Erythroderma (exfoliative dermatitis). Part 2: energy homeostasis and dietetic management strategies.

Erythroderma (exfoliative dermatitis) is associated with important metabolic changes that include an enhancement in energy expenditure. The key components to total energy expenditure (TEE) include basal metabolic rate (~68% of TEE), physical activity (~22% of TEE) and thermic effect of food (~10% of TEE). In the erythrodermic state, there are likely multiple contributors to the increase in basal metabolic rate, such as 'caloric drain' resulting from increased evaporation of water from enhanced transepidermal water loss, increased activity of the cardiovascular system (including high-output cardiac failure), increased nonshivering thermogenesis and hormonal changes such as hypercortisolaemia. A change in the patient's level of physical activity and appetite as a result of ill health status may further impact on their TEE and energy consumption. In Part 2 of this two-part concise review, we explore the key constituents of energy homeostasis and the potential mechanisms influencing energy homeostasis in erythroderma, and suggest much-needed dietetic management strategies for this important condition.

Erythroderma (exfoliative dermatitis). Part 1: underlying causes, clinical presentation and pathogenesis.

Erythroderma (exfoliative dermatitis), first described by Von Hebra in 1868, manifests as a cutaneous inflammatory state, with associated skin barrier and metabolic dysfunctions. The annual incidence of erythroderma is estimated to be 1-2 per 100 000 population in Europe with a male preponderance. Erythroderma may present at birth, or may develop acutely or insidiously (due to progression of an underlying primary pathology, including malignancy). Although there is a broad range of diseases that associate with erythroderma, the vast majority of cases result from pre-existing and chronic dermatoses. In the first part of this two-part concise review, we explore the underlying causes, clinical presentation, pathogenesis and investigation of erythroderma, and suggest potential treatment targets for erythroderma with unknown causes.

The emerging importance of tranexamic acid in dermatology.

Tranexamic acid (TA) is an antifibrinolytic agent, increasingly recognized as being of utility for a wide variety of skin diseases. We review the evidence supporting the use of TA for a range of dermatological indications, including (among others) melasma, postinflammatory hyperpigmentation, urticaria, angio-oedema and haemostasis, in addition to practical considerations of its use by dermatologists.

Leptospirosis presenting as severe cardiogenic shock: A case report.

BACKGROUND: Leptospirosis is a rare infectious illness caused by the Spirochaete Leptospira. It has a wide-varying spectrum of presentation. We present a rare case of severe cardiogenic shock secondary to leptospirosis, in the absence of its common clinical features. CASE PRESENTATION: A 36-year-old woman presented to our unit with severe cardiogenic shock and subsequent multi-organ failure. Her clinical course was characterised by ongoing pyrexia of unknown origin with concurrent cardiac failure. She was initially managed with broad-spectrum antibiotics and inotropes. Percutaneous cardiac biopsy excluded major causes of myocarditis. On day 21 after presentation, she was found to be IgM-positive for leptospirosis. CONCLUSIONS: This is a rare case of severe cardiogenic shock secondary to leptospirosis infection. The case also highlights the importance of obtaining a thorough social history when assessing a patient with an unusual presentation, as clues can often be missed.

Intravenous immunoglobulins in dermatology. Part 1: biological mechanisms and methods of administration.

Intravenous immunoglobulin (IVIg) is a solution of human IgG, salt, sugars and solvents, which is used to treat a multitude of diseases. Although IVIg has been known to treat many diseases safely and successfully, there are relatively few supporting randomized controlled trials. In this article, we review the biological mechanisms of IVIg in dermatological disorders and the practicalities of its use, including its mechanism of action, dosing, availability, costs and adverse effects.

Intravenous immunoglobulins in dermatology. Part 2: clinical indications and outcomes.

Intravenous immunoglobulin (IVIg) is a solution of human IgG, salt, sugars and solvents used to treat a multitude of diseases. Although IVIg has been known to treat many diseases safely and successfully, there are relatively few supporting randomized controlled trials. In part two of this review, we assess the clinical indications of IVIg in dermatological disorders and the outcomes of its use.

Treatment of keloid scars using light-, laser- and energy-based devices: a contemporary review of the literature.

Keloid scars are common and have a predilection for young, ethnic skin often with a family history. Keloids can be painful and pruritic and cause significant emotional distress when particularly visible or prominent. In this article, we review the evidence underlying the use of laser- and energy-based devices for treatment of keloid scars, either as monotherapy or in conjunction with other therapies such as corticosteroids, surgery and silicone gel in the treatment of keloid scars.

The role of fillers in the management of acne scars.

Acne scars are present in 95% of patients with acne, and can cause profound psychosocial morbidity. Fillers are commonly used for facial soft tissue augmentation, and there is increasing interest in their use for the treatment of acne scars, particularly for the atrophic subtype. We review the evidence for the use of temporary, semi-permanent and permanent fillers for acne scars. The use of permanent methylmethacrylate fillers for acne scarring is supported by a randomized controlled trial, and is approved by the United States Food and Drug Administration. There is initial evidence supporting the use of poly-L-lactic acid and hyaluronic acid fillers, but evidence is still lacking about the use of polyacrylamide and polyalkylimide fillers.

Use of nicotinamide in dermatology.

Nicotinamide (niacinamide) is the water-soluble, amide form of vitamin B3. We review the evidence underlying the use of nicotinamide for various dermatological indications, including nonmelanoma cancer prophylaxis, blistering disorders, acne vulgaris and cosmetic indications, and speculate upon its future role in dermatological practice.

Fractional radiofrequency treatment in acne scars: Systematic review of current evidence.

Fractional radiofrequency (FRF) is renowned for its use in cosmetic dermatology, with regard to the treatment of rhytides, striae, scarring and cellulite. We have systemically analysed its evidence for the use of FRF in acne scars. Our search identified 15 articles, one single-blinded randomised controlled trial, two split-face trials and thirteen prospective clinical studies, mostly single-centred. Case reports were excluded. In total 362 patients were treated. The longest follow-up was for 210 days, and on average the follow-up was for three months, varying between one and seven months. This review has found that there are many small studies showing promising results for the use of FRF in acne scars, either as an adjunct or more importantly as the sole treatment. There is however a need for larger trials against ablative and non-ablative lasers, in order to affirm the evidence present already. This is the first systematic review on the use of FRF in acne scars.

Non-cosmetic dermatological uses of botulinum neurotoxin.

Botulinum neurotoxin (BoNT) is renowned for its inhibitory effects on the neuromuscular junction. The evidence for its use in cosmetic dermatology and in non-dermatological indications is well established. We have systemically analysed the evidence for the non-cosmetic dermatological uses of BoNT. This review presents the many small studies showing promising results for the use of BoNT in a multitude of dermatological diseases, including (but not limited to) hyperhidrosis, Darier's disease, Hailey-Hailey disease, pompholyx and hidradenitis suppurativa. There is, however, the need for larger, double-blinded randomized control trials against established treatments to cement the evidence base underlying the use of BoNT in dermatology.

The use of picosecond lasers beyond tattoos.

Picosecond lasers are a novel laser with the ability to create a pulse of less than one nanosecond. They have been available in the clinical context since 2012. Dermatologists are now using picosecond lasers regularly for the treatment of blue and green pigment tattoo removal. This article reviews the use of picosecond lasers beyond tattoo removal. The overall consensus for the use of picosecond lasers beyond tattoo treatment is positive. With examples of this in the treatment of nevus of Ota, minocycline-induced pigmentation, acne scarring, and rhytides.

Ivor-Lewis oesophagogastrectomy with Roux-en-Y duodenal bypass.

Oesophagectomies and gastrectomies are performed predominantly for the treatment of malignant disease. However, in this case series, we describe three patients with benign disease who had a laparoscopic oesophagogastrectomy with gastroduodenal detachment and Roux-en-Y biliary diversion, and discuss the operative feasibility and consequent patient outcomes. Our aim was to modify the procedure using an established reconstruction already practised in gastric and bariatric surgery, thereby preventing operative sequelae that lead to a poor quality of life (eg reflux oesophagitis and vomiting). During the first postoperative year, our first two patients experienced weight loss, indigestion and lower bowel symptoms with no apparent improvement in gastric function compared with a standard gastric tube pull-up reconstruction. In the longer term, in both patients, the gastric tube interpositions appeared to function well and there was no evidence of gastro-oesophageal reflux disease, delayed gastric emptying or troublesome indigestion. Our third patient, who had lifelong severe reflux symptoms, was eating normally three months after the operation with no need for antacid medication. We therefore conclude that laparoscopic Ivor-Lewis oesophagogastrectomy with Roux-en-Y bypass is a more complex reconstruction with added risks but may in the long term result in better overall outcomes and satisfaction for patients, particularly those with benign disease.