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Botulinum toxin in dermatology - beyond wrinkles and sweat.

Botulinum toxin (BTX) types A and B have been used with success in cosmetic dermatology and hyperhidrosis treatment. The present review focuses on other uses of BTX in dermatology. Discussed in particular are the available data on BTX in inflammatory diseases, proctology, and some other indications. From studies in various types of eczema, it seems that BTX-A not only acts as a potent inhibitor of acetylcholine but also as an inhibitor of substance P and of glutamate as well. By those mechanisms, BTX-A may be antipruritic, which may help explain the benefits of BTX-A in lichen simplex and dyshidrotic hand eczema. In Hailey-Hailey disease, facial eccrine hidrocystomas, salivary fistulas, and intrinsic rhinitis, BTX-A blocks the secretion of sweat/saliva/mucus. BTX-A has important applications in proctology where it has become the most powerful nonsurgical therapy for anal fissures. In proctalgia fugax and after hemorrhoidectomy, BTX-A is analgesic. Current treatment applications of BTX-A and its limitations are reviewed in this paper.

Journal Article↗

A retrospective study of the efficacy of intense pulsed light for the treatment of dermatologic disorders presenting to a cosmetic skin clinic.

BACKGROUND: One hundred seven patients presenting to a cosmetic skin clinic were treated with intense pulsed light (IPL) over a 12-month period. The main categories of patients offered treatment were those with vascular problems such as rosacea, facial telangiectasia, and spider nevi; pigmentation disorders such as solar damage, lentigines, and hyperpigmentation; and assorted problems such as scarring and poikiloderma. METHODS: Each patient who entered into the study had the full medical history taken and a dermatologic assessment. Polaroid photographs were taken and the images used for comparison before and after treatment. Outcomes were assessed by physicians' global assessment and a patients' postal questionnaire. Patients were treated with a Lumina IPL (Lynton Lasers Ltd) using a multiple pulsing facility with variable interpulse spacing, incorporating a 585-nm head. Fluence levels varied between 10 and 40 J/cm(2), although the average fluence over all patients was 25 J/cm(2). The delay was set between 10 and 30 ms and two to four pulses were used. Results Excellent results were seen in 80% of patients treated. There was a high patient satisfaction rate and low prevalence of side effects. CONCLUSIONS: IPL has been shown to provide a safe and effective noninvasive treatment for a wide range of dermatologic disorders and is suitable for wider use in primary care.

Journal Article↗

Dermatologic laser surgery.

The laser is becoming an increasingly important surgical and medical instrument in the field of dermatology. Developments in the areas of laser technology and application have significantly broadened its clinical use over the past several years. These rapid changes and advances in the use of the laser for cutaneous processes may make it difficult for the physician to maintain a current base of knowledge in this area. Relevant laser systems and their clinical applications are presented and discussed, as are investigational laser systems, which may be of importance for the future. This will allow the dermatologic surgeon the opportunity to update concepts and evaluate the various laser systems and their cutaneous applications.

Argon↗

Dermatologic cosmetic surgery.

Many cosmetic surgery procedures performed today were either developed or refined by dermatologic surgeons. The role played by dermatologic surgeons in the development of dermabrasion, hair transplantation, liposuction, blepharoplasty, face-lift, cutaneous implants, fat transplantation, chemical peel, and sclerotherapy is described.

Dermabrasion↗

Management of patients taking anticoagulants and platelet inhibitors prior to dermatologic surgery.

BACKGROUND: The use of anticoagulants and platelet inhibitors can increase the risk of intraoperative and postoperative hemorrhagic complications in cutaneous surgery. Currently there are no general guidelines and no consensus among dermatologic surgeons on how to manage patients taking these medicines. OBJECTIVE: To address many of the issues involved in the management of these patients. CONCLUSION: General recommendations are made for managing patients taking anticoagulants and platelet inhibitors prior to dermatologic surgery.

Anticoagulants↗

The polymerase chain reaction. Applications in dermatology.

Within the space of the last 5 years, application of the revolutionary in vitro method of deoxyribonucleic acid (DNA) amplification known as the polymerase chain reaction (PCR), has become ubiquitous. The rapidly increasing number of clinical and research articles utilizing this technology, both in the dermatologic and general medical literature, requires one to have at least a basic understanding of how the PCR is conducted, what it has to offer, and the potential shortcomings. Such knowledge will hopefully allow a more critical appraisal of an increasingly complex literature. This review aims to describe the methodology and medical applications of this powerful technique with special consideration to the increasing role PCR may have on dermatologic research and practice.

Genetic Diseases, Inborn↗

Is dermatologic usage of coal tar carcinogenic? A review of the literature.

BACKGROUND: Coal tar ointments have been used for decades in the treatment of various dermatoses, most notably eczema and psoriasis. Occupational exposure to coal tar poses an increased risk of developing cutaneous malignancies. The evidence of an increased risk of skin cancer in humans, as a result of dermatologic usage of tar, however, is conflicting. OBJECTIVE: A consensus on the carcinogenicity of tar is sought. METHODS: The existing literature (in vitro, animal, and human studies) on this subject is reviewed. RESULTS: The carcinogenicity of coal tar has clearly been demonstrated by in vitro and animal studies, and appears to be potentiated by concomitant use of ultraviolet radiation. Systemic absorption of mutagens from topically applied tar has been demonstrated in humans. Epidemiologic studies in humans, however, have not definitively shown an increase in skin cancer with therapeutic use of tar. CONCLUSIONS: Conclusive evidence for the carcinogenicity of tar used in dermatologic practice is lacking. Further controlled studies are necessary.

Animals↗

Split-thickness skin grafting of leg ulcers. The University of Miami Department of Dermatology's experience (1990-1993).

BACKGROUND: Skin grafting for large and recalcitrant lower extremity ulcers is a commonly used therapy. However, the success rate for grafts performed by dermatologists is largely unknown. OBJECTIVE: To analyze our experience with meshed split-thickness skin grafts for leg ulcers. METHODS: We retrospectively analyzed all hospitalized dermatology patients who underwent meshed split-thickness skin grafting for lower extremity ulceration due to a variety of causes performed by the Department of Dermatology at the University of Miami over a 3-year period (1990-1993). RESULTS: Twenty-nine patients with 36 ulcers were grafted. Greater than 90% of ulcers had initial graft take. At long-term follow-up, 52% of ulcers were healed, 26% were partially healed, and 22% recurred. CONCLUSION: We conclude that meshed split-thickness skin grafting is a safe and effective therapy for recalcitrant lower extremity ulcers.

Adolescent↗

Randomized, double-blind, placebo-controlled study evaluating the lidocaine/tetracaine patch for induction of local anesthesia prior to minor dermatologic procedures in geriatric patients.

BACKGROUND: Topical anesthetics offer a noninvasive method of anesthesia. OBJECTIVE: To evaluate the efficacy and safety of the lidocaine/tetracaine patch, a 1:1 (wt:wt) eutectic mixture of lidocaine and tetracaine, for local anesthesia before minor dermatologic procedures in geriatric patients. METHODS: In a multicenter, randomized, double-blind, placebo-controlled study, 79 patients over the age of 65 years received a 30-minute application of either the lidocaine/tetracaine patch or placebo immediately before a shave biopsy or superficial excision. The primary measure of efficacy was patient assessment of procedural pain using the visual analog scale (VAS). Secondary efficacy end points included patient, investigator, and independent observer assessments. RESULTS: There was a statistically significant difference (p = .041) in patient ratings of pain by VAS score in the active group (9.5 mm) compared with the placebo group (22.5 mm). None of the secondary end points showed a statistically significant difference between groups. No adverse events were reported. CONCLUSION: The lidocaine/tetracaine patch is a safe and effective method for noninvasive induction of local anesthesia for minor dermatologic procedures in patients over the age of 65 years.

Aged↗

A statistical analysis of a pediatric dermatology clinic.

Statistical analysis was performed of the diseases seen and therapies utilized during the first two years of the Pediatric Dermatology Clinic at the University of Miami School of Medicine, Miami, Florida. This survey includes 2,821 patient visits made by 1,578 patients. This analysis classifies patients by diagnosis, sex, age, race, and treatment. Diagnostic and treatment frequencies, sex and race ratios, and trends in the patient's age at presentation are also noted. This survey reveals a wide spectrum of pediatric dermatologic disease with 154 different diagnoses made. A review of the 86 different therapeutic modalities utilized is also presented.

Acne Vulgaris↗

Progressive early dermatologic changes in Hutchinson-Gilford progeria syndrome.

We describe evolving dermatologic findings in a male with progeria from age 1 month to 21.5 months. At 18 months of age, irregular pigmentary changes of the abdomen, early occipital alopecia, superficial scalp veins, glyphic nasal tip, absent ear lobules, coarse hair that stands on end, crowded dentition with delayed tooth development, and dystrophic nails permitted the diagnosis of progeria. Radiographs showed evidence of resorption of the distal ends of the clavicles, attenuation of the terminal phalanges, diffuse osteopenia, and fishmouth vertebral bodies, which are typical of this syndrome. Appreciation of the evolution of early dermatologic findings may permit earlier diagnosis of this condition in infants with skin changes.

Diagnosis, Differential↗

Chronic granulomatous disease: two members of a single family with different dermatologic manifestations.

Case 1: A 33-year-old man with a 14-year history of localized skin disease on the face and scalp was evaluated at the department of dermatology. The physical examination revealed plaques with papules, pustules, and a golden yellow crusting on the forehead, cheeks, upper lip, and chin (Figure 1). The scalp presented fine, whitish scales. At the beginning of his disease, the patient presented large red and painful purulent boils. The 14-year clinical course of these lesions was characterized by partial remissions and recurrences, but he did not specify any treatment related to improvement. The clinical diagnosis given for the scalp lesions was seborrheic dermatitis. For the facial lesions, many differential diagnoses were considered, among them: seborrheic dermatitis, acneiform dermatitis, impetigo, folliculitis, seborrheic pemphigus, and demodicidosis. The histopathologic study of a biopsy taken from the cheek (Figure 2) showed superficial spongiform dermatitis with neutrophils and folliculitis that are compatible with the diagnosis of seborrheic dermatitis. Both Gram and periodic acid-Schiff stains were negative. Follow-up of the patient was not possible since he did not come back. The disease in this patient initially manifested at age five by the presence of recurrent ganglionic abscesses. At age 15, he presented a pulmonary abscess of a left lobule that was surgically removed; at this point the diagnosis of chronic granulomatous disease was established. At age 28, an exploratory laparotomy was performed due to peritonitis and multiple hepatic abscesses. At that time, he was treated with antibiotics (mainly trimethoprim-sulfamethoxazole) and interferon-g. The patient had two brothers who died due to complications of chronic granulomatous disease. In addition, both his mother and sister presented a history of discoid lupus-like lesions. Case 2: Coincidentally, his 27-year-old sister was seen in our department of dermatology 5 years before, presenting infiltrated and erythematous plaques with fine scales (Figure 3) on the right side of the nose and the left annular finger. No other cutaneous or mucous lesions were seen. She referred onset in childhood with similar lesions on sun-exposed areas that disappeared without scarring. A biopsy was performed and the results were compatible with the diagnosis of discoid lupus erythematosus (Figure 4). Direct immunofluorescence was not available. At that time, she did not mention the family history of chronic granulomatous disease. Clinical follow-up was not possible, but his brother referred that she afforded complete remission only with sun protection.

Adult↗

Dermatological hazards in the electronics industry.

The advent of the electronics age has resulted in the rapid growth and increasing importance of the electronics industry on a global scale. The main industrial processes are fabrication of semiconductor wafers, printed circuit boards, the assembly of semiconductor devices, printed circuit boards and the final electronic products. The process carry the risk of various work hazards, among them dermatological hazards. These include exposure to irritants and allergens during common operations such as soldering, cleaning operations, materials handling, procedures for control of static electricity and low humidity in the work environment. Even the use of protective clothing may be associated with the risk of dermatitis. In spite of the numerous dermatological hazards, the risk for work-related skin disorders among electronics workers appears to be low when compared to other industries. However, the vast size of the electronics workforce will contribute to large numbers of workers with occupational dermatoses. Occupational health personnel responsible for factories in the electronics industry should therefore be aware of the cutaneous hazards present, and how these may lead to work-related dermatoses.

Dermatitis, Occupational↗

The influence of topical dermatological treatment modalities on epidermal Langerhans cells and contact sensitization in mice.

The influence of the widely used topical dermatological treatment modalities anthralin, coal tar and pyrogallol on surface markers of epidermal Langerhans cells and contact sensitization was studied and compared with that of a PUVA treatment. A common effect of all dermatological therapies tested was inhibition of Langerhans cell ATPase, whereas an effect on MHC class II antigens was found only after PUVA or tar treatment. The induction of contact hypersensitivity was inhibited only by PUVA, and not by the other treatments. These results show that various forms of topical therapy influence surface markers and immunological function of epidermal Langerhans cells differently.

Adenosine Triphosphatases↗

'Eczema school' to improve compliance in an occupational dermatology clinic.

From the beginning of 1990 a trained nurse has been employed at our Department of Dermatology to give information about skin care, allergen avoidance and skin protection to the patients. To find out the possible benefit obtained by this patient education, a questionnaire was sent out to 540 patients who had been diagnosed with an occupational skin disease established at the Department of Dermatology between 1985 and 1992. It is evident that direct comparison in this kind of longitudinal follow-up must be carried out with great criticism, since changes in patients' work exposure and socioeconomical situation during the follow-up time will also affect the prognosis. In this study, 424 patients returned the questionnaire, 252 who had been examined before 1990 and 172 later. According to the answers, it appeared that during the last 12 months, the majority (65%) had suffered from dermatitis, 13% from constant and 52% from periodic symptoms. However, when the diagnosis had been irritant contact dermatitis without allergens found, the prognosis was significantly better (p<0.008) among those who had received "extra education" and none had persistent dermatitis. Patients with contact allergy to metals or synthetic resins had also managed better, as compared to those who had received traditional treatment (p<0.002, p<0.003). Other factors such as personal motivation and possibilities for work reorganization were also important for the prognosis. 60% of patients were not initially aware of the decision given by the insurance companies, although 94% of their skin diseases had been accepted as occupational dermatoses. Generally, the patients were satisfied with the extra information given by the nurse.

Adult↗

Epidemiology of malignant melanoma in central Europe: risk factors and prognostic predictors. Results of the Central Malignant Melanoma Registry of the German Dermatological Society.

The Central Malignant Melanoma Registry (CMMR) of the German Dermatological Society was established in 1983, and 7789 cutaneous malignant melanomas (CMM) were registered by 35 dermatological departments in Germany, Austria and Switzerland until the end of 1989. Population-based incidence rates, risk factors for developing CMM and prognostic parameters for predicting the final outcome were investigated in separate multicenter studies performed by the CMMR. Among the 7789 CMM registered, there was a preponderance of females (57.7%) versus males (42.3%). The age distribution peaked in the 5th and 6th decade of life for both sexes with a mean age of 52 years. The mean detection age was 50 years for superficial spreading melanoma, 53 for nodular melanoma, and 65 for lentigo maligna melanoma. Mean tumor thickness decreased from 2 mm in 1983 to 1.5 mm in 1989, indicating better CMM-awareness of the population and the medical community in this area. 90% of the patients presented with clinical stage I CMM without detectable metastases at first diagnosis. The incidence of CMM in Berlin (West) was assessed based on 960 cases diagnosed between 1980 and 1986. The incidence increased by 49% between 1980-81 and 1985-86, and the age standardized-incidence rate (European standard population) was 9.8 for males and 7.8 for females per 100,000 inhabitants and year in 1985-86. Mortality rates decreased in this period from 3.5 to 2.6 for males and slightly increased for females from 1.2 to 1.6 per 100,000 inhabitants and year. A case control study on the relative risk (RR) for developing CMM revealed the total number of melanocytic nevi (MCN) to be the strongest risk predictor (15x -50x increased RR), followed by the presence of dysplastic MCN (7x increased RR) and the skin type I (2x increased RR). Interestingly, no differences between CMM-cases and controls were found with respect to the history of sunburns or other parameters of sun exposure in this study. Multivariate analysis of 5093 stage I CMM-patients from four departments with long-term follow-up revealed that tumor thickness is the strongest predictor of survival with an almost linear correlation to the risk of death for tumor thickness up to 6 mm with no further increase in mortality for higher tumor thickness. The best classification of tumor thickness for survival prediction was less than or equal to 1 mm, 1.01-2 mm, 2.01-4 mm and greater than 4 mm in our data set on 5093 patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

[Antimicrobial therapy in dermatology].

The extensive and sometimes indiscriminate use of antibiotics sometimes without strict indications has led to increases in both bacterial resistance and sensitization of patients. Systemic antibiotics in skin infections are indicated when a severe local infection occurs which spreads into the surrounding tissue or when there are signs of systemic infection. There are special indications in patients with peripheral arterial occlusive disease,diabetes or immunosuppression. Topical use of antibiotics should be abandoned and replaced by antiseptics. The beta-lactam antibiotics are the antibiotics of first choice for many skin infections. They are usually effective, have a well-defined profile of adverse events and most are affordable. Penicillin G or V are the first line treatment for erysipelas. Infections with Staphylococcus aureus are usually treated with isoxazolyl penicillins or second generation cephalosporins. In mixed infections in patients with diabetes or peripheral arterial occlusive disease,the treatment of choice is metronidazole plus beta-lactam-/beta-lactamase inhibitor antibiotics, but quinolones or second generation cephalosporins can also be used, once again with metronidazole. The aim of this review is to define the indications for antibiotics in dermatology, to highlight their modes of action and adverse effects and to make suggestions for rational antibiotic therapy in cutaneous infections frequently encountered in the practice of dermatology.

Administration, Topical↗

The cost of treatment of dermatological disorders in hospital versus health centre.

Well-run outpatient services and reasonable charges to patients for drugs have led to reduced hospitalisation of dermatological patients and hence a reduction in the total cost of nursing and treating such patients in comparison with previous years, when there was greater emphasis on hospital treatment. There is at present no waiting list for dermatological beds at the National Hospital.

Ambulatory Care Facilities↗