerous emollients. Patients and dermatologists reported high
satisfaction with the therapy including the cosmetic outcome.
Conclusion: Our data show the high need for experience at the dermatologist side and information at the patient side. Moreover,
the method of treatment for imiquimod-related skin reactions definitively asks for standardization.
The study was registered at ClinicalTrials.gov (NCT01151956). Decision by ClinicalTrials.gov: Federal University Teaching Hospital,
Feldkirch, Austria Protocol Record OBIMQ465-AK-08, Imiquimod and actinic keratoses: an observational study.
J Drugs Dermatol. 2012;11(5):574-578.
Kristen Lo Sicco MD and Jo-Ann Latkowski MD
No abstract details for the moment.
Hilary Baldwin MD,a Diane Berson MD,b Maria Vitale MS,c Margarita Yatskayer MS,c
Nannan Chen PhD,c and Christian Oresajo MD PhDc,d
Rosacea is a condition most commonly characterized by central facial erythema and pupulopustules. There are highly effective drugs, both oral and topical, for papulopustular disease. At the present time, consistently effective pharmacologic therapy for erythematotelangiectatic rosacea is lacking. Patients whose papulopustular disease has been adequately treated are often still bothered by central facial erythema for which there is no adequate treatment short of laser and light. We present a study utilizing a novel topical composition evaluated for its ability to reduce background erythema remaining after adequate care of papulopustular disease. Patient, investigator and photographic evidence of erythema reduction was seen in 24/25 patients in this 8-week study.
J Drugs Dermatol. 2014;13(3):326-331.
Neal Bhatia MD,a Varsha Bhatt PhD,b Gina Martin MOT,b Radhakrishnan Pillai PhDb
Topical therapy of acne vulgaris (acne) is very common, however cutaneous tolerability can influence patient adherence, and concerns about skin irritation have lead to a number of comparative split-face studies. Advances in formulation technology have provided new fixed combinations with lower concentrations of potentially irritating ingredients without compromising efficacy. These developments now afford the opportunity to formulate fixed combinations with higher concentrations of active ingredients that may provide the greater efficacy needed in more severe disease with good tolerability.
Here, we compare the tolerability of two such developments, clindamycin-BP 3.75% gel and adapalene 0.3%-BP 2.5% gel, in healthy volunteers with no apparent facial redness or dryness over 21-days, using a split-face methodology.
Clindamycin-BP 3.75% gel was more tolerable than adapalene 0.3%-BP 2.5% gel over the duration of the two studies, with statistically significant differences in cumulative change from baseline starting as early as day 4 (stinging), day 5 (erythema, dryness, and scaling), day 6 (burning), and day 8 (itching); and in composite irritation index (stinging, erythema, dryness, scaling, burning, and itching) from day 4. Transepidermal water loss was less with clindamycin-BP 3.75% gel (statistically significant from day 8). Adverse events were twice as common with adapalene 0.3%-BP 2.5% gel.
These data suggest that clindamycin-BP 3.75% gel is likely to be better tolerated than adapalene 0.3%-BP 2.5% gel in moderate-to-severe acne.
J Drugs Dermatol. 2016;15(6):721-726.
Ern Loh MD PhDa and Gregory A. Hosler MD PhDa,b
Vemurafenib is a recently approved targeted therapy for advanced melanoma harboring the B-Raf valine-to-glutamate mutation at residue 600 (V600E). In many patients, the use of vemurafenib leads to a rapid onset of cutaneous neoplasms, including squamous cell carcinomas, keratoacanthomas, and benign keratoses. Paradoxical activation of the mitogen-activated protein kinase (MAPK) pathway by vemurafenib in the setting of RAS hyperactivation has been demonstrated in the laboratory and may account for the pathogenesis of some of these neoplasms. Activating RAS mutations have been discovered in vemurafenib-associated squamous cell carcinomas, but have not been reported in benign keratoses, which are a more common side effect that affects patient quality of life. Here, we report on the mutational analysis of RAS genes at known activating hotspots in verrucous keratoses from a stage IV melanoma patient undergoing vemurafenib therapy. The results lend genetic evidence to the current hypothesis for how some of these lesions develop and suggest potential strategies in the research on preventive and therapeutic measures.
J Drugs Dermatol. 2014;13(4):495-497.
Jennifer Soung MD, Wangui Muigai, Nilam Amin DO, Dana K. Stern MD, Mark G. Lebwohl MD
PUVA has become a common form of treatment for early stage mycosis fungoides (MF). The purpose of this retrospective
study was to review the clinical data of 51 MF patients (96% stage IA or IB) treated with PUVA at the Mt.
Sinai MF clinic over the past 20 years. We analyzed the efficacy, safety, and remission duration in patients who were
treated with a modified PUVA regimen. Forty-four of 51 patients (86%) achieved complete clinical clearing for all
stages after initial PUVA therapy. The mean duration of remission with maintenance treatment was more than 27
months (range: 3 weeks to 130 months). The mean duration of disease from start of first PUVA therapy for all patients
was 4.8 years (range: 0.7 to 130 months). PUVA for patients with early-stage MF is a safe and effective therapeutic
modality with prolonged disease-free remissions, however, PUVA alone was not adequate for more advanced disease.
Mark A. Strom BS,a Girish C. Mohan MD,b and Peter A. Lio MDa
Dermatologists frequently employ combination therapy to treat various diseases, but the evidence to support the use of such combinations is often lacking. Synergy is an appealing although somewhat ambiguous concept in medicine. Utilizing synergy allows clinicians to provide the most efficacious combination of treatments to patients, while potentially minimizing adverse effects and reducing the development of drug resistance. Definitions of synergy vary, but ultimately converge on finding a therapeutic advantage in combining treatments. Here we discuss the concept of ‘therapeutic synergy’, which can be defined as an increase in the efficacy of a combination of treatments in comparison to any of its individual parts alone. We review the concept of therapeutic synergy in dermatology by discussing some of the evidence regarding combination therapies utilized in the management of atopic dermatitis, acne vulgaris, psoriasis, and cutaneous lupus erythematosus. Further meaningful investigation of therapeutic synergy and its applications in dermatology should be undertaken.
J Drugs Dermatol. 2016;15(10):1203-1207.
Leon H. Kircik MD, Clive Liu MD, Bernard S. Goffe MD
Background: Efalizumab therapy and narrow-band ultraviolet B (NB-UVB) phototherapy have different mechanisms of action; com-
bined therapy may be more effective than either treatment alone in treating moderate to severe plaque psoriasis.
Methods: This study investigated the efﬁ cacy and safety of efalizumab (1 mg/kg/wk) combined with NB-UVB 3 times a week for 12
weeks, followed by efalizumab monotherapy for 12 additional weeks.
Results: Twenty patients were enrolled with mean Psoriasis Area and Severity Index (PASI) of 12.8±7.4, mean physician’s global
assessment (PGA) of 5±1, and mean body surface area (BSA) affected of 18.2%±15.3% at baseline. At week 12, 65% of patients
(n=13) achieved PASI 75; mean PGA was 2±1, corresponding to a 60% reduction; and mean BSA was 4.7%±4.1%, corresponding
to a 74% reduction. The improvements seen at week 12 were maintained during the ensuing efalizumab monotherapy.
Conclusion: Combination of efalizumab and NB-UVB followed by efalizumab monotherapy was effective and well tolerated, this warranting further investigation.
Background: 5-fluorouracil (5-FU) and imiquimod creams are accepted topical therapies for actinic keratosis (AK). Both are associated with a prolonged course of treatment with an inflammatory response that may preclude the treatment process. Objectives: To describe the treatment regimen and the extent of side effects in the use of the combined application of 5-FU and imiquimod creams in patients presenting with AKs and to demonstrate the convenience and ease of the methodology of this regimen. Methods: The patients applied 5-FU and imiquimod creams to their lesions daily for one week each month over the course of 3 months. The patients were seen after the completion of each one-week course to evaluate their progress and side effects. Results: There were 64 patients in the study, 48 of whom completed the study and demonstrated a clearing of their AKs by the end of the third course of treatment. All of the patients developed an inflammatory response at the sites of their AKs as well as at subclinical sites with no apparent AKs. Nearly all of these inflammatory reactions were confined to localized sites without involvement of the surrounding skin. Conclusions: Therapy with the combined application of 5-FU and imiquimod creams is a relatively rapid and convenient form of therapy as compared to the separate use of each medication.
Ali Murat Ceyhan MD, Ipek Gurses MD, Mehmet Yildirim MD, Vahide Baysal Akkaya MD
Erythromelalgia is a rare chronic disorder characterized by intense burning pain, redness, swelling and increased skin temperature.
It occurs primarily in the feet, but may also involve the hands, face and ears. Warming of the extremity or placing and maintaining
the extremity in a dependent position can exacerbate symptoms. These symptoms are typically refractory to various medications,
but are relieved by elevation or exposure to cold. Although a specific therapy is not available for erythromelalgia yet, several treatment
modalities may be used as therapeutic options, including: aspirin, indomethacine beta-blockers, calcium channel antagonists,
misoprostol, diltiazem, tricyclic antidepressants, serotonin reuptake inhibitors and number of more aggressive procedures—such as
intravenous lidocaine, epidural anaesthesia, intrathecal opiates and sympathetic ganglion blockade. There are very few reports in the
literature of gabapentin successfully treating erythromelalgia. Here, the authors report a case of primary erythromelalgia in a 20-yearold
woman responding to gabapentin therapy.
Kathleen J. Smith MDa and Marguerite Germain MDb
BACKGROUND: Leflunomide (LEF) is an immune modulator used most commonly for rheumatoid arthritis (RA). The mechanisms of action of LEF also include anti-microbial effects, particularly anti-viral effects.
OBSERVATIONS: We present three patients with atopic dermatitis on azathioprine therapy who had multiple verrucae and in two molluscum contagiosum (MC) that were resistant to repeated conventional therapies.
These patients were switched to LEF, and all the patients showed complete resolution of their verrucae and MC within 2 months of starting therapy. In addition, all three patients showed equivalent to better control of their atopic dermatitis with LEF.
CONCLUSIONS: LEF has previously been reported to be a useful immune modulator for the treatment of severe atopic dermatitis. The spectrum of anti-viral effects previously seen with leflunomide did appear beneficial in these patients in clearing verrucae and MC, which had been resistant to conventional therapies while the patients were on azathioprine.
J Drugs Dermatol. 2015;14(3):230-234.
Lichen striatus (LS) is an uncommon linear dermatosis that is primarily seen in children from 4 months to 15 years of age. While
some of these eruptions are asymptomatic, others can be quite pruritic. In darker-skinned individuals, post-inflammatory hypopigmentation
can be significant and may provide a cause for concern for the patients and/or their parents. In our case series of 4
patients, we observed rapid resolution of LS by combining a topical retinoid with a topical steroid. To our knowledge, this is the
first report of successful treatment with this kind of combination therapy in the English literature. The patients not only achieved
satisfying cosmesis, but also complete resolution of their pruritus. The most common side effect of topical tazarotene is localized
irritation at treatment sites, but the patients in this particular series tolerated the treatment well.
J Drugs Dermatol. 2012;11(7):872-875.
Laura Diluvio MDa, Elena Campione PhDa, Cristina Mordenti MDa, Valentina Bagnolo MDb, Caterina Cerminara MDb, Sergio Chimenti MDa, and Luca Bianchi MDa
No abstract details for the moment.
Neil Sadick MD FACP FAACS
Recent advances in light therapy coupled with photosensitizers offer alternatives to topical creams and gels and systemic oral agents
for acne treatment. To examine the safety and efficacy of the photosensitizer 5-aminolevulinic acid (ALA) in patients with moderateto-
severe acne, a randomized, split-face study, using ALA on one side of the face, was followed by exposure of the entire face to
532 nm potassium titanyl phosphate (KTP) laser. Eight patients completed three treatments for up to 12 weeks. The average acne
grading at baseline was 3.20, and improved to 2.12 at 12 weeks (34% improvement). Use of ALA improved acne by 52% compared
with 32% on the side that did not receive the photosensitizer. Further studies are warranted to establish optimal parameters for
photosensitizer use combined with light therapy for treatment of moderate-to-severe acne; however, the combined use of ALA and
a 532 nm laser suggests promising results for acne treatment.
Ronald Vender MD FRCPC
Background: The past several years have seen the approval of five different biologic agents for the treatment of moderate to severe
plaque psoriasis in the United States and Canada. Psoriasis has proven to be a difficult disease to treat and treatment failures, even
with newer biologic therapies, are not uncommon. The vast majority of clinical data for these medications is derived from treatment
of biologic-naïve patients, or patients who have not responded to, or lost response to, or not tolerated systemic therapy for psoriasis.
There is currently little data available on therapeutic response of a second biologic therapy after loss of response, or no response,
to the first biologic therapy initiated. It has become common clinical practice to switch medications that are structurally distinct but
therapeutically similar in order to achieve an improved clinical outcome. Therapeutic interchange now is being applied to the biologic
agents used to treat psoriasis.
Objectives: Using a proof of concept study, describe the response of etanercept after adalimumab has failed to produce a satisfactory
response in moderate to severe plaque psoriasis.
Methods: A total of 10 biologically naïve patients with moderate to severe psoriasis who were initiated on adalimumab for at least
12 weeks but had a Physician’s Global Assessment (PGA) of mild or worse were transitioned to commercial etanercept 50 mg twice
weekly (BIW) for 12 weeks followed by a dose reduction to 50 mg once weekly (OW) for an additional 12 weeks. Ethics approval
was obtained and the study registered with ClinicalTrials.gov (NCT00833729). The primary outcome measured was the mean change
in Physician’s Global Assessment (PGA) score (range 0-5) from baseline (when the first etanercept injection is given) to 12 weeks
of etanercept therapy. The secondary outcomes measures included the mean change in Dermatology Quality of Life Index (DLQI),
mean change in body surface area (BSA) covered in psoriasis, Subject’s Global Assessment of disease (SGA), proportion of patients
achieving an improvement in PGA score from baseline to 12 weeks and again at 24 weeks and safety.
Results: Overall, there were significant favorable changes in all outcomes measured (PGA, SGA, BSA and DLQI) with respect to etanercept’s
efficacy after an inadequate response to at least 12 weeks of adalimumab therapy. There were no significant safety issues
noted especially during the transition period from adalimumab to etanercept. ClinicalTrials.gov identifier: NCT00833729.
J Drugs Dermatol. 2011;10(4):396-402.
Katherine H. Flanagan MD, Rosemary King PA-C, Dee Anna Glaser MD
Severe hyperhidrosis affects 2.8% of the population and can be emotionally devastating. First-line therapy employs topical
agents such as aluminum chloride (AC), but efficacy and tolerability vary widely. Botulinum toxin type A (BTX-A)
is FDA-approved for the treatment of primary focal axillary hyperhidrosis unresponsive to topical therapy. A single-center,
randomized, parallel, open-label, 12-week study was performed to compare the efficacy and safety of BTX-A with 20%
AC for the treatment of primary focal axillary hyperhidrosis. Twenty-five subjects were randomized to either BTX-A or
AC treatment, and were evaluated for treatment response by an improvement of ≥2 grades on the Hyperhidrosis Disease
Severity Scale (HDSS). At week 4, 92% of the subjects in the BTX-A group achieved treatment response compared with
33% of the subjects in the AC group. Overall, treatment with BTX-A was more effective and provided greater patient
satisfaction than with AC. Treatment with AC was effective and tolerated in 29% of the subjects.
Disseminated histoplasmosis is a serious disease that affects the skin, lungs, and internal organs. It is one of the
diseases that characterize acquired immunodeficiency syndrome (AIDS), and in endemic areas is one of the
more commonly observed infections in AIDS patients. The mortality rate in patients with AIDS and histoplasmosis
is high if untreated. Disseminated histoplasmosis may have a variety of dermatological manifestations.
In this article, we provide the first report of diffuse ulcerations due to disseminated histoplasmosis. These
ulcers developed while the patient was on stavudine, lamivudine, and indinavir, and had a CD-4 count of 525
mm3. The patient’s histoplasmosis resolved with itraconazole monotherapy.
Histoplasmosis is a well-described opportunistic infection that accompanies human-immunodeficiency virus
(HIV) infection. We report an unlikely victim of disseminated histoplasmosis who suffered this infection while
on antiretroviral therapy and with a CD-4 count of 525/mm3. Notably, he had a normal chest x-ray and disseminated
cutaneous ulcers. The diagnosis was made by skin biopsy, and his infection responded promptly to
itraconazole therapy. This case serves as a reminder that the immunological derangements and cutaneous alterations
wrought by HIV remain unpredictable in nature and extent.
James Q. Del Rosso DO FAOCDa and Leon H. Kircik MDb
Superficial cutaneous fungal infections (SCFIs) are commonly encountered in clinical practice in the United States, and comprise infections of the skin by dermatophytes and yeasts. The most common organisms causing SCFI are dermatophytes, especially Trichophyton spp. With the exception of onchomycosis and tinea capitis, most cases of SCFIs are amenable to properly selected topical antifungal therapy used over an adequate period of time.
A variety of topical antifungal agents are available for the treatment of SCFIs, and they encompass a few major chemical classes: the polyenes (ie, nystatin), imidazoles (ie, ketoconazole, econazole, oxiconazole, etc), allylamines (ie, naftifine, terbinafine), benzylamines (ie, butenafine), and hydroxypyridones (ie, ciclopirox). The 2 major classes that represent the majority of available topical antifungal agents are the azoles and the allylamines. Overall, the allylamines are superior to the azoles in activity against dermatophytes, although both are clinically effective. The reverse is true against yeasts such as Candida spp and Malassezia spp, although topical allylamines have proven to be efficacious in some cases of tinea versicolor and cutaneous candidiasis.
Naftifine, a topical allylamine, is fungicidal in vitro against a wide spectrum of dermatophyte fungi and has been shown to be highly effective against a variety of cutaneous dermatophyte infections. Rapid onset of clinical activity and favorable data on sustained clearance of infection have been documented with naftifine. The more recent addition of naftifine 2% cream has expanded the armamentarium, with data supporting a clinically relevant therapeutic reservoir effect after completion of therapy.
J Drugs Dermatol. 2013;12(suppl 11):s165-s171.
Shivani Reddy BSa and Jashin J. Wu MDb
No abstract details for the moment.
Edward L Lain MDMBA, Ramsey F Markus MD
The use of cyclosporine to treat psoriasis has been widely adopted since 1997, when the microemulsion form (Neoral) became available.
While the causal relationship between cyclosporine and the development of malignant neoplasms has been well described in
the transplant literature, it is difficult to apply this relationship to cyclosporine-treated psoriasis, since lower dosages are used (3-
5 mg/kg/d vs. 7-15mg/kg/d) for a shorter duration. Current literature suggests that cancer risk is not increased when cyclosporine is
used in dermatologic doses for less than 2 years in healthy patients who are not on other immunosuppressants1. We report two patients
with explosive basal cell carcinoma and keratoacanthoma development, respectively, within 3 months of initiation of cyclosporine.
Neither patient had a history of skin cancer, had received PUVA therapy, or was on additional immunosuppressive therapy. To our
knowledge, there have been no previous reports of the development of similar lesions in cyclosporine-treated psoriatic patients within
such a short timeframe. The results of these patients may herald the need for increased awareness by dermatologists for explosively-
growing neoplasms in the setting of cyclosporine-treated psoriasis
Jill Waibel MD, Adam Jared Wulkan MD, and Ashley Rudnick
BACKGROUND and OBJECTIVES: Onychomycosis affects five percent of the worldwide population. Onychomycosis is a therapeutic challenge.
Current therapies on the market are either ineffective or require patient monitoring. Laser and light technologies are being investigated
as a possible treatment option for onychomycosis. The proposed mechanism of action is unknown. All infectious agents may be
killed by heat (except prions). One possible theory is the photothermal effect from water absorbing lasers creates bulk heating in the
nail plate to kill fungal hyphae. Laser technology may be a promising new treatment option for onychomycosis. This is a prospective trial
with real-time temperature feedback to evaluate efficacy and safety of laser therapy for onychomycosis.
METHODS: Twenty-one patients with PAS or culture proven fungal onychomycosis were prospectively treated with laser until target
temperature of 46 - 48 degrees Celsius was achieved using real-time infrared temperature feedback. The laser and light therapies used
were 1319nm, 1064nm and BroadBand Light. Exclusion criteria included mixed infection and no other prior therapeutic interventions.
Subjects received four treatment sessions one week apart. Assessments included PAS & cultures at one, three and six months post
treatment. Patients also were asked a pain score from 1-10 during treatment.
RESULTS: Patients tolerated the procedures well with high satisfaction. Average treatment time was 10 minutes. No adverse events
were noted. Patients reported mild-moderate transient discomfort during treatment. Six-month culture results revealed 20/21 negative
for fungal organisms.
CONCLUSION: Laser therapy offers a safe and effective new option for onychomycosis. This may be the optimal therapy for a large market
that needs alternative or adjunct to current therapies. Laser is quick, painless therapy that does not require any oral medications or
blood test for monitoring. Additional larger scientific studies are needed to confirm our pilot study results.
J Drugs Dermatol. 2013;12(11):1237-1242.
Nicole Van Buren MS and Tina S. Alster MD
Of the estimated 11.7 million cosmetic surgical and nonsurgical procedures performed in the United States (U.S.) in 2007, 22%
were performed on racial and ethnic minorities. Laser and light treatments rank in the top five most requested procedures in annual
surveys of cosmetic and dermatologic surgeons.
Recent U.S. population statistics reveal dramatically shifting demographics that would anticipate a likely increase in this percentage.
U.S. Census Bureau data projects that by 2050, people of color are expected to become the majority, comprising 54% of the
U.S. population, with Latinos accounting for 30%, African Americans 15%, and Asians 9.2%. The rising popularity of cutaneous
laser surgery as an accepted therapy for various skin pathologies, coupled with the diverse face of the patient population, has led to
increased demand for laser treatment of darker skin tones.
Although difficult, effective laser therapy in patients with darker skin phototypes can be achieved. When determining a treatment
protocol for an individual patient, the proper laser energy and wavelength are important in ensuring a substantial margin of safety
while still achieving satisfactory results.
Joseph Wilson McGowan IV BS, Carl Allen Johnson MD, Annette Lynn MD
We describe a patient with pyoderma gangrenosum (PG) whose lesions responded to etanercept therapy. This disease has been recognized
for diverse underlying pathology and associated immune disturbances. Although the role of cytokines in pathogenesis is not
fully understood, tumor necrosis factor alpha (TNF-?) may facilitate induction and maintenance of the disease. This is supported
by the successful use of infliximab, a recombinant anti-TNF-? monoclonal antibody, in cases of PG associated with inflammatory
bowel disease (IBD). Etanercept is a divalent recombinant fusion protein that binds soluble TNF-?. To our knowledge, the utility
of etanercept for PG has not been reported.
A patient with recalcitrant and widespread PG that was unresponsive to systemic corticosteroids was treated with etanercept. Rapid
and complete clearing of the skin lesions was observed, and steroid taper to 5 mg /day was sustained for two months. Treatment was
well-tolerated with no adverse reactions reported. CONCLUSIONS: Etanercept therapy offered rapid and complete resolution of all
PG lesions. Such response supports the use of etanercept as a steroid-sparing agent in recalcitrant disease and suggests the role of
TNF-? in pathogenesis of PG.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Adam S. Aldahan BS,a Stephanie Mlacker BS,a Vidhi V. Shah BA,a Lucy L. Chen MD,a Keyvan Nouri MD,a and James M. Grichnik MD PhDa,b
Cherry hemangiomas are common vascular proliferative lesions that can be concerning from a cosmetic perspective. Laser therapy is often used to eradicate cherry hemangiomas, but some lesions require multiple treatments or do not resolve at all. The suboptimal response to laser treatment may be due to limitations in penetration depth by vascular lasers such as the pulsed dye laser. Optical coherence tomography is a low-energy, light-based imaging device that can evaluate the depth and extent of vascular lesions such as cherry hemangiomas by allowing visualization of tissue structure and blood vessel architecture, which cannot be appreciated by clinical or dermatoscopic examination alone. We present optical coherence tomography images of a cherry hemangioma to demonstrate the precision and resolution of this imaging modality. Optical coherence tomography provides valuable information that has the potential to predict response to laser therapy without unnecessary attempts. Future prospective studies will determine its value for this purpose.
J Drugs Dermatol. 2016;15(6):713-714.
A Kapp MD PhD, B Wedi MD PhD
Chronic urticaria (CU) involves release of histamine from mast cells and/or basophils, which in turn promotes the classic inflammatory
cascade. The resultant symptoms can severely impact sufferers’ quality of life and in severe cases prevent them from leading a normal
existence, with consequent burdens on family and society.
Rapid initiation of effective reliable therapy is important in combating CU, together with avoidance of triggers or exacerbating factors,
if known. While newer immunologically-based therapies are beginning to be developed, antihistamines remain a cornerstone of
effective therapy. Treatment should be tailored to individual patient circumstances, but in principle the choice of antihistamine component
should be governed by the availability of evidence of rapid and prolonged efficacy specifically in CU and evidence of good tolerability
and safety. Increasingly, evidence of beneficial effects on patient quality of life is also required for rational selection of an
antihistamine from amongst those available. Levocetirizine is a new single-isomer antihistamine with a proven efficacy on chronic
urticaria as documented in two recent clinical studies, which have included effectiveness and quality of life assessments.
Kelley Pagliai Redbord MD, C. William Hanke MD MPH FACP
Background: 5-fluorouracil (5-FU) and imiquimod creams are accepted topical therapies for actinic keratosis (AK). Both
are associated with a prolonged course of treatment with an inflammatory response that may preclude the treatment process.
Objectives: To describe the treatment regimen and the extent of side effects in the use of the combined application of
5-FU and imiquimod creams in patients presenting with AKs and to demonstrate the convenience and ease of the methodology
of this regimen.
Methods: The patients applied 5-FU and imiquimod creams to their lesions daily for one week each month over the course
of 3 months. The patients were seen after the completion of each one-week course to evaluate their progress and side effects.
Results: There were 64 patients in the study, 48 of whom completed the study and demonstrated a clearing of their AKs
by the end of the third course of treatment. All of the patients developed an inflammatory response at the sites of their
AKs as well as at subclinical sites with no apparent AKs. Nearly all of these inflammatory reactions were confined to localized
sites without involvement of the surrounding skin.
Conclusions: Therapy with the combined application of 5-FU and imiquimod creams is a relatively rapid and convenient
form of therapy as compared to the separate use of each medication.
Kendra Gail Bergstrom, MD, FAAD
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Kendra Gail Bergstrom, MD, FAAD
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Lawrence F. Eichenfield MD and Sheila Fallon Friedlander MD
Fungal infection of the nails is an increasingly recognized disease in infants and children. However, it can be difficult to distinguish clinically from other nail dystrophies. In addition, many mistakenly believe that onychomycosis does not occur in childhood. Under-recognition of this infectious disorder therefore occurs. Although many consider “nail fungus” a trivial cosmetic concern, it can lead to discomfort, risk of secondary infection, and a more significant health threat in immunocompromised or diabetic individuals. It should always be considered in the differential diagnosis of nail plate disorders in children as it is one of the more common causes.
Here we review the latest data on prevalence of the disease, reasons for its relatively low incidence compared with adults, and important predisposing factors. It is important to confirm the clinical diagnosis of onychomycosis in children, and affected individuals should be examined for concomitant tinea pedis. As familial disease often occurs, it is important to check parents and siblings as well for onychomycosis and tinea pedis.
Treatment of onychomycosis is challenging, and recurrence appears to be more common in children than in adults. Prolonged systemic antifungal therapy is commonly required. However, pediatric practitioners and parents alike hesitate when asked to treat young children with a systemic drug that requires laboratory monitoring and can have systemic toxicities. Due to their thinner, faster-growing nails, children are theoretically more likely to respond to topical monotherapy than adults, and therefore good candidates for topical antifungal therapy.
The clinical data on the use of topical antifungals in pediatric onychomycosis is scarce. We review data that exist from case reports and small clinical trials. New topical antifungals are now available that afford better nail penetration and additional delivery routes to the site of infection. Pediatric trials are now on-going, and should clarify the usefulness of these agents in children.
J Drugs Dermatol. 2017;16(2):105-109.
A significant number of patients with moderate-to-severe inflammatory acne are candidates for oral antibiotic therapy. Use of tetracycline for acne has yielded to second-generation molecules doxycycline and minocycline, which are associated with numerous benefits over their predecessor, especially less frequent dosing and improved safety. Nonetheless, these agents are associated with certain potential side effects, including gastrointestinal (GI) concerns, staining of developing teeth in children, candidiasis, vestibular concerns and, somewhat more controversially, photosensitivity. Additionally, minocycline may be associated with the development of autoantibodies, including anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA) and anti-phospholipid antibodies with or without associated clinical symptoms. Given their similar efficacy for the management of moderate-to-severe acne vulgaris, the choice of doxycycline or minocycline may depend on specific clinical considerations, including patient satisfaction with
therapy, compliance and convenience. Data and clinical experience suggest that enteric-coated doxycycline, with its low rate of GI symptoms, may represent a more tolerable treatment option for many acne patients and therefore be associated with better likelihood of compliance.
Joseph Alcalay MD,a Gil Tauber MD,b Eyal Fenig MD,c and Emmilia Hodak MDb
BACKGROUND: Vismodegib, a hedgehog pathway inhibitor has been recently introduced as an oral therapy for locally advanced and metastatic basal cell carcinoma. Although treatment of patients with basal cell carcinoma with vismodegib has been associated with partial or complete clinical response, it is still unclear if it is also associated with histological cure.
PATIENTS: Two patients with 3 large and aggressive basal cell carcinomas were treated with Vismodegib for 6 months. The treatment was followed by Mohs micrographic surgery.
RESULTS: Two tumors disappeared clinically and one was reduced dramatically in its size following treatment with vismodegib. Mohs surgery in all three tumors revealed residual islands of BCC although margins were cleared at the end of surgery.
CONCLUSIONS: Neoadjuvant therapy with vismodegib for 6 months prior to Mohs surgery was effective in reducing the size of primary and recurrent aggressive basal cell carcinoma. However, residual tumor nests were found during surgery. Further larger studies are needed to evaluate the efficacy of Vismodegib as a neoadjuvant treatment prior to Mohs surgery.
J Drugs Dermatol. 2015;14(3):219-221.
Etanercept is approved for the treatment of plaque psoriasis at a subcutaneous (SC) dosage of 50 mg twice-weekly for three months, followed
by 50 mg SC once-weekly thereafter. It is of note, however, that many patients experience loss of efficacy when they step down to etanercept 50 mg/week, often instigating a switch to another biological. The current pilot study investigated the adjunctive use of a topical calcipotriene 0.005% and betamethasone dipropionate 0.064% combination ointment, approved for the treatment of psoriasis, to sustain the original efficacy of etanercept by augmenting response to the 50 mg/week SC dose, thus stabilizing the disease.
Trial Design: In this single-center, open-label study, subjects (n=20) underwent 12 weeks treatment with etanercept 100 mg/week (50 mg, 2x week; weeks –12 to -1), followed by etanercept 50 mg/week maintenance therapy for 40 weeks (weeks 0 to 40). Subjects were followed at four-week intervals. Starting at week 4, subjects who demonstrated an increase from baseline (week 0) body surface area (BSA) of >2% initiated therapy with calcipotriene 0.005% and betamethasone dipropionate 0.064% ointment for four weeks. The study is limited by its small sample size, open-label nature, and lack of blinding.
Findings: Mean BSA involvement decreased significantly from week –12 to 0 with etanercept 50 mg twice a week. At week 4, on the etanercept 50 mg/week dose, mean BSA increased to 9.42±9.39 compared to week 0. With introduction of calcipotriene 0.005%/betamethasone dipropionate 0.064% ointment at week 4, mean BSA decreased to 4.62±8.19 by week 24 and was relatively stable for the remainder of the study period. Similarly, mean PASI (Psoriasis Area and Severity Index) scores improved from week -12 to week 0, increased at week 4, then decreased significantly by week 24 with adjunctive topical treatment.
Conclusion: Topical calcipotriene 0.005% and betamethasone dipropionate 0.064% ointment is a safe and effective adjunct to etanercept
50 mg/week maintenance therapy.
J Drugs Dermatol. 2011;10(8):881-885.
Stephanie J. Kang DO,a Scott A. Davis MA,a Steven R. Feldman MD PhD,a,b,c and Amy J. McMichael MDa
BACKGROUND: Dyschromias are becoming a more common concern among patients, particularly among persons of color. There are a variety of treatments, including more novel agents for dyschromias. Evaluating common agents prescribed among various races may prompt efforts to enhance care for dyschromias in patients of color.
OBJECTIVE: To determine whether racial or ethnic groups are treated differently for dyschromia. The secondary objective is to discover the main treatments used and determine trends over time in demographics.
METHODS: We searched the 1993-2010 National Ambulatory Medical Care Survey (NAMCS) for visits associated with a diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09). The demographics and leading treatments were tabulated, and trends over time were assessed by linear regression.
RESULTS: There were about 24.7 million visits for dyschromia over the 18-year period. Among 5,531,000 patients with the sole diagnosis of dyschromia, there were 2,800 visits from females and 1,200 visits from males per 100,000 population. Females were more likely to receive prescription combination therapy for dyschromia than males by a ratio of 10 to 1. Leading treatments overall prescribed by dermatologists included hydroquinone, topical corticosteroids, and retinoids. Asians were 27% more likely to receive a combination therapy than non-Asians. African Americans and Hispanics were less likely to have a procedure performed for dyschromia.
LIMITATIONS: Data are based on a number of ambulatory care visits, which does not allow direct estimation of prevalence.
CONCLUSIONS: Dyschromia is a significant concern for many patients, and this is especially true among patients of color. Treatment for dyschromia is influenced by skin type, and thus ethnic or racial groups are treated differently. Studies have shown that combination therapy may offer better results than a single medication for hyperpigmentation disorders. Combination agents may be underutilized in African Americans and Hispanics for dyschromia.
J Drugs Dermatol. 2014;13(4):401-406.
Richard A. Krathen MD, Cindy N. Berthelot MD, Sylvia Hsu MD
Background: Infliximab inhibits T-cell activation by binding tumor necrosis factor-? (TNF-?). This medication is widely
used in the US for treatment of psoriasis as an off-label indication. The durability of its effect is largely unknown.
Objective: To assess the proportion of patients still on infliximab 12 months after initiation of therapy for psoriasis.
Methods: Retrospective chart review analysis of 73 patients with psoriasis treated with infliximab for at least 12 months
or those who experienced treatment failure in less than 12 months. The point where infusions were deemed to no longer be
efficacious was determined by physicians global assessment (PGA).
Results: Of 73 patients who started infliximab at least 12 months prior to this chart review, 22 (30.1%) had discontinued
treatment secondary to loss of efficacy. Thirty seven patients (50.7%) had no loss of efficacy and continued to receive
infusions. Two patients (2.7%) discontinued due to loss of efficacy after greater than 12 months. Of the 22 patients who
discontinued treatment due to loss of efficacy, 2 were on concomitant methotrexate (5-7.5 mg/wk) therapy. Of the 37
patients still receiving treatment with no loss of efficacy at 12 months, 3 patients were on concomitant methotrexate
therapy. Five patients (6.8%) discontinued secondary to minor adverse events: sinus infection (1), acne (1), fever (1),
arthralgia (1), and transient rash (1). Three patients (4.1%) discontinued due to major adverse events: reactivation of
tuberculosis (1), breast cancer (1), and gastrointestinal bleeding (1). One patient discontinued infliximab secondary to
concerns of possible lymphoma risk (though there were no signs of symptoms of disease on examination), and 3 patients
discontinued due to insurance concerns.
Conclusion: Infliximab treatment resulted in significant improvement in psoriasis, with 37 out of 73 patients (50.7%) experiencing
no loss of efficacy. This longitudinal retrospective chart review demonstrates continued benefit of infliximab infusions in about half of parients after 1 year, though a notable percentag (30.1%) experienced loss of efficacy as determined by physicians global assessement (PGA) and a number of others discontinued due to adverse events or insurance difficulty.
Rebecca G. Pomerantz BA, Ezra D. Mirvish BA, Larisa J. Geskin MD
Cutaneous toxicities are the most common adverse effects of antineoplastic therapy with epidermal growth factor receptor (EGFR)
inhibitors. Skin reactions to this class of agents usually present as papular and/or pustular follicular eruptions developing within two
weeks of treatment onset. Other manifestations include generalized xerosis and pruritis, as well as abnormalities of the hair and nails.
For most EGFR inhibitors, the incidence and severity of cutaneous toxicity are associated with clinical benefit. At the same time,
cutaneous toxic effects may detract substantially from health-related quality of life, leading to interruption, discontinuation or dose reduction
of EGFR inhibitor therapy in significantly affected patients. Current recommendations for treatment of EGFR inhibitor-induced
eruptions are based primarily on anecdotal evidence from published case series and physicians’ own experiences, and include antibiotics,
corticosteroids and retinoids. Randomized controlled trials are needed to enable the development of evidence-based paradigms
for the treatment of EGFR inhibitor-induced skin eruptions.
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Anne Han MD, Carolin Penrose MD, Arathi Goldsmith DO, Ellen S. Marmur MD
Dermatologic conditions associated with prolonged sun exposure represent a substantial portion of visits to the dermatologist’s office,
particularly among elderly populations. Actinic keratoses are premalignant lesions that increase in frequency with each decade
of life and have the potential to progress to squamous cell carcinoma. Non-melanoma skin cancers, such as squamous cell carcinoma
and basal cell carcinoma, also represent sun-related conditions that require early and aggressive treatment. Therapeutic options for
these conditions are abundant and range from topical field-directed therapies to destructive, lesion-directed procedures. Choice of
therapy depends on the types and extent of lesions with which a patient presents; often, a combination of treatments provides the
optimal means for successful outcomes. The following case-based review represents typical situations where multiple treatments
were combined to manage actinic keratosis, squamous cell carcinoma and basal cell carcinoma in patients over an extended treatment
Hereditary angioedema (HAE) is a rare genetic disease caused by a deficiency in functional C1-esterase inhibitor characterized by recurrent episodes of angioedema in the absence of associated urticaria. Subcutaneous swellings are experienced by virtually all patients
with HAE, and dermatologists are likely to encounter this manifestation, requiring that they be knowledgeable about diagnosis and
treatment options. Diagnosis of HAE is often delayed because several of the symptoms can mimic other disease states. Delays in
diagnosis can lead to increased inappropriate treatment and decreased patient quality of life. Once a proper diagnosis is made, treatment
needs to be targeted to the individual patient and includes on-demand therapy and an option for short- and long-term prophylaxis.
On-demand therapy is required for all patients who are diagnosed with HAE and effective options include plasma-derived and recombinant
C1 inhibitors, kallikrein inhibitors, and bradykinin B2-receptor antagonists. Options available for prophylaxis include plasma-derived
C1 inhibitors, attenuated androgens, and antifibrinolytic agents, although the latter 2 options are associated with significant adverse
events. This article reviews the diagnosis and options for effective management of patients with HAE.
J Drugs Dermatol. 2015;14(2):151-157.
Joseph F. Fowler Jr. MD
Research into the pathophysiology of rosacea suggests a central role for inflammatory mediators such as nitric oxide
(NO), reactive oxygen species (ROS), and matrix metalloproteinases (MMPs). Effective treatments for rosacea,
including topical metronidazole and systemic antibiotics, have anti-inflammatory activity, which may be more important
than their antimicrobial activity in this setting. Phase III studies have substantiated the efficacy of anti-inflammatory
dose doxycycline (40-mg doxycycline monohydrate controlled-release capsules) administered once daily for the
treatment of inflammatory lesions of rosacea. Results of a 16-week, randomized, double-blind, placebo-controlled study
of anti-inflammatory dose doxycycline plus topical metronidazole gel 1% for mild to moderate rosacea are presented here.
At week 12, metronidazole was discontinued and patients continued on either placebo or doxycycline. Combination
therapy significantly reduced inflammatory lesion counts as early as week 4 and through week 12 compared to topical
metronidazole 1% gel monotherapy. The combined therapy appeared effective and well-tolerated.
Diane M. Thiboutot MD, Alan B. FleischerMD, James Q. Del Rosso DO,Phoebe Rich MD
This two-phase, multicenter study was undertaken to examine the safety and effi cacy of combination therapy with oral doxycycline
and topical azelaic acid (AzA) 15% gel in moderate-to-severe papulopustular rosacea and to determine the effect of subsequent
maintenance monotherapy with AzA 15% gel alone. In the initial open-label, non-randomized phase of the study, subjects (n=172)
received topical AzA 15% gel and oral doxycycline (100 mg), both twice daily, for ≤ 12 weeks. In the second, double-blind study
phase, subjects who had initially undergone at least four weeks of combination treatment in phase 1 and who achieved ≥75% infl ammatory
lesion count reduction (n=136) were randomized to receive either AzA 15% gel or its vehicle twice daily for an additional 24
weeks. Assessments of effi cacy were obtained at four-week intervals throughout both phases of the study and included change
in infl ammatory lesion count, investigator global assessment (IGA) of rosacea severity, and separate assessments of erythema and
telangiectasia severity. At the last visit for each phase of the study, the investigator and participant each rated overall improvement,
with the participant rating cosmetic acceptability and the investigator rating treatment as “success” or “failure” based on IGA score.
During the second phase of the trial, the rate of relapse—defi ned as either a 50% deterioration in the lesion count improvement from
phase 1, an increase in erythema intolerable to the subject or maintenance therapy failure as judged by the investigator and/or the
subject—was obtained. Safety assessments were conducted for both phases of the study and included analysis of adverse events
(AEs) and a rating of cutaneous tolerability by the subject.
By week 12 of the open-label phase of the study, 81.4% of subjects had reached a 75% or greater reduction in infl ammatory lesion
count, and 64% of patients achieved treatment success. During the second study phase (maintenance phase), AzA 15% gel consistently
provided a better maintenance response than vehicle, with maintenance of remission in 75% of patients over the six-month
duration of the maintenance phase. Additionally AzA 15% gel showed a statistically signifi cantly lower deterioration in absolute
infl ammatory lesion counts than did vehicle after 8, 16, 20 and 24 weeks of maintenance therapy. No serious treatment-related AEs
were encountered in the study, and 98.5% of subjects were satisfi ed with the local tolerability of both AzA gel and vehicle.
BACKGROUND: This study incorporates concurrent thermal camera imaging as a means of both safely extending the length of each
treatment session within skin surface temperature tolerances and to demonstrate not only the homogeneous nature of skin surface
temperature heating but the distribution of that heating pattern as a reflection of localization of subcutaneous fat distribution.
METHODS: Five subjects were selected because of a desire to reduce abdomen and flank fullness. Full treatment field thermal camera
imaging was captured at 15 minute intervals, specifically at 15, 30, and 45 minutes into active treatment with the purpose of monitoring
skin temperature and avoiding any patterns of skin temperature excess.
RESULTS: Peak areas of heating corresponded anatomically to the patients’ areas of greatest fat excess ie, visible “pinchable” fat.
CONCLUSION: Preliminary observation of high-resolution thermal camera imaging used concurrently with focused field RF therapy show
peak skin heating patterns overlying the areas of greatest fat excess.
J Drugs Dermatol. 2014;13(7):864-866.
R Balkrishnan PhD, A P Kelly MD, A McMichael MD, H Torok MD
Melasma is a common hyperpigmentation of the face or neck that can have severe adverse psychological and emotional effects on
affected individuals. Although a variety of treatments have been used over the years, results have typically been less than satisfactory.
An open-label, community-based trial was undertaken at 393 centers in the United States, enrolling 1290 patients representing a
broad range of races/ethnicities and all Fitzpatrick skin types, to evaluate the efficacy and safety of a new melasma treatment that
combines fluocinolone acetonide 0.01%, hydroquinone 4.0%, and tretinoin 0.05% (FA+HQ+RA) in a hydrophilic cream formulation.
An additional objective of the study was to assess the impact of this therapy on the quality of life. Efficacy and safety were evaluated
at 4 and 8 weeks, and changes in a variety of quality of life parameters were analyzed at the conclusion of the study. All measures
of efficacy showed that FA+HQ+RA significantly (p<0.0001) improved melasma at 4 weeks with further improvement at 8 weeks across
all races/ethnicities and Fitzpatrick skin types. The treatment was safe and well tolerated. After 8 weeks of therapy, patients reported
that FA+HQ+RA had provided a variety of benefits that had enhanced their quality of life.
Alice B Gottlieb MD PhD, Kenneth B Gordon MD, Mark G Lebwohl MD, Ivor Caro MD, Patricia A Walicke MD PhD, Nicole Li PhD,Craig L Leonardi MD, for the Efalizumab Study Group
Agents that safely provide long-term control of psoriasis are needed. To determine the safety and efficacy of extended efalizumab therapy,
339 patients with moderate to severe chronic plaque psoriasis received 2 mg/kg subcutaneous (SC) efalizumab weekly for 12
weeks. At Week 12, 290 patients who achieved ?50% Psoriasis Area and Severity Index (PASI-50) improvement or a static
Physician’s Global Assessment grading of “mild,” “minimal,” or “clear” entered maintenance treatment with weekly SC efalizumab.
At Week 12, 82%, 41%, and 13% of 339 patients achieved a PASI-50, PASI-75, and PASI-90 response, respectively. At 15 months,
65%, 50%, and 25% of patients achieved a PASI-50, PASI-75, and PASI-90 response, respectively (intent-to-treat, n = 339). The
incidence of adverse events did not increase over time, and no new common adverse events were reported. The majority of patients
experienced sustained efficacy with no increase in toxicity. This study is planned to continue; patients will receive up to 36 months
of continuous efalizumab.
James Q. Del Rosso DO FAOCD
Information is limited on the management of truncal acne vulgaris. Survey results suggest that most dermatologists
commonly prescribe oral antibiotic therapy when treating acne involving the chest and back. This article reports therapeutic
outcomes based on an investigator-blinded, randomized, 10-week observational trial completed in patients presenting
with moderate or severe truncal acne vulgaris. One group received treatment with benzoyl peroxide (BP) 9%
cleanser daily, clindamycin 1% foam daily, and doxycycline 100 mg twice daily. The other group received BP cleanser
9% daily and doxycycline 100 mg twice daily without clindamycin 1% foam. Baseline, week 6, and week 10 evaluations
were completed. Efficacy parameters included inflammatory and total lesion count reduction, and investigator global
assessment. Global evaluations of treatment response were recorded and skin tolerability was also evaluated. This trial
was designed to capture observational experience reflective of treatment of patients with truncal acne in a private practice
Pemphigus vulgaris, foliaceous, and vegetans are potentially fatal, autoimmune, vesiculobullous mucocutaneous diseases. In order to prevent potentially fatal infection and other complications, most patients with pemphigus require treatment with systemic corticosteroids and immunosuppressive agents, although these medications often cause chronic and serious adverse effects. Many case reports and several trials have documented remissions and clinical improvement in cases of pemphigus recalcitrant to standard therapy, who were treated with either intravenous immunoglobulin (IVIG) or rituximab, alone or in combination with each other. Collectively, the body of evidence from these reports is large enough to spark consideration of these treatments early in the management of pemphigus. Among the potential benefits of a therapeutic strategy that includes these biologic agents are more rapid induction of remission, prevention of corticosteroid-related adverse effects, and decreased cost of therapy. Considering the outcomes from recent trials with these novel therapies, reevaluation of the best-practice treatment of pemphigus seems prudent and timely.
J Drugs Dermatol. 2012;11(10):1200-1206.
Mauricio Sandoval MD, Claudia Albornoz RN, Sonia Muñoz RN, Mirta Fica RN,Isidora García-Huidobro MD, Renato Mertens MD, Ariel Hasson MD
Introduction: Venous leg ulcers are an important problem in public health due to their high prevalence and treatment cost. The gold
standard therapy is the compression bandage. Addition of different substances to the compression therapy in order to accelerate
ulcer healing has been attempted but none of them has yielded optimal results.
Objective: To describe the treatment efficacy of venous leg ulcers treated with triple compression bandage and chitosan gel.
Methods: A longitudinal and descriptive study was conducted in a sample of 16 patients with 26 venous leg ulcers that were treated
with triple compression bandage plus a chitosan gel every seven days during nine weeks. Ulcer surface was measured during each
Results: At the end of the treatment period, 89 percent reduction of the ulcer area was found when compared to the initial area at
the beginning of the study. This value represents a reduction rate of 1.8 cm2/week.
Discussion: The results obtained in ulcer healing were higher than those previously reported when the compression bandage treatment
of venous leg ulcers was performed alone. The observed difference might be due to the effect of the chitosan gel.
(J Drugs Dermatol. 2011;1075-79.)
Stacy R. Smith MD, Vera B. Morhenn MD, Daniel J. Piacquadio MD
Actinic keratoses (AKs) are a common precancerous condition and are said to account for 14% of visits to dermatologists in
the US each year. Along with cryotherapy, topical treatments are a mainstay of therapy for these lesions. One of the potential
benefits of topical therapy is less pain and irritation as compared to cryotherapy. Additionally, topical therapies have a
perceived benefit of treating subclinical lesions along with clinically evident keratoses. We conducted a bilateral comparison
study of the efficacy and tolerability of diclofenac 3% gel used for 90 days and 5% fluorouracil cream used for 28 days in thirty
patients with AK of the face and scalp. The diclofenac gel and 5-fluorouracil cream each demonstrated substantial efficacy
in the number of lesions cleared and the proportion of patients with significant lesion clearing. In most patients, diclofenac
induced only mild signs of inflammation compared to 5-fluoruracil, despite a longer treatment period. A greater number of
patients expressed significant satisfaction with diclofenac gel compared to the 5-fluorouracil cream.
Craig Leonardi MD, Bruce Strober MD PhD, Alice B. Gottlieb MD PhD, Boni E. Elewski MD, Jean-Paul Ortonne MD, Peter van de Kerkhof MD, Chiun-Fang Chiou PhD, Meleana Dunn MA, Angelika Jahreis MD PhD
Background: In two previous phase 3 studies, up to 60 weeks of etanercept therapy significantly improved the symptoms of psoriasis
and was well tolerated.
Objective: To evaluate the long-term safety of etanercept in an open-label extension study for up to 72 weeks in patients with
moderate-to-severe plaque psoriasis.
Methods: A total of 912 patients received 50 mg subcutaneous etanercept once weekly (QW) for the first 12 weeks of this extension
study. Thereafter, eligible patients could maintain the 50 mg QW dose (n=321) or escalate to 50 mg twice weekly (BIW; n=591)
anytime thereafter based on one of three predetermined criteria.
Results: Etanercept was well tolerated during 1056 patient-years of exposure; no difference was observed between the 50 mg QW
and 50 mg BIW dosages in rates of adverse events and infections. Improvement in skin disease was maintained throughout the
study. Patients who stopped and then restarted etanercept also showed improvement in psoriasis.
Conclusion: Psoriatic patients continued to benefit from open-label etanercept treatment, both continuous and interrupted therapy,
which was generally well tolerated after a combined 2.5 years of experience.
Karin Blecher BA and Adam Friedman MD
News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic
Thomas Dirschka MD,a,b Lutz Schmitz MD,a,c and Ágota Bartha MDa
We report the case of a German female patient presenting with papulopustular rosacea (PPR) with a high count of facial inflammatory lesions and severe erythema who had not responded well to treatment with traditional therapies for a decade. In this patient, a sequential therapy consisting of oral modified-release doxycycline 40 mg (initially as monotherapy, then in combination with topical metronidazole), followed by topical ivermectin 10 mg/g was both rapidly active and effective. Following reduction of the inflammation with modified-release doxycycline 40 mg upfront and the disease becoming moderate in severity, the dose of this agent could be reduced and combination therapy with metronidazole 7.5 mg/g lotion started to continue decreasing inflammatory lesions count and erythema severity, before treatment with the recently approved agent ivermectin 10 mg/g was implemented to provide almost complete clearance. This sequential treatment was effective in reducing both the number of papules and pustules and the severity of erythema, with a good safety profile. In addition, a large improvement was documented in the patient’s DLQI score, contributing to her overall wellbeing.
J Drugs Dermatol. 2016;15(6):769-771.
Bobbak Mansouri MD, Mary E. Horner MD, Alan Menter MD
Tumor necrosis factor (TNF)-α inhibitors are currently the gold standard for treating moderate to severe plaque psoriasis and other immune-mediated diseases. The presence of previously existing demyelinating disease is amongst the contraindications to their use. However, controversy surrounds the use of TNF-α inhibitors in patients who are more predisposed to developing multiple sclerosis (MS), specifically first-degree relatives of MS patients. In fact, the major guidelines committees’ recommendations on this issue by the American Academy of Dermatology, the British Association of Dermatologists, and the European S3-Guidelines are not consistent. The data we present suggest that the number needed to treat is at least an order of magnitude smaller than the number needed to harm across all comparisons of anti-TNF-α agents and first-degree relative relationships. Based on these data, physicians could weigh the treatment options available and work closely with neurological colleagues when prescribing anti-TNF-α therapy in this patient population rather than practicing absolute prohibition of anti-TNF-α agents in patients who have a first-degree relative with MS.
J Drugs Dermatol. 2015;14(8):876-878
Kyle B. Bartlett MD,a Scott A. Davis MA,a and Steven R. Feldman MD PhDa,b,c
BACKGROUND: Thirty to 40% of patients using topical treatments do not comply with their treatment regimen.
OBJECTIVE: To examine how tolerability is assessed, tolerability ratings, and clinical significance of tolerability ratings of topical antimicrobials for acne.
METHODS: A literature search was performed using the terms “tolerability AND acne AND (benzoyl peroxide OR antimicrobial OR clindamycin OR erythromycin OR dapsone OR sulfur OR sulfacetamide).” Inclusion criteria were: 1) evaluation of tolerability, 2) use of an identified topical antimicrobial for acne treatment without combination retinoid use, 3) an original study, in English.
RESULTS: Thirty-four of 132 articles met the inclusion criteria. Tolerability was measured through subject and investigator assessment of specific tolerability parameters and by reporting of adverse events. Nearly all of the acne treatments were well tolerated. Treatment related study discontinuation rates were low and had little to no relation to the degree of tolerability measures.
LIMITATIONS: Patients may be more adherent in clinical trials than in clinical practice. Differences in the measure used to assess tolerability make comparisons difficult.
CONCLUSIONS: Topical antimicrobial acne therapy is generally well tolerated. Discontinuation rates are low under study conditions. Tolerability of topical antimicrobial therapy for acne may not have great clinical significance.
J Drugs Dermatol. 2014;13(6):658-662.
Aman Samrao MD,a Jennifer M. Fu MD,a,b Steven T. Harris MD,b and Vera H. Price MDa
Background: Intralesional corticosteroid injections are a common treatment for patchy alopecia areata, the most prevalent subtype of this autoimmune hair disorder. To date, no studies have examined the potential adverse effects of this therapy on bone mineral density (BMD).
Methods: In this retrospective, cross-sectional case series, 18 patients with patchy alopecia areata treated at 4- to 8-week intervals with intralesional triamcinolone acetonide for at least 20 months were evaluated for BMD using dual-energy x-ray absorptiometry (DXA). Follow-up DXA measurements were obtained in those with abnormal findings.
Results: Nine out of 18 patients (50%) had abnormal DXA results. Patients with the following risk factors were more likely to have abnormal BMD: age older than 50 years, body mass index less than 18.5 kg/m2, lack of weight-bearing exercise, smoking history, postmenopausal status, past stress fracture, family history of osteopenia or osteoporosis, and a cumulative intralesional triamcinolone acetonide dose of greater than 500 mg.
Conclusion: Patients with patchy alopecia areata who receive chronic intralesional triamcinolone acetonide therapy should be counseled on preventive measures for osteoporosis and monitored for effects on BMD.
J Drugs Dermatol. 2013;12(2):e36-e40.
Lawrence F. Eichenfield MD,1 James Q. Del Rosso DO FAOCD,2 Anthony J. Mancini MD,3
Fran Cook-Bolden MD,4 Linda Stein Gold MD,5 Seemal Desai MD FAAD,6 Jonathan Weiss MD,7
David Pariser MD,8 Joshua Zeichner MD,9 Neal Bhatia MD,10 Leon Kircik MD11
As the pathophysiology of acne is complex and multifactorial, the continued influx of new basic science and clinical information requires careful analysis before drawing conclusions about what truly contributes to the development and progression of this chronic disease. Our objective is to review the latest evidence and highlight a number of important perspectives on the pathophysiology of acne. An improved understanding of acne pathogenesis should lead to more rational therapy and a better understanding of the role of P acnes opens new perspectives for the development of new treatments and management. Further research may be directed at targeting receptors, adhesion molecules, cytokines, chemokines or other pro-inflammatory targets implicated in the activation of immune detection and response (i.e., toll-like receptors [TLRs], protease-activated receptors [PARs]) that appear to contribute to the pathophysiology of acne. Therapeutic options that reduce the need for topical and/or oral antibiotic therapy for acne are welcome as bacterial resistance to antibiotics is a clinically relevant concern both in the United States and globally.
J Drugs Dermatol. 2015;14(3):263-268.
Martha P. Arroya. MD, PhD and Louisa Tift, BA
Vitiligo is a disfiguring skin disease. Many insights into its pathogenesis have been identified in recent years;
however, treatment remains a challenge. In this article, the various treatment options for the treatment of
vitiligo are outlined and newer treatment options are discussed.
Bruce E. Strober, MD, PhD and Shari Clark, BA
Etanercept is a self-administered medication that has FDA approval for the treatment of rheumatoid arthritis, juvenile rheumatoid
arthritis, psoriatic arthritis, and ankylosing spondylitis. Etanercept is a human fusion protein of the tumor necrosis factor receptor
(TNFR) and the Fc region of IgG1 that binds to and presumably inhibits the pro-inflammatory and pro-proliferative activity of the
tumor necrosis factor (TNF). A recent multisite, randomized, double-blind, placebo-controlled study conclusively demonstrates that
etanercept as monotherapy effectively treats patients with moderate-to-severe plaque psoriasis. This effect is dose-responsive, with
the etanercept 50 mg twice-weekly dose significantly more effective than the 25 mg twice-weekly dose in reducing the Psoriasis Area
and Severity Index (PASI) score over both 12 and 24 weeks of continuous therapy1.
Nevertheless, clinical trials do not instruct the dermatologist on how to practically integrate etanercept into a patient’s pre-existing
treatment regimen. Many psoriasis patients are already on other systemic therapies or have a medical history that necessitates a tailored
approach to their therapy. Further, in some patients, etanercept at 25 mg twice weekly is ineffective in maximally clearing a
patient of psoriasis. Below are cases that demonstrate how etanercept can be combined with other medications in order to both maximize clinical efficacy and minimize potential risk.
Jennifer F. Conde BA, Christopher B. Yelverton MD MBA, Rajesh Balkrishnan PhD, Alan B. Fleischer Jr. MD, Steven R. Feldman MD PhD
Background: Rosacea is an extremely common chronic dermatosis affecting an estimated 14 million Americans. Rosacea
is most commonly managed with topical metronidazole, sometimes in combination with oral antibiotics.
Purpose: To review published studies about topical metronidazole therapy for rosacea, both as a monotherapy and in conjunction
with oral antibiotics.
Methods: Medline searches were conducted for clinical trials using metronidazole, tetracycline, and doxycycline for rosacea.
Results: Topical metronidazole has been well studied as a rosacea therapy. Twice-daily dosing of metronidazole 1.0% cream
is as effective as 250 mg tetracycline twice daily. Metronidazole 1.0% gel used once daily is as effective as azelaic acid 15%
gel dosed twice daily. When dosed at subantimicrobial levels, doxycycline 20 mg taken twice daily is effective in decreasing
inflammatory lesions and erythema associated with rosacea. Metronidazole 0.75% lotion is more effective when used in
combination with doxycycline 20 mg dosed twice daily.
Discussion: Metronidazole in 0.75% strength lotion, cream, and gel and 1.0% metronidazole cream and gel are all efficacious
in treating rosacea. Combination treatment with oral antibiotics at both antimicrobial and subantimicrobial doses
is an efficacious means of treating rosacea. Maintenance treatment with topical metronidazole decreases relapses and allows
for longer intervals between flares.
Karine Zakarian MD, Alain Nguyen MD, Julie Letsinger MD, John Koo MD
Background: Fiber-optically targeted ultraviolet B (UVB) therapy has been shown to clear plaques of psoriasis in a significantly
fewer number of treatments and reduce overall cumulative UVB dose than traditional UVB phototherapy.
Objective: This article reviews existing theories in the literature attempting to explain the superior efficacy of targeted UVB.
Methods: Medline was used to perform a comprehensive review of the literature from 1965 to present. Only information
from the English language journals are reported in this study.
Results: The theories proposed to explain the higher efficacy of the excimer (XeCl) laser relative to traditional UVB
include the ability to use higher intensities of ultraviolet (UV) light and a more efficient induction of T cell apoptosis.
Conclusion: The possible explanations for the superior efficacy of the excimer laser over traditional UVB therapy for psoriasis
include: 1) a higher intensity UV light to plaques, which is more effective in clearing psoriasis; 2) penetration into
the dermis where it may induce T cell apoptosis, potentially to a greater extent than the wavelength or given energy level
predicts; and 3) the difference in the delivery of UVB light may result in cell death and skin immune system suppression
more effectively than traditional UVB.
Anupam M. Desai MD, John Browning MD, Theodore Rosen MD
A patient developed a typical, painful, and debilitating reaction on the thighs following injection of ostensibly medical grade
“silicone” to achieve alteration of body contours. The refractory silicone granuloma responded dramatically to treatment
Dhaval Bhanusali MD, Marcelyn Coley MD, Jonathan I. Silverberg MD MPH PhD, Andrew Alexis MD MPH and Nanette B. Silverberg MD
Background: Tinea capitis periodically undergoes demographic shifts in causative dermatophyte and therapeutic response to oral
Objective: To determine prevalent fungal species and response to standard antifungal therapy in inner-city children of color.
Methods: An IRB-approved chart review of demographic, clinical, diagnostic, and therapeutic data was conducted for children and
young adults (0 to 18 years of age) who had scalp fungal culture performed for scalp hyperkeratosis and/or alopecia over a 2.5 year
time-period. Supplemental parental phone interview was performed for missing data points.
Results: A total of 84 patients with final diagnosis of tinea capitis were identified—52% male, 60.6% African-American, 28.2% Hispanic,
and 9.9% Caucasian. Complete resolution at 4 weeks was uncommon in all demographic groups (Hispanic: 11.7%, African-American:
41.3%). The Hispanic group and the youngest patients (aged less than 4 years) were less likely to respond to initial therapy, but the results
were not significant. Of the 80 tinea capitis patients initially treated with griseofulvin, 41 out of 54 children (76%) had complete response
to micronized suspension +/- crushed tablet (33% required shift to tablets from suspension) and 20 out of 26 (76.9%) cleared on crushed
tablets alone. Of the 19 griseofulvin failures, 5 cleared on fluconazole suspension, 7 on terbinafine sprinkles, 3 on itraconazole therapy,
and 4 were lost to follow-up. Of the 47 patients who could be evaluated long-term after a single course of oral griseofulvin at 6 weeks or
greater, 38 had documented long-term mycological cure (80.8%) and 42 had long-term clinical cure (89%). Trichophyton tonsurans (n=40)
was the most prevalent causative species identified on culture, followed by Alternaria species (n=10) and Microsporum canis (n=1).
Limitations: Retrospective chart review: patient population has a high rate of usage of over-the-counter antifungal creams and shampoos,
affecting culture results.
Conclusions: Tinea capitis is still the most common cause of Trichophyton tonsurans in New York City. Response rates to griseofulvin
are similar to rates seen in the 1970s, but require higher dosing and conversion to crushed tablets in partial responders. Usage of
crushed ultramicronized griseofulvin, terbinafine sprinkles, itraconazole, and fluconazole are alternative regimens for those children
whose tinea capitis does not clear on griseofulvin suspension.
J Drugs Dermatol. 2012;11(7):852-856.
Background: Female pattern hair loss affects many women; its pathogenetic basis has been held to be similar to men with common baldness.
Objective: The objective of this study was to determine the role of immunity and inflammation in androgenetic alopecia in women and modulate therapy according to inflammatory and immunoreactant profiles.
Materials and Methods: 52 women with androgenetic alopecia (AA) underwent scalp biopsies for routine light microscopic assessment and direct immunofluroescent studies. In 18 patients, serologic assessment for antibodies to androgen receptor, estrogen receptor and cytokeratin 15 was conducted.
Results: A lymphocytic folliculitis targeting the bulge epithelium was observed in many cases. Thirty-three of 52 female patients had significant deposits of IgM within the epidermal basement membrane zone typically accompanied by components of complement activation. The severity of changes light microscopically were more apparent in the positive immunoreactant group. Biopsies from men with androgenetic alopecia showed a similar pattern of inflammation and immunoreactant deposition. Serologic assessment for antibodies to androgen receptor, estrogen receptor or cytokeratin 15 were negative. Combined modality therapy with minocycline and topical steroids along with red light produced consistent good results in the positive immunoreactant group compared to the negative immunoreactant group.
Conclusion: A lymphocytic microfolliculitis targeting the bulge epithelium along with deposits of epithelial basement membrane zone immunoreactants are frequent findings in androgenetic alopecia and could point toward an immunologically driven trigger. Cases showing a positive immunoreactant profile respond well to combined modality therapy compared to those with a negative result.
J Drugs Dermatol. 2011;10(12):1404-1411.
Jennifer K. Tan MD, Adam D. Lipworth MD, Andrew A. Nelson MD, Artur Zembowicz MD PhD, Samuel L. Moschella MD; James Click MD, Sarah Gee MD, Raul Cortes MD, Lydia Gedmintas MD, Joseph F. Merola MD, Vivian Bykerk MD, Arturo Saveedra MD PhD MBA
No abstract details for the moment.
LCDR Sean J Murphy MC USN, CPT Clifton R Dobbs MC USA
A 32-year-old Philippino male presented to the clinic with a penile rash of 2 months duration. The rash was diagnosed as lichen
nitidus and was successfully treated with the non-indicated therapy of Protopic 0.1% (Tacrolimus) for 4 weeks.
Martha P. Arroyo, MD, PhD; Patricia Heller, MD and Miriam Keltz Pomeranz, MD
A healthy 47-year-old woman developed diffuse pustules and edema of the skin after exposure to diltiazem and cephalexin. Bacterial, fungal and viral cultures were sterile suggesting a noninfectious etiology. A skin biopsy showed spongiosis, subcorneal collection of neutrophils, papillary dermal edema and a superficial perivascular mixed cell infiltrate. The clinical and histopathologic findings were consistent with acute generalized exanthematous pustulosis (AGEP). The patient was treated with supportive care and the pustular dermatitis cleared. AGEP is a rare complication of drug therapy and should be considered in the differential diagnosis of patients presenting with acute onset pustular dermatitis.
Drug reactions are an uncommon and unpredictable complication of medical therapy. Cutaneous drug reaction rates occur with a frequency of 1% to 8% and can be higher for certain classes of drugs1. They can range from mild morbilliform eruptions to more severe forms such as drug-hypersensitivity syndrome, toxic epidermal necrolysis or anaphylaxis. Acute generalized exanthematous pustulosis (AGEP) is a rare presentation of a drug reaction and can be difficult to distinguish from other pustular dermatoses. Herein we review a case of AGEP and include a discussion of salient clinical and histological features of AGEP.
Background: Alefacept is an effective intermittent treatment for psoriasis that can provide long-lasting remissions. Combination therapy with narrow-band ultraviolet B (nbUVB) phototherapy may enhance treatment outcomes and accelerate the onset of clinical response.
Objective: To assess the efficacy of alefacept in combination with nbUVB phototherapy compared to alefacept alone in subjects with moderate to severe psoriasis.
Methods: Ninety-eight adults with moderate to severe psoriasis were randomized to treatment with alefacept 15 mg intramuscularly (IM) once weekly for 12 weeks alone or in combination with three times weekly nbUVB treatments in this prospective, open-label, assessor-blinded, randomized, multicenter, parallel-group, 36-week study.
Results: A statistically significantly greater proportion of subjects in the alefacept plus nbUVB arm achieved the primary endpoint of PASI 75 at week 16 compared to subjects in the alefacept alone arm (44.9% vs 22.5%, P=0.032). Secondary outcomes were also in favor of the alefacept plus nbUVB group, including the proportion of subjects achieving a Physician Global Assessment (PGA) score of clear or almost clear at any time during the study (59.2% vs 34.7%, P=0.026) and reduction in percent body surface area (BSA) involved with psoriasis at week 16 (13.4% vs 8.0%, P<0.001). The onset of clinical response was significantly faster in the combination therapy group compared to monotherapy (mean time to PASI 75: 82 vs 107 days, P=0.007). Both treatments were generally well tolerated.
Limitations: Open-label, assessor-blinded study without a phototherapy-only treatment arm.
Conclusion: The addition of nbUVB to treatment with alefacept significantly enhanced and accelerated the clinical benefits of alefacept therapy and was generally safe and well-tolerated.
J Drugs Dermatol. 2012;11(8):929-937.
Few long-term treatment regimens for severe acne vulgaris have been investigated in clinical trials. Data were combined from two consecutive, randomized, double-blind, controlled studies to evaluate the efficacy, safety and subject satisfaction of four nine-month regimens in severe acne vulgaris treatment. Subjects were first randomized to receive doxycycline (DCN) and adapalene 0.1% - benzoyl peroxide 2.5% (A/BPO) or vehicle once daily for 12 weeks. Subjects who had at least 50% global improvement were subsequently randomized to receive A/BPO or its vehicle once daily for 24 weeks. Over nine months, there were four regimens: A/BPO and DCN followed by A/BPO, vehicle and DCN followed by A/BPO, A/BPO and DCN followed by vehicle, and vehicle and DCN followed by vehicle. Among the four regimens, A/BPO and DCN followed by A/BPO led to the highest percentage of subjects rated "clear" or "almost clear" (50.0% vs. 40.4%, 26.2% and 25.0%, respectively), biggest reduction in total lesion counts (76% vs. 70%, 51% and 47%, respectively) and greatest subject satisfaction (85.0% vs. 75.5%, 63.3% and 52.4%, respectively) at week 36. It provided a faster onset of action compared to groups started with vehicle and DCN (P<.05 at week 2). Subjects receiving A/BPO and DCN followed by vehicle experienced deterioration once the active treatment was discontinued. All regimens were safe and well-tolerated. In conclusion, efficacious initial therapy and long-term treatment are both important. An initial combination therapy with adapalene-BPO and DCN followed by longer-term adapalene-BPO treatment is an efficacious and satisfactory new regimen for severe acne subjects.
J Drugs Dermatol. 2012;11(2):174-180.
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
Jordan B. Slutsky MD, Richard A. F. Clark MD, Alexander A. Remedios MD, Peter A. Klein MD
Background: There is a long history of using topical coal tar for the treatment of psoriasis and atopic dermatitis (AD).
Objective: To review the literature on coal tar and its derivatives, without the use of ultraviolet light, for the treatment of psoriasis
Methods: MEDLINE/PubMed and Cochrane Database of Systematic Reviews literature searches were performed to identify randomized
controlled trials and clinical trials of topical coal tar for the treatment of psoriasis or AD. Studies were graded according to
a modified version of Sackett’s criteria for clinical evidence and evaluated to determine if they support or do not support the use of
coal tar therapy.
Results: Twenty-five studies meeting the authors’ search criteria were identified, only two of which were placebo-controlled. The
majority (21, or 84%) supported the use of coal tar products in the treatment of psoriasis or AD, while four (16%) did not support the
use of coal tar products.
Conclusion: Most studies support the use of coal tar products, although their level of evidence is not strong. Topical coal tar was
found to be efficacious in the treatment of psoriasis in two placebo-controlled trials. Coal tar products appear to be therapeutic in
psoriasis and AD, are well tolerated with few side effects, and are cost-effective. Staining and odor are deterrents to coal tar therapy.
Large, randomized, double-blind, placebo-controlled studies with precise point estimates of treatment effect are needed to establish
the efficacy of coal tar preparations.
Joseph Lillis BA, Roger I. Ceilley MD, Paula Nelson RN
Merkel cell carcinoma (MCC) has been shown to have a higher incidence in many etiologically distinct immunosuppressed
populations. We report a case of aggressive MCC diagnosed in a man with autoimmune hepatitis who was treated
with immunosuppressive therapy for more than 30 years.
Scalp psoriasis is a common life-altering skin condition causing a great deal of distress. It significantly affects quality of life and is difficult to manage. Treatment can provide variable results, often impacting patient compliance with therapy.
Salicylic acid is used as adjunctive therapy to other topical treatments because of its marked keratolytic effect. Its effectiveness as a monotherapy is not fully understood.
An emollient foam formulation of 6% salicylic acid (Salkera) in an ammonium lactate vehicle has recently become available. Efficacy, tolerability and patient acceptability of salicylic acid 6% emollient foam were assessed in an open-label pilot study of 10 subjects with scalp psoriasis.
All psoriasis severity parameters were reduced with a significant decrease in Psoriasis Scalp Severity Index (PSSI) score from 15.3 to 3.0 after four weeks of monotherapy (P<0.001). Sixty percent of subjects were either "completely cleared" or “almost cleared” of their psoriasis. No adverse events (AEs) were reported. All signs and symptom tolerability measures demonstrated statistically significant score decreases with the exception of oiliness severity and patient-reported burning tolerability.
Salicylic acid 6% emollient foam provides a useful option in the treatment of psoriasis that is highly effective, well tolerated and acceptable to patients.
J Drugs Dermatol. 2011;10(3):270-273.
Johanna Sheu MS,a Susan V. Kattapuram MD,b James M. Stankiewicz MD,c and Joseph F. Merola MD MMScd
IMPORTANCE: Dimethyl fumarate received FDA approval in March 2013 for treatment of multiple sclerosis and has had a rapid uptake in the field due in large part to a favorable safety profile. Side effects of dimethyl fumarate include flushing, gastrointestinal discomfort, and peripheral eosinophilia. We report a case of eosinophilic fasciitis-like disorder occurring in the setting of oral dimethyl fumarate therapy. Eosinophilic fasciitis is rare and may be related to the peripheral eosinophilia known to occur with this medication.
OBSERVATIONS: We present a case of a 36-year-old male treated with oral dimethyl fumarate for 16 weeks who developed a bilateral eosinophilic fasciitis-like disorder of the thighs. Magnetic resonance imaging revealed a fluid collection in the fascial plane and histopathologic examination revealed an inflammatory infiltrate with dermal and subcutaneous edema and sclerosis consistent with eosinophilic fasciitis. We discuss studies reporting peripheral eosinophilia with fumaric acid medications as well as the literature exploring possible mechanisms.
CONCLUSIONS: With the anticipated widespread use of dimethyl fumarate for multiple sclerosis patients, it is important for practitioners to recognize the symptoms of eosinophilic fasciitis and be aware of a possible association of oral dimethyl fumarate treatment with the development of an eosinophilic fasciitis-like disorder.
J Drugs Dermatol. 2014;13(9):1144-1147.
Noel M. Prevost MPAS PA-C, Joseph C. English III MD
Lichen planus of the nails is a destructive inflammatory onychodystrophy that is often difficult to treat. We report a case
of treatment with combined topical therapy of tazarotene gel and clobetasol gel. This modality may be effective for
patients with nail lichen planus without the potential adverse affects of systemic treatments.
Benzoyl peroxide (BP) exerts its therapeutic effect for acne vulgaris through reduction of Propionibacterium acnes. A 1.0 to 2.0 log reduction
in P acnes has been demonstrated primarily on the face with use of “leave-on” BP formulations, but also with some BP cleansers.
In addition to use for facial acne vulgaris, cleanser formulations of BP are commonly used for truncal acne vulgaris due to ease of use on
a large body-surface area and to avoid bleaching of fabric. To date, evaluation of P acnes reduction on the trunk has not been well studied
with BP formulations, especially with the use of recognized and standardized methods to accurately determine P acnes colony counts. A
previous study demonstrated that a BP 8% cleanser did not reduce counts of P acnes on the back when subjects were instructed to apply
the cleanser in the shower, allow it to dry for 20 seconds on the skin, and then rinse off the cleanser. Evaluation of specified time intervals
between application on the back and rinsing with BP formulations would help to better define the necessary skin contact time associated
with high reductions of P acnes (>90%), recognizing also the potential roles of BP concentration and vehicle. This 2 week study using quantitative
bacteriologic cultures evaluates the effectiveness of BP 9.8% emollient foam in reducing P acnes levels on the back with 2 minutes
of skin contact time and compares results with a BP 5.3% “leave-on” emollient foam formulation. Short contact therapy utilizing a 2 minute
skin contact time with BP 9.8% emollient foam used once daily over a 2 week duration was highly effective in reducing the quantity of P
acnes organisms on the back and provided comparable colony count reduction to “leave on” therapy using BP 5.3% emollient foam.
J Drugs Dermatol. 2012;11(7):830-833.
A 53-year old man with HIV infection and hepatitis C infection presented with multiple, firm nodules on the
hands and ankles. Erythema elevatum diutinum is a rare, chronic cutaneous vasculitis that may be associated
with hematologic, autoimmune, and infectious diseases, which include HIV infection. First-line therapy
includes dapsone, as well as treatment of any underlying cause or infection.
Rebecca Kleinerman MD, Suzanne L. Kilmer MD, and Vera A. Chotzen MD
Mitomycin C (MMC) is an antineoplastic antibiotic that has been used off-label in the treatment of hypertrophic scars and keloids.
Herein we report our successful use of this agent in a patient with sternal keloids refractory to other means of therapy. We further
review the literature regarding the use of MMC in the treatment of keloids.
J Drugs Dermatol. 2013;12(6):701-703.
Jeffrey L. Sugarman MD PhD and Lawrence Charles Parish MD
Objectives: The authors assessed the efficacy of a ceramide-dominant, triple-lipid barrier repair formulation (EpiCeram®), which designed
to correct the lipid-biochemical abnormalities in atopic dermatitis (AD) in comparison to fluticasone propionate cream.
Methods: In a five-center, investigator-blinded, randomized trial, EpiCeram was compared to fluticasone (Cutivate®) cream in 121
patients with moderate-to-severe AD. Primary outcome measures were: 1) reduction in disease severity, assessed as SCORAD (Severity
Scoring for Atopic Dermatitis) scores; 2) improvement in pruritus; and 3) improvements in sleep habits.
Results: EpiCeram reduced clinical disease severity, decreased pruritus and improved sleep habits both 14 and 28 days after initiation
of therapy. Although the fluticasone-treated group showed significantly greater improvement at 14 days, SCORAD, pruritus and sleep
habit scores for EpiCeram did not differ significantly from the fluticasone-treated group by 28 days.
Conclusion: The ceramide-dominant, physiological-lipid based formulation could represent an effective stand-alone or ancillary therapy
for many pediatric patients with AD.
Scott A. Davis MAa and Steven R. Feldman MD PhDa-c
BACKGROUND: Psoriasis is treated with several classes of treatments that may be used in combination, but the ways combination therapies are used are not well characterized.
PURPOSE: To determine the frequency of prescribing calcipotriene and other psoriasis drugs in combination.
METHODS: Visits with a sole diagnosis of psoriasis were selected from 1990-2010 data from the National Ambulatory Medical Care Survey. The number of combination therapies used, the leading therapies in each class of medications, and the leading types used in combination were analyzed.
RESULTS: About 10.2 million of 20.3 million psoriasis visits used multiple treatments. The mean number of prescribed medications increased over time (P=.0003). The top 10 treatments included 6 topical steroids, calcipotriene, 2 other topicals, and methotrexate. The most common combinations were topical steroid plus other topical (15.0%), multiple topical steroids (11.5%), topical steroid plus vitamin D analogue (9.7%), and topical steroid plus systemic treatment (6.9%). Vitamin D analogues and systemic treatments were prescribed with increasing frequency over time, while fewer topical steroids were used, and use of other topicals did not change significantly.
LIMITATIONS: Visits with multiple diagnoses had to be excluded to ensure that the medications listed were for psoriasis.
CONCLUSIONS: Combination therapy is the most common way to treat psoriasis in the United States. The wide range of combination therapies prescribed may reflect increased attention to individualization of treatment to match patients’ diverse preferences.
J Drugs Dermatol. 2013;12(5):546-550.
Abbas Rasi MD, Ashkan Heshmatzade Behzadi MD, Siamak Davoudi MD, Parviz Rafizadeh MD, Yasamin Honarbakhsh MD, Mahsa Mehran MD, Pirouz Piran MD, Nasir Dehghan MD
Introduction: Response to different antimicrobial agents supports the infection hypothesis for lichen planus (LP). There are individual
case reports describing the improvement of LP with oral metronidazole treatment in patients with concomitant intestinal amebiasis
or giardiasis. There are two small studies that reported metronidazole might be effective in some patients with idiopathic LP who
did not have concomitant protozoal infections of the intestinal or genital tracts. The authors performed an open trial to evaluate the
effectiveness of metronidazole, as a single treatment, on different forms of LP.
Patients and Methods: A total of 49 patients, 24 male and 25 female, were selected from the dermatology outpatient clinic with
a diagnosis of LP in one of its forms. Metronidazole was administered at 250 mg every eight hours daily without any concomitant
therapy. Patients were examined at baseline and at days 21, 42, 63, 84 of treatment, and the follow-up period was three months. The
authors used SPSS software (Version 15) for data analysis.
Results: A total of 20 (40.82%) skin lesions had complete response (CR) to treatment by metronidazole, 16 (32.65%) had relative
healing (PR) and 13 (26.53%) did not improve (NR). The overall treatment response (CR +PR) of LP skin lesions was 73.47 percent in
this study. In mucosal involvement, the overall treatment response was 66.6 percent, and finally the overall treatment response for
itching was obtained in 75 percent of the cases.
Conclusion: Based on the authors’ findings, metronidazole can be an alternative therapy in treatment of LP, and is a safe agent to
Tamoxifen, a triphenylethylethylene, is an adjuvant therapy used for the treatment of oestrogen-receptor positive breast carcinoma due
to its oestrogen receptor antagonist effect.1 We report here a case of rapid onset of hirsutism following administration of tamoxifen.
J Drugs Dermatol. 2011;10(7):799-801.
Uwe Wollina MD, Gesina Hansel Dipl.-Med, Andre Koch MD, Erich Köstler MD
We report on a 12-year-old boy suffering from acne fulminans in combination with Marfan syndrome. The trigger for
acne induction seemed to be a testosterone therapy. The particular therapeutic problems in the present case are
described. No acne keloids were observed but atrophic scars that may be due to Marfan syndrome.
Meredith K. Shaw,a Scott A. Davis MA,a Steven R. Feldman MD PhD,a,b,c and Alan B. Fleischer Jr. MDa
BACKGROUND: Moderate-to-severe psoriasis generally requires systemic therapy, and is often undertreated.
OBJECTIVE: To determine and analyze what courses of treatment and in what frequency are being utilized to combat psoriasis in the
METHODS: Analysis of data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical
Care Survey (NHAMCS) of the National Center for Health Statistics. Data were analyzed to examine the prevalence of different therapy
techniques to combat psoriasis from 1993 through 2010. The trends for phototherapy, methotrexate (MTX), retinoids, cyclosporine A
(CSA), systemic steroids, and biologics were all analyzed over the entire 18-year period and independently before and after the introduction
of biologics in 2002.
RESULTS: From 1993 to 2010, the trend for total systemic treatments has not significantly increased (P=0.5). Frequency of phototherapy
treatments significantly decreased from 1993 to 2010 (P<0.001). Since the introduction of biologics in 2002, their frequency has significantly
increased, becoming the most frequently used treatment from 2008-2010 (P<0.0001).
LIMITATIONS: Severity of psoriasis was not recorded in the NAMCS and NHAMCS.
CONCLUSIONS: The frequency of systemic treatments to treat psoriasis has not significantly increased from 1993 to 2010. Despite the
introduction of biologics, it appears that little progress has been made in reducing under-treatment of moderate-to-severe psoriasis.
J Drugs Dermatol. 2014;13(8):917-920.
David H. Chu, Md, PhD; Elizabeth K. Hale, MD and Perry Robbins, MD
We describe the case of a 71-year-old woman with a six-year history of generalized eruptive keratoacanthomas
on the extremities. We review the diagnostic clinical and histologic features of the rare Grzybowski variant
of generalized eruptive keratoacanthoma. The course of this disease is chronic and often demonstrates a poor
response to therapy.
Teo Soleymani MD,a Janna M. Vassantachart MS4,b and Jashin J. Wu MD FAADc
There are several well-established guidelines for the treatment of psoriasis. Guidelines have been proposed in the United States by the American Academy of Dermatology (AAD), in Europe by the European S3, in the United Kingdom by the National Institute for Health and Care Excellence (NICE), and in Canada by the Canadian Dermatology Association. These guidelines are predominantly evidence-based, supported by expert panel consensus where evidence is lacking. Cyclosporine, a potent calcineurin inhibitor that acts selectively on T-cells, revolutionized the world of immunosuppression upon its discovery in 1970. Since its approval in 1997 by the U.S. Food and Drug Administration for the treatment of psoriasis, cyclosporine has been used with great efficacy in the treatment of not only psoriasis but also a wide consortium of dermatological diseases. However, in the past decade or so, many dermatologists have become increasingly
hesitant to use this important drug because of its potent toxicity profile.
The purpose of this article is to review and compare the current evidence-based guideline recommendations for the use of cyclosporine in the treatment of psoriasis.
Although the various guidelines are similar in their initial treatment recommendations, significant differences exist in recommendations on maximal treatment duration (1 year versus 2 years), intermittent short-term versus continuous therapy, use in erythrodermic and palmoplantar psoriasis, as well as recommendations on managing cyclosporine-associated side effects. By following guideline recommendations,
cyclosporine remains an excellent and indispensable tool for the dermatologist treating moderate-to-severe psoriasis.
J Drugs Dermatol. 2016;15(3):293-301.
Stephen W. Dusza MPH, Ruby Delgado MD, Klaus J. Busam MD, Ashfaq A. Marghoob MD, Allan C. Halpern MD
Objective: To assess the clinical and histologic effects of topical imiquimod therapy on dysplastic nevi, and to determine the
feasibility of using in vivo confocal microscopy (CSLM) to non-invasively monitor histological response of
dysplastic nevi to imiquimod therapy.
Design: Single-blinded pilot study with patients not blinded as to treatment status.
Setting: Dermatology Outpatient Clinic, Memorial Sloan-Kettering Cancer Center, New York, NY.
Patients: The study population comprised of 10 patients with clinically dysplastic (atypical) nevi and at least 8 large nevi,
(?5 mm) on their trunk.
Intervention: Sixteen weeks of imiquimod 5% cream applied to treatment lesions 3 times per week.
Main Outcome Measure: Clinical response as gauged by comparison of baseline and week 20 1:1 standardized photographs
for all study nevi and histological assessment of each patient’s 4 largest study nevi at completion of therapy.
Results: There were no obvious clinical changes in the size and morphology of the study nevi. Subtle changes in nevus color
could not be assessed due to imperfect spectral registration of images over the course of the study. Histologically, 4 of 14 treated
nevi and 0 of 14 untreated nevi p=0.03 showed a significant relative reduction of junctional and intraepidermal nevocytes
accompanied by papillary dermal fibroses and variable inflammation suggestive of partial regression. Non-invasive CSLM
imaging of study nevi demonstrated previously reported in vivo features of dysplastic nevi. but the imaging equipment and
protocol utilized proved inconsistent across lesions and time.
Conclusions: The histological changes seen in a subset of treated nevi suggest a possible role for the use of topical immune
response modifiers for the treatment of dysplastic nevi with the intent of melanoma chemoprevention. The dose regimen of
topical imiquimod utilized in this study failed to induce sufficient clinical or histological responses to warrant further study.
Targeting of dysplastic nevi and intermediate endpoints for melanoma chemoprevention with more intense and/or prolonged
treatment regimens with imiquimod or the use of other immune response modifiers seems promising. Technical improvements
are required for the use of non-invasive CSLM imaging in lieu of invasive histology for the study of topical nevus
Lana N. Pho MD, Mark J. Eliason MD, Michelle Regruto MD, Christopher M. Hull MD, Douglas L. Powell MD
Background: Chronic urticaria (CU) is a cutaneous disease that can be debilitating, difficult to treat, and sometimes life-threatening. Treatment with antihistamines is often ineffective. Immunosuppressants are second line therapy but can have significant side effects. Data is needed on effective therapies with safer profiles.
Objectives: To determine the efficacy and side-effects of colchicine in patients with CU. Methods: Patients were identified through retrospective chart reviews at the University of Utah from 2002-2007. We identified 36 patients with a diagnosis of chronic urticaria based on history, physical examination, and a skin biopsy. Length of treatment ranged from one month to 17 months.
Results: Subjective clinical responses to colchicine therapy reported as complete (n=15) or partial (n=5) were found in 56 percent of patients. The mean±SD duration of treatment was 7±6 months. Three patients (15%) who had resolution of urticaria stopped colchicine secondary to diarrhea and hematuria. Of the complete responders, nine individuals (60%) have remained symptom free and four individuals (27%) had recurrence after colchicine was stopped.
Limitations: Short-term follow-up and retrospective study design.
Conclusions: This retrospective study demonstrated that colchicine was an effective and well-tolerated treatment for patients unresponsive to antihistamines. The data supports the use of colchicine for CU patients and further controlled studies are warranted to better characterize the use of colchicine in patients with CU refractory to antihistamines.
J Drugs Dermatol. 2011;10(12):1423-1428.
Dornechia George MD, Ted Rosen MD
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.
Koichiro Kameyama MD PhD
Background and Objective: Deep heating or denaturation of collagen has been reported to be necessary for nonablative
skin rejuvenation. The purpose of this study was to examine whether thermally damaged collagen is an indispensable factor
to increase the amount of collagen in vivo. Epidermal and dermal responses to infrared light therapy using a Titan source
were examined with the aim of correlating histological and clinical responses in human and amelanotic mouse skin.
Study Design/Materials and Methods: Ten, 20, or 30 J/cm2 infrared light were irradiated on the human subject’s skin
(thigh), while 5, 10, 20, or 30 J/cm2 were used on amelanotic mouse skin. Biopsies were taken and analyzed using hematoxylin
and eosin (H&E) and Elastica von Gieson stain.
Results: Ten or 20 J/cm2 infrared light increased the amount of both collagen and elastin in all layers of the dermis without
denaturing the collagen in human skin. A higher dose of 30 J/cm2 also increased the amount of collagen and elastin,
but denatured the collagen in human skin. (In addition to the thigh, 2 treatments of 10 J/cm2 infrared light improved
skin toning and texture on the subject’s face.) In mouse skin, 5 or 10 J/cm2 remarkably increased the amount of both collagen
and elastin, and of epidermal cells. Twenty or 30 J/cm2 increased the amount of collagen and elastin and the number
of keratinocytes, but caused some vacuolated degeneration of keratinocytes. The presence of denatured collagen was
not evident due to the high density of collagen.
Conclusions: This study shows that the denaturation of collagen is not required to increase the amounts of collagen or
elastin in vivo in human skin. The activation of the mitochondria as well as the denaturation of collagen may play important
roles in infrared phototherapy.
Cutaneous T-cell lymphomas (CTCLs) are a relatively uncommon group of lymphoproliferative disorders in
which a malignant population of T cells is localized to the skin at presentation. Of the 4 classic CTCL phases
(patches, infiltrated plaques, tumors, Sézary syndrome), the majority of patients present with early stage patch
or plaque disease, which can usually be effectively managed using skin-directed therapies. Traditional skindirected
therapies include topical corticosteroids, topical chemotherapeutic agents (mechlorethamine, carmustine),
electron beam therapy (local and total skin), and phototherapy (UV-A, UV-B). Each of these has
demonstrated efficacy in early stage disease; however, with the exception of topical corticosteroids, all have
some disadvantages and are associated with significant adverse events, particularly secondary skin malignancies
and skin damage. Bexarotene is a synthetic retinoid analog that selectively activates retinoid X receptors. In
clinical trials, bexarotene gel demonstrated efficacy for the topical treatment of cutaneous lesions in patients
with stage IA or IB CTCL who have refractory or persistent disease following other therapies or who cannot
tolerate other therapies. Initial evidence indicates that bexarotene gel may be active as first-line therapy in
early stage disease. Its role in combination with other treatments remains to be determined. Topical bexarotene
gel is generally well tolerated and offers patients greater convenience compared with traditional skin-directed
therapies, with a flexible administration regimen. The availability of bexarotene gel provides patients and
physicians with a new skin-directed treatment option for early stage CTCL.
Miriam Hanson MD, Vesna Petronic-Rosic MD
Diltiazem hydrochloride is a commonly prescribed medication in the treatment of cardiovascular disease. A case of diltiazem-induced
hyperpigmentation in a patient after signifi cant sun exposure is reported. The morphological appearance was reticulated and slategray
to blue in color. The pathogenesis of the hyperpigmentation is discussed and possible treatment options are reviewed.
Alan Fleischer MD, Suephy Chen MD
Objective: To examine both the short-term clinical efficacy and quality-of-life changes resulting from treatment of
rosacea with regimens that reflect the participating physicians’ standards of care while incorporating azelaic acid gel.
Design: Longitudinal, open-label, observational study.
Patients: 583 patients with mild to moderate rosacea participated in this study.
Interventions: Patients received azelaic acid gel either alone or in combination with other standard treatment for
rosacea according to each participating physician’s standards of care.
Main Outcome Measures: Change in Investigator’s Global Assessment score, measuring the severity of rosacea
symptoms, from baseline to follow-up, and change in scores on the RosaQoL?, a rosacea-related quality-of-life
instrument with 4 component measures (Overall, Emotion, Symptom, and Function) completed by patients at both
baseline and follow-up.
Results: Over the course of treatment, the mean Investigator’s Global Assessment score dropped from 3.52 to 2.10
(P < .0001). Patients who were prescribed combination therapy had significantly greater improvement than those who
were prescribed azelaic acid gel alone (P < .0001). All 4 components of the RosaQoL? also showed significant
improvement over the course of treatment, regardless of the type of therapy prescribed (P < .0001).
Conclusion: Azelaic acid gel, either alone or in combination with other medications, is efficacious in the treatment of
mild to moderate rosacea, as shown by observational data collected in the clinical setting from both treating physicians
I report a patient with phenylketonuria who presented with pemphigus foliaceus or tinea amiantacea. The rash resolved
with treatment with tetracycline and niacinamide. This article outlines the uses and mechanisms of this therapy with
particular attention to its use in pemphigus, treatments, and scalp findings of pemphigus foliaceus and the dermatological
manifestations of PKU.
Clara Yu DO , Maryam Shahsavari DO , Gloria Stevens MD,Ronald Liskanich DO , David Horowitz DO
Sebaceous hyperplasia is a common benign lesion composed of sebaceous glands. It is characterized as yellow or flesh-toned papules
with central umbilication. The authors report the case of a 57-year-old Caucasian female with a longstanding history of sebaceous
hyperplasia refractory to treatment on her face. Isotretionoin was used as an alternative therapy and was found to be effective.
Andrea Chiricozzi MD,a Francesca Specchio MD,b Annunziata Dattola MD,b Monika Fida MD,c
Luca Bianchi MD,b and Sergio Chimenti MD,b
and Rosita Saraceno MDb
The therapeutic paradigm in psoriasis includes antitumor necrosis alpha agents that have been proved effective and safe as long-term therapy. Recently, it has been described a correlation between the use of biologic agents and the occurrence of monoclonal gammopathies, which are haematological conditions characterized by clonal plasma cells proliferation producing a monoclonal immunoglobulin that accumulates in the blood.
OBJECTIVE: The aim of this study is to detect electrophoretic abnormalities in psoriatic patients undergoing treatment with infliximab.
RESEARCH DESIGN AND METHODS: A retrospective study evaluating all charts from the clinic database of all patients treated with infliximab. The evaluation of serum protein profile is routinely performed in the clinical setting during biologic therapies. We reported the occurrence MGUS in infliximab-treated patients.
RESULTS: The study analysis included 141 charts. Overall, 23 patients showed a MGUS in their electrophoretic profile, though in 6 cases MGUS was detected at the baseline. Thereby, 17 cases (12.06% of the study population) developed MGUS during infliximab therapy.
CONCLUSIONS: Serum protein electrophoresis test represents a useful tool to detect and monitor any potentially harmful condition that could occur during treatment with a biologic agent. Particularly, it could be crucial for the detection of MGUS, which does not affect clinical response, and it does not represent a criteria to withdraw the treatment.
J Drugs Dermatol. 2016;15(2):134-138.
Reena Jogi MD, Mary Garman MD, Josie Pielop MD, Ida Orengo MD, Sylvia Hsu MD
Although cutaneous reactions from antineoplastic therapy are common, a reticulate pattern of hyperpigmentation has
not been frequently reported in the literature. We report 2 cases of reticulate hyperpigmentation associated with cancer
chemotherapy with 5-fluorouracil and idarubicin. These 2 cases serve to raise awareness of this particular pattern
of hyperpigmentation as a potential side effect of chemotherapeutic regimens.
Jeaneen A. Chappell MD, Nicole M. Burkemper MD, Natalie Semchyshyn MD
Sorafenib, a multitargeted kinase inhibitor used for the treatment of unresectable hepatocellular carcinoma and advanced renal cell
carcinomas, received FDA approval in 2005. Since its introduction to the market, there have been various dermatologic side effects
reported in the literature, the most well known being hand-foot skin reaction. This article presents a case of an atypical localized
cutaneous eruption with an unusual course and protracted resolution time associated with sorafenib therapy.
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.
Michael Jude Welsch, MD
Acute pustular psoriasis is characterized by fiery-red erythema followed by formation of pustules. Precipitating
factors include drugs, infections, pregnancy, solar irradiation, and psychological stress. We present a case of a
woman who developed acute onset of pustular psoriasis precipitated by hydroxychloroquine therapy and systemic
steroids. The patient’s course was complicated by leukocytoclastic vasculitis presumptively caused by levofloxacin.
Mary Elizabeth Lott MD, Daniel J. Sheehan MD, Loretta S. Davis MD
Pæcilomyces lilacinus (P. lilacinus) is a saprophytic fungus with increasing prevalence as a source of infection in the immunosuppressed
patient population. We report a P. lilacinus infection with a sporotrichoid pattern spreading in a renal transplant
recipient that responded to itraconazole therapy. There was no recurrence at 3 years follow-up.
Jeffrey M. Weinberg, MD; Ritu Saini, BA and William D. Tutrone, BS
Over the last several years, a new generation of therapies for psoriasis has been in development. These biologic
therapies target the activity of T lymphocytes and cytokines responsible for the inflammatory nature of this
disease. In this review, we present an update on the progress of the four biologic agents in the forefront: infliximab,
etanercept, efalizumab, and alefacept. The mechanism of each drug will be reviewed, as well as the most
recent efficacy and safety data.
Craig L. Leonardi MD,a Kristina Unnebrink PhD,b and Wendell C. Valdecantos MDc
INTRODUCTION: We evaluated post hoc the relationship between Humira® (adalimumab) therapy and high-sensitivity C-reactive protein (hs-CRP) levels in patients with moderate-to-severe hand and/or foot psoriasis from the 16-week placebo-controlled period of REACH.
METHODS: REACH was a phase 4, multicenter, randomized, double-blind trial, evaluating adalimumab treatment for patients with psoriasis of the hands and/or feet. Adults were randomized 2:1 to adalimumab 40 mg every other week (following 80 mg at week 0) or matching placebo from weeks 1 to 16, followed by a 12-week, open-label extension. In this post hoc analysis, changes in hs-CRP were reported as observed from baseline to week 16.
RESULTS: Of the 72 patients (23 placebo, 49 adalimumab) who participated in REACH, 63 (19 placebo, 44 adalimumab) with hs-CRP measurements at baseline and at week 16 were included in this analysis. Baseline median hs-CRP values were 1.6 mg/L (placebo) and 2.2 mg/L (adalimumab), and were 3 times higher for patients with, as compared with those without, psoriatic arthritis (5.45 vs 1.8 mg/L). At week 16, the adalimumab group showed greater improvements (median reduction) from baseline than the placebo group in hs-CRP overall (−0.55 vs +0.10 mg/L), regardless of achievement of PGA of the hands and/or feet (hfPGA) 0 or 1 at week 16 (−0.80 vs 0 mg/L for patients who achieved hfPGA 0/1; −0.40 vs +0.30 mg/L, patients who did not achieve hfPGA 0/1), baseline psoriatic arthritis history (−2.35 mg/L with history [adalimumab group; no history for placebo group]; −0.40 vs +0.10 mg/L without history), and body mass index (BMI) category (defined by median BMI) (−0.80 vs +0.20 mg/L for BMI <30.28 kg/m2; −0.40 vs 0 mg/L for BMI ≥30.28 kg/m2).
CONCLUSION: Treatment with adalimumab 40 mg every other week resulted in greater overall reductions in hs-CRP levels among patients in this post hoc analysis, compared with placebo at 16 weeks regardless of baseline characteristics.
ClinicalTrials.gov Registry for REACH: NCT00735787
J Drugs Dermatol. 2016;15(5):562-566.
Background: Atopic dermatitis (AD) is a common chronic relapsing disease particularly affecting children. The emollient used for protection of skin barrier function is the standard treatment for patients with AD. Currently, there is a growing interest in the use of nonsteroidal anti-inflammatory agents such as dexpanthenol (vitamin B5) as an alternative treatment.
Objective: To compare the effectiveness of 5% dexpanthenol (DT) ointment with 1% hydrocortisone (HC) ointment in childhood AD therapy.
Method: Patients were treated topically with 5% DT ointment on the right side of the body and 1% HC ointment on the other side twice daily for 4 weeks. The clinical responses were evaluated by SCORAD (Scoring Atopic Dermatitis index) with statistical analysis using paired t-test.
Result: Of the 30 children enrolled, 26 completed the protocol; mean age was 7.19 years. The average baseline SCORAD score of the DT-treated side and the HC-treated side was 30.95 and 30.54, respectively. There was no statistically significant difference in SCORAD score reduction between the 2 agents. The edematous score of the HC-treated side exhibited faster resolution than that of the DT-treated side, with a statistically significant difference at week 1 and without a statistically significant difference at weeks 2 to 4. The lichenification response rate of HC treatment was more rapid than that of DT treatment; however, there was no statistical group difference. No adverse events were observed with either agent.
Conclusion: The effectiveness of 5% DT ointment is equal to that of 1% HC ointment. DT ointment may be used as alternative treatment in mild to moderate childhood AD therapy.
J Drugs Dermatol. 2012;11(3):366-374.
David R. Berk MD, Arthur Z. Eisen MD
Erythromelalgia is characterized by episodes of erythematous, warm, burning acral skin, which is exacerbated by heat and
relieved by cold. Erythromelalgia usually affects the feet and/or hands but, although rare, erythromelalgia may affect the
ears. The authors present a 65-year-old woman with erythromelalgia of the ears with disabling symptoms whose diagnosis
was delayed for 6 years. The patient failed to respond to numerous therapies before rapidly improving with oral amitriptyline
and amitriptyline 1% to 2% and ketamine 0.5% to 1% topical gel.
Brad A. Yentzer MD, Hilary Baldwin MD, Alan R. Shalita MD, Guy Webster MD, Steven R. Feldman MD PhD
Acne vulgaris can cause both physical and emotional scarring. Effective treatment requires an understanding of acne pathogenesis and the key elements of keratinocyte differentiation and comedone formation, sebum production, colonization with Propionibacterium acnes (P. acnes) and subsequent inflammation. Addressing issues of compliance is critical for good outcomes, and newer combination therapies help improve adherence to daily therapy.
Grace Sun MD, Carina A. Wasko MD, Sylvia Hsu MD
Tumor necrosis factor-alpha (TNF-?) antagonists are used to treat many autoimmune disorders including Crohn’s disease,
ulcerative colitis, rheumatoid arthritis, and more recently, psoriasis. The adverse effects of the treatment regimen for psoriasis
are not as well documented as those for Crohn’s disease and rheumatoid arthritis. We report the development of acne
vulgaris in 3 patients with psoriasis after initiating anti-TNF-? therapy.
Ryan R. Bogner,a Elizabeth K. Blixt MD,b Alison J. Bruce MB ChB,b,c and Gabriel F. Sciallis MDb,c
We report two cases of doxycycline-induced solar urticaria that developed shortly after initiation of therapy with persistence despite discontinuation. Consequently, dermatologists should be aware of the association between doxycycline and solar urticaria and counsel their patients on the potential for this side effect when prescribing doxycycline.
J Drugs Dermatol. 2015;14(11):1358-1359.
Jennifer J. Lee MD, Thomas F. Downham II MD
Bullous pemphigoid (BP) is an acquired autoimmune disease characterized by subepidermal vesicles and bullae. The etiology
for BP is mostly idiopathic with the highest occurrence in elderly patients; however, it is now well-accepted that BP has
been triggered by or associated with drug therapy. We present a case of furosemide-induced bullous pemphigoid and review
the literature of drug-induced bullous pemphigoid (DIBP).
Robert Baran, MD and Aditya K. Gupta, MD, PhD, FRCP(C)
It is widely accepted that there is a finite failure rate when treating onychomycosis; a case report from the author serves as an example of multiple failures following treatments of varying duration and combinations, including oral-local, then oral-oral therapies. This article discusses the results obtained by authors who have varied the standard duration of therapy, increased the dosage of the oral antifungal agents, or have used two oral drugs in treating this condition.
Leon H. Kircik MD and James Q. Del Rosso DO
Introduction: Psoriasis is one of several systemic diseases that presents chiefly with cutaneous symptoms and has the potential
to negatively impact patients' overall health and quality of life. Physicians who treat patients with psoriasis must be cognizant of the
chronic, lifelong character of the disease and of the potential for multisystem pathology. According to the National Institutes of Health
(NIH), between 5.8 and 7.5 million persons in the U.S.-approximately 2.2% of the population-have psoriasis; worldwide, it affects
an estimated 125 million people. The annual cost of treating psoriasis may exceed $3 billion annually. Immunologic mechanisms are
now accepted as the pathophysiologic basis for the development of psoriatic disease. Treatment strategies-which include topical
treatment, phototherapy, methtrexate, cyclosporine and acitretin-also encompass several biologic agents that target immune mediators
associated with the condition.
Discussion: Patients with mild disease may obtain symptomatic relief with topical agents and targeted phototherapy. Patients with
moderate-to-severe disease are likely to benefit from systemic therapy. Shortcomings of the traditional agents, particularly their
adverse event profiles, have motivated research and development of biologic agents. Currently three anti-TNF agents - etanercept,
infliximab and adalimumab - are FDA-approved for treatment of psoriasis. Differences exist among study designs and, therefore,
in interpretation of data; however, the improvements observed in the psoriasis study populations participating in clinical trials are
dramatic. Long-term clinical data continue to accumulate and demonstrate sustained benefits with anti-TNF agents. Safety data also
continue to be collected over the long-term; key safety considerations are infection, cytopenia, demyelinating disease, lupus-like
syndromes, congestive heart failure and malignancies. Combination therapy should also be considered when managing psoriasis for
such reasons as augmenting an inadequate response to monotherapy or improving tolerability. Combination therapy with an anti-TNF
agent and phototherapy has shown considerably higher rates of response compared with either intervention alone.
Objective: The objective of this paper is to critically examine the anti-TNF studies to assess the efficacy and safety of the agents
in patients with psoriasis and determine applicability of the data in clinical practice. In light of the chronic nature of this disease, the
emphasis will be on the longest-term data available.
Conclusion: The treatment of plaque psoriasis with TNF-α antagonists is still a relatively recent addition to the pharmacologic armamentarium
available to clinicians. The collection of long-term data is, therefore, small but growing as results from newer studies
emerge. From the data reviewed here, the clinician can attempt to arrive at a satisfactory assessment of the benefits and risks of
treatment with these agents.
Christine S. Ahn BA,a Farah Awadalla MD,e Karen E. Huang MS,a Brad Yentzer MD,a
Tushar S. Dabade MD,a,d and Steven R. Feldman MD PhDa,b,c
BACKGROUND: Psoriasis is a chronic disease that significantly impacts patients’ quality of life. It most commonly manifests as localized disease, for which there are various treatment options.
OBJECTIVE: To determine the prescription patterns of topical corticosteroids and vitamin D analogs for the treatment of psoriasis in the United States and how their use has changed over time.
METHODS: Data from the National Ambulatory Medical Care Survey (NAMCS) from 1994 to 2010 were queried for visits linked with a psoriasis diagnosis. Prescriptions for topical corticosteroids and vitamin D analogs were described. Vitamin D analogs usage was compared across physician specialties. For each sampled visit reported in the NAMCS, visits meeting our inclusion criteria that also mentioned the following medications were identified: topical calcipotriene, topical calcipotriene/betamethasone or any topical corticosteroid indicated for the treatment of psoriasis.
RESULTS: There were an estimated 2.05 million psoriasis visits per year over the 1994-2010 interval. Dermatologists were responsible for 67% of these encounters followed by family practice (14%) and internal medicine (11%). Dermatologists prescribed a vitamin D product at 15% of psoriasis visits, followed by family physicians at 12%, and internists at 5%. Dermatologists prescribed calcipotriene, calcipotriene/betamethasone, and topical corticosteroids in 15%, 4% and 59% of psoriasis visits, respectively. Over time, there was no significant change in the use of topical steroids or vitamin D products by physicians.This study is limited by the inability to determine the severity of psoriasis from the data collected, and the lack of data on the length of treatment with different medications.
CONCLUSIONS: Despite their demonstrated efficacy and safer side effect profile, vitamin D analogs are used less often than topical corticosteroids for the treatment of psoriasis. These findings suggest that vitamin D products may not be utilized to their fullest potential as effective topical therapy or adjuncts to therapy for localized plaque psoriasis.
J Drugs Dermatol. 2013;12(8):906-910.
Background and Objective: Many tinea inguinalis infections are characterized by pronounced inflammatory lesions and pruritus.
Therefore, a therapy with a topical corticosteroid in addition to a topical antimycotic agent might be beneficial. In this multicenter,
retrospective study, we compared the mycological and clinical efficacy and tolerability of isoconazole nitrate alone vs isoconazole
nitrate and diflucortolone valerate in 58 adult patients with tinea inguinalis.
Patients and Methods: Treatment duration was three weeks. The efficacy of the treatment was based on the assessment of
several signs and symptoms, which were collected on a 4-point scale. All patients were examined clinically before the beginning
of the treatment, one week later, two weeks later, and at the end of the treatment. Mycological examinations were performed
before the beginning of the treatment and at the end of the study.
Results: Treatment results with the combination of isoconazole nitrate and diflucortolone valerate were superior regarding erythema
and pruritus. Both erythema and pruritus resolved in a larger percentage of patients and more quickly. Both regimens were
well tolerated. Mycological cure rates were similar in both groups of patients.
Conclusions: Combination therapy with isoconazole nitrate and diflucortolone valerate is an effective and well-tolerated regimen
in adult patients with tinea inguinalis.
J Drugs Dermatol. 2012;11(11)e70-e73.
Morgan L. Wilson MD, Lindsay D. Sewell MD, Christen M. Mowad MD
Primary cutaneous infection with Cryptococcus neoformans is uncommon, but can occur following an inoculation injury
to the skin. Tumor necrosis factor-alpha (TNF-?) is important in the immune response to Cryptococcus, and patients taking
inhibitors of TNF-? may have increased susceptibility to cryptococcal infection. We report a case of primary cutaneous
cryptococcosis in a patient taking adalimumab, methotrexate, and hydroxychloroquine for rheumatoid arthritis.
Infliximab is a chimeric monoclonal antibody, which acts by binding to both the soluble and membrane-bound tumor necrosis factor-a. In clinical practice, it is used as either monotherapy or in combination with other systemic therapies, particularly methotrexate. This study reviews clinical response and adverse events in 120 psoriasis patients with moderate-to-severe psoriasis who have received infliximab for a minimum of one year. The medical records of 120 infliximab-treated psoriasis patients at our referral psoriasis clinic in Dallas between 2002-2008 were reviewed for response rates, side effects and concomitant therapies. Of 120 charts reviewed, 112 (93%) patients had plaque type psoriasis, six (5%) had recalcitrant palmoplantar disease and two (1.6%) had severe acropustulosis of Hallopeau. Eighty-four (70%) patients had symptomatic psoriatic arthritis. The mean follow-up time was 2.2±1.1 years. One hundred and nine (91%) of the 120 patients had clearance of their psoriasis (response of more than 90% of initial BSA) at a median time of 12 weeks. Concomitant systemic treatments, primarily methotrexate, were given to 62 (52%) patients. Nineteen patients (16%) discontinued infliximab in the post-one-year treatment period for a variety of reasons, primarily failure to maintain adequate response. One hundred and four (87%) of patients required more than the standard dose of 5 mg/kg every eight weeks to maintain clearance. Infliximab either as monotherapy or in combination with traditional antipsoriatic agents is an effective and well-tolerated treatment option
for patients with moderate to severe psoriasis and psoriatic arthritis on therapy for over one year and continuing for the long term.
J Drugs Dermatol. 2011;10(5):539-544.
David Rosmarin MD, Anne LaRaia MD, Scott Schlauder MD, Alice B. Gottlieb MD PhD
A 61-year-old-female with a 4-year history of disseminated granuloma annulare was successfully treated with the antitumor necro-
sis factor (TNF)-alpha antibody, adalimumab. The patient had failed high potency topical glucocorticoids, hydroxychloroquine, and
narrow-band ultraviolet light (UV)-B phototherapy. Anti-TNF-alpha therapy may be a therapeutic option in patients with disseminated
granuloma annulare poorly controlled with conventional medications.
Zahida Khan Maskatia BS, John Koo MD
Psoriasis rebound after efalizumab discontinuation is well-documented in the literature. We report the case of a patient
who experienced psoriasis rebound 2 months after efalizumab discontinuation, despite being on more than 5 mg/kg/day
of cyclosporine. This case illustrates an instance where high doses of a very efficacious antipsoriasis therapy were not sufficient
to prevent efalizumab-associated rebound. In addition to describing this case, we also propose a theoretical mechanism
to explain how rebound after efalizumab discontinuation comes about.
Periorbital hyperpigmentation (POH) is a common worldwide problem. It is challenging to treat, complex in pathogenesis, and lacking straightforward and repeatable therapeutic options. It may occur in the young and old, however the development of dark circles under the eyes in any age is of great aesthetic concern because it may depict the individual as sad, tired, stressed, and old. While “dark circles” are seen in all skin types, POH is often more commonly seen in skin of color patients worldwide.1 With a shifting US demographic characterized by growing number of aging patients as well as skin of color patients, we will encounter POH with greater frequency. As forecasted by the US Census, by 2030 1 in 5 Americans will be 65 plus years old and greater than 50% of the population will possess ethnic skin of color.2 The disparity in the medical community’s understanding of POH versus popular demand for treatment is best illustrated when you have only 65 cited articles to date indexed on PubMed line3 compared to the 150,000,000 results on Google search engine.4 Most importantly POH may be a final common pathway of dermatitis, allergy, systemic disorders, sleep disturbances, or nutritional deficiences that lends itself to medical, surgical, and cosmeceutical treatments. A complete medical history with ROS and physical examination is encouraged prior to treating the aesthetic component. Sun protection is a cornerstone of therapy. Safety issues are of utmost concern when embarking upon treatments such as chemical peeling, filler injection, and laser therapy as not to worsen the pigmentation. Without intervention, POH usually progresses over time so early intervention and management is encouraged. The objective of this study was to review the current body of knowledge on POH, provide the clinician with a guide to the evaluation and treatment of POH, and to present diverse clinical cases of POH that have responded to different therapies including non-ablative fractional photothermolysis in two skin of color patients.
J Drugs Dermatol. 2014;13(4):472-482.
Philip R. Cohen MD, Keith E. Schulze MD, Bruce R. Nelson MD
Methotrexate-related hematologic toxicity may include leukopenia, thrombocytopenia, megaloblastic anemia, and
pancytopenia. We report a woman with hypertensive renal disease who was receiving hemodialysis and developed
pancytopenia following a single intradermal infiltration of 25 mg of methotrexate. Caution should be exercised
when considering the use of either systemic or intralesional methotrexate therapy in patients with risk factors that
have been implicated in the development of adverse hematologic side effects: renal dysfunction, possible drug interactions,
and advanced age.
Ming H. Jin, MD; Arash Kimyai-Asadi, MD and William R. Lewis. MD
A 25-year-old man with a history of mid-borderline (BB) Hansen's disease developing a reversal reaction after starting dapsone and rifampin therapy is presented. His clinical features included erythematous, edematous plaques and peripheral neuropathy. Reversal reactions are caused immunologically by enhanced cell-mediated (Th-1) immunity to Mycobacterium leprae, resulting in inflammation of infected tissues, such as skin and nerves. Acute neuritis can lead to permanent nerve damage and necessitate prompt treatment with prednisone and/or clofazamine.
Aditya K. Gupta MD PhD FRCPC FAADa,b and Radhakrishnan Pillai PhDc
BACKGROUND: Transungual nail penetrance has traditionally been considered to be the only route of delivery for topical antifungals in onychomycosis. Subungual penetrance may be an alternate route of delivery.
OBJECTIVE: To evaluate the ability of efinaconazole vehicle solution to reach the site of toenail onychomycosis through application to the hyponychium or hyponychium and dorsal nail surface, and assess the impact of the air gap between the nail plate and nail bed.
METHODS: Twenty-three participants with moderate to severe, mycologically-confirmed onychomycosis were enrolled (mean age, 48.5 years). Two separate applications of vehicle solution containing fluorescein for visualization were applied at the hyponychium or hyponychium
and dorsal nail surface. Affected nails were later clipped to allow examination of the nail bed and further examination of the ventral surface of the nail. Spread of formulation was assessed under visible and UV light conditions by photographing target toenails after vehicle application and after nail clipping.
RESULTS: There was a positive correlation between the size of the air gap and degree of affected nail involvement (R2=0.064). Assessments
under both visible and UV light indicated that the vehicle had spread to the site of infection, with deposition of fluorescein wherever vehicle had reached, irrespective of application methodology or size of air gap. Nail clippings also indicated absorption into the ventral surface of the nail plate.
LIMITATIONS: The relative contributions of subungual versus transungual application of drug to the nail plate to the efficacy of efinaconazole
topical solution, 10% in treating onychomycosis were not assessed.
CONCLUSIONS: This study suggests that the low surface tension vehicle developed for efinaconazole topical solution, 10% can reach the site of infection by application to the hyponychium, dorsal or ventral nail surface and nail folds. This multidirectional approach to drug delivery at the site of fungal infection may contribute to the magnitude of efficacy seen in clinical trials.
J Drugs Dermatol. 2015;14(8):859-863.
Evren Odyakmaz Demirsoy MD,a Rebiay Kıran MD,a Selma Salman MD,a Çiğdem Çağlayan MD,b
Aysun Şikar Aktürk MD,a Dilek Bayramgurler MD,a and Nilgün Bilen MDa
BACKGROUND: Nails, one of the most visible sites of body, are frequently involved in psoriasis and accepted as the most difficult site for topical treatment because of their anatomical structure. Healing of the psoriatic nails usually occurs when systemic therapy is initiated to treat severe skin psoriasis or joint involvement, but sometimes systemic therapy is essential for severe nail psoriasis, although Psoriasis Area and Severity Index (PASI) score is low or none of the joints are affected. In this case, knowing which systemic agent is most potent on nail findings is important.
AIM: We aimed to evaluate the effect of systemic antipsoriatic agents on nail findings.
METHODS: Eighty-seven psoriatis patients with fingernail involvement who required systemic treatment but had not used any systemic treatment in the previous 12 weeks were included in this study. Different systemic treatment agents were given to patients, considering factors such as age, sex, and joint involvement, but not nail involvement. The control group was recruited from psoriatis patients with nail involvement who were not receiving any systemic treatment. Baseline and week 16 Nail Psoriasis Severity Index (NAPSI) and PASI were detected in all groups. At the end of the study, effects of the agents on both PASI and NAPSI were compared statistically.
RESULTS: Patients were divided into 5 groups to receive either: 1) methotrexate, 2) narrow-band ultraviolet B phototherapy, 3) biological agents, 4) acitretin, or 5) no treatment (control group). None of the conventional treatment agents caused any significant difference on NAPSI at the end of week 16 compared with control group, although PASI decreased significantly. Rate of NAPSI changes were more prominent in the biological treatment group, and a statistically significant difference was detected when compared with the control group.
J Drugs Dermatol. 2013;12(9):1039-1043.
Daniel W. Collison MD
Clarence S. Livingood and his mentors, Pillsbury and Sulzberger, wrote the Manual of Dermatology, a book that was the dermatologic
handbook of choice for thousands of medical officers in World War II. By virtue of its wide distribution among a
variety of physicians practicing in the medical boom of the 40s, 50s, and 60s, this book (and its formulary) was one of the
most influential dermatologic texts of the 20th century. Livingood would repeat the strategies employed in writing this book
over and over in his long career advancing dermatology among American medical specialties.
Irbesartan, an angiotensin II receptor antagonist(AIIRA), is an antihypertensive agent that inhibits the activity of angiotensin II by selectively binding to angiotensin II type 1 (AT1) receptors. The new onset of sustained periorbital, facial, and neck edema following the initiation of irbesartan therapy is described in a hypertensive 52-year-old woman. The patient's edema was not life threatening, remained unchanged following discontinuation of the medication, and persisted when treatment with the drug was subsequently reinstituted. Facial edema is a very uncommon adverse event that may occur in patients receiving irbesartan.
Neal Bhatia MD, Timothy Wallace MD, Ajit Divgi MD, Vicky Short CMA
We report a case of an elderly female in remission from acute myelogenous leukemia that presented with a nonhealing enlarging
asymptomatic nodule on her right thigh. A wide excision of the nodule and histological examination revealed myeloid
sarcoma without evidence or overlap of leukemia cutis, which had been suspected from nodules that had developed early
in the course of the disease. The patient subsequently underwent radiation therapy to the area with sustained clearance.
Tejaswi Mudigonda BS, Tushar S. Dabade MD, Steven R. Feldman MD PhD
Background: 308 nm excimer laser phototherapy is efficacious in the treatment of localized psoriasis. Different approaches regarding
dose fluency, number of treatments, and maintenance have been utilized, and there is yet to be a consensus on standard protocol.
Objective: To characterize treatment parameters for 308 nm excimer laser phototherapy.
Methods: We performed a PubMed search for studies describing excimer laser treatment protocol with particular attention to dosage
determination, dose adjustment, dose fluency, number of treatments, and maintenance.
Results: Seven prospective studies were found describing the excimer efficacy for psoriasis. All studies determined the initial treatment
dose using either the minimal erythema dose (MED) or induration. Fluency ranged from 0.5 MED (low) to 16 MED (high); one study demon-
strated that medium to high fluencies yielded better improvement in fewer number of treatments. Fluency adjustments during the course
of treatment were important to minimize phototherapy-associated side effects. The use of higher fluencies was reported to result in higher
occurrences of blistering. One study implemented a maintenance tapering of dose-frequency phase to better manage psoriasis flare-ups.
Conclusion: The 308 nm excimer laser is an effective therapy for psoriasis regardless of the method used to determine initial dosage,
dose fluency, or number of treatments. As its usage as a targeted monotherapy increases, future trials should consider evaluating and
modifying these parameters to determine the most optimal management of localized psoriasis. Based on our reviewed studies, there is
no consensus for a single excimer laser therapy protocol and as a result, patient preferences should continue to be an important consid-
eration for phototherapy regimen planning.
J Drugs Dermatol. 2012;11(1):92-97.
Thomas Lambert BA, Kimberly Mullinax MD, Jennifer Smith MD
A 73-year-old Caucasian male was treated in the dermatology clinic for squamous cell carcinoma (SCC) of the scalp by
Mohs micrographic surgery. The patient subsequently received radiation therapy because of possible calvarium invasion.
Approximately 2 years later, the patient developed Bowen’s disease within the previously irradiated skin flap. The lesion was
treated with topical 5-fluorouracil (5-FU) twice daily for 4 weeks, and subsequently developed a 2 x 2 cm full-thickness
ulceration with exposed calvarium.
Emil Tanghetti MD,a Sunil Dhawan MD,b Lawrence Green MD,c Mark Ling MD PhD,d Jeanine Downie MD,e Marguerite A. Germain MD,f J. Scott Kasteler MD,g Leon Kircik MD,h Michael G. Oefelein MD,i Zoe Draelos MDj
Background: Acne pathogenesis is multifactorial and includes inflammation. Combining drugs targeting multiple components of
acne pathogenesis is standard practice.
Objective: To assess the safety and efficacy of dapsone gel 5%, an anti-inflammatory agent, in combination with tazarotene cream
0.1% for treatment of acne vulgaris.
Methods: Patients were randomized to receive combination therapy (dapsone gel 5% twice-daily plus tazarotene cream 0.1% daily)
or monotherapy (tazarotene cream 0.1% daily). Efficacy and safety data were collected after 1, 2, 4, 8, and 12 weeks of treatment.
Results: Patients in both arms (n=86, dapsone + tazarotene; n=85, tazarotene) showed significant reductions from baseline in inflammatory,
noninflammatory and total lesion counts (P<.001 for all). At 12 weeks, patients treated with dapsone plus tazarotene
showed a greater reduction from baseline in noninflammatory (comedonal) and total lesion counts than tazarotene-treated patients
(noninflammatory, 59.7 percent vs. 46.5 percent, P=.01; total, 63.3% vs. 53.6%, P=.02). The percentage of patients achieving treatment
success (an investigator subjective score of 0 [none] or 1 [minimal]) was greater in dapsone plus tazarotene-treated patients
(42.2%) than in tazarotene-treated patients (21.8%;P=.01). Both treatments were well tolerated.
Conclusion: Combination therapy with dapsone gel 5% plus tazarotene cream 0.1% was more effective than tazarotene monotherapy
for treatment of comedonal acne. The results suggest that anti-inflammatory agents such as dapsone can effectively treat
early stages of acne (both comedonal and noncomedonal) when used in combination with a retinoid.
J Drugs Dermatol. 2011;10(7):783-792.
Molly Wanner MD MBA, Mathew Avram MD JD
Cellulite, a skin surface change that is nearly ubiquitous in women, is a condition that remains elusive to treatment. In
fact, no treatment is completely successful as none are more than mildly and temporarily effective. Despite the lack of
evidence to support efficacy, treatment options continue to proliferate. This article will briefly review the currently available
data about cellulite treatments including noninvasive devices such as massage, radiofrequency, and laser and lightbased
treatments; invasive modalities including liposuction, mesotherapy, and subcision; and other treatments including
topical creams and carboxy therapy.
Lissy Hu BA,a Christina Alexander BA,b Nicole F. Velez MD,c F. Clarissa Yang MD,c
Alvaro Laga Canales MD MMSc,c,d Stephanie Liu MD,c and Ruth Ann Vleugels MD MPHc,
Topical tacrolimus has been observed to induce granulomatous rosacea (GR) in prior case reports and series. In most cases, patients recover fully after withdrawing tacrolimus and initiating doxycycline or minocycline. Herein, we describe a case of severe GR, which required further therapy. Clinicians should be aware of this rare complication because of the frequent use of topical tacrolimus.
J Drugs Dermatol. 2015;14(6):628-630.
Omar M. Alakloby MD, Salih H. AlJabre PhD, Mohammad Akram Randhawa PhD, Alhusain J. Alzahrani PhD, Khalid M. AlWunais MD, Iqbal A. Bukhari MD
Background: Herpes zoster (HZ), caused by varicella zoster virus (VZV), initially produces chicken-pox, then the virus
lies dormant in the dorsal root ganglia. The virus can reactivate after many years and results in HZ along ganglion’s distribution.
Old age, trauma, stress, diabetes mellitus, and immune suppression are important risk factors for the reactivation.
Herpes zoster is characterized by unilateral radicular pain and vesicular eruption that is generally limited to the
dermatome innervated by the affected ganglion. In immunocompromised individuals, disseminated zoster may develop.
The aims of therapy in HZ are to control pain or reduce its severity by the use of analgesics, reduce the duration and eruption
of new lesions, and prevent complications, particularly postherpetic neuralgia (PHN) by appropriate anti viral therapy.
Methods: All cases of HZ seen in the dermatology clinic at King Fahd Hospital of the University (KFHU) from 1988 to
2006 were included in the study. Their diagnoses were based on the clinical presentation. The following parameters were
collected and analyzed: age, sex, nationality, symptoms, dermatomal distribution, complications, coexisting diseases, and
Results: Of 22 749 new cases seen in the dermatology clinic over 18 years, 141 were HZ, with an occurrence of 0.62%.
Male to female ratio was 2:1 and the age ranged from 14 months to 80 years. The thoracic dermatomes were the most
commonly involved. The most frequent coexisting disease was diabetes mellitus, and the most common complication of
HZ was PHN. Most patients with HZ ophthalmicus developed eye complications.
Conclusion: The occurrence of HZ is 0.62% in patients reporting to the dermatology clinic of the hospital. Males are
little more affected than females. The thoracic dermatomes are the most frequently involved. Diabetes mellitus is the most
frequent coexisting disease. Postherpetic neuralgia is the most common complication of HZ.
Jonathan Weiss MD,a Linda Stein Gold MD,b Matthew Leoni MD,c Maria Jose Rueda MD,d Hong Liu Msc,c and Emil Tanghetti MDe
BACKGROUND: More effective therapies are needed in the specific treatment of severe inflammatory acne vulgaris.
OBJECTIVES: To demonstrate superior efficacy of adapalene 0.3%-benzoyl peroxide 2.5% gel (0.3% A/BPO) vs. vehicle, and to assess efficacy of 0.3% A/BPO vs. 0.1% A/BPO in subjects with severe inflammatory acne (Investigator’s Global Assessment [IGA] of 4) in the context of a larger trial in a moderate and severe population.
METHODS: This was a multicenter, randomized, double-blind, parallel-group, 12-week study. Subjects were randomized to receive 0.3% A/BPO, 0.1% A/BPO (benchmark) or vehicle (comparator) once daily for 12 weeks. Co-primary efficacy endpoints were success rate at week 12 (percentage of subjects rated “clear” or “almost clear,” ≥3-grade IGA improvement), and change in inflammatory (IN) and noninflammatory (NIN) lesion counts from baseline to week 12. Secondary efficacy endpoints were percent changes in IN and NIN lesion
counts. Safety endpoints were incidence of adverse events (AEs) and local tolerability signs/symptoms.
RESULTS: In the severe inflammatory acne population, a total of 252 subjects were randomized with 106, 112 and 34 subjects in the 0.3% A/BPO, 0.1% A/BPO and vehicle groups, respectively, reaching a high rate of study completion (88.5%). At week 12, both 0.3% A/BPO and 0.1% A/BPO were superior to vehicle in terms of lesion count reduction. However for success rate, only 0.3% A/BPO achieved significantly greater efficacy over vehicle with a treatment difference of 20.1% (31.9% vs. 11.8%; 95% Confidence Interval (CI): [6.0%, 34.2%], P=.029), whereas 0.1% A/BPO did not (treatment difference vs. vehicle of 8.8%; P=.443). This translates to an 11% difference between active treatments in favor of 0.3% A/BPO. Also, 0.3% A/BPO was safe and well tolerated.
CONCLUSIONS: Availability of this new treatment option should allow clinicians to better customize severe inflammatory acne management,
and the high-strength product provides a step-up treatment when needed.
J Drugs Dermatol. 2015;14(12):1427-1435.
Anthony Rossi MD,a,d Rebecca Lu MD,a Melissa K. Frey MD,d Takako Kubota MD,c
Lauren A. Smith MD,e and Maritza Perez MDa,b
BACKGROUND: Keloids can be quite resistant to conventional methods of treatment. A wide range of treatment modalities exists, often
with suboptimal results, recurrences, and adverse events occurring. Laser therapy with the carbon dioxide, erbium:YAG, Q switched
frequency doubled neodymium-doped yttrium aluminium garnet (Nd:YAG), and 585/595 nm pulsed dye lasers have all be purported as
potential treatment modalities however with limited efficacy and data especially in the skin of color population is limited. We report the
successful use of the 300 microsecond 1064 nm Nd:YAG laser in treating keloids in patients with skin types ranging from Fitzpatrick I
through VI with special attention in treating skin of color patients.
OBJECTIVE: We examined the use of the 300 microsecond 1064 nanometer (nm) Nd:YAG laser for the treatment keloids in patients with
skin types ranging from Fitzpatrick I through VI.
METHODS & MATERIALS: A retrospective analysis of treatment efficacy was conducted on 44 patients with keloids. Three separate
treatment groups were compared. The groups consisted of: a “control group” in which the whole keloid was only treated with intralesional
corticosteroid (triamcinolone 10mg/cc) (16 patients); a “laser only” group in which the patient’s keloid was only treated with the
1064nm Nd:YAG laser at a fluency of 13 to 18 Joules / centimeter2 (J/cm2), a fixed pulse duration of 300 microseconds, 5mm spot size,
and a total of 2000 pulses (14 patients); and a “combination group” that received both the aforementioned laser therapy and adjuvant
intralesional triamcinolone (14 patients).
RESULTS: Patients in the "combination group" treated with the 300 microsecond 1064nm Nd:YAG laser therapy plus intralesional
corticosteroid and the "laser only" group both were observed to have durable clinical reduction in the thickness and erythema of the
keloids. These results were shown to be superior to the "control group" whom were only treated with intralesional corticosteroids.
Only mild and transient post treatment erythema was noted as an adverse effect.
STATISTICAL ANALYSIS: Data analysis was performed using IBM SPSS Statistics 19.0.0 (Armonk, NY). In order to assess the statistical
significance of differences in keloid improvement among the three treatment groups, The Kruskal-Wallis test (non-parametric ANOVA
test) was applied. The level of statistical significance was set at P<0.05. A statistically significant difference in keloid improvement was
appreciated between treatment groups (P<0.0001).
LIMITATIONS: A small sample size and the retrospective nature of the analysis are limitations to the study.
CONCLUSION: The 300 microsecond 1064nm Nd:YAG laser proved effective in improving the clinical appearance of keloids. We recommended
this laser protocol in conjunction with intralesional corticosteroids as a treatment option for patients with keloids, especially
in the skin of color population. The 1064nm Nd:YAG laser did not show post inflammatory hyperpigmentation nor hypopigmenatation,
which are concerns for skin types IV to VI, and therefore is a suitable option for such patients.
J Drugs Dermatol. 2013;12(11):1256-1262.
Tatjana Pavicic MD, Thomas Ruzicka MD, Hans-Christian Korting MD, Gerd Gauglitz MD MMS
Human immunodeficiency virus (HIV)-associated facial lipoatrophy (FLA) represents a common and highly stigmatizing side effect of
retroviral therapy. By causing loss of subcutaneous adipose tissue mainly in the cheek, temple and periocular area, FLA can significantly
affect the patient’s quality of life, both physically and psychologically. A limited quantity of data has been published on various
filling substances for the management of FLA. Here, the authors present two patients with HIV-associated FLA successfully treated
with a novel HA filler over a period of 24 months.
Fitza Singh, BA and Jeffrey M. Weinberg, MD
Psoriasis is a chronic skin disorder that affects approximately 2% of the US and European population. Over the last several years,
one of the major focuses in psoriasis research has been the development of novel biologic therapies for this disease. The aim of these
therapies is to provide selective, immunologically directed intervention, with the hope that such specificity will result in fewer side
effects than traditional therapies. In addition to these therapies, there are also oral medications in development for psoriasis. The
goal of this article is to review oral tazarotene, a novel retinoid, and oral pimecrolimus, a novel macrolactam therapy, for the treatment
of moderate to severe psoriasis.
Background: Although the exact pathogenesis of vitiligo is not fully understood, it appears to be an autoimmune disease. It is hypothesized
that tumor necrosis factor alpha (TNF-α) plays an important role in vitiligo. TNF-α can destroy melanocytes through the induction
of various apoptotic pathways. In addition, TNF-α can inhibit melanocyte stem cell differentiation.
Objective: To evaluate the efficacy and safety of treating vitiligo patients with anti-TNF-α agents.
Methods: A total of 6 patients were recruited. All patients had widespread non-segmental vitiligo. Biologics, including infliximab,
etanercept, and adalimumab, were given according to treatment regimens used for psoriasis. Photographs were taken at the initial
visit, every two months during the therapy and then six months after therapy completion.
Results: All patients completed the treatment; two patients were treated with infliximab, two with etanercept, and two with adalimumab.
All of the biologics were well tolerated throughout the treatment period, and none of the patients reported any significant
adverse events. Digital images were compared before, during and after treatment. Repigmentation of the vitiliginous areas was not
observed in any of the patients. Vitiligo worsened in one patient who was treated with infliximab and developed a psoriasiform rash.
However, the remaining patients did not develop any new depigmented patches during treatment or at the six-month follow-up; vitiligo
was considered stable in these five patients.
Conclusions: Although the anti-TNF-α agents were well tolerated in all six vitiligo patients, efficacy was not observed. Further evaluation
with larger studies may be required.
J Drugs Dermatol. 2012;11(4):534-539.
Lionel Resnick MD, Harold Rabinovitz MD, David Binninger PhD, Maria Marchetti PhD, Herbert Weissbach PhD
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
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.
Alice B. Gottlieb MD PhD,1 Robert E. Kalb MD,2 Richard G. Langley MD,3 Gerald G. Krueger MD,4
Elke M.G.J. de Jong MD PhD,5 Lynn Guenther MD,6 Kavitha Goyal MD,7 Steven Fakharzadeh MD PhD,7
Marc Chevrier MD PhD,7 Stephen Calabro MS,7 Wayne Langholff PhD,8 Alan Menter MD9
BACKGROUND: Long-term data are essential to assess the safety of biologic agents for the treatment of psoriasis.
OBJECTIVE: To evaluate the incidence of adverse events of interest (AEIs), including all-cause mortality, major adverse cardiovascular
events (MACE), malignancy (excluding nonmelanoma skin cancer), and serious infections (SI), in patients treated for psoriasis in
clinical practice settings.
METHODS: PSOLAR is a large, ongoing, observational study of patients receiving, or eligible to receive, biologic or systemic therapy
for psoriasis. Cumulative incidence rates of AEIs per 100 patient-years (PY) are reported across treatment cohorts: (1) infliximab, (2)
ustekinumab, (3) other biologics (eg, adalimumab and etanercept), and (4) non-biologic agents. Significant predictors of each AEI were
identified using Cox proportional hazards regression methodology.
RESULTS: PSOLAR is now fully enrolled at 12095 patients followed for 31818PY. The cumulative rate was 0.46/100PY for death,
0.36/100PY for MACE, 0.68/100PY for malignancy, and 1.50/100PY for SI. Increasing age was a significant predictor of all AEIs. A history
of cardiovascular disease, malignancy, and significant infection was associated with a higher risk of developing MACE, malignancy,
and SI, respectively. Exposure to infliximab (Hazard Ratio [HR]=3.101, P<0.001) and exposure to other biologics (HR=1.736, P<0.001)
were significant predictors of SI. Use of immunomodulators (HR=1.954, P=0.005) was a significant predictor of MACE. Compared with
non-biologic therapy, the use of biologic agents was not a significant predictor of death, MACE, or malignancy.
CONCLUSIONS: Based on PSOLAR data through 2013, no new safety concerns were observed with infliximab for all-cause mortality,
MACE, or malignancy; the data suggest that infliximab was associated with serious infections.
J Drugs Dermatol. 2014;13(12):1441-1448.
Here we present the first case of a patient from Ottawa Canada, presenting with leprosy-like illness associated with Mycobacterium lepromatosis. The patient had no history of travel to leprosy-endemic areas or any obvious risk factors. Clinically, the patient presented with an anesthetic maculopapular rash on the trunk, back, and extremities. A skin biopsy of a lesion revealed a dermal lymphohistiocytic
infiltration involving the vessels with an inflammatory process extending to the nerves. A neurological exam also identified a severe sensorimotor polyneuropathy. Concurrently, the patient was diagnosed with non-resectable, non small cell carcinoma of the lung, further complicating his clinical presentation. A Kinyoun stain of nasal blows and a Fite stain of the skin biopsy revealed few to moderate acid fast bacilli respectively. Cultures of the skin biopsy and multiple nasal blows were negative. Molecular studies of a skin biopsy sample including sequence analysis of a 765 bp region of the 16s rRNA gene eventually identified the organism with 100% homology to M. lepromatosis. The patient was treated for leprosy and appeared to improve slightly on therapy but died as a result of his malignancy approximately five months after the initiation of therapy. This represents the first case of a patient with M. lepromatosis like illness outside of Mexico and Singapore.
J Drugs Dermatol. 2012;11(2):229-233.
Lena Samuel MS, Eve J. Lowenstein MD PhD
Recombinant human interferon beta-1b is an immune-modulatory drug used for a variety of conditions including multiple
sclerosis (MS). Skin reactions to therapeutic use of injectable interferon beta-1b are relatively common, including injection
site reactions and exacerbation of underlying skin disease. Injection site reactions are seen much more frequently in females.
We discuss a case of prolonged susceptibility to injection site reaction with over a decade of use of interferon beta 1-b for MS.
Given the prevalence of such reactions, the dermatologist should be aware of the phenomenon and that it frequently does
not necessitate discontinuation of therapy.
Geoffrey F. S. Lim BS,a Catherine Y. Ding MD,b Katy Burris MDb
Leuprolide acetate, a gonadotropin-releasing hormone agonist, is used in the treatment of prostate cancer. We report a unique case of a disseminated papular rash following leuprolide acetate injections in a 65-year-old man that shares clinical and histopathological features of papuloerythroderma of Ofuji. Leuprolide-induced papuloerythroderma, as well as a limited number of other disseminated cutaneous eruptions caused by this drug, is extremely rare, with only one case previously reported. Our case calls attention to this uncommon side effect in a commonly used hormonal therapy.
J Drugs Dermatol. 2014;13(6):755-757.
Nikhil G. Rao, BA and Robert J. Pariser, MD
Annular erythema is an unusual, often idiopathic disorder that tends to respond poorly to topical therapy.
Two patients with idiopathic, topical corticosteroid-resistant annular erythema showed prompt clearing of
lesions treated with 0.1% tacrolimus ointment and persistence of untreated ones which themselves responded
to subsequent treatment.
These two cases demonstrate a clear-cut therapeutic response of chronic, topical corticosteroid-resistant annular
erythema to topical tacrolimus ointment 0.1% BID. Additional experience with tacrolimus ointment, hopefully
in controlled circumstances, should clarify its potential value in treating annular erythema.
Progressive pigmented purpura (PPP) is a group of dermatoses that are benign and usually self-limited. However, they may
persist for months or years with frequent recurrences. Numerous treatments have been tried, but no effective therapy has yet
proven to be successful. This report documents the treatment of a patient with one subtype of PPP using ascorbic acid and
a bioflavonoid rutoside given orally. A 42-year-old male with biopsy-proven Eczematoid-like Purpura of Doucas and
Kapetanakis was treated with ascorbic acid 500 mg twice a day and a bioflavonoid rutoside 50 mg twice a day. Treatment
was successful, with quick defervescence of the rash and no recurrence to date.
Background: Acne vulgaris is a common skin disease that affects 70% to 96% of individuals. Topical benzoyl peroxide has
been used successfully for acne treatment; however, it may be accompanied by drying and or flaking skin. The addition of
a 10% urea to the product excipient is theorized to moisturize the skin due to its humectant properties, aid in the efficacy
of benzoyl peroxide due to its keratolytic properties, and effectively combat Propionibacterium acnes due to its
Objective: To assess the efficacy and tolerability of the treatment of acne vulgaris with multiple strengths of benzoyl
peroxide in a 10% urea vehicle gel or cream and cleanser.
Methods: A multicenter, non-randomized, open-label study in which 1,089 patients with acne vulgaris were enrolled at
133 participating physician office sites. Qualifying and consenting patients were prescribed either 4.5% or 8.5% benzoyl
peroxide in a 10% urea vehicle cream or gel and cleanser. Additional medications were permitted during the study with the
exception of those containing benzoyl peroxide. The physician assessed lesion counts, both inflammatory and non-inflammatory,
at baseline and Week 4. Dryness and erythema were rated by the physician on a scale from 0 (none) to 8 (severe or
deep) at baseline and Week 4.
Results: Nine hundred sixty-three patients completed the study. The following significant treatment arms were analyzed:
patients treated with 4.5%/8.5% benzoyl peroxide in a 10% urea vehicle product only, patients treated with 4.5%/8.5% benzoyl
peroxide in a 10% urea vehicle products along with oral doxycycline, and patients treated with 4.5%/8.5% benzoyl
peroxide in a 10% urea vehicle products along with oral minocycline. A 44% (n=567) mean reduction in total lesion count
was observed after 4 weeks of treatment with 4.5%/8.5% benzoyl peroxide in a 10% urea vehicle products only. Dual
therapy using oral doxycycline (n=17) proved to be even more effective with a significant mean reduction in lesion count of
52% after only 4 weeks of treatment. Dual therapy using oral minocycline (n=21) yielded a significant mean reduction in
lesion count of 34% after 14 weeks of treatment. The overall tolerability of the treatment illustrated the utility of urea as a moisturizing agent.
Conclusion: Benzoyl peroxide in a 10% urea vehicle gel or cream and cleanser, used once daily for 4 weeks found to be both effective and well tolerated for the treatment of symptoms related to acne vulgaris.
Monique Kademian MD, Mark Bechte MD, Matt Zirwas MD
Nicotinamide is the amide form of niacin and has anti-inflammatory properties that have led to its use in the treatment
of several inflammatory dermatologic conditions, such as rosacea. Niacin has established its role in the prevention of coronary
artery disease. Cutaneous flushing is a well-known and often dose-limiting side effect of niacin therapy, which does
not occur with nicotinamide. We report a patient with rosacea who developed new onset flushing due to unauthorized
substitution of niacin for nicotinamide. The anti-inflammatory mechanisms of nicotinamide and flushing mechanisms of
niacin are discussed.
The repair and maintenance of the epidermal barrier is of the utmost importance in the treatment of atopic dermatitis (AD). While barrier
creams and emollients are considered to be a foundation of AD therapy, there is little comparative data between various product options.
This was a pilot study with a small sample size to investigate the use of skin barrier emulsion cream vs a commonly used moisturizing
lotion to improve the epidermal barrier in subjects with atopic dermatitis.
J Drugs Dermatol. 2014;13(12):1482-1484.
Joseph English, III, MD; Kenneth E. Greer, MD; Sara A. McCrone, MD James W. Patterson, MD and J. Scott Vanloock, MD
Allergic granulomatous vasculitis, or Churg-Strauss syndrome, is a small-vessel, multisystem vasculitis that
can affect the skin, lungs, heart, and nervous system. Recent reports have implicated leukotriene receptor
antagonists and inhaled corticosteroids in the development of this rare syndrome. We present a patient with
no history of allergic asthma who acutely developed skin-limited Churg-Strauss-like granulomatous
vasculitis after initiating therapy with inhaled fluticasone and salmeterol (Advair Diskus).
Benjamin B. Hayes MD PhD, Robert H. Cook-Norris BS, Jami L. Miller MD, Adrian Rodriguez MD, John A. Zic MD
In the last several years, amantadine has been increasingly prescribed for akinesia in Parkinson’s disease and to combat
fatigue associated with multiple sclerosis. Amantadine is a well-known medication involved in drug-induced livedo reticularis
(LR),1 yet remains under-reported in the English literature. We describe 2 patients with amantadine livedo reticularis:
one patient with multiple sclerosis had, previous to this eruption, tolerated 4 years of amantadine therapy without adverse
reactions and another patient with Parkinson’s disease who developed LR 1 month after starting amantadine.
Vidya Rajpara MD, Stacy Frankel MD, Cindy Rogers MD, Keyvan Nouri MD
Trichophyton tonsurans is an uncommon cause of tinea corporis, and an even more uncommon cause of Majocchi’s
granuloma. We report a patient who developed tinea corporis with Majocchi’s granuloma from T. tonsurans infection.
Immunocompromised hosts are predisposed to develop cutaneous fungal infections, as was the case with this
patient. Majocchi’s granuloma is a rare complication with immunosuppression, but is significant to consider when
a fungal infection is suspected because it may require more aggressive therapy.
Christina Lee Chung MD, Carrie Ann Cusack MD
Wells syndrome, also known as eosinophilic cellulitis, is an uncommon condition whose etiology often remains a mystery.
Patients present with recurrent cutaneous swellings that are often cellulitic in appearance. Histopathologic evaluation of the
skin lesions reveals a dense dermal eosinophilic infiltrate, marked edema, and characteristic “flame figures.” Notably, the picture
is devoid of vasculitis. Therapy with low-dose systemic steroids has proven variably successful. Clinical evidence lending
support for the efficacy of other medications has been, for the most part, anecdotal. We present a case of Wells syndrome,
review the literature, and discuss therapeutic options.
Tejaswi Mudigonda BS, William Kaufman MD, and Steven R. Feldman MD PhD
Severe atopic dermatitis can have an enormous impact on a child and the child’s caregivers. Topical corticosteroids can be highly effective,
but not all patients respond. If atopic dermatitis does not improve with a topical corticosteroid, poor adherence should be strongly considered as the cause of treatment failure. We report a child with horrendous atopic dermatitis whose disease resolved rapidly in the hospital when therapy was changed to a product that was easier to apply.
J Drugs Dermatol. 2016;15(1):114-115.
Kathleen M. Casamiquela BAa and Philip R. Cohen MDa-c
Combination chemotherapy is associated with cutaneous and mucosal side effects. Antineoplastic agents have been associated with mucosal and nail pigmentation. We describe a 16-year-old Saudi Arabian girl with combination chemotherapy-associated black tongue hyperpigmentation and blue lunula. The diagnosis of drug-associated pigmentary changes is based on correlating the onset of the clinical observations with the temporal initiation of the patient's chemotherapy agents. Spontaneous fading of antineoplastic therapy-induced tongue or nail dyschromia may subsequently occur following discontinuation of the causative drug.
J Drugs Dermatol. 2013;12(2):223-226.
Melanie R. Clemenz MD, Joseph Wilson McGowan IV MD, Marshall J. Shuler MD, and Annette W. Lynn MD
We report a case of hemolytic anemia in a female patient with juvenile dermatomyositis. Rapidly progressive hemolysis developed during prednisone and azathioprine combination therapy 4 days after completing intravenous immunoglobulin (IVIG) treatment. While the blood smear revealed spherocytes and polychromasia, direct and indirect antiglobulin tests were negative. In the following case report, we propose probable IVIG-induced hemolytic anemia and explore the pathomechanisms that may account for hemolysis.
J Drugs Dermatol. 2013;12(1):111-113.
Catherine N. Tchanque-Fossuo MD MS,a,b,* Derek Ho BS,a,b,* Sara E. Dahle DPM MPH,b,c Eugene Koo MS,a R. Rivkah Isseroff MD,a,b and Jared Jagdeo MD MSa,b,d
BACKGROUND: Diabetic foot ulcers (DFU) represent a significant complication of diabetes mellitus (DM). DFU affect one in four patients
with DM and treatments of DFU are limited and challenging. The management of DFU remains a significant healthcare and socioeconomic
burden ($245 billion). There is a wide range of advanced therapies for DFU, but these are costly and have demonstrated only
minimal efficacy in limited published studies. An emerging treatment modality to improve DFU and optimize wound healing is the use
of low-level light therapy (LLLT). LLLT involves the use of light in the form of low-level or low-power laser or light emitting diodes to alter
biochemical pathways, which may result in changes to cell shape, cell migration, and cell signaling.
OBJECTIVE: To review published clinical experiences (case series and case reports) using LLLT for treatment of DFU, and provide
evidence-based recommendations and future directions on the potential of LLLT as a therapeutic modality for DFU.
METHODS AND MATERIALS: On January 16, 2016 we searched the published literature using databases: PubMed, EMBASE, CINAHL,
and Web of Science with key terms: “diabetic foot” AND (“low level laser therapy” OR “low level light therapy” OR “LLLT” OR “light
emitting diode” OR “phototherapy” OR “laser”).
RESULTS: After screening of titles, abstracts and/or full-text, 7 original articles were suitable in our review. Our review contains 5 case
series and 2 case reports that evaluated LLLT for treatment of DFU, and all reviewed studies have shown positive improvement of DFU
using LLLT with no adverse events, albeit with limitations that may be minimized with future RCTs.
CONCLUSIONS: LLLT is an emerging and promising treatment modality to current alternatives that are costly and have shown limited
success. Based upon the published evidence, we envision additional research may allow for stronger recommendation with LLLT for
treatment of DFU.
J Drugs Dermatol. 2016;15(7):843-848.
Joanne E. Smucker BSa and Joslyn S. Kirby MDb
Riehl melanosis is a rare cause of skin hyperpigmentation that typically occurs on the face and neck and is characterized by the rapid onset of gray-brown reticular pigmentation. It is theorized to be a pigmented contact dermatitis or a lichenoid immune reaction that may be caused by intrinsic as well as extrinsic factors. Treatment is challenging; laser and intense pulsed light (IPL) therapy is a common treatment for other pigmented skin conditions. IPL has been reported twice for the treatment of Riehl melanosis and we report a case of Riehl melanosis successfully treated with q-switched Nd:YAG after proving recalcitrant to IPL treatment.
J Drugs Dermatol. 2014;13(3):356-358.
Hypopigmented patches and plaques are a rare presentation of cutaneous sarcoidosis. We describe a case of generalized hypopigmented cutaneous sarcoidosis that showed good response to minocycline therapy.
J Drugs Dermatol. 2012;11(3):385-389.
Jason S. Ballin DO and Nathan S. Uebelhoer DO
To date, reports on the safe and effective treatment of severe inflammatory facial acne with the low-fluence 1064 nm Nd:YAG
laser are limited. The authors report a case of treatment for severe inflammatory acne in a pregnant Asian female (Fitzpatrick
skin type IV) with the low fluence 1064 nm Nd-YAG laser. These findings suggest that this modality may be a safe, effective, and well-tolerated alternative for patients with acne who have contraindications to the use of systemic anti-acne therapies.
Zülal Erbagci MD, A. Almıla Tuncel MD, Ibrahim Erbagci MD
Porokeratosis is a group of cutaneous disorders of keratinization characterized by a predisposition to malignant transformation.
The condition, which may be associated with immune suppression, is usually resistant to therapy and has a high frequency
of recurrence. Imiquimod, a potent topical immune response modifier with antiviral, antitumor, and immunoregulatory
properties, is currently approved for the treatment of external anogenital warts and actinic keratosis. However, there
have been also several reports demonstrating its efficacy in a variety of premalignant and malignant conditions. We report
on 2 cases with immunosuppression-associated porokeratosis successfully treated with 5% topical imiquimod application.
Acne vulgaris is a chronic inflammatory cutaneous disease and is the most common skin disease in the United States, affecting 80% of the population at some point in their lifespan. Because the pathogenesis of acne is not fully understood, it is imperative that the dermatology healthcare practitioner expand their medical knowledge on the current understanding of the development of this condition so that effective treatment strategies may be explored and initiated with confidence. There is need for dermatologists to expand their knowledge of the rationale for combination therapy for the treatment of inflammatory acne, and to understand the efficacy of fixed dose combinations in the reduction of inflammatory and non-inflammatory acne lesions and acne severity and the reduction in skin irritation and dryness.
George Cohen MD and Annyce Treherne MD
The advent of highly active anti-retroviral therapy (HAART) has extended the lives of patients affected by human immunodeficiency
virus (HIV) disease. A common cutaneous side effect of HAART is facial lipoatrophy. The hollowed out cheeks, temples and eye
sockets often lead to a gaunt cachetic facies which can be a disconcerting stigmata of the disease and a psychological burden to
the patient. Autologous fat transfer (ATF) is a minimally invasive surgical procedure that can temporarily improve the appearance in
patients with facial lipoatrophy. Other corrective procedures (e.g., injectable fillers) are available, but, to date, the ideal procedure for
permanent correction of facial lipoatrophy has not been found.
Kimberly J. Butterwick MD, Lorren S. Butterwick, Amy Han MD
Acne rosacea is a multifactorial, somewhat mercurial disorder that can be a challenge to control with standard
pharmacologic agents. Laser and light sources have been increasingly utilized, particularly for control of the generalized
erythema, flushing, and telangiectasia of rosacea. This paper will review the clinical studies presented in the literature
specifically treating patients with rosacea. Long-pulsed dye lasers and intense pulsed light devices can offer patients effective
treatment without the purpura of short-pulsed dye lasers. Long-term efficacy has not been studied but maintenance therapy
may be necessary to control the vascular manifestations of this disease.
Allergan's Tazorac is at the Vanguard of the Next Generation of Topical Retinoids
Over the last 4 decades, topical retinoids have become standard therapy for the treatment of acne vulgaris. Although the market currently encompasses multiple formulations of next-generation topical retinoids, Tazorac is unique among them due to its dual role as a treatment option for both acne vulgaris and psoriasis vulgaris. Tazorac has also demonstrated that it is highly effective for the treatment of acne vulgaris as a monotherapy or in combination with other agents. Recent studies show that Tazorac can be combined effectively with dapsone 5% gel or with a benzoyl-peroxide - containing formulation to augment efficacy. Additionally, Tazorac does not have a generic substitution, so physicians can be assured that their patients will receive exactly what they have been prescribed.
Salma Z. Pothiawala MD MPH, Brooke T. Baldwin MD, Basil S. Cherpelis MD, L. Frank Glass MD, Neil Alan Fenske MD
Phototherapy is well-recognized as effective therapy in early stage cutaneous T-cell lymphoma (patch and plaque), often resulting in complete clearance of clinical disease and subsequent remission. Although not curable, long-term remission can often be attained utilizing maintenance phototherapy, consisting of a course of less frequent treatments over time. Herein, the authors review the literature regarding the role of maintenance phototherapy in cutaneous T-cell lymphoma (CTCL) and its success in prolonging clinical remission and disease-free survival in CTCL.
Georgia Schuller-Levis MD,a William Levis MD,b and Israel Dvoretzkyc
Prior studies have identified local heat therapy as a treatment for recalcitrant warts. We have employed a thermal pad that raises local temperature to 42-43ºC for at least 2 hours in a proof of concept study of three patients with recalcitrant warts. The recalcitrant warts cleared in all three patients beginning in the fourth and fifth weeks after daily treatment with the pads. There were no adverse events. We conclude that the timing of clearance following use of these thermal pads is likely via direct viral killing and immunologic mechanisms. Further controlled trials are underway.
J Drugs Dermatol. 2014;13(10):1194-1196.
Yasuhiro Horiuchi MD, SangJae Bae MD, Ichiro Katayama MD
Treatment of prurigo nodularis (PN) is often very difficult even with strong corticosteroid dressing and other available
means. Macrolide roxithromycin (RXM) is used in consideration of its immunosuppressive effects in treating several skin
disorders. Tranilast (N-(3,4-dimethoxycinnamoyl) is useful for treating atopic disorders and hypertrophic scars as well, suggesting
its capacity to inhibit fibroblast proliferation. More adequate and effective therapy for this disorder has been requested.
We report 3 cases of uncontrollable PN treated with 300 mg/day roxithromycin and 200 mg/day tranilast. Complete
and/or remarkable regression of PN was observed on treatment with roxithromycin and tranilast in combination within 4 to
6 months. The 2 agents in combination can be used effectively for the treatment of uncontrollable PN.
Lucia Seminario-Vidal MD PhD, Wendy Cantrell DNP, and Boni E. Elewski MD
Tofacitinib is a novel drug that inhibits the JAK-STAT signaling pathway. It has been approved for the treatment of psoriatic arthritis and it is under investigation for the treatment of psoriasis and other inflammatory disorders. We report a case of pulmonary cryptococcosis in an otherwise immunocompetent patient taking tofacitinib for psoriasis. We hypothesized that tofacitinib contributed to this infection through inhibition of cytokines required for differentiation of T cells and suppression of macrophage activation. As dermatologists begin to use this drug they should be aware of the potential for cryptococcocal infection, because delay of diagnosis may increase the risk of a life-threatening outcome.
J Drugs Dermatol. 2015;14(8):901-902.
Lisa Prussick BSc,a,b Natalia Plotnikova MD,a and Alice Gottlieb MD PhDa,b
Atopic Dermatitis (AD) is a chronic inflammatory skin disease that is a significant cause of morbidity, quality-of-life impairment and health-care costs. Although many patients can be treated satisfactorily with topical medications and phototherapy, a smaller subset requires more aggressive systemic therapies. Multiple studies have shown promise for the use of mycophenolate mofetil (MMF) to treat refractory AD. This report summarizes the evidence for use of MMF in the treatment of recalcitrant AD for both children and adults. Familiarity with these studies on the benefits and risks of MMF will enable the clinician and patient to select the most appropriate therapy.
J Drugs Dermatol. 2016;15(6):715-718.
Christina Shwereb, Eve J Lowenstein MD PhD
Benzoyl peroxide (BP) has been a standard and effective topical treatment for acne vulgaris for the past 35 years. Previous studies
and case reports have documented benzoyl peroxide to be a strong irritant and a weak allergen, with many cases of tolerance induced
with repeat use of this irritant. While less common, numerous cases of BP-induced allergic contact dermatitis (delayed type hypersensitivity
reaction) have been reported in the literature. We report here an individual with an incipient edematous reaction to topical
BP used for acne therapy. This under-recognized presentation is discussed in the context of published literature on BP-induced
hypersensitivity and irritation.
Joshua L. Owen BS, Isha E. Lopez MD, and Seemal R. Desai MD
Vemurafenib, a BRAF inhibitor, is FDA-approved for the treatment of metastatic melanoma in patients who harbor the BRAF V600E
mutation. By inhibiting BRAF, vemurafenib prevents the mitogen-activated protein kinase (MAPK) pathway from driving melanoma
growth. Here we present a patient with paradoxical activation of the MAPK pathway by vemurafenib, ultimately resulting in deleterious
cutaneous manifestations. An emphasis on close follow-up is warranted for new or changing lesions for patients on this
medication and other BRAF inhibitors.
J Drugs Dermatol. 2015;14(5):509-510.
S Gupta MD, NM Gandhi MD, J Ferguson MD
A 61-year-old patient who had been treated with lisinopril in the past without any problems was commenced on ramipril for left ventricular
dysfunction. He developed a painful symmetrical purpuric eruption over both feet after three days. A full vasculitis screen
was negative. Ramipril was stopped and he required a course of steroids after which the rash improved slowly.
The ACE inhibitors can cause various skin side effects; however, it rarely causes cutaneous vasculitis. Ramipril-induced cutaneous
vasculitis is particularly rare and our case was atypical because the patient had tolerated lisinopril before. Previous successful treatment
with one ACE inhibitor does not rule out the vasculitis caused by the drug from the same group.
Here we report ramipril-induced cutaneous vasculitis in a patient who required steroid therapy to control it.
John L. Meisenheimer MD
CD30+ cutaneous lymphoproliferative disorders, the second most common cutaneous T cell lymphoma after mycosis fungoides,
represent a spectrum of conditions ranging from lymphomatoid papulosis to borderline CD30+ lesions to anaplastic
large-cell lymphoma. We report the case of a solitary cutaneous CD30+ lymphoproliferative nodule that was successfully
treated with a 308-nm excimer laser. Our findings suggest that the 308-nm excimer laser may be a safe, effective, and welltolerated
therapy for primary localized CD30+ cutaneous lymphoproliferative lesions.
Jason Chouake MD,a Aimee Krausz BA,b Brandon L. Adler BA,b Hillel W. Cohen PhD MPH,c
Joshua D. Nosanchuk MD,d,e and Adam Friedman MDb,f
IMPORTANCE: There is currently no data detailing the degree to which dermatologists follow CDC/Infectious Diseases Society of America
(IDSA) guidelines in the treatment of abscesses, which recommend that incision and drainage (I+D) as primary therapy for skin and
soft tissue infections (SSTI).
OBJECTIVE: To evaluate the management of skin abscesses by dermatologists.
DESIGN, SETTING, PARTICIPANTS: A national email survey of 780 dermatologists was conducted from May-June 2012. Awareness, experience,
and preparedness of respondents for abscess treatment, as well as the treatment practices in different clinical scenarios were
evaluated. Response rate = 65% (n=510). Eligibility criteria: board certified/eligible dermatologists practicing in US. Main practice affiliation:
solo (20%), group (33%), university health system/academic (32%), multi-specialty (13%), and other (2%). Main practice setting:
urban (49%), suburban (42%), and rural (9%).
MAIN OUTCOME and MEASURES: Practitioner report of: awareness of national guidelines, use of I+D in initial management of uncomplicated
abscess found on face, trunk, and extremity on patients age 6 months, 3, 15, 50, and 80 years, and use of antibiotics in the
RESULTS: 99% of respondents were capable of performing I+D in their practice. The IDSA recommends cultures in all patients treated with
antibiotic therapy, and does not recommend antibiotics for the treatment of simple abscess. 18% of respondents reported culturing abscesses
less than 50% of the time, while 91% incorporated antibiotics into initial treatment. Nearly a quarter (24%) of respondents would
choose an initial antibiotic that would not cover Methicillin-resistant Staphylococcus aureus (MRSA). For facial abscesses, as the age of
the patient increased from infant, respondents were more likely to incorporate I+D into their initial treatment. For abscesses on the trunk
and extremities, respondents were less likely to I+D infants and toddlers, compared to adolescents, adults and the elderly.
CONCLUSION: Although most dermatologists were prepared to manage uncomplicated abscesses (98%), this survey identifies gaps in
clinical standards of care established by the CDC/IDSA. Identification of these practice gaps may impact physician practice and dermatology
residency curricula, and may serve to improve abscess management and antibacterial stewardship in the outpatient setting.
J Drugs Dermatol. 2014;13(2):119-124.
Joshua A. Zeichner MD, Rita V. Patel MD, Madelaine Haddican MD, and Vicky Wong BS
Combination therapy addressing multiple pathogenic factors should be used to achieve optimal outcomes in treating acne. The following
study demonstrated both safety and efficacy of fixed-dose clindamycin phosphate 1.2%/benzoyl peroxide 2.5% in the morning with micronized
tretinoin 0.05% gel in the evening. Both products were applied to the skin following the use of a ceramide containing moisturizing lotion.
J Drugs Dermatol. 2012;11(6):748-752
Hobart W. Walling MD PhD and Brian L. Swick MD
Fixed drug eruption (FDE) is an uncommon medication-induced cutaneous reaction. A case of fluconazole-induced FDE is described.
A 64-year-old woman presented with eight ovoid hyperpigmented patches on the arms, palm and lower leg that had recurred multiple times at the identical sites at seemingly random intervals over the prior six months. The clinicopathologic diagnosis strongly favored FDE, though the culprit medication remained elusive. Further evaluation and oral rechallenge confirmed the diagnosis of FDE
to fluconazole. The patient had not related the eruption to this medication due to the short courses of therapy and prior use without incident. FDE to fluconazole has only been rarely reported in the literature. The presentation and evaluation of FDE is reviewed.
Hobart W. Walling, MD, PhD; Michael Messingham, MD; Laura M. Myers, MD; Camille L. Mason, MD and John S. Strauss, MD
Acanthosis nigricans (AN) is an eruption of hyperpigmented, velvety thickened patches, often with papillomatosis, that occurs symmetrically
on any body site but most commonly at the axillae, neck, groin, and flexural surfaces. We report a case of a 55-year-old
obese male who developed acanthosis nigricans with striking papillomatosis and tripe palms who experienced improvement on a
long-term tapering dosage of isotretinoin, with additional benefit with the addition of metformin. While oral retinoids have been
reported to positively impact AN, improvement of AN with metformin has been reported in only two prior cases. Combined therapy
with isotretinoin and metformin for AN has not been reported previously.
Topical antifungal treatment is a mainstay of therapy for Seborrehic Dermatitis (SD). Although the amidazole and ciclopyridine antifungals have been extensively studied, few clinical efficacy data are available for topical allylamine therapy in SD. The objective of
this open-label exploratory study was to evaluate the efficacy and safety of natifine HCl 1% gel applied twice daily for 4 weeks, as
topical treatment of moderate SD of the scalp. Nine subjects (5 men, 4 women) with a mean age of 56 (33-81) years with SD of
the scalp were enrolled and made 4 visits to the site. At Visit 1 (Week 0), subjects were screened, enrolled, baseline efficacy data
were obtained, and treatment was initiated. Subjects returned at Week 2, Week 4 (end of treatment), and Week 6 for efficacy and
safety assessments. Efficacy was evaluated by changes from baseline in investigator-rated scores on 0-5-grade scales: (1) SD Global
Evaluation Scale (SDGES), (2) Erythema Severity Scale, (3) Scaling Severity Scale, (4) % Scalp Involvement Scale, and subject-rated
scores on the (4) Itching Severity Scale, and (5) Global Improvement Scale, where 0=none and 5=most severe. Mean severity
scores for the SDGES and % Scalp Involvement scales progressively declined (improved) 66% and 54% from respective baseline
levels at Week 6. Mean erythema rating decreased 38% from baseline and scaling decreased 50% from baseline by Weeks 4 and 6.
Itching improved in 5 of 9 (56%) subjects by the end of treatment. A total of 8 of 9 (89%) subjects rated their symptoms as improved
from baseline at the end of treatment and Week 6. There were no treatment-related adverse events during the study. These results
suggest that naftifine 1% gel applied twice daily for 4 weeks is effective and safe topical treatment for moderate SD of the scalp.
J Drugs Dermatol.2012;11(4):514-518.
Lucija Kroepfl MBChBa and Jason J. Emer MDb
Acne is one of the most prevalent skin conditions seen by dermatologists. The cosmetic sequelae of severe acne, including scarring and pigmentation, have a profound psychological impact on those in icted. Topical (eg, retinoids, antibiotics, dapsone, hydroxyacids) and oral treatments (eg, antibiotics and/or spironolactone) are often bene cial to control acne or in the instance of oral isotretinoin use, rid the acne permanently; however, these treatments have very little affect on the ultimate cosmetic outcome of the acne scarring and skin texture that results. Given the variety of scar types that can form and the variability of responses seen in various skin types and textures, treatment options are vast without appropriate guidelines for pathways that dictate best timing, combinations, and options in given clinical scenarios. Current treatment options include solo or combina- tions of energy-based (eg, laser, radiofrequency), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and llers and/or fat injections. Most recently, fractional radiofrequency-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation. In severe cystic ares, scarring treatments are often postposed till the acne is under control and in many instances this can limit the dermatologists ability to affect future cosmetic treatments. Based on personal experience of various clinical scenarios in a busy laser practice that treats a signi cant number of patients with acne scarring, fractional radiofrequency is an excellent choice for treating all forms of acne scars with minimal risk to patients, even those on concurrent treatments such as isotretinoin. Additionally, fractional radiofrequency can be used in combination with all other treatment options to speed the time to clinical improvement appreciated by the patient. Here we present personal experiences of combination treatments for acne scarring, pigmentation and textural issues, and suggest that fractional radiofrequency be considered a “gold standard” treatment of acne scarring in those with dark or sensitive skin types or those on concurrent isotretinoin.
J Drugs Dermatol. 2016;15(11):1413-1419.
Data continue to establish the role of inflammation, not only in the pathogenesis of acne but also in the development of its most devastating
sequelum, scarring. Although topical therapy is preferred by most acne patients and the physicians who treat them, historically
no topical intervention has provided primarily anti-inflammatory effects. Topical dapsone 5% gel offers documented efficacy for
the reduction of both inflammatory and non-inflammatory acne lesions. It has been proven safe, presenting none of the hematologic
risks associated with oral dapsone. Data suggest the vehicle formulation enhances healing and contributes to tolerability, making
topical dapsone 5% gel a worthwhile anti-inflammatory treatment for many patients with mild-to-moderate acne vulgaris.
Noah S. Scheinfeld, JD, MD; Damian D. DiCostanzo, MD and Steven R. Cohen, MD, MPH
A Hispanic man with a twenty-eight year history of systemic lupus erythematosus (SLE) and a high titer of anticardiolipin IgG antibodies
was noted to have reticulate and stellate acral pigmentation. The patient reported that hand swelling and erythema developed
soon after the diagnosis of SLE was established. This episode resolved quickly without recurrence or immediate sequelae.
We postulate that this eruption was related to SLE and anticardiolipin antibodies. Reticulate and stellate acral pigmentation
should be considered a possible manifestation of SLE and high titers of anticardiolipin antibodies, or a consequence of
Ninety percent of people with rosacea say it lowers their self-esteem and can be accompanied by burning, itching, and stinging; but tolerable, effective therapies are increasingly available due to improved understanding of rosacea's inflammatory mediators and molecular basis.
Since being approved by the FDA over a decade ago, azelaic acid (AzA) 15% gel has boasted a long track-record in efficacy and safety in the topical treatment of papulopustular rosacea (PPR), both as monotherapy and in combination with oral therapy. AzA 15% gel markedly reduced both papulopustular lesions and overall facial erythema in pivotal Phase 3 studies.
This supplement gives the latest information on the pharmacologic properties of AzA that correlate with therapeutic action in rosacea; and explores new horizons related to formulation development, such as an oil-in-water emulsion foam of micronized AzA 15% that is proving to be well-tolerated and effective for patients with moderate to severe PPR.
Kristin Noiles BSc, Ronald Vender MD FRCPC
Background: Psoriasis of the skin is in itself a disturbing disorder both physically and psychologically. However, most often the scaly
plaques can be hidden by clothing. When psoriasis involves the face it can be more disabling and can decrease the patient’s quality of
life. Facial psoriasis is difﬁcult to treat and is associated with severe cutaneous disease. Patients who have a long duration of psoriasis
or early age of onset are more likely to suffer from facial involvement. Facial psoriasis may also be associated with pruritus, psoriatic
arthritis, and with a family history of psoriasis.
Objective: The authors report a case of a female patient with psoriasis with severe cutaneous disease and extensive facial involvement
successfully treated with adalimumab. This 50-year-old Caucasian female had a history of cutaneous psoriasis since 1990 and psoriatic
arthritis since 2005. The patient had associated pruritus and a family history (maternal). Systematic treatment with mycophenolate
mofetil and acitretin proved unsuccessful. The patient also lost efﬁcacy after months of ultraviolet light B and topical psoralen plus
ultraviolet light A phototherapy.
Results: In 2007, the patient was screened and initiated therapy with a monoclonal humanized tumor necrosis factor alpha inhibitor,
adalimumab. She had severe facial and body involvement with a body surface area of 25%, a Psoriasis Area and Severity Index of
20.4 (PASI), and a head and neck psoriasis area and severity index (HNPASI) of 3.6. Photographic documentation was carried out
with improvement noted as soon as 4 weeks with continuing signiﬁcant response thereafter. No adverse effects were noted. The
patient’s quality of life also improved.
Limitations: Although severe facial psoriasis is rare and associated with only the most extensive and severe psoriatic cases, it is
likely the most psychologically disturbing and cosmetically disrupting to the patient because it cannot easily be covered or concealed.
The authors hope this case can illustrate an excellent therapeutic option for these patients.
Conclusion: Although facial psoriasis is difﬁcult to treat, with newer systemic therapy now available in the form of biologics, patients
now have a hope for this disease, especially devastating when associated with severe and extensive cutaneous involvement. The
case gives promise in a serial photo-documented fashion of the success that can be achieved.
Ustekinumab is effective in the treatment of a variety of autoimmune conditions including psoriasis. As a relatively new therapeutic agent, its long-term effects are still under investigation. Short-term studies, however, have revealed ustekinumab to be generally well tolerated and safe. This article provides a comprehensive review of the pharmacokinetics of ustekinumab, its safety profile, adverse effects, and use in pregnancy. The effect of diabetes and prior immunosuppressant therapy is also addressed.
J Drugs Dermatol. 2012;11(8):907-910.
Linda F. Stein Gold MD,a Tracey Vlahovic DPM,b Amit Verma DrPH,c Babajide Olayinka MSc,c
Alan B. Fleischer Jr. MDc
BACKGROUND: Naftifine hydrochloride (naftifine) is a topical antifungal of the allylamine class, displaying fungicidal and fungistatic activity. Naftifine is generally used to treat interdigital tinea pedis; however, systemic therapy is often prescribed by healthcare providers for moccasin tinea pedis. Well-controlled clinical data on topical antifungal therapy for moccasin tinea pedis is limited.
OBJECTIVE: The objective of this analysis is to present data from two pooled randomized, vehicle-controlled studies that evaluated efficacy of once daily topical naftifine gel 2% and vehicle at end of treatment (week 2) and at 4 weeks post-treatment in subjects with moccasin tinea pedis.
METHODS: At visit 1, subjects were randomized to naftifine gel 2% or vehicle groups and subjects underwent baseline mycology culture, KOH, and symptom (erythema, scaling, and pruritus) severity grading. Naftifine gel 2% and vehicle treatment were applied once daily for 2 weeks and the subjects returned at weeks 2 and 6 for efficacy evaluation (mycology culture and grading of symptom severity). A total of 1174 subjects were enrolled with interdigital tinea pedis with or without moccasin infection. Of these subjects, 674 subjects had interdigital presentation while 500 subjects had moccasin infection in addition to the interdigital presentation. All 1174 subjects with interdigital presentation satisfied the inclusion criteria of a minimum of moderate erythema and scaling, and mild pruritus. Of the 500 subjects who had moccasin presentation, 380 satisfied the same inclusion criteria as mentioned above. Since data was analyzed as observed cases, between 337 and 349 subjects had data available for analysis of efficacy. Mycologic cure is defined as a negative dermatophyte culture and KOH, treatment effectiveness is defined as mycologic cure and symptom severity scores of 0 or 1, and complete cure is defined as mycologic cure and symptoms severity scores of 0.
RESULTS: At week 6, the cure rates in the naftifine arm vs. the vehicle were statistically higher (P<0.0001) for mycological cure rate (65.8% vs. 7.8%), treatment effectiveness (51.4% vs 4.4%), and complete cure rate (19.2% vs 0.9%).
CONCLUSION: Two weeks application of topical naftifine gel 2% is an effective monotherapy treatment for moccasin tinea pedis.
J Drugs Dermatol. 2015;14(10):1138-1144.
Jesse Lewin MD, Rachel Farley-Loftus MD, Miriam Keltz Pomeranz MD
The authors present a case of erythema multiforme-like drug reaction to the multikinase inhibitor sorafenib. While considered targeted therapy, multikinase inhibitors have been demonstrated to have various cutaneous effects. It is important to distinguish allergic reactions from adverse side effects as the latter may permit cautious re-challenge with medications that can potentially prolong survival in patients with advanced or metastatic disease.
J Drugs Dermatol.2011;10(12):1462-1463.
Miriam Bettencourt MD
Oral lichen planus is a very difficult condition to treat and causes patients to experience pain and difficulty eating. Therapeutic approaches focus on minimizing flares and relieving pain and discomfort to improve patient quality of life. Topical preparations are the mainstay of therapy, but they are often insufficiently efficacious for more severe cases. The use of systemic agents can be complicated by potentially serious adverse effects, the need for regular monitoring, suboptimal efficacy, and cost. Reported here are 3 recalcitrant cases of oral lichen planus that were effectively treated with apremilast, a drug recently approved for psoriasis and psoriatic arthritis.
J Drugs Dermatol. 2016;15(8):1026-1028.
Michael Kockaert, MD and Martino Neumann, MD, PhD
The rejuvenation of aging skin is a common desire for our patients, and several options are available. Although there are some systemic methods, the most commonly used treatments for rejuvenation of the skin are applied topically. The most frequently used topical drugs include retinoids, alpha hydroxy acids (AHAs), vitamin C, beta hydroxy acids, anti-oxidants, and tocopherol. Combination therapy is frequently used; particularly common is the combination of retinoids and AHAs1. Systemic therapies available include oral retinoids and vitamin C. Other available therapies such as chemical peels, face-lifts, collagen, and botulinum toxin injections are not discussed in this article.
Aton M. Holzer MD, Frank Martiniuk PhD, William R. Levis MD
Heat-shock proteins (HSPs) serve as both a valuable target as well as a potent tool in the therapy of melanoma and human
papillomavirus infections. HSPs have been found to associate with key pathogenic antigens and, under different circumstances,
activate or suppress both innate and adaptive immunity via several mechanisms. The dominant mechanism
of HSP is as a chaperonin to upregulate antigens on antigen-presenting cell surfaces. While no HSP-based therapies are
currently FDA approved, several are currently in phase III clinical trials. This study reviews the current literature on therapeutic
studies of HSP and the significant role these proteins are likely to play in future therapeutic approaches to neoplasms,
infections, and inflammatory diseases of the skin.
Jordan Fabrikant DO,a Khasha Touloei DO,b and Stuart M. Brown MDc
Afamelanotide ([Nle4-D-Phe7]-alpha-MSH) is an analog of alpha-melanocyte stimulating hormone given as a subcutaneous injection. Afamelanotide is currently undergoing phase II and III trials in Europe and the US for skin diseases including vitiligo, erythropoietic protoporphyria, polymorphic light eruption and prevention of actinic keratoses in organ transplant recipients. Unregulated analogs and chemicals are being sold online ahead of formal approval. A number of counterfeit chemicals, ‘Melanotans’ are being sold for tanning purposes. Currently, afamelanotide is already on the market in Italy and Switzerland for patients with erythropoietic protoporphyria. This paper will review the current literature on this promising compound.
J Drugs Dermatol. 2013;12(7):775-779.
Jeffrey M. Weinberg MD, Clement J. Bottino BA, James Lindholm BA, Robin Buchholz MD
Psoriasis is a chronic skin disorder that affects approximately 2% of the US and European population. Over the last
several years, one of the major focuses in psoriasis research has been the development of biologic therapies for this disease.
The aim of these therapies is to provide selective, immunologically directed intervention with fewer side effects
than traditional therapies. The goal of this article is to update the progress of the tumor necrosis inhibitors which are
available, or under investigation, for clinical use in psoriasis: infliximab, etanercept, and adalimumab, as well as the
T-cell-targeted therapies efalizumab and alefacept (Table 1).
Kimberly Kazinski 2LT USA MC, Kathleen M. Joyce Capt USAF MC, Darryl Hodson MAJ USA MC
Acrodermatitis continua of Hallopeau (ACH) is a rare form of pustular psoriasis which poses a challenge to treat and
causes considerable pain and suffering for those afflicted. Tumor necrosis factor-alpha (TNF-?) is a pro-inflammatory
cytokine involved in the pathogenesis of ACH and other forms of psoriasis. Inhibition of TNF-? has been shown to
provide benefit in such inflammatory conditions as rheumatoid arthritis, psoriatic arthritis, and, most recently, plaque
psoriasis. In this report, we present the case of a 65-year-old man with a 9-year history of recalcitrant ACH who demonstrated
significant and sustained clinical improvement when etanercept, a competitive inhibitor of TNF-?, was added
to his treatment regimen of acitretin and topical corticosteroids over a 12-week period.
Matthew C. Matsunaga MDa and Paul S. Yamauchi MD PhDb
Atopic dermatitis (AD) is a chronic, prevalent, multi-factorial condition that affects infants, children, and adults. Beyond topical therapy, a variety of systemic agents such as steroids, methotrexate, cyclosporine, azathioprine, mycophenoloic acid, and other agents are utilized to treat moderate to severe AD. However, these agents are associated with potential long term adverse events and organ toxicity. There is an unmet need for a safer, long-term systemic agent to adequately control moderate to severe AD. The role of the Th2 cytokines, IL-4 and IL-13, in AD has led to the development of biologic agents to treat AD. The aim of this article is to review the role of IL-4 and IL-13 in the pathogenesis of AD and discuss some of the clinical trial data that target and inhibit IL-4 and IL-13 in positively altering the course and outcome of AD.
J Drugs Dermatol. 2016;15(8):925-929.
Joshua A. Zeichner MD
Acne vulgaris (AV) is an inflammatory skin disease characterized by the presence of comedones, papules, pustules, and nodules. Consensus guidelines recommend the use of combination therapy using different drugs with complementary mechanisms of action to best address as many acne pathogenic factors as possible at the same time. Topical acne medications exist as individual agents that may be combined in physician-recommended regimens or as pre-formulated fixed-dose combination products. In addition, there are several new and promising topical therapies currently being developed that work by different mechanisms of action from traditionally used acne therapies. The following review will cover commonly used drugs, newcomers to the market, and what the future holds for the topical treatment of AV.
J Drugs Dermatol. 2016;15(1 Suppl 1):s11-s16.
Mark Lebwohl MD, Kathryn Martin PharmD
Acitretin, the only oral retinoid indicated for the treatment of psoriasis, has shown activity when used in combination,
rotational, and sequential therapy regimens with other therapies. When used with phototherapy, significantly greater
activity has been observed at lower doses than with either approach as monotherapy. While initial anecdotal evidence is
promising, clinical trials are needed to evaluate whether sequential or rotational use of biologic agents with acitretin may
yield improved efficacy and an acceptable safety profile with decreased risk of immunosuppression. Acitretin and other
retinoids also work as chemopreventative agents in psoriasis patients with extensive exposure to psoralen ultraviolet
A (PUVA) and in solid-organ transplant patients where a number of studies have reported decreased numbers of squamous
cell cancers when treated with acitretin.
Psoriasis is a chronic inflammatory disease of the skin that can have a major effect on patient quality of life. Conventional psoriasis
treatments, often identified empirically, fail to meet the clinical needs for a safe and remittive therapy. These unmet needs, together
with the rapid advances in understanding the molecular basis of psoriasis, have led to the development of targeted biologic therapies.
Using recombinant DNA technology, a new generation of therapeutic agents is being designed to interfere at specific pathogenic steps
that involve T-cells or T-cell-mediated immune responses. These targeted therapies promise improved tolerability and safety in the
treatment of psoriasis. Furthermore, they will redefine clinical response in psoriasis by providing long-lasting remissions of disease
and extended treatment-free periods.
Stanislav N. Tolkachjov MD and Nneka I. Comfere MD
Hypopigmented mycosis fungoides (HMF) is a rare variant of cutaneous T-cell lymphoma (CTCL) that often manifests in younger patients
with darker skin types in a centripetal distribution.1 Average age of diagnosis is often 14 years.2 The diagnosis is often missed
due to its low incidence and lack of clinical suspicion. Misdiagnosis and failure to obtain biopsies lead to a long latency period from
onset of hypopigmented patches to diagnosis and treatment.
HMF has a clinically benign course and responds well to therapy; however, relapse is common.3 We report a case of HMF misdiagnosed
as vitiligo in order to illuminate diagnostic, histopathological, and treatment modalities.
J Drugs Dermatol. 2015;14(2):193-194.
James L. Campbell Jr. MD MS
Many physicians regularly prescribe combination therapy involving a retinoid for their acne patients. The most common
retinoid-containing regimens include either oral antibiotics or topical benzoyl peroxide and antibiotic products. A fair number
of studies have been conducted to evaluate the efficacy of these combination therapies, but there is a lack of comparative
studies examining different regimens head-to-head. Also, many of the noncomparative studies have very similar trial
designs. A review of these studies was conducted in order to organize the available data side by side from the different regimens.
Although not derived from comparative studies, this presentation of data is expected to provide dermatologists with
valuable information from which they can easily make their own comparisons among similarly designed trials.
Catherine D. Buzney MA,a Alice B. Gottlieb MD PhD,a,b David Rosmarin MDa,b
Type 2 helper T cell (Th2)-mediated inflammation plays a critical role in the pathogenesis of allergic asthma and atopic dermatitis (AD). Recent research focusing on the suppression of the Th2 axis with targeted inhibitors in atopic disease is showing promising early results. In particular, the simultaneous blockage of interleukin (IL)-4 and IL-13 has successfully mitigated symptoms of allergic asthma and AD in preliminary clinical trials. Given the current therapeutic challenges of treating these chronic and severe diseases, this review brings to light new data demonstrating that agents targeting IL-4 and IL-13 are relatively safe and effective medications in blocking the inflammatory cascade responsible for allergic asthma and atopic dermatitis.
J Drugs Dermatol. 2016;15(2):165-171.
Leon H. Kircik MD FAAD
Combination therapy has become the standard for the management of acne, particularly for moderate-to-severe cases. Among these
combinations, those regimens containing benzoyl peroxide (BPO), clindamycin and a retinoid have been used frequently as they address
most aspects of acne pathogenesis. This study compares the effi cacy and safety of two common topical treatment regimens
in the treatment of a moderate to severe facial acne vulgaris: fi xed-combination gel containing BPO 5% and clindamycin 1% (BPO/C)
plus tretinoin microsphere gel 0.04% (RAM) versus a regimen of a fi xed-combination gel containing clindamycin phosphate 1.2%
and tretinoin 0.025% (CPT) plus a once-daily BPO 5% wash. While both regimens were safe and effective, regimen BPO/C+RAM
yielded a more rapid onset of effect versus regimen CPT+BPO against both non-infl ammatory and infl ammatory lesions. Both treatment
regimens were well-tolerated.
Emily Warshauer, Bruce L. Warshauer MD
The short-term and long-term outcomes of 108 patients with 122 nodular basal cell carcinomas (BCCs), morpheaform
BCCs, or low-risk squamous cell carcinomas (SCCs) treated with imiquimod 5% cream at a community-based dermatology
practice were retrospectively reviewed. The overall initial tumor clinical cure rate was 93.4% (114/122), with an
initial clinical cure rate of 90% (72/80) for BCCs combined, and 100% (42/42) for SCCs combined. During a median
follow-up time of 18 months, there was only 1 recurrence in the 114 tumors considered initially clinically cured. Imiquimod
may be an appropriate initial treatment for these tumors in patients with good posttreatment follow-up.
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.
Austin Liu MD, Deborah J. Yang MD, Peter C. Gerhardstein PhD, Sylvia Hsu MD
Background: Isotretinoin is the most effective systemic treatment option for patients with nodulocystic acne or acne vulgaris who have failed a treatment with systemic antibiotics.
Methods: We conducted a retrospective study of 405 acne patients treated with isotretinoin to evaluate the incidence of recurrence after a course of at least 150 mg/kg of isotretinoin.
Results: Of the 405 patients evaluated, 94 (23.2%) experienced relapses severe enough for the patient to request further medical
management. Of the 94 patients, 76 (80.9%) relapsed within the first 2 years following completion of a course of isotretinoin.
Limitations: This was a retrospective study at a single practice site.
Conclusion: Almost one-fifth of patients have a recurrence of acne within the first 2 years. Patients should be made aware of this information, as it will contribute to the development of accurate and appropriate expectations of therapy.
David A. Kasper DO MBA, Joel L. Cohen MD, Aradhna Saxena MD, Greg S. Morganroth MD
Traditional scar revision has addressed issues of thickness with intralesional corticosteroids, superficial contours with dermabrasion
or laser resurfacing, and postrepair erythema with hemoglobin-targeted laser therapy. Historically, collagen fillers
have been used to address several types of scars, including acne, varicella, and trauma, as well as larger soft tissue contour
defects.1,2With the introduction of new types of fillers to the dermatologic surgeon’s armamentarium, many types of scars
with longer lasting results can be addressed. Success has been noted with the use of these newer and more durable fillers,
such as hyaluronic acid and calcium hydroxylapatite, to fill and blend postsurgical depressed scars following the reconstruction
of skin cancer defects.
Objectives: Psoriasis is a chronic inflammatory condition that occurs worldwide; however, few studies have examined this condition in non-Caucasian populations. The purpose of this study was to investigate racial/ethnic differences in demographics, psoriasis severity,
efficacy, safety, and health-related quality of life in patients treated with etanercept using data from the Etanercept Assessment of Safety and Effectiveness (EASE) in Psoriasis trial.
Patients and Methods: This is an investigator-initiated evaluation of data from the EASE study.
Results:The study included 2511 patients (Caucasian n=2164; Hispanic/Latino n=173; African American n=98; Asian n=76). Although
baseline Physicians' Global Assessment (PGA) scores were similar, we found significant baseline differences in patient characteristics, prior therapy, percentage of body surface area (%BSA) affected and Dermatology Life Quality Index (DLQI) scores between the groups. At baseline, the Caucasian group had the longest disease duration (19 years), but the lowest percentage of BSA involvement (28%). The Asian group had the highest percentage of BSA involvement (41%). Baseline DLQI score was lowest for Caucasians (12.0) and highest for Hispanic/Latinos (14.6).
At week 12, response to therapy was similar in all ethnic/racial groups. The BSA involvement was reduced by more than 50 percent
for all groups, but remained significantly higher for the Asian group (17%) than for the Caucasian (13%; P=0.0105) and African American groups (13%; P=0.0461).
At week 12, the mean Asian DLQI score of 5.2 was significantly higher (worse) than scores for the Caucasian (3.5; P=0.0001) and Hispanic/Latino groups (3.8; P=0.028). For both percentage of BSA and DLQI, differences among racial/ethnic groups in the percentage improvement from baseline were not statistically significant. Adverse event rates were similar for the groups.
Conclusions:Patient characteristics at enrollment differed among ethnic groups, but no significant racial/ethnic differences were found in safety or efficacy of etanercept. However, racial/ethnic differences in the impact of psoriasis on quality of life were observed.
J Drugs Dermatol. 2011;10(8):862-868.
Alopecia areata is an organ specific autoimmune disease in which hair is lost in various patterns. Its most extreme form,
alopecia universalis, is the total loss of all scalp and body hair. This form of the condition is very resistant to treatment
and spontaneous remission is quite rare. The following is a case of a 54-year-old male with longstanding alopecia universalis
who began to grow dense hair on his scalp as well as patchy hair growth on his face, pubic and axillary areas one month
after starting a course of simvastatin 40 mg and ezetimibe 10 mg daily prescribed for his hyperlipidemia. For 2 years prior
to starting the combination drug, he had taken simvastatin 40 mg alone without evidence of any hair growth. The combination
of simvastatin and ezetimibe has previously demonstrated synergistic immunomodulatory effects, which most likely
accounts for the clinical response in this case.
James Q. Del Rosso DO FAOCD
Combination therapy is the standard of care in the management of acne vulgaris. It is essential to treat as many aspects
of acne pathogenesis as possible. Due to increasing insensitivity of Propionibacterium acnes to antibiotics, the concomitant
use of other topical agents that exhibit other modes of antibacterial and anti-inflammatory activity is integral to the
successful treatment of acne. The combination of topical benzoyl peroxide and clindamycin gel has been shown to be
more effective than either agent alone. The addition of a topical retinoid may further enhance therapeutic results. This
12-week study evaluated the safety and efficacy of initial topical benzoyl peroxide 5%/clindamycin 1% gel as monotherapy
and in combination with adapalene gel versus adapalene gel monotherapy in the management of acne.
Corticosteroids have been combined with other agents in the treatment of melasma for years. In early studies by Kligman and Willis,
topical dexamethasone as monotherapy produced little depigmentation even after 3 months of therapy. A significant concern is that
topical corticosteroids used alone in this setting, especially on the face, may result in epidermal atrophy, telangiectasia, rosacea-like
erythemas, acne, and perioral dermatitis.
Topical corticosteroids, however, including low-potency fluocinolone acetonide, also exert an anti-metabolic effect, resulting in
decreased epidermal turnover, and, thus, may produce a mild depigmenting effect. When used in combination with tretinoin and
hydroquinone in the treatment of melasma, fluocinolone acetonide 0.01% suppresses biosynthetic and secretory functions of
melanocytes, and thus melanin production, leading to early response in melasma, synergy among the three agents, and no significant
side effects over an 8-week period.
Mohamed Réda Khmamouche MD,a,b Adil Debbagh MD,a Tarik Mahfoud MD,b Rachid Aassab MD,a
Siham Lkhoyaali MD,a Mohamed Ichou MD,b and Hassan Errihani MDa
Bleomycin is an antibiotic with antineoplastic properties. It is used in the treatment of different tumors in oncology. The mucocutaneous
side effects of this drug include ulcers, scaly erythematous and bullous lesions, sclerosis, stomatitis, and pigmentary
alterations. Flagellate erythema is a characteristic hyperpigmentation of bleomycin. We report a case of flagellate erythema following
the administration of bleomycin in a 34-year-old woman with ovarian teratoma. She developed linear lesions two weeks
after the first injection of bleomycin. Flagellate erythema is a specific reaction to bleomycin therapy, which occurs in susceptible
individuals independently of dose, route of administration, and type of malignant disease treated.
J Drugs Dermatol. 2014;13(8):983-984.
Brian Berman MD PhDa,b and Eggert Stockfleth MD PhDc
There is a need for early, effective field treatments for actinic keratosis (AK) that target subclinical as well as clinically visible lesions to minimize the recurrence and emergence of new lesions. Ingenol mebutate gel is an effective and well-tolerated topical field therapy that has demonstrated sustained clearance and long-term reduction of AKs. This article reviews findings from the FIELD study program and highlights health-related quality of life (HRQoL) outcomes for patients receiving ingenol mebutate. Efficacy data from the FIELD study program are discussed and the tolerability profile of ingenol mebutate in the treatment of areas of up to 100 cm2 is considered. These findings are then placed in the context of HRQoL outcomes and their relevance for patients.
J Drugs Dermatol. 2016;15(5):535-542.
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.
Scott Fretzin MD, Jeffrey Crowley MD, Loretta Jones FNP-C, Melodie Young MSN RN ANP-C, Jeffrey Sobell MD
Hand and foot psoriasis can appear in a plaque-type or pustular-type form. Any form of psoriasis that occurs on the hands
and feet can have a debilitating effect on the patient’s daily functions. Here we present a case series of patients with plaqueor
pustular-type hand and foot psoriasis whose conditions were successfully managed with the biologic agent efalizumab.
In many of these patients, the disease was refractory to multiple systemic psoriasis treatments. Treatment with efalizumab was
effective and well-tolerated, with few adverse events. Many of the patients described here reported an improvement in both
their physical functioning and health-related quality of life. The efficacy of efalizumab in treating these cases of hand and
foot psoriasis suggests that it may provide therapeutic benefit.
Maira E. Herz Ruelas MD, Minerva Gómez MD, Oliverio Welsh MD DrSc, Horacio Decanini Arcaute MD, Jorge Ocampo-Candiani MD
Pityriasis rubra pilaris has no single effective therapy and there are some cases resistant to multiple treatments. Psoriasis has
clinical and therapeutic response overlaps with pityriasis rubra pilaris and there are several therapies common to both, such
as retinoids, methotrexate, cyclosporine A, phototherapy, and most recently infliximab. We report a case of a 10-year-old
boy with pityriasis rubra pilaris unresponsive to topical corticosteroids, salicylic acid, pimecrolimus, calcitriol, calcipotriol,
ultraviolet B targeted phototherapy, isotretinoin, systemic PUVA, acitretin, and etanercept. He was treated with efalizumab
1 mg/kg weekly and a successful outcome was obtained with a 50% improvement after the first dose. The patient remains
in remission after 9 months of treatment.
Dana Kaslow, MD and Mark Lebwohl, MD
Bexarotene has recently been approved in the United States and Europe as a single orally administered retinoid for the treatment of cutaneous T-cell lymphoma (CTCL) in patients who are refractory to at least one prior systemic therapy. We describe a 47-year old female with a 4-year history of mycosis fungoides (MF) who developed debilitating side effects from acitretin and PUVA, and subsequently responded to bexarotene 75 mg orally once daily combined with PUVA. Bexarotene has been approved at an optimal starting dose of 300 mg/m2/d but has not yet been approved for use in combination with PUVA. We used a low dose (75 mg) combined with PUVA in an attempt to minimize side effects while maintaining treatment efficacy. Our patient's response to a novel regimen of low dose bexarotene combined with PUVA has been excellent and suggests that this regimen may be a useful method for treatment of MF.
Shereene Idriss MD and Jacob Levitt MD
Malathion is an under-recognized and under-utilized therapy for head lice and scabies largely due to misperceptions about its safety
profile. Specifically, its pure form as it exists in pharmaceutical preparations is non-toxic to humans in the low doses available. While
labeled for ages six and up, recent studies showed no cholinesterase inhibition in head lice patients aged two-to-six treated with
malathion. Flammability of malathion in isopropyl alcohol has reportedly resulted in human injury once in over one million prescriptions
filled. Recent efficacy studies of malathion in United States (U.S.) head lice demonstrate efficacy rates of 97–98%. In the present
era of permethrin and lindane resistance to head lice, malathion is a first-line option. For scabies, it is a reasonable alternative to
permethrin 5% cream, especially when treatment of the scalp or hairy areas is desired.
Xiao Yang MD, Oliver A. Perez MD, Joseph C. English III MD
Background: The current medical therapies for perniosis are diverse. The agents used have produced variable results and lack evidence-based data.
Objective: To determine outcomes of patients with perniosis treated with hydroxychloroquine.
Methods: In this retrospective study, patients with a diagnosis of perniosis treated with hydroxychloroquine were analyzed for dosage required, subjective improvement in signs and symptoms, and adverse drug reactions.
Results: Hydroxychloroquine resulted in improvement of symptoms in four of five patients. Review of the literature has revealed 12
out of 51 cases have responded to hydroxychloroquine alone or in combination with other therapies.
Conclusion: Hydroxychloroquine is a relatively safe, well tolerated alternative therapy for the treatment of perniosis and should be
considered as part of the initial management. Additional data are needed to further evaluate this drug in a prospective manner and in
a larger population of patients.
Stephen F. D'Addario, MD; Matthew E. Bryan, MD; Warren A. Stringer, MD and Sandra Marchese Johnson, MD
Minocycline hydrochloride, a synthetic tetracycline, is a systemic antibiotic that has received much attention over the past several years. Currently, minocycline is considered the most widely prescribed oral antibiotic in the management of acne1. Minocycline has been associated with autoimmune events2, hepatitis3, lupus-like syndromes4, serum sickness, vasculitis, Sweet's syndrome5, and hyperpigmentation6,7 . We report a case of a patient who developed drug-induced immune thrombocytopenic purpura (DITP) after taking minocycline. The initial clinical presentation of nonpalpable, discrete nonblanching petechiae and cayenne pepper-like macules on his lower legs was diagnosed as pigmented purpuric dermatosis (Schamberg's disease). We report the first case of DITP with the clinical picture of Schamberg's disease associated with minocycline therapy.
Infantile hemangiomas are benign vascular neoplasms of childhood that often have implications on development, cosmesis, and comfort.
Traditional therapy has involved either observation or corticosteroids, depending on location and size. Recent studies have reported
the successful use of beta-adrenergic antagonists in treating infantile hemangiomas. This succinct review discusses the properties and
current applications of beta-adrenergic antagonists as well as the established treatments for infantile hemangioma.
J Drugs Dermatol. 2012;11(7):826-829.
Tiffani K. Hamilton MD
Psoriasis and psoriatic arthritis (PsA) are chronic inflammatory disorders. Efalizumab targets several T-cell interactions central to psoriasis
immunopathogenesis. Etanercept and infliximab are antitumor necrosis factor (anti-TNF) agents that modify the inflammatory
and cell-mediated immune responses involved in the pathogenesis of psoriasis and PsA. All 3 agents are approved for the treatment
of plaque psoriasis, and etanercept and infliximab are also approved for the treatment of PsA. Twenty patients with psoriasis and PsA
have been successfully treated with a combination of efalizumab (1 mg/kg/wk) and etanercept (25 mg or 50 mg/wk) or infliximab (5 to
6 mg/kg). To date, no serious adverse events have been reported. Combination therapy was well tolerated and effectively controlled
both skin disease and arthritis. The complementary activity of efalizumab with an anti-TNF agent is most likely attributable to their differing mechanisms of action. Further investigation is warranted.
Jashin J. Wu MDa and Kwun-Yee T. Poon MSb
OBJECTIVES: To stratify MI risk reduction in those treated with a TNF inhibitor for psoriasis only, psoriatic arthritis only, or both psoriasis
and psoriatic arthritis.
DESIGN: Retrospective cohort study
SETTING: Between January 1, 2004 and November 30, 2010
PARTICIPANTS: At least 3 ICD9 codes for psoriasis (696.1) or psoriatic arthritis (696.0) (without antecedent MI.
MAIN OUTCOME MEASURE: Incident MI
RESULTS: When comparing to those not treated with TNF inhibitors (reference group), of those treated with TNF inhibitors: those with
psoriasis only (N= 846) had a significant decrease in MI risk (hazard ratio (HR), 0.26; 95% CI, 0.12-0.56); those with psoriatic arthritis
only (N= 112) had a non-significant decrease in MI risk (HR, 0.86; 95% CI, 0.28-2.70); those with both psoriasis and psoriatic arthritis
(N= 715) had a non-significant decrease in MI risk (HR, 0.76; 95% CI, 0.47-1.24).
CONCLUSIONS: In the TNF inhibitor cohort, those with psoriasis only have the strongest association with MI risk reduction, followed by
those with psoriatic arthritis only, and then followed by those with both psoriasis and psoriatic arthritis.
J Drugs Dermatol. 2014;13(8):932-934.
Sara L. Swineford MD and Carol R. Drucker MD
Malignant acanthosis nigricans (MAN) with oral florid papillomatosis is a rare paraneoplastic condition affecting the skin and mucocutaneous
tissues associated with an underlying malignancy. It is characterized by proliferation of keratinocytes resulting in papillomatous
change and hyperpigmentation of the skin and multiple confluent warty or verrucous lesions of the oral mucous membranes.
The oral involvement can interfere with the patient’s ability to eat and drink. There is no specific therapy for this complication. Treatment
of the underlying malignancy can lead to improvement of symptoms, but the degree of improvement varies. Here, the authors
present a case of MAN with oral florid papillomatosis associated with gastric adenocarcinoma that was treated with oral retinoids resulting in significant clinical improvement of the hyperkeratosis and hyperpigmentation as well as improved patient functionality.
Impaired epidermal barrier function plays a role in causing inflammatory dermatoses, so skin care regimens are recognized by dermatologists to be critical for efficient barrier function and healthy skin. Acne vulgaris, however, has always presented a challenge when it comes to skin care products, as a delicate balance needs to be struck between maintaining the skin barrier whilst controlling oil and shine.
Cetaphil® DermaControl™ Moisturizer SPF 30 (Galderma Laboratories, L.P., Fort Worth, Texas) is a new widely available and affordable skin care therapy specifically designed for use by patients with acne-prone skin and acne-affected skin. Its state-of-the-art psuedoceramide technology helps maintain barrier function without adding excessive surface greasiness, which leads to better compliance and fewer side effects; and it also provides protection against ultraviolet radiation.
Nawaf Al-Mutairi MD FRCP(C), Arun Joshi MD, Osama Nour-Eldin MSc
Hereditary punctate palmoplantar keratoderma (Buschke-Fischer-Brauer disease) is a rare disorder of keratinization.
We describe here a 49-year-old male patient of this condition with many unusual features such as late onset of the disease
in the fourth decade and nail changes (longitudinal pigmented striations, curved nails and pits in the fingernails;
and nail thickening, subungual hyperkeratosis and yellowish discoloration in toenails). The patient developed
histopathologically proven skin lesions typical of psoriasis 7 years after appearance of the keratoderma. This association
has not been reported earlier. The patient’s skin lesions cleared completely with acitretin therapy within
James Q. del Rosso, Do, FAOCD
The use of topical agents for treatment of most dermatologic disorders is integral to the practice of dermatology. The
innate properties and therapeutic mechanisms of the active component(s) of a topical preparation and the ability of the
vehicle formulation to deliver adequate concentrations of drug to the site of disease directly affect clinical efficacy.
Other factors influencing efficacy in clinical practice correlate closely with the extent of patient compliance, including
the degree of local tolerability and patient acceptability of the product, frequency of application and duration of therapy.
The following provides a discussion of newer medical therapies for the treatment of actinic keratosis based on current literature
and clinical experience.
Vicky Kwan Wong, BA; Christine Della Croce, MA; Sara Schonfeld; Anthony M. Mastrangelo, PhD and Mark Lebwohl, MD
Topical corticosteroids have improved the management of many inflammatory skin diseases, such as psoriasis
and atopic dermatitis. However, these medications are associated with certain adverse effects that are potentially
serious. The potent anti-inflammatory actions of these drugs increase susceptibility to bacterial and fungal
infections, and therefore may preclude them from use when infection is the known cause of the disease. In
addition, children may be more vulnerable than adults to systemic effects of topical corticosteroids because percutaneous
absorption is proportionately greater. These are important considerations, and physicians need to
weigh and compare the risks and benefits associated with these medications before initiating treatment. This
involves an appreciation of which patient populations are at high risk, which skin conditions are incompatible
with topical corticosteroid therapy, and which alternative nonsteroidal medications are effective in treating
inflammatory skin diseases.
Novie Sroa MD, Shannon Campbell DO, Mark Bechtel MD
Scleromyxedema is a chronic, idiopathic disorder characterized by cutaneous dermal mucin deposition in association with increased
dermal collagen and absence of thyroid disease. The clinical features involve sclerosis of skin with numerous, 2–3 mm, firm, waxy,
papules in a symmetrical distribution pattern. The skin lesions may progress to widespread and indurated plaques resulting in patient
disability via decreased mobility, sclerodactyly and microstomia. Abnormalities in the muscular, neurologic, rheumatologic, pulmonary,
renal and cardiovascular systems may accompany the cutaneous lesions. Multiple attempts at therapeutic interventions have
failed due to inconsistent, unsatisfactory results and/or severe adverse effects.1–6 Herein, the authors describe a case of scleromyxedema
successfully treated with high-dose intravenous immunoglobulin (hdIVIG).
Rajiv I. Nijhawan MD,a Jeremy M. Hugh MD,b and Achiamah Osei-Tutu MDa
Increased cases of acquired epidermodysplasia verruciformis (EDV) have been reported in patients with human immunodeficiency virus (HIV). With regard to management, there are no randomized controlled trials in either immunocompetent or immunocompromised patients, and only a limited number of anecdotal treatment options. Systemic retinoids, either independently or in combination with other treatment modalities, have been used with limited success, demonstrating transient clinical response and recurrence of lesions after cessation of therapy. We report a case of an HIV-positive patient with acquired EDV who achieved sustained clinical resolution even after discontinuation of oral acitretin by applying topical imiquimod to prevent recurrence of his lesions.
J Drugs Dermatol. 2013;12(3):348-349.
The successful treatment of acne still remains problematic. Conventional therapies often prove inconsistent with unacceptable
side effects and recurrence rates, leading to patient noncompliance. A thermal phototherapy treatment using
a combination of blue light and red light has recently attracted much attention and seems to offer an effective alternative.
The objective of this study was to evaluate the efficacy of blue light (415 nm) in combination with red light (633 nm)
in the reduction of inflammatory lesions on the face of subjects (n=21) with mild to moderate acne vulgaris after a course
of 8 20-minute (blue) or 30-minute (red) alternated light treatments, self-administered by a handheld unit over a period
of 4 weeks. Lesion counts progressively reduced throughout the 4-week light therapy period and continued to reduce up
to 8 weeks posttherapy, with a final average reduction of 69% seen 8 weeks after the treatment course (P>.001). This pattern
is similar to previously reported studies.
Primary axillary hyperhidrosis is a medical condition characterized by excessive underarm sweating that is thought to result from localized
hyperstimulation of sweat glands by cholinergic sympathetic nerve fibers. It can be associated with significant professional, physical,
and emotional impairment as well as considerable difficulties in social situations and in personal relationships. Available therapies
have been limited by short-lived effectiveness and in some cases significant adverse effects that can put patients at risk for potentially
serious complications. Chemodenervation of sweat glands using botulinum toxin type A (BTX-A), which has long-lasting therapeutic
efficacy with minimal adverse effects, has emerged as a unique therapy for treating primary axillary hyperhidrosis. This article
reviews the chemodenervation procedure, including patient preparation, BTX-A administration, and patient assessment and follow-
Jeffrey R. Smith MPH, Russell S. Akin MD, Michael J. Wells MD
Efaluzimab has recently been described as a treatment for alopecia areata. Conflicting reports and studies have spurred discussion
as to whether efaluzimab is an effective treatment of alopecia areata. Proposed mechanisms for this immune-modifying agent have
suggested that efficacy is derived from efaluzimab’s effects on T cells. However, a recent molecular study found no alteration in T cell
action around hair follicles at six months of treatment and thus the study concluded that efaluzimab was not an effective treatment.
This article describes a nine-year-old male with recalcitrant alopecia totalis for seven years who had been nonresponsive to therapeutic
intervention. He was started on efaluzimab for severe atopic dermatitis and began to re-grow scalp hair at one year of treatment.
This discussion suggests that longer treatment durations may be needed for treatment effects to be seen in some patients.
Onychomycosis is a very common nail disorder seen in dermatological practice. It is difficult to treat successfully for a multitude of
reasons, and although topical antifungal therapy might be considered ideal for mild to moderate onychomycosis, efficacy has been
limited by poor nail penetration of active ingredient through the nail plate into the nail bed and nail matrix to the site of infection. The
intrinsic properties of an antifungal and its vehicle formulation are both considered important contributors to effective treatment.
Here we review the formulation approach to efinaconazole topical solution, 10% an effective and well-tolerated treatment for onychomycosis.
We demonstrate that the low surface tension formulation affords better penetration of efinaconazole through the nail
plate, and also to the site of infection by spreading into the space between the nail and nail bed.
J Drugs Dermatol. 2014;13(12):1457-1461.
Kattie J. Allen MD, Stephen E. Wolverton MD
Rituximab is a chimeric murine-human monoclonal antibody that targets the CD20 antigen found on B cells and results
in rapid depletion of this cell population. It is indicated for patients with relapsed or refractory, low-grade or follicular,
CD20-positive, B cell non-Hodgkin’s lymphoma. In addition, rituximab has been used for many other diseases, including
refractory pemphigus. In this study, 42 case reports of patients with refractory pemphigus vulgaris, pemphigus foliaceus,
and paraneoplastic pemphigus treated with rituximab were reviewed for clinical efficacy and safety. Forty-one of the 42
patients had at least some improvement following the rituximab therapy, while 6 suffered infectious adverse events. Though
rituximab appears to be effective in the treatment of refractory pemphigus diseases, further studies are warranted to clarify
its overall safety, especially concerning the risk of infectious adverse events in this patient population.
Pooja Khera MD, John Y. Koo MD
Retinoids, a group of compounds encompassing Vitamin A and its analogs, have been shown to inhibit tumor growth
in laboratory studies. Based on these findings, a number of clinical trials have been conducted to investigate the chemoprotective
and chemotherapeutic effects of retinoids. This paper reviews the current database regarding the use of oral
and topical retinoids in the prevention and treatment of cutaneous and internal malignancies. Clinical studies have
shown that retinoids have beneficial effects in the prevention and treatment of certain neoplasms. In view of the
heightened concern of malignancy associated with the use of biologic agents in the treatment of psoriasis, retinoids may
be an attractive option for combination therapy with the biologic agents. Future clinical investigations are needed to
precisely define how this combination will fit into the treatment algorithm for moderate-to-severe psoriasis.
Michael B. Chang BS, Jennifer C. Sri MD, Marcia Driscoll MD, Anthony A. Gaspari MD
Tumor necrosis factor-α (TNF-α) inhibitors, such as adalimumab, are often used to treat psoriasis and psoriatic arthritis. While it is well known that these agents increase the risk of reactivation tuberculosis, recent evidence suggests that the risk of other nontuberculous mycobacterial (NTM) infections is on the rise. We report cutaneous Mycobacterium fortuitum in a 60-year-old woman with psoriasis who had been receiving adalimumab therapy for psoriatic arthritis for six months. No other risk factors were identified. M. fortuitum was cultured from a lesion on the right leg. Following resolution of the lesion, the patient has been successfully treated with infliximab infusions and subsequently certalizumab without complication for the past three years. To our knowledge, this is the first report of M. fortuitum occurring in a patient receiving adalimumab with successful subsequent treatment without complication while on another TNF-α inhibitor.
J Drugs Dermatol. 2011;10(8):927-929.
Jeffrey M. Weinberg MD
Available for more than 5 decades, benzoyl peroxide has been a “workhorse” of acne therapy. The benefits of this agent
include reduction in Propionibacterium acnes (P. acnes) with decrease in inflammatory lesions, efficacy as both “leave on” and
cleanser formulations and reduced emergence of antibiotic-resistant P. acnes strains. As the effect of benzoyl peroxide on
P. acnes is a direct toxic effect rather than as a “true” antibiotic, resistance to benzoyl peroxide does not occur and has never
Benzoyl peroxide in hydrophase base (Brevoxyl® Creamy Washes and Gels) has shown significant efficacy in the treatment
of acne, with lower irritancy than other benzoyl peroxide preparations. It is felt that the low irritancy of this product is related
to a unique delivery vehicle containing dimethyl isosorbide, which dissolves benzoyl peroxide crystals on the skin. Clinical
studies demonstrating the efficacy and safety of benzoyl peroxide in hydrophase base will be reviewed.
Emil Tanghetti MD, Wm. Philip Werschler MD
It is timely to compare the efficacy and tolerability of 2 actinic keratosis (AK) therapies—5% 5-fluorouracil (5-FU)
cream and imiquimod cream. Thirty-six patients with 4 or more AKs were randomly assigned to receive 5% 5-FU cream
twice daily for 2 to 4 weeks or 5% imiquimod cream twice weekly for 16 weeks. Five percent 5-FU was more effective
than imiquimod in exposing what were presumed to be subclinical AKs, reducing the final AK count (total AK count
declined during the 24-week study by 94% vs. 66%, P<.05), achieving complete clearance (incidence of 84% vs. 24%
by week 24, P<.01), and achieving clearance rapidly. Tolerability was similar except for erythema, which was initially
significantly higher with 5-FU than imiquimod but resolved rapidly and was significantly lower than imiquimod by
week 16. Five percent 5-FU remains the gold standard field therapy for AKs.
Gina R. Chacon MD, David J. Wolfson MD, Carlos Palacio MD, Animesh A. Sinha MD PhD
Darier’s disease is a rare disorder of keratinization of the epidermis, nails, and mucous membranes. Patients usually present
with pruritus and pain along with multiple small, red-brown papules on the seborrheic areas. Other cutaneous signs
include punctate keratotic pits of the palms and soles and dystrophy of the nails. Darier’s disease is the result of a mutation
in the ATP2A2 gene. A case which was difficult to diagnose because its presentation resembled more commonly seen
skin conditions is reported. The patient was misdiagnosed with acne, eczema, and seborrheic dermatitis, and was treated
without improvements. This case highlights the fact that skin disorders that do not respond to conventional therapy should
lead physicians to suspect an uncommon or even serious cutaneous disorder. The diagnosis of Darier’s disease, based on
family history, clinical appearance, and histopathology, expedited the appropriate treatment.
Julie R. Kenner MD PhD
Facial aesthetics and rejuvenation techniques have been evolving, with the most commonly applied techniques being the use of
hyaluronic acid fillers and botulinum neurotoxins. Because of complementary actions, it is common for both products to be used in
the same anatomical sites to optimize outcomes, either administered consecutively at one visit or at two separate visits. The author
shows for the first time that hyaluronic acid (HA) and botulinum neurotoxin (BNT) can be delivered in combination in the same syringe
— at the same time — to rejuvenate the upper face. Not only does concomitant administration result in excellent clinical outcome,
without apparently compromising the attributes of either product alone, but this technique enhances the patient experience by allowing
the use of small-gauge needles and inherently decreasing, by half or more, the number of needle sticks incurred. Larger studies
are underway to study optimal techniques for administering HA and BNT combined in a single syringe.
Sabrina Guillen Fabi MD, Carlotta Hill MD, Joslyn N. Witherspoon MD MPH, Susan L. Boone MD,Dennis P. West PhD FCCP CIP
Thalidomide is increasingly being used due to its effectiveness in the treatment of a variety of dermatologic conditions refractory to
other treatments. Although thalidomide’s side effects have been well-documented in the literature since its entry in the 1950s, some
of the risks associated with its use are still being discovered. Recently, increased incidence of venous thrombosis following thalidomide
use has been reported in the treatment of diseases with disease-related thrombotic risks, such as malignancy and lupus with
antiphospholipid antibody syndrome, as well as concomitant therapy with chemotherapy and/or systemic corticosteroids. We report
a case of deep venous thrombosis (DVT) and pulmonary embolus (PE) following thalidomide use in a patient with leprosy (erythema
nodosum leprosum, ENL) who was concurrently treated with prednisone, as well as a review of relevant literature. Our findings substantiate
an increase in risk for thrombosis following thalidomide use in the dermatology and non-cancer clinical setting.
The maintenance of normal hydration is an important function of the skin. The stratum corneum provides an antimicrobial, antioxidant,
and UV barrier and plays an integral role in maintaining skin hydration. Environmental factors and disease states may compromise
the barrier function of the stratum corneum, leading to excessively dry skin. Evidence supports the use of moisturizers in
the treatment of various skin conditions, and a wide variety of these products are currently available. The presence of moisturizing
agents in a compound, however, may not guarantee optimal moisturization effects. Pharmacologic and physiologic (eg, concentration,
bioavailability, proper determination of moisturization effects), as well as patient-based considerations, can potentially influence
the effects of moisturizer ingredients. While moisturizers as adjunctive therapy have proven benefits in enhancing the management
of certain dermatologic conditions, the incorporation of moisturizing ingredients into topical treatments may not translate into clinical
benefit, particularly in enhancing skin barrier function.
Marie S. Tuttle MD, Neil J. Korman MD PhD, Jeremy Bordeaux MPH MD
Skin cancer risk from the use of immunosuppressive medications used to treat inflammatory conditions is not well understood,
though studies clearly establish an exaggerated risk of skin cancer in solid organ transplant recipients (SOTRs) receiving these
medications. The authors report a patient with Behcet’s disease treated with combination immunosuppressive therapy and common
variable immunodeficiency developing multiple squamous cell carcinomas (SCCs) of the skin, necessitating adjustment of her immunosuppressive
regimen. As more patients are treated with immunosuppressive medications for chronic inflammatory diseases,
clinicians must be aware of the possible increased risk of skin cancers associated with these medications. Skin cancer risk assessment,
screening for sub-clinical malignancies and frequent skin exams of high risk patients may represent strategies to improve the
safety of these medications.
Tiago Torres MD, Teresa Pinto Almeida MD, Rosario Alves MD, Madalena Sanches MD, Manuela Selores MD
Granuloma annulare is a benign, usually self-limited, dermatosis of unknown cause. Generalized lesions occur in approximately 15
percent of patients with GA and may cause mild to severe cosmetic disfigurement. The treatment of generalized granuloma annulare
can be challenging. We report the case of a 36-year-old male patient with a generalized granuloma annulare who had failed topical
and systemic glucocorticoids, systemic retinoids, dapsone, minocycline, PUVA therapy, and hydroxicloroquine and was successfully
treated with adalimumab, an anti-TNF-α monoclonal antibody. Adalimumab may be an additional option in the treatment of recalcitrant
forms of granuloma annulare.
J Drugs Dermatol. 2011;10(12):1466-1468.
Z. Paul Lorenc MD FACSa and Elizabeth Daro-Kaftan PhDb
Reversal of the visible signs of facial aging with the use of injectable products as an alternative to surgery has become more popular,
with nearly 5 million procedures performed in the United States in 2012. Volume augmentation products, such as hyaluronic acid
(HA), calcium hydroxylapatite (CaHA), and poly-L-lactic acid (PLLA), are often used in combination with one another and with neurotoxins
for facial rejuvenation because of the complementary modes of action. This article presents 2 case reports involving patientspecific
combinations of 2 different HA products, injectable PLLA, and CaHA with incobotulinumtoxinA or abobotulinumtoxinA. The
combination of HA, CaHA, PLLA, and neurotoxins has resulted in outstanding outcomes for many patients, with no clinical evidence
of increased adverse events secondary to combination therapy.
J Drugs Dermatol. 2014;13(2):191-195.
Introduction: Many commonly prescribed prescription drugs such as dopaminergic therapies can cause temporary hair loss.
Sertraline is a selective serotonin reuptake inhibitor. Its relative potency for dopamine reuptake inhibition is one of its
differentiations with other selective serotonin reuptake inhibitors such as fluoxetine.
Case Report: This is a report of a woman with a major depressive disorder who complained of diffuse scalp hair loss during
treatment with sertraline. This case is unique because before taking sertraline and after the discontinuation of sertraline,
the patient had taken fluoxetine. There was no report of hair loss during the fluoxetine therapy.
Discussion: The different impacts of sertraline and fluoxetine on dopamine reuptake inhibition were identified as a possible
reason for this side effect. Therefore, this rare side effect of sertraline should be noted and further studies may show
that switching from one selective serotonin reuptake inhibitor to another may prevent hair loss
Alexa Boer Kimball MD MPH, J. Mark Jackson MD, Jeffrey M. Sobell MD, Erin E. Boh MD PhD, Steven Grekin MD, Elaine B. Yu PharmD MS, J. Michael Woolley PhD, H. Amy Xia PhD, Chiun-Fang Chiou PhD, Seth R. Stevens MD
The Experience Diagnosing, Understanding Care, and Treatment with Enbrel® (EDUCATE) trial is a phase IV, 24-week,
multicenter, open-label study of etanercept 50 mg weekly in the treatment of psoriatic arthritis (PsA) in community dermatology
clinics. In this study, patients with active PsA and moderate to severe plaque psoriasis have measurable uses of
healthcare resources at baseline, reflecting a burden of illness. Etanercept significantly reduced healthcare resource utilization,
absenteeism, and caregiver assistance in PsA patients after 24 weeks of treatment. These results could translate
into savings on both direct and indirect costs and improvements in health-related quality of life for patients with PsA.
Joseph Alcalay MD, Dani Ben-Amitai, Ronen Alkalay MD MBA
Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer in humans, and is the most common malignant
neoplasm among adults in the US. The peak incidence occurs in the seventh decade of life. Childhood onset of BCC
is rare and usually associated with genetic disorders such as basal cell nevus syndrome, Bazex syndrome, albinism, and
xeroderma pigmentosum or due to radiation therapy. Idiopathic childhood onset is less common. A girl with idiopathic
onset of BCC who was treated with Mohs micrographic surgery is reported.
A computerized review of the literature was performed. A total of 108 children including this patient were reported with
idiopathic de novo BCC. Most of the tumors were nodular and located on the head, the same as in adults. Basal cell carcinoma
in children is probably the result of genetic background and intense ultraviolet radiation exposure. The preferred
treatment is excision with the Mohs micrographic technique.
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.
Vismodegib Ushers in New Era for the Treatment of Basal Cell Carcinoma
Approximately 2.8 million basal cell carcinomas (BCCs) occur in the United States each year, accounting for 80% of all non-melanoma skin cancers. Historically, BCCs that are not surgically resectable or candidates for radiation therapy have had few treatment options. However, the development of vismodegib and its approval by the United States Food and Drug Administration (FDA) for use in patients with locally advanced or metastatic BCC carries with it a renewed sense of hope. Vismodegib is the first oral medication approved by the FDA for adults with metastatic or locally advanced BCCs who are not candidates for surgery or radiation or for BCCs that have recurred after surgery. The overwhelming majority of BCCs are the result of hedgehog pathway activation, and vismodegib inhibits a key regulatory protein in the hedgehog pathway, resulting in response rates of between 30% to 60% for locally advanced and metastatic BCCs.
Malgorzata Olszewska MD, Lidia Rudnicka MD
Dihydrotestosterone is the main molecule responsible for androgenic alopecia. Finasteride, which reduces transformation
of testosterone into dihydrotestosterone and decreases dihydrotestosterone activity, is approved for treatment of
androgenic alopecia in men. We describe the case of a 46-year-old woman with androgenic alopecia, non-responsive
to minoxidil, who initially benefited from finasteride. Due to only limited improvement after finasteride and persisting
profound psychological distress resulting from androgenic alopecia, another 5-reductase inhibitor, dutasteride, was
introduced. Clinical evaluation and trichogram were applied for assessment of dutasteride efficacy in this patient.
Additionally, mean hair diameter was monitored by means of computer dermoscopy. After 6 months of therapy, significant
improvement was observed and after 9 months the clinical diagnosis of androgenic alopecia could no longer
be made in this patient. No side effects were observed. In conclusion, theoretical data and our experience in this case
show that dutasteride might develop into a true alternative in treatment of androgenic alopecia.
Stephanie Feldstein MDa and Jared Jagdeo MD MSb,c,d
Tattoo reactions can be clinically challenging to diagnose and treat. We present a case of a biopsy-proven granulomatous reaction to purple tattoo ink that clinically mimicked lichen planus. This reaction was successfully treated with one course of intralesional kenalog (ILK), with no recurrence six months after treatment. To our knowledge, this is the first report of a granulomatous tattoo reaction appearing clinically like lichen planus, and one of the few reports of a reaction to purple tattoo pigment. It highlights the importance of biopsying tattoo-related dermatoses prior to treatment in order to confirm the diagnosis. It also illustrates how a minimally invasive technique utilizing ILK to treat a granulomatous tattoo reaction can result in excellent dermatologic, cosmetic, and symptomatic outcomes. Based on this therapeutic success, we believe treatment with ILK injections should be attempted before more invasive modalities such as excision or laser therapy.
J Drugs Dermatol. 2015;14(6):638-640.
Maria Rita Nasca MD PhD, Rocco De Pasquale MD, Giuseppe Micali MD
We report a case of a 43-year-old uncircumcised Caucasian, diabetic man with a 4-year history of Zoon’s balanitis unresponsive
to topical steroids, in whom control of the disease was achieved with topical imiquimod. A histopathological examination
of a biopsy specimen was performed before and after treatment with imiquimod 5% cream applied 3 times a
week. A moderate to marked increased local skin reaction occurred several times throughout the treatment period, necessitating
multiple rest periods of several days’ duration. Clinical but not histological resolution was obtained after 4 months
of treatment, with no relapses at an 18-month follow-up. This positive treatment outcome indicates that imiquimod may
have a role in the management of Zoon’s balanitis. However, the dose and duration of therapy required to achieve complete
clinical response still needs to be established. Also, the question of whether normalization of histology can be achieved
with topical imiquimod has yet to be answered.
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.
Audrey S. Wang MD,a Larissa Larsen MD,a Shurong Chang MD PhD,a Tiffany Phan BA,a Jared Jagdeo MD MSa,b,c
Dermatofibromas are benign skin lesions that may be treated if symptomatic or for cosmetic concerns. We present a case of an African
American woman with an enlarging, pruritic dermatofibroma on the thigh that was treated with fractionated carbon dioxide (CO2) laser
three times approximately 5 weeks apart. Between laser treatments, topical corticosteroids were applied to the lesion for a total of 13
weeks. The dermatofibroma completely flattened and became asymptomatic within 1 month after the final laser treatment. We hypothesize
that the fractionated CO2 laser ablated a portion of the stromal component of the lesion and introduced microscopic channels
that facilitated deeper penetration of the topical corticosteroids into the lesion. This is the first reported case demonstrating the successful
treatment of a symptomatic dermatofibroma using combination therapy with fractionated CO2 laser and topical corticosteroids.
J Drugs Dermatol. 2013;12(12):1483-1484.
Deborah S. Sarnoff MD FAAD FACP, Ritu Saini MD FAAD
Epidermolytic hyperkeratosis is a rare genetic disorder of keratinization. In childhood, patients are erythrodermic and have
a compromised stratum corneum, replaced with generalized hyperkeratosis as the patients age. Treatment consists of topical
emollients as well as, topical and oral retinoids. Ultraviolet (UV) light, often in combination with psoralen ultraviolet
A (PUVA) is widely used as a therapeutic modality for a multitude of hyperproliferative disorders. Although not strictly
indicated for epidermolytic hyperkeratosis, it has been utilized as experimental treatment, particularly in the days prior
to retinoids. Psoralen ultraviolet A has also been implicated in the development of nonmelanoma skin cancers, especially,
squamous cell carcinoma (SCC). Retinoids are well-known to protect against nonmelanoma skin. A patient with epidermolytic
hyperkeratosis with multiple nonmelanoma skin cancers, previously treated with PUVA and long-standing oral
retinoids is reported.
Leon H. Kircik MDa and Panagiotis Zografos MScb
Psoriasis is a chronic inflammatory skin disease where the use of topical corticosteroids is a mainstream treatment. However, the continuous use of high potency topical corticosteroids is limited by a variety of well known adverse events which include, atrophy, and telangiectasia. Also, inhibition of lipid synthesis by steroids can cause impairment of the epidermal barrier, which is already disrupted in most of the inflammatory cutaneous disorders such as psoriasis. This will further lead to increase transepidermal water loss (TEWL), decreased hydration, dry skin, and irritation. On the other hand, topical vitamin D analogs directly affect keratinocyte proliferation and differentiation as well as modulation of epidermal lipids and antimicrobial peptides. Although the exact mechanism of action of topical vitamin D analogs is not well understood in the treatment of psoriasis, their efficacy and safety has been shown in several clinical trials over the years and they are widely used for psoriasis. Therefore, combination of topical steroids and vitamin D analogs may be a logical option for the treatment of psoriasis.
J Drugs Dermatol. 2015;14(10):1113-1116.
Michael H. Gold MD, Jaggi Rao MD, Mitchel P. Goldman MD, Tancy M. Bridges NP, Virginia L. Bradshaw NP, Molly M. Boring NP, April N Guilder RN
Background: Blue light sources have been shown to be effective in the treatment of mild to moderate inflammatory acne vulgaris
Objective: We evaluated the safety and efficacy of a new blue light source in the treatment of mild to moderate inflammatory
acne vulgaris in comparison to topical 1% clindamycin solution.
Results: Blue light therapy reduced inflammatory acne vulgaris lesions by an average of 34%, as compared to 14% for topical
1% clindamycin solution.
Conclusions: The blue light source presented in this report is a safe and effective treatment option available to our patients
with mild to moderate inflammatory acne lesions.
Andreas J. Bircher, MD and Christian Surber, MD
Unconventional (i.e. alternative, traditional, or complementary) treatments are used by many individuals for a variety of
symptoms and disorders. Reports on fraudulent products used for unconventional treatments are not uncommon.
These include herbal remedies offered as "natural" while containing non-labeled synthetic pharmacological ingredients
or even toxic agents, patients not being informed of active ingredients, products containing no active substances,
or unqualified individuals or "clinics" delivering dangerous advice or treatment. Reports on tainted topical products
remain rare due to the high analytical demands necessary to detect minimal traces of unknown ingredients, the fact
that patients often use medications from different sources, and patient over-reliance on the effectiveness of folk remedies
or advertised claims. The patients' assumption of receiving a safe and effective therapy by "natural" products has
shown to be unreliable. The authors urge that quality standards for "natural" and pharmaceutical products should be the
same and that only qualified professionals should deliver treatment and medical advice.
Zoe Diana Draelos MD,a Susana Raab BS,b Margarita Yatskayer MS,b Nannan Chen PhD,b
Yevgeniy Krol BS,c and Christian Oresajo PhDb
Facial dyspigmentation treatment is an unmet need in dermatology with increasing challenges due to the questionable safety of
hydroquinone. This research examined a new OTC formulation containing hydroxyphenoxy propionic acid, ellagic acid, yeast extract,
and salicylic acid on subjects who previously completed 12 weeks of treatment with 4% hydroquinone and 0.025% retinoic acid. The
goal of this study was to evaluate the skin lightening and tolerability profile of a 20-week maintanence therapy with a cosmeceutical
formulation during the summer months. 33 healthy subjects ages 25-60 years with moderate facial dyspigmentation defined as a
score of 3 on a 5-point scale were enrolled. There was statistically significant improvement at week 20 in terms of even skin tone
(P<0.001), spot intensity (P<0.001), spot size (P<0.05) and overall hyperpigmentation (P=0.002).
J Drugs Dermatol. 2015;14(4):386-390.
Adelaide A. Hebert MD and Fran E. Cook-Bolden MD for the Desonide Hydrogel Study Group, Sarmistha Basu PhD, Barry Calvarese MS, Ronald J. Trancik PhD
Low to mid potency corticosteroids remain a cornerstone of therapy for atopic dermatitis (AD). Since AD is most
prevalent in the younger pediatric population and is chronic in nature, safety is of particular concern especially for children
under 2 years of age. A novel desonide (0.05%) formulation was developed in a nonirritating and moisturizing
aqueous gel (hydrogel) that is free of alcohol and surfactants. The safety and efficacy of this new class VI low potency
topical steroid was substantiated in 2 phase III clinical trials in mild to moderate AD subjects aged 3 months to 18 years
(mean age 6.7 years and 30% under 3 years). A total of 425 subjects were treated with desonide hydrogel and 157 subjects
with the hydrogel vehicle. Desonide hydrogel 0.05% was extremely well-tolerated and provided statistically significant
improvements in all primary (P<.001) and secondary (P?.006) efficacy endpoints in both studies. This novel
desonide formulation represents an advancement in the treatment of AD.
Heather Woolery-Lloyd MD FAAD, Mohamed L. Elsaie MD MBA FAAD, Nidhi Avashia BS
Hyperhidrosis is a psychosocially embarrassing condition with a treatment history of varied success1, including topical application
of antiperspirants with aluminum salts (eg, Drysol®), oral anticholinergics, iontophoresis, and endoscopic
transthoracic sympathectomy. The use of botulinum toxin type A (Botox®) in humans for the treatment of hyperhidrosis
didn’t emerge until 1996.2,3 Botulinum toxin A is a safe and effective treatment for hyperhidrosis, and it has been shown
to improve the quality of life in affected patients.4 The toxin works by inhibiting the release of acetylcholine at the neuromuscular
junction, and affecting the postganglionic sympathetic innervation of sweat glands.5,6 The authors report a case
of inguinal hyperhidrosis treated with botulinum toxin A. Very few cases with similar treatments have been found in the
medical literature. More work should be done to find the optimal dose for treating this area, and affected patients should
be informed of the potential benefits of botulinum toxin therapy.
Kalindi Raval PharmD, Jennifer H. Lofland PharmD MPH PhD, Heidi C. Waters MS MBA, Catherine Tak Piech MBA
Plaque psoriasis is a chronic, inflammatory skin disease that can be difficult to treat. Traditional systemic agents, topical agents,
phototherapy and biologic therapies can be used for patients with psoriasis. The authors reviewed published results from a variety
of sources in order to better understand the effects of psoriasis treatments on patient satisfaction, patient adherence, healthcare
resource utilization and productivity. Patients with psoriasis consider many factors when evaluating therapies, including the time for
the therapy to be effective, cosmetic issues common with topical therapies and travel to and from phototherapy centers. Satisfaction
with and adherence to biologic therapies appears to be greater than for traditional therapies. Although biologic therapies are generally
more expensive than are traditional, these agents may contribute to decreased healthcare utilization and increased productivity.
J Drugs Dermatol. 2011;10(2):189-196.
Steven L. Harlan MD FAAD
Background: There have been many reports of topical steroids treatment for the face causing perioral dermatitis, steroid
acne, and steroid rebound phenomenon.
Objective: To assess patient reported outcomes in patients receiving compounded topical (hydrocortisone 0.75% and precipitated
sulfur 0.5%) lotion for up to 15 years for common dermatological conditions of the face.
Methods: In a retrospective study, 300 patients were randomly sampled from the dermatology clinic who had used, or were
continuing to use, a lotion based, pharmacy-compounded topical preparation for the face. The topical compound was used
in therapies for seborrheic dermatitis and combination with prescription topical therapy for patients with acne and rosacea
with tolerability problems.
Results: None of the 300 patients experienced steroid acne, rebound phenomenon, or perioral dermatitis associated with
use of hydrocortisone 0.75% and precipitated sulfur 0.5% on the face.
Conclusion: There was no evidence found that perioral dermatitis, steroid acne, or rebound phenomenon occurs when
sulfur is compounded with topical hydrocortisone 0.75%.
Angelo Landriscina BA,a* Jamie Rosen BA,a* and Adam J. Friedman MDa,b,c
Chronic wounds are a major source of morbidity and mortality within the United States. Wound dressings remain a cornerstone of dermatologic
therapy. Selection of the proper wound dressing proves difficult given the range of wounds encountered and the numerous dressing options available to the clinician. Nevertheless, selection of a proper wound dressing is a crucial step in management that can significantly alter the course of wound healing. There are a variety of wound dressings available, including moisture retentive/occlusive dressings as well as dressings impregnated with antimicrobial agents. Here we outline the characteristics and indications of specific wound dressings in order to provide clinicians with a basic understanding of the types of dressings available. This review provides a tool for dermatologists to better assess and treat chronic wounds. Using the algorithm provided, clinicians will be able to select the appropriate dressing in order to accelerate wound healing, prevent infection and improve health outcomes.
J Drugs Dermatol. 2015;14(7):740-744.
Qurat ul Ain Kamili MD and Alan Menter MD
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.
Julian S. Conejo-Mir, MD; Susana del Canto, MD; Miguel Angel Muñoz, MD; Lourdes Rodríguez-Freire, MD; Amalia Serrano, MD; Carlos Hernandez, MD and Agueda Pulpillo, MD
Recurrent erythema multiforme is a rare disorder, clinically characterized by symmetrically distributed, erythematous, and
bullous skin and mucous lesions, mainly precipitated by a preceding herpes simplex infection. In rare cases, EM presents
continuous or persistent relapses, and has been related to an Epstein-Barr virus infection. We report 2 cases of severe, persistent
erythema multiforme, treated with thalidomide, with complete disease suppression in both cases. Thalidomide
induces immunomodulator, anti-inflammatory, and anti-angiogenic effects, and may be considered as the elective treatment
of this rare variety of erythema multiforme. However, in order to avoid neuropathic side effects, patients under
thalidomide therapy should be monitored every 6 months with nerve conduction studies while taking the drug.
Bacterial resistance became a true clinical concern for dermatologists in the 1980s, when the first reports emerged of the resistance of Propionibacterium acnes to oral antibiotics. Subsequent studies have documented acne treatment failure associated with resistance to topical antibiotics. Beyond dermatology practice, antibiotic resistance has now become recognized as a worldwide health concern. In contrast to antibiotics commonly used in the treatment of acne, benzoyl peroxide (BP)'s mechanism of action is different. Benzoyl peroxide is a bactericidal agent. Combining BP with a topical antibiotic in a stable formulation has been proven in clinical trials to reduce total P acnes count by 99.7% after 1 week of therapy, eliminating both susceptible and resistant strains of P acnes. However, we have recently noticed BP's benefits as monotherapy in the treatment of acne. Benzoyl peroxide works rapidly on P acnes without causing antibiotic resistance. Hence, we may have to reconsider the role of topical antibiotics such as clindamycin in the treatment paradigm of acne vulgaris.
J Drugs Dermatol. 2013;12(suppl 6):s73-s76.
Meng Chen MD, Michael J. Holland MD, Mohsin R. Mir MD, Michael G.Wong BA, Brian P. Kelley MD, Kelli D. Grim MD, Sunaina S. Bhuchar MD, Sylvia Hsu MD
Tumor necrosis factor-α (TNF-α) inhibitors are biologic agents that are currently in wide use for the treatment of psoriasis as well as other inflammatory diseases. Following reports of thrombocytopenia as a potential adverse effect of anti-TNF-α therapy, we performed a retrospective study to determine the frequency of thrombocytopenia, defined as a platelet count <50x109 cells/L, in a cohort of 187 psoriatic patients treated with anti-TNF-α agents over a nine-year period. Although none of our patients met serologic criteria for thrombocytopenia or displayed clinical manifestations of thrombocytopenia, two patients developed platelet counts below 100×109 cells/L. Thrombocytopenia induced by anti-TNF-α agents is a potential adverse effect, it is a rare occurrence that will require further investigation in large, placebo-controlled, double-blind, prospective studies.
J Drugs Dermatol. 2011;10(3):280-284.
Laurel M. Morton MD,a Kevin C. Smith MD FRCPC,b Jeffrey S. Dover MD FRCPC,a,c,d,e Kenneth A. Arndt MDa,d,e,f
The potential for bruising is a frequent concern for patients undergoing minimally invasive procedures, particularly injection-based soft
tissue fillers and botulinum toxin type A. Decreasing the risk of this side effect with good technique and careful patient selection is
key, but interventions that quicken the resolution of bruising are also helpful. Many practitioners have employed the theory of selective
photothermolysis, using laser and light devices, to target hemoglobin and its breakdown products to speed time to bruise resolution.
585-595nm pulsed dye, pulsed 532nm and 1064 nm long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and
intense pulsed light may be utilized with best results achieved when treatment is performed 1-2 days after the appearance of purpura.
Specific therapy recommendations, side effects and contraindications will be addressed in this review.
J Drugs Dermatol. 2013;12(11):1219-1222.
Ghada A. BinSaif MD, Abdullah Al Samary MD, Saad Al Mohizea MD
Background: It was found that acetylcholine concentration increased with a significantly reduced expression of acetylcholinesterase
in vitiliginous patches that return to normal upon repigmentation.
Objective: To evaluate the efficacy and safety of botulinum toxin A in patients with localized vitiligo.
Methods: Ten patients were recruited. Eight patients had two or more focal vitiliginous patches. Two had segmental vitiligo. For each
patient with focal vitiligo, one or two vitiliginous patches were treated. For each patient with segmental vitiligo, half of the lesion was
treated. The untreated parts were used as a control. Botulinum toxin was injected. The response was analyzed at the initial visit, and
then two weeks, two months and six months after therapy.
Results: Thirteen vitiliginous patches were treated. Reassessment showed no evidence of repigmentation. Comparing treated versus
untreated sides, no differences were found. No adverse effects were reported.
Conclusion: Botulinum toxin is not effective in the treatment of localized vitiligo.
Multiples of certain cutaneous lesions should alert the clinician to a wider differential diagnosis and possible systemic associations
although the individual skin lesion is often benign in nature and banal in appearance.
This article focuses on such findings in selected multiple cutaneous lesions that may be classified according to the primary cutaneous feature
as vascular, pigmentary, nevoid hamartomas, and tumors/neoplastic conditions. The clinical presentation of each entity and its significance,
appropriate diagnostic evaluation, therapeutic and prognostic considerations and pertinent differential diagnoses will be reviewed.
J Drugs Dermatol. 2012;11(7):812-817.
INTRODUCTION: Injectable botulinum toxin is a safe, effective, and popular therapy that blocks neural impulses to achieve a desired effect. Using monopolar RF, percutaneous selective neuromodulation can achieve a similar but more persistent effect.
METHODS: Bilateral treatment was performed on a woman (48 years of age) to ablate the angular nerves of the face, inhibiting muscular function and reduce the appearance of glabellar lines. The cannula was inserted at the mid-pupillary line and advanced toward the lateral border of the nose. After isolating the nerve via low-level stimulation, anesthetic was given through a port in the cannula and energy was applied; tissue temperature of 85°C was maintained for 70 seconds.
RESULTS: Full ablative lesioning of the angular nerve of the patient was achieved and function was therapeutically inhibited with minimal pain. Results have persisted for more than two years.
J Drugs Dermatol. 2016;15(3):354-356.
Francisco A. Kerdel BSc MBBS
We present a case of a 36-year-old man with a 20-year history of stable plaque psoriasis admitted to our inpatient dermatology
unit with subacute annular pustular psoriasis. Two weeks prior to admission the patient’s dermatologist discontinued
the use of 5 lbs (2.3 kg) of triamcinolone 0.1% cream, which the patient had been applying to his skin weekly over
the last 8 years. The patient subsequently developed generalized erythematous annular and irregularly shaped, well-defined
plaques and confluent pustules. Approximately 80% of his total body surface area was involved, sparing the face and the
genitals. Initial therapy included cyclosporine 300 mg twice daily, topical hydrocortisone 1% ointment to affected areas,
acetaminophen/oxycodone 10/325 mg every 4 hours for pain as needed, and subcutaneous etanercept 50 mg twice
weekly. The patient was discharged on day 7 with significant improvement of skin lesions. On discharge the cyclosporine
was increased to 400 mg twice daily. The patient continued etanercept 50 mg twice weekly. One month after discharge
the patient was clear with only postinflammatory changes
Vincent W. Li MD, William W. Li MD, Katherine E. Talcott, Amy W. Zhai
Imiquimod (imidazoquinoline 5%) is a topical immune response modifier agent that inhibits angiogenesis, the growth
of new blood vessels. In addition to its stimulation of cell-mediated immunity, imiquimod’s antiangiogenic activity contributes
to its clinical efficacy by interfering with pathological neovascularization that promotes disease progression.
The antiangiogenic mechanisms of imiquimod are due to its: 1) induction of cytokines that themselves inhibit angiogenesis
(interferons, IL-10, IL-12); 2) local up-regulation of endogenous angiogenesis inhibitors (TIMP, TSP-1