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Blue light curing units--a dermatological hazard?

The setting reactions of a large number of dental materials are activated upon exposure to visible blue light emitted from a curing unit. Although the wavelength (lambda) from such devices is principally in the visible spectrum (lambda > 400 nm) a small amount of ultraviolet radiation (UV) is also present. Little attention has been paid to the consequences of such exposure upon the skin of dental surgeons' fingers. This investigation studied the level of UVA I (lambda = 340-400 nm) emitted by three commonly used polymerisation sources and assessed the level of protection afforded by six brands of surgical glove. The integrated irradiances of the Translux, Topaz T100 and Heliomat units in the UVA I range were 15861, 3611 and 305 mW/m2 respectively. For all gloves the mean % transmission, at lambda = 400 nm, was less than 4% with the exception of one brand where, in the stretched state, the level of transmission was 7%. It is concluded that the risk of initiating adverse dermatological consequences as a result of exposure to UVA I, emitted by light polymerisation units, is minimal in normal usage. The combined effects of exposure to radiation of this type and contamination of the fingers with quantities of irritant chemicals, such as found in many dental materials, are unknown. Due to the ability of the gloves to shield the skin from both chemicals and UVA I it is recommended that gloves are routinely worn for all light curing procedures.

Dental Equipment↗

Dermatological findings correlated with CD4 lymphocyte counts in a prospective 3 year study of 1161 patients with human immunodeficiency virus disease predominantly acquired through intravenous drug abuse.

Several prospective studies on dermatological findings in human immunodeficiency virus (HIV) type 1 infected patients have been published, mostly in populations in which the predominant risk factor for HIV infection is homosexuality. We attempted to identify cutaneous diseases associated with HIV-1 infection and to assess disease progression in a cohort of Spanish patients in whom the predominant cause of HIV infection was intravenous drug abuse. We prospectively examined 1161 HIV-1-positive patients for 38 months. Seventy-four per cent of patients were intravenous drug abusers, whereas heterosexual contact was the only risk factor in 14% and homosexuality in 9%. Centers for Disease Control stage II disease predominated (51%), whereas stage IV disease was less frequent (39%). The mean CD4 count was 353/mm3. We took patients' past and present medical history and performed a complete physical examination as well as taking photographs and carrying out the necessary diagnostic procedures. CD4 counts/mm3 were measured at each visit. A diagnosis of cutaneous disease was made in 799 patients (69%). Oral candidiasis and seborrhoeic dermatitis were the most common skin disorders, followed by xerosis, drug eruptions, dermatophytosis and the papular eruption of acquired immunodeficiency syndrome. Condyloma acuminatum, herpes zoster and herpes simplex were the most frequent viral infections. Conditions that have a statistically significant association with advanced stage and low CD4 levels include drug eruptions, xerosis, light reactions, diffuse alopecia, herpes simplex, oral candidiasis, psoriasis, oral hairy leucoplakia, molluscum contagiosum, Kaposi's sarcoma, furuncles, candidal intertrigo, folliculitis and ungual infection, as well as onychomycosis and tinea pedis or manuum. Dermatoses commonly associated with homosexuality, such as Kaposi's sarcoma and oral hairy leucoplakia, were rare in our patients.

AIDS-Related Opportunistic Infections↗

Resistance to antibiotics used in dermatological practice.

The increased prevalence of bacterial resistance is one of the major problems of medicine today. Antibiotic resistance can be defined as the situation where the minimal inhibitory concentration is greater than the concentration obtainable in vivo. Resistance genes are easily transferred among bacteria, especially bacteria on skin and mucous membranes. In dermatological patients the most important resistance problems are found among staphylococci, Propionibacterium acnes and, to some extent, streptococci. Staphylococcus aureus strains have developed worldwide resistance to penicillin due to betalactamase production in > 90% of cases, and methicillin resistance is now a major problem with resistance levels of > 50% in certain areas of the world. These resistant strains are often multiresistant, and include resistance to erythromycin and tetracycline, with resistance to quinolone developing rapidly. Group A streptococci are still susceptible to penicillin, but increasing problems with erythromycin and tetracycline have been reported. After treatment with both systemic and oral antibiotics, P. acnes develops resistance in more than 50% of cases, and it is estimated that one in four acne patients harbours strains resistant to tetracycline, erythromycin, and clindamycin. To limit the development of antibiotic resistance, it is necessary to establish an antibiotic policy (prescription rules, reimbursement strategy, development of both national and local guidelines, and limitations on non-medical use). Clinicians also need access to rapid diagnostic methods, including resistance testing. This may provide further data for surveillance systems, reporting both antibiotic consumption and resistance levels. The involvement of clinical doctors in teaching and research in this area is probably the most important aspect, along with their involvement in the formulation of national and local guidelines. In the future we may consider it more important to ensure that future patients can be offered antibiotic treatment, rather than focusing on the patient presenting today.

Drug Resistance, Microbial↗

Fusidic acid in dermatology.

Fusidic acid is an antibiotic that belongs to a group of its own, the fusidanes. The molecule has a steroid-like structure but does not possess any steroid activity. The structure is thought to be responsible for the steroid-like high penetration, and for the fact that no cross-resistance or cross-allergy has been seen with other antibiotics in routine clinical use. The anti-microbial activity of fusidic acid is specifically aimed at the most common skin pathogens, including Staphylococcus aureus, towards which it is one of the most potent antibiotics. The place of fusidic acid in dermatology is in the treatment of mild to moderately severe skin and soft-tissue infections, e.g. impetigo, folicullitis, erythrasma, furunculosis, abscesses and infected traumatic wounds, whereas it is of less use in conditions such as hidradenitis suppurativa, chronic leg ulcers, burns and pressure sores. The topical combinations of fusidic acid with either betamethasone or hydrocortisone are extremely useful in the treatment of atopic dermatitis/eczema whenever staphylococcal/secondary infection is suspected, and in more persistent cases of eczema where staphylococcal superantigen may be playing an important exacerbating role.

Anti-Bacterial Agents↗

Liver cytochrome P450 CYP1A2 is markedly inhibited by systemic but not by bath PUVA in dermatological patients.

BACKGROUND: Methoxsalen (8-MOP) may cause important pharmacokinetic drug interactions as it has been shown to inhibit and/or induce several drug-metabolizing enzymes in vitro, in animal models and in humans. OBJECTIVES: In order to assess the clinical importance of acute and chronic 8-MOP effects on the liver cytochrome P-450 enzyme CYP1A2 in vivo, we measured caffeine clearance in dermatological patients before the onset of systemic or bath psoralen + ultraviolet A radiation (PUVA) (8-MOP + UVA) therapy, on the first day and after 1 week of treatment. METHODS: Data from four patients with systemic PUVA and seven patients with bath PUVA were available (age range 23-71 years, five women and six men). RESULTS: For all of the patients, individual pre-PUVA caffeine clearance values were above the lower limit of previously assessed reference ranges. Systemic PUVA markedly decreased caffeine clearance by factors of 0.17 [90% confidence interval (CI) 0.07-0.42] on the first day and 0.14 (90% CI 0.05-0.36) after 1 week of treatment, respectively, and values thus dropped below the reference ranges. In contrast, bath PUVA had no obvious effect on pre-PUVA clearance values as the latter changed by factors of 1.00 (90% CI 0.81-1.23) and 1.05 (90% CI 0.75-1.49) on the first day and after 1 week of treatment, respectively. CONCLUSIONS: Systemic PUVA causes pronounced inhibition of liver CYP1A2, while bath PUVA has no such effect. The extent of interaction makes a dose adjustment for most CYP1A2 substrates such as theophylline mandatory in patients undergoing systemic PUVA.

Administration, Cutaneous↗

The role of photodynamic therapy in dermatology.

Photodynamic therapy (PDT) involves selective photosensitization of a target tissue by means of a topically or systemically administered agent which is then activated by light to effect an oxygen dependent cytotoxic reaction. The production of reactive oxygen intermediates, including singlet oxygen, is localized to where the photosensitizer accumulates and induces apoptosis and vascular endothelial damage. First-generation photosensitizers are haematoporphyrin derivatives and are effective in treating certain nonmelanoma skin cancers. However, they induce cutaneous photosensitization for at least 4-6 weeks and have a limited role in dermatology. Many second-generation photosensitizers, such as 5-aminolaevulinic acid, are associated with less prolonged photosensitization. Although PDT remains largely experimental, it has potential applications in both benign and malignant skin disease.

Basal Cell Carcinoma↗

Dermatological practice in Guadeloupe (French West Indies).

Guadeloupe is a French Caribbean island, with a population of mainly African ancestry, and a high standard of living. We recorded the dermatological diagnoses in 5000 new patients attending dermatologists. The main diagnoses were acne (16.4%), superficial mycoses (12.8%), and eczema (10.5%). Diseases considered to be specific to the tropics were scarce. The main dermatoses attributable to a tropical environment were superficial mycoses, and prurigo. Concerning ethnicity, the majority of Afro-Caribbeans and resident Caucasians visited dermatologists for the same diseases. The main difference attributable to ethnicity was a high rate of visits by Caucasians for melanocytic naevus and malignant/premalignant neoplasms. Dermatoses restricted to Afro-Caribbeans were only secondary ailments. The spectrum of diseases registered in our study was similar to that in Northern countries; this probably reflects the influence of the high standard of life in Guadeloupe.

Adult↗

Keratinocyte adhesion and the missing link: from Dowling-Meara to Hay-Wells. St John's Hospital Dermatological Society Annual Oration 2000.

Maintaining a protective barrier against the environment is an essential function of normal skin. Critical to this role are several structural proteins and glycoproteins that contribute to adhesive junctions linking adjacent keratinocytes and basal keratinocytes to the underlying dermis, as well as other regulatory proteins involved in aspects of epidermal development, differentiation and proliferation. Inherited abnormalities in the genes that encode these components may give rise to a range of genodermatoses, many of which are characterized structurally by a 'missing' or perturbed adhesive link and clinically by congenital skin blistering. This oration reviews some of the original clinical descriptions and observations made in this field, as well as providing an update on the corresponding recent molecular discoveries. The emphasis is on contributions made by past and present members of the St John's Hospital Dermatological Society.

Cell Adhesion↗

Dermatological applications of DNA array technology.

The Human Genome Project and other large scale sequencing consortia continue to generate huge amounts of DNA sequence data. Despite the identification of specific disease-related genes and genetic markers, we still appear to know little about how diverse gene products actually interact with each other or respond to other chemical or biological stimuli. Such information is of course fundamental to understanding complex disease pathways and biochemical processes and, as such, has spawned new fields of investigative genetics, that of functional genomics and proteomics. DNA array technology is emerging as a powerful, high-throughput and versatile tool that can be applied to the study of functional genomics. This article reviews the methodology involved in array analysis and provides insight into how, as an investigative tool, DNA arrays are becoming increasingly useful in understanding fundamental abnormalities in dermatological disease and also in refining the management of patients with certain skin disorders.

Gene Expression Profiling↗

A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic.

BACKGROUND: This is a retrospective study of the epidemiology and morbidity of herpes zoster and the risk factors for herpes zoster morbidity in Singapore. RESULTS: The mean age of 164 patients with herpes zoster seen at our dermatology clinic between January 1994 and December 1995 was 48.8 years, with a sex ratio of 1:1. The common presenting symptoms were pain (90%), feelings of helplessness and depression (20%), and flu-like symptoms (12%). The commonest prodromes were pain (41%), itching (27%), and paresthesia (12%). Prodromal pain was more frequently experienced by patients aged more than 50 years (42%) than by patients aged less than 30 years (25%). The thoracic (45%) and cervical (23%) dermatomes were the most commonly affected in all age groups. There was no statistically significant difference in the frequency of dermatomal distribution among the different age groups and between the sexes. Pain was experienced by almost all (95%) patients during the course of their disease. It tended to be more severe in older patients. Burning (26%), stabbing (15%), and shooting (15%) pain were the most common types experienced. Post-herpetic neuralgia was significantly more common in older patients. The prevalence of post-herpetic neuralgia decreased over time in all age groups. A higher proportion of older patients (more than 50 years of age) (20%) suffered from post-herpetic neuralgia compared with younger patients (less than 30 years of age) (7%) (not significant). Patients in all age groups considered acute pain (46%) and persistent pain (25%) to be their most unbearable symptoms during the course of herpes zoster. The most significant problems caused by herpes zoster pain were insomnia (25%), misery (feeling helpless and depressed) (20%), limitation of movement (9%), and inability to continue work (8%). Insomnia was significantly more commonly experienced by patients more than 50 years of age (36%) than those less than 30 years of age (P = 0.026). Few patients (9%) consulted their general practitioner (GP) during the prodrome or on the day of appearance of skin eruptions. Most patients (45%) consulted their GP within the first 3 days of the onset of skin eruptions; 33% sought treatment more than 3 days after the appearance of zoster symptoms. Only 30% of patients were willing to pay more than S$200 for antiviral therapy. Most (43%) were only prepared to pay for antiviral treatment if it cost less than S$200. The most important features the patients wished to derive from antiviral therapy were a shortening of the duration of skin lesions (55%) and a reduction in the severity of pain (acute and chronic) (30%). CONCLUSIONS: Our study indicated that older patients (aged more than 50 years) were at a higher risk of developing post-herpetic neuralgia. They were also more likely to suffer morbidity, e.g. insomnia. There is a need to educate patients at risk to identify the prodrome and skin eruptions of herpes zoster so that early antiviral therapy can be considered.

Adult↗

Cutaneous lymphomas in Tokyo: analysis of 62 cases in a dermatology clinic.

BACKGROUND: The epidemiology of cutaneous lymphomas revealed that the incidence of lymphomas differed depending on various factors including area, race, and sex, among others. OBJECTIVE: This study was undertaken to analyse the incidence of cutaneous lymphomas in Tokyo. METHODS: The clinical records and histologic material from 50 patients with lymphomas of the skin and 12 patients with lymphomatoid papulosis seen during the last 10 years at the Department of Dermatology, The Jikei University School of Medicine, Tokyo, have been reviewed. RESULTS: T-cell lymphomas including mycosis fungoides (MF)-Sézary's syndrome (SS) complex and adult T-cell leukemia/lymphoma (ATL) were more frequent than B-cell lymphomas. The incidence of ATL is associated with the number of human T-cell lymphotropic virus type 1 (HTLV-1) carriers in the general population. Cutaneous B-cell lymphoma (CBCL) is not as rare as previously thought in Japan. CONCLUSIONS: Although the frequency of these cases depends on many unrelated factors, these values can provide a rough indication of the incidence of cutaneous lymphomas in Tokyo. The incidence of cutaneous lymphomas may be influenced by changes in environmental factors including viral infections.

Adolescent↗

Clinical and mycological study of occult tinea pedis and tinea unguium in dermatological patients from Tokyo.

An epidemiological investigation was conducted to determine the prevalence and circumstances of untreated, unsuspected tinea pedis and tinea unguium, morbid conditions that could be termed occult athlete's foot, in patients visiting a dermatology clinic in Tokyo, Japan, for the first time, for other complaints. All subjects completed a questionnaire covering comprehensive anamnestic details, and were examined for disposition of toes, presence of signs suggestive of tinea pedis, other diseases of the foot, score of clinical signs and symptoms, potassium hydroxide (KOH) test, severity score, and mycological culture. The results showed that the prevalence of occult athlete's foot was 25%, and that 59% of those cases were complicated by tinea unguium. The characteristics of patients with occult athlete's foot included a higher proportion of men and a tendency toward a low clinical score together with a high severity score. In the patient background, a strong correlation was observed between a positive KOH test result and characteristics such as age, disposition of toes, and predisposing disease.

Adolescent↗

Dermatological presentations of infantile myofibromatosis: a review of 27 cases.

Twenty-seven cases of infantile myofibromatosis presenting with dermatological manifestations were retrospectively reviewed. Approximately 80% were solitary lesions and 50% of these appeared on the head and neck. Around 60% were present at or soon after birth. Most lesions were dermal or subcutaneous, although some were intramuscular and intraosseous. The clinical appearance was non-specific leading to frequent misdiagnosis. While most patients presented with nodules, atrophic depressed lesions and warty pedunculated lesions were also seen. Although 7% of lesions recurred after excision, spontaneous resolution was also documented.

Bone Neoplasms↗

Dermatological immune restoration syndrome: does it exist?

Dermatological conditions are often an early clue to HIV infection and are common. As the disease progresses patients develop a dominant Th-2 immunological response that may facilitate the development of a number of skin conditions. With antiretroviral therapy the Th-1 response is restored and some skin problems regress. But, paradoxically, some cutaneous conditions may worsen, such as herpes zoster, mucocutaneous herpes, eosinophilic folliculitis and mycobacterial infections. This may be because immune restoration of a host's immunity causes recognition of silent or latent infection and results in development of the condition.

AIDS-Related Opportunistic Infections↗

Local anesthesia and malignant hyperthermia: review of the literature and recommendations for the dermatologic surgeon.

BACKGROUND: Malignant hyperthermia (MH) is a rare syndrome that is a major cause of anesthetic-related morbidity and mortality in otherwise well patients. The role of local anesthetics, stress, and epinephrine in inducing this syndrome has been subjected to controversy. OBJECTIVE: To examine the role of local anesthetics, stress, and epinephrine in producing clinically relevant adverse effects in patients with MH. METHODS: A critical review of the literature. RESULTS: Local anesthesia is safe for use in usual doses in MH-susceptible patients. The role of stress and epinephrine in precipitating episodes of MH is likely minimal, but controversy remains in the anesthesia and dental literature. CONCLUSION: Recommendations for diagnosis, treatment, and safety precautions to be taken by dermatologic surgeons when treating MH patients are made.

Anesthesia, Local↗

The use of conscious sedation for outpatient dermatologic surgical procedures.

BACKGROUND: Dermatologic surgery has undergone increasing levels of sophistication over the past few decades. Commensurate with this demand, an established anesthesia technique called conscious sedation has been employed. OBJECTIVES: Methods for performing office-based conscious sedation are described. Recommendations are made regarding prerequisites for conscious sedation in an office setting, patient selection, complications management, and postoperative discharge requirements. CONCLUSION: The goals of anesthesia are to provide for patient safety and comfort, to increase patient acceptance of the procedure, and to enhance the surgeon's efficiency and satisfaction.

Ambulatory Surgical Procedures↗

Healing of venous ulcers of long duration with a bilayered living skin substitute: results from a general surgery and dermatology department.

BACKGROUND: A laboratory-grown bilayered living skin substitute (LSS) has been shown to accelerate the healing of venous ulcers. However, issues related to optimal wound bed preparation prior to the application of LSS have not been addressed. OBJECTIVE: When combined with standard compression therapy and near elimination of wound exudate, bioengineered skin can achieve complete closure of venous ulcers which have been present for more than a year and which are difficult to heal. METHODS: In the general surgery (center A) and dermatology (center B) departments at two separate medical centers, LSS was used to treat venous ulcers of more than 1 year's duration and which had been unresponsive to conventional therapy. Wound bed preparation at both centers had as common goals the removal of necrotic tissue, optimal formation of granulation tissue, and elimination of wound exudate. RESULTS: There was great comparability between the two centers in the patients being treated, wound size and duration, and number of LSS applications. Both centers achieved a frequency of complete wound closure of greater than 70% within 6 months. CONCLUSION: At two separate clinical and specialty sites having a common goal of optimal wound preparation, treatment with LSS was associated with a high rate of complete closure of hard to heal venous ulcers.

Aged↗

Long-term care dermatology.

Long-term care dermatology is a growing specialty, serving a U.S. population of over 2.7 million patients. Included here is an overview of the medical and administrative structures of extended care facilities, basics of nursing home management, risk assessment tools, and treatment recommendations.

Aged↗